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Gac. sanit. (Barc., Ed. impr.) ; 32(2): 167.e-167.e10, mar.-abr. 2018. ilus, tab
Artigo em Espanhol | IBECS | ID: ibc-171472


Los médicos no disponen del tiempo ni de los recursos para considerar la evidencia subyacente en las innumerables decisiones que tienen que tomar diariamente. En consecuencia, dependen de las recomendaciones de las guías de práctica clínica. Los paneles de las guías deben considerar todos los criterios relevantes que influyen en una decisión o recomendación de manera estructurada, explícita y transparente, y proporcionar a los médicos recomendaciones factibles. En este artículo describiremos los marcos de la evidencia a la decisión (EtD) para las recomendaciones de práctica clínica. La estructura general de un marco EtD para recomendaciones clínicas es similar a la de los marcos EtD para otras recomendaciones y decisiones, e incluye la formulación de la pregunta, la evaluación de los distintos criterios y las conclusiones. Las recomendaciones clínicas requieren que los criterios se consideren de forma diferente, dependiendo de si se adopta una perspectiva individual o poblacional. Por ejemplo, desde la perspectiva individual, los gastos personales son un aspecto importante a considerar, mientras que desde la perspectiva poblacional son más importantes el uso de recursos (no solo los gastos personales) y el coste-efectividad. Son también importantes desde la perspectiva poblacional la equidad, la aceptabilidad y la factibilidad, mientras que la importancia de estos criterios suele ser limitada en el caso de la perspectiva individual. Los subgrupos específicos para los cuales pueden necesitarse recomendaciones deben estar claramente identificados y considerados con relación a cada criterio, porque los juicios pueden variar entre subgrupos. El siguiente artículo es una traducción del artículo original publicado en British Medical Journal. Los marcos EtD se utilizan actualmente en el Programa de Guías de Práctica Clínica en el Sistema Nacional de Salud, coordinado por GuíaSalud (AU)

Clinicians do not have the time or resources to consider the underlying evidence for the myriad decisions they must make each day and, as a consequence, rely on recommendations from clinical practice guidelines. Guideline panels should consider all the relevant factors (criteria) that influence a decision or recommendation in a structured, explicit, and transparent way and provide clinicians with clear and actionable recommendations. In this article, we will describe the Evidence to Decision (EtD) frameworks for clinical practice recommendations. The general structure of the EtD framework for clinical recommendations is similar to EtD frameworks for other types of recommendations and decisions, and includes formulation of the question, an assessment of the different criteria, and conclusions. Clinical recommendations require considering criteria differently, depending on whether an individual patient or a population perspective is taken. For example, from an individual patient's perspective, out-of-pocket costs are an important consideration, whereas, from a population perspective, resource use (not only out-of-pocket costs) and cost effectiveness are important. From a population perspective, equity, acceptability, and feasibility are also important considerations, whereas the importance of these criteria is often limited from an individual patient perspective. Specific subgroups for which different recommendations may be required should be clearly identified and considered in relation to each criterion because judgments might vary across subgroups. This article is a translation of the original article published in the British Medical Journal. The EtD frameworks are currently used in the Clinical Practice Guideline Programme of the Spanish National Health System, co-ordinated by GuíaSalud (AU)

Humanos , Masculino , Feminino , Técnicas de Apoio para a Decisão , Sistemas de Apoio a Decisões Clínicas/organização & administração , Análise Custo-Benefício/organização & administração , Tomada de Decisões/métodos , Sistemas Nacionais de Saúde , Fibrilação Atrial/tratamento farmacológico
Hastings Cent Rep ; 48 Suppl 1: S65-S69, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-29453844


By their nature, the most vexing social problems reflect collisions between social and economic interests of parties with highly divergent views and perspectives on the cause and character of what is at issue and the consequences that flow from it. Conflicts around biotechnology applications are good examples of these problems. When considering the potential consequences of proposed biotechnology applications, an enormous range of perspectives arise reflecting the breadth of different and often competing interests with a stake in life's future. This essay starts from an assumption that the traditional tool of cost-benefit analysis is not adequate for adjudicating competing claims around the introduction of new biotechnology applications. It tends to require implicit simplifying assumptions that reduce or mask true underlying levels of complexity and uncertainty, and the results it produces deliver a definitive and singular answer, as opposed to a multiplicity of outcomes. In this essay, I describe some of the key elements of formal scenario planning to show how CBA could be redeployed as a supporting tool within the broader decision support methodology of formal scenario planning.

Análise Custo-Benefício/métodos , Análise Custo-Benefício/organização & administração , Tecnologia Biomédica/economia , Tomada de Decisões
Appl Health Econ Health Policy ; 16(1): 79-90, 2018 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-29081000


BACKGROUND: The Patient Protection and Affordable Care Act instituted pay-for-performance programs, including Hospital Value-Based Purchasing (HVBP), designed to encourage hospital quality and efficiency. OBJECTIVE AND METHOD: While these programs have been evaluated with respect to their implications for care quality and financial viability, this is the first study to assess the relationship between hospitals' cost inefficiency and their participation in the programs. We estimate a translog specification of a stochastic cost frontier with controls for participation in the HVBP program and clinical and outcome quality for California hospitals for 2012-2015. RESULTS: The program-participation indicators' parameters imply that participants were more cost inefficient than their peers. Further, the estimated coefficients for summary process of care quality indexes for three health conditions (acute myocardial infarction, pneumonia, and heart failure) suggest that higher quality scores are associated with increased operating costs. CONCLUSION: The estimated coefficients for the outcome quality variables suggest that future determination of HVBP payment adjustments, which will depend solely on mortality rates as measures of clinical care quality, may not only be aligned with increasing healthcare quality but also reducing healthcare costs.

