Class of 2015 Abstract / Objectives: Characterize all patients in the emergency room diagnosed with anxiety disorders from 11/01/2013 until 5/31/2014 to identify insurance coverage and demographic trends. Methods: Retrospective descriptive study of patients who present to the emergency department between 11/01/2013 – 05/31/2014 and discharged with a primary documented diagnosis of an anxiety disorder. Age, race, and gender were recorded in addition to insurance coverage. Results: 406 visits were reviewed: 212 (52.2%) males and 194 (47.8%) females. Average age per visit: 40.34 (SD=13.388). Race recorded with each visit: 189 (46.6%) white, 146 (36.0%) Hispanic, 42 (10.3%) African American, and 29 (2.2%) other. The most common insurance coverage was Medicaid at 63.3%, while 6.4% of visits had no insurance coverage. There was a significant difference in the distribution in number of ED visits between genders (Mann-Whitney U=17,407.5, p=0.007, sig ≥0.05). A Kruskal-Wallis Test showed a significant difference in the number of ED visits between racial groups X²=43.434, p=0.000 as well as a significant difference between Medicaid and other insurance groups X²=37.778, p=0.021. Conclusions: Men appear to have a higher frequency in anxiety symptoms requiring an ED visit than women do. White patients tend to have a greater frequency in anxiety symptoms followed by Hispanic patients. Medicaid tends to be the most prevalent insurance coverage used.

No description available.

Introdução: As morbidades e mortalidade relacionadas ao uso de medicamentos (MRM) representam um desafio para a saúde pública e são consequências da utilização não efetiva e insegura dos medicamentos. Estudos internacionais mostram como as MRM afetam pacientes internados no hospital e como podem ser evitadas na maioria dos casos. Entretanto, pouco é conhecido sobre as MRM na prática ambulatorial. Estas pesquisas têm abordado as consequências clínicas negativas para os usuários de medicamentos e sugerem que vultosas somas de recursos financeiros são utilizadas para manejar e resolver estas morbidades ao redor do mundo. Já no Brasil, o conhecimento sobre as MRM é escasso em ambas perspectivas e o seu impacto econômico é desconhecido. Objetivo: O propósito desta Tese foi obter uma estimativa sobre os gastos com morbidade e mortalidade associadas ao uso de medicamentos no Brasil, utilizando modelos farmacoeconômicos (teórico e empírico). Métodos: Foram considerados como morbidades relacionadas a medicamentos os novos problemas de saúde advindos da utilização de uma farmacoterapia (por exemplo, reações adversas, dependência a medicamentos e intoxicação por overdose) e as falhas terapêuticas (por exemplo, efeito insuficiente dos medicamentos e problemas de saúde não tratados). Foram conduzidos dois estudos utilizando abordagens distintas (bottom up e top down) na coleta de dados sobre custos. O primeiro estimou, por meio da análise do tipo microcosting, os custos para resolução de Morbidades Relacionadas a Medicamentos em casos identificados no serviço de emergência de um hospital universitário. Resultados: O custo médio para tratar cada um desses pacientes é de aproximadamente R$ 2.200. Reações adversas a medicamentos, falta de adesão à farmacoterapia e problemas resultantes da administração de doses incorretas foram as causas mais prevalentes das morbidades. No segundo estudo, um modelo do tipo cost-of-illness foi traduzido e adaptado para a realidade brasileira, e então um painel com especialistas (farmacêuticos e médicos) foi realizado para estimar a proporção de pacientes que experimentam uma MRM, a proporção de MRM evitáveis e as consequências clínicas resultantes desta morbidade. A partir disto, o custo das MRM para o sistema de saúde brasileiro foi modelado, baseado em estatísticas nacionais sobre o consumo de serviços de saúde. Os especialistas julgaram as morbidades relacionadas a medicamentos como um evento bastante frequente. De acordo com esta estimativa central, as MRM seriam responsáveis por um