CONTEXTO: El trasplante pulmonar es a día de hoy una alternativa terapéutica válida para los pacientes en insuficiencia respiratoria crónica. Actualmente las indicaciones superan con creces el número de órganos disponibles lo que genera tiempos de espera prolongados. En el año 2005 Estados Unidos implementó un sistema innovador para priorizar los candidatos de la lista de espera mediante un estimador que calcula el beneficio neto que supondría realizar un trasplante pulmonar. Para ello se realiza un cálculo que combina la urgencia médica y la supervivencia post-trasplante de cada paciente. La mayoría del resto de programas de trasplante pulmonar basa la distribución de órganos en el orden cronológico en el que los pacientes son incluidos en la lista de espera. OBJETIVOS: El objetivo principal de este trabajo es analizar si el LAS hubiera sido útil como factor pronóstico en los 170 pacientes trasplantados en el Hospital Vall d´Hebron de Barcelona entre 2006 y 2009. MÉTODOS: Estudio prospectivo que recoge los pacientes mayores de 12 años que recibieron un trasplante pulmonar durante el periodo comprendido entre el 1 de Enero de 2006 y el 31 de Diciembre de 2009. La cohorte se estratificó en 3 grupos: LAS < 32.5 (n=58, 37%), LAS 32.5-36 (n=50, 32%) y LAS > 36 (n=49, 31%), denominados LAS bajo (LASB), LAS intermedio (LASI) y LAS alto (LASA) respectivamente. La estimación de probabilidad de supervivencia se realizó mediante el método de Kaplan-Meier y el modelo de regresión de Cox expresado en Hazard Ratio. RESULTADOS: La supervivencia al año del trasplante pulmonar en el grupo de pacientes LAS alto (LAS>36) fue significativamente menor que la del resto de candidatos (67% vs. 83%; p=0.03). Los pacientes con LAS alto mostraron 1.99 veces (HR=1.99) más probabilidades de fallecer que el resto durante el primer año postrasplante. Además los pacientes del grupo LAS alto presentaron mayor frecuencia de ventilación mecánica durante su estancia en la lista de espera en relación a los pacientes con LAS menor. Para terminar, los pacientes con LAS alto presentaron mayor frecuencia de complicaciones bronquiales. CONCLUSIÓN: El LAS es útil como modelo predictivo de morbimortalidad en el trasplante pulmonar en la serie de pacientes trasplantados en el Hospital Vall d´Hebron. Los pacientes que pertenecen al grupo LAS alto presentaron una supervivencia al primer año menor y una mayor frecuencia de complicaciones postoperatorias. / BACKGROUND: Lung transplantation has become a widely accepted treatment in the management of a broad spectrum of end stage pulmonary diseases. However, the number of donor organs remains far less than the number of patients who may potentially benefit from this procedure. The development of the lung allocation system (LAS) in the United States in 2005 marked the first time an estimate of benefit was used to prioritize organ allocation. The LAS was designed to prioritize wait-list candidates based on a combination of wait-list urgency and post-transplant survival, whereas, the lung allocation policy in the majority of lung transplant programmes abroad is based on time accrued on the waiting list. OBJECTIVES: The purpose of this study was to examine if the LAS at the time of the lung transplantation would be a prognostic factor with regards to morbidity and mortality for the 170 patients who underwent a lung transplant between 2006-2009 in Vall d´Hebron Hospital, Barcelone (Spain). METHODS: All recipients aged > 12 years undergoing first-time lung transplantation during the period from January 1, 2006 to December 31, 2009 were included in the study. The cohort was divided into three groups: LAS < 32.5 (n=58, 37%), LAS 32.5-36 (n=50, 32%) and LAS > 36 (n=49, 31%), referred to as low LAS (LLAS), intermediate LAS (ILAS) and high LAS (HLAS). A time to event analysis was performed for risk of death after transplantation using Kaplan-Meier survival and Cox proportional hazard models. RESULTS: Patients in high risk group (LAS>36) had significantly worse first year survival compared with lower LAS recipients (67% vs. 83%; p=0.03 by log rank test). Patients with high risk group were also found to have increased risk of death (Hazard Ratio 1.99) compared with low risk group. HLAS recipients were more likely to require mechanical ventilatory support at the time of transplant compared with patients in the low-intermediate risk groups. Patients in the high risk group were also found to have increased airway complications. CONCLUSIONS: The lung allocation score is useful as a prognostic factor for the cohort of patients who underwent a lung transplant in the Vall d´Hebron Hospital. HLAS is associated with decreased one year survival and increased complications during the post-transplant hospitalization.

