Introdução: O medicamento, imprescindível no tratamento e recuperação da saúde, cresce em importância, tanto para os profissionais de saúde como para a população. Objetivo: Incluir a experiência da população de baixa renda, na pesquisa em saúde pública, sobre necessidade de tomar medicamentos; apresentar dificuldades vivenciadas, em busca destes; relatar as estratégias adotadas, diante da impossibilidade de consegui-los gratuitamente; estudar a compreensão do valor monetário deste produto; identificar a possibilidade de aquisição de medicamentos de médio e alto custo. Método: Metodologia qualitativa, usando a técnica de grupo focal, com a construção de 3 grupos, com a participação de 31 sujeitos, no período de dezembro de 2008 a março de 2009. Os sujeitos são moradores da região do Butantã, SP/SP, com 40 anos ou mais, com renda mensal até 3 salários mínimos e usuários do SUS, fazendo uso de pelo menos um medicamento. Os três grupos foram formados por usuários de medicamentos de uso contínuo; usuários de medicamentos de médio e alto custo e por moradores de uma favela. As discussões foram conduzidas por 2 profissionais e, foram baseadas em 5 perguntas referentes aos objetivos. Para a análise das discussões, optou-se pelo método do DSC (Discurso do Sujeito Coletivo), com utilização do software Qualiquantisoft®. Resultados: As discussões geraram 23 respostas categorizadas, destacando: a necessidade do medicamento, a dificuldade para consegui-lo gratuitamente; a má divulgação e a falta de informação sobre os programas de distribuição gratuita; a dependência de terceiros para aquisição; a necessidade de procura do medicamento em vários postos de saúde; a necessidade de compra. Medicamentos com preço até 50 reais foram considerados caros para a maioria. Os de alto custo são adquiridos, com algumas dificuldades, destacando-se tempo de espera, e falhas na dispensação. Conclusão: O acesso aos medicamentos mostrou-se parcial, apesar do avanço das políticas públicas na área, fazendo-se necessário um amplo conjunto de medidas, que priorize a manutenção de estoques regulares, a humanização do atendimento, a disponibilidade de profissionais competentes e que tenham compromisso social, para que a população de baixa renda alcance gratuitamente o sucesso terapêutico desejado, de forma regular e sistemática. / Introduction: Prescription drugs are indispensable to medical treatment for both health professionals and the general population. Objective: the goals of this study were to include in public health research the experience of the poor population who needs prescription drugs; to describe practical difficulties of the poor population to obtain prescription drugs from public health units; to report the main actions taken by this population when it is not possible to obtain free drugs in public health units; to evaluate the comprehension of the financial value of these drugs within this demographic segment of the population; to identify the strategies to obtain prescription drugs of medium and high cost. Method: The focal group qualitative method was selected for this research, with three groups comprising 31 subjects, studied in the period from December 2008 to March 2009. Subjects had to be residents of Butantã District, São Paulo-SP; besides being over 40 years old, in use of at least one prescription drug; to have a monthly income of up to three minimum salaries; to be a regular user of the public health system and units. All subjects lived in slums and were under treatment with medium-high cost drugs of continuous use. Two professionals conducted discussions on the five questions concerning the objectives. The collective subject method (CSM) was used for the analysis, which was performed with the Qualiquantisoft® computer program. Results: the five questions generated 23 answers, which were characterized as follows: necessity of the drug; difficulty to obtain the drug from public health units; deficiency in the advertisement programs and lack of information on free distribution programs; reliance on other people to obtain the drugs; necessity to reach many public health units to obtain the drugs; necessity to buy the drug. Drugs with prices up to R$ 50,00 were considered expensive. High cost drugs are purchased with some difficulty, such as slot time and dismissing flaws. Conclusion: Despite the advances in public health policies, the access to prescription drugs was biased, revealing a demand for a set of actions to prioritize storage and regular maintenance of these drugs, well prepared professionals to speed up and humanize the advising and assistance strategies in public health units, in order to promote a better distribution of these drugs and the effective achievement of therapeutic success for this population in a regular and systematic way.

