Sex-dependent effect of socioeconomic status on cardiovascular event risk in a population-based cohort of patients with type 2 diabetes.

BACKGROUND: Socioeconomic status (SES) factors often result in profound health inequalities among populations, and their impact may differ between sexes. The aim of this study was to estimate and compare the effect of socioeconomic status indicators on incident cardiovascular disease (CVD)-related events among males and females with type 2 diabetes (T2D). METHODS: A population-based cohort from a southern European region including 24,650 patients with T2D was followed for five years. The sex-specific associations between SES indicators and the first occurring CVD event were modeled using multivariate Fine-Gray competing risk models. Coronary Heart Disease (CHD) and stroke were considered secondary outcomes. RESULTS: Patients without a formal education had a significantly higher risk of CVD than those with a high school or university education, with adjusted hazard ratios (HRs) equal to 1.24 (95%CI: 1.09-1.41) for males and 1.50 (95%CI: 1.09-2.06) for females. Patients with <18 000€ income had also higher CVD risk than those with ≥18 000€, with HRs equal to 1.44 (95%CI: 1.29-1.59) for males and 1.42 (95%CI: 1.26-1.60) for females. Being immigrant showed a HR equal to 0.81 (95%CI: 0.66-0.99) for males and 1.13 (95%CI: 0.68-1.87) for females. Similar results were observed for stroke, but differed for CHD when income is used, which had higher effect in females. CONCLUSION: Socioeconomic inequalities in CVD outcomes are present among T2D patients, and their magnitude for educational attainment is sex-dependent, being higher in females, suggesting the need to consider them when designing tailored primary prevention and management strategies.

Multimodal Prehabilitation in Heart Transplant Recipients Improves Short-Term Post-Transplant Outcomes without Increasing Costs.

(1) Background and aim: This study aimed to investigate the impact of prehabilitation on the postoperative outcomes of heart transplantation and its cost-effectiveness. (2) Methods: This single-center, ambispective cohort study included forty-six candidates for elective heart transplantation from 2017 to 2021 attending a multimodal prehabilitation program consisting of supervised exercise training, physical activity promotion, nutritional optimization, and psychological support. The postoperative course was compared to a control cohort consisting of patients transplanted from 2014 to 2017 and those contemporaneously not involved in prehabilitation. (3) Results: A significant improvement was observed in preoperative functional capacity (endurance time 281 vs. 728 s, p < 0.001) and quality-of-life (Minnesota score 58 vs. 47, p = 0.046) after the program. No exercise-related events were registered. The prehabilitation cohort showed a lower rate and severity of postoperative complications (comprehensive complication index 37 vs. 31, p = 0.033), lower mechanical ventilation time (37 vs. 20 h, p = 0.032), ICU stay (7 vs. 5 days, p = 0.01), total hospitalization stay (23 vs. 18 days, p = 0.008) and less need for transfer to nursing/rehabilitation facilities after hospital discharge (31% vs. 3%, p = 0.009). A cost-consequence analysis showed that prehabilitation did not increase the total surgical process costs. (4) Conclusions: Multimodal prehabilitation before heart transplantation has benefits on short-term postoperative outcomes potentially attributable to enhancement of physical status, without cost-increasing.

Revisiting systematic geographical variations in tonsils surgery in children in the Spanish National Health System: spatiotemporal ecological study on hospital administrative data.

OBJECTIVE: To provide new evidence on how tonsils surgery in children has geographically varied over time in the context of the Spanish National Health System. DESIGN: Observational ecological spatiotemporal study on geographical variations in medical practice, using linked administrative datasets, including virtually all surgeries performed from 2003 to 2015. SETTING: The Spanish National Health System, a quasi-federal structure with 17 autonomous communities (ACs), and 203 healthcare areas (HCAs). PARTICIPANTS: Patients aged 19 and younger residing in the HCAs and ACs. INTERVENTIONS: Tonsillectomy with adenoidectomy (T&A); and tonsillectomies alone (T). MAIN ENDPOINTS: (1) Evolution of T&A and T rates; (2) spatiotemporal variation in the risk of receiving T&A or T surgery at regional level (ACs) and HCAs; and (3) the fraction of the variation (FV) attributed to each of the components of variation-ACs, HCAs, year and interaction ACs year. RESULTS: T&A age-sex standardised rates increased over the period of analysis from 15.2 to 20.9 (5.7 points per 10 000 inhabitants). T alone remained relatively lower than T&A rates, evolving from 3.6 in 2003 to 3.9 in 2015 (0.3 points per 10 000 inhabitants). Most of the risk variation was captured at the HCAs level in both procedures (FV: 55.3% in T&A and 72.5% in T). The ACs level explained 27.6% of the FV in the risk in T&A versus 8% in T. The interaction ACs year was similar in both procedures (FV: 15.5% in T&A and 17.5% in T). The average trend hardly explained 1.46% and 1.83% of the variation, respectively. CONCLUSION: Our study showed wide persistent variations with a steady increase in rates and risk of T&A and a stagnation of T alone, where most of the variation risk was explained at HCA level.

