The Economic Burden of Heart Conditions in Brazil / Os Custos das Doenças Cardíacas no Brasil

Abstract Background: Heart conditions impose physical, social, financial and health-related quality of life limitations on individuals in Brazil. Objectives: This study assessed the economic burden of four main heart conditions in Brazil: hypertension, heart failure, myocardial infarction, and atrial fibrillation. In addition, the cost-effectiveness of telemedicine and structured telephone support for the management of heart failure was assessed. Methods: A standard cost of illness framework was used to assess the costs associated with the four conditions in 2015. The analysis assessed the prevalence of the four conditions and, in the case of myocardial infarction, also its incidence. It further assessed the conditions' associated expenditures on healthcare treatment, productivity losses from reduced employment, costs of providing formal and informal care, and lost wellbeing. The analysis was informed by a targeted literature review, data scan and modelling. All inputs and methods were validated by consulting 15 clinicians and other stakeholders in Brazil. The cost-effectiveness analysis was based on a meta-analysis and economic evaluation of post-discharge programs in patients with heart failure, assessed from the perspective of the Brazilian Unified Healthcare System (Sistema Unico de Saude). Results: Myocardial infarction imposes the greatest financial cost (22.4 billion reais/6.9 billion USD), followed by heart failure (22.1 billion reais/6.8 billion USD), hypertension (8 billion reais/2.5 billion USD) and, finally, atrial fibrillation (3.9 billion reais/1.2 billion USD). Telemedicine and structured telephone support are cost-effective interventions for achieving improvements in the management of heart failure. Conclusions: Heart conditions impose substantial loss of wellbeing and financial costs in Brazil and should be a public health priority.

Resumo Fundamento: As doenças cardíacas impõem limitações à qualidade de vida nos aspectos físicos, sociais, financeiros e de saúde no Brasil. Objetivos: Este estudo avaliou o custo de quatro importantes doenças cardíacas no Brasil: hipertensão, insuficiência cardíaca, infarto do miocárdio e fibrilação atrial. Além disso, avaliou a relação de custo-efetividade de telemedicina e suporte telefônico estruturado para o manejo de insuficiência cardíaca. Métodos: Um custo padrão da estrutura de enfermidade foi usado para avaliar os custos associados às quatro condições em 2015. Analisou-se a prevalência das quatro doenças e, em caso de infarto do miocárdio, também sua incidência. Avaliaram-se ainda as despesas associadas ao tratamento, a perda de produtividade a partir da redução do emprego, os custos do fornecimento de assistência formal e informal e o bem-estar perdido referentes às condições. A análise teve por base uma revisão de literatura-alvo, varredura de dados e modelagem. Todos os inputs e métodos foram validados por 15 clínicos consultores e outras partes interessadas no Brasil. A análise de custo-efetividade baseou-se em uma meta-análise e uma avaliação econômica de programas após a alta de pacientes com insuficiência cardíaca, considerados a partir da perspectiva do Sistema Único de Saúde do Brasil. Resultados: Infarto do miocárdio acarretou o mais alto custo financeiro (R$ 22,4 bilhões/6,9 bilhões de dólares), seguido de insuficiência cardíaca (R$ 22,1 bilhões/6,8 bilhões de dólares), hipertensão (R$ 8 bilhões/2,5 bilhões de dólares) e, finalmente, fibrilação atrial (R$ 3,9 bilhões/1,2 bilhão de dólares). Telemedicina e suporte telefônico estruturado são intervenções custo-efetivas para o aprimoramento do manejo da insuficiência cardíaca. Conclusões: As doenças cardíacas determinam substanciais custos financeiros e perda de bem-estar no Brasil e deveriam ser uma prioridade de saúde pública.

