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Background Socioeconomic position (SEP) powerfully affects health status in the childhood population. However, the knowledge of which diseases are more affected by SEP and whose outcomes could be improved by having a more equitable society remains uncertain on a population basis. Methods We measured socioeconomic and gender inequalities in the pre-COVID-19 era for 29 diseases in the entire childhood population in Catalonia to identify which diseases are most impacted by inequalities. This population-based study included 1,449,816 children under 15 years old from 2014 to 2017 (48.52% girls) and each of their registered diagnoses within the Catalonia National Health System. We calculated frequency measures by SEP and their sex ratios for each disease. We estimated four regression-based inequality measures: slope index of inequality, relative index of inequality (RII), absolute population-attributable fraction, and population-attributable fraction. Results Twenty-five of the 29 diseases examined showed SEP inequalities. The diseases with the greatest inequalities in both sexes were tuberculosis, obesity, adjustment and anxiety disorders, essential hypertension, poisoning, short gestation, low birth weight, foetal growth retardation and intrauterine hypoxia and birth asphyxia and trauma (RII ≥ 2.0); only food allergy showed the opposite pattern (RII p p Conclusions Socioeconomic and gender inequalities are widely present in childhood health. This indicates that SEP plays a common role in their development although it varies in magnitude according to each disease. It is also a phenomenon that comprises all SEP groups in society. Action needs to be taken to ensure a fairer start in life in terms of health.

BackgroundChildren with medical complexity (CMC) denotes the profile of a child with diverse acute and chronic conditions, making intensive use of the healthcare services and with special health and social needs. Previous studies show that CMC are also affected by the socioeconomic position (SEP) of their family. The aim of this study is to describe the pathologic patterns of CMC and their socioeconomic inequalities in order to better manage their needs, plan healthcare services accordingly, and improve the care models in place.MethodsCross-sectional study with latent class analysis (LCA) of the CMC population under the age of 15 in Catalonia in 2016, using administrative data. LCA was used to define multimorbidity classes based on the presence/absence of 57 conditions. All individuals were assigned to a best-fit class. Each comorbidity class was described and its association with SEP tested. The Adjusted Morbidity Groups classification system (Catalan acronym GMA) was used to identify the CMC. The main outcome measures were SEP, GMA score, sex, and age distribution, in both populations (CMC and non-CMC) and in each of the classes identified.Results71% of the CMC population had at least one parent with no employment or an annual income of less than €18,000. Four comorbidity classes were identified in the CMC: oncology (36.0%), neurodevelopment (13.7%), congenital and perinatal (19.8%), and respiratory (30.5%). SEP associations were: oncology OR 1.9 in boys and 2.0 in girls; neurodevelopment OR 2.3 in boys and 1.8 in girls; congenital and perinatal OR 1.7 in boys and 2.1 in girls; and respiratory OR 2.0 in boys and 2.0 in girls.ConclusionsOur findings show the existence of four different patterns of comorbidities in CMC and a significantly high proportion of lower SEP children in all classes. These results could benefit CMC management by creating more efficient multidisciplinary medical teams according to each comorbidity class and a holistic perspective taking into account its socioeconomic vulnerability.

Lung cancer screening programs with computed tomography of the chest reduce mortality by more than 20%. Yet, they have not been implemented widely because of logistic and cost implications. Here, we sought to: (1) use real-life data to compare the outcomes and cost of lung cancer patients with treated medically or surgically in our region and (2) from this data, estimate the cost-benefit ratio of a lung cancer screening program (CRIBAR) soon to be deployed in our region (Catalunya, Spain). We accessed the Catalan Health Surveillance System (CHSS) and analysed data of all patients with a first diagnosis of lung cancer between 1 January 2014 and 31 December 2016. Analysis was carried forward until 30 months (t = 30) after lung cancer diagnosis. Main results showed that: (1) surgically treated lung cancer patients have better survival and return earlier to regular home activities, use less healthcare related resources and cost less tax-payer money and (2) depending on incidence of lung cancer identified and treated in the program (1-2%), the return on investment for CRIBAR is expected to break even at 3-6 years, respectively, after its launch. Surgical treatment of lung cancer is cheaper and offers better outcomes. CRIBAR is estimated to be cost-effective soon after launch.

Background: In Spain, legislation was passed in 2012 excluding undocumented migrants from the public health-care system. Catalonia was one of the Spanish regions that did not implement this legislation, and continued to guarantee access to health care to the whole population. We aimed to analyse health-care use and health status among undocumented migrants in Catalonia, and compare health-care use and health status with legal residents classified according to their socioeconomic position (SEP). Methods: We did a population-based, cross-sectional study, with administrative individual data. The study included the resident population in Catalonia, Spain, in 2017, aged younger than 65 years and with a maximum annual income of less than €18 000 per year, and classified into three socioeconomic (SEP) groups—low SEP, very low SEP, and undocumented migrants. Indicators regarding health-care service use (primary care, emergency care, mental health care, acute care), drug prescriptions, and selected chronic and infectious diseases were analysed. Findings: Between Jan 1 and Dec 31, 2017, 4 071 988 residents of Catalonia were included in this study; undocumented migrants represented 2·8% (n=113 450) of this population. Of all undocumented migrants, 25 942 (61·0%) female participants aged 15–64 years and 19 819 (46·0%) male participants aged 15–64 years attended primary health-care centres: these rates were lower than in individuals with a very low SEP (84·8% in female participants and 72·1% in male participants). Hospital admission rates among male participants aged 15–64 years in the very low SEP group were more than three times as high as in undocumented migrants (111·6 vs 35·7). The highest tuberculosis rate was found in undocumented male migrants (incidence rate 4·35 [95% CI 3·55–5·16]). Interpretation: Undocumented migrants made less use of health-care services than those in the low and very low SEP groups, but for some infectious diseases, incidence was higher in undocumented migrants. These results constitute an additional argument to support the maintenance of universal health coverage for all citizens. Funding: None. © 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license

Aim To describe nursing-sensitive indicators measured in Catalonia. Background In Catalonia, since 2012, under the umbrella of the Results Centre, outcomes of every health care setting have been published and made open to health care professionals and citizens. Methods Trends study of nursing-sensitive indicators was based on data collected systematically from each setting from 2012 to 2018. Percentages and rates were calculated for each of 14 indicators analysed from all primary care, hospitals and long-term care centres. Results Percentage of population aged 60 years or older correctly vaccinated against flu has been decreasing, while percentage of population aged 14 years or under with correct vaccine status is high (over 91%) and has remained stable over time. Mortality in patients who have developed complications has increased, from 27.1% in 2012 to 34.0% in 2017. Most centres achieved functional improvements during the first 30 days of admission. Conclusions Among all indicators measured in primary care, hospital and long-term care, only 14 analysed are nursing-sensitive; no nursing-sensitive indicators regarding mental health are measured. Implications for nursing management Research focused on development of nursing-sensitive indicators offers an opportunity to measure and benchmark nurses' quality of care and their contribution in achieving populations' health improvement and health care system sustainability.

Background According to many conceptual frameworks, the first step in the monitoring cycle of health inequalities is the selection of relevant topics and indicators. However, some difficulties may arise during this selection process due to a high variety of contextual factors that may influence this step. In order to help accomplish this task successfully, a comprehensive review of the most common topics and indicators for measuring and monitoring health inequalities in countries/regions with similar socioeconomic and political status as Catalonia was performed. Methods We describe the processes and criteria used for selecting health indicators from reports, studies, and databases focusing on health inequalities. We also describe how they were grouped into well-known health topics. The topics were filtered and ranked by the number of indicators they accounted for. Results We found 691 indicators used in the study of health inequalities. The indicators were grouped into 120 topics, 34 of which were selected for having five indicators or more. Most commonly found topics in the list include “Life expectancy”, “Infant mortality”, “Obesity and overweight (BMI)”, “Mortality rate”, “Regular smokers/tobacco consumption”, “Self-perceived health”, “Unemployment”, “Mental well-being”, “Cardiovascular disease/hypertension”, “Socioeconomic status (SES)/material deprivation”. Conclusions A wide variety of indicators and topics for the study of health inequalities exist across different countries and organisations, although there are some clear commonalities. Reviewing the use of health indicators is a key step to know the current state of the study of health inequalities and may show how to lead the way in understanding how to overcome them.

