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Francisco Jesús Olmo-Montes,1 José Ramón Caeiro-Rey,2 Pilar Peris,3 Verónica Pérez del Río,4,5 Íñigo Etxebarria-Foronda,6 José Manuel Cancio-Trujillo,7 Teresa Pareja,8 Esteban Jódar,9 Antonio Naranjo,10 María Jesús Moro-Álvarez,11 Manuel García-Goñi,12 Josep Vergés,13 Stefano Maratia,14 Ignasi Campos Tapias,15 Miriam Prades,16 Susana Aceituno16 1Internal Medicine Department, Hospital Universitario Virgen de la Macarena, Sevilla, Spain; 2Traumatology Department, Hospital Clínico Universitario de Santiago, Santiago de Compostela, Spain; 3Rheumatology Department, Hospital Clinic de Barcelona, Barcelona, Spain; 4Traumatology Department, Hospital San Juan de la Cruz, Úbeda, Spain; 5Medicine and Dermatology Department, Faculty of Medicine of Universidad de Málaga, Málaga, Spain; 6Traumatology Department, Hospital Alto Deba, Gipuzkoa, Spain; 7Geriatrics Department, Badalona Serveis Assistencials, Badalona, Spain; 8Geriatrics Department, Hospital Universitario de Guadalajara, Guadalajara, Spain; 9Endocrinology Department, Hospital Universitario Quirón de Madrid, Madrid, Spain; 10Rheumatology Department, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, Spain; 11Internal Medicine Department, Hospital Central Universitario Cruz Roja “San Jose y Santa Adela”, Madrid, Spain; 12Department of Applied & Structural Economics and History, Faculty of Economics and Business, Universidad Complutense de Madrid, Madrid, Spain; 13Asociación Española con la Osteoporosis y la Artrosis (AECOSAR), Madrid, Spain; 14UCB Pharma S.A., Madrid, Spain; 15Amgen S.A., Barcelona, Spain; 16Outcomes’ 10, S.L.U., Castellón de la Plana, SpainCorrespondence: Antonio Naranjo, Department of Rheumatology, Hospital Universitario de Gran Canaria Doctor Negrín, Barranco de la Ballena s/n, Las Palmas de Gran Canaria, 35011, Spain, Tel +34 928450600, Email anarher@gobiernodecanarias.orgPurpose: This study evaluates the Social Return on Investment (SROI) of implementing measures to prevent fragility fractures in postmenopausal women with osteoporosis (OP) in Spain.Methods: A group of 13 stakeholders identified necessary actions for improving refracture prevention and assessed the investment required from the Spanish National Health System (SNHS), considering direct, indirect, and intangible costs over a one-year period. Unitary costs were sourced from scientific literature and official data, and intangible costs were estimated through surveys on women’s willingness to pay for better health-related quality of life. The SROI ratio was calculated from both a social perspective (including all returns) and the SNHS perspective (including only direct and intangible costs). A sensitivity analysis evaluated the returns in worst- and best-case scenarios over three years.Results: Stakeholders agreed on four main actions: 1) establishing fracture liaison services; 2) harmonizing clinical practice guidelines and provide training for healthcare professionals (HCPs); 3) promoting HCPs’ adherence to fracture registries and 4) raising awareness of OP and fragility fractures. From the social perspective, implementing these actions would cost the SNHS € 4,375,663 but yield a social return of € 96,939,931 in the first year, resulting in a SROI ratio of € 22.15 per euro invested (€ 28.69, 23.14, 24.29, and 10.70 for the four actions, respectively). From the SNHS perspective, the return would be € 36,453,509 (€ 21,523,444 tangible), with a SROI of € 8.33 (€ 4.92 tangible) and for the four actions: € 9.99, 9.39, 8.45, and 3.79, respectively (€ 5.89, 5.54, 4.96 and 2.27 tangible). The investment would be lower than the return for all actions (3.49%, 4.32%, 4.12% and 9.34% of social perspective return, respectively) and scenarios.Conclusion: According to our SROI method, implementing different actions to improve secondary fracture prevention would achieve a considerable social benefit, which, in terms of direct, indirect, and intangible costs, would far outweigh the investment.Keywords: economic evaluation, healthcare investment, prevention measures, healthcare outcomes, fracture liaison services, health-related quality of life

