Análise de impacto orçamentário de dispositivos contraceptivos na saúde suplementar brasileira / Budget impact analysis of contraceptive devices on Brazilian supplementary health

Objetivo: Analisar o impacto orçamentário da adoção de dispositivos contraceptivos reversíveis de longa duração em uma operadora de plano de saúde localizada no Sul do Brasil. Especificamente, analisamos a incorporação do implante subdérmico de etonogestrel (Implanon®) como alternativa ao sistema intrauterino de levonorgestrel (DIU Mirena® ou DIU Kyleena®), ao longo de um período de 15 anos. Métodos: Realizamos uma análise do impacto orçamentário incremental, considerando a inclusão gradual do implante subdérmico de etonogestrel. Foram considerados dados de uma operadora de planos de saúde com mais de 600.000 beneficiários. O horizonte temporal de 15 anos permitiu uma avaliação abrangente dos efeitos financeiros. Resultados: Identificamos 5.345 pacientes elegíveis para a utilização de contraceptivos reversíveis de longa duração. No cenário em que somente o sistema intrauterino de levonorgestrel era adotado, projetou-se um impacto orçamentário total de R$ 746.379.857,80 ao longo de 15 anos. No cenário alternativo, com a incorporação gradual do implante subdérmico, o impacto orçamentário total foi calculado em R$ 689.800.196,83. Isso resultou em um impacto orçamentário incremental negativo de -R$ 56.579.660,97 ao longo do período. Conclusão: A análise de impacto orçamentário realizada indica um potencial benefício financeiro ao adotar o implante subdérmico de etonogestrel como alternativa ao sistema intrauterino de levonorgestrel para contracepção. Esse achado sugere possíveis reduções de custos na área de saúde suplementar no Brasil, reforçando a importância de avaliar opções economicamente viáveis.

Objective: To analyze the budgetary impact of the adoption of long-acting reversible contraceptive devices in a health plan operator located in southern Brazil. Specifically, we analyzed the incorporation of the etonogestrel subdermal implant (Implanon®) as an alternative to the levonorgestrel intrauterine system (Mirena® IUD or Kyleena® IUD), over a period of 15 years. Methods: We performed an analysis of the incremental budgetary impact, considering the gradual inclusion of the etonogestrel subdermal implant. Data from a health plan operator with more than 600,000 beneficiaries were considered. The 15-year time horizon allowed for a comprehensive assessment of the financial effects. Results: We identified 5,345 patients eligible for the use of long-acting reversible contraceptives. In the scenario where only the levonorgestrel intrauterine system was adopted, a total budget impact of BRL 746,379,857.80 was projected over 15 years. In the alternative scenario, with the gradual incorporation of the subdermal implant, the total budgetary impact was calculated at BRL 689,800,196.83. This resulted in a negative incremental budgetary impact of -R$56,579,660.97 over the period. Conclusion: The budget impact analysis carried out indicates a potential financial benefit in adopting the etonogestrel subdermal implant as an alternative to the levonorgestrel intrauterine system for contraception. This finding suggests possible cost reductions in the supplementary healthcare area in Brazil, reinforcing the importance of evaluating economically viable options.

Optimized pathway to schistosomiasis elimination in China: a scrutiny using a marginal benefit approach / 中国血吸虫病防治杂志

Following concerted efforts for over 7 decades, great achievements have been gained in the national schistosomiasis control program of China. Currently, China is moving towards the stage of schistosomiasis elimination, when the major task is to make full use of available resources to improve schistosomiasis surveillance and response to sustainably consolidate gained schistosomiasis control achievements and prevent re-emerging schistosomiasis. There is therefore an urgent need for optimization of interventions for schistosomiasis elimination. Based on analysis of socioeconomic features at different stages of the national schistosomiasis control program in China, this review discusses the relationship between the needs of assessment of schistosomiasis elimination interventions and the optimized strategy of schistosomiasis elimination at different stages of the national schistosomiasis control program using a marginal benefit approach and proposes the optimized schistosomiasis elimination strategy that allows the highest marginal benefit with currently available schistosomiasis elimination costs, so as to provide the optimal strategic pathway to schistosomiasis elimination and facilitate the achievement of the targets set in Healthy China 2030.

Expected Benefits and Challenges of Using Economic Evaluations to Make Decisions About the Content of Newborn Screening Programs in Vietnam: A Scoping Review of the Literature

Abstract Screening newborns for genetic and other diseases is one of the most effective ways to improve health and reduce disease in a population. In developed countries, newborn screening has been a cornerstone of public health for decades. In many developing countries, however, newborn screening is still in its infancy. Many countries still lack screening programs. When a program is available, it generally lacks well-defined criteria on which decision-makers can justify the choice of diseases screened for and the methods used. One of the reasons put forward to understand this observation is the fact that little consideration is given by decision-makers to economic evaluations as a pillar of decision-making, as is the case in industrialized countries. This article provides a brief description of the challenges of using economic evaluation of newborn screening in developing countries. This will be illustrated by the example of the national newborn screening program in Vietnam.

Cost-effectiveness analysis of ‘test and treat’ policy for antiretroviral therapy among heterosexual HIV population in India

Background & objectives: The World Health Organisation recommended immediate initiation of antiretroviral therapy (ART) in all adult human immunodeficiency virus (HIV) patients regardless of their CD4 cell count. This study was undertaken to ascertain the cost-effectiveness of implementation of these guidelines in India. Methods: A Markov model was developed to assess the lifetime costs and health outcomes of three scenarios for initiation of ART treatment at varying CD4 cell count <350/mm3, <500/mm3 and test and treat using health system perspective using life-time horizon. A few input parameters for this model namely, transition probabilities from one stage to another stage of HIV and incidence rates of TB were calculated from the data of Centre of Excellence for HIV treatment and care, Chandigarh; whereas, other parameters were obtained from the published literature. Total HIV-related deaths averted, HIV infections averted and incremental cost-effectiveness ratio per quality adjusted life years (QALYs) gained were calculated. Result: Test and treat intervention slowed down the progression of disease and averted 18,386 HIV-related deaths, over lifetime horizon. It also averted 16,105 new HIV infections and saved 343,172 QALYs as compared to the strategy of starting ART at CD4 cell count of 500/mm3. Incremental cost per QALY gained for the immediate initiation of ART as compared to ART at CD4 cell count of 500/mm3 and 350/mm3 was ? 46,599 and 80,050, respectively at reported rates of adherence to the therapy. Interpretation & conclusions: Immediate ART (test and treat) is highly cost-effective strategy over the past criteria of delayed therapy in India. Cost-effectiveness of this policy is largely because of reduction in the transmission of HIV

