Cost/efficacy analysis of preferred Spanish AIDS study group regimens and the dual therapy with lopinavir/ritonavir plus lamivudine for initial ART in HIV infected adults.

INTRODUCTION: The National AIDS Plan and the Spanish AIDS study group (GESIDA) proposes "preferred regimens" (PR) of antiretroviral treatment (ART) as initial therapy in HIV-infected patients. In 2013, the recommended regimens were all triple therapy regimens. The Gardel Study assessed the efficacy of a dual therapy (DT) combination of lopinavir/ritonavir (LPV/r) plus lamivudine (3TC). Our objective is to evaluate the GESIDA PR and the DT regimen LPV/r+3TC cost/efficacy ratios. METHODS: Decision tree models were built. EFFICACY: probability of having viral load <50 copies/mL at week 48. ART regime cost: costs of ART, adverse effects, and drug resistance tests during the first 48 weeks. RESULTS: Cost/efficacy ratios varied between 5,817 and 13,930 euros per responder at 48 weeks, for the DT of LPV/r+3TC and tenofovir DF/emtricitabine+raltegravir, respectively. CONCLUSIONS: Taking into account the official Spanish prices of ART, the most efficient regimen was DT of LPV/r+3TC, followed by the triple therapy with non-nucleoside containing regimens.

Quality of life of patients with rheumatic diseases.

OBJECTIVE: Health-related quality of life (HRQoL) is an important indicator of population health and can measure the impact of medical actions. The main objective of this study was to determine the HRQoL of patients with rheumatic diseases (RD) and compare it with that of the general population. METHODS: Observational, cross-sectional, single-center study, with consecutive inclusion of outpatients over 18 years of age seen at a Rheumatology hospital-based outpatient clinic in Madrid. Sociodemographic, clinical variables and HRQoL were recorded. HRQoL was measured with the 5-dimension, 5-level EuroQoL (EQ-5D-5L), which includes the EQ-Index (0-1 scale) and a visual analog scale (VAS, 0-100 scale). A descriptive analysis and a comparison with the HRQoL of the Spanish general population were performed. RESULTS: 1144 patients were included, 820 (71.68%) women, with a mean age of 56.1 years (range 18-95), of whom 241 (25.44%) were new patients. In patients with RD, the HRQoL measured with the EQ-Index and with the VAS, was 0.186 and 12 points lower, respectively, than in the general population. The decrease in HRQoL affected the 5 health dimensions, especially "pain/discomfort", followed by "daily activities" and "mobility". This reduction in HRQoL was observed in both men and women, and in all age ranges, although it was greater between 18 and 65 years of age. The reduction in HRQoL affected all RD subtypes, especially the "peripheral and axial mechanical pathology" and the "soft tissue pathology" group. CONCLUSIONS: Patients with rheumatic diseases report worse HRQoL when compared to the general population in all dimensions of HRQoL.

[Objective KONTROL study: therapeutic inertia in hypertensive patients attended in primary care of Spain]. / Inercia terapéutica en pacientes hipertensos asistidos en atención primaria en España. Estudio Objetivo Kontrol.

OBJECTIVES: To determine the level of therapeutic inertia (TI), and the factors associated to the patient, doctor and the health organisation, in hypertensive patients treated in Primary Care (PC). DESIGN: Cross-sectional, multicentre study. SETTING: A sample of PC Teams from all over Spain. PARTICIPANTS: The study was conducted among PC doctors using a questionnaire and clinical records of 4 patients. MAIN MEASUREMENTS: The TI was calculated for each patient (TIp) as the proportion of visits in which there was no change in medication when this was indicated. RESULTS: A total of 543 PC doctors provided data on 2,032 patients, who fulfilled the indication of a change in requirement. There was TI In 77.8% of cases. The TIp observed was non-existent or low for 17.1% of the patients, intermediate for 42% and high for 40.8%. For the patients, the factors most associated with TIp were, age (P<.001), diabetes (P<.001), stroke (P<.01), obesity (P<.01) and a low education level (P<.001). To be female, be less than 40 years or more than 55 years, to be a family doctor with a training program other than MIR and to work in the public sector increased the probability of TIp (P<.001 for all the assumptions). CONCLUSIONS: The results of the study indicate that there is TI in 7 out every 10 visits made by hypertensive patients in Primary care. There are significant differences as regards the clinical characteristics of the patients and of the doctors.

