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Objective: The aim of the study was to estimate the direct costs of healthcare provided to patients with type 2 diabetes mellitus (T2DM) in the Basque Country and to compare them with those of the population with chronic diseases., Material and Methods: A retrospective, cross-sectional, population-based study. Direct healthcare costs for patients aged over 35 years diagnosed with T2DM in the Basque Country (n=126,894) were calculated, stratified by age, sex and deprivation index, and compared to the costs for the population diagnosed with a chronic disease other than T2DM (n=1,347,043)., Results: The annual average healthcare cost of a person with T2DM was €3,432. Cost gradually increased with age to €4,313 in patients aged 80 to 84 years. Cost in males were €161 higher as compared to costs in females (P<.001). In the most socioeconomically disadvantaged areas, cost per patient was €468 (14.9%) greater than in the most privileged areas (P<.001). Moreover, cost was 68.5% higher (P<.001) for patients with T2DM than for patients with other chronic diseases. Total annual direct costs amounted to €435.5 million, or 12.78% of total public health expenditure in the region., Conclusions: Direct mean healthcare costs in the Basque Country for patients with T2DM were higher in males, in the most underprivileged areas, in patients with comorbidities, and in older age groups, and represented €3,432 per person per year., (Copyright © 2016 SEEN. Publicado por Elsevier España, S.L.U. All rights reserved.)

Objective: To evaluate the technical efficiency of primary care units operating in the Basque Health Service during the period 2010-2013, corresponding to the implementation of a care integration strategy by health authorities., Methods: This study included 11 of the 12 primary care units in the Basque Health Service during the period 2010-2013. Data envelopment analysis (DEA) was used to assess the technical efficiency of the units. In particular, we applied the extension DEA windows to analyse all units as if they were in a single period (33 observations) as well as a conditional model, which allowed incorporation of the effect of the characteristics of the population covered. The outputs considered were a quality index based on fulfilment of different requirements related to primary care delivery and the rate of avoidable hospitalizations (treated as an undesirable output). The inputs used were the number of physicians, the number of nurses and the costs of prescriptions. The morbidity index was included as an exogenous variable., Results: The results showed that the efficiency of all the units improved during the study period. However, this improvement was not greater in the units incorporated in the integrated healthcare organisation., Discussion: In a context of global transformation of care delivery in the Basque country in the study period, primary care units increased their efficiency. However, this effect was not larger in vertically integrated primary care providers., (Copyright © 2015 SESPAS. Published by Elsevier Espana. All rights reserved.)

Background: Hypoglycaemia is an acute complication of diabetes mellitus which poses a serious threat. This study aims to describe the annual rate of people suffering episodes of severe hypoglycaemia and to estimate the healthcare costs for individuals who have suffered such events., Methods: A descriptive study involving all patients with type 2 diabetes (T2DM) from the Basque Country (period: 1/09/2010 to 31/08/2011) aged ≥35 years (N = 134,413). The rate of hypoglycaemic episodes treated in hospitals (Accident and Emergency and in-patient services) was calculated using an algorithm based on diagnostics and laboratory tests. The variables recorded included demographic, comorbidity (diagnoses categorised using the Adjusted Clinical Groups case-mix system) and socioeconomic variables (deprivation index of the area of residence). The annual healthcare cost for people with T2DM who suffered those episodes was compared with those who did not by regression analysis., Results: The incidence of hypoglycaemia in the Basque Country was 0.56 %. This percentage was higher among women and people with a lower socioeconomic status. These episodes were associated with age and high values of glycosylated haemoglobin (HbA1c) > 7 %. Adjusting for the other variables, on average, people who suffered hypoglycaemia accounted for an additional €2509 in annual healthcare costs., Conclusions: Hypoglycaemia has high morbi-mortality and a major economic impact. As such, health services must monitor its appearance and promote specific actions, especially in the higher risk sub-populations.