Economic evaluation of hepatitis A vaccines by income level of the country: A systematic review

Background & objectives: Although several reviews of economic evaluation (EE) studies on hepatitis A virus (HAV) vaccine exist, there remains a need to corroborate such data from time to time. This study aimed to systematically review the literature for reports on EE of HAV vaccination by type of population, characteristics of intervention and income level of the country. Methods: PubMed and Scopus were searched to identify relevant studies from inception up to May 2021 using topic-specific key words in various combinaiton. Full EE studies comparing HAV vaccination to no vaccine or immunoglobulin were included. The risk of bias was assessed by using the ECOBIAS checklist. Results: Among the 1984 identified studies, 43 were found eligible. Of these, 27 were from high-income countries (HICs), 15 from middle-income countries (MICs), and one from low income country. Majority of the studies used Markov model and/or decision tree (n=26). Eight studies used a dynamic model. The discount rate, perspective and time horizon varied across the studies. Universal HAV vaccination without screening was cost-effective among children (14/16, 87.5%) and adolescents (1/5, 20%) but not in adults (0/4, 0%). Analysis by the level of income found that universal HAV vaccination among children without screening was cost-effective in 81.8 per cent of the studies conducted in MICs (9/11) as compared to 66.7 per cent in HICs (4/6). About one-third of the studies conducted among children found that screening and HAV vaccination were cost-effective compared to no vaccination. Interpretation & conclusions: The finding of this review suggest that universal vaccination of children without screening was likely to be cost-effective, especially in MICs. Nevertheless, it should be noted that the methodology varied across studies. Several aspects should also be considered in transferring the EE results across jurisdictions.

Gestão do cuidado ao paciente com doença hemato-oncológica sob a perspectiva do SUS: análise de hospitalizações e avaliação econômica do daratumumabe no tratamento do mieloma múltiplo / Health care manegement for patients with hematologic malignances from the perspective of the Brazilian Public Health System: analysis of hospitalizations and economic evaluation of daratumumab in the treatment of multiple myeloma

Com o objetivo de contribuir para a gestão do Sistema único de Saúde (SUS) no que se refere às neoplasias hematológicas (NH), este trabalho apresenta a elaboração de dois estudos: (a) analise de custos por hospitalização por NH, e (b) avaliação de custo-efetividade da adição de daratumumabe ao esquema de tratamento do Mieloma Múltiplo (MM) em pacientes não elegíveis para transplante autológico de células tronco hematopoiéticas (TCTH). Por meio da extração de dados do sistema de internações hospitalares do SUS, desenvolveu-se uma análise retrospectiva descritiva de frequências e custos das internações por NH de acordo com sua distribuição temporal, espacial (por estados e regiões), e por patologia, na década compreendida entre os anos de 2010 e 2019. Foram também calculados custo médio pro procedimento e taxa de acesso. Foi observado que houve uma tendência de crescimento estável das frequências e dos custos ao longo do período analisado. Além disso, contatou-se uma significativa discrepância na frequência dos procedimentos entre as regiões Norte e Sudeste, que registraram o menor e o maior número de procedimentos, respectivamente. Observou-se também eu a frequência das internações por patologia não refletiu a incidência estimada pela literatura no país para cada uma das patologias avaliadas. Para o estudo de custo-efetividade, foi desenvolvido um modelo de simulação de sobrevida particionado para a adição do daratumumabe ao esquema de tratamento composto por bortezomibe, melfalano e prednisona (VMP). O horizonte temporal de 30 anos e a perspectiva de análise do SUS, foram usados. Com base nos dados da literatura foi possível observar que a adição deste medicamento ao VMP no tratamento desses pacientes pode aumentar a sobrevida global e a sobrevida livre de progressão. Considerados os custos relacionados a esta tecnologia e ao manejo do paciente no cenário brasileiro, no entanto, a inclusão do daratumumabe está aparentemente acima do limiar de aceitabilidade adotado pelo SUS. Para que esta estratégia seja custo-efetiva no cenário observado, a tecnologia precisaria sofrer uma redução de quase 50% no custo. O estudo, portanto, não recomenda a adição do daratumumabe ao VMP no tratamento do MM em pacientes não elegíveis para TCTH.

Aiming to contribute to the management of the Brazilian Public Health System (SUS) regarding hematologic malignances (NH), this work presents the development of two studies: (a) cost analysis per hospitalization for NH, and (b) cost-effectiveness evaluation of adding daratumumab to the treatment scheme for Multiple Myeloma (MM) in patients not eligible for autologous hematopoietic stem cell transplantation (TCTH). By extracting data from the SUS hospital admissions system, we developed a retrospective descriptive analysis of frequencies and costs of NH admissions according to their temporal, spatial distribution (by states and regions), and by pathology, in the decade between the years 2010 and 2019. Average cost per procedure and access rate were also estimated. It was observed that there was a stable growth trend in frequencies and costs over the analyzed period. Furthermore, a significant discrepancy in the procedure frequency was found between the North and Southeast regions, which recorded the lowest and highest number of procedures, respectively. It was also observed that the frequency of hospitalizations per pathology did not reflect the incidence estimated by the literature in the country for each of the pathologies evaluated. For the cost-effectiveness study, a partitioned survival simulation model was developed for the inclusion of daratumumab in the treatment scheme consisting of bortezomib, melphalan, and prednisone (VMP). A 30-year time horizon and the perspective of the SUS were used for the analysis. Based on literature data, it was possible to observe that the inclusion of this drug to VMP in the treatment of these patients can increase overall survival and progression-free survival. Considering the costs related to this technology and patient management in the Brazilian scenario, however, the inclusion of daratumumab is seemingly above the threshold of acceptability adopted by SUS. For this strategy to be cost-effective in the observed scenario, the technology would require a cost reduction of almost 50%. The study, therefore, does not recommend the inclusion of daratumumab to VMP in the treatment of MM in patients not eligible for TCTH.

