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Abstract Background SAIATU is a program of specially trained in-home social assistance and companionship which, since February 2011, has provided support to end-of-life patients, enabling the delivery of better clinical care by healthcare professionals in Osakidetza (Basque Health Service), in Guipúzcoa (Autonomous Community of the Basque Country). In January 2012, a retrospective observational study was carried out, with the aim of describing the characteristics of the service and determining if the new social service and the associated socio-health co-ordination had produced any effect on the use of healthcare resources by end-of-life patients. The results of a comparison of a cohort of cases and controls demonstrated evidence that the program could reduce the use of hospital resources and promote the continuation of living at home, increasing the home-based activity of primary care professionals. The objective of this study is to analyse whether a program of social intervention in palliative care (SAIATU) results in a reduction in the consumption of healthcare resources and cost by end-of-life patients and promotes a shift towards a more community-based model of care. Method/design Comparative prospective cohort study, with randomised selection of patients, which will systematically measure patient characteristics and their consumption of resources in the last 30 days of life, with and without the intervention of a social support team trained to provide in-home end-of-life care. For a sample of approximately 150 patients, data regarding the consumption of public healthcare resources, SAIATU activity, home hospitalisation teams, and palliative care will be recorded. Such data will also include information dealing with the socio-demographic and clinical characteristics of the patients and attending carers, as well as particular characteristics of patient outcomes (Karnofsky Index), and of the outcomes of palliative care received (Palliative Outcome Scale). Ethical approval for the study was given by the Clinical Research Ethics Committee of Euskadi (CREC-C) on 10 Dec 2012. Discussion The results of this prospective study will assist in verifying or disproving the hypothesis that the in-home social care offered by SAIATU improves the efficiency of healthcare resource usage by these patients (quality of life, symptom control). This project represents a dramatic advance with respect to other studies conducted to date, and demonstrates how, through the provision of personnel trained to provide social care for patients in the advanced stages of illness, and through strengthening the co-ordination of such social services with existing healthcare system resources, the resulting holistic structure obtains cost savings within the health system and improves the efficiency of the system as a whole.

Abstract Background Chronic diseases are an increasing threat to people’s health and to the sustainability of health organisations. Despite the need for routine monitoring systems to assess the impact of chronicity in the population and its evolution over time, currently no single source of information has been identified as suitable for this purpose. Our objective was to describe the prevalence of various chronic conditions estimated using routine data recorded by health professionals: diagnoses on hospital discharge abstracts, and primary care prescriptions and diagnoses. Methods The ICD-9-CM codes for diagnoses and Anatomical Therapeutic Chemical (ATC) codes for prescriptions were collected for all patients in the Basque Country over 14 years of age (n=1,964,337) for a 12-month period. We employed a range of different inputs: hospital diagnoses, primary care diagnoses, primary care prescriptions and combinations thereof. Data were collapsed into the morbidity groups specified by the Johns Hopkins Adjusted Clinical Groups (ACGs) Case-Mix System. We estimated the prevalence of 12 chronic conditions, comparing the results obtained using the different data sources with each other and also with those of the Basque Health Interview Survey (ESCAV). Using the different combinations of inputs, Standardized Morbidity Ratios (SMRs) for the considered diseases were calculated for the list of patients of each general practitioner. The variances of the SMRs were used as a measure of the dispersion of the data and were compared using the Brown-Forsythe test. Results The prevalences calculated using prescription data were higher than those obtained from diagnoses and those from the ESCAV, with two exceptions: malignant neoplasm and migraine. The variances of the SMRs obtained from the combination of all the data sources (hospital diagnoses, and primary care prescriptions and diagnoses) were significantly lower than those using only diagnoses. Conclusions The estimated prevalence of chronic diseases varies considerably depending of the source(s) of information used. Given that administrative databases compile data registered for other purposes, the estimations obtained must be considered with caution. In a context of increasingly widespread computerisation of patient medical records, the complementary use of a range of sources may be a feasible option for the routine monitoring of the prevalence of chronic diseases.

Purpose: Biomarkers as screening for precision medicine is a fundamental step. The purpose of this article is twofold. First, to highlight the existing barriers in the implementation of Precision Medicine in Spain, with a special emphasis on barriers in access to the determination of biomarkers. Second, to provide a Roadmap that can help implement Precision Medicine equitably at the national level and optimize the use of biomarkers., Methods: A systematic review of literature (SRL) and a focus group (FG) with multidisciplinary experts has been carried out in 2023. Participants were contacted individually, and discourse analysis was processed anonymously., Results: We carried out a quantitative (SRL) and a qualitative approach (FG). The discourse analysis and roadmap were sent individually to each expert for approval., Conclusions: The potential of Precision Medicine has not been fulfilled in Spain. While several regional initiatives are in place, a national plan or strategy around Precision Medicine and use of biomarkers is lacking. In a general context of rapid progress at a global and European level, including the 2021 Europe's Beating Cancer Plan, it is time to define and implement a National Plan to make the promise come true. While some comparable countries within Europe - such as the UK or France - are mature enough to adopt such strategies, in Spain there is still a long way to go. We consider that the different strands of work outlined in the Roadmap can be used as basis for such purpose., (© 2024. The Author(s).)