Background: In recent years, worldwide opioid use has seen a sharp increase, especially for the treatment of chronic non-cancer pain. Catalonia is no exception to this trend. However, no recent studies have addressed the socioeconomic and gender inequalities in opioid use in the different geographical areas of Catalonia.Methods: We performed an ecological study to analyse the associations between socioeconomic status, gender and the use of opioids in the 372 Health Areas of Catalonia. Robust Poisson models were performed to analyse the data provided from the Central Register of Insured Persons and dispensing data from the Electronic Prescription Database.Results: The results show that socioeconomic status has a major impact on opioid use, with the most deprived areas presenting the highest levels of use. There are major inequalities in the DDD/1,000 inhabitants per areas. Moreover, women have much higher utilization rates than men, especially in more deprived areas. The greatest difference is observed in the use of weak opioids in women: the DDD/1,000 inhabitants per day was 2.34 in the area with the lowest use, compared with 22.18 in the area with the highest use.Conclusions: Our findings suggest that stronger action is needed to promote best practices in prescribing for chronic pain and to reduce socioeconomic and gender variation between geographical areas. This study provides a model for routine monitoring of opioid prescription for targeted interventions aimed at lowering high-dose consumption in specifically identified areas.

Background The number of days spent at home in the last six months of life has been proposed as a comprehensive indicator of high-value patient-centered care; however, information regarding the determinants of this outcome is scarce, particularly among the general population. We investigated the determinants of spending time at home within the six months preceding death. Methods Population-based, retrospective analysis of administrative databases of the Catalan government. The analysis included adult (≥18 years) individuals who died in Catalonia (North-east Spain) in 2017 and met the McNamara criteria for palliative care. The primary outcome was the number of days spent at home within the last 180 days of life. Other variables included the cause of death, demographic characteristics, and socioeconomic status, stratified as very low, low, mid, and high level. Results The analysis included 40,137 individuals (19,510 women; 20,627 men), who spent a median of 140 days (IQR 16–171) at home within the six months preceding death (women 140 [16–171]; men 150 [100–171]). Female gender was an independent factor of staying fewer days at home (OR 0.80 [95% CI 0.77–0.82]; ppppp Conclusions Our results suggest that end-of-life care is associated with gender and socioeconomic inequalities; women and individuals with lower socioeconomic status spend less time at home within the last 180 days of life.

Rationale: Randomized controlled trials do not support a role for continuous positive airway pressure (CPAP) in preventing major cardiovascular events or mortality in patients with obstructive sleep apnea (OSA). However, these trials' setting does not apply to most CPAP-treated patients. Objectives: We aimed to assess the effect of CPAP on mortality in real-world patients. Methods: We performed a population-based longitudinal observational study including all patients with OSA prescribed CPAP during 2011 in Catalonia, Spain, and non-OSA control subjects matched (1:2) by sex, 5-year age group, and region who were followed from 2011 to 2016. Results: A total of 9,317 CPAP-treated patients with OSA and 18,370 control subjects without OSA were included (median age, 67 [57-72] years; 74% male). During a median follow-up of 5.5 years, 2,301 deaths were recorded. After adjustment by a composite of diagnosed comorbidities and previous use of healthcare resources, CPAP-treated patients showed a lower risk of death than control subjects (hazard ratio [HR], 0.67; 95% confidence interval [CI], 0.61-0.74), with the association not being statistically significant in women. Cancer-related deaths were the main drivers of this association (men: HR, 0.44; 95% CI, 0.36-0.54; women: HR, 0.44; 95% CI, 0.28-0.68). No significant associations were found for cardiovascular-related deaths. CPAP-treated women had an increased risk of respiratory-related death (HR, 2.41; 95% CI, 1.37-4.23). Conclusions: CPAP-treated patients had a lower mortality rate than control subjects. This relationship was driven by cancer-related, but not cardiovascular-related, deaths. Results suggest a role for sex when prescribing CPAP, especially considering respiratory-related deaths, and foster a debate on the relationship between OSA and cardiovascular outcomes.

BackgroundAdvance directives (ADs) have been legally regulated to promote autonomy over health decisions among patients who later lose decision-making capacity.Aims and objectivesTo analyse the differences in clinical practice at end of life among people who had completed an AD versus those who had not.MethodsRetrospective case–control study (1:2), matched by age, sex, year, cause of death and region of residence. The data sources used were the ADs registry, central registry of insured persons, hospital discharge, pharmacy and billing databases, and the mortality registry. Conditional logistic regression models (crude and adjusted by socioeconomic level) were performed. The outcome variable was the frequency of medical procedures performed during the last year of life.Results1723 people with ADs who died in Catalonia during 2014–2015 were matched with 3446 dead controls (without ADs). Thoracentesis was the procedure with the greatest reduction among women with an AD (adjusted OR (ORadj) 0.54, 95% CI: 0.32 to 0.89) in conjunction with artificial nutrition (ORadj 0.54, 95% CI: 0.31 to 0.95). Intubation was the procedure with the greatest reduction (ORadj 0.56, 95% CI: 0.33 to 0.94) among men. Slight differences could be seen in the case of cancer deaths. There were no relevant differences when adjusting by socioeconomic level.ConclusionsADs are an effective tool to adjust the realisation of some procedures at end of life. These results can help better plan for the treatment of patients with ADs, as well as increase the awareness among clinical personnel, families and the general population.

BACKGROUND: Over the last decade, telemedicine services have been introduced in the public health care systems of several industrialized countries. In Catalonia, the use of eConsulta, an asynchronous teleconsultation service between primary care professionals and citizens in the public health care system, has already reached 1 million cases. Before the COVID-19 pandemic, the use of eConsulta was growing at a monthly rate of 7%, and the growth has been exponential from March 15, 2020 to the present day. Despite its widespread usage, there is little qualitative evidence describing how this tool is used. OBJECTIVE: The aim of this study was to annotate a random sample of teleconsultations from eConsulta, and to evaluate the level of agreement between health care professionals with respect to the annotation. METHODS: Twenty general practitioners retrospectively annotated a random sample of 5382 cases managed by eConsulta according to three aspects: the type of interaction according to 6 author-proposed categories, whether the practitioners believed a face-to-face visit was avoided, and whether they believed the patient would have requested a face-to-face visit had eConsulta not been available. A total of 1217 cases were classified three times by three different professionals to assess the degree of consensus among them. RESULTS: The general practitioners considered that 79.60% (4284/5382) of the teleconsultations resulted in avoiding a face-to-face visit, and considered that 64.96% (3496/5382) of the time, the patient would have made a face-to-face visit in the absence of a service like eConsulta. The most frequent uses were for management of test results (26.77%, 1433/5354), management of repeat prescriptions (24.30%, 1301/5354), and medical enquiries (14.23%, 762/5354). The degree of agreement among professionals as to the annotations was mixed, with the highest consensus demonstrated for the question "Has the online consultation avoided a face-to-face visit?" (3/3 professionals agreed 67.95% of the time, 827/1217), and the lowest consensus for the type of use of the teleconsultation (3/3 professionals agreed 57.60% of the time, 701/1217). CONCLUSIONS: This study shows the ability of eConsulta to reduce the number of face-to-face visits for 55% (79% × 65%) to 79% of cases. In comparison to previous research, these results are slightly more pessimistic, although the rates are still high and in line with administrative data proxies, showing that 84% of patients using teleconsultations do not make an in-person appointment in the following 3 months. With respect to the type of consultation performed, our results are similar to the existing literature, thus providing robust support for eConsulta's usage. The mixed degree of consensus among professionals implies that results derived from artificial intelligence tools such as message classification algorithms should be interpreted in light of these shortcomings., This study was conducted with the support of the Secretary of Universities and Research of the Department of Business and Knowledge of the Government of Catalonia

Background eConsulta is a teleconsultation service involving general practitioners (GPs) and patients. It is part of the information system belonging to Catalonia’s primary care service. It has been in operation since the end of 2015 in conjunction with face-to-face consultations with Primary Care Teams as one of the services offered in the patient’s Personal Health Folder. Objective This study aimed to assess the ability of using eConsulta to reduce the number of face-to-face visits to Primary Care Teams. Methods Using 13 categories proposed by the researchers, 18 GPs from the Central Catalonia Health Region retrospectively classified 2268 cases managed with eConsulta and indicated whether, in their opinion, the teleconsultations reduced the number of face-to-face visits. Results There was broad consensus among the GPs that eConsulta has the potential to resolve patient queries for every type of consultation. eConsulta avoided the need for a face-to-face visit in 87.9% of cases. In addition, the GPs reported that the ease of access increased the demand for health care support in 27.7% of cases; otherwise, the patient would not have initiated the queries. Therefore, based on the equation (88% x [1-28%]), eConsulta could replace 63%-88% of conventional appointments. The most frequent uses of the teleconsultation service were for management of test results (35.2%), medical enquiries (16.0%), and the management of repeat prescriptions (12.2%). On average, the teleconsultations consisted of a mean 1.57 messages (SD 0.54 messages); 45.9% (1040/2268) of the teleconsultations consisted of 1 message, and the majority of the remaining teleconsultations consisted of 2-5 interactions. The patient initiated 60.0% (1361/2268) of the teleconsultations. Conclusions Based on the GPs’ perceptions, eConsulta could replace 63%-88% of conventional appointments. Therefore, asynchronous teleconsultations between practitioners and patients in primary care could avoid interactions that have limited added clinical value.

