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elderly patients &#40;aged &#8805;65 years&#41;&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">We performed a prospective analysis of costs in patients undergoing cardiac surgery in a high-volume surgical center between September 2011 and September 2012&#46; Patients aged &#8805;65 years who underwent elective coronary bypass graft surgery &#40;CABG&#41;&#44; valve surgery and combined CABG and valve surgery were included&#46; Urgent procedures and reoperations were excluded&#46; Subsequently&#44; two patients who underwent a repeat procedure within a month were excluded despite initially fulfilling the inclusion criteria&#44; as were another seven who were transferred to other hospitals&#44; making it impossible to calculate costs&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The study was approved by the hospital&#39;s ethics committee and all included patients gave their written informed consent&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Costs can be calculated by different methods with different degrees of precision&#46; The most precise method is micro-costing&#44; which produces a unit cost&#44; while the least precise is the mean daily cost of hospitalization&#46; Analytical accounting uses mean daily cost for all categories of costs&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">6</span></a> Micro-costing&#44; while probably better reflecting real costs&#44; is more complicated and costly to apply to all categories of costs&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">6</span></a> We decided to use micro-costing for items for which it was feasible and provided information that justified the resources required for its calculation&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">6</span></a> while costs for other categories were calculated on the basis of length of stay in different sectors of the department &#40;ward&#44; intensive care unit &#91;ICU&#93; and operating theater&#41;&#46;</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Micro-costing</span><p id="par0040" class="elsevierStylePara elsevierViewall">This method was used to calculate the costs of the following categories&#58; diagnostic exams and medical acts&#44; medications&#44; transfusion products and surgical material&#46; The number of medical acts provided for each patient in each category was obtained from the hospital&#39;s computer records and then multiplied by the corresponding unit cost&#46; The unit costs of diagnostic exams and medical acts were taken from the price list set out in Order in Council 839-A&#47;2009&#44; the prices of transfusion products were provided by the hospital&#39;s hematology department&#44; and the prices of medications and surgical material were obtained from the hospital administration&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Costing by mean length of stay</span><p id="par0045" class="elsevierStylePara elsevierViewall">Mean values were calculated on the basis of the time the patient spent in each sector of the department&#44; which was divided into three sectors&#58; ward&#44; operating theater and ICU&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">A database was constructed in which the time each patient spent in each sector and the total costs per patient&#44; per sector and for each of the following categories were recorded&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Equipment &#40;maintenance&#44; compresses&#44; syringes&#44; needles&#44; etc&#46;&#41;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0060" class="elsevierStylePara elsevierViewall">Hospital accommodation &#40;clothing&#44; cleaning&#44; electricity&#44; water&#44; food&#44; etc&#46;&#41;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0065" class="elsevierStylePara elsevierViewall">Personnel &#40;physicians&#44; nurses&#44; technicians&#44; auxiliaries&#44; administrative staff&#41;&#46;</p></li></ul></p><p id="par0070" class="elsevierStylePara elsevierViewall">The cost of each patient for each category was calculated using the following formula&#58;<elsevierMultimedia ident="eq0005"></elsevierMultimedia></p><p id="par0075" class="elsevierStylePara elsevierViewall">The costs for all patients were calculated in the same way&#44; using micro-costing for certain cost categories and mean length of stay for others&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Payment method</span><p id="par0080" class="elsevierStylePara elsevierViewall">The method of payment for hospitals&#44; set out in their contract agreements&#44; is based on the total price of each line of production&#44; using specific formulas for hospitalization&#44; outpatient care&#44; external consultations&#44; emergency services&#44; day care&#44; chronic inpatient care and homecare&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">7</span></a> With regard to hospitalization&#44; the most relevant to cardiac surgery&#44; payment is made according to the following formula&#58;<elsevierMultimedia ident="eq0010"></elsevierMultimedia></p><p id="par0085" class="elsevierStylePara elsevierViewall">The number of equivalent patients for each DRG is calculated on the basis of the number of hospitalization episodes&#44; obtained after conversion of days of hospital stay&#44; episodes of exceptional duration&#44; and patient transfers&#44; into equivalent typical or normal episodes of that DRG&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">8</span></a> Normal hospitalization times have been defined for each DRG&#59; a patient discharged following a normal or long hospitalization is considered an equivalent patient&#46; Formulas supplied by the Central Administration of the Health System &#40;ACSS&#41; are applied in cases of short hospitalizations&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">9</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">The case-mix index is calculated as the number of equivalent patients multiplied by the relative weights of the respective DRGs&#44; divided by the total number of equivalent patients&#46; The national case-mix index for each year is&#44; by definition&#44; 1&#44; but can be higher or lower in individual hospitals depending on the complexity of the patients treated&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">5&#44;8</span></a> The base rate for each hospital group is calculated on the basis of unit costs per equivalent patient&#44; using as the reference value the mean of the 30&#37; most efficient hospitals in that group&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">5&#44;8</span></a> The prices paid by the NHS in accordance with the contract agreement and the case-mix of our hospital and cardiac surgery department for 2011 and 2012 were supplied by the hospital administration&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Statistical analysis</span><p id="par0095" class="elsevierStylePara elsevierViewall">The Kolmogorov-Smirnov test was used to test the normality of the variables of age&#44; EuroSCORE I&#44; and ICU and total hospital stay&#44; with p values &#60;0&#46;05 considered statistically significant&#46; The Kruskal-Wallis test was used to compare two or more samples of continuous variables and multiple one-way ANOVA if at least one of the samples was different&#46; The latter two tests were used to analyze EuroSCORE I and ICU and total hospital stay for each procedure&#46; These variables were chosen because they are directly related to greater complexity and potentially higher costs&#46; Multifactorial regression was used to analyze costs including the explanatory factors of gender&#44; age&#44; type of procedure&#44; EuroSCORE I and proportion of hospital stay in the ICU&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Results</span><p id="par0100" class="elsevierStylePara elsevierViewall">The final population consisted of 250 patients&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows their gender distribution&#44; functional class&#44; comorbidities and type of procedure&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Mortality</span><p id="par0105" class="elsevierStylePara elsevierViewall">Mean age was 74&#46;22 years &#40;SD 5&#46;58&#41;&#44; median 74&#46;0&#46; Thirty-day mortality was 3&#46;2&#37;&#46; Predicted in-hospital 30-day mortality according to EuroSCORE I was 5&#46;97 &#40;SD 4&#46;50&#41;&#44; median 4&#46;81&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">10&#44;11</span></a> EuroSCORE I for patients undergoing combined coronary and valve surgery was 7&#46;12 &#40;SD 4&#46;45&#41;&#44; significantly higher than the 3&#46;89 &#40;SD 4&#46;71&#41; for those undergoing isolated CABG &#40;p&#60;0&#46;001&#41; but not significantly different from the 6&#46;66 &#40;SD 4&#46;14&#41; for isolated valve surgery &#40;p&#61;0&#46;807&#41;&#46; Mortality in valve surgery patients was significantly higher than for CABG patients &#40;p&#60;0&#46;001&#41;&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Hospital stay</span><p id="par0110" class="elsevierStylePara elsevierViewall">Mean ICU stay was 3&#46;27 days &#40;SD 4&#46;7&#41;&#44; median 2&#46;00 days&#46; It was significantly longer in combined CABG and valve surgery patients &#40;5&#46;89 days &#91;SD 10&#46;47&#93;&#44; median 2&#46;00&#41; and in isolated