Preventing glaucoma progression using the trabecular micro-bypass implant iStent inject®. A cost-effectiveness analysis / Prevenindo a progressão do glaucoma por meio do implante de by-pass trabecular iStent inject®. Uma análise de custo-efetividade

ABSTRACT Objective To assess the economic impact of reducing glaucoma progression by using the trabecular micro-bypass implant, iStent inject®, in the Reference Centers for glaucoma treatment within the Brazilian Public Unified Health System (SUS). Methods In a cost-effectiveness analysis, a Markov model was developed, and the costs were obtained from the SUS perspective (medical direct costs). Effectiveness was measured in progression-free life-years. The time horizon was the mean life expectancy of the Brazilian population. The model parameters were obtained through a review and a critical analysis of the literature. The base case comprised a hypothetical cohort of patients with open-angle glaucoma, using anti-glaucoma eye drops and followed up at Reference Centers of SUS. We tested whether the incorporation of iStent inject® as an alternative second-line therapy would be cost-effective. The outcome measure was the incremental cost-effectiveness ratio (R$/progression-free life-years). We tested the robustness of the model by univariate and probabilistic sensitivity analyses. Results The use of iStent inject® led to decreased progression rate of glaucoma, evidenced by the amount of progression-free life-years obtained with each treatment strategy (7.82 progression-free life-years with iStent inject® versus 6.33 progression-free life-years with medical treatment), thereby improving glaucoma control. There was also a reduction in future costs associated with eye drops, filtering surgeries, and treatment complications. Incremental cost-effectiveness ratio ranged from R$ 6,429.30 to R$ 7,550.97/progression-free life-years. The model proved to be robust in the sensitivity analyses. Conclusion This analysis showed that iStent inject®, when used after the failure of the first-line therapy, is able to reduce the rate of glaucoma progression at an acceptable cost.

RESUMO Objetivo Avaliar o impacto econômico da redução da progressão do glaucoma pelo uso do implante de by-pass trabecular iStent inject® no ambiente dos Centros de Referência para tratamento do Sistema Único de Saúde (SUS). Métodos Em uma análise de custo-efetividade, elaborou-se um modelo de Markov, cujos custos foram obtidos a partir da perspectiva do SUS financiador (custos médicos diretos). A efetividade foi medida em anos de vida livres de progressão. O horizonte temporal foi a expectativa de vida média da população brasileira. Os parâmetros do modelo foram obtidos pela revisão e pela análise crítica da literatura. O caso base foi composto de uma coorte hipotética de portadores de glaucoma de ângulo aberto em uso de colírios antiglaucomatosos e em acompanhamento nos Centros de Referência do SUS. Testou-se se a incorporação do iStent inject® como alternativa à segunda linha de tratamento seria custo-efetiva. A medida de desfecho foi a razão de custo-efetividade incremental (R$/anos de vida livres de progressão). A robustez do modelo foi testada por meio de análises de sensibilidade univariada e probabilística. Resultados A utilização do iStent inject® proporcionou uma diminuição da velocidade de progressão do glaucoma, evidenciada pela quantidade de anos de vida livres de progressão obtida com cada estratégia de tratamento (7,82 anos de vida livres de progressão com iStent inject® versus 6,33 anos de vida livres de progressão com tratamento com colírios), melhorando, dessa forma, o controle do glaucoma. Houve ainda redução nos custos futuros associados aos colírios, às cirurgias filtrantes e às complicações do tratamento. A razão de custo-efetividade incremental variou de R$6.429,30 a R$7.550,97/anos de vida livres de progressão. O modelo mostrou-se robusto nas análises de sensibilidade. Conclusão O iStent inject®, quando usado após a falha do primeiro medicamento, é capaz de reduzir a taxa de progressão do glaucoma a um custo aceitável.

Custo-efetividade do uso do dispositivo de by-pass trabecular (iStent® Trabecular MicroBypass) associado a cirurgia de catarata para o tratamento conjunto do glaucoma primário de ângulo aberto e da catarata sob a perspectiva do Sistema de Saúde Suplementar no Brasil / Cost-effectiveness of using the trabecular by-pass device (iStent® Trabecular Micro-Bypass) combined with cataract surgery for the treatment of primary open-angle glaucoma and cataract from the Supplementary Health System perspective in Brazil

Objetivo: Avaliar se a incorporação do implante trabecular iStent® Trabecular Micro-Bypass é custo- -efetiva para o tratamento do glaucoma primário de ângulo aberto (GPAA) em pacientes que serão submetidos a cirurgia de catarata sob a perspectiva do Sistema de Saúde Suplementar no Brasil. Métodos: Foi elaborado um modelo analítico de Markov, cujos custos foram obtidos a partir da perspectiva da saúde suplementar brasileira (custos médicos diretos). A efetividade foi medida em "anos de vida livres de progressão (PFLY)". O horizonte temporal foi a expectativa de vida média da população brasileira. Os dados foram obtidos por meio da revisão e da análise crítica da literatura. O caso base foi: portadores de GPAA e catarata submetidos a cirurgia de catarata isolada e manutenção do uso de colírios antiglaucomatosos. Testou-se se a incorporação do iStent® Trabecular Micro-Bypass nesse cenário seria custo-efetiva. A medida de desfecho foi a razão de custo-efetividade incremental (RCEI: R$/PFLY). Realizou-se análise de sensibilidade univariada e probabilística para testar a robustez do modelo. Resultados: A incorporação do iStent® Trabecular Micro-Bypass gera um aumento dos custos inicialmente, mas melhora o controle da doença, tornando o glaucoma estável por mais tempo e diminuindo os custos futuros relacionados à progressão da doença. A RCEI foi de R$ 5.491,99/PFLY. O modelo mostrou-se robusto nas análises de sensibilidade. Conclusão: Esta análise sugere que a incorporação do implante iStent® Trabecular Micro-Bypass combinado com a cirurgia de catarata seria custo-efetiva para o tratamento conjunto da catarata e do GPAA no cenário da saúde suplementar no Brasil.

Objective: To evaluate whether the incorporation of the iStent® Trabecular Micro-Bypass implant is cost-effective for the treatment of primary open-angle glaucoma (POAG) in patients undergoing cataract surgery from the perspective of the supplementary healthcare system in Brazil. Methods: An analytical Markov model was developed and costs were obtained from the Brazilian supplementary health perspective (direct medical costs). Effectiveness was measured in "progression free life years (PFLY)". The time horizon was the average life expectancy of the Brazilian population. Data were obtained through review and critical analysis of the literature. The base case was: glaucomatous patients with cataract who underwent isolated cataract surgery and continued use of antiglaucomatous eye drops. We tested whether incorporating iStent® Trabecular Micro-Bypass in this scenario would be cost effective. The outcome measure was the incremental cost-effectiveness ratio (ICER: R$/PFLY). We performed univariate and probabilistic sensitivity analyses to test the robustness of the model. Results: Incorporating the iStent® Trabecular Micro-Bypass increases initial costs but improves disease control, making glaucoma stable longer and reducing future costs due to disease progression. The ICER was R$ 5,491.99/PFLY. The model was robust in sensitivity analyses. Conclusion: This analysis suggests that the incorporation of the iStent® Trabecular Micro-Bypass combined with cataract surgery would be cost-effective for joint cataract and POAG treatment in the supplementary health setting in Brazil.

