Variation in Ischemic Stroke Payments in the USA: A Medicare Beneficiary Study.

INTRODUCTION: The growing cost of stroke care has created the need for outcome-oriented and cost-saving payment models. Identifying imbalances in the current reimbursement model is an essential step toward designing impactful value-based reimbursement strategies. This study describes the variation in reimbursement fees for ischemic stroke management across the USA. METHODS: This Medicare Fee-For-Service claims study examines USA beneficiaries who suffered an ischemic stroke from 2021Q1 to 2022Q2 identified using the Medicare-Severity Diagnosis-Related Groups (MS-DRGs). Demographic national and regional US data were extracted from the Census Bureau. The MS-DRG codes were grouped into four categories according to treatment modality and clinical complexity. Our primary outcome of interest was payments made across individual USA and US geographic regions, assessed by computing the mean incremental payment in cases of comparable complexity. Differences between states for each MS-DRG were statistically evaluated using a linear regression model of the logarithmic transformed payments. RESULTS: 227,273 ischemic stroke cases were included in our analysis. Significant variations were observed among all DRGs defined by medical complexity, treatment modality, and states (p < 0.001). Differences in mean payment per case with the same MS-DRG vary by as high as 500% among individual states. Although higher payment rates were observed in MS-DRG codes with major comorbidities or complexity (MCC), the variation was more expressive for codes without MCC. It was not possible to identify a standard mean incremental fee at a state level. At a regional level, the Northeast registered the highest fees, followed by the West, Midwest, and South, which correlate with poverty rates and median household income in the regions. CONCLUSIONS: The payment variability observed across USA suggests that the current reimbursement system needs to be aligned with stroke treatment costs. Future studies may go one step further to evaluate accurate stroke management costs to guide policymakers in introducing health policies that promote better care for stroke patients.

Comparison of COVID-19 hospitalization costs across care pathways: a patient-level time-driven activity-based costing analysis in a Brazilian hospital.

BACKGROUND: The COVID-19 pandemic raised awareness of the need to better understand where and how patient-level costs are incurred in health care organizations, as health managers and other decision-makers need to plan and quickly adapt to the increasing demand for health care services to meet patients' care needs. Time-driven activity-based costing offers a better understanding of the drivers of cost throughout the care pathway, providing information that can guide decisions on process improvement and resource optimization. This study aims to estimate COVID-19 patient-level hospital costs and to evaluate cost variability considering the in-hospital care pathways of COVID-19 management and the patient clinical classification. METHODS: This is a prospective cohort study that applied time-driven activity-based costing (TDABC) in a Brazilian reference center for COVID-19. Patients hospitalized during the first wave of the disease were selected for their data to be analyzed to estimate in-hospital costs. The cost information was calculated at the patient level and stratified by hospital care pathway and Ordinal Scale for Clinical Improvement (OSCI) category. Multivariable analyses were applied to identify predictors of cost variability in the care pathways that were evaluated. RESULTS: A total of 208 patients were included in the study. Patients followed five different care pathways, of which Emergency + Ward was the most followed (n = 118, 57%). Pathways which included the intensive care unit presented a statistically significant influence on costs per patient (p <  0.001) when compared to Emergency + Ward. The median cost per patient was I$2879 (IQR 1215; 8140) and mean cost per patient was I$6818 (SD 9043). The most expensive care pathway was the ICU only, registering a median cost per patient of I$13,519 (IQR 5637; 23,373) and mean cost per patient of I$17,709 (SD 16,020). All care pathways that included the ICU unit registered a higher cost per patient. CONCLUSIONS: This is one of the first microcosting study for COVID-19 that applied the TDABC methodology and demonstrated how patient-level costs vary as a function of the care pathways followed by patients. These findings can be used to develop value reimbursement strategies that will inform sustainable health policies in middle-income countries such as Brazil.

Extracorporeal membrane oxygenation outcomes in COVID-19 patients: Case series from the Brazilian COVID-19 Registry.

