COST SURVEY OF PROCEDURE W I TH UNNA BOOT I N PATI ENTS W I TH VENOUS ULCER
1Cleide Mar ia Caet ano Bapt ist a2
Valér ia Cast ilh o3
Bapt ist a CMC, Cast ilho V. Cost sur vey of pr ocedur e w it h Unna boot in pat ient s w it h venous ulcer. Rev Lat ino- am En f er m agem 2 0 0 6 n ov em br o- dezem br o; 1 4 ( 6 ) : 9 4 4 - 9 .
Aim s w as t o iden t if y t h e social- dem ogr aph ic ch ar act er ist ics an d t h e lesion s of pat ien t s w it h v en ou s
ulcer ( VU) , as w ell as t o est im at e t he t ot al dir ect cost of m at er ials and nur sing per sonnel necessar y for t he
pr ocedur e w it h unna boot , by t he aver age t ot al dir ect cost ( ATDC) and t he obser ved cost ( OTDC) . The t heor et ical
r ef er en t ial adopt ed f or cost calcu lat ion w as t h e cost in g sy st em by absor pt ion of pr ocedu r e or pr odu ct . Th is
st u dy w as con du ct ed at t h e Un iv er sit y Hospit al of Sao Pau lo Un iv er sit y ( HU) Am bu lat or y . Th e sam ple w as
const it ut ed by 65 pr ocedur es in nine pat ient s w it h VU. The r esult s show t hat t he pr edom inant age gr oups w er e
4 9 t o 5 6 y ear s ( 3 3 , 3 3 % ) and 6 5 t o 7 2 y ear s ( 3 3 , 3 3 % ) , in fem ale pat ient s ( 7 7 , 7 8 % ) . Regar ding associat ed
diseases, t her e w as a pr edom inance of Syst em ic Ar t er ial Hyper t ension ( 33,33% ) and Diabet es Mellit us ( 22,22% ) .
The ATDC w as R$ 107,99 and t he OTDC w as R$ 96,47.
DESCRI PTORS: occlusiv e dr essings; v ar icose ulcer ; cost s and cost analy sis
LEVANTAMENTO DEL COSTO DEL PROCEDI MI ENTO COM BOTA
DE UN N A EN PACI EN TES COM ÚLCERA VEN OSA ( UV)
El obj et ivo fue ident ificar caract eríst icas sócio- dem ográficas y de las lesiones de los pacient es con úlcera
v enosa ( UV) , y calcular el cost o t ot al dir ect o de los m at er iales y de per sonal de enfer m er ía ut ilizados en del
procedim ient o con bot a de unna, por el cost o t ot al direct o m edio ( CTDM) y por lo observado ( CTDO) . El referencial
t eór ico adopt ado par a la m edición de los cost os fue el sist em a de cost eo por absor ción por pr ocedim ient o o
pr oduct o. El est udio fue r ealizado en el Consult or io Ex t er no el Hospit al Univ er sit ar io de la Univ er sidad de Sao
Paulo ( HUUSP) . La m uest r a fue const it uida por 65 pr ocedim ient os en nuev e pacient es con UV. Los r esult ados
m uest ran que la faj a et ária predom inant e fue 49 a 56 años ( 33,33% ) y de 65 a 72 años ( 33,33% ) y del sexo
fem enino ( 77, 78% ) . Cuant o a la enfer m edad asociada, hubo pr edom inio de Hiper t ensión Ar t er ial Sist em át ica
( 33,33% ) y Diabet es Mellit us ( 22,22% ) . El CTDM fue de R$ 107,99 y el CTDO fue de R$ 96,47.
DESCRI PTORES: apósit os oclusiv os; úlcer a v ar icose; cost os y análisis de cost o
LEVANTAMENTO DO CUSTO DO PROCEDI MENTO COM BOTA
DE UN N A EM PACI EN TES COM ÚLCERA VEN OSA
O ob j et iv o f oi id en t if icar car act er íst icas sociod em og r áf icas e d as lesões d os p acien t es com ú lcer a
venosa ( UV) e calcular o cust o t ot al dir et o dos m at er iais e de pessoal de enfer m agem ut ilizados no pr ocedim ent o
com b ot a d e Un n a, p elo cu st o t ot al d ir et o m éd io ( CTDM) e p elo ob ser v ad o ( CTDO) . O r ef er en cial t eór ico
adot ado par a afer ição dos cust os foi o sist em a de cust eio por absor ção por pr ocedim ent o ou pr odut o. O est udo
foi r ealizado no Am bulat ór io do Hospit al Univer sit ár io da Univer sidade de São Paulo ( HU) . A am ost r a foi const it uída
de 65 pr ocedim ent os em nov e pacient es com UV. Os r esult ados m ost r ar am pr edom inância das faix as et ár ias
de 4 9 a 5 6 an os ( 3 3 , 3 3 % ) e de 6 5 a 7 2 an os ( 3 3 , 3 3 % ) , e do sex o f em in in o ( 7 7 , 7 8 % ) . Qu an t o à doen ça
associad a, h ou v e p r ed om ín io d e h ip er t en são ar t er ial sist êm ica ( 3 3 , 3 3 % ) e d iab et es m ellit u s ( 2 2 , 2 2 % ) . O
CTDM foi de R$ 107,99 e o CTDO foi de R$ 96,47.
