Cost-effectiveness of procedures for the postponement of the terminal stage of chronic kidney disease associated with diabetes mellitus and hypertension from the perspective of the Unified Health System

O objetivo deste estudo foi realizar uma an??lise de custo-efetividade de propostas para o adiamento da fase terminal da doen??a renal cr??nica (ADRC) associada ?? hipertens??o arterial e ao diabetes mellitus no contexto nacional, sob a perspectiva do Sistema ??nico de Sa??de. Dentre as possibilidades de manejo da doen??a analisadas constam a experi??ncia do ambulat??rio de DRC da Universidade do Estado do Rio de Janeiro e aabordagem cl??nica tradicional, representada pela aten????o fornecida hoje pelo SUS. As alternativas estudadas foram: Tratamento Tradicional do SUS com o uso de Inibidor da enzima conversora de angiotensina (IECA) para o controle da press??o arterial; ADRC 1, representado pelo Programa de ADRC da UERJ; ADRC 2, como uma proposta de programa de ADRC de acordo com as diretrizes cl??nicas incluindo o uso do ARA II; ADRC 3, como uma proposta de programa de ADRC de acordo com as diretrizes cl??nicas incluindo com o uso de estatina; ADRC 4 como uma proposta de ADRC completa incluindo o uso de ARA II e estatina . O ADRC UERJ foi uma alternativa avaliada como um referencial para o SUS de um programa que oferece cuidado integral ao paciente portador de DRC com abordagem multiciplinar. Os resultados mostraram que pacientes com nefropatia diab??tica no SUS, teriam uma expectativa de vida aproximada de 6,66 anos, enquanto que na UERJ a expectativa de vida seria de 11,56 anos. As alternativas ADRC 3 e ADRC 4 proporcionariam uma expectativa de vida de cerca de 16 anos, e 10 QALYS extras com rela????o ao SUS. Ao relacionar as dimens??es custo e efetividade aplicando-se uma taxa de desconto de 5 por cento ao ano, verificou-se que a alternativa mais vantajosa foi o ADRC 3, apresentando economia da ordem de R$ 10.525,27 com rela????o ao SUS para cada ano adicional sobre a expectativa de vida, isto porque os pacientes prescindiriam de hemodi??lise. A conclus??o deste estudo ?? de que a simples disponibiliza????o de medicamentos de efic??cia reconhecida para o ADRC n??o ?? suficiente como estrat??gia para o cuidado adequado aos pacientes portadores de DRC no ??mbito do SUS, mas que ?? fundamental a implementa????o efetiva das pr??ticas j?? definidas pelo Minist??rio da Sa??de para o manejo cl??nico dos pacientes.The objective of this study was to estimate the cost-effectiveness for some alternatives of Conservative Management of Chronic Kidney Disease (CKD) related to hypertension and diabetes mellitus under Brazilian Public Health System (SUS) perspective. These options include an experience of a conservative management based on a multidisciplinary approach performed by the University of Rio de Janeiro (UERJ) and the current practice that have been carried out in SUS. The point was to evaluate both, benefits and incremental costs that would result from a full coverage of technologies that are not still largely available in brazilian primary care, like Angiotensin II-Receptor Antagonists (ARA II) and Statins. The alternatives assessed were: Current practice in SUS including Angiotensin-converting enzyme (ACE) inhibitors to treat hypertension; ADRC 1 represented by UERJ Program; ADRC 2 as a hypothetical program based on current guidelines, including the prescription of statins; ADRC 3 as a hypothetical program based on current guidelines, including the prescription of ARA II; and ADRC 4 as a hypothetical program based on current guidelines, including the prescription of ARA II and statins. The UERJ program was an alternative evaluated as a reference to SUS and as an example of a clinical management that offers a whole care to their CKD patients with a multidisciplinary team support. Results showed that SUS patients with diabetic nephropahy have a life expectancy of 6,66 years while UERJ patients have 11,56 years. Both alternatives ADRC 3 and 4, increase the SUS quality-adjusted life expectancy in about 10 years. The results of cost-effectiveness ratios discounted at 5% a.a. showed that the dominant strategy was ADRC 3 indicating costs savings of R$ 10.525,27 for each year of life added compared to SUS. This occurs because in this alternative patients would not need hemodialysis during their lifetime. The conclusion is that, the addition of new drugs with efficacy evidence is not a sufficient strategy to provide an adequate management of CKD patients in SUS. Instead of it, it is essential the effective implementation of the practices that are already defined by the Ministry of Health for the manegement of CKD patients