Socioeconomic inequalities in cardiometabolic control in patients with type 2 diabetes.

BACKGROUND: The aim of this study was to determine if the achievement of control targets in patients with type 2 diabetes was associated with personal socioeconomic factors and if these associations were sex-dependent. METHODS: This cross-sectional, population-based study was conducted in Spain. Glycated haemoglobin (HbA1c) level and other clinical parameters were obtained from electronic primary care records (n = 32,638 cases). Socioeconomic status was determined using education level and yearly income. Among patients, having their HbA1c level checked during the previous year was considered as an indirect measure of the process of care, whereas tobacco use and clinical parameters such as HbA1c, low-density lipoprotein cholesterol (LDL-c) and blood pressure (BP) were considered intermediate control outcomes. General linear mixed effect models were used to assess associations. RESULTS: The achievement of metabolic and cardiovascular control targets in patients with type 2 diabetes was associated with educational level and income, and socioeconomic gradients differed by sex. The probability of having had an HbA1c test performed in the previous year was higher in patients with lower education levels. Patients in the lowest income and education level categories were less likely to have reached the recommended HbA1c level. Males in the lowest education level categories were less likely to be non-smokers or to have achieved the blood pressure targets. In contrast, patients within the low income categories had a higher probability of reaching the recommended LDL-c level. CONCLUSIONS: Our results suggest the presence of socioeconomic inequalities in the achievement of cardiovascular and metabolic control that differed in direction and magnitude depending on the measured outcome and sex of the patient. These findings may help health professionals focus on high-risk individuals to decrease health inequalities.

Effect of cost sharing on adherence to evidence-based medications in patients with acute coronary syndrome.

OBJECTIVES: Cost-sharing scheme for pharmaceuticals in Spain changed in July 2012. Our aim was to assess the impact of this change on adherence to essential medication in patients with acute coronary syndrome (ACS) in the region of Valencia. METHODS: Population-based retrospective cohort of 10 563 patients discharged alive after an ACS in 2009-2011. We examined a control group (low-income working population) that did not change their coinsurance status, and two intervention groups: pensioners who moved from full coverage to 10% coinsurance and middle-income to high-income working population, for whom coinsurance rose from 40% to 50% or 60%. Weekly adherence rates measured from the date of the first prescription. Days with available medication were estimated by linking prescribed and filled medications during the follow-up period. RESULTS: Cost-sharing change made no significant differences in adherence between intervention and control groups for essential medications with low price and low patient maximum coinsurance, such as antiplatelet and beta-blockers. For costlier ACE inhibitor or an angiotensin II receptor blocker (ACEI/ARB) and statins, it had an immediate effect in the proportion of adherence in the pensioner group as compared with the control group (6.8% and 8.3% decrease of adherence, respectively, p<0.01 for both). Adherence to statins decreased for the middle-income to high-income group as compared with the control group (7.8% increase of non-adherence, p<0.01). These effects seemed temporary. CONCLUSIONS: Coinsurance changes may lead to decreased adherence to proven, effective therapies, especially for higher priced agents with higher patient cost share. Consideration should be given to fully exempt high-risk patients from drug cost sharing.

Trends and area variations in Potentially Preventable Admissions for COPD in Spain (2002-2013): a significant decline and convergence between areas.

BACKGROUND: Potentially Preventable Hospitalizations (PPH) are hospital admissions for conditions which are preventable with timely and appropriate outpatient care being Chronic Obstructive Pulmonary Disease (COPD) admissions one of the most relevant PPH. We estimate the population age-sex standardized relative risk of admission for COPD-PPH by year and area of residence in the Spanish National Health System (sNHS) during the period 2002-2013. METHODS: The study was conducted in the 203 Hospital Service Areas of the sNHS, using the 2002 to 2013 hospital admissions for a COPD-PPH condition of patients aged 20 and over. We use conventional small area variation statistics and a Bayesian hierarchical approach to model the different risk structures of dependence in both space and time. RESULTS: COPD-PPH admissions declined from 24.5 to 15.5 per 10,000 persons-year (Men: from 40.6 to 25.1; Women: from 9.1 to 6.4). The relative risk declined from 1.19 (19 % above 2002-2013 average) in 2002 to 0.77 (30 % below average) in 2013. Both the starting point and the slope were different for the different regions. Variation among admission rates between extreme areas dropped from 6.7 times higher in 2002 to 4.6 times higher in 2013. CONCLUSIONS: COPD-PPH conditions in Spain have undergone a strong decline and a reduction in geographical variation in the last 12 years, suggesting a general improvement in health policies and health care over time. Variability among areas still remains, with a substantial room for improvement.