Unhealthy dietary habits and sedentarism coexist with a rising incidence of excess weight and associated comorbidities. We aimed to analyze the dietary and drinking patterns of patients with excess weight, their main characteristics, plausible gender differences and impact on cardiometabolic risk factors, with a particular focus on the potential contribution of beer consumption. Data from 200 consecutive volunteers (38 ± 12 years; 72% females) living with overweight or class I obesity attending the obesity unit to lose weight were studied. Food frequency questionnaires and 24 h recalls were used. Reduced-rank regression (RRR) analysis was applied to identify dietary patterns (DPs). Anthropometry, total and visceral fat, indirect calorimetry, physical activity level, comorbidities and circulating cardiometabolic risk factors were assessed. Study participants showed high waist circumference, adiposity, insulin resistance, dyslipidemia, pro-inflammatory adipokines and low anti-inflammatory factors like adiponectin and interleukin-4. A low-fiber, high-fat, energy-dense DP was observed. BMI showed a statistically significant ( p < 0.05) correlation with energy density (r = 0.80) as well as percentage of energy derived from fat (r = 0.61). Excess weight was associated with a DP low in vegetables, legumes and whole grains at the same time as being high in sweets, sugar-sweetened beverages, fat spreads, and processed meats. RRR analysis identified a DP characterized by high energy density and saturated fat exhibiting negative loadings (>-0.30) for green leafy vegetables, legumes, and fruits at the same time as showing positive factor loadings (>0.30) for processed foods, fat spreads, sugar-sweetened beverages, and sweets. Interestingly, for both women and men, wine represented globally the main source of total alcohol intake ( p < 0.05) as compared to beer and distillates. Beer consumption cannot be blamed as the main culprit of excess weight. Capturing the DP provides more clinically relevant and useful information. The focus on consumption of single nutrients does not resemble real-world intake behaviors.

Since the first biosimilar medicine, Omnitrope ® (active substance somatropin) was approved in 2006, 53 biosimilars have been authorized in Spain. We estimate the budget impact of biosimilars in Spain from the perspective of the National Health System (NHS) over the period between 2009 and 2019. Drug acquisition costs considering commercial discounts at public procurement procedures (hospital tenders) and uptake data for both originator and biosimilar as actual units consumed by the NHS were the two variables considered. Two scenarios were compared: a scenario where no biosimilars are available and the biosimilar scenario where biosimilars are effectively marketed. All molecules exposed to biosimilar competition during this period were included in the analysis. The robustness of the model was tested by conducting multiple sensitivity analyses. From the payer perspective, it is estimated that the savings produced by the adoption of biosimilars would reach EUR 2306 million over 11 years corresponding to the cumulative savings from all biosimilars. Three molecules (infliximab, somatropin and epoetin) account for 60% of the savings. This study provides the first estimation of the financial impact of biosimilars in Spain, considering both the effect of discounts that manufacturers give to hospitals and the growing market share of biosimilars. We estimate that in our last year of data, 2019, the savings derived from the use of biosimilars relative total pharmaceutical spending in Spain is 3.92%. Although more research is needed, our evidence supports the case that biosimilars represent a great opportunity to the sustainability of the NHS through rationalizing pharmaceutical spending and that the full potential of biosimilar-savings has not been achieved yet, as there is a high variability in biosimilar uptake across autonomous regions.

Background: Mental illness, multi-morbidity, and socio-economic inequalities are some of the main challenges for the public health system nowadays, and are further aggravated by the process of population aging. Therefore, it is widely accepted that health systems need to focus their strategies for confronting such concerns. With guaranteed access to health care services under universal coverage in many health systems, it is expected that all services be provided equally to patients with the same level of need., Methods: In this paper, we explore the existence of inequalities in the access to services of patients with mental illness taking into account whether they are multimorbid patients, their socioeconomic status, and their age. We take advantage of a one-year (2010-2011) database on individual healthcare utilization and expenditures for the total population (N = 2,262,698) of the Basque Country., Results: More comorbidity leads to greater inequality in prevalence, being the poor sicker, although with age, this inequality decreases. All health services are more oriented towards greater utilization of the poor and sicker, particularly in the case of visits to specialists and emergency care., Conclusions: Mental health inequalities in prevalence have been identified as being disproportionally concentrated in the least affluent areas of the Basque Country. However, inequalities in the utilization of publicly-provided health services present a pro-poor orientation. As this region has adopted a system-wide transformation towards integrated care, its mental health delivery model offers excellent potential for international comparisons and benchlearning.

