O nosso estudo contribui com análise econômica completa, prospectiva, de vida real, com avaliação de desfechos clínicos e de qualidade de vida relevantes para a tomada de decisão. Destaca-se o aprofundamento das análises baseadas em dados primários e modelagem, por meio de árvores de decisão, com estratificação conforme o tempo de tratamento dos casos, além das diferentes perspectivas do hospital e do sistema público de saúde. Ademais, os resultados de RCUI, calculados por meio do QALY, permitem comparação da utilidade da TEAPA frente a outras intervenções em saúde.
A estratificação da análise pelo tempo de tratamento em nosso estudo permitiu identificar que os casos com duração de tratamento de até 14 dias podem não ser custo-efetivos no cenário nacional. Porém, este resultado necessita de confirmação por futuros estudos, mediante medidas de utilidade com maior amostra, neste mesmo padrão de população alvo. Há carência de dados na literatura sobre a relação entre custos e tempo de tratamento, porém destacam-se duas avaliações econômicas comparativas que evidenciaram desvantagem econômica da TEAPA, devido ao tempo de tratamento excedente, em relação ao regime de internação (14,46). Este dado endossa a importância da adesão aos protocolos na seleção criteriosa dos pacientes a serem encaminhados para TEAPA e o monitoramento contínuo dos resultados, que considere tanto os aspectos de desfecho clínico, como também pelo seu impacto econômico (1,2,24,53,68).
Os custos relativos à estrutura do serviço e da equipe multidisciplinar para viabilizar o atendimento de TEAPA devem ser considerados na análise da implementação (1,9,25,69). No nosso estudo, esses custos estão contemplados nas diárias e taxas que refletem a alocação, por paciente, dos gastos gerais das unidades assistenciais (overheads) onde se deu o atendimento do caso. Esses foram os principais componentes na distribuição dos custos totais, os quais corresponderam a 80,3% na perspectiva do hospital e 72,7% na perspectiva do sistema de saúde.
O tomador de decisão pode, por meio das informações disponíveis neste estudo, avaliar a demanda de pacientes em terapia antimicrobiana parenteral e ponderar a viabilidade técnica e logística para implantar a TEAPA, em seu contexto. Há que se considerar que, somado aos benefícios clínicos e econômicos da TEAPA, o paciente e seu acompanhante são favorecidos pelo retorno precoce ao ambiente familiar, às suas rotinas pessoais e, eventualmente, às atividades profissionais. Os dias de internação evitados, por meio da TEAPA, possibilitam liberação de leitos e contribuem para melhor gestão do atendimento de casos de maior complexidade e que exigem regime de hospitalização. No entanto, o atendimento ambulatorial pode gerar outros gastos ao paciente, especialmente os relativos ao transporte para o atendimento em TEAPA e por medicações de uso contínuo não fornecidas pelo
serviço de saúde. Avaliações econômicas que considerem a perspectiva do paciente poderão analisar o impacto destes custos.
As perspectivas de pesquisas futuras sobre o tema incluem aprofundar a análise econômica quanto ao tempo de terapêutica, com maior número de casos acompanhados e em diferentes modalidades de TEAPA. Também seria importante a realização de análise de impacto orçamentário da TEAPA pela perspectiva do SUS, a qual deveria ponderar as diferentes modalidades de administração dos antimicrobianos, tipo de infecção e tempo de terapêutica.
CONCLUSÃO
O estudo permite concluir que:
• A TEAPA, em modalidade de centro de infusão em hospital-dia, é uma estratégia efetiva na perspectiva do hospital e do SUS, em comparação ao regime de internação;
• A eficiência da TEAPA também é observada em outros contextos internacionais, apesar de ser relatada por estudos heterogêneos e, em sua maioria, de baixa qualidade metodológica;
• No HC-Unicamp, a TEAPA evitou hospitalização, aumentou a qualidade de vida dos pacientes e economizou recursos;
• O modelo analítico de custo-utilidade desenvolvido é adaptável a outros contextos.
REFERÊNCIAS
1. Norris A, Shrestha N, Allison G, Keller S, Bhavan K, Zurlo J, et al. 2018 IDSA Clinical Practice Guideline for the Management of Outpatient Parenteral Antimicrobial Therapy. Clin Infect Dis. 2018;1–35.
2. Chapman A. Outpatient parenteral antimicrobial therapy in a changing NHS: challenges and opportunities. Clin Med. 2013;13(1):35–6.