IntroductionIn Catalonia caesarean rates have always been analysed as a single percentage. The objective is to estimate caesarean section rates using the Robson classification in publicly funded hospitals in Catalonia between 2013 and 2017, considering sociodemographic, institutional and obstetric characteristics.Materials and methodsCross-sectional population-based study in Catalonia including all women delivering within publicly funded hospitals between 2013-2017 (n = 210 020). The modified Robson classification distribution was estimated, the caesarean rate and the overall contribution, analysed for each year, and by confounders, through logistic regression models.ResultsCS rates decreased steadily between 2013 and 2017 in Catalonia within publicly funded hospitals from 24.3% to 22.8% (cOR 0.92, 95% CI; 0.89 to 0.95). Once adjusted for changes in sociodemographic, institutional and obstetric characteristics the observed decline was even more pronounced (aOR 0.87, 95% CI; 0.84 to 0.90). Within the different groups of Robson once adjusted for confounders, groups 1+2 (aOR 0.88, 95% CI; 0.83 to 0.93), 3+4 (aOR 0.83, 95% CI; 0.78 to 0.89) and 10 (aOR 0.78, 95% CI; 0.68 to 0.90) presented a reduction in caesarean section rates, whereas group 5 showed no significant decrease (aOR 0.95, 95% CI; 0.87 to 1.03%).ConclusionsThe decrease in caesarean section rates in Catalonia is more pronounced when adjusted for known confounders, suggesting retrospective overutilization of caesarean section and percentages of (in)adequacy in the past. In any case, it remains above the recommended by experts. Further efforts should be made to achieve optimum rates, including improvement on obstetric data collection.

Mental disorders (MD) are one of the main causes of the disease burden worldwide. Associations between socioeconomic status (SES) and presence of MD in parents have been related with increased odds of MD in offspring. However, there is a lack of population-based research in this field. The aim of the present study was to examine together the relationship between the presence of MD in children, and the SES and presence of MD in their parents, in a whole of population data. A gender approach was undertaken aiming to discern how these variables influence children's mental health when related with the father and the mother. Using administrative individual data from the National Health System, a retrospective cross-sectional study was conducted. The entire children population aged 6 to 15 resident in Catalonia in 2017 was examined. A logistic regression model was performed. Low SES was associated with increased odds of children's MD. Offspring of a parent with MD were at more risk of presenting MD than offspring of parents without these problems. Although these associations were consistent for both boys and girls when looking at the father's or mother's SES and MDs, the mother's SES and MDs showed a higher association with the offspring's MDs than the father's. Lowest associations, found for boys when looking at the father's SES and MDs, were: OR of 1.21, 95%CI 1.16 to 1.27 for lowest SES, and OR of 1.66, 95%CI 1.61 to 1.70 for parental MDs. Children's familiar environment, which includes SES and mental health of parents, plays an important role in their mental health. Socially constructed gender roles interfere with SES and parent's MD. These findings support the relevance of examining MD and its risk factors within a gender approach.

Introduction: Suicide attempts represent an important public health burden. Centralised electronic health record (EHR) systems have high potential to provide suicide attempt surveillance, to inform public health action aimed at reducing risk for suicide attempt in the population, and to provide data-driven clinical decision support for suicide risk assessment across healthcare settings. To exploit this potential, we designed the Catalonia Suicide Risk Code Epidemiology (CSRC-Epi) study. Using centralised EHR data from the entire public healthcare system of Catalonia, Spain, the CSRC-Epi study aims to estimate reliable suicide attempt incidence rates, identify suicide attempt risk factors and develop validated suicide attempt risk prediction tools. Methods and analysis: The CSRC-Epi study is registry-based study, specifically, a two-stage exposure-enriched nested case-control study of suicide attempts during the period 2014-2019 in Catalonia, Spain. The primary study outcome consists of first and repeat attempts during the observation period. Cases will come from a case register linked to a suicide attempt surveillance programme, which offers in-depth psychiatric evaluations to all Catalan residents who present to clinical care with any suspected risk for suicide. Predictor variables will come from centralised EHR systems representing all relevant healthcare settings. The study's sampling frame will be constructed using population-representative administrative lists of Catalan residents. Inverse probability weights will restore representativeness of the original population. Analysis will include the calculation of age-standardised and sex-standardised suicide attempt incidence rates. Logistic regression will identify suicide attempt risk factors on the individual level (ie, relative risk) and the population level (ie, population attributable risk proportions). Machine learning techniques will be used to develop suicide attempt risk prediction tools. Ethics and dissemination: This protocol is approved by the Parc de Salut Mar Clinical Research Ethics Committee (2017/7431/I). Dissemination will include peer-reviewed scientific publications, scientific reports for hospital and government authorities, and updated clinical guidelines. This project was supported by ISCIII/FEDER PI17/00521, ISCIII/FEDER PI17/01205, and Generalitat de Catalunya (2017 SGR 452). The Catalonia Suicide Risk Code surveillance programme is an initiative of the Mental Health and Addictions Plan of the Department of Health of the Catalan Government. PM has a Sara Borrell research contract awarded by the ISCIII (CD18/00049). ME has a Juan de la Cierva research contract awarded by the ISCIII (FJCI-2017–31738). VPS and ME want to thank unrestricted research funding from Secretaria d′Universitats i Recerca del Departament d′Economia i Coneixement (2017 SGR 134 to ‘Mental Health Research Group’), and Generalitat de Catalunya (Government of Catalonia). BPG and ADIT received funding from ISCIII FI18/00012 and FPU2017-06447, respectively. LBC received funding by Ministerio de Educación, Cultura y Deporte (FPU15/05728). DP and JA received funding by ISCIII/FEDER PI17/01205.

Background: the primary care service in Catalonia has operated an asynchronous teleconsulting service between GPs and patients since 2015 (eConsulta), which has generated some 500,000 messages. New developments in big data analysis tools, particularly those involving natural language, can be used to accurately and systematically evaluate the impact of the service. Objective: the study was intended to examine the predictive potential of eConsulta messages through different combinations of vector representation of text and machine learning algorithms and to evaluate their performance. Methodology: 20 machine learning algorithms (based on 5 types of algorithms and 4 text representation techniques)were trained using a sample of 3,559 messages (169,102 words) corresponding to 2,268 teleconsultations (1.57 messages per teleconsultation) in order to predict the three variables of interest (avoiding the need for a face-to-face visit, increased demand and type of use of the teleconsultation). The performance of the various combinations was measured in terms of precision, sensitivity, F-value and the ROC curve. Results: the best-trained algorithms are generally effective, proving themselves to be more robust when approximating the two binary variables "avoiding the need of a face-to-face visit" and "increased demand" (precision = 0.98 and 0.97, respectively) rather than the variable "type of query"(precision = 0.48). Conclusion: to the best of our knowledge, this study is the first to investigate a machine learning strategy for text classification using primary care teleconsultation datasets. The study illustrates the possible capacities of text analysis using artificial intelligence. The development of a robust text classification tool could be feasible by validating it with more data, making it potentially more useful for decision support for health professionals.

