Trends in healthcare resource use and expenditure before and after ischaemic stroke. A population-based study.

INTRODUCTION: Despite improved survival rates, stroke represents an increasing healthcare and socioeconomic burden. We describe the main characteristics of patients with ischaemic stroke and resource use and associated expenditure one year before and 3 years after stroke, using a population-based dataset. METHODS: The information technology systems of the Catalan Health Service were used to identify patients with ischaemic strokes occurring between January 2012 and December 2016. For each patient, information from one year before the stroke and up to 3 years thereafter was linked across databases. We describe annual and monthly resource use and healthcare expenditure per patient. RESULTS: We identified 36 044 patients with ischaemic stroke (mean age, 74.7 ± 13.3 years). The survival rate at 3 years was 63%. Average expenditure per patient was €3230 the year before stroke, €11 060 for year 1 after stroke, €4104 for year 2, and €3878 for year 3. The greatest determinants of cost in year 1 were hospitalisation (including initial hospitalisation), representing 45% of the difference in expenditure compared to the previous year, and convalescence and rehabilitation services, representing 33% of this difference. After year one, the increase in expenditure was mainly determined by additional hospital admissions and drug treatment. CONCLUSION: After ischaemic stroke, healthcare expenditure increases primarily because of initial hospitalisation. After year one, the expenditure decreases but remains above baseline values. Information from population-based datasets is useful for improving the planning of stroke services.

A systematic review of cost-effectiveness evidence of endoscopic saphenous vein harvesting: is it efficient?

OBJECTIVE: Greater saphenous vein harvest for coronary and lower extremity bypass requires the longest incision of any surgical procedure. Endoscopic vein harvest allows better results in some clinical variables compared to open harvesting techniques. The objective of this study is to present the results of a systematic review of the scientific evidence about the efficiency of endoscopic saphenous vein harvest. METHODS: We performed a systematic review in the bibliographical databases Pubmed, National Health Service Economic Evaluation Database, and NHS Health Technology Assessment Database. The search strategy was "endoscopic AND harvesting", in the period January 1970-December 2009. RESULTS: We identified only 3 economic evaluation studies, 2 cost analyses with some methodological limitations, and 1 cost-utility analysis. All of them suggest lower hospital costs for endoscopic harvesting. CONCLUSIONS: Available evidence does not allow recommendations to be made based on the efficiency of endoscopic saphenous vein harvest, although it suggests lower costs for endoscopic harvesting. More scientific evidence about the long-term efficacy and the effectiveness of this technique is necessary, with studies measuring final outcomes, and carrying out complete and rigorous economic evaluations.

Meta-analysis of passive immunoprophylaxis in paediatric patients at risk of severe RSV infection.

AIM: To review respiratory syncytial virus (RSV), passive immunoprophylaxis (PI) trials and meta-analysis (MA). METHODS: A literature review. RESULTS: Two MA of PI were found. Overall 3927 patients were randomized. PI reduces RSV hospitalization in patients with bronchopulmonary dysplasia (RR 0.58; 95% CI 0.41, 0.82) and with acyanotic congenital heart disease (RR 0.29; 95% CI 0.14, 0.62). In patients with cyanotic heart disease or premature infants without bronchopulmonary dysplasia, results are inconclusive. Passive immunoprophylaxis has a null effect in mechanical ventilation and death. CONCLUSION: Passive immunoprophylaxis reduces RSV hospitalization in a subset of patients. However, it has no effect in harder endpoints of RSV disease severity.

Trends in healthcare resource use and expenditure before and after ischaemic stroke. A population-based study. / Evolución del gasto en servicios sanitarios antes y después del ictus isquémico: análisis de base poblacional.

