The surgical-interventional cleavage in cardiovascular medicine: A brazilian health care system analysis
DOI:
https://doi.org/10.33448/rsd-v14i2.48176Keywords:
Cardiovascular diseases; Cardiovascular surgical procedures; Hospital mortality; Unified Health System; Health inequities.Abstract
This study aims to compare in-hospital mortality, costs, and length of stay between traditional cardiovascular surgery and interventional cardiology in SUS (2009–2023), evaluate temporal trends in technological substitution, and quantify long-term effects using risk-adjusted models. An ecological design analyzed aggregated data from 2,303,648 procedures. ARIMA models and negative binomial regression adjusted temporal trends and mortality risk. Results revealed accelerated technological substitution (-1.27% annual decline in surgeries; p < 0.001), with initial mortality advantage for interventional procedures (RR = 0.43; 95% CI: 0.11–0.76). However, synthetic projections showed benefit inversion by 2023 (+72.38 excess deaths), linked to an inverse learning curve for interventions (+0.83% mortality per 1% volume increase; p < 0.001). Cost savings (R$5,524/case) and shorter hospitalization (-5.07 days) coexisted with rising complexity in surgical cohorts, increasing baseline mortality risk by 0.59% annually (p < 0.001). The study concludes that technological substitution in SUS achieved economic efficiency but requires parallel investments in training and risk stratification for clinical sustainability.
References
Ali Khan, W., Raj, H., Khan, S., & Khan, F. R. (2024). The cost-effectiveness of early invasive procedures for acute coronary syndrome in low-income regions: A prospective cohort study in Pakistan. Cureus, 16(8), e68266. https://doi.org/10.7759/cureus.68266
Bernardi, F. L. M., Abizaid, A. A., Brito, F. S., Jr, Lemos, P. A., Siqueira, D. A. A., Costa, R. A., Leite, R. E. G. S., Mangione, F. M., Thiago, L. E. K. S., Mangione, J. A., Lima, V. C., Oliveira, A. D., Marino, M. A., Cardoso, C. J. F., Caramori, P. R. A., Tumelero, R., Portela, A. L. F., Prudente, M., Henriques, L. A., Souza, F. S., … Ribeiro, H. B. (2024). Learning curve for in-hospital mortality of transcatheter aortic valve replacement: Insights from the Brazilian National Registry. Arquivos Brasileiros de Cardiologia, 121(7), e20230622. https://doi.org/10.36660/abc.20230622
Burt, B. M., ElBardissi, A. W., Huckman, R. S., Cohn, L. H., Cevasco, M. W., Rawn, J. D., Aranki, S. F., & Byrne, J. G. (2015). Influence of experience and the surgical learning curve on long-term patient outcomes in cardiac surgery. The Journal of Thoracic and Cardiovascular Surgery, 150(5), 1061–1068.e3. https://doi.org/10.1016/j.jtcvs.2015.07.068
Byers, A.L. et al. (2003) ‘Application of negative binomial modeling for discrete outcomes’, Journal of Clinical Epidemiology, 56(6), pp. 559–564. doi:10.1016/s0895-4356(03)00028-3.
Caldonazo, T., et al. (2025). Cardiac surgeons at the start of their practice have similar volume/outcome association compared with established surgeons. Journal of the American Heart Association [Preprint]. https://doi.org/10.1161/jaha.124.039104
Dolan, P., & Metcalfe, R. (2010). “Oops…I did it again”: Repeated focusing effects in reports of happiness. Journal of Economic Psychology, 31(4), 732–737. https://doi.org/10.1016/j.joep.2010.05.008
Elbardissi, A. W., Duclos, A., Rawn, J. D., Orgill, D. P., & Carty, M. J. (2013). Cumulative team experience matters more than individual surgeon experience in cardiac surgery. The Journal of Thoracic and Cardiovascular Surgery, 145(2), 328–333. https://doi.org/10.1016/j.jtcvs.2012.09.022
García, C. B., Salmerón, R., García, C., & García, J. (2019). Residualization: Justification, properties and application. Journal of Applied Statistics, 47(11), 1990–2010. https://doi.org/10.1080/02664763.2019.1701638
Graham, G. N. (2016). Why your ZIP code matters more than your genetic code: Promoting healthy outcomes from mother to child. Breastfeeding Medicine, 11, 396–397. https://doi.org/10.1089/bfm.2016.0113
Guo, C., Sarkar, S., Garcia, S., & Adams, R. (2024). A theory of innovation diffusion: A simulation study. Journal of Marketing Theory and Practice, 1–23. https://doi.org/10.1080/10696679.2024.2380717
Gokhale, S. et al. (2023) ‘Hospital length of stay prediction tools for all hospital admissions and General Medicine Populations: Systematic Review and meta-analysis’, Frontiers in Medicine, 10. doi:10.3389/fmed.2023.1192969.
Hennessy, C. A., & Goodhart, C. A. (2023). Goodhart’s law and machine learning: A structural perspective. International Economic Review, 64(3), 1075–1086. https://doi.org/10.1111/iere.12633
Hidalgo, C. A. (2021). Economic complexity theory and applications. Nature Reviews Physics, 3(2), 92–113. https://doi.org/10.1038/s42254-020-00275-1
Hutubessy, R., Chisholm, D. and Edejer, T.T.-T. (2003) ‘Generalized cost-effectiveness analysis for national-level priority-setting in the health sector’, Cost Effectiveness and Resource Allocation, 1(1). doi:10.1186/1478-7547-1-8.
