Total intravenous anesthesia vs inhalational anesthesia in patients undergoing surgery under general anesthesia. Cost-minimization study / Anestesia total endovenosa vs. anestesia basada en halogenados en pacientes llevados a cirugía bajo anestesia general. Estudio de minimización de costos

Abstract Introduction: The methods most frequently used at the present time in Colombia for the administration of general anesthesia are based on halogenated and intravenous drugs. However, in view of the lack of differential clinical outcomes, the existence of cost variations between the two is not clear. Objective: To determine the expected cost of the use of both techniques in patients taken to surgery, within the framework of the Colombian national health system. Methods: A cost minimization study was carried out using the decision tree as the analytical model. A time frame of 6 postoperative hours was used as the assumption. Only direct healthcare-related costs were included using a case study approach. An econometric model was used based on the frequency with which each technology is applied and the type of drug used, and a deterministic and probabilistic sensitivity analysis was performed. Results: For the case study, total intravenous anesthesia (TIVA) is more costly than the inhalational technique, with an incremental cost of $102,718 per patient. The deterministic analysis shows that both the incidence of postoperative nausea and vomiting (PONV) as well as the use of target controlled infusion (TCI) techniques are the main cost determinants. The probabilistic analysis shows that the cost difference can even be nil in more than 50% of the simulated settings, when the difference in the risk of PONV is higher. Conclusions: Although the total intravenous technique can be more costly than the inhalational technique, this difference is offset by a lower cost of the postanesthesia care unit, given the lower risk of postoperative nausea and vomiting.

Resumen Introducción: Actualmente, los métodos más usados en Colombia para la administración de anestesia general son las técnicas basadas en halogenados y en medicamentos intravenosos. No obstante, y ante la falta de desenlaces clínicos diferenciales, no es claro si existe una variación en los costos. Objetivo: Determinar el costo esperado del uso de ambas técnicas en pacientes llevados a cirugía bajo la perspectiva del sistema nacional de salud colombiano. Métodos: Se realizó un estudio de minimización de costos. Se empleó el árbol de decisión como modelo analítico. Se asumió un horizonte temporal de 6 horas postoperatorio. Se incluyeron solo los costos sanitarios directos mediante un caso tipo. Se empleó un modelo econométrico basado en la frecuencia de uso de cada tecnología y medicamento empleado y se realizó análisis de sensibilidad determinístico y probabilístico. Resultados: Para el caso tipo, la técnica total endovenosa es más costosa que la técnica basada en halogenados, con un costo incremental de $102.718 por paciente. El análisis determinístico muestra que tanto la incidencia de náuseas y vómito postoperatorio como el uso de tecnologías TCI (targetcontrolled infution) son los principales determinantes de estos costos. El análisis probabilístico muestra que la diferencia de costos puede ser incluso de cero pesos en más del 50 % de los escenarios simulados cuando se tiene una mayor diferencia del riesgo de náuseas y vómito postoperatorio. Conclusiones: Aunque la técnica total endovenosa puede ser más costosa que la basada en halogenados, esto se compensa con un costo inferior en la unidad de recuperación postanestésica debido a un menor riesgo de náuseas y vómito postoperatorio.

Cost minimization analysis of an in-house molecular test for cytomegalovirus in relation to a commercial molecular system

