Value can be defined as a cost-to-result ratio. Better results, better delivery of certain
processes, or lower costs translate to higher value. This concept has currently been used
with propriety in health care as well, reinforcing the idea that it is necessary to obtain
the best possible results, such as survival, functional independence, and satisfaction, at
the lowest possible cost. This takes on added importance when we remember that health care
resources, whether funds, personnel, or equipment, are finite, and doing more with less is
crucial to provide care to all who need. Let us then imagine the value, for a mechanically
ventilated patient, of adequate analgesia, of a protective ventilatory strategy, of a
weaning protocol, of elevation of the head of the bed, of personnel hand-washing-all of
which are interventions that produce excellent results and are quite inexpensive. The
Brazilian recommendations for mechanical ventilation, the main objective of which is to add
value to mechanical ventilation, were published in two parts, because of their length and
scope, by two Brazilian journals: the Brazilian Journal of Pulmonology(
11. Brazilian recommendations of mechanical ventilation 2013. Part I. J
Bras Pneumol. 2014;40(4):327-63.
http://dx.doi.org/10.1590/S1806-37132014000400002
https://doi.org/10.1590/S1806-3713201400...
,
22. Brazilian recommendations of mechanical ventilation 2013. Part 2. J
Bras Pneumol. 2014;40(5):458-486.
) and the Brazilian Journal of Intensive Care Medicine.(
33. Barbas CS, Isola AM, Farias AM, Cavalcanti AB, Gama AM, Duarte AC, et
al. Brazilian recommendations of mechanical ventilation 2013. Part I. Rev Bras Ter
Intensiva. 2014;26(2):89-121.
http://dx.doi.org/10.5935/0103-507X.20140017
https://doi.org/10.5935/0103-507X.201400...
,
44. Brazilian recommendations of mechanical ventilation 2013. Part 2. Rev
Bras Ter Intensiva. 2014;26(3):215-39.
)
Respiratory failure is a common disease, and, in potentially reversible cases, ventilatory
support is life-saving. Extrapolating epidemiological data from the United
States(
55. Wunsh H, Linde-Zwirbe WT, Angus DC, Hartman ME, Milbrandt EB, Kahn
JM. The epidemiology of mechanical ventilation use in the United States. Crit Care
Med. 2010;38(10):1947-53.
)-2.8 mechanically ventilated patients per 1,000 population/year-to Brazil
(current population of 203,175,000 inhabitants, according to the Brazilian Institute of
Geography and Statistics),(
66. Instituto Brasileiro de Geografia e Estatística - IBGE [homepage on
the Internet]. Brasília: Instituto Brasileiro de Geografia e Estatística [updated
2014; cited 2014 Sep 30]. Projeção da população do Brasil e das Unidades da
Federação. Available from:
http://www.ibge.gov.br/apps/populacao/projecao/
http://www.ibge.gov.br/apps/populacao/pr...
) we can estimate that approximately 570,000 patients require invasive
ventilatory support every year. Assuming a mean duration of mechanical ventilation of three
days, we reach a figure of 1,706,670 ventilator days, and, on the basis of information from
the 2011 Census by the Brazilian Association of Intensive Care Medicine,(
77. Associação de Medicina Intensiva Brasileira - AMIB [homepage on the
Internet]. São Paulo: AMIB [c2012; cited 2014 Sep 30]. Relatório de Unidades de
Terapia Intensiva. Available from:
http://www.amib.org.br/index.php?id=631
http://www.amib.org.br/index.php?id=631...
) which calculated that there are approximately 25,000 ICU beds in Brazil, we
can estimate that, every day, 19% of the ICU beds are used by intubated patients. In
addition, the aforementioned data from the United States,(
55. Wunsh H, Linde-Zwirbe WT, Angus DC, Hartman ME, Milbrandt EB, Kahn
JM. The epidemiology of mechanical ventilation use in the United States. Crit Care
Med. 2010;38(10):1947-53.
) according to which the cost of hospitalization for patients with respiratory
failure and requiring mechanical ventilation is estimated to be US$34,000, allow us to
extrapolate that Brazil will spend nearly R$54.5 billion/year, considering 12% of
healthcare expenditures(
88. Organização Pan-Americana de Saúde. Organização Mundial da Saúde.
[homepage on the Internet]. Washington, DC: a Organização [cited 2014 Sep 30].
Available from: http://www.paho.org/hq/
http://www.paho.org/hq/...