valve surgery patients &#40;3&#46;06 &#91;SD 3&#46;09&#93;&#44; median 2&#46;00&#41; than in isolated CABG patients &#40;2&#46;72 &#91;SD 3&#46;8&#93;&#44; median 2&#46;00&#41; &#40;p&#60;0&#46;05&#41;&#46; There was no significant difference between isolated valve surgery and combined CABG and valve surgery &#40;p&#61;0&#46;35&#41;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Mean hospital stay was 9&#46;92 days &#40;SD 6&#46;30&#41;&#44; median 8&#46;00 days&#46; Mean hospital stay of valve surgery patients was 9&#46;87 &#40;SD 5&#46;45&#41;&#44; median 8&#46;00&#44; and was 13&#46;70 &#40;SD 11&#46;51&#41; for combined CABG and valve surgery patients&#44; significantly longer than for CABG &#40;mean 8&#46;51 &#91;SD 4&#46;47&#93;&#44; median 7&#46;00&#41; &#40;p&#60;0&#46;05&#41;&#46; There was no significant difference between isolated valve surgery and combined CABG and valve surgery &#40;p&#61;0&#46;61&#41;&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Costs</span><p id="par0120" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the costs per procedure and per cost category&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> reveals that the cost categories of surgical material&#44; diagnostic exams and medical acts and personnel costs account for around 75&#37; of the total costs&#46; The total costs do not have a normal distribution &#40;p&#60;0&#46;05&#41;&#44; which is explained by the fact that eight patients incurred extremely high costs&#46; After eliminating these patients and performing a logarithmic transformation of the variable &#8220;costs&#8221;&#44; the normality of the transformed variable cannot be rejected &#40;p&#62;0&#46;05&#41;&#46; A multifactorial regression can then be performed with the logarithmically transformed dependent variable &#8220;costs&#8221; and the explanatory factors of gender&#44; age&#44; type of procedure&#44; EuroSCORE I and proportion of hospital stay in the ICU&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The results show higher costs for female gender &#40;p&#60;0&#46;05&#41;&#44; but no association between age and costs &#40;p&#62;0&#46;05&#41;&#46; Regarding type of procedure&#44; isolated CABG incurred lower costs than valve surgery or combined CABG and valve surgery &#40;p&#60;0&#46;05&#41;&#46; EuroSCORE I only had predictive value &#40;p&#60;0&#46;1&#41; in the sense that higher scores were associated with higher costs&#44; while a greater proportion of hospital stay in the ICU was significantly associated with higher costs &#40;p&#60;0&#46;05&#41;&#46; The variance explained by the model was 33&#37;&#44; and there were therefore other factors that significantly influenced costs which were not included in the model&#46; The importance of extreme values should be noted in the effect of longer stays in the ICU&#44; which considerably increased overall costs&#46; Of the cost categories&#44; surgical material accounted for the largest proportion of total costs&#44; and the variance explained by this category is therefore greater than the other categories&#46; Age was associated with higher personnel and equipment costs &#40;p&#62;0&#46;05&#41;&#44; while EuroSCORE I showed no association with any cost category&#46; Combined CABG and valve surgery was associated with higher costs in all categories&#44; while isolated valve surgery incurred higher costs than CABG in surgical material&#44; equipment and hospital accommodation&#46; A greater proportion of hospital stay in the ICU was associated with higher costs in all categories except hospital accommodation&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Prices</span><p id="par0135" class="elsevierStylePara elsevierViewall">We then calculated the prices paid for the patients in our sample&#44; based on values for 2011 and 2012 stipulated in the contract agreement provided by the hospital administration&#46; In 2011 the hospital&#39;s case-mix index was 2&#46;0572 and in 2012 it was 2&#46;2107&#46; The base rate was &#8364;2300 in 2011 and &#8364;2116 in 2012&#46; Payment for each cardiac surgery patient was thus &#8364;4732&#46;38 in 2011 and &#8364;4678&#46;66 in 2012&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Considering that the mean case-mix of our patients was 6&#46;4761 &#40;SD 2&#46;72&#41; in 2011 and 6&#46;2618 &#40;SD 2&#46;13&#41; in 2012&#44; and using the same base rates&#44; the prices adjusted for complexity would be &#8364;14<span class="elsevierStyleHsp" style=""></span>895&#46;03 &#40;SD 6254&#46;42&#41; in 2011 and &#8364;13<span class="elsevierStyleHsp" style=""></span>249&#46;97 &#40;SD 4518&#46;33&#41; in 2012 &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0145" class="elsevierStylePara elsevierViewall">The price paid according to the contract agreement was lower than the calculated costs for all patients in the study&#44; while the complexity-adjusted price was well above the calculated costs for all patients&#46; Consequently&#44; if payment were made per DRG episode &#40;the base rate payment&#41;&#44; costs would be completely covered&#46; Since prices paid under the contract agreement are substantially lower than the costs&#44; cardiac surgery is a net contributor to the underfunding of the hospital&#46;</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Discussion</span><p id="par0150" class="elsevierStylePara elsevierViewall">In this study we compared the calculated costs in a cardiac surgery department with the payments made according to the hospital&#39;s contract agreement&#46; The procedures under analysis were isolated CABG&#44; isolated valve surgery and combined CABG and valve surgery&#44; in patients aged &#8805;65 years&#46; Calculated costs were broken down into seven categories&#58; medication&#44; surgical material&#44; diagnostic exams and medical acts&#44; blood products&#44; personnel&#44; equipment and maintenance&#44; and hospital accommodation&#46; Calculations were based on micro-costing for categories in which this was feasible and on mean length of stay otherwise&#46; The mean overall calculated cost per surgery was &#8364;8166&#46;29 &#40;SD 4945&#46;18&#41;&#46; Certain variables were associated with higher costs in certain categories&#58; female gender &#40;higher costs for diagnostic exams&#41;&#44; type of procedure &#40;combined CABG and valve surgery&#44; the most complex&#44; incurred the highest costs in all categories&#44; while valve surgery was more costly in terms of surgical material&#44; equipment and hospital accommodation than CABG&#41;&#44; and a greater proportion of hospital stay in the ICU &#40;higher costs in all categories except hospital accommodation&#41;&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">The calculated costs were considerably lower than those reported in published studies&#44; most from the US&#44; and were closer to those seen in European hospitals&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">12&#8211;14</span></a> Studies have reported a mean cost of &#8364;29<span class="elsevierStyleHsp" style=""></span>000 for CABG<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">15</span></a> and &#8364;28<span class="elsevierStyleHsp" style=""></span>000-&#8364;40<span class="elsevierStyleHsp" style=""></span>000 for aortic valve surgery in the USA&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">12&#44;16</span></a> The prices paid for cardiac surgery vary widely between American centers&#44; and in most cases are higher than in Europe&#44; although higher prices do not produce better results&#44; and so health authorities in the USA are seeking to lower prices to the levels of those in the least expensive centers&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">17</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">The price paid per patient in our hospital was &#8364;4732&#46;38 in 2011 and &#8364;4678&#46;66 in 2012&#44; whereas the mean calculated cost in our sample was &#8364;8166&#46;29 &#40;SD 4945&#46;18&#41;&#46; It may thus appear that the cardiac surgery department has a negative impact on the hospital&#39;s budget&#44; but this is not in fact the case&#46; The hospital&#39;s case-mix index was 2&#46;0572 in 2011 and 2&#46;2107 in 2012&#44; while in our sample it was three times higher&#44; 6&#46;4761 in 2011 and 6&#46;2618 in 2012&#46; If the case-mix used to calculate prices were that of our patients&#44; the prices to be paid would be &#8364;14<span class="elsevierStyleHsp" style=""></span>895&#46;03 per patient in 2011 and &#8364;13<span class="elsevierStyleHsp" style=""></span>249&#46;97 in 2012&#44; well above both the payment made and the calculated mean cost&#46; The same amount was paid for all the patients in our sample&#46; Our analysis shows that payments for more complex patients should be calculated differently&#44; as shown by the fact that costs for combined CABG and valve surgery were higher in all categories&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Risk should also be a consideration when calculating prices&#44; since our study reveals a tendency for higher EuroSCORE I to be associated with higher costs&#46; Clinical performance&#44; although known to affect costs&#44; was not considered in this study&#46; Nevertheless&#44; the fact that predicted mortality was 6&#37;&#44; while actual mortality was around half of