Revisión sistemática: costo-efectividad, acceso y adherencia a programas de ejercicio supervisado en pacientes con claudicación intermitente / Systematic review: cost-effectiveness, access and adherence to supervised exercise programs in patients with intermittent claudication

OBJETIVO: Determinar las razones de la escasa derivación, acceso, y adherencia a programas de ejercicio supervisado (PES) en pacientes con claudicación intermitente (CI) y la costo-efectividad de estos programas a nivel Internacional. MÉTODOS: Se utilizaron las fuentes de datos de PubMed y ScienceDirect. Se incluyeron revisiones con acceso completo, publicados desde el año 2010, que incluían como mínimo 3 artículos de tipo cuantitativo. RESULTADOS: Se incluyeron 5 Revisiones asociadas a los resultados del ejercicio supervisado, su costo-efectividad, la baja derivación y adherencia a PES de los pacientes con CI. En cuanto a la costo-efectividad los resultados indican que los PES fueron rentables con un ICER de £711 a £1.608 por QALY ganado al compararlos con ejercicio no supervisado, y al compararlos con la cirugía de revascularización (CR) no hay diferencia significativa en QALY ganados, sin embargo, el costo por QALY fue €381.694 más alto para la CR. Por otro lado, las principales razones de la subutilización de los PES, es que los pacientes se resisten a asistir, ya que involucra un esfuerzo y responsabilidad, además de tener problemas de reembolso, teniendo baja adherencia. Sumado a esto, el interés personal de los médicos por realizar intervenciones que involucran pago por servicio produce una baja derivación (45% de cirujanos en Europa refieren menos del 50% de sus pacientes). CONCLUSIÓN: Las principales dificultades para adoptar los PES serían una carencia en la destinación de recursos, falta de centros, dificultad de traslado, falta de tiempo, o de interés por parte de los pacientes, además de incentivos financieros a otras alternativas de tratamiento por sobre PES lo que limita su derivación.

OBJECTIVE: To determine the reasons for the limited derivation, access and adherence to supervised exercise programs (SEP) in patients with intermittent claudication (IC) and the cost-effectiveness of these programs internationally. METHODS: PubMed and ScienceDirect databases were searched. Revisions with full access, published since 2010, which included at least 3 quantitative type articles. RESULTS: 5 reviews were included, these were associated with the results of the supervised exercise, its cost-effectiveness, the low referral and adherence to programs of patients with IC. Regarding cost-effectiveness, the results indicated that SEP were more cost-effective with an ICER of £711 to £1.608 per QALY gained when compared with unsupervised exercise, and that when compared with revascularization surgery (RC) there was no significant difference in QALYs, however the cost per QALY was € 381.694 higher for the RC. On the other hand, the main reasons for the underutilization of SEP are that patients are reluctant to attend, since it involves effort and responsibility, in addition to having reimbursement problems, therefore having low adherence. Added to this, the personal interest of doctors in performing interventions that involve payment for service produce a low referral (45% of surgeons in Europe refer less than 50% of their patients) CONCLUSION: The main difficulties in adopting the SEP would be a lack in the allocation of resources, lack of centers, difficulty of transportation, lack of time or lack of interest from patients, in addition to financial incentives to other treatment alternatives over SEP, which limits their referral.

Relationship between availability of physiotherapy services and ICU costs / Relação entre a disponibilidade de serviços de fisioterapia e custos de UTI

ABSTRACT Objective: To determine whether 24-h availability of physiotherapy services decreases ICU costs in comparison with the standard 12 h/day availability among patients admitted to the ICU for the first time. Methods: This was an observational prevalence study involving 815 patients ≥ 18 years of age who had been on invasive mechanical ventilation (IMV) for ≥ 24 h and were discharged from an ICU to a ward at a tertiary teaching hospital in Brazil. The patients were divided into two groups according to h/day availability of physiotherapy services in the ICU: 24 h (PT-24; n = 332); and 12 h (PT-12; n = 483). The data collected included the reasons for hospital and ICU admissions; Acute Physiology and Chronic Health Evaluation II (APACHE II) score; IMV duration, ICU length of stay (ICU-LOS); and Omega score. Results: The severity of illness was similar in both groups. Round-the-clock availability of physiotherapy services was associated with shorter IMV durations and ICU-LOS, as well as with lower total, medical, and staff costs, in comparison with the standard 12 h/day availability. Conclusions: In the population studied, total costs and staff costs were lower in the PT-24 group than in the PT-12 group. The h/day availability of physiotherapy services was found to be a significant predictor of ICU costs.

RESUMO Objetivo: Determinar se a disponibilidade de serviços de fisioterapia 24 h/dia reduz os custos de UTI comparada à disponibilidade padrão de 12 h/dia entre pacientes admitidos pela primeira vez na UTI. Métodos: Estudo de prevalência observacional, envolvendo 815 pacientes ≥ 18 anos de idade que estavam em ventilação mecânica invasiva (VMI) por ≥ 24 h e que tiveram alta de uma UTI para uma enfermaria em um hospital universitário terciário no Brasil. Os pacientes foram divididos em dois grupos de acordo com a disponibilidade de serviços de fisioterapia na UTI em h/dia: 24 h (PT-24; n = 332); e 12 h (PT-12; n = 483). Os dados coletados incluíram os motivos das internações hospitalares e das admissões na UTI; a pontuação Acute Physiology and Chronic Health Evaluation II (APACHE II); a duração da VMI; o tempo de permanência na UTI (TP-UTI); e o escore Ômega. Resultados: A gravidade da doença foi similar em ambos os grupos. A disponibilidade ininterrupta de serviços de fisioterapia foi associada a tempos menores de VMI e TP-UTI, bem como a menores custos (totais, médicos e com pessoal), comparada à disponibilidade padrão de 12 h/dia. Conclusões: Na população estudada, os custos totais e os custos com pessoal foram menores no grupo PT-24 do que no grupo PT-12. A disponibilidade em h/dia dos serviços de fisioterapia mostrou ser um preditor significativo dos custos de UTI.