ABSTRACT Introduction: Cytomegalovirus may cause severe disease in immunocompromised patients. Nowadays, quantitative polymerase chain reaction is the gold-standard for both diagnosis and monitoring of cytomegalovirus infection. Most of these assays use cytomegalovirus automated molecular kits which are expensive and therefore not an option for small laboratories, particularly in the developing world. Objective: This study aimed to optimize and validate an in-house cytomegalovirus quantitative polymerase chain reaction test calibrated using the World Health Organization Standards, and to perform a cost-minimization analysis, in comparison to a commercial cytomegalovirus quantitative polymerase chain reaction test. Study design: The methodology consisted of determining: optimization, analytical sensitivity, analytical specificity, precision, curve variability analysis, and inter-laboratorial reproducibility. Patients (n = 30) with known results for cytomegalovirus tested with m2000 RealTime System (Abbott Laboratories, BR) were tested with the in-house assay, as well as patients infected with other human herpes virus, in addition to BK virus. A cost-minimization analysis was performed, from a perspective of the laboratory, assuming diagnostic equivalence of the methodologies applied in the study. Results: The in-house assay had a limit of detection and quantification of 60.3 IU/mL, with no cross-reactivity with the other viral agents tested. Moreover, the test was precise and had a R 2 of 0.954 when compared with the m2000 equipment. The cost analysis showed that the assay was economically advantageous costing a median value of 37.8% and 82.2% in comparison to the molecular test in use at the hospital and the m2000 equipment, respectively. Conclusions: These results demonstrated that in-house quantitative polymerase chain reaction testing is an attractive alternative in comparison to automated molecular platforms, being considerably less expensive and as efficacious as the commercial methods.

Custo-minimização da troca entre imunoglobulinas de diferentes vias e marcas: sustentabilidade relacionada ao tratamento na saúde suplementar / Cost minimizing the switching between immunoglobulin of different routes and brands: of treatment-related in the supplementary health

Objetivo: Avaliar custo-minimização da troca entre as versões intravenosa (IVIg) e subcutânea (SCIg) das imunoglobulinas (Ig) em operadora de saúde com mais de 500.000 vidas. Métodos: Estudo retrospectivo, transversal, descritivo, seguido de custo-minimização entre os pacientes que utilizaram IVIg, de 1º de outubro de 2018 a 30 de setembro de 2019. Simulou-se a troca entre as IVIg e SCIg, objetivando descrever a economia de uma hipotética substituição. Estabeleceram-se como critérios de exclusão: o não pagamento e a liberação com dose acima de 60.000 mg. Após exclusão, calcularam-se as despesas totais, somando-se os custos do produto e taxas de infusão. Resultados: Evidenciou-se que 133 pacientes, totalizando 1.175 liberações, utilizaram IVIg no período avaliado. Identificou-se a utilização de 34.797.500 mg de IVIg, por 10 especialidades, totalizando R$ 12.408.192,50 de despesas. Quando aplicada simulação, há uma potencial economia de recursos de até 29,83%, dependendo da SCIg escolhida. Conclusão: A análise econômica no tratamento com imunoglobulinas evidenciou significativa relevância, pois contribui com o uso adequado da terapêutica garantindo a sustentabilidade do sistema de saúde. Medicamentos subcutâneos apresentam-se como uma opção custo-minimizatória em comparação ao tratamento intravenoso para saúde suplementar brasileira.

Objective: Cost-minimization evaluation of the switch from intravenous (IVIg) to subcutaneous (SCIg) immunoglobulin (Ig) in a Brazilian Health Maintenance Organization (HMO), with more than 500.000 lives. Methods: This is a retrospective, transversal and descriptive study, followed by a cost-minimization analysis among patients using IVIg between 2018, October, 1st and 2019, September, 30th. The simulation was performed supposing the exchange from IVIg to SCIg, in order to calculate possible savings. Exclusion criteria: non-payment (gloss), and infusions with doses above 60.000 miligrams. After exclusion, total expenditures were calculated by summing product and infusion costs. Results: There were133 patients, with1,175 IVIg infusion events in the period evaluated. It was identified the use of 34,797,500 milligrams of IVIg, for 10 specialties, with R$ 12,408,192.50 of final expenditure. The simulation previews hypothetical reduction in the final cost of up to 29.83%, depending on the SCIg brand chosen. Conclusion: The economic analysis in the treatment with immunoglobulins showed significant relevance, as it contributes to the appropriate use of therapy ensuring the sustainability of the health system. Subcutaneous drugs are a cost-minimizing option compared to intravenous treatment for Brazilian HMOs.