) and 1.1% of the gross domestic product,99. Instituto Brasileiro de Geografia e Estatística - IBGE [homepage on
the Internet]. Brasília: Instituto Brasileiro de Geografia e Estatística [updated
2014; cited 2014 Sep 30]. Contas Nacionais Trimestrais. Available from:
http://www.ibge.gov.br/home/estatistica/indicadores/pib/defaultcnt.shtm
http://www.ibge.gov.br/home/estatistica/...
) on hospital treatment of patients with acute respiratory failure or acute
exacerbation of chronic respiratory failure.
The figures presented above, bearing in mind that they are the result of a simple
epidemiological, mathematical, and financial exercise, draw attention to the huge impact
that respiratory failure and mechanical ventilation have on heath policy in Brazil.
However, it is important to remember that ventilatory support is known to be a
cost-effective treatment for most patients. Studies published in recent years have shown
figures ranging from US$26,000 to US$175,000 per quality-adjusted life year (QALY),
depending on the etiology of respiratory failure, comorbidities, and patient
age.(
1010. Cooke CR. Economics of mechanical ventilation and respiratory
failure. Crit Care Clin. 2012;28(1):39-55.
http://dx.doi.org/10.1016/j.ccc.2011.10.004
https://doi.org/10.1016/j.ccc.2011.10.00...
) Although arbitrary, it is current practice to accept treatments resulting in
US$50,000-150,000/QALY as cost-effective.(
1111. Neumann PJ, Cohen JT, Weinstein MC. Updating cost-effectiveness--the
curious resilience of $50,000-per-QALY threshold. N Engl J Med. 2014;371(9):796-7.
http://dx.doi.org/10.1056/NEJMp1405158
https://doi.org/10.1056/NEJMp1405158...
)
The published recommendations(
11. Brazilian recommendations of mechanical ventilation 2013. Part I. J
Bras Pneumol. 2014;40(4):327-63.
http://dx.doi.org/10.1590/S1806-37132014000400002
https://doi.org/10.1590/S1806-3713201400...
2. Brazilian recommendations of mechanical ventilation 2013. Part 2. J
Bras Pneumol. 2014;40(5):458-486.
3. Barbas CS, Isola AM, Farias AM, Cavalcanti AB, Gama AM, Duarte AC, et
al. Brazilian recommendations of mechanical ventilation 2013. Part I. Rev Bras Ter
Intensiva. 2014;26(2):89-121.
http://dx.doi.org/10.5935/0103-507X.20140017
https://doi.org/10.5935/0103-507X.201400...
-
44. Brazilian recommendations of mechanical ventilation 2013. Part 2. Rev
Bras Ter Intensiva. 2014;26(3):215-39.
) state that the results of treatment of patients with acute respiratory failure
have improved greatly in recent decades, and what is most interesting is that this advance
is more attributable to a better understanding of the pathophysiology of respiratory
failure and to the prevention of ventilator-associated complications than to the
development of new drugs or technologies. Mechanical ventilators, in their basic essence,
have changed very little over this period, but the way they are used has changed
completely, evolving from an aggressive strategy to correct hypoxemia and/or hypercapnia to
a strategy focused on delivering a minimum alveolar ventilation to ensure gas exchange,
sparing the lungs from further injury and thereby providing the time needed for lung
recovery. Brazil has played a decisive role in the development of these modern concepts of
mechanical ventilation, particularly in the understanding of the pathophysiology of ARDS
and in being a pioneer in demonstrating the benefits of using protective ventilatory
strategies. (
1212. Azevedo LC, Park M, Salluh JI, Rea-Neto A, Souza-Dantas VC,
Varaschin P, et al. Clinical outcomes of patients requiring ventilatory support in
Brazilian intensive care units: a multicenter, prospective, cohort study. Crit Care.
2013;17(2):R63. http://dx.doi.org/10.1186/cc12594
https://doi.org/10.1186/cc12594...
,
1313. Amato MB, Barbas CS, Medeiros DM, Magaldi RB, Schettino GP,
Lorenzi-Filho G, et al. Effect of a protective-ventilation strategy on mortality in
the acute respiratory distress syndrome. N Engl J Med. 1998;338(6):347-54.
http://dx.doi.org/10.1056/NEJM199802053380602
https://doi.org/10.1056/NEJM199802053380...