Around 5% of coronavirus disease 2019 (COVID-19) patients develop critical disease, with severe pneumonia and acute respiratory distress syndrome (ARDS). In these cases, extracorporeal membrane oxygenation (ECMO) may be considered when conventional therapy fails. This study aimed to describe the clinical characteristics and in-hospital outcomes of COVID-19 patients with ARDS refractory to lung-protective ventilation and prone positioning on ECMO support, as well as to review the available literature on ECMO use and COVID-19 patients' outcome. Patients from this case series were selected from the Brazilian COVID-19 Registry. From the 7646 patients included in the registry, only eight received ECMO support (0.1%), in four hospitals. The median age of the entire sample was 59 (interquartile range 54.2-64.4) years old and 87.5% were male. Hypertension (50.0%), diabetes mellitus (50.0%) and obesity (37.5%) were the most frequent comorbidities. The indications for ECMO were PaO2 /FiO2 ratio <80 mm Hg for more than 6 h or PaO2 /FiO2 ratio <60 mm Hg for more than 3 h. The mortality rate was 87.5%. In conclusion, in this case series of COVID-19 patients with ARDS refractory to conventional therapy who received ECMO support, a very high mortality was observed. Our findings are not different from previous studies including a small number of patients; however, there is a huge difference from Extracorporeal Life Support Organization results, which encourages us to keep looking for improvement.

Value-Based Healthcare Initiatives in Practice: A Systematic Review.

EXECUTIVE SUMMARY: Value-based initiatives are growing in importance as strategic models of healthcare management, prompting the need for an in-depth exploration of their outcome measures. This systematic review aimed to identify measures that are being used in the application of the value agenda. Multiple electronic databases (PubMed/MEDLINE, Embase, Scopus, Cochrane Central Register of Controlled Trials) were searched. Eligible studies reported various implementations of value-based healthcare initiatives. A qualitative approach was used to analyze their outcome measurements. Outcomes were classified according to a tier-level hierarchy. In a radar chart, we compared literature to cases from Harvard Business Publishing. The value agenda effect reported was described in terms of its impact on each domain of the value equation. A total of 7,195 records were retrieved; 47 studies were included. Forty studies used electronic health record systems for data origin. Only 16 used patient-reported outcome surveys to cover outcome tiers that are important to patients, and 3 reported outcomes to all 6 levels of our outcome measures hierarchy. A considerable proportion of the studies (36%) reported results that contributed to value-based financial outcomes focused on cost savings. However, a gap remains in measuring outcomes that matter to patients. A more complete application of the value agenda by health organizations requires advances in technology and culture change management.

Advances in Value-Based Healthcare by the Application of Time-Driven Activity-Based Costing for Inpatient Management: A Systematic Review.

OBJECTIVES: Implementation of value-based initiatives depends on cost-assessment methods that can provide high-quality cost information. Time-driven activity-based costing (TDABC) is increasingly being used to solve the cost-information gap. This study aimed to review the use of the TDABC methodology in real-world settings and to estimate its impact on the value-based healthcare concept for inpatient management. METHODS: This systematic review was conducted by screening PubMed/MEDLINE and Scopus databases following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, including all studies up to August 2019. The use of TDABC for inpatient management was the main eligibility criterion. A qualitative approach was used to analyze the different methodological aspects of TDABC and its effective contribution to the implementation of value-based initiatives. RESULTS: A total of 1066 studies were retrieved, and 26 full-text articles were selected for review. Only studies focused on surgical inpatient conditions were identified. Most of the studies reported the types of activities on a macrolevel. Professional and structural cost variables were usually assessed. Eighteen studies reported that TDABC contributed to value-based initiatives, especially cost-saving findings. TDABC was satisfactorily applied to achieve value-based contributions in all the studies that used the method for this purpose. CONCLUSIONS: TDABC could be a strategy for increasing cost accuracy in real-world settings, and the method could help in the transition from fee-for-service to value-based systems. The results could provide a clearer idea of the costs, help with resource allocation and waste reduction, and might support clinicians and managers in increasing value in a more accurate and transparent way.

A standardized framework to evaluate the quality of studies using TDABC in healthcare: the TDABC in Healthcare Consortium Consensus Statement.