Cost-minimization analysis of biological disease-modifying antirheumatic drugs in the Brazilian public health system (SUS) considering patients' weight / Análise de custo-minimização de medicamentos modificadores de curso da doença biológicos no Sistema Único de Saúde (SUS) no Brasil considerando o peso dos pacientes

Objective: To perform a cost-minimization analysis comparing the cohort with the current average patient weight of 70 kg (MoH current assumption). Since most rheumatoid arthritis (RA) patients in Brazil are women (60 kg or less), we also aimed to define this percentage at Brazilian public healthcare system (SUS). Methods: Treatment-naïve RA patients using biologics from January 2008 to November 2018 were retrieved from Datasus as well as the number of patients ≤ 60 kg and their drug use distribution. Data on drug costs were assessed from the last payment reported by MoH and then recalculated using the weighted average of 60 kg and a 52-weeks a year to assess cost-minimization. Results: In the studied cohort, 33,646 patients (33.3%) were classified as ≤ 60 kg. Annual cost per patient, considering an average weight of 60 kg, ranged from 2,872,29 USD to 4,223.93 USD. Tocilizumab 80 mg was the only drug demonstrating a reduction in annual cost per patient (-526.79 USD). Conclusion: Cost-minimization analysis based on weight-dependent dosage showed that tocilizumab could reduce MoH costs with RA treatment in 14.28%. By adopting weight-dependent dose of 60 kg, the Brazilian government could save up to 916,651.31 USD per year using tocilizumab versus other biological disease-modifying antirheumatic drugs (DMARDs). In ten years, it represents an accumulative saving of 9,166,513.57 USD.

Objetivo: Realizar uma análise de custo-minimização comparando a coorte com o peso médio de pacientes de 70 kg (atual premissa do Ministério da Saúde ­ MS). Como a maioria dos pacientes são mulheres (≤ 60 kg), também se objetivou definir esse percentual no sistema público de saúde brasileiro (SUS). Métodos: Pacientes com artrite reumatoide (AR) virgens de tratamento utilizando biológicos de janeiro/2008 a novembro/2018 foram retirados do Datasus, assim como o número de pacientes com ≤ 60 kg e a distribuição de uso das drogas. Os custos dos medicamentos foram avaliados a partir do último pagamento relatado pelo MS e recalculados utilizando a média de 60 kg e um ano de 52 semanas para estimar a custo-minimização. Resultados: Na coorte estudada, 33.646 pacientes (33,3%) foram classificados com ≤ 60 kg. O custo anual por paciente, considerando o peso médio de 60 kg, variou de 2.872.29 a 4.223,93 USD. Tocilizumabe 80 mg foi o único que demonstrou redução no custo anual por paciente (-526,79 USD). Conclusão: A custo-minimização baseada em dose peso-dependente mostrou que o tocilizumabe poderia reduzir os custos do MS no tratamento de AR em 14,28%. Ao adotar o peso de 60 kg, o governo poderia economizar até 916.651,31 USD ao ano utilizando tocilizumabe vs. outros medicamentos modificadores do curso da doença biológicos (MMCDb). Em 10 anos, isso representa uma economia acumulada de 9.166.513,57 USD.

Entropy Generation Minimization Analysis of Active Magnetic Regenerators

Abstract A performance assessment of active magnetocaloric regenerators using entropy generation minimization is presented. The model consists of the Brinkman-Forchheimer equation to describe the fluid flow and coupled energy equations for the fluid and solid phases. Entropy generation contributions due to axial heat conduction, fluid friction and interstitial heat transfer are considered. Based on the velocity and temperature profiles, local rates of entropy generation per unit volume were integrated to give the cycle-average entropy generation in the regenerator, which is the objective function of the optimization procedure. The solid matrix is a bed of gadolinium spherical particles and the working fluid is water. Performance evaluation criteria of fixed cross-section (face) area (FA) and variable geometry (VG) are incorporated into the optimization procedure to identify the most appropriate parameters and operating conditions under fixed constraints of specified temperature span and cooling capacity.

