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 cost-effectiveness ratio, ICER) represents the cost for each additional result unit. 252 Cost-utility analyses consider individuals’ quality of life and the time of life that they will obtain as a result of an intervention. This is a particular case of cost effectiveness in which results are measured in terms of full-life lived years, usually expressed in quality-adjusted life-years (QALYs) or disability-adjusted life-years (DALY). The WHO recommends a value for DALY equivalent to three times the gross domestic product per capita. Return on investment is a nondimensional relationship between the monetary value invested and the monetary gain resulting from these investments, and measures the efficiency of the investment. 270 5.3. Literature Review A systematic literature review of cost-benefit review studies on the adoption of telemedicine services was conducted by the Federal University of Minas Gerais (UFMG) in 2016, gathering publications from 2000 to 2016. 105 Considering the keywords employed in the study, a search was performed on the PubMed database with the inclusion criterion being only studies related to cardiology. Other reviews manually searched in databases and/or journals of the area were also added. Thus, the search included literature review articles on the assessment of the incorporation of telemedicine in cardiology from 2000 to April 2019. Variables related to the economic analysis method, purpose of telemedicine in cardiology, clinical effectiveness, and cost reduction were extracted from the studies. For effectiveness, the impact on the reduction of mortality and hospitalizations, improvement of medication management, and anticipation of diagnosis were evaluated. From the search and application of exclusion criteria, 35 articles were fully analyzed by two researchers (A.E. and B.Z.) for the collection of variables. Figure 5.1 presents the flowchart of the selection of the articles. The number of studies focusing on telemedicine, especially the monitoring of chronic diseases, has increased over the last decade. Of the 35 studies identified, 19 were published after 2015. Table 5.1 summarizes the characteristics of the articles. Among the studies, 26 evaluated the telemedicine telemonitoring service mHealth as primary intervention versus usual face-to-face treatment. According to the authors, the ease of use of mobile phones, through the use of applications for remote monitoring and quick communication with patients, was the most common. 271 The most common outcomes in the evaluated studies were a reduction in mortality rate (54% of the reviews) and in the number of hospital readmissions (57% of the reviews), with at least one of these outcomes appearing in 26 studies. Other expected results were reduced hospitalization, early diagnosis, and better medication adherence. On the other hand, economic evaluations were less frequent. Only 16 reviews found conclusive results with cost analyses, of which 13 concluded that telemedicine provided savings to the paying source by reducing costs. Eight reviews included the economic evaluation of incorporating telemedicine in cardiology, with cost effectiveness being the most frequent evaluation (seven studies), while cost minimization was included in a single study. One study suggested that the few existing economic assessments have Figure 5.1 – Flowchart of selection of articles on economic analysis of Telemedicine applied to cardiology. PubMed search: 225 articles PAHO: 80 articles Total: 305 PubMed search: 50 articles PAHO: 6 articles Total: 56 46 articles for full evaluation 35 articles selected for analysis Exclusion criteria (PubMed): be unrelated to the economic assessment of telemedicine in cardiology Inclusion criteria (PAHO): to be related to the assessment of telemedicine in cardiology 10 duplicates were excluded 11 articles were excluded for not being directly related to cardiology 1037