BACKGROUND: This Consensus Statement introduces a standardized framework, in a checklist format, to support future development and reporting of TDABC studies in healthcare, and to encourage their reproducibility. Additionally, it establishes the first formal networking of TDABC researchers through the creation of the TDABC in Healthcare Consortium. METHODS: A consensus group of researchers reviewed the most relevant TDABC studies available in Medline and Scopus databases to identify the initial elements of the checklist. Using a Focus Group process, each element received a recommendation regarding where in the scientific article section it should be placed and whether the element was required or suggested. A questionnaire was circulated with expert researchers in the field to provide additional recommendations regarding the content of the checklist and the strength of recommendation for each included element. RESULTS: The TDABC standardized framework includes 32 elements, provides recommendations where in the scientific article to include each element, and comments on the strength of each recommendation. All 32 elements were validated, with 21 elements classified as mandatory and 11 as suggested but not mandatory. CONCLUSIONS: This is the first standardized framework to support the development and reporting of TDABC research in healthcare and to stablish a community of experts in TDABC methodology. We expect that it can contribute to scale strategies that would result in cost-savings outcomes and in value-oriented strategies that can be adopted in healthcare systems and institutions.

Proposition of a Shared and Value-Oriented Work Structure for Hospital-Based Health Technology Assessment and Enterprise Risk Management Processes.

BACKGROUND: Healthcare organizations have invested efforts on hospital-based health technology assessment (HB-HTA) and enterprise risk management (ERM) processes for novel systems to obtain more accurate data on which to base strategic decisions. This study proposes to analyze how HB-HTA and ERM processes can share personal resources and skills to achieve principles with value-oriented results. METHODS: Literature on ERM and HB-HTA and data from interviews with healthcare managers compose the research data sources, which were submitted to a qualitative data analysis. It was oriented to identify the association between ERM and HB-HTA application in hospitals and the common principles between both processes, in addition to proposing the capability to share personal resources between both teams in a matrix. RESULTS: The common principles and personal background suggested for HB-HTA and ERM teams allowed the build of a matrix identifying how both teams can work in an integrated manner being more effective and value-oriented. The shared resource matrix reports how each professional (with a specific background) may interact with each activity associated to HB-HTA or ERM implementation guidelines. CONCLUSIONS: The identification of common principles and capabilities between ERM and HB-HTA suggested advances with the literature from both research areas. The opportunity to share personal resources also contributes to the implementation of those processes in hospitals with less financial resources, approaching its own management to be more efficient with the care chain.

Development of an enterprise risk inventory for healthcare.

BACKGROUND: The first phase of an enterprise risk management (ERM) program is the identification of risks. Accurate identification is essential to a proactive and effective ERM function. The authors identified a lack of such risk identification in the literature and in practical cases when interviewing the chief risk officers from healthcare organizations. A risk inventory specific to healthcare organizations that includes detailed risk scenarios and risk impacts currently does not exist. Thus, the objective of this research is to develop an enterprise risk inventory for healthcare organizations to create a common understanding of how each type of risk impacts a healthcare organization. METHOD: ERM guidelines and data from 15 interviews with chief risk officers were analyzed to create the risk inventory. The identified risks were confirmed through a survey of risk managers from a range of global healthcare organizations during the ASHRM conference in 2017. Descriptive statistics were developed and cluster analysis was performed using the survey results. RESULTS: The risk inventory includes 28 risks and their specific risk scenarios. Cyberattack was ranked as the principal risk by the participants, followed by sentinel events and risks associated with human capital management (organizational culture, use of electronic medical records and physician wellness). The data analysis showed that the specific characteristics of the survey participants, such as the length of time working in risk management, the size of the organization, and the presence of a school of medicine, do not impact an individual's opinion of the importance of the risks identified. A personal background in risk management (clinical or enterprise) was a characteristic that showed a small difference in the perceived importance of the risks from the proposed risk inventory. CONCLUSIONS: In addition to defining specific risk scenarios, the enterprise risk inventory presented in this research can contribute to guiding the risk identification phase of an ERM program and thereby support the development of a risk culture. Patient data security in hospitals that operate with high levels of technology is fundamental to delivering high quality and safe care to patients. At the top of the risk ranking, the identification of cyberattacks reflects the importance that healthcare risk managers place on this risk by allocating time and other resources. Exploring opportunities to improve cyber risk management and evaluating the benefits of using the risk inventory at the beginning of the risk identification phase in an ERM program are suggestions for future studies.

Improvements in technology and the expanding role of time-driven, activity-based costing to increase value in healthcare provider organizations: a literature review.