Revisão sistemática e análise de custo- minimização de lipegfilgrastim na profilaxia da neutropenia e da neutropenia febril relacionadas à quimioterapia citotóxica / Systematic review and cost-minimization analysis of lipegfilgrastim in the prophylaxis of neutropenia and febrile neutropenia related to cytotoxic chemotherapy

Objetivo: Realizar avaliação econômica de lipegfilgrastim, fator de crescimento de longa duração (G-CSF), com os demais medicamentos da classe terapêutica disponíveis para a diminuição da duração da neutropenia grave (NG) e da incidência de neutropenia febril (NF), em pacientes adultos tratados com quimioterapia citotóxica para neoplasias malignas. Métodos: Revisão sistemática da literatura de evidências científicas sobre a eficácia e a segurança de lipegfilgrastim e análise de custo-minimização em comparação com pegfilgrastim ou filgrastim sob a perspectiva do Sistema Suplementar no Brasil. A análise incluiu tempo de tratamento de estudos clínicos, custo de infusão/ honorários médicos e custo com aquisição de medicamentos, distribuídos em três perspectivas: cenário 1 (conservador), cenário 2 (moderado) e cenário 3 (mundo real). Resultados: Seis estudos foram incluídos na análise, sendo três estudos randomizados e três revisões sistemáticas. O lipegfilgrastim resultou numa duração média de NG significativamente menor ao placebo e não inferior ao pegfilgrastim. Um estudo que comparou indiretamente lipegfilgrastim com filgrastim não encontrou diferenças estatisticamente significativas em redução de duração de NG e incidência de NF. O lipegfilgrastim apresentou redução de custos diretos de -R$ 3.673,50/paciente comparado com pegfilgrastim em todos os cenários avaliados e, na comparação com filgrastim, observou-se redução de -R$ 57.403,40; -R$ 19.183,67 e de -R$ 42,50/paciente nos cenários 1, 2 e 3, respectivamente. Conclusões: Lipegfilgrastim apresentou perfil de custo-minimização favorável em comparação com pegfilgrastim ou filgrastim, e surge como uma importante alternativa para o tratamento da redução da duração da neutropenia e da incidência da neutropenia febril durante a realização de tratamento quimioterápico, que pode representar economia de recursos para o Sistema de Saúde Suplementar.

jective: To develop an economic evaluation of lipegfilgrastin, long acting G-CSF, compared to other available G-CSF to reduce the duration of severe neutropenia (SN) and the incidence of febrile neutropenia (FN) in adult patients treated with cytotoxic chemotherapy for cancer in the Brazilian private Health System. Methods: Systematic literature review of scientific evidence evaluating the efficacy and safety of lipegfilgrastin and cost-minimization analysis comparing to pegfilgrastin or filgrastin in the Brazilian private Health System. The analysis includes time of treatment with filgrastin from clinical trials (scenario 1) or real world data (scenario 2 and 3) and considers direct medical costs. Results: Six studies were included in the analysis: three randomized controlled trials and three systematic reviews. Lipegfilgrastin resulted in a statistically significant reduction of median SN duration compared to placebo and non-inferior compared to pegfilgrastin. A study that performed an indirect comparison of lipegfilgrastin and filgrastin did not find any difference statistically significant reduction of SN duration and FN incidence. Lipefilgrastin resulted in a cost-difference of -R$ 3.673,50/patient compared to pegfilgrastin in all scenarios and -R$ 57.403,40; -R$ 19.183,67 and -R$ 42,50/patient compared to filgrastin in scenario 1, 2 and 3 respectively. Conclusions: Lipegfilgrastim showed a favorable cost-minimization profile compared to pegfilgrastin or filgrastin and is an important alternative treatment in reducing the duration of neutropenia and the incidence of febrile neutropenia during the course of chemotherapy, and may result in resource savings for the Brazilian Private Health System.