Análise do impacto econômico da falta de suplementação multivitamínica em mulheres em idade reprodutiva e suas consequências em recém-nascidos / Analysis of the economic impact of lack of vitamin supplementation on women at childbearing age and the repercussions on the newborns

Objetivo: Avaliar o impacto econômico da falta de suplementação multivitamínica de mulheres no período reprodutivo e suas consequências em recém-nascidos, por meio da estimativa do número de casos e dos custos implicados no tratamento de complicações decorrentes da falta de suplementação, sob a perspectiva do sistema público de saúde. Métodos: A população foi definida a partir do número de gestantes e nascidos vivos no Brasil, ajustado para o ano de 2019, e de pessoas que utilizam exclusivamente o SUS, considerando um crescimento linear. Por meio de revisão de literatura, os riscos de desenvolvimento de defeitos do fechamento do tubo neural, pré-eclâmpsia e anemia foram determinados. Para a estimativa dos custos diretos médicos, realizou-se um microcusteio com base na utilização de recursos determinados por condutas médicas estabelecidas e opiniões de especialistas. A ocorrência de eventos e os respectivos custos foram calculados multiplicando o número de indivíduos pelo risco de desenvolvimento das complicações e os custos individuais pela quantidade de eventos. Resultados: O custo total da falta de suplementação vitamínica foi estimado em 2,47 bilhões de reais. A falta de suplementação vitamínica seria capaz de gerar a ocorrência anual de 5.352, 796.283, 298.801 e até 345.628 casos de defeitos do fechamento do tubo neural, anemia, parto prematuro e pré-eclâmpsia, respectivamente. Conclusões: A ausência de suplementação vitamínica pode gerar um custo anual de até 2,47 bilhões de reais para o sistema público de saúde brasileiro, com ocorrência de pelo menos 796 mil casos de complicações decorrentes por ano

Objective: To evaluate the economic impact of the absence of vitamin supplementation in women at childbearing age and the consequences in the newborns by estimating the number of cases and costs involved in the treatment in perspective of the Brazilian public health system. Methods: The number of pregnant and live births in Brazil was considered, adjusted for 2019 considering a linear growth. Through literature review, the risk of development of neural tube defects, pre-eclampsia and anemia was determined. For the estimation of direct medical costs, a micro costing was performed based on the use of resources determined by established medical conduct and expert opinions. Events occurrence and their costs were calculated by multiplying the number of individuals by the risk of developing complications and individual costs by the number of events. Results: Total cost of vitamin supplementation absence in this group was estimated at 2.47 billion Brazilian real (BRL). The absence of vitamin supplementation would be able to generate annually 5,352, 796,283, 298,801, and up to 345,628 cases of neural tube closure defects, anemia, preterm delivery and preeclampsia, respectively. Conclusions: The lack of vitamin supplementation can generate an annual cost of 2,47 billion BRL for the Brazilian public health system with at least 796,000 cases of complications arising per year

Cost effectiveness analysis of plasma genotyping versus tumor genotyping in detection of advanced non-small-cell lung cancer with epidermal growth factor receptor and T790M mutation under the Brazilian private healthcare system perspective / Custo-efetividade do uso da biópsia líquida versus biópsia tecidual para detecção de câncer de pulmão de não pequenas células avançado com receptor do fator de crescimento epidérmico e mutação T790M sob a perspectiva do sistema suplementar de saúde do Brasil

Objective: Comparing the costs and effectiveness of plasma genotyping versus tumor genotyping for detecting the T790M mutation in advanced non-small cell lung cancer (NSCLC) with a mutation in the epidermal growth factor receptor (EGFR) and that progressed after use of an EGFR tyrosine kinase inhibitor (EGFR-TKI), from the perspective of the private healthcare system in Brazil. Methods: Patients with a post-EGFR-TKI T790M mutation are eligible for a second-line treatment with a third-generation EGFR-TKI (osimertinib). In order to estimate the costs associated with the diagnosis method for the T790M mutation, a decision tree model has been used. Resource use was estimated by a team of experts, and the direct costs were estimated based on official databases. Results: Plasma genotyping provided a R$391 reduction per patient, due to the reduced cost with complications; it prevented 40.96% of the patients from undergoing an invasive procedure and 31.91% of the patients from having any kind of complication. Conclusion: Data found support a new paradigm for treating the resistance to EGFR-TKIs, with plasma genotyping as the first diagnostic choice, what can help to define the treatment and to reduce the costs of Brazilian private healthcare system.

Objetivo: Comparar os custos e efetividade da biópsia líquida versus biópsia tecidual para detecção da mutação T790M no câncer de pulmão de não pequenas células (CPNPC) avançado com mutação no receptor do fator de crescimento epidérmico (EGFR) e que progrediram após o uso de um inibidor do sítio da tirosina cinase associada ao EGFR (EGFR-TKI), sob a perspectiva do sistema suplementar de saúde do Brasil. Métodos: Pacientes com mutação EGFR-T790M pós-EGFR-TKI são elegíveis ao tratamento de segunda linha com um EGFR-TKI de terceira geração (osimertinibe). Para a estimativa dos custos relacionados ao método de diagnóstico de mutação T790M, foi elaborado um modelo de árvore de decisão. A utilização de recursos foi estimada por painel de especialistas e os custos diretos foram estimados utilizando-se bases de dados oficiais. Resultados: A biópsia líquida proporcionou redução de R$ 391 por paciente, devido a uma redução no custo com complicações; evitou que 40,96% dos pacientes passassem por um procedimento invasivo e que 31,95% dos pacientes tivessem algum tipo de complicação. Conclusão: Os dados observados embasam um novo paradigma para o manejo da resistência aos EGFR-TKIs, com genotipagem pelo plasma como primeira opção diagnóstica, o que pode auxiliar na melhor definição do tratamento e reduzir custos ao sistema de saúde suplementar brasileiro.

Impacto econômico do mieloma múltiplo no sistema privado de saúde do Brasil / The economic impact of multiple myeloma in the Brazilian private health care system

Objetivos: Avaliar o impacto econômico do mieloma múltiplo (MM) no sistema privado de saúde brasileiro. Métodos: A base de dados Orizon, uma base administrativa para fins de reembolso contendo dados de pacientes que realizaram procedimentos médicos em ambiente hospitalizar e ambulatorial, foi analisada retrospectivamente de jan./2013 a ago./2016. A base incluiu pacientes que foram diagnosticados com MM (CID-10 C90.0) durante o período de tempo mencionado e todos os procedimentos subsequentes realizados pelo paciente após o diagnóstico. Foram utilizados como critério de elegibilidade pacientes com MM tratados entre jan./2013 e jun./2015, com acompanhamento de pelo menos 365 dias, tendo pelo menos um registro durante esse período. Os desfechos foram expressos em custos médicos diretos (CMD) por paciente/ano, calculados como a soma dos gastos médicos por paciente divididos por pacientes-ano, por um período máximo de 12 meses. Os CMDs foram categorizados em exames, procedimentos, medicamentos (incluindo quimioterapia e outros tratamentos) e outros custos (materiais, gases medicinais, pacotes e taxas diversas). Foram conduzidas análises adicionais para quimioterapia e internações. Resultados: Dos 1.332 pacientes com MM, 973 atenderam ao critério de elegibilidade, sendo incluídos na análise. O CMD total foi de R$ 124.144 por paciente-ano, do qual R$ 66.757 (54%) são relacionados a medicamentos, R$ 45.474 (37%) a internações e R$ 11.912 (10%) a outros custos ambulatoriais. Um total de 3.050 internações foi identificado em 741 (76%) pacientes, com custo médio de R$ 23.151 por internação. Conclusões: O tratamento do MM representa impacto econômico significativo para operadoras de saúde. Custos de medicamentos e internações representam 90% do custo total.

