Operational Challenges in the Use of Structured Secondary Data for Health Research

Neonatal mortality of live births with congenital diaphragmatic hernia in São Paulo State, Brazil: Failure of care?

OBJECTIVE

The aim of this study was to analyze if the healthcare organization of perinatal care and availability of referral neonatal intensive care units (NICU) impacted congenital diaphragmatic hernia (CDH) neonatal mortality in the period 2004-2020. This study analyzed the spatial distribution of neonatal deaths of live births with CDH in São Paulo State, Brazil, and its association with NICU beds' availability.

METHODS

Population-based study of all live births in São Paulo State from mothers residing in the same State, from 2004 to 2020. CDH definition was based on WHO-ICD-10 codes; CDH-associated neonatal death was defined as death up to 27 days after birth of infants with CDH. The distribution of CDH-associated neonatal mortality (per 10,000 live births) and NICU beds' availability (≥1 or not available) was mapped, and their association was evaluated by the Mann-Whitney test.

RESULTS

Among 10,246,686 live births, there were 1378 CDH-associated neonatal deaths across 124/645 (19.2%) municipalities of the State. The median CDH-associated neonatal mortality rate in municipalities with NICU beds was 1.22 (95%CI 0.99-1.51), similar to that found in municipalities with no NICU beds (1.40; 95%CI 1.15-1.67; p=0.224).

CONCLUSIONS

CDH-associated neonatal deaths were spread throughout São Paulo State with no difference in CDH-associated neonatal mortality rates between municipalities with and without NICU beds available. These findings suggest the necessity of implementing regionalization strategies for CDH perinatal care in the State.

Evolution of orthodontic services in the Brazilian Unified Health System: a time series analysis (2011-2022)

BACKGROUND

Although malocclusion is the third most prevalent oral health condition, orthodontics is not part of the minimum list of mandatory specialties to be offered in the Dental Specialty Centers of the Brazilian public health system, but rather as optional. Since the acknowledgment of this field as a part of the Brazilian Unified Health System (SUS), access to orthodontic procedures has become optional by municipal governments. Therefore, this study analyzed the evolution of orthodontic procedure provision within SUS from 2011 to 2022.

METHODOLOGY

We conducted a retrospective observational study of time series analysis trends on the number of orthodontic procedures and municipalities offering them. The presentation of findings followed the recommendations of the Reporting of Studies Conducted using Observational Routinely Collected Data. Secondary data from 2011 to 2022 were collected from the SUS Department of Informatics. Orthodontic procedures were organized by year, region, state, and municipality. The study applied descriptive analyses, and the Prais-Winsten generalized linear regressions for time series analysis.

RESULTS

The quantity of municipalities offering orthodontic procedures have shown a small increasing during period analyzed (from 128 to 157). Northeast and South macro-regions have increased consistently the municipalities with orthodontic offering. All regions showed stable trends for each procedure, except for the South, which exhibited increasing rates of space maintainer placement (Annual Percentage Change (APC): 72.95; 95% CI: 31.6, 127.3) and maintenance sessions (APC: 15.40; 95% CI: 4.5, 27.5). The study showed decreasing trends for appliance removal in the South (APC: -38.07; 95% CI: -47.1, -27.5) and Northeast (APC: -25.19; 95% CI: -36.5, -11.9) regions.

CONCLUSION

From 2011 to 2022, there was a small increase in number of municipalities offering orthodontic procedures in the Brazilian public health system, in addition to a stationary trend for almost all types of procedures.

Epidemiological trends of isolated and non-isolated central nervous system congenital malformations in live births in a middle-income setting

OBJECTIVES

This study aimed to analyze, in the São Paulo state of Brazil, time trends in prevalence, neonatal mortality, and neonatal lethality of central nervous system congenital malformations (CNS-CM) between 2004 and 2015.