3. Chapman A, Dixon S, Andrews D, Lillie P, Bazaz R, Patchett J. Clinical efficacy and cost-effectiveness of outpatient parenteral antibiotic therapy (OPAT): a UK perspective. J Antimicrob Chemother [Internet]. 2009 Sep;64(6):1316–24. Available from:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt =AbstractPlus&list_uids=19767623
4. Esposito S, Noviello S, Leone S, Tice A, Seibold G, Nathwani D, et al. Outpatient parenteral antibiotic therapy (OPAT) in different countries: a comparison. Int J Antimicrob Agents [Internet]. 2004;24(5):473–8. Available from:
http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=med5&NEWS= N&AN=15519480
5. Chapman A, Seaton R, Cooper M, Hedderwick S, Goodall V, Reed C, et al. Good practice recommendations for outpatient parenteral antimicrobial therapy (OPAT) in adults in the UK: a consensus statement. J Antimicrob Chemother. 2012;67:1053–1062.
6. Tice A, Rehm S, Dalovisio J, Bradley J, Martinelli L, Graham D, et al. Practice guidelines for outpatient parenteral antimicrobial therapy. IDSA guidelines. Clin Infect Dis [Internet]. 2004;38(12):1651–72. Available from:
http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=med5&NEWS= N&AN=15227610
7. Durojaiye O, Cartwright K, Ntziora F. Outpatient parenteral antimicrobial therapy (OPAT) in the UK: a cross-sectional survey of acute hospital trusts and health boards. Diagn Microbiol Infect Dis. 2018;
8. Mackenzie M, Rae N, Nathwani D. Outcomes from global adult outpatient parenteral antimicrobial therapy programmes: A review of the last decade. Int J Antimicrob Agents [Internet]. 2014;43(1):7–16. Available from:
http://www.embase.com/search/results?subaction=viewrecord&from=export&id= L52852206
9. Durojaiye O, Bell H, Andrews D, Ntziora F, Cartwright K. Clinical efficacy, cost analysis and patient acceptability of outpatient parenteral antibiotic therapy (OPAT): a decade of Sheffield (UK) OPAT service. Int J Antimicrob Agents. 2018;51:26–32.
10. López Cortés L, Mujal Martínez A, Mandojana M, Martín N, Bermejo M, Aznar J, et al. Executive summary of outpatient parenteral antimicrobial therapy:
Guidelines of the Spanish Society of Clinical Microbiology and Infectious Diseases and the Spanish Domiciliary Hospitalisation Society. Enferm Infecc Microbiol Clin. 2018;(May).
11. Oliveira P, Carvalho V, Cimerman S, Lima A, Diretrizes Brasileiras para Terapia Antimicrobiana Parenteral Ambulatorial Group. Recommendations for outpatient
parenteral antimicrobial therapy in Brazil. Braz J Infect Dis. 2017;21(6):648–655. 12. The British Society for Antimicrobial Chemotherapy. National outcomes registry
(NORS). OPAT Registry. User guide for NORS (Adult & Pediatric). [Internet]. 2015. Available from: http://www.e-opat.com/wp-
content/uploads/2016/04/NORS-user-guide_October-2015.pdf
13. Wee L, Sundarajoo M, Quah W, Farhati A, Huang J, Chua Y. Sociodemographic and clinical factors associated with acceptance of outpatient parenteral antibiotic therapy in a Singapore tertiary hospital from 2014 to 2017. Eur J Clin Microbiol Infect Dis. 2018;
14. Yong C, Fisher D, Sklar G, Li S. A cost analysis of Outpatient Parenteral Antibiotic Therapy (OPAT): an Asian perspective. Int J Antimicrob Agents [Internet]. 2008/10/01. 2009;33(1):46–51. Available from:
http://www.embase.com/search/results?subaction=viewrecord&from=export&id= L50283193
15. Wolter JM, Cagney RA, McCormack JG. A randomized trial of home vs hospital intravenous antibiotic therapy in adults with infectious diseases. J Infect.
2004/03/06. 2004;48(3):263–8.
16. Peña A, Zambrano A, Alvarado M, Cerda J, Vergara R. Evaluación de la efectividad, seguridad y costos del tratamiento antimicrobiano intravenoso ambulatorio (TAIA) vs hospitalizado en infección urinaria en pediatría [Evaluation of the effectiveness, safety and costs of outpatient intravenous antimicrobial t. Rev Chil Infectol. 2013;30(4):426–34.
