Allocation of Residency Training Positions in Spain: Contextual Effects on Specialty Preferences.

In Spain's 'MIR' system, medical school graduates are ranked by their performance on a national exam and then sequentially choose from the available residency training positions. We took advantage of a unique survey of participants in the 2012 annual MIR cycle to analyze preferences under two different choice scenarios: the residency program actually chosen by each participant when it came her turn (the 'real') and the program that she would have chosen if all residency training programs had been available (the 'counterfactual'). Utilizing conditional logit models with random coefficients, we found significant differences in medical graduates' preferences between the two scenarios, particularly with respect to three specialty attributes: work hours/lifestyle, prestige among colleagues, and annual remuneration. In the counterfactual world, these attributes were valued preferentially by those nearer to the top, while in the real world, they were valued preferentially by graduates nearer to the bottom of the national ranking. Medical graduates' specialty preferences, which we conclude, are not intrinsically stable but depend critically on the 'rules of the game'. The MIR assignment system, by restricting choice, effectively creates an externality in which those at the bottom, who have fewer choices, want what those at the top already have. Copyright © 2016 John Wiley & Sons, Ltd.

Secular trend in the incidence of hip fracture in Catalonia, Spain, 2003-2014.

Objectives: to describe the secular trend and seasonal variation in the incidence of hip fracture (HF) over 12 years (2003-2014) in Catalonia, the community with the highest incidence of HF in Spain. Methods: data about age, gender, type of fracture and month of hospitalisation among patients aged 65 years and older discharged with a diagnosis of HF were collected. Crude and age-standardised annual incidence rate were reckoned. To analyse HF trend, the age/sex-adjusted average annual change in incidence (incidence rate ratio, IRR) was calculated. Results: we identified 100,110 HF in the period, with an increase of 16.9% (women 13.4%; men 28.4%). Trochanteric fractures were the most frequent (55.8%). The crude incidence rate (per 100,000 population) decreased from 677.2 (95% confidence interval (95% CI) 662.0-692.7) to 657.6 (95% CI 644.0-671.5). The standardised incidence rate decreased from 754.0 (95% CI 738.6-769.3) to 641.5 (95% CI 627.7-655.3), with a sharp decrease in women (-16.8%) while it was stable in men. The incidence by type of fracture was stable. The trend throughout the period showed a slight decrease with IRR 0.99 (95% CI 0.98-0.99; P = 0.025). The incidence was stable in the oldest group (+85 years), while there was a downward trend in the younger groups. A significant seasonal pattern was observed, with more cases in winter and less in summer (spring as reference). Conclusions: the secular trend reveals a decreasing incidence of HF although the absolute number has increased in the last 12 years in Catalonia. Trochanteric fractures were the most prevalent and a seasonal pattern was observed, with more cases in winter.

Cross-sectional study comparing public and private hospitals in Catalonia: is the practice of routine episiotomy changing?

BACKGROUND: In Spain, the Strategy for Assistance in Normal Childbirth (SANC) promoted a model of care, which respects the physiological birth process and discards unnecessary routine interventions, such as episiotomies. We evaluated the rate of episiotomy use and perineal trauma as indicators of how selective introduction of the SANC initiative has impacted childbirth outcomes in hospitals of Catalonia. METHODS: Cross-sectional study of all singleton vaginal term deliveries without instrument registered in the Minimum Basic Data Set (MBDS) of Catalonia in 2007, 2010 and 2012. Hospitals were divided into types according to funding (public or private), and four strata were differentiated according to volume of births attended. Episiotomies and perineal injury were considered dependent variables. The relationship between qualitative variables was analysed using the chi-squared test, and Student's t-test was used for quantitative variables. Comparison of proportions was performed on the two hospital groups between 2007 and 2012 using a Z-test. Logistic regression models were used to analyse the relationship between episiotomy or severe perineal damage and maternal age, volume of births and hospital type, obtaining odds ratios (OR) and 95% confidence intervals (CI). RESULTS: The majority of normal singleton term deliveries were attended in public hospitals, where maternal age was lower than for women attended in private hospitals. Analysis revealed a statistically significant (P < 0.001) decreasing trend in episiotomy use in Catalonia for both hospital types. Private hospitals appeared to be associated with increased episiotomy rate in 2007 (OR = 1.099, CI: 1,057-1,142), 2010 (OR = 1.528, CI: 1,472-1,587) and 2012 (OR = 1.459, CI: 1,383-1,540), and a lower rate of severe perineal trauma in 2007 (OR = 0.164, CI: 0.095-0.283), 2010 (OR = 0.16, CI: 0.110-0.232) and 2012 (OR = 0.19, CI: 0.107-0.336). Regarding severe perineal injury, when independent variables were adjusted, maternal age ceased to have a significant correlation in 2012 (OR = 0.994, CI: 0.970-1.018). CONCLUSIONS: Episiotomy procedures during normal singleton vaginal term deliveries in Catalonia has decreased steadily since 2007. Study results show a stable incidence trend below 1% for severe perineal trauma over the study period.

