Cost-Effectiveness of High, Moderate and Low-Dose Statins in the Prevention of Vascular Events in the Brazilian Public Health System / Efetividade de Estatinas em Dose Alta, Moderada e Baixa na Prevenção de Eventos Vasculares no SUS

Background: Statins have proven efficacy in the reduction of cardiovascular events, but the financial impact of its widespread use can be substantial. Objective: To conduct a cost-effectiveness analysis of three statin dosing schemes in the Brazilian Unified National Health System (SUS) perspective. Methods: We developed a Markov model to evaluate the incremental cost-effectiveness ratios (ICERs) of low, intermediate and high intensity dose regimens in secondary and four primary scenarios (5%, 10%, 15% and 20% ten-year risk) of prevention of cardiovascular events. Regimens with expected low-density lipoprotein cholesterol reduction below 30% (e.g. simvastatin 10mg) were considered as low dose; between 30-40%, (atorvastatin 10mg, simvastatin 40mg), intermediate dose; and above 40% (atorvastatin 20-80mg, rosuvastatin 20mg), high-dose statins. Effectiveness data were obtained from a systematic review with 136,000 patients. National data were used to estimate utilities and costs (expressed as International Dollars - Int$). A willingness-to-pay (WTP) threshold equal to the Brazilian gross domestic product per capita (circa Int$11,770) was applied. Results: Low dose was dominated by extension in the primary prevention scenarios. In the five scenarios, the ICER of intermediate dose was below Int$10,000 per QALY. The ICER of the high versus intermediate dose comparison was above Int$27,000 per QALY in all scenarios. In the cost-effectiveness acceptability curves, intermediate dose had a probability above 50% of being cost-effective with ICERs between Int$ 9,000-20,000 per QALY in all scenarios. Conclusions: Considering a reasonable WTP threshold, intermediate dose statin therapy is economically attractive, and should be a priority intervention in prevention of cardiovascular events in Brazil. .

Fundamento: Estatinas tem eficácia comprovada na redução de eventos cardiovasculares, mas o impacto financeiro de seu uso disseminado pode ser substancial. Objetivo: Conduzir análise de custo-efetividade de três esquemas de doses de estatinas na perspectiva do SUS. Métodos: Foi desenvolvido modelo de Markov para avaliar a razão de custo-efetividade incremental (RCEI) de regimes de dose baixa, intermediária e alta, em prevenção secundária e quatro cenários de prevenção primária (risco em 10 anos de 5%, 10%, 15% e 20%). Regimes com redução de LDL abaixo de 30% (ex: sinvastatina 10mg) foram considerados dose baixa; entre 30-40% (atorvastatina 10mg, sinvastatina 40mg), dose intermediária; e acima de 40% (atorvastatina 20-80 mg, rosuvastatina 20 mg), dose alta. Dados de efetividade foram obtidos de revisão sistemática com aproximadamente 136.000 pacientes. Dados nacionais foram usados para estimar utilidades e custos (expressos em dólares internacionais - Int$). Um limiar de disposição a pagar (LDP) igual ao produto interno bruto per capita nacional (aproximadamente Int$11.770) foi utilizado. Resultados: A dose baixa foi dominada por extensão nos cenários de prevenção primária. Nos cinco cenários, a RCEI da dose intermediária ficou abaixo de Int$10.000 por QALY. A RCEI de dose alta ficou acima de Int$27.000 por QALY em todos os cenários. Nas curvas de aceitabilidade de custo-efetividade, dose intermediária teve probabilidade de ser custo-efetiva acima de 50% com RCEIs entre Int$9.000-20.000 por QALY em todos os cenários. Conclusões: Considerando um LDP razoável, uso de estatinas em doses intermediárias é economicamente atrativo, e deveria ser intervenção prioritária na redução de eventos cardiovasculares no Brasil. .

Aspectos clínicos e socioeconômicos das dislipidemias em portadores de doenças cardiovasculares / Clinical and socioeconomic aspects of dyslipidemia in patients with cardiovascular diseases

O presente artigo aborda os aspectos clínicos e socioeconômicos decorrentes da presença de dislipidemias em portadores de doenças cardiovasculares (DCV). Existem inúmeros estudos relacionados às DCV, uso de hipolipemiantes orais como as estatinas, e os aspectos econômicos envolvidos com impacto na área da saúde. Além de evidenciar a importância do tratamento das dislipidemias, o artigo busca demonstrar o ponto de vista farmacoeconômico, ou seja, dos custos gerados com o tratamento farmacológico desta patologia versus os custos decorrentes dos eventos cardiovasculares acometidos e suas consequências. Existe, portanto, relevante relação entre os impactos sociais decorrentes de incapacidade física e laborativa, aposentadorias precoces, entre outros custos importantes que poderiam ser evitados com uma análise econômica abrangente e eficiente realizada nos serviços de saúde do Brasil. Neste contexto, é enfatizada a importância da análise conjunta dos aspectos clínicos e socioeconômicos das dislipidemias que poderiam influenciar nas decisões das autoridades de saúde no momento da elaboração de protocolos clínicos de tratamentos farmacológicos a serem implementados no SUS.

