Direct costs of integrated procedures of conventional hemodialysis performed by nursing professionals 1

ABSTRACT Objective: to analyze the mean direct cost of the constituent procedures of conventional hemodialysis, performed in three public teaching and research hospitals. Method: quantitative, exploratory-descriptive study, of the multiple case study type. The mean direct cost was calculated by multiplying the time (timed) spent by nursing professionals, on the execution of procedures, by the unit cost of direct labor, added to the cost of materials and solutions/medications. Results: the total mean direct cost, in patients with an arteriovenous fistula corresponded to US$25.10 in hospital A, US$37.34 in hospital B and US$25.01 in hospital C, and in patients with a dual lumen catheter, US$32.07 in hospital A, US$40.58 in hospital B and US$30.35 in hospital C. The weighted mean values obtained were US$26.59 for hospital A, US$38.96 for hospital B and US$27.68 for hospital C. It was noted that the “installation and removal of hemodialysis fistula access” caused a significantly lower economic impact compared to “installation and removal of hemodialysis catheter access”. Conclusion: with the knowledge developed it will be possible to support hospital managers, technical managers and nursing professionals in the decision making process, with a view to the rational allocation of the necessary inputs for the performance of conventional hemodialysis.


Introduction
The worldwide increase in the prevalence of Chronic Kidney Disease (CKD) has required the adoption of one of the available types of dialysis -hemodialysis, peritoneal dialysis, renal transplantation, significantly burdening the finite health budgets (1)(2) . In Brazil, government agencies have been preoccupied with the costs of renal replacement therapies, since care for patients with CKD, usually performed at dialysis centers of hospital organizations, is one of the main areas that make up the high complexity of the Brazilian Nation Health System (SUS), consuming a large amount of financial resources (3) .
Hemodialysis represents the main type of dialysis adopted worldwide for the treatment, control and vital maintenance of patients with CKD (2) , which requires specialized care and advanced technology. Increased demand for health services, high healthcare costs and limited resources strongly pressure health organizations to become efficient, increase their productivity and minimize their spending.
To that end, their care and management processes must be meticulously studied in order to align resources and actions (4) .
Considering these facts, the present study was carried out in order to analyze the mean direct cost of the integrated procedures of conventional hemodialysis performed by nursing professionals in three public teaching and research hospitals in the state of São Paulo.

Method
This was a quantitative, exploratory-descriptive, multiple case type study (5)  The dialysis centers of these hospitals, referred to as A, B and C, were selected due to presenting good nursing practices, together with the adequate technological structure and human resources, quantitative and qualitative, necessary for the care of patients with CKD. Prior meetings were held with the coordinators of the dialysis centers for the detailed presentation of the research project and they stated that, with the approval of the respective Research Ethics Committees, there would be no impediments to the release of the information for the costing of the procedures.
The sample size was calculated by a statistics professional, based on a 95% confidence interval and a tolerable statistical error of 10%, corresponding to at least 100 observations of each of the hemodialysis components studied at the three dialysis centers. Thus, the study sample consisted of 1,928 observations of procedures, such as "preparation of extracorporeal circuit for hemodialysis" (n=614), "installation of hemodialysis arteriovenous fistula or dual lumen catheter access" (n=657) and "removal of hemodialysis arteriovenous fistula or dual lumen catheter access" (n=657). Considering that the professionals empirically attribute higher costs to installation/removal of catheter access, even without knowing their costs, it was decided to present these procedures, separately, according to the access route used.
The intervening variables in the direct cost of the integrated hemodialysis procedures, as well as the relationship of these variables, were first established, with the total mean direct cost obtained by the sum of the mean costs (6) : Considering that the procedures would consume different quantities of inputs, the total mean direct cost of each procedure was established composed of three parts: mean direct cost of materials , of solutions/ medications and of labor : The mean direct cost of the materials was obtained by summing the mean costs of each of the materials consumed: The mean cost of each material was obtained from the product of the mean quantity of this material by its mean unit price:  there is the possibility of identification with the product or department. Direct cost is defined as any that can be measured, that is, that can be identified and clearly quantified (7) . The hospital units are basically composed of labor, inputs and equipment used directly in the care process (8) . Direct labor refers to personnel who work directly on the products or services provided, as long as it is possible to measure the time spent and identify who performed the work. It is composed of salaries, social charges, holiday provisions and 13 th salary (7) .

Discussion
In the procedures studied, the participation of indication of arteriovenous fistula has proven to be of great benefit to patients undergoing hemodialysis (9) , with catheter use being associated with a higher incidence of infections, hospitalizations, and increased patient mortality (10) .
It was found that the procedures of "installation and removal of hemodialysis arteriovenous fistula access" presented a lower economic impact on the total mean direct cost compared to the procedures "installation and similarly to the results of other studies on the direct costs of procedures performed by nursing professionals (11)(12) .
With regard to the extracorporeal circuits, the submitted to manual processing and should be used for the same patient for a maximum of 12 times (13) .
If the dialysis centers of hospitals A and C had already adopted the provisions of RDC No.11/2014 (13) and did not reprocess the extracorporeal circuits, the total mean direct cost of "preparation of the .
The high cost of material resources has intensified the concern of health organization managers who need to invest in the improvement of material management systems in order to provide continuity of quality care at a lower cost by ensuring adequate quantity and quality (15) .
It is known that hospitals are involved in a very complex economic environment, with technical and technological updates being necessary to ensure the quality and competence in the provision of services. The demand for services is also increasing and the lack of resources, for both SUS and health insurance operators, aggravates their financial situation (16) .
Thus, the rapid increase in costs to meet the different care demands in hospital organizations requires studies on the financial aspects involved, which will make it possible to propose strategies for the efficient use of resources, balancing the provision of health services and their economic viability (17) .
Hospital organizations undoubtedly need detailed and consistent information on the costs incurred in the provision of their services, since they assist in the adequate application of scarce resources, especially in hospitals providing services to the SUS (12) . However, efforts need to be centered beyond cost containment strategies, since it is necessary to know how these cost are formed in the different care processes, in order to improve the distribution of resources and services without losing quality, increasing the accessibility for the users (18) .
The comparison of the costs of "preparation of hemodialysis equipment" between two dialysis centers that reprocessed the extracorporeal circuits (A and C) and one that did not (B), due to being within the prescribed period for compliance with RDC No.
11/2014 (13) , can be considered a limitation of this study.
However, because in the national scenario, there is little research in which the costs of procedures, especially those related to dialysis, have been calculated, this study represents an initial and unpublished approach, in which a methodology is proposed that can be reproduced and will enable the calculation and management of the direct costs of constituent procedures of conventional hemodialysis.
As implications for professional practice, it is hoped that the analysis of the direct costs of the integrated hemodialysis procedures, by adding knowledge to this thematic area, supports hospital managers, technicians responsible and nursing professionals in detecting inefficiencies and waste, as well as intervening in the productive process for the rational allocation of the inputs available in the dialysis centers.

Conclusion
The weighted means of the direct mean costs