Obstetric interventions in two groups of hospitals in Catalonia: a cross-sectional study.

BACKGROUND: Childbirth assistance in highly technological settings and existing variability in the interventions performed are cause for concern. In recent years, numerous recommendations have been made concerning the importance of the physiological process during birth. In Spain and Catalonia, work has been carried out to implement evidence-based practices for childbirth and to reduce unnecessary interventions.To identify obstetric intervention rates among all births, determine whether there are differences in interventions among full-term single births taking place in different hospitals according to type of funding and volume of births attended to, and to ascertain whether there is an association between caesarean section or instrumental birth rates and type of funding, the volume of births attended to and women's age. METHODS: Cross-sectional study, taking the hospital as the unit of analysis, obstetric interventions as dependent variables, and type of funding, volume of births attended to and maternal age as explanatory variables. The analysis was performed in three phases considering all births reported in the MBDS Catalonia 2011 (7,8570 births), full-term single births and births coded as normal. RESULTS: The overall caesarean section rate in Catalonia is 27.55% (CI 27.23 to 27.86). There is a significant difference in caesarean section rates between public and private hospitals in all strata. Both public and private hospitals with a lower volume of births have higher obstetric intervention rates than other hospitals (49.43%, CI 48.04 to 50.81). CONCLUSIONS: In hospitals in Catalonia, both the type of funding and volume of births attended to have a significant effect on the incidence of caesarean section, and type of funding is associated with the use of instruments during delivery.

[Important differences between faculties of medicine. Implications for family and community medicine]. / Importantes diferencias entre facultades de medicina. Implicaciones para la medicina de familia y comunitaria.

OBJECTIVE: To determine if there are significant differences between universities in the proclivity to choose Family and Community Medicine (FCM), given the constraints imposed by the number of choice. To test the hypothesis that the Schools of Medicine that have the FCM as a compulsory subject in the degree (3 of 27) had the highest preference for this specialty. DESIGN: Observational study on the data file of all the individuals taking the MIR examination between 2003 and 2011. LOCATION: Spain. PARTICIPANTS: All those who sat the examinations called by MIR 2003-2011. MAIN MEASUREMENTS: Position in the ranking of each candidate, elected position (specialty and center), post code of residence, sex, nationality and university in which they studied, and post code location for the residence chosen. RESULTS: The percentage electing FCM is highly correlated with the position in the ranking: 8% of graduates for the 'best' college, 46% for the worst. Very noticeable and consistent differences in the preparation for the MIR among the 27 medical schools. Ranking in the exam, female and foreigner, help predict the choice of FCM. The FCM compulsory curriculum from three universities does not seem to exert any influence. CONCLUSIONS: The convenient yardstick competition between the schools of medicine, FCM in their curriculum and the emphasis on the most attractive attributes of the specialty can contribute to the necessary renewal of FCM.

[Human resource management in health. Consensual paths forward. SESPAS Report 2024]. / Gestión de recursos humanos en sanidad. Vías de avance consensuables. Informe SESPAS 2024.

Healthcare professionals deserve good management, and Spain, stagnant in its productivity, needs it. Good management is possible, as evidenced during the states of alarm in 2020. None of the lessons learned have been consolidated. Dismissing the term "public management" as an oxymoron is extreme, as there has never been a greater need for a well-functioning state, along with a better market, for reasons beyond the consolidation of the welfare state. The opposite extreme of thinking that salvation lies only within the civil service is also unhelpful. Bureaucratic sclerosis, a sign of deterioration, focused on legality or its appearance, cannot continue to ignore the need for effectiveness. The quality of management, both in general and in the healthcare sector, can be measured, and there is knowledge on how to improve it. More flexible models of labor relations -for selection, recruitment, and retention based on improved criteria of "equality, merit, and capability"- require modifications in institutional architecture, as proposed in this article: competitor benchmarking among autonomous centers and responsible entities that share standardized rules. The healthcare system, the jewel of the country, thanks in large part to the quality of its human resources, not only deserves to have its potential unleashed but can also lead the necessary increase in its resolution capacity, ensuring its impact on social well-being. It can also document its research and innovative capabilities in intellectual property, thereby contributing to the gross domestic product.