[Characterization of folate supplementation in pregnancy, based on a combination of health information systems]. / Caracterización de la suplementación de folatos en el embarazo a partir de la combinación de sistemas de información sanitaria.

OBJECTIVES: To explore the utility of combining health information systems from the Valencia Health Agency to characterize folate supplementation in pregnant women in the autonomous region of Valencia (Spain). METHODS: The cohort comprised women who gave birth during 2009 in hospitals within the Valencian Health Agency. These women were retrospectively followed-up using ABUCASIS electronic medical records and the GAIA electronic prescription system to identify folate consumption in the 3 months before and after conception. RESULTS: In 2009, there were 38,069 births in hospitals of the Valencian Health Agency, of which 37,040 (97.3%) were included for analysis. In 34% of women, at least one folate dispensation was registered with an official prescription form within the periconceptional period (6.6% in the 3 months prior to conception). Dispensation with an official prescription form was associated with older women, free pharmaceutical prescriptions, birth in Spain, antiepileptic medications, and a diagnosis of diabetes. Eight percent of women (23.6% of the folate-treated women) received folates at high doses. CONCLUSIONS: Folate consumption during pregnancy is systematically under-registered by healthcare information systems because health professionals do not use the official prescription form for prescription and dispensation. Database linkage is an inadequate approach to assess folic acid supplementation during pregnancy.

Are prescribing doctors sensitive to the price that their patients have to pay in the Spanish National Health System?

BACKGROUND: This study aims to design an empirical test on the sensitivity of the prescribing doctors to the price afforded for the patient, and to apply it to the population data of primary care dispensations for cardiovascular disease and mental illness in the Spanish National Health System (NHS). Implications for drug policies are discussed. METHODS: We used population data of 17 therapeutic groups of cardiovascular and mental illness drugs aggregated by health areas to obtain 1424 observations ((8 cardiovascular groups * 70 areas) + (9 psychotropics groups * 96 areas)). All drugs are free for pensioners. For non-pensioner patients 10 of the 17 therapeutic groups have a reduced copayment (RC) status of only 10% of the price with a ceiling of €2.64 per pack, while the remaining 7 groups have a full copayment (FC) rate of 40%. Differences in the average price among dispensations for pensioners and non-pensioners were modelled with multilevel regression models to test the following hypothesis: 1) in FC drugs there is a significant positive difference between the average prices of drugs prescribed to pensioners and non-pensioners; 2) in RC drugs there is no significant price differential between pensioner and non-pensioner patients; 3) the price differential of FC drugs prescribed to pensioners and non-pensioners is greater the higher the price of the drugs. RESULTS: The average monthly price of dispensations to pensioners and non-pensioners does not differ for RC drugs, but for FC drugs pensioners get more expensive dispensations than non-pensioners (estimated difference of €9.74 by DDD and month). There is a positive and significant effect of the drug price on the differential price between pensioners and non-pensioners. For FC drugs, each additional euro of the drug price increases the differential by nearly half a euro (0.492). We did not find any significant differences in the intensity of the price effect among FC therapeutic groups. CONCLUSIONS: Doctors working in the Spanish NHS seem to be sensitive to the price that can be afforded by patients when they fill in prescriptions, although alternative hypothesis could also explain the results found.

[Population analysis by area of health of changes in consumption, price and expenditure of cardiovascular drugs in eight autonomous communities, Spain, 2005]. / Análisis poblacional por áreas de salud de las variaciones en consumo, precio y gasto de medicamentos cardiovasculares en 8 comunidades autónomas, españa, 2005.

