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A. SARCINA

A. SARCINA. ANTONIO SARCINA antonio.sarcina@poliambulanza.it. Intervention for FEMPOP arteries ( claudicatio CLI separately) 2010-2011: 20.000 procedures (England) NIH England founded. PTA with bail-out BMS (standard care) Vs PTA with no BMS PTA with bail-out DES DEB

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A. SARCINA

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  1. A. SARCINA

  2. ANTONIO SARCINA antonio.sarcina@poliambulanza.it

  3. Intervention for FEMPOP arteries (claudicatio CLI separately) 2010-2011: 20.000 procedures (England) NIH England founded PTA with bail-out BMS (standard care) Vs PTA with no BMS PTA with bail-out DES DEB Primary BMS Primary DES Brachytherapy Stent grafts Cryoplasty

  4. DEB ha ilmigliorcosto-beneficio • Il limitedeilavoriconsideratiè la mancanzadicollegamentopervietà/esitoclinico: si parte dallapresunzionechepervietà = riduzionecosti per minor reinterventi. Ma PTA fallitasiassocia a reinterventi in media del 26% neipazienti con CI e 71% in quelli con CLI • Il vantaggio del drug eluting deveancoraesseretestatonel tempo (almeno 2 anni) quandol’efficacia del farmacoèminorerispettoaiprimimesi

  5. Measuringeffectiveness and costeffectiveness: the QALY With the rapidadvances in modern medicine, most people acceptthat no publiclyfundedhealthcare system, including the NHS, can possiblypayforeverynewmedical treatment whichbecomesavailable. The enormouscostsinvolvedmeanthatchoiceshavetobemade.Itmakessenseto focus on treatmentsthatimprove the quality and/or lengthofsomeone's life and, at the sametime, are aneffectiveuseof NHS resources.NICEtakesallthesefactorsinto account whenitcarries out itstechnologyappraisals (TAs) on newdrugs. Our expert reviewgroups (comprisingbothhealthprofessionals and patients) examineindependently-verifiedevidence on howwell a drugworks and whetheritprovidesgoodvalueformoney. Toensureourjudgements are fair, weuse a standard and internationallyrecognisedmethodto compare differentdrugs and measuretheirclinicaleffectiveness: the quality-adjusted life yearsmeasurement (the ‘QALY').

  6. Measuringeffectiveness and costeffectiveness: the QALY Howisthiscalculated? Althoughone treatment might help someone live longer, itmightalsohaveserious side effects. (Forexample, itmightmakethemfeelsick, put them at riskofotherillnesses or leavethempermanentlydisabled.) Another treatment mightnot help someoneto live as long, butitmayimprovetheirqualityof life whilethey are alive (forexample, byreducingtheirpain or disability). The QALY methodhelpsusmeasurethesefactors so thatwe can compare differenttreatmentsfor the same and differentconditions. A QALY givesan idea ofhowmany extra months or yearsof life of a reasonablequality a personmightgainas a resultof treatment (particularlyimportantwhenconsideringtreatmentsforchronicconditions). A numberoffactors are consideredwhenmeasuringsomeone'squalityof life, in termsoftheirhealth. They include, forexample, the levelofpain the personis in, theirmobility and theirgeneral mood. The qualityof life rating can rangefrom negative valuesbelow0 (worstpossiblehealth) to1 (the best possiblehealth).

  7. Measuringeffectiveness and costeffectiveness: the QALY Whataboutcosteffectiveness? Havingused the QALY measurementto compare howmuchsomeone's life can beextended and improved, wethenconsidercosteffectiveness - thatis, howmuch the drug or treatment costs per QALY. Thisis the costofusing the drugstoprovide a yearof the best qualityof life available - itcouldbeonepersonreceivingone QALY, butis more likelytobe a numberof people receiving a proportionof a QALY - forexample 20 people receiving 0.05 of a QALY. Costeffectivenessisexpressedas ‘£ per QALY'.Eachdrugisconsidered on a case-by-casebasis. Generally, however, if a treatment costs more than £20,000-30,000 per QALY, thenitwouldnotbeconsideredcosteffective.

  8. Incrementalcost-effectivenessratio The incrementalcost-effectivenessratio (ICER) isanequationusedcommonly in healtheconomicstoprovide a practicalapproachtodecisionmakingregardinghealthinterventions. Itistypicallyused in cost-effectivenessanalysis. health economics to provide a practical approach to decision making regarding health interventions. ICER is the ratioof the change in costtoincrementalbenefitsof a therapeuticintervention or treatment. The equationfor ICER is: ICER = (C1-C2)/(E1-E2) where C1 and E1 are the cost and effect in the intervention or treatment group and where C2 and E2 are the cost and effect in the control care group. Cost are usuallydescribed in monetaryunitswhile benefit/effect in health status ismeasured in termsof quality-adjusted life years (QALYs) gained or lost.