INTRODUCTION: Despite improved survival rates, stroke represents an increasing healthcare and socioeconomic burden. We describe the main characteristics of patients with ischaemic stroke and resource use and associated expenditure one year before and 3 years after stroke, using a population-based dataset. METHODS: The information technology systems of the Catalan Health Service were used to identify patients with ischaemic strokes occurring between January 2012 and December 2016. For each patient, information from one year before the stroke and up to 3 years thereafter was linked across databases. We describe annual and monthly resource use and healthcare expenditure per patient. RESULTS: We identified 36,044 patients with ischaemic stroke (mean age, 74.7±13.3 years). The survival rate at 3 years was 63%. Average expenditure per patient was €3,230 the year before stroke, €11,060 for year one after stroke, €4,104 for year 2, and €3,878 for year 3. The greatest determinants of cost in year one were hospitalisation (including initial hospitalisation), representing 45% of the difference in expenditure compared to the previous year, and convalescence and rehabilitation services, representing 33% of this difference. After year one, the increase in expenditure was mainly determined by additional hospital admissions and drug treatment. CONCLUSION: After ischaemic stroke, healthcare expenditure increases primarily because of initial hospitalisation. After year one, the expenditure decreases but remains above baseline values. Information from population-based datasets is useful for improving the planning of stroke services.

[What kind of health information does the public need? Results of a qualitative study]. / ¿Qué necesidades de información de salud tienen la ciudadanía y los profesionales? Resultados de un estudio cualitativo.

INTRODUCTION: In 2016, the users of a Results Centre were asked directly about their health information needs. Three objectives were set: to define the groups interested in receiving the information generated, to determine the contents of the information to be included in the different products, and to identify the formats and channels most suitable for each of the stakeholders. MATERIAL AND METHODS: Semi-structured personal interviews and focus groups were organised to find out the interests of the users. Personal interviews and on-line consensus dynamics were also performed to determine the interests of the different health professionals, and those of professionals in communication. An analysis of content and discourse was done through the literal transcription of the focus groups and interviews held, as well as the open responses of the consensus dynamics. RESULTS: Two major interest groups were defined: that of professionals and of the users, with the former sub-divided into different groups according to their professional profile. The main contents of health information to include in the products generated differed for each interest group, as well as the most suitable formats and channels in each case. DISCUSSION: The information needs of professionals were oriented to the improvement of their professional practice. The importance of working on the dissemination of the information already generated, was also shown. The users stated that they only need information directly related to their health status, and identified their referring doctor as the person in charge of having this information and transmitting it.

Real World Data in Adaptive Biomedical Innovation: A Framework for Generating Evidence Fit for Decision-Making.

Analyses of healthcare databases (claims, electronic health records [EHRs]) are useful supplements to clinical trials for generating evidence on the effectiveness, harm, use, and value of medical products in routine care. A constant stream of data from the routine operation of modern healthcare systems, which can be analyzed in rapid cycles, enables incremental evidence development to support accelerated and appropriate access to innovative medicines. Evidentiary needs by regulators, Health Technology Assessment, payers, clinicians, and patients after marketing authorization comprise (1) monitoring of medication performance in routine care, including the materialized effectiveness, harm, and value; (2) identifying new patient strata with added value or unacceptable harms; and (3) monitoring targeted utilization. Adaptive biomedical innovation (ABI) with rapid cycle database analytics is successfully enabled if evidence is meaningful, valid, expedited, and transparent. These principles will bring rigor and credibility to current efforts to increase research efficiency while upholding evidentiary standards required for effective decision-making in healthcare.

Management of Helicobacter pylori in duodenal ulcer: a cost-effectiveness analysis.

BACKGROUND: Empirical eradication therapy of H. pylori has been proposed as a therapeutic alternative for duodenal ulcer. AIM: To identify the cost-effectiveness of empirical eradication therapy vs. test-and-treatment for the management of patients already diagnosed with a duodenal ulcer. METHODS: A decision analysis was performed to compare the cost-effectiveness of empirical eradication therapy of H. pylori diagnosed duodenal ulcer vs. eradication therapy after confirmatory diagnosis of Helicobacter pylori infection by means of several diagnostic tests. RESULTS: The empirical eradication therapy of duodenal ulcer was found to be the most effective and cost-effective strategy of all the alternatives. Amongst the alternatives, which included the previous performance of confirmatory diagnostic tests, the best cost-effectiveness ratio used a serology test. The model was robust in the face of changes in the values of therapeutic effectiveness, sensitivity and specificity of the diagnostic tests, prevalence of H. pylori infection in duodenal ulcer, duration of the antisecretory therapy, and number of medical visits. CONCLUSIONS: Based on our cost-effectiveness analysis, a treat approach is more effective and cost-effective than a test-and-treat approach in the clinical management of already diagnosed duodenal ulcer.