Jonsson, A., Binongo, J., Patel, P., Wang, Y., Garner, V., Mitchell-Cooks, D., & Halkos, M. E. (2023). Mastering the learning curve for robotic-assisted coronary artery bypass surgery. The Annals of Thoracic Surgery, 115(5), 1118–1125. https://doi.org/10.1016/j.athoracsur.2023.02.045
Li, R., Prastein, D. J., & Choi, B. G. (2024). Socioeconomic disparity in transcatheter and surgical aortic valve replacement: A population study of National Inpatient Sample from 2015 to 2020. Scientific Reports, 14(1), 11762. https://doi.org/10.1038/s41598-024-62797-3
Martins, E. B., Hueb, W., Brown, D. L., Scudeler, T. L., Lima, E. G., Rezende, P. C., Soares, P. R., Garzillo, C. L., Filho, J. P. P. L., Batista, D. V., Ramires, J. A. F., & Filho, R. K. (2021). Surgical and percutaneous revascularization outcomes based on SYNTAX I, II, and residual scores: A long-term follow-up study. Journal of Cardiothoracic Surgery, 16(1), 248. https://doi.org/10.1186/s13019-021-01616-6
Ministry of Health. (2023, August 25). Ordinance GM/MS No. 1,174, of August 25, 2023. Provides guidance on QualiSUS Cardio. Official Gazette of the Union.
Morgenstern H. (1995). Ecologic studies in epidemiology: concepts, principles, and methods. Annual review of public health, 16, 61–81. https://doi.org/10.1146/annurev.pu.16.050195.000425
Oliveira, G. M. M., Brant, L. C. C., Polanczyk, C. A., Biolo, A., Nascimento, B. R., Malta, D. C., & Souza, M. F. M. (2020). Estatística cardiovascular Brasil 2020. Arquivos Brasileiros de Cardiologia, 115(3), 308–439. https://doi.org/10.36660/abc.20200812.
Pereira A. S. et al. (2018). Metodologia da pesquisa científica. [free e-book]. Editora UAB/NTE/UFSM.
Renzi, C., Asta, F., Fusco, D., Agabiti, N., Davoli, M., & Perucci, C. A. (2014). Does public reporting improve the quality of hospital care for acute myocardial infarction? Results from a regional outcome evaluation program in Italy. International Journal for Quality in Health Care, 26(3), 223–230. https://doi.org/10.1093/intqhc/mzu041
Riggs, K. R., & Ubel, P. A. (2014). The role of professional societies in limiting indication creep. Journal of General Internal Medicine, 30(2), 249–252. https://doi.org/10.1007/s11606-014-2980-0
Roth, C., Berger, R., & Kuhn, M. (2019). The role of the socio-economic environment on medical outcomes after ST-segment elevation myocardial infarction. BMC Public Health, 19(1). https://doi.org/10.1186/s12889-019-6966-z
Santos, J. M., Martinez, A. B. R., Silva, E. J., Souza, G. R. S., & Lopes, J. K. (2021). Stroke and myocardial infarction: Effects of the “Hiperdia” and “Mais Médicos” programs on the hospitalizations trends in Brazil. International Journal of Cardiovascular Sciences, 34(5), 44–52.
Schultz, W. M., Kelli, H. M., Lisko, J. C., Varghese, T., Shen, J., Sandesara, P., & Sperling, L. S. (2018). Socioeconomic status and cardiovascular outcomes: Challenges and interventions. Circulation, 137(20), 2166–2178. https://doi.org/10.1161/CIRCULATIONAHA.117.029652
Shitsuka, R. et al. (2014). Matemática fundamental para tecnologia. (2a ed.). Editora Erica.
Souza e Silva, C. G., Klein, C. H., Godoy, P. H., Salis, L. H. A., & Silva, N. A. (2018). Up to 15-year survival of men and women after percutaneous coronary intervention paid by the Brazilian Public Healthcare System in the State of Rio de Janeiro, 1999–2010. Arquivos Brasileiros de Cardiologia, 111(4), 553–561. https://doi.org/10.36660/ijcs.20200270.
Spitzer, S., di Lego, V., Kuhn, M., Roth, C., & Berger, R. (2022). Socioeconomic environment and survival in patients after ST-segment elevation myocardial infarction (STEMI): A longitudinal study for the City of Vienna. BMJ Open, 12(7), e058698. https://doi.org/10.1136/bmjopen-2021-058698
Vieira, S. (2021). Introdução à bioestatistica. Editora GEN/Guanabara Koogan.
Villela, P. B., Klein, C. H., & Oliveira, G. M. M. (2019). Socioeconomic factors and mortality due to cerebrovascular and hypertensive disease in Brazil. Revista Portuguesa de Cardiologia, 38(3), 205–212. https://doi.org/10.1016/j.repc.2018.07.007.
Wadhera, R. K., Bhatt, D. L., Wang, T. Y., Lu, D., Lucas, J., Figueroa, J. F., Garratt, K. N., Yeh, R. W., & Joynt Maddox, K. E. (2019). Association of State Medicaid Expansion with quality of care and outcomes for low-income patients hospitalized with acute myocardial infarction. JAMA Cardiology, 4(2), 120–127. https://doi.org/10.1001/jamacardio.2018.4577
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2025 Gabriel Kaleb Martins; Maria Rayane Félix Pacífico; Maria Eduarda Dantas de Souza Reis; Karina de Jesus do Nascimento; Louise Pereira de Moraes Vieira; André Gonçalves Martins Santos; Emilly Karolliny Santos
This work is licensed under a Creative Commons Attribution 4.0 International License.
Authors who publish with this journal agree to the following terms:
1) Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution License that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.
2) Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgement of its initial publication in this journal.
3) Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work.
