Tradução, adaptação transcultural e confiabilidade da escala de utilidade clínica de Tyson e Connell / Traducción, adaptación intercultural y fiabilidad de la escala de utilidad clínica de Tyson y Connell / Translation, cross-cultural adaptation and reliability of the clinical utility scale of Tyson and Connell

RESUMO O objetivo deste estudo foi traduzir e adaptar a escala de utilidade clínica de Tyson e Connell para o português brasileiro, além de avaliar sua confiabilidade interexaminador e intraexaminador. O processo de tradução e adaptação transcultural foi desenvolvido em cinco estágios: tradução; síntese das traduções; retrotradução; avaliação pelo comitê de especialistas; e teste da versão pré-final. Para avaliação da confiabilidade intra e interexaminador da escala, 20 instrumentos de avaliação foram analisados de forma independente por dois examinadores (confiabilidade interexaminador). Além disso, um dos examinadores fez todas as avaliações, em dois momentos distintos, com um intervalo de 30 dias entre uma e outra (confiabilidade intraexaminador). A tradução e a adaptação transcultural foram realizadas de forma sistemática, seguindo os critérios propostos, de modo que houve apenas pequenas alterações em dois itens para tornar a escala mais útil a todos os instrumentos disponíveis na literatura. Em relação à confiabilidade interexaminador da escala de utilidade clínica de Tyson e Connell-Brasil, o valor encontrado foi CCI=0,85 (IC 95%, 0,79-0,87), enquanto para a confiabilidade intraexaminador o resultado foi CCI=0,89 (IC 95%, 0,85-0,93). Os resultados deste processo indicaram adequado grau de equivalência semântica, conceitual e cultural. Além disso, as medidas de confiabilidade intra e interexaminadores foram consideradas adequadas. Esses achados demonstraram que a escala é adequada para avaliar a utilidade clínica de instrumentos de avaliação comumente utilizados em pacientes. Dessa forma, deve ser incorporada na prática clínica e em pesquisas para a escolha do melhor instrumento.

RESUMEN O objetivo deste estudo foi traduzir e adaptar a escala de utilidade clínica de Tyson e Connell para o português brasileiro, além de avaliar sua confiabilidade interexaminador e intraexaminador. O processo de tradução e adaptação transcultural foi desenvolvido em cinco estágios: tradução; síntese das traduções; retrotradução; avaliação pelo comitê de especialistas; e teste da versão pré-final. Para avaliação da confiabilidade intra e interexaminador da escala, 20 instrumentos de avaliação foram analisados de forma independente por dois examinadores (confiabilidade interexaminador). Além disso, um dos examinadores fez todas as avaliações, em dois momentos distintos, com um intervalo de 30 dias entre uma e outra (confiabilidade intraexaminador). A tradução e a adaptação transcultural foram realizadas de forma sistemática, seguindo os critérios propostos, de modo que houve apenas pequenas alterações em dois itens para tornar a escala mais útil a todos os instrumentos disponíveis na literatura. Em relação à confiabilidade interexaminador da escala de utilidade clínica de Tyson e Connell-Brasil, o valor encontrado foi CCI=0,85 (IC 95%, 0,79-0,87), enquanto para a confiabilidade intraexaminador o resultado foi CCI=0,89 (IC 95%, 0,85-0,93). Os resultados deste processo indicaram adequado grau de equivalência semântica, conceitual e cultural. Além disso, as medidas de confiabilidade intra e interexaminadores foram consideradas adequadas. Esses achados demonstraram que a escala é adequada para avaliar a utilidade clínica de instrumentos de avaliação comumente utilizados em pacientes. Dessa forma, deve ser incorporada na prática clínica e em pesquisas para a escolha do melhor instrumento.

ABSTRACT This study aimed to translate and adapt the Clinical Utility Scale of Tyson and Connell into Brazilian Portuguese, in addition to evaluating intra- and inter-rater reliability. The process of cross-cultural translation and adaptation was developed in five stages: translation, synthesis of translations, retro translation, evaluation by the committee of experts and testing of the pre-final version. To evaluate the intra- and inter-rater reliability of the Clinical Utility Scale of Tyson and Connell, 20 assessment instruments were independently assessed by two examiners (inter-rater reliability). In addition, one of the examiners performed all assessments at two different times with a 30-day interval (intra-rater reliability). The translation and cross-cultural adaptation were performed in a systematic way, following the proposed criteria, and only minor changes in two items were necessary to make the scale more useful to all instruments currently available in the literature. Regarding the inter-rater reliability of the Clinical Utility Scale of Tyson and Connell, the value found was ICC=0.85 (IC 95%, 0,79-0,87), while for intra-rater reliability the result was ICC=0,89 (IC 95%, 0,85-0,93). The results of this process indicated an adequate degree of semantic, conceptual and cultural equivalence. In addition, intra- and inter-rater reliability measures were considered adequate. These findings have shown the scale is adequate to assess the clinical utility of evaluation instruments usually applied to patients. Therefore, it must be incorporated into clinical practice and research when choosing the best evaluation instrument to be used.