METHODS

Population-based study of all live births with gestational age ≥22 weeks and/or birthweight ≥400 g from mothers living in São Paulo State, during 2004-2015. CNS-CM was defined by the presence of International Classification Disease 10th edition codes Q00-Q07 in the death and/or live birth certificates. CNS-CM was classified as isolated (only Q00-Q07 codes), and non-isolated (with congenital anomalies codes nonrelated to CNS-CM). CNS-CM associated neonatal death was defined as death between 0 and 27 days after birth in infants with CNS-CM. CNS-CM prevalence, neonatal mortality, and lethality rates were calculated, and their annual trends were analyzed by Prais-Winsten Model. The annual percent change (APC) with 95% confidence interval (95%CI) was obtained.

RESULTS

7,237,628 live births were included in the study and CNS-CM were reported in 7526 (0.1%). CNS-CM associated neonatal deaths occurred in 2935 (39.0%). Isolated CNS-CM and non-isolated CNS-CM were found respectively in 5475 and 2051 livebirths, with 1525 (28%) and 1410 (69%) neonatal deaths. CNS-CM prevalence and neonatal lethality were stationary, however neonatal mortality decreased (APC -1.66; 95%CI -3.09 to -0.21) during the study. For isolated CNS-CM, prevalence, neonatal mortality, and lethality decreased over the period. For non-isolated CNS-CM, the prevalence increased, neonatal mortality was stationary, and lethality decreased during the period. The median time of CNS-CM associated neonatal deaths was 18 h after birth.

CONCLUSIONS

During a 12-year period in São Paulo State, Brazil, neonatal mortality of infants with CNS-CM in general and with isolated CNS-CM showed a decreasing pattern. Nevertheless CNS-CM mortality remained elevated, mostly in the first day after birth.

Real-world treatment patterns of rheumatoid arthritis in Brazil: analysis of DATASUS national administrative claims data for pharmacoepidemiology studies (2010-2020)

Our study assessed DATASUS as a potential source for pharmacoepidemiologic studies in rheumatoid arthritis (RA) in the Brazilian population focusing on treatment patterns and determinants of initiating or switching to a novel therapy. This was a descriptive database study of RA patients with at least one claim of RA and ≥ 2 claims of disease-modifying anti-rheumatic drug (DMARD); conventional synthetic (cs), biologic (b) or targeted synthetic (ts) DMARD with more than 6 months of follow-up from 01-Jan-2010 to 31-Dec-2020. Analyses were stratified for SUS-exclusive and SUS+ private user cohorts. We identified 250,251 patients with RA in DATASUS: mean age of 58.4 years, majority female (83%) and white (58%). 62% were SUS-exclusive and 38% SUS+ private. Most common bDMARDs were adalimumab and etanercept. Age (adjusted odds ratio 1.78 [50+]; 95% CI 1.57-2.01), SUS exclusive status (0.53; 0.47-0.59), distance to clinic [160+ km] (0.57; 0.45-0.72), and pre-index csDMARD claims (1.23; 1.08-1.41) were independent predictors of initiating a novel oral tsDMARD. Switching from bDMARD to tsDMARD, associations were similar, except for the direction of associations for SUS exclusive status (adjusted hazard ratio 1.10; 1.03-1.18), distance to clinic (1.18; 1.03-1.35), and number of previous bDMARD (0.15; 0.14-0.16). DATASUS is a source suitable for treatment-related analyses in RA reflecting the public health system in Brazil.

The burden of inappropriate birth weight on neonatal survival in term newborns: a population-based study in a middle-income setting

Introduction

Premature birth, perinatal asphyxia, and infections are the main causes of neonatal death. Growth deviations at birth also affect neonatal survival according to week of gestation at birth, particularly in developing countries. The purpose of this study was to verify the association between inappropriate birth weight and neonatal death in term live births.

Methods

This is an observational follow-up study with all term live births from 2004 to 2013 in Sao Paulo State, Brazil. Data were retrieved with the deterministic linkage of death and birth certificates. The definition of very small for gestational age (VSGA) and very large for gestational age (VLGA) used the 10th percentile of 37 weeks and the 90th percentile of 41 weeks + 6 days, respectively, based on the Intergrowth-21st. We measured the outcome in terms of time to death and the status of each subject (death or censorship) in the neonatal period (0-27 days). Survival functions were calculated using the Kaplan-Meier method stratified according to the adequacy of birth weight into three groups (normal, very small, or very large). We used multivariate Cox regression to adjust for proportional hazard ratios (HRs).

