Cette thèse étudie les facteurs d’offre et de demande associés au recours au dépistage du cancer du sein. Parmi les facteurs d’offre, j’examine comment la coexistence du dépistage organisé au côté du dépistage individuel influence le contenu de l’examen de dépistage ainsi que le recours régulier au dépistage. En plus des facteurs de demande tels les caractéristiques socioéconomiques, une attention particulière est portée à la possibilité d’expliquer le recours régulier au dépistage par les préférences face au risque et temporelles ainsi que les perceptions. À partir de régularités psychologiques identifiées dans les travaux d’économie comportementale et de psychologie, trois interventions de type nudge sont testées dans le cadre d’une expérience randomisée sur le terrain visant à augmenter le taux de dépistage dans le programme national. / This thesis explores supply and demand factors associated with the use of breast cancer screening. Among the supply factors, I examine how the coexistence of organized and opportunistic screenings influences the content of the screening exam and screening regularity. Besides the usual demand factors such as socioeconomic characteristics, a special attention is being given to the possibility of explaining screening regularly by individuals’ risk and time preferences and perceptions. Based on psychological patterns identified in the literature in behavioral economics and psychology, three nudge interventions are tested in a randomized field experiment to increase the national program uptake rate.

ATMP (Advanced Therapy Medicinal Products) is a new type of treatment with the potential to cure otherwise severe and even deadly diseases, for which there are only inhibitive medicine available. This means that the healthcare sector now have access to treatments that greatly increases the number of QALY:s received. However, the problem with the implementation of ATMP lies within the disparity between its large upfront costs and the return, which is spread over a long time-period. There is also the problem with lack of information, causing further risks when investing in ATMP. Seeing as the treatment is a “one-off” where the results are uncertain, and the costs are high and lumped together at the beginning. By constructing a laboratory setting we analyze the health evaluating outcome when changing endogenous variables and modelling scenarios from real world estimates, forming a hypothetical base case which represents the difficulty decision makers face when evaluating treatments with ATMP- characteristics. Furthermore, we find that there is a prominent cost difference between the two alternatives as well as an enhanced sensitivity to the methodologically execution. To mitigate the risk of these types of long-term investments we present different types of strategies, which are built upon financial theory by the utilization of options and swaps. We also suggest using these payment schemes based upon our results, this can open opportunities to elude the decision uncertainty present for these types of long-term investments within the public healthcare sector. Making use of real options and venture capitalist structures we present a variety of solutions that might be suitable for different types of scenarios and ATMP:s. These different types of payment solutions and risk mitigating strategies could potentially also be used in combination with each other depending on the availability of a counterparty and the duration of the contract. In conclusion, we find that financial theory can mediate decisionmakers in situations that suffer from ATMP characteristics. We find financial solutions that can price long-term uncertainty and alleviate irreversibility from decisionmakers. Relying on already preferred solutions in the health sector i.e., negotiated contracts and outcome-based payment structures, financial theory has the possibility to use public funds more effectively with mitigated uncertainty. / ATMP (Avancerade terapiläkemedel) är en ny typ av behandling som har potentialen att bota i andra fall allvarliga och även dödliga sjukdomar, för vilka det enbart finns lindrande åtgärder eller inga alternativa behandlingar alls. Detta betyder att sjukvården numer har tillgång till behandlingar som ökar antalet erhållna QALY:s avsevärt. Problematiken vid implementeringen av ATMP ligger däremot i de stora engångskostnaderna som tillkommer direkt och de hälsoeffekter som de ger, vilka återfinns på lång sikt. Det finns även en problematik i informationsbristen, vilket skapar risker vid investeringar i ATMP. Anledningen till detta är att behandlingen är en engångsbehandling med osäkra resultat och höga kostnader. Genom att konstruera en analysmodell skapar vi ett basscenario utifrån