Cost-consequence analysis of Pharmaceutical Care program for systemic arterial hypertension in the public health system in Brazil

Article Cost-consequence analysis of Pharmaceutical Care program for systemic arterial hypertension in the public health system in Brazil Maurílio de Souza Cazarim1  *  Altacílio Aparecido Nunes2  Leonardo Régis Leira Pereira1  1Department of Pharmaceutical Sciences, School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo, Ribeirão Preto, São Paulo, Brazil 2Department of Social Medicine, School of Medicine of Ribeirão Preto, University of São Paulo, Ribeirão Preto, São Paulo, Brazil ABSTRACT In Brazil, 80% of hypertensive patients have no blood pressure controlled, this fact has caused severe financial consequences for the public health system (PHS) and the Pharmaceutical Care (PC) has emerged as an effective alternative. The aim of this study was to analyze the costs and outcomes of systemic arterial hypertension (SAH) for conventional assistance compared to assistance with PC in the PHS. This is a pharmacoeconomic study with cost-consequence analysis nested to clinical trial. Hypertensives patients were followed-up from 2006 to 2012. During 2009 they were assisted by the PC program in Ribeirão Preto-SP, Brazil. Clinical indicators, systolic and diastolic blood pressure (SBP and DBP), triglycerides, total cholesterol (TC) and its fractions and healthcare indicators, consumption of antihypertensive medication and consultations were analyzed. Costs were listed as direct medical and direct non-medical. The average cost of conventional care for 104 patients followed-up was US$ 198.97, in the PC period and after discharge was US$ 407.91 and US$ 214.96 patient/year. After discharge of patients from PC there was reduction of SBP, DBP, TC and cardiovascular risk, 9.4 mmHg, 4.6 mmHg, 12.0 mg/dL, and 23% [p<0.005], respectively. The PC program optimized clinical and healthcare indicators and impacted in the SAH costs for the PHS. Keywords: Pharmaceutical economics; Pharmaceutical services; Health Expenditures; Hypertension; Pharmaceutical care; Costs and cost analysis INTRODUCTION Of a total of 56 million deaths worldwide in 2012, 38 million were due to chronic non-transmittable diseases. Among them, is highlighted the Systemic arterial hypertension (SAH) (WHO, 2003; Brasil, 2008; WHO, 2014a). It has affected, approximately, one third of the population, reaching over 50 % of people in old age and 5 % of children and adolescents (Cipullo et al., 2010; WHO, 2013; WHO, 2014b; Malachias et al., 2016). Blood pressure, if not controlled, is considered an important risk factor for the occurrence of other diseases of the circulatory system i.e. cardiovascular diseases (CVD) (WHO, 2011; WHO, 2013; WHO, 2014b; Malachias et al., 2016). In addition, 20 % of hypertensive patients have blood pressure within the recommended range of the VII guideline of the Brazilian Society of Cardiology (BSC), which is considered a low rate (Pontes-Neto et al., 2008; Malachias et al., 2016). There are studies that show a control pressure percentage below 20 % among hypertensive patients in Brazil (Jardim et al., 2007; Rosário et al., 2009). The consequence of this SAH situation in Brazil was presented by the VII guideline of the BSC (Malachias et al., 2016), which translates to about 1.2 million hospital admissions in Brazil being linked to CVDs. This reality refers to the fact that SAH has an annual cost of about 780 million dollars for health systems, showing that the representative portion for the Public Health System (PHS) amounts to approximately 462 million dollars (Malachias et al., 2016). The PHS has sought alternatives to work around this panorama of SAH in Brazil, outlining strategies and care proposals that promote improved clinical results and preventive patient care (Araújo, Ueta, Freitas, 2005; Malachias et al., 2016). A health technology capable of providing better prospects in the control of chronic diseases, especially SAH, is Pharmaceutical Care (PC) (Araújo, Ueta, Freitas, 2005; De-Castro, Correr, 2007; Lyra-Jr, Marcellini, Pelá, 2008; Pereira, Freitas, 2008; Zubioli et al., 2013). It is a model of professional practice in which the pharmacist uses clinical and humanistic skills to promote patient care through pharmacotherapeutic follow up (Ivama et al., 2002). Some studies have shown that PC is effective not only in controlling blood pressure, but also in reducing health complications caused by SAH (Machado et al., 2007; Aguwa, Ukwe, Ekwunife, 2008; Lyra-Jr, Marcellini, Pelá, 2008). However there is a need to assess the financial impact of PC together with clinical results achieved so this practice is encouraged in the PHS. Pharmacoeconomics is a science that studies the economic evaluation of health products and services. Among different pharmacoeconomic analyses there is the cost-consequence analysis, which enables to visualize the costs and outcomes for a specific morbidity, thus, generate hypotheses and design scenarios to assist health management. In this context, the aim of this study was to analyze the costs and outcomes of SAH for conventional assistance compared to assistance with PC in the PHS. SUBJECTS AND METHOD Study design and delineation This is a pharmacoeconomic study nested to clinical trial with a cost-consequence analysis in perspectives to PHS. From March to November 2014 data were collected for this study. These data are divided into clinical, healthcare, and economic. Clinical and healthcare data refer to the monitoring of hypertensive patients during the years 2006 to 2012 by the Research Centre for Pharmaceutical Care and Clinical Pharmacy (CPAFF), Faculty of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo (FCFRP-USP). In 2009 there was a PC program developed by the CPAFF, which assisted these patients for twelve months. Thus, the clinical data of the three years preceding the program (2006-2008) represented this study of years without PC, with conventional care, it is proposed in three levels of care in the PHS, basic care; Specialized/emergency care; Tertiary care (hospital admissions and more complex care). All care levels provide multiprofessional care and the patients get free basic medicines to treat hypertension. 2009 was the year with PC, and the three subsequent years (2010-2012) represented the years Post PC. Clinical data were collected through patient medical records and pharmaceutical and healthcare records through the Hygiaweb® computerized system. This study has approval by the Ethics in Research Committee of the FCFRP/USP, February 10, 2014, with the release of approval No. 004/2014 and protocol CEP/FCFRP 324, CAAE 21162713.8.0000.5403 and protocol No. 526.507 (http://plataformabrasil.saude.gov.br). Pharmaceutical Care program implemented for the care of hypertension Individuals diagnosed with SAH were included in the PC program, being residents of Ribeirão Preto, SP, aged over 20 years, in medical care for SAH, PHS users a (...truncated)