uso considerável de recursos, podendo chegar a 23% do orçamento público anual total destinado à saúde no Brasil. Para cada real gasto com medicamentos, pelo Ministério da Saúde no Brasil, cinco reais seriam gastos para resolver as MRM. Da mesma forma foi verificado que mais da metade dos casos seriam evitáveis. Conclusão: As MRM são, de fato, um problema de ordem econômica-orçamentária, clínica e humanística para os usuários de medicamentos e para o sistema de saúde brasileiro, e que é imperiosa a criação de políticas públicas e ações capazes de evitar os danos gerados pelo uso não racional de medicamentos, garantir a segurança dos pacientes, bem como uma melhor alocação de recursos em saúde. / Introduction: Drug related morbidities and mortality (DRM) is a challenge to public health due to the consequences of ineffective and unsafe medicines use. It is well known that the DRM are common among hospitalized patients, and are preventable to some extent, but little is known about DRM outside the hospital. In Brazil, the knowledge on the subject is scarce and its economic impact is unknown. However, international studies suggest that DRM result in considerable amounts of financial resources to manage and resolve these morbidities around the world and the negative clinical consequences for those who use medicines. Aim: In this thesis, the drug related morbidities include: new medical problems arising from the pharmacotherapy (adverse effects, addiction to drugs and intoxication by overdose) and therapeutic failure (e.g. insufficient drug effect and untreated health problems). Methods: Two studies were conducted using different methodologies. The first study was a cross-sectional study, based on a microcosting analysis, where patients admitted to a teaching hospital emergency were identified in order to determine the proportion of people seeking health services due to a DRM, and, consequently, to obtain the cost for manage these patients. Results: It was observed that 14.6% of patients visiting an emergency service, do so because of a DRM and the average cost to treat each of these patients is approximately R$ 2,000. Adverse drug reactions, lack of adherence to pharmacotherapy and problems resulting from the administration of incorrect doses were the most prevalent causes of morbidity. In the second study, a cost-of-illness model was translated to portuguese and adapted, and then a panel of experts (pharmacists and physicians) was conducted to estimate the proportion of patients experiencing DRM, the proportion of preventable DRM, and the negative outcomes resulting from this morbidity. From this, the DRM cost for the Brazilian Health System was modeled, based on national statistics on the consumption of health services. Experts have judged drug-related morbidities to be a fairly frequent event. According to central estimate, the DRM would be responsible for a considerable use of resources, being able to reach 23% of the total annual public health budget in Brazil. For each real (R$ 1,00) spending on medicines, by the Brazilian Ministry of Health, five reais (R$ 5,00) would be spent to manage the DRM. Likewise, in this study it was also verified that more than half of the cases would be avoidable. In the second, a panel of experts (pharmacists and physicians) was performed to estimate the proportion of patients experiencing an DRM, DRM preventable ratio and the clinical consequences of this morbidity. From this, the cost of DRM for the Brazilian health system was modeled, based on national statistics on the consumption of health services. Conclusion: Based on these and many other results presented in this thesis, it is concluded that the DRM are indeed, an economic, clinical and humanistic issue for those who use medicines and to the Brazilian health system, and that is overriding the establishment of public policies and actions to prevent the damage caused by the non-rational use of medicines to ensure patient safety and to the best allocation of health resources.