Medicare/economia , Serviço Hospitalar de Compras/economia , Aquisição Baseada em Valor/economia , California , Análise Custo-Benefício/economia , Análise Custo-Benefício/legislação & jurisprudência , Análise Custo-Benefício/organização & administração , Economia Hospitalar , Custos Hospitalares , Humanos , Programas Obrigatórios/economia , Programas Obrigatórios/organização & administração , Medicare/organização & administração , Modelos Econométricos , Serviço Hospitalar de Compras/legislação & jurisprudência , Serviço Hospitalar de Compras/organização & administração , Processos Estocásticos , Estados Unidos , Aquisição Baseada em Valor/legislação & jurisprudência , Aquisição Baseada em Valor/organização & administração
Appl Health Econ Health Policy ; 16(1): 31-41, 2018 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-28702875


BACKGROUND: The appropriate structure, scope and cost of government incentives in the private health insurance (PHI) market is a matter of ongoing debate. OBJECTIVE: In order to inform policy decisions we designed a two-stage study to (1) model the uptake of PHI covering hospital treatment in Australia, and (2) identify the costs of various policy scenarios to the government. METHODS: Using a microsimulation with a cost-benefit component, we modelled the insurance decisions made by individuals who collectively represented the Australian insurance population in the financial year 2014-15. RESULTS: We found that the mean willingness to pay (WTP) for PHI ranged from A$446 to A$1237 per year depending on age and income. Our policy scenarios showed a considerable range of impacts on the government budget (from A$4 billion savings to A$6 billion expense) and PHI uptake (from 3.4 million fewer to 2.5 million more individuals insured), with cost-effectiveness ranging from -A$305 to A$22,624 per additional person insured, relative to the status quo. CONCLUSIONS: Based on the scenario results we recommend policy adjustments that either increase the PHI uptake at a small per-person cost to the public budget or substantially reduce government subsidisation of PHI at a relatively small loss in terms of persons insured.

Análise Custo-Benefício/métodos , Seguro Saúde/economia , Setor Privado/economia , Reembolso de Incentivo/economia , Austrália , Análise Custo-Benefício/organização & administração , Custos de Cuidados de Saúde , Gastos em Saúde , Humanos , Seguro Saúde/organização & administração , Formulação de Políticas , Setor Privado/organização & administração , Reembolso de Incentivo/organização & administração
Intern Med ; 57(9): 1191-1200, 2018 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-29279514


In order to maintain and develop a universal health insurance system, it is crucial to utilize limited medical resources effectively. In this context, considerations are underway to introduce health technology assessments (HTAs), such as cost-effectiveness analyses (CEAs), into the medical treatment fee system. CEAs, which is the general term for these methods, are classified into four categories, such as cost-effectiveness analyses based on performance indicators, and in the comparison of health technologies, the incremental cost-effectiveness ratio (ICER) is also applied. When I comprehensively consider several Japanese studies based on these concepts, I find that, in the results of the analysis of the economic performance of healthcare systems, Japan shows the most promising trend in the world. In addition, there is research indicating the superior cost-effectiveness of Rituximab against refractory nephrotic syndrome, and it is expected that health economics will be actively applied to the valuation of technical innovations such as drug discovery.

Análise Custo-Benefício/organização & administração , Economia , Avaliação da Tecnologia Biomédica/organização & administração , Antineoplásicos Imunológicos/economia , Antineoplásicos Imunológicos/uso terapêutico , Humanos , Japão , Síndrome Nefrótica/tratamento farmacológico , Rituximab/economia , Rituximab/uso terapêutico
Rev. panam. salud pública ; 42: e40, 2018. tab, graf
Artigo em Inglês | LILACS | ID: biblio-961817


ABSTRACT Objective To analyze economic evaluations of interventions related to tuberculosis (TB) diagnostics/screening, treatment, and prevention in homeless people. Methods A systematic review was conducted. The eligibility criteria were original studies reporting economic evaluation results. The search was not restricted by language or year. A critical appraisal approach was used. Results A total of 142 studies were identified, including five research articles (three full economic evaluations and two partial) that were selected for the final review. Most of the studies were conducted in the United States, adopted a public health perspective, and analyzed active TB. Interventions related to diagnostics/screening (the use of interferon-gamma release assay (IGRA) and mobile screening units), treatment (incentives for continuing treatment, and housing programs), and prevention (with the Bacillus Calmette-Guérin (BCG) vaccine) were identified. Conclusions No high-quality data were found on cost-effectiveness of interventions on TB diagnostics/screening, treatment, or prevention in homeless people. However, active searching for cases via mobile screening, and financial incentives, could help increase treatment adherence, and the use of IGRA helps boost detection. TB in homeless people is neglected worldwide, especially in developing countries, where this disease tends to afflict more people made vulnerable by their precarious living conditions. Public funding mechanisms should be created to develop cross-sectoral actions targeting homeless people, as the complex dynamics of this group tend to hamper prevention and diagnosis of TB and the completion of TB treatment.