The case for investment in tobacco control: lessons from four countries in the Americas / El caso de la inversión en el control del tabaco: las enseñanzas de cuatro países de la Región de las Américas / Em defesa do investimento no controle do tabaco: lições de quatro países das Américas

ABSTRACT Objective. To synthesize learnings from four national tobacco control investment cases conducted in the Americas (Colombia, Costa Rica, El Salvador, Suriname) under the World Health Organization Framework Convention on Tobacco Control (WHO FCTC) 2030 project, to describe results and how national health authorities have used the cases, and to discuss implications for the role of investment cases in advancing tobacco control. Methods. We draw on findings from four national investment cases that included 1) a cost-of-illness analysis calculating the health and economic burden of tobacco use, 2) a return-on-investment analysis of implementing key tobacco control demand reduction measures, and 3) a subsidiary analysis of one tobacco control topic of national interest (e.g., equity implications of cigarette taxation). Co-authors reported how cases have been used to advance tobacco control. Results. In Colombia, Costa Rica, El Salvador, and Suriname, tobacco use causes social and economic losses equivalent to between 1.0 to 1.8 percent of GDP. Across these countries, implementing WHO FCTC demand reduction measures would save an average of 11 400 lives per year over the next 15 years. Benefits of the measures would far outweigh the costs of implementation and enforcement. Governments are using the cases to advance tobacco control, including to improve tobacco control laws and their enforcement, strengthen tobacco taxation, prioritize tobacco control planning, coordinate a multisectoral response, and engage political leaders. Conclusions. National investment cases can help to strengthen tobacco control in countries, including by increasing public and political support for implementation of the WHO FCTC and by informing effective planning, legislation, coordination and financing.

RESUMEN Objetivo. Resumir las enseñanzas de cuatro casos nacionales de inversión en el control del tabaco llevados a cabo en la Región de las Américas (Colombia, Costa Rica, El Salvador y Surinam) en el marco del proyecto 2030 del Convenio Marco de la Organización Mundial de la Salud para el Control del Tabaco (CMCT), describir los resultados y cómo las autoridades nacionales de salud han empleado los casos, y abordar las implicaciones para la función de los casos de inversión en el avance del control del tabaco. Métodos. Este estudio está basado en los hallazgos de cuatro casos de inversión nacional que incluían 1) un análisis del costo de la enfermedad que estima la carga sanitaria y económica del consumo de tabaco, 2) un análisis del rendimiento de la inversión de la ejecución de medidas clave de reducción de la demanda en el control del tabaco, y 3) un análisis subsidiario de un tema de interés nacional sobre el control del tabaco (por ejemplo, el impacto en la equidad de los impuestos sobre los cigarrillos). Los coautores notificaron cómo se han utilizado los casos para avanzar en el control del tabaco. Resultados. En Colombia, Costa Rica, El Salvador y Surinam, el consumo de tabaco causa pérdidas sociales y económicas equivalentes a entre el 1,0 y el 1,8 por ciento del PIB. En todos estos países, la aplicación de las medidas de reducción de la demanda recogidas en el CMCT de la OMS salvaría una media de 11 400 vidas al año en los próximos 15 años. Los beneficios de estas medidas superarían con creces los costos de ejecución y cumplimiento. Los gobiernos están utilizando los casos para avanzar en el control del tabaco, como para mejorar las leyes de control y su aplicación, reforzar los impuestos sobre el tabaco, priorizar la planificación del control del tabaco, coordinar una respuesta multisectorial e involucrar a los líderes políticos. Conclusiones. Los casos de inversión nacional pueden ayudar a fortalecer el control del tabaco en los países, por ejemplo, al aumentar el apoyo público y político a la aplicación del CMCT de la OMS y al informar sobre una planificación, legislación, coordinación y financiación eficaces.

RESUMO Objetivo. Sintetizar as lições aprendidas com quatro casos de investimento nacional no controle do tabaco nas Américas (Colômbia, Costa Rica, El Salvador e Suriname) no âmbito do projeto Convenção-Quadro para o Controle do Tabaco da Organização Mundial da Saúde (CQCT-OMS) 2030, descrever os resultados e as formas como as autoridades sanitárias nacionais utilizaram os casos e discutir as implicações para o papel dos casos de investimento no avanço do controle do tabaco. Métodos. O presente estudo recorre aos achados de quatro casos de investimento nacional, incluindo: 1) análise de custo da doença, com o cálculo da carga do tabagismo para a saúde e a economia; 2) análise do retorno sobre o investimento na implementação de medidas fundamentais de redução da demanda para controle do tabaco; e 3) análise secundária de um tópico de controle do tabaco de interesse nacional (por exemplo, implicações da tributação de cigarros para a equidade). Os coautores relatam como os casos foram utilizados para promover o controle do tabaco. Resultados. Na Colômbia, na Costa Rica, em El Salvador e no Suriname, o tabagismo provoca perdas sociais e econômicas que equivalem a 1,0 a 1,8% do produto interno bruto. Nesses países, a implementação de medidas de redução da demanda da CQCT-OMS pouparia em média 11.400 vidas por ano nos próximos 15 anos. Os benefícios dessas medidas superariam em muito os custos de implementação e fiscalização. Os governos estão usando esses casos para promover o controle do tabaco, inclusive para melhorar as leis de controle do tabaco e sua fiscalização, reforçar a tributação do tabaco, priorizar o planejamento do controle do tabaco, coordenar uma resposta multissetorial e envolver líderes políticos. Conclusões. Casos de investimento nacional podem ajudar a fortalecer o controle do tabaco nos países, aumentando o apoio político e do público para a implementação da CQCT-OMS e contribuindo para um planejamento, legislação, coordenação e financiamento efetivos.

