Implante transcateter de valva aórtica para o tratamento da estenose aórtica grave: uma revisão sistemática de estudos de avaliação econômica completa / Transcatheter aortic valve implantation for the treatment of severe aortic stenosis: a systematic review of complete economic evaluation studies

Objetivo: Comparar o implante transcateter de valva aórtica (TAVI) ao tratamento conservador em pacientes inoperáveis ou à cirurgia de troca valvar (SAVR) em pacientes com risco cirúrgico alto ou intermediário conforme a Society of Thoracic Surgeons (STS), por meio de uma revisão sistemática de avaliações econômicas completas. Avaliar a variabilidade de modelos econômicos, parâmetros, pressupostos e sua influência nos resultados finais. Métodos: Foi realizada uma busca da literatura nas bases Medline, EMBASE, Cochrane Library, Web of Science, SciELO e International HTA Base e busca manual. Foram incluídas análises econômicas completas baseadas em modelos econômicos publicadas entre 2011 e 2022, em português, inglês e espanhol. A qualidade dos estudos foi avaliada usando o instrumento QHES (Quality of Health Economic Studies). Resultados: Foram incluídos 36 estudos, majoritariamente análises de custo-utilidade (64%), da Europa (41%), utilizando dados de eficácia dos estudos PARTNER. O modelo de Markov (61%) foi predominante. O custo da prótese do TAVI foi um parâmetro de impacto na análise de sensibilidade nos três grupos. Os estudos alcançaram uma boa qualidade no instrumento QHES. Conclusão: O TAVI tendeu a ser custo-efetivo em relação aos comparadores. Os modelos não foram homogêneos nos parâmetros, horizontes temporais e taxa de desconto, podendo impactar a custo-efetividade do TAVI e dificultar a comparação dos resultados entre diferentes países e perspectivas.

ABSTRACT Objective: To compare transcatheter aortic valve implantation (TAVI) to conservative treatment in inoperable patients or to valve replacement surgery (SAVR) in patients at high or intermediate surgical risk according to the Society of Thoracic Surgeons (STS), through a systematic review of comprehensive economic evaluations. Evaluate the variability of economic models, parameters, assumptions and their influence on final results. Methods: A literature search was performed in Medline, EMBASE, Cochrane Library, Web of Science, SciELO and International HTA Base and manual search. Complete economic analyzes based on economic models published between 2011 and 2022 in Portuguese, English and Spanish were included. The quality of the studies was evaluated using the QHES (Quality of Health Economic Studies) instrument. Results: Thirty-six studies were included, mostly cost-utility analyses (64%), from Europe (41%), and using efficacy data from the PARTNER studies. The Markov model (61%) was predominant. The cost of the TAVI prosthesis was the most important parameter in the sensitivity analysis in the three groups. The studies achieved a good quality in QHES instrument. Conclusion: TAVI tended to be cost-effective relative to comparators. The models were not homogeneous in parameters, time horizons and discount rate, which may have an impact on the cost-effectiveness of TAVI, making it difficult to compare the results between different countries and perspectives.

Cost Analysis of a Culturally Appropriate, Community-Delivered Intervention to Increase Physical Activity.

PURPOSE: Understand the cost of delivering existing community-based, no cost to participant, aerobic dance and yoga classes in an underserved, racial and ethnic minority community in the Midwest. DESIGN: Pilot 4-month observational, descriptive, cost analysis of community fitness classes. SETTING: Community-wide, group-based, fitness classes online, and in parks and community centers in traditionally Black neighborhoods in Kansas City. PARTICIPANTS: Participants (N = 1428) were recruited from underserved, racial and ethnic minority areas of Kansas City, Missouri. INTERVENTION: Aerobic dance and yoga classes were provided free of charge to all residents of Kansas City, Missouri online and in-person. Each class was approximately 1 hour, with a warmup and cooldown. All classes were delivered by African American women. METHODS: Descriptive statistics of the costs for the program are presented. Cost per metabolic equivalents (MET) were calculated. Independent samples t-tests were conducted to examine differences between aerobic dance and yoga cost per MET. RESULTS: The total program costs were $10,759.88 USD, with 1428 participants attending 82 classes over the 4-month intervention. The cost per MET was $1.67, $1.11, and $0.74/MET-hour/session/attendee for low, moderate, and high-intensity aerobic dance, respectively, and $3.02/MET-hour/session/attendee for yoga. Aerobic dance had a significantly lower cost per MET than yoga (t = 13.6, P < .001, t = 47.6, P < .001, t = 92.8, P < .001, for low, moderate, and high-intensity, respectively). CONCLUSIONS: Delivering community-based, physical activity interventions in racial and ethnic minority communities is a potential way to increase physical activity. The costs of group-based fitness classes are similar to other physical activity interventions. Further research needs to be conducted on the costs to increase physical activity of traditionally underserved populations who suffer from higher rates of inactivity and comorbidities.