this &#40;3&#46;2&#37;&#41;&#44; demonstrates good clinical performance&#44; similar to the best centers&#44; which report mortality that is half of that predicted by EuroSCORE I&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Since the Portuguese NHS is funded almost entirely by the state budget&#44; and is thus under government control&#44; a funding system could be implemented that included changes in the coding of DRGs&#44; took patient complexity into consideration&#44; and indexed results to risk&#46; This should be borne in mind when considering changing the status of some departments to that of responsibility centers&#44; since funding needs to take account of the complexity of the patients treated&#46; This thinking also underlies the contract agreement system and is already applied to different types of hospital group but&#44; unfortunately&#44; not yet to different departments&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">It is hard to tell whether the frequent claims that the health system is underfunded are entirely true&#46; What we do know is that funding does not take full account of differences in the complexity of practices&#46; If every department were funded in accordance with the complexity of its cases&#44; the volume of its activity and its performance&#44; the discrepancy between prices paid and costs incurred would not be so striking&#46; Ideally&#44; funding would take into account not only complexity but also performance&#44; as shown by clinical outcomes and efficiency&#44; often now jointly defined as effectiveness&#46; The difference between prices and costs&#44; which would in this case be much less than seen in our study&#44; would ideally function as an incentive &#40;or disincentive&#41; for managers&#44; but we are still far from such a situation&#46; Our aim is not to argue as to which funding system to adopt but to take full advantage of the existing system&#44; which&#44; if the will is there&#44; can ensure that payment is in line with performance&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Limitations</span><p id="par0180" class="elsevierStylePara elsevierViewall">When calculating costs&#44; we did not include indirect costs&#44; including those resulting from patients&#8217; inability to work and care provided by families&#46; The patients in our study population were aged &#8805;65 years and had thus reached retirement age&#44; and their inability to work could therefore not be included in the costing&#44; while the costs to patients&#8217; families were not included because they are difficult to quantify and account for only a small proportion of the total costs&#46; Certain fixed costs were also excluded&#44; such as the acquisition of equipment like ventilators&#44; initial installation costs and property costs&#44; as well as the fixed costs of the hospital administration&#44; which would be hard to calculate&#46; However&#44; we have provided a detailed description of the methods used&#44; thus enabling comparison with other centers&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Conclusion</span><p id="par0185" class="elsevierStylePara elsevierViewall">The prices paid for cardiac surgery in accordance with the contract agreement were considerably lower than the calculated costs&#46; This difference may to some extent be artificial&#44; since cardiac surgery is funded according to the hospital&#39;s case-mix and not according to the case-mix of patients in the department&#46; Costs for patients undergoing CABG are significantly lower than those undergoing valve surgery&#44; which suggests that prices should be higher for more complex patients&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Ethical disclosures</span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Protection of human and animal subjects</span><p id="par0190" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Confidentiality of data</span><p id="par0195" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Right to privacy and informed consent</span><p id="par0200" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article&#46; The corresponding author is in possession of this document&#46;</p></span></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Conflicts of interest</span><p id="par0205" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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    "tienePdf" => true
    "fechaRecibido" => "2016-04-01"
    "fechaAceptado" => "2016-08-11"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec790454"
          "palabras" => array:4 [
            0 => "Costs"
            1 => "Cardiac surgery"
            2 => "Price"
            3 => "Case-mix"
          ]
        ]
      ]
      "pt" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palavras-chave"
          "identificador" => "xpalclavsec790455"
          "palabras" => array:4 [
            0 => "Custos"
            1 => "Cirurgia card&#237;aca"
            2 => "Pre&#231;o"
            3 => "<span class="elsevierStyleItalic">Case mix</span>"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction and Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Payment for cardiac surgery in Portugal is based on a contract agreement between hospitals and the health ministry&#46; Our aim was to compare the prices paid according to this contract agreement with calculated costs in a population of patients aged &#8805;65 years undergoing cardiac surgery in one hospital department&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Data on 250 patients operated between September 2011 and September 2012 were prospectively collected&#46; The procedures studied were coronary artery bypass graft surgery &#40;CABG&#41; &#40;n&#61;67&#41;&#44; valve surgery &#40;n&#61;156&#41; and combined CABG and valve surgery &#40;n&#61;27&#41;&#46; Costs were calculated by two methods&#58; micro-costing when feasible and mean length of stay otherwise&#46; Price information was provided by the hospital administration and calculated using the hospital&#39;s mean case-mix&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Thirty-day mortality was 3&#46;2&#37;&#46; Mean EuroSCORE I was 5&#46;97 &#40;standard deviation &#91;SD&#93; 4&#46;5&#37;&#41;&#44; significantly lower for CABG &#40;p&#60;0&#46;01&#41;&#46; Mean intensive care unit stay was 3&#46;27 days &#40;SD 4&#46;7&#41; and mean hospital stay was 9&#46;92 days &#40;SD 6&#46;30&#41;&#44; both significantly shorter for CABG&#46; Calculated costs for CABG were &#8364;6539&#46;17 &#40;SD 3990&#46;26&#41;&#44; for valve surgery &#8364;8289&#46;72 &#40;SD 3319&#46;93&#41; and for combined CABG and valve surgery &#8364;11<span class="elsevierStyleHsp" style=""></span>498&#46;24 &#40;SD 10<span class="elsevierStyleHsp" style=""></span>470&#46;57&#41;&#46; The payment for each patient was &#8364;4732&#46;38 in 2011 and &#8364;4678&#46;66 in 2012 based on the case-mix index of the hospital group&#44; which was 2&#46;06 in 2011 and 2&#46;21 in 2012&#59; however&#44; the case-mix in our sample was 6&#46;48 in 2011 and 6&#46;26 in 2012&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The price paid for each patient was lower than the calculated costs&#46; Prices would be higher than costs if the case-mix of the sample had been used&#46; Costs were significantly lower for CABG&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction and Objectives"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusion"
          ]
        ]
      ]
      "pt" => array:3 [
        "titulo" => "Resumo"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introdu&#231;&#227;o</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">O pagamento da cirurgia card&#237;aca &#233; feito com base num contrato entre os hospitais e o minist&#233;rio da Sa&#250;de&#46; Compar&#225;mos o pre&#231;o com o custo apurado num servi&#231;o espec&#237;fico&#44; nos doentes com idade igual ou superior a 65 anos&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material e m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudo prospetivo entre setembro 2011 e setembro 2012 em 250 doentes submetidos a cirurgia de revasculariza&#231;&#227;o coron&#225;ria &#40;n&#61;67&#41;&#44; valvular &#40;n&#61;156&#41; e coron&#225;ria associada a valvular &#40;n&#61;27&#41;&#46; Os custos foram apurados sempre que poss&#237;vel pelo m&#233;todo de microcusteio em alternativa pelo valor m&#233;dio&#46; O pre&#231;o por doente foi facultado pela administra&#231;&#227;o hospitalar&#44; calculado usando o <span class="elsevierStyleItalic">case mix</span> m&#233;dio do centro hospitalar&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Mortalidade aos 30 dias foi de 3&#44;2&#37;&#46; <span class="elsevierStyleItalic">Euroscore I</span> m&#233;dio foi 5&#44;97 desvio padr&#227;o &#40;DP&#41; 4&#44;50&#37; significativamente inferior na cirurgia coron&#225;ria&#46; Tempo m&#233;dio de UCI &#40;3&#44;27 DP 4&#44;7&#41;&#44; internamento total &#40;9&#44;92 DP 6&#44;30&#41; dias&#44; ambos significativamente inferiores na cirurgia coron&#225;ria isolada&#46; Os custos apurados para cirurgia coron&#225;ria foram &#40;6539&#44;17 DP 3990&#44;26 &#8364;&#41;&#44; valvulares &#40;8289&#44;72 DP 3319&#44;93 &#8364;&#41;&#44; valvulares com coron&#225;ria associada &#40;11<span class="elsevierStyleHsp" style=""></span>498&#44;24 DP 10<span class="elsevierStyleHsp" style=""></span>470&#44;57 &#8364;&#41;&#46; Cada doente foi pago a 4732&#44;38 em 2011 e a 4678&#44;66 em 2012&#46; usando o <span class="elsevierStyleItalic">case mix</span> do centro hospitalar que foi em 2011 &#40;2&#44;06&#41; e em 2012 &#40;2&#44;17&#41;&#46; O <span class="elsevierStyleItalic">case mix</span> da amostra foi 6&#44;48 em 2011 e 6&#44;26 em 2012&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#227;o</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">O pre&#231;o pago por doente foi inferior ao custo apurado&#46; Caso tivesse sido usado o <span class="elsevierStyleItalic">case mix</span> da amostra&#44; o pre&#231;o teria sido superior ao custo&#46; A cirurgia coron&#225;ria &#233; significativamente mais barata que a valvular&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Introdu&#231;&#227;o"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Material e m&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclus&#227;o"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Coelho P&#44; Rodrigues V&#44; Miranda L&#44; Fragata J&#44; Pita Barros P&#46; Ser&#227;o pre&#231;o e custo coincidentes na cirurgia card&#237;aca do idoso&#63; Rev Port Cardiol&#46; 2017&#59;36&#58;35&#8211;41&#46;</p>"