17. Keyloun K, Weber D, Gardstein B, Berger A, Gillard P, Ganz M. Economic burden of hospital admissions for patients with acute bacterial skin and skin structure infections in the United States. Hosp Pract. 2018;
18. Seaton RA, Barr DA, R.A. S, D.A. B, Seaton RA, Barr DA. Outpatient parenteral antibiotic therapy: Principles and practice. Eur J Intern Med [Internet].
2013;24(7):617–23. Available from:
http://www.embase.com/search/results?subaction=viewrecord&from=export&id= L52544230
19. Psaltikidis E, Resende M, Mattos K, Leichsenring M, Fagnani R, Lima T, et al. Identifying inpatients to outpatient parenteral antimicrobial therapy: a point prevalence study. Value Heal. 2017;20:A853–A943.
20. Brasil. Ministério da Saúde. Portaria n.o 44 / GM de 10 de janeiro de 2001.
Aprovar no âmbito do Sistema Único de Saúde a modalidade de assistência - hospital Dia. 2001.
21. Brasil. Lei no 12.401, de 28 de abril de 2011. Altera a Lei no 8.080, de 19 de
setembro de 1990, para dispor sobre a assistência terapêutica e a incorporação de tecnologia em saúde no âmbito do Sistema Único de Saúde - SUS. 2011. 22. Brasil. Ministério da Saúde. Secretaria de Ciência Tecnologia e Insumos
Estratégicos. Departamento de Ciência e Tecnologia. Diretrizes metodológicas: elaboração de pareceres técnico-científicos [Methodological guideline:
elaborating rapid HTAs]. 4th ed. Brasília; 2014. 1-80 p.
23. Brasil. Ministério da Saúde. Secretaria de Ciência Tecnologia e Insumos
Estratégicos. Departamento de Ciência e Tecnologia. Diretrizes metodológicas: diretriz de avaliação econômica [Methodological guideline: economic evaluation of health technologies]. 2nd ed. Brasília; 2014. 1-131 p.
24. Russel L, Siegel J, Daniels N, Gold M, Luce B, Mandelblatt J. Cost-effectiveness analysis as a guide to resource allocation in health: roles and limitations. In: Gold M, Siegel J, Russell L, Weinstein M, editors. Cost-Effectiveness in Health and Medicine. Oxford University Press; 1996.
25. Palmer S, Raftery J. Opportunity cost. Britsh Med J. 1999;318:1551–2. 26. Canadian Agency for Drugs and Technologies in Health (CADTH). Guidelines
for the economic evaluation of health technologies: Canada. 4th ed. CADTH, editor. Ottawa; 2017. 79 p.
27. Drummond M, Sculpher M, Torrance G. Methods for the economic evaluation of health care programmes. Oxford: Oxford University Press; 1997.
28. Ramsey S, Willke R, Glick H, Reed S, Augustovsk I, Jonsson B, et al. Cost- effectiveness analysis alongside clinical trials II—an ISPOR good research practices task force report. Value Heal. 2015;18:161–72.
29. Ribeiro A, Neyeloff J, Itria A, Santos V, Vianna C, Silva E, et al. Methodological guidelines for economic evaluation studies of health technologies in Brazil. J Bras Econ Saúde. 2016;8(3):174–84.
30. Frick K. Micro-Costing Quantity Data Collection Methods. Med Care. 2009;47(7 Suppl 1):S76–S81.
31. Charles J, Edwards R, Bywater T, Hutchings J. Micro-Costing in public health economics: steps towards a standardized framework, using the incredible years toddler parenting program as a worked example. Prev Sci. 2013;14:377–389. 32. Hendriks M, Kundu P, Boers A, Bolarinwa O, te Pas M, Akande T, et al. Step-by-
step guideline for disease-specific costing studies in low- and middle-income countries: a mixed methodology. Glob Heal Action [Internet]. 2014;7(23573):1– 10. Available from: http://dx.doi.org/10.3402/gha.v7.23573
33. Silva E, Silva M, Pereira M. Identifying, measuring and valuing health costs. Epidemiol Serv Saúde. 2016;25(6):437–9.
34. Moher D, Liberati A, Tetzlaff J, DG A, Group P. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med. 2009;151(4):264–9.
35. van Mastrigt G, Hiligsmann M, Arts J, Broos P, Kleijnen J, Evers S. How to prepare a systematic review of economic evaluations for informing evidence- based healthcare decisions: a five-step approach (part 1/3). Expert Rev Pharmacoecon Outcomes Res. 2016;16(6):689–704.
