Time-driven activity-based costing as a strategy to increase efficiency: An analyses of interventional coronary procedures.

Monitoring the costs is one of the key components underlying value-based health care. This study aimed to evaluate the cost-saving opportunities of interventional coronary procedures (ICPs). Data from 90 patients submitted to elective ICP were evaluated in five Brazilian hospitals. Time-driven activity-based costing, that guides the cost estimates using the time consumed and the capacity cost rates per resource as the data input, was used to assess costs and the time spent over the care pathway. Descriptive cost analyses were followed by a labour cost-saving estimate potentially achieved by the redesign of the ICP pathway. The mean cost per patient varied from $807 to $2639. The length of the procedure phase per patient was similar among the hospitals, while the post-procedure phase presented the highest variation in length. The highest direct cost saving opportunities are concentrated in the procedure phase. By comparing the benchmark service with the most expensive one, it was estimated that redesigning physician practices could decrease 51% of the procedure cost. This application is pioneered in Brazil and demonstrates how detailed cost information can contribute to driving health care management to value by identifying cost-saving opportunities.

Nuclear Medicine Methods for Assessment of Chronic Chagas Heart Disease

Abstract Several different imaging methods can be used to evaluate patients with Chagas heart disease (CHD) for diagnostic and prognostic purposes, including plain chest radiography; echocardiography; myocardial perfusion scintigraphy, for detection of ischemia and fibrosis; radionuclide gated-angiography, for evaluation of biventricular function; 123I-MIBG labeling of sympathetic myocardial innervation; MRI, for detection and quantitation of myocardial fibrosis; and coronary angiography. This study aims to review the contributions of these nuclear medicine methods to understanding of the pathophysiology of chronic Chagas cardiomyopathy (CCC). Careful analysis and integration of findings provided by these imaging methods in patients with CCC at different stages has contributed significantly to improving understanding of several peculiarities of the disease. Clinical and experimental studies in animal models show that perfusion abnormalities detected in association with dysfunctional but viable myocardium are a common finding in CCC patients and correspond to areas of cardiac sympathetic denervation, as assessed by 123I-MIBG imaging. Furthermore, recent reports have demonstrated a close relationship between coronary microvascular disturbances and myocardial inflammation. Thus, ongoing research, mainly focused on refinements of 18F-FDF -PET techniques and further exploration of nuclear methods, such as SPECT, have the potential to contribute to detection and monitoring of early subclinical myocardial damage thereby enabling evaluation of therapeutic strategies targeting inflammation and microvascular ischemia that could result in better prognostic stratification of patients with CHD.

Sudden Cardiac Death in Brazil: A Community-Based Autopsy Series (2006-2010) / Morte Súbita Cardíaca no Brasil: Análise dos Casos de Ribeirão Preto (2006-2010)

Background: Sudden cardiac death (SCD) is a sudden unexpected event, from a cardiac cause, that occurs in less than one hour after the symptoms onset, in a person without any previous condition that would seem fatal or who was seen without any symptoms 24 hours before found dead. Although it is a relatively frequent event, there are only few reliable data in underdeveloped countries. Objective: We aimed to describe the features of SCD in Ribeirão Preto, Brazil (600,000 residents) according to Coroners’ Office autopsy reports. Methods: We retrospectively reviewed 4501 autopsy reports between 2006 and 2010, to identify cases of SCD. Specific cause of death as well as demographic information, date, location and time of the event, comorbidities and whether cardiopulmonary resuscitation (CPR) was attempted were collected. Results: We identified 899 cases of SCD (20%); the rate was 30/100000 residents per year. The vast majority of cases of SCD involved a coronary artery disease (CAD) (64%) and occurred in men (67%), between the 6th and the 7th decades of life. Most events occurred during the morning in the home setting (53.3%) and CPR was attempted in almost half of victims (49.7%). The most prevalent comorbidity was systemic hypertension (57.3%). Chagas’ disease was present in 49 cases (5.5%). Conclusion: The majority of victims of SCD were men, in their sixties and seventies and the main cause of death was CAD. Chagas’ disease, an important public health problem in Latin America, was found in about 5.5% of the cases. .