Caracterização dos padrões de variação dos cuidados de saúde a partir dos gastos com internações por infarto agudo do miocárdio no Sistema Único de Saúde / Characterization of the variation of health care taking into account the costs of hospital admissions for acute myocardial infarction in Brazilian Unified Health System

RESUMO: Introdução: O cenário epidemiológico mundial revela um crescimento das doenças cardiovasculares, no qual se destaca o infarto agudo do miocárdio (IAM), devido à sua grande magnitude e severidade. No Brasil, doenças coronarianas representam já cerca de 5% dos gastos com internação hospitalar. Objetivo: Caracterizar as internações dos pacientes do Sistema Único de Saúde (SUS) por IAM por meio da identificação de agrupamentos sugeridos por uma análise de agrupamentos tradicional e por uma análise de correspondência múltipla (ACM). Métodos: Registros do Sistema de Internações Hospitalares (SIH/SUS) com diagnóstico principal de IAM, no Estado do Rio de Janeiro, 2002, foram selecionados e posteriormente relacionados aos do Sistema de Informações sobre Mortalidade (SIM/SUS). A seguir, uma ACM e uma métrica chamada distância de tolerância foram utilizadas para a identificação de clusters , sendo a variável de interesse "gastos com internação" classificada em duas categorias (acima e abaixo de R$ 905,00). Resultados: Foi possível associar "maiores gastos" com "utilização de Centro de Tratamento Intensivo (CTI)" e com "gravidade moderada do caso", e "menores gastos" com "gravidade leve" e "não utilização de CTI". Por outro lado, casos de alta gravidade apresentaram-se isolados, sem associação com CTI ou outras variáveis. Também foi detectada associação entre a categoria "menores gastos" e as categorias: "não deslocamento do paciente", "sexo feminino", "idade entre 56 e 75 anos", "óbito até 30 dias" e "óbito até 1 ano". Conclusão: o aspecto isolado dos casos de maior gravidade e a associação entre "óbitos" e "menores gastos" sugere que os recursos tecnológicos disponíveis durante a internação por IAM não estão sendo adequadamente empregados.

ABSTRACT: Introduction: The global epidemiologic scenario indicates an increase in cardiovascular disease rates, with special emphasis on acute myocardial infarction (AMI), owing to its large magnitude and severity. In Brazil, coronary diseases now account for about 5% of hospital admission expenditures. Objective: To characterize the admissions in the Brazilian Unified Health System of patients with AMI, by identifying clusters suggested by a traditional cluster analysis and by a multiple correspondence analysis (MCA). Methods: The records of the Hospital Information System/Brazilian Unified Health System with a primary diagnosis of AMI in the State of Rio de Janeiro, Brazil, 2002, were selected and subsequently related to the records of the Mortality Information System. Next, an MCA and a metric called the tolerance distance were used for cluster identification. The variable of interest was "hospital expenditures", classified into two categories (above and below BRL 905). Results: "Higher costs" were associated with "use of the Intensive Care Unit (ICU)" and "moderate severity of the case" and "lower costs" with "low severity" and "nonuse of the ICU". On the other hand, high severity cases, with no apparent association with "use of ICU" or other categories. Other associations identified were "lower costs" and "no displacement of the patient," "female," "age between 56 and 75 years," "death within 30 days," and "death within 1 year". Conclusions: The nonclustered characteristic of the most serious cases and the association between "deaths" and "lower costs" suggests that the technological resources available during hospitalization for AMI are not being properly used.

Costo efectividad de un programa de rehabilitación cardiovascular para personas post infarto agudo al miocardio: un análisis teórico / Cardiovascular rehabilitation program in post myocardial infarction: a theoretical analysis of cost effectiveness