) Nevertheless, recent data have shown that the mortality rate of mechanically
ventilated patients in Brazil remains high when compared with those found in developed
countries.(
1414. Serpa Neto A, Cardoso SO, Manetta JA, Pereira VG, Espósito DC,
Pasqualucci Mde O, et al. Association between use of lung-protective ventilation with
lower tidal volumes and clinical outcomes among patients without acute respiratory
distress syndrome: a meta-analysis. JAMA. 2012;308(16):1651-9.
http://dx.doi.org/10.1001/jama.2012.13730
https://doi.org/10.1001/jama.2012.13730...
) Limited access to ICU beds, the unsatisfactory number and poor training of
health professionals assigned to the care of patients with respiratory failure, obsolete
equipment, and, especially, the lack of adherence to best care practices are factors that
certainly contribute to this worrisome finding.
The 2013 Brazilian recommendations for mechanical ventilation(
11. Brazilian recommendations of mechanical ventilation 2013. Part I. J
Bras Pneumol. 2014;40(4):327-63.
http://dx.doi.org/10.1590/S1806-37132014000400002
https://doi.org/10.1590/S1806-3713201400...
2. Brazilian recommendations of mechanical ventilation 2013. Part 2. J
Bras Pneumol. 2014;40(5):458-486.
3. Barbas CS, Isola AM, Farias AM, Cavalcanti AB, Gama AM, Duarte AC, et
al. Brazilian recommendations of mechanical ventilation 2013. Part I. Rev Bras Ter
Intensiva. 2014;26(2):89-121.
http://dx.doi.org/10.5935/0103-507X.20140017
https://doi.org/10.5935/0103-507X.201400...
-
44. Brazilian recommendations of mechanical ventilation 2013. Part 2. Rev
Bras Ter Intensiva. 2014;26(3):215-39.
) are an important initiative. Having been made by competent and experienced
professionals, they represent the state of the art in mechanical ventilation, presented in
a clear and objective manner and with a view toward adjustment to the way critical care
medicine is practiced in Brazil.
Despite acknowledging all of the individual and collective efforts by the authors and
coordinators of that work, we need to be aware that this is the easiest step in the quest
for better care for mechanically ventilated patients; the hard part, the great challenge,
not only here but worldwide, is to transform recommendations and good intentions into value
for patients.(
1515. Grol R, Grimshaw J. From best evidence to best practice: effective
implementation of change in patients' care. Lancet. 2003;362(9391):1225-30.
http://dx.doi.org/10.1016/S0140-6736(03)14546-1
https://doi.org/10.1016/S0140-6736(03)14...
) I emphasize that most of those recommendations do not require new technologies
or greater financial resources and are, for the most part, intuitive and already known by
professionals working in ICUs in Brazil. We have another complicating factor: how to
implement them in a country such as Brazil-a heterogeneous country of continental
dimensions, where we are creative but have little discipline to follow recommendations,
there is a lack of qualified professionals, there is no culture of training and continuing
professional education for health professionals, and there is little measurement of the
actual quality of care delivered by public or private health care institutions.
The authors of those recommendations(
11. Brazilian recommendations of mechanical ventilation 2013. Part I. J
Bras Pneumol. 2014;40(4):327-63.
http://dx.doi.org/10.1590/S1806-37132014000400002
https://doi.org/10.1590/S1806-3713201400...
2. Brazilian recommendations of mechanical ventilation 2013. Part 2. J
Bras Pneumol. 2014;40(5):458-486.
3. Barbas CS, Isola AM, Farias AM, Cavalcanti AB, Gama AM, Duarte AC, et
al. Brazilian recommendations of mechanical ventilation 2013. Part I. Rev Bras Ter
Intensiva. 2014;26(2):89-121.
http://dx.doi.org/10.5935/0103-507X.20140017
https://doi.org/10.5935/0103-507X.201400...
-
44. Brazilian recommendations of mechanical ventilation 2013. Part 2. Rev
Bras Ter Intensiva. 2014;26(3):215-39.
) have done their part, and we have another excellent guide toward delivering
higher-quality, safer, and higher-value mechanical ventilation to patients with respiratory
failure. The content and the rationale are laid out; now it is time to transform the
evidence and recommendations into practice, and this will only happen with work,
discipline, and involvement from each of us. Let us get to work!