Discussion on economic value of pharmaceutical care in medical institutions based on cost-benefit analysis / 中国药房

OBJECTIVE To evalu ate relat ed researches about the cost- benefit of pharmaceutical care in medical institutions with cost- benefit analysis，in order to provide evidence-based basis for related policy decisions and provide methodological reference for the cost- benefit evaluation of pharmaceutical care in the future. METHODS Retrieved from PubMed ，Embase，the Cochrane Library ，CBM，Wanfang database ，VIP and CNKI ，cost-benefit analysis was used to evaluate the researches about the cost-benefit of pharmaceutical care in medical institutions. Two researchers independently screened the research and extracted data according to the “Consolidated Health Economic Evaluation Reporting Standards Checklist ”. The quality of included studies was scored and evaluated systematically. RESULTS A total of 46 studies from 17 countries were included. Most of them came from the United States （21.74％），China（19.57％）and France （8.70％）. Average score of 46 literature was 14.30，of which 1 literature was excellent ，5 literature were good ，25 literature were qualified and 14 literature were unqualified. There were 25 research protocols of prospective study type ；the type of pharmaceutical care involved mostly was pharmaceutical monitoring （60.87％）， followed by prescription review （23.91％），medication reconciliation （8.70％）and outpatient pharmacy （6.52％）were less. The median cost-benefit ratio of pharmaceutical care was 5.05 （3.08，11.28）. CONCLUSIONS Pharmaceutical care shows good economic value ，and pharmacists have played an important role in saving medical resources ，but the design level and report quality of the existing studies need to be improved.

Economic evaluation of medication therapeutical management services for patients with stable coronary heart disease / 中国药房

OBJECTIVE To ex plore the economic value of medication therapeutical management （MTM）service for patients with stable coronary disease. METHODS Totally 140 patients with stable coronary disease were divided into a control group and a intervention group ，70 cases in each group. Patients in control group were received routine medical services ，and patients in intervention group additionally received standardized MTM services on this basis. Medication complication ，satisfaction degree ， safety indexes and efficacy indexes were compared between 2 groups. From the perspective of the whole society ，the economic value of MTM service for patients with stable coronary disease were evaluated by pharmacists using cost minimization analysis. RESULTS A total of 15 patients did not complete the study ，including 5 cases in intervention group and 10 cases in control group ； there was no death endpoint during the follow-up period. MMAS- 8 score，satisfaction score of drug communication dimension and score of overall satisfactionin of intervention group were obviously higher than control group （P＜0.01）. There was no significant difference in blood pressure standard rate ，blood lipid standard rate ，the incidence of adverse drug reaction ，and the incidence of acute coronary events between 2 groups（P＞0.05）. The total cost of intervention group was lower than that of control group （P＜ 0.01）；the results of sensitivity analysis were consistent with those of cost minimization analysis. CONCLUSIONS Pharmacists implement MTM service for patients with stable coronary disease can reduce total cost ，save medical resources and has economic advantages.

Overdentures as an alternative to conventional dentures: a micro-costing analysis for Public Health Service in Brazil / Overdentures como alternativa às próteses convencionais: uma análise de micro-custeio para o Sistema Único de Saúde

Abstract This study aimed to estimate cost and compatibility with public financial incentives of two technologies for treating the edentulous mandible: lower complete dentures (CD) and overdentures retained by two dental implants (OD). This study consisted of a partial economic evaluation, with a micro-costing bottom-up approach for the calculation of direct costs. The estimates involved the number of consultations, proportion of materials, equipment, instruments' lifetime, and human resources, described in the price panel website of the Ministry of Economy in Brazil. Complementary information was obtained from a panel of experts. A sensitivity analysis was based on 20% variation. The estimated cost of a CD was R$ 189.89 (base scenario), and this varied between R$ 151.91 and R$ 227.89 according to sensibility analysis. The cost of an OD was R$ 663.05 (ranging from R$ 795.66 to R$ 530.44 - 1US=R$ 3.80/July 2019). The Ministry of Health covers appropriately the costs of the CD and OD. Both technologies showed costs that are within the limits of financial public incentives obtained by municipalities. The technologies are economically viable and should be induced through public policies due to their positive impacts on several functional domains of health.

Resumo Estimar os custos e a compatibilidade dos incentivos públicos de duas tecnologias para o tratamento da mandíbula edêntula: prótese total convencional (PTC) e overdenture retida por dois implantes (OD). Este estudo consistiu em uma avaliação econômica parcial, com abordagem "bottom-up" para o cálculo dos custos diretos. As estimativas levaram em consideração o número de consultas, proporção de materiais, equipamentos, vida útil dos instrumentais e recursos humanos. Os custos foram baseados no painel de preços do Ministério da Economia do Brasil e informações complementares foram obtidas de um painel de especialistas. Uma análise de sensibilidade foi baseada na variação de 20% dos custos. Os custos da PTC foram estimados em R$ 189,89 (cenário base) com variação entre R$ 151,91 e R$ 227,89 na análise de sensibilidade. Os custos da OD foram R$ 663,05 (variando de R$ 795,66 a R$ 530,44). O Ministério da Saúde cobre apropriadamente os custos de ambas as tecnologias nos cenários base e mais otimista. Ambas as tecnologias apresentaram custos dentro dos limites dos incentivos públicos recebidos. As tecnologias são economicamente viáveis e devem ser induzidas por políticas públicas diante do impacto positivo em vários domínios funcionais da saúde.