vilket vi kan ändrade variabler för att generera olika utfall som ska representera underlaget till vilket beslutfattare ska agera. Vid 1000 iterationer kan vi visa hur ATMP är överlägset en konventionell behandling för t.ex. akut lymfatisk leukemi när det kommer till att generera QALY:s. Vidare finner vi att det finns en framträdande kostnadsskillnad mellan de två alternativen samt en ökad känslighet för metodologiskt utförande. För att främja beslutsprocessen och hantera risken vid den här typen av långsiktiga investeringen lägger vi fram olika typer av strategier som är rotade i finansiell teori genom nyttjandet av optioner och swappar. Vi föreslår betalningslösningar som är baserade på de resultat vi fick och som har möjligheten att minska beslutosäkerheten som uppstår vid den här typen av långsiktiga investeringar inom sjukvården. Genom att använda realoptioner och riskkapitaliststrukturer ger vi en bred mängd lösningar som kan vara lämpliga för olika typer av scenarion och avancerade terapiläkemedel. Dessa olika typer av betalningslösningar och riskhanteringsstrategier kan potentiellt även användas i kombination med varandra, beroende på tillgången till en motpart och längden på kontraktet. Sammanfattningsvis finner vi att finansiell teori kan hjälpa beslutsfattare i situationer som lider av ATMP karakteristik. Vi föreslår finansiella lösningar som kan hjälpa till med att prissätta osäkerhet på lång sikt och minska irriversibiliteten från beslutsfattaren. Vi använder väletablerade metoder och föredragna betalningslösningar, det vill säga förhandlade kontrakt och evidensbaserade betalningsstrukturer, tillsammans med finansiell teori för att konstruera betalningslösningar som använder offentliga medel mer effektivt och ger lägre osäkerhet.

Det finns tydliga synergier mellan transportsystemet, klimatpåverkan och folkhälsa. Detta skulle transportplaneringen kunna använda till sin fördel för en mer hållbar planering för att åstadkomma en förflyttning från personbilen till hållbara och aktiva transporter i linjer med uppsatta globala och nationella målsättningar. Trots detta kritiseras transportplaneringen för att inte beakta folkhälsa i tillräckligt stor utsträckning, med risk för försämrad välfärd, ökade samhällsklyftor och försämrad folkhälsa som konsekvens. Den här uppsatsen har kartlagt hur kommunala och regionala aktörer arbetar för en förflyttning till aktiva transporter, vilken roll folkhälsoperspektivet har i planeringen samt hur aktörerna förhåller sig till planeringsverktyg och hälsoekonomiska beräkningar för att synliggöra och beakta transportsystemets hälsoeffekter.  Fallen Lidingö stad tillsammans med Region Stockholm och Lunds kommun tillsammans med Region Skåne har studerats genom en intervju- och dokumentstudie. Resvanedata har analyserats för att förstå nuvarande omfattning samt potential för aktiva transporter. Vidare har det samhällsekonomiska värdet av aktiva transporter beräknats som konsekvens av den ökade fysisk aktivitet som genererats. Detta har beräknats med hjälp av Världshälsoorganisationens Health Economic Assessment Tool.  Uppsatsen visar att det finns utrymme att öka andelen aktiva transporter på kortare resor då personbilen utgör 11–22 procent av färdmedelsfördelningen på resor upp till 2,5 kilometer och 49–55 procent på resor mellan 2,5–8 kilometer. Antal sparade liv genom aktiva resor, skulle kunna öka med 45–100 procent om en fullständig förflyttning skulle ske, motsvarande ett betydande samhällsekonomiskt värde.  Kartläggningen visar även att synergierna mellan transportsystemet, klimatpåverkan och folkhälsa inte tas tillvara fullt ut idag och att det finns möjlighet att bredda förståelsen för hållbar transportplanering genom att koppla denna till folkhälsa. Dagens planering uppvisar flera brister när det gäller att beakta folkhälsoperspektivet och missar möjligheter att stärka folkhälsans roll. Bristerna skulle kunna elimineras genom utvecklade målsättningar med ett holistiskt förhållningssätt, utvecklade tvärsektoriella samarbeten samt genom ökad involvering. För att beakta hälsoeffekter i planeringsprocessen behöver planeringsverktyg tas fram och implementeras samt behöver kunskapsnivån om effektsambanden stärkas för att beslutsfattare också ska våga agera utifrån ett folkhälsoperspektiv. / There are clear synergies between the transport system, climate change, and public health. This could be used as an advantage in transport planning for more sustainable planning in order to achieve a major shift from the passenger car to sustainable and active transportation in line with global and national goals. Transport planning is however criticized for not taking public health into account to a sufficient extent with subsequent deteriorating welfare, increasing societal gaps, and deteriorating public health as consequences. Therefore, this thesis has investigated how municipal and regional actors work to achieve a shift toward active transportation, what role the public health perspective has in the planning process, and what the actors think of including planning tools and health economic assessments in order to take health effects of the transport system into account.  