Objective: Post-stroke spasticity (PSS) is a common complication in stroke survivors, causing severe burden to patients living with it. The aim of this review was to conduct a cost-effectiveness analysis (CEA) of the treatment of post-stroke spasticity, in adults, with abobotulinumtoxinA compared to the best supportive care, based on results from a systematic literature review. Given that abobotulinumtoxinA (aboBoNT-A) is always accompanied by the best supportive care treatment, the CEA compared aboBoNT-A plus the best supportive care with the best supportive care alone., Methods: A systematic literature review in EMBASE (including Medline and PubMed), Scopus, and other sources (Google Scholar) was conducted. Articles of all types, providing information on the costs and/or effectiveness measures for the current treatments of PSS in adults were included. The synthesis of information from the review provided the parameters for the design of a cost-effectiveness analysis of the mentioned treatment of interest. The societal perspective was compared to a perspective where only direct costs were observed., Results: In total, 532 abstracts were screened. Full information was revised from 40 papers and 13 of these were selected as core papers for full data extraction. Data from the core publications formed the basis for the development of a cost-effectiveness model. In all the included papers physiotherapy was the best supportive care treatment (SoC). The cost-effectiveness analysis showed that even in the most conservative scenario, assuming the worst case scenario, the probability of a cost per quality-adjusted life-year (QALY) gained below €40,000, for aboBoNT-A together with physiotherapy is above 0.8, and with certainty below €50,000/QALY when either a direct costs, or a societal perspective was taken. On average, the probabilistic model obtains a negative mean incremental cost-effectiveness ratio of around -15,000 €/QALY., Conclusion: The cost-effectiveness analyses show that aboBoNT-A together with physiotherapy would be a cost-effective treatment compared with physiotherapy alone, independently of the perspective considered., Competing Interests: Conflicts of interest María Errea Rodríguez, independent researcher, declares she has received funding from Ipsen for developing the CEA modeling, interpretation of the results and contribution in writing the article. Juan del Llano and Roberto Nuño-Solinís, declare they have received funding for their work on this project from Ipsen via the Gaspar Casal Foundation. María Fernandez declares that she worked at Ipsen while the study was conducted but her contribution has not influenced the study results., (Copyright © 2023 Sociedad Española de Farmacia Hospitalaria (S.E.F.H). Publicado por Elsevier España, S.L.U. All rights reserved.)

The paradigm of value-based health care is spreading worldwide; however, Value-Based Digital Health (VBDH) is still an emerging concept. VBDH is understood as the use of digital tools to facilitate the generation of value in health. It is accelerated by technological change, cultural, and organizational factors. An accurate diagnosis of the organizational VBDH maturity is crucial to define and implement strategic actions to progress with VBDH transformation. This study aimed to validate a VBDH questionnaire, which measures the degree of maturity of VBDH from the perspective of managers (N = 146) in Spanish healthcare organizations. Results show good internal consistency of the questionnaire. Factor analysis identified seven dimensions to measure VBHC maturity: (1) Resources, incentives, and financing; (2) Knowledge and participation of patients and workers in the strategy of progress towards VBDH; (3) Training of professionals and tool knowledge for advancement in VBDH; (4) Innovation initiatives; (5) Information and its quality; (6) Leadership, strategy and governance; and (7) Knowledge of the fundamentals and objectives, as well as access to relevant VBDH information. The questionnaire presents good validity and internal consistency and meets the requirements to be an instrument for routine use to assess VBDH organizational maturity.

Introduction: In the face of a growing ageing population and rising care needs, compassionate communities seek to visualize the community as an equal partner in the complex task of providing quality social and health care at the end of life., Description: Getxo Zurekin is a social innovation example for the creation of a compassionate community in Getxo, one of the most populated cities in the province of Biscay, with 25.46% of its population aged over 65. Mixed methodologies have been applied, active listening and co-creation of actions and strategies towards improving care and quality of life for people and families facing advanced disease and end of life situations, with more than 80 people interviewed to conform the basis for a collective sense making. The initiative has reached more than 1,000 people in Getxo., Discussion: Following a systemic approach, horizontal relationships and cross-sectoral collaborations have allowed engaging the active involvement of local agents in the collective sense making and co- creation process., Conclusion: Getxo Zurekin represents an example of a participatory action research model, which has shown to be effective to meet initial targets towards creation of a compassionate community., Competing Interests: The authors have no competing interests to declare., (Copyright: © 2022 The Author(s).)