CHIVA to treat saphenous vein insufficiency in chronic venous disease: characteristics and results / CHIVA para tratar insuficiência de veia safena em doença venosa crônica: características e resultados

There is considerable debate in the literature with relation to the best method to treat patients with chronic venous disease (CVD). CHIVA is an office-based treatment for varicose veins performed under local anesthesia. The aim of the technique is to lower transmural pressure in the superficial venous system and avoid destruction of veins. Recurrence of varicosities, nerve damage, bruising and suboptimal aesthetic results are common to all treatments for the disease. This paper evaluates and discusses the characteristics and results of the CHIVA technique. We conclude that CHIVA is a viable alternative to common procedures that is associated with less bruising, nerve damage, and recurrence than stripping saphenectomy. The main advantages are preservation of the saphenous vein, local anesthesia, low recurrence rates, low cost, low pain, and no nerve damage. The major disadvantages are the learning curve and the need to train the team in venous hemodynamics

Existe uma grande discussão na literatura sobre o tratamento da doença venosa crônica (DVC). A cura conservadora e hemodinâmica da insuficiência venosa em ambulatório (CHIVA) consiste no tratamento ambulatorial de varizes sob anestesia local. O objetivo da técnica é diminuir a pressão transmural no sistema venoso superficial para evitar a destruição das veias, incluindo as veias safenas. Recorrência de varizes, lesão de nervos, hematomas e resultado estético abaixo do ideal são uma constante em todos tratamentos de varizes. O objetivo desta revisão é avaliar e discutir a técnica CHIVA quanto a suas características e resultados. A CHIVA é uma alternativa válida frente aos outros procedimentos, apresentando menos hematomas, recorrência e lesão nervosa que a safenectomia. Preservação da veia safena, anestesia local, baixa taxa de recorrências, baixo custo, pouca dor e ausência de lesões nervosas são as principais vantagens. A longa curva de aprendizado para treinar a equipe em hemodinâmica venosa é a principal desvantagem

Cost-effectiveness analysis of abiraterone, docetaxel or placebo plus androgen deprivation therapy for hormone-sensitive advanced prostate cancer / Análise de custo-efetividade da adição de abiraterona ou quimioterapia ao tratamento do câncer de próstata metastático hormônio-sensível

ABSTRACT Objective To evaluate the cost-effectiveness of the addition of chemotherapy or abiraterone to androgen deprivation. Methods We developed an analytical model to determine the cost-effectiveness of the addition of docetaxel or abiraterone versus androgen deprivation therapy alone. Direct and indirect costs were included in the model. The effects were expressed in Quality-Adjusted Life Years adjusted for side effects. Results Compared to androgen deprivation therapy alone, the addition of chemotherapy and of abiraterone generated 0.492 and 0.999, respectively, in Quality-Adjusted Life Years. Abiraterone led to a Quality-Adjusted Life Years gain of 0.506 compared to docetaxel. The incremental costs per Quality-Adjusted Life Years were R$ 133.649,22 for docetaxel, R$ 330.828,70 for abiraterone and R$ 571.379,42 for abiraterone compared to docetaxel, respectively. Conclusion The addition of chemotherapy to androgen deprivation therapy is more cost-effective than the addition of abiraterone to androgen deprivation therapy. However, discounts on abiraterone cost might improve cost-effectiveness.

RESUMO Objetivo Avaliar a relação custo-efetividade da adição de quimioterapia ou abiraterona à terapia de privação hormonal. Métodos Um modelo analítico foi desenvolvido para determinar a relação custo-efetividade da adição de docetaxel ou abiraterona comparada à terapia de privação hormonal isolada. Custos diretos e indiretos foram incluídos no modelo. Os efeitos foram expressos em Anos de Vida Ajustados para Qualidade corrigidos pelos efeitos colaterais de cada terapia. Resultados A adição de quimioterapia e de abiraterona à terapia de privação hormonal aumentou os Anos de Vida Ajustados para Qualidade em 0,492 e 0,999, respectivamente, em comparação à terapia de privação hormonal isolada. A abiraterona promoveu ganho de Anos de Vida Ajustados para Qualidade de 0,506 em relação ao docetaxel. O custo incremental por Anos de Vida Ajustados para Qualidade foi R$ 133.649,22 para o docetaxel, R$ 330.828,70 para a abiraterona e R$ 571.379,42 para a abiraterona comparada ao docetaxel. Conclusão A adição de quimioterapia à terapia de privação hormonal é mais custo-efetiva que a adição de abiraterona à terapia de privação hormonal. Contudo, descontos no custo da abiraterona poderiam tornar esse tratamento mais custo-efetivo.

Cost-utility of quadrivalent versus trivalent influenza vaccine in Brazil - comparison of outcomes from different static model types

