¿Se puede permitir la gente pagar por la atención sanitaria? Nueva evidencia sobre la protección financiera en España

Este estudio forma parte de una serie de informes nacionales que han generado nueva evidencia sobre la protección financiera en los sistemas sanitarios europeos. La protección financiera es fundamental para la cobertura sanitaria universal y es una dimensión básica del desempeño de los sistemas sanitarios. A pesar de haber empeorado durante la crisis económica entre los años 2008 y 2014, la incidencia de los gastos catastróficos en salud en España es mucho menor de lo que cabría esperar dada la dependencia relativamente elevada de los pagos directos en España. Esto puede explicarse por los puntos fuertes de las políticas decobertura en el Sistema Nacional de Salud (SNS): cobertura sanitaria basada en la residencia, con la misma cobertura para los inmigrantes en situación no regularizada; una cartera de servicios completa en general; uso limitado de los copagos, y diferentes mecanismos para proteger a los usuarios de los copagos. Sin embargo, la cobertura presenta algunas deficiencias. Las causas principales del gasto catastrófico son la atención dental y los productos sanitarios en todos los quintiles de consumo, principalmente porque la atención dental y óptica están excluidas en gran medida de la cobertura del SNS. En el quintil más pobre, la causa del gasto catastrófico son los medicamentos de dispensación ambulatoria debidoa los copagos y a una protección inadecuada de los hogares de bajos ingresos con personas en edad de trabajar. Para reducir las necesidades insatisfechas y las dificultades financieras, las políticas deben centrarse en ampliar la cobertura del SNS para la atención dental y la atención óptica, así como seguir mejorando las modalidades de copago para reforzar la protección de los hogares más pobres en todos los grupos de edad.

Can people afford to pay for health care? New evidence on financial protection in Spain

This review is part of a series of country-based studies generating new evidence on financial protection in European health systems. Financial protection is central to universal health coverage and a core dimensionof health system performance. Despite worsening during the economic crisis from 2008 to 2014, the incidence of catastrophic health spending in Spain is much lower than would be expected given Spain’s relatively heavy reliance on out-of-pocket payments. This can be explained by strengths in the design of coverage policy in the National Health System (NHS): entitlement to the NHS based on residence, with the same degree of entitlement for undocumented migrants; a generally comprehensive benefits package; limited use of co-payments; and multiple mechanisms to protect people from co-payments. There are gaps in coverage, however. Catastrophic spending is driven by dental care and medical products in all consumption quintiles, mainly because dental and optical care for eyesight problems are largely excluded from NHS coverage. Catastrophic spending in the poorest quintile is also driven by outpatient medicines, reflecting co-payments and inadequate protection for low-incomehouseholds of working age. To reduce unmet need and financial hardship, policy should focus on expanding NHS coverage of dental care and optical care and further improving the design of co-payments to strengthenprotection for poorer households in all age groups.

Budget impact of ferric carboxymaltose treatment in patients with chronic heart failure and iron deficiency in Spain.

OBJECTIVE: The treatment of iron deficiency (ID) with ferric carboxymaltose (FCM) improves the functional class and quality of life of chronic heart failure (CHF) patients with reduced left ventricular ejection fraction (LVEF), and reduces the rate of hospitalization due to worsening CHF. This study aims to evaluate the budget impact for the Spanish National Health System (SNHS) of treating ID in reduced LVEF CHF with FCM compared to non-iron treatment. METHODS: We simulated a hypothetical cohort of 1000 CHF patients with ID and reduced LVEF based on the Spanish population characteristics. A decision-analytic model was also built using the data from the largest FCM clinical trial (CONFIRM-HF) that lasted for a year. We considered the use of healthcare resources from a national prospective study. A deterministic sensitivity analysis was carried out varying the corresponding baseline data by ±25%. RESULTS: The cost of treating the simulated population with FCM was €2,570,914, while that of the non-iron treatment was €3,105,711, which corresponds to a cost saving of €534,797 per 1,000 patients in one year. Cost savings were mainly due to a decrease in the number of hospitalizations. All sensitivity analysis showed cost savings for the SNHS. CONCLUSIONS: FCM results in an annual cost saving of €534.80 per patient, and would thus be expected to reduce the economic burden of CHF in Spain.

