Economic Burden of Cardiovascular Diseases in Brazil: Are Telemedicine and Structured Telephone Support the Solution?

Keywords:
Cardiovascular Diseases; Health Policy; Cost-Effectiveness-Evaluation; Quality Management; Telemedicine/trends; Telephone/trends

The study by Stevens et al.¹ results from a project of Delloite Consulting, financed by Novartis and aimed at estimating the economic burden that heart failure, acute myocardial infarction, atrial fibrillation and systemic arterial hypertension (SAH) impose on Latin American countries, and at assessing the cost-effectiveness of telemedicine and structured telephone support as interventions that can relieve it.¹ The publication in this issue of the Arquivos Brasileiros de Cardiologia focused on presenting the results of the assessment in the Brazilian scenario.

This study provided us with the opportunity to reflect on important questions related to quality, interpretation and applicability of economic studies. Such studies have gained increasing relevance in the incorporation/disincorporation of technologies and the development of health policies and programs to improve healthcare quality. In addition, they are often used in other countries to support decision-making processes, although that is not a routine in Brazil.²

Several guidelines have been proposed in recent decades to improve the quality of the studies on economic assessment and their usefulness to healthcare systems. The Consolidated Health Economic Evaluation Reporting Standards (CHEERS)³ is a collection of those recommendations, recently updated and published in JAMA,² which were only partially followed by Steven et al.

The measures used, for example, derived from sources not clearly indicated by the authors, who seem to have ignored any other related comorbidity besides the four conditions in question, such as stroke and chronic renal failure, as well as the presence or absence of other relevant comorbidities, such as diabetes, indicated by the NHS as one of the ten major causes of permanent disability and of high consumption of health resources currently.⁴ In addition, the differences in the levels of severity and heterogeneity between the Brazilian geographic regions seem not to have been considered. The incidence of sequelae and the rate of progression of those conditions resulting in morbidity, deaths and quality of life loss vary according to the intensity of the treatment provided, differing, thus, from region to region.^5-7

The results reported by the studies in Venezuela⁸ and Mexico⁹ were neither cited nor discussed by the authors, although the cost-utility measures obtained were identical or very close in the three countries, suggesting that, at least partially, the data used were common to the three assessments.

The cost of primary attention seems to have been inferred from hospital expenditure data, assuming that the costs were equal. However, in at least one systematic review about the economic burden of heart failure, hospital expenditure was at least three times greater than outpatient clinic expenses, including the costs with procedures, tests and medicines.¹⁰

In addition, the prevalence estimates seem little accurate. According to Picon et al.,¹¹ the prevalence of SAH has been decreasing by 3.7% every decade in Brazil. In the 1990s, the prevalence of SAH was estimated at 32.9%, while from 2000 to 2010, it was estimated at 28.7%, which would result in an expected prevalence from 2010 to 2020 lower than that observed in the previous decades. The authors started from a prevalence of 31.2% without indicating exactly what was the source of that information.

In the cost-effectiveness analysis, the interventions were not clearly defined, with disagreement between what the study claimed to assess (“telemedicine”) and the technology studied by the NHS report, on which the authors claimed to be based (“telemonitoring”).¹² Especially for cost-effectiveness studies, depending on the intervention assessed, the results can be diametrically opposed, completely changing the recommendations.

In addition, according to the authors, the healthcare system costs attributable to those four conditions added up to 35 billion reais in 2015, which would represent one third of the total budget approved for health by the Brazilian Congress in that same year,¹³ suggesting that the estimates presented are overestimated.

Therefore, despite the relevance of the topic, the study by Stevens et al. provides convincing information on neither the burden of the selected diseases nor the cost-effectiveness of telemedicine or structured telephone support for approaching those conditions. The study has important limitations that prevents a clear interpretation of its results, as well as its application in the national scenario in a comprehensive manner.

• Short Editorial regarding the article: The Economic Burden of Heart Conditions in Brazil

References

• ¹
  Stevens B, Pezzullo L, Verdian L, Tomlinson J, George A, Bacal F. Deloitte Access Economics Pty Ltd. Os custos das doenças cardíacas no Brasil. Arq Bras Cardiol. 2018; 111(1):29-36.
• ²
  Sanders GD, Neumann PJ, Basu A, Brock DW, Feeny D, Krahn M, et al. Recommendations for conduct, methodological practices, and reporting of cost-effectiveness analyses: second panel on cost-effectiveness in health and medicine. JAMA. 2016;316(10):1093-103.
• ³
  Husereau D, Drummond M, Petrou S, Carswell C, Moher D, Greenberg D, et al; CHEERS Task Force. Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement. Int J Technol Assess Health Care. 2013;29(2):117-22.
• ⁴
  GBD 2016 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet. 2017;390(10100):1211-59.
• ⁵
  Duncan BB, França EB, Passos VM, Cousin E, Ishitani LH, Malta DC, et al. The burden of diabetes and hyperglycemia in Brazil and its states: findings from the Global Burden of Disease Study 2015. Rev Bras Epidemiol. 2017; 20Suppl 01(Suppl 01):90-101.
• ⁶
  Szwarcwald CL, Souza Junior PR, Marques AP, Almeida WD, Montilla DE. Inequalities in healthy life expectancy by Brazilian geographic regions: findings from the National Health Survey, 2013. Int J Equity Health. 2016;15(1):141.
• ⁷
  de Andrade LO, Pellegrini Filho A, Solar O, Rígoli F, de Salazar LM, Serrate PC, et al. Social determinants of health, universal health coverage, and sustainable development: case studies from Latin American countries. Lancet. 2015;385(9975):1343-51.
• ⁸
  Stevens B, Pezzullo L, Verdian L, Tomlinson J, George A, Parejo JA. La carga económica de las condiciones cardíacas en Venezuela. Med Interna (Caracas). 2017;33(1):42-50.
• ⁹
  Stevens B, Pezzullo L, Verdian L, Tomlinson J, Estrada-Aguilar C, George A, et al. The economic burden of hypertension, heart failure, myocardial infarction, and atrial fibrillation in Mexico. Arch Cardiol Mex. 2018 Apr 11. [Epub ahead of print].
• ¹⁰
  Shafie AA, Tan YP, Ng CH. Systematic review of economic burden of heart failure. Heart Fail Rev. 2018;23(1):131-45.
• ¹¹
  Picon RV, Fuchs FD, Moreira LB, Riegel G, Fuchs SC. Trends in prevalence of hypertension in Brazil: a systematic review with meta-analysis. PLoS One. 2012;7(10):e48255.
• ¹²
  Pandor A, Thokala P, Gomersall T, Baalbaki H, Stevens JW, Wang J, et al. Home telemonitoring or structured telephone support programmes after recent discharge in patients with heart failure: systematic review and economic evaluation. Health Technol Assess. 2013;17(32):1-207, v-vi.
• ¹³
  Brasil. Senado Federal. Congresso Nacional aprova orçamento de 2015. [Citado em 2017 jan 10]. Disponível em: https://www.senado.leg.br/noticias/materias/2015/03/17/congresso-nacional-aprova-prcamento-de-2015
  » https://www.senado.leg.br/noticias/materias/2015/03/17/congresso-nacional-aprova-prcamento-de-2015

Publication Dates

• Publication in this collection
  July 2018