The cases of Lidingö municipality together with the region of Stockholm and Lunds municipality together with the region of Skåne have been studied through an interview and document study. Travel habit data have been analyzed to understand the current scope and potential for active transportation. Furthermore, the socio-economic value of active transportation has been calculated on the basis of the level of physical activity it generates. This has been done by using the World Health Organization’s Health Economic Assessment Tool.  The thesis shows that there is room to increase the proportion of active transport on shorter trips, as the passenger car makes up 11–22 percent of trips up to 2,5 kilometers and 49–55 percent for trips between 2,5–8 kilometers. The number of lives saved through active transportation could increase by 45–100 percent if a complete shift was to take place, corresponding to a significant socio-economic value.  The thesis also shows that the synergies between the transport system, climate change, and public health are not fully utilized today and that there is possible to broaden the understanding of sustainable transport planning by linking this to public health. Today’s planning also shows several shortcomings considering the public health perspectives and missing opportunities to strengthen the role of public health. The shortcomings could be eliminated through further developed objectives with a holistic approach, developed cross-sectional collaborations, and increased involvement. In order to take health effects into account in the planning process, planning tools need to be developed and implemented, and the knowledge about the relationship between cause and effect needs to be strengthened so that decision-makers to an increased degree could act from a public health perspective.

<p>Despite the proven clinical benefits of use of adjuvant hormone therapy with tamoxifen or aromatase inhibitors for breast cancer, adherence to and persistence with adjuvant hormone therapy are suboptimal. It is critical to understand the clinical and economic impacts of low adherence to and low persistence with adjuvant hormone therapy in breast cancer. The overall objective was to assess associations between adherence to and persistence with adjuvant hormone therapy and mortality, healthcare utilization, and healthcare costs among older women with breast cancer. A retrospective longitudinal analysis of the Surveillance, Epidemiology, and End Results (SEER) registry linked with Medicare claims was conducted. This study included 25,796 older women diagnosed with hormone receptor-positive stage I-III breast cancer from 2009 through 2017. Adherence was defined as having proportion of days covered (PDC) of 0.80 or more. Persistence was defined as having no hormone therapy discontinuation, i.e., a break of at least 180 continuous days. Length of persistence was calculated as time from therapy initiation to discontinuation. All analyses were conducted using SAS 9.4 and RStudio for Linux environment. An <em>a priori</em> alpha level of 0.05 was used to determine significance for all the analyses. Time-dependent Cox models were used to assess associations between adherence to and persistence with adjuvant hormone therapy and mortality. Hurdle generalized linear mixed models were used to assess associations between adherence and persistence with annual number of hospitalizations, hospital days, hospital outpatient visits, inpatient costs, and outpatient costs across five years to account for excess zeroes.  Generalized linear mixed models were used for other types of healthcare utilization and costs. Annual adherence rates were 78.1 percent, 75.2 percent, 72.4 percent, 70.0 percent, and 61.5 percent from year-one to year-five after hormone therapy initiation. Persistence rates were 87.5 percent, 81.7 percent, 77.1 percent, 72.9 percent, and 68.9 percent through cumulative intervals of one year up to five years after hormone therapy initiation. Adherence was associated with lower risk of all-cause mortality, but was not significantly associated with breast cancer-specific mortality. Both being persistent and longer persistence were associated with lower risk of all-cause mortality and lower risk of breast cancer-specific mortality. Being adherent was associated with fewer hospitalizations, fewer