Some reflections on the use of inappropriate comparators in CEA.

Although the choice of the comparator is one of the aspects with a highest effect on the results of cost-effectiveness analyses, it is one of the less debated issues in international methodological guidelines. The inclusion of an inappropriate comparator may introduce biases on the outcomes and the recommendations of an economic analysis. Although the rules for cost-effectiveness analyses of sets of mutually exclusive alternatives have been widely described in the literature, in practice, they are hardly ever applied. In addition, there are many cases where the efficiency of the standard of care has never been assessed; or where the standard of care has demonstrated to be cost-effective with respect to a non-efficient option. In all these cases the comparator may lie outside the efficiency frontier, so the result of the CEA may be biased. Through some hypothetical examples, the paper shows how the complementary use of an independent reference may help to identify potential inappropriate comparators and inefficient use of resources.

[Impact of Great Recession on mental health in Spain. SESPAS Report 2020]. / El impacto de la Gran Recesión en la salud mental en España. Informe SESPAS 2020.

The objective of this article is to identify the effects of the Great Recession on the mental health of people residing in Spain. After presenting a conceptual framework on the mechanisms through which economic crises affect mental health, we describe the main results of 45 papers identified in our search. Studies indicate a worsening of mental health in Spain in the years of economic crisis, especially in men. Working conditions (unemployment, low wages, instability, precariousness) emerge as one of the main channels through which mental health is put at risk or deteriorates. This deterioration occurs with intensity in particularly vulnerable groups, such as immigrant population and families with economic burdens. In the case of suicides, the results were inconclusive. Regarding the use of health care services, an increase in the consumption of certain drugs seems to be identified, although the conclusions of all the studies are not coincidental. Social inequalities in mental health do not seem to have remitted. We conclude that Spain needs to improve information systems to a better understanding of the health effects of economic crises. In terms of public policies, together with the reinforcement of health services aimed at addressing mental health problems, an income guarantee network for people in vulnerable situations should be promoted, as well as the development of policies aimed at the labour market.

The Association Between Poor Glycemic Control and Health Care Costs in People With Diabetes: A Population-Based Study.

OBJECTIVE: To analyze the differences in health care costs according to glycemic control in people with type 2 diabetes. RESEARCH DESIGN AND METHODS: Data on health care resource utilization from 100,391 people with type 2 diabetes were extracted from the electronic database used at the Catalan Health Institute. Multivariate regression models were carried out to test the impact of glycemic control (HbA1c) on total health care, hospital admission, and medication costs; model 1 adjusted for a variety of covariates, and model 2 also included micro- and macrovascular complications. Glycemic control was classified as good for HbA1c <7%, fair for ≥7% to <8%, poor for ≥8% to <10%, and very poor for ≥10%. RESULTS: Mean per patient annual direct medical costs were €3,039 ± SD €6,581. Worse glycemic control was associated with higher total health care costs: compared with good glycemic control, health care costs increased by 18% (€509.82) and 23% (€661.35) in patients with very poor and poor glycemic control, respectively, when unadjusted and by €428.3 and €395.1, respectively, in model 2. Medication costs increased by 12% in patients with fair control and by 28% in those with very poor control (model 2). Patients with poor control had a higher probability of hospitalization than those with good control (5% in model 2) and a greater average cost when hospitalization occurred (€811). CONCLUSIONS: Poor glycemic control was directly related to higher total health care, hospitalization, and medication costs. Preventive strategies and good glycemic control in people with type 2 diabetes could reduce the economic impact associated with this disease.

[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 pre-existing radial artery pathology by histological assessment on the maturation, function and patency of the radiocephalic fistula for hemodialysis.