DESCRI TORES: cur at iv os oclusiv os; úlcer a v ar icosa; cust os e análise de cust o
1 Paper ext r act ed fr om t he Mast er ´ s Thesis; 2 RN, M.Sc. in Nur sing, Head of t he Clinical Sur ger y Sect ion, Univer sit y Hospit al, Univer sit y of São Paulo; 3 RN,
Assist ant Pr ofessor, Univer sit y of São Paulo College of Nur sing, e- m ail: valer iac@usp.br
I NTRODUCTI ON
I
n view of t he populat ion’s incr eased dem and for healt h service and due t o t he lack of m ainly financialr esour ces, it is fundam ent al for ser v ice m anagem ent
t hat healt h pr ofessionals, in public as w ell as pr iv at e inst it ut ions, k now about t he cost s of t he pr ocedur es
t h ey per f or m .
Procedures direct ly relat ed t o nursing act ions w hich inv olv e hum an and m at er ial r esour ces include
w ou n d t r eat m en t .
N u r se s p l a y a n i m p o r t a n t r o l e i n w o u n d t r e a t m e n t a n d n e e d t o b e a w a r e o f t h e i r
r esponsibilit ies, bot h in t er m s of t echnical k now ledge
for per m anent w ound assessm ent and t he qualit y and quant it y of t he input s used. Mor eover, know ing about
t he cost of t he adopt ed t r eat m ent m ak es it possible
t o obt ain solid ar gum ent s in favor of it s cont inuit y by obt ain in g t h e n ecessar y r esou r ces.
I nt er nat ional lit er at ur e show s high spending
on w ound t r eat m ent in t he Unit ed St at es, am ount ing t o 1, 335 billion dollar s per year, w it hout consider ing
s p e n d i n g o n a n t i b i o t i c s t h e r a p y a n d o t h e r
p h a r m a co l o g i ca l a g en t s( 1 - 3 ). I n Br a zi l , t h er e i s n o in f or m at ion av ailab le ab ou t h ow m u ch is sp en t on
t h ese t r eat m en t s.
W i t h r e s p e c t t o v e n o u s l e g u l c e r s , i t i s
est im at ed t h at t h ey af f ect 5 8 0 , 0 0 0 p er son s in t h e
Unit ed Kingdom , and t r eat m ent cost s r ange bet w een 300 and 600 t housand pounds per y ear( 4).
Sevent y per cent of leg ulcer s ar e venous and,
in t his t ot al, 47% of individuals have already suffered t w o or m or e episodes of u lcer at ion , w h ile 2 1 % h ad
six or m or e( 5).
Approxim at ely five m illion people in t he Unit ed S t a t e s h a v e s o m e e v i d e n c e o f c h r o n i c v e n o u s
insufficiency, and bet w een 400 and 599 t housand of
t h em h av e alr ead y or w ill d ev elop v en ou s u lcer in t he com ing m ont hs or y ear s( 6).
Ven ou s u lcer, a ch r on ic leg in j u r y w it h h igh
clinical incidence lev els, does not only cause phy sical su f f er in g t o p at ien t s, b u t also p r ev en t s t h em f r om
w or king, as t he inj ur y oft en cont inues open for m ont hs
o r y ear s. Th i s cau ses so ci o eco n o m i c p r o b l em s f o r pat ient s as w ell as healt h or ganizat ions and societ y.
The m ost com m on cause of it s developm ent is venous
i n s u f f i c i e n c y, w h i c h i s p r e c i p i t a t e d b y v e n o u s h y p er t en sion .