ABSTRACT Background: Influenza burden in Brazil is considerable with 4.2-6.4 million cases in 2008 and influenza-like-illness responsible for 16.9% of hospitalizations. Cost-effectiveness of influenza vaccination may be assessed by different types of models, with limitations due to data availability, assumptions, and modelling approach. Objective: To understand the impact of model complexity, the cost-utility of quadrivalent versus trivalent influenza vaccines in Brazil was estimated using three distinct models: a 1-year decision tree population model with three age groups (FLOU); a more detailed 1-year population model with five age groups (FLORA); and a more complex lifetime multi-cohort Markov model with nine age groups (FLORENCE). Methods: Analysis 1 (impact of model structure) compared each model using the same data inputs (i.e., best available data for FLOU). Analysis 2 (impact of increasing granularity) compared each model populated with the best available data for that model. Results: Using the best data for each model, the discounted cost-utility ratio of quadrivalent versus trivalent influenza vaccine was R$20,428 with FLOU, R$22,768 with FLORA (versus R$20,428 in Analysis 1), and, R$19,257 with FLORENCE (versus R$22,490 in Analysis 1) using a lifetime horizon. Conceptual differences between FLORA and FLORENCE meant the same assumption regarding increased all-cause mortality in at-risk individuals had an opposite effect on the incremental cost-effectiveness ratio in Analysis 2 versus 1, and a proportionally higher number of vaccinated elderly in FLORENCE reduced this ratio in Analysis 2. Discussion: FLOU provided adequate cost-effectiveness estimates with data in broad age groups. FLORA increased insights (e.g., in healthy versus at-risk, paediatric, respiratory/non-respiratory complications). FLORENCE provided greater insights and precision (e.g., in elderly, costs and complications, lifetime cost-effectiveness). Conclusion: All three models predicted a cost per quality-adjusted life year gained for quadrivalent versus trivalent influenza vaccine in the range of R$19,257 (FLORENCE) to R$22,768 (FLORA) with the best available data in Brazil (Appendix A).

Systematic Review of Health Economic Evaluations of Diagnostic Tests in Brazil: How accurate are the results?

The aim of this study is to identify and characterize the health economic evaluations (HEEs) of diagnostic tests conducted in Brazil, in terms of their adherence to international guidelines for reporting economic studies and specific questions in test accuracy reports. We systematically searched multiple databases, selecting partial and full HEEs of diagnostic tests, published between 1980 and 2013. Two independent reviewers screened articles for relevance and extracted the data. We performed a qualitative narrative synthesis. Forty-three articles were reviewed. The most frequently studied diagnostic tests were laboratory tests (37.2%) and imaging tests (32.6%). Most were non-invasive tests (51.2%) and were performed in the adult population (48.8%). The intended purposes of the technologies evaluated were mostly diagnostic (69.8%), but diagnosis and treatment and screening, diagnosis, and treatment accounted for 25.6% and 4.7%, respectively. Of the reviewed studies, 12.5% described the methods used to estimate the quantities of resources, 33.3% reported the discount rate applied, and 29.2% listed the type of sensitivity analysis performed. Among the 12 cost-effectiveness analyses, only two studies (17%) referred to the application of formal methods to check the quality of the accuracy studies that provided support for the economic model. The existing Brazilian literature on the HEEs of diagnostic tests exhibited reasonably good performance. However, the following points still require improvement: 1) the methods used to estimate resource quantities and unit costs, 2) the discount rate, 3) descriptions of sensitivity analysis methods, 4) reporting of conflicts of interest, 5) evaluations of the quality of the accuracy studies considered in the cost-effectiveness models, and 6) the incorporation of accuracy measures into sensitivity analyses.

Evaluación económica para Ia toma de decisiones sobre cobertura en salud: ¿qué debe saber el profesional de la salud? / Economic evaluation for decisions in health care: ¿what should the health professional know?

Los sistemas de salud enfrentan el gran desafío de mejorar la salud de las personas en un escenario de continuos cambios en el perfil epidemiológico, de nuevas tecnologías en salud y de restricción de recursos. En este contexto, el sistema se ve obligado a priorizar en base a un conjunto de elementos que den cuenta del valor que tiene una nueva intervención para ese sistema de salud. La evaluación económica es uno de los elementos técnicos que informa este juicio de valor. El presente artículo introduce la evaluación económica en salud al médico clínico, desde la perspectiva de un sistema de salud que busca lograr el máximo de salud con los recursos disponibles. Se contextualiza este instrumento en el proceso de evaluación de tecnologías en salud y se discute su relevancia en el actual contexto chileno.

Health care face the challenge of improving population in the context of continous epidemiological changes, development of new technologies and budget constraints. The system is forced to prioritize interventions based on a set of elements related to the value of a new intervention in that health system. Economic evaluation is one among different technical elements needed to arrive at a value judgement. This article to introduce the clinical physician to health economic evaluation with a perspective of obtaining the maximal health benefits given the available resources. The value of this instrument in the evaluation of health technologies and the implications for the current Chilean situation are discussed.

Costo efectividad de un programa de rehabilitación cardiovascular modelo para personas post infarto agudo al miocardio en el Servicio de Salud Metropolitano Norte / Cost effectiveness of a theoretical cardiac rehabilitation program after myocardial infarction

Background: Secondary prevention programs are an essential part of comprehensive care of patients with cardiovascular disease (CVD), and its effectiveness in reducing morbidity or mortality has been proved. Aim: To determine the cost-effectiveness of a theoretical comprehensive cardiac rehabilitation (CCR) outpatient program after Myocardial Infarction, to be implemented in a Chilean Public Health System. Material and Methods: We designed a theoretical protocol of a CCR program based on recommendations of international guidelines, but adapted to local needs. A cost analysis was developed. Life years due to premature death were estimated with and without participation in CCR. The gained life-years and cost-effectiveness of the program were thus calculated. Results: The annual cost of cardiac rehabilitation center is $ 64,407,065 Chilean pesos (CLP). The Incremental Cost Effectiveness Ratio (ICER) considering a reduction of late mortality of 25%, is $ 475,209.7 CLP per year of life gained. Since this figure is lower than one unit of per capita gross domestic product, the intervention is considered very cost-effective. Conclusions: A comprehensive cardiac rehabilitation program after myocardial infarction is very cost-effective in the context of its implementation in a public health service.