BACKGROUND: We prospectively analyzed the effect of preexisting structural changes of the radial artery (RA) wall by histological examination on the wrist radiocephalic fistula (RCF) outcomes. METHODS: During RCF creation, one segment of the RA wall was collected and its histomorphometric analysis was performed. The RCF function was evaluated by measuring blood flow rate. RESULTS: At the end of follow-up, 75.7% of the thirty-seven patients enrolled were performing hemodialysis by using their successful RCF and 24.3% of them showed early RCF failure. Compared to patients with a healthy RA, the RCF of those with medial RA microcalcification reached up a lower flow and a shorter primary patency (P=0.005 and P=0.040, respectively). The RA microcalcification was predictive of the RCF function (coefficient -614.9, 95% CI: -994.7 to -235.1, P=0.003). Compared to patients with successful RCF, those with failed RCF had a greater frequency of weak RCF thrill after releasing the clamps (P=0.045). Dependence on hemodialysis during RCF placement was predictive of its early failure (OR: 23.2, 95% CI: 1.76 to 306.9, P=0.017). Both having at least one cardiovascular comorbidity (HR 4.30, 95% CI: 1.29 to 14.39, P=0.018) and a thicker media layer of the RA (HR 1.60, 95% CI: 1.87 to 2.15, P=0.002) were predictive of primary RCF patency. CONCLUSIONS: The function and survival of the successful RCF were related to preoperative RA abnormalities such as microcalcification and media layer thickness. Both dependence on hemodialysis during RCF placement and an attenuated RCF thrill were associated with early RCF failure.

Abdomen abierto o laparotomía contenida. Aspectos actuales / Open abdomen or contained laparotomy. Current aspects

RESUMEN La cirugía abdominal se ha incrementado notablemente en cantidad y complejidad debido al desarrollo tecnológico de los últimos años. En este con-texto se observa con mayor frecuencia en los servicios de cuidados críticos las denominadas catástrofes abdominales. Actualmente, en el ámbito de la cirugía general, es atribuido principalmente a un paciente crítico, afectado por una patología severa y con Abdomen Abierto (AA), condición que conlleva una elevada mortalidad (20 a 60%). Sobre el manejo del AA trata esta revisión. (1)

ABSTRACT Abdominal surgery has increased significantly in quantity and complexity due to the technological development of recent years. In this context, the so-called abdominal catastrophes are observed more frequently in critical care services. Currently, in the field of general surgery, it is mainly attributed to a critical patient, affected by a severe pathology and with Open Abdomen (AA), a condition that carries a high mortality (20 to 60%). On the management of AA, this review is addressed.

Effect of a Mobile App on Preoperative Patient Preparation for Major Ambulatory Surgery: Protocol for a Randomized Controlled Trial.