[Rebuilding the healthcare system: governance, organization and digitalization. SESPAS Report 2022]. / Reconstrucción del sistema sanitario: gobernanza, organización y digitalización. Informe SESPAS 2022.

Reflection on three major levers for rebuilding the healthcare system: governance, integration of health and social care and digitalization. Spain has worrying levels of quality of democracy and public confidence in its politicians, and major changes are required in public administration to achieve a better state. Healthcare suffers from a deficient institutional architecture that prevents adequate macrogovernance. There is also a lack of autonomy in the management of public health centers, which hinders competition by comparison, care integration and coordination within and between levels of care. The pandemic has highlighted the value of professionalism and has shown that agile healthcare management is possible, but the challenge is to maintain this flexibility outside state of alarm. Care integration is more necessary as the population ages (albeit healthily), and per capita financing is a powerful tool to achieve it. Digitization concerns practically all areas of healthcare and population health, and will bring with it far-reaching organizational changes, requiring new methods of evaluation that differ according to the degree of intrusiveness in individual health. Telemedicine, sponsored during the pandemic with a view to permanence, induces changes in labor relations, among others. It is necessary to measure the value of digital tools and technologies. Spain has a unique opportunity for its digital transformation, thanks to European funds.

The evolution of health status and chronic conditions in Catalonia, 1994-2006: the paradox of health revisited using the Blinder - Oaxaca decomposition.

BACKGROUND: The paradox of health refers to the improvement in objective measures of health and the increase in the reported prevalence of chronic conditions. The objective of this paper is to test the paradox of health in Catalonia from 1994 to 2006. METHODS: Longitudinal cross-sectional study using the Catalonia Health Interview Survey of 1994 and 2006. The approach used was the three-fold Blinder - Oaxaca decomposition, separating the part of the differential in mean visual analogue scale value (VAS) due to group differences in the predictors (prevalence effect), due to differences in the coefficients (severity effect), and an interaction term. Variables included were the VAS value, education level, labour status, marital status, all common chronic conditions over the two cross-sections, and a variable for non-common chronic conditions and other conditions. Sample weights have been applied. RESULTS: Results show that there is an increase in mean VAS for men aged 15-44, and a decrease in mean VAS for women aged 65-74 and 75 and more. The increase in mean VAS for men aged 15-44 could be explained by a decrease in the severity effect, which offsets the increase in the prevalence effect. The decrease in mean VAS for women aged 65-74 and 75 and more could be explained by an increase in the prevalence effect, which does not offset the decrease in the severity effect. CONCLUSIONS: The results of the present analysis corroborate the paradox of health hypothesis for the population of Catalonia, and highlight the need to be careful when measuring population health over time, as well as their usefulness to detect population's perceptions.

[What is an efficient health intervention in Spain in 2020?] / ¿Qué es una intervención sanitaria eficiente en España en 2020?

Fifteen years ago, Gaceta Sanitaria published the article entitled "What is an efficient health technology in Spain?" The growing interest in setting the price of new technologies based on the value they provide to health systems and the experience accumulated by the countries in our environment make it opportune to review what constitutes an efficient health intervention in Spain in 2020. Cost-effectiveness analysis continues to be the reference method to maximize social health outcomes with the available resources. The interpretation of its results requires establishing reference values that serve as a guide on what constitutes a reasonable value for the health care system. Efficiency thresholds must be flexible and dynamic, and they need to be updated periodically. Its application should be based on and transparency, and consider other factors that reflect social preferences. Although setting thresholds is down to political decision-makers, in Spain it could be reasonable to use thresholds of 25,000 and 60,000 Euros per QALY. However, currently, in addition to determining exact figures for the threshold, the key question is whether the Spanish National Health System is able and willing to implement a payment model based on value, towards achieving gradual financing decisions and, above all, to improve the predictability, consistency and transparency of the process.

[The impact of drugs on social welfare. 2008 SESPAS Report]. / El impacto de los medicamentos en el bienestar. Informe SESPAS 2008.

The reasons and rationale for state intervention in the pharmaceutical industry are discussed with emphasis on two of the most frequent perspectives: the health-focused view and the income-centered approach; these perspectives tend to be ignored, to come into conflict, or to be confused in Spain. The growing impact of drugs on health and on the productivity of a knowledge-intensive industry - such as the pharmaceutical sector - is discussed. The impact of drugs on welfare will depend on how prescription is dealt with within the framework of some macro policies that could clearly be improved. The present article focuses on the effectiveness of Spanish pharmaceutical policy and assesses three families of policies. Several recommendations are made: greater use of price competition, regulatory signals rewarding the most innovative drugs (those that offer the greater incremental cost-effectiveness with respect to the already existing alternatives), a shake-up of the national system of innovation, and the indispensable alignment of prescriber incentives and the health system. An integrated pharmaceutical policy would help to bridge the quality chasm of the Spanish health system by making it more desirable, and therefore sustainable.

