Design of a multiple criteria decision analysis framework for prioritizing high-impact health technologies in a regional health service.

OBJECTIVES: This study aims to develop a framework for establishing priorities in the regional health service of Murcia, Spain, to facilitate the creation of a comprehensive multiple criteria decision analysis (MCDA) framework. This framework will aid in decision-making processes related to the assessment, reimbursement, and utilization of high-impact health technologies. METHOD: Based on the results of a review of existing frameworks for MCDA of health technologies, a set of criteria was proposed to be used in the context of evaluating high-impact health technologies. Key stakeholders within regional healthcare services, including clinical leaders and management personnel, participated in a focus group (n = 11) to discuss the proposed criteria and select the final fifteen. To elicit the weights of the criteria, two surveys were administered, one to a small sample of healthcare professionals (n = 35) and another to a larger representative sample of the general population (n = 494). RESULTS: The responses obtained from health professionals in the weighting procedure exhibited greater consistency compared to those provided by the general public. The criteria more highly weighted were "Need for intervention" and "Intervention outcomes." The weights finally assigned to each item in the multicriteria framework were derived as the equal-weighted sum of the mean weights from the two samples. CONCLUSIONS: A multi-attribute function capable of generating a composite measure (multicriteria) to assess the value of high-impact health interventions has been developed. Furthermore, it is recommended to pilot this procedure in a specific decision context to evaluate the efficacy, feasibility, usefulness, and reliability of the proposed tool.

Economic burden of Cardiac Arrest in Spain: analyzing healthcare costs drivers and treatment strategies cost-effectiveness.

BACKGROUND: Cardiac arrest is a major public health issue in Europe. Cardiac arrest seems to be associated with a large socioeconomic burden in terms of resource utilization and health care costs. The aim of this study is the analysis of the economic burden of cardiac arrest in Spain and a cost-effectiveness analysis of the key intervention identified, especially in relation to neurological outcome at discharge. METHODS: The data comes from the information provided by 115 intensive care and cardiology units from Spain, including information on the care of patients with out-of-hospital cardiac arrest who had a return of spontaneous circulation. The information reported by theses 115 units was collected by a nationwide survey conducted between March and September 2020. Along with number of patients (2631), we also collect information about the structure of the units, temperature management, and prognostication assessments. In this study we analyze the potential association of several factors with neurological outcome at discharge, and the cost associated with the different factors. The cost-effectiveness of using servo-control for temperature management is analyzed by means of a decision model, based on the results of the survey and data collected in the literature, for a one-year and a lifetime time horizon. RESULTS: A total of 109 cardiology units provided results on neurological outcome at discharge as evaluated with the cerebral performance category (CPC). The most relevant factor associated with neurological outcome at discharge was 'servo-control use', showing a 12.8% decrease in patients with unfavorable neurological outcomes (i.e., CPC3-4 vs. CPC1-2). The total cost per patient (2020 Euros) was €73,502. Only "servo-control use" was associated with an increased mean total cost per hospital. Patients treated with servo-control for temperature management gained in the short term (1 year) an average of 0.039 QALYs over those who were treated with other methods at an increased cost of €70.8, leading to an incremental cost-effectiveness ratio of 1,808 euros. For a lifetime time horizon, the use of servo-control is both more effective and less costly than the alternative. CONCLUSIONS: Our results suggest the implementation of servo-control techniques in all the units that are involved in managing the cardiac arrest patient from admission until discharge from hospital to minimize the neurological damage to patients and to reduce costs to the health and social security system.

[Approximation to the budgetary cost of universalizing oral health in Spain]. / Una aproximación al coste presupuestario de universalizar la salud bucodental en España.

OBJECTIVE: To make an approximation to an estimate of the impact that an increase in the portfolio of oral health benefits would have on public health spending, which would at least cover most of the therapeutic treatments that households currently pay for privately. METHOD: This estimate is based on the level of expenditure on dental services of the Health Accounts System for the year 2020. The data of increased demand is extracted from a RAND's study on universalization of services. Then we carry out various linear projections of increased spending by introducing several linear co-payment assumptions to explore the impact of different mixed financing mechanisms. RESULTS: The increase in the demand for treatment would be 47.54% with respect to the current level of spending and that, under the starting assumptions, the increase in public spending would reach some 5345 million euros. Various co-pay scenarios could reduce budget impact. CONCLUSIONS: Despite the improvement in the oral health of the Spanish population, there are still problems derived from the existence of a socioeconomic gradient that promotes the concentration of the presence and prevalence of diseases in the lowest socioeconomic levels. Extending the services of the oral-dental portfolio to attend to the entire population would increase public health spending by 0.48 points over GDP and, even so, Spanish public health spending would continue to be below the EU-27 average.