      ]
    ]
    "multimedia" => array:5 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1222
            "Ancho" => 2215
            "Tamanyo" => 169622
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Costs of cardiac surgery according to case-mix&#44; calculated costs&#44; and prices paid under the hospital&#39;s contract agreement&#46;</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">CABG&#58; coronary artery bypass graft surgery&#59; CS&#58; Canadian Cardiovascular Society&#59; COPD&#58; chronic obstructive pulmonary disease&#59; NYHA&#58; New York Heart Association&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Gender&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">129&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">51&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">121&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">48&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Angina &#40;CCS class&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">I&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">135&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">87&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">34&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Functional class &#40;NYHA&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">I&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">112&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">44&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">120&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hypertension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">231&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">92&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hypercholesterolemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">210&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">84&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">COPD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">230&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">92&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Creatinine &#62;2 mg&#47;dl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">245&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">98&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Smoking&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Current&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ex-smoker&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Non-smoker&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">186&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">74&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ejection fraction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Good &#40;&#62;50&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">201&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">80&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Reasonable &#40;30-50&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Poor &#40;&#60;30&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Combined CABG and valve&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Valve&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">156&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">62&#46;4&nbsp;\t\t\t\t\t\t\n
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                  <table border="0" frame="\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">559 &#40;SD 1351&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">193 &#40;SD 624&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3101 &#40;SD 699&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3421 &#40;SD 776&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2741 &#40;SD 925&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1602 &#40;SD 1251&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2606 &#40;SD 3479&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1735 &#40;SD 1731&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Blood products&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">336 &#40;SD 456&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">465 &#40;SD 580&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">735 &#40;SD 802&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">460 &#40;SD 587&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Personnel costs&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1694 &#40;SD 859&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2397 &#40;SD 2616&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1726 &#40;SD 1214&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">386 &#40;SD 217&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">387 &#40;SD 262&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8289 &#40;SD 3319&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr></tbody></table>
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                    0 => array:2 [
                      "titulo" => "A utiliza&#231;&#227;o dos GDH como instrumento de financiamento hospitalar"
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                          "etal" => true
                          "autores" => array:3 [
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                    0 => array:1 [
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                        "tituloSerie" => "J Rev Gest Hosp"
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                        "paginaFinal" => "42"
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                0 => array:3 [
                  "comentario" => "volume tem&#225;tico&#58; 7"
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                        0 => array:2 [
                          "etal" => false
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                    0 => array:1 [
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              "identificador" => "bib0100"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Os sistemas nacionais de sa&#250;de da uni&#227;o europeia&#44; principais modelos de gest&#227;o hospitalar e efici&#234;ncia no sistema hospitalar Portugu&#234;s"
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                        "editorial" => "GANEC Gabinete de an&#225;lise econ&#243;mica&#44; Faculdade de Economia de Lisboa&#46; Universidade Nova de Lisboa"
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                      "titulo" => "Economia da sa&#250;de&#58; conceitos e comportamentos"
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                    0 => array:1 [
                      "Libro" => array:4 [
                        "edicion" => "2nd revised ed&#46;"
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                        "paginaFinal" => "266"
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                0 => array:1 [
                  "referenciaCompleta" => "ACSS Administra&#231;&#227;o Central do Sistema de Sa&#250;de&#44; Metodologia para a defini&#231;&#227;o de pre&#231;os e fixa&#231;&#227;o de objectivos 2010&#46; Available at <a id="intr0010" class="elsevierStyleInterRef" href="http://www.acss.min-saude.pt/%C3%81reaseUnidades/FinanciamentoeContratualiza%C3%A7%C3%A3o/Contratualiza%C3%A7%C3%A3oHHULS/Contratualiza%C3%A7%C3%A3o2010/tabid/469/language/pt-PT/Default.aspx">www&#46;acss&#46;min-saude&#46;pt&#47;&#37;C3&#37;81reaseUnidades&#47;FinanciamentoeContratualiza&#37;C3&#37;A7&#37;C3&#37;A3o&#47;Contratualiza&#37;C3&#37;A7&#37;C3&#37;A3oHHULS&#47;Contratualiza&#37;C3&#37;A7&#37;C3&#37;A3o2010&#47;tabid&#47;469&#47;language&#47;pt-PT&#47;Default&#46;aspx</a>&#46;"
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                      "titulo" => "Methods for the economic evaluation of health care programmes"
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                            0 => "M&#46;F&#46; Drummond"
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Original Article
Do prices reflect the costs of cardiac surgery in the elderly?