Objective: This study evaluated the influence of technology on accurately measuring costs using time-driven activity-based costing (TDABC) in healthcare provider organizations by identifying the most recent scientific evidence of how it contributed to increasing the value of surgical care. Methods: This is a literature-based analysis that mainly used two data sources: first, the most recent systematic reviews that specifically evaluated TDABC studies in the surgical field and, second, all articles that mentioned the use of CareMeasurement (CM) software to implement TDABC, which started to be published after the publication of the systematic review. The articles from the systematic review were grouped as manually performed TDABC, while those using CM were grouped as technology-based studies of TDABC implementations. The analyses focused on evaluating the impact of using technology to apply TDABC. A general description was followed by three levels of information extraction: the number of cases included, the number of articles published per year, and the contributions of TDABC to achieve cost savings and other improvements. Results: Fourteen studies using real-world patient-level data to evaluate costs comprised the manual group of studies. Thirteen studies that reported the use of CM comprised the technology-based group of articles. In the manual studies, the average number of cases included per study was 160, while in the technology-based studies, the average number of cases included was 4,767. Technology-based studies, on average, have a more comprehensive impact than manual ones in providing accurate cost information from larger samples. Conclusion: TDABC studies supported by technologies such as CM register more cases, identify cost-saving opportunities, and are frequently used to support reimbursement strategies based on value. The findings suggest that using TDABC with the support of technology can increase healthcare value.

Estimated costs for Duchenne muscular dystrophy care in Brazil.

BACKGROUND: The economic burden of rare diseases on health systems is still not widely measured, with the generation of accurate information about the costs with medical care for subjects with rare diseases being crucial when defining health policies. Duchenne Muscular Dystrophy (DMD) is the most common form of muscular dystrophy, with new technologies recently being studied for its management. Information about the costs related to the disease in Latin America is scarce, and the objective of this study is to evaluate the annual hospital, home care and transportation costs per patient with DMD treatment in Brazil. RESULTS: Data from 27 patients were included, the median annual cost per patient was R$ 17,121 (IQR R$ 6,786; 25,621). Home care expenditures accounted for 92% of the total costs, followed by hospital costs (6%) and transportation costs (2%). Medications and loss of family, and patient's productivity are among the most representative consumption items. When disease worsening due to loss of the ability to walk was incorporated to the analysis, it was shown that wheelchair users account for an incremental cost of 23% compared with non-wheelchair users. CONCLUSIONS: This is an original study in Latin America to measure DMD costs using the micro-costing technique. Generating accurate information about costs is crucial to provide health managers with information that could help establish more sustainable policies when deciding upon rare diseases in emerging countries.

Micro-Costing of a Remotely Operated Referral Management System to Secondary Care in the Unified Health System in Brazil.

Referral of cases from primary to secondary care in the Brazilian public healthcare system is one of the most important issues to be tackled. Telehealth strategies have been shown effective in avoiding unnecessary referrals. The objective of this study was to estimate cost per referred case by a remotely operated referral management system to further inform the decision making on the topic. Analysis of cost by applying time-driven activity-based costing. Cost analyses included comparisons between medical specialties, localities for which referrals were being conducted, and periods of time. Cost per referred case across localities ranged from R$ 5.70 to R$ 8.29. Cost per referred case across medical specialties ranged from R$ 1.85 to R$ 8.56. Strategies to optimize the management of referral cases to specialized care in public healthcare systems are still needed. Telehealth strategies may be advantageous, with cost estimates across localities ranging from R$ 5.70 to R$ 8.29, with additional observed variability related to the type of medical specialty.

Telemedicine Versus Face-to-Face Care in Ophthalmology: Costs and Utility Measures in a Real-World Setting.

OBJECTIVES: Advances in telemedicine offer a unique opportunity to expand access to the health system. Nevertheless, few studies have described the impact of telediagnosis implementation on health and economic outcomes. METHODS: An ophthalmology telediagnosis service (TeleOftalmo) was compared with traditional face-to-face care provided by the Brazilian public health system. For both groups, utility data were collected at 2 time points using the Visual Function Questionnaire-Utility Index instrument from interviews with 536 patients. The cost per patient encounter was analyzed according to the time-driven activity-based costing. Value analyses were conducted to ascertain whether and how telemedicine service has the potential to generate cost savings for the health system. RESULTS: Visual function-related quality of life did not differ significantly between TeleOftalmo and face-to-face care groups. Using the current model, the telemedicine service assisted an average of 1159 patients per month at a median cost per telediagnosis of Int$97 (interquartile range, Int$82-Int$119) versus Int$77 (interquartile range, Int$75-Int$80) for face-to-face care. If the telemedicine service was redesigned, considering the opportunities for improvement identified, it could operate at a cost of Int$53 per telediagnosis (a 31% cost savings) and could serve 3882 patients per month. CONCLUSIONS: This study demonstrates the potential value of a telemedicine service. There was no difference in patient-perceived utility between a telediagnostic ophthalmology service and face-to-face care by an eye specialist. TeleOftalmo has the potential to be a cost-saving strategy for the Brazilian health system and could be a template for implementation of telediagnostic services in other regions.