Aplicación del programa ERAS® como una política de salud pública en el sistema de salud de Alberta, Canadá / ERAS® as a public health policy: Implementation in the Alberta Health System

RESUMEN El protocolo de recuperación optimizada Enhanced Recovery After Surgery (ERAS®) se puso en marcha a partir de 2013 en el sistema de salud de Alberta, un sistema estatal de cobertura médica totalmente financiado con fondos provinciales. Su aplicación en cirugía colorrectal en múltiples centros provincia les disminuyó la incidencia de complicaciones en un 12% y redujo la estancia hospitalaria en un día. Posteriormente, la introducción del programa en ginecología oncológica redujo las complicaciones postoperatorias en un 17% y la duración de la estancia en 2 días en los procedimientos quirúrgicos complejos. Se estima que la ejecución del programa produjo un ahorro neto de 7,22 millones de dóla res canadienses (CAD) en 5 años para la provincia, con un rendimiento de la inversión de 1,05 a 7,31 dólares por cada dólar invertido en el proyecto. La participación de los pacientes permitió que el pro grama tuviera éxito, y el apoyo, la educación y la atenuación del estrés de los pacientes se identificaron como los componentes principales del éxito. El conocimiento y la motivación de los profesionales sani tarios fueron esenciales para garantizar el cumplimiento continuo de las recomendaciones del progra ma ERAS. La educación de los profesionales sanitarios y la demostración de la mejora de los resultados de los pacientes mediante supervisiones es una forma de garantizar que los profesionales sanitarios sigan motivados. Es esencial contar con líderes en el sistema de salud para proporcionar un mensaje coherente y apoyar las iniciativas. El liderazgo también es importante entre los médicos y coordina dores de enfermería para garantizar el cumplimiento y la integración adecuada de la recuperación optimizada en la práctica diaria. La aplicación del programa ERAS en un sistema de salud unificado ha mejorado los resultados de los pacientes y ahorrado recursos. Se está investigando la posibilidad de ampliar el programa a los hospitales comunitarios y a todos los ámbitos quirúrgicos.

ABSTRACT Enhanced Recovery After Surgery (ERAS®) was implemented across Alberta Health Services, a single payer publicly funded provincial health system starting in 2013. Implementation across multiple provincial sites in colorectal surgery reduced postoperative complications by 12% and median length of stay by one day. Subsequent implementation in gynecologic oncology reduced postoperative complications by 17% and length of stay by 2 days in high complexity surgery. Implementation has had an estimated net savings in the province of $7.22 million Canadian dollars (CAD) over 5 years with a return on investment of $1.05 to $7.31 for every dollar invested in the project. Patient involvement enabled success of the program, with support, education, and mitigation of patient stress identified as key components for success. Provider knowledge and motivation were essential to ensure ongoing compliance with ERAS guidelines. Provider education, and demonstration of improvement in patient outcomes using audit is one method to ensure continued motivation from care providers. System-level leadership is essential to provide consistent messaging and support for initiatives, while provider-level leadership in the form of physician champions and nurse coordinators ensures compliance and appropriate integration of ERAS into daily practice. Implementation of ERAS across a unified health care system has improved patient outcomes while saving resources. Further research into expansion of the program to community hospitals and all surgical domains is underway.

Beneficios clínicos y de costos de un modelo de estandarización en el manejo de la apendicitis aguda / Clinical and cost benefits of a standardization model in the managementof acute appendicitis

Introducción. La apendicitis aguda es la patología quirúrgica más frecuente en Colombia y en el mundo, con un riesgo de presentación del 7-8 % en la población general. El tratamiento de elección es la apendicectomía, la cual puede realizarse por vía convencional o por vía laparoscópica. El objetivo de este estudio fue comparar los desenlaces clínicos y costos de un modelo de estandarización en el manejo de la apendicitis aguda versus la no estandarización. Métodos. Estudio observacional, analítico, para comparar el manejo de atención estandarizado y no estandarizado. Se incluyeron pacientes mayores de 18 años, que ingresaron al servicio de urgencias con diagnóstico de apendicitis aguda en el período de enero de 2016 a diciembre de 2018, y quienes fueron llevados a apendicectomía convencional o laparoscópica en la institución. Resultados. Se incluyeron 1392pacientes, 591 que cumplieron los criterios del modelo estandarizado y 801 que cumplieron los criterios del modelo no estandarizado. Al comparar los procesos de estandarización y no estandarización, se encontraron diferencias estadísticamente significativas en los resultados crudos de estancia hospitalaria y costos totales. En los estimativos ajustados por variables de confusión no se encontraron diferencias en los costos totales. Discusión. El modelo de estandarización demostró una disminución en los días de hospitalización. No encontró diferencias en términos de costos totales

Introduction. Acute appendicitis is the most frequent surgical pathology in Colombia and in the world, with a risk of presentation of 7-8% in the general population. The treatment of choice is appendectomy, which can be performed conventionally or laparoscopically. The objective of this study is to compare the clinical outcomes and costs of a standardization model in the management of acute appendicitis.Methods. Observational, analytical study to compare standardized versus non-standardized care management. Patients older than 18 years, who were admitted to the emergency department with a diagnosis of acute appendicitis in the period from January 2016 to December 2018 and underwent conventional or laparoscopic appendectomy at the institution were included. Results. 1392 patients were included; 591 met the criteria of the standardized model and 801 met the criteria of the non-standardized model. When comparing the standardization versus non-standardization processes, statistically significant differences were found in the hospital stay and total costs. In the estimates adjusted for confounding variables, no differences were found in total costs. Discussion. The standardization model showed a decrease in hospital length of stay. No differences were found in terms of total costs

COVID-19-related hospital cost-outcome analysis: The impact of clinical and demographic factors

ABSTRACT Introduction: Although patients' clinical conditions have been shown to be associated with coronavirus disease (COVID-19) severity and outcome, their impact on hospital costs are not known. This economic evaluation of COVID-19 admissions aimed to assess direct and fixed hospital costs and describe their particularities in different clinical and demographic conditions and outcomes in the largest public hospital in Latin America, located in São Paulo, Brazil, where a whole institute was exclusively dedicated to COVID-19 patients in response to the pandemic. Methods: This is a partial economic evaluation performed from the hospitaĺs perspective and is a prospective, observational cohort study to assess hospitalization costs of suspected and confirmed COVID-19 patients admitted between March 30 and June 30, 2020, to Hospital das Clínicas of the University of São Paulo Medical School (HCFMUSP) and followed until discharge, death, or external transfer. Microand macro-costing methodologies were used to describe and analyze the total cost associated with each patient's underlying medical conditions, itinerary and outcomes as well as the cost components of different hospital sectors. Results: The average cost of the 3254 admissions (51.7% of which involved intensive care unit stays) was US$12,637.42. The overhead cost was its main component. Sex, age and underlying hypertension (US$14,746.77), diabetes (US$15,002.12), obesity (US$18,941.55), chronic renal failure (US$15,377.84), and rheumatic (US$17,764.61), hematologic (US $15,908.25) and neurologic (US$15,257.95) diseases were associated with higher costs. Age strata >69 years, reverse transcription polymerase chain reaction (RT-PCR)-confirmed COVID-19, comorbidities, use of mechanical ventilation or dialysis, surgery and outcomes remained associated with higher costs. Conclusion: Knowledge of COVID-19 hospital costs can aid in the development of a comprehensive approach for decision-making and planning for future risk management.