Conversion to Mycophenolate Mofetil Monotherapy in Liver Recipients: Calcineurin Inhibitor Levels are Key

Abstract: The use of calcineurin inhibitors (CNI) after liver transplantation is associated with post-transplant nephrotoxicity. Conversion to mycophenolate mofetil (MMF) monotherapy improves renal function, but is related to graft rejection in some recipients. Our aim was to identify variables associated with rejection after conversion to MMF monotherapy. Conversion was attempted in 40 liver transplant recipients. Clinical variables were determined and peripheral mononuclear blood cells were immunophenotyped during a 12-month follow- up. Conversion was classified as successful (SC) if rejection did not occur during the follow-up. MMF conversion was successful with 28 patients (70%) and was associated with higher glomerular filtration rates at the end of study. It also correlated with increased time elapsed since transplantation, low baseline CNI levels (Tacrolimus ≤ 6.5 ng/mL or Cyclosporine ≤ 635 ng/mL) and lower frequency of tacrolimus use. The only clinical variable independently related to SC in multivariate analysis was low baseline CNI levels (p = 0.02, OR: 6.93, 95%, CI: 1.3-29.7). Mean baseline fluorescent intensity of FOXP3+ T cells was significantly higher among recipients with SC. In conclusion, this study suggests that baseline CNI levels can be used to identify recipients with higher probability of SC to MMF monotherapy. Clinicaltrials.gov identification: NCT01321112.

Calidad metodológica de las evaluaciones económicas completas, publicadas en revistas médicas cubanas (1999-2014) / Methodological quality of complete economic evaluations published in Cuban medical journals from 1999 to 2014

Objetivo: determinar la calidad metodológica de las evaluaciones económicas completas publicadas en revistas médicas cubanas. Métodos: estudio observacional, descriptivo y transversal en 21 artículos, declarados por su autores como evaluaciones económicas completas, publicados entre 1999 y 2014 en 47 revistas médicas cubanas reconocidas por el Ministerio de Ciencia, Tecnología y Medio Ambiente. A todos se les aplicó una guía de evaluación que incluyó: año de publicación, revista, objetivo, problema, opciones, horizonte temporal, perspectiva, costo, efectos sobre la salud y cálculo de las razones costo/efectividad. Resultados: los artículos se concentraron en ocho revistas. La mayor cantidad está en la Revista Cubana de Farmacia. Le siguieron en importancia la Revista Cubana de Salud Pública y MEDISAN. Ninguno de los aspectos estaba correctamente tratado en más de 80 por ciento de los trabajos revisados. Los resultados más desfavorables estaban en la declaración de la perspectiva, presente en menos de 20 por ciento de los trabajos y el análisis de sensibilidad en menos de 30 por ciento. Menos de la mitad de los trabajos abordaron adecuadamente la presentación del problema de investigación, los objetivos, el horizonte temporal, los costos y la razón costo efectividad incremental. No se encontró ningún artículo en los últimos tres años. Conclusiones: son escasas las evaluaciones económicas publicadas. La mayoría tiene limitaciones metodológicas. Se observa insuficiente desarrollo de esta temática en el país y apunta hacia la importancia de continuar insistiendo en la divulgación de los aspectos metodológicos básicos de estas evaluaciones tanto para investigadores como para revisores y editores de revistas científicas(AU)

Objective: to determine the methodical quality of complete economic evaluations published in Cuban medical journals from 1999 to 2014. Methods: observational, descriptive and cross-sectional study of articles classified by their authors as complete economic evaluations and published from 1999 to 2014 in 47 Cuban medical journals authorized by the Ministry of Science, Technology and Environment. The applied evaluation guide included year of publication, journal, objective, problem, options, time frame, prospects, cost, health effects and estimation of the cost/effectiveness ratio. Results: twenty one papers were found, but in the last three years no paper has been published. These papers were mainly published in eight journals, being the first Revista Cubana de Farmacia, followed by Revista Cubana de Salud Publica and MEDISAN. None of the aspects was correctly addressed in over 80 percent of revised papers. The worst results were found in statement of perspective present in less than 20 percent of papers in addition to sensitivity analysis in less than 30 percent of them. Almost 50 of papers adequately dealt with the submission of research problems, objectives, time frame, costs and the incremental cost/effectiveness ratio. Conclusions: published economic evaluations are still scanty and most of them exhibit methodological faults. There is insufficient development in this area nationwide, which points to the importance of insisting once again on the dissemination of the basic methodological aspects of these evaluations aimed at researchers who act as reviewers and as editors of scientific journals(AU)

