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      Evaluación de la costo-efectividad de un modelo integral de tratamiento ambulatorio en pacientes con síndrome coronario agudo: aplicación de un modelo de Markov probabilístico Translated title: Evaluation of the cost-effectiveness of an integral model of ambulatory treatment in patients with acute coronary syndrome: application of a probabilistic Markov model Translated title: Avaliação da relação custo-eficácia de um modelo integral de tratamento ambulatorial em pacientes com síndrome coronariana aguda: aplicação de um modelo probabilístico de Markov

      research-article
      1 , 2 , 3 , 4 , 4 , 4 , 1 , 1 , 4
      Revista Panamericana de Salud Pública
      Organización Panamericana de la Salud
      Evaluación de costo-efectividad, cadenas de Markov, síndrome coronario agudo, cuidado ambulatorio, cuidado gestionado, rehabilitación cardíaca, Colombia, Cost-effectiveness evaluation, Markov chains, acute coronary syndrome, ambulatory care, disease management, cardiac rehabilitation, Colombia, Avaliação de custo-efetividade, cadeias de Markov, síndrome coronariana aguda, assistência ambulatorial, gerenciamento clínico, reabilitação cardíaca, Colômbia

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          RESUMEN

          Objetivo

          Evaluar la costo-efectividad de un modelo integral de tratamiento ambulatorio en pacientes que presentaron un síndrome coronario agudo.

          Métodos

          Se realizó una evaluación económica a partir de un estudio de intervención cuasi-experimental, que incluyó 442 pacientes con edades entre 30 y 70 años, quienes presentaron un síndrome coronario agudo. El grupo de intervención (n = 165) recibió un modelo integral de tratamiento ambulatorio fundamentado en el cuidado gestionado (disease management), mientras que el grupo control (n = 277) recibió rehabilitación cardiovascular convencional. Durante un año de seguimiento, se evaluó la presentación de reeventos cardiovasculares y hospitalizaciones. Se desarrolló un modelo de Markov probabilístico. La perspectiva de estudio se aplicó dentro del Sistema General de Seguridad Social en Salud Colombiano, incluidos los costos sanitarios directos; el horizonte temporal fue de 50 años con descuentos de 3,42% para costos y efectividades; y la medida de efectividad fue los años de vida ganados ajustados por calidad. Se realizó un análisis de sensibilidad probabilístico y multivariante mediante de la simulación de Montecarlo.

          Resultados

          Durante el año de seguimiento, los costos directos relacionados con el valor pagado fueron en promedio de USD 2 577 para el grupo control y USD 2 245 para el grupo de intervención. En el análisis de sensibilidad probabilístico, 91,3% de las simulaciones se ubicaron en el cuadrante correspondiente a costos incrementales negativos y efectividades incrementales positivas (intervención evaluada de menor costo, más efectiva). En las simulaciones, se observó un ahorro promedio anual por paciente de USD 1 215 por cada año de vida ganado ajustado por calidad.

          Conclusiones

          El modelo integral de tratamiento ambulatorio implementado en pacientes que sufrieron un síndrome coronario agudo mostró ser menos costoso y más efectivo en comparación con el cuidado convencional. Por ser una alternativa dominante, se recomienda como modelo de cuidado en esta población.

          ABSTRACT

          Objective

          To evaluate the cost-effectiveness of an integral model of ambulatory treatment in patients who presented an acute coronary syndrome.

          Methods

          An economic evaluation was made from a quasi-experimental intervention study, which included 442 patients aged 30 to 70 years who presented an acute coronary syndrome. The intervention group (n = 165) received an integral model of ambulatory treatment based on managed care (disease management), while the control group (n = 277) received conventional cardiovascular rehabilitation. During one year of follow-up, the presentation of cardiovascular events and hospitalizations was evaluated. A probabilistic Markov model was developed. The study perspective was applied within the General System of Health Social Security in Colombia, including the direct health costs; the time horizon was 50 years with discounts of 3.42% for costs and effectiveness; and the measure of effectiveness was quality-adjusted life years (QALYs). A probabilistic and multivariate sensitivity analysis was performed using the Montecarlo simulation.