Fundamento: Morte súbita cardíaca (MSC) é um evento súbito e inesperado, de causa cardiovascular, que ocorre em menos de uma hora após o início dos sintomas, em indivíduo sem qualquer condição clínica prévia potencialmente fatal ou assintomático nas últimas 24 horas antes do óbito, em caso de morte não testemunhada. Apesar de ser um evento relativamente frequente, há poucos dados confiáveis na literatura sobre países em desenvolvimento. Objetivo: Descrever as características da MSC em Ribeirão Preto (SP 600.000 habitantes) baseando-se nos relatórios de autopsias do Serviço de Verificação de Óbitos do Interior. Métodos: Foram revisados retrospectivamente 4.501 relatórios de autopsias entre 2006 e 2010, para identificar casos de MSC. Foram coletados dados como causa específica do óbito, características demográficas e comorbidades das vítimas, data, local e hora do evento, e se foram realizadas manobras de ressuscitação cardiopulmonar (RCP). Resultados: Foram identificados 899 casos de MSC (20%; razão 30/100.000 habitantes por ano). A principal causa de MSC foi doença arterial coronariana (DAC - 64%), acometendo homens (67%) entre a sexta e a sétima década de vida. A maior parte dos eventos ocorreu durante a manhã, no domicílio (53,3%), e a RCP foi realizada em quase metade das vítimas (49,7%). A comorbidade mais prevalente foi hipertensão arterial sistêmica (57,3%). Doença de Chagas foi detectada em 49 casos (5,5%). Conclusão: A maioria dos casos de MSC ocorreu por DAC em homens entre a sexta e a sétima década de vida. Doença de Chagas, um importante problema de saúde pública na América Latina, foi detectada em 5,5% dos casos. .

Avaliação a médio prazo do controle de fatores de risco de doença cardiovascular em corte prospectiva de pacientes de alto risco tratados por intervenção coronária percutânea / Middle-term assessment of cardiovascular risk factor control in a prospective cohort of high-risk patients treated by percutaneous coronary intervention

INTRODUÇÃO: A prevenção secundária após intervenção coronária percutânea (ICP) é fundamental para melhorar a sobrevida livre de eventos e consiste principalmente no controle de fatores de risco. Analisou-se a prevenção secundária de pacientes de alto risco, incluídos prospectivamente no estudo Sequence Variation in Platelet Aggregation in Response to Clopidogrel and aspirin (SPARC). MÉTODOS: Foram arrolados 187 pacientes consecutivos entre dezembro de 2009 e fevereiro de 2011, tratados por ICP com stent e avaliados em retornos ambulatoriais de 30 dias, 3 meses, 6 meses e 12 meses quanto ao controle de hipertensão arterial, disglicemia, dislipidemia e tabagismo, e medidas terapêuticas respectivas. RESULTADOS: Houve aumento significativo de pacientes com controle pressórico (29%; P = 0,02), que cessaram tabagismo (18%; P = 0,003), e que receberam hipolipemiantes (19%; P < 0,0001) entre a internação para ICP e o primeiro retorno após o procedimento. Esse melhora do controle de fatores de risco refletiu-se em redução do escore de risco de Framingham médio observado no mesmo período (9,9%; P < 0,0001). Durante seguimento de até 12 meses o ganho atingido na internação para ICP se manteve para todos os fatores de risco. CONCLUSÕES: Observou-se efeito importante relativamente à internação índice para ICP, com aumento da prescrição de medicamentos para controle de fatores de risco e alcance de metas. Esse estudo identifica relevante janela de oportunidade para priorização do controle de fatores de risco na internação inicial, quando ganhos expressivos são observados e mantidos. Mas também explicita que esforços adicionais são necessários para expandir o benefício da prevenção secundária no seguimento a médio prazo de pacientes tratados por ICP.

BACKGROUND: Secondary prevention after percutaneous coronary intervention (PCI) is essential to increase event-free survival and consists mainly in risk factor control. We analyzed the secondary prevention of high-risk patients included prospectively in the Sequence Variation in Platelet Aggregation in Response to Clopidogrel and aspirin trial (SPARC). METHODS: From December 2009 to February 2011 we enrolled 187 consecutive patients who were submitted to PCI with stent implantation and were evaluated in outpatient visits at 1, 3, 6, and 12 months of follow-up for the control of hypertension, dysglycemia, hyperlipidemia and smoking and their respective therapeutic measures. RESULTS: There was a significant increa­se in the number of patients with controlled hypertension (29%; P = 0.02), who stopped smoking (18%; P = 0.003), and received statins (19%; P < 0.0001) between the index PCI and the first follow-up visit. The risk factor control improvement led to a decrease in the mean Framingham risk score (9.9%; P < 0.0001). During the 12 months follow-up the gains achieved at PCI admission were maintained for all risk factors. CONCLUSIONS: An important effect was observed on the index PCI admission with increased prescription of risk factor control drugs and achievement of therapeutic goals. This study identifies a relevant opportunity window for risk factor control at the index admission, when substantial gains are observed and maintained. However, it also shows further efforts are required to expand the benefit of secondary prevention in the middle-term follow-up of patients treated by PCI.