This paper discusses the clinical and socioeconomic factors arising from the presence of dyslipidemia in patients with cardiovascular disease (CVD). There are numerous studies related to CVD, oral use of statins as statins, and the economics aspects involved with an impact on health. In addition to demonstrating the importance of the treatment of dyslipidemia, the paper shows the pharmacoeconomic viewpoint, i.e. costs generated by the pharmacological treatment of this disease versus the costs of cardiovascular events and their consequences. There is therefore relevant relationship between the social impacts arising from physical disability and work, early retirements, among other important costs that could be avoided with a comprehensive economic analysis and efficient health services in Brazil. In this context, we emphasize the importance of joint analysis of the clinical and socioeconomic aspects of dyslipidemia that could influence the decisions of health authorities at the time of preparation of clinical protocols of pharmacological treatments to be implemented within the SUS.

Rheumatic fever and rheumatic heart disease: primary prevention is the cost effective option.

OBJECTIVE: To measure the economic output/input ratios for the various options of prevention of rheumatic fever/rheumatic heart disease (RF/RHD) and check the viability of primary prevention vis-à-vis secondary and tertiary preventions. METHODS: Cost accounting of the various prevention options was calculated for each variable as available in literature. Actual data as obtainable for the financial year ending March 2006 were computed for the Pondicherry population. Both direct and indirect costs (including community/social costs) were worked out using mostly primary data and wherever necessary, secondary data. Certain scientific assumptions were used where exact data was not available. RESULTS: Primary prevention is the definite viable economic option (1:1.56) compared to secondary (1: 1.07) and tertiary (1: 0.12) preventions. In fact, the current stress on only secondary and tertiary preventions is found to be economically unviable. CONCLUSION: It is postulated that primary prevention as a practical policy in tackling RF and RHD can be recommended.

Prevención del cáncer colorrectal (CCR) / Prevention of colorectal cancer

Colorectal cancer (CRC) is the second leading cause of cancer death in Argentina. The cumulative lifetime risk of developing CRC for both men and women is 4-6%. Despite advances in the management of this disease, the 5-year survival rate is about 60% because only 35% of patients are diagnosed when the disease is localized. Risk factors for CRC include age, diet and life style factors, personal or family history of adenomas or CRC and personal history of inflammatory bowel disease. Scientific evidence shows that primary and secondary prevention, through screening programs, permit to reduce incidence and mortality significantly. Chemopreventive agents, including nonsteroidal antiinflammatory drugs, folate, and calcium, have been shown to have some preventive effect. Physical inactivity and excess body weight are consistent risk factors for CRC. Tobacco exposure, diet high in red meat and low in vegetables and alcohol consumption, probably in combination with a diet low in folate, appear to increase risk. The dietary fiber and risk of CRC has been studied but the results are still inconclusive. Screening for CRC is cost-effective compared with no screening, but a single optimal strategy cannot be determined from the currently available data. The advantages and disadvantages or limitations of screening modalities for CRC are analyzed. The literature and clinical practice guidelines are reviewed, with an emphasis on advances and evolving screening methods and recommendations for patients with average, moderate and high-risk CRC.

El cáncer colorrectal (CCR) ocupa el segundo lugar en mortalidad por tumores malignos en Argentina. Elriesgo de padecer un CCR a través de toda la vida es de 4-6%. A pesar de los avances en el tratamiento, la sobrevidaa 5 años del CCR se ubica en el 60% debido a que sólo el 35% de los pacientes tienen enfermedadlocalizada en el momento del diagnóstico. Los factores de riesgo incluyen la edad, dieta y estilo de vida, historia personal o familiar de adenomas o CCR y antecedentes de enfermedad inflamatoria intestinal. La evidenciacientífica permite señalar que la prevención primaria y secundaria a través de programas de pesquisapermitiría reducir la incidencia y la mortalidad significativamente. Agentes quimiopreventivos, como los antiinflamatorios no esteroideos, ácido fólico y calcio han mostrado algún efecto preventivo. El sedentarismoy el exceso de peso son convincentes factores de riesgo de CCR. El tabaco, una dieta rica en carnes rojas,pobre en vegetales y el consumo de alcohol, probablemente en combinación con una reducción de la ingestade ácido fólico, parecen incrementar el riesgo de CCR. La relación entre la ingesta de fibra y el riesgo deCCR ha sido largamente estudiada pero los resultados no son aún concluyentes. La pesquisa del CCR es costoefectivacomparada con su no realización. Se analizan las ventajas y desventajas o limitaciones de las diferentes estrategias. La literatura y las distintas normativas fueron revisadas evaluando los avances, nuevos métodosy recomendaciones para personas con riesgo promedio, moderado y alto.