Pese a que la efectividad de los programas de prevención secundaria en pacientes con enfermedades cardiovasculares (ECV) ha sido ampliamente demostrada, su implementación tanto Chile como a nivel internacional ha sido pobre. Objetivo: Determinar la tasa costo-efectividad de una propuesta teórica de Programa de Rehabilitación cardiovascular (PRC) basada en la evidencia y validada por expertos, en personas post Infarto Agudo al Miocardio (IAM) en el nivel secundario de atención en salud, pertenecientes al Servicio de Salud Metropolitano Norte, Región Metropolitana. Método: Se elaboró un protocolo teórico de un PRC integral basado en las guías clínicas internacionales (AHA, AACVPD, NICE, ESC, NHMRC, Victoria), ajustado a la realidad chilena, el cual fue costeado. Luego se estimó los años de vida por muerte prematura con y sin participación en un PRC, para obtener finalmente los Años de Vida Ganados (AVG). Con ello se calculó la tasa de costo-efectividad. Resultados: El costo anual del centro de rehabilitación cardíaca es de $64.407.065 CLP. La Razón Incremental de Costo Efectividad (ICER), considerando una reducción de la mortalidad tardía del 25%, es de CLP$475.209,72/AVG. Valor que al ser menor al Producto Interno Bruto per cápita, se considera como una intervención muy costo efectiva. Conclusión: Un programa de rehabilitación cardiaca integral post-IAM parece muy costo-efectivo.

Although the effectiveness of secondary prevention programs in patients with cardiovascular disease (CVD) has been widely demons-trated, its implementation both in Chile and other countries has been scarce. Aim: To determine the cost-effectiveness of an evidence-based theoretical comprehensive cardiac rehabilitation (CCR), validated by experts, for post-acute myocardial infarction (AMI) patients at the secondary level from the Chilean Public Health System. Methods: A theoretical protocol of a CCR program based on recommendations from international guidelines (AHA, AACVPD, NICE, ESC, NHMRC, Victoria) was elaborated and adjusted to the Chilean conditions. A cost analysis was performed. Life years due to premature death were estimated with and without participation in the cardiac rehabilitation program (CRP). We obtained gained life-years, and calculated the ratio of cost-effectiveness. Results: The annual cost of the cardiac rehabilitation center is $ 64,407,065 CLP. The Incremental Cost Effectiveness Ratio (ICER) considering a reduction in late mortality of 25%, is CLP$475.209,72/ AVG. Since it is less than one per capita gross domestic product, it is considered as a very cost-effective intervention. Conclusion: A comprehensive cardiac rehabilitation program post AMI is very cost-effective for use in a in public health service. It should be considered to review Optimal frequency and intensity of exercise in order to achieve optimal results should be determined.

Há relação entre custos hospitalares e tempo porta-balão? / Is there an association between hospital costs and door-to-balloon time?

O tempo porta-balão (TPB) tornou-se uma medida de desempenho e é foco de iniciativas de melhoria da qualidade assistencial. Este estudo teve como objetivo avaliar a relação entre o TPB e seu impacto nos custos de internação hospitalar. Métodos: Pacientes tratados com intervenção coronária percutânea primária, entre 2008 e 2013, foram divididos de acordo com o TPB < ou ≥ 90 minutos. Todos os custos registrados na alta hospitalar foram ajustados por meio do Índice de Variação de Custos Médico-Hospitalares.Resultados: Foram incluídos 141 pacientes, agrupados em TPB < 90 minutos (n = 77) e TPB ≥ 90 minutos(n = 64). Os TPB foram 64,0 ± 14,1 minutos e 133,8 ± 35,2 minutos, respectivamente. Não foram observadasdiferenças nos desfechos clínicos entre os grupos. Os custos foram de R$ 34.883,24 ± 27.749,46, sendo ocusto médio para TPB < 90 minutos de R$ 33.194,24 ± 27.387,61, e para TPB ≥ 90 minutos, de R$ 36.947,58± 28.267,80 (p = 0,43). Os custos, segundo a artéria culpada, foram de R$ 29.588,53 ± 16.358,85 para acoronária direita; R$ 48.494,62 ± 44.015,04 para a circunflexa; e de R$ 34.016,96 ± 26.503,94 paraa descendente anterior. Houve diferença entre os custos dos procedimentos relativos à artéria circunflexacomparados aos da coronária direita ou da descendente anterior (p = 0,01), mas não houve diferença entre os custos relativos à coronária direita, comparados à descendente anterior (p = 0,68). Conclusões: Não houve diferença nos custos hospitalares, no âmbito da saúde suplementar, quando os grupos foram divididos de acordo com o TPB. Os desfechos clínicos foram semelhantes, e foi encontrada uma diferença de custos em pacientes com a artéria circunflexa culpada...