Research progress, challenges, and recommendations of health economic evaluation in osteoporosis drugs / 中华内分泌代谢杂志

The economic evaluation compares the costs and effectiveness of different strategies for osteoporosis prevention and treatment to facilitate decision-making. In this paper, international and Chinese economic evaluation studies on osteoporosis prevention strategies were reviewed and results were summarized. We have found that the research design and quality of reporting need to be improved. Furthermore, both general and osteoporosis-specific health economic evaluation guidelines were introduced to improve the quality of economic evaluation in osteoporosis in China. Accuracy and integrity of data used in economic evaluation also should be improved.

Review of economic evaluation of lung cancer screening with low-dose computed tomography / 上海预防医学

Objective:To analyze recent economic evaluation studies of low-dose CT screening for lung cancer in order to provide recommendations for such economic evaluation in China. Methods:A systematic search and analysis was conducted to identify articles on low-dose CT screening for lung cancer published from 2015 to 2019. Results:According to the literature inclusion criteria， 15 studies were included. Most of the studies were conducted in Europe， the United States and other developed countries. The majority adopted model simulation approaches. Low-dose CT screening was suggested to be cost-effective compared with no-screening or chest radiography for lung cancer in 13 studies. Only 2 studies showed no cost-effectiveness. Conclusion:The latest evidence of economic evaluation shows that low-dose CT screening for lung cancer is cost-effective and has a more consistent result than previous reviews. Methodologically， use of microsimulation models is increasing for better economic evaluation at the individual level. However， evidence from developing countries is still insufficient. It is necessary to conduct economic evaluation in combination with the domestic practice of lung cancer screening and localized data．

Evaluación de Sitagliptina para el tratamiento de pacientes adultos con diabetes mellitus tipo 2: revisión sistemática de costo-efectividad / Evaluation of Sitagliptin for the treatment of adult patients with type 2 diabetes mellitus: a systematic review of cost-effectiveness

Introducción: La diabetes mellitus tipo 2 es un problema de salud pública mundial y es una de las principales causas de mortalidad en Ecuador. La Sitagliptina fue el primer fármaco potenciador del sistema de las incretinas comercializado localmente. Los países no tienen recursos ilimitados para atender las necesidades de salud de su población, por lo que deben adoptar las intervenciones sanitarias más adecuadas, considerando los costos que un país pueda asumir y sostener. Objetivo: Sintetizar los resultados de estudios de costo-efectividad de la sitagliptina para el tratamiento oral combinado de pacientes adultos con diabetes tipo 2 en comparación con sulfonilureas. Metodología: Se realizó una revisión sistemática sin metaanálisis basado en las recomendaciones PRISMA. Los términos de búsqueda se estructuraron en base a la estrategia PICO y la pesquisa se realizó en las bases de datos: Pubmed, Tripdatabase y Pubmed Central para artículos de evaluaciones de tecnologías sanitarias, evaluaciones económicas y guías de práctica clínica, y para las políticas de cobertura se utilizó HTAiVortal y Google avanzado. Resultados: Se seleccionaron 3 ensayos clínicos y 8 revisiones sistemáticas-metaanálisis, 2 estudios de cohorte, 3 políticas de cobertura y 1 estudio de costo-efectividad. Tres revisiones sistemáticas establecieron pocos efectos modestos en cuanto a los efectos hipoglicemiantes de sitagliptina en adultos y adultos mayores; con un bajo riesgo de hipoglicemia. Un metaanálisis de 25 ensayos clínicos reportó mayor riesgo cardiovascular en los pacientes tratados con sitagliptina. Una revisión sistemática con evaluación económica mostró que la sitagliptina con metformina fue una alternativa costo-efectiva versus añadir una sulfonilurea o roziglitazona. Conclusiones: Por el perfil de costo-efectividad podría considerarse a la sitagliptina como segundo fármaco para pacientes que no consiguen control glicémico con dosis máximas de metformina, o en donde su asociación a una sulfonilurea no sea factible (por riesgos de hipoglicemia o adultos mayores).

Introduction: Type 2 diabetes mellitus is a global public health problem, being one of the main causes of mortality in Ecuador. Sitagliptin was the first locally marketed incretin-enhancing drug. Countries do not have unlimited resources to meet the health needs of their population, so they must adopt the most appropriate health interventions, considering the costs that a country can assume and sustain. Objective: To synthesize the results of cost-effectiveness studies of sitagliptin for combined oral treatment of adult patients with type 2 diabetes, compared with sulfonylureas.Methodology: This is a systematic review study without meta-analysis, conducted on PRISMA recommendations. The in-formation search was structured under the PICO strategy and the searches were conducted in Pubmed, Tripdatabase and Pubmed Central for articles on health technology evaluations, economic evaluations and clinical practice guides and for coverage policies HTAiVortal and advanced Google were used.Results: 3 clinical trials and 8 systematic reviews-meta-analysis, 2 cohort studies, 3 coverage policies and 1 cost-effectiveness study were selected. Three systematic reviews establish few effects regarding the hypoglycemic effects of sitagliptin in adults and elderly, with a low risk of hypoglycemia. A meta-analysis of 25 clinical trials reported an increased cardiovascular risk in patients treated with sitagliptin. A systematic review with economic evaluation showed that sitagliptin with metformin was a cost-effective alternative, versus adding a sulfonylurea or roziglitazone.Conclusions: Due to its cost-effectiveness profile, sitagliptin could be considered as a second drug for patients who do not achieve glycemic control with maximum doses of metformin, or where its association with a sulfonylurea is not feasible (due to risks of hypoglycemia or elderly).