Social protection systems are related to each community’s culture. In most of the developed countries with welfare systems, healthcare provides universal access to their population. Despite its achievements, the main concern today of public health systems is financial sustainability. The challenge results from the fact that most of the health systems are very set in their ways and do not seem much prepared to answer the upcoming challenges in healthcare. Specifically, health systems might be ill-pepared to implement the interventions likely to be required to fight against the inequity that will result from those future developments. This forces to rethink our systems and to direct universalism to a greater extent towards the most needy, fragile population that have been left behind by the economic crisis and may suffer loss of access to some innovations in healthcare. This is particularly the case of the Spanish system. This does not seem prepared to prioritise services and set proper population targets to show resilience to the consequences of future technological and economic changes. In Catalonia, a wealthy region in Spain,1 despite rather good health outcomes for a reasonable healthcare expenditure, in terms of equality, the gap in socioeconomic inequalities has already increased during the last decades, first by immigration, driven by the economic boom, followed by unemployment caused by the economic crisis. They have generated new vulnerable groups (unemployed, children and elderly). In addition, some proposals from the former Spanish conservative government to change the terms of access to universal health services to pursue fiscal deficit control2 may make things worse. The economic consequences of the past crisis overlap with problems related to technological innovation and pressures on utilisation of the health system, emerging further issues on equity. We know that in order to face them, the old universalism of the …

Background: Telemedicine (interconsultation between primary and hospital care teams) has been operating in the counties of Central Catalonia Bages, Moian&egrave, s and Bergued&agrave, since 2011, specializing in teledermatology, teleulcers, teleophthalmology and teleaudiometries. For the period until the end of 2019, a total of 52,198 visits were recorded. Objective: To analyze the differential costs between telemedicine and usual care in a semi-urban environment. Methodology: A cost-minimization evaluation, including direct and indirect costs from a societal perspective, distinguishing healthcare and user&rsquo, s costs, was carried out over a three-month period. Results: Telemedicine saved &euro, 780,397 over the period analyzed. A differential cost favorable to telemedicine of about &euro, 15 per visit was observed, with the patient being the largest beneficiary of this saving (by 85%) in terms of shorter waiting times and travel costs. From the healthcare system perspective, moving the time spent in a hospital care consultation to primary care is efficient in terms of the total time devoted per patient. In social terms and in this context, telemedicine is more efficient than usual care. Conclusion: Allowing users to save time in terms of consultation and travel is the main driver of interconsultation between primary and hospital care savings in a semi-urban context. The telemedicine service is also economically favorable for the healthcare system, enabling it to provide a more agile service, which also benefits healthcare professionals.

BackgroundClinical management of patients with chronic obstructive pulmonary disease (COPD) shows potential for improvement provided that patients’ heterogeneities are better understood. The study addresses the impact of comorbidities and its role in health risk assessment.ObjectiveTo explore the potential of health registry information to enhance clinical risk assessment and stratification.DesignFixed cohort study including all registered patients with COPD in Catalonia (Spain) (7.5 million citizens) at 31 December 2014 with 1-year (2015) follow-up.MethodsA total of 264 830 patients with COPD diagnosis, based on the International Classification of Diseases (Ninth Revision) coding, were assessed. Performance of multiple logistic regression models for the six main dependent variables of the study: mortality, hospitalisations (patients with one or more admissions; all cases and COPD-related), multiple hospitalisations (patients with at least two admissions; all causes and COPD-related) and users with high healthcare costs. Neither clinical nor forced spirometry data were available.ResultsMultimorbidity, assessed with the adjusted morbidity grouper, was the covariate with the highest impact in the predictive models, which in turn showed high performance measured by the C-statistics: (1) mortality (0.83), (2 and 3) hospitalisations (all causes: 0.77; COPD-related: 0.81), (4 and 5) multiple hospitalisations (all causes: 0.80; COPD-related: 0.87) and (6) users with high healthcare costs (0.76). Fifteen per cent of individuals with highest healthcare costs to year ratio represented 59% of the overall costs of patients with COPD.ConclusionsThe results stress the impact of assessing multimorbidity with the adjusted morbidity grouper on considered health indicators, which has implications for enhanced COPD staging and clinical management.Trial registration numberNCT02956395.

Rationale: Despite substantial progresses on standard of care recommendations, management of Chronic Obstructive Pulmonary (COPD) patients show potential for improvement provided that patients’ heterogeneities are better understood. Objectives: To perform a population-based analysis of the COPD patients in Catalonia (ES) (7,5 M citizens) aiming at exploring the potential of the health registry information to enhance risk assessment and stratification in the clinical arena. Methods: The characteristics of 264,830 COPD cases registered in 2014 in the Health Surveillance System were assessed. Multiple logistic regression analysis was used to elaborate predictive models for four health indicators: (i) mortality, (ii) unplanned hospitalizations (all and COPD-related hospitalizations), (iii) multiple exacerbators, and, (iv) high users of healthcare resources. No clinical, nor forced spirometry data were available. Main Results: Multimorbidity, expressed by GMA (adjusted morbidity groups) scoring, was the covariate with highest impact in the four predictive models. This score explained a substantial percentage of interindividual variability (AUC): (i) mortality (0.763); (ii) unplanned hospitalizations (0.829); (iii) multiple exacerbators (0.766); and, (iv) higher use of healthcare resources (0.803). Patients above the 85 percentile in terms of healthcare costs per year represented 59% of the overall costs of COPD patients. Conclusions: The predictive models stress the explanatory role of the covariate multimorbidity. The results highly encourage further developments fostering interoperability between health registries and electronic health records to enhance clinical risk prediction.

Introduction During the twentieth century, vaccination has been one of the measures of greatest public health impact. Vaccine administration has helped reduce the burden of disease and mortality from infectious diseases. At present, there is increasing concern about infectious diseases and the ability of health systems to control them, highlighting the need for evaluation of vaccination programs. The aim of this study was to conduct a systematic review of economic evaluation studies carried out regarding Spain on vaccines. Methods Systematic review. Search of articles in major bibliographic databases available online from January 1983 to June 2011. References identified were limited to full economic evaluations carried out regarding Spain that evaluated vaccination programs. For each of the selected papers, a set of predefined variables were extracted. Results A total of 46 studies met inclusion criteria. The topics studied were pneumococcal vaccination, influenza vaccination, Hepatitis B vaccination and varicella vaccination. Cost-minimization analysis, perspective of society, long time horizon, use of modeling techniques, and the inclusion of direct and indirect costs were the most common methodological characteristics. The results of the studies reviewed showed, in most cases, net savings or cost-effectiveness ratios below €30,000/QALY. Conclusions Although there has been an improvement in the methodological quality of studies, they still show shortcomings that should be addressed. From a public health perspective, it would be relevant to evaluate vaccines targeted to major health problems in Spain, including all relevant costs and benefits. In order to obtain a more efficient use of health resources, economic evaluation methods should be applied more rigorously and results should be used consistently in decision-making processes.