Objectives: To evaluate the economic impact of multiple myeloma (MM) in the Brazilian private health care system. Methods: The Orizon database, an administrative claims database containing inpatient and outpatient data, was retrospectively analyzed from Jan/2013 to Aug/2016. The database included patients who had been diagnosed with MM (ICD-10 C90.0) during the aforementioned timeframe and all subsequent procedures performed by the patient after the diagnosis. Eligibility criteria were patients with MM (ICD-10 code C90.0) treated between Jan/2013 and Jun/2015, who were followed by at least 365 days (1 year) and had at least one claim during this period. Outcome was direct medical costs (DMC) per patient-year, calculated as the sum of the medical claims for each patient included in the analysis divided by total patient-years, for a maximum period of 12-months. DMC was categorized in exams, procedures, medications (including chemotherapy and other medications) and other cost (materials, medicinal gases, packages and others costs). Further analysis was conducted for chemotherapy and hospitalizations. Results: From 1,332 patients with MM identified in the database, 973 met the eligibility criteria and were included in the analysis. Total DMC in this population was R$ 124,144 per patient-year, from which R$ 66,757 (54%) were related to medications, R$ 45,474 (37%) to hospitalizations and R$ 11,912 (10%) to other outpatient costs. A total of 3,050 hospitalizations were identified in 741 (76%) patients, with an average cost of R$ 23,151 per hospitalization. Conclusions: Patients with MM represent a significant economic burden to private payers. Drugs and hospitalization costs accounts for 90% of the total costs.

Can hydrophilic coated catheters be beneficial for the public healthcare system in Brazil? - A cost-effectiveness analysis in patients with spinal cord injuries

ABSTRACT Introduction Detrusor sphincter dyssynergia affects 70% to 80% of all spinal cord injury patients, resulting in increased risk of urinary tract infections (UTIs) and potential exposure to antimicrobial resistance. In Brazil, local guidelines recommend intermittent catheterization as the best method for bladder emptying, and two catheter types are available: the conventional uncoated PVC and the hydrophilic coated catheters. Objective To evaluate the cost-effectiveness of two types of catheters for intermittent catheterization from the perspective of the Brazilian public healthcare system. Materials and Methods A Markov model was used to evaluate cost-effectiveness in those with spinal cord injuries. A primary analysis was conducted on all possible adverse events, and a secondary analysis was performed with urinary tract infections as the only relevant parameter. The results were presented as cost per life years gained (LYG), per quality-adjusted life years (QALY) and per number of urinary tract infections (UTIs) avoided. Results The base scenario of all adverse events shows a cost-effective result of hydrophilic coated catheters compared to uncoated PVC catheters at 57,432 BRL (Brazilian Reais) per LYG and 122,330 BRL per QALY. The secondary scenario showed that the use of hydrophilic coated catheters reduces the total number of UTIs, indicating that an additional cost of hydrophilic coated catheters of 31,240 BRL over a lifetime will reduce lifetime UTIs by 6%. Conclusions Despite the higher unit value, the use of hydrophilic coated catheters is a cost-effective treatment from the perspective of the Brazilian public healthcare system.

Can hydrophilic coated catheters be beneficial for the public healthcare system in Brazil? - A cost-effectiveness analysis in patients with spinal cord injuries.

INTRODUCTION: Detrusor sphincter dyssynergia affects 70% to 80% of all spinal cord injury patients, resulting in increased risk of urinary tract infections (UTIs) and potential exposure to antimicrobial resistance. In Brazil, local guidelines recommend intermittent catheterization as the best method for bladder emptying, and two catheter types are available: the conventional uncoated PVC and the hydrophilic coated catheters. OBJECTIVE: To evaluate the cost-effectiveness of two types of catheters for intermittent catheterization from the perspective of the Brazilian public healthcare system. MATERIALS AND METHODS: A Markov model was used to evaluate cost-effectiveness in those with spinal cord injuries. A primary analysis was conducted on all possible adverse events, and a secondary analysis was performed with urinary tract infections as the only relevant parameter. The results were presented as cost per life years gained (LYG), per quality-adjusted life years (QALY) and per number of urinary tract infections (UTIs) avoided. RESULTS: The base scenario of all adverse events shows a cost-effective result of hydrophilic coated catheters compared to uncoated PVC catheters at 57,432 BRL (Brazilian Reais) per LYG and 122,330 BRL per QALY. The secondary scenario showed that the use of hydrophilic coated catheters reduces the total number of UTIs, indicating that an additional cost of hydrophilic coated catheters of 31,240 BRL over a lifetime will reduce lifetime UTIs by 6%. CONCLUSIONS: Despite the higher unit value, the use of hydrophilic coated catheters is a cost-effective treatment from the perspective of the Brazilian public healthcare system.

Cost-Effectiveness Analysis of Everolimus versus Mycophenolate in Kidney Transplant Recipients Receiving No Pharmacological Prophylaxis for Cytomegalovirus Infection: A Short-Term Pharmacoeconomic Evaluation (12 Months).

BACKGROUND: Modern immunosuppressive regimens, although associated with improved 1-year graft survival, are associated with adverse effects, including opportunistic infections, diabetes mellitus after transplantation, cardiovascular complications, and de novo malignancies. OBJECTIVES: To determine the short-term (12 months) cost-effectiveness of everolimus (EVR) versus mycophenolate sodium (MPS) in kidney transplant recipients receiving induction therapy, tacrolimus, prednisone, and no prophylaxis for cytomegalovirus infection. METHODS: A Markov state transition model was designed. Data from a single-center prospective trial were used along with data from the center's medical bills database. The target population comprised adults with low immunological risk submitted to first ABO-compatible transplantation with kidneys recovered from living or deceased donors. The time horizon was 12 months. The interventions included tacrolimus and prednisone plus a single 3-mg/kg dose of rabbit antithymocyte globulin (ATG) and EVR or basiliximab (BAS) and EVR or BAS and MPS. The clinical outcomes considered for this analysis were cytomegalovirus infection/disease, acute rejection, graft dysfunction, surgical complications, graft loss, and life-years gained. RESULTS: ATG/EVR was cost-saving compared with BAS/MPS on all evaluated outcomes; BAS/EVR outperformed BAS/MPS on most of the evaluated outcomes. Results were confirmed by sensitivity analysis. CONCLUSIONS: Compared with MPS, EVR is an alternative immunosuppressive agent that is able to provide resource-saving to the health care provider with effectiveness gains for the patient.

