The cost of stroke in private hospitals in Brazil: a one-year prospective study / O custo do AVC em hospitais privados no Brasil: um estudo prospectivo

ABSTRACT Few studies from low- and middle-income countries have assessed stroke and cerebral reperfusion costs from the private sector. Objective To measure the in-hospital costs of ischemic stroke (IS), with and without cerebral reperfusion, primary intracerebral hemorrhage (PIH), subarachnoid hemorrhage (SAH) and transient ischemic attacks (TIA) in two private hospitals in Joinville, Brazil. Methods Prospective disease-cost study. All medical and nonmedical costs for patients admitted with any stroke type or TIA were consecutively determined in 2016-17. All costs were adjusted to the gross domestic product deflator index and purchasing power parity. Results We included 173 patients. The median cost per patient was US$3,827 (IQR: 2,800-8,664) for the 131 IS patients; US$2,315 (IQR: 1,692-2,959) for the 27 TIA patients; US$16,442 (IQR: 5,108-33,355) for the 11 PIH patients and US$28,928 (IQR: 12,424-48,037) for the four SAH patients (p < 0.00001). For the six IS patients who underwent intravenous thrombolysis, the median cost per patient was US$11,463 (IQR: 8,931-14,291), and for the four IS patients who underwent intra-arterial thrombectomy, the median cost per patient was US$35,092 (IQR: 31,833-37,626; p < 0.0001). A direct correlation was found between cost and length of stay (r = 0.67, p < 0.001). Conclusions Stroke is a costly disease. In the private sector, the costs of cerebral reperfusion for IS treatment were three-to-ten times higher than for usual treatments. Therefore, cost-effectiveness studies are urgently needed in low- and middle-income countries.

RESUMO Poucos estudos determinam o custo do AVC em países de baixa e média renda nos setores privados. Objetivos Mensurar o custo hospitalar do tratamento do(a): AVC isquêmico com e sem reperfusão cerebral, hemorragia intracerebral primária (HIP), hemorragia subaracnóidea e ataque isquêmico transitório (AIT) em hospitais privados de Joinville, Brasil. Métodos Estudo prospectivo de custo de doença. Os custos médicos e não médicos dos pacientes admitidos com qualquer tipo de AVC ou AIT foram consecutivamente verificados em 2016-17. Os valores foram ajustados ao índice do deflator do produto interno bruto e à paridade do poder de compra. Resultados Nós incluímos 173 pacientes. A mediana de custo por paciente foi de US$ 3.827 (IQR: 2.800-8.664) para os 131 pacientes com AVC isquêmico; US$ 2.315 (1.692-2.959) para os 27 pacientes com AIT; US$ 16.442 (5.108-33.355) para os 11 pacientes com HIP e US$ 28.928 (12.424-48.037) para os quatro pacientes com HSA (p < 0,00001). Para seis pacientes submetidos à trombólise intravenosa, a mediana do custo por paciente foi de US$ 11.463 (8.931-14.291) e, para quatro pacientes submetidos à trombectomia intra-arterial, a mediana de custo por paciente foi de US$ 35.092 (31.833-37.626; p < 0,0001). Uma correlação direta foi encontrada entre custo e tempo de permanência (r = 0,67, p < 0,001). Conclusão O AVC é uma doença cara. Em ambiente privado, os custos da reperfusão cerebral foram de três a dez vezes superiores aos tratamentos habituais do AVC isquêmico. Portanto, estudos de custo-efetividade são urgentemente necessários em países de baixa e média rendas.

Comparison of thromboprophylaxis patterns in arthroplasty in public and private hospitals / Comparação entre padrões de tromboprofilaxia na artroplastia em hospitais público e privado