Education programs are beneficial for patients with different chronic conditions. Prior studies have examined direct education, where information is transferred directly to patients. In contrast, in this program, information is transferred directly to nurses who become specialists and transfer education individually to patients. Hence, this paper evaluates the impact of having specialist nurses for stoma patients at hospitals, as those nurses provide healthcare to patients but also inform and educate patients about their condition and needs. The analysis uses an observational study with ostomized patients in Spain at hospitals with and without specialist nurses, and measures health service utilization and health-related quality of life (HRQL), besides performing a cost analysis and a cost-effectiveness analysis at both types of hospitals. The results show that patients with access to specialist nurses self-manage better, present lower adverse events and a better evolution of HRQL, and significantly demand more consultations with specialist nurses and less to A&E, primary care or specialists, resulting in important savings for the health system. Consequently, specializing or hiring nurses to provide indirect education to stoma patients is cost-effective and highly beneficial for patients. This type of indirect education strategy might be considered for specific conditions with low incidence or difficulties in identifying target patients or delivering information directly to them.

The analysis of the available databases related to HIV/AIDS confirms a paradigm shift in the patient's life expectancy: now HIV has become a chronic disease, so patients are aging. However, this advance is accompanied by a negative counterpart: due to the increase in the number of years of life gained, there is a prevalence of comorbidities greater than the general population and at an earlier age. Reducing the risk associated with all the comorbidities that the ageing patient with HIV/AIDS may develop, must now be a health objective; it must be added to the traditional objectives that until now were part of the strategy to reduce the impact of the HIV infection. In the specific case of women, it is also necessary to train peri and postmenopausal women to increase their skills and motivation to care for their health; It is also very important to examine the role that hormone replacement therapy can play in reducing their symptoms.

Objective: Predictive statistical models used in population stratification programmes are complex and usually difficult to interpret for primary care professionals. We designed FINGER (Forming and Identifying New Groups of Expected Risks), a new model based on clinical criteria, easy to understand and implement by physicians. Our aim was to assess the ability of FINGER to predict costs and correctly identify patients with high resource use in the following year., Design: Cross-sectional study with a 2-year follow-up., Setting: The Basque National Health System., Participants: All the residents in the Basque Country (Spain) ≥14 years of age covered by the public healthcare service (n=1 946 884)., Methods: We developed an algorithm classifying diagnoses of long-term health problems into 27 chronic disease groups. The database was randomly divided into two data sets. With the calibration sample, we calculated a score for each chronic disease group and other variables (age, sex, inpatient admissions, emergency department visits and chronic dialysis). Each individual obtained a FINGER score for the year by summing their characteristics' scores. With the validation sample, we constructed regression models with the FINGER score for the first 12 months as the only explanatory variable., Results: The annual FINGER scores obtained by patients ranged from 0 to 57 points, with a mean of 2.06. The coefficient of determination for healthcare costs was 0.188 and the area under the receiver operating characteristic curve was 0.838 for identifying patients with high costs (>95th percentile); 0.875 for extremely high costs (>99th percentile); 0.802 for unscheduled admissions; 0.861 for prolonged hospitalisation (>15 days); and 0.896 for death., Conclusion: FINGER presents a predictive power for high risks fairly close to other classification systems. Its simple and transparent architecture allows for immediate calculation by clinicians. Being easy to interpret, it might be considered for implementation in regions involved in population stratification programmes., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: Education leads to better health-related decisions and protective behaviors, being especially important for patients with chronic conditions. Self-management education programs have been shown to be beneficial for patients with different chronic conditions and to have a higher impact on health outcomes than does didactic education., Objective: To investigate improvements in glycemic control (measured by glycated hemoglobin A1c) in patients with type 2 diabetes mellitus., Methods: Our comparative trial involved one group of patients receiving patient-centered education and another receiving didactic education. We dealt with selection bias issues, estimated the different impact of both programs, and validated our analysis using quantile regression techniques., Results: We found evidence of better mean glycemic control in patients receiving the patient-centered program, which engaged better patients. Nevertheless, that differential impact is nonmonotonic. Patients initially at the healthy range at the patient-centered program maintained their condition better. Patients close to, but not within, the healthy range benefited equally from attending either program. Patients with very high glycemic level benefited significantly more from attending the patient-centered program. Finally, patients with the worst initial glycemic control (far from the healthy range) improved equally their diabetic condition, regardless of which program they attended., Conclusions: Different patients are sensitive to different categories of education programs. The optimal, cost-effective design of preventative programs for patients with chronic conditions needs to account for the different impact in different "patient categories." This implies stratifying patients and providing the appropriate preventative education program, or looking for alternative policy implementations for unresponsive patients who have the most severe condition and are the most costly., (Copyright © 2016 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.)