Background: Cardiovascular diseases (CVD) are a major cause of death worldwide and Hypercholesterolemia (HC) is an important cardiovascular risk factor. In Spain, approximately 25% of middle-aged adults suffer from HC. Our objective was to analyse current health strategies and plans in Spain related to CVD and HC in order to define possible future courses of action to bring about better control from a health management and policy perspective., Methods: The study was observational and descriptive. In the first step, a literature review was carried out, followed by six semi structured interviews. In the second step, a group of 12 experts in the field identified existing barriers to HC control and suggested ways to reduce premature mortality due to CVD., Results: A total of 51 documents were identified, of which 43% referred to HC. There was a high variability at the regional level in the implementation of measures and initiatives for the control of HC. Barriers that were identified were : trivialization of HC, lack of active participation by key stakeholders, lack of understanding of the impact of HC, existing care models and pathways, and short-term health policies that limit the provision of resources for HC care and control., Conclusion: Despite the considerable medical and socioeconomic burden of CVD and HC in Spain, the importance of HC is not reflected in health policies. There is a lack of HC control measures, even when they are shown to be highly feasible and beneficial. This article proposes specific measures to improve control of this issue.

The number of Hematopoietic Stem Cell Transplantations has risen in the past 20 years. The practice of outpatient Hematopoietic Stem Cell Transplantation programs is increasing in an attempt to improve the quality of patient care and reduce the demand for hospital admission. A systematic review of 29 comparative studies between in-hospital and outpatient treatment of Hematopoietic Stem Cell Transplantation, with no restriction by outpatient regime was conducted. This study aims to analyse the current evidence on the effects of the outpatient model on patient-centred outcomes, comparing both in-hospital and outpatient models for autologous and allogeneic HSCT using the Triple Aim framework: health outcomes, costs and experience of care. We found evidence on improved health outcomes and quality of life, on enhanced safety and effectiveness and on reduced overall costs and hospital stays, with similar results on overall survival rates comparing both models for autologous and allogeneic patients. We also found that the outpatient Hematopoietic Stem Cell Transplantation is a safe practice as well as less costly, it requires fewer days of hospital stay both for autologous and allogeneic transplantations. Under a situation of an increasing number of transplants, rising healthcare costs and shortages of hospital capacity, incorporating outpatient models could improve the quality of care for people requiring Hematopoietic Stem Cell Transplantation programs., Competing Interests: This research did not receive conditioning funding but has been developed as a by-product of a project funded by the pharmaceutical company Merck Sharp & Dohme Spain. FFA serves as a consultant for MSD and Celgene, receives honoraria from MSD, Celgene, Gilead and Amgen, aids to teaching from MSD, Celgene and Gilead, and aids for innovation from Celgene and Amgen. There are no patents, products in development or marketed products associated with this research to declare. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

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

Background: The aim of this paper is to analyze the differences in the coordination of chronic illness care between the different public hospital management models coexisting in the Spanish region of Madrid (25 hospitals) during the period 2013-2017., Methods: The performance of hospitals might be affected by the characteristics of the population they serve and, therefore, this information should be taken into account when estimating efficiency measures. For this purpose, we apply the nonparametric Data Envelopment Analysis (DEA) conditioned to some contextual variables and adapted to a dynamic framework, so that we can assess hospitals during a five-year period. The outputs considered are preventable hospitalizations, readmissions for heart failure and readmissions for chronic obstructive pulmonary disease, whereas the inputs considered are the number of beds, personnel (physicians and other healthcare professionals) and total expenditure on goods and services., Results: The results suggest that the level of efficiency demonstrated by the public-private collaboration models of hospital management is higher than traditionally managed hospitals throughout the analyzed period. Nevertheless, we notice that efficiency differences among hospitals are significantly reduced when contextual factors were taken into account., Conclusions: Hospitals managed under public-private collaboration models are more efficient than those under traditional management in terms of chronic illness care coordination, being this difference attributable to more agile and flexible management under the collaborative models.

Parkinson's disease is one of the main reasons for neurological consultation in Spain. Due to the nature of the disease, it impacts patients, families, and caregivers. Parkinson's disease is a degenerative disease with no cure, although second-line therapies have recently improved the quality of life of patients in advanced stages. The aim of this study was to analyse the costs of the following therapies: deep brain stimulation (DBS), continuous duodenal levodopa/carbidopa infusion (CDLCI), and continuous subcutaneous apomorphine infusion (CSAI). The methodology used was based on real-world data obtained from an integrated healthcare organization in the Basque Country from 2016 to 2018. This bottom-up retrospective approach only took into account the healthcare perspective. The results revealed the annual cost over 3 years and the projected cost for an additional 2 years. The total costs for 5 years of treatment were as follows: €53,217 for DBS, €208,163 for CDLCI, and €170,591 for CSAI. These costs are in line with those found in the available literature on the subject. Additionally, the analysis provided details of the different costs incurred during intervention with the therapies and compared the costs to those reported in other studies., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2020 Elisa Gomez-Inhiesto et al.)