Introduction: Multimorbidity is more common in the elderly population and negatively affects health-related quality of life (QoL). The aims of the study were to report the QoL of users of the Basque telecare public service (BTPS) and to establish its relationship with multimorbidity., Methods: The EuroQol questionnaire was administered to 1125 users of the service. Their sociodemographic and healthcare characteristics were obtained from BTPS databases and the Basque healthcare service. Multiple regression analysis was performed on the overall questionnaire index to determine the effect of chronic diseases and sociodemographic. Moreover, the effects of the different diseases on specific dimensions of the test were explored by logistic regression., Results: Of the users interviewed, 82% were women, 88% ≥75 years and 66% lived alone. The average of chronic pathologies was higher among men (5.3 vs. 4.6), for the lower age range and among those not living alone (P<0.001). For QoL, men and people aged over 84 obtained better scores (0.64 and 0.61, respectively). Worse QoL was associated with being a woman, multimorbidity, and living with one or more people. The existence of multimorbidity meant impaired QoL of 2.6 points for each additional disease over the overall score (P<0.001)., Conclusions: This study reveals that for the population covered by BTPS the impact of chronic pathologies, multimorbidity and their social context affects QoL very diversely. These diverse social and healthcare needs of community-dwelling elders allow the development and implementation of personalised services, such as telecare that facilitate them to remain at home., (Copyright © 2015 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.)

Background: Multimorbidity is a common problem in ageing societies and has a wide range of individual and social consequences. The objective of this study was to compare multimorbidity in a population with type 2 diabetes (T2DM) with that in other chronic patients, and identify disease clusters in patients with T2DM., Methods: We included all citizens in the Basque Health Service aged ≥ 35 years, and identified the population with chronic conditions (from a list of 51 diseases) and those with T2DM. We performed a descriptive analysis of both populations, including their comorbidities. The average of chronic conditions unadjusted and adjusted by socioeconomic variables was obtained. Further, among patients with T2DM, we performed agglomerative hierarchical clustering to identify clinically relevant subgroups with the same concurrent conditions., Results: In 2011, out of a population of 1,473,937, 15.2% had T2DM and 48% some other type of chronic condition. Overall, 87.6% men and 92% of women with T2DM had multimorbidity, while the figures were respectively 54.2% and 57% in chronic patients without T2DM. Patients with T2DM had a higher risk than the general chronic population of having 21 of the 51 chronic conditions considered. We identified 10 relevant disease clusters in patients with T2DM., Conclusions: There are notable differences between chronic patients with and without T2DM, the prevalence of multimorbidity being greater among the former. Multimorbidity is a complex phenomenon and more research is required to establish the clinical implications of the disease clusters found, to guide the introduction of integrated care management programmes., (Copyright © 2015 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.)

Introduction: Risk stratification tools were developed to assess risk of negative health outcomes. These tools assess a variety of variables and clinical factors and they can be used to identify targets of potential interventions and to develop care plans. The role of multimorbidity in these tools has never been assessed., Objectives: To summarize validated risk stratification tools for predicting negative outcomes, with a specific focus on multimorbidity., Methods: MEDLINE, Cochrane Central Register of Controlled Trials and PubMed database were interrogated for studies concerning risk prediction models in medical populations. Review was conducted to identify prediction models tested with patients in both derivation and validation cohorts. A qualitative synthesis was performed focusing particularly on how multimorbidity is assessed by each algorithm and how much this weighs in the ability of discrimination., Results: Of 3674 citations reviewed, 36 articles met criteria. Of these, 29 had as outcome hospital admission/readmission. The most common multimorbidity measure employed in the models was the Charlson Comorbidity Index (12 articles). C-statistics ranged between 0.5 and 0.85 in predicting hospital admission/ readmission. The highest c-statistics was 0.83 in models with disability as outcome. For healthcare cost, models which used ACG-PM case mix explained better the variability of total costs., Conclusions: This review suggests that predictive risk models which employ multimorbidity as predictor variable are more accurate; CHF, cerebro-vascular disease, COPD and diabetes were strong predictors in some of the reviewed models. However, the variability in the risk factors used in these models does not allow making assumptions., (Copyright © 2015 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.)

Background: Type 2 diabetes mellitus is associated with a diverse range of pathologies. The aim of the study was to determine the incidence of diabetes-related complications, the prevalence of coexistent chronic conditions and to report multimorbidity in people with type 2 diabetes living in the Basque Country., Methods: Administrative databases, in four cross sections (annually from 2007 to 2011) were consulted to analyse 149,015 individual records from patients aged ≥ 35 years with type 2 diabetes mellitus. The data observed were: age, sex, diabetes-related complications (annual rates of acute myocardial infarction, major amputations and avoidable hospitalisations), diabetes-related pathologies (prevalence of ischaemic heart disease, renal failure, stroke, heart failure, peripheral neuropathy, foot ulcers and diabetic retinopathy) and other unrelated pathologies (44 diseases)., Results: The annual incidence for each condition progressively decreased during the four-year period: acute myocardial infarction (0.47 to 0.40%), major amputations (0.10 to 0.08%), and avoidable hospitalisations (5.85 to 5.5%). The prevalence for diabetes-related chronic pathologies was: ischaemic heart disease (11.5%), renal failure (8.4%), stroke (7.0%), heart failure (4.3%), peripheral neuropathy (1.3%), foot ulcers (2.0%) and diabetic retinopathy (7.2%). The prevalence of multimorbidity was 90.4%. The highest prevalence for other chronic conditions was 73.7% for hypertension, 13.8% for dyspepsia and 12.7% for anxiety., Conclusions: In the type 2 diabetes mellitus population living in the Basque Country, incidence rates of diabetes complications are not as high as in other places. However, they present a high prevalence of diabetes related and unrelated diseases. Multimorbidity is very common in this group, and is a factor to be taken into account to ensure correct clinical management.