Which statin is most efficient for the treatment of hypercholesterolemia? A cost-effectiveness analysis.

A review of the cost-effectiveness literature indicated that the hydroxymethylglutaryl coenzyme A-reductase inhibitor fluvastatin is more cost-effective for achieving minor-to-moderate reductions in low-density lipoprotein cholesterol (LDL-C) levels than 3 other statins: lovastatin, pravastatin, and simvastatin. The main goal of this study was to verify the applicability of these conclusions to Spanish health care costs and patterns of resource consumption related to the treatment of hypercholesterolemia. A stochastic simulation model was used to predict both the costs and effects of treating high-risk hypercholesterolemic patients with fluvastatin, lovastatin, pravastatin, or simvastatin. Epidemiologic data were used to find a suitable theoretic probability distribution model for baseline LDL-C values in high-risk hypercholesterolemic patients. The model was then used to generate 10,000 random observations of baseline LDL-C values; the corresponding LDL-C values after a 2-year treatment period were predicted as a function of the baseline value and the percentage reduction expected with a particular statin and dose, according to the results obtained in 2 meta-analyses. The probability of treatment discontinuation was also taken into account using estimates obtained in usual practice. The effects of treatment were expressed as the rate of success in achieving the goal level of LDL-C, as defined in the current Spanish recommendations for the treatment of hypercholesterolemia. The average costs of treatment were computed from both the social and public-financing perspectives, including the cost of lipid-lowering drugs, physician visits, laboratory tests, and days off work, as appropriate. The occurrence of nonscheduled visits and workdays lost because of side effects were taken into account to compute indirect costs relevant to the social perspective. The potential costs of treating side effects were ignored. A cost-effectiveness analysis was performed to compare the cost-effectiveness ratios obtained with each of the 4 statins considered in this study. Model-based predictions of the effects, total costs, and cost-effectiveness ratios were made. Cost-effectiveness ratios were interpreted as the cost per patient meeting the goal of therapy, according to current Spanish recommendations. The data showed that fluvastatin had the lowest cost-effectiveness ratios when LDL-C levels required reduction to < or =25% of baseline levels. In this situation, fluvastatin was more cost-effective than lovastatin, pravastatin, or simvastatin from public-financing and social perspectives.

[Declaring conflict of interest in scientific publications. Time for the spotlights and stenographers in the backroom of research financed by the industry?]. / La declaración del conflicto de intereses en las publicaciones científicas. Tiempo para las luces y los taquígrafos en la trastienda de la investigación financiada por la industria?

The term conflict of interests is applied to those situations in which the research validity and integrity may be influenced by a secondary interest, typically an economic benefit, but also an ideological, personal or professional interest. In this work we describe some ways of conflict of interests--particularly those related with the publication of clinical and epidemiological research supported by the industry--and the regulation of this problem from medical journals, including references to the situation in Spain. The conflict of interest is not synonymous of scientific fraud neither malpraxis in research, but in the medical literature there exists enough evidence to consider it as an important source of biases. The usual form of facing the conflict of interests is to make it public, so that readers can judge its importance. The editorial policies of the Spanish journals are, in general, far from giving importance to this problem, an aspect which could favor an attitude of the investigators, to maintain funding or to obtain new contracts, unnecessarily subordinated to the interests of the companies.

[Patient classification systems in intermediate and long-term stay institutions: evolution and future perspectives]. / Sistemas de clasificación de pacientes en centros de media y larga estancia: evolución y perspectivas de futuro.