Door-to-balloon time (DBT) has become a measure of performance and is the focus in quality of care improvement initiatives. This study aimed to evaluate the association between DBT and its impacton hospital costs. Methods: Patients treated with primary percutaneous coronary intervention between 2008 and 2013 were divided according to the DBT < or ≥ 90 minutes. All costs recorded at hospital discharge were adjusted bythe Medical-Hospital Cost Variation Index. Results: A total of 141 patients were included, grouped as DBT < 90 minutes (n = 77) and DBT ≥ 90 minutes(n = 64). DBT was 64.0 ± 14.1 minutes and 133.8 ± 35.2 minutes, respectively. There were no diferences in clinical outcomes between the groups. The costs were R$ 34,883.24 ± 27,749.46, with the mean cost for DBT < 90 minutes being R$ 33,194.24 ± 27,387.61 and the cost for DBT ≥ 90 minutes R$ 36,947.58 ±28,267.80 (p = 0.43). The costs, according to the culprit artery, were R$ 29,588.53 ± 16,358.85 for the rightcoronary artery; R$ 48,494.62 ± 44,015.04 for the left circumflex artery; and R$ 34,016.96 ± 26,503.94 forthe left anterior descending artery. There was a difference between the costs of procedures related to theleft circumflex artery when compared to the right coronary or left anterior descending arteries (p = 0.01),but there was no difference between the costs related to the right coronary, when compared to the left anterior descending artery (p = 0.68). Conclusions: There was no difference in hospital costs regarding the private health insurance, when the groups were divided according to the DBT. Clinical outcomes were similar and a difference in costs wasfound for patients with the circumflex artery as the culprit vessel...

The Association of Socioeconomic Status with Three-Year Clinical Outcomes in Patients with Acute Myocardial Infarction Who Underwent Percutaneous Coronary Intervention

The aim of this study was to evaluate whether the clinical outcomes were associated with socioeconomic status (SES) in patients with acute myocardial infarction (AMI) who underwent percutaneous coronary intervention (PCI). The author analyzed 2,358 patients (64.9 +/- 12.3 yr old, 71.5% male) hospitalized with AMI between November 2005 and June 2010. SES was measured by the self-reported education (years of schooling), the residential address (social deprivation index), and the national health insurance status (medical aid beneficiaries). Sequential multivariable modeling assessed the relationship of SES factors with 3-yr major adverse cardiovascular events (MACEs) and mortality after the adjustment for demographic and clinical factors. During the 3-yr follow-up, 630 (26.7%) MACEs and 322 (13.7%) all-cause deaths occurred in 2,358 patients. In multivariate Cox proportional hazards regression modeling, the only lower education of SES variables was associated with MACEs (hazard ratio [HR], 1.41; 95% confidence interval [CI], 1.04-1.91) and mortality (HR, 1.93; 95% CI, 1.16-3.20) in the patients with AMI who underwent PCI. The study results indicate that the lower education is a significant associated factor to increased poor clinical outcomes in patients with AMI who underwent PCI.