Introdução: As morbidades e mortalidade relacionadas ao uso de medicamentos (MRM) representam um desafio para a saúde pública e são consequências da utilização não efetiva e insegura dos medicamentos. Estudos internacionais mostram como as MRM afetam pacientes internados no hospital e como podem ser evitadas na maioria dos casos. Entretanto, pouco é conhecido sobre as MRM na prática ambulatorial. Estas pesquisas têm abordado as consequências clínicas negativas para os usuários de medicamentos e sugerem que vultosas somas de recursos financeiros são utilizadas para manejar e resolver estas morbidades ao redor do mundo. Já no Brasil, o conhecimento sobre as MRM é escasso em ambas perspectivas e o seu impacto econômico é desconhecido. Objetivo: O propósito desta Tese foi obter uma estimativa sobre os gastos com morbidade e mortalidade associadas ao uso de medicamentos no Brasil, utilizando modelos farmacoeconômicos (teórico e empírico). Métodos: Foram considerados como morbidades relacionadas a medicamentos os novos problemas de saúde advindos da utilização de uma farmacoterapia (por exemplo, reações adversas, dependência a medicamentos e intoxicação por overdose) e as falhas terapêuticas (por exemplo, efeito insuficiente dos medicamentos e problemas de saúde não tratados). Foram conduzidos dois estudos utilizando abordagens distintas (bottom up e top down) na coleta de dados sobre custos. O primeiro estimou, por meio da análise do tipo microcosting, os custos para resolução de Morbidades Relacionadas a Medicamentos em casos identificados no serviço de emergência de um hospital universitário. Resultados: O custo médio para tratar cada um desses pacientes é de aproximadamente R$ 2.200. Reações adversas a medicamentos, falta de adesão à farmacoterapia e problemas resultantes da administração de doses incorretas foram as causas mais prevalentes das morbidades. No segundo estudo, um modelo do tipo cost-of-illness foi traduzido e adaptado para a realidade brasileira, e então um painel com especialistas (farmacêuticos e médicos) foi realizado para estimar a proporção de pacientes que experimentam uma MRM, a proporção de MRM evitáveis e as consequências clínicas resultantes desta morbidade. A partir disto, o custo das MRM para o sistema de saúde brasileiro foi modelado, baseado em estatísticas nacionais sobre o consumo de serviços de saúde. Os especialistas julgaram as morbidades relacionadas a medicamentos como um evento bastante frequente. De acordo com esta estimativa central, as MRM seriam responsáveis por um uso considerável de recursos, podendo chegar a 23% do orçamento público anual total destinado à saúde no Brasil. Para cada real gasto com medicamentos, pelo Ministério da Saúde no Brasil, cinco reais seriam gastos para resolver as MRM. Da mesma forma foi verificado que mais da metade dos casos seriam evitáveis. Conclusão: As MRM são, de fato, um problema de ordem econômica-orçamentária, clínica e humanística para os usuários de medicamentos e para o sistema de saúde brasileiro, e que é imperiosa a criação de políticas públicas e ações capazes de evitar os danos gerados pelo uso não racional de medicamentos, garantir a segurança dos pacientes, bem como uma melhor alocação de recursos em saúde. / Introduction: Drug related morbidities and mortality (DRM) is a challenge to public health due to the consequences of ineffective and unsafe medicines use. It is well known that the DRM are common among hospitalized patients, and are preventable to some extent, but little is known about DRM outside the hospital. In Brazil, the knowledge on the subject is scarce and its economic impact is unknown. However, international studies suggest that DRM result in considerable amounts of financial resources to manage and resolve these morbidities around the world and the negative clinical consequences for those who use medicines. Aim: In this thesis, the drug related morbidities include: new medical problems arising from the pharmacotherapy (adverse effects, addiction to drugs and intoxication by overdose) and therapeutic failure (e.g. insufficient drug effect and untreated health problems). Methods: Two studies were conducted using different methodologies. The first study was a cross-sectional study, based on a microcosting analysis, where patients admitted to a teaching hospital emergency were identified in order to determine the proportion of people seeking health services due to a DRM, and, consequently, to obtain the cost for manage these patients. Results: It was observed that 14.6% of patients visiting an emergency service, do so because of a DRM and the average cost to treat each of these patients is approximately R$ 2,000. Adverse drug reactions, lack of adherence to pharmacotherapy and problems resulting from the administration of incorrect doses were the most prevalent causes of morbidity. In the second study, a cost-of-illness model was translated to portuguese and adapted, and then a panel of experts (pharmacists and physicians) was conducted to estimate the proportion of patients experiencing DRM, the proportion of preventable DRM, and the negative outcomes resulting from this morbidity. From this, the DRM cost for the Brazilian Health System was modeled, based on national statistics on the consumption of health services. Experts have judged drug-related morbidities to be a fairly frequent event. According to central estimate, the DRM would be responsible for a considerable use of resources, being able to reach 23% of the total annual public health budget in Brazil. For each real (R$ 1,00) spending on medicines, by the Brazilian Ministry of Health, five reais (R$ 5,00) would be spent to manage the DRM. Likewise, in this study it was also verified that more than half of the cases would be avoidable. In the second, a panel of experts (pharmacists and physicians) was performed to estimate the proportion of patients experiencing an DRM, DRM preventable ratio and the clinical consequences of this morbidity. From this, the cost of DRM for the Brazilian health system was modeled, based on national statistics on the consumption of health services. Conclusion: Based on these and many other results presented in this thesis, it is concluded that the DRM are indeed, an economic, clinical and humanistic issue for those who use medicines and to the Brazilian health system, and that is overriding the establishment of public policies and actions to prevent the damage caused by the non-rational use of medicines to ensure patient safety and to the best allocation of health resources.