The importance of long term care sector is increasingly growing. Actually, the use of patient classification systems is a useful tool for the planning and management of health services for chronic and geriatric patients. Despite being much less known, patient classification systems have had a richer and earlier development in the long term care sector than in the acute care sector. Thus, one could could see the evolution from classifications based on the assessment of functional dependency to classifications progressively including variables corresponding to clinical complexity, and finally to complex systems such as RUG-III. Patient classification systems were first utilised as tools for the financing of long term centres, based on the patients' characteristics. Later, their applications have spread out to objectives related to the management of centres, assessment of quality of care, staff allocation level, control of access and national policies. In Spain, the only experience in the use of a patient classification system is the one used by the Catalan Health Care Administration which uses a classification for the financing of their centres.

[Relation of direct hospitalization costs with length of stay]. / Relación de los costes directos de hospitalización con la duración de la estancia.

OBJECTIVE: Our main objective is to analyse to the relationship between the direct cost of a hospitalary discharge and the length of stay controlling for other care variables. METHODS: Analysis of the direct costs of pharmacy, laboratory, pathology and radiology tests of the 21,883 discharged patients in two Barcelona hospitals during 1993, in relationship to care variables contained in the basic minimum data set for discharged patient (BMDSDP). Using both hospital information systems in which are detailed the complete activity carried out and the assignment of unitary costs by means of different methods adapted to the available information, the direct cost is built up for patient and it is assembled by DRG. With the direct cost information and the care variables of the BMDSDP, a simple linear regression (least squared method) is carried out. RESULTS: The average direct cost is up to 31,533 pesetas. The regression by least squared method explains 70% of the variance (R2) and the variables with higher explanatory power are the length of stay and the relative weight of average DRG direct costs, that acts like variable of adjustment. CONCLUSIONS: The variability of the direct cost is explained principally by the length of stay. In addition, the length of stay is also very important on explaining the internal variability of DRG direct cost.

Economic evaluation of interventions for malignant neoplasms in Spain: systematic review and comparative analysis.

OBJECTIVE: To review standard methods used to evaluate the efficiency of oncology interventions, comparing their main characteristics with those of the studies aimed for other conditions. METHODS: We performed a systematic review and comparative analysis calculating odds ratios (OR). We searched the biomedical literature to assess economic evaluation studies on malignant neoplasms in Spain published between 1983 and 2008. Their characteristics were reviewed and summarised, including the following variables: journal and year of publication, intervention, type and design of study, perspective, type of costs, financing source, and decision-making recommendations. RESULTS: Sixty-three studies were included. Main characteristics of the reports were: cost-effectiveness analysis and therapeutic interventions (60.3%; n=38). Seventeen studies (27.0%) used an observational design. Economic evaluations of malignant neoplasms showed the following associations (compared to those studies addressing other causes [n=411]): cost minimisation analysis (OR: 1.73; 95% confidence interval [CI]: 0.91-3.27), diagnostic interventions (OR: 2.18; 95% CI: 1.07-4.43), decision analysis design (OR: 0.46; 95% CI: 0.24-0.87), societal perspective (OR: 0.20; 95% CI: 0.05-0.86) and for-profit source of financing (OR: 0.52; 95% CI: 0.30-0.93). CONCLUSIONS: Economic evaluations of interventions for malignant neoplasms are not common despite the gradual increase produced during recent years in Spain. Reports presented heterogeneity in the quality of the information regarding the methods and the data sources used. Further efficiency evaluations of oncology interventions are needed and methodological quality should be warranted.

[Economic evaluation of neurological and mental disorders in Spain: systematic review and comparative analysis]. / Evaluacion economica sobre enfermedades neurologicas y mentales en Espana: revision sistematica y analisis comparativo.