Análisis de costo efectividad de un programa preventivo de enfermedad vesicular en Chile / Cost effectiveness analysis of a screening program for gallbladder disease in Chile

Background. Chilean women have one of the highest mortality rates from gallstone disease in the world. There is no primary prevention for the disease and the benefits of prophylactic cholecystectomy in high risk groups have not been studied. Aim: To analyze the cost and effectiveness of a screening program for gallbladder disease in the Chilean women population. Methods. A decision analytic model is used to compare lifetime cost and effectiveness of standard care with three screening strategies. The first two strategies consider "universal ultrasound screening" for all women 40 years old and laparoscopic cholecystectomy for those with gallstones ("elective intervention") or with calculous ü3 cm ("high risk intervention"). The third strategy is based on "selective screening" for obese women. Results. The lifetime probability of a 40 years old Chilean woman of dying from gallbladder disease is reduced by 70 percent in the universal screening/elective intervention, by 63 percent in the high risk intervention and by 18 percent in the selective screening strategy. Her lifetime expectancy increases by 5.25, 4.64 and 1.24 months respectively. The incremental cost-effectiveness ratio of each screening strategy is US$ 180, US$ 147 and US$ 481 respectively. Conclusion. A screening program for gallbladder disease in a high risk population achieves significant benefits at a low incremental cost and acceptable cost-effectiveness

Primary prophylaxis of variceal bleeding in liver cirrhosis: failure to learn from past experience.

In patients with cirrhosis of liver, variceal bleeding is the most serious complication, with a mortality of up to 50%. Primary prophylaxis of variceal bleeding with shunt surgery or endoscopic variceal sclerotherapy was attempted and then abandoned, as higher rates of complications and mortality were observed. Endoscopic variceal ligation is now being recommended for primary prophylaxis in some centers, as it has fewer complications than sclerotherapy. But this has been done with inadequate evaluation of the cost-effectiveness of variceal ligation. Propranolol therapy is also being widely used for a selected group of patients (large varices with cherry red spots), despite its several limitations and side effects, to reduce frequency of bleeding but without improving survival. Is primary prophylaxis of variceal bleeding cost-effective? The cost involved needs to be accurately assessed in different countries.

Economic analysis of malaria control for migrant workers in eastern Thailand.

A randomized, double-blind field trial was carried out to compare the economic impact of permethrin-treated nets with that of untreated nets as a method of malaria control. The study was conducted in 261 long-term migrant workers and 138 seasonal agricultural migrant workers in the eastern rural areas known to be highly endemic for multidrug-resistant Plasmodium falciparum infection. One hundred and twenty-six longterm migrants and 59 seasonal migrants used treated nets, while 135 and 79, respectively, used untreated nets. The impregnated-nets program was cost-saving as well as offering improved effectiveness. The net benefit of using a treated net was US$1.17 per worker from the Malaria Division's perspective and US$1.61 per worker from the worker viewpoint. The use of impregnated nets with large-scale primary health care programs likely will be the most cost-effective and cost-beneficial method for controlling malaria in eastern Thailand.

On the economic analysis of response to preventive measures

A efetividade de muitas intervençöes preventivas depende da capacidade do paciente em alterar seu comportamento ou estilo de vida. Säo intervençöes nas quais o indivíduo exerce um papel ativo. Procurou-se mostrar como o instrumental econômico pode ser usado para: (i) prever comportamentos e descrever sua lógica; e (ii) avaliar medidas de prevençäo que, por implicarem mudança de comportamento, geram "custos" em termos de queda na qualidade de vida (Apêndice). O caso do fumo e doença coronariana do coraçäo é utilizado como ilustraçäo. Enquanto a análise do primeiro ítem utiliza técnicas gráficas, a do segundo (Apêndice) utiliza-se de um modelo mais formal, porém simples (de livro-texto) para a representaçäo de utilidade ao longo do ciclo de vida. Mostrou-se também que técnicas freqüentemente utilizadas na avaliaçäo de programas de saúde como os "QALYs" ("Quality-Adjusted Life Years" ou Anos de Vida Qualitativamente Ajustado) säo inadequados para programas preventivos voltados à alteraçäo de comportamento. Säo sugeridos alguns tópicos que necessitam de investigaçäo mais profunda