Introdução: O medicamento, imprescindível no tratamento e recuperação da saúde, cresce em importância, tanto para os profissionais de saúde como para a população. Objetivo: Incluir a experiência da população de baixa renda, na pesquisa em saúde pública, sobre necessidade de tomar medicamentos; apresentar dificuldades vivenciadas, em busca destes; relatar as estratégias adotadas, diante da impossibilidade de consegui-los gratuitamente; estudar a compreensão do valor monetário deste produto; identificar a possibilidade de aquisição de medicamentos de médio e alto custo. Método: Metodologia qualitativa, usando a técnica de grupo focal, com a construção de 3 grupos, com a participação de 31 sujeitos, no período de dezembro de 2008 a março de 2009. Os sujeitos são moradores da região do Butantã, SP/SP, com 40 anos ou mais, com renda mensal até 3 salários mínimos e usuários do SUS, fazendo uso de pelo menos um medicamento. Os três grupos foram formados por usuários de medicamentos de uso contínuo; usuários de medicamentos de médio e alto custo e por moradores de uma favela. As discussões foram conduzidas por 2 profissionais e, foram baseadas em 5 perguntas referentes aos objetivos. Para a análise das discussões, optou-se pelo método do DSC (Discurso do Sujeito Coletivo), com utilização do software Qualiquantisoft®. Resultados: As discussões geraram 23 respostas categorizadas, destacando: a necessidade do medicamento, a dificuldade para consegui-lo gratuitamente; a má divulgação e a falta de informação sobre os programas de distribuição gratuita; a dependência de terceiros para aquisição; a necessidade de procura do medicamento em vários postos de saúde; a necessidade de compra. Medicamentos com preço até 50 reais foram considerados caros para a maioria. Os de alto custo são adquiridos, com algumas dificuldades, destacando-se tempo de espera, e falhas na dispensação. Conclusão: O acesso aos medicamentos mostrou-se parcial, apesar do avanço das políticas públicas na área, fazendo-se necessário um amplo conjunto de medidas, que priorize a manutenção de estoques regulares, a humanização do atendimento, a disponibilidade de profissionais competentes e que tenham compromisso social, para que a população de baixa renda alcance gratuitamente o sucesso terapêutico desejado, de forma regular e sistemática. / Introduction: Prescription drugs are indispensable to medical treatment for both health professionals and the general population. Objective: the goals of this study were to include in public health research the experience of the poor population who needs prescription drugs; to describe practical difficulties of the poor population to obtain prescription drugs from public health units; to report the main actions taken by this population when it is not possible to obtain free drugs in public health units; to evaluate the comprehension of the financial value of these drugs within this demographic segment of the population; to identify the strategies to obtain prescription drugs of medium and high cost. Method: The focal group qualitative method was selected for this research, with three groups comprising 31 subjects, studied in the period from December 2008 to March 2009. Subjects had to be residents of Butantã District, São Paulo-SP; besides being over 40 years old, in use of at least one prescription drug; to have a monthly income of up to three minimum salaries; to be a regular user of the public health system and units. All subjects lived in slums and were under treatment with medium-high cost drugs of continuous use. Two professionals conducted discussions on the five questions concerning the objectives. The collective subject method (CSM) was used for the analysis, which was performed with the Qualiquantisoft® computer program. Results: the five questions generated 23 answers, which were characterized as follows: necessity of the drug; difficulty to obtain the drug from public health units; deficiency in the advertisement programs and lack of information on free distribution programs; reliance on other people to obtain the drugs; necessity to reach many public health units to obtain the drugs; necessity to buy the drug. Drugs with prices up to R$ 50,00 were considered expensive. High cost drugs are purchased with some difficulty, such as slot time and dismissing flaws. Conclusion: Despite the advances in public health policies, the access to prescription drugs was biased, revealing a demand for a set of actions to prioritize storage and regular maintenance of these drugs, well prepared professionals to speed up and humanize the advising and assistance strategies in public health units, in order to promote a better distribution of these drugs and the effective achievement of therapeutic success for this population in a regular and systematic way.