Cost utility analysis of cryopreserved amniotic membrane versus topical cyclosporine for the treatment of moderate to severe dry eye syndrome.

BACKGROUND: The purpose is to perform a cost effectiveness analysis amniotic membrane vs. topical medications in the use of treating dry eye disease. A cost effectiveness analysis comparing amniotic membrane + other topical medications to topical cyclosporine A + other topical medications was evaluated using accepted decision tree modeling software. METHODS: TreeAge Pro 2019 software was used to evaluate the base case costs over a one year timeframe. Sensitivity analysis was performed on those variables which had the greatest effect on choosing one therapy versus the other based on cost. Monte Carlo simulation was run 1,000 times to determine the most effective, least costly alternative. Costs were evaluated from a societal level (direct + indirect). Quality of life utility scores were evaluated using known time tradeoffs from prior studies (scale 0-1; with 1 being perfect vision). RESULTS: Over a one year timeframe, the base case demonstrated that amniotic membrane + topical medications was the less expensive alternative and provided for incremental utilities versus topical cyclosporine + other medications (Cost/utility: $18,275/0.78 vs. $20,740/0.74). If examining direct costs only, topical cyclosporine was the least expensive option over a one year timeframe: $4,112 vs. $10,300. Sensitivity analysis demonstrated that in order for topical cyclosporine to be the less expensive alternative the following variables would need to be: < 68 days productivity lost; < $161 productivity lost/day; > 79% of amniotic membrane implants would need to be re-implanted at month 4 (for whatever reason); > $2677 per amniotic membrane implant procedure (Medicare reimbursement rate); > 96% positive response to topical cyclosporine A at month 4; > 58% positive response to topical cyclosporine A at month 6 and; < 54% probability clinical improvement with amniotic membrane. Monte Carlo simulation demonstrated that amniotic membrane was the less costly, most effective alternative 91.5% of the time. CONCLUSION: Based on improved outcomes using amniotic membrane, patient productivity was improved resulting in lower societal costs (less days lost from work). When considering the untoward effects of dry eye disease on societal costs, an improvement of the dry eye disease condition was accomplished most often with amniotic membrane.

Health status, comorbidities and cost-of-illness in females with stress urinary incontinence living in the Canton of Bern.

INTRODUCTION: Two thirds of women suffering from stress urinary incontinence (SUI) reported a negative impact on quality of life (QoL). SUI can also lead to less physical activity and more comorbidities. SUI may result in a substantial economic burden on health care services but numbers are not clear. Therefore, the aim of this study was to estimate the health status, the comorbidities and the health costs of women with SUI living in the Canton of Bern (Switzerland). METHODS: This cost-of-illness (COI) study was embedded in an RCT (n=96) exploring the effect of two pelvic floor muscle training protocols in women with SUI. A prevalence-based COI study with a societal perspective and a bottom-up approach was applied. Baseline demographics, comorbidities and cost data were collected prospectively during 16 weeks. Descriptive statistics, a frequency and a one-way sensitivity analysis were performed. RESULTS: Thirty-seven participants volunteered in this COI study. About 95 % had at least one comorbidity. The most commonly reported problem was back pain (47.6 %). Fifty-one percent consulted a medical doctor, the prevalence of drug consumption was 70 %, 11 % reported less efficiency whilst working and 30 % less physical activity. Mental stress was mentioned by 59.5 % of the participants. The average health costs were CHF 2256. DISCUSSION: This COI study provided data on health status, comorbidities, QoL, health care use, productivity losses and costs of SUI. The high prevalence of comorbidities observed in this study was comparable to obese females of a similar age group. The high economic burden of SUI requires cost-effective preventive actions and clinical treatment concepts.