hospital days, fewer emergency room visits, and fewer hospital outpatient visits, but was not associated with physician office visits. Being persistent was associated with fewer hospital days, fewer emergency room visits, and fewer hospital outpatient visits, but was associated with more physician office visits. Longer persistence was associated with fewer hospital days, fewer emergency room visits, and fewer hospital outpatient visits, but was not significantly associated with physician office visits. Adherent women had lower inpatient costs, lower outpatient costs, lower medical costs, and lower total healthcare costs despite higher prescription drug costs. Both being persistent and longer persistence were associated with lower inpatient costs, lower outpatient costs, lower medical costs, and lower total healthcare costs despite higher prescription drug costs. </p>

Introduction: There are no economic evaluations to determine the value of PRSs. The objective of this study was to determine if the addition of a PRS to traditional risk factors to guide statin therapy is a cost-effective intervention for the prevention of primary MI cases in the Ontario healthcare payer perspective. Methods: A PRS cost-effectiveness model was constructed to produce various statin prescription strategies in conjunction with the FRS. Upper PRS thresholds (between 25% to 70%) were set such that individuals falling into them would be eligible for statins while those in lower PRS thresholds (between 1% to 25%) were deemed protected and removed from consideration. The model determined number of incident MIs saved or not saved by statins, costs, quality of life, and the effect of statins on preventing MIs over a 10-year time horizon, discounted at 1.5% annually. One-way sensitivity analysis and a PSA were performed by varying all model parameters. Non-related participants of white British descent from 96,736 participants in the UK Biobank at intermediate risk for cardiovascular disease, determined using the Canadian Cardiovascular Society dyslipidemia guidelines of 2016, were used for the study. Results: The optimal clinical and economic strategy was one whereby the top 70% PRS individuals are eligible for statins, with the lower 5% PRS excluded. A base-case analysis at a PRS cost of $70 produced an ICER of $747,184.10/QALY, ranging from $525,678.90/QALY to $930,144.40/QALY in a one-way sensitivity analysis. In the PSA, the intervention has approximately a 50% probability of being cost-effective at $750,000/QALY. At a genotyping cost of $0, statin strategies guided by PRS dominated standard care when at least 12% of the lower PRS individuals were withheld from statins. When the predictive performance of the PRS is increased, the ICER drops drastically depending on the cost of genotyping and statin strategy. Conclusion: The cost-effectiveness model considers MI cases exclusively and a short, 10-year time horizon which likely overestimate the ICER. However, this study elucidates that the PRS has the potential to be extremely cost-effective in the future. / Thesis / Master of Science (MSc) / Approximately 1 in 3 Canadians live with at least one genetically linked chronic disease. Together, these diseases constitute a large economic burden on the healthcare system and well-being of individuals. Recent advancements in genetics allow risk prediction of developing complex, but common chronic diseases such as cardiovascular disease. Termed as polygenic risk scores, they have the potential to carry beneficial clinical outcomes such as an improved quality of life. However, the economics is not yet understood. This study determined that when targeting heart attacks, approximately $750,000 is required to gain an additional life-year for an adult. Although this may seem high, the result is closer to an upper-limit estimate than the true cost since polygenic risk scores have more benefits than solely for heart attacks. In the future, when accounting for their entire potential, the cost per life-year is likely to be lower, and perhaps even a money-returning investment.

