Brazilian Public Health System Perspective Research Articles

MT8 A Cost-Utility Analysis of Artificial Urinary Sphincter Versus BSC in Severe Male Postprostatectomy Incontinence - Brazilian Public Health System Perspective

Despite being considered the ''gold standard'' for the treatment of severe male postprostatectomy incontinence, the artificial urinary sphincter (AUS) is not incorporated and provided in the Brazilian public health system. The objective of the presented study was to evaluate the cost-utility of AUS in this perspective.

Cost-Utility of the CDK 4/6 Inhibitors for Postmenopausal Women With Luminal Advanced Breast Cancer in Brazil

Several trials have demonstrated the benefit of the CDK 4/6 inhibitors for postmenopausal women with luminal advanced breast cancer. This research aims to compare the cost-utility of the CDK 4/6 inhibitors in patients with no history of resistance to endocrine therapy. A Markov model was constructed to estimate the incremental cost per quality-adjusted life-years (QALYs) of treatments from the Brazilian public health system perspective over a lifetime horizon (30 years) with 5% annual discount rate for both benefits and costs. Efficacy parameters were extracted from the pivotal studies. Costs were based on open data from the Brazilian Ministry of Health. The utilities were calculated according to the overall population preferences from a British study. Deterministic and probabilistic sensitivity analyses evaluated the robustness of the results. The most cost-effective drug was ribociclib (US$50 748/QALY), followed by abemaciclib (US$64 052/QALY) and palbociclib (US$65 289/QALY). The univariate analysis showed that the incremental cost-utility ratio (ICUR) was mainly sensitive to the overall survival hazard ratio. The one thousand-probabilistic simulation showed that all ICUR values were above classical thresholds such as 1 to 3 gross domestic product (GDP) per capita per QALY. Even though there is no established willingness to pay threshold in Brazil, the estimated ICUR for CDK 4/6 inhibitors is >6 times the Brazilian GDP per capita (GDP per capita= US$5694.73), which might be a barrier to their inclusion in the Brazilian public health system.

Cost-Effectiveness of Molecular Method Diagnostic for Rapid Detection of Antibiotic-Resistant Bacteria

ObjectivesThis study aimed to perform a cost-effectiveness analysis (CEA) of the molecular diagnostic method (MM) associated with conventional diagnostic method (CM) compared with the CM alone, for the detection of resistant profile in bacteremia, from the perspective of the Brazilian Public Health System, in intensive care units setting. MethodsThe clinical parameters regarding methicillin-resistant Staphylococcus aureus (MRSA), carbapenem-resistant Gram-negative bacteria (CRGNB), and vancomycin-resistant Enterococcus spp. (VRE) infections were collected from searches on PubMed, Scopus, and SciELO, using specific keywords. Data on direct medical costs to treat these infections were collected according to Brazilian Public Health System perspective from Brazilian databases, in tables of 2018 to 2019. CEA was performed after building a dynamic model, which was calibrated and validated according to international recommendations. The incremental cost-effectiveness ratio of the MM + CM compared with the CM was calculated using the outcomes “avoided death” and “avoided resistant infections.” One-way sensitivity analyses were performed. ResultsThis CEA demonstrated that the MM + CM was dominant in all scenarios. Estimates showed that for MRSA, CRGNB, and VRE infections, every avoided death would lead to savings of Brazilian real (R$) 4.9 million ($937 301), R$2.2 million ($419 899), and R$1.3 million ($248 919), respectively. The same infections assessed by avoided resistant infections savings were projected to be R$24 964 ($4686), R$40 260 ($7558), and R$23 867 ($4480). ConclusionsMM leads to cost reduction and increased benefits, optimizing the use of financial resources on the health system in the intensive care unit setting, in bacteremia caused by MRSA, CRGNB, and VRE.

Profile of hospitalization and death records associated to dengue and severe dengue in Minas Gerais between 2000 and 2015 from the Brazilian Public Health System perspective.