Submitted by Mariana Granado Barbosa (mgranadobarbosa@gmail.com) on 2018-06-15T03:38:39Z No. of bitstreams: 1 TA MarianaGB v.final 12062018.pdf: 802684 bytes, checksum: 999853e56c5ed01ebb9085705e158cdd (MD5) / Approved for entry into archive by Simone de Andrade Lopes Pires (simone.lopes@fgv.br) on 2018-06-15T16:58:24Z (GMT) No. of bitstreams: 1 TA MarianaGB v.final 12062018.pdf: 802684 bytes, checksum: 999853e56c5ed01ebb9085705e158cdd (MD5) / Approved for entry into archive by Isabele Garcia (isabele.garcia@fgv.br) on 2018-06-15T20:24:22Z (GMT) No. of bitstreams: 1 TA MarianaGB v.final 12062018.pdf: 802684 bytes, checksum: 999853e56c5ed01ebb9085705e158cdd (MD5) / Made available in DSpace on 2018-06-15T20:24:22Z (GMT). No. of bitstreams: 1 TA MarianaGB v.final 12062018.pdf: 802684 bytes, checksum: 999853e56c5ed01ebb9085705e158cdd (MD5) Previous issue date: 2018 / Filas de espera constituem um problema crônico nos países que optaram por sistemas universais. Entretanto, no Brasil há poucos estudos sobre filas de espera nos serviços de saúde. Este é um estudo de caso que pretende contribuir acrescentando métrica nessa discussão e fundamentando-a em torno da viabilidade econômico-financeira das decisões em saúde e da regulação, de modo mais amplo. Partindo do contexto de um hospital municipal da zona sul da cidade de São Paulo, analisamos dois cenários diferentes, a demanda proveniente da atenção básica para consulta com especialista, que nem sempre termina na indicação de cirurgia, e as filas de espera internas ao hospital para cirurgia ginecológica, de pacientes já avaliadas e com cirurgia indicada, aguardando seu agendamento. Da análise desses dados, traçamos um novo modelo de gerenciamento da fila de espera para cirurgia ginecológica eletiva nesse hospital. Nossa proposta não tem o objetivo de atingir espera zero. Tampouco é fundamentada em estratégia única. Nossa principal conclusão é que a estratégia mais eficiente para o gerenciamento das filas de espera envolve o fortalecimento das ações de integração com a rede de atenção. No Sistema Único de Saúde, o olhar de linha de cuidado, pode viabilizar efetivamente a entrega de maior valor na assistência prestada e pode ser feita através de iniciativas locais. / Waiting lists are a chronic problem in countries that opted for universal health systems. However, there are few studies on waiting lists in health services in Brazil. This case study aims to contribute by adding metrics to this discussion and grounding it around the economic-financial viability of health care decisions and access regulation in a broader way. Starting from the context of a municipal hospital in the south of the city of São Paulo, we analyzed two different scenarios: the demand for primary care for consultation with a specialist, which does not always end with the recommendation of surgery, and inpatient waiting lists, which have patients that were already evaluated and are waiting for the surgery. From this data analysis, we draw a new management model of gynaecologic elective surgery waiting list in this hospital. Our proposal does not aim to achieve zero wait, nor is it based on a single strategy. Our main conclusion is that the most efficient strategy for the waiting lists management involves the strengthening of health care networks’ integration actions. In the Unified Health System it can effectively enable the delivery of greater value in the assistance provided and can be done through local initiatives.