Tesis por compendio / [ES] La digitalización en la sanidad sigue poco desarrollada en comparación con muchos otros sectores, pero ofrece la posibilidad de hacer frente a retos cada vez mayores. A partir del caso de un sistema digital de gestión del flujo de trabajo implantado en el quirófano, esta tesis examina cuál podría ser el impacto de la digitalización en la calidad, la eficiencia y la economía de la gestión hospitalaria. La metodología de investigación se basa en un enfoque cuantitativo. En primer lugar, se ha desarrollado una visión general y un análisis del mercado sanitario europeo, así como una amplia y sistemática revisión bibliográfica. Esta se ha enfocado en la eficiencia y el impacto económico de la estandarización y digitalización de los procesos intraoperatorios en el quirófano. Los resultados proporcionaron la base para derivar las preguntas de investigación en torno a los sistemas digitales de gestión del flujo de trabajo. Para cubrir las lagunas de investigación identificadas, se han obtenido y analizado de forma retrospectiva datos de un hospital, como estudio de caso, sobre un sistema digital de gestión del flujo de trabajo, Surgical Process Manager (SPM), en ortopedia y cirugía general. Los datos adicionales proporcionados por los pacientes, se han utilizado de forma retrospectiva para realizar cálculos económicos con el fin de responder a la pregunta principal de la investigación en cirugía general, centrándose en la cirugía de la obesidad. Las principales conclusiones de la tesis muestran que la implantación de sistemas digitales de gestión del flujo de trabajo, como el SPM, mejora la eficiencia y la economía en la cirugía de la obesidad. El análisis de odds ratio (razón de oportunidades/probabilidades) para evaluar el impacto en la calidad no permitió extraer conclusiones ni en ortopedia ni en cirugía de la obesidad. El cálculo coste-beneficio en cirugía de la obesidad mostró un ahorro de costes de 318 euros por paciente, lo que supuso un total de 10.073 euros. Este beneficio económico se consiguió gracias a la disminución de la duración de la estancia (-1,2 días). Por primera vez, esta investigación aporta pruebas sobre el valor económico de los procesos digitalizados y estandarizados en el quirófano en cirugía general y ambulatoria. Los resultados facilitarán las decisiones de inversión en digitalización de la gestión hospitalaria y ofrecerán opciones para superar la carga económica en el mercado sanitario actual. Además, los resultados proporcionan detalles en profundidad sobre estructuras de costes específicas, cálculos, así como reembolsos y cómo medir eficazmente el impacto financiero en los sistemas digitales en el quirófano. / [CA] La digitalització de l'assistència sanitària encara està endarrerida en comparació amb moltes altres indústries, però ofereix el potencial per fer front als reptes creixents. Aquesta tesi examina sobre l'exemple d'un sistema de gestió de flux de treball digital, implementat al quiròfan quirúrgic (OR), quin podria ser l'impacte de la digitalització en la qualitat, l'eficiència i l'economia per a la gestió hospitalària. La metodologia d'aquesta investigació es basa en un enfocament quantitatiu. En primer lloc, es va fer una visió general i anàlisi del mercat sanitari i una extensa revisió sistemàtica de la literatura. Es va centrar en l'eficiència i l'impacte econòmic de l'estandardització i la digitalització dels processos intraoperatoris al quiròfan. Les troballes van proporcionar la base per derivar les preguntes de recerca al voltant dels sistemes de gestió de flux de treball digitals. Per cobrir els buits de recerca identificats, s'han extret i analitzat retrospectivament dades d'hospitals d'un sol centre en un sistema de gestió de flux de treball digital, Surgical Process Manager (SPM), en ortopèdia i cirurgia general i visceral (G&V). S'han utilitzat retrospectivament dades addicionals dels pacients per a càlculs econòmics per concloure la pregunta principal de recerca en G&V amb un enfocament en la cirurgia de l'obesitat. Les principals conclusions de la tesi mostren que la implementació de sistemes digitals de gestió de flux de treball, a partir de l'exemple de l'SPM, millora l'eficiència i l'economia en la cirurgia de l'obesitat. L'anàlisi d'odds ratio per avaluar l'impacte en la qualitat no va permetre treure conclusions ni en ortopèdia ni en cirurgia de l'obesitat. El càlcul cost-benefici en cirurgia de l'obesitat va mostrar un estalvi de costos de 318 € per pacient, que va ascendir a 10.073 €. Aquest benefici econòmic es va aconseguir mitjançant la disminució de la durada de l'estada (-1,2 dies). Per primera vegada la investigació proporciona evidència sobre el valor econòmic dels processos digitalitzats i estandarditzats a la sala d'operacions en G&V. Els resultats facilitaran les decisions d'inversió en la digitalització de la gestió hospitalària i oferiran opcions per superar la càrrega econòmica del mercat sanitari actual. A més, les troballes proporcionen detalls detallats sobre estructures de costos específiques, càlculs, així com el reemborsament i com mesurar eficaçment l'impacte financer en els sistemes digitals de l'OR. / [EN] Digitalization in healthcare still lags compared to many other industries but offers the potential to cope with increasing challenges. This thesis examines the example of digital workflow management implemented in the surgical Operating Room (OR) and what the impact of digitalization on quality, efficiency and economics for hospital management could be. The methodology for this research is based on a quantitative approach. First, an overview and analysis of the healthcare market and an extensive systematic literature review were carried out. It was focused on the efficiency and economic impact of standardization and digitalization of intraoperative processes in the OR. The findings provided the basis for the research questions around digital workflow-management-systems. Single-center hospital data on a digital workflow-management-system, Surgical Process Manager (SPM), has been retrospectively extracted and analyzed in orthopedics and general & visceral surgery (G&V) to fill identified research gaps. Additionally, provided patient data has been retrospectively used for economic calculations to conclude the main research question in G&V, focusing on obesity surgery. The main findings of the thesis show that implementing digital workflow management systems, in the example of the SPM, improves efficiency and economics in obesity surgery. The odds ratio analysis to assess the impact on quality did not allow conclusions in orthopedics or obesity surgery. The cost-benefit calculation in obesity surgery showed cost savings of 318 € per patient, totaling 10,073€. This economic benefit was achieved by decreasing the length of stay (-1.2 days). For the first time, research provides evidence of the economic value of digitized and standardized processes in the OR in G&V. The results will facilitate investment decisions in digitization of hospital management and offer options to overcome the financial burden in the current healthcare market. Also, the findings provide in-depth details on specific cost structures, calculations, reimbursement, and how to effectively measure the financial impact on digital systems in the OR. / Von Schudnat, C. (2024). An economic analysis of digitalized and standardized workflows within the operating room [Tesis doctoral]. Universitat Politècnica de València. https://doi.org/10.4995/Thesis/10251/203008 / Compendio

This study offers insights into the impact of competition among Managed Care organizations (MCOs) on infant birthing charges and birth outcomes. Kentucky provides one of the nation’s first case studies to determine successes and failures of Medicaid MCOs, and by doing so, provides a prediction of the impact of Patient Protection Affordable Care Act (PPACA) competition on healthcare costs and birth outcomes. An analysis of a natural policy experiment in the state of Kentucky reveals that infants insured by a Medicaid MCO stay longer in hospitals, are less healthy, and cost more than those insured under Traditional Medicaid prior to a policy change. Utilizing a difference-in-difference-in-difference (DDD) estimation, this study found initial evidence in a competitive MCO environment of Traditional Medicaid average birth charges substantially more than births under a Medicaid MCO, while outcomes also revealed the incidence of normal delivery increased almost identical to that of private insurance. However, after a short time, average birth charges for infants born under Medicaid MCO climb higher than other payer-types and infant health begins to decline. Outcomes of this study signal that Managed Care infants are actually less healthy and cost substantially more than anticipated but it is possible that these outcomes can be attributed to insurance selection.

The U.S. is the only OECD country that does not offer any form of federal paid parental leave. Only three states—California, New Jersey and Rhode Island—have state paid parental leave policies; implemented in 2004, 2009 and 2014, respectively. Through descriptive statistics and a regression analysis of women and men’s wages in those three states, before and after the implementation of the policies, we assess the effects of paid leave programs on the gender wage gaps in those states. Our results show us that California’s paid family leave policy had greater effects on decreasing the gender wage gap than the policies in New Jersey and Rhode Island. In addition, our regression analysis shows us that women of childbearing age (19-45 years) saw an increase in their wages after the policy implementations, while men of childbearing age saw a decrease in their wages. This led us to the conclusion that paid family leave policies may be effective in decreasing the gender wage gap; however it is problematic that men’s wages decreased, implying that the policies may not be totally welfare optimizing. However, we came to an important conclusion that will hopefully entice more states and the federal government to implement policies to better support working parents.