[Impact of the Dependency Act on regional spending on social services]. / Impacto de la Ley de Dependencia sobre el gasto autonómico en servicios sociales.

OBJECTIVE: In this paper we address whether the System for Personal Autonomy and Care of Dependent Persons contributes to increasing the volume of resources of the public social services system (displacement effect) or, on the contrary, whether this development has taken place at the expense of other social services (substitution effect). METHOD: Panel data analysis is used to explain how per capita expenditure on social services evolves in the Spanish Regions under the common regime in the period 2002-2016. RESULTS: The implementation of the Dependency Act is associated with a 14% increase in the level of per capita expenditure on social services. This effect raises 25% when the variable explained is expenditure on current transfers of a social nature. On the other hand, law changes introduced in 2012 and 2013 were associated with a reduction in per capita expenditure on current transfers of around 10%. CONCLUSIONS: This evidence would refute the hypothesis that the System for Personal Autonomy and Care of Dependent Persons had merely a "substitution" effect on autonomous spending on social services.

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.

Converting Parkinson-Specific Scores into Health State Utilities to Assess Cost-Utility Analysis.

OBJECTIVES: The aim of this study was to compare the Parkinson's Disease Questionnaire-8 (PDQ-8) with three multi-attribute utility (MAU) instruments (EQ-5D-3L, EQ-5D-5L, and 15D) and to develop mapping algorithms that could be used to transform PDQ-8 scores into MAU scores. METHODS: A cross-sectional study was conducted. A final sample of 228 evaluable patients was included in the analyses. Sociodemographic and clinical data were also collected. Two EQ-5D questionnaires were scored using Spanish tariffs. Two models and three statistical techniques were used to estimate each model in the direct mapping framework for all three MAU instruments, including the most widely used ordinary least squares (OLS), the robust MM-estimator, and the generalized linear model (GLM). For both EQ-5D-3L and EQ-5D-5L, indirect response mapping based on an ordered logit model was also conducted. Three goodness-of-fit tests were employed to compare the models: the mean absolute error (MAE), the root-mean-square error (RMSE), and the intra-class correlation coefficient (ICC) between the predicted and observed utilities. RESULTS: Health state utility scores ranged from 0.61 (EQ-5D-3L) to 0.74 (15D). The mean PDQ-8 score was 27.51. The correlation between overall PDQ-8 score and each MAU instrument ranged from - 0.729 (EQ-5D-5L) to - 0.752 (EQ-5D-3L). A mapping algorithm based on PDQ-8 items had better performance than using the overall score. For the two EQ-5D questionnaires, in general, the indirect mapping approach had comparable or even better performance than direct mapping based on MAE. CONCLUSIONS: Mapping algorithms developed in this study enable the estimation of utility values from the PDQ-8. The indirect mapping equations reported for two EQ-5D questionnaires will further facilitate the calculation of EQ-5D utility scores using other country-specific tariffs.

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.

[Monetary value of the human costs of road traffic injuries in Spain]. / La valoración monetaria de los costes humanos de la siniestralidad vial en España.

Cost-benefit analyses in the field of road safety compute human costs as a key component of total costs. The present article presents two studies promoted by the Directorate-General for Traffic aimed at obtaining official values for the costs associated with fatal and non-fatal traffic injuries in Spain. We combined the contingent valuation approach and the (modified) standard gamble technique in two surveys administered to large representative samples (n1=2,020, n2=2,000) of the Spanish population. The monetary value of preventing a fatality was estimated to be 1.4 million euros. Values of 219,000 and 6,100 euros were obtained for minor and severe non-fatal injuries, respectively. These figures are comparable to those observed in neighboring countries.