Th e se u l ce r s a f f e ct 0 . 1 t o 0 . 5 % o f t h e
pr oduct ive adult populat ion, w it h incr easing incidence
lev els ov er t h e y ear s. Ulcer s ar e p r ev alen t am on g
w om en, at a pr opor t ion of 2.6: 1( 6- 7).
I n Br azil, w e hav e not found r esear ch about t he cost of t reat ing t hese inj uries. How ever, w e believe
t hat t he cost of t he Unna boot pr ocedur e is high in
com p ar ison w it h ot h er op t ion s, m er ely con sid er in g m at er ial and hum an r esour ce cost s needed t o per for m
i t . H o w e v e r, w o u n d d r e s s i n g f r e q u e n c y c a n
com pensat e for t hese cost s.
I n v i ew of t h e scar ce l i t er at u r e ab ou t t h e
subj ect , in t his research, w e int end t o verify t he cost
of t he Unna boot pr ocedur e for VU t r eat m ent , w it h a view t o st ar t ing t he st udy about a cost ing m et hodology
for t his pr ocedur e, w hich w ill suppor t fut ur e analyses
a b o u t t h e c o s t - e f f e c t i v e n e s s o f v e n o u s u l c e r t r eat m ent s. Anot her obj ect iv e is t o obt ain dat a t hat
can help in cost m anagem ent of t his pr ocedur e.
Th u s, t h i s r esea r ch a i m ed t o i d en t i f y t h e s o c i o d e m o g r a p h i c a n d c l i n i c a l c h a r a c t e r i s t i c s o f
pat ient s suffering from VU of t he inj uries t hem selves;
as w ell as t o calculat e t he t ot al dir ect cost ( TDC) of m at er ials and nur sing st aff used t o per for m t he Unna
boot pr ocedur e by t w o m et hods, one based on m eans
( ATDC) and t he ot her on obser vat ions ( OTDC) .
CASUI STI CS AND METHOD
Th i s ex p l o r a t o r y a n d d escr i p t i v e r esea r ch ad op t ed a q u an t it at iv e ap p r oach an d an aly zed t h e
dir ect cost of m at er ial and st aff used t o per for m t he
Unna boot pr ocedur e in VU pat ient s at t ended in t he Ou t p at ien t Clin ic of t h e Un iv er sit y Hosp it al at t h e
Universit y of São Paulo ( HU- USP) , w hich is one of t he
sect ions in t he division t hat at t ends ext ernal pat ient s. Th e Clin ic offer s 5 9 con su lt at ion r oom s for m edical,
n u r s i n g , n u t r i t i o n , s p e e c h a n d h e a r i n g s c i e n c e ,
psy chological and psy chiat r ic car e, w her e an av er age of 10,000 out pat ient consult at ions occur ever y m ont h.
The t ar get populat ion consist ed of pr ocedur es
per for m ed in m ale and fem ale VU pat ient s for w hom t op ical t h er ap y w it h Un n a b oot w as in d icat ed . Th e
sam ple com pr ised 65 pr ocedur es, car r ied out on nine
VU pat ient s.
We u sed t h e absor pt ion cost in g sy st em per
pr oduct t o ver ify pr ocedur e cost s( 8). How ever, w e only
sur veyed t he dir ect cost s ( m at er ial and st aff ) of t he pr ocedu r e, as it is n ot clear at t h e st u dy sit e w h at
cost allocat ion form s are used, w hich m akes it difficult y
f o l l o w e d t h e s t e p s a d o p t e d i n p r o c e d u r e c o s t
r esear ch( 9- 10), w hich ar e: const r uct ion of a w or k sheet
w it h a list of input s in gr oups, det er m inat ion of t he dat a collect ion period, sam ple definit ion, choice of dat a
collect ion sour ces and r ealizat ion of calculi t o find a
m ean v alu e.
Th i s r e s e a r c h p r o j e c t w a s a s s e s s e d a n d
appr ov ed by t he Resear ch Et hics Com m it t ee and by
t he inst it ut ion’s Teaching and Resear ch Gr oup. Befor e t he st ar t of dat a collect ion, w e invit ed
t h r e e n u r s e s w i t h p r e v i o u s e x p e r i e n c e i n s k i n
assessm en t an d w ou n d dr essin g t o collabor at e. Th e r esear ch er an d t h e n u r se w h o led t h e in st it u t ion ’s
St om al Ther apy Gr oup pr ov ided t r aining, including a
t h e o r e t i c a l - p r a c t i c a l a p p r o a c h a b o u t t h e phy siopat hology of VU and t he Unna boot t echnique,
aft er w hich dat a collect ion st ar t ed.