To determine whether the road safety policies introduced between 2000 and 2010 in Catalonia, Spain, which aimed primarily to reduce deaths from road traffic collisions by 50% by 2010, were associated with economic benefits to society.A cost analysis was performed from a societal perspective with a 10-year time horizon. It considered the costs of: hospital admissions; ambulance transport; autopsies; specialized health care; police, firefighter and roadside assistance; adapting to disability; and productivity lost due to institutionalization, death or sick leave of the injured or their caregivers; as well as material and administrative costs. Data were obtained from a Catalan hospital registry, the Catalan Traffic Service information system, insurance companies and other sources. All costs were calculated in euros (€) at 2011 values.A substantial reduction in deaths from road traffic collisions was observed between 2000 and 2010. Between 2001 and 2010, with the implementation of new road safety policies, there were 26 063 fewer road traffic collisions with victims than expected, 2909 fewer deaths (57%) and 25 444 fewer hospitalizations. The estimated total cost savings were around €18 000 million. Of these, around 97% resulted from reductions in lost productivity. Of the remaining cost savings, 63% were associated with specialized health care, 15% with adapting to disability and 8.1% with hospital care.The road safety policies implemented in Catalonia in recent years were associated with a reduction in the number of deaths and injuries from traffic collisions and with substantial economic benefits to society.Résumé OBJECTIF: Déterminer si les politiques de sécurité routière introduites entre 2000 et 2010 en Catalogne, Espagne, qui visaient principalement à réduire de 50% les décès causés par des collisions routières avant 2010, ont été associées à des avantages économiques pour la société. MÉTHODES: Une analyse des coûts a été réalisée dans une perspective sociétale sur un horizon temporel de 10 ans. Elle a pris en compte les coûts suivants: les admissions à l’hôpital, les transports en ambulance, les autopsies, les soins de santé spécialisés, la police, les pompiers et les dépannages routiers, l’adaptation au handicap et la productivité perdue en raison du placement des personnes dans des établissements spécialisés, les décès ou les congés des blessés ou de leurs aidants, ainsi que les coûts matériels et les frais administratifs. Les données provenaient du registre d’un hôpital catalan, du système d´information du Service catalan de la circulation, des compagnies d'assurance et d’autres sources. Tous les coûts ont été calculés en euros (€), selon les valeurs de l’année 2011. RÉSULTATS: Une diminution substantielle des décès causés par collision routière a été observée entre 2000 et 2010. Entre 2001 et 2010, grâce à la mise en œuvre de nouvelles politiques de sécurité routière, on a recensé une diminution de 26 063 collisions routières avec victimes, une diminution de 2909 décès (57%) et une diminution de 25 444 hospitalisations. Le total des économies estimé sur les coûts était d’environ 18 000 millions d’euros. En ce qui concerne ce chiffre, environ 97% résultaient de la réduction des coûts liés à la perte de productivité. Parmi les économies restantes, 63% étaient associées aux soins de santé spécialisés, 15% à l’adaptation au handicap et 8,1% aux soins hospitaliers. CONCLUSION: Les politiques de sécurité routière mises en place en Catalogne ces dernières années ont été associées à une réduction du nombre de décès et de blessures causés par des collisions routières et à des avantages économiques substantiels pour la société.Resumen OBJETIVO: Determinar si las políticas de seguridad vial introducidas entre los años 2000 y 2010 en Cataluña, España, cuyo propósito principal era la reducción de los fallecimientos causados por accidentes de tráfico en un 50% hasta el 2010, estuvieron asociadas a un beneficio económico para la sociedad. MÉTODOS: Se llevó a cabo un análisis de costes desde una perspectiva social y un horizonte temporal de 10 años. Se tomaron en consideración los costes de las hospitalizaciones, el transporte en ambulancia, las autopsias, la atención sanitaria especializada, la policía, bomberos y asistencia en carretera, la adaptación a la discapacidad y la pérdida de productividad debido a la institucionalización, las bajas por enfermedad o fallecimiento de los heridos o sus cuidadores, así como los costes materiales y administrativos. Los datos se obtuvieron del registro de un hospital catalán, el sistema de información del servicio catalán de tráfico, compañías aseguradoras y otras fuentes. Todos los costes se calcularon en euros (€) según los valores del 2011. RESULTADOS: Entre los años 2000 y 2010 se observó una reducción importante de los fallecimientos causados por accidentes de tráfico. Entre el 2001 y el 2010, con la puesta en práctica de las nuevas políticas de seguridad vial, se produjeron 26 063 colisiones con víctimas menos de las esperadas, 2909 fallecimientos menos (57%), así como 25 444 hospitalizaciones menos. El ahorro total estimado fue de aproximadamente 18 000 millones de euros. De éstos, un 97% se derivó de la reducción de la pérdida de productividad, y del ahorro restante, el 63% estuvo asociado con la atención sanitaria especializada, el 15% con la adaptación a la discapacidad y el 8,1% con la atención hospitalaria. CONCLUSIÓN: Las políticas de seguridad vial puestas en marcha en Cataluña en los últimos años estuvieron asociadas a una reducción en el número de fallecidos y heridos por accidentes de tráfico, así como con beneficios económicos importantes para la sociedad.ملخص الغرض : تحديد ما إذا كانت سياسات السلامة على الطرق التي تم سنها في الفترة من 2000 إلى 2010 في كاتالونيا، بإسبانيا، والتي استهدفت بشكل رئيسي خفض الوفيات الناجمة عن التصادمات المرورية على الطرق بنسبة 50 % بحلول عام 2010، مرتبطة بفوائد اقتصادية للمجتمع. الطريقة : تم إجراء تحليل للتكلفة من منظور مجتمعي بأفق زمني قدره 10 سنوات. ووضع في الاعتبار تكاليف ما يلي: دخول المستشفيات؛ والنقل بسيارات الإسعاف؛ والتشريح؛ والرعاية الصحية المتخصصة؛ والشرطة ورجال الإطفاء والمساعدة على الطرق؛ والتكيف مع العجز؛ والإنتاجية المفقودة بسبب إضفاء الطابع المؤسسي والوفاة أو الإجازة المرضية للمصابين أو مقدمي الرعاية لهم؛ بالإضافة إلى التكاليف المادية والإدارية. وتم الحصول على البيانات من سجل إحدى المستشفيات الكتالونية ونظام معلومات الخدمات المرورية الكتالوني وشركات التأمين وغيرها من المصادر. وتم حساب جميع التكاليف باليورو بقيم عام 2011. النتائج : لوحظ حدوث انخفاض كبير في الوفيات الناجمة عن التصادمات المرورية على الطرق في الفترة بين عامي 2000 و2010. وبين عامي 2001 و2010 ومع تنفيذ السياسات الجديدة المعنية بالسلامة على الطرق، كان هناك 26063 حادثا تصادم مروري بعدد ضحايا أقل من المتوقع و2909 حالة وفاة أقل (57 %) و25444 حالة إدخال إلى المستشفى أقل. وكان إجمالي وفورات التكاليف وفق التقديرات حوالي 18000 مليون يورو. وكان حوالي 97 % من هذه الوفورات ناتجاً عن انخفاضات في الإنتاجية المفقودة. وكانت 63 % من وفورات التكاليف المتبقية مرتبطة بالرعاية الصحية المتخصصة و15 % بالتكيف مع العجز و8.1 % بالرعاية التي تقدمها المستشفيات. الاستنتاج : ارتبطت سياسات السلامة على الطرق التي تم تنفيذها في كاتالونيا في السنوات الأخيرة بالانخفاض في عدد الوفيات والإصابات الناجمة عن التصادمات المرورية وبفوائد اقتصادية كبرى على المجتمع.摘要 目的: 确定2000 年和2010 年之间在西班牙加泰罗尼亚引入的道路安全政策是否与社会经济效益相关，该政策主要旨在到2010 年将道路交通碰撞死亡率减少 50%。 方法: 从社会角度进行10 年时间期的成本分析。其中考虑的成本包括：住院；救护车出车；尸检、专业卫生保健；警察、消防队员和路边援助；残疾适应和由于制度化、死亡或受伤者的病假及其照顾者而损失的生产力；以及物质和管理成本。数据来源于加泰罗尼亚医院登记、加泰罗尼亚交通服务信息系统、保险公司和其他来源。所有费用按2011 年的欧元(€)值计算。 结果: 据观察，2000 年和2010 年之间的交通事故死亡率显著减少。在2001 年和2010 年之间，随着新的道路安全政策的实施，道路交通碰撞受害者比预期减少26063 例，死亡数减少2909 例（57%），住院人数减少25444 例。估计总成本节省大约为 180 亿欧元。其中，约97%是因为减少了生产力损失。其余的成本节约中，63%与专业卫生保健相关，15%与残疾适应相关，8.1%与医院护理相关。 结论: 近年来在加泰罗尼亚实施的道路安全政策与交通事故死亡和受伤人数的减少有关，并带来了可观的社会经济效益。Резюме Цель: Определить, явилась ли политика безопасности дорожного движения, реализуемая с 2000 по 2010 годы в Каталонии, Испания, направленная, в первую очередь, на снижение смертности от дорожно-транспортных происшествий на 50% к 2010 г., экономически выгодной для общества. Методы: С данной целью был проведен анализ затрат в течение 10-летнего периода с социальной точки зрения. Учитывались следующие затраты: госпитализация, скорая помощь, проведение вскрытий, специализированная медицинская помощь; полиция, пожарные и помощь на дорогах; адаптация к инвалидности; потери производительности по причине госпитализации, смерти или временной нетрудоспособности потерпевших или их опекунов; а также материальные и административные расходы. Данные были получены из записей региональной больницы Каталонии, информационной системы службы дорожного движения Каталонии, от страховых компаний и из других источников. Все затраты были рассчитаны в евро в ценах 2011 г. Результаты: В период между 2000 и 2010 годами наблюдалось существенное снижение смертности в результате дорожно-транспортных происшествий. Благодаря внедрению новой политики безопасности дорожного движения с 2001 по 2010 годы было зарегистрировано на 26 063 меньше случаев ДТП с пострадавшими, чем ожидалось, на 2 909 меньше смертельных исходов (57%) и на 25 444 меньше случаев госпитализации. Расчетная общая экономия затрат составила около 18 млрд. евро. Из этой суммы около 97% пришлось на потери производительности. Из оставшихся сумм экономии затрат 63% было связано со специализированной медико-санитарной помощью, 15% – с адаптацией к инвалидности и 8,1% – с уходом при госпитализации. Вывод: Политика безопасности дорожного движения, применяемая в Каталонии в последние годы, привела не только к сокращению числа смертей и травм в результате дорожно-транспортных происшествий, но и к существенной экономической выгоде для общества.