Pedro Coelhoa,
Corresponding author
, Vanessa Rodriguesa, Luís Mirandaa, José Fragataa,b, Pedro Pita Barrosb
a Serviço de Cirurgia Cardiotorácica, Hospital Santa Marta, Lisboa, Portugal
b Universidade Nova de Lisboa, Lisboa, Portugal
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Costs of cardiac surgery according to case-mix&#44; calculated costs&#44; and prices paid under the hospital&#39;s contract agreement&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The Portuguese National Health Service &#40;NHS&#41; was established in 1979&#44; funded by the State budget&#44; and hospitals were paid on the basis of historical costs&#46; In the late 1980s the first steps were taken to assess the production of hospital services with the adoption of the system of classifying patients by diagnosis-related groups &#40;DRGs&#41;&#44; and in the early 1990s hospital funding moved to a contract system based on DRGs&#44; but continuing to be allocated a budget rather than payment per episode&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">1</span></a> There are two main contract systems&#58; retrospective&#44; paid on the basis of previous expenditure&#59; and prospective&#44; based on the type&#44; volume and price of the services provided&#44; which can be calculated in advance&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In recent years there have been attempts&#44; not always successful&#44; to reduce health care costs&#46; New prospective funding models have been adopted in the European Union aimed at making management more accountable for the results obtained&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">3</span></a> The amount paid for services is established in advance&#44; which encourages savings but introduces an element of uncertainty into the funding of health organizations&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">4</span></a> Payment for health care services provided by public hospitals to NHS patients is currently based on previously established contract agreements&#44; but it is questionable whether payments made for patients for particular services&#44; especially cardiac surgery&#44; match the real costs at a state of efficiency&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Patients may be overfunded or underfunded when different specialties are considered separately&#46; It is thus important to analyze the differences between what cardiac surgery actually costs the NHS and the corresponding price that is established &#40;perhaps artificially&#41; in the hospital&#39;s funding model&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Objectives</span><p id="par0020" class="elsevierStylePara elsevierViewall">To compare the price of cardiac surgery according to the contract agreement with calculated costs in one hospital department in a specific patient group &#8211; elderly patients &#40;aged &#8805;65 years&#41;&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">We performed a prospective analysis of costs in patients undergoing cardiac surgery in a high-volume surgical center between September 2011 and September 2012&#46; Patients aged &#8805;65 years who underwent elective coronary bypass graft surgery &#40;CABG&#41;&#44; valve surgery and combined CABG and valve surgery were included&#46; Urgent procedures and reoperations were excluded&#46; Subsequently&#44; two patients who underwent a repeat procedure within a month were excluded despite initially fulfilling the inclusion criteria&#44; as were another seven who were transferred to other hospitals&#44; making it impossible to calculate costs&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The study was approved by the hospital&#39;s ethics committee and all included patients gave their written informed consent&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Costs can be calculated by different methods with different degrees of precision&#46; The most precise method is micro-costing&#44; which produces a unit cost&#44; while the least precise is the mean daily cost of hospitalization&#46; Analytical accounting uses mean daily cost for all categories of costs&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">6</span></a> Micro-costing&#44; while probably better reflecting real costs&#44; is more complicated and costly to apply to all categories of costs&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">6</span></a> We decided to use micro-costing for items for which it was feasible and provided information that justified the resources required for its calculation&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">6</span></a> while costs for other categories were calculated on the basis of length of stay in different sectors of the department &#40;ward&#44; intensive care unit &#91;ICU&#93; and operating theater&#41;&#46;</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Micro-costing</span><p id="par0040" class="elsevierStylePara elsevierViewall">This method was used to calculate the costs of the following categories&#58; diagnostic exams and medical acts&#44; medications&#44; transfusion products and surgical material&#46; The number of medical acts provided for each patient in each category was obtained from the hospital&#39;s computer records and then multiplied by the corresponding unit cost&#46; The unit costs of diagnostic exams and medical acts were taken from the price list set out in Order in Council 839-A&#47;2009&#44; the prices of transfusion products were provided by the hospital&#39;s hematology department&#44; and the prices of medications and surgical material were obtained from the hospital administration&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Costing by mean length of stay</span><p id="par0045" class="elsevierStylePara elsevierViewall">Mean values were calculated on the basis of the time the patient spent in each sector of the department&#44; which was divided into three sectors&#58; ward&#44; operating theater and ICU&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">A database was constructed in which the time each patient spent in each sector and the total costs per patient&#44; per sector and for each of the following categories were recorded&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Equipment &#40;maintenance&#44; compresses&#44; syringes&#44; needles&#44; etc&#46;&#41;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0060" class="elsevierStylePara elsevierViewall">Hospital accommodation &#40;clothing&#44; cleaning&#44; electricity&#44; water&#44; food&#44; etc&#46;&#41;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0065" class="elsevierStylePara elsevierViewall">Personnel &#40;physicians&#44; nurses&#44; technicians&#44; auxiliaries&#44; administrative staff&#41;&#46;</p></li></ul></p><p id="par0070" class="elsevierStylePara elsevierViewall">The cost of each patient for each category was calculated using the following formula&#58;<elsevierMultimedia ident="eq0005"></elsevierMultimedia></p><p id="par0075" class="elsevierStylePara elsevierViewall">The costs for all patients were calculated in the same way&#44; using micro-costing for certain cost categories and mean length of stay for others&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Payment method</span><p id="par0080" class="elsevierStylePara elsevierViewall">The method of payment for hospitals&#44; set out in their contract agreements&#44; is based on the total price of each line of production&#44; using specific formulas for hospitalization&#44; outpatient care&#44; external consultations&#44; emergency services&#44; day care&#44; chronic inpatient care and homecare&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">7</span></a> With regard to hospitalization&#44; the most relevant to cardiac surgery&#44; payment is made according to the following formula&#58;<elsevierMultimedia ident="eq0010"></elsevierMultimedia></p><p id="par0085" class="elsevierStylePara elsevierViewall">The number of equivalent patients for each DRG is calculated on the basis of the number of hospitalization episodes&#44; obtained after conversion of days of hospital stay&#44; episodes of exceptional duration&#44; and patient transfers&#44; into equivalent typical or normal episodes of that DRG&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">8</span></a> Normal hospitalization times have been defined for each DRG&#59; a patient discharged following a normal or long hospitalization is considered an equivalent patient&#46; Formulas supplied by the Central Administration of the Health System &#40;ACSS&#41; are applied in cases of short hospitalizations&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">9</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">The case-mix index is calculated as the number of equivalent patients multiplied by the relative weights of the respective DRGs&#44; divided by the total number of equivalent patients&#46; The national case-mix index for each year is&#44; by definition&#44; 1&#44; but can be higher or lower in individual hospitals depending on the complexity of the patients treated&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">5&#44;8</span></a> The base rate for each hospital group is calculated on the basis of unit costs per equivalent patient&#44; using as the reference value the mean of the 30&#37; most efficient hospitals in that group&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">5&#44;8</span></a> The prices paid by the NHS in accordance with the contract agreement and the case-mix of our hospital and cardiac surgery department