RESUMEN Objetivo Analizar la evaluación económica de intervenciones relacionadas con el diagnóstico y tamizaje, el tratamiento y la prevención de la tuberculosis en las personas sin hogar. Métodos Se realizó una revisión sistemática en la cual se usó como criterio de selección estudios originales en los que se presentaran los resultados de una evaluación económica. No se restringió la búsqueda por idioma ni por año. Se usó el enfoque de la evaluación crítica. Resultados Se encontraron en total 142 estudios, entre los cuales había cinco artículos de investigación (tres evaluaciones económicas completas y dos parciales) que se seleccionaron para la revisión final. En la mayoría de los estudios, realizados en los Estados Unidos, se adoptó una perspectiva de salud pública y se analizó la tuberculosis activa. Se encontraron intervenciones relacionadas con el diagnóstico y tamizaje (el uso de la prueba de liberación de interferón gamma —IGRA, por su sigla en inglés— y los equipos móviles de tamizaje), el tratamiento (incentivos para continuar el tratamiento y programas de viviendas) y la prevención (el uso de la vacuna BCG). Conclusiones No se encontraron datos de calidad alta sobre la costo-efectividad de las intervenciones relacionadas con el diagnóstico o tamizaje, el tratamiento o la prevención de la tuberculosis en personas sin hogar. Sin embargo, la búsqueda activa de casos mediante el uso de equipos móviles para el tamizaje, así como los incentivos financieros, podrían ayudar a aumentar la adhesión al tratamiento; además, el uso de la prueba IGRA ayuda a lograr una mayor detección. La tuberculosis en las personas sin hogar se subestima en todo el mundo, especialmente en los países en desarrollo donde esta enfermedad tiende a afectar a más personas que pasan a ser vulnerables por la precariedad de sus condiciones de vida. Deben crearse mecanismos de financiamiento con fondos públicos para llevar adelante medidas intersectoriales dirigidas a las personas sin hogar, puesto que la compleja dinámica de este grupo tiende a obstaculizar tanto la prevención y el diagnóstico de la tuberculosis como la finalización del tratamiento antituberculoso.

RESUMO Objetivo Examinar as análises econômicas de intervenções relacionadas à prevenção, detecção precoce/diagnóstico e tratamento da tuberculose (TB) em pessoas sem-teto. Métodos Foi realizada uma revisão sistemática. Os critérios para inclusão foram estudo original contendo resultados de análise econômica. A busca não foi restrita por idioma ou ano. Foi usada uma abordagem de análise crítica. Resultados Foram identificados ao todo 142 estudos, dentre eles cinco artigos de pesquisa (três análises econômicas completas e duas parciais) que foram selecionados para a revisão final. A maioria dos estudos foi realizada nos Estados Unidos, partindo de uma perspectiva de saúde pública e com análise de TB ativa. Foram identificadas intervenções relacionadas à detecção precoce/diagnóstico (ensaio de liberação de interferon-gama [IGRA] e unidades móveis para prevenção), tratamento (incentivos para o tratamento continuado e programas de moradia) e prevenção (vacinação com o bacilo de Calmette-Guérin [BCG]). Conclusões Não foram encontrados dados de alta qualidade sobre o custo-efetividade das intervenções de detecção precoce/diagnóstico, tratamento ou prevenção de TB em pessoas sem-teto. Porém, a busca ativa de casos por meio da triagem em unidades móveis e incentivos financeiros poderiam ajudar a melhorar a adesão ao tratamento e o uso do IGRA intensifica a detecção de infecção. A TB em pessoas sem-teto é uma doença negligenciada em todo o mundo, principalmente nos países em desenvolvimento onde ela costuma afligir um número maior de pessoas por sua vulnerabilidade devido às condições de vida precárias. Mecanismos públicos de financiamento devem ser criados para desenvolver ações intersetoriais voltadas aos sem-teto, porque a dinâmica complexa deste grupo dificulta a prevenção, o diagnóstico e a conclusão do tratamento de TB.

Humanos , Tuberculose/prevenção & controle , Pessoas em Situação de Rua , Análise Custo-Benefício/organização & administração
Interv. psicosoc. (Internet) ; 26(3): 171-179, dic. 2017. tab, graf, ilus
Artigo em Inglês | IBECS | ID: ibc-169593


Some long-term societal benefits of early psychosocial interventions supporting children and youth at various developmental risks can be estimated with school results as a mediatory. In this paper we develop causal education-earnings links for educational achievement thresholds at the end of the nine-year compulsory school (CS) and the three-year upper secondary school (USS) in Sweden. Gross earnings are calculated with age profiles estimated on micro-level register data for the whole population. We also estimate the indirect costs of education (forgone earnings) with this data and find that they can be ignored. For the base case, we calculate the expected net present value of meeting minimum requirements for transition from CS to a national USS-program to euros112,000 (SEK 1.1 million) and for graduation from such a program to euros163,000 (SEK 1.6 million) (AU)