36. Husereau D, Drummond M, Petrou S, Carswell C, Moher D, Greenberg D, et al. Consolidated Health Economic Evaluation Reporting Standards (CHEERS) - Explanation and elaboration: a report of the ISPOR health economic evaluation publication guidelines good reporting practices task force. Value Heal.
2013;16:231–50.
37. Weinstein M, Torrance G, McGuire A. QALYs: the basics. Value Heal. 2009;12(Suppl.):S5-9.
38. QALY Brasil. Estudo QALY Brasil [QALY Brazil study] [Internet]. Available from: http://natsinc.org/wpress/euroqol/?page_id=767
39. Santos M, Cintra M, Monteiro A, Santos B, Gusmão-Filho F, Andrade M, et al. Brazilian valuation of EQ-5D-3L health states: results from a saturation study.
Med Decis Mak. 2016;36(2):253–63.
40. U.S.Department of Health and Human Services. Common terminology criteria for adverse events (CTCAE). 2010. (v4.03).
41. The World Bank Group. PPP conversion factor, GDP (LCU per international $) [Internet]. 2019 [cited 2019 Feb 19]. Available from:
http://data.worldbank.org/indicator/PA.NUS.PPP
42. Petrou S, Gray A. Economic evaluation using decision analytical modelling: design, conduct, analysis, and reporting. BMJ. 2011;342:d1766.
43. Lacroix A, Revest M, Patrat-Delon S, Lemaitre F, Donal E, Lorleac’h A, et al. Outpatient parenteral antimicrobial therapy for infective endocarditis: a cost- effective strategy. Med Mal Infect [Internet]. 2014;44(7):327–30. Available from: http://www.embase.com/search/results?subaction=viewrecord&from=export&id= L53233542
44. Antoniskis A, Anderson B, Van Volkinburg E, Jackson J, Gilbert D. Feasibility of outpatient self-administration of parenteral antibiotics. West J Med.
1978;128(3):203–6.
45. Graf von der Schulenburg J, Greiner W, Klettke U, Wahn U. Ökonomische aspekte der behandlung zystischer fibrose mit chronischer pulmonaler pseudomonasinfektion [Economic aspects of treatment of cystic fibrosis with chronic pulmonal pseudomonas infection]. Med Klin. 1998/01/31.
1997;92(10):626–9.
46. Kameshwar K, Karahalios A, Janus E, Karunajeewa H. False economies in home-based parenteral antibiotic treatment: a health-economic case study of management of lower-limb cellulitis in Australia. J Antimicrob Chemother. 2016;71:830–835.
47. Al Ansari A, Al Alawi S, Al Qahtani M, Darwish A. Outpatient parenteral antimicrobial terapy (OPAT) in the Kingdom of Bahrain: efficacy, patient satisfaction and cost effectiveness. Open Infect Dis J [Internet]. 2013;7:90–5. Available from: http://benthamopen.com/toidj/articles/V007/90TOIDJ.pdf
48. Teuffel O, Amir E, Alibhai S, Beyene J, Sung L. Cost effectiveness of outpatient treatment for febrile neutropaenia in adult cancer patients. Br J Cancer [Internet]. 2011 Jan;104(9):1377–1383. Available from:
http://www.crd.york.ac.uk/CRDWeb/ShowRecord.asp?ID=22011000889 49. Welte R, Feenstra T, Jager H, Leidl R. A decision chart for assessing and
improving the transferability of economic evaluation results between countries. Pharmacoeconomics. 2004;22(13):857–76.
50. Galvao T, Silva E, Silva M, Bronstein A, Pereira M. Economic evaluation of poison centers: a systematic review. Int J Technol Assess Heal Care. 2012;28(2):86–92.
51. Liu C, Bayer A, Cosgrove S, Daum R, Fridkin S, Gorwitz RJ. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis. 2011;52(3):e18-55.