Background: In the context of public expenditure reduction and cuts, in 2012, the Spanish government approved the RDL 16/2012, which significantly affected the core values of the national health system. The measure particularly affected undocumented immigrants over 18 years of age, excluding them from accessing the full range of healthcare services in Spain, except for emergency care. In 2014, Red de Denuncia y Resistencia al RDL 16/2012 (REDER) was created as a public awareness and resistance network to defend universal access to healthcare and to stop its infringement. This study aims to analyse the social impact of REDER as a solidarity movement in response to the exclusion of undocumented immigrants from their universal right to health., Methods: Qualitative research methodologies were used for the research. Data were collected between November 2017 and December 2017, using eight semi-structured interviews with key informants from the main REDER stakeholders. Additionally, key publications, documents, and presentations of researchers and experts in the field were analysed. For data analysis, a framework extracted from the literature on exclusionary and transformative dimensions of solidarity was used to identify barriers and drivers in REDER's intervention., Results: From its creation to the present, REDER has been able to achieve many of its objectives to defend the right to medical care of groups in irregular situations, contributing to the identification of 4,755 cases of discrimination in healthcare access and helping solve over 90% of these cases by delivering either healthcare assistance or administrative support. REDER has also played an important role in: stimulating social activation and empowering citizens to claim their fundamental rights, organising actions against restrictions on accessibility and creating synergies to restore universal healthcare coverage., Conclusions: REDER has been shown to be effective in leading the defence of universal healthcare rights, and some achievements in the years following 2012 could be directly attributed to the work done by the network, such as the elimination of legal requirements to obtain health cards or the reduction of the minimum time required to access healthcare. Despite context particularities, the initiatives and main actions of this network may be implemented in other settings that are facing similar limitations to healthcare access, in order to address injustices and promote solidarity.

Worldwide most health systems are facing a series of common challenges characterized by the increasing burden of chronic diseases and multimorbidity, and the accelerated pace of biomedical and technological innovations, on the other side. There is a growing recognition that many changes are needed at the macro, meso and micro management levels to tackle these challenges. Therefore, knowing if healthcare organizations are ready for change is a key issue, as high organizational readiness for change (ORC) has been positively related with higher organizational effort and staff motivation for overcoming barriers and setbacks in change endeavours. In practice, readiness for change is not commonly measured and there is a need of adequate metrics for it. In this commentary, a new tool for measuring readiness change is reviewed, the OR4KT. It has been developed based on a solid theoretical background and with the involvement of experts and potential users in the design and it has been tested and validated in three languages and in different organizational settings. Although its generalizability needs to be further tested, it seems to be a promising and useful tool to diagnose if organizations are ready to implement evidence-informed changes. A broader recognition of the key role that the science of implementation can play in the success of much needed transformations in healthcare provides a good opportunity for the dissemination of the OR4KT., (© 2018 The Author(s); Published by Kerman University of Medical Sciences. This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

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

Background: Multimorbidity is becoming increasingly common and is a leading challenge currently faced by societies with aging populations. The presence of multimorbidity requires patients to coordinate, understand, and use the information obtained from different health care professionals, while simultaneously striving to distinguish the symptoms of different diseases and self-manage their sometimes conflicting health problems. Electronic health (eHealth) tools provide a means to disseminate health information and education for both patients and health professionals and hold promise for more efficient and cost-effective care processes., Objective: The aim of this study was to analyze the use of eHealth tools, taking into account the citizens' sociodemographic and clinical characteristics, and above all, the presence of multimorbidity., Methods: Cross-sectional and exploratory research was conducted using online survey data from July 2011 to August 2011. Participants included a total of 14,000 citizens from 14 European countries aged 16 to 74 years, who had used an eHealth tool in the past 3 months. The variables studied were sociodemographic variables of the participants, the questionnaire items assessing the frequency of using eHealth tools, the degree of morbidity, and the eHealth adoption gradient. Chi-square tests were conducted to examine the relationship between the sociodemographic and clinical variables of participants and the group the participants were assigned to according to their frequency of eHealth use (eHealth user group). A one-way analysis of variance (ANOVA) allowed for assessing the differences in the eHealth adoption gradient average between different groups of individuals according to their morbidity level. A two-way between-groups ANOVA was performed to explore the effects of multimorbidity and age group on the eHealth adoption gradient., Results: According to the eHealth adoption gradient, most participants (68.15%, 9541/14,000) were labeled as rare users, with the majority of them (55.1%, 508/921) being in the age range of 25 to 54 years, with upper secondary education (50.3%, 464/921), currently employed (49.3%, 454/921), and living in medium-sized cities (40.7%, 375/921). Results of the one-way ANOVA showed that the number of health problems significantly affected the use of eHealth tools (F 2,13996 =11.584; P<.001). The two-way ANOVA demonstrated that there was a statistically significant interaction between the effects of age and number of health problems on the eHealth adoption gradient (F 4,11991 =7.936; P<.001)., Conclusions: The eHealth adoption gradient has proven to be a reliable way to measure different aspects of eHealth use. Multimorbidity is associated with a more intense use of eHealth, with younger Internet users using new technologies for health purposes more frequently than older groups with the same level of morbidity. These findings suggest the need to consider different strategies aimed at making eHealth tools more sensitive to the characteristics of older populations to reduce digital disadvantages., (©Francisco Lupiáñez-Villanueva, Dimitra Anastasiadou, Cristiano Codagnone, Roberto Nuño-Solinís, Maria Begona Garcia-Zapirain Soto. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 03.05.2018.)