Dengue is one of the most important arboviruses and public health problem associated with increasingly large outbreaks, especially in tropical countries such as Brazil. The state of Minas Gerais, in particular, has had high numbers of cases of this infection in recent years. Our study evaluated the epidemiological impact of dengue fever in the state of Minas Gerais from the National Health System (Sistema Único de Saúde, SUS) perspective between 2000 to 2015 using the Brazilian Notifiable Diseases Information System (SINAN, notification cases) and Hospital Information System (SIH)/SUS (hospitalization registers) databases. The SUS database recorded 34,996 reports of dengue (International Classification of Diseases [ICD]: A90) as well as 1984 verified cases of severe dengue (ICD-A91). These hospitalizations for dengue and cases of severe dengue generally affected individuals aged 15-24 (17.74%) and 5-14 (20.86%) years, respectively. The epidemiological burden of dengue was substantial in Minas Gerais state, with the highest number of notifications nationally in 2013. From retrospective data associated with dengue records, our study sought to better highlight the locations with the largest number of dengue cases in the Minas Gerais state, and contribute to direct educational and surveillance actions of these regions applied to this infection.

PBI17 Cost-Efectiveness Analysis of Biological Agents to Moderate to Severe Plaque Psoriasis Treatmente from the Brazilian Public Health System Perspective

PBI17 Cost-Efectiveness Analysis of Biological Agents to Moderate to Severe Plaque Psoriasis Treatmente from the Brazilian Public Health System Perspective

Cost-utility analysis of the anti-TNF therapy for rheumatoid arthritis in a real-world based model

ABSTRACT Background Spending on drugs provided by the Brazilian Public Health System (BPHS) for the treatment of rheumatoid arthritis (RA) increased substantially with the beginning of the supply of biological disease-modifying anti-rheumatic drugs (bDMARD). This study aims to perform a cost-utility analysis of the most used biological drugs for the treatment of RA in Brazil. Methods a Markov model was used to carry out the cost-utility analysis. The data were obtained from a prospective cohort of RA patients using adalimumab, etanercept, and golimumab in Brazil. The BPHS perspective was adopted and the time horizon was five years. Deterministic and probabilistic sensitivity analyses were performed to evaluate the uncertainty. Results golimumab was the most cost-effective drug. Etanercept was dominated by golimumab. Adalimumab presented an incremental cost-utility ratio (ICUR) of $95,095.37 compared to golimumab in five years of follow-up. These results were confirmed by sensitivity analyses. Conclusion the utility among adalimumab, etanercept, and golimumab was similar and the cost was the component that most impacted the economic model. Therefore, depending on the agreed price with the drug manufacturers, the incremental cost-utility ratio may vary among them.

Cost-Effectiveness Analysis and Budget Impact: Antimuscarinics and Mirabegron for the Treatment of Patients With Urge Urinary Incontinence: The Brazilian Public Health System Perspective

ObjectivesThe Brazilian public health system does not cover pharmacotherapy for urge urinary incontinence (UUI). The aim of this study was to estimate the cost-effectiveness and budget impact of providing tolterodine, solifenacin, oxybutynin (OXY), darifenacin, and mirabegron for the treatment of UUI in Brazilian public health system. MethodsA cost-effectiveness analysis with budget impact was performed. Six scenarios were assessed: in one scenario, all 5 therapeutic alternatives approved for coverage, and in the remaining 5 scenarios, only 1 alternative is approved for adoption for all patients. Clinical data were derived from a rapid systematic review conducted in several databases. One-way sensitivity analysis was also performed. The time horizon was 12 months. ResultsThe cost-effectiveness analysis showed that patients treated with OXY had the lowest incremental cost-effectiveness ratio (ICER) per outcomes assessed (change in urinary incontinence episodes (UIE): R$1180.08; change in urge incontinence episodes: R$757.85 and change in micturition frequency: R$907.75), corresponding to a budget impact of R$17.9 billion over 5 years. The change in effectiveness measures was the parameter that most influenced the results of the ICER per patient-year. ConclusionThe results of the study have shown that OXY and solifenacin had the lowest ICER per patient-year and the lowest budget impact when compared with other drugs.