          Results

          During the year of follow-up, the direct costs related to the value paid were, on average, USD 2 577 for the control group and USD 2 245 for the intervention group. In the probabilistic sensitivity analysis, 91.3% of the simulations were located in the quadrant corresponding to incremental negative costs and positive incremental effectiveness (evaluated intervention at a lower cost, more effective). In the simulations, an average annual savings per patient of USD 1 215 per QALY was observed.

          Conclusions

          The integral model of ambulatory treatment implemented in patients who suffered an acute coronary syndrome was found to be less expensive and more effective compared to conventional care. Considering it is a dominant alternative, it is recommended as a model of care in this population.

          RESUMO

          Objetivo

          Avaliar a relação custo-eficácia de um modelo integral de tratamento ambulatorial em pacientes que apresentaram síndrome coronariana aguda.

          Métodos

          Uma avaliação econômica foi feita a partir de um estudo de intervenção quase experimental, que incluiu 442 pacientes com idade entre 30 a 70 anos que apresentaram síndrome coronariana aguda. O grupo de intervenção (n = 165) recebeu um modelo integral de tratamento ambulatorial com base em cuidados gerenciados (gerenciamento de doenças), enquanto o grupo controle (n = 277) recebeu reabilitação cardiovascular convencional. Durante um ano de acompanhamento, foi avaliada a apresentação de eventos cardiovasculares e hospitalizações. Um modelo probabilístico de Markov foi desenvolvido. A perspectiva do estudo foi aplicada no Sistema Geral de Segurança Social na Saúde da Colômbia, incluindo os custos diretos de saúde; o horizonte temporal foi de 50 anos com descontos de 3,42% em custos e efetividade; e a medida de eficácia foi os anos de vida ajustados pela qualidade (QALY). Uma análise de sensibilidade probabilística e multivariada foi realizada utilizando a simulação de Montecarlo.

          Resultados

          Durante o ano de acompanhamento, os custos diretos relacionados ao valor pago foram, em média, USD 2 577 para o grupo controle e USD 2 245 para o grupo de intervenção. Na análise de sensibilidade probabilística, foram localizadas 91,3% das simulações no quadrante correspondente a custos negativos incrementais e eficácia incremental positiva (intervenção avaliada a menor custo, mais efetiva). Nas simulações, observou-se uma economia anual média por paciente de US $ 1 215 por QALY.

          Conclusões

          O modelo integral de tratamento ambulatorial implementado em pacientes que sofreram síndrome coronariana aguda foi considerado menos caro e mais eficaz em comparação com os cuidados convencionais. Por ser uma alternativa dominante, é recomendado como modelo de cuidados nesta população.

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          Most cited references34

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          Global burden of cardiovascular diseases: part I: general considerations, the epidemiologic transition, risk factors, and impact of urbanization.

          This two-part article provides an overview of the global burden of atherothrombotic cardiovascular disease. Part I initially discusses the epidemiologic transition which has resulted in a decrease in deaths in childhood due to infections, with a concomitant increase in cardiovascular and other chronic diseases; and then provides estimates of the burden of cardiovascular (CV) diseases with specific focus on the developing countries. Next, we summarize key information on risk factors for cardiovascular disease (CVD) and indicate that their importance may have been underestimated. Then, we describe overarching factors influencing variations in CVD by ethnicity and region and the influence of urbanization. Part II of this article describes the burden of CV disease by specific region or ethnic group, the risk factors of importance, and possible strategies for prevention.
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            Chronic disease self-management program: 2-year health status and health care utilization outcomes.

            To assess the 1- and 2-year health status, health care utilization and self-efficacy outcomes for the Chronic Disease Self-Management Program (CDSMP). The major hypothesis is that during the 2-year period CDSMP participants will experience improvements or less deterioration than expected in health status and reductions in health care utilization. Longitudinal design as follow-up to a randomized trial. Community. Eight hundred thirty-one participants 40 years and older with heart disease, lung disease, stroke, or arthritis participated in the CDSMP. At 1- and 2-year intervals respectively 82% and 76% of eligible participants completed data. Health status (self-rated health, disability, social/role activities limitations, energy/fatigue, and health distress), health care utilization (ER/outpatient visits, times hospitalized, and days in hospital), and perceived self-efficacy were measured. Compared with baseline for each of the 2 years, ER/outpatient visits and health distress were reduced (P <0.05). Self-efficacy improved (P <0.05). The rate of increase is that which is expected in 1 year. There were no other significant changes. A low-cost program for promoting health self-management can improve elements of health status while reducing health care costs in populations with diverse chronic diseases.
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              A reengineered hospital discharge program to decrease rehospitalization: a randomized trial.