Pueden calcularse algunos de los beneficios sociales a largo plazo de las intervenciones psicosociales precoces que respaldan a los niños y jóvenes con ciertos riesgos evolutivos utilizando los resultados escolares como hilo mediador. En este documento desarrollamos vínculos causales educación-ingresos para los umbrales del logro educativo al finalizar la escuela obligatoria (EO) de nueve años de duración y la escuela secundaria superior (ESS) en Suecia. Se calculan los ingresos brutos con los perfiles de edad estimados en un registro de datos a micronivel para la totalidad de la población. También calculamos los costes educativos indirectos (ingresos no percibidos) con estos datos, y encontramos que pueden ser ignorados. Para el caso básico, calculamos el valor actual neto previsto del logro de los requisitos mínimos para la transición de la EO al programa nacional de ESS de 112,000euros (1.1 millones de coronas suecas) y para la graduación en dicho programa de 163,000euros (1.6 millones de coronas suecas) (AU)

Humanos , Criança , Adolescente , Adulto Jovem , Avaliação de Programas e Projetos de Saúde/métodos , Medição de Risco/métodos , Estudantes/psicologia , Avaliação Educacional/economia , Psicologia Educacional/economia , Serviços de Saúde Mental/organização & administração , Análise Custo-Benefício/métodos , Análise Custo-Benefício/organização & administração
J Am Acad Orthop Surg ; 25(11): e244-e250, 2017 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-29059115


Lean methodology was developed in the manufacturing industry to increase output and decrease costs. These labor organization methods have become the mainstay of major manufacturing companies worldwide. Lean methods involve continuous process improvement through the systematic elimination of waste, prevention of mistakes, and empowerment of workers to make changes. Because of the profit and productivity gains made in the manufacturing arena using lean methods, several healthcare organizations have adopted lean methodologies for patient care. Lean methods have now been implemented in many areas of health care. In orthopaedic surgery, lean methods have been applied to reduce complication rates and create a culture of continuous improvement. A step-by-step guide based on our experience can help surgeons use lean methods in practice. Surgeons and hospital centers well versed in lean methodology will be poised to reduce complications, improve patient outcomes, and optimize cost/benefit ratios for patient care.

Análise Custo-Benefício/organização & administração , Procedimentos Ortopédicos/normas , Avaliação de Processos e Resultados (Cuidados de Saúde)/métodos , Segurança do Paciente , Complicações Pós-Operatórias/prevenção & controle , Melhoria de Qualidade/organização & administração , Humanos , Procedimentos Ortopédicos/efeitos adversos , Procedimentos Ortopédicos/economia , Avaliação de Processos e Resultados (Cuidados de Saúde)/organização & administração , Estados Unidos
Health Policy Plan ; 32(suppl_2): i22-i31, 2017 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-29028226


There are numerous challenges in planning and implementing effective disease control programmes in Myanmar, which is undergoing internal political and economic transformations whilst experiencing massive inflows of external funding. The objective of our study-involving key informant discussions, participant observations and linked literature reviews-was to analyse how tuberculosis (TB) control strategies in Myanmar are influenced by the broader political, economic, epidemiological and health systems context using the Systemic Rapid Assessment conceptual and analytical framework. Our findings indicate that the substantial influx of donor funding, in the order of one billion dollars over a 5-year period, may be too rapid for the country's infrastructure to effectively utilize. TB control strategies thus far have tended to favour medical or technological approaches rather than infrastructure development, and appear to be driven more by perceived urgency to 'do something' rather informed by evidence of cost-effectiveness and sustainable long-term impact. Progress has been made towards ambitious targets for scaling up treatment of drug-resistant TB, although there are concerns about ensuring quality of care. We also find substantial disparities in health and funding allocation between regions and ethnic groups, which are related to the political context and health system infrastructure. Our situational assessment of emerging TB control strategies in this transitioning health system indicates that large investments by international donors may be pushing Myanmar to scale up TB and drug-resistant TB services too quickly, without due consideration given to the health system (service delivery infrastructure, human resource capacity, quality of care, equity) and epidemiological (evidence of effectiveness of interventions, prevention of new cases) context.

Assistência à Saúde/economia , Tuberculose Pulmonar/tratamento farmacológico , Tuberculose Pulmonar/economia , Análise Custo-Benefício/organização & administração , Assistência à Saúde/organização & administração , Grupos Étnicos , Organização do Financiamento , Disparidades em Assistência à Saúde/economia , Disparidades em Assistência à Saúde/organização & administração , Humanos , Mianmar/epidemiologia , Tuberculose Resistente a Múltiplos Medicamentos/tratamento farmacológico , Tuberculose Resistente a Múltiplos Medicamentos/economia , Tuberculose Pulmonar/prevenção & controle
Glob Health Action ; 10(1): 1370194, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-29035166


BACKGROUND: Achieving sustainable universal health coverage depends partly on fair priority-setting processes that ensure countries spend scarce resources wisely. While general health economics capacity-strengthening initiatives exist in Africa, less attention has been paid to developing the capacity of individuals, institutions and networks to apply economic evaluation in support of health technology assessment and effective priority-setting. OBJECTIVE: On the basis of international  lessons, to identify how research organisations and partnerships could contribute to capacity strengthening for health technology assessment and priority-setting in Africa. METHODS: A rapid scan was conducted of international formal and grey literature and lessons extracted from the deliberations of two international and regional workshops relating to capacity-building for health technology assessment. 'Capacity' was defined in broad terms, including a conducive political environment, strong public institutional capacity to drive priority-setting, effective networking between experts, strong research organisations and skilled researchers. RESULTS: Effective priority-setting requires more than high quality economic research. Researchers have to engage with an array of stakeholders, network closely other research organisations, build partnerships with different levels of government and train the future generation of researchers and policy-makers. In low- and middle-income countries where there are seldom government units or agencies dedicated to health technology assessment, they also have to support the development of an effective priority-setting process that is sensitive to societal and government needs and priorities. CONCLUSIONS: Research organisations have an important role to play in contributing to the development of health technology assessment and priority-setting capacity. In Africa, where there are resource and capacity challenges, effective partnerships between local and international researchers, and with key government stakeholders, can leverage existing skills and knowledge to generate a critical mass of individuals and institutions. These would help to meet the priority-setting needs of African countries and contribute to sustainable universal health coverage.