PRO8 MEDICATIONS FOR ACROMEGALY: COST-UTILITY AND VALUE OF INFORMATION ANALYSIS

To conduct a cost-utility analysis comparing first- and second-line drug strategies involving octreotide, lanreotide, pasireotide, and pegvisomant for the treatment of patients with acromegaly who have failed surgery, from a Brazilian public health system perspective. A probabilistic cohort Markov model was developed. One-year cycles were employed. The patients started at 45 years of age and were followed lifelong. Costs, efficacy, and quality of life parameters were retrieved from the literature. A discount rate (5% per year) was applied to both costs and effects. Incremental cost-effectiveness ratios (ICERs) were calculated when applicable, and reported as cost per quality-adjusted life year (QALY). Scenario analyses considered alternative dosages, discount rates, tax exemption, and continued use of treatment despite lack of response. Value of information (VOI) analysis was conducted to explore uncertainty and to estimate the costs to be spent in future research. One American dollar (U$) equals approximately 4 Brazilian reais (R$) in 2020. Of the 11 strategies compared, four were not dominated. Only lanreotide autogel showed a reasonable ICER for having its use considered in clinical practice (R$ 112,138/QALY compared to “no treatment”). Considering a threshold of 3 times the GDP per capita (R$ 91,645), lanreotide autogel had a 38.19% probability of being cost-effective compared to “no treatment”. Scenario analyses corroborated the base-case result. VOI analysis showed that much uncertainty surrounds the parameters, and future clinical research should cost less than R$ 43,230,000 per year. VOI also showed that almost all uncertainty that precludes an optimal strategy choice involves quality of life. With current information, the only strategy that can be considered cost-effective in Brazil is lanreotide autogel. No second-line treatment is recommended. Significant uncertainty of parameters impairs optimal decision-making, and this conclusion can be generalized to other countries. Future research should focus on acquiring utility data.

PIN34 COST-UTILITY ANALYSIS OF DIRECT ACTING ANTIVIRALS FOR EARLY-STAGE GENOTYPE 1 HCV PATIENTS IN BRAZIL

We aimed to conduct a cost-utility analysis of available interferon-free treatments for genotype 1 chronic hepatitis C patients at the early disease stage from a Brazilian public health system perspective. We built a Markov model using a cohort of stage F0–F2 patients (non-cirrhotic) treated with the following drug combinations as recommended by the Brazilian national guidelines: sofosbuvir + daclatasvir; elbasvir + grazoprevir; sofosbuvir + ledipasvir; glecaprevir + pibrentasvir (GLE+PIB); and sofosbuvir + velpatasvir (SOF+VEL). Efficacy outcomes are expressed in terms of quality-adjusted life years and only direct costs were considered. The incremental cost-effectiveness ratio was calculated for non-dominated strategies. Probabilistic sensitivity analysis was performed and presented as a scatterplot and a cost-effectiveness acceptability graph. The treatment GLE+PIB dominated all other treatments: it was associated with a lower treatment cost and similar QALY compared to the other strategies, followed by SOF+VEL. This result was also confirmed in probabilistic sensitivity analysis where these two direct-acting antiviral combinations presented a higher number of iterations, proving to be the most cost-effective treatments (56% of interactions for GLE+PIB; 43% for SOF+VEL). Similar results were observed in all other scenarios. The present cost-utility analysis shows that GLE+PIB was the most cost-effective treatment, followed by SOF+VEL, whereas sofosbuvir + daclatasvir was considerate the least cost-effective.

Cost-effectiveness of Anti-VEGF treatments for age-related macular degeneration: a Brazilian perspective.

To study the cost-effectiveness of ranibizumab and bevacizumab for the treatment of age-related macular degeneration. We used a decision tree model to analyze the cost-effectiveness of ranibizumab and bevacizumab for the treatment of age-related macular degeneration, from the Brazilian Public Health System (SUS) perspective. Ranibizumab and bevacizumab were administered to patients with the same treatment procedure, and the difference in treatment costs was calculated based on the cost of the drugs. Direct costs were estimated using the information provided by the Brazilian SUS. Effectiveness in terms of quality-adjusted life years (QALYs) was calculated based on the utility values for visual impairment. Incremental cost-effectiveness ratio was calculated by comparing both treatments. The analytical horizon was one year. The decision tree analysis showed that the difference in treatment effectiveness was 0.01 QALY. Incremental cost-effectiveness ratio showed that ranibizumab treatment required an incremental annual cost of more than R$ 2 million to generate 1 additional QALY, as compared to bevacizumab. From the Brazilian SUS perspective, bevacizumab is more cost-effective than ranibizumab for the treatment of neovascular age-related macular degeneration. Its use could allow potential annual savings in health budget.