52. Sriskandarajah S, Hobbs J, Roughead E, Ryan M, Reynolds K. Safety and effectiveness of ‘hospital in the home’ and ‘outpatient parenteral antimicrobial therapy’ in different age groups: A systematic review of observational studies. Int J Clin Pr. 2018;
53. Tice AD, Rehm SJ, Dalovisio JR, Bradley JS, Martinelli LP, Graham DR, et al. Practice guidelines for outpatient parenteral antimicrobial therapy. Clin Infect Dis [Internet]. 2004;38:1651–72. Available from:
http://www.embase.com/search/results?subaction=viewrecord&from=export&id= L38781656
54. Mansour O, Heslin J, Townsend J. Impact of the implementation of a nurse- managed outpatient parenteral antibiotic therapy (OPAT) system in Baltimore: a case study demonstrating cost savings and reduction in re-admission rates. J Antimicrob Chemother [Internet]. 2018; Available from:
https://doi.org/10.1016/j.diagmicrobio.2018.07.013
55. Li W, Branley J, Sud A. Outpatient parenteral antibiotic therapy in a suburban tertiary referral centre in Australia over 10 years. Infection. 2018;46:349–355. 56. World Health Organization. Antimicrobial resistance: draft global action plan on
antimicrobial resistance. In: Sixty-Eighth World Health Assembly A68/20 (2015) [Internet]. 2015. Available from:
http://apps.who.int/gb/ebwha/pdf_files/WHA68/A68_20-en.pdf
57. Gilchrist M, Franklin BD, Patel JP, M. G, B.D. F, J.P. P, et al. An outpatient parenteral antibiotic therapy (OPAT) map to identify risks associated with an OPAT service. J Antimicrob Chemother [Internet]. 2008;62(1):177–83. Available from:
http://www.embase.com/search/results?subaction=viewrecord&from=export&id= L351865894
58. Williams D, Baker C, Kind A, Sannes M. The history and evolution of outpatient parenteral antibiotic therapy (OPAT). Int J Antimicrob Agents. 2015;46(3):307– 12.
59. Brasil. Conselho Federal de Enfermagem. Resolução COFEN no 0582 / 2018.
2018.
60. Vargas-Palacios A, Meads D, Twiddy M, Murray C, Hulme C, Mitchell E, et al. Cost-effectiveness of outpatient parenteral antibiotic therapy: a simulation modelling approach. J Antimicrob Chemother. 2017;72:2392–2400.
61. Minton J, Murray C, Meads D, Hess S, Vargas-Palacios A, Mitchell E, et al. The Community IntraVenous Antibiotic Study (CIVAS): a mixed-methods evaluation of patient preferences for and cost-effectiveness of different service models for delivering outpatient parenteral antimicrobial therapy. Heal Serv Deliv Res. 2017;5(6):1–271.
62. Mitchell E, Murray C, Meads D, Minton J, Wright J, Twiddy M. Clinical and cost- effectiveness, safety and acceptability of community intravenous antibiotic service models: CIVAS systematic review. BMJ Open. 2017;7:e013560. 63. Pajarón M, Lisa M, Fernández-Miera M, Dueñas J, Arnaiz A, Sanroma-
Mendizábal P. Efficiency of a self-administered outpatient parenteral
antimicrobial therapy (s-opat) for infective endocarditis within the context of a shortened hospital admission based on hospital at home program. Hosp Pract. 2017;45(5):246–52.
64. Keller S, Williams D, Levering M, Cosgrove S. Health-Related Quality of Life in Outpatient Parenteral Antimicrobial Therapy. Open Forum Infect Dis.
2018;5(7):1–4.
of-life assessment in an outpatient parenteral antibiotic program. Ann Pharmacother [Internet]. 2002;36(12):1851–5. Available from:
http://www.embase.com/search/results?subaction=viewrecord&from=export&id= L35429553
66. Wai AO, Frighetto L, Marra CA, Chan E, Jewesson PJ, A.O. W, et al. Cost analysis of an adult outpatient parenteral antibiotic therapy (OPAT) programme. A Canadian teaching hospital and Ministry of Health perspective.
Pharmacoeconomics [Internet]. 2001/01/11. 2000;18(5):451–7. Available from: http://www.embase.com/search/results?subaction=viewrecord&from=export&id= L30825703
67. González-Ramallo V, Mirón-Rubio M, Mujal A, Estrada O, Forné C, Aragón B, et al. Costs of outpatient parenteral antimicrobial therapy (OPAT) administered by Hospital at Home units in Spain. Int J Antimicrob Agents. 2017;50:114–118. 68. Gilchrist M, Seaton R. Outpatient parenteral antimicrobial therapy and
antimicrobial stewardship: challenges and checklists. J Antimicrob Chemother. 2015;70(4):965–70.
69. Heintz BH, Halilovic J, Christensen CL. Impact of a multidisciplinary team review of potential outpatient parenteral antimicrobial therapy prior to discharge from an academic medical center. Ann Pharmacother [Internet]. 2011;45(11):1329–37. Available from:
http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=medl&NEWS=N &AN=21990938