BACKGROUND: Inadequate preoperative patient preparation causes organizational, economic, and emotional problems to patients and professionals. In Spain, no current evidence is available on either the rate of compliance or the impact of good compliance with preoperative recommendations by patients in the ambulatory setting. However, it is known that around 25% of surgical cancellations in the major ambulatory surgery (MAS) are due to poor compliance with these recommendations and, therefore, avoidable. Introducing innovative tools based on mobile health (mHealth) apps may help patients meet the preoperative recommendations and, consequently, reduce the rate of cancellations in the ambulatory setting. OBJECTIVE: The objective of this study was to evaluate the effectiveness of the Listeo+ mHealth app as a tool for improving compliance with preoperative recommendations in MAS versus standard of care (SOC). METHODS: A multicenter, randomized, open-label clinical trial that compares SOC with the additional use of Listeo+, a specific mHealth app for MAS preoperative patient monitoring, is being conducted. The study will include patients aged ≥18 years with surgical indication for MAS who meet the necessary technological and connectivity requirements. Patients in the control group will receive written preoperative recommendations, while those in the intervention group will additionally use the Listeo+ mHealth app. There will be a competitive recruitment of 790 patients during 6 months in 4 hospitals in Andalusia (Spain) that belong to the National Health System. The primary efficacy outcome is the level of compliance with preoperative recommendations. Secondary outcomes include the rate of cancellations, associated resource consumption, and perceived usability and utility with Listeo+ by participants of the intervention group. Simple randomization 1:1 procedure will be used to allocate patients to each study group. RESULTS: The technological development of Listeo+ and the integration and interoperability of information systems was completed in September 2017. Subsequently, simulation tests were performed with Listeo+, and a pilot study was initiated with real patients that concluded successfully in October 2017. Patient recruitment began in December 2017 in the 4 participating centers. After an intermediate analysis performed 10 months after the start of the recruitment phase, the data collection and cleaning phases are estimated to be completed in April 2019, and the analysis with the final results will be conducted in July 2019. CONCLUSIONS: Progress in the integration and interoperability of information systems represents a major step forward in the field of mHealth. The app will allow health professionals to monitor in real-time patients' preparation and critical preoperative recommendations fulfillment. We expect a reduction in avoidable preoperative cancellations due to a lack of or a poor patient preparation. Self-assessed Web-based questionnaires and focus group will provide important information about the perceived usability and utility of Listeo+ app among patients and health care professionals. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/10938.

Spain: Health System Review.

This analysis of the Spanish health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. Overall health status continues to improve in Spain, and life expectancy is the highest in the European Union. Inequalities in self-reported health have also declined in the last decade, although long-standing disability and chronic conditions are increasing due to an ageing population. The macroeconomic context in the last decade in the country has been characterized by the global economic recession, which resulted in the implementation of health system-specific measures addressed to maintain the sustainability of the system. New legislation was issued to regulate coverage conditions, the benefits package and the participation of patients in the National Health System funding. Despite the budget constraints linked to the economic downturn, the health system remains almost universal, covering 99.1% of the population. Public expenditure in health prevails, with public sources accounting for over 71.1% of total health financing. General taxes are the main source of public funds, with regions (known as Autonomous Communities) managing most of those public health resources. Private spending, mainly related to out-of-pocket payments, has increased over time, and it is now above the EU average. Health care provision continues to be characterized by the strength of primary care, which is the core element of the health system; however, the increasing financing gap as compared with secondary care may challenge primary care in the long-term. Public health efforts over the last decade have focused on increasing health system coordination and providing guidance on addressing chronic conditions and lifestyle factors such as obesity. The underlying principles and goals of the national health system continue to focus on universality, free access, equity and fairness of financing. The evolution of performance measures over the last decade shows the resilience of the health system in the aftermath of the economic crisis, although some structural reforms may be required to improve chronic care management and the reallocation of resources to high-value interventions.

Spain: health system review

This analysis of the Spanish health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. Overall health status continues to improve in Spain, and life expectancy is the highest in the European Union. Inequalities in self-reported health have also declined in the last decade, although long-standing disability and chronic conditions are increasing due to an ageing population. The macroeconomic context in the last decade in the country has been characterized by the global economic recession, which resulted in the implementation of health system-specific measures addressed to maintain the sustainability of the system. New legislation was issued to regulate coverage conditions, the benefits package and the participation of patients in the National Health System funding. Despite the budget constraints linked to the economic downturn, the health system remains almost universal, covering 99.1% of the population. Public expenditure in health prevails, with public sources accounting for over 71.1% of total health financing. General taxes are the main source of public funds, with regions (known as Autonomous Communities) managing most of those public health resources. Private spending, mainly related toout-of-pocket payments, has increased over time, and it is now above the EU average. Health care provision continues to be characterized by the strength of primary care, which is the core element of the health system; however, the increasing financing gap as compared with secondary care may challenge primary care in the long term. Public health efforts over the last decade have focused on increasing health system coordination and providing guidance on addressing chronic conditions and life style factors such as obesity. The underlying principles and goals of the national health system continue to focus on universality, free access, equity and fairness of financing. The evolution of performance measures over the last decade shows the resilience of the health system in the aftermath of the economic crisis, although some structural reforms may be required to improve chronic care management and the reallocation of resources to high-value interventions.