Th e f o l l o w i n g t e c h n i q u e w a s a d o p t e d t o per f or m t h e pr ocedu r e:
- placem en t of clien t w it h t h e low er m em ber r aised
on a suppor t ( t o facilit at e v enous r et ur n) ;
- r em oval of pr evious dr essing and exposur e of inj ur y;
- w ashing of t he low er m em ber w it h w at er and neut r al
so a p ;
- m easur em ent of ankle cir cum fer ence and below t he
k n e e ;
- m easur em ent of inj ur y ;
- w ashing of ulcer w it h phy siological ser um 0.9% ;
- placem ent of r ay on® on t he inj ur y ; - applicat ion of Unna boot ;
- p lacem en t of ad h esiv e p ap er b an d ag e an d f ix in g
w it h adhesiv e paper t ape;
- secondar y dr essing w it h gauze or zobec® accor ding
t o t he quant it y of ex udat e secr et ion;
- fix at ion of secondar y dr essing w it h adhesiv e paper ban dage an d t ape;
- p l a ce m e n t o f e l a st i c b a n d a g e a n d f i x a t i o n w i t h
ad h esiv e t ap e;
- r em ov al of pat ient fr om t he bed;
- supply of m at er ial for hom e use.
Dat a w er e collect ed b y t h e r esear ch er an d her collabor at or s bet w een Januar y 21st and May 5t h
2002 and pr ocedur es w er e per for m ed once per w eek,
on Wednesday s or Thur sday s, depending on t he day t r eat m ent had st ar t ed. The nur se w ho per for m ed t he
pr ocedur e r egist er ed dat a, w r it ing dow n t he beginning
and end t im e of t he pr ocedur e.
D u r i n g t h e f i r s t p r o c e d u r e , t h e c l i e n t s ’
d e m o g r a p h i c a n d cl i n i ca l d a t a w e r e co l l e ct e d , a s
w e l l a s i n j u r y ch a r a ct e r i st i cs, t i m e sp e n t o n t h e
pr ocedu r e an d n u m ber of st af f t o per f or m it , besides
t h e m a t e r i a l s u s e d a n d s u p p l i e d f o r h o m e u s e .
D u r i n g su b se q u e n t p r o ce d u r e s, o n l y d a t a a b o u t
i n j u r y ch a r a ct e r i st i cs, t i m e , n u m b e r o f st a f f a n d
m a t e r i a l s u se d a n d su p p l i e d f o r h o m e u se w e r e
r e g i st e r e d .
Th e n u r se r eco r d ed t h e st a r t t i m e o f t h e
pr ocedur e as soon as t he pat ient ent er ed t he r oom ,
and t he end t im e aft er pr oviding t he m at er ial for hom e
u se.
As t o a d h e si v e t a p e , w e e st a b l i sh e d t w o
pieces of appr ox im at ely t hir t y cent im et er s t o fix t he
elast ic b an d ag e; an d t w o p ieces of ad h esiv e p ap er
t ap e, m easu r in g ap p r ox im at ely t w elv e cen t im et er s,
t o fix t he adhesiv e paper bandage on t he Unna boot
an d t h e secon dar y dr essin g.
The nur sing aids w ho collabor at ed t o change
t he dr essings w her e t he ones scheduled at t he sect or.
Aft er t he st ar t of t he pr ocedur e, t hey ent er ed t he r oom
t o help w ashing t he low er m em ber and r em ained in
t he r oom unt il t he pat ient w as r em oved fr om t he bed,
st aying an aver age of t en m inut es less t han t he nur se.
Dat a about m at er ial cost s w er e obt ained fr om
t h e Mat er ial Sect ion at t h e HU- USP an d r ef er r ed t o
t he inst it ut ion’s last t hr ee pur chases.
To ca l cu l a t e co st / h o u r, w e u sed t h e m o st
fr equent w age r ange for bot h pr ofessional cat egor ies
( nur se and nur sing aid) t hat per for m ed t he pr ocedur es,
obt ained fr om t he Per sonnel Sect ion.