Introdução: As morbidades e mortalidade relacionadas ao uso de medicamentos (MRM) representam um desafio para a saúde pública e são consequências da utilização não efetiva e insegura dos medicamentos. Estudos internacionais mostram como as MRM afetam pacientes internados no hospital e como podem ser evitadas na maioria dos casos. Entretanto, pouco é conhecido sobre as MRM na prática ambulatorial. Estas pesquisas têm abordado as consequências clínicas negativas para os usuários de medicamentos e sugerem que vultosas somas de recursos financeiros são utilizadas para manejar e resolver estas morbidades ao redor do mundo. Já no Brasil, o conhecimento sobre as MRM é escasso em ambas perspectivas e o seu impacto econômico é desconhecido. Objetivo: O propósito desta Tese foi obter uma estimativa sobre os gastos com morbidade e mortalidade associadas ao uso de medicamentos no Brasil, utilizando modelos farmacoeconômicos (teórico e empírico). Métodos: Foram considerados como morbidades relacionadas a medicamentos os novos problemas de saúde advindos da utilização de uma farmacoterapia (por exemplo, reações adversas, dependência a medicamentos e intoxicação por overdose) e as falhas terapêuticas (por exemplo, efeito insuficiente dos medicamentos e problemas de saúde não tratados). Foram conduzidos dois estudos utilizando abordagens distintas (bottom up e top down) na coleta de dados sobre custos. O primeiro estimou, por meio da análise do tipo microcosting, os custos para resolução de Morbidades Relacionadas a Medicamentos em casos identificados no serviço de emergência de um hospital universitário. Resultados: O custo médio para tratar cada um desses pacientes é de aproximadamente R$ 2.200. Reações adversas a medicamentos, falta de adesão à farmacoterapia e problemas resultantes da administração de doses incorretas foram as causas mais prevalentes das morbidades. No segundo estudo, um modelo do tipo cost-of-illness foi traduzido e adaptado para a realidade brasileira, e então um painel com especialistas (farmacêuticos e médicos) foi realizado para estimar a proporção de pacientes que experimentam uma MRM, a proporção de MRM evitáveis e as consequências clínicas resultantes desta morbidade. A partir disto, o custo das MRM para o sistema de saúde brasileiro foi modelado, baseado em estatísticas nacionais sobre o consumo de serviços de saúde. Os especialistas julgaram as morbidades relacionadas a medicamentos como um evento bastante frequente. De acordo com esta estimativa central, as MRM seriam responsáveis por um uso considerável de recursos, podendo chegar a 23% do orçamento público anual total destinado à saúde no Brasil. Para cada real gasto com medicamentos, pelo Ministério da Saúde no Brasil, cinco reais seriam gastos para resolver as MRM. Da mesma forma foi verificado que mais da metade dos casos seriam evitáveis. Conclusão: As MRM são, de fato, um problema de ordem econômica-orçamentária, clínica e humanística para os usuários de medicamentos e para o sistema de saúde brasileiro, e que é imperiosa a criação de políticas públicas e ações capazes de evitar os danos gerados pelo uso não racional de medicamentos, garantir a segurança dos pacientes, bem como uma melhor alocação de recursos em saúde. / Introduction: Drug related morbidities and mortality (DRM) is a challenge to public health due to the consequences of ineffective and unsafe medicines use. It is well known that the DRM are common among hospitalized patients, and are preventable to some extent, but little is known about DRM outside the hospital. In Brazil, the knowledge on the subject is scarce and its economic impact is unknown. However, international studies suggest that DRM result in considerable amounts of financial resources to manage and resolve these morbidities around the world and the negative clinical consequences for those who use medicines. Aim: In this thesis, the drug related morbidities include: new medical problems arising from the pharmacotherapy (adverse effects, addiction to drugs and intoxication by overdose) and therapeutic failure (e.g. insufficient drug effect and untreated health problems). Methods: Two studies were conducted using different methodologies. The first study was a cross-sectional study, based on a microcosting analysis, where patients admitted to a teaching hospital emergency were identified in order to determine the proportion of people seeking health services due to a DRM, and, consequently, to obtain the cost for manage these patients. Results: It was observed that 14.6% of patients visiting an emergency service, do so because of a DRM and the average cost to treat each of these patients is approximately R$ 2,000. Adverse drug reactions, lack of adherence to pharmacotherapy and problems resulting from the administration of incorrect doses were the most prevalent causes of morbidity. In the second study, a cost-of-illness model was translated to portuguese and adapted, and then a panel of experts (pharmacists and physicians) was conducted to estimate the proportion of patients experiencing DRM, the proportion of preventable DRM, and the