Background: The aim of the study was to estimate the prevalence of depression in the population diagnosed with diabetes type 2 and to test the hypothesis that the presence of depression in such cases was associated with a) worse glycaemic control, and b) higher healthcare costs., Methods: We conducted a cross-sectional analysis, from 1st September 2010 to 31st August 2011, among patients with type 2 diabetes aged 35 years and over in the Basque Country. It was identified how many of them had also depression. The database included administrative individual level information on age, sex, healthcare costs, other comorbidities, and values of glycaemic control (HbA1c). Deprivation index variable was used as socioeconomic measure and, to observe the coexistent pathologies, all the patients diagnoses were categorized by Adjusted Clinical Groups. We used a measure of association, a logistic and a linear regression for analysis., Results: 12.392 (9.8%) of type 2 diabetes patients were diagnosed with depression, being the prevalence 5.2% for males and 15.1% for females. This comorbidity was higher among the most deprived population. There was no association between the presence of depression and glycaemic control. We estimated that the comorbidity average cost per patient/year was 516€ higher than in patients with just type 2 diabetes (P < 0.001) adjusted by the other covariates., Conclusions: We did not find any relationship between depression and glycaemic control in patients with type 2 diabetes. However, the comorbidity was associated with significantly high healthcare costs compared to that of type 2 diabetes occurring alone, after adjusting by other illness. Thus, there is a need of more precise recognition, screening and monitoring of depression among diabetic population. Evidence-based treatment for depression should be included in type 2 diabetes clinical guidelines.

Background: Hospitalizations are undesirable events that can be avoided to some degree through proactive interventions. The objective of this study is to determine the capability of models based on Adjusted Clinical Groups (ACG), in our milieu, to identify patients who will present unplanned admissions in the following months to their classification, in both the general population and in subpopulations of chronically ill patients (diabetes mellitus, chronic obstructive pulmonary disease and heart failure)., Methods: Cross-sectional study which analyzes data from a two year period, of all residents over 14 years old in the Basque Country (N = 1,964,337). Data from the first year (demographic, deprivation index, diagnoses, prescriptions, procedures, admissions and other contacts with the health service) were used to construct the independent variables; hospitalizations of the second year, the dependent ones. We used the area under the ROC curve (AUC) to evaluate the capability of the models to discriminate patients with hospitalizations and calculated the positive predictive value and sensitivity of different cutoffs., Results: In the general population, models for predicting admission at 6 and 12 months, as well as long-term hospitalizations showed a good performance (AUC> 0.8), while it was acceptable (AUC 0.7 to 0.8) in the groups of chronic patients., Conclusion: A hospitalization risk stratification system, based on ACG, is valid and applicable in our milieu. These models allow classifying the patients on a scale of high to low risk, which makes possible the implementation of the most expensive preventive interventions to only a small subset of patients, while other less intensive ones can be provided to larger groups.

Objectives. This study aimed to establish the prevalence of multimorbidity in women diagnosed with osteoporosis and to report it by deprivation index. The characteristics of comorbidity in osteoporotic women are compared to the general female chronic population, and the impact on healthcare expenditure of this population group is estimated. Methods. A cross-sectional analysis that included all Basque Country women aged 45 years and over (N = 579,575) was performed. Sociodemographic, diagnostic, and healthcare cost data were extracted from electronic databases for a one-year period. Chronic conditions were identified from their diagnoses and prescriptions. The existence of two or more chronic diseases out of a list of 47 was defined as multimorbidity. Results. 9.12% of women presented osteoporosis and 85.04% of them were multimorbid. Although multimorbidity in osteoporosis increased with age and deprivation level, prevalence was higher in the better-off groups. Women with osteoporosis had greater risk of having other musculoskeletal disorders but less risk of having diabetes (RR = 0.65) than chronic patients without osteoporosis. People with poorer socioeconomic status had higher healthcare cost. Conclusions. Most women with osteoporosis have multimorbidity. The variety of conditions emphasises the complexity of clinical management in this group and the importance of maintaining a generalist and multidisciplinary approach to their clinical care.