The verificat ion of t he procedure’s Tot al Direct
Cost w as based on t he m ean values of t he 17 pr oduct s
u sed. Th ese w er e, in t h e f ollow in g or der : P1 st er ile
gauze ( pouch) ; P2 non- st er ile gauze ( unit ) ; P3 r ay on®
( unit ) ; P4 zobec ®
( unit ) ; P5 adhesive paper bandage10
( unit ) ; P6 adhesive paper t ape ( cm ) ; P7 adhesive t ape
( cm ) ; P8 ph y siological ser u m 0 9 . 0 % ( m l) ; P9 elast ic
ban dage ( u n it ) ; P10 pr ocedu r e glov e ( u n it ) ; P1 1 n on
-st er ile gauze ( pouch) ; P12 zobec® ( unit ) ; P13 adhesiv e
paper bandage ( unit ) ; P14 Unna boot ( unit ) ; P15 gloves
( pair ) ; P16 soap ( m l) and P17 t im e ( m in) .
Non - st er ile gau ze ( P1 1) an d Z obec ( P1 2) ar e
pr ovided t o t he pat ient t o change t he ext er nal dr essing
at hom e, w hich is w hy t hese pr oduct s w er e v er ified
separ at ely fr om P2 and P4 .
To calculat e t he ATDC:
1. We consider ed t he m ean unit cost of t he
last t hr ee pur chases of each of t he 16 pr oduct s used
in t he procedure. To calculat e t he unit cost of t he t im e
t h e cost of t h e n u r se’s an d t h e n u r sin g aid ’s w or k
hour base don t he m ost fr equent gr oss salar y in t he
t w o ca t e g o r i e s, a d d i n g 2 9 . 5 % i n b e n e f i t s a n d a
m on t h ly h ou r load of 1 5 0 h ou r s. We calcu lat ed t h e
v alue of t he nur se’s salar y per m inut e for dr essings
t h at w er e on ly per f or m ed by t h is pr of ession al, an d
t h e v alu e of t h e n u r se’s salar y per m in u t e plu s t h e
n u r s i n g a i d ’ s s a l a r y p e r m i n u t e f o r d r e s s i n g s
per for m ed by bot h pr ofessionals. Nex t , w e calculat ed
t he m ean of t hese v alues.
2 . We calculat ed t he m ean consum pt ion for
each of t he 1 7 elem ent s used in t he pr ocedur e and
t he ATDC, using for m ula No 1:
ATDC = c1. P1 + c2. P2 + ... + c17. P17 ( 1)
w h er e c1 , c2, . . ., C1 7 ar e t h e 1 7 u n i t co st s
m ent ioned abov e and P1, P2,..., P17 ar e t he 17 m ean
con su m p t ion s.
To calculat e t he OTDC
-3 . Th e u n i t co st f o r t h e 1 6 p r o d u ct s w a s
est ablished in t he sam e way as for t he ATDC. For t he
unit cost of pr ocedur e t im e ( P17) , w e separ at ed t he
65 dr essings in t w o gr oups: gr oup only per for m ed by
t he nur se ( gr oup A) and gr oup per for m ed by t he nur se
a n d t h e n u r si n g a i d ( g r o u p B) . Fo r g r o u p A, w e
calculat ed t he 43 associat ed cost s, using t he cost of
t he nur se’s w or k hour and, for gr oup B, w e calculat ed
t he 22 cost s, adding up t he cost of t he nur se’s and
n u r si n g a i d ’ s w o r k h o u r, a cco r d i n g t o t h e sa m e
p r o ced u r e;
4. We calculat ed t he t ot al cost associat ed w it h
each of t he 65 pr ocedur es under analy sis, using t he
f ollow in g f or m u la:
CTDOi = c1. Pi1 + c2. Pi2 + ... + c17. Pi17, wit hi =
1, t w o,..., 65 ( 2)
w here c1 ,c2, ..., c17 r epr esent t he 17 unit cost s
m ent ioned above and Pij , w it h i = 1, 2, ..., 65 and j =
1, ..., 17 , t he consum pt ion of t he pr oduct ( or der j ) in
t he pr ocedur e ( or der i) .
I t sh ou ld be obser v ed t h at c17 ( u n it cost of
pr ocedur e t im e) v ar ies accor ding t o t he gr oup.
5. Aft er calculat ing each of t he 65 t ot al cost s
t hrough t he est ablished for m ula, w e assessed t he t ot al
cost , using t he m ean value of t he 65 cost , as w ell as
St andar d Deviat ion and int er val est im at ed of t he t ot al
r eal cost .
