title: Burden of migraine in Brazil: estimate of cost of migraine to the public health system and an analytical study of the cost-effectiveness of a stratified model of care.
abstract: BACKGROUND
  The search for rationality in health expenses in developing countries collides with the lack of effectively conducted epidemiologic studies.
  
  
  OBJECTIVE
  To present an estimate of the impact and costs of migraine in the Brazilian public health system and to estimate the impact on these costs and the effectiveness of a model of stratified care in the management of migraine.
  
  
  METHODS
  An analytical model of utilization of the Brazilian public health system was constructed. Data refer to 1999 and were obtained in accordance with the following steps: (1) Brazilian demographic characteristics; (2) characteristics of the public health system related to its 3 hierarchical levels-primary, secondary, and tertiary care, the last being subdivided into emergency department and hospital care; and (3) estimation of the number of migraine consultations at each complexity level. In Brazil, migraineurs seen in the public health system are most often discharged with an acute treatment, usually a nonspecific medication. We compared this treatment with a proposed stratified care model that uses a triptan as an acute care medication. We have made the following assumptions: (1) 15% of the patients would fall into the Migraine Disability Assessment (MIDAS) grade I category, 25% would fall into the MIDAS grade II category, 30% into the grade III category, and 30% into the MIDAS grade IV category; (2) the mean number of migraine attacks per year are: MIDAS I, 7.49; MIDAS II, 8.02; MIDAS III, 12.22; and MIDAS IV, 27.01. The annual costs of the treatment were calculated according to the following equation: AC = P x N x C + P x Cp + P x Cat x AMA, where P is the number of patients; N, the number of consultations per patient; C, the cost of consultation per level; Cp, the cost of preventive drugs; Cat, the cost of acute therapy drugs; and AMA is the number of migraine attacks per year. Results.-The public health system resources included 55 735 ambulatory units (primary and secondary) and 6453 emergency department and public hospital units, with a corresponding budget of US $2 820 899 621.26. The estimated cost of a consultation on the primary care level was US $11.53; on the secondary care level, US $22.18; in the emergency department, $34.82; and for hospitalization, US $217.93. The total estimated public health system expenses for migraine were US $140 388 469.60. The proposed model would imply a cost reduction of 6.2% (US $7 514 604.40) with an improvement in the quality of the public health system from the actual 18.2% to an estimated 84.5%.
  
  
  CONCLUSIONS
  Migraine seems to pose a huge burden on the Brazilian public health system. The implementation of a stratified care model of treatment that would include specific acute migraine therapies could result in a dramatic increase in the quality of migraine care and a significant reduction in cost.
authors.affiliation: Department of Neurology, Albert Einstein College of Medicine, Bronx, NY, USA.
authors.forename: Marcelo E
authors.initials: ME
authors.lastname: Bigal
authors.forename: Alan M
authors.initials: AM
authors.lastname: Rapoport
authors.forename: Carlos A
authors.initials: CA
authors.lastname: Bordini
authors.forename: Stewart J
authors.initials: SJ
authors.lastname: Tepper
authors.forename: Fred D
authors.initials: FD
authors.lastname: Sheftell
authors.forename: José G
authors.initials: JG
authors.lastname: Speciali
mesh_terms: D001938:Brazil / Q000453:epidemiology; D017281:Cost of Illness; D003362:Cost-Benefit Analysis; D003365:Costs and Cost Analysis; D004358:Drug Therapy / Q000145:classification / Q000191:economics; D006801:Humans; D008881:Migraine Disorders / Q000191:economics* / Q000453:epidemiology / Q000628:therapy*; D008962:Models, Theoretical; D009313:National Health Programs / Q000191:economics* / Q000706:statistics & numerical data