Background: As cancer survival rates increase, the challenge of ensuring that cancer survivors reclaim their quality of life (QoL) becomes more important. This paper outlines the research element of a research and training program that is designed to do just that., Objective: Bridging sectors, disciplines, and geographies, it brings together eight PhD projects and students from across Europe to identify the underlying barriers, test different technology-enabled rehabilitative approaches, propose a model to optimize the patient pathways, and examine the business models that might underpin a sustainable approach to cancer survivor reintegration using technology., Methods: The program, funded under the European Union's Horizon 2020 research and innovation program under the Marie Sklodowska-Curie grant agreement No 722012, includes deep disciplinary PhD projects, intersectoral and international secondments, interdisciplinary plenary training schools, and virtual subject-specific education modules., Results: The 8 students have now been recruited and are at the early stages of their projects., Conclusions: CATCH will provide a comprehensive training and research program by embracing all key elements-technical, social, and economic sciences-required to produce researchers and project outcomes that are capable of meeting existing and future needs in cancer rehabilitation., (©Nicola Mountford, Enrique Dorronzoro Zubiete, Threase Kessie, Begonya Garcia-Zapirain, Roberto Nuño-Solinís, David Coyle, Kristin B Munksgaard, Luis Fernandez-Luque, Octavio Rivera Romero, Matilde Mora Fernandez, Pedro Valero Jimenez, Ailish Daly, Ruth Whelan, Brian Caulfield. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 24.01.2018.)

Objective: To analyse the use of health resources and its budget in the last months of life of the population who died from malignant neoplasm in the Basque Autonomous Country (Spain)., Method: Retrospective observational study of a population with a diagnosis of malignancy deceased in the Basque Country (2010 and 2011)., Data Source: MDS and Mortality Register., Variables: gender, age, place of death, tumour location, clinical activity data and costs in the last three months of life. We performed a descriptive analysis of clinical activity and costs, and lineal multivariate regressions to obtain the adjusted mean costs by gender, age and place of death., Results: 9,333 deaths from malignancy were identified in 2010 and 2011. 65.4% were men, 61.5% aged 70 or over, mean age 72.9 years, 71.1% died in hospital. People who died in the hospital had an average cost of about double that of the people who died at home (€14,794 and €7,491, respectively; p <0.001) and 31.3% higher than in the nursing home (€11,269; p <0.001)., Conclusions: Greater interventions at the end of life at the community level are necessary, strengthening the care capacity of primary health care, both from training and support from expert teams in order to change the current care profile to a more outpatient care that allows a lower consumption of resources and greater care at home., (Copyright © 2016 SESPAS. Publicado por Elsevier España, S.L.U. All rights reserved.)

Progress in health care integration is largely linked to changes in processes and ways of doing. These changes have knowledge management and learning implications. For this reason, the use of the concept of organisational learning is explored in the field of integrated care. There are very limited contributions that have connected the fields of organisational learning and care integration in a systematic way, both at the theoretical and empirical level. For this reason, hybridization of both perspectives still provides opportunities for understanding care integration initiatives from a research perspective as well as potential applications in health care management and planning.

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.)

Introduction: The goal of chronic hepatitis C (CHC) treatment is to achieve a sustained virologic response (SVR). The new generation of direct-acting antivirals (DAAs) offers 90-100% SVR rates. However, access to these treatments is generally limited to patients with advanced liver disease. The aim of this review is to provide an overview of the clinical and economic benefits of achieving SVR and to better understand the full value of CHC treatment in all stages of liver disease., Methods: A comprehensive literature review was performed using the PubMed, Embase, and Cochrane library databases to identify articles examining the clinical, economic, and quality of life benefits associated with SVR. Articles were limited to those published in English language from January 2006 through January 2016. Inclusion criteria were (1) patients with CHC, (2) retrospective and prospective studies, (3) reporting of mortality, liver morbidity, extrahepatic manifestations (EHMs), and economic outcomes and, (4) availability of an abstract or full-text publication., Results: Overall this review identified 354 studies involving more than 500,000 CHC patients worldwide. Evidence from 38 studies (n = 73,861) shows a significant mortality benefit of achieving SVR in patients with all stages of fibrosis. Long-term studies with follow-up of 5-12 years suggest that, particularly among non-cirrhotic patients, there is a significant decrease in mortality in SVR versus non-SVR groups. Ninety-nine studies conducted in 235,891 CHC patients in all stages of fibrosis show that SVR reduces liver-related mortality, incidence of hepatocellular carcinoma (HCC), and decompensation. A total of 233 studies show that chronic HCV infection is associated with several serious EHMs, some of which can have high mortality. Evidence from four modeling studies shows that delaying treatment to CHC patient populations could significantly increase mortality, morbidity, and medical costs., Conclusions: There is a robust body of evidence demonstrating diverse sources of value from achieving SVR in all stages of liver disease. While access to treatment is generally limited to late-stage patients, less restrictive treatment strategies that target HCV eradication have the potential to abate the burdens of mortality, liver morbidity and extrahepatic manifestations, and the associated healthcare costs.