We calcu lat ed t h e m ean p r oced u r e cost in
r eal and dollar. Considering t he dollar rat e ( pur chase)
bet w een 0 1 / 2 2 / 2 0 0 2 an d 0 5 / 0 6 / 2 0 0 2 , i. e. t h e dat a
collect ion per iod, w e applied t he Kolm ogor ov- Sm ir nov
Nor m alit y Test and found t hat t hese values follow ed
a nor m al dist r ibut ion, w it h a m ean of R$ 2.36 ( SD =
0.04) and var iat ion bet w een R$ 2.27 and 2.47.
Descript ive analysis of all st udy variables w as
realized, adopt ing dist ribut ions and frequencies, m ean
d e s c r i p t i v e m e a s u r e s , s t a n d a r d d e v i a t i o n a n d
v ar iat ion ( m inim um and m ax im um ) in t he pr oduct ion
of punct ual est im at es and 95% confidence int er v als,
in t he pr oduct ion of int er v al est im at es.
I n f e r e n t i a l a n a l y s i s b a s i c a l l y i n v o l v e d
correlat ion analyses bet w een t he variables of int erest .
RESULTS
So ci o d em o g r ap h i c an d Cl i n i cal Ch ar act er i zat i o n o f
Pat ien t s
Ta b l e 1 - Pa t i e n t s w i t h V U, a c c o r d i n g t o
sociodem ogr aph ic an d clin ical v ar iables. São Pau lo,
2 0 0 2
e l b a i r a
V Distribution
) s r a e y ( e g
A N %
6 5 o t 9
4 3 33.33
4 6 o t 7
5 2 22.22
2 7 o t 5
6 3 33.33
0 8 o t 3
7 1 11.11
l a t o
T 9 100.00
) D S ( n a e
M 61.89(9.89)
n o i t a i r a
V 49to80
n a e M r o f % 5 9 I
C 61.89±7.60
r e d n e G
e l a
M 2 22.22
e l a m e
F 7 77.78
l a t o
T 9 100.00
y g o l o h t a P d e t a i c o s s A
n o i s n e t r e p y H l a i r e t r
A 3 33.33
s u t il l e M s e t e b a i
D 2 22.22
n o i t c r a f n
I 1 11.11
l o r e t s e l o h C h g i
H 1 11.11
s i t il u ll e
C 1 11.11
n o i t a ll i r b i F l a i r e t r
A 1 11.11
l a t o
T 9 100.00
Ve n o u s u l ce r s a r e m o r e co m m o n a s a g e
adv ances, in accor dance w it h ot her st udies( 11- 13). The
pr edom inant age r ange is bet w een 60 and 80 y ear s
old. These st udies r epor t t hat 72% of VU pat ient s had
t heir fir st ulcer befor e t hey w er e 60 y ear s old, 22%
befor e t he age of 40 and 13% befor e 30.
We found no differ ence in t er m s of age and
gender bet w een our r esear ch and ot her st udies( 11- 12).
A s s o c i a t e d d i s e a s e s , s u c h a s d i a b e t e s
Ta b l e 3 - Av e r a g e t o t a l d i r e ct co st o f Un n a b o o t pr ocedu r e. São Pau lo, 2 0 0 2
am ong ot her s, exer t a negat ive im pact on t he healing
p r o ce ss o f t h e i n j u r i e s, m a i n l y o n a n g i o g e n e si s.
Mor eov er, diabet es pat ient s w it h unbalanced glucose levels are m ore predisposed t o infect ion, w hich delays
healing( 13- 15).
On e p at ien t p r esen t ed m or e t h an on e an d five ( 55.55% ) pat ient s did not pr esent any associat ed
p at h olog y.
Table 2 - Exist ence t im e and locat ion of VU. São Paulo,
2 0 0 2
St udies have show n t hat 34% of VU pat ient s
had t his pr oblem for m or e t han fiv e y ear s, and t hat
t h e p r o b ab i l i t y o f r ecu r r en ce i s h i g h er i n p at i en t s
w hose VU appear ed at an ear ly age, t hat is, in younger
in div idu als( 6 ).
Ot h er st u dies( 1 3 - 1 4 ) h av e ev iden ced t h at t h e
highest incidence levels of venous ulcers are found in
t h e Malleolu s r eg ion , f ollow ed b y ot h er leg or f oot
r egions. These dat a ar e com pat ible w it h our findings.
Ver if icat ion of ATDC an d OTDC
We f ou n d t h at t h e t ot al cost of t h e n u r ses’
and t he nur sing aids’ w or k hour w as R$ 19.22 and R$
9 . 4 6 , r esp ect iv ely. On t h e av er ag e, t h e aid s sp en d
50 m inut es per pr ocedur e. Hence, t he cost of t he aid’s
w or k t im e decr eases t o R$ 7.88. Thus, t he nur se and
t h e n u r sin g aid’s w or k t im e spen t on t h e pr ocedu r e
cost s an average of R$ 27.10 per hour.
