varicose veins treatment cost

varicose veins treatment cost


 Costs of treatment of telangiectasias and truncal varices with sclerotherapy with foam at the "Freyre de Andrade" Hospital in Havana

 

Cost of the treatment of t elangiectases and varicose veins with foam sclerotherapy in ¨Freyre de Andrade¨hospital in Havana





Anai García FariñasI; Antonio Suárez CabreraII; Estela Argentina Perez LeónIII; Addis Márquez FuretIV

IInstituto de Farmacia y Alimentos. University of Havana, Cuba.
IIS Angiology and Vascular Surgery Service of the Freyre de Andrade Hospital. Havana Cuba.
III National Institute of Hygiene, Epidemiology and Microbiology. Havana Cuba.
IVPoliclínico "Reina". Havana Cuba.





SUMMARY

Objective: to determine how much the treatment of varicose veins by the foam sclerotherapy technique in the outpatient department of Angiology and Vascular Surgery of the C.Q. Hospital costs per patient. "Freyre de Andrade".
Method: economic evaluation of type description of cost. The direct institutional cost of outpatient treatment for varicose veins in lower extremities with foam sclerotherapy was studied and the active ingredient was 0.5% Polidocanol at a dose of 2ml. The items human resources, expendable material and medicine were used. The average cost per patient, total and according to type of consultation was determined.
Results: the total cost per patient attended was 68.60 Cuban pesos. The average cost per patient of the classification consultation was 0.18 cents of Cuban pesos (DS 95% = 0.12). The average cost of the treatment consultation was 50.60 Cuban pesos (DS 95% = 7.65). There were no significant differences between the different types of varicose veins to be treated.
Conclusions: the direct institutional cost of the treatment of telangiectasia and truncal varicose veins with foam sclerotherapy was similar. In the short term, the treatment of varicose veins with sclerotherapy with foam generates lower costs than the surgical option.

Key words: sclerotherapy with foam, costs, truncal varices, telangiectasia.

ABSTRACT

Objective: to determine the cost of the treatment of varicose veins per patient with the foam sclerotherapy in the angiology and vascular surgery outpatient service of "Freyre de Andrade" clinical and surgical hospital.
Method: a cost description-type economic assessment. The institutional direct cost of the leg varicose veins treatment with foam sclerotherapy at the outpatient service, using the active principle called 0.5% polidocanol at a dose of 2 ml, was studied. The variables were human resources, disposable materials and drugs. The average cost per patient, the total cost and type of service-depending cost were all estimated.
Results: the total cost per patient was 68.60 Cuban pesos. The mean cost per patient at the classification service was 0.18 Cuban cents (SD 95% = 0.12). The average cost of the treatment service was 50.60 Cuban pesos (95% SD = 7.65). There were no significant differences between the different types of varices under treatment.
Conclusions: the institutional direct cost of the treatment of telangiectases and varicose veins by using foam sclerotherapy was comparable. In the short term, the treatment of varicose veins with this method brings lower costs than those of the surgical alternative.

Keywords: foam sclerotherapy, costs, varicose veins, telangiectases.




INTRODUCTION

Since ancient times there has been the concern of humanity for the treatment of varicose veins, resorting to various methods, from the invocation of the gods to surgery and sclerotherapy.

In fact, in the 4th century BC Lysimachid Achinae, son of Lysimachos begs Askepios to heal him of his varicose condition by offering him a marble leg with varicose veins. (Fig. 1)The varicose veins are the veins that are dilated and tortuous under the skin. The veins normally allow the flow of blood in one direction and its function is to return blood to the heart. The veins of the legs have valves inside that open to allow the passage of blood upwards and close to prevent their return. Varicose veins are formed by the inability of these valves to close properly, allowing the backflow of blood in the opposite direction.

There are currently several treatment options, which are applicable according to the individual case, such as 1: sclerotherapy, sclerotherapy with foam, intravenous laser, phlebectomy or varicectomy among others.