Assessment of Epstein-Barr virus nucleic acids in gastric but not in breast cancer by next-generation sequencing of pooled Mexican samples

Gastric (GC) and breast (BrC) cancer are two of the most common and deadly tumours. Different lines of evidence suggest a possible causative role of viral infections for both GC and BrC. Wide genome sequencing (WGS) technologies allow searching for viral agents in tissues of patients with cancer. These technologies have already contributed to establish virus-cancer associations as well as to discovery new tumour viruses. The objective of this study was to document possible associations of viral infection with GC and BrC in Mexican patients. In order to gain idea about cost effective conditions of experimental sequencing, we first carried out an in silico simulation of WGS. The next-generation-platform IlluminaGallx was then used to sequence GC and BrC tumour samples. While we did not find viral sequences in tissues from BrC patients, multiple reads matching Epstein-Barr virus (EBV) sequences were found in GC tissues. An end-point polymerase chain reaction confirmed an enrichment of EBV sequences in one of the GC samples sequenced, validating the next-generation sequencing-bioinformatics pipeline.

Análise crítica dos estudos com os novos anticoagulantes / Critical anlysis of studes on the novel anticoagulantes

Os eventos tromboembólicos são complicações significativas da fibrilação atrial (FA) e podem ser prevenidos com a anticoagulação oral plena. A varfarina reduz em 64% o risco de tromboembolismo, no entanto, a dificuldade no seu manejo clínico motivou a busca por novos anticoagulantes orais (NOACs). Os NOACs inibem especificamente um único fator na cascata da coagulação, têm meia vida curta, efeito previsível e estável, dispensam monitorização e interagem pouco com alimentos e medicamentos.Os estudos RE-LY, ROCKET-AF, ARISTOTLE e ENGAGE AFTIMI48 compararam a varfarina com a dabigratana, rivaroxabana,apixabana e edoxabana, respectivamente, e evidenciaram que os NOACS são equivalentes (dabigatrana 110 mg, rivaroxabana,edoxabana) ou superiores (dabigatrana 150 mg, apixabana) à varfarina na prevenção de tromboembolismo sistêmico ou AVC em pacientes com FA não valvar. Ademais, apresentam índices de hemorragias intracranianas substancialmente menores do quea varfarina. Já a apixabana foi superior à aspirina na prevençãode AVC, com os mesmos índices de sangramento. Os NOACs não devem ser usados em gestantes, crianças, e em pacientes com estenose mitral significativa, próteses valvares ou função renal muito deprimida. Porém, podem ser usados nos cenários de cardioversão e ablação da FA. Ainda não há estudos comparativos entre os diversos NOACs, nem consenso de quando recomendara troca da varfarina em pacientes com RNI estável. Cerca de 50%dos pacientes com FA e indicação de anticoagulação não recebem terapia anticoagulante. Portanto, com advento dos NOACs, a expectativa é reduzir essa parcela, diminuindo a incidência de fenômenos tromboembólicos na FA.

Thromboembolic events are important complications of atrialfibrillation (AF) and can be prevented by oral anticoagulation.Warfarin reduces by 64% the risk of thromboembolism,however, the difficulties in its clinical management promptedthe search for novel oral anticoagulants (NOACs). The NOACsspecifically inhibit a single factor in the coagulation cascade,have a short half-life, predictable and stable effect, do not requiremonitoring and have minor interactions with food and drugs.The RE-LY, ROCKET-AF, ARISTOTLE and ENGAGE AFTIMI48 trials compared warfarin to dabigatran, rivaroxaban,apixaban and edoxaban, respectively, and showed that NOACSare equivalent (110 mg dabigatran, rivaroxaban, edoxaban) orsuperior (dabigatran 150 mg, apixaban) to warfarin in preventingstroke or systemic embolism in patients with nonvalvular AF.Furthermore, they are associated with substantially lower levelsof intracranial bleeding than warfarin. Apixaban was superiorto aspirin in preventing strokes, with the same rate of bleeding.The NOACs should not be used in pregnant women, children,and patients with significant mitral stenosis, prosthetic valvesor impaired renal function. However, these novel drugs can beused in the scenarios of cardioversion and AF ablation. Thereare no studies comparing individual NOACs or consensus aboutswitching patients on warfarin with stable INR. Approximately50% of patients with AF and recommendation for anticoagulationdo not receive anticoagulant therapy. Therefore, with the adventof NOACs, the expectation is to improve this figure, ultimatelydecreasing the incidence of thromboembolic events in AF.

Cost-effectiveness analysis for triple markers serum screening for Down's syndrome in Thai setting.

BACKGROUND: Down’s syndrome is an important congenital chromosomal disorder that can be seen around the world. The antenatal screening for this disorder is an important processing in present obstetrics. OBJECTIVE: Due to the concept of first do no harm, the use of noninvasive test is recommended. The triple marker screening test has been introduced for a few years and acceptable for its effi cacy. RESULT: However, an important concern is on its costeffectiveness. Here, the author analyze and present the cost-effectiveness of the triple markers serum screening for Down’s syndrome in Thai setting. CONCLUSION: According to this work, the cost per effectiveness of triple markers serum screening is slightly lower than standard amniocentesis test.