Public healthcare in the Basque Country (Spain) faces high rates of ageing and chronicity, which stress the sustainability of the system. In response to this situation, the Basque Chronicity Strategy was launched in 2010. This large-scale and far-reaching transformation initiative focused on changing the healthcare provision model towards integrated care of chronicity. Developed in the context of economic and financial crisis, strong political opposition and resistance or passivity of many relevant stakeholders, the design and implementation of the Strategy introduced some noteworthy elements, such as: a narrative of change different to the austerity discourse, which was the dominant narrative at that time; a strategic approach supported by an evidence base and solid theoretical references; and an implementation strategy that favoured local innovation and the "bottom up" approach. In spite of this, it was not possible to overcome the political barriers or bureaucratic immobility, which limited the implementation and scope of the changes, especially those related to the scalability of successful local innovations. However, some changes in the healthcare integration culture at clinical and managerial level have been introduced as a result of the Strategy, as well as organisational progression towards a chronicity-targeted healthcare model., (Copyright © 2016 SESPAS. Publicado por Elsevier España, S.L.U. All rights reserved.)

Introduction: The experience of chronic patients with the care they receive, fuelled by the focus on patient-centeredness and the increasing evidence on its positive relation with other dimensions of quality, is being acknowledged as a key element in improving the quality of care. There are a dearth of accepted tools and metrics to assess patient experience from the patient's perspective that have been adapted to the new chronic care context: continued, systemic, with multidisciplinary teams and new technologies., Methods: Development and validation of a scale conducting a literature review, expert panel, pilot and field studies with 356 chronic primary care patients, to assess content and face validities and reliability., Results: IEXPAC is an 11+1 item scale with adequate metric properties measured by Alpha Chronbach, Goodness of fit index, and satisfactory convergence validity around three factors named: productive interactions, new relational model and person's self-management., Conclusions: IEXPAC allows measurement of the patient experience of chronic illness care. Together with other indicators, IEXPAC can determine the quality of care provided according to the Triple Aim framework, facilitating health systems reorientation towards integrated patient-centred care.

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.)

Introduction: The Instrumento de Evaluación de Modelos de Atención ante la Cronicidad/Assessment of Readiness for Chronicity in Health Care Organisations instrument was developed to implement the conceptual framework of the Chronic Care Model in the Spanish national health system. It has been used to assess readiness to tackle chronicity in health care organisations. In this study, we use self-assessments at macro-, meso- and micro-management levels to (a) describe the two-year experience with the Instrumento de Evaluación de Modelos de Atención ante la Cronicidad/Assessment of Readiness for Chronicity in Health Care Organisations tool in Spain and (b) assess the validity and reliability of this instrument., Methods: The results from 55 organisational self-assessments were included and described. In addition to that, the internal consistency, reliability and construct validity of Instrumento de Evaluación de Modelos de Atención ante la Cronicidad/Assessment of Readiness for Chronicity in Health Care Organisations were examined using Cronbach's alpha, the Spearman-Brown coefficient and factorial analysis., Results: The obtained scores reflect opportunities for improvement in all dimensions of the instrument. Cronbach's alpha ranged between 0.90 and 0.95 and the Spearman-Brown coefficient ranged between 0.77 and 0.94. All 27 components converged in a second-order factorial solution that explained 53.8% of the total variance, with factorial saturations for the components of between 0.57 and 0.94., Conclusions: Instrumento de Evaluación de Modelos de Atención ante la Cronicidad/Assessment of Readiness for Chronicity in Health Care Organisations is an instrument that allows health care organisations to perform self-assessments regarding their readiness to tackle chronicity and to identify areas for improvement in chronic care.

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

Background: Adverse events (AE) are also the cause of suffering in health professionals involved. This study was designed to identify and analyse organization-level strategies adopted in both primary care and hospitals in Spain to address the impact of serious AE on second and third victims., Methods: A cross-sectional study was conducted in healthcare organizations assessing: safety culture; health organization crisis management plans for serious AE; actions planned to ensure transparency in communication with patients (and relatives) who experience an AE; support for second victims; and protective measures to safeguard the institution's reputation (the third victim)., Results: A total of 406 managers and patient safety coordinators replied to the survey. Deficient provision of support for second victims was acknowledged by 71 and 61% of the participants from hospitals and primary care respectively; these respondents reported there was no support protocol for second victims in place in their organizations. Regarding third victim initiatives, 35% of hospital and 43% of primary care professionals indicated no crisis management plan for serious AE existed in their organization, and in the case of primary care, there was no crisis committee in 34% of cases. The degree of implementation of second and third victim support interventions was perceived to be greater in hospitals (mean 14.1, SD 3.5) than in primary care (mean 11.8, SD 3.1) (p < 0.001)., Conclusions: Many Spanish health organizations do not have a second and third victim support or a crisis management plan in place to respond to serious AEs.