for 2011 and 2012 were supplied by the hospital administration&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Statistical analysis</span><p id="par0095" class="elsevierStylePara elsevierViewall">The Kolmogorov-Smirnov test was used to test the normality of the variables of age&#44; EuroSCORE I&#44; and ICU and total hospital stay&#44; with p values &#60;0&#46;05 considered statistically significant&#46; The Kruskal-Wallis test was used to compare two or more samples of continuous variables and multiple one-way ANOVA if at least one of the samples was different&#46; The latter two tests were used to analyze EuroSCORE I and ICU and total hospital stay for each procedure&#46; These variables were chosen because they are directly related to greater complexity and potentially higher costs&#46; Multifactorial regression was used to analyze costs including the explanatory factors of gender&#44; age&#44; type of procedure&#44; EuroSCORE I and proportion of hospital stay in the ICU&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Results</span><p id="par0100" class="elsevierStylePara elsevierViewall">The final population consisted of 250 patients&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows their gender distribution&#44; functional class&#44; comorbidities and type of procedure&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Mortality</span><p id="par0105" class="elsevierStylePara elsevierViewall">Mean age was 74&#46;22 years &#40;SD 5&#46;58&#41;&#44; median 74&#46;0&#46; Thirty-day mortality was 3&#46;2&#37;&#46; Predicted in-hospital 30-day mortality according to EuroSCORE I was 5&#46;97 &#40;SD 4&#46;50&#41;&#44; median 4&#46;81&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">10&#44;11</span></a> EuroSCORE I for patients undergoing combined coronary and valve surgery was 7&#46;12 &#40;SD 4&#46;45&#41;&#44; significantly higher than the 3&#46;89 &#40;SD 4&#46;71&#41; for those undergoing isolated CABG &#40;p&#60;0&#46;001&#41; but not significantly different from the 6&#46;66 &#40;SD 4&#46;14&#41; for isolated valve surgery &#40;p&#61;0&#46;807&#41;&#46; Mortality in valve surgery patients was significantly higher than for CABG patients &#40;p&#60;0&#46;001&#41;&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Hospital stay</span><p id="par0110" class="elsevierStylePara elsevierViewall">Mean ICU stay was 3&#46;27 days &#40;SD 4&#46;7&#41;&#44; median 2&#46;00 days&#46; It was significantly longer in combined CABG and valve surgery patients &#40;5&#46;89 days &#91;SD 10&#46;47&#93;&#44; median 2&#46;00&#41; and in isolated valve surgery patients &#40;3&#46;06 &#91;SD 3&#46;09&#93;&#44; median 2&#46;00&#41; than in isolated CABG patients &#40;2&#46;72 &#91;SD 3&#46;8&#93;&#44; median 2&#46;00&#41; &#40;p&#60;0&#46;05&#41;&#46; There was no significant difference between isolated valve surgery and combined CABG and valve surgery &#40;p&#61;0&#46;35&#41;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Mean hospital stay was 9&#46;92 days &#40;SD 6&#46;30&#41;&#44; median 8&#46;00 days&#46; Mean hospital stay of valve surgery patients was 9&#46;87 &#40;SD 5&#46;45&#41;&#44; median 8&#46;00&#44; and was 13&#46;70 &#40;SD 11&#46;51&#41; for combined CABG and valve surgery patients&#44; significantly longer than for CABG &#40;mean 8&#46;51 &#91;SD 4&#46;47&#93;&#44; median 7&#46;00&#41; &#40;p&#60;0&#46;05&#41;&#46; There was no significant difference between isolated valve surgery and combined CABG and valve surgery &#40;p&#61;0&#46;61&#41;&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Costs</span><p id="par0120" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the costs per procedure and per cost category&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> reveals that the cost categories of surgical material&#44; diagnostic exams and medical acts and personnel costs account for around 75&#37; of the total costs&#46; The total costs do not have a normal distribution &#40;p&#60;0&#46;05&#41;&#44; which is explained by the fact that eight patients incurred extremely high costs&#46; After eliminating these patients and performing a logarithmic transformation of the variable &#8220;costs&#8221;&#44; the normality of the transformed variable cannot be rejected &#40;p&#62;0&#46;05&#41;&#46; A multifactorial regression can then be performed with the logarithmically transformed dependent variable &#8220;costs&#8221; and the explanatory factors of gender&#44; age&#44; type of procedure&#44; EuroSCORE I and proportion of hospital stay in the ICU&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The results show higher costs for female gender &#40;p&#60;0&#46;05&#41;&#44; but no association between age and costs &#40;p&#62;0&#46;05&#41;&#46; Regarding type of procedure&#44; isolated CABG incurred lower costs than valve surgery or combined CABG and valve surgery &#40;p&#60;0&#46;05&#41;&#46; EuroSCORE I only had predictive value &#40;p&#60;0&#46;1&#41; in the sense that higher scores were associated with higher costs&#44; while a greater proportion of hospital stay in the ICU was significantly associated with higher costs &#40;p&#60;0&#46;05&#41;&#46; The variance explained by the model was 33&#37;&#44; and there were therefore other factors that significantly influenced costs which were not included in the model&#46; The importance of extreme values should be noted in the effect of longer stays in the ICU&#44; which considerably increased overall costs&#46; Of the cost categories&#44; surgical material accounted for the largest proportion of total costs&#44; and the variance explained by this category is therefore greater than the other categories&#46; Age was associated with higher personnel and equipment costs &#40;p&#62;0&#46;05&#41;&#44; while EuroSCORE I showed no association with any cost category&#46; Combined CABG and valve surgery was associated with higher costs in all categories&#44; while isolated valve surgery incurred higher costs than CABG in surgical material&#44; equipment and hospital accommodation&#46; A greater proportion of hospital stay in the ICU was associated with higher costs in all categories except hospital accommodation&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Prices</span><p id="par0135" class="elsevierStylePara elsevierViewall">We then calculated the prices paid for the patients in our sample&#44; based on values for 2011 and 2012 stipulated in the contract agreement provided by the hospital administration&#46; In 2011 the hospital&#39;s case-mix index was 2&#46;0572 and in 2012 it was 2&#46;2107&#46; The base rate was &#8364;2300 in 2011 and &#8364;2116 in 2012&#46; Payment for each cardiac surgery patient was thus &#8364;4732&#46;38 in 2011 and &#8364;4678&#46;66 in 2012&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Considering that the mean case-mix of our patients was 6&#46;4761 &#40;SD 2&#46;72&#41; in 2011 and 6&#46;2618 &#40;SD 2&#46;13&#41; in 2012&#44; and using the same base rates&#44; the prices adjusted for complexity would be &#8364;14<span class="elsevierStyleHsp" style=""></span>895&#46;03 &#40;SD 6254&#46;42&#41; in 2011 and &#8364;13<span class="elsevierStyleHsp" style=""></span>249&#46;97 &#40;SD 4518&#46;33&#41; in 2012 &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0145" class="elsevierStylePara elsevierViewall">The price paid according to the contract agreement was lower than the calculated costs for all patients in the study&#44; while the complexity-adjusted price was well above the calculated costs for all patients&#46; Consequently&#44; if payment were made per DRG episode &#40;the base rate payment&#41;&#44; costs would be completely covered&#46; Since prices paid under the contract agreement are substantially lower than the costs&#44; cardiac surgery is a net contributor to the underfunding of the hospital&#46;</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Discussion</span><p id="par0150" class="elsevierStylePara elsevierViewall">In this study we compared the calculated costs in a cardiac surgery department with the payments made according to the hospital&#39;s contract agreement&#46; The procedures under analysis were isolated CABG&#44; isolated valve surgery and combined CABG and valve surgery&#44; in patients aged &#8805;65 years&#46; Calculated costs were broken down into seven categories&#58; medication&#44; surgical material&#44; diagnostic exams and medical acts&#44; blood products&#44; personnel&#44; equipment and maintenance&#44; and hospital accommodation&#46; Calculations were based on micro-costing for categories in which this was feasible and on mean length of stay otherwise&#46; The mean overall calculated cost per surgery was &#8364;8166&#46;29 &#40;SD 4945&#46;18&#41;&#46; Certain variables were associated with higher costs in certain categories&#58; female gender &#40;higher costs for diagnostic exams&#41;&#44; type of procedure &#40;combined CABG and valve surgery&#44; the most complex&#44; incurred the highest costs in all categories&#44; while valve surgery was more costly in terms of surgical material&#44; equipment and hospital accommodation than CABG&#41;&#44; and a greater proportion of hospital stay in the ICU &#40;higher costs in all categories except hospital accommodation&#41;&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">The calculated costs were considerably lower than those reported in published studies&#44; most from the US&#44; and were closer to those seen in European hospitals&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">12&#8211;14</span></a> Studies have reported a