Oncology and Palliative Care Integration Model: A Cost Analysis Study in a Brazilian Hospital Setting.

Background: In 2019, the São Paulo State Cancer Institute (ICESP) implemented a novel model integrating Oncology with Palliative Care specialists. We evaluated the impact of this model on healthcare resource utilization and costs. Methods: We analyzed data from all patients who passed away in February (1 month prior to implementation) and November (8 months after model implementation group) at ICESP, Brazil. Healthcare utilization data, including emergency department visits, hospital and intensive care unit admissions, chemotherapy, and radiotherapy use, were retrieved from Electronic Medical Records. Unit cost values were obtained from the administrative database. Results: A total of 198 patients who died in February and 196 in November were included in the analysis. Groups exhibited similarities in sex, age, ECOG, cancer type, previous outpatient palliative care consultations, and place of death (ward: 56.6% pre-intervention, 50% post-intervention). The mean cost per patient was US$13,226.29 pre-intervention and US$11,445.82 post-intervention (P = .007). Statistically significant differences were noted in days hospitalized in the surgical ward (227 vs 115), emergency department visits (233 vs 45), chemotherapy sessions (140 vs 26), and radiotherapy sessions (146 vs 10). Excluding outpatient treatments, the total costs for chemotherapy and radiotherapy in the last 30 days of life were US$16,924.45 pre-intervention and US$7851.65 post-intervention. Reductions were more pronounced in patients with ECOG 3-4 (P = .039). Conclusion: Our data suggests that the integration model was associated with a reduction in potentially inappropriate treatments during the last month of life, leading to decreased healthcare utilization and costs.

Coronary atherosclerotic burden assessed by SYNTAX scores and outcomes in surgical, percutaneous or medical strategies: a retrospective cohort study.

INTRODUCTION: Coronary atherosclerotic burden and SYNTAX Score (SS) are predictors of cardiovascular events. OBJECTIVES: To investigate the value of SYNTAX scores (SS, SYNTAX Score II (SSII) and residual SYNTAX Score (rSS)) for predicting cardiovascular events in patients with coronary artery disease (CAD). DESIGN: Retrospective cohort study. SETTING: Single tertiary centre. PARTICIPANTS: Medicine, Angioplasty or Surgery Study database patients with stable multivessel CAD and preserved ejection fraction. INTERVENTIONS: Patients with CAD undergoing coronary artery bypass graft (CABG), percutaneous coronary intervention (PCI) or medical treatment (MT) alone from January 2002 to December 2015. PRIMARY AND SECONDARY OUTCOMES: Primary: 5-year all-cause mortality. Secondary: composite of all-cause death, myocardial infarction, stroke and subsequent coronary revascularisation at 5 years. RESULTS: A total of 1719 patients underwent PCI (n=573), CABG (n=572) or MT (n=574) alone. The SS was not considered an independent predictor of 5-year mortality in the PCI (low, intermediate and high SS at 6.5%, 6.8% and 4.3%, respectively, p=0.745), CABG (low, intermediate and high SS at 5.7%, 8.0% and 12.1%, respectively, p=0.194) and MT (low, intermediate and high SS at 6.8%, 6.9% and 6.5%, respectively, p=0.993) cohorts. The SSII (low, intermediate and high SSII at 3.6% vs 7.9% vs 10.5%, respectively, p<0.001) was associated with a higher mortality risk in the overall population. Within each treatment strategy, SSII was associated with a significant 5-year mortality rate, especially in CABG patients with higher SSII (low, intermediate and high SSII at 1.8%, 9.7% and 10.0%, respectively, p=0.004) and in MT patients with high SSII (low, intermediate and high SSII at 5.0%, 4.7% and 10.8%, respectively, p=0.031). SSII demonstrated a better predictive accuracy for mortality compared with SS and rSS (c-index=0.62). CONCLUSIONS: Coronary atherosclerotic burden alone was not associated with significantly increased risk of all-cause mortality. The SSII better discriminates the risk of death. TRIAL REGISTRATION NUMBER: ISRCTN66068876.

Health Economic Evaluations of Cancer in Brazil: A Systematic Review.

Background: A large number of health economic evaluation (HEE) studies have been published in developed countries. However, Brazilian HEE literature in oncology has not been studied. OBJECTIVE: To investigate whether the scientific literature has provided a set of HEE in oncology capable of supporting decision making in the Brazilian context. Methods: A systematic review was conducted to identify and characterize studies in this field. We searched multiple databases selecting partial and full HEE studies in oncology (1998-2013). Results: Fifty-five articles were reviewed, of these, 33 (60%) were full health economic evaluations. Type of cancers most frequently studied were: breast (38.2%), cervical (14.6%), lung (10.9%) and colorectal (9.1%). Procedures (47.3%) were the technologies most frequently evaluated. In terms of the intended purposes of the technologies, most (63.6%) were treatments. The majority of the incremental cost-effectiveness ratios (ICERs) reported have been below the cost-effectiveness threshold suggested by the World Health Organization (WHO). Conclusions: There has been an increase in the number of HEEs related to cancer in Brazil. These studies may support decision-making processes regarding the coverage of and reimbursement of healthcare technologies for cancer treatment in Brazil.