Custo-efetividade do fator VII ativado recombinante (rFVIIa) e complexo protrombínico parcialmente ativado (CCPa) no tratamento sob demanda do sangramento leve/moderado de pacientes com hemofilia congênita complicada por inibidores sob a perspectiva do sistema público de saúde do Brasil / Cost-effectiveness of rFVIIa and CCPa in the on-demand treatment of congenital haemophilia with inhibitors in the Brazilian public setting

Objetivo: Fornecer evidências econômicas que suportem o uso do fator VII ativado recombinante (rFVIIa) em comparação ao complexo protrombínico parcialmente ativado (CCPa) para o tratamento do episódio de sangramento leve a moderado devido a hemofilia com anticorpos inibidores no Sistema Único de Saúde (SUS). Métodos: Estudos que investigaram a eficácia clínica dos tratamentos CCPa e rFVIIa indicam diferenças entre eles na capacidade de controlar os sangramentos. A análise de custo-efetividade foi desenvolvida com base em dois modelos de árvore de decisão propostos por You et al. (2009) e Jiménez-Yuste et al. (2013). O desfecho clínico foi o percentual de pacientes que controlam o sangramento e o desfecho econômico incluiu custos médicos diretos. O horizonte de tempo variou com a gravidade da hemorragia. Os custos unitários foram obtidos do Diário Oficial da União (1 µg de rFVIIa R$ 2,09 e 1U de CCPa R$ 2,28). No modelo de You foram considerados também custos com ácido tranexâmico e centro de tratamento, extraídos da CMED (Câmara de Regulação do Mercado de Medicamentos) e do SIGTAP (Sistema de Gerenciamento da Tabela de Procedimentos), respectivamente. Resultados: O modelo de You indicou maior percentual de pacientes que tiveram o sangramento controlado com rFVIIa comparado ao CCPa (89,2% vs. 75,1%) com menor custo de tratamento (R$ 18.921 vs. R$ 28.691). Considerando Jiménez-Yuste, o percentual de pacientes com sangramento controlado também é maior com rFVIIa (79,0% vs. 61,0%), com menor custo de tratamento (R$ 63.446 vs. R$ 68.952). Conclusão: O rFVIIa é uma alternativa cost-saving para o tratamento de pacientes com hemofilia congênita com inibidores comparado ao CCPa.

Objective: To provide economic evidences that support the use of recombinant activated factor VII (rFVIIa) in comparison to activated prothrombin complex concentrate (aPCC) for the treatment of episodes of mild to moderate bleeding due to haemophilia with inhibitors in Sistema Único de Saúde (SUS). Methods: Studies that explored the clinical efficacy of aPCC and rFVIIa treatments have shown differences between them in their capacity for controlling bleeding episodes. The cost-effectiveness analysis was developed based on two decision tree models proposed by You et al. (2009) and Jiménez-Yuste et al. (2013). The clinical outcome was the percentage of patients with controlled bleeding, and the economic outcome was direct medical costs. The time horizon varied according to hemorrhage severity. Drugs unit costs were obtained from the Diário Oficial da União (1 µg of rFVIIa R$ 2.09 and 1U of aPCC R$ 2.28). In You model, also considered the costs with tranexamic acid and treatment center, extracted from CMED (Câmara de Regulação do Mercado de Medicamentos) and SIGTAP (Sistema de Gerenciamento da Tabela de Procedimentos), respectively. Results: You model showed a higher percentage of patients that controlled bleeding with rFVIIa compared to aPCC (89.2% vs. 75.1%) and with lower treatment cost (R$ 18,921 vs. R$ 28,691). Considering Jiménez-Yuste, the percentage of patients that controlled bleeding was also greater with rFVIIa (79.0% vs. 61.0%) with lower treatment cost (R$ 63,446 vs. R$ 68,952). Conclusion: rFVIIa is a cost-saving alternative for the treatment of patients with congenital haemophilia with inhibitors compared to aPCC.

Análise de custo-efetividade da toxina onabotulínica A no tratamento preventivo da migrânea crônica sob a perspectiva do sistema privado de saúde do Brasil / Cost-effectiveness analysis of onabotulinumtoxinA in the preventive treatment of chronic migraine under the Brazilian private health care system perspective

Objetivo: Avaliar o custo-efetividade da toxina onabotulínica A (TB) versus ausência de tratamento "não tratar" (NT) da migrânea crônica refratária a pelo menos dois medicamentos em um Sistema de Saúde Suplementar. Métodos: Modelo analítico de decisão simulou desfechos e custos em 24 semanas. Os desfechos clínicos foram: dias com cefaleia (DC); dias com cefaleia moderada/severa (DCMS); episódios de cefaleia (EC); dias com migrânea (DM) e episódios de migrânea (EM). Para o braço NT, utilizaram-se os valores basais do placebo. Para o braço TB, utilizaram-se os valores basais aplicando as reduções relacionadas ao uso do tratamento. Os custos incluídos foram custos médicos diretos. Os dados que subsidiaram as análises foram extraídos da literatura. Avaliou-se uma aplicação de TB (155U) a cada 12 semanas, totalizando duas aplicações em 24 semanas. Custos foram extraídos de bases oficiais do Brasil. Considerou-se taxa de descontinuação de 3,8% para TB na semana 24. Análises de sensibilidade probabilística (ASP) e univariada (ASU) foram realizadas para o desfecho DM. Resultados: O uso de TB proporcionou redução de 52,42% nos DC; 47,97% nos DCMS; 37,60% nos EC; 50,49% nos DM; 35,68% nos EM e uma redução de R$ 1.193 com consulta médica e hospitalização. Houve incremento de R$ 8.646 com aplicação da TB, resultando numa Razão de Custo-Efetividade Incremental (RCEI) de R$ 142,16/DC; R$ 155,35/DCMS; R$ 198,22/EC; R$ 147,61/DM e R$ 208,85/EM. A ASP e ASU comprovaram os resultados do caso base. Conclusão: Uso de TB proporciona redução dos desfechos clínicos, variando de 44% a 49%, além de redução de 54% a 60% nos custos com visitas médicas e hospitalização.

Objective: To evaluate the cost-effectiveness of onabotulinumtoxinA (OT) versus "no treatment" (NT) of chronic refractory migraine to at least two drugs in the Supplementary Brazilian Health Care System. Methods: An analytical decision model simulated outcomes and costs at 24 weeks. Clinical outcomes were: days with headache (DH); days with moderate/severe headache (DMSH); headache episodes (HE); days with migraine (DM) and episodes of migraine (EM). For the NT arm, the baseline values of placebo were used. For the OT arm, baseline values were used as reductions related to treatment use. Costs included were direct medical costs. The data that supported the analyzes were extracted from the literature. One OT application (155U) was evaluated every 12 weeks totaling 2 applications in 24 weeks. Costs were extracted from Brazilian official databases. A 3.8% discontinuation rate was considered for OT at week 24. Probabilistic (PSA) and univariate (USA) sensitivity analyzes were performed for the DM outcome. Results: The use of OT provided a reduction of 52.42% in DH; 47.97% in DMSH; 37.60% in HE; 50.49% in DM; 35.68% in EM and a reduction of R$ 1,193 with medical visits and hospitalization. There was an increase of R$ 8,646 with OT application; resulting in an incremental cost-effectiveness ratio (ICER) of R$ 142.16/DH; R$ 155.35/DMSH; R$ 198.22/HE; R$ 147.61/DM and R$ 208.85/EM. PSA and USA proved the base case results. Conclusion: Use of OT provides a reduction in clinical outcomes ranging from 44% to 49%, as well as a reduction of 54% to 60% in costs with medical visits and hospitalization.