Resultado clínico e econômico de um programa de reabilitação cardiopulmonar e metabólica / Clinical and economic outcome of a cardiopulmonary and metabolic rehabilitation program

OBJETIVO: Avaliar o resultado clínico e econômico de um Programa de Reabilitação Cardiopulmonar e Metabólica (PRCM) criado por um plano de saúde. MÉTODOS: A amostra foi constituída por 96 clientes, divididos em dois grupos de 48 indivíduos (grupo tratamento - GT, indivíduos que participavam do programa de RCPM; e grupo controle - GC, indivíduos que não participavam do programa), de ambos os sexos, idade entre 54 e 79 anos. O tempo de treinamento do GT foi de 22 (±3) meses. Para avaliação do resultado clínico antes e após a PRCM, foram determinadas as tolerâncias ao esforço físico, perfil lipoprotéico plasmático (CT, LDL-C, HDL-C, CT/HDL-C e triglicérides); pressão arterial sistêmica (PAS) de repouso e composição corporal (índice de massa corporal - IMC e relação cintura/quadril - RC/Q). RESULTADOS: O GT apresentou, respectivamente na avaliação pré e pós-PRCM: CT (mg/dl) 242,5 (±48,32) e 189,47(±39,83); LDL-C (mg/dl) 162(±37,72) e 116,3(±33,28); HDL-C (mg/dl) 46,5(±8,59) e 57,8(±10,36); Tg (mg/dl) 165,15(±90,24) e 113,29(±54,92); CT/HDL-C 5,42 (±1,10) e 3,35 (±0,81); VO2 pico (ml/kg/min) 26,92±7 e 32,64±5,92; IMC 29,35 (±3,93) e 28,12 (±3,55) para mulheres e 29,17 (±5,14) e 27,88 (±4,83) para homens; RC/Q 0,93(±0,05) e 0,94(±0,04) para mulheres e 0,93(±0,07) e 0,92(±0,06) para homens; PAS (mmHg) 151(±13,89) e 132(±9,56); PAD (mmHg) 83(±8,07) e 77(±5,92); despesas mensais GC (R$) 8.840,05 (±5.656,58) e 8.978,32 (±5.500,78); despesas mensais GT (R$) 2.016,98 (±2.861,69) e 1.470,73 (±1.333,25). CONCLUSÃO: No grupo submetido ao programa de PRCM foram observadas modificações clínicas favoráveis em relação a perfil lipoprotéico plasmático, PAS e tolerância ao esforço físico, sem relação com modificação de medicamentos.

OBJECTIVE: To evaluate the clinical and economic outcome of a Cardiopulmonary and Metabolic Rehabilitation Program (CPMR) created by an HMO. METHODS: The sample was comprised of 96 clients, divided into two groups of 48 individuals (treatment group - TG, individuals who participated in the CPMR program, and control group - CG, individuals who did not participate in the program) of both genders, with age ranging between 54 and 79 years. Training time of the TG was 22 (±3) months. To assess the clinical outcome before and after CPMR, exercise tolerance, plasma lipoprotein profile (TC, LDL-C, HDL-C, TC/HDL-C and triglycerides), resting blood pressure (BP), and body composition (Body mass index - BMI and Waist-to-hip ratio - W/HR) were determined. RESULTS: The TG presented the following results in the pre and post CPMR assessment, respectively: TC (mg/dL) 242,5 (±48,32) and 189.47(±39.83); LDL-C (mg/dL) 162(±37.72) and 116,3(±33,28); HDL-C (mg/dL) 46,5(±8,59) and 57.8(±10.36); Tg (mg/dL) 165.15(±90.24) and 113.29(±54,92); TC/HDL-C 5.42 (±1.10) and 3.35 (±0.81); VO2 peak (mL/Kg/min) 26.92 ± 7 and 32.64 ± 5.92; BMI 29.35 (±3.93) and 28.12 (±3.55) for women and 29.17 (±5.14) and 27.88 (±4.83) for men; W/HR 0.93(±0.05) and 0.94(±0.04) for women and 0.93(±0.07) and 0.92(±0.06) for men; BP (mmHg) 151(±13.89) and 132(±9.56); DBP (mmHg) 83(±8.07) and 77(±5.92); monthly expenses CG (R$) 8,840.05 (±5,656.58) and 8,978.32 (±5,500.78); monthly expenses TG (R$) 2,016.98 (±2,861.69) and 1,470.73 (±1,333.25). CONCLUSION: In the group undergoing the CPMR Program, favorable clinical changes were observed in relation to the plasma lipoprotein profile, blood pressure, and exercise tolerance, with no relation to changes in medications.