Health economics and RSV.

An economic analysis was performed in Spain to evaluate the efficiency (cost-effectiveness) of palivizumab in preventing severe RSV infection in premature infants with GA 32-35 and two or more risk factors (RF). The design was a decision tree model using data from the scientific literature and the FLIP I and FLIP II studies IRIS Study Group. The main effectiveness measure was quality-adjusted life years (QALY) gained from both the National Health System (NHS) and societal perspectives. Prophylaxis with palivizumab was found to produce an incremental cost-effectiveness ratio (ICER) of 13,849euro/QALY from the NHS perspective, and 4,605euro/QALY from the societal perspective. Palivizumab is a cost-effective therapy as prophylaxis against RSV in infants with GA 32-35 and two or more RF. Its use is efficient from the NHS perspective, since the cost of a QALY, even in the least favourable scenarios, is lower than the threshold of 30,000euro/QALY considered socially acceptable in Europe.

[Integration and boundaries between health and social care. 2008 SESPAS Report]. / Integración y fronteras entre la atención sanitaria y social. Informe SESPAS 2008.

We examine the opportunities to establish integrated services in Spain. The new law on services for disabled people approved by the Spanish Parliament in December 2006 and the Mental Health Plan of the Spanish Ministry of Health are used to illustrate policies that will require a high degree of integration among organizational, financial and clinical levels. In this context, some of the following questions arise: what do we know about the effectiveness of the integration of health and social services? Who should be the targets of integration and what are the structures needed for patient-centered services? Who should be responsible for and manage these services? An outline of Leutz's five criteria for integration is reviewed and the results from international experiences are discussed. We conclude that Spain is at a crossroads for the integration of services for disabled people and people with mental health problems. We recommend that a system of integrated services be organized for people with moderate or severe disability. This system should be decentralized at the levels of local health and social services, with a single budget estimated on a capitation basis. Clinical and financial responsibility should be shared between the interdisciplinary team and the case manager (nursing or social work professionals).

Delphi consensus statement: Quality Indicators for Inflammatory Bowel Disease Comprehensive Care Units.

BACKGROUND AND AIMS: While it is commonly accepted that Inflammatory bowel disease (IBD) Comprehensive Care Units (ICCUs) facilitate the delivery of quality care to Crohn's disease and ulcerative colitis patients, it remains unclear how an ICCU should be defined or evaluated. The aim of the present study was to develop a comprehensive set of Quality Indicators (QIs) of structure, process, and outcomes for defining and evaluating an ICCU. METHODS: A Delphi consensus-based approach with a standardized three-step process was used to identify a core set of QIs. The process included an exhaustive search using complementary approaches to identify potential QIs, and two Delphi voting rounds to select the QIs defining the core requirements for an ICCU. RESULTS: The consensus selected a core set of 56 QIs (12 structure, 20 process and 24 outcome). Structure and process QIs highlighted the need for multidisciplinary management and continuity of care. The minimal IBD team should include an IBD nurse, gastroenterologists, radiologists, surgeons, endoscopists and stoma management specialists. ICCUs should be able to provide both outpatient and inpatient care and admission should not break the continuity of care. Outcome QIs focused on the adequate prophylaxis of disease complication and drug adverse events, the need to monitor appropriateness of treatment and the need to reinforce patient autonomy by providing adequate information and facilitating the patients' participation in their own care. CONCLUSIONS: The present Delphi consensus identified a set of core QIs that may be useful for evaluating and certifying ICCUs.

Rheumatology in the community of Madrid: current availability of rheumatologists and future needs using a predictive model.