O presente estudo visa analisar o contexto internacional na produção estratégica de insumos nucleares para a área da saúde e como o processo de crescente interação política entre os países influencia na tomada de decisão dos gestores dos sistemas nacionais de saúde, tendo em vista a importância de alcançarem maiores graus de autonomia frente aos oligopólios mundiais que dominam a produção de equipamentos para a saúde. Neste contexto, utilizou-se a abordagem teórica fornecida pelo estudo do Complexo Industrial em Saúde (GADELHA, 2003), que fornece elementos para discutir a interação entre o sistema de saúde e o sistema econômico-industrial, mostrando a dicotomia existente na relação entre ambos, que se exprime na deterioração do potencial de inovação do país e na vulnerabilidade externa da política de saúde. Para tanto, a escolha pela investigação do caso empírico de criação do Reator Multipropósito Brasileiro se deu pelo envolvimento de diferentes setores institucionais no processo e que influenciam diretamente na estruturação de um parque de alta densidade tecnológica e científica ligado à área da saúde que poderiam elevar o país a um patamar diferenciado em termos de cooperação internacional e estratégia geopolítica. Os métodos utilizados incluíram pesquisa bibliográfica sobre o tema e análise de dados secundários que circundam o processo de incorporação da tecnologia estudada / This study aims to analyze the international context in the production of strategic nuclear supplies to the health sector and how the process of increasing political interaction between countries influence in decision-making of managers of the national health systems, in view of the importance of achieving greater degrees of autonomy against the oligopolies that dominate the world production of equipment for health. In this context, the theoretical approach was provided by the study of the health Industrial complex (GADELHA, 2003), which provides elements to discuss the interaction between the health system and the economicindustrial system, showing the dichotomy that exists in the relationship between the two, which is expressed in the deterioration of the innovation potential of the country and in the external vulnerability of health policy. For both, the choice by the empirical case investigation of Brazilian Multipurpose Reactor took place by the involvement of different institutional sectors in the process and that influence directly in the structuring of a high scientific and technological density linked to healthcare that could elevate the country to a plateau in terms of international cooperation and geopolitical strategy. The methods used included bibliographical research and secondary data analysis that surround the process of incorporation of technology

INTRODUÇÃO: A Artrite Reumatóide (AR) é caracterizada pelo aspecto inflamatório crônico articular e é a doença autoimune mais comum em todo o mundo. A categoria de medicamentos modificadores do curso da doença (MMCD) é dividido em dois grupos, sintéticos e biológicos. Há controversos estudos em relação a comparação entre estas alternativas, principalmente, devido ao elevado custo dos biológicos. O objetivo deste estudo foi realizar uma avaliação econômica do tratamento da AR, comparando a terapia combinada de MMCD sintéticos versus MMCD biológicos, utilizando de dados da literatura e de custo na perspectiva do SUS. MÉTODOS: Foi realizado uma revisão sistemática com metanálise das bases Medline e Embase os ensaios clínicos randomizados(ECR) que fizeram comparação direta entre o uso de MMCD sintéticos versus os MMCD biológicos. A remissão foi considerada para DAS28 < 2,6. Os itens que compõe o custo seguiram a diretrizes do Ministério da Saúde do Brasil e os valores foram recuperados da tabela do Sistema de Informação Ambulatorial do SUS, e do Sistema de Gerenciamento da Tabela de Procedimentos, Medicamentos e OPM do SUS, dados do ano 2016/2017. RESULTADOS: Foram incluídos 6 ECR. No seguimento de até 6 meses o RR=0,70 (IC95% 0,57 a 0,85) a favor dos biológicos. No seguimento entre 12 a 24 meses não houve diferença estatisticamente significante, RR=0,91 (IC95% 0,80 a 1,05). Um ano do tratamento com MMCDs combinado custa R$2445,60 e os Anti-TNF custa R$ 52.821,57. CONCLUSÃO: A remissão da atividade clínica da AR pode ser obtida pelo uso de DMARD sintéticos ou por Agentes Biológicos. Análise de custo-minimização mostrou que uma economia substancial a cada mês evitado de uso dos MMCD biológicos / INTRODUCTION: Rheumatoid arthritis (RA) is the most common autoimmune disease in the world, which leads to a chronic joint inflammation. There are two types of disease-modifying anti-rheumatic drugs (DMARD): synthetical and biological. The comparison between both drugs is controversial, mostly because of the high cost of the biological ones. The aim of this study was to develop an economic evaluation of RA treatments, comparing combined therapy with synthetic DMARD versus biological DMARD, based on literature review and cost analysis on SUS data. METHODS: Systematic review with meta-analysis of randomized clinical trials (RCT) was conducted on Medline and Embase database about direct comparisons of synthetic DMARD and biological DMARD. Remission was set for DAS28 < 2.6. Cost analysis was based on the guidelines of the Brazilian Ministry of Health and cost values were extracted from the SUS\'s Ambulatory Information System table, Management System of Procedures Table, and Medicine and OPM table, for 2016/2017. RESULTS: Six RCT were included. For six months follow-up, RR=0.70 (IC95% 0.57 to 0.85) in favour of biologicals. For 12-24 months follow-up, both DMARD were similar, RR=0.91 (IC95% 0.80 to 1.05). One-year treatment with DMARD costs R$2445,60 e Anti-TNF costs R$ 52.821,57. CONCLUSION: Remission of clinical activity of RA can be reached with synthetic or biologic DMARD. Minimizing-cost analysis showed a monthly expressive saving avoinding the biologic DMARD