negative outcomes resulting from this morbidity. From this, the DRM cost for the Brazilian Health System was modeled, based on national statistics on the consumption of health services. Experts have judged drug-related morbidities to be a fairly frequent event. According to central estimate, the DRM would be responsible for a considerable use of resources, being able to reach 23% of the total annual public health budget in Brazil. For each real (R$ 1,00) spending on medicines, by the Brazilian Ministry of Health, five reais (R$ 5,00) would be spent to manage the DRM. Likewise, in this study it was also verified that more than half of the cases would be avoidable. In the second, a panel of experts (pharmacists and physicians) was performed to estimate the proportion of patients experiencing an DRM, DRM preventable ratio and the clinical consequences of this morbidity. From this, the cost of DRM for the Brazilian health system was modeled, based on national statistics on the consumption of health services. Conclusion: Based on these and many other results presented in this thesis, it is concluded that the DRM are indeed, an economic, clinical and humanistic issue for those who use medicines and to the Brazilian health system, and that is overriding the establishment of public policies and actions to prevent the damage caused by the non-rational use of medicines to ensure patient safety and to the best allocation of health resources.

Il est bien établi que l'exposition à court terme aux particules fines dans l’air ambiant en milieu urbain a des effets sur la santé. Toutefois, peu d'études épidémiologiques ont évalué la relation entre les particules fines (PM2.5) de sources spécifiques comme celles dérivées de feux de forêt et les effets sur la santé. Pour l’instant, les risques de mortalité et de morbidité associés aux PM2.5 résultant de la combustion de végétation semblent similaires à ceux des PM2.5 urbaines. Dans le présent mémoire, nous avons comparé deux méthodes pour quantifier les risques de mortalité et de morbidité associés à l'augmentation des niveaux de PM2.5 à Montréal, dérivées de deux épisodes des feux de forêts majeurs dans le Nord du Québec. La première approche consistait à comparer les décès et les visites aux urgences observées enregistrées au cours des deux épisodes à Montréal à leurs moyennes respectives attendues durant des jours de référence. Nous avons également calculé la surmortalité et la surmorbidité prédites attribuables aux PM2.5 lors des épisodes, en projetant les risques relatifs (RR) rapportés par l’Environmental Protection Agency (EPA) des États-Unis pour les PM2.5 urbaines, ainsi qu’en appliquant des fonctions de risque estimées à partir des données estivales spécifiques à Montréal. Suivant la première approche, nous avons estimé une surmortalité de +10% pendant les deux épisodes. Cependant, aucune tendance claire n'a été observée pour les visites à l'urgence. Et suivant la 2e approche, la surmortalité prédite attribuable aux niveaux des PM2.5 dérivées des feux de forêt étaient moins élevés que ceux observés, soit de 1 à 4 cas seulement. Une faible surmortalité attribuable aux niveaux élevés des PM2.5 issues de feux de la forêt boréale du Québec a été estimée par les fonctions de risque ainsi que par la méthode de comparaison des décès observés aux moyennes attendues, sur l’Île de Montréal, située à des centaines de km des sites de feux. / The association between adverse health effects and short term exposure to urban particulate matter in ambient air is well established. Few epidemiological studies have assessed the relation between fine particles (PM2.5) of specific sources like forest fires, and health effects. According to the published literature to date, risks of mortality and morbidity associated with PM2.5 from combustion sources appear similar to those of urban PM2.5. In the present thesis, we compared two methods to quantify mortality and morbidity risks associated with the increase in PM2.5 levels in Montreal, due to two major forest fire episodes in Northern Quebec. In the first approach we compared mortality and emergency room visits counts recorded during the episodes to their respective averages expected on “usual” days. We also calculated deaths and emergency room visits attributable to PM2.5 levels on episode days, using the range of relative risks (RRs) reported by the United-States Environmental Protection Agency (EPA) for urban PM2.5 levels, as well as specific risk functions developed with Montreal summer data. With the first method, increases of deaths of more than 10% were observed for both episodes. However no clear tendency was observed in emergency room visits. Estimated attributable deaths associated with the increase in PM2.5 levels were smaller than those observed and ranged between 1 to 4 cases. PM2.5 from Quebec boreal forest fires were associated with small increases in mortality estimated either with the risk function method or by contrasting observed deaths on “episode” days to“usual” days, on the Island of Montreal, hundreds of kilometers away from the fire sites.