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.

[Controversial Issues in Economic Evaluation (II): health Outcomes of Health Care Interventions]. / Cuestiones controvertidas en evaluación económica (II): medidas de resultado en salud de las intervenciones sanitarias.

In this second article of a series of three, we will discuss using the Metaplan technique on controversial issues of health outcomes in economic evaluation of health care interventions. The four-discussion areas focus on: choice of health outcomes measures, where any outcome measure is superior to another; extrapolation and transferability of health outcomes measures, which should not be assumed the results of an EEIS of one country to another without making certain adjustments; appropriate instruments to measure quality of life in Spain, where the EQ-5D was indicated as convenient due to its widespread international use; and, indirect comparisons, where the combination of both comparisons, direct and indirect, it would be advisable if the test for indirect estimates is consistent and has been validated. Finally, research lines to try to overcome the identified discrepancies were identified in each of these areas, some of those are: doing studies of correlation between scores of specific and generic instruments measuring quality of life; update or create a database of economic evaluations in Spain; estimating utilities for the Spanish population by existing generic and specific instruments; or, establish a common way to show the results of a meta-analysis network.

[Controversial issues in economic evaluation (I): perspective and costs of Health Care interventions]. / Cuestiones controvertidas en evaluación económica (I): perspectiva y costes de intervenciones sanitarias.

Economic evaluation of health care interventions has experienced a strong growth over the past decade and is increasingly present as a support tool in the decisions making process on public funding of health services and pricing in European countries. A necessary element using them is that agents that perform economic evaluations have minimum rules with agreement on methodological aspects. Although there are methodological issues in which there is a high degree of consensus, there are others in which there is no such degree of agreement being closest to the normative field or have experienced significant methodological advances in recent years. In this first article of a series of three, we will discuss on the perspective of analysis and assessment of costs in economic evaluation of health interventions using the technique Metaplan. Finally, research lines are proposed to overcome the identified discrepancies.

Health care and nonhealth care costs in the treatment of patients with symptomatic chronic heart failure in Spain.

INTRODUCTION AND OBJECTIVES: Chronic heart failure is associated with high mortality and utilization of health care and social resources. The objective of this study was to quantify the use of health care and nonhealth care resources and identify variables that help to explain variability in their costs in Spain. METHODS: This prospective, multicenter, observational study with a 12-month follow-up period included 374 patients with symptomatic heart failure recruited from specialized cardiology clinics. Information was collected on the socioeconomic characteristics of patients and caregivers, health status, health care resources, and professional and nonprofessional caregiving. The monetary cost of the resources used in caring for the health of these patients was evaluated, differentiating among functional classes. RESULTS: The estimated total cost for the 1-year follow-up ranged from € 12,995 to € 18,220, depending on the scenario chosen (base year, 2010). The largest cost item was informal caregiving (59.1%-69.8% of the total cost), followed by health care costs (26.7%- 37.4%), and professional care (3.5%). Of the total health care costs, the largest item corresponded to hospital costs, followed by medication. Total costs differed significantly between patients in functional class II and those in classes III or IV. CONCLUSIONS: Heart failure is a disease that requires the mobilization of a considerable amount of resources. The largest item corresponds to informal care. Both health care and nonhealth care costs are higher in the population with more advanced disease.

[The social value of informal care provided to elderly dependent people in Spain]. / El valor social de los cuidados informales provistos a personas mayores en situación de dependencia en España.