Pesquisa Biomédica/organização & administração , Fortalecimento Institucional/organização & administração , Análise Custo-Benefício/organização & administração , Avaliação da Tecnologia Biomédica/organização & administração , Cobertura Universal do Seguro de Saúde/organização & administração , África , Humanos
Reumatol. clín. (Barc.) ; 13(5): 258-263, sept.-oct. 2017. ilus, tab
Artigo em Espanhol | IBECS | ID: ibc-165223


Objetivo. En España, el estudio FRIDEX ha aportado recientemente unos umbrales de riesgo coste-efectivos para el manejo de la osteoporosis. El objetivo del estudio es evaluar el impacto de su aplicación en la práctica clínica habitual, comparándola también con los umbrales de la National Osteoporosis Guidelines Group (NOGG). Material y métodos. Estudio transversal realizado en mujeres remitidas a una unidad de densitometría ósea. El riesgo absoluto de presentar una fractura mayor o de cadera se calculó mediante la fórmula FRAX® española y británica para poder emplear los umbrales de intervención de la calibración FRIDEX y de la guía NOGG, respectivamente. Se descartaron mujeres con tratamiento antirresortivo. Resultados. Fueron incluidas 607 mujeres con una mediana de edad de 59,4 (RIQ=14) años. El 31,4% recibieron tratamiento después de la densitometría ósea. El empleo de la calibración FRIDEX indicaría una densitometría ósea al 35,4% y tratamiento al 26,7%, lo que supondría una reducción de gastos a los 5años del 18,8%. Según la guía NOGG precisarían densitometría ósea el 32% y tratamiento el 21,3%, siendo el ahorro de un 35% a los 5años respeto a la actitud habitual. La concordancia de la guía NOGG y del FRIDEX según el coeficiente kappa de Cohen fue baja tanto a nivel diagnóstico (0,16 [IC95%: 0,09-0,24]) como terapéutico (0,39 [IC95%: 0,31-0,47]). Conclusiones. La aplicación de la calibración FRIDEX y de la guía NOGG aumentaría la eficiencia del manejo de la osteoporosis, aunque su concordancia es baja, indicando tratamiento en diferentes perfiles de mujeres (AU)

Objective. The recent FRIDEX calibration proposed cost-effectiveness thresholds for the Spanish population. The aim of our study is to evaluate the impact of its application in routine clinical practice and to compare its thresholds with those of the National Osteoporosis Guideline Group (NOGG). Material and methods. Cross-sectional study in women referred to a bone densitometry unit who were not receiving antiresorptive therapy. The absolute risk of major fracture or hip fracture was calculated with the Spanish and British formulas of the FRAX® tool using the intervention thresholds of the FRIDEX calibration and the NOGG guideline, respectively. Results. The study included 607 women with a median age of 59.4 (IQR=14) years. Treatment was initiated in 31.4% after bone mineral densitometry. With the application of the FRIDEX calibration, bone mineral density testing would have been indicated in 35.4% of the sample and treatment in 26.7%, reducing costs by 18.8% over a 5-year period. The NOGG guideline would have recommended testing in 32% and treatment in 21.3% of the participants, resulting in a reduction in costs of 35% over 5years, when compared with the standard approach. Agreement between the FRIDEX calibration and the NOGG guideline, as defined by Cohen's kappa coefficient, was low in terms of both diagnostic (0.16 [95%CI, 0.09-0.24]) and therapeutic indications (0.39 [95%CI, 0.31-0.47]). Conclusions. The application of the FRIDEX calibration and the NOGG guideline improves efficiency in the management of osteoporosis, although the level of agreement between the two is low (AU)

Humanos , Feminino , Adulto , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Osteoporose/terapia , Osteoporose , Osteoporose/economia , Calibragem/normas , Análise Custo-Eficiência , Estudos Transversais/métodos , Densitometria/métodos , Estudos de Coortes , Análise Custo-Benefício/organização & administração , Análise Custo-Benefício/normas
Rev. Rol enferm ; 40(9): 578-584, sept. 2017. ilus
Artigo em Espanhol | IBECS | ID: ibc-165952