Objective To compare therapy for prophylaxis of venous thromboembolism and costs related to hospitalization of patients undergoing total knee and hip replacement within the context of the Brazilian health system.Methods A retrospective study of patients undergoing arthroplasty in 2010 in a public hospital and two private hospitals in the state of São Paulo, conducted by means of medical record review. Costs were estimated based on the use of health care resources during hospitalization. A descriptive analysis was performed using frequency and mean (standard deviation) according to the type of care delivered (by public or private organization).Results A total of 215 patients were evaluated, and 56.3% were submitted to knee surgery and 43.7%, to hip replacement. Approximately 88% and 98% of patients from public and private health services, respectively, received some form of venous thromboembolism prophylaxis, and enoxaparin was the drug most widely used in both systems. The total cost of prophylaxis was R$ 1,873.01 (R$ 26.38 per patient) in the public service and R$ 21,559.73 (R$ 163.33 per patient) in the private service. For the individuals who presented with thromboembolism, the average cost of hospitalization was R$ 6,210.80 and R$ 43,792.59 per patient in public and private health services, respectively.Conclusion Thromboembolism prophylaxis in patients undergoing arthroplasty is most commonly used in the private health services than public organizations, despite its high costs in both services. The cost per patient with thrombosis during hospitalization was higher than the total cost of prophylaxis, suggesting that prevention is associated to better cost-benefit ratio.

Objetivo Comparar a terapia para profilaxia de tromboembolismo venoso e os custos de pacientes submetidos à artroplastia total de joelho e de quadril dentro do sistema de saúde brasileiro.Métodos Estudo retrospectivo com pacientes submetidos à artroplastia no ano de 2010, em um hospital público e dois hospitais privados no Estado de São Paulo, por meio da revisão de prontuários. Os custos foram estimados com base na utilização de recursos em saúde durante a hospitalização. Análise descritiva de frequência e média (desvio padrão), de acordo com o tipo de atendimento em saúde (público ou privado).Resultados Um total de 215 pacientes foram avaliados, sendo 56,3% submetidos à cirurgia de joelho e 43,7% à cirurgia de quadril. Cerca de 88% e 98% dos pacientes provenientes do serviço público e privado de saúde, respectivamente, receberam algum tipo de profilaxia para tromboembolismo, sendo a enoxaparina o medicamento mais utilizado em ambos sistemas. O custo total da profilaxia foi de R$ 1.873,01 (R$ 26,38 por paciente) no serviço público e R$ 21.559,73 (R$ 163,33 por paciente) no serviço privado. Para os indivíduos com tromboembolismo, o custo médio da internação foi de R$ 6.210,80 e R$ 43.792,59 por paciente atendido nos serviços de saúde público e privado, respectivamente.Conclusão A profilaxia em pacientes submetidos à artroplastia é mais utilizada em pacientes do serviço de saúde privado do que público, apesar dos altos custos em ambos os serviços. Os pacientes com tromboembolismo tiveram um custo maior do que aqueles apenas com profilaxia, mostrando que a prevenção está associada a um maior custo-benefício.

Mortality, Length of Stay, and Inpatient Charges for Heart Failure Patients at Public versus Private Hospitals in South Korea

PURPOSE: This study compared in-hospital mortality within 30 days of admission, lengths of stay, and inpatient charges among patients with heart failure admitted to public and private hospitals in South Korea. MATERIALS AND METHODS: We obtained health insurance claims data for all heart failure inpatients nationwide between November 1, 2011 and May 31, 2012. These data were then matched with hospital-level data, and multi-level regression models were examined. A total of 8406 patients from 253 hospitals, including 31 public hospitals, were analyzed. RESULTS: The in-hospital mortality rate within 30 days of admission was 0.92% greater and the mean length of stay was 1.94 days longer at public hospitals than at private hospitals (mortality: 5.18% and 4.26%, respectively; LOS: 12.08 and 10.14 days, respectively). The inpatient charges were 11.4% lower per case and 24.5% lower per day at public hospitals than at private hospitals. After adjusting for patient- and hospital-level confounders, public hospitals had a 1.62-fold higher in-hospital mortality rate, a 16.5% longer length of stay, and an 11.7% higher inpatient charge per case than private hospitals, although the charges of private hospitals were greater in univariate analysis. CONCLUSION: We recommend that government agencies and policy makers continue to monitor quality of care, lengths of stay in the hospital, and expenditures according to type of hospital ownership to improve healthcare outcomes and reduce spending.