Monetary Valuation of Informal Care Based on Carers' and Noncarers' Preferences.

OBJECTIVES: To elicit willingness-to-accept (WTA) values for informal care based on the preferences of informal carers and noncarers. METHODS: Two surveys were conducted with a sample of carers (n = 202) and a sample of noncarers (n = 200). Individuals in both groups were asked three questions in which they had to state the minimum monetary compensation they would require (WTA) if they had to look after a person described in a hypothetical scenario for one extra hour per day. Furthermore, carers were asked for the compensation they would demand if they had to be in charge of their actual care recipient for one extra hour per day. RESULTS: No significant differences were found between the distributions of carers' and noncarers' WTA values. Overall, respondents' valuations were sensitive to and consistent with their preferences over the tasks to be carried out in the extra hour of informal care. On average, carers required a lower monetary compensation for one extra hour taking care of their loved one (mean/median WTA values €5.2/€4.5) than if they had to devote that time to look after the hypothetical care recipient (mean/median WTA values €6.4/€5.5). More than half of the carers stated the same value under the two caring situations, which suggests that carers' WTA values were influenced by their own experience providing informal care. CONCLUSIONS: Our results show that it is feasible to derive a monetary valuation for informal care from the preferences of noncarers.

[Variability in antibiotic consumption within a regional health service, according to health area and model of healthcare coverage: national health system vs. civil servants' mutual insurance society]. / Variabilidad del consumo de antibióticos en una región sanitaria según áreas de salud y modelo de cobertura: sistema nacional de salud vs. mutualidad de funcionarios.

INTRODUCTION: The aim of this study is to describe antibiotic consumption in the Region of Murcia in 2011, within the Spanish and European context, as well as to analyze the differences within the Region, both between health areas, and between users of the regional health service and those protected by the civil servants' mutual insurance society (MUFACE). METHODS: Retrospective observational study of prescriptions dispensed by the pharmacies in the Region of Murcia during 2011. Consumption rates were expressed as defined daily doses (DDD) per 1,000 inhabitants/day and standardized consumption ratios (SCR). RESULTS: Overall antibiotics consumption rate in the Region of Murcia in 2011 was 30.05 DDD/1000/ day (DID), which is much above the average rate for Spain (20.9 DID) and for the European Union (21.57 DID). Health areas within the Region with the highest and lowest consumption rate are, respectively, Vega Alta (SCR: 124.44; CI95% 124.26 to 124.61) and Cartagena (SCR:84.16; CI95% 84.10 to 84.22). Civil servants covered by the mutual society have higher consumption rates than users of the regional health service (SCR: 105.01; CI95% 104.86 to 105.17). CONCLUSIONS: There is a high level of antibiotic prescription in the Region of Murcia Region in relative terms. A great variability in antibiotics consumption was observed between the different health areas, which might be related to the higher rate of the frequency of visits. The highest amount of variability in antibiotics prescription was found in cephalosporins and macrolides.

[Privatization in healthcare management: an adverse effect of the economic crisis and a symptom of bad governance. SESPAS report 2014]. / La privatización de la gestión sanitaria: efecto secundario de la crisis y síntoma de mal gobierno. Informe SESPAS 2014.

It is often asserted that public management of healthcare facilities is inefficient. On the basis of that unproven claim, it is argued that privatization schemes are needed. In this article we review the available evidence, in Spain and other countries, on the application of private management mechanisms to publicly funded systems similar to the Spanish national health system. The evidence suggests that private management of healthcare services is not necessarily better than public management, nor vice versa. Ownership-whether public or private-of health care centers does not determine their performance which, on the contrary, depends on other factors, such as the workplace culture or the practice of suitable monitoring by the public payer. Promoting competition among centers (irrespective of the specific legal form of the management arrangements), however, could indeed lead to improvements under some circumstances. Therefore, it is advisable to cease the narrow-minded debate on the superiority of one or other model in order to focus on improving healthcare services management per se. Understanding that good governance affects health policies, the management of health care organizations, and clinical practice is, undoubtedly, an essential requirement but may not necessarily lead to policies that stimulate the solvency of the system.

Valuing QALYs at the end of life.