Research and Applications of Shop Scheduling Based on Genetic Algorithms

ABSTRACT Shop Scheduling is an important factor affecting the efficiency of production, efficient scheduling method and a research and application for optimization technology play an important role for manufacturing enterprises to improve production efficiency, reduce production costs and many other aspects. Existing studies have shown that improved genetic algorithm has solved the limitations that existed in the genetic algorithm, the objective function is able to meet customers' needs for shop scheduling, and the future research should focus on the combination of genetic algorithm with other optimized algorithms. In this paper, in order to overcome the shortcomings of early convergence of genetic algorithm and resolve local minimization problem in search process,aiming at mixed flow shop scheduling problem, an improved cyclic search genetic algorithm is put forward, and chromosome coding method and corresponding operation are given.The operation has the nature of inheriting the optimal individual ofthe previous generation and is able to avoid the emergence of local minimum, and cyclic and crossover operation and mutation operation can enhance the diversity of the population and then quickly get the optimal individual, and the effectiveness of the algorithm is validated. Experimental results show that the improved algorithm can well avoid the emergency of local minimum and is rapid in convergence.

CHECKING: A última fronteira para a redução de riscos em contextos festivos / CHECKING: The last frontier for harm reduction in party settings

No contexto atual de proliferação de novas substâncias psicoativas (NSP) e de adulteração de substâncias psicoativas que circulam no mercado negro o Drug Checking é aqui encarado como uma estratégia major de redução de riscos e minimização de danos (RRMD). É um serviço que se tem vindo a afirmar como uma necessidade em termos de saúde pública, através da monitorização informal de mercados informais de substâncias psicoativas e emitindo alertas sempre que se identificam substâncias potencialmente tóxicas. É também uma boa prática na mediação da comunicação entre o técnico de RRMD e o utilizador de substâncias psicoativas, fornecendo informação objetiva sobre a substância que o utilizador disponibilizou para análise e produzindo e disseminando informação sobre os padrões de adulteração locais. Através da apresentação de práticas e resultados referentes à intervenção do projeto CHECK!NG, pretende-se neste artigo levantar pistas para uma reflexão sobre a pertinência e as particularidades de um serviço de Drug Checking em contexto festivos.

In the current context of proliferation of new psychoactive substances, and of adulteration of substances that circulate in the black market, Drug Checking is viewed here as a major Harm Reduction strategy. It is a service that has become a need in terms of public health, as it monitors informal drug markets and disseminates alerts whenever potentially toxic substances are identified. It also mediates communication between the harm reduction technician and the drug user, providing objective information about the drug that the user supplied for analysis, and also producing and disseminating information about local adulteration patterns. By presenting the main processes and outcomes of the intervention of the CHECK!NG project, the authors intend to reflect on the relevance, characteristics and constraints of a Drug Checking service in party settings.

Necesidad de la eficiencia económica en salud / Need of the economic efficiency in health

En cualquier sociedad con independencia de su nivel de desarrollo, los recursos siempre son insuficientes respecto a las demandas potenciales de sus individuos; por ello, se presenta el dilema de su uso alternativo, con lo cual siempre habrá que renunciar a determinadas opciones. Con el presente trabajo se demuestra la necesidad de la eficiencia económica en el sector sanitario, y se ofrecen algunas ideas generales de cómo contribuir a una mayor eficiencia en sanidad. La salud, como componente del bienestar general, demanda una cantidad cada vez mayor de recursos económicos, debido a las distintas transiciones que están teniendo lugar. Por otra parte, la relativa escasez de los recursos en relación con las demandas personales, impone la necesidad de su uso eficiente, a fin de lograr un mayor beneficio social.

In any society regardless of its development level, resources are always insufficient regarding the potential demands of its individuals; that is why the dilemma of its alternative use is presented, with which it will always be necessary to give up certain options. With the present work the necessity of the economic efficiency is demonstrated in the health sector, and some general ideas on how to contribute to a higher efficiency in health are offered. Health, as part of the general welfare, demands an increasing amount of economic resources, due to the different transitions that are taking place. Moreover, the relative scarcity of resources in relation to personal demands, imposes the need for its efficient use, in order to achieve a higher social benefit.