Análise de custo-efetividade da intervenção coronária percutânea guiada pelo fluxo fracionado de reserva do miocárdio
Análise de custo-efetividade da intervenção coronária percutânea guiada pelo fluxo fracionado de reserva do miocárdio
Arquivos
Data
2016
Autores
Cruz, Bruno Azevedo da
Journal Title
Journal ISSN
Volume Title
Publisher
Instituto Nacional de Cardiologia
Resumo
INTRODUÇÃO: A doença aterosclerótica coronariana figura entre as maiores causas
de mortalidade em todo o mundo e a intervenção coronária percutânea, constitui
importante estratégia de seu tratamento. O uso do fluxo fracionado de reserva do
miocárdio - FFR - se propõe a ser ferramenta na definição dessa intervenção. Análises
econômicas em diversos países tem resultados atrativos, mas a relação de custo-
efetividade no âmbito do Sistema Único de Saúde (SUS) é desconhecida. OBJETIVO:
Realizar análise de custo-efetividade da intervenção coronária percutânea guiada pelo
FFR. MÉTODOS: Foi realizado um modelo analítico do tipo árvore de decisão,
incluindo pacientes com doença arterial coronariana e indicação de intervenção
coronária percutânea, para estimar a razão de custo-efetividade incremental da
intervenção coronária percutânea guiada pelo FFR em comparação a estratégia
guiada pela coronariografia, sob perspectiva do SUS e com horizonte temporal de um
ano. Mortalidade foi a medida de efetividade. Análises de sensibilidade determinística
e probabilísticas forma efetuadas. RESULTADOS: O resultado foi incremento de
custos com o FFR (R$ 8.954,10 contra R$ 7.286,11 da estratégia convencional),
apesar de ser mais efetivo (redução de 3% nos óbitos). O custo incremental foi de
R$1.668,00 e a razão de custo-efetividade incremental foi de R$ 68.891,38 por vida
salva. Na análise de sensibilidade determinística, o custo da intervenção coronária
percutânea e o custo do cateter de medida do FFR se destacaram e, mesmo assim,
em cerca de 23,4% das simulações de Monte Carlo, a estratégia foi dominante. Em
cenário com redução do custo do cateter para até R$ 2.900,00, a intervenção
coronária percutânea guiada pelo FFR passa a ser custo-efetiva, e com redução até
R$ 2.706,41, passaria a ser dominante, considerando-se o limiar de disposição para
pagar de um produto interno bruto (PIB) per capita (R$ 27.229 – 2014). Se
aumentarmos o limiar até R$ 52.000, novamente teremos o FFR como estratégia
custo-efetiva. CONCLUSÃO: Apesar de mais dispendiosa em primeiro momento, a
estratégia de intervenção coronária percutânea guiada pelo FFR, gera menos
intervenções, tem menor mortalidade e potencial para se tornar economicamente
atrativa. Inicialmente, a redução do custo do cateter de medida do FFR para uso em
maior escala pode se apresentar como um fator determinante.
BACKGROUND: Coronary atherosclerosis is one of the major causes of mortality worldwide and percutaneous coronary intervention is an important treatment strategy. The use of fractional flow reserve - FFR – is intended to be a tool in the application of this intervention. Economic analysis of this intervention within several countries has attractive results, but the cost-effectiveness ratio under the Unified Health System (SUS) is unknown. OBJECTIVE: To perform a cost-effectiveness analysis of percutaneous coronary intervention guided by FFR. METHODS: We conducted an analytical model type decision tree, including patients with coronary artery disease with an indication for percutaneous coronary intervention to estimate the incremental cost- effectiveness ratio of percutaneous coronary intervention guided by FFR compared to the strategy guided by angiography. We performed data analysis under the perspective of SUS and for a period of one year. Mortality was the measure of effectiveness. Deterministic and probabilistic sensitivity analysis were made. RESULTS: The result was increased costs with the FFR strategy (R$ 8.954,10 compared to R$ 7.286,11 with conventional strategy), although it was more effective (reduction in mortality of 3%). The incremental cost was R$ 1.668,00 and the incremental cost-effectiveness ratio was R$ 68.891,38 per life saved. In deterministic sensitivity analysis, the cost of both percutaneous coronary intervention and the FFR measurement catheter stood out. In addition, in approximately 23.4% of Monte Carlo simulations, the FFR strategy was dominant. Considering a scenario with reduction of the cost of the catheter to R$ 2.900,00, the percutaneous coronary intervention guided by FFR becomes cost- effective, and with a reduction to R$ 2.706,41, the FFR strategy would become dominant, considering the willingness to pay of one gross domestic product (GDP) per capita (R$ 27.229 - 2014). If we increase the threshold of willingness to pay up to R$ 52.000, we will again have the FFR as a cost-effective strategy. CONCLUSION: Although initialy more expensive, percutaneous coronary intervention strategy guided by FFR generates fewer interventions, demonstrates lower mortality and has the potential to become an interesting economic strategy. The reduction of the cost of FFR measurement catheter for use in larger scale may be presented as a determinant factor.
BACKGROUND: Coronary atherosclerosis is one of the major causes of mortality worldwide and percutaneous coronary intervention is an important treatment strategy. The use of fractional flow reserve - FFR – is intended to be a tool in the application of this intervention. Economic analysis of this intervention within several countries has attractive results, but the cost-effectiveness ratio under the Unified Health System (SUS) is unknown. OBJECTIVE: To perform a cost-effectiveness analysis of percutaneous coronary intervention guided by FFR. METHODS: We conducted an analytical model type decision tree, including patients with coronary artery disease with an indication for percutaneous coronary intervention to estimate the incremental cost- effectiveness ratio of percutaneous coronary intervention guided by FFR compared to the strategy guided by angiography. We performed data analysis under the perspective of SUS and for a period of one year. Mortality was the measure of effectiveness. Deterministic and probabilistic sensitivity analysis were made. RESULTS: The result was increased costs with the FFR strategy (R$ 8.954,10 compared to R$ 7.286,11 with conventional strategy), although it was more effective (reduction in mortality of 3%). The incremental cost was R$ 1.668,00 and the incremental cost-effectiveness ratio was R$ 68.891,38 per life saved. In deterministic sensitivity analysis, the cost of both percutaneous coronary intervention and the FFR measurement catheter stood out. In addition, in approximately 23.4% of Monte Carlo simulations, the FFR strategy was dominant. Considering a scenario with reduction of the cost of the catheter to R$ 2.900,00, the percutaneous coronary intervention guided by FFR becomes cost- effective, and with a reduction to R$ 2.706,41, the FFR strategy would become dominant, considering the willingness to pay of one gross domestic product (GDP) per capita (R$ 27.229 - 2014). If we increase the threshold of willingness to pay up to R$ 52.000, we will again have the FFR as a cost-effective strategy. CONCLUSION: Although initialy more expensive, percutaneous coronary intervention strategy guided by FFR generates fewer interventions, demonstrates lower mortality and has the potential to become an interesting economic strategy. The reduction of the cost of FFR measurement catheter for use in larger scale may be presented as a determinant factor.
Description
Palavras-chave
Doença aterosclerótica coronariana, Intervenção coronária percutânea, Fluxo fracionado de reserva do miocárdio, Coronary artery disease, Percutaneous coronary intervention, Fractional flow reserve
Citação
Cruz BA. Análise de custo-efetividade da intervenção coronária percutânea guiada pelo fluxo fracionado de reserva do miocárdio. Rio de Janeiro. dissertação [Mestrado Profiossional em Avaliação de Tecnologias em Saúde] Instituto Nacional de Cardiologia - INC; 2016.