Evaluación económica de las alternativas terapéuticas en pacientes con hiperestesia dentinaria / Economic evaluation of the therapeutic alternatives in patients with dentin hyperesthesia

Introducción: La hiperestesia dentinaria es una sensación dolorosa de intensidad variable, que va de leve a moderada y, al encontrarse la dentina expuesta, puede convertirse en una molestia constante. Objetivo: Determinar la alternativa menos costosa en el tratamiento de pacientes con hiperestesia dentinaria. Método: Se realizó una evaluación económica completa del tipo minimización de costo, en la Clínica Estomatológica Provincial Docente Mártires del Moncada de Santiago de Cuba, desde enero hasta mayo de 2019. Se revisaron 40 historias clínicas, escogidas a conveniencia, ya que contaban con los datos necesarios para la investigación. Se crearon 2 grupos de estudios, cuyos integrantes fueron tratados con laca flúor y láser, respectivamente. Se analizaron las variables de edad, sexo, efectividad de los tratamientos, costo directo e indirecto y costo unitario. Resultados: En la serie predominaron el grupo etario de 15-24 años (30,0 %), seguido por el de 25- 34 (25,0 %), así como el sexo femenino (70,0 %). El costo unitario del tratamiento con laca flúor fue de $7,77 y con láser de $5,74, para una diferencia de $2,03. Conclusión: La alternativa menos costosa en el tratamiento de pacientes con hiperestesia dentinaria resultó ser la aplicación de láser; mientras que la evaluación económica realizada demostró ser apropiada en materia de eficiencia económica.

Introduction: Dentin hyperesthesia is a painful sensation of variable intensity that goes from light to moderate and, as dentin is exposed, it can become a constant discomfort. Objective: To determine the less expensive alternative in the treatment of patients with dentin hyperesthesia. Method: A complete economic evaluation of the cost minimization type was carried out in Martires del Moncada Teaching Provincial Stomatological Clinic in Santiago de Cuba, from January to May, 2019. Forty medical records were reviewed, chosen of convenience, since they had the necessary data for the investigation. Two groups of studies were created whose members were treated with lacquer fluorine and laser, respectively. The age, sex, effectiveness of the treatments, direct and indirect cost and unitary cost variables were analyzed. Results: In the series there was a prevalence of the 15-24 age group (30.0 %), followed by that of 25-34 (25.0 %), as well as the female sex (70.0 %). The unitary cost of the treatment with lacquer fluorine was of $7.77 and with laser of $5.74, for a difference of $2.03. Conclusion: The less expensive alternative in the treatment of patients with dentin hyperesthesia was the laser application; while the economic evaluation carried out demonstrated to be appropriate as regards economic efficiency.

Economic evaluation of the SP142 versus 22C3 PD-L1 assays in the treatment of atezolizumab plus nab-paclitaxel for patients with advanced triple negative breast cancer in the Brazilian private healthcare systemp / Avaliação econômica dos testes de PD-L1 SP142 versus 22C3 no tratamento com atezolizumabe mais nab-paclitaxel em pacientes com câncer de mama triplo-negativo avançado no sistema de saúde suplementar no Brasil

Objective: The aim of the study was to demonstrate the economic impact of two PD-L1 immunohistochemistry (IHC) assays, SP142 versus 22C3, in the treatment with atezolizumab plus nab-paclitaxel in patients with advanced triple negative breast cancer (aTNBC) in the Brazilian private healthcare system (BPHS). Methods: The study performed two analyses: one per patient and other of the potential population projected for the BPHS (budget impact analysis). Data of progressionfree survival and overall survival were extracted from a post hoc analysis of the IMpassion130 trial to develop a partitioned-survival model to simulate the economic impact of the treatment with atezolizumab plus nab-paclitaxel guided by the SP142 and 22C3 assays on patients with aTNBC. The analyses included only direct costs that were based on CBHPM (Classificação Brasileira Hierarquizada de Procedimentos Médicos) and CMED (Câmara de Regulação do Mercado de Medicamentos) PF18% tables. A univariate sensitivity analysis was performed with the parameters varying ± 20%. Results: The study has demonstrated that the SP142 assay has the potential to save ­BRL 179,730 with the treatment of atezolizumab plus nab-paclitaxel per patient with aTNBC in five years. Conclusion: The SP142 assay can optimize the use of atezolizumab plus nab-paclitaxel avoiding its prescription in patients who will not have a significant clinical improvement.

Objetivo: O objetivo do estudo foi demonstrar o impacto econômico de dois testes de imuno-histoquímica, SP142 versus 22C3, no tratamento com atezolizumabe + nab-paclitaxel em pacientes com câncer de mama triplo-negativo avançado (CMTNa) no sistema de saúde suplementar (SSS) no Brasil. Métodos: O estudo realizou duas análises: uma por paciente e outra na população potencial projetada para o SSS (análise de impacto no orçamento). Dados de sobrevida livre de progressão e de sobrevida global foram extraídos da análise post hoc do estudo IMpassion130 para o desenvolvimento de um modelo de sobrevida particionado que simulasse o impacto econômico do tratamento com atezolizumabe + nab-paclitaxel direcionado pelos testes SP142 e 22C3 em pacientes com CMTNa. A análise considerou somente os custos diretos baseados nas tabelas CBHPM (Classificação Brasileira Hierarquizada de Procedimentos Médicos) e CMED (Câmara de Regulação do Mercado de Medicamentos) PF18%. Uma análise de sensibilidade univariada foi realizada variando os parâmetros em ± 20%. Resultados: O estudo demonstrou que o teste SP142 apresenta um potencial de economia de -179.730 reais (BRL) no tratamento de atezolizumabe + nab-paclitaxel por paciente com CMTNa em cinco anos. Conclusão: O uso do teste SP142 possibilita otimizar o uso de atezolizumabe + nab-paclitaxel evitando a sua prescrição em pacientes que não irão se beneficiar de forma significativa.