Effectiveness and Cost-Effectiveness of Triple Therapy With Telaprevir and Boceprevir for Chronic Hepatitis C: A Decision Analysis From the Brazilian Public Health System Perspective

ObjectivesBecause of the lack of evidence regarding long-term effectiveness and cost-effectiveness of first-generation direct-acting antivirals for chronic hepatitis C (CHC) treatment in Brazil, we performed a cost-utility analysis comparing standard dual therapy (peginterferon plus ribavirin [pegIFN/RBV]), boceprevir, and telaprevir for CHC patients. MethodsWe developed a state-transition Markov model simulating the progression of CHC. Long-term outcomes included remaining life expectancy in life-years (LYs), quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER). Short-term outcomes included sustained virological response rates (SVR). Direct medical costs were obtained from Brazilian databases. A lifelong time horizon was considered and a 5% annual discount rate was applied for costs and clinical outcomes. A willingness-to-pay threshold of approximately $20 000 per QALY was used. We performed multiple sensitivity analyses. ResultsFor short- and long-term scenarios, therapy with boceprevir was dominated by telaprevir, which was more effective than standard dual therapy (75.0% vs 40.4% SVR rate, 13.47 vs 12.59 LYs, and 9.74 vs 8.49 QALYs, respectively) and was also more expensive ($15 742 vs $5413). The corresponding ICERs were $29 854/SVR, $11 803/LY, and $8277/QALY. Based on our model, triple therapy with telaprevir was the most cost-effective treatment for the Brazilian health system. Despite a lack of data regarding the Brazilian population, we incorporated as many applicable parameters as possible. ConclusionsTelaprevir is more effective and cost-effective than boceprevir. Our model may be applied for other settings with a few adjustments in the input parameters.

VP21 Economic Burden Of Pertussis Treatment In Brazil, 2014

IntroductionDespite availability of a cheap, widely accessible vaccine, pertussis remains an important cause of morbidity and mortality in children worldwide. A resurgence of pertussis in Brazil peaked at 8,815 cases in 2014. We estimate the economic burden of pertussis hospitalizations and outpatient cases in Brazil in 2014.MethodsTaking the Brazilian public health system (SUS) perspective we obtained numbers of hospitalizations from the National Hospitalization Information System (SIH) for discharge diagnosis ICD10:A37 and numbers of confirmed outpatient cases from the surveillance information system (SINAN). We estimated costs per case for seven age groups (<1, 1-4, 5-9, 10-19, 20-39, 40-64, and 65+ years). Hospitalization costs were obtained from SIH, which reimburses direct medical (hospital stay, healthcare professional services, and physical therapy) and non-medical costs (parent/caregiver stay accompanying a hospitalized child). Cost of outpatient management was estimated from national guidelines (diagnostic exams, medical visits, and medications) and national pricing lists. Total economic burden was derived by multiplying costs/case by numbers of hospitalized and outpatient cases, respectively, and converted to US Dollars (USD) (December 2014: 1 BRL = USD 0.39).ResultsA total of 8,815 pertussis cases occurred in Brazil in 2014; 55.9 percent were hospitalized. Total cost to the public health care system was USD 2.6 million, 95 percent for hospitalizations. Cost/case was highest at the extremes of age for both hospitalized <1y, BRL 1,378.54 (USD 537); 65y+, BRL 1,875.00 (USD 731) and outpatient cases BRL 41 (USD 16) for <4y and 20y + . Children <4 years accounted for 95.4 percent of hospitalizations, 51.2 percent of outpatient cases, and 95.4 percent of total costs. Children <1 year accounted for 88.1 percent of hospitalizations, 29.1 percent of outpatient cases, and 89.3 percent of total costs.ConclusionsPertussis economic burden in an outbreak year was largely due to hospitalizations in children <1y. Additional prevention strategies are required targeting this population.