Il est bien établi que l'exposition à court terme aux particules fines dans l’air ambiant en milieu urbain a des effets sur la santé. Toutefois, peu d'études épidémiologiques ont évalué la relation entre les particules fines (PM2.5) de sources spécifiques comme celles dérivées de feux de forêt et les effets sur la santé. Pour l’instant, les risques de mortalité et de morbidité associés aux PM2.5 résultant de la combustion de végétation semblent similaires à ceux des PM2.5 urbaines. Dans le présent mémoire, nous avons comparé deux méthodes pour quantifier les risques de mortalité et de morbidité associés à l'augmentation des niveaux de PM2.5 à Montréal, dérivées de deux épisodes des feux de forêts majeurs dans le Nord du Québec. La première approche consistait à comparer les décès et les visites aux urgences observées enregistrées au cours des deux épisodes à Montréal à leurs moyennes respectives attendues durant des jours de référence. Nous avons également calculé la surmortalité et la surmorbidité prédites attribuables aux PM2.5 lors des épisodes, en projetant les risques relatifs (RR) rapportés par l’Environmental Protection Agency (EPA) des États-Unis pour les PM2.5 urbaines, ainsi qu’en appliquant des fonctions de risque estimées à partir des données estivales spécifiques à Montréal. Suivant la première approche, nous avons estimé une surmortalité de +10% pendant les deux épisodes. Cependant, aucune tendance claire n'a été observée pour les visites à l'urgence. Et suivant la 2e approche, la surmortalité prédite attribuable aux niveaux des PM2.5 dérivées des feux de forêt étaient moins élevés que ceux observés, soit de 1 à 4 cas seulement. Une faible surmortalité attribuable aux niveaux élevés des PM2.5 issues de feux de la forêt boréale du Québec a été estimée par les fonctions de risque ainsi que par la méthode de comparaison des décès observés aux moyennes attendues, sur l’Île de Montréal, située à des centaines de km des sites de feux. / The association between adverse health effects and short term exposure to urban particulate matter in ambient air is well established. Few epidemiological studies have assessed the relation between fine particles (PM2.5) of specific sources like forest fires, and health effects. According to the published literature to date, risks of mortality and morbidity associated with PM2.5 from combustion sources appear similar to those of urban PM2.5. In the present thesis, we compared two methods to quantify mortality and morbidity risks associated with the increase in PM2.5 levels in Montreal, due to two major forest fire episodes in Northern Quebec. In the first approach we compared mortality and emergency room visits counts recorded during the episodes to their respective averages expected on “usual” days. We also calculated deaths and emergency room visits attributable to PM2.5 levels on episode days, using the range of relative risks (RRs) reported by the United-States Environmental Protection Agency (EPA) for urban PM2.5 levels, as well as specific risk functions developed with Montreal summer data. With the first method, increases of deaths of more than 10% were observed for both episodes. However no clear tendency was observed in emergency room visits. Estimated attributable deaths associated with the increase in PM2.5 levels were smaller than those observed and ranged between 1 to 4 cases. PM2.5 from Quebec boreal forest fires were associated with small increases in mortality estimated either with the risk function method or by contrasting observed deaths on “episode” days to“usual” days, on the Island of Montreal, hundreds of kilometers away from the fire sites.