Use of Drug-eluting Stents Versus Bare-metal Stents in Korea: A Cost-minimization Analysis Using Population Data / 예방의학회지

OBJECTIVES: The goal of this study was to perform an economic analysis of a primary stenting with drug-eluting stents (DES) compared with bare-metal stents (BMS) in patients with acute myocardial infarction (AMI) admitted through an emergency room (ER) visit in Korea using population-based data. METHODS: We employed a cost-minimization method using a decision analytic model with a two-year time period. Model probabilities and costs were obtained from a published systematic review and population-based data from which a retrospective database analysis of the national reimbursement database of Health Insurance Review and Assessment covering 2006 through 2010 was performed. Uncertainty was evaluated using one-way sensitivity analyses and probabilistic sensitivity analyses. RESULTS: Among 513 979 cases with AMI during 2007 and 2008, 24 742 cases underwent stenting procedures and 20 320 patients admitted through an ER visit with primary stenting were identified in the base model. The transition probabilities of DES-to-DES, DES-to-BMS, DES-to-coronary artery bypass graft, and DES-to-balloon were 59.7%, 0.6%, 4.3%, and 35.3%, respectively, among these patients. The average two-year costs of DES and BMS in 2011 Korean won were 11 065 528 won/person and 9 647 647 won/person, respectively. DES resulted in higher costs than BMS by 1 417 882 won/person. The model was highly sensitive to the probability and costs of having no revascularization. CONCLUSIONS: Primary stenting with BMS for AMI with an ER visit was shown to be a cost-saving procedure compared with DES in Korea. Caution is needed when applying this finding to patients with a higher level of severity in health status.

Custos da cadeia de procedimentos no tratamento do infarto agudo do miocárdio em hospitais brasileiros de excelência e especializados / Costs of the chain of treatment procedures in acute myocardial infarction in Brazilian reference and specialized hospitals

OBJETIVO: Apresenta a metodologia e os resultados de uma pesquisa de campo para avaliar os custos da cadeia de procedimentos para tratamento do Infarto Agudo do Miocárdio (IAM), realizada em 11 hospitais brasileiros de excelência e especializados. MÉTODOS: A apuração do custo utilizou o sistema de custo por procedimento e o sistema por patologia. Os procedimentos associados ao tratamento do IAM foram organizados com sua sequência lógica (protocolos), dando origem a um fluxograma. Os instrumentos de coleta da pesquisa contemplavam informações relativas aos preços e as quantidades (particular, convênios, tabela SUS e Associação Médica Brasileira - AMB), praticados no ano de 2008, bem como os custos pertinentes. RESULTADOS: De forma geral, o custo total dos procedimentos que integram o "tratamento-padrão" do IAM, totalizou R$ 12.873,69 se a intervenção coronária percutânea (ICP) não envolver utilização de stent. Caso este se torne necessário, o custo se eleva para R$ 23.461,87. CONCLUSÃO: Entre os resultados obtidos destacam-se: o fato de os valores dos procedimentos mais caros não apresentarem variações estatísticas significativas entre os hospitais, independentemente de sua localização, clientela predominante ou natureza jurídica; e o fato de os hospitais, que tratam predominantemente de usuários do Sistema Único de Saúde, registrar custos menores, mas não estatisticamente significativos, para toda a cadeia de procedimentos associada à patologia.

OBJECTIVE: To present the methodology and the results of a field survey to assess the chain costs of procedures for treatment of acute myocardial infarction (AMI), carried out in 11 Brazilian reference and specialized hospitals. METHODS: The cost assessment used the cost per procedure and per pathology systems. The procedures associated with the treatment of AMI were organized and their logical sequence (protocols) was used to create a flowchart. Data collection tools gathered information on prices and quantities in 2008 (private, health insurance, SUS, and Brazilian Medical Association - AMB price lists), as well as the applicable costs. RESULTS: Overall, the total cost of the procedures involving the 'standard treatment' of AMI was R$ 12,873.69, if percutaneous coronary intervention (PCI) did not involve stent use. If the stent becomes necessary, the cost increases to R$ 23,461.87. CONCLUSION: Among the results, we emphasize the fact that the costs of the more expensive procedures did not present statistically significant variations between hospitals, regardless of their location, predominant clientele or legal nature, and the fact that hospitals that treat predominantly users of the Brazilian Unified Health System registered the lowest costs, albeit not statistically significant regarding the entire chain of procedures associated with the pathology.