Healthcare providers are often evaluated by studying variability in their indicators. However, the usefulness of this analysis may be limited if we do not distinguish the variability attributable to health professionals and organizations from that associated with their patients.Our objectives are to describe the main process and outcome indicators of primary healthcare services, analyzing the contribution to variability in these indicators from different levels: individual, health professional, health center, and health district.This is a cross-sectional study that includes all.All the individuals covered by the public Basque Health Service (children [age 0-13], n = 247,493; adults [≥14 years old], n = 1,959,682) over a 12-month period.We calculated the number of visits to primary care doctors, number of referrals, prescription costs, and potentially avoidable hospitalizations for ambulatory care sensitive conditions (ACSCs). Using multilevel analysis, we determined the percentage of variance attributable to each level.After adjusting for the characteristics of patients (demographic, socioeconomic, and morbidity), doctors (panel size), health center (size, staff satisfaction, demographic structure of the community), and health district, the variance in the indicators was mainly attributable to differences between patients, independently of the attending health professional, the center, or the healthcare organization, both in children (94.21% for visits to the doctor; 96.66% for referrals; 98.57% for prescription costs; 90.02% for potentially avoidable hospitalizations for ACSCs) and in adults (88.10%; 96.26%; 97.92%; and 93.77%, respectively).The limited contribution of health professionals and organizations to variability in indicators should be taken into account when performing evaluations and planning quality improvement strategies.

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.

Objectives: To explain the variability in the frequency of potentially preventable hospitalisations (ambulatory care sensitive conditions, ACSCs) based on factors at multiple levels (individual, health professional, health centre and health district), and specifically using resource efficiency indicators for general practitioners (GPs)., Design: Cross-sectional study. We analysed primary care electronic health records and hospital discharge data using multilevel mixed models., Setting: Primary care network of the Basque Health Service (Spain)., Participants: All the residents in the Basque Country ≥14 years of age, covered by the public healthcare system (n=1,959,682), and all the GPs (n=1193) and health centres (n=130)., Main Outcome Measures: Individuals admitted for ACSCs, over a 12- month period., Results: Admissions for ACSCs were less frequent among patients who were female, middle-aged or from the highest socioeconomic classes. The health centre variables considered and GP list size were not found to be significant. After adjusting for the variables studied including morbidity, the risk of hospital admission was higher among individuals under the care of GPs with greater than expected numbers of patient visits and prescribing costs (OR=1.27 (95% CI 1.18 to 1.37); 1.16 (1.08 to 1.25)), and who make fewer referrals than the mean among their colleagues (OR=1.33 (1.22 to 1.44))., Conclusions: When assessing activities and procedure indicators in primary care, we should also define outcome-based criteria. Specifically, GPs who are repeatedly visited by their patients, have higher prescribing costs and are more reluctant to refer patients to specialists obtain poorer outcomes., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Adverse events (AEs) cause harm in patients and disturbance for the professionals involved in the event (second victims). This study assessed the impact of AEs in primary care (PC) and hospitals in Spain on second victims., Methods: A cross-sectional study was conducted. We carried out a survey based on a random sample of doctors and nurses from PC and hospital settings in Spain. A total of 1087 health professionals responded, 610 from PC and 477 from hospitals., Results: A total of 430 health professionals (39.6%) had informed a patient of an error. Reporting to patients was carried out by those with the strongest safety culture (Odds Ratio -OR- 1.1, 95% Confidence Interval -CI- 1.0-1.2), nurses (OR 1.9, 95% CI 1.5-2.3), those under 50 years of age (OR 0.7, 95% CI 0.6-0.9) and primary care staff (OR 0.6, 95% CI 0.5-0.9). A total of 381 (62.5%, 95% CI 59-66%) and 346 (72.5%, IC95% 69-77%) primary care and hospital health professionals, respectively, reported having gone through the second-victim experience, either directly or through a colleague, in the previous 5 years. The emotional responses were: feelings of guilt (521, 58.8%), anxiety (426, 49.6%), re-living the event (360, 42.2%), tiredness (341, 39.4%), insomnia (317, 38.0%) and persistent feelings of insecurity (284, 32.8%). In doctors, the most common responses were: feelings of guilt (OR 0.7 IC95% 0.6-0.8), re-living the event (OR 0.7, IC95% o.6-0.8), and anxiety (OR 0.8, IC95% 0.6-0.9), while nurses showed greater solidarity in terms of supporting the second victim, in both PC (p = 0.019) and hospital (p = 0.019) settings., Conclusions: Adverse events cause guilt, anxiety, and loss of confidence in health professionals. Most are involved in such events as second victims at least once in their careers. They rarely receive any training or education on coping strategies for this phenomenon.