Economic burden of HIV and TB/HIV coinfection in a middle-income country: a costing analysis alongside a pragmatic clinical trial in Brazil

ObjectiveThe objective of this study was to measure the costs of people living with HIV (PLHIV) as well as active tuberculosis (TB/HIV), latent tuberculosis infection (LTBI/HIV) or without TB (HIV/AIDS).MethodsWe...

Cost of visceral leishmaniasis care in Brazil.

To estimate the Brazilian direct and indirect costs of human visceral leishmaniasis (VL) in 2014. Cost-of-illness study on the Brazilian public health system and societal perspective. VL cases registered in the Notifiable Diseases Information System in the year of 2014 were considered. Direct medical costs regarding diagnostic, treatment and care provided to patients with VL were estimated through the top-down approach. The indirect costs related to productivity loss due to premature mortality and morbidity were estimated by means of the human-capital method. In 2014, 9895 suspected cases of VL were reported in the Notifiable Diseases Information System, and 3453 were later confirmed. There were 234 patients with Leishmania-HIV coinfection underwent a secondary prophylaxis. The total cost of VL in Brazil was US$ 14190701.50 (US$ 14189150.10 to 14199940.53) that varied according to the sensitivity analysis. The total of direct medical costs corresponded to US$ 1873681.96 (US$1872130.55 to 1882920.99), and the majority of costs was associated with hospitalisation (40%), followed by treatment (22%), and secondary prophylaxis (18%). Productivity loss corresponded to US$ 11421683.37 for premature mortality and US$ 895336.18 for work absence due to hospitalisation by the illness. VL represents an expensive health problem for the Brazilian public health system and society, mainly because of its productivity loss due to premature mortality. Interventions to reduce VL lethality could have a great impact on decreasing the cost of illness.

PSY26 - The Cost Effectiveness of Oxycodone In Patients Who Do Not Respond To Morphine From The Brazilian Public Health System Perspective

PSY26 - The Cost Effectiveness of Oxycodone In Patients Who Do Not Respond To Morphine From The Brazilian Public Health System Perspective

PIN87 - Direct Costs Associated to Meningococcal Disease and Related Sequelae in Children – Analysis Based on the Brazilian Public Health System Perspective

PIN87 - Direct Costs Associated to Meningococcal Disease and Related Sequelae in Children – Analysis Based on the Brazilian Public Health System Perspective

PND14 - Budgetary Impact Analysis of Levetiracetam use for Focal Epilepsy Patients’ Treatment with or without Secondary Generalization from the Brazilian Public Health System Perspective

PND14 - Budgetary Impact Analysis of Levetiracetam use for Focal Epilepsy Patients’ Treatment with or without Secondary Generalization from the Brazilian Public Health System Perspective

Cost-utility analysis of methylphenidate treatment for children and adolescents with ADHD in Brazil.

Objective:To perform a cost-utility analysis on the treatment of attention deficit hyperactivity disorder (ADHD) with methylphenidate immediate-release (MPH-IR) in children and adolescents from Brazil.Method:A Markov model was constructed to compare MPH-IR vs. no treatment. A 24-week naturalistic study was conducted to collect transition probabilities and utility data. Effectiveness was expressed as quality-adjusted life-years (QALY), and costs reported in 2014 international dollars (I$). The perspective was the Brazilian Unified Health System as payer, and the time horizon was 6 years.Results:Of 171 patients, 73 provided information at baseline, and 56 at week 24. Considering the MPH-IR monthly cost of I$ 38, the incremental cost-effectiveness ratio (ICER) of treatment was I$ 9,103/QALY for children and I$ 11,883/QALY for adolescents. In two-way sensitivity analysis, considering one Gross National Product per capita (I$ 11,530) as willingness-to-pay, a cost of no-treatment lower than I$ 45/month would render MPH-IR a cost-saving strategy.Discussion:MPH-IR treatment of children and adolescents is cost-effective for ADHD patients from the Brazilian public health system perspective. Both patients and the healthcare system might benefit from such a strategy.Trial registration number:NCT01705613.