The Socioeconomic Burden of Coronary Heart Disease in Korea / 예방의학회지

OBJECTIVES: We aimed to estimate the annual socioeconomic burden of coronary heart disease (CHD) in Korea in 2005, using the National Health Insurance (NHI) claims data. METHODS: A prevalence-based, top-down, cost-of-treatment method was used to assess the direct and indirect costs of CHD (International Classification of Diseases, 10th revision codes of I20-I25), angina pectoris (I20), and myocardial infarction (MI, I21-I23) from a societal perspective. RESULTS: Estimated national spending on CHD in 2005 was 2.52 billion dollar . The majority of the spending was attributable to medical costs (53.3%), followed by productivity loss due to morbidity and premature death (33.6%), transportation (8.1%), and informal caregiver costs (4.9%). While medical cost was the predominant cost attribute in treating angina (74.3% of the total cost), premature death was the largest cost attribute for patients with MI (66.9%). Annual per-capita cost of treating MI, excluding premature death cost, was 3183 dollar, which is about 2 times higher than the cost for angina (1556 dollar). CONCLUSIONS: The total insurance-covered medical cost (1.13 billion dollar) of CHD accounted for approximately 6.02% of the total annual NHI expenditure. These findings suggest that the current burden of CHD on society is tremendous and that more effective prevention strategies are required in Korea.

Costo institucional del infarto agudo del miocardio en en el Instituto de Cardiología y Cirugía Cardiovascular / Institutional cost of acute myocardial infarction at the Institute of Cardiology and Cardiovascular Surgery

Mejorar los indicadores de salud es una tarea de toda la sociedad, donde se impone el control y el empleo racional de los recursos en el sistema de salud. Determinar el costo institucional del infarto agudo del miocardio en los pacientes atendidos en el Instituto de Cardiología y Cirugía Cardiovascular en el año 2006. Se realizó un estudio retrospectivo, del tipo de descripción de costos. El enfoque metodológico utilizado fue el costo de la enfermedad. Los costos se clasificaron como costos directos, totales y promedios o costos unitarios. Los costos fueron expresados en pesos cubanos no convertibles del año 2006. La perspectiva de análisis adoptada fue la institucional. El universo de estudio estuvo constituido por 88 pacientes. En el cálculo del costo total institucional se consideraron las siguientes variables: costo por medicamentos, por medios diagnósticos, por salarios, por materiales de curación y por otros servicios. El costo total institucional de la atención del paciente con infarto agudo del miocardio fue de 470 273,92 pesos cubanos, con un costo unitario según días / paciente de 508,95 pesos cubanos y un costo promedio según número de pacientes de 5 344,02 pesos. El costo total de la atención del paciente con infarto agudo del miocardio para el Instituto de Cardiología y Cirugía cardiovascular estuvo dado fundamentalmente por el tiempo dedicado a la atención del paciente, la cantidad de profesionales y técnicos altamente calificados necesarios en el manejo de la enfermedad, y los tratamiento empleados.

To improve the health indicators is the whole society´s task in which the control and rational use of resources allocated to the health care system are necessary. To determine the institutional cost of the acute myocardial infarction affecting patients who are cared for by the Institute of Cardiology and Cardiovascular Surgery in 2006. A retrospective cost description-type study was conducted. The methodological approach was the cost of disease. These costs were classified into direct, total and average/unit costs and given in inconvertible Cuban pesos for the year 2006. The analysis perspective was institutional. The universe of study was composed by 88 patients. The calculation of the total institutional cost took into consideration the following variables: drug cost, diagnostic means cost, salary cost, curing materials cost and other services cost. The total institutional cost of the care to a patient with acute myocardial infarction was 470 272,92 Cuban pesos, with a unit cost per day/patient of 508,95 pesos and an average cost per number of patients of 5 344,02 pesos. The total cost of care to a patient with acute myocardial infarction for the Institute of Cardiology and Cardiovascular Surgery was fundamentally represented by the length of time devoted to care for the patient, the number of required highly qualified professionals and technicians to manage the disease and the therapies used.