References
-
1Brazilian recommendations of mechanical ventilation 2013. Part I. J Bras Pneumol. 2014;40(4):327-63. http://dx.doi.org/10.1590/S1806-37132014000400002
» https://doi.org/10.1590/S1806-37132014000400002 -
2Brazilian recommendations of mechanical ventilation 2013. Part 2. J Bras Pneumol. 2014;40(5):458-486.
-
3Barbas CS, Isola AM, Farias AM, Cavalcanti AB, Gama AM, Duarte AC, et al. Brazilian recommendations of mechanical ventilation 2013. Part I. Rev Bras Ter Intensiva. 2014;26(2):89-121. http://dx.doi.org/10.5935/0103-507X.20140017
» https://doi.org/10.5935/0103-507X.20140017 -
4Brazilian recommendations of mechanical ventilation 2013. Part 2. Rev Bras Ter Intensiva. 2014;26(3):215-39.
-
5Wunsh H, Linde-Zwirbe WT, Angus DC, Hartman ME, Milbrandt EB, Kahn JM. The epidemiology of mechanical ventilation use in the United States. Crit Care Med. 2010;38(10):1947-53.
-
6Instituto Brasileiro de Geografia e Estatística - IBGE [homepage on the Internet]. Brasília: Instituto Brasileiro de Geografia e Estatística [updated 2014; cited 2014 Sep 30]. Projeção da população do Brasil e das Unidades da Federação. Available from: http://www.ibge.gov.br/apps/populacao/projecao/
» http://www.ibge.gov.br/apps/populacao/projecao/ -
7Associação de Medicina Intensiva Brasileira - AMIB [homepage on the Internet]. São Paulo: AMIB [c2012; cited 2014 Sep 30]. Relatório de Unidades de Terapia Intensiva. Available from: http://www.amib.org.br/index.php?id=631
» http://www.amib.org.br/index.php?id=631 -
8Organização Pan-Americana de Saúde. Organização Mundial da Saúde. [homepage on the Internet]. Washington, DC: a Organização [cited 2014 Sep 30]. Available from: http://www.paho.org/hq/
» http://www.paho.org/hq/ -
9Instituto Brasileiro de Geografia e Estatística - IBGE [homepage on the Internet]. Brasília: Instituto Brasileiro de Geografia e Estatística [updated 2014; cited 2014 Sep 30]. Contas Nacionais Trimestrais. Available from: http://www.ibge.gov.br/home/estatistica/indicadores/pib/defaultcnt.shtm
» http://www.ibge.gov.br/home/estatistica/indicadores/pib/defaultcnt.shtm -
10Cooke CR. Economics of mechanical ventilation and respiratory failure. Crit Care Clin. 2012;28(1):39-55. http://dx.doi.org/10.1016/j.ccc.2011.10.004
» https://doi.org/10.1016/j.ccc.2011.10.004 -
11Neumann PJ, Cohen JT, Weinstein MC. Updating cost-effectiveness--the curious resilience of $50,000-per-QALY threshold. N Engl J Med. 2014;371(9):796-7. http://dx.doi.org/10.1056/NEJMp1405158
» https://doi.org/10.1056/NEJMp1405158 -
12Azevedo LC, Park M, Salluh JI, Rea-Neto A, Souza-Dantas VC, Varaschin P, et al. Clinical outcomes of patients requiring ventilatory support in Brazilian intensive care units: a multicenter, prospective, cohort study. Crit Care. 2013;17(2):R63. http://dx.doi.org/10.1186/cc12594
» https://doi.org/10.1186/cc12594 -
13Amato MB, Barbas CS, Medeiros DM, Magaldi RB, Schettino GP, Lorenzi-Filho G, et al. Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome. N Engl J Med. 1998;338(6):347-54. http://dx.doi.org/10.1056/NEJM199802053380602
» https://doi.org/10.1056/NEJM199802053380602 -
14Serpa Neto A, Cardoso SO, Manetta JA, Pereira VG, Espósito DC, Pasqualucci Mde O, et al. Association between use of lung-protective ventilation with lower tidal volumes and clinical outcomes among patients without acute respiratory distress syndrome: a meta-analysis. JAMA. 2012;308(16):1651-9. http://dx.doi.org/10.1001/jama.2012.13730
» https://doi.org/10.1001/jama.2012.13730 -
15Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients' care. Lancet. 2003;362(9391):1225-30. http://dx.doi.org/10.1016/S0140-6736(03)14546-1
» https://doi.org/10.1016/S0140-6736(03)14546-1
Publication Dates
-
Publication in this collection
Sep-Oct 2014