Cost-effectiveness Analysis of Interventions to Improve Control of High Blood Pressure in Low Resource Settings: The Case of Nigeria.

Objectives: Prevalence of hypertension is on the rise in most African countries while control remains poor. In the literature, there are effective interventions which could be implemented in hospitals of low resource setting such as Nigeria to improve control of blood pressure. This study aimed to evaluate the cost-effectiveness of three of such interventions namely: self-monitoring; health professional led care; and organization driven care interventions. Methods: A Markov model was used to represent a life cycle of Nigerian hypertensive female patients in low risk of having a cardiovascular event. Health care costs were obtained from existing databases and calibrated to Nigerian setting or derived through a cost analysis using a Nigerian hospital. Costs were presented in 2013 US dollars value. Uncertainties in the input parameters used in the analyses were captured using distributions appropriate for each parameter. Probabilistic cost-effectiveness analysis was performed using Markov Chain Monte Carlo simulation, and presented as costeffectiveness acceptability frontiers. Population expected value of perfect information analysis was conducted. Results: Compared to null scenario (i.e. no intervention), professional led care intervention will require $190/QALY to emerge the most cost-effective option. The Population Expected Value of Perfect Information (EVPI) analysis showed that the opportunity cost surrounding the choice of professional led care intervention as the most cost-effective option does not amount to very much. Conclusions: The result of this study shows that among the interventions compared health professional led care through a pharmaceutical care model or nurse led care is the most cost-effective option for ensuring that patients with high blood pressure are adequately followed for better control of blood pressure.

Custo-benefício do serviço de telecardiologia no Estado de Minas Gerais: projeto Minas Telecardio / Cost-benefit of the telecardiology service in the state of Minas Gerais: Minas Telecardio Project

FUNDAMENTO: A telecardiologia é instrumento que pode auxiliar na atenção cardiovascular, principalmente em municípios localizados em áreas remotas. Entretanto, as avaliações econômicas sobre o assunto são escassas e com resultados controversos. OBJETIVO: Avaliar o custo-benefício da implantação do serviço de telecardiologia em municípios remotos, de pequeno porte, no estado de Minas Gerais, Brasil. MÉTODOS: O estudo utilizou a base de dados do Projeto Minas Telecardio (MTC), desenvolvido de junho/2006 a novembro/2008, em 82 municípios do interior do estado. Cada município recebeu um microcomputador com eletrocardiógrafo digital, com possibilidade de envio dos traçados e comunicação com plantão de cardiologia em pólo universitário. A análise custo-benefício foi realizada comparando o custo de realização de um ECG no projeto MTC ao custo de realizar este exame por encaminhamento em outra localidade. RESULTADOS: O custo médio de um ECG no projeto MTC foi de R$ 28,92, decomposto em R$ 8,08 referente ao custo de implantação e R$ 20,84 ao de manutenção do programa. A simulação do custo do ECG com encaminhamento variou de R$ 30,91 a R$ 54,58, sendo a relação custo-benefício sempre favorável ao programa MTC, independente da forma de cálculo da distância de encaminhamento. Nas simulações, foram consideradas as abordagens do financiador e da sociedade. A análise de sensibilidade com variação dos parâmetros de calibração confirmou esses resultados. CONCLUSÃO: A implantação de sistema de telecardiologia como apoio a atenção primária em cidades brasileiras de pequeno porte é factível e economicamente benéfica, podendo ser transformada em programa regular do sistema público de saúde.

BACKGROUND: Telecardiology is a tool that can aid in cardiovascular care, mainly in towns located in remote areas. However, economic assessments on this subject are scarce and have yielded controversial results. OBJECTIVE: To evaluate the cost-benefit of implementing a Telecardiology service in remote, small towns in the state of Minas Gerais, Brazil. METHODS: The study used the database from the Minas Telecardio (MTC) Project, developed from June 2006 to November 2008, in 82 towns in the countryside of the state. Each municipality received a microcomputer with a digital electrocardiograph, with the possibility of transmitting ECG tracings and communicating with the on-duty cardiologist at the University hospital. The cost-benefit analysis was carried out by comparing the cost of performing an ECG in the project versus the cost of performing it by patient referral to another city. RESULTS: The average cost of an ECG in the MTC project was R$ 28.92, decomposed into R$ 8.08 for the cost of implementation and R$ 20.84 for maintenance. The cost simulation of the ECG with referral ranged from R$ 30.91 to R$ 54.58, with the cost-benefit ratio being always favorable to the MTC program, regardless of the type of calculation used for referral distance. The simulations considered the financial sponsor's and society's points-of-view. The sensitivity analysis with variation of calibration parameters confirmed these results. CONCLUSION: The implementation of a Telecardiology system as support to primary care in small Brazilian towns is feasible and economically beneficial, and can be used as a regular program within the Brazilian public health system.