[Rational drug use: an economic approach to decision making]. / Uso racional de medicamentos: uma abordagem econômica para tomada de decisões.

The present article approaches rational drug use (RDU) from the economical point of view. The implementation of RDU implies in costs and involves acquisition of knowledge and behavioral changes of several agents. The difficulties in implementing RDU may be due to shortage problems, information asymmetry, lack of information, uncertain clinical decisions, externalities, time-price, incentives for drug prescribers and dispensers, drug prescriber preferences and marginal utility. Health authorities, among other agencies, must therefore regularize, rationalize and control drug use to minimize inefficiency in pharmaceutical care and to prevent exposing the population to unnecessary health risks.

Association of orthogeriatric services with long-term mortality in patients with hip fracture.

PURPOSE: To assess the impact of the comprehensive orthogeriatric care model (OGM) on 2-year survival, length of stay (LOS), discharges to nursing homes, and antiosteoporotic treatment (AOT) in patients with hip fracture. METHODS: Retrospective cohort study. Hospitals were classified as OGM if the patient was cared for in a comprehensive orthogeriatric unit. We included data from patients ≥ 65 years old discharged between 2012 and 2013. The main outcome was 12- and 24-month mortality. The variables collected were sex, type of fracture, comorbidities, AOT, LOS, and discharge to nursing homes. Survival analysis was performed with Kaplan-Meier method and comparison with Mantel-Haenszel test. Factors associated with death were determined by logistic regression. RESULTS: First admissions in the 12 (out of 32) hospitals with OGM were 3580 of 9215 (38.8%). Patients in OGM had more comorbidities and discharges to nursing homes, shorter LOS, and less prescription of AOT. Two years after the admission the deceased patients were 3000 (32.6%). The survival was lower in males (p < 0.001), in the older age groups (p < 0.001), and in patients with Charlson > 1 (p < 0.001). Factors associated with increased risk of death at 12 and 24 months (logistic regression) were male gender, age and Charlson > 1, while care in the OGM decreased the risk. OGM benefited more patients > 80 years and those with Charlson < 1. CONCLUSIONS: Patients admitted in OGM have shorter stays, more discharges to nursing homes, lower prescription of AOT, and better 12- and 24-month survival adjusted by sex, age, and comorbidities compared to non-OGM care.

[Public health: politics help those who help themselves [in health services]]. / Salud pública: a la política rogando y con el mazo dando (en los servicios sanitarios).

Poor countries health improves with the application of public health knowledge, but this requires from institutional capacity and political will, not automatically guaranteed by income growth alone. Generalized cost-benefit analysis, explicit establishment of priorities and even consensus (knowledge sharing) are suitable methods to select appropriate policies. Some problems, such as the increasing inequalities among countries or the global warming, may require a change of our institutions given than both market mechanisms and traditional policy intervention by nation-states may prove insufficient. <> could be the motto for the necessary conciliation between individual and collective actions on health. It has a similar importance to act upon the differences between individuals with similar exposures as diminishing the global risk of those social groups where misfortunes cluster. In a country such a Spain the aforementioned conciliation happens though a Welfare State capable of achieving social 'desirability' based upon democratic legitimacy and effective behavior, effectiveness that can not be obtained without the best combination of clinical and Public Health interventions.

Tax on sugar sweetened beverages in Spain. / El impuesto sobre bebidas azucaradas en España.

This article provides a critical review about the challenges that taxes on sugary drinks as an instrument of health policy must face to reverse the trend of the current epidemics of obesity. We analyzed the experiences of the leading countries, particularly Mexico, and reflect on the counterweight exerted by the industry against obesity policies, and on the power of lobbyists. Those tax policies for public health have to overcome the enormous strength of the industry, which is exerted in several-science and research, brand reputation, influence on regulators-levels. We suggest that a specific tax on sugary drinks has enough potential to reduce noncommunicable diseases and risk -diabetes, Hypertriglyceridemia, hyperholesterolemia LDL, hypertension- via reduced consumption thanks to the high price elasticity of those drinks. Furthermore, the effects are amplified even in the medium term, once established new habits to healthier eating. These taxes could encourage business innovation without inflicting costs of lost jobs and contribute to reducing the social gradient in obesity.