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Gestão da síncope numa unidade de saúde privada: avaliação das práticas clínicas e do impacto económico
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RESUMO - Introdução: A síncope representa um motivo frequente de admissão no serviço de urgência (SU), com prática clínica heterogénea e impacto económico substancial. Em Portugal, a investigação de custos com dados reais permanece incipiente. Tanto quanto é do nosso conhecimento, até à data não foram publicados estudos no setor privado. Definiu-se como objetivo principal deste estudo quantificar os custos hospitalares diretos por doente associados à avaliação da síncope e, adicionalmente, caracterizar o padrão de consumo de recursos, determinar a estrutura de custos por trajetória de cuidados e por componente funcional, identificar determinantes do custo total por doente e estimar a poupança potencial no SU decorrente da adesão às diretrizes da European Society of Cardiology de 2018 para a síncope.
Métodos: Estudo observacional, de coorte retrospetivo, conduzido numa instituição hospitalar privada de Lisboa, Portugal, entre 01/01 e 31/12/2023, incluindo doentes pediátricos (<18 anos) e adultos (≥18 anos) com diagnóstico principal de síncope no SU (CID-9-CM 780.2/992.1). Os custos diretos foram apurados por micro-custeio (abordagem bottom-up) na perspetiva hospitalar (ano-base 2023), com análise ao nível do doente. O custo total por doente foi modelado por modelo linear generalizado em função da idade, sexo, etiologia e número total de comorbilidades. A poupança no SU foi estimada por simulação contrafactual independente por dois médicos especialistas.
Resultados: Analisaram-se 375 doentes (idade média de 49,4 ± 26,5 anos; distribuição etária bimodal aos 15 e 80 anos; 60,3% do sexo feminino). A etiologia foi definida em 41,1% da coorte, com predomínio de síncope reflexa (32,3%), permanecendo 58,1% como síncope inexplicada. O custo total agregado foi de 661 992,74€ e o custo médio de 1 765,31 ± 4 995,96€ por doente. Na desagregação, os exames complementares de diagnóstico (ECD) representaram 63,3% do custo total. Na análise multivariável, idade ≥80 anos, sexo masculino e etiologia cardíaca associaram-se a custos hospitalares significativamente superiores. Cada comorbilidade adicional associou-se a um aumento médio de aproximadamente 15%, estatisticamente significativo. A poupança potencial no SU foi de 80 228,28€, correspondendo a uma média de 213,94 ± 411,09€ por doente.
Conclusões: A síncope representa um encargo económico hospitalar expressivo, num contexto de gestão heterogénea. A padronização de processos clínicos, alinhada com as diretrizes internacionais, poderá sustentar uma utilização mais parcimoniosa de ECD e melhorar a eficiência na alocação dos recursos.
ABSTRACT - Introduction: Syncope is a common reason for emergency department (ED) visits, characterized by heterogeneous clinical practice and a substantial economic impact. In Portugal, research on costs using real-world data remains limited. To the best of our knowledge, no studies have been published to date in the private sector. The primary objective of this study was to quantify direct hospital costs per patient associated with the evaluation of syncope. Additionally, we aimed to characterize the pattern of resource utilization, determine the cost structure by care pathway and functional component, identify determinants of total per-patient cost, and estimate potential ED savings resulting from adherence to the 2018 European Society of Cardiology syncope guidelines. Methods: We conducted an observational, retrospective cohort study at a private hospital in Lisbon, Portugal, from 01/01 through 12/31/2023, including pediatric (<18 years) and adult (≥18 years) patients with a principal ED diagnosis of syncope (ICD-9-CM 780.2/992.1). Direct costs were assessed by micro-costing (bottom-up approach) from the hospital perspective (base year 2023), with patient-level analysis. Total per-patient cost was modeled using a generalized linear model as a function of age, sex, etiology, and total number of comorbidities. ED savings were estimated via counterfactual simulation independently by two specialist physicians. Results: We analyzed 375 patients (mean age 49.4 ± 26.5 years; bimodal age distribution peaking at 15 and 80 years; 60.3% female). Etiology was defined in 41.1% of the cohort, with reflex syncope predominating (32.3%); 58.1% remained unexplained syncope. Aggregate total cost was €661,992.74, and mean cost was €1,765.31 ± €4,995.96 per patient. In the cost breakdown, diagnostic testing accounted for 63.3% of total cost. In multivariable analysis, age ≥80 years, male sex, and cardiac etiology were associated with significantly higher hospital costs. Each additional comorbidity was associated with an average increase of approximately 15%, statistically significant. Potential ED savings were €80,228.28, corresponding to a mean of €213.94 ± €411.09 per patient. Conclusions: Syncope represents a significant hospital economic burden in a context of heterogeneous management. Standardization of clinical processes, aligned with international guidelines, may support a more parsimonious use of diagnostic tests and improve the efficiency of resource allocation.
ABSTRACT - Introduction: Syncope is a common reason for emergency department (ED) visits, characterized by heterogeneous clinical practice and a substantial economic impact. In Portugal, research on costs using real-world data remains limited. To the best of our knowledge, no studies have been published to date in the private sector. The primary objective of this study was to quantify direct hospital costs per patient associated with the evaluation of syncope. Additionally, we aimed to characterize the pattern of resource utilization, determine the cost structure by care pathway and functional component, identify determinants of total per-patient cost, and estimate potential ED savings resulting from adherence to the 2018 European Society of Cardiology syncope guidelines. Methods: We conducted an observational, retrospective cohort study at a private hospital in Lisbon, Portugal, from 01/01 through 12/31/2023, including pediatric (<18 years) and adult (≥18 years) patients with a principal ED diagnosis of syncope (ICD-9-CM 780.2/992.1). Direct costs were assessed by micro-costing (bottom-up approach) from the hospital perspective (base year 2023), with patient-level analysis. Total per-patient cost was modeled using a generalized linear model as a function of age, sex, etiology, and total number of comorbidities. ED savings were estimated via counterfactual simulation independently by two specialist physicians. Results: We analyzed 375 patients (mean age 49.4 ± 26.5 years; bimodal age distribution peaking at 15 and 80 years; 60.3% female). Etiology was defined in 41.1% of the cohort, with reflex syncope predominating (32.3%); 58.1% remained unexplained syncope. Aggregate total cost was €661,992.74, and mean cost was €1,765.31 ± €4,995.96 per patient. In the cost breakdown, diagnostic testing accounted for 63.3% of total cost. In multivariable analysis, age ≥80 years, male sex, and cardiac etiology were associated with significantly higher hospital costs. Each additional comorbidity was associated with an average increase of approximately 15%, statistically significant. Potential ED savings were €80,228.28, corresponding to a mean of €213.94 ± €411.09 per patient. Conclusions: Syncope represents a significant hospital economic burden in a context of heterogeneous management. Standardization of clinical processes, aligned with international guidelines, may support a more parsimonious use of diagnostic tests and improve the efficiency of resource allocation.
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Síncope Custos e Análise de Custo Fidelidade a Diretrizes Serviço Hospitalar de Emergência Hospitais Privados Syncope Costs and Cost Analysis Guideline Adherence Hospital Emergency Service Private Hospitals