Custo-efetividade da trombólise pré-hospitalar vs intra-hospitalar no infarto agudo do miocárdio / Cost-effectiveness of prehospital versus inhospital thrombolysis in acute myocardial infarction

FUNDAMENTO: Existe evidência de que a trombólise pré-hospitalar melhora os desfechos no infarto agudo do miocárdio (IAM) com supradesnivelamento do segmento ST. OBJETIVO: Comparar as relações de custo-efetividade entre trombólise pré-hospitalar e trombólise intra-hospitalar para o IAM com supradesnivelamento do segmento ST, pela perspectiva do Sistema Único de Saúde. MÉTODOS: Modelo analítico de decisão foi utilizado para comparar as duas estratégias. O desfecho do estudo foi "anos de vida ganhos". O uso de recursos e os custos foram estimados pela perspectiva do Sistema Único de Saúde. Árvore de decisão e modelo de Markov foram construídos com resultados de ensaios clínicos publicados. Os custos foram valorados em real (R$), para o ano de 2005. RESULTADOS: Para um horizonte de tempo de vinte anos, a expectativa de vida média com a trombólise pré-hospitalar foi de 11,48 anos e a trombólise intra-hospitalar proporcionou expectativa de vida média de 11,32 anos. Os custos foram de R$ 5.640,00 para a trombólise pré-hospitalar e de R$ 5.816,00 para a trombólise intra-hospitalar. Houve custo adicional de R$ 176,00 por paciente com a trombólise intra-hospitalar. A trombólise pré-hospitalar proporcionou adicional de 0,15 ano de expectativa de vida comparado à trombólise intra-hospitalar. CONCLUSÃO: Esse modelo sugere que, pela perspectiva do Sistema Único de Saúde, implementar a trombólise pré-hospitalar para o IAM com supradesnivelamento do segmento ST pode representar sobrevida extra e menor custo que comparativamente à trombólise intra-hospitalar.

BACKGROUND: There is evidence that prehospital thrombolysis improves the outcome in ST-elevation myocardial infarction (STEMI). OBJECTIVE: This study aimed at comparing the cost-effectiveness of prehospital compared to inhospital thrombolysis for STEMI from the National Health System perspective. METHODS: A decision-analytic model was used to compare these two strategies. The study endpoint was life-years gained. Resource use and costs were estimated from the National Health System perspective. The Decision tree and Markov Model were constructed using the results of published clinical trials. Costs were expressed in Reais (R$), for the year 2005. RESULTS: For a time horizon of 20 years, prehospital thrombolysis had an average life expectancy of 11.48 years and inhospital thrombolysis had an average life expectancy of 11.32 years. Costs were R$ 5,640 for prehospital thrombolysis and R$ 5,816 for inhospital thrombolysis. Inhospital thrombolysis led to an additional cost of R$ 176 per patient. Pre-hospital thrombolysis led to additional 0.15 years of life-expectancy gain compared with inhospital thrombolysis. CONCLUSION: This model suggests that, from the National Health System perspective, implementing prehospital thrombolysis for ST-elevation myocardial infarction (STEMI) may lead to extra survival and fewer costs when compared to inhospital thrombolysis.

Uso de la estreptoquinasa recombinante cubana. Atencion de enfermeria / The therapeutic use of Cuban recombinat streptokinase. Nursing care

Se realizan estudios y aplicacion de agentes tromboliticos en las primeras horas de diagnosticado e instalado el infarto, con el objetivos de recuperar la reperfusion coronaria y preservar el musculo cardiaco. Se analiza el empleo de la estreptoquinasa recombinante cubana (heberkinasa) en esta, que es la cuarta investigacion sobre ella y su aplicacion en los pacientes infartados (AUU