Open Access; Open Peer Review.-- et al., [Background]: Cost-effectiveness analysis has been recognized as an important tool to determine the efficiency of healthcare interventions and services. There is a need for evaluating the reporting of methods and results of cost-effectiveness analyses and establishing their validity. We describe and examine reporting characteristics of methods and results of cost-effectiveness analyses conducted in Spain during more than two decades. [Methods]: A methodological systematic review was conducted with the information obtained through an updated literature review in PubMed and complementary databases (e.g. Scopus, ISI Web of Science, National Health Service Economic Evaluation Database (NHS EED) and Health Technology Assessment (HTA) databases from Centre for Reviews and Dissemination (CRD), Índice Médico Español (IME) Índice Bibliográfico Español en Ciencias de la Salud (IBECS)). We identified cost-effectiveness analyses conducted in Spain that used quality-adjusted life years (QALYs) as outcome measures (period 1989-December 2014). Two reviewers independently extracted the data from each paper. The data were analysed descriptively. [Results]: In total, 223 studies were included. Very few studies (10; 4.5 %) reported working from a protocol. Most studies (200; 89.7 %) were simulation models and included a median of 1000 patients. Only 105 (47.1 %) studies presented an adequate description of the characteristics of the target population. Most study interventions were categorized as therapeutic (189; 84.8 %) and nearly half (111; 49.8 %) considered an active alternative as the comparator. Effectiveness of data was derived from a single study in 87 (39.0 %) reports, and only few (40; 17.9 %) used evidence synthesis-based estimates. Few studies (42; 18.8 %) reported a full description of methods for QALY calculation. The majority of the studies (147; 65.9 %) reported that the study intervention produced >more costs and more QALYs> than the comparator. Most studies (200; 89.7 %) reported favourable conclusions. Main funding source was the private for-profit sector (135; 60.5 %). Conflicts of interest were not disclosed in 88 (39.5 %) studies. [Conclusions]: This methodological review reflects that reporting of several important aspects of methods and results are frequently missing in published cost-effectiveness analyses. Without full and transparent reporting of how studies were designed and conducted, it is difficult to assess the validity of study findings and conclusions., FC-L and RT-S are partially funded by Generalitat Valenciana (PROMETEOII/2015/021), INCLIVA and Institute of Health Carlos III/CIBERSAM. MR, EB-D and SP are partially funded by the Spanish Health Services Research on Chronic Patients Network (REDISSEC). BH is supported by a New Investigator Award from the Canadian Institutes of Health Research and the Drug Safety and Effectiveness Network.

ResumenEn los últimos años ha aumentado de forma notable el interés por la evaluación de las intervenciones en salud, especialmente en relación a su utilidad social y su eficiencia económica. Sin embargo, todavía estamos lejos de tener un grado suficiente de consenso en los aspectos básicos de la evaluación, como son la terminología, la finalidad y la metodología de trabajo. En este marco se revisan las principales definiciones y clasificaciones de la evaluación aplicada a los programas y políticas en salud pública. En relación a la evaluación de resultados, se presentan los principales diseños evaluativos y sus componentes, y se revisan las amenazas a la validez interna de los resultados de los diseños evaluativos débiles. Se analizan y discuten las características de las intervenciones de salud pública que limitan las opciones de evaluación con diseños tradicionales. Entre estas limitaciones destacan la complejidad de las intervenciones, que habitualmente tienen múltiples componentes, y la dificultad de establecer un grupo de comparación sin intervención, en especial mediante asignación aleatoria. Para finalizar, se describe una propuesta de evaluación a partir de diseños evaluativos débiles, consistente en la valoración de la adecuación y la plausibilidad. La adecuación estaría determinada por la existencia de un cambio observable en los indicadores de resultados, y podría ser suficiente para tomar decisiones bajo determinadas condiciones; otras veces sería necesario analizar la plausibilidad, o atribución de los resultados observados al programa.AbstractIn the last few years, interest has markedly increased in evaluating health programs, especially their social utility and economic efficiency. However, consensus on key issues in evaluation, such as terminology, goals and methods is still a long way off. In this context, we review the main definitions and classifications of evaluation applied to public health programs and policies. We describe the main evaluation designs and their components, focusing on outcome evaluation. Threats to the internal validity of the results of weak evaluation designs are also discussed. The characteristics of public health interventions that limit evaluation with traditional designs are also analyzed. These limitations include the complexity of interventions, usually with multiple components, and the difficulty of forming an equivalent control group with no intervention, especially through random assignment. Finally, a two-step approach to evaluation through weak designs, which takes into account adequacy and plausibility, is described. Adequacy consists of the observation of a change in the selected indicators after the intervention, and would be sufficient to take decisions under certain conditions; at other times, plausibility would need to be analyzed, defined as attribution of the results to the program or intervention.

BACKGROUND: : Traffic collisions are an important public health problem worldwide, in terms of mortality, morbidity, and economic burden. The goal of this study is to estimate the social cost of injured people in traffic collisions in Catalonia in the year 2007. METHODS: : We performed a cost-of-illness analysis, under the perspective of the healthcare system, the public sector, and the society, using a 1-year time horizon. In Catalonia, during 2007, there were a total of 26,063 collisions with victims, which translates into 34,565 non-mortal victims and 521 deaths. As direct costs, all healthcare costs (primary care, acute hospital care, emergency care, ambulances and transport, long-term care, and specialized care); costs of adaptation to disability, disability benefits, material costs, and administrative costs; and costs of police, fire-fighters, and road assistance have been included. As indirect costs, productivity losses as a result of hospital and long-term institutionalization as well as productivity losses from work sick leave and productivity losses of carers have been taken into account. RESULTS: : From the perspective of the healthcare system, the cost of the injured people in traffic collisions was 31,803,024.03€ in 2007; from the perspective of the public sector, it was 134,047,059.27€ (up to 1,463,645,407.13€ in the sensitivity analysis) and 144,043,238.88€ (up to 1,558,926,995.12€ in the sensitivity analysis) from the perspective of the society. The cost per injured person ranged from 3,855.38€ from the perspective of the healthcare system to 17,461.90€ from the perspective of the society (up to 188,983.76€ in the sensitivity analysis). CONCLUSIONS: : The importance of the costs of injured people in traffic collisions is an argument more-besides the epidemiologic and social impact-to start off preventive policies. Language: en

Aim: To review respiratory syncytial virus (RSV), passive immunoprophylaxis (PI) trials and meta-analysis (MA). Methods: A literature review. Results: Two MA of PI were found. Overall 3927 patients were randomized. PI reduces RSV hospitalization in patients with bronchopulmonary dysplasia (RR 0.58; 95% CI 0.41, 0.82) and with acyanotic congenital heart disease (RR 0.29; 95% CI 0.14, 0.62). In patients with cyanotic heart disease or premature infants without bronchopulmonary dysplasia, results are inconclusive. Passive immunoprophylaxis has a null effect in mechanical ventilation and death. Conclusion: Passive immunoprophylaxis reduces RSV hospitalization in a subset of patients. However, it has no effect in harder endpoints of RSV disease severity.