Custo-benefício de programa de exercício físico para redução de peso em adultos / Cost-effectiveness of exercise program to reduce weight in adults

O objetivo foi estimar o custo-benefício de programa de mudança de estilo de vida na redução da obesidade. Foram reunidos dados de 271 adultos (ambos sexos) participantes de programa de exercício físico, com protocolos distintos em tipo e duração (2, 6 ou 12 meses), envolvendo aconselhamento alimentar ou adequação de fibras alimentares. Aferiu-se peso e estatura para cálculo do Índice de Massa Corporal (IMC). Considerou-se R$0,79/pessoa/ano o custo da hospitalização relacionada à obesidade e do programa R$1.580,00/mês. Em 2 meses, o grupo de caminhada e o de exercícios mistos (caminhada e força) e adequação de fibras alimentares tiveram maior redução de peso e IMC. A eutrofia aumentou em 2 meses com exercícios mistos e adequação de fibras, 6 meses de caminhada, 1 ano de exercícios mistos ou caminhada. Pelos cálculos a economia aos cofres públicos com 2 meses de exercícios mistos e fibras seria de aproximadamente R$2 milhões e, com 1 ano de exercícios mistos, de R$726.000 e com caminhada de R$2,4 milhões. O programa mostrou que a economia gerada seria suficiente para financiar a replicação deste programa em todos os municípios brasileiros.

The objective was to estimate the cost-effectiveness of lifestyle-modification program in reducing the obesity. Was collected data from 271 adults (both genders) they participated in exercise program, with different protocols as regards type and duration (2, 6 or 12 months), envolved nutritional counseling or food fiber adequacy. Weight and height were measured to calculate the Body Mass Index (BMI). The considered expenditure with obesity were R$ 0,79/person/year, and the monthly cost of the program R$1.580,00. For 2 months, the group following walk and mixed exercises (walk and strength) with food fiber adequacy achieved greater weight loss and BMI reduction, and in 6 months was the group walk. The eutrophy increased in 2 months of mixed exercises with fiber, 6 months with walk, 1 year of mixed and walk. According to the cost-benefit estimates, the economy of public revenue with 2 months of mixed exercises with fiber would be almost R$ 2,4 million, with 1 year of mixed it would be R$ 726.000 and R$ 2,4 million of walk. The program has shown that, if applied nationwide cities, the generated savings would be enough sufficient to implement this program in all municipalities in this country.

Principios básicos y alcances metodológicos de las evaluaciones económicas en salud / Basic principles and methodological considerations of health economic evaluations

La economía de la salud es un instrumento indispensable para la gestión sanitaria y las evaluaciones económicas, se pueden considerar como la herramienta que asiste a la toma de decisiones para asignar recursos en el área de la salud. Hoy en día, su uso es creciente en todas las regiones del mundo y fomenta la toma de decisiones basadas en la evidencia, buscando alternativas eficientes y racionales dentro del conjunto de actividades de los servicios. En esta revisión se efecturá una visión general y se delinea los tipos básicos de evaluación económica, sobre todo de las Evaluaciones Económicas (EE) completas. Así mismo se revisará los conceptos más relevantes sobre las perspectivas desde las que se pueden realizar las EE, los tipos de costos, el horizonte temporal, los descuentos, la evaluación de la incertidumbre y las reglas de decisión. Finalmente, se describirán conceptos sobre la transferibilidad y la generalización de las Evaluaciones Económicas en salud.

Health Economics is an essential instrument for health management, and economic evaluations can be considered as tools assisting the decision-making process for the allocation of resources in health. Currently, economic evaluations are increasingly being used worldwide, thus encouraging evidence-based decision-making and seeking efficient and rational alternatives within the framework of health services activities. In this review, we present an overview and define the basic types of economic evaluations, with emphasis on complete Economic Evaluations (EE). In addition, we review key concepts regarding the perspectives from which EE can be conducted, the types of costs that can be considered, the time horizon, discounting, assessment of uncertainty and decision rules. Finally, we describe concepts about the extrapolation and spread of economic evaluations in health.

Avaliação: conceitos e métodos / Rating: concepts and methods

Membros do Grupo de Pesquisa Interdisciplinar em Saúde da Universidade de Montreal, no Canadá, criaram um modelo para a avaliação das intervenções em saúde e o apresentaram – pela primeira vez de forma completa – em 2009, em um livro em francês. A publicação, dirigida especialmente a pesquisadores e gestores, foi traduzida para o português e lançada no Brasil pela Editora Fiocruz. O modelo de que trata o livro, desenvolvido há duas décadas, foi testado com sucesso em pesquisas avaliativas realizadas não só no Canadá, mas também em países da Europa, África e América do Sul, especialmente no Brasil. As indicações contidas no livro podem ser aplicadas para a avaliação de diferentes intervenções em saúde, como políticas, programas, organizações, tratamentos e tecnologias. Mas “o modelo de avaliação proposto é suficientemente amplo e global para ser utilizado em outros campos tais como a educação, os serviços sociais ou a administração pública, para citar somente esses”, sublinham os organizadores. Os capítulos detalham seis tipos de avaliação: análise estratégica; análise lógica; análise da produção; análise dos efeitos; análise econômica; e análise da implantação.

Comparison of Benefit Estimation Models in Cost-Benefit Analysis: A Case of Chronic Hypertension Management Programs

PURPOSE: Cost-benefit analysis is one of the most commonly used economic evaluation methods, which helps to inform the economic value of a program to decision makers. However, the selection of a correct benefit estimation method remains critical for accurate cost-benefit analysis. This paper compared benefit estimations among three different benefit estimation models. METHODS: Data from community-based chronic hypertension management programs in a city in South Korea were used. Three different benefit estimation methods were compared. The first was a standard deterministic estimation model; second, a repeated-measures deterministic estimation model; and third, a transitional probability estimation model. RESULTS: The estimated net benefit of the three different methods were $1,273.01, $-3,749.42, and $-5,122.55 respectively. CONCLUSION: The transitional probability estimation model showed the most correct and realistic benefit estimation, as it traced possible paths of changing status between time points and it accounted for both positive and negative benefits.