Custo-efetividade de terapias anti-PD-1 comparadas com ipilimumabe para o tratamento de melanoma avançado sob a perspectiva do sistema de saúde suplementar brasileiro / Cost-effectiveness of anti-PD-1 therapies compared with ipilimumab for the treatment of advanced melanoma under the Brazilian supplementary health system perspective

Objetivo: Realizar uma análise de custo-efetividade das terapias imuno-oncológicas anti-PD-1 aprovadas no Brasil versus ipilimumabe no tratamento do paciente sem tratamento prévio com melanoma metastático (estádios III ou IV), independentemente da mutação BRAF sob a perspectiva do sistema de saúde suplementar brasileiro. Métodos: Foi desenvolvido um modelo com três estados de saúde mutuamente exclusivos (livre de progressão, progressão da doença e morte) para simular a condição clínica de pacientes tratados com nivolumabe ou pembrolizumabe comparado ao ipilimumabe. Os custos de medicamentos, materiais, exames e procedimentos foram calculados com base na lista oficial de preços no Brasil ­ CMED (março/2017), revistas Kairos e Simpro, Planserv 2008 e CBHPM 2015. O desfecho clínico considerado para a análise foi de anos de vida salvos. Resultados: O nivolumabe produziu uma razão de custo-efetividade incremental de R$ 37.231 e o pembrolizumabe, de R$ 72.760. Ambas as intervenções demonstraram benefício clínico dentro do limiar de disposição a pagar recomendado pela OMS (três vezes o PIB per capita), mostrando que as tecnologias são custoefetivas. Na análise de sensibilidade univariada foi demonstrado que as RCEIs para ambas as análises foram mais sensíveis aos parâmetros referentes à taxa de desconto anual e aos custos de acompanhamento. Entre as terapias imuno-oncológicas anti-PD-1, o nivolumabe apresentou benefício clínico maior a um custo menor. Conclusão: Ambas as terapias anti-PD-1 (nivolumabe e pembrolizumabe) são custo-efetivas versus ipilimumabe, sugerindo-se o nivolumabe como melhor opção para a alocação de recursos no tratamento de pacientes sem tratamento prévio com melanoma avançado, independentemente da mutação BRAF, sob a perspectiva do sistema de saúde suplementar brasileiro.

Objective: The aim of this study was to evaluate the cost-effectiveness of anti-PD-1 therapies approved in Brazil versus ipilimumab for the treatment of previously untreated patients with metastatic melanoma (stage III/IV) irrespective of BRAF status under the Brazilian supplementary health system perspective. Methods: A cost-effectiveness model with three mutually exclusive health state (pre-progression, post-progression and death) was developed to simulate the clinical condition of patients with metastatic melanoma treated with nivolumab or pembrolizumab compared with ipilimumab. The cost of drugs, materials, exams and procedures were obtained from official Brazilian price list ­ CMED, Kairos and Simpro magazines, Planserv 2008 and CBHPM 2015. The clinical outcome considered in the analysis was life years saved. Results: Nivolumab produced an incremental cost-effectiveness ratio of R$ 37,231 and pembrolizumab of R$ 72,760. Both interventions offered clinical benefit within the willingness-to-pay threshold recommended by World Health Organization (WHO) (three times per-capita GDP), showing that the technologies are cost-effective. It was demonstrated in the univariate sensitivity analyses that the parameters in which ICER of the comparison of nivolumab vs. ipilimumab and pembrolizumab vs. ipilimumab were more sensitive to annual discount rate (costs) and follow-up costs. Conclusion: Both nivolumab and pembrolizumab are cost-effective versus ipilimumab, suggesting that it would be more willing to be adopted for the treatment of previously untreated patients with advanced melanoma regardless of BRAF mutation under Brazilian supplementary health system perspective.

Custo-efetividade de trimetazidina no tratamento de angina estável em pacientes diabéticos não respondedores a betabloqueadores, nitratos e bloqueadores do canal de cálcio / Cost-effectiveness of trimetazidine for stable angina treatment in non-responder diabetics after beta blockers, nitrates and calcium channel blockers

Objetivo: Avaliar o custo-efetividade da trimetazidina (TMZ) associada ao tratamento convencional (diurético, ácido acetilsalicílico [AAS], betabloqueador, inibidores da enzima de conversão da angiotensina (IECA), nitrato, estatina, digitálico e antagonista dos canais de cálcio) versus tratamento convencional isolado no tratamento de pacientes diabéticos com angina estável não respondedores a betabloqueadores, nitratos e bloqueadores do canal de cálcio sob a perspectiva do Sistema Público de Saúde (SUS). Métodos: Foi elaborado um modelo de Markov, com ciclos de 1 ano, que acompanhou os pacientes ao longo do curso natural da doença até o final de suas vidas. Dados clínicos foram obtidos a partir de revisão da literatura. Custos unitários foram extraídos de bases de dados oficiais. Apenas custos médicos diretos foram contemplados. Custos e benefícios foram descontados a uma taxa de 5% ao ano. Desfecho clínico foi expresso como episódio de hospitalização por angina pectoris (EHAP) evitado. Análise de sensibilidade univariada foi realizada para determinar os parâmetros de maior influência nos resultados, variando-os em mais ou menos 20% comparado ao cenário base. Resultados: O tratamento com TMZ mostrou maior benefício comparado ao tratamento convencional e gerou uma Razão de Custo-Efetividade Incremental de R$ 7.344,96 por EHAP evitado. O parâmetro de maior impacto no resultado foi o número de episódios de angina pectoris. Apesar do alto impacto, este não alterou o resultado da análise, mantendo-o custo-efetivo. Conclusão: TMZ associada ao tratamento convencional mostrou ser uma alternativa eficaz, segura e custo-efetiva para o tratamento de pacientes diabéticos com angina estável não respondedores a betabloqueadores, nitratos e bloqueadores do canal de cálcio.

Objective: To assess the cost-effectiveness analysis of trimetazidine (TMZ) associated with conventional treatment (diuretic, acetylsalicylic acid [ASA], beta blocker, angiotensin converting enzyme inhibitor (ACEI), nitrate, statine, digitalis and calcium channel antagonist) versus conventional treatment alone in the treatment of diabetic patients with stable angina non-responders to beta blockers, nitrates and calcium channel blockers from the perspective of the Public Health System (SUS). Methods: A Markov model was developed, with one year cycles, to follow the patients along the natural course of disease until the end of your lifes. Clinical data were obtained from the literature review. Unit costs were extracted from official databases. Only direct medical costs were included. Costs and benefits were discounted at a rate of 5% per year. Outcome were expressed as hospitalization due to angina pectoris (HAP) avoided. Univariate sensitivity analysis was performed to determine the parameters of greatest influence on the results, varying them by plus or minus 20% compared to the baseline scenario. Results: Treatment with TMZ showed greater benefit compared to conventional treatment and generated an Incremental Cost-Effectiveness Ratio of USD 2,225.75 per HAP avoided (1USD = 3.30BRL). The parameter with the greatest impact on outcome was the number of angina pectoris episodes. Despite the high impact, it did not change the result, keeping it cost-effective. Conclusion: TMZ associated with conventional treatment has been shown to be an effective, safe and cost-effective alternative for the treatment of diabetic patients with stable angina non-responders to beta blockers, nitrates and calcium channel blockers.