Moving the Brazilian ischaemic stroke pathway to a value-based care: introduction of a risk-adjusted cost estimate model for stroke treatment.

The unsustainable increases in healthcare expenses and waste have motivated the migration of reimbursement strategies from volume to value. Value-based healthcare requires detailed comprehension of cost information at the patient level. This study introduces a clinical risk- and outcome-adjusted cost estimate model for stroke care sustained on time-driven activity-based costing (TDABC). In a cohort and multicentre study, a TDABC tool was developed to evaluate the costs per stroke patient, allowing us to identify and describe differences in cost by clinical risk at hospital arrival, treatment strategies and modified Rankin Score (mRS) at discharge. The clinical risk was confirmed by multivariate analysis and considered patients' National Institute for Health Stroke Scale and age. Descriptive cost analyses were conducted, followed by univariate and multivariate models to evaluate the risk levels, therapies and mRS stratification effect in costs. Then, the risk-adjusted cost estimate model for ischaemic stroke treatment was introduced. All the hospitals collected routine prospective data from consecutive patients admitted with ischaemic stroke diagnosis confirmed. A total of 822 patients were included. The median cost was I$2210 (interquartile range: I$1163-4504). Fifty percent of the patients registered a favourable outcome mRS (0-2), costing less at all risk levels, while patients with the worst mRS (5-6) registered higher costs. Those undergoing mechanical thrombectomy had an incremental cost for all three risk levels, but this difference was lower for high-risk patients. Estimated costs were compared to observed costs per risk group, and there were no significant differences in most groups, validating the risk and outcome-adjusted cost estimate model. By introducing a risk-adjusted cost estimate model, this study elucidates how healthcare delivery systems can generate local cost information to support value-based reimbursement strategies employing the data collection instruments and analysis developed in this study.

Hospital characteristics associated with COVID-19 mortality: data from the multicenter cohort Brazilian Registry.

The COVID-19 pandemic caused unprecedented pressure over health care systems worldwide. Hospital-level data that may influence the prognosis in COVID-19 patients still needs to be better investigated. Therefore, this study analyzed regional socioeconomic, hospital, and intensive care units (ICU) characteristics associated with in-hospital mortality in COVID-19 patients admitted to Brazilian institutions. This multicenter retrospective cohort study is part of the Brazilian COVID-19 Registry. We enrolled patients ≥ 18 years old with laboratory-confirmed COVID-19 admitted to the participating hospitals from March to September 2020. Patients' data were obtained through hospital records. Hospitals' data were collected through forms filled in loco and through open national databases. Generalized linear mixed models with logit link function were used for pooling mortality and to assess the association between hospital characteristics and mortality estimates. We built two models, one tested general hospital characteristics while the other tested ICU characteristics. All analyses were adjusted for the proportion of high-risk patients at admission. Thirty-one hospitals were included. The mean number of beds was 320.4 ± 186.6. These hospitals had eligible 6556 COVID-19 admissions during the study period. Estimated in-hospital mortality ranged from 9.0 to 48.0%. The first model included all 31 hospitals and showed that a private source of funding (ß = - 0.37; 95% CI - 0.71 to - 0.04; p = 0.029) and location in areas with a high gross domestic product (GDP) per capita (ß = - 0.40; 95% CI - 0.72 to - 0.08; p = 0.014) were independently associated with a lower mortality. The second model included 23 hospitals and showed that hospitals with an ICU work shift composed of more than 50% of intensivists (ß = - 0.59; 95% CI - 0.98 to - 0.20; p = 0.003) had lower mortality while hospitals with a higher proportion of less experienced medical professionals had higher mortality (ß = 0.40; 95% CI 0.11-0.68; p = 0.006). The impact of those association increased according to the proportion of high-risk patients at admission. In-hospital mortality varied significantly among Brazilian hospitals. Private-funded hospitals and those located in municipalities with a high GDP had a lower mortality. When analyzing ICU-specific characteristics, hospitals with more experienced ICU teams had a reduced mortality.