The possibility of weighting QALYs differently for different groups of patients has been a source of debate. Most recently, this debate has been extended to the relative value of QALYs at the end of life (EoL). The objective of this study is to provide evidence of societal preferences in relation to this topic. Three cross-sectional surveys were conducted amongst Spanish general population (n = 813). Survey 1 compared increases in life expectancy for EoL patients with health gains from temporary health problems. Survey 2 compared health gains for temporary health problems with quality of life gains at the EoL (palliative care). Survey 3 compared increases in life expectancy with quality of life gains, both for EoL patients. Preferences were elicited using Person Trade-Off (PTO) and Willingness to pay (WTP) techniques presenting two different durations of health benefit (6 and 18 months). Health benefits, measured in QALYs, were held constant in all comparisons. In survey 1 mean WTP was higher for life extending treatments than for temporary health problems and the majority of respondents prioritised life extension over temporary health problems in response to the PTO questions. In survey 2 mean WTP was higher for palliative care than for temporary health problems and 83% prioritized palliative care (for both durations) in the PTO questions. In survey 3 WTP values were higher for palliative care than for life extending treatments and more than 60% prioritized palliative care in the PTO questions. Our results suggest that QALYs gained from EoL treatments have a higher social value than QALYs gained from treatments for temporary health problems. Further, we found that people attach greater weight to improvements in quality of life than to life extension at the end of life.

Validation and comparison of 15-D and EQ-5D-5L instruments in a Spanish Parkinson's disease population sample.

PURPOSE: To contribute to the ongoing discussion on the choice of a preference-based health-related quality of life (HRQoL) instrument to be used in cost-effectiveness analysis by studying and comparing the validity, sensitivity and relative efficiency of 15-D and EuroQol 5D 5L (EQ-5D-5L) in a Spanish Parkinson's disease (PD) population sample. METHODS: One hundred and thirty-three volunteers were asked to complete an interview using 15-D and EQ-5D-5L. Spearman's rank correlation coefficient (r) was used to test the convergent validity of these instruments with specific PD measures. Sensitivity and efficiency were compared using receiver operating characteristic (ROC) curves and relative efficiency statistic, respectively. RESULTS: A strong correlation (r > 0.65; p < 0.001) was found between both 15-D and EQ-5D-5L utilities with the summary score of the PDQ-8, and a strong correlation (r > 0.50; p < 0.001) was found between 15-D and EQ-5D-5L utilities with the EQ-VAS. The areas under the ROC of both instruments all exceeded 0.5 (p < 0.001). The 15-D instrument was 4.1-29.8 % less efficient at detecting differences between patients with optimal HRQoL, while this instrument was 11 % more efficient at detecting differences between patients at mild and moderate to strong severity of the PD symptoms. CONCLUSIONS: 15-D and EQ-5D-5L are showed to be valid and sensitivity generic HRQoL measures in Spanish PD patients with both instruments showing similar HRQoL dimension coverage and ceiling/floor effects. The 15-D has better efficiency and greater sensitivity to detect clinical changes in PD severity of the symptoms meanwhile the EQ-5D-5L is better to detect clinical HRQoL changes. Additionally, the EQ-5D-5L questionnaire requires less time than 15-D to be administered, and it might be more appropriate for studies conducted in Spain, since a country-specific "value set" is available for this instrument and not for the 15-D.

Inverse probability weighted estimation of social tariffs: an illustration using the SF-6D value sets.

This paper presents a novel approach to model health state valuations using inverse probability weighting techniques. Our approach makes no assumption on the distribution of health state values, accommodates covariates in a flexible way, eschews parametric assumptions on the relationship between the outcome and the covariates, allows for an undetermined amount of heterogeneity in the estimates and it formally tests and corrects for sample selection biases. The proposed model is semi-parametrically estimated and it is illustrated with health state valuation data collected for Spain using the SF-6D descriptive system. Estimation results indicate that the standard regression model underestimates the utility loss that the Spanish general population assigns to departures from full health, particularly so for severe departures.

[Quality assessment of economic evaluations in health care: a checklist and user guide]. / La medición de la calidad de los estudios de evaluación económica: Una propuesta de "checklist" para la toma de decisiones.