Mortality, Length of Stay, and Inpatient Charges for Heart Failure Patients at Public versus Private Hospitals in South Korea

PURPOSE: This study compared in-hospital mortality within 30 days of admission, lengths of stay, and inpatient charges among patients with heart failure admitted to public and private hospitals in South Korea. MATERIALS AND METHODS: We obtained health insurance claims data for all heart failure inpatients nationwide between November 1, 2011 and May 31, 2012. These data were then matched with hospital-level data, and multi-level regression models were examined. A total of 8406 patients from 253 hospitals, including 31 public hospitals, were analyzed. RESULTS: The in-hospital mortality rate within 30 days of admission was 0.92% greater and the mean length of stay was 1.94 days longer at public hospitals than at private hospitals (mortality: 5.18% and 4.26%, respectively; LOS: 12.08 and 10.14 days, respectively). The inpatient charges were 11.4% lower per case and 24.5% lower per day at public hospitals than at private hospitals. After adjusting for patient- and hospital-level confounders, public hospitals had a 1.62-fold higher in-hospital mortality rate, a 16.5% longer length of stay, and an 11.7% higher inpatient charge per case than private hospitals, although the charges of private hospitals were greater in univariate analysis. CONCLUSION: We recommend that government agencies and policy makers continue to monitor quality of care, lengths of stay in the hospital, and expenditures according to type of hospital ownership to improve healthcare outcomes and reduce spending.

Costos directos de atención médica de accidentes de tránsito en Bogotá D. C / Direct costs involved in providing medical attention associated with traffic accidents in Bogotá

Objetivo Determinar los costos de atención médica generados por la accidentalidad vial en Bogotá. Metodología Estudio observacional prospectivo con datos de pacientes mayores de edad atendidos en la central de urgencias de 6 instituciones hospitalarias. Resultados El promedio del costo totalde atención por paciente fue de $1'112.000 El costo promedio día de paciente hospitalizado fue de $1'200.000. Pacientes con atención ambulatoria tuvieron un costo promedio de $247.400. El costo promedio por accidente se calculó en $2'333.700. Los costos médicos por accidentes en el periodo de análisis en Bogotá fueron aproximadamente $2.301'028.200. Cifras en pesos de 2011. Conclusiones Los costos de la atención médica de los accidentes de tránsito constituyen una carga económica considerable.

Objective To determine the cost of medical attention associated with traffic accidents in Bogotá, Colombia. Methods Prospective observational study with data from adult patients attended to in the emergency centers of 6 hospitals. Results Average total cost per patient was $1'112.000 COP. Average daily cost of hospitalized patients was $1'200.000 COP. Average cost of ambulatory treated patients ascended to $247.400 COP. Cost per accident calculated was $2'333.700 COP. In the whole city during study period, total medical costs were around $2.301'028.200 COP. All data was expressed in 2011 Colombian pesos. Conclusion The medical cost of transit accidents is a significant economic burden.

Impacto económico de la resistencia a la meticilina en pacientes con bacteriemia por Staphylococcus aureus en hospitales de Bogotá / Economic burden of methicillin-resistant Staphylococcus aureus bacteremia in critical care patients in hospitals in Bogotá

Introducción. Las infecciones por microorganismos resistentes, especialmente las que involucran el torrente sanguíneo, se asocian a un mayor uso de recursos. Sus estimaciones son variables y dependen de la metodología utilizada. Staphylococcus aureus es el agente de sangre aislado con mayor frecuencia en nuestro medio. No existe información sobre el costo asociado con la atención de bacteriemias por S. aureus resistente a meticilina en nuestro país. Objetivo. Presentar una aproximación del costo de atención de las bacteriemias por S. aureus resistente a la meticilina en nueve hospitales de Bogotá. Materiales y métodos. Se incluyeron 204 pacientes en un estudio de cohortes multicéntrico en una razón de 1:1 según la resistencia. Se aproximaron los costos médicos directos con base en las facturas del período de hospitalización; en cuanto al período de la bacteriemia, los costos detallados se calcularon aplicando las tarifas estandarizadas. Resultados. No se encontraron diferencias significativas en las características clínicas y demográficas de los grupos, salvo en los antecedentes de la bacteriemia. El 53 % de los sujetos falleció durante la hospitalización. La estancia y el valor total facturado por la hospitalización fueron significativamente mayores en el grupo con bacteriemia por S. aureus resistente a la meticilina, así como los costos de la estancia en cuidados intensivos, de los antibióticos, los líquidos parenterales, los exámenes de laboratorio y la terapia respiratoria. El incremento crudo del costo de la atención asociado con la resistencia a meticilina fue de 31 % y, el ajustado, de 70 %. Conclusión. Este estudio constituye un respaldo a los tomadores de decisiones para la búsqueda y la financiación de programas de prevención de infecciones causadas por microorganismos resistentes.