Cost-Effectiveness Methods and Newborn Screening Assessment.

Nowadays, health funding decisions must be supported by sound arguments in terms of both effectiveness and economic criteria. After more than half a century of newborn screening for rare diseases, the appropriate economic evaluation framework for these interventions is still challenging. The validity of standard methods for economic evaluation heavily relies on the availability of robust evidence, but collection of such evidence is precluded by the rareness of the conditions that may benefit from screening. Furthermore, there are a series of conceptual and methodological limitations that warrant further careful consideration when assessing the cost-effectiveness of newborn screening programs. In this chapter we provide a general overview of current economic evaluation methods and the challenges for their application to newborn screening programs.

Análise da produtividade da política de fusão de unidades hospitalares em Portugal integradas no Serviço Nacional de Saúde / Productivity analysis of hospital mergers in Portuguese National Health System

Objetivo: Avaliar a variação da produtividade dos hospitais sujeitos a uma política de fusão entre os anos 2005 e 2013. Métodos: Para a medição da produtividade recorreu-se ao índice de Malmquist, que considera em simultâneo a variação da eficiência e a variação da tecnologia (fronteira ou melhores práticas). A população-alvo foram os Centros Hospitalares criados entre 2003 e 2010. Os dados de custos e da produção realizada foram obtidos através da revisão crítica da literatura (relatórios de gestão do Ministério da Saúde). Foram comparados os Centros Hospitalares criados antes e depois da fusão com os hospitais que não foram submetidos a este processo. Resultados: 60% dos hospitais não apresentaram melhoria de produtividade com a reforma em estudo. A produtividade média antes da fusão era de 1,004 e após fusão desceu para 0,977. Os hospitais não sujeitos a processo de fusão apresentaram melhores resultados com produtividade média de 0,994. Conclusões: A política de fusão de unidades de saúde não gerou ganhos de produtividade no médio prazo e os resultados em média demonstraram-se menos positivos no período pós fusão.

Objective: Evaluation of the productivity in hospitals merger between 2005 and 2013. Methods: Malmquist index for the measurement of productivity resorted to the Malmquist index. This method considers the simultaneous variation of the efficiency and the variation of technology (best practices). The target population were the hospitals created between 2003 and 2010. Data were obtained from critical literature review (Ministry of Health management reports). The model considers the change in efficiency and the change in technology, achieved on the basis of cost and production data held for the hospital centers created before and after the merger and for comparison with the hospitals that were not merged. Results: 60% of hospitals showed no improvement in productivity with the reform in the study, the average productivity before the merger was 1,004 and after melting down to 0.977. Hospitals not subject to merger process showed better results with an average yield of 0.994. Conclusions: The health units merger policy does not generate productivity gains in the medium term and the results showed on average are less positive.

Cost-effectiveness of a computerized provider order entry system in improving medication safety ambulatory care.