Estratégias populacionais em promoção de saúde cardiovascular / Population strategies in promoting cardiovascular health

De acordo com a Organização Mundial de Saúde, "saúde é um estado de completo bem-estar físico, mental e social, e não apenas a ausência de doenças". Tendo em vista este ideal, a saúde é mantida e melhorada, não só por meio da promoção e aplicação da Medicina, mas também pela melhoria da qualidade de vida do indivíduo e da sociedade. Um terço de todos os óbitos mundiais é resultado das doenças cardiovasculares, colocando-as como a principal causa de morte, afetando principalmente a faixa etária mais produtiva de uma nação, prejudicando o desenvolvimento socioeconômico e familiar de todo um país. A piora dos hábitos alimentares, o aumento do nível de sedentarismo e do tabagismo incrementou a ocorrência destas doenças. O monitoramento da prevalência dos fatores de risco para DCV, no âmbito epidemiológico, permite, por meio das evidências científicas observadas, a implementação de ações preventivas com melhor custo-efetividade. No entanto, uma mudança no padrão comportamental e nos hábitos de vida de uma população, está estreitamente relacionada com padrões culturais, sociais, do modismo, do consumo, da oferta e demandas estabelecidas pela sociedade que a compõem. Desta forma além de prevenção primária, a promoção da saúde tem-se demonstrado uma alternativa teórica e prática para a resolução integral dos fatores que constituem o quadro epidemiológico das DCVs. O envolvimento de organizações comunitárias promove estratégias que visam mudança de comportamento de risco e de sua sustentabilidade, com base na prevenção primária dos fatores de risco e na promoção da saúde por meio da mobilização comunitária, de comunicação de massa e interação individual, identificação populacional e intervenções que visam a mudanças ambientais. Algumas experiências comunitárias realizadas desde os meados do último século comprovaram a importância de uma ação global e abrangente. Muitos estudos populacionais demonstraram que é possível mudar o rumo da incidência das doença...

According to the World Helth Orgazination, "Health s a state of complete physical, mental and social well-being, and not merely the absence of disease". In view of this ideal, healt is maintained and improved, not only by promoting and applying the Medicine, but also by improving the quality of life of the individual and of society. A third of all global deaths result from cardiovascular disease placing them as the leading cause of death mainly affecting the most productive age group harming the socioeconomic and family development of na entire nation. The worsening dietary habits, na increase in the level of physical inactivity and smoking increased the occurence of these disease. The monitoring of the prevalence of CVD risk factors in the epidemiological scope allows, by means of scientific evidence observed, the implementation of preventive actions with better cost effectiveness, However a change in ehavioral pattern and life habits of a population is closely related to culture, social standard, fad, consuptiom, supply and demands laid down by the society. In this way, in addition to the primary prevention, health promotion has been shown to be a theoretical and practical alternative to the full resolution of the factors that constitute the framework of epidemiological CVDs. The envolvement of community organizations will promote strategies aimed at changing risky behavior and its sustainability, based on the primary prevention and risk factors in health promotion through community mobilization, mass media and individual interaction, population identification and interventions aimed at enviromental changes. Some community experiences carried out since the middle of last century have proved the importance of a global and comprehensive action. Many population studies have shown that it is possible to change the direction of incidence of cardiovascular diseases...

Prediction of left ventricular wall motion recovery after acute myocardial infarction by Tl-201 gated SPECT: incremental value of integrated contractile reserve assessment.

BACKGROUND: This investigation tested the application of low-dose dobutamine (LDD) gated single photon emission computed tomography (SPECT) with thallium 201 for myocardial viability detection early after acute myocardial infarction (AMI). METHODS AND RESULTS: Thirty-two hemodynamically stable post-AMI patients (aged 55 +/- 5 years [mean +/- SEM]; 20 men) who were exhibiting regional left ventricular dysfunction underwent stress-redistribution Tl-201 scanning within 4 to 8 days, followed by 2 additional gated SPECT acquisitions after Tl-201 reinjection, at rest and during LDD. A visual 5-point score was computed for segmental radiotracer uptake (0, normal; 4, absent) and a 4-point score for left ventricular wall motion (1, normal; 4, dyskinesis). Predominant viable myocardium in dyssynergic regions was predicted by a mean Tl-201 uptake score of 2 or less or ischemic area of 30% or greater. These indices showed a significant association with wall motion improvement in follow-up echocardiographic studies (overall accuracy = 0.69, sensitivity = 0.93, and specificity = 0.50). Regarding the response to LDD stimulus, an increase in mean wall motion score of 30% or greater was predictive of predominant viable myocardium. Contractile reserve assessment yielded a significant increment in the predictive accuracy for function recovery (overall accuracy = 0.84, sensitivity = 0.71, and specificity = 0.94). CONCLUSIONS: Evaluation of contractile reserve by means of LDD gated SPECT with Tl-201 is safely feasible early after AMI, with incremental value over perfusion assessment alone for myocardial viability detection.