mean cost of &#8364;29<span class="elsevierStyleHsp" style=""></span>000 for CABG<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">15</span></a> and &#8364;28<span class="elsevierStyleHsp" style=""></span>000-&#8364;40<span class="elsevierStyleHsp" style=""></span>000 for aortic valve surgery in the USA&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">12&#44;16</span></a> The prices paid for cardiac surgery vary widely between American centers&#44; and in most cases are higher than in Europe&#44; although higher prices do not produce better results&#44; and so health authorities in the USA are seeking to lower prices to the levels of those in the least expensive centers&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">17</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">The price paid per patient in our hospital was &#8364;4732&#46;38 in 2011 and &#8364;4678&#46;66 in 2012&#44; whereas the mean calculated cost in our sample was &#8364;8166&#46;29 &#40;SD 4945&#46;18&#41;&#46; It may thus appear that the cardiac surgery department has a negative impact on the hospital&#39;s budget&#44; but this is not in fact the case&#46; The hospital&#39;s case-mix index was 2&#46;0572 in 2011 and 2&#46;2107 in 2012&#44; while in our sample it was three times higher&#44; 6&#46;4761 in 2011 and 6&#46;2618 in 2012&#46; If the case-mix used to calculate prices were that of our patients&#44; the prices to be paid would be &#8364;14<span class="elsevierStyleHsp" style=""></span>895&#46;03 per patient in 2011 and &#8364;13<span class="elsevierStyleHsp" style=""></span>249&#46;97 in 2012&#44; well above both the payment made and the calculated mean cost&#46; The same amount was paid for all the patients in our sample&#46; Our analysis shows that payments for more complex patients should be calculated differently&#44; as shown by the fact that costs for combined CABG and valve surgery were higher in all categories&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Risk should also be a consideration when calculating prices&#44; since our study reveals a tendency for higher EuroSCORE I to be associated with higher costs&#46; Clinical performance&#44; although known to affect costs&#44; was not considered in this study&#46; Nevertheless&#44; the fact that predicted mortality was 6&#37;&#44; while actual mortality was around half of this &#40;3&#46;2&#37;&#41;&#44; demonstrates good clinical performance&#44; similar to the best centers&#44; which report mortality that is half of that predicted by EuroSCORE I&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Since the Portuguese NHS is funded almost entirely by the state budget&#44; and is thus under government control&#44; a funding system could be implemented that included changes in the coding of DRGs&#44; took patient complexity into consideration&#44; and indexed results to risk&#46; This should be borne in mind when considering changing the status of some departments to that of responsibility centers&#44; since funding needs to take account of the complexity of the patients treated&#46; This thinking also underlies the contract agreement system and is already applied to different types of hospital group but&#44; unfortunately&#44; not yet to different departments&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">It is hard to tell whether the frequent claims that the health system is underfunded are entirely true&#46; What we do know is that funding does not take full account of differences in the complexity of practices&#46; If every department were funded in accordance with the complexity of its cases&#44; the volume of its activity and its performance&#44; the discrepancy between prices paid and costs incurred would not be so striking&#46; Ideally&#44; funding would take into account not only complexity but also performance&#44; as shown by clinical outcomes and efficiency&#44; often now jointly defined as effectiveness&#46; The difference between prices and costs&#44; which would in this case be much less than seen in our study&#44; would ideally function as an incentive &#40;or disincentive&#41; for managers&#44; but we are still far from such a situation&#46; Our aim is not to argue as to which funding system to adopt but to take full advantage of the existing system&#44; which&#44; if the will is there&#44; can ensure that payment is in line with performance&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Limitations</span><p id="par0180" class="elsevierStylePara elsevierViewall">When calculating costs&#44; we did not include indirect costs&#44; including those resulting from patients&#8217; inability to work and care provided by families&#46; The patients in our study population were aged &#8805;65 years and had thus reached retirement age&#44; and their inability to work could therefore not be included in the costing&#44; while the costs to patients&#8217; families were not included because they are difficult to quantify and account for only a small proportion of the total costs&#46; Certain fixed costs were also excluded&#44; such as the acquisition of equipment like ventilators&#44; initial installation costs and property costs&#44; as well as the fixed costs of the hospital administration&#44; which would be hard to calculate&#46; However&#44; we have provided a detailed description of the methods used&#44; thus enabling comparison with other centers&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Conclusion</span><p id="par0185" class="elsevierStylePara elsevierViewall">The prices paid for cardiac surgery in accordance with the contract agreement were considerably lower than the calculated costs&#46; This difference may to some extent be artificial&#44; since cardiac surgery is funded according to the hospital&#39;s case-mix and not according to the case-mix of patients in the department&#46; Costs for patients undergoing CABG are significantly lower than those undergoing valve surgery&#44; which suggests that prices should be higher for more complex patients&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Ethical disclosures</span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Protection of human and animal subjects</span><p id="par0190" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Confidentiality of data</span><p id="par0195" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Right to privacy and informed consent</span><p id="par0200" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article&#46; The corresponding author is in possession of this document&#46;</p></span></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Conflicts of interest</span><p id="par0205" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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              "titulo" => "Payment method"
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    "fechaRecibido" => "2016-04-01"
    "fechaAceptado" => "2016-08-11"
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          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec790454"
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            0 => "Costs"
            1 => "Cardiac surgery"
            2 => "Price"
            3 => "Case-mix"
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          "palabras" => array:4 [
            0 => "Custos"
            1 => "Cirurgia card&#237;aca"
            2 => "Pre&#231;o"
            3 => "<span class="elsevierStyleItalic">Case mix</span>"
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    "resumen" => array:2 [
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction and Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Payment for cardiac surgery in Portugal is based on a contract agreement between hospitals and the health ministry&#46; Our aim was to compare the prices paid according to this contract agreement with calculated costs in a population of patients aged &#8805;65 years undergoing cardiac surgery in one hospital department&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Data on 250 patients operated between September 2011 and September 2012 were prospectively collected&#46; The procedures studied were coronary artery bypass graft surgery &#40;CABG&#41; &#40;n&#61;67&#41;&#44; valve surgery &#40;n&#61;156&#41; and combined CABG and valve surgery &#40;n&#61;27&#41;&#46; Costs were calculated by two methods&#58; micro-costing when feasible and mean length of stay otherwise&#46; Price information was provided by the hospital administration and calculated using the hospital&#39;s mean case-mix&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Thirty-day mortality was 3&#46;2&#37;&#46; Mean EuroSCORE I was 5&#46;97 &#40;standard deviation &#91;SD&#93; 4&#46;5&#37;&#41;&#44; significantly lower for CABG &#40;p&#60;0&#46;01&#41;&#46; Mean intensive care unit stay was 3&#46;27 days &#40;SD 4&#46;7&#41; and mean hospital stay was 9&#46;92 days &#40;SD 6&#46;30&#41;&#44; both significantly shorter for CABG&#46; Calculated costs for CABG were &#8364;6539&#46;17 &#40;SD 3990&#46;26&#41;&#44; for valve surgery &#8364;8289&#46;72 &#40;SD 3319&#46;93&#41; and for combined CABG and valve surgery &#8364;11<span class="elsevierStyleHsp" style=""></span>498&#46;24 &#40;SD 10<span class="elsevierStyleHsp" style=""></span>470&#46;57&#41;&#46; The payment for each patient was &#8364;4732&#46;38 in 2011 and &#8364;4678&#46;66 in 2012 based on the case-mix index of the hospital group&#44; which was 2&#46;06 in 2011 and 2&#46;21 in 2012&#59; however&#44; the case-mix in our sample was 6&#46;48 in 2011 and 6&#46;26 in 2012&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The price paid for each patient was lower than the calculated costs&#46; Prices would be higher than costs if the case-mix of the sample had been used&#46; Costs were significantly lower for CABG&#46;</p></span>"
