Dados de mundo real no processo de tomada de decisão: uma análise sob a perspectiva do sistema brasileiro de saúde suplementar / Real-world evidence in decision-making process: analysis from the Brazilian private healthcare system perspective

O debate sobre a necessidade de melhoria da utilização de recursos em saúde fez aumentar o interesse em evidências do mundo real (EMR) nos últimos anos. No sétimo congresso Latino-Americano da Sociedade Internacional de Farmacoeconomia e Pesquisa de Desfechos, diferentes palestrantes exploraram como o manejo desses dados pode auxiliar no processo de tomada de decisão. Quatro membros representando diferentes segmentos do Sistema de Saúde Suplementar (SSS) brasileiro foram convidados a participar de um painel de especialistas, a fim de entender suas percepções sobre o assunto. O nível de confiança na informação atualmente disponível variou entre 70% e 90% e os dados são utilizados na rotina de tomada de decisão. Considerando a utilização de evidências para prever decisões, os especialistas relatam não existir uma matriz institucional, mas que as informações existentes são utilizadas na construção de modelos preditivos por meio da criação de pacotes de serviços. A priorização da tomada de decisão é hoje essencialmente baseada em estimativas de custos. Apesar disso, são observadas diferentes situações em que dados de mundo real podem balizar esse processo. Existiu consenso de que uma mudança de paradigmas está ocorrendo e que esses processos representam um futuro plausível. O uso de EMR é de grande importância no processo de tomada de decisão na perspectiva do SSS e, acima de tudo, no suporte de modelos de saúde baseados em valor, sendo recomendado pela Agência Nacional de Saúde Suplementar como um pilar estratégico para a sustentabilidade do sistema.

The debate about the needs for healthcare resource utilization improvement has been soaring during the last years. As a result, discussions on enhancements of the decision-making process through the leverage of real-world evidence (RWE) has also been fostered. In the 7th Latin American congress of the International Society for Pharmacoeconomics and Outcomes Research, different speakers explored how the management of these data support real-life healthcare decisions. Four members representing different segments from the Brazilian Supplementary Healthcare System (SHS) were invited to participate on an expert panel in order to understand their perceptions on this subject. The confidence level on available data ranges from 70% to 90% and information is used on decision-making routine. When the use of real-world evidence to predict decision was considered, panelists reported the absence of an institutional decision matrix, but that existing information is used to build predictive models through the creation of service packages. The prioritization of decision-making today is essentially based on the estimation of costs. However, different situations in which real-world data can guide this process are observed. There was a consensus on a paradigm shift ongoing and that these processes represent a plausible future. The use of RWE is of great importance on decision-making process from the SHS perspective and, above all, in a support of value-based healthcare model which is recommended by Brazilian private agency (ANS) as the strategic pillar to system sustainability

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.

Higher MELD score increases the overall cost on the waiting list for liver transplantation: a micro-costing analysis based study / Altos valores de MELD aumentam o custo total em lista de espera para o transplante hepático. Um estudo de microcusteio

ABSTRACT BACKGROUND: The pre-transplant period is complex and includes lots of procedures. The severity of liver disease predisposes to a high number of hospitalizations and high costs procedures. Economic evaluation studies are important tools to handle costs on the waiting list for liver transplantation. OBJECTIVE: The objective of the present study was to evaluate the total cost of the patient on the waiting list for liver transplantation and the main resources related to higher costs. METHODS: A cost study in a cohort of 482 patients registered on waiting list for liver transplantation was carried out. In 24 months follow-up, we evaluated all costs of materials, medicines, consultations, procedures, hospital admissions, laboratorial tests and image exams, hemocomponents replacements, and nutrition. The total amount of each resource or component used was aggregated and multiplied by the unitary cost, and thus individual cost for each patient was obtained. RESULTS: The total expenditure of the 482 patients was US$ 6,064,986.51. Outpatient and impatient costs correspond to 32.4% of total cost (US$ 1,965,045.52) and 67.6% (US$ 4,099,940.99) respectively. Main cost drivers in outpatient were: medicines (44.31%), laboratorial tests and image exams (31.68%). Main cost drivers regarding hospitalizations were: medicines (35.20%), bed use in ward and ICU (26.38%) and laboratorial tests (13.72%). Patients with MELD score between 25-30 were the most expensive on the waiting list (US$ 16,686.74 ± 16,105.02) and the less expensive were those with MELD below 17 (US$ 5,703.22 ± 9,318.68). CONCLUSION: Total costs on the waiting list for liver transplantation increased according to the patient's severity. Individually, hospitalizations, hemocomponents reposition and hepatocellular carcinoma treatment were the main cost drivers to the patient on the waiting list. The longer the waiting time, the higher the total cost on list, causing greater impact on health systems.

RESUMO CONTEXTO: O período pré-transplante é complexo e inclui grande quantidade de procedimentos. A gravidade da doença hepática predispõe a um alto número de internações e procedimentos de alto custo. Estudos em avaliação econômica são uma importante ferramenta para o manejo dos custos em lista de espera para o transplante hepático. OBJETIVO: O objetivo do presente estudo foi avaliar o custo total do paciente em lista de espera para o transplante hepático e os principais recursos relacionados ao alto custo. MÉTODOS: Foi realizado um estudo de coorte em 482 pacientes registrados em lista de espera para o transplante hepático. Os pacientes foram acompanhados por um período de 24 meses, no qual foram avaliados todos os custos de materiais, medicamentos, consultas, procedimentos internações, exames laboratoriais e de imagem, reposição de hemocomponentes e nutrição recebida. A quantidade total de cada recurso e componente utilizado foi obtida e multiplicada pelo seu valor unitário e, desta maneira, o custo individual de cada paciente foi obtido. RESULTADOS: O total gasto pelos 482 pacientes foi de US$ 6.064.986,51. Os custos ambulatoriais corresponderam a 32,4% do total (US$ 1.965.045,52) e os custos em internação corresponderam a 67,6% do total (US$ 4.099.940,99). Os principais determinantes do custo em ambulatório foram: medicamentos (44,31%) e exames laboratoriais e de imagem (31,68%). Os principais determinantes de custo em internações foram: medicamentos (35,20%), utilização do leito em enfermaria e em UTI (26,38%) e exames laboratoriais (13,72%) Pacientes com valores de MELD entre 25-30 foram os de maiores custos em lista de espera (US$ 16.686,74 ± 16,105.02) e os de menor custo foram os pacientes com MELD abaixo de 17 (US$ 5.703,22 ± 9.318,68). CONCLUSÃO: O custo total em lista de espera para o transplante hepático aumenta de acordo com a gravidade do paciente. Individualmente, internações, reposição de hemocomponentes e o tratamento do paciente com carcinoma hepatocelular são os principais determinantes de custo para os pacientes em lista de espera para o transplante hepático. Quanto maior o tempo de espera, maiores serão os custos em lista, causando maior impacto nos sistemas de saúde.