El aumento significativo de las indicaciones de la anticoagulación hace que el número de pacientes que precisan de seguimiento y control en AP crezca cada día, situación que requiere por parte de los gestores adecuar las agendas de los profesionales –médicos y enfermeras– a esta necesidad creciente. La prescripción colaborativa enfermera se está desarrollando en Andalucía. Esta actividad permitiría en nuestra Unidad de Gestión Clínica optimizar los tiempos dedicados al seguimiento de pacientes anticoagulados. La determinación y dosificación de los pacientes por parte de la enfermera supone menores tiempo de dedicación a esta actividad por parte del médico de familia y que oriente su actividad a otras tareas, como aumentar el número de citas disponibles o el tiempo que dedica actualmente a las mismas, atender las urgencias del centro, entre otras. Se realiza un estudio piloto diseñando un ensayo clínico (EC) para determinar la viabilidad del proyecto e implementar esta práctica. Se realiza el seguimiento de 146 pacientes asignados de manera aleatoria al grupo experimental y control y durante 4 meses y medio. Se midió el gasto en el consumo de tiras, coste en tiempo del servicio, valores de INR, tiempo en rango terapéutico y de dedicación a la consulta. Los resultados, con significación estadística contrastada, indican que, cuando la enfermera dosifica y sigue al paciente, los pacientes están más tiempo en rango terapéutico, el número de visitas es menor y el gasto en tiras se reduce (AU)

The increase of anticoagulation drug therapy indications translates into a rise of patients, which need primary healthcare monitoring and control. Managers have to adjust health professionals’ timetables –of doctors and nurses– to adapt them to the increasing demand. Collaborative nurse prescription is being tested in Andalusia. Implementing this development would allow our clinical management unit to optimize the amount of time dedicated to monitor patients taking anticoagulation drug therapy. When nurses monitor patients and determine anticoagulant drug therapy dosage, the amount of time that general practitioners dedicate to this group of patients is reduced, increasing their time for other duties such as: augmenting the amount of available medical appointments, providing better attention during the appointments, and increasing their availability to respond to emergencies within the unit, among others. We ran a pilot study designing a clinical trial to establish the viability of the project. We monitored 146 patients randomly assigned patients, both to the control and experimental group during four and a half months. We evaluated the expenditure of test strips, the cost of service time, INR values, the time of therapeutic range and consultations. Results showed a statistical significant difference: when nurses dose and monitor patients, patients have more time of therapeutic range, the number of visits declines, and the expenditure of test strips is reduced (AU)

Humanos , Otimização , Atenção à Saúde , Atenção Primária à Saúde , Enfermeiras Clínicas/legislação & jurisprudência , Enfermeiras Clínicas/organização & administração , Papel do Profissional de Enfermagem , Prescrições de Medicamentos/enfermagem , Assistência à Saúde , Análise Custo-Benefício/organização & administração , Análise Custo-Benefício/normas , Estudos Prospectivos , Estudos Longitudinais , Protocolos/métodos
J Glob Health ; 7(1): 010409, 2017 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-28400955


BACKGROUND: Treatment of childhood pneumonia is a key priority in low-income countries, with substantial resource implications. WHO revised their guidelines for the management of childhood pneumonia in 2013. We estimated and compared the resource requirements, total direct medical cost and cost-effectiveness of childhood pneumonia management in 74 countries with high burden of child mortality (Countdown countries) using the 2005 and 2013 revised WHO guidelines. METHODS: We constructed a cost model using a bottom up approach to estimate the cost of childhood pneumonia management using the 2005 and 2013 WHO guidelines from a public provider perspective in 74 Countdown countries. The cost of pneumonia treatment was estimated, by country, for year 2013, including costs of medicines and service delivery at three different management levels. We also assessed country-specific lives saved and disability adjusted life years (DALYs) averted due to pneumonia treated in children aged below five years. The cost-effectiveness of pneumonia treatment was estimated in terms of cost per DALY averted by fully implementing WHO treatment guidelines relative to no treatment intervention for pneumonia. RESULTS: Achieving full treatment coverage with the 2005 WHO guidelines was estimated to cost US$ 2.9 (1.9-4.2) billion compared to an estimated US$ 1.8 (0.8-3.0) billion for the revised 2013 WHO guidelines in these countries. Pneumonia management in young children following WHO treatment guidelines could save up to 39.8 million DALYs compared to a zero coverage scenario in the year 2013 in the 74 Countdown countries. The median cost-effectiveness ratio per DALY averted in 74 countries was substantially lower for the 2013 guidelines: US$ 26.6 (interquartile range IQR: 17.7-45.9) vs US$ 38.3 (IQR: US$ 26.2-86.9) per DALY averted for the 2005 guideline respectively. CONCLUSIONS: Child pneumonia management as detailed in standard WHO guidelines is a very cost-effective intervention. Implementation of the 2013 WHO guidelines is expected to result in a 39.5% reduction in treatment costs compared to the 2005 guidelines which could save up to US$ 1.16 (0.68-1.23) billion in the 74 Countdown countries, with potential savings greatest in low HIV burden countries which can implement effective community case management of pneumonia.

