ABC | Volume 113, Nº5, November 2019

Guidelines Guideline of the Brazilian Society of Cardiology on Telemedicine in Cardiology – 2019 Arq Bras Cardiol. 2019; 113(5):1006-1056 applications, is growing exponentially. 249 Many health care providers worldwide are adopting this technology as a way to provide low-cost care for common problems that could result in a visit to the emergency department. 250 Most of these applications rely solely on video and audio connections with additional software for scheduling, billing, sharing of still images, and documentation. Also, some peripherals, such as smartphone-compatible heart rate sensing devices, 251 are available for purchase at decreasing prices. Limited financial availability for the acquisition and maintenance of telemedicine equipment and infrastructure remains a barrier to the widespread deployment of telemedicine. 252 This is particularly true for many health care providers or small systems that may lack the required resources and often have conflicting demands for available funds. Other costs associated with telemedicine programs include salary, administrative support and supplies, software and application development and upgrade costs, training programs, and initiatives to promote the program to patients. 253 With increased mobile connectivity, smartphones, and video compression, the costs to implement simple telemedicine interactions have decreased. Currently, none of the procedures used in telemedicine are included in the Supplementary Health List of Procedures and Events in Health, i.e. , a regulatory vacuum current places telemedicine in a field of conjecture and frustrated expectations dissociated from the interest of the regulated sector. There is also no concrete scientific evidence available to support the formal use of this technology. 38 Telemedicine is a disruptive innovation with the potential to change health, and its influence is likely to increase rapidly. Guided by what is best for patients, telemedicine, if properly applied, will help usher in a new age for health care that will be built by patients and physicians, identifying new ways of care, increasing quality and rationalizing costs also in supplementary care. 240 5. Economic Evaluation and Budgetary Impact of the Incorporation of Telemedicine in Cardiology in Brazil 5.1. Concepts of Economic Evaluation in Telemedicine The implementation of telemedicine services seeks to provide accessible and quality health care at a low cost. 254 Since the 1990s, as technological communication capabilities advanced, telemedicine services became more prevalent. 255 The emergence of new telemedicine-related capabilities and their integration into care systems offers opportunities to enhance value-based clinical care, promote health, and prevent diseases. 256 The values associated with the adoption of telemedicine services include the collaboration with the agile accessibility of patients to highly complex centers, 257 along with a reduction in mortality 258 and frequency of hospitalizations. 259 In cardiology, recent publications portray telemedicine and teleconsultation services as effective in the management of patients with chronic heart failure, 260,261 preparation of ECG reports, guidance of patients through mobile applications, 262 and cardiac rehabilitation, 263 among others. From reported experiences, telemedicine is universally seen as offering interesting benefits for improving accessibility and quality of health. 264 However, scientific and financial investments required to introduce these technologies into the health care system are high, 265 which potentiates the importance of accurate studies on economic analysis to guide decisions upon implementation of telemedicine services. 265,266 Economic analysis is one of the pillars of health care assessment that aims to support and guide decision making. For a new technology to be applied to a process, it must replace existing alternatives with equal or better results. That is, it must be effective. In addition, the results thus obtained should be less expensive than the alternatives or present reasonable values related to benefits, i.e., it must be cost effective. However, the economic evaluation of telemedicine strategies has some specificities: constant change of technology, lack of an adequate study design to manage undersized samples, inadequacy of conventional economic assessment techniques, and health outcome assessment problems not directly related to health. 267 As a consequence, different types of cost analysis have gained an important role in the evaluation of telemedicine services. 5.2. Applied Economic Methods Different approaches have been used to assess the economic impact of telemedicine services with varying levels of acceptability. Basically, five methods are available for calculation of cost effectiveness between conventional and telemedicine interventions: cost-minimization analysis, cost- benefit analysis, cost-effectiveness analysis, and cost-utility analysis. Additionally, return on investment has been used in telemedicine projects. 268 Cost-minimization analyses assume that both alternatives (conventional and telemedicine) are equally effective in health outcomes but differ in cost. A cost-minimization analysis considers changes but keeps health outcomes unaltered. For example, telecardiology for ECG reports assumes the same result but with different costs. Consequently, managers have to consider only differences in costs when deciding which alternative is less expensive. 269 Cost-benefit analysis recognizes that different projects are equally effective, but results and costs change. Changes in health costs and outcomes are considered simultaneously and attribute a monetary or numerical value not only to costs but also to health outcomes in order to express the nondimensional cost/benefit ratio. However, the idea of attributing monetary values to health outcomes, such as years of life, is not always acceptable to health decision makers. Cost-effectiveness analysis appears as a solution when costs and results are considered simultaneously, without attributing monetary values to results. Each outcome is defined according to its specific unit so that the final indices demonstrate a relationship between economic and health outcomes. Therefore, the final decision depends on the relationship that the decision maker considers best. This ratio (incremental 1036