Background The objective of this study was to analyse inequalities in cirrhosis mortality at individual and area levels, using data from Barcelona for two time periods. Methods Deaths from cirrhosis in Barcelona of men and women aged 25-74 years during the periods 1992-97 and 1998-2004 were included in the study. A multilevel Poisson regression analysis was performed, with the individual and the area as the respective units of analysis. Results Inequalities in cirrhosis mortality were observed in relationship to individual and area socioeconomic levels, with the highest death rates among those with lowest educational level and in socioeconomically deprived areas. In the multilevel analysis, the largest effects were observed at the individual level. Between the two periods, death rates decreased for the highest and lowest educational levels (eg, from 116.2 to 88.7 per 100 000 inhabitants among men or men with no education aged 50-74 years), but not for intermediate levels. At the area level, absolute inequalities in mortality tended to decrease; however, higher mortality RR persisted in the least favoured compared to most favoured areas (eg, in men, from 1.74 (95% CI 1.36 to 2.24) to 1.80 (95% CI 1.42 to 2.27) in the two periods). Conclusion This study demonstrated the persistence of socioeconomic inequalities in cirrhosis mortality in Barcelona between socioeconomic groups and city areas.

ResumenEl concepto de «pago por calidad» (P4P) reúne un conjunto de diferentes estrategias que intentan estimular la mejora de la calidad asistencial remunerando a los proveedores de atención sanitaria según sus resultados en el cumplimiento de objetivos de calidad o productividad predefinidos. Pese a que la efectividad del P4P para mejorar la calidad de la atención está poco establecida, estos sistemas se están difundiendo ampliamente en el Reino Unido, Estados Unidos y otros países, incluida España. Los elementos del diseño de los esquemas de P4P determinantes de su efectividad se refieren a quién debe recibir los incentivos, cuánto debe pagarse, qué debe retribuirse, la necesidad de incorporar ajustes de riesgos (sobre todo en los indicadores de resultados intermedios) y de tener en cuenta el clima organizativo, y la combinación óptima de incentivos financieros y no financieros. Las limitaciones más importantes que cabe considerar son: la orientación exclusiva hacia la reducción de la infrautilización, la afectación de la equidad, el efecto «lupa», la validez de los indicadores, la confusión entre recomendaciones de guías de práctica e indicadores de calidad, la ingeniería documental, el paternalismo con los pacientes, el posible impacto negativo sobre el profesionalismo y la motivación interna de los médicos, y el abordaje de la calidad como un problema de decisiones imperfectas, antes que como un sistema imperfecto.AbstractThe concept of pay-for-performance (P4P) encompasses different strategies that aim to stimulate health care quality improvement by remunerating healthcare providers according to their performance in specific measures of efficiency or quality. Although the effectiveness of P4P in improving quality of care is largely unknown, these systems are being widely adopted in the United Kingdom, the United States and other countries, including Spain. The elements of P4P design that are most decisive for the effectiveness of these schemes are as follows: 1) who should receive the incentives, how they should be paid, what should be rewarded, the need to incorporate risk adjustments (mainly if surrogate outcomes are used as indicators) and the need to bear organizational climate and the optimal combination of financial and non-financial incentives in mind. The most important limitations to consider are the following: 1) the exclusive focus on reducing subutilization; 2) the effect on equity; 3) the “magnifying glass” effect; 4) the validity of indicators; 5) the confusion between the recommendations of clinical guidelines and quality indicators; 6) “document engineering”; 7) paternalism; 8) the negative impact on professionalism and clinicians’ internal motivation, and 9) the assumption that quality problems result from imperfect individual decisions rather than from an imperfect system.

Objective: To examine the quantity and quality of economic evaluations analyzing preventive interventions in Spain to September 2005, with the further goal of extracting conclusions for further research and the design of future programs. Methods: We performed a systematic review of the evidence. First, we defined the criteria for including studies in our review. Second, a search was conducted of specialized search engines (Pubmed, NHS EED, DARE, HTA, HRSPROJ, IME, EMBASE) and a manual search was performed of journals and the web sites of Spanish public health organizations. In a third phase, the characteristics relevant to our analysis were extracted from the selected articles. Lastly, the characteristics collected were analyzed through uni- and bivariate analyses. Results: Forty-nine articles were found that complied with the inclusion criteria, of which 40 were reviewed. The technique most extensively used was cost-effectiveness analysis (60% of all articles). Twenty-eight evaluations (70%) focused on immunization campaigns. The quality of publications increased over time, from an average score of 4.21 (1985-1995) to 6.38 (1995-2004), although several methodological areas still require improvement. Lastly, 72.5% of the studies supported the universal use or expansion of the policy analyzed. Conclusions: The Spanish research community should increase efforts to improve the quantity and quality of economic evaluations in preventive health. Three basic strategies are suggested: a) evaluation of the preventive programs currently in place in Spain and dissemination of the results; b) efforts to publish and index articles in international scientific journals; and c) adherence to international economic evaluation guidelines and manuals.

El futuro cercano de los sistemas sanitarios de muchos paises desarrollados estara todavia mas caracterizado por el aumento de los avances medicos y farmaceuticos. Innovaciones en pruebas geneticas, tecnicas de diagnostico por la imagen, tecnologias reproductivas, vacunas y nuevos medicamentos, asi como nuevas aplicaciones de las tecnologias de la informacion y la telemedicina, han de producir cambios importantes en la practica medica. Si bien las innovaciones medicas, de forma mayoritaria, conducen a reducciones heterogeneas de la mortalidad y la morbilidad, su introduccion y difusion pueden comprometer la financiacion de los sistemas publicos de salud. En la mayoria de los casos, la sostenibilidad de las finanzas publicas indica que no sera posible continuar pagando el precio de cualquier innovacion medica o farmaceutica que pueda utilizarse para mejorar la salud de la poblacion. En este contexto resulta pertinente preguntarse: ?cual es el valor economico de las mejoras adicionales en el estado de salud que han aportado los cambios tecnologicos en el diagnostico y tratamiento de las enfermedades? ?Que parte de la mejora en la esperanza y calidad de vida es atribuible a la atencion sanitaria? ?Valen lo que cuestan los aumentos en el gasto en servicios sanitarios? La eritropoyetina es una hormona reguladora de la eritropoyesis, que participa en el proceso de generacion de celulas precursoras eritrocitarias de la medula osea, con el resultado de un aumento del hematocrito1 . Desde hace mas de 15 anos la eritropoyetina recombinante humana se utiliza con exito en el tratamiento medico de la anemia asociada a la insuficiencia renal cronica. Tambien se ha introducido con exito en el tratamiento de la anemia asociada al cancer, la infeccion por el virus de la inmunodeficiencia humana, la anemia de recien nacidos prematuros, en pacientes quirurgicos con riesgo elevado de hemorragia y en programas de donacion de sangre autologa. El objetivo de este articulo es presentar los resultados de una revision sistematica de la evidencia cientifica sobre la eficiencia, entendida como relacion entre los costes y la efectividad, de la administracion de eritropoyetina en sus principales indicaciones: cirugia, hemodialisis, pacientes con anemia y ninos.

Background: The objective of performance assessment is to provide governments and populations with appropriate information about the state of their health care system. The objective of this paper is to present the most recent developments in performance assessment and their application in urban contexts. Methods: Literature review in PubMed (1970-2004). We identified additional papers and grey literature from retrieved references. Results: Performance assessment initiatives were identified in Australia, Canada, the United Kingdom, and New Zealand. The World Health Report 2000 is one of the best known examples of a transnational approach to performance assessment. Conclusion: The best developed initiatives to date are those that define precise categories, criteria and indicators with which to analyse and assess health care systems, based on a solid conceptual framework. Performance assessment fits perfectly in urban contexts, as it is a useful tool for designing and monitoring policies, assessing the quality of the services provided, and measuring the health status of city dwellers. Barcelona and Montreal are currently collaborating together on a project to assess the performance assessment of their respective health care services.