Custo-efetividade do afatinibe versus pemetrexede associado a cisplatina, erlotinibe e gefitinibe no tratamento de primeira linha de pacientes com câncer de pulmão não pequenas células localmente avançado ou metastático, com mutação do receptor do fator de crescimento epidermoide (EGFR+), na perspectiva do Sistema de Saúde Suplementar do Brasil / Cost-effectiveness of afatinib versus pemetrexed plus cisplatin, erlotinib and gefitinib as first line treatment in patients with locally advanced or metastatic epidermal growth factor receptor mutation (EFGR+) non-small cell lung cancer in the Brazilian private healthcare system

Objetivo: Comparar os custos e efetividade do afatinibe versus pemetrexede associado a cisplatina (PEM/CIS), erlotinibe e gefitinibe no tratamento de primeira linha de pacientes com câncer de pulmão não pequenas células (CPNPC) com mutação no receptor de fator de crescimento epidermoide (EGFR+) localmente avançado ou metastático, no Sistema de Saúde Suplementar brasileiro. Métodos: O modelo de Markov foi utilizado para estimar anos de vida livres de progressão (PFLY), anos de vida (LY), anos de vida ajustados pela qualidade (QALY) e desfechos clínicos por sete anos. Utilizaram-se dados de sobrevida, segurança e utilidade dos estudos LUX-Lung 1, 3 e 6 e LUCEOR. A eficácia comparativa versus gefitinibe e erlotinibe foi estimada utilizando modelos bayesianos de comparação indireta. A utilização dos recursos foi estimada por painel de especialistas, e custos diretos foram estimados utilizando-se bases de dados oficiais. Resultados: Afatinibe mostrou aumento da sobrevida livre de progressão (0,41 PFLY), sobrevida global (0,16 LY) e qualidade de vida (0,21 QALY) com custo incremental (R$ 8.549), resultando em razão de custo-efetividade incremental (RCEI) de R$ 20.639/PFLY. Comparado ao erlotinibe, o afatinibe mostrou aumento de 0,46 PFLY, 0,13 LY e 0,20 QALY, com menor custo (-R$ 21.327). Comparado ao gefitinibe, o afatinibe mostrou incrementos de 0,53 PFLY, 0,37 LY, 0,34 QALY, com custo incremental de R$ 24.890, resultando em RCEI de R$ 46.709/PFLY. Considerando-se três vezes o PIB per capita como limiar de custo-efetividade (R$ 86.628), o afatinibe é custo-efetivo versus PEM/CIS e gefitinibe e dominante quando comparado ao erlotinibe. Conclusão: Sugere-se que o afatinibe é uma opção custo-efetiva quando comparado ao PEM/CIS, erlotinibe e gefitinibe no tratamento de primeira linha de pacientes com CPNPC EGFR+.

Objective: To compare costs and effectiveness of afatinib versus pemetrexed plus cisplatin (PEM/ CIS), erlotinib and gefitinib, as first line treatment in patients with locally advanced or metastatic epidermal growth factor receptor mutation (EGFR+) non-small cell lung cancer (NSCLC) in the Brazilian Private Healthcare System. Methods: A Markov model was used to estimate 7year progression-free life years (PFLY), life years (LY), quality-adjusted life years (QALY) and clinical outcomes of afatinib. Partitioned survival, safety and utility data from the LUX-Lung 1, 3 and 6 and LUCEOR trials were used. Comparative effectiveness versus gefitinib and erlotinib was estimated using Bayesian indirect treatment comparison. Resource use was estimated by an expert panel and direct costs were estimated from official databases. Results: Compared with PEM/CIS, afatinib was associated with increased progression free survival (0.41 PFLY), increased overall survival (0.16 LY) and increased quality of life (0.21 QALY) with incremental cost (BRL 8,549), resulting in an incremental cost-effectiveness ratio (ICER) of BRL 20.639/PFLY. Compared to erlotinib, afatinib was associated with additional 0.46 PFLY, 0.13 LY and 0.20 QALYs with lower cost (- BRL 21,327). When compared to gefitinib, afatinib was associated with incremental 0.53 PFLY, 0.37 LY and 0.34 QALY and increased cost (BRL 24,890), resulting in an ICER of BRL 46,709/PFLY. Considering 3 PIB per capita as a threshold (BRL 86,628), afatinib is a cost-effective technology versus PEM/CIS and gefitinib and dominant when compared to erlotinib. Conclusion: Findings suggest that afatinib is a cost-effective option, when compared to PEM/CIS, erlotinib and gefitinib, as first line treatment in EGFR+ NSCLC patients.

Custo-efetividade do uso do sistema intrauterino liberador de 52 mg de levonorgestrel (SIU-LNG) versus contraceptivos hormonais de curta duração na prevenção de gravidez não desejada em adolescentes entre 15 e 19 anos sob a perspectiva do Sistema Único de Saúde do Brasil (SUS) / Cost-effectiveness analysis of 52 mg levonorgestrel-releasing intrauterine system (LNG-IUS) versus short-acting hormonal contraceptives in avoiding unintended pregnancy (UP) in 15 to 19 year-old adolescents under the Brazilian Public Healthcare System (SUS)

Objetivo: O objetivo deste trabalho foi avaliar se o uso do sistema liberador de levonorgestrel (SIU- -LNG) Mirena® é custo-efetivo na prevenção de gravidez não planejada em adolescentes, entre 15 e 19 anos, quando comparado aos contraceptivos hormonais de curta duração sob a perspectiva do Sistema Único de Saúde (SUS). Métodos: Para avaliação econômica, foi elaborado um modelo de Markov, com ciclos de um ano, que acompanhou as adolescentes ao longo do curso natural do uso do método contraceptivo por um horizonte de tempo de cinco anos. Dados clínicos foram obtidos de revisão da literatura. Custos unitários foram extraídos de bases de dados oficiais. Apenas custos médicos diretos foram contemplados. Custos e benefícios foram descontados a uma taxa de 5% ao ano. Desfechos foram expressos como gravidez não planejada evitada. Resultados: Os resultados da análise de custo-efetividade mostraram que SIU-LNG é capaz de gerar economia de recursos com ganho em efetividade quando comparado com os métodos de maior prevalência de uso na adolescência (ACO e ACI). Análises de sensibilidade foram realizadas comprovando os resultados encontrados no caso-base. Conclusão: Levando-se em conta os resultados satisfatórios clínicos e econômicos, SIU-LNG deve ser considerado uma importante opção para evitar a gravidez não planejada na adolescência e todas as suas consequências.