Cost effectiveness of heptavalent pneumococcal conjugate vaccine in populations of high risk in Colombia / Costo efectividad de la vacuna conjugada heptavalente de neumococo en poblaciones de alto riesgo en Colombia: el caso de la vacunación en niños de bajo peso al nacer

Objective: To estimate the economic impact of the introduction of heptavalent pneumococcal conjugate vaccine (PCV-7) in high risk populations of Colombia. Methods: A full economic evaluation was done regarding potential introduction of PCV-7. A cost-effectiveness study from the perspective of the third payer was done using a Decision Model. The model considered two alternatives: with and without vaccination. As measurement of results the avoided events were taken [cases, hospitalizations, deaths and Life-Years Saved (LYS)]. In addition the net costs and the incremental cost-effectiveness ratio (ICER) were evaluated. Results: In a cohort of 70 thousand children of under 2 years old in situation of high risk, can generate 532 deaths that would produce a little more than 21 thousand Years of Life Lost (YLL) with costs between 7.7 and 13.3 million dollars. If we vaccinate this same cohort the deaths can be reduced to 355, and the costs of burden of disease would be between 5.7 and 10 million dollars. It is estimated a reduction of 25% of the costs of burden of disease and of 33% of the deaths. In addition the ICER by YLS would be between 590 and 762 dollars. Conclusion: The introduction of the Heptavalent Pneumococcal Conjugate Vaccine in populations of high risk is highly cost effective in Colombia.

Objetivo: Evaluar económicamente la introducción de la vacuna heptavalente de neumococo en poblaciones de alto riesgo en Colombia. Métodos: Se realizó un análisis de costo-efectividad desde la perspectiva del tercer pagador utilizando un modelo de decisiones que consideró dos alternativas: con y sin programa de vacunación. Como medida de resultados se tomaron los eventos evitados [casos, hospitalizaciones, muertes y años de vida salvados (AVS)]. Además, se valoraron los costos netos y la razón de costo-efectividad incremental (RCEI). Resultados: En una cohorte de 70 mil niños menores de dos años en situación de alto riesgo (bajo peso al nacer), se puede generar 532 muertes que producirían un poco más de 21 mil años de vida perdidos. Los costos de atención estarían entre 7,7 y 13,3 millones de dólares. Si vacunásemos esta misma cohorte con la vacuna conjugada heptavalente las muertes se reducirían a 355 y los costos de la carga estarían entre 5,7 y 10 millones de dólares. Es decir, una reducción cerca de 25% de los costos de la carga y 33% de las muertes. Además el CEI por AVS estaría entre 590 y 762 dólares del año 2006. Conclusiones: La introducción de la vacuna contra neumococo en poblaciones de alto riesgo (bajo peso al nacer) en Colombia es altamente costo-efectiva.

Metodología para la evaluación de la relación costo-efectividad en centros de atención primaria de Chile / Methodology for evaluating cost-effectiveness in primary health care centers in Chile

OBJETIVO: Presentar una metodología para la evaluación de la relación costo-efectividad en centros de atención primaria de salud (APS) a partir del modelo de atención familiar promovido en Chile y evaluar los resultados de los dos primeros años de funcionamiento del primer centro piloto que funciona bajo este nuevo modelo de atención primaria. MÉTODOS. Se realizó un estudio de costo-efectividad, con una perspectiva social y un horizonte temporal de un año. Para comparar el centro intervenido (universitario) con el centro de control (municipal) se construyó el índice compuesto de calidad de los centros de salud familiar (ICCESFAM), que combina indicadores técnicos y la percepción de los usuarios de los centros en seis dimensiones: accesibilidad, continuidad de la atención médica, enfoque clínico preventivo y promocional, resolutividad, participación, y enfoque biopsicosocial y familiar. Para calcular los costos se tomó en cuenta el gasto en los centros, el ahorro producido al resto del sistema sanitario y el gasto de bolsillo de los pacientes. Se estimó la razón costo-efectividad incremental (RCEI) y se realizó un análisis de sensibilidad. RESULTADOS: El centro de salud universitario resultó 13,4 por ciento más caro (US$ 8,93 anuales adicionales por inscrito) y más efectivo (ICCESFAM 13,3 por ciento mayor) que el municipal. Estos resultados hacen que la RCEI sea de US$ 0,67 por cada punto porcentual adicional que aumenta el ICCESFAM. CONCLUSIONES: Según el modelo elaborado de evaluación de centros de APS, los centros que siguen el modelo de salud familiar chileno son más efectivos, tanto por sus indicadores técnicos como por la valoración de sus usuarios, que los centros de APS tradicionales.