PSY30 - Penicillin and amoxicillin prophylaxis in children with sickle cell disease (SCD): compliance and cost comparison

To discuss the amoxicillin use as an alternative to penicillin and compare its cost for antibiotic prophylaxis in children with SCD. We searched for evidences in MEDLINE (Pubmed) with the terms "Anemia, Sickle Cell"[Mesh] and "Antibiotic Prophylaxis"[Mesh]. In a deterministic fashion, adopting the Brazilian public health system perspective, we did a budget impact analysis comparing amoxicillin to penicillin. The target population was estimated from hidroxyurea consumption in children with SCD and acquisition costs, both obtained from Ministry of Health databases (2012 values; exchange rate: US$ 1 = R$ 2.04). Data about dosage according to age and bodyweight were extracted from literature. A systematic review supports the use of penicillin prophylaxis in children with SCD, based on 3 RCTs (OR: 0.37; CI 95%: 0.16 to 0.86), with no results for amoxicillin. Although, prospective studies show a low compliance of this approach (40 to 60%). Comparisons of amoxicillin to penicillin in other settings, as rheumatic fever prevention, demonstrate that once-daily oral amoxicillin is not inferior to twice-daily penicillin. We estimated a range of 143 to 325 children, less than 5 years old, with SCD as our target population. Assuming oral daily doses of 1500 mg (or 750 mg if bodyweight less than 30 kg) for amoxicillin and 500 mg (or 250 mg if bodyweight less than 20 kg) for penicillin, the annual acquisition costs of penicillin, oral solution, to treat this population can lead to expenses of US$ 41,161.93 to US$ 93,704.65. In contrast, expenses with amoxicillin, oral solution, would be a range of US$ 3,019.94 to US$ 6,863.49. As well as penicillin, amoxicillin seems to be a good option for preventing pneumococcal infection in children with SCD as its use could represent annual savings of US$ 38,141.99 to US$ 86,841.15 and the once-daily administration could improve the prophylaxis compliance.

Cost-effectiveness analysis of medical treatment of benign prostatic hyperplasia in the Brazilian public health system

To perform a cost-effectiveness analysis of medical treatment of benign prostatic hyperplasia (BPH) under Brazilian public health system perspective (Unified Health System--"Sistema Unico de Saude (SUS)"). A revision of the literature of the medical treatment of BPH using alpha-blockers, 5-alpha-reductase inhibitors and combinations was carried out. A panel of specialists defined the use of public health resources during episodes of acute urinary retention (AUR), the treatment and the evolution of these patients in public hospitals. A model of economic analysis (Markov) predicted the number of episodes of AUR and surgeries (open prostatectomy and transurethral resection of the prostate) related to BPH according to stages of evolution of the disease. Brazilian currency was converted to American dollars according to the theory of Purchasing Power Parity (PPP 2010: US$ 1 = R$ 1.70). The use of finasteride reduced 59.6% of AUR episodes and 57.9% the need of surgery compared to placebo, in a period of six years and taking into account a treatment discontinuity rate of 34%. The mean cost of treatment was R$ 764.11 (US$ 449.78) and R$ 579.57 (US$ 340.92) per patient in the finasteride and placebo groups, respectively. The incremental cost-effectiveness ratio (ICERs) was R$ 4.130 (US$ 2.429) per episode of AUR avoided and R$ 2.735 (US$ 1.609) per episode of surgery avoided. The comparison of finasteride + doxazosine to placebo showed a reduction of 75.7% of AUR episodes and 66.8% of surgeries in a 4 year time horizon, with a ICERs of R$ 21.191 (US$ 12.918) per AUR episodes avoided and R$ 11.980 (US$ 7.047) per surgery avoided. In the sensitivity analysis the adhesion rate to treatment and the cost of finasteride were the main variables that influenced the results. These findings suggest that the treatment of BPH with finasteride is cost-effective compared to placebo in the Brazilian public health system perspective.