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.)

Background: To determine whether there is greater employee satisfaction in organisations that have made more progress in implementation of the European Foundation for Quality Management (EFQM) model., Methods: A series of cross-sectional studies (one for each assessment cycle) comparing staff satisfaction survey results between groups of healthcare organisations by degree of implementation of the EFQM model (assessed in terms of external recognition of management quality in each organisation)., Setting: 30 healthcare organisations including hospitals, primary care and mental health providers in Osakidetza, the Basque public health service., Participants: Employees of 30 Osakidetza organisations., Intervention: Progress in implementation of EFQM model., Main Outcome Measures: Scores in 9 dimensions of employee satisfaction from questionnaires administered in healthcare organisations in 4 assessment cycles between 2001 and 2010., Results: Comparing satisfaction results in organisations granted Gold or Silver Q Awards and those without this type of external recognition, we found statistically significant differences in the dimensions of training and internal communication. Then, comparing recipients of Gold Q Awards with those with no Q Certification, differences in leadership style and in policy and strategy also emerged as significant., Conclusions: Progress of healthcare organisations in the implementation of the EFQM Excellence Model is associated with increases in their employee satisfaction in dimensions that can be managed at the level of each organisation, while dimensions in which no statistically significant differences were found represent common organisational elements with little scope for self-management.

Background: A prospective Population Risk Stratification (PRS) tool was first introduced in the public Basque Health Service in 2011, at the level of its several Primary Care (PC) practices. This paper aims at exploring the new tool's implementation process, as experienced by its potential adopters/users, ie. PC clinicians (doctors and nurses). Findings could help guide future PRS implementation strategies., Methods: Three focus groups exploring clinicians' opinions and experiences related to the PRS tool and its implementation in their daily practice were conducted. A purposive sample of 12 General Practitioners and 11 PC nurses participated in the groups. Discussions were digitally recorded, transcribed verbatim and analysed by two independent researchers using thematic analysis based on Graham et al.'s Knowledge Translation Theory., Results: Exploring PC clinicians' experience with the new PRS tool, allowed us to identify certain elements working as barriers and facilitators in its implementation process. This series of closely interrelated elements, which emerged as relevant in building up the complex implementation process of the new tool, as experienced by the clinicians, can be grouped into four domains: 1) clinicians' characteristics as potential adopters, 2) clinicians' perceptions of their practice settings where PRS is to implemented, 3) clinicians' perceptions of the tool, and 4) the implementation strategy used by the PRS promoter., Conclusions: Lessons from the implementation process under study point at the need to frame the implementation of a new PRS tool within a wider strategy encouraging PC clinicians to orientate their daily practice towards a population health approach. The PRS tool could also improve the perceived utility by its potential adopters, by bringing it closer to the clinicians' needs and practice, and allowing it to become context-sensitive. This would require clinicians being involved from the earliest phases of conceptualisation, design and implementation of the new tool, and mounting efforts to improve communication between clinicians and tool promoters.Graham et al.'s Knowledge Translation Theory proved a suitable framework to explore the implementation process of a new PRS tool in the public Basque Health Service's PC practice, and hence to identify implementation barriers and facilitators as experienced by the clinicians.

Objective: To explore the perception of primary care health professionals in the Basque Country (Spain) of multiple comorbidities and their influence on clinical practice and the organization of health services., Design: Qualitative study based on interviews, a storytelling workshop and cocreation., Setting: The autonomous community of the Basque Country. Primary care in the Basque health system., Participants: Fourteen health professionals: 6 specialists in family medicine, 3 hospital specialists (internal medicine, pneumology, and geriatrics), 4 nurses, and 1 community pharmacist., Methods: A qualitative, exploratory study was carried out, based on a cocreation workshop (12 participants) and 10 interviews with health professionals. The research was performed between February and June 2013. All interviews and the group workshop were audio recorded and some were video recorded., Results: The emerging dominant themes were as follows: a) the challenges posed by multiple comorbidities for a "disease-centered" health system; b) the manifestation of these challenges in daily clinical practice in aspects such as the patient-health professional relationship, clinical decision-making, polypharmacy management, and coordination between healthcare settings; c) the barriers to the appropriate care of these patients: training, decision-making tools, lack of time, etc.; and d) the question of the most appropriate professional competencies and profiles., Conclusions: The increase in multiple comorbidities is a reality that worries primary care professionals, who express the need for adequate training, decision-making tools and support in daily clinical practice dealing with the most frequent situations and combinations of multiple comorbidities. The most effective approach to these problems requires a shift in the healthcare model toward an integrated view of the patient, a transition from a paternalist approach to a more proactive approach, and the development of healthcare integration., (Copyright © 2014 Elsevier España, S.L. All rights reserved.)