OBJECTIVE: Present a methodology for evaluating cost-effectiveness in primary health care centers (PHCs) in Chile based on the family health care model promoted in Chile and evaluate the results of the first two years of operation of the first pilot center to work under this new primary-care model. METHODS: A cost-effectiveness study with a social perspective and a one-year time frame was conducted. In order to compare the university health center in question with the control (a municipal health center), a Family Health Center Composite Quality Index (FHCCQI) was devised. It combines technical indicators and user perceptions of the health centers in six areas: access, continuity of medical care, a preventive and promotional clinical approach, problem-solving capability, participation, and a biopsychosocial and family approach. In order to calculate the costs, the centers' expenses, the savings realized in the rest of the health system, and patients' out-of-pocket expenditures were considered. The incremental cost-effectiveness ratio (ICR) was estimated and a sensitivity analysis was performed. RESULTS: The university health center was 13.4 percent more expensive (an additional US$ 8.93 per annum per enrollee) and was more effective (FHCCQI 13.3 percent greater) than the municipal one. Accordingly, the ICR is US$ 0.67 for each additional percentage point of FHCCQI increase. CONCLUSIONS: According to the PHC evaluation model that was implemented, the centers that follow the Chilean family health care model are more effective than traditional PHC centers, as measured by both technical indicators and user ratings.

Contaminación del aire en la Florida (Talca, Chile): Beneficios económicos en salud por la reducción de los niveles PM10 / Hypothetical health and economic benefits associated with a reduction in air pollution in a Chilean city (Talca)

Background: Environmental air pollution is associated with a higher incidence of respiratory diseases, absenteeism and costs. Aim: To model the health related economic benefits associated to a reduction in air pollution and the resulting lower prevalence of respiratory diseases, in a Chilean city. Material and Methods: A time series model for year 2006 was elaborated. The dependent variable was the number of consultations for respiratory disease. The independent variables were air pollution expressed as particulate matter of 10 micrometers or less (PM10), minimum and maximum environmental temperatures, environmental humidity and number of consultations for chronic diseases. Results: The variables that best explained the number of consultations for respiratory diseases were PM10, minimal environmental temperatures and preexisting respiratory diseases. In a hypothetical scenery of a 67 percent reduction in PM10, 69 percent of medical consultations for respiratory diseases would be avoided. This would result in a net saving of US$ 345,000 per year. Conclusions: The reduction in PM10 emissions would result in an important reduction in consultations for respiratory diseases and monetary savings.

Custo-efetividade de cardiodesfibriladores implantáveis no Brasil nos setores público e privado / Cost-effectiveness of implantable cardioverter defibrillators in Brazil in the public and private sectors

FUNDAMENTO: Vários ensaios clínicos randomizados demonstraram a efetividade do cardiodesfibrilador implantável (CDI) na redução de morte de pacientes com insuficiência cardíaca congestiva (ICC). Estudos de países desenvolvidos já avaliaram a custo-efetividade do CDI, porém as informações não são transferíveis para o Brasil. OBJETIVO: Avaliar a custo-efetividade do CDI em pacientes com ICC sob duas perspectivas: pública e saúde suplementar. MÉTODOS: Um modelo de Markov foi criado para analisar a relação de custo-efetividade incremental (RCEI) do CDI, comparado à terapia convencional, em pacientes com ICC. Efetividade foi medida em anos de vida ajustados para qualidade (QALY). Na literatura, buscaram-se dados de efetividade e complicações. Custos foram extraídos das tabelas do SUS e de valores praticados pelos convênios, assim como médias de internações hospitalares. Análises de sensibilidade univariadas foram feitas em todas as variáveis do modelo. RESULTADOS: A RCEI foi de R$ 68.318/QALY no cenário público e R$ 90.942/QALY no privado. Esses valores são superiores aos sugeridos como pontos de corte pela Organização Mundial da Saúde, de três vezes o PIB per capita (R$ 40.545 no Brasil). Variáveis mais influentes na análise de sensibilidade foram: custo do CDI, intervalo de troca do gerador e efetividade do CDI. Em simulação de cenário semelhante ao MADIT-I, as relações foram de R$ 23.739/QALY no cenário público e R$ 33.592/QALY no privado. CONCLUSÃO: Para a população em geral com ICC, a relação de RCEI do CDI, tanto na perspectiva pública como na privada, é elevada. Resultados mais favoráveis ocorrem em pacientes com alto risco de morte súbita.

BACKGROUND: Many randomized clinical trials have demonstrated the effectiveness of the implantable cardioverter-defibrillator (ICDs) in death reduction of chronic heart failure (CHF) patients. Some developed countries studies have evaluated its cost-effectiveness, but these data are not applicable to Brazil. OBJECTIVE: To evaluate the cost-effectiveness of ICD in CHF patients under two perspectives in Brazil: public and supplementary health systems. METHODS: A Markov model was developed to analyze the incremental cost-effectiveness ratio (ICER) of ICD compared to conventional therapy in patients with CHF. Effectiveness was measured in quality-adjusted life years (QALYs). We searched the literature for data regarding effectiveness and complications. Costs were retrieved from public and health insurances reimbursement codebooks and from mean cost of admissions from a public and a private hospital. One-way sensitivity analysis was performed in all variables of the model. RESULTS: ICER was R$ 68,318/QALY in the public and R$ 90,942/QALY in the private perspective. These values are much higher than the one suggested by the World Health Organization of 3 times the gross domestic product per head (R$ 40,545 in Brazil). The results were sensitive to the cost of the device, battery replacement interval and ICD effectiveness. In a simulation resembling MADIT-I population survival and ICD benefit, ICER was R$ R$ 23,739/QALY in the public and R$ 33,592/QALY in the private perspective. CONCLUSION: The ICER aof ICD is elevated in the general ICC population, in either the public or private perspective. A more favorable result occurs in patients with a high sudden death risk.