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 low methodological rigor, not allowing an assertive conclusion about the economic viability of the implementation. 264,271 Briefly, studies on heart failure telemonitoring have shown that support strategies (video conferencing or telephone) are cost effective, meaning, they have a potential for financial return. Studies evaluating monitoring by cardiac devices showed an incremental cost-effective ratio of US$ 13,979 per QALYs. In a meta-analysis, device telemonitoring was related to a 44% reduction in hospital visits, with no effect on mortality, but a 15-50% reduction in direct health costs. 272 The economic results of noninvasive telemonitoring are even more heterogeneous. Some clinical trials have shown neutral results, while one showed a significant reduction in heart failure readmissions and a direct total cost reduction of € 3,546 per patient for 6 months of follow-up. 273 In a Dutch clinical trial, the TEHAF trial, the likelihood of cost- effectiveness for remote monitoring was 48% ( € 50,000/ QALY threshold), probably due to differences between institutions. One of the most detailed studies was developed for the UK health system perspective using a Markov model comparing usual treatment, telephone support, or remote telemonitoring for patients with heart failure after hospital discharge. Assuming monthly costs of £ 27 for standard care, £ 179 for telephone support, and £ 175 for telemonitoring during business hours, the most cost-effective strategy was telemonitoring, with values below £ 20,000 per QALY. The telephone support strategy was very unfavorable, with an ICER of £ 228,035/QALY compared with telemonitoring. 274 Variables evaluating effectiveness repeat across the studies, notably the reduction in mortality and in hospitalization frequency. However, accurate cost collection methods, definition of which cost variables should be collected, and the application of economic models still lack standard recommendations in the literature. More than 70% of the studies did not consider at least one category: health care costs, patient and family expenses, or lost productivity. Many failed to include salaries and benefits, training time, amortized capital investments, data and follow-up operations, and overhead costs. Moreover, an important constraint in these economic analyses has been the great heterogeneity of technology (intervention) and even the control group (alternatives). Technologies supporting telemedicine services advance at an impressive pace and range from complex structures and large investments less than 10 years ago to cost-effective solutions based on cell phones and mobile devices. 256,263 These are distinct services requiring a high initial investment, but most data point to a return on investment over time due to the volume of patients who then do not require the use of the traditional health care system. 260,269 Economic assessment methods must, therefore, track the service over time, including the outcomes of patients receiving care or monitored by the telemedicine services. Given the diversity of the benefits gained, the applied cost methodology – dedicated data reflecting conditions of the local health care system – must be evaluated for a proper understanding of the cost effectiveness of these technologies. 5.4. Economic Evaluations of Telemedicine in Brazil These new technologies are being gradually introduced in the routine of hospitals, clinics, and offices in the private and public sectors in Brazil. The first of these technologies to be applied was the transmission of ECG data for remotely reporting. In 1994, the company Telecardio started using this technology, transmitting the tests by telephone, and in 1995, the Instituto do Coração (InCor) created a service called ECG-FAX. Later, in 2005, a telecardiology system or Minas Telecardio project was implemented at UFMG’s Clinics Hospital. 275 In 2007, the Ministry of Health, aiming to develop actions to support primary care teams through permanent education and virtual technologies, created the Telessaúde Brasil program, later renamed Telessaúde Brasil Redes . Nine Brazilian Telehealth Centers ( Núcleos de Telessaúde no Brasil ) were initially established, offering teleconsulting (consultation between professionals) and telediagnosis (ECG) in the public sector. Currently, several companies offer remote reporting of ambulatory BP monitoring (ABPM), Holter, and remote echocardiography and imaging analysis. AI is currently used in teleconsulting and is at an advanced stage in the preparation of diagnostic test reports. Telemonitoring of patients with heart failure is also ongoing in Brazil. The routine use of these technologies in Brazil is an indirect indication of their effectiveness, and the continuing operation of companies in this sector is an indirect measure of cost- effectiveness, although there are few formal studies on this subject in Brazil. At least two initiatives for the application of new technologies in cardiology in Brazil focused on these cost- effectiveness studies: 1) the telemedicine service and remote patient monitoring of InCor at the University of São Paulo Medical School and 2) the telediagnosis and teleconsultation system of the Minas Gerais Teleasssistance Network (RTMG) of the Clinics Hospital at UFMG. In addition to the results from telecardiology services, an analysis of savings estimates for the state of Rio Grande do Sul through the TelessaúdeRS project, which offers 20 clinical specialty teleconsultation services, was conducted and are presented in this chapter as a third approach to an economic evaluation of telemedicine in Brazil. 5.5. InCor-FMUSP Telemedicine and Patient Monitoring Service Stevens et al. evaluated the economic burden and impact on patients’ disability of four main heart conditions – heart failure, AMI, AFib, and hypertension – in 2015 in Brazil. 276 Specifically for hypertension, the authors assessed the cost effectiveness of conventional care versus telemedicine and structured telephone support over a 30-year time horizon after 2015. A summary of the results found in the study is shown in Table 5.2. Both technologies were considered cost effective by the authors, assuming the standard defined by the WHO of an intervention being considered cost effective when having a cost per life-year between one and three times the gross domestic product per capita per QALY. However, the Brazilian health authorities have not yet defined the country’s ICER. Thus, safe inferences cannot be made on whether the procedures applied in telemedicine within the SUS would be cost effective or not within these scenarios. 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