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Introducing a technology in one of the largest healthcare systems in the world

Mariana Borges Dias, MD

Image credit: Courtesy of Mariana Borges Dias

The Brazilian Unified Health System (SUS) is one of the largest public healthcare systems in the world, covering more than 207 million citizens and with a well-defined process to evaluate medical technologies for Reimbursement based on their clinical benefits and economic impact.

We spoke with Mariana Borges Dias, MD who is responsible for the General Coordination of Home Care (CGAD) within the Brazilian Ministry of Health, to talk about the importance of the incorporation by the SUS of Invasive Home Mechanical Ventilation (IHMV) in cases of chronic respiratory insufficiency. Dr. Mariana highlights the benefits to patients and public healthcare in Brazil.

Can you tell us about your background and how you joined the General Coordination of Home Care (CGAD) of the Brazilian Ministry of Health?

Thirty years ago, I graduated from the Medical Sciences School of Minas Gerais, Brazil. I then had my Residence in Medicine and Specialization in Evidence-based Health Policy Management. I have always worked in the SUS in all areas of care delivery: primary care, specialized care, urgencies, and hospital management. The experience I acquired since 1997 with the integral care of the patients who need home care led to an invitation to join the General Coordination of Home Care (CGAD) of the Ministry of Health in 2011; and in 2014, I was appointed as Coordinator there.

What is your responsibility within the CGAD?

At CGAD, I coordinate the team that analyzes all requests from municipalities and states to join the Best at Home program, a service provided and funded by the Brazilian Ministry of Health for people who have temporary or permanent difficulties to leave their homes to reach a health unit, or for people who are in situations where home care is the most appropriate for their treatment.

The team and I support the Best at Home program implementation and development throughout the country. This means the elaboration and dissemination of several instruments for the continued education of the teams, support to municipalities and states in the implementation, diffusion, understanding and operationalization of the program, as well as its monitoring and evaluation.

How has the Best at Home program worked and what are the benefits of home care?

Currently, the Best at Home Program delivers care services for 35,000 to 40,000 patients every month, with its 1,048 teams in 390 municipalities of various sizes in all parts of Brazil. Although our teams are structured the same way as those working in another initiative from the Ministry of Health (Family Health program) with doctors, nurses, physiotherapists, social workers, nursing technicians and others, we are unique in the sense that we work exclusively in-home care, 7 days a week. In all, we have 56 million citizens as patients within our scope.

Home care provides services that are closer to the patients’ families and routines, preventing unnecessary hospitalizations and reducing the risk of infections, besides leaving patients in the comfort of their homes. In addition, the program represents a development for the management of the entire public health system, as it helps to release hospital beds and provides a continuity of treatment initiated in the emergency services and hospitals with safety and quality.

What are the main challenges for Invasive Home Mechanical Ventilation (IHMV) in Brazil?

Mechanical ventilation is indicated when there is dependence on ventilatory assistance by people who cannot breathe spontaneously due to neuromuscular diseases, trauma, and other injuries. It is said to be invasive when it is done with the use of devices that are connected to patients at the site of the tracheostomy (an artificial orifice surgically created in the trachea to allow for the passage of airflow). Home use requires the setting up of a minimum care structure and the follow-up with health teams, family and trained caregivers, as well as an assured background of emergency services and hospitals.

To date, only non-invasive home mechanical ventilation is included in the current legislation and public Reimbursement structure. However, for almost 20 years, SUS teams have been performing invasive home mechanical ventilation, mostly because of legal court orders. These teams showed us that with responsibility, good organization of care, and adequate background structure for complications, the IHMV is perfectly viable within the SUS. Thus, the main challenge is to disseminate the treatment in an orderly, safe, and supported manner considering our large, complex, and diverse national territory.

Are there any international data on IHMV? How is the topic viewed internationally?