OBJECTIVES: To: 1) describe the distribution of the public sector rheumatologists; 2) identify variables on which the workload in Rheumatology depends; and 3) build a predictive model on the need of rheumatologists for the next 10 years, in the Community of Madrid (CM). METHODOLOGY: The information was obtained through structured questionnaires sent to all services/units of Rheumatology of public hospitals in the CM. The population figures, current and forecasted, were obtained from the National Statistics Institute. A predictive model was built based on information about the current and foreseeable supply, current and foreseeable demand, and the assumptions and criteria used to match supply with demand. The underlying uncertainty in the model was assessed by sensitivity analysis. RESULTS: In the CM in 2011 there were 150 staff rheumatologists and 49 residents in 27 centers, which is equivalent to one rheumatologist for every 33,280 inhabitants in the general population, and one for every 4,996 inhabitants over 65 years. To keep the level of assistance of 2011 in 2021 in the general population, it would be necessary to train more residents or hire more rheumatologists in scenarios of demand higher than 15%. However, to keep the level of assistance in the population over 65 years of age it would be necessary to train more residents or hire more specialists even without increased demand. CONCLUSIONS: The model developed may be very useful for planning, with the CM policy makers, the needs of human resources in Rheumatology in the coming years.

Quality of care standards for nursing clinics in rheumatology.

BACKGROUND: Nursing clinics in rheumatology (NCR) are organizational models in the field of nursing care. There are various NCR models, but there is no consensus on its operational definition. Our objective is to develop quality standards to define and characterize a NCR. METHOD: Two-round Delphi method. The panel consisted of 67 experts: Rheumatologists and nurses of the nursing working group of the Spanish Society of Rheumatology (SSR). The Delphi questionnaire was developed after a literature and experience review from previous SSR projects. The questionnaire consists of 7 sections: general considerations, standards of structure, process, treatment and monitoring, health education, training and research and quality of care. Each item was scored from 1 (least important) to 9 (most important) or by assigning a number (e.g., waiting days). The degree of agreement among the experts was categorized according to the coefficient of variation (CoV) between very high (CoV≤25%) and very low (CoV>100%). RESULTS: The second round questionnaire (182 items) was answered by 46 panelists (34 rheumatologists and 12 nurses). A very important agreement was reached on the general standards of structure, process, treatment and monitoring, health education and quality of care. Less agreement was observed on standards related to training time, number of recommended nurses' research projects and publications. CONCLUSION: The standards developed in this study would be useful for establishing desirable quality standards of structure and process, and criteria for clinical work, research and teaching that can be used to develop and evaluate the NCRs.

[Variations among Spanish regions in the use of three cardiovascular technologies]. / Variabilidad entre comunidades autónomas en el uso de tres tecnologías cardiovasculares.

INTRODUCTION AND OBJECTIVES: There is evidence that some geographic variations in the use of medical technologies are not explained by differences in disease burden. The objectives of this study were to quantify variability in the use of percutaneous coronary intervention (PCI), implantable cardioverter-defibrillators (ICDs), and cardiac resynchronization therapy (CRT) in Spanish autonomous regions and to try to explain the variability found for the first two technologies. METHODS: Linear regression models were developed in which the number of procedures performed per million population (pmp) in 2003 in each autonomous region was the dependent variable. Independent variables used included indices of technology provision, regional wealth, and disease burden. RESULTS: For PCI, the mean utilization rate for the whole of Spain was 1038 procedures pmp, with a high-low ratio of 1.95. Differences in gross domestic product explained 21% of the variability, but there was no relationship between the number of procedures performed and disease burden. For ICDs, the mean number of procedures performed in the whole of Spain was 46 pmp, with a high-low ratio of 3.04. As for PCI, differences in regional wealth explained 40% of the variability, with disease burden making no contribution. For CRT, the mean number of procedures performed in Spain in 2003 was 15 pmp, with a high-low ratio of 15.7. CONCLUSIONS: The considerable regional variation that exists in the use of these three medical technologies is principally explained by differences in regional wealth and not in disease burden.