Análise Custo-Benefício/organização & administração , Guias como Assunto/normas , Pneumonia/tratamento farmacológico , Pneumonia/economia , Organização Mundial da Saúde , Administração de Caso/normas , Mortalidade da Criança/tendências , Pré-Escolar , Efeitos Psicossociais da Doença , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Pneumonia/mortalidade , Anos de Vida Ajustados por Qualidade de Vida , Organização Mundial da Saúde/organização & administração
Rev Epidemiol Sante Publique ; 65(2): 159-167, 2017 Apr.
Artigo em Francês | MEDLINE | ID: mdl-28214229


BACKGROUND: The International organization for standardization (ISO) is the world leader in providing industrial and commercial standards and certifications. Beyond medical devices, four French clinical research and innovation departments have received an ISO 9001 certification (the standard for quality management). Simultaneously, medico-economic studies have become increasingly important in the public decision process. Using the clinical research and innovation department from the Léon-Bérard Cancer Center as an example, the purpose of this article is to show how the scope of the ISO 9001 certification has been extended to cover medico-economic studies. METHOD: All of the processes, procedures, operating modes, documents, and indicators used by the clinical research and innovation department of the Léon-Bérard center were investigated. Literature searches were conducted using Medline keywords. The recommendations from the French national authority for health and other organizations, such as the International society for pharmacoeconomics and outcomes research (ISPOR), were also considered, as well as the recommendations of the General inspectorate of social affairs. RESULTS: In accordance with the national and international recommendations, two procedures were created and four procedures were revised at this center. Five indicators of quality and an evaluation chart were developed. CONCLUSION: By adopting the ISO 9001 certification into its medico-economic studies, the clinical research and innovation department of the Léon-Bérard center has used an innovative approach in the context of the growing importance of economic studies in decision-making.

Pesquisa Biomédica/normas , Certificação , Análise Custo-Benefício/organização & administração , Invenções/economia , Invenções/normas , Garantia da Qualidade dos Cuidados de Saúde/organização & administração , Pesquisa Biomédica/organização & administração , Análise Custo-Benefício/normas , Humanos , Cooperação Internacional , Liderança , Avaliação de Resultados (Cuidados de Saúde)/economia , Avaliação de Resultados (Cuidados de Saúde)/normas , Garantia da Qualidade dos Cuidados de Saúde/normas , Padrões de Referência
Radiología (Madr., Ed. impr.) ; 59(1): 40-46, ene.-feb. 2017. tab
Artigo em Espanhol | IBECS | ID: ibc-159695


Objetivo. Realizar estudio de costo-efectividad de la biopsia por aspiración al vacío (BAV) (9 G) guiada por estereotaxia vertical o ecografía comparada con biopsia con aguja gruesa (BAG) (14 G) y biopsia con arpón. Material y métodos. Analizamos 997 biopsias mamarias (181 BAV, 626 BAG y 190 arpones). Calculamos costes totales (directos e indirectos) de los tres tipos de biopsia. No calculamos costes intangibles. El efecto a medir fue el “porcentaje de diagnósticos correctos” obtenidos con cada una de las técnicas. Calculamos los ratios medios de los tres tipos de biopsias e identificamos la opción dominante más costo-efectiva. Resultados. Costes totales de BAG 225,09 €, de BAV 638,90 € y de biopsia con arpón 1780,01 €. Porcentaje de diagnósticos correctos globales con BAG 91,81%, BAV 94,03% y biopsia con arpón 100%, sin diferencias significativas (p=0,3485). En microcalcificaciones, los porcentajes de diagnósticos correctos fueron con BAG 50% y con BAV 96,77%, p<0,0001. En nódulos tampoco hubo diferencias significativas. El ratio medio costo-efectividad considerando todas las lesiones en conjunto, fue para BAG 2,45, BAV 6,79 y arpón 17,80. Conclusión. La BAG fue la opción dominante para el diagnóstico de lesiones mamarias sospechosas de malignidad en general. En el caso de las microcalcificaciones, el bajo porcentaje de diagnósticos de la BAG (50%) desaconsejan su uso y colocan a la BAV como técnica de elección; la BAV es, además, más costo-efectiva que el arpón, que es la otra técnica indicada para biopsiar microcalcificaciones (AU)

Objectives. To determine the cost effectiveness of breast biopsy by 9G vacuum-assisted guided by vertical stereotaxy or ultrasonography in comparison with breast biopsy by 14G core-needle biopsy and surgical biopsy. Material and methods. We analyzed a total of 997 biopsies (181 vacuum-assisted, 626 core, and 190 surgical biopsies). We calculated the total costs (indirect and direct) of the three types of biopsy. We did not calculate intangible costs. We measured the percentage of correct diagnoses obtained with each technique. To identify the most cost-effective option, we calculated the mean ratios for the three types of biopsies. Results. Total costs were €225.09 for core biopsy, €638.90 for vacuum-assisted biopsy, and €1780.01 for surgical biopsy. The overall percentage of correct diagnoses was 91.81% for core biopsy, 94.03% for vacuum-assisted biopsy, and 100% for surgical biopsy; however, these differences did not reach statistical significance (p=0.3485). For microcalcifications, the percentage of correct diagnoses was 50% for core biopsy and 96.77% for vacuum-assisted biopsy (p<0.0001). For nodules, there were no significant differences among techniques. The mean cost-effectiveness ratio considering all lesions was 2.45 for core biopsy, 6.79 for vacuum-assisted biopsy, and 17.80 for surgical biopsy. Conclusion. Core biopsy was the dominant option for the diagnosis of suspicious breast lesions in general. However, in cases with microcalcifications, the low percentage of correct diagnoses achieved by core biopsy (50%) advises against its use in this context, where vacuum-assisted biopsy would be the technique of choice because it is more cost-effective than surgical biopsy, the other technique indicated for biopsying microcalcifications (AU)