Economic Evaluation of a Telemedicine Service to expand Primary Health Care in Rio Grande do Sul: TeleOftalmo's microcosting analysis. / Avaliação Econômica de um Serviço de Telemedicina para ampliação da Atenção Primária à Saúde no Rio Grande do Sul: o microcusteio do Projeto TeleOftalmo.

This study evaluated the cost of public telediagnostic service in ophthalmology. The time-driven activity-based costing method (TDABC) was adopted to examine the cost components related to teleophthalmology. This method allowed us to establish the standard unit cost of telediagnosis, given the installed capacity and utilization of professionals. We considered data from one year of telediagnoses and evaluated the cost per telediagnosis change throughout technology adaptation in the system. The standard cost calculated by distance ophthalmic diagnosis was approximately R$ 119, considering the issuance of 1,080 monthly ophthalmic telediagnostic reports. We identified an imbalance between activities, which suggests the TDABC method's ability to guide management actions and improve resource allocation. The actual unit cost fell from R$ 783 to R$ 283 over one year - with room to approach the estimated standard cost. Partial economic evaluations contribute significantly to support the incorporation of new technologies. The TDABC method deserves prominence, as it enables us to retrieve more accurate information on the cost of technology, improving the scalability and management capacity of the healthcare system.

Este estudo avaliou o custo de um serviço público de telediagnóstico em oftalmologia. O método de custeio baseado em atividades e tempo (TDABC) foi adotado para examinar os componentes de custos relacionados à teleoftalmologia. Com este método, também foi possível estabelecer o custo unitário padrão que o telediagnóstico deveria ter, dada a capacidade instalada e utilização de profissionais. Dados de um ano de telediagnósticos foram considerados, e avaliou-se a mudança do custo por telediagnóstico ao longo do período de adaptação da tecnologia no sistema. O custo padrão calculado por diagnóstico oftalmológico a distância foi de R$ 119, considerando a emissão de 1.080 laudos de telediagnóstico oftalmológico por mês. Foi identificado um desequilíbrio entre as atividades que sugere a capacidade do método TDABC orientar ações de gestão e melhoria na alocação dos recursos. Ao longo de um ano, o custo unitário real passou de R$ 783 para R$ 283, ainda havendo espaço para se aproximar do custo padrão estimado. Avaliações econômicas parciais possuem importante aporte para subsidiar a incorporação de novas tecnologias. O TDABC merece destaque nesse sentido, pois permite obter informações mais precisas sobre custo da tecnologia, melhorando a capacidade de dimensionamento e gerenciamento da organização de saúde.

Value-based health care in heart failure: Quality of life and cost analysis

Abstract Objectives: To measure Quality of Life (QoL) and costs of Heart Failure (HF) outpatients in Brazil as an introduction to the Value-Based Health Care (VBHC) concept. Materials and methods: Cross-sectional study, patients with HF, with ejection fraction <50%, were recruited from three hospitals in Brazil. Two QoL (36-Item Short Form Survey [SF-36] and Minnesota Living with Heart Failure Questionnaire [MLHFQ]) and two anxiety/depression questionnaires were applied. SF-36 scores were stratified by domains. Treatment costs were calculated using the Time-Driven Activity-Based Costing (TDABC) method. Results were stratified by NYHA functional class and sex. Results: From October 2018 to January 2021, 198 patients were recruited, and the median MLHFQ (49.5 [IQR 21.0, 69.0]) and SF-36 scores demonstrated poor QoL, worse at higher NYHA classes. A third of patients had moderate/severe depression and anxiety symptoms, and women had higher anxiety scores. Mean costs of outpatient follow-up were US$ 215 ± 238 for NYHA I patients, US$ 296 ± 399 for NYHA II and US$ 667 ± 1012 for NYHA III/IV. Lab/exam costs represented 30% of the costs in NYHA I, and 74% in NYHA III/IV (US $ 63.26 vs. US$ 491.05). Conclusion: Patients with HF in Brazil have poor QoL and high treatment costs; both worsen as the NYHA classification increases. It seems that HF has a greater impact on the mental health of women. Costs increase mostly related to lab/exams. Accurate and crossed information about QoL and costs is essential to drive care and reimbursement strategies based on value.