Varicectomy is the removal by surgical procedure of those very dilated vein knots. It is performed by minimal and punctiform wounds that do not require the use of sutures or stitches. It is an outpatient procedure, and uses local anesthesia.

Sclerotherapy is the treatment with chemical substances that are applied inside the vein, in the form of foam or in liquid form, and that allow the vein to fibrose (dry). Once the vein has been sclerosed, it is reabsorbed by the body's natural mechanisms. Finally it disappears after a few weeks and with it, pain and unpleasant appearance. Especially sclerotherapy with foam has become popular in recent years, but the idea of ​​combining air with drugs is not new. Orbach described a technique of blocking with air in 1944 and in 1993 Cabrera proposed the use of a sodium sulfate foam of tetradecyl or polidocanol for the treatment of varicose veins. In the year 2000 Tessari presented the technique using a three-step wrench with which it was possible to obtain high quality micro foam at very low cost. 2

Despite the development of foam sclerotherapy in recent years, no treatment technique is recognized as appropriate for all cases of varicose veins. Although it is recognized that sclerotherapy is a safe technique that if applied by trained personnel, the risk of side effects is minimized, there is still no complete consensus on what would be all the clinical cases in which sclerotherapy would be the treatment of choice. For example, for some specialists3 sclerotherapy is the first-line treatment for telangiectasia and is indicated for the treatment of varicose veins of short size, however regarding the treatment of large varicose veins or perforators there is no consensus regarding the place that must occupy this technique.

In this context, research continues in order to provide evidence to support the decisions, and in this regard, the importance of carrying out evaluations that not only contemplate the clinical benefits and complications but also include the assessment of costs has been insisted on. short and long term before proposing the widespread use of these new treatment options. The review carried out by Cochrane in 2004 5 confirmed that the studies carried out up to that point generally documented the clinical effects of the different varicose treatment alternatives, but the information on the cost-effectiveness ratio was not reported adequately, so it was not possible base a recommendation based on the efficiency levels achieved with each technique.

In Cuba, some local studies have been developed, especially in the population over 60 years of age, 6,7 which have reported that among the types of angiopathies that most frequently occur are varicose veins. If this element is combined with the known fact that among the first five causes of death at the national level are located vascular diseases can be expected that the demand for health services for this disease is not negligible.

For many years the technique used for the treatment of varicose veins in the country has been surgery, either saphenectomy or the reception of varicose veins by small incisions, however during the last year an experience of treatment of both telangiectasia and Trunk varicose veins with foam sclerotherapy in the outpatient department of Angiology of the "Freyre de Andrade" Hospital. So far, there is no information regarding the cost of this therapeutic alternative. Due to this and the novelty of the therapy for the country, this research was carried out with the objective of determining how much the treatment of varicose veins by the sclerotherapy foam technique is cost per patient. With this article, we intend to provide information on the cost of this treatment option in order to lay the foundations for a future cost-effectiveness study.METHODS

The investigation was carried out in the outpatient department of Angiology and Vascular Surgery of Hospital C.Q. "Freyre de Andrade" during the month of February 2008. A partial economic evaluation was carried out, of the type description of cost. The direct institutional cost of ambulatory treatment for varicose veins in the lower extremities was calculated with sclerotherapy with foam and where the active ingredient used was 0.5% Polidocanol at a dose of 2ml. The foam was obtained by hand in the consultation itself before application, from the combination of 2 ml of active principle with 6 or 8 ml of air.

The process of patient care with this technique consists of at least two main consultations:

1. Classification consultation: the anamnesis is performed, the patient is registered, the type and amount of varicose veins is evaluated, and the presence of aspects that prevent the application of the technique such as deep vein thrombosis without recanalization is examined. , Bronchial Asthma, Chronic arterial insufficiency among others. Finally, the patient receives a date for the treatment consultation.
2. Treatment consultation: the sclerotherapy protocol with foam that is carried out in this service for more than 2 years is applied. The outpatient service of Angiology and Vascular Surgery of the Hospital "Freyre de Andrade" has a fixed day a week for each consultation. For this research, the Angiology outpatient clinic was visited both days of the week during the month of February. The care process was observed for all the patients who attended during the morning. Information on age, sex and type of varicose veins was collected from each patient (telangiectasia also known as microvárice or truncal varices or macrovárice) The type of varicose was determined by the angiology specialist who works in the practice according to: the criteria If the patient were to receive treatment for both types of varices, this was not included in the study, this strategy was followed in order to guarantee the independence of the observation in relation to the type of varicose vein.

