Costo efectividad y análisis de impacto presupuestario del óxido nítrico inhalatorio neonatal en un hospital, desde la perspectiva del sistema público de salud / Cost effectiveness and budget impact analysis of inhaled nitric oxide in a neonatal unit from the perspective of the public health system

El óxido nítrico inhalatorio (ONi) es actualmente la terapia de primera línea en la insuficiencia respiratoria hipoxémica grave del recién nacido; la mayor parte de los centros neonatales de regiones en Chile no cuentan con esta alternativa terapéutica. Objetivo: Determinar el costo-efectividad del ONi en el tratamiento de la insuficiencia respiratoria asociada a hipertensión pulmonar del recién nacido, comparado con el cuidado habitual y el traslado a un centro de mayor complejidad. Pacientes y método: Se modeló un árbol de decisiones clínicas desde la perspectiva del sistema de salud público chileno, se calcularon razones de costo-efectividad incremental (ICER), se realizó análisis de sensibilidad determinístico y probabilístico, se estimó el impacto presupuestario, software: TreeAge Health Care Pro 2014. Resultados: La alternativa ONi produce un aumento promedio en los costos de 11,7 millones de pesos por paciente tratado, con una razón de costo-efectividad incremental comparado con el cuidado habitual de 23 millones de pesos por muerte o caso de oxigenación extracorpórea evitada. Al sensibilizar los resultados por incidencia, encontramos que a partir de 7 casos tratados al año resulta menos costoso el óxido nítrico que el traslado a un centro de mayor complejidad. Conclusiones: Desde la perspectiva de un hospital regional chileno incorporar ONi en el manejo de la insuficiencia respiratoria neonatal resulta la alternativa óptima en la mayoría de los escenarios posibles.

Inhaled nitric oxide (iNO) is currently the first-line therapy in severe hypoxaemic respiratory failure of the newborn. Most of regional neonatal centres in Chile do not have this therapeutic alternative. Objective: To determine the cost effectiveness of inhaled nitric oxide in the treatment of respiratory failure associated with pulmonary hypertension of the newborn compared to the usual care, including the transfer to a more complex unit. Patients and method: A clinical decision tree was designed from the perspective of Chilean Public Health Service. Incremental cost effectiveness rates (ICER) were calculated, deterministic sensitivity analysis was performed, and probabilistic budget impact was estimated using: TreeAge Pro Healthcare 2014 software. Results: The iNO option leads to an increase in mean cost of $ 11.7 million Chilean pesos (€ 15,000) per patient treated, with an ICER compared with the usual care of $ 23 million pesos (€ 30,000) in case of death or ECMO avoided. By sensitising the results by incidence, it was found that from 7 cases and upwards treated annually, inhaled nitric oxide is less costly than the transfer to a more complex unit. Conclusions: From the perspective of a Chilean regional hospital, incorporating inhaled nitric oxide into the management of neonatal respiratory failure is the optimal alternative in most scenarios.

Economic problem of referred trauma cases in Siriraj Hospital.

To improve the service for referred trauma patients, the authors have to know the types of injury, the cost, and the reimbursement for each individual category. Therefore, the authors studied the characteristics of accident of patients transferred for treatment at Siriraj Hospital, including types of trauma (wounds), cost of treatment (excluding doctor's fees) and charges for treatments for each group. There were 678 trauma cases referred to the Division of Trauma Surgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital from 1st September 2002 to 31st August 2003 and of these, 571 cases were admitted From the admitted cases, the most common injury was the musculoskeletal system (38.6%), followed by nervous system injury (15.1%), eye injury (8.1%), toxic substance injury (6.3%), burns (5.8%), and others. The total cost of treatment was 36,249,150 baht. The reimbursement was 30,135,709 baht. There were four categories where the reimbursed amount was below the actual cost. They were burns, followed by nervous system injury, eye injury and skin or subcutaneous tissue injury. To deal with the referred cases in trauma center level I, the center should prepare to manage the common trauma groups such as musculoskeletal system injury, nervous system injury and eye injury. Burns, nervous system injury, eye injury and skin or subcutaneous tissue injuries are the major groups that cost more than the reimbursement amount. The reimbursement of these groups should be reconsidered in the future to solve the problem.

Neurological and neurosurgical referrals overseas from the Queen Elizabeth Hospital, Barbados, 1987-1996

This paper reports on neurological and neurosurgical referrals overseas from the Queen Elizabeth Hospital (QEH) for the period November 1987 to November 1996, and is a follow up to an earlier report for the period January 1984 to November 1987. It outlines the pattern of referral, diagnoses, referral centres and costs based on examination of the files of all QEH patients transferred overseas under a government aided scheme. There were 203 transfers of 191 patients (69 males, 122 females) including 10 patients who were transferred twice and one patient who was transferred three times. Patients' ages ranged from 1 to 80 years (mean 37 years). Twenty overseas centres were used during the period but most patients were transferred to Brooklyn Hospital, New York in 1988, Mount Sinai Medical Center, New York, between 1989 and 1994, and Hospital de Clinicas Caracas, Venezuela (1992 to 1996). 65of the referrals were for neurosurgery and 25were for magnetic resonance imaging scans for diagnosis. The largest diagnostic categories were central nervous system tumors (40) and subarachnoid haemorrhage (25). Estimated costs reached almost BDS$11 million, but the mean actual cost was BDS$63,916 based on information from 123 patient transfers. Thus, the actual total government expenditure was probably closer to BDS$13 million. This study demonstrates the urgent need to establish a neurosurgical service at the QEH and the cost effectiveness of doing so.