Background: Multimorbidity is clearly a major challenge for healthcare systems. However, currently, its magnitude and impact on healthcare expenditures is still not well known. The objective of this paper is to present an overview of the prevalence of multimorbidity by deprivation level in the elderly population of the Basque Country., Methods: We conducted a cross-sectional analysis that included all the inhabitants of the Basque Country aged 65 years and over (N = 452,698). This was based on data from primary care electronic medical records, hospital admissions, and outpatient care databases, for a 4-year period. The health problems of the patients were identified from their diagnoses and prescriptions. Multimorbidity was defined as the presence of two or more chronic diseases out of a list of 47 of the most important and common chronic conditions consistent with the literature. In addition, we explored socio-economic and demographic variables such as age, sex, and deprivation level., Results: Multimorbidity was found in 66.13% of the population aged 65 and over and increases with age until 80 years. The prevalence of multimorbidity was higher in deprived (69.94%) than better-off (60.22%) areas. This pattern of differences between the most and least disadvantaged areas was observed in all age groups and more marked in female (70.96-59.78%) than in male (68.54-60.86%) populations. In almost all diseases studied (43 out of 47), 90% of patients had been diagnosed with at least one other illness. It was also frequent the coexistence of mental and physical health problems in the same person and the presence of multiple physical diseases is higher in patients with mental disease than in the rest of population (74.97% vs. 58.14%)., Conclusion: Multimorbidity is very common among people over 65 years old in the Basque Country, particularly in unfavourable socioeconomic environments. Given the ageing population, multimorbidity and its consequences should be taken into account in healthcare policy, organization of care and medical research. Administrative health databases are readily available sources of a range of information that can be useful for such purposes.

Background: Chronic diseases are posing an increasing challenge to society, with the associated burden falling disproportionally on more deprived individuals and geographical areas. Although the existence of a socioeconomic health gradient is one of the main concerns of health policy across the world, health information systems commonly do not have reliable data to detect and monitor health inequalities and inequities. The objectives of this study were to measure the level of socioeconomic-related inequality in prevalence of chronic diseases and to investigate the extent and direction of inequities in health care provision., Methods: A dataset linking clinical and administrative information of the entire population living in the Basque Country, Spain (over 2 million individuals) was used to measure the prevalence of 52 chronic conditions and to quantify individual health care costs. We used a concentration-index approach to measure the extent and direction of inequality with respect to the deprivation of the area of residence of each individual., Results: Most chronic diseases were found to be disproportionally concentrated among individuals living in more deprived areas, but the extent of the imbalance varies by type of disease and sex. Most of the variation in health care utilization was explained by morbidity burden. However, even after accounting for differences in morbidity, pro-poor horizontal inequity was present in specialized outpatient care, emergency department, prescription, and primary health care costs and this fact was more apparent in females than males; inpatient costs exhibited an equitable distribution in both sexes., Conclusions: Analyses of comprehensive administrative clinical information at the individual level allow the socioeconomic gradient in chronic diseases and health care provision to be measured to a level of detail not possible using other sources. This frequently updated source of information can be exploited to monitor trends and evaluate the impact of policy reforms.

Background: The public telecare service in the Basque Autonomous Community (betiON) is a service offered by the Department of Employment and Social Policy of the Basque Government and offers telephone support to elderly and disabled populations, providing communication with an assistance centre. This connection with health care devices makes it possible to implement shared information systems with health and social data, which enable a characterization of the population attended to and the development of integrated models for health and social provision., Objective: To describe the distribution of chronic diseases and multimorbidity among users of betiON, to estimate the cost of their health care and to compare these indicators with those of the general population., Methods: We extracted information from betiON and public healthcare databases. We characterized the telecare population above 65 years (N = 23.742) and compared it with the total population in the Basque Autonomous Community (N = 2.262.707) with respect to variables in demography socio-economic burden, costs and ambulatory care conditions., Results: In the telecare population, the average age is 83 years, 80% are women, 55.1% live alone and reside in poorer neighbourhoods. Forty-two point five per cent of males and 36.5% of women are affected by five or more chronic conditions, averaging 4.06 pathologies per person. They also show higher healthcare costs than the general population., Conclusions: Telecare users have a higher disease burden, greater need for healthcare and unfavourable social conditions. Telecare provides an opportunity for innovation and intervention, through the coordination of social and healthcare services.