  9. CODICI DIAGNOSI 440.20 Aterosclerosi delle arterie native degli arti, non specificata 440.21 Aterosclerosi delle arterie native degli arti con claudicazione intermittente 440.22 Aterosclerosi delle arterie native degli arti con dolore a riposo 440.23 Aterosclerosi delle arterie native degli arti con ulcerazioni 440.24 Aterosclerosi delle arterie native degli arti con gangrena 440.29 Altre aterosclerosi delle arterie native degli arti 444.2 Embolia e trombosi delle arterie degli arti 444.21 Embolia e trombosi delle arterie degli arti superiori 444.22 Embolia e trombosi delle arterie degli arti inferiori 444.81 Embolia e trombosi dell’arteria iliaca 444.89 Embolia e trombosi di altre arterie

  10. CODICI PROCEDURE PTA 00.4 Procedure aggiuntive relative al sistema vascolare Nota: questi codici possono essere applicati sia per i vasi coronarici che per quelli periferici. Questi codici devono essere utilizzati insieme agli altri codici delle procedure terapeutiche per fornire informazioni aggiuntive circa il numero di vasi sui quali la procedura e' stata effettuata e/o sul numero di stent inseriti. Codificare sia il numero dei vasi trattati (00.40- 00.43), sia il numero degli stent inseriti (00.45-00.48) 39.50 Angioplastica o aterectomia di altro/i vaso/i non coronarico/i Angioplastica transluminale percutanea (PTA) di vaso non coronarico: vasi delle estremita' inferiori arteria mesenterica arteria renale vasi delle estremita' superiori 39.90 Inserzione di stentnon medicato in vaso periferico

  11. DRG prodottidadiagnosie procedure utilizzatinelperiferico RIVASCOLARIZZAZIONI 479 PM: 1,6087 RIMB: Euro 3.683 553 PM: 2,0652 RIMB: Euro 5.995 554 PM: 2,6490 RIMB: Euro 5.995 AMPUTAZIONI 114 RIMB: Euro 5.191 113 RIMB: Euro 9.740

  12. Italia Vs R. Lombardia (2010)

  13. Rimborsi “teorici” (2010) Italia Vs Lombardia

  14. DRG prodottidadiagnosie procedure utilizzatinelperiferico 440.2X Aterosclerosi (claudicatio, dolori a riposo, ulcere, gangrena ecc) + PTA +/- STENT Iliaca, SFA, tibiali (non relativo a tipodidiagnosi, nr otipo stent) BYPASS Vena, protesico, poplitea, solo femoraleotibiali e/o 479 PM: 1,6087 RIMB: Euro 3.683

  15. DRG prodottidadiagnosie procedure utilizzatinelperiferico 2507.X diabete con complicanze circolatorie + 440.2X Aterosclerosi (claudicatio, dolori a riposo, ulcere, gangrena ecc) R. Lombardia PTA +/- STENT Iliaca, SFA, tibiali (non relativo a tipodidiagnosi, nr otipo stent) BYPASS Vena, protesico, poplitea, solo femoraleotibiali e/o 553 PM: 2,0652 RIMB: Euro 5.995

  16. DRG prodottidadiagnosie procedure utilizzatinelperiferico + 2507.X diabete con complicanze circolatorie 440.2X Aterosclerosi (claudicatio, dolori a riposo, ulcere, gangrena ecc) R. Lombardia + Altre comorbidità (FA, BPCO, complicpostop ecc.) PTA +/- STENT Iliaca, SFA, tibiali (non relativo a tipodidiagnosi, nr otipo stent) BYPASS Vena, protesico, poplitea, solo femoraleotibiali e/o 554 PM: 2,6490 RIMB: Euro 5.995

  17. IL RIMBORSO NON è LEGATO ALLA DIFFICOLTA’ o al TIPO DI INTERVENTO ma alla DIAGNOSI • Qualsiasi PTA +/– stent (qualsiasinumero) +/- altro device (aterotomo, DCB ecc) in qualsiasidistretto (iliaca come piede) non modificailrimborso • Qualsiasiprocedura “open” (TEA, bypass) in qualsiasidistrettoperiferico (axillo, femorale, piede) con qualsiasimateriale (protesio vena) non modificailrimborso

  18. INTRODUZIONI NUOVI DEVICES • Costosingolaprocedura • Esitodellacura (costo-efficacia)

  19. INTRODUZIONI NUOVI DEVICES (ImpattosulleAziendeOspedaliere) • Costivariabiliaumentano • Costifissi = (aumentoattività > tettodi prod.?) • Margineoperativosiriduce • Aziende con economievirtuose (bilanci +, fondi ad hoc) COSTO SINGOLA PROCEDURA

  20. INTRODUZIONI NUOVI DEVICES (Impattosul SSN) • Outcomes • n. procedure • Appropriatezza • PDT COSTO GLOBALE DELLA CURA DELLA CLI

  21. Rete di patologia • Definire e condividere outcome attesi • Definire i PDT • Verificasullapopolazionedegli outcome • Costi • Piano SanitarioRegionale

  22. Rete di patologia Ricerca Clinica

  23. NET VASC Lombardia (progetto pilota) N° Centri: 8 1. Stenosi carotidea sintomatica 2. AAA sintomatico 3. IC degli arti inferiori 4. TVP Ospedale MultiMedicaCastellanza (Capofila) IRCCS Policlinico MultiMedica Sesto San Giovanni IRCCS Fondazione ‘Ca GrandaOspedale Policlinico Milano Ospedale di Circolo Busto Arsizio Ospedale di Circolo Fondazione Macchi Varese Ospedale Fondazione Poliambulanza Brescia Ospedale Manzoni Lecco Spedali Civili Brescia

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