The largest worldwide study on mechanical ventilation shows that every 6.6 out of 100,000 people use mechanical ventilation, whether invasive or not. The studies also point out that this number should grow exponentially until 2021, especially in the noninvasive modality (as in sleep apnea, for example). In March of this year, we participated in the 15th International Conference of Home Mechanical Ventilation in Lyon, France, presenting the results of the evaluations and the progress made in the execution of our project to implement IHMV in the SUS. Throughout the world, there are several forms of care for people who need mechanical ventilation at home, and in general, they do not have health professionals available 24 hours for patients. In Brazil, this is one of the main discussions among private home care companies, which, unlike SUS, at least have the 24-hour nursing duty as a rule for these types of patients.

How did the project for the inclusion of IHMV within the SUS get started, and what was your role in it?

As already mentioned, since the beginning of the 2000s some teams (from SUS included) have been working with IHMV in Brazil, although in other formats. In August 2011, the Best at Home Program was created, aiming to be a qualified exit door for hospitals and emergency rooms. Since then, CGAD has been structuring a way to include within home care programs for patients with several types of needs such as those with complex chronic diseases, including users of mechanical ventilation. This was corroborated by the frequent, mainly judicial demand of patients with chronic respiratory insufficiency who require invasive mechanical ventilation at home. My role, together with my team, was to elaborate a project to highlight the needs, propose strategies, and make this technology inclusion feasible within the SUS.

How was the development of the project: people involved, construction of the report and analyses, presentation at CONITEC, etc.?

In order to include this technology in the SUS and provide support for the IHMV to be carried out safely, it took two years of studies and actions, which included research in home care services with experience in IHMV and the elaboration of a dossier containing scientific/technical evidence, observational field study reports, and economic evaluations. This dossier was commissioned from the German Hospital Oswaldo Cruz, which through the Proadi-SUS and in partnership with the CGAD contracted ValueConnected for its experience in elaborating the required technical and economic analyses that were eventually sent to the National Commission for the Incorporation of Technologies at SUS (CONITEC). After the formal public consultation period, the final CONITEC appraisal that came out in January this year was favorable to the incorporation, considering the proposal was submitted to the Tripartite Interagency Committee (CIT) to evaluate details of its financing methods by the SUS.

In addition to the production of the dossier and submission to CONITEC, the project also included the holding of an International Seminar on the theme, training of more than 400 professionals related to the Best at Home, and the preparation of a manual of recommendations for the implementation of mechanical home ventilation by home care teams.

What is the impact of this approval and how can this benefit patients who use invasive mechanical ventilation?

This approval will represent a major development in the history of SUS, favoring the dehospitalization of chronic patients in mechanical ventilation, many of them living in hospital ICUs for several years and who could be living with their families. In addition to the reduction of hospitalization (i.e., a chronic dehospitalized ICU patient on average releases resources to treat 53 other new patients per year in the same ICU), a major financial impact was demonstrated with the analyses. The costs of a hospital patient are 11 times the costs of the same patient treated at home. Hence, considering that half of all patients in the hospital due to mechanical ventilation in 2017 would go home, there would be a reduction of expenses with this procedure of around BRL 1.8 billion per year (approximately EUR 408 million), with a scenario of a total savings of BRL 9 billion (approximately EUR 2 billion) by 2021. In addition, home treatment allows for much higher quality of life and dignity for patients, in combination with family satisfaction as demonstrated by the survey results from our field research.

Can you comment on your experience working with ValueConnected and the next steps with IHMV in Brazil?

The experience was extremely positive for all involved. It was an initiative that required determination, patience, and a lot of alignment. It was a huge challenge, especially since it is such a complex issue that can change the lives of thousands of people. Without the experience of ValueConnected in the Value dossier preparation, we would not have been able to obtain CONITEC Health Technology Assessment approval. We are now awaiting the final step, and that is the approval by the Tripartite Interagency Committee (CIT), which is still to be scheduled.

Interview conducted by Heliana Nogueira