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          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction and Objectives"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Methods"
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          2 => array:2 [
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            "titulo" => "Results"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introdu&#231;&#227;o</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">O pagamento da cirurgia card&#237;aca &#233; feito com base num contrato entre os hospitais e o minist&#233;rio da Sa&#250;de&#46; Compar&#225;mos o pre&#231;o com o custo apurado num servi&#231;o espec&#237;fico&#44; nos doentes com idade igual ou superior a 65 anos&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material e m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudo prospetivo entre setembro 2011 e setembro 2012 em 250 doentes submetidos a cirurgia de revasculariza&#231;&#227;o coron&#225;ria &#40;n&#61;67&#41;&#44; valvular &#40;n&#61;156&#41; e coron&#225;ria associada a valvular &#40;n&#61;27&#41;&#46; Os custos foram apurados sempre que poss&#237;vel pelo m&#233;todo de microcusteio em alternativa pelo valor m&#233;dio&#46; O pre&#231;o por doente foi facultado pela administra&#231;&#227;o hospitalar&#44; calculado usando o <span class="elsevierStyleItalic">case mix</span> m&#233;dio do centro hospitalar&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Mortalidade aos 30 dias foi de 3&#44;2&#37;&#46; <span class="elsevierStyleItalic">Euroscore I</span> m&#233;dio foi 5&#44;97 desvio padr&#227;o &#40;DP&#41; 4&#44;50&#37; significativamente inferior na cirurgia coron&#225;ria&#46; Tempo m&#233;dio de UCI &#40;3&#44;27 DP 4&#44;7&#41;&#44; internamento total &#40;9&#44;92 DP 6&#44;30&#41; dias&#44; ambos significativamente inferiores na cirurgia coron&#225;ria isolada&#46; Os custos apurados para cirurgia coron&#225;ria foram &#40;6539&#44;17 DP 3990&#44;26 &#8364;&#41;&#44; valvulares &#40;8289&#44;72 DP 3319&#44;93 &#8364;&#41;&#44; valvulares com coron&#225;ria associada &#40;11<span class="elsevierStyleHsp" style=""></span>498&#44;24 DP 10<span class="elsevierStyleHsp" style=""></span>470&#44;57 &#8364;&#41;&#46; Cada doente foi pago a 4732&#44;38 em 2011 e a 4678&#44;66 em 2012&#46; usando o <span class="elsevierStyleItalic">case mix</span> do centro hospitalar que foi em 2011 &#40;2&#44;06&#41; e em 2012 &#40;2&#44;17&#41;&#46; O <span class="elsevierStyleItalic">case mix</span> da amostra foi 6&#44;48 em 2011 e 6&#44;26 em 2012&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#227;o</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">O pre&#231;o pago por doente foi inferior ao custo apurado&#46; Caso tivesse sido usado o <span class="elsevierStyleItalic">case mix</span> da amostra&#44; o pre&#231;o teria sido superior ao custo&#46; A cirurgia coron&#225;ria &#233; significativamente mais barata que a valvular&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Coelho P&#44; Rodrigues V&#44; Miranda L&#44; Fragata J&#44; Pita Barros P&#46; Ser&#227;o pre&#231;o e custo coincidentes na cirurgia card&#237;aca do idoso&#63; Rev Port Cardiol&#46; 2017&#59;36&#58;35&#8211;41&#46;</p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Costs of cardiac surgery according to case-mix&#44; calculated costs&#44; and prices paid under the hospital&#39;s contract agreement&#46;</p>"
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          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">CABG&#58; coronary artery bypass graft surgery&#59; CS&#58; Canadian Cardiovascular Society&#59; COPD&#58; chronic obstructive pulmonary disease&#59; NYHA&#58; New York Heart Association&#46;</p>"
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Gender&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">129&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">51&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">121&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">48&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Angina &#40;CCS class&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">I&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">135&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">87&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">34&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Functional class &#40;NYHA&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">I&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">112&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">44&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">120&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hypertension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">231&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">92&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hypercholesterolemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">210&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">84&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">COPD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">230&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">92&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Creatinine &#62;2 mg&#47;dl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">245&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">98&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Smoking&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Current&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ex-smoker&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Non-smoker&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">186&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">74&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ejection fraction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Good &#40;&#62;50&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">201&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">80&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Reasonable &#40;30-50&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Poor &#40;&#60;30&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Procedure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CABG&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Combined CABG and valve&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Valve&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">156&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">62&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">CABG&#58; coronary artery bypass graft surgery&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">CABG&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Valve&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">CABG and valve&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Medication&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">182 &#40;SD 777&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">135 &#40;SD 192&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">559 &#40;SD 1351&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">193 &#40;SD 624&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Surgical material&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1631 &#40;SD 324&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3101 &#40;SD 699&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3421 &#40;SD 776&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2741 &#40;SD 925&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diagnostic exams and medical acts&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1694 &#40;SD 1584&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1602 &#40;SD 1251&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2606 &#40;SD 3479&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1735 &#40;SD 1731&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Blood products&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">336 &#40;SD 456&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">465 &#40;SD 580&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">735 &#40;SD 802&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">460 &#40;SD 587&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Personnel costs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1529 &#40;SD 954&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1694 &#40;SD 859&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2397 &#40;SD 2616&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1726 &#40;SD 1214&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Equipment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">833 &#40;SD 587&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11<span class="elsevierStyleHsp" style=""></span>498 &#40;SD 10<span class="elsevierStyleHsp" style=""></span>470&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8166 &#40;SD 4945&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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Article information
ISSN: 21742049
Original language: English
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Idiomas
Revista Portuguesa de Cardiologia (English edition)
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