TAVI e cirurgia de troca valvar aórtica em hospital terciário do sus: avaliação comparativa de desfechos clínicos e de custo aos 30 dias / TAVI and aortic valve replacement surgery in a tertiary SUS hospital: comparative assessment of clinical and cost outcomes at 30 days

INTRODUÇÃO: O implante por cateter de prótese aórtica(TAVI) constitui opção de tratamento para pacientes (pts) idosos com estenose aórtica(EA) grave e sintomáticos. Realizado no Brasil há cerca de 15 anos, recentemente o TAVI foi incorporado ao Sistema Único de Saúde (SUS). Avaliamos e comparamos os desfechos ocorridos em até 30 dias em pts submetidos a cirurgia (SAVR) e TAVI em hospital terciário do SUS e os custos associados à internação índice. MÉTODOS: Estudo retrospectivo, observacional e unicêntrico. Selecionados pts≥50 anos portadores de EA importante, submetidos a TAVI ou SAVR no período de 01/01/2018 a 31/12/22. Excluídos pts submetidos a cirurgia de urgência, cirurgias combinadas, pts com endocardite e re-operações; ou TAVI por via não-transfemoral. Os desfechos clínicos de 30 dias foram avaliados conforme VARC-3 (óbito, AVC, sangramentos maiores, complicaçòes vasculares ou cardíaca estrutural, insuficiência renal, implante de marcapasso definitivo, presença de insuficiência aórtica (IAo) ≥ moderada e re-hospitalização). Custos diretos reportados conforme materiais utilizados e remuneração dos profissionais envolvidos no procedimento; custos da internação foram baseados em valores de diária-hospitalar extrapolados da literatura, aplicados ao tempo de internação observado na amostra. RESULTADOS: Incluídos 139 pts no grupo TAVI e 181 no grupo SAVR. Pts submetidos a TAVI eram mais idosos (77,9 ± 7,0 vs 64,9 ± 7,5 anos, p<0,001) e com maior risco cirúrgico conforme STS (3,6 ± 2,3 vs 1,6 ± 0,9%, p<0,001). Desfechos clínicos semelhantes entre TAVI e SAVR, com taxas de óbito de 2,8% vs 5% (p=0,404) e AVC de 0,7% vs 3,3% (p=0,144), respectivamente. Considerando-se todos os eventos adversos e re-hospitalizações, estes ocorreram menos frequentemente após TAVI (31% vs 42%, p=0,047), com menor tempo de internação neste grupo (3,4 ± 4,4 vs 11,6 ± 12,8, dias p<0,001). O custo médio estimado para uma internação de TAVI vs SAVR variou de R$66.059,00 a R$69.276,50 vs R$16.028,2 a R$40.853,50 (p<0,001), respectivamente. Análise exploratória estimou custo de R$ 2.583,91 por unidade clínica de sobrevida livre de eventos adversos ou re-hospitalizações em 30 dias. CONCLUSÃO: Em nossa casuística, TAVI foi indicado a pts mais idosos e de maior risco cirúrgico, com menor ocorrência de eventos adversos combinados e menor tempo de internação. Em análise de curto prazo, a avaliação de custo-utilidade sugere que o TAVI pode ser economicamente viável no cenário do SUS.

Revisão de remuneração do SUS para linha de cuidado do AVC isquêmico por meio de microcusteio / Review of SUS remuneration for ischemic stroke care line through micro-costing