To calculat e t he ADTC, w e considered t he unit
cost of p r oced u r e t im e, t h e m ean u n it cost of t h e
nur se’s w or k t im e plus t he nur sing aid’s w or k t im e,
r esu lt in g in a u n it cost of R$ 2 3 . 1 6 per h ou r or R$
0.39 per m inut e.
e l b a i r a
V Distribution
) r a e y ( e m i t U
V n %
2
< 4 44.44
5 o t
2 1 11.11
5
> 4 44.44
L A T O
T 9 100.00
) D S ( n a e
M 13.05(16.41)
n o i t a i r a
V 0.06to40
n a e M r o f % 5 9 I
C 13.04±12.61
n o i t a c o l U V I s u l o e ll a
M 3 33.33
E s u l o e ll a
M 2 22.22
E / I s u l o e ll a
M 1 11.11
I l i t n u E s u l o e ll a
M 1 11.11
D n i h S l a n r e t n
I 1 11.11
D t o o f l a s r o
D 1 11.11
l a t o
T 9 100.00
* St er ile gauze ( P11) and Zobec ( P12)ar e m at er ials pr ovided t o t he pat ient t o change t he ext er nal dr essing at hom e.
Ta b l e 3 sh o w s a n e st i m a t e d AD TC o f R$
107.99. Accor ding t o t he m ean dollar r at e for t he st udy per iod, t he est im at ed ADTC is US$ 45. 76.
Th e m at er ial w it h t h e h igh est av er age cost w as t he elast ic bandage, follow ed by t he Unna boot
and st aff t im e.
To cal cu l at e t h e ODTC, w e con si d er ed t h e sam e unit cost s as in Table 3. As for pr ocedur e t im e, w e separ at ed t he 65 w ound dr essings in t w o gr oups
( A an d B) . Gr ou p A con sist ed of t h e 4 3 d r essin g s r ealized by nur ses only at a unit cost of R$ 0.32 per m inut e ( 19.22/ 60 = 0.32) , w hile gr oup B included t he 22 dr essings per for m ed by t he nur se and nur sing aid,
at a unit cost of R$ 0.45 per m inut e ( 27.10/ 60 = 0.45) .
Table 4 - Dist r ibu t ion of Un n a boot pr ocedu r e cost . São Paulo, 2002
Table 4 show s t hat t her e ar e no st at ist ically significant differ ences in m ean ODTC bet w een gr oups
A, B and A + B.
t c u d o r
P Mean
n o i t p m u s n o C t s o C t i n U ) $ R ( t s o C ) $ R ( ) h c u o p ( e z u a g e l i r e t s -1 .
P 1.98 0.22 0.44
) t i n u ( e z u a g e l i r e t s -n o n -2 .
P 28.08 0.0115 0.32
) t i n u ( n o y a r -3 .
P 1.89 1.85 3.49
) t i n u ( c e b o z -4 .
P 1.32 0.87 1.15
) t i n u ( 0 1 e g a d n a b r e p a p e v i s e h d a -5 .
P 2.78 0.23 0.64
) m c ( e p a t r e p a p e v i s e h d a -6 .
P 83.54 0.0009 0.08
) m c ( e p a t e v i s e h d a -7 .
P 58.5 0.0047 0.27
) l m ( % 0 , 9 0 m u r e s l a c i g o l o i s y h p -8 .
P 88.46 0.0027 0.24
) t i n u ( d n a b c i t s a l e -9 .
P 1.38 29 39.33
) t i n u ( e v o l g e r u d e c o r p -0 1 .
P 2.65 0.407 1.08
* ) h c u o p ( e z u a g e l i r e t s -1 1 .
P 13.65 0.22 3.00
* ) t i n u ( c e b o z -2 1 .
P 8 0.87 6.96
) t i n u ( e p a t r e p a p e v i s e h d a -3 1 .
P 6.72 0.23 1.55
) t i n u ( t o o b a n n u -4 1 .
P 1 31.85 31.85
) r i a p ( e v o l g e l i r e t s -5 1 .
P 1 0.06 0.06
) l m ( p a o s -6 1 .
P 50 0.01285 0.64
e m i T -7 1 .