              Emergency department visits and rehospitalization are common after hospital discharge. To test the effects of an intervention designed to minimize hospital utilization after discharge. Randomized trial using block randomization of 6 and 8. Randomly arranged index cards were placed in opaque envelopes labeled consecutively with study numbers, and participants were assigned a study group by revealing the index card. General medical service at an urban, academic, safety-net hospital. 749 English-speaking hospitalized adults (mean age, 49.9 years). A nurse discharge advocate worked with patients during their hospital stay to arrange follow-up appointments, confirm medication reconciliation, and conduct patient education with an individualized instruction booklet that was sent to their primary care provider. A clinical pharmacist called patients 2 to 4 days after discharge to reinforce the discharge plan and review medications. Participants and providers were not blinded to treatment assignment. Primary outcomes were emergency department visits and hospitalizations within 30 days of discharge. Secondary outcomes were self-reported preparedness for discharge and frequency of primary care providers' follow-up within 30 days of discharge. Research staff doing follow-up were blinded to study group assignment. Participants in the intervention group (n = 370) had a lower rate of hospital utilization than those receiving usual care (n = 368) (0.314 vs. 0.451 visit per person per month; incidence rate ratio, 0.695 [95% CI, 0.515 to 0.937]; P = 0.009). The intervention was most effective among participants with hospital utilization in the 6 months before index admission (P = 0.014). Adverse events were not assessed; these data were collected but are still being analyzed. This was a single-center study in which not all potentially eligible patients could be enrolled, and outcome assessment sometimes relied on participant report. A package of discharge services reduced hospital utilization within 30 days of discharge. Agency for Healthcare Research and Quality and National Heart, Lung, and Blood Institute, National Institutes of Health.
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                Author and article information

                Journal
                Rev Panam Salud Publica
                Rev. Panam. Salud Publica
                rpsp
                Revista Panamericana de Salud Pública
                Organización Panamericana de la Salud
                1020-4989
                1680-5348
                16 March 2018
                2018
                : 42
                : e10
                Affiliations
                [1 ] originalEntidad Promotora de Salud SURA, Medellín, Colombia
                [2 ] originalEscuela de Estadística, Universidad Nacional de Colombia, Sede Medellín, Colombia
                [3 ] originalFacultad de Medicina, Universidad de Antioquia, Medellín, Colombia
                [4 ] originalCentro Clínico y de Investigación Soluciones Integrales de Conocimiento en Riesgo Cardiovascular, Medellín, Colombia
                Author notes
                Enviar la correspondencia a Dagnóvar Aristizábal: dagnovar@ 123456une.net.co

                Conflictos de interés. Ninguno declarado por los autores.

                Article
                RPSP.2018.10
                10.26633/RPSP.2018.10
                6385638
                f24ffa2e-1d07-4cdf-b6b5-4d1630912932

                This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs 3.0 IGO License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited. No modifications or commercial use of this article are permitted. In any reproduction of this article there should not be any suggestion that PAHO or this article endorse any specific organization or products. The use of the PAHO logo is not permitted. This notice should be preserved along with the article's original URL.

                History
                : 20 February 2017
                : 19 June 2017
                Page count
                Figures: 2, Tables: 3, Equations: 1, References: 42
                Categories
                Investigación Original

                evaluación de costo-efectividad,cadenas de markov,síndrome coronario agudo,cuidado ambulatorio,cuidado gestionado,rehabilitación cardíaca,colombia,cost-effectiveness evaluation,markov chains,acute coronary syndrome,ambulatory care,disease management,cardiac rehabilitation,avaliação de custo-efetividade,cadeias de markov,síndrome coronariana aguda,assistência ambulatorial,gerenciamento clínico,reabilitação cardíaca,colômbia

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