Objective: The aim of this study was to evaluate the cost- effectiveness of levonorgestrel-releasing intrauterine system (LNG-IUS) Mirena® in avoiding unintended pregnancy in 15 to 19 year-old adolescents compared to short-term hormonal contraceptives under the Brazilian Public Healthcare System (SUS) perspective. Methods: For economic evaluation, a Markov model was developed, with one year cycles, to follow the adolescents along the natural course of contraceptives use, under a time horizon of five years. Clinical data were obtained from the literature review. Unit costs were extracted from official databases. Only direct medical costs were included. Costs and benefits were discounted at a rate of 5% per year. Outcomes were expressed as unplanned pregnancy avoided. Results: The cost-effectiveness results showed that LNG-IUS is able to bring savings with gain in effectiveness when compared to the most common methods used by adolescents (oral and injectable contraceptives). Sensitivity analyses confirmed the results found in the base case. Conclusion: Considering the satisfactory clinical and economic results, LNG-IUS should be considered as an important option for avoiding unplanned pregnancy in adolescence, along with all its consequences.

Análise de custo-efetividade do n-butil-cianoacrilato para fixação de telas em hernioplastias inguinais sob a perspectiva da saúde suplementar brasileira / Cost-effectiveness of n-buthyl-cyanoacrylate for mesh fixation in inguinal hernioplasty under the perspective of Supplementary Healthcare in Brazil

Objetivo: Estimar a custo-efetividade do n-butil-cianoacrilato (NBCA) para fixação de telas em pacientes submetidos a hernioplastias inguinais por reparo aberto ou laparoscópico, sob a perspectiva da Saúde Suplementar do Brasil. Métodos: Foi elaborado modelo analítico de decisão para estimar a razão de custo efetividade incremental (RCEI) em horizonte de tempo de um ano após procedimento cirúrgico com o uso do adesivo sintético versus técnicas tradicionais de fixação (sutura e grampos). Alternativamente, o uso de NBCA foi comparado à cola de fibrina. Os desfechos clínicos avaliados foram incidência de dor aguda e crônica. A estimativa de custos médicos diretos totais para as diferentes abordagens cirúrgicas e terapia da dor foi elaborada a partir da opinião de especialistas e coletadas em bases de dados secundárias. Resultados: A RCEI obtida através do modelo evidenciou economia substancial de recursos financeiros relacionada ao uso de NBCA de aproximadamente R$ 2.800 por procedimento após reparo laparoscópico e R$ 60 reais por procedimento para reparo aberto, resultados direcionados majoritariamente pela menor tendência de dor (efetividade incremental de 21,74% em termos de dor evitada) versus métodos de fixação tradicional. No cenário alternativo, no qual comparou-se NBCA com a cola biológica (adesivo de fibrina), atingiu-se economia financeira com nível de efetividade equivalente do ponto de vista estatístico entre os comparadores. Conclusão: Pode-se atribuir que o uso de NBCA para fixação de telas em cirurgias de reparo de hérnia inguinal constitui alternativa segura, efetiva e viável economicamente, quando comparado tanto a técnicas de fixação tradicionais como à cola biológica.

Objective: To estimate the cost-effectiveness of n-butyl-cyanoacrylate (NBCA) for mesh fixation in patients undergoing inguinal hernia repair by open or laparoscopic methods, from the perspective of the Brazilian supplementary health sector. Methods: A decision model was developed to estimate the incremental cost-effectiveness ratio (ICER) in time horizon of one year after surgery with the use of synthetic adhesive versus traditional fixation techniques (suture and staples). Alternatively, the use of NBCA was compared to the fibrin glue. Clinical outcomes applied to the model were incidence of acute and chronic pain. The estimation of total direct medical costs for surgical approach and pain therapy was developed based on experts' opinions and collected from secondary databases. Results: The ICER obtained through the model indicated substantial savings of financial resources related to the use of NBCA of approximately 2,800 BRL per procedure after laparoscopic repair and 60 BRL per procedure for open repair, results primarily due to the lower tendency of pain (incremental effectiveness of 21.74% in terms of avoided pain) versus traditional fixation methods. In the alternative scenario, which compared NBCA with biological glue (fibrin glue), it was achieved financial savings, with statistically equivalent level of effectiveness among the comparators. Conclusion: The use of NBCA for mesh fixation in inguinal hernia repair surgery is a safe, effective and feasible alternative from an economic point of view, when compared to both traditional fixation techniques as the biological glue.

Cost of diseases related to alcohol consumption in the Brazilian Unified Health System.

OBJECTIVE: To estimate the direct costs associated to outpatient and hospital care of diseases related to alcohol consumption in the Brazilian Unified Health System. METHODS: Attributable populational risks were estimated for the selected diseases related to the use of 25 g/day or more of ethanol (risk consumption), considering a relative risk (RR) ≥ 1.20. The RR estimates were obtained from three meta-analysis. The risk consumption rates of the Brazilian population ≥ 18 years old were obtained by a national survey. Data from the Hospital Information System of SUS (HIS-SUS) were used to estimate the annual costs of the health system with the diseases included in the analysis. RESULTS: The total estimated costs for a year regarding diseases related to risk consumption were U$8,262,762 (US$4,413,670 and US$3,849,092, for outpatient and hospital care, respectively). CONCLUSIONS: Risk consumption of alcohol is an important economic and health problem, impacting significantly the health system and society.

Cost of diseases related to alcohol consumption in the Brazilian unified health system / Custos de doenças relacionadas ao consumo de álcool no sistema único de saúde

ABSTRACT OBJECTIVE To estimate the direct costs associated to outpatient and hospital care of diseases related to alcohol consumption in the Brazilian Unified Health System. METHODS Attributable populational risks were estimated for the selected diseases related to the use of 25 g/day or more of ethanol (risk consumption), considering a relative risk (RR) ≥ 1.20. The RR estimates were obtained from three meta-analysis. The risk consumption rates of the Brazilian population ≥ 18 years old were obtained by a national survey. Data from the Hospital Information System of SUS (HIS-SUS) were used to estimate the annual costs of the health system with the diseases included in the analysis. RESULTS The total estimated costs for a year regarding diseases related to risk consumption were U$8,262,762 (US$4,413,670 and US$3,849,092, for outpatient and hospital care, respectively). CONCLUSIONS Risk consumption of alcohol is an important economic and health problem, impacting significantly the health system and society.

RESUMO OBJETIVO Estimar os custos diretos associados ao atendimento ambulatorial e hospitalar de doenças relacionadas com o consumo de álcool no Sistema Único de Saúde brasileiro. MÉTODOS Riscos atribuíveis populacionais foram calculados para doenças selecionadas relacionadas ao uso de 25 g/dia ou mais de etanol (consumo de risco), considerando-se o risco relativo (RR) ≥ 1,.20. As estimativas de RR foram obtidas a partir de três meta-análises e as taxas de consumo de risco em brasileiros ≥ 18 anos obtidos em pesquisa nacional. Os dados do Sistema de Informações Hospitalares do SUS (SIH-SUS) e do Sistema de Informações Ambulatoriais do SUS (SIA-SUS) foram utilizados para estimar os custos anuais do SUS com as doenças incluídas na análise. RESULTADOS Os custos totais estimados em um ano com todas as doenças relacionadas com consumo de risco foram US$8.262.762 (US$4.413.670 e US$3.849.092 para pacientes ambulatoriais e internados, respectivamente). CONCLUSÕES Consumo de risco de álcool representa importante problema econômico e de saúde, com um impacto significativo para o sistema de saúde e para a sociedade.