Introduction: Resistant infections, especially those involving the bloodstream, are associated with a greater use of resources. Their estimates are variable and depend on the methodology used. Staphylococcus aureus is the main pathogen isolated in blood in our hospitals. There is no consolidated data about economic implications of methicillin-resistant S. aureus infection. Objective: To describe the cost of care of methicillin-resistant S. aureus bacteremia in a reference population from nine hospitals in Bogotá. Materials y methods: A multicenter cohort study included 204 patients in a 1:1 ratio according to resistance. Direct medical costs were calculated from hospitalization bills, while the bacteremia period was calculated by applying microcosting based on standard fares. Results: We found no significant differences between groups in demographic and clinical characteristics, except for resistance risk factors. Fifty-three percent of patients died during hospitalization. Hospital stay and total invoiced value during hospitalization were significantly higher in the group with methicillin-resistant S. aureus bacteremia. For this group, higher costs in ICU stay, antibiotics use, intravenous fluids, laboratory tests and respiratory support were recorded. A crude increase of 31% and an adjusted increase of 70% in care costs associated with methicillin resistance were registered. Conclusion: Our study supports decision makers in finding and funding infection prevention programs, especially those infections caused by resistant organisms.

Public private partnership in vascular surgery / Parceria público-privada em cirurgia vascular

Objective To describe and analyze the results of a public-private partnership between the Ministry of Health and a private hospital in a project of assistance and scientific research in the field of endovascular surgery. Methods: The flows, costs and clinical outcomes of patients treated in a the public-private partnership between April 2012 and July 2013 were analyzed. All patients underwent surgery and stayed at least one day at the intensive care unit of the private hospital. They also participated in a research protocol to compare two intravenous contrast media used in endovascular surgery (iodinated contrast and carbon dioxide). Results A total of 62 endovascular procedures were performed in 57 patients from the public healthcare system. Hospital and endovascular supplies expenses were significantly higher as compared to the amount paid by the Unified Health System (SUS - Sistema Único de Saúde) in two out of three disease groups studied. Among outpatients, the average interval between appointment and surgery was 15 days and, in hospitalized patients 7 days. All procedures were successful with no conversion to open surgery. The new contrast medium studied - carbon dioxide – was effective and cheaper. Conclusion The waiting time for patients between indication and accomplishment of surgery was significantly reduced. Public-private partnerships can speed up care of patients from public health services, and generate and improve scientific knowledge. .

Objetivo Descrever e analisar os resultados de parceria público-privada entre o Ministério da Saúde e um hospital privado em projeto de assistência e pesquisa científica na área de cirurgia endovascular. Métodos: Foram analisados fluxos, custos e resultados clínicos dos pacientes atendidos numa parceria público-privada entre abril de 2012 e julho de 2013. Todos os pacientes foram operados, ficaram pelo menos um dia na unidade de terapia intensiva do hospital privado e participaram de um protocolo de pesquisa para comparação entre dois contrastes endovenosos para cirurgia endovascular (contraste iodado e dióxido de carbono). Resultados Foram realizados 62 procedimentos endovasculares em 57 pacientes provenientes do sistema público. Os gastos hospitalares e com material endovascular mostraram-se significativamente maiores em relação ao que é pago pelo Sistema Único de Saúde (SUS) em dois dos três grupos de doenças estudados. Entre os pacientes ambulatoriais, o intervalo médio entre a consulta e a cirurgia foi de 15 dias e, nos internados, 7 dias. Todos os procedimentos foram bem sucedidos, sem conversão para cirurgia aberta. O novo contraste estudado, o dióxido de carbono, mostrou-se eficaz e mais barato. Conclusão O tempo de espera dos pacientes entre indicação cirúrgica e sua realização foi significativamente reduzido. Parcerias público-privadas podem trazer agilidade no atendimento dos pacientes do SUS, permitindo também geração de conhecimento científico. .

Desempenho hospitalar no Brasil: em busca da excelência / Hospital Performance in Brazil: The Search for Excellence

O livro retrata a situação da rede hospitalar no país, seja ela pública ou privada, e traz algumas recomendações para melhorar essa gestão. Entre as conclusões apontadas no livro está o fato da baixa governança dos hospitais públicos, com pouca autonomia e responsabilização dos gestores, com mecanismos de financiamento sem relação com os custos e não focados no desempenho.