A health benefit and cost-effectiveness analysis of pneumococcal conjugate vaccination program in Nigeria

Background: Nigeria ranks third just behind India and China in the global disease burden of pneumococcal disease. The current sustainability approach for an affordable pneumococcal conjugate vaccine (PCV) for the national immunization program from 2014 till 2025 involves a cost sharing plan funded with a 75% financial support from GAVI and a subsidy from Pfizer pharmaceuticals. There is a strong need to generate evidence on the cost-effectiveness of the national PCV program in Nigeria from 2014-2025 and beyond 2025.Methods: The following parameters (demography, disease burden, health services utilization and costs, vaccination coverage, vaccine efficacy, and vaccination costs) were used in a static cohort model to estimate the total cost, health and economic benefit, and cost-effectiveness of the implementation of PCV vaccination program, compared with no PCV vaccination among under-five children in Nigeria from 2014-2025 and from 2026-2033. A sensitivity analysis was conducted to evaluate the robustness of the data used.Results: The national PCV vaccination program would have an approximated 31.4% and 30% reduction of the total burden of pneumococcal diseases over the period of 2014-2025 and 2026-2033 respectively. One-way sensitivity analysis reveals vaccine efficacy as most sensitive parameter followed by disease incidence rate and treatment cost. Removal and addition of DTP3 and 3+1 (measles vaccine) dose respectively resulted to a similar ICER from both.Conclusions: The estimated ICER suggests that the national PCV program in Nigeria will be cost-effective post 2025 era. In addition, it is recommended for policy-makers adoption considering the budget and equity impact of the intervention in Nigeria.

Evaluación económica del costo de estadía hospitalaria en una unidad de paciente crítico

RESUMEN Introducción: La Unidad de Paciente Crítico (UPC) representa un servicio de elevada complejidad. La conformación de equipos avanzados que puedan abordar la población crítica, así como la gestión del cuidado, exigen el uso eficiente de recursos humanos y financieros. Objetivo: Realizar una evaluación económica de costos asociados a la estadía hospitalaria de usuarios internados en la UPC adultos, de un hospital público de la red de salud de Chile. Material y Método: El universo estuvo conformado por 194 usuarios. Se realizó una evaluación económica que contempló costos directos, indirectos y recursos humanos, utilizando la perspectiva del prestador para el período enero-marzo 2017. Los costos totales fueron valorizados en pesos chilenos (CLP). El valor día/cama se estimó a través del cálculo proporcional del gasto total sobre el número de unidades disponibles. Resultados: El costo de estadía hospitalaria/día en UPC es de $351.735 CLP. El servicio de procedencia que domina la usabilidad del servicio es la unidad de emergencia adultos, a la que se asocia un 47,7% del gasto mensual. El Riesgo Relativo (RR) de tener una larga estadía es mayor si el usuario proviene del servicio de emergencia adulto: RR= 1,07 (IC 95%: 0,51-2,26) o si cuenta con diagnóstico de sepsis RR= 2,08 (IC 95%: 0,91- 4,73). Conclusiones: La evaluación económica ofrece una perspectiva interesante para mejorar la gestión de los recursos a nivel hospitalario y debe ser considerada para la toma de decisiones en salud.

ABSTRACT Introduction: The Critical Care Unit (CCU) represents a highly complex service. Organizing an advanced staff that can cater to critically ill patients, as well as providing care management, requires the efficient use of human and financial resources. Objective: To carry out an economic evaluation of costs associated with the hospital stay of adult users admitted to the CCU of a public hospital of the Chilean health network. Material and method: The population consisted of 194 users. An economic cost evaluation that included direct and indirect costs and human resources was carried out, using the perspective of the health provider for the period January-March 2017. The costs were calculated in Chilean pesos (CLP). The bed-day value was estimated through the proportional calculation of the total cost over the number of available units. Results: The cost of hospital stay/day in the CCU is $351,735 CLP. The unit with the highest level of CCU usability is the adult emergency unit, which registers 47.7% of the monthly expenditures. The Relative Risk (RR) of having a lengthy stay is greater if the user comes from the adult emergency service: RR=1.07 (CI 95%: 0.51-2.26) or if they have a sepsis diagnosis RR=2.08 (CI 95%: 0.91-4.73). Conclusions: The economic evaluation offers an interesting perspective for improving resource management at the hospital level and should be considered for health decision-making.

RESUMO Introdução: A unidade de Paciente Crítico (UPC) representa um serviço altamente complexo. A formação de equipes avançadas que possam atender a população crítica, assim como a gestão do cuidado, requer o uso eficiente de recursos humanos e financeiros. Objetivo: realizar uma avaliação econômica dos custos associados à internação hospitalar de usuários internados na UPC adulto, de um hospital público da rede de saúde chilena. Material é Método: O universo esteve composto por 194 usuários. Foi realizada uma avaliação econômica que considerou custos diretos, indiretos e recursos humanos, da perspectiva do provedor para o período de janeiro a março de 2017. Os custos totais foram valorizados em pesos chilenos (CLP). O valor do dia/leito foi estimado através do cálculo proporcional da despesa total sobre o número de unidades disponíveis. Resultados: O custo de internação hospitalar/dia em UPC é de $351.735 CLP. O serviço de origem que domina a usabilidade do serviço é o pronto-socorro adulto, ao qual está associado 47,7% da despesa mensal. O Risco Relativo (RR) de ter uma longa internação é maior se o usuário provém do serviço do pronto-socorro adulto: RR= 1,07 (IC 95%: 0,51-2,26) ou se conta com diagnóstico de sepse RR= 2,08 (IC 95%: 0,91-4,73). Conclusões: A avaliação econômica oferece uma perspectiva interessante para melhorar a gestão dos recursos no nível hospitalar e deve ser considerada para a tomada de decisões em saúde.