For the description of costs, only the direct institutional costs were considered. The cost was determined according to type of consultation: classification and treatment. According to the average values ​​of each of them, the average cost of general treatment of a patient with this technique was determined.

The cost of each type of consultation was the sum of the cost for human resources, material expendable and medication. The cost for human resources was calculated as the product of the time spent for each human resource directly linked to the technique for the salary received per unit of time. They identified themselves as human resources directly linked to the activity: a doctor specializing in Angiology, a graduate in nursing and a technician in nursing. The time spent in each type of consultation was obtained from the observation and direct measurement with a clock, always by the same researcher.

The cost per expendable material was calculated from the sum of the products of the quantities of each material used for the price. The expendable materials considered were: Small syringes, Large syringes, Swabs, Wrench, Adhesive tape, Needle, Dressing, Gloves and Alcohol. The quantities were recorded from the direct observation always carried out by the same researcher and the prices were taken from the product sheets of the hospital store "Freyre de Andrade". In the case of alcohol, it was impossible to achieve an accurate measurement of the amount used, which, together with the very low cost, finally determined that it was not included in the cost calculation.

The cost per medicine was calculated as the sum of the product of the dose used in each patient, the frequency of use of the dose and the price of the medicine per dose unit. The dose and frequency were observed directly from the medical practice and the price of the medication was provided by the CECMED.The cost was expressed in Cuban pesos of 2008 and the official exchange rate of the Ministry of Finance and Prices of Cuba of 1.00 Cuban peso (MN) = 1.00 Cuban convertible peso (CUC) was used.

Total cost and per patient were calculated. For the cost per patient, the mean value, the median, the minimum, the maximum and the standard deviation were calculated. The contribution of each one of the general cost variables (human resources, expendable material and medication) to the total cost was determined, which was expressed as a percentage. In a similar way, the composition of the cost for human resources and material expendable was determined from the contribution percentage of each variable used for its calculation.

In relation to the cost of the treatment consultation, the existence of differences in the mean value was explored according to the type of varicose treated (micro or macrovárice). For this, the statistical test of comparison of two means was applied and 95% confidence level was established. Previously, the compliance of the assumption of normal distribution of the cost of the treatment consultation was verified by calculating the Skewness and Kurtosis coefficients, which in a normal distribution are equal to zero. For the statistical treatment, the SPSS program was used.

In order to carry out the research, we counted on the consent of the doctors of the hospital and the Angiology consultation, as well as the informed consent of the patients who attended the consultation.



RESULTS

In the study period, 112 patients attended the consultation. The majority of patients were female (80.4%). The average age was 49.64 (SD 95% = 12.78), the minimum value was 15 years and the maximum was 80. Between 35 and 59 years, 67.07% of patients accumulated. (Table 1).

Of the 112 patients, 35 (31.25%) attended for the first time and received a classification consultation. The duration of the classification consultation was between 2 and 18 minutes, with an average value of 5.29 minutes (DS 95% = 3.64 minutes). These 35 patients represented a total cost per consultation of classification of 6.14 Cuban pesos, with an average value per patient of 0.18 cents of Cuban pesos (DS 95% = 0.12). 48.86% of the cost of the classification consultation was due to the salary expense of the specialist. (table 2).

77 patients (68.75%) attended the treatment consultation. Of these, 29 (37.66%) received treatment for telangiectasia and 48 (62.33%) for truncal varicose veins. The duration of the treatment consultation was between 5 and 20 minutes, for an average treatment duration of 10.07 minutes (DS 95% = 3.92).