Objetivo: O objetivo do estudo é medir o custo assistencial por paciente e revisar o ressarcimento do Sistema Único de Saúde (SUS) na linha de cuidado de acidente vascular cerebral isquêmico (AVCi). Métodos: Estudo prospectivo, com 24 pacientes na amostra, na unidade de referência na instituição para tratamento de AVC, no período de novembro/2019 a dezembro/2019. O método utilizado para apuração de custos foi o custeio baseado em atividade e tempo (TDABC), no qual os custos são coletados focando o paciente e os cuidados dispensados durante a assistência. A perspectiva do estudo é a do prestador de serviços do SUS, que se concentrou na avaliação de custos. Foram realizadas as análises de custo total por paciente, componente de custo, custo e tempo por fase na linha de cuidado, custo médio diário e custo médio diário do SUS. Resultados: O custo médio do paciente com AVCi auferido pelo método TDABC é de R$ 14.079,70, sendo a sua maioria justificada em custos de estrutura da unidade de AVC. A atividade com mais custos foi a unidade de AVC e realização de exames. Conclusões: Foi identificado no estudo que os principais contribuintes para a geração de custos na linha de cuidado são as atividades que demandam mais tempo, os medicamentos dispensados e os exames denominados de "alto custo" realizados. Os custos reais aferidos em relação ao ressarcimento previsto pelo SUS e estabelecimentos de saúde credenciados neste estudo demonstram que apenas 39% do custo real está coberto pelo SUS no AVCi.

Objective: The objective of the study is to measure the cost of care per patient and review the SUS reimbursement in the ischemic stroke (CVA) line of care. Methods: A prospective study, 24 patients in the sample at the reference unit at the institution for the treatment of stroke from November/2019 to December/2019. The method used to calculate costs was activity and timebased costing (TDABC), in which costs are collected focusing on the patient and the care provided during care. The perspective of the study is that of the SUS service provider who focused on cost assessment. Analyzes of total cost per patient, per cost component, cost and time per phase in the care line, average daily cost and average daily SUS cost were performed. Results: The average cost of a patient with ischemic stroke earned by the TDABC method is R$ 14,079.70, most of which are justified in the cost of the structure of the stroke unit. The activity with the most costs was the stroke unit and examinations. Conclusions: The main contributors to the generation of cost in the care line were identified in the study: the activities that demand more time, the medicines dispensed, and the so-called "high cost" tests performed. The real costs measured in relation to the reimbursement provided by the SUS and accredited health establishments in this study demonstrate that only 39% of the real cost is covered by the SUS in Ischemic Stroke.

Micro-Costing of a Remotely Operated Referral Management System to Secondary Care in the Unified Health System in Brazil / Microcusteio de um Sistema de Regulação Remoto para o Cuidado Especializado no Sistema Único de Saúde no Brasil

Abstract Referral of cases from primary to secondary care in the Brazilian public healthcare system is one of the most important issues to be tackled. Telehealth strategies have been shown effective in avoiding unnecessary referrals. The objective of this study was to estimate cost per referred case by a remotely operated referral management system to further inform the decision making on the topic. Analysis of cost by applying time-driven activity-based costing. Cost analyses included comparisons between medical specialties, localities for which referrals were being conducted, and periods of time. Cost per referred case across localities ranged from R$ 5.70 to R$ 8.29. Cost per referred case across medical specialties ranged from R$ 1.85 to R$ 8.56. Strategies to optimize the management of referral cases to specialized care in public healthcare systems are still needed. Telehealth strategies may be advantageous, with cost estimates across localities ranging from R$ 5.70 to R$ 8.29, with additional observed variability related to the type of medical specialty.

Resumo O encaminhamento de casos da atenção primária para a secundária no Sistema Único Brasileiro é uma das questões mais importantes a ser enfrentada. As estratégias de telessaúde têm se mostrado eficazes para evitar encaminhamentos desnecessários. O objetivo deste estudo foi estimar o custo por caso encaminhado por meio de um sistema de gerenciamento de referenciamentos operado remotamente para subsidiar a tomada de decisão sobre o tema. Análise de custo por meio da aplicação de custeio baseado em atividades orientado pelo tempo (time-driven activity-based costing ou TDABC). As análises de custo incluíram comparações entre especialidades médicas, localidades para as quais os encaminhamentos estavam sendo conduzidos e períodos de tempo. O custo por referenciamento em todas as localidades variou entre R$ 5,70 a R$ 8,29. O custo por referenciamento nas especialidades médicas variou entre R$ 1,85 a R$ 8,56. Estratégias para otimizar a gestão dos referenciamentos para a atenção especializada nos sistemas públicos de saúde ainda são necessárias. As estratégias de telessaúde podem ser vantajosas, com estimativas de custo entre as localidades variando entre R$ 5,70 a R$ 8,29, com variabilidade adicional observada relacionada ao tipo de especialidade médica.