BACKGROUND: Variability in cardiovascular drugs is of great interest because of its high population use, its high expenditure and the availability of strong evidence supporting its use. The aim of this study is to describe variation in dispensation, price and pharmaceutical expenditure for 11 subgroups of cardiovascular drugs by healthcare areas. METHODS: This was a population study describing dispensation for 11 subgroups of cardiovascular drugs among healthcare areas in 2005. POPULATION: 93 healthcare areas of the 8 participant Autonomous Regions. ANALYSIS: Descriptive analysis of dispensation (Defined Daily Dose (DDD) per 1,000 pensioners and day (DDD/1000P/Day), average price (euros per DDD), pharmaceutical expenditure (euros per 100 pensioners) and standardized consumption ratios. Small-area variation analysis was used to analyze observed variability. RESULTS: Consumption of cardiovascular drugs oscillated between 324 DDD/1000p/Day for drugs with action on the renin-angiotensin system, and 6.5 DDD/1000p/Day for anti-aldosterone diuretics. Variation in consumption for areas in the 5th and 95th percentiles went from 1.8 times (digitalics) to 17.2 times (flavonoids), although most of the groups showed an extremal quotient of around 5. Variation in average prices was lower than in consumption (1.1 times for doxazosin and 3.7 for flavonoids) and variations in pharmaceutical expenditure was similar to variation in consumption (from 2.0 timesfor digitalics to 13.0 times for flavonoids). CONCLUSIONS: Major variations in the consumption of cardiovascular drugs between healthcare areas, together with discreet variations in price mean there are big differences in pharmaceutical expenditure from one population to another.

[Variability in Spanish National Health System hospital emergency services utilization]. / Variabilidad en la utilización de los servicios de urgencias hospitalarios del Sistema Nacional de Salud.

OBJECTIVE: The aims of this study were to estimate the rate of hospital emergency services (HES) visits per health area, the associated percentage of admissions and the standardized HES utilization ratio, and to analyze their relationship with hospital resources. METHODS: We performed an ecological study that combined information from distinct sources (Survey of Health Care Hospitalization Establishments 2006 and Minimum Data Set 2006) to estimate the rate of HES visits and the percentage of associated emergency admissions in 164 health areas in 14 autonomous communities (AC). RESULTS: Among 35.3 million inhabitants in the 164 areas examined, there were 16.2 million visits to the HES (45.75 per 100 inhabitants); more than 2 million (12.6%) were hospitalized. Excluding 5% of extreme areas, rates oscillated between 31.60 and 78.69 HES visits/100 inhabitants, and the percentage of admissions was between 7.6% and 27.9%. These differences were not attenuated after standardization. The AC factor explained 29% of variance in HES visits and 82% of variance in admissions. The rate of visits was not associated with the number of beds or staff physicians but did correlate with the number HES doctors, and smaller and non-teaching hospitals. CONCLUSIONS: There is wide variability in the rates of HES visits and emergency admissions in the different areas of the Spanish National Health System. This variability seems to be associated with a differential use for minor problems.

Is there much variation in variation? Revisiting statistics of small area variation in health services research.

BACKGROUND: The importance of Small Area Variation Analysis for policy-making contrasts with the scarcity of work on the validity of the statistics used in these studies. Our study aims at 1) determining whether variation in utilization rates between health areas is higher than would be expected by chance, 2) estimating the statistical power of the variation statistics; and 3) evaluating the ability of different statistics to compare the variability among different procedures regardless of their rates. METHODS: Parametric bootstrap techniques were used to derive the empirical distribution for each statistic under the hypothesis of homogeneity across areas. Non-parametric procedures were used to analyze the empirical distribution for the observed statistics and compare the results in six situations (low/medium/high utilization rates and low/high variability). A small scale simulation study was conducted to assess the capacity of each statistic to discriminate between different scenarios with different degrees of variation. RESULTS: Bootstrap techniques proved to be good at quantifying the difference between the null hypothesis and the variation observed in each situation, and to construct reliable tests and confidence intervals for each of the variation statistics analyzed. Although the good performance of Systematic Component of Variation (SCV), Empirical Bayes (EB) statistic shows better behaviour under the null hypothesis, it is able to detect variability if present, it is not influenced by the procedure rate and it is best able to discriminate between different degrees of heterogeneity. CONCLUSION: The EB statistics seems to be a good alternative to more conventional statistics used in small-area variation analysis in health service research because of its robustness.

[Health system interventions assessment in Spain: an approach through the analysis of the time trends and the geographical variability of avoidable mortality between 1986 -2001]. / Medida del resultado de las intervenciones sanitarias en España: una aproximación mediante el análisis temporal y espacial de la mortalidad evitable entre 1986-2001.