The aim of this paper is to promote the efficiency in the process of incorporating new health technologies, as well as to guide their implementation by physicians. An iterative method has been used to draw a checklist based on parsimony and measurability criteria. Authors made a first version of the checklist on the basis of theoretical literature and economic evaluation guidelines. This preliminary version was discussed and its validity was tested in two focus groups by doctors and managers of the regional public health systems of Murcia and Andalusia. As a result of this iterative process, we present a 12 criteria checklist in which a score is assigned to everyone of its items. The overall score a study receives (with a maximum of 100 points) is confronting to a set of cost per QALY thresholds, in order to assess if the technology been evaluated is cost-effective or not. The thresholds was selected from a previous study. We present a checklist and user guide which includes a cost per QALY thresholds matrix. This is an original proposal that has not been previously published in the Spanish literature. Our instrument needs some future improvements in terms of its validation and its spread to other types of cost-effectiveness analysis, apart from those that use QALYs. Nevertheless, our proposal may be useful to provide guidance on the usage and financing of new health technologies in Spain.

[How should health and healthcare priorities be set and evaluated? Prioritization methods and regional disparities. 2008 SESPAS Report]. / Cómo se deben establecer y evaluar las prioridades en salud y servicios de salud? Métodos de priorización y disparidades regionales. Informe SESPAS 2008.

The conflict between scarce resources and unlimited needs is perhaps more prominent in the healthcare sector than in any other areas. Thus, setting priorities in health care emerges as an unavoidable task. The laudable aim of adopting any health technology that improves the population's health is impossible when confronted by budgetary constraints. Therefore, the outstanding health problems of a society and the most efficient health technologies in terms of their cost-effectiveness must be identified and patients must be prioritized, bearing in mind aspects of equity and efficiency. The present article reviews the issue of setting health care priorities by examining the experiences that have been put into practice in Spain and abroad. The problem is analyzed at three levels: the "macro" level (strategic planning, identification of higher priority areas and the selection of health care interventions); the "meso" level (incorporation of cost-effectiveness analyses into clinical practice guidelines), and the "micro" level (how to design priority systems for patients on waiting lists based on clinical and social criteria). In all these levels, there is substantial heterogeneity between Spanish regional health services, the steps that need to be taken and the ground that needs to be covered. Thus, we suggest that the first steps that some regional health services have made, together with international initiatives, could serve as a reference for the definitive incorporation of new approaches in priority setting in the Spanish health system as a whole.

Cost accounting and public reimbursement schemes in Spanish hospitals.

The objective of this paper is to provide a description and analysis of the main costing and pricing (reimbursement) systems employed by hospitals in the Spanish National Health System (NHS). Hospitals cost calculations are mostly based on a full costing approach as opposite to other systems like direct costing or activity based costing. Regional and hospital differences arise on the method used to allocate indirect costs to cost centres and also on the approach used to measure resource consumption. Costs are typically calculated by disaggregating expenditure and allocating it to cost centres, and then to patients and DRGs. Regarding public reimbursement systems, the impression is that unit costs are ignored, except for certain type of high technology processes and treatments.

Conocimiento, actitudes y prácticas sobre las drogas entre los estudiantes de medicina de la UASD

Se realizó un estudio prospectivo, longitudinal y descriptivo para determinar los conocimientos, actitudes y prácticas sobre las drogas entre los estudiantes del departamento de Medicina de la Facultad de Ciencias de la Salud de la Universidad Autónoma de Santo Domingo, República Dominicana. En esta investigación se establecen las relaciones de conocimientos, actitudes y prácticas con algunas variables socio-demográficas y socio-económicas, en una muestra no selectiva de 214 alunos investigados durante el período enero-agosto de 1989. Los estudiantes con edades comprendidas entre 20 y 30 años representaron el 100%; los de 20 a 22 años (37.7%) fueron los más frecuentes; los del sexo femenino representaron el 60.2%; los solteros 87.0%; y los católicos 66.4%. Los de procedencia urbana 56.51%; ingreso familiar de $ 1,500.00 y con un conocimiento relativo en cuanto a drogas. Además de una actitud bien definida a fin de lograr erradicar la dependencia y con una práctica que se corresponde con la de toda sociedad, que es la posibilidad de caer en esta lamentable situación