The total and average cost according to the different items considered in the treatment consultation is shown in Table 3. The total cost for the 77 patients observed was 3 896.16 Cuban pesos. The average value per patient for the treatment consultation was 50.60 Cuban pesos (DS 95% = 7.65). The study did not show differences of the average cost per patient for the consultation of treatment according to the type of varice treated.

The 97.98% of the cost of the treatment consultation was due to spending on expendable materials, of which 80.93% was contributed by the variables "Small syringes" and "Large syringes". (table 4). The contribution of the salary and medication items was very low. However, the cost per drug was double the salary. The composition of cost per salary was similar to that of the classification consultation where approximately half of the cost was due to the contribution of the specialist.

Based on the average costs found for the classification and treatment consultations, the total cost per patient of sclerotherapy treatment with foam was 68.60 Cuban pesos.



DISCUSSIONCosts studies for vascular diseases are scarce worldwide, however it has been reported that the treatment of these conditions is accompanied by high costs for health systems 8 hence being able to provide elements that allow a rational decision regarding What alternative treatment to use for each patient will always be well received by the health authorities. For Cuba, the results provided in this research constitute an approach to the economic benefits that could be expected as a consequence of the use of sclerotherapy with foam for the treatment of varicose veins.

It should be noted that the composition of the cost found in this research differs from that reported for other health technologies and / or services, 9,10,11 where human resources tend to be the item with the greatest contribution to costs. This echo indicates a niche of possible increase in the efficiency of this therapeutic alternative if it is considered that most of the expendable material that was used in this treatment is imported. The implementation of future commercial or import substitution strategies aimed at reducing the purchase price of these materials would result in a considerable reduction in the cost of the procedure, which would favor the efficiency of the same.

The results found also indicate the possibility of a more rational use of health services in particular in the treatment of patients with truncal varices, which, until now, are mostly treated by surgical intervention. A team from the General Teaching Hospital Dr. Enrique Cabrera of Havana City 12 reported in 2002 that the cost for surgical intervention was between 568.26 pesos and 210.02 pesos depending on the procedure followed: traditional or by CHIVAS; hence, the introduction of sclerotherapy with foam for patients who were traditionally treated through surgery represents the possibility of reducing direct institutional costs per patient from 3 to 8 times.

The finding of a decrease in costs with foam sclerotherapy with respect to surgical options coincides with that reported by other authors in other countries. 3,13,14,15 Although the element "minor costs" has contributed to presenting sclerotherapy as an attractive option, especially when compared with the invasive or minimally invasive options traditionally used for the treatment of this type of patient, 16,17 It should be mentioned that this result is valid in the short term because the horizon of the studies carried out so far has been limited to the moment of discharge of the patient. Regarding the economic effect in the medium and long term some authors report that although sclerotherapy shows lower costs, the benefits are only superior to those of surgery during the first years.5,18,19

However, the results of this study allow us to visualize situations where it seems reasonable to apply sclerotherapy as the first option. If it is considered that 15.17% of the patients who attended the consultation were older than 65 years and that the life expectancy at birth in Cuba is 75 years, one could think of sclerotherapy with foam as an alternative of preference for the treatment of varicose veins in this age group. These patients would gain the advantages of an ambulatory technique with few adverse effects and with the possibility of an early recovery while guaranteeing the greatest benefits in terms of the relationship between the average survival time and the loss of benefits reported in the long term. .

The present study paves the way for later studies where the cost information is completed with the one regarding benefits and effectiveness for different age groups and types of varicose veins; After that we will be in a better position to recommend with greater evidence the conditions where the application of sclerotherapy should be considered as the treatment of choice.

In conclusion, it can be said that the direct institutional cost of treatment of telangiectasias and truncal varicose veins with foam sclerotherapy was similar. In the short term, the treatment of varicose veins with sclerotherapy with foam generates lower costs than the surgical option.



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