P 43.31 0.39 16.89
t s o C l a t o
T 107.99
t s o
C GroupA GroupB GroupA+B
n % n % n %
2 0 . 5 6 o t 0 0 . 3
4 26 60.47 13 59.09 39 60.00 5 0 . 7 8 o t 3 0 . 5
6 15 34.88 7 31.82 22 33.85
8 0 . 9 0 1 o t 6 0 . 7
8 1 2.33 1 4.55 2 3.08
1 1 . 1 3 1 o t 9 0 . 9 0
1 1 2.33 0 0.00 1 1.54
4 1 . 3 5 1 o t 2 1 . 1 3
1 0 0.00 0 0.00 0 0.00
7 1 . 3 5 1 o t 5 1 . 3 5
1 0 0.00 1 4.55 1 1.54
l a t o
T 43 100.00 22 100.00 65 100.00 n
a e
M 63.68 67.54 64.99
D
S 13.00 21.30 16.22
m u m i n i
M 45.35 49.73 45.35
m u m i x a
M 116.63 153.17 153.17
n a e m r o f % 5 9 I
I n US dollar s, t he m ean ODTC of Gr oup A+ B
v ar ies bet w een US$ 25.83 and US$ 29.83.
FI NAL CONSI DERATI ONS
Th e d i r e ct t o t a l co st w a s v e r i f i e d b y t w o
co st i n g m et h o d s i n o r d er t o ch eck f o r si g n i f i ca n t
dif f er en ces bet w een t h em . We f ou n d t h at , alt h ou gh t h e m e a n c o n s u m p t i o n m e t h o d p r o d u c e s a n
apparent ly overest im at ed cost , it is a m or e sim plified
m et hod of finding t he pr ocedur e cost . The ver ificat ion of t he obser v ed dir ect t ot al cost allow ed us t o infer
abou t t h e act u al v ar iat ion in pr ocedu r e cost . Th u s,
w e con clu d e t h at t h e b est cost v er if icat ion m et h od depends on w hat dat a w ill be used for.
One im por t ant aspect is t hat t his st udy helped
t o get t o know t he consum pt ion pat t er n and m at er ial cost used in t he Unna boot pr ocedur e. How ever, it did
not clarify w het her t he cost is high or not . This requires
a co st su r v ey o f al t er n at i v e p r o ced u r es f o r t h ese pat ien t s an d cost - effect iv en ess st u dies.
O n t h e a v e r a g e , f o u r p r o c e d u r e s a r e
p er f or m ed p er p at ien t p er m on t h . Usin g t h e m ean ODTC f or gr ou p A + B, t h is r esu lt s in a cost of R$
259.96 for t he hospit al. Accor ding t o a pr e- est ablished
t able, t h e Sin gle Healt h Sy st em ( SUS) t r an sf er s R$
0 . 5 1 p er p r o ced u r e, w h i ch o b l i g es t h e h o sp i t al t o assum e R$ 257.92 per pat ient . I t should be r em inded
t hat w e only v er ified dir ect cost s.
I nst it ut es need t o dev elop st udies about t he cost s of t h eir pr ocedu r es as qu ick ly as possible, as
t h i s i s t h e o n l y w a y f o r t h e m t o f i g h t f o r b e t t e r
t r an sf er s f r om t h e SUS an d m ak e t h eir em p loy ees a w a r e a b o u t t h e n e e d t o r a t i o n a l i z e m a t e r i a l
r esou r ces, av oidin g cost - in cr easin g w ast e.
Nu r se s p l a y a r e l e v a n t r o l e i n m a n a g i n g m at er ials and t heir cost s in hospit al unit s, pr ov iding
k now ledge and m eans for decision m ak ing, based on
sci e n t i f i c e v i d e n ce a b o u t ca r e d e l i v e r y. Th i s w i l l su p p o r t t h ei r a r g u m en t s t o h o sp i t a l m a n a g em en t
a b o u t sp en d i n g n eed s i n v i ew o f d i f f er en t w o u n d
t reat m ent product t ypes, as w ell as t heir j ust ificat ions about t he allocat ion of hum an r esour ces t o differ ent
act iv it ies.
We a l s o h i g h l i g h t t h a t t h i s s t u d y i s n o t conclusiv e. Ther e is a need for a lar ger sam ple and
replicat ion in ot her inst it ut ions, as w e found no sim ilar
st u d i e s f o r d a t a co m p a r i so n , w h i ch i m p a i r e d t h e r ealizat ion of t his r esear ch.
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