BACKGROUND: High-cost healthcare users (HCUs) are patients who use disproportionate healthcare resources compared to their peers. A better understanding of their co-morbidity status, medication use, and healthcare utilization is needed to improve health interventions and policies. OBJECTIVES: We aimed to: (1) synthesize what is known about HCUs and interventions for managing them, (2) characterize how HCUs differ from non-HCUs, and (3) explore the impact of medications and whether prescribing quality contributes to differences in healthcare costs and HCU status development. METHODS: We synthesized what is known about HCUs and used the GRADE framework to evaluate the evidence for interventions designed to improve their health. We conducted retrospective population-based matched cohort and case-control studies of incident older adult HCUs using health administrative data. We examined prescribing and medication costs over the non-HCU to HCU transition period and compared them to non-HCUs. We conducted logistic regression to evaluate associations between HCU status development and the use of high-cost drugs and potentially inappropriate medications. RESULTS: HCU interventions to date have shown inconsistent effects on clinical outcomes and healthcare costs and the overall quality of evidence supporting their efficacy is low. Compared to non-HCUs, HCUs have higher rates of polypharmacy, hospitalization, and mortality. Medications are the highest healthcare cost category in the pre-HCU year and these costs rise nearly 1.7-fold in the HCU year. High-cost drug use increases significantly during the HCU transition period and 3.6% achieve HCU status based on drug costs alone. Use of several potentially inappropriate medications and high-cost drugs significantly increase the odds of HCU development. CONCLUSIONS: Medications can contribute to high-cost healthcare directly through drug costs alone or indirectly through adverse effects on health. Medication optimization interventions and policies to reduce inappropriate medication use and ensure cost-effective medication use are needed to manage high-cost healthcare and prevent HCU development. / Thesis / Doctor of Philosophy (PhD) / High-cost healthcare users (HCUs) are patients who use disproportionate healthcare resources compared to their peers. More research is needed to better understand HCUs to design interventions to improve their health outcomes and costs. In this thesis, we evaluated what previous studies have discovered about HCUs and we used Ontario’s health system data to explore whether the quality of prescribing and medication use in older adults influences their risk of becoming a HCU. We found that current interventions for HCUs have had inconsistent effects on improving health outcomes and costs. We also found two medication-related factors contributing to the risk of becoming an older adult HCU: (1) use of very expensive medications, and (2) use of potentially inappropriate medications where the risk of harm may outweigh potential benefits. Interventions and health policies to optimize the appropriate and cost-effective use of medications are needed to manage high-cost healthcare and prevent HCU development.

O levantamento do número de medicamentos inovadores licenciados no Brasil pela agência reguladora de medicamentos durante quatro anos, entre 1998 e 2001, mostrou 154 medicamentos inovadores (fármacos com nova estrutura molecular). A maioria deles (57,1% do total) foi concentrada em quatro classes terapêuticas: quimioterapia sistêmica (39 produtos), analgesia e anestesia (20), aparelho cardiovascular (15) e hormônios e anti-hormônios (14). Medicamentos inovadores para uso crônico foram lançados com preços mais altos com relação às opções pré-existentes de sua mesma classe terapêutica. Quando comparados apenas a fármacos com estrutura química semelhante, o custo foi menor. O custo estimado de tratamento por um mês variou entre 14% do salário mínimo (R$ 27,90) até 580% (R$ 1.159,80), portanto quase seis vezes. O estudo mostrou que no Brasil os medicamentos inovadores não são acessíveis para as famílias de baixa renda. / During the four-year period of 1998-2001, the Brazilian government licensed 154 medicines with new molecular entities. Most of them (57,1%) belong to only four therapeutic classes: anti-infectives (39 products), anesthetics and analgesics (20), cardiovascular (15) and hormones and anti-hormones (14). New medicines for chronic term use were launched with prices higher than the pre-existing competitors of the same therapeutic class. When compared with drugs resembling similar molecular structure, the price was lower. When compared to the minimal monthly wage, the estimated cost of on month of treatment was between 14% (R$ 27,90) and 580% (1159,80), therefore almost six times more. The study showed that in Brasil medicines with new molecular entities are not affordable to families with low income.

O levantamento do número de medicamentos inovadores licenciados no Brasil pela agência reguladora de medicamentos durante quatro anos, entre 1998 e 2001, mostrou 154 medicamentos inovadores (fármacos com nova estrutura molecular). A maioria deles (57,1% do total) foi concentrada em quatro classes terapêuticas: quimioterapia sistêmica (39 produtos), analgesia e anestesia (20), aparelho cardiovascular (15) e hormônios e anti-hormônios (14). Medicamentos inovadores para uso crônico foram lançados com preços mais altos com relação às opções pré-existentes de sua mesma classe terapêutica. Quando comparados apenas a fármacos com estrutura química semelhante, o custo foi menor. O custo estimado de tratamento por um mês variou entre 14% do salário mínimo (R$ 27,90) até 580% (R$ 1.159,80), portanto quase seis vezes. O estudo mostrou que no Brasil os medicamentos inovadores não são acessíveis para as famílias de baixa renda. / During the four-year period of 1998-2001, the Brazilian government licensed 154 medicines with new molecular entities. Most of them (57,1%) belong to only four therapeutic classes: anti-infectives (39 products), anesthetics and analgesics (20), cardiovascular (15) and hormones and anti-hormones (14). New medicines for chronic term use were launched with prices higher than the pre-existing competitors of the same therapeutic class. When compared with drugs resembling similar molecular structure, the price was lower. When compared to the minimal monthly wage, the estimated cost of on month of treatment was between 14% (R$ 27,90) and 580% (1159,80), therefore almost six times more. The study showed that in Brasil medicines with new molecular entities are not affordable to families with low income.