Results

The neonatal death rate during the study period was 12.03/10,000 live births. We found 1.8% newborns with VSGA and 2.7% with VLGA. The adjusted analysis showed a significant increase in mortality risk for VSGA infants (HR = 4.25; 95% CI: 3.89-4.65), independent of sex, 1-min Apgar score, and five maternal factors.

Discussion

The risk of neonatal death in full-term live births was approximately four times greater in those with birth weight restriction. The development of strategies to control the factors that determine fetal growth restriction through planned and structured prenatal care can substantially reduce the risk of neonatal death in full-term live births, especially in developing countries such as Brazil.

Congenital diaphragmatic hernia in a middle-income country: Persistent high lethality during a 12-year period

BACKGROUND

In high- and middle-income countries, mortality associated to congenital diaphragmatic hernia (CDH) is high and variable. In Brazil, data is scarce regarding the prevalence, mortality, and lethality of CDH. This study aimed to analyze, in São Paulo state of Brazil, the temporal trends of prevalence, neonatal mortality and lethality of CDH and identify the time to CDH-associated neonatal death.

METHODS

Population-based study of all live births with gestational age ≥ 22 weeks, birthweight ≥400g, from mothers residing in São Paulo State, Brazil, during 2004-2015. CDH definition and its subgroups classification were based on ICD-10 codes reported in the death and/or live birth certificates. CDH-associated neonatal death was defined as death up to 27 days after birth of infants with CDH. CDH prevalence, neonatal mortality and lethality were calculated and their annual percent change (APC) with 95% confidence intervals (95%CI) was analyzed by Prais-Winsten. Kaplan-Meier estimator identified the time after birth that CDH-associated neonatal death occurred.

RESULTS

CDH prevalence was 1.67 per 10,000 live births, with a significant increase throughout the period (APC 2.55; 95%CI 1.30 to 3.83). CDH neonatal mortality also increased over the time (APC 2.09; 95%CI 0.27 to 3.94), while the lethality was 78.78% and remained stationary. For isolated CDH, CDH associated to non-chromosomal anomalies and CDH associated to chromosomal anomalies the lethality was, respectively, 72.25%, 91.06% and 97.96%, during the study period. For CDH as a whole and for all subgroups, 50% of deaths occurred within the first day after birth.

CONCLUSIONS

During a 12-year period in São Paulo State, Brazil, CDH prevalence and neonatal mortality showed a significant increase, while lethality remained stable, yet very high, compared to rates reported in high income countries.

Clusters of preterm live births and respiratory distress syndrome-associated neonatal deaths: spatial distribution and cooccurrence patterns

Background

Prematurity and respiratory distress syndrome (RDS) are strongly associated. RDS continues to be an important contributor to neonatal mortality in low- and middle-income countries. This study aimed to identify clusters of preterm live births and RDS-associated neonatal deaths, and their cooccurrence pattern in São Paulo State, Brazil, between 2004 and 2015. 

Methods

Population-based study of all live births with gestational age ≥ 22 weeks, birthweight ≥ 400 g, without congenital anomalies from mothers living in São Paulo State, Brazil, during 2004–2015. RDS-associated neonatal mortality was defined as deaths < 28 days with ICD-10 codes P22.0 or P28.0. RDS-associated neonatal mortality and preterm live births rates per municipality were submitted to first- and second-order spatial analysis before and after smoothing using local Bayes estimates. Spearman test was applied to identify the correlation pattern between both rates.

Results

Six hundred forty-five thousand two hundred seventy-six preterm live births and 11,078 RDS-associated neonatal deaths in São Paulo State, Brazil, during the study period were analyzed. After smoothing, a non-random spatial distribution of preterm live births rate (I = 0.78; p = 0.001) and RDS-associated neonatal mortality rate (I = 0.73; p = 0.001) was identified. LISA maps confirmed clusters for both, with a negative correlation (r = -0.24; p = 0.0000). Clusters of high RDS-associated neonatal mortality rates overlapping with clusters of low preterm live births rates were detected.

Conclusions

Asymmetric cluster distribution of preterm live births and RDS-associated neonatal deaths may be helpful to indicate areas for perinatal healthcare improvement.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13629-4.