Patients with multimorbidity are responsible for more than half of all healthcare utilization, challenging the healthcare budgets of all European nations. Although the European Union is showing signs of a fragile economic recovery, achieving sustainable growth will depend on delivering a combination of fiscal responsibility, structural reforms, and improved efficiency. Addressing the challenges of multimorbidity and providing more effective, affordable, and sustainable care, has climbed the political agenda at a global, European, and national level. Current healthcare systems are poorly adapted to cope with the challenges of patients with multimorbidity. Little is known about the epidemiology and natural history of multimorbidity; the evidence base is weak; clinical guidelines are not always relevant to this population; and financing and delivery systems have not evolved to adequately measure and reward quality and performance. Pockets of innovation are, however, beginning to emerge. In Spain, for example, the ongoing economic crisis has forced regional governments to deliver substantial efficiency savings and, with this in mind, integrated care programmes have been introduced across the country for people with chronic disease and multimorbidity. Early results suggest that formalized integrated care for patients with multimorbidity improves their perceptions of care coordination, reduces hospital and emergency admissions and readmissions, and reduces average costs per capita. Such innovations require meaningful investments at a national level - something that is now supported within the framework of the European Union's Stability and Growth Pact., Competing Interests: The authors declare no conflicts of interest.

Introduction: Access to ART and health services is guaranteed under universal coverage to improve life expectancy and quality of life for HIV patients. However, it remains unknown whether patients of different socioeconomic background equally use different types of health services., Methods: We use one-year (2010-2011) data on individual healthcare utilization and expenditures for the total population (N = 2262698) of the Basque Country. We observe the prevalence of HIV and use OLS regressions to estimate the impact on health utilization of demographic, socioeconomic characteristics, and health status in such patients., Results: HIV prevalence per 1000 individuals is greater the lower the socioeconomic status (0.784 for highest; 2.135 for lowest), for males (1.616) versus females (0.729), and for middle-age groups (26-45 and 46-65). Health expenditures are 11826€ greater for HIV patients than for others, but with differences by socioeconomic group derived from a different mix of services utilization (total cost of 13058€ for poorest, 14960€ for richest). Controlling for health status and demographic variables, poor HIV patients consume more on pharmaceuticals; rich in specialists and hospital care. Therefore, there is inequity in health services utilization by socioeconomic groups., Conclusions: Equity in health provision for HIV patients represents a challenge even if access to treatment is guaranteed. Lack of information in poorer individuals might lead to under-provision while richer individuals might demand over-provision. We recommend establishing accurate clinical guidelines with the appropriate mix of health provision by validated need for all socioeconomic groups; promoting educational programs so that patients demand the appropriate mix of services, and stimulating integrated care for HIV patients with multiple chronic conditions.