Thai clinical laboratory responsible to economic crisis.

Nowadays, Thailand encounters a serious economic crisis. A clear consensus has been made that a cost-saving system must be the important tool. Both private and government organizations are engaged in this situation. We studied the cost-saving in the clinical laboratory. A questionnaire was distributed to 45 hospital laboratories located in Bangkok. Results showed that efforts to control the cost are the essential policy. There was a variety of factors contributing to the cost-saving process. The usage of public utility, non-recycle material and unnecessary utility were reconsidered. Besides, capital cost (wages and salary) personnel incentive are assessed. Forty three of the 45 respondents had attempted to reduce the cost via curtailing the unnecessary electricity. Eliminating the needless usage of telephone-call. water and unnecessary material was also an effective strategy. A reduction of 86.9%, 80 % and 80.0% of the mentioned factors respectively, was reported. An inventory system of the reagent, chemical and supplies was focused. Most of the laboratories have a policy on cost-saving by decreased the storage. Twenty eight of the 45 laboratories considered to purchase the cheaper with similar quality reagents instead. And some one would purchase a bulky pack when it is the best bargain. A specific system "contact reagent with a free rent instrument" has been used widely (33.3%). Finally, a new personnel management system has been chosen. Workload has rearranged and unnecessary extra-hour work was abandoned.

Conta hospitalar: análise crítica das definiçöes de diária e taxa de sala cirurgica / Hospital account: critical analysis of definitions of dayly expenses and rate of surgical room

Trata do problema da imprecisäo nas definiçöes de diária hospitalar e de taxa de sala cirúrgica praticas pelos hospitais no Brasil. Aponta a necessidade de se definir tais termos em razäo de aspectos administrativos, econômicos e jurídicos. Infere a possibilidade de melhoria da competitividade e da eficiência no setor saúde.

Intention of private hospitals to become contractors in the prepaid social security scheme in Thailand: why and why not?

The objective of the study was to examine whether private hospitals wanted be main contractors (MCs) under the social security scheme. Data were obtained from a cross-sectional survey of 94 private hospitals in Bangkok and its vicinity area conducted between August 1995 and May 1996 using in-person interview and hospital survey forms. The overall response rate was 88.3%. The results showed that some 46 hospitals (55%) expressed their intention to become MCs. However, nearly 40% of MCs in 1995 indicated that they really did not want to join the scheme while several non-MC hospitals said that they wanted to participate. The most prevalent justifications for the intention of the hospitals to become MCs, or not, were operational and marketing-related in nature. While the scheme was considered a profitable market opportunity by many, it affected hospital positioning. Participation in the scheme might also complicate health services delivery. Whether private hospitals wanted, or did not want, to become MCs was associated with ownership status (p = 0.001) and leading competitive strategies of the hospitals (p = 0.041).

Sistema Hospitalar / Hospital system

O objetivo desta análise é traçar, ao longo de 4 volumes, o perfil do setor hospitalar brasileiro, nos seguintes aspectos: histórico, forma de organizaçäo, relaçäo com os diversos setores e segmentos da economia (equipamentos, convênios médicos, mäo-de-obra, etc.) e aspectos legais relevantes. Neste volume I, aborda os seguintes pontos: - Introduçäo: apresentaçäo das principais características de organizaçäo do setor hospitalar, incluindo breve histórico de seu desenvolvimento e relaçäo com o setor de infra-estrutura do País (saneamento básico); - Estrutura: é descrita a estrutura dos serviços de saúde no País - com particular atençäo ao setor hospitalar -, perfil do sistema hospitalar conforme a natureza do prestador (instituiçöes públicas, privadas com ou sem fins lucrativos), distribuiçäo do número de leitos e gasto público per capta por regiäo; - Organizaçäo: o Sistema Unico de Saúde (SUS) e seu financiamento, hierarquizaçäo da atençäo à saúde, recursos; - Financiamento e investimentos: Banco Nacional de Desenvolvimento Econômico e Social (BNDES), Banco Mundial e BID; - Panorama internacional: Aborda os gastos mundiais com a saúde, além de traçar um perfil do setor nos Estados Unidos