Internal Consistency of the SF-6D as a Health Status Index in the Brazilian Urban Population.

OBJECTIVES: To investigate the internal consistency of the SF-6D as a health status index in the Brazilian urban population. STUDY DESIGN: Cross-sectional population based study. METHODS: Five thousand individuals, older than the age of 15, were assessed in the five regions of the country. Two different methods of scoring the SF-6D where compared: "weighting the items" of the questionnaire through the Brazilian official weight coefficients, and "unweighting the items" through a parallel non preference scoring rule solely based on patients' answers to SF-6D health classification system (SF-6DHSI). Principal component factor analysis was used for the development of the SF-6DHSI. Pearson's, Spearman's, and intraclass correlation coefficients were used to assess the psychometric properties. RESULTS: The SF-6DHSI scoring formula summarized the pattern of factor loadings and the item-internal consistency (Cronbach's α = 0.858). The scale showed good item-internal consistency, exceeding the 0.70 standard. The association between weighted and unweighted (SF-6DHSI) scores was extremely high (Spearman's ρ = 0.971). The correlations of the SF-6DHSI with the Physical Component of the 12-Item Short-Form Health Survey (SF-12) and the Health Assessment Questionnaire was moderate to strong. The intraclass correlation coefficient obtained (0.917) also suggested that the concordance between the weighted and unweighted score distributions was prominent. CONCLUSIONS: A nonweighted approach to score the SF-6D provides a reliable global measure of health status. The SF-6D health classification system is useful for assessing quality of life in a large and representative sample of the Brazilian population.

Integrated care pathway for rectal cancer treatment: health care resource utilization, costs, and outcomes.

AIM: Managed Flow C20 (MFC20) is an integrated care pathway (ICP) for rectal cancer implemented at a public teaching hospital. This study aims to quantify resource utilization and estimate direct costs and outcomes associated with the use of this ICP. METHODS: We evaluated consecutive rectal cancer patients treated with neoadjuvant chemoradiotherapy (nCRT) followed by surgery, comparing the period before the ICP implementation (Pre-MFC20 group) and after (MFC20 group). We assessed times between treatment steps and quantified the resources utilized, as well as their costs. RESULTS: There were 112 patients in the Pre-MFC20 group and 218 in the MFC20 group. The mean treatment intervals were significantly shorter in the MFC20 group - from the first medical consultation to nCRT (48.3 vs. 87.5 days; P < 0.001); and from nCRT to surgery (14.8 vs. 23.0 weeks; P < 0.001) - as was the mean total treatment time (192.0 vs. 290.2 days; P < 0.001). Oncology consultations, computed tomography, MRI, and radiotherapy sessions were utilized more frequently in the Pre-MFC20 group (P < 0.001). The median per-patient cost was US$11 180.92 in the Pre-MFC20 group, compared with US$10 412.88 in the MFC20 group (P = 0.125). Daily hospital charges and consultations were the major determinants of the total cost of the treatment. There was no statistical difference in overall survival in the time periods examined. CONCLUSION:: Implementation of a rectal cancer ICP reduced all treatment intervals and promoted rational utilization of oncology consultations and imaging, without increment in per-patient costs or detrimental effects in overall survival.

Many Miles to Go: A Systematic Review of the State of Cost-Utility Analyses in Brazil.

BACKGROUND: Little is known about the quality and quantity of cost-utility analyses (CUAs) in Brazil. OBJECTIVE: The objective of this study was to provide a systematic review of published CUAs of healthcare technologies in Brazil. METHODS: We performed a systematic review of economic evaluations studies published in MEDLINE, EMBASE, LILACS (Latin American and Caribbean Health Sciences Literature), SciELO (Scientific Electronic Library Online), NHS EED (National Health Service Economic Evaluation Database), HTA (Health Technology Assessment) Database, Web of Science, Scopus, Bireme (Biblioteca Regional de Medicina), BVS ECOS (Health Economics database of the Brazilian Virtual Library of Health), and SISREBRATS (Sistema de Informação da Rede Brasileira de Avaliação de Tecnologias em Saúde [Brazilian Network for the Evaluation of Health Technologies]) from 1980 to 2013. Articles were included if they were CUAs according to the classification devised by Drummond et al. Two independent reviewers screened articles for relevance and carried out data extraction. Disagreements were resolved through discussion or through consultation with a third reviewer. We performed a qualitative narrative synthesis. RESULTS: Of the 535 health economic evaluations (HEEs) relating to Brazil, only 40 were CUAs and therefore included in the analysis. Most studies adhered to methodological guidelines for quality of reporting and 77.5% used quality-adjusted life-years (QALYs) as the health outcome. Of these studies, 51.6% did not report the population used to elicit preferences for outcomes and 45.2% used a specific population such as expert opinion. The preference elicitation method was not reported in 58.1% of these studies. The majority (80.6%) of studies did not report the instrument used to derive health state valuations and no publication reported whether tariffs (or preference weights) were national or international. No study mentioned the methodology used to estimate QALYs. CONCLUSIONS: Many published Brazilian cost-utility studies adhere to key recommended general methods for HEE; however, the use of QALY calculations is far from being the current international standard. Development of health preferences research can contribute to quality improvement of health technology assessment reports in Brazil.