It is important to identify the best initial work-up in patients with uninvestigated dyspepsia because of its epidemiological and economical relevance. The objective of the study was to assess systematically the effectiveness and cost-effectiveness of invasive and non-invasive strategies for the management of dyspepsia.A decision analysis was performed to compare prompt endoscopy, score and scope, test and scope, test and treat, and empirical antisecretory treatment. Published and local data on the prevalence of different diagnoses, rates of Helicobacter pylori infection, accuracy values of diagnostic tests, and effectiveness of drug treatments were used. The perspective of analysis was that of the public healthcare payer, and only direct costs were included, with a one-year post-therapy time horizon. The main outcome measure was cost per asymptomatic patient, valued in 2003 Euros.Endoscopy was found to be the most effective strategy for the management of dyspepsia (38.4% asymptomatic patients), followed by test and scope (35.5%), test and treat (35.3%), score and scope (34.7%), and empirical treatment (28.5%). Incremental cost-effectiveness ratios showed that score and scope was the most cost-effective alternative (483.17 Euros per asymptomatic patient), followed by prompt endoscopy (1396.85 Euros). Sensitivity analyses showed variations when varying the values of prevalence of duodenal ulcer, and the values of healing of functional dyspepsia with antisecretory and eradication drugs. There were no changes when varying the prevalence of H. pylori in dyspepsia.We would recommend stratifying patients by a score system, referring first to endoscopy those patients at higher risk of organic dyspepsia.

Aims The objective of this study was to estimate the social cost of the consumption of illegal drugs in Spain. Design We performed a cost-of-illness study, using a prevalence approximation and a societal perspective. The estimation of costs and consequences referred to 1997. As direct costs we included health-care costs, prevention, continuing education, research, administrative costs, non-governmental organizations and crime-related costs. As indirect costs we included lost productivity associated with mortality and the hospitalization of patients. Estimation of intangible costs was not included. Findings The minimum cost of illegal drug consumption in Spain is 88 800 million pesetas (PTA) (467 million dollars). Seventy-seven per cent of the costs correspond to direct costs. Of those, crime-related costs represent 18%, while the largest part corresponds to the health-care costs (50% of direct costs). From the perspective of the health-care system, the minimum cost of illegal drug consumption is 44 000 million PTA (231 million dollars). The cost of illegal drug consumption represents 0.07% of the Spanish GDP. This gross figure compares with 2250 million PTA (12.5 million dollars) invested in prevention programmes during the same year, and with 12 300 million PTA (68.3 million dollars) spent on specific programmes and resources for the drug addict population. Conclusions Although there are limitations intrinsic in this type of study and the estimations obtained in the present analysis are likely to be an underestimate of the real cost of this condition, we estimate that illegal drug consumption costs the Spanish economy at least 0.2% of GDP.

Objectives: The objective of this study was to assess the quality of economic analysis studies published in the medical and economical literature assessing the clinical management of functional dyspepsia.Methods: Bibliographic search in the main biomedical databases, in articles from bibliographic references, health technology assessment reports, and in gray literature. A specific protocol with economic and clinical items was designed for the evaluation.Results: Overall, 18 of 162 studies met the inclusion criteria for the assessment. The compared treatment options were very diverse. The main methodologic deficiencies were in perspective of analysis, inclusion of indirect costs, and sources of clinical information.Conclusions: Specific checklists with clinical and economical items may help to better assess the quality of economic analysis in the field of functional dyspepsia. The methodologic rigor in the application of economic analysis techniques, as well as the use of appropriate clinical outcome measures, is essential to guarantee the reproducibility of the studies.

Context : The aims of the Observatory of Innovation in Healthcare Management in Catalonia are to collect, validate, organize and value, the knowledge of the Catalan health system from many innovative experiences that are being developed today. The Observatory brings together the efforts made by the organisations in innovating in several spheres of management. It provides a forum for compiling innovative experiences and it offers an innovation community web page fostering interaction among 450 professionals who exchange their experiences. Methods : The process to register an innovative experience starts first with the signing up in the Innovation community. Innovative experiences should met criteria on implementation, bringing a change, impact on resources and scalability. Secondly, organisations may submit a self-assessment of their experiences. Then, the review and the self-assessment evaluation of the innovative management experiences constitutes the third context in which the Observatory operates, conducting a quality analysis done by the OIGS, to check that the experience meets with the established inclusion criteria. Experiences which pass the assessment phase are then awarded a certificate of quality issued by the AQuAS. Results : The Observatory compiles a total of 183 innovative experiences. The majority of these experiences are focused on improving strategic and care processes, handling patients with chronic illnesses, use of healthcare information technology and the consumption of pharmaceuticals in the area of primary and specialized care. A total of 49 out of the 183 experiences fall within the specialized care in coordination with primary care area of action; 45 experiences refer to the area of specialized care. In terms of key themes, 101 experiences deal with improvements in care procedures and strategies, followed by 26 experiences concerning management of chronic care patients, 25 regarding ICT and telemedicine, and 12 pharmaceutical experiences. Discussion : The Observatory of Innovation in Healthcare Management in Catalonia brings together the efforts made by the organisations in innovation in several spheres of management One of the main challenges however will be to support scalability and transferability of these innovative experiences (new care pathway, service or technology) that have the potential for wide scale spread in other areas to improve in the end outcomes and patient satisfaction. Conclusions : The identification of innovative experiences allows compiling some of the best practices observed in the system. The Observatory through the public and innovation community website constitutes a display cabinet for supporting transferability of good practices and it also forges ties among institutions creating synergies and joint projects. One of the main challenges in the future will be to identify barriers and drivers for the implementation, sharing problems, acknowledging failures and finding solutions in different contexts for the adoption and spread of good practices.

Background: Empirical eradication therapy of H. pylori has been proposed as a therapeutic alternative for duodenal ulcer. Aim: To identify the cost-effectiveness of empirical eradication therapy vs. test-and-treatment for the management of patients already diagnosed with a duodenal ulcer. Methods: A decision analysis was performed to compare the cost-effectiveness of empirical eradication therapy of H. pylori diagnosed duodenal ulcer vs. eradication therapy after confirmatory diagnosis of Helicobacter pylori infection by means of several diagnostic tests. Results: The empirical eradication therapy of duodenal ulcer was found to be the most effective and cost-effective strategy of all the alternatives. Amongst the alternatives, which included the previous performance of confirmatory diagnostic tests, the best cost-effectiveness ratio used a serology test. The model was robust in the face of changes in the values of therapeutic effectiveness, sensitivity and specificity of the diagnostic tests, prevalence of H. pylori infection in duodenal ulcer, duration of the antisecretory therapy, and number of medical visits. Conclusions: Based on our cost-effectiveness analysis, a treat approach is more effective and cost-effective than a test-and-treat approach in the clinical management of already diagnosed duodenal ulcer.

A review of the cost-effectiveness literature indicated that the hydroxymethylglutaryl coenzyme A-reductase inhibitor fluvastatin is more cost-effective for achieving minor-to-moderate reductions in low-density lipoprotein cholesterol (LDL-C) levels than 3 other statins: lovastatin, pravastatin, and simvastatin. The main goal of this study was to verify the applicability of these conclusions to Spanish health care costs and patterns of resource consumption related to the treatment of hypercholesterolemia. A stochastic simulation model was used to predict both the costs and effects of treating high-risk hypercholesterolemic patients with fluvastatin, lovastatin, pravastatin, or simvastatin. Epidemiologic data were used to find a suitable theoretic probability distribution model for baseline LDL-C values in high-risk hypercholesterolemic patients. The model was then used to generate 10,000 random observations of baseline LDL-C values; the corresponding LDL-C values after a 2-year treatment period were predicted as a function of the baseline value and the percentage reduction expected with a particular statin and dose, according to the results obtained in 2 meta-analyses. The probability of treatment discontinuation was also taken into account using estimates obtained in usual practice. The effects of treatment were expressed as the rate of success in achieving the goal level of LDL-C, as defined in the current Spanish recommendations for the treatment of hypercholesterolemia. The average costs of treatment were computed from both the social and public-financing perspectives, including the cost of lipid-lowering drugs, physician visits, laboratory tests, and days off work, as appropriate. The occurrence of nonscheduled visits and workdays lost because of side effects were taken into account to compute indirect costs relevant to the social perspective. The potential costs of treating side effects were ignored. A cost-effectiveness analysis was performed to compare the cost-effectiveness ratios obtained with each of the 4 statins considered in this study. Model-based predictions of the effects, total costs, and cost-effectiveness ratios were made. Cost-effectiveness ratios were interpreted as the cost per patient meeting the goal of therapy, according to current Spanish recommendations. The data showed that fluvastatin had the lowest cost-effectiveness ratios when LDL-C levels required reduction to < or =25% of baseline levels. In this situation, fluvastatin was more cost-effective than lovastatin, pravastatin, or simvastatin from public-financing and social perspectives.