OBJECTIVE: To analyze one part of the social benefit derived from non-professional (informal) caregivers by analyzing the hypothetical amount of resources that would need to be invested if informal care were substituted by formal care. METHODS AND DATA: Using data from the Survey of Disabilities, Personal Autonomy and Situations of Dependency (EDAD-2008), we estimated the cost to society if informal care were substituted by formal care of the population aged 65 years and older. For this purpose, first we computed the total amount of informal caregiving hours provided in Spain in 2008, and then we obtained its monetary worth by using the proxy good method. RESULTS: The monetary worth of informal care provided in 2008 ranged from 25,000 and 40,000 million euros, depending on the shadow price used to value one hour of care. These figures represented between 2.3% and 3.8% of the GDP for the same year. In regional terms, the valuation of informal care across Spain's autonomous regions showed a significant degree of dispersion, and in some regions, amounted to 6% of their GDP. CONCLUSIONS: The comprehensive approach to the care of the elderly should take the role and needs of informal caregivers into consideration. Caregivers should be given greater social recognition.

[Innovative patient access schemes for the adoption of new technology: risk-sharing agreements]. / Esquemas innovadores de mejora del acceso al mercado de nuevas tecnologías: los acuerdos de riesgo compartido.

The incorporation of new treatments, procedures and technologies into the services' portfolio of healthcare providers should aim to improve three areas equally: patient access to innovative solutions, the sustainability of the health system and compensation for innovation. However, traditional schemes based on fixed prices that fail to consider the product's appropriate use or its results in terms of effectiveness may lead to inefficient decision-making processes. Recently, risk-sharing agreements have appeared as new access schemes based on results that aim to reduce the uncertainty of the distinct health care players involved in reaching an agreement on new health technology financing and conditions of use. Key elements in the debate on these instruments are the huge variety of instruments available (especially those based on results), the implications for different players involved in their design and supervision, and their possible implementation in Spain. Our main conclusion is that risk-sharing agreements should be used in highly limited cases when standard conditions of access cannot be applied due to uncertainty about long-term effectiveness. These measures are aimed not only at regulating price but also at acting on the appropriate use of new technology. However, because international experience is limited, drawing a solid conclusion on the final results of the application of risk-sharing agreements would be premature.

Spanish recommendations on economic evaluation of health technologies.

The economic evaluation of health technologies has become a major tool in health policy in Europe for prioritizing the allocation of health resources and the approval of new technologies. The objective of this proposal was to develop guidelines for the economic evaluation of health technologies in Spain. A group of researchers specialized in economic evaluation of health technologies developed the document reported here, following the initiative of other countries in this framework, to provide recommendations for the standardization of methodology applicable to economic evaluation of health technologies in Spain. Recommendations appear under 17 headings or sections. In each case, the recommended requirements to be satisfied by economic evaluation of health technologies are provided. Each recommendation is followed by a commentary providing justification and compares and contrasts the proposals with other available alternatives. The economic evaluation of health technologies should have a role in assessing health technologies, providing useful information for decision making regarding their adoption, and they should be transparent and based on scientific evidence.

[A proposed guideline for economic evaluation of health technologies]. / Propuesta de guía para la evaluación económica aplicada a las tecnologías sanitarias.

Over the last few years, economic evaluation of health technologies has become a major tool used by European health policy decision-makers to create strategies for prioritizing the allocation of health resources and the approval of new technologies. Spain was a pioneer in proposing the standardization of methodology applicable to economic evaluation studies. However, because health policy decision-makers refused to support the initiative, the methodology was never put into practice. In the medium term, evidence of the economic value of new health technologies financed by the national health system will probably be increasingly required. At that time, stakeholders and decision-makers will have to agree upon a clear and concise set of rules on the technical and methodological issues that must be followed by economic evaluations of health technologies. Consequently, we have provided guidelines and recommendations for producing first-rate economic evaluations. The recommendations appear under seventeen headings or sections. In each case, the recommended requirements to be satisfied by an economic evaluation of health technologies are provided and each recommendation is followed by a commentary, providing a justification and comparing and contrasting the proposal with other available alternatives.