BACKGROUND: Many studies have proposed Avoidable Mortality (ME) to monitor the performance of health services although its usefulness is limited by the multiplicity of the avoidable mortality lists being used. Time trends from 1986-2001 and the geographical distribution of avoidable mortality by provinces, are presented for Spain. METHODS: An Avoidable Mortality consensus list is being used. It includes avoidable mortality through the intervention of health services (ISAS in Spanish) and through health policy interventions (IPSI in Spanish). Time trends are analyzed adjusting Poisson or Joinpoint regression models and the annual percentages of change (APC) are estimated. Changes in geographical distribution between the first half of the analysed period and the second are tested by means of standard mortality ratios (SMR) and comparative mortality rates (CMR) for each province. RESULTS: Between 1986 and 2001 avoidable mortality decreased (APC: -1.68; CI: -1.99 and -1.38) slightly more than non-avoidable mortality (APC: -1.28; CI: -1.40 and -1.17). Higher reduction was observed for ISAS mortality (APC: -2.77; CI: -2.89 and -2.65) and an irregular trend for IPSI (between 1986-1990 increase APC: 4.86; CI: 3.32 and 6.41, between 1990-95 stabilization APC: -0.03; CI: -2.32 and 2.31 and finally 1995-2001 decrease APC: -3.57; CI: -4.72 and -2.40). CONCLUSIONS: Avoidable mortality decreased more than non avoidable mortality and important geographical variability can be observed among provinces which should be monitored in order to identify the health services weaknesses. The higher ISAS mortality was observed in southern provinces and the higher IPSI mortality in some areas on the coast. The pattern is somewhat similar for both analyzed periods.

Exploring the impact of complications on length of stay in major surgery diagnosis-related groups.

STUDY OBJECTIVE: To analyze, in terms of the length of stay (LOS), the use of resources by patients classified under surgical diagnosis-related groups (DRGs) with complication and/or comorbidity (DRGCCs), divided into subgroups where complications were and were not detected, and to explore the repercussions on hospital reimbursement. DESIGN: The Complication Screening Program(Copyright ) (CSP) was used to divide the patients in 14 DRGCCs into subgroups with and without complications, and to compare the LOS between the subgroups and with the equivalent DRG without CC. The ratios between the LOS and the relative weight of the DRGs for reimbursement were also compared. SETTING: The population hospitalized for major surgery between 1995 and 1999 in the Hospital of Mataró, Catalonia, Spain. PARTICIPANTS: Patients (4227) hospitalized for major surgery. MAIN RESULT: The percentage of complications identified by the CSP ranged from 17.5% to 52.4%. The LOS of the DRGCCs was almost twice as long as in the DRGs without CC; 2.48 times greater if the DRGCC was flagged by the CSP and 70% greater if it was not. On average, the DRGCCs selected were reimbursed at a rate 93% higher than their counterpart DRGs without CC. In 11 of the 14 DRG pairs with or without CC, the reimbursement ratio was lower than the LOS ratio. CONCLUSIONS: DRGCCs can be classified into clearly differentiated groups based on the presence or absence of CSP-flagged complications. CSP-flagged complications produce an increase in LOS greater than the increase in the relative weights for reimbursement.

Accuracy of pharmaceutical advertisements in medical journals.

BACKGROUND: Because of the effect of the ever-growing evidence-based medicine movement on prescribing behaviour of doctors, the pharmaceutical industry incorporates bibliographical references to clinical trials that endorse their products in their advertisements. We aimed to assess whether the references about efficacy, safety, convenience, or cost of antihypertensive and lipid-lowering drugs included in advertisements supported the promotional claims. METHODS: We assessed all advertisements for antihypertensive and lipid-lowering drugs published in six Spanish medical journals in 1997 that had at least one bibliographical reference. Two pairs of investigators independently reviewed the advertisements to see whether the studies quoted to endorse the advertising messages supported the corresponding claims. FINDINGS: We identified 264 different advertisements for antihypertensive drugs and 23 different advertisements for lipid-lowering drugs. We recorded at least one reference in 31 advertisements in the antihypertensive group and at least one reference in every seven advertisements in the lipid-lowering group, providing a total of 125 promotional claims with references. We could not retrieve 23 (18%) references from monographic works and non-published data on file. 79 (63%) of the 125 references were from journals with a high impact factor; 84 (82%) of the 102 references retrieved were from randomised clinical trials. In 45 claims (44.1%; 95% CI 34.3-54.3) the promotional statement was not supported by the reference, most frequently because the slogan recommended the drug in a patient group other than that assessed in the study. INTERPRETATION: Doctors should be cautious in assessment of advertisements that claim a drug has greater efficacy, safety, or convenience, even though these claims are accompanied by bibliographical references to randomised clinical trials published in reputable medical journals and seem to be evidence-based.