BACKGROUND: Computerized provider order entry (CPOE) is the process of entering physician orders directly into an electronic health record. Although CPOE has been shown to improve medication safety and reduce health care costs, these improvements have been demonstrated largely in the inpatient setting; the cost-effectiveness in the ambulatory setting remains uncertain. OBJECTIVE: The objective was to estimate the cost-effectiveness of CPOE in reducing medication errors and adverse drug events (ADEs) in the ambulatory setting. METHODS: We created a decision-analytic model to estimate the cost-effectiveness of CPOE in a midsized (400 providers) multidisciplinary medical group over a 5-year time horizon- 2010 to 2014-the time frame during which health systems are implementing CPOE to meet Meaningful Use criteria. We adopted the medical group's perspective and utilized their costs, changes in efficiency, and actual number of medication errors and ADEs. One-way and probabilistic sensitivity analyses were conducted. Scenario analyses were explored. RESULTS: In the base case, CPOE dominated paper prescribing, that is, CPOE cost $18 million less than paper prescribing, and was associated with 1.5 million and 14,500 fewer medication errors and ADEs, respectively, over 5 years. In the scenario that reflected a practice group of five providers, CPOE cost $265,000 less than paper prescribing, was associated with 3875 and 39 fewer medication errors and ADEs, respectively, over 5 years, and was dominant in 80% of the simulations. CONCLUSIONS: Our model suggests that the adoption of CPOE in the ambulatory setting provides excellent value for the investment, and is a cost-effective strategy to improve medication safety over a wide range of practice sizes.

Cáncer de colon: análisis del costo de enfermedad para los estadios III y IV en Cansercoop ips / Colon cancer: analysis of disease cost to iii and iv stages in Cansercoop ips

El cáncer de colon presenta una incidencia creciente en la sociedad colombiana y es una de las principales causas de morbi-mortalidad en este grupo de enfermedades, con una gran carga emocional y económica. Desde el punto de vista del efecto económico no hay mucha información en el contexto colombiano. Por tal razón, este trabajo hace un análisis de caso en una institución prestadora de servicios (ips), aplicando la metodología de “costo enfermedad” basada en la prevalencia de la enfermedad. Objetivo: estimar costos totales, directos e indirectos, para cáncer de colon, establecer una distribución de recursos para estadios iii y iv. Método: se empleó el modelo de análisis de costo de enfermedad por prevalencia, en pacientes diagnosticados en estadios iii y iv con cáncer de colon, entre enero de 2005 y octubre de 2007, y se revisó una base de datos en cansercoop ips. Resultados: se identificaron 79 individuos, 44 en estadio iii de la enfermedad y 35 en estadio iv; el 59,5 son mujeres. De acuerdo con la edad, el 45,6 son mayores de 60 años, y el 58,2 están afiliados a Salud Total como empresa promotora de salud (eps). El costo total fue $ 348.254.762; 98,41 costos directos y 1,59 costos indirectos; el costo promedio por paciente fue $ 1.700.816 (49.288-11.529.013), estadio iii y $ 7.653.742 (13.523-70.354.423), estadio iv. El 65,66 de los costos totales corresponde a medicamentos. Conclusiones: los costos totales, de acuerdo con los estadios iii y iv de cáncer de colon, son de $ 77.143.347 y $ 271.111.415, respectivamente, en los que los medicamentos representan $ 42.444.492 para el estadio iii y $ 182.570.717 para el iv. Este análisis puede considerarse un estudio preliminar; sin embargo, representa un paso para posteriores evaluaciones económicas en salud.

The cancer colon has an increased incidence in Colombia and is a leading causes of mortality and morbidity in this group of diseases with a high economic and emotional burden, from the standpoint of economic impact there is little information in the Colombian context, for this reason, this work makes a case study in a health institution providing services, applying the methodology of “Cost of Illness” based on the prevalence of disease. Aim: To estimate the whole costs, both direct and indirect to cancer colon; establishing a distribution resources to iii and iv stages. Method: analysis cost of Illness was used in patients were diagnosed as having both iii and iv stages with cancer colon, from January 2005 to October 2007; checking a base data in cansercoop ips. Results: 79 people were identified, 44 (iii stage) and 35 (iv stage), 59.9 of all of them are women up to 60 years old and 58.2 belong to Salud Total. The total cost was $ 348.254.762, 98.4 were direct costs and 1.59 were indirect costs. Average cost for each patient was $ 1.700.816 (49.288-11.529.013), iii stage and $ 7.653.742 (13.523-70.354.423), iv stage. 65.66 are medicines. Conclusions: the total costs, both iii and iv stages were $ 77.143.347 and $ 271.111.415 in iii stage and $182.570.717 in iv stage. This analysis can be considered as a preliminary study; however it means a step to subsequent economic health assessments.