Custo-efetividade da infiltração contínua da ferida cirúrgica com ropivacaína versus morfina para controle de dor aguda / Cost-effectiveness of ropivacaine continuous wound infiltration versus morphine for acute pain control

OBJETIVOS: Avaliar a custo-efetividade da infiltração contínua da ferida cirúrgica (ICFC) com ropivacaína versus infusão de morfina, sob a perspectiva da Saúde Suplementar Brasileira, em horizonte de 48 horas após cirurgias de grande porte. MÉTODOS: Análise de custo-efetividade por modelo analítico de decisão, empregando dados clínicos de sucesso de analgesia e redução de efeitos colaterais, como náuseas e vômitos pós-operatórios ligados à analgesia com opioides (PONV), obtidos por revisão de literatura. Foram considerados no modelo custos médicos diretos e custos relacionados à internação (receita líquida por leito). RESULTADOS: A eficácia clínica da tecnologia de ICFC mostrou-se superior em todos os cenários apresentados, quando comparada à morfina endovenosa, com menor incidência de PONV, maior taxa de sucesso da analgesia e menor necessidade de opioides de resgate. Ainda, a ICFC mostrou-se menos dispendiosa do que o comparador selecionado, seja administrado por infusão em bolus ou por dispositivo de infusão de fármacos. O resultadose deve, majoritariamente, à redução do tempo de permanência hospitalar. CONCLUSÃO: A ICFC é uma alternativa extremamente efetiva, do ponto de vista clínico, para controle de dor aguda. A tecnologia pode trazer ainda economia de recursos financeiros em curto prazo, já que a dor aguda ea incidência de PONV, além de aumentar o consumo de medicamentos, como opioides e antieméticos, pode prolongar a recuperação do paciente e a sua permanência hospitalar.

OBJECTIVES: To assess cost-effectiveness of continuous wound infiltration (CWI) with ropivacaine versus intravenous morphine, under the perspective of the Brazilian Supplementary Health System, in a time horizon of 48 hours after major surgeries. METHODS: Cost-effectiveness analysis through an analytic decision model, applying clinical data of success rate of analgesia and reduction of side effects, such as opioid related postoperative nausea and vomiting (PONV), obtained through literature review. The model accomplishes direct medical costs and costs related to hospital stay (incomeper hospital bed). RESULTS: Clinical efficacy of CWI has shown superior results in all scenarios presented, when compared to intravenous morphine, with lower incidence of PONV, higher success rates in analgesia and less need of rescue with opioids. CWI has also shown less expensive than the selected comparator administered either in bolus or drug infusion devices. This result is specially derived from the reduction on the hospital length of stay. CONCLUSION: CWI is an extremely effective alternative for acute pain control, in the clinical point of view. It can also generate cost-savings in the short term, as acute pain and PONV incidence, besides increasing consumption of opioids and antiemetic drugs, can jeopardize patient recovery and prolong unnecessarily his hospital stay.

Cost-effectiveness analysis of medical treatment of benign prostatic hyperplasia in the Brazilian public health system.

OBJECTIVE: To perform a cost-effectiveness analysis of medical treatment of benign prostatic hyperplasia (BPH) under Brazilian public health system perspective (Unified Health System--"Sistema Unico de Saude (SUS)"). MATERIAL AND METHODS: A revision of the literature of the medical treatment of BPH using alpha-blockers, 5-alpha-reductase inhibitors and combinations was carried out. A panel of specialists defined the use of public health resources during episodes of acute urinary retention (AUR), the treatment and the evolution of these patients in public hospitals. A model of economic analysis (Markov) predicted the number of episodes of AUR and surgeries (open prostatectomy and transurethral resection of the prostate) related to BPH according to stages of evolution of the disease. Brazilian currency was converted to American dollars according to the theory of Purchasing Power Parity (PPP 2010: US$ 1 = R$ 1.70). RESULTS: The use of finasteride reduced 59.6% of AUR episodes and 57.9% the need of surgery compared to placebo, in a period of six years and taking into account a treatment discontinuity rate of 34%. The mean cost of treatment was R$ 764.11 (US$ 449.78) and R$ 579.57 (US$ 340.92) per patient in the finasteride and placebo groups, respectively. The incremental cost-effectiveness ratio (ICERs) was R$ 4.130 (US$ 2.429) per episode of AUR avoided and R$ 2.735 (US$ 1.609) per episode of surgery avoided. The comparison of finasteride + doxazosine to placebo showed a reduction of 75.7% of AUR episodes and 66.8% of surgeries in a 4 year time horizon, with a ICERs of R$ 21.191 (US$ 12.918) per AUR episodes avoided and R$ 11.980 (US$ 7.047) per surgery avoided. In the sensitivity analysis the adhesion rate to treatment and the cost of finasteride were the main variables that influenced the results. CONCLUSIONS: These findings suggest that the treatment of BPH with finasteride is cost-effective compared to placebo in the Brazilian public health system perspective.

Cost-effectiveness analysis of medical treatment of benign prostatic hyperplasia in the Brazilian public health system

OBJECTIVE: To perform a cost-effectiveness analysis of medical treatment of benign prostatic hyperplasia (BPH) under Brazilian public health system perspective (Unified Health System - "Sistema Único de Saúde (SUS)"). MATERIAL AND METHODS: A revision of the literature of the medical treatment of BPH using alpha-blockers, 5-alpha-reductase inhibitors and combinations was carried out. A panel of specialists defined the use of public health resources during episodes of acute urinary retention (AUR), the treatment and the evolution of these patients in public hospitals. A model of economic analysis(Markov) predicted the number of episodes of AUR and surgeries (open prostatectomy and transurethral resection of the prostate) related to BPH according to stages of evolution of the disease. Brazilian currency was converted to American dollars according to the theory of Purchasing Power Parity (PPP 2010: US$ 1 = R$ 1.70). RESULTS: The use of finasteride reduced 59.6% of AUR episodes and 57.9% the need of surgery compared to placebo, in a period of six years and taking into account a treatment discontinuity rate of 34%. The mean cost of treatment was R$ 764.11 (US$449.78) and R$ 579.57 (US$ 340.92) per patient in the finasteride and placebo groups, respectively. The incremental cost-effectiveness ratio (ICERs) was R$ 4.130 (US$ 2.429) per episode of AUR avoided and R$ 2.735 (US$ 1.609) per episode of surgery avoided. The comparison of finasteride + doxazosine to placebo showed a reduction of 75.7% of AUR episodes and 66.8% of surgeries in a 4 year time horizon, with a ICERs of R$ 21.191 (US$ 12.918) per AUR episodes avoided and R$ 11.980 (US$ 7.047) per surgery avoided. In the sensitivity analysis the adhesion rate to treatment and the cost of finasteride were the main variables that influenced the results. CONCLUSIONS: These findings suggest that the treatment of BPH with finasteride is cost-effective compared to placebo in the Brazilian public health system perspective.