Sistema Hospitalar / Hospital system

O objetivo desta análise é traçar ao longo de 4 volumes, o perfil do setor hospitalar brasileiro, nos seguintes aspectos: histórico, forma de organizaçäo, relaçäo com os diversos setores e segmentos da economia (equipamentos, convênios médicos, mäo-de-obra, etc.) e aspectos legais relevantes. Neste Volume III, säo abordados os seguintes pontos: - Introduçäo: definiçäo da instituiçäo, funçäo e atividade hospitalares; - Indicadores: principais indicadores da atividade hospitalar (qualidade, custos e econômico-financeiros); - Desempenho do setor: análise do conjunto de 49 hospitais, integrantes do Balanço Anual, da Gazeta Mercantil, entre 1990-97; - Perfil: perfil e desempenho de diversos hospitais

Produtividade em hospitais de acordo com alguns indicadores hospitalares / Hospital productivity in the light of hospital indicators

Dos equipamentos utilizados pela área de saúde para provisäo de cuidados assistenciais, os hospitais certamente säo preferidos tanto pela populaçäo como também pelos profissionais da área. Isto ocorre devido às facilidades e segurança que oferecem face à concentraçäo de recursos humanos e tecnológicos. Este fato, porém, representa custos elevados que devem ser amenizados com aumento da produtividade e da qualidade. Em relaçäo a aspectos como gestäo de qualidade, produtividade, dimensionamento de pessoal, aos poucos foram desenvolvidos os trabalhos no Brasil. Assim, foi realizada pesquisa que visa a conhecer a produtividade dos hospitais, utilizando-se de indicadores hospitalares como a média de permanência, índice de rotatividade, índice intervalo de substituiçäo, e também a relaçäo funcionários/leito e/ou cama

La medicina privada en México: resultados del Censo Nacional de Unidades Hospitalarias Privadas / Private medicine in Mexico: results from the National Census on Private Hospitalization Units

El objetivo de este estudio fue cuantificar los recursos de la medicina privada mediante un censo de unidades médicas con servicio de hospitalización, realizado en el primer trimestre de 1994 con base en la información jurisdiccional. Se registraron en todo el país 2 723 unidades médicas del sector privado con camas de hospitalización. En el Distrito Federal y los estados de México, Guanajuato, Michoacán, Baja California y Veracruz se concentra cerca de la mitad de las unidades. El total de camas censables registradas en el país de 33 937, de tal manera que la medicina privada es el principal proveedor de camas de hospitalización del Sistema Nacional de Salud; se encontraron resultados similares en cuanto al resto de recursos materiales humanos

A census of private health establishments was carried out by the Secretary of Health, in order to quantify its resources and to describe their geographical distribution. The census, conducted in 1994, was limited to private units which offered hospitalization services, and the reference period was the previous year. Results showed that there are 2 723 private hospitalization units in Mexico, and nearly a half of the units are concentrated in the Federal District, and the states of Mexico, Guanajuato, Michoacan, Baja California and Veracruz. The number of private hospitalization beds registered in the country are 33 937, these figures indicate that private medicine is the main hospital care provider in the national health system. Similar results were obtained regarding other material and human resources. It is important to stress the need for further research regarding the role of private medicine in Mexico, including aspects related to the quality of the services being provided.

A utilizaçäo dos custos hospitalares em hospitais paulistas: um estudo preliminar / The utilization of the hospital costs in hospitals of Säo Paulo: preliminary study

Objetivou-se conhecer as metodologias implementadas nos sistemas de apuraçäo de custos e o da utilizaçäo das informaçöes resultantes como instrumentos de gerenciamento hospitalar, foram estudados dois hospitais, um com finalidade lucrativa e outro sem finalidade lucrativa, localizados na cidade de Säo Paulo, Brasil. A pesquisa foi do tipo descritivo e de desenvolvimento metodológico. Os dados foram coletados através da observaçäo direta e de entrevistas semi-estruturadas com funcionários e dirigentes dos estabelecimentos investigados, utilizando-se dois roteiros. Para a determinaçäo dos custos, os hospitais pesquisados fazem uso do custeamento por absorçäo, obtendo um valor médio para os diferentes serviços prestados. As metodologias para a apuraçäo dos custos em ambas as instituiçöes é a da reduçäo escalar ou "step-down", similar à proposta pela Associaçäo Americana de Hospitais. No que se refere à utilizaçäo das informaçöes de custos pelas equipes gestoras, esta é limitada a nível do controle administrativo com pouca aplicaçäo nos aspectos estratégicos das instituiçöes