A. SARCINA
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A. SARCINA. ANTONIO SARCINA [email protected] 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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A sarcina

A. SARCINA


A sarcina

ANTONIO SARCINA

[email protected]


A sarcina

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


A sarcina

  • 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


Measuring effectiveness and cost effectiveness the qaly

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').


Measuring effectiveness and cost effectiveness the qaly1

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).


Measuring effectiveness and cost effectiveness the qaly2

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.


Incremental cost effectiveness ratio

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.


A sarcina

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


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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


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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


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Italia Vs R. Lombardia (2010)


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Rimborsi “teorici” (2010) Italia Vs Lombardia


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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


A sarcina

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


A sarcina

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


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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


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INTRODUZIONI NUOVI DEVICES

  • Costosingolaprocedura

  • Esitodellacura (costo-efficacia)


A sarcina

INTRODUZIONI NUOVI DEVICES

(ImpattosulleAziendeOspedaliere)

  • Costivariabiliaumentano

  • Costifissi = (aumentoattività > tettodi prod.?)

  • Margineoperativosiriduce

  • Aziende con economievirtuose (bilanci +, fondi ad hoc)

    COSTO SINGOLA PROCEDURA


A sarcina

INTRODUZIONI NUOVI DEVICES

(Impattosul SSN)

  • Outcomes

  • n. procedure

  • Appropriatezza

  • PDT

    COSTO GLOBALE DELLA CURA DELLA CLI


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Rete di patologia

  • Definire e condividere outcome attesi

  • Definire i PDT

  • Verificasullapopolazionedegli outcome

  • Costi

  • Piano SanitarioRegionale


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Rete di patologia

Ricerca Clinica


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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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