Background: Multimorbidity is a major challenge for healthcare systems. However, currently, its magnitude and impact in healthcare expenditures is still mostly unknown., Objective: To present an overview of the prevalence and costs of multimorbidity by socioeconomic levels in the whole Basque population., Methods: We develop a cross-sectional analysis that includes all the inhabitants of the Basque Country (N=2,262,698). We utilize data from primary health care electronic medical records, hospital admissions, and outpatient care databases, corresponding to a 4 year period. Multimorbidity was defined as the presence of two or more chronic diseases out of a list of 52 of the most important and common chronic conditions given in the literature. We also use socioeconomic and demographic variables such as age, sex, individual healthcare cost, and deprivation level. Predicted adjusted costs were obtained by log-gamma regression models., Results: Multimorbidity of chronic diseases was found among 23.61% of the total Basque population and among 66.13% of those older than 65 years. Multimorbid patients account for 63.55% of total healthcare expenditures. Prevalence of multimorbidity is higher in the most deprived areas for all age and sex groups. The annual cost of healthcare per patient generated for any chronic disease depends on the number of coexisting comorbidities, and varies from 637 € for the first pathology in average to 1,657 € for the ninth one., Conclusion: Multimorbidity is very common for the Basque population and its prevalence rises in age, and unfavourable socioeconomic environment. The costs of care for chronic patients with several conditions cannot be described as the sum of their individual pathologies in average. They usually increase dramatically according to the number of comorbidities. Given the ageing population, multimorbidity and its consequences should be taken into account in healthcare policy, the organization of care and medical research.

This paper analyses the application of hybrid risk adjustment versus either prospective or concurrent risk adjustment formulae in the context of funding pharmaceutical benefits for the population of an integrated healthcare delivery organisation in Catalonia during years 2002 and 2003. We apply a mixed formula and find that, compared to prospective only models, a hybrid risk adjustment model increases incentives for efficiency in the provision for low risk individuals in health organisations, not only as a whole but also within each internal department, by reducing within-group variation of drug expenditures.

Star celebrities such as Rock Hudson, Freddie Mercury, Magic Johnson, and Isaac Asimov have unfortunately something in common: they were all victims of the HIV global pandemic. Since then HIV infection has become considered a pandemic disease, and it is regarded as a priority in healthcare worldwide. It is ranked as the first cause of death among young people in industrialized countries, and it is recognized as a public healthcare problem due to its human, social, mass media, and economic impact. Incorporation of new and highly active antiretroviral treatment, available since 1996 for HIV/AIDS treatment, has provoked a radical change in the disease pattern, as well as in the impact on patient survival and quality of life. The pharmaceutical industry's contribution, based on the research for more active new drugs, has been pivotal. Mortality rates have decreased significantly in 20 years by 50% and now AIDS is considered a chronic and controlled disease. In this review we have studied the impact of HAART treatment on infected patients, allowing them to maintain their status as active workers and the decreased absenteeism from work derived from this, contributing ultimately to overall social wealth and, thus, to economic growth. Furthermore, an analysis of the impact on healthcare costs, quality of life per year, life per year gained, cost economic savings and cost opportunity among other parameters has shown that society and governments are gaining major benefits from the inclusion of antiretroviral therapies in HIV/AIDS patients.

Introduction: Understanding the quality, costs and outcomes of healthcare services requires precise determination of the morbidity in a population. Measurement of morbidity in a population and its association with the services provided remains to be performed. The aim of this article was to present our experience of using clinical risk groups (CRGs) to measure morbidity in an integrated healthcare organization (IHO)., Methods: We studied the population attended by an IHO in a county (approximately 120,000 patients) from 2002 to 2005. CRGs were used to measure morbidity. A descriptive analysis was performed of the population's distribution in CRG categories and utilization rates., Results: One or more chronic diseases was found in 15.5% of the population, significant acute illness was found in 9%, minor chronic diseases was found in 7% and very severe diseases was found in 0.5%. Between 2002 and 2005, the number of individuals with chronic disease increased by 8%. The burden of illness increased with age. However, at all ages, at least 40% of the population remained healthy. Comorbidity in chronic illnesses was a crucial factor in explaining healthcare resource utilization., Conclusions: The CRG grouping system aids analysis at different levels for clinical administration. Due to its composition, this system allows better understanding of the use, costs and quality of the set of services received by a population.