Humanos , Feminino , Adolescente , Adulto Jovem , Adulto , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Biópsia/classificação , Biópsia/economia , Biópsia , Biópsia com Agulha de Grande Calibre/economia , Biópsia com Agulha de Grande Calibre , Biópsia Guiada por Imagem/economia , Mama , Análise Custo-Benefício/economia , Análise Custo-Benefício/organização & administração , Análise Custo-Benefício/normas , Avaliação de Custo-Efetividade , Estudos Retrospectivos , Análise Estatística
Prev Med ; 99: 49-57, 2017 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-28087465


The World Health Organization recommends that countries implement population-wide cardiovascular disease (CVD) risk assessment and management programmes. The aim of this study was to conduct a systematic review to evaluate whether this recommendation is supported by cost-effectiveness evidence. Published economic evaluations were identified via electronic medical and social science databases (including Medline, Web of Science, and the NHS Economic Evaluation Database) from inception to March 2016. Study quality was evaluated using a modified version of the Consolidated Health Economic Evaluation Reporting Standards. Fourteen economic evaluations were included: five studies based on randomised controlled trials, seven studies based on observational studies and two studies using hypothetical modelling synthesizing secondary data. Trial based studies measured CVD risk factor changes over 1 to 3years, with modelled projections of longer term events. Programmes were either not, or only, cost-effective under non-verified assumptions such as sustained risk factor changes. Most observational and hypothetical studies suggested programmes were likely to be cost-effective; however, study deigns are subject to bias and subsequent empirical evidence has contradicted key assumptions. No studies assessed impacts on inequalities. In conclusion, recommendations for population-wide risk assessment and management programmes lack a robust, real world, evidence basis. Given implementation is resource intensive there is a need for robust economic evaluation, ideally conducted alongside trials, to assess cost effectiveness. Further, the efficiency and equity impact of different delivery models should be investigated, and also the combination of targeted screening with whole population interventions recognising that there multiple approaches to prevention.

Doenças Cardiovasculares/prevenção & controle , Análise Custo-Benefício/economia , Medição de Risco , Análise Custo-Benefício/organização & administração , Gerenciamento Clínico , Humanos
J. investig. allergol. clin. immunol ; 27(2): 89-97, 2017. ilus, tab, graf
Artigo em Inglês | IBECS | ID: ibc-162316


Objectives: Fractional exhaled nitric oxide (FeNO) is a marker for type 2 airway inflammation. The objective of this study was to evaluate the cost-effectiveness and budget impact of FeNO monitoring for management of adult asthma in Spain. Methods: A cost-effectiveness analysis model was used to evaluate the effect on costs of adding FeNO monitoring to asthma management. Over a 1-year period, the model estimated the incremental cost per quality-adjusted life year and incremental number of exacerbations avoided when FeNO monitoring was added to standard guideline-driven asthma care compared with standard care alone. Univariate and multivariate sensitivity analyses were applied to explore uncertainty in the model. A budget impact model was used to examine the impact of FeNO monitoring on primary care costs across the Spanish health system. Results: The results showed that adding FeNO to standard asthma care saved €62.53 per patient-year in the adult population and improved quality-adjusted life years by 0.026 per patient-year. The budget impact analysis revealed a potential net yearly saving of €129 million if FeNO monitoring had been used in primary care settings in Spain. Conclusions: The present economic model shows that adding FeNO to the treatment algorithm can considerably reduce costs and improve quality of life when used to manage asthma in combination with current treatment guidelines (AU)

Objetivos: La fracción exhalada del óxido nítrico (FeNO) es un marcador de la inflamación bronquial de tipo Th-2. El objetivo de este estudio ha sido evaluar el coste-efectividad e impacto presupuestario de la monitorización del FeNO en el manejo del asma del adulto en España. Métodos: Se ha utilizado un modelo de análisis de coste-efectividad para evaluar los resultados económicos cuando se utilizó el FeNO en el manejo del asma durante un año. El modelo estimó el incremento de coste por calidad de vida ajustada por año (QALY) y el número de exacerbaciones evitadas cuando se añadió el FeNO a la guía habitual de tratamiento del asma en comparación con la guía habitual. Se aplicó un análisis univariante y multivariante para valorar la posible incertidumbre del modelo. Se utilizó un modelo de impacto presupuestario para evaluar el impacto económico de la introducción de la monitorización con el FeNO en consultas de atención primaria del estado español y teniendo en cuenta el sistema sanitario español. Resultados: Se ha demostrado que el añadir el FeNO al tratamiento habitual del asma ahorra 62,53€ por paciente por año en adultos con asma y mejoró la QALYs en 0,026 por paciente y año. El análisis económico resultó en un ahorro estimado de 129 millones de euros netos por año en consultas de atención primaria. Conclusiones: El modelo económico utilizado ha mostrado que el añadir el FeNO al algoritmo habitual de tratamiento del asma conlleva a un importante ahorro en recursos económicos y un aumento de la calidad de vida (AU)

Humanos , Masculino , Feminino , Asma/economia , Óxido Nítrico/uso terapêutico , Biomarcadores Farmacológicos/análise , Qualidade de Vida , Atenção Primária à Saúde , Asma/epidemiologia , Análise Custo-Benefício/organização & administração , Avaliação de Custo-Efetividade , Análise Multivariada , Orçamentos/organização & administração , Espanha/epidemiologia