AIM: We analyzed the trends over time and the characteristics of economic evaluation studies of neurological and mental disorders published in Spain between 1983 and 2008. MATERIALS AND METHODS: Systematic review and comparative analysis calculating odds ratios (OR). Electronic searches for literature were conducted in PubMed/Medline, Scopus, ISI Web of Knowledge, CRD, IME and IBECS, and manually in specialized journals and technical reports. RESULTS: The 52 studies included in the review showed heterogeneity in the quality of the information regarding methods of analysis and data sources. Economic evaluation studies of neurological and mental disorders showed the following associations, compared to a cohort of studies of other disease conditions (n = 425): cost-utility analysis (OR = 1.57; 95% confidence interval, 95% CI = 0.77-3.22), treatments (OR = 3.02; 95% CI = 1.33-6.88), simulation mathematics models (OR = 2.51; 95% CI = 1.30-4.87), and healthcare system perspective (OR = 1.43; 95% CI = 0.80-2.54). CONCLUSIONS: Findings suggested that there is little research on economic evaluation research on neurological and mental disorders in Spain. In the future, more and better quality economic evaluation studies -according to their burden generated- are expected.

[Economic evaluation of interventions for infectious diseases in Spain: systematic review and comparative analysis]. / Evaluación económica de intervenciones en enfermedades infecciosas en España: revisión sistemática y análisis comparativo.

BACKGROUND: There exists the need to evaluate interventions addressed to prevent, control and reduce the burden of the infectious diseases; being economic evaluation an instrument can help to allocate healthcare resources efficiently. In this context, we assessed the evolution of economic evaluation of interventions for infectious diseases published in Spain, as well as we compared their main methodological characteristics with those of the studies directed to other diseases. METHODS: Systematic review and comparative analysis calculating odds ratios (OR). Electronic searches for literature beetwen 1983 and 2008 were conducted in PubMed/MEDLINE, SCOPUS, ISI Web of Knowledge, CRD, IME e IBECS, and manually in specialized journals and technical reports. The following variables were identified to analyze the characteristics of the reports: journal and year of publication, intervention, type of study, design, perspective, type of costs, financing source, and decision-making recommendations. RESULTS: One-hundred and one studies were included in the review. The main characteristics of the reports were: cost-effectiveness analysis (n=56; 55.4%), treatments evaluations (n=60; 59.4%) and the use of decision analysis and mathematical simulation models (n=63; 62.4%). Economic evaluation studies of infectious diseases showed the following associations (compared to a cohort of studies of other disease conditions [n=376]): cost-benefit analysis (OR, 3.55; 95% confidence interval [CI], 1.63 to 7.74), prevention (OR, 4.14; 95% CI, 2.49 to 6.90), and societal perspective (OR, 2.55; 95% CI, 1.43 to 4.56). CONCLUSION: Although there is an increase in the number of economic evaluations of infectious diseases published during last decades, the studies showed heterogeneity in the quality of the information regarding methods of analysis and data sources.

The economic cost of road traffic crashes in an urban setting.

The objective of this article is to assess the total economic costs of road traffic crashes in Barcelona, a metropolitan city located in Southern Europe. A cost-of-illness study was conducted using a prevalence approximation, a societal and healthcare system perspective, and a 1-year time horizon. Results were measured in terms of Euros in 2003. Total costs of road traffic crashes in Barcelona in 2003 were euro367 million. Direct costs equalled euro329 million (89.8% of total costs), including property damage costs, insurance administration costs and hospital costs. Police, emergency costs and transportation costs had a minimum effect on total direct costs. Indirect costs were euro37 million, including lost productivity due to hospitalization and mortality. The results of the sensitivity analysis showed the upper limit of total economic cost of road traffic crashes in Barcelona to be euro782 million. This is the first study to estimate the costs of road traffic crashes for a city in a developed country. The importance of the problem calls for further interventions to reduce road traffic crashes.

Twenty years of health care economic analysis in Spain: are we doing well?

The rising demand for health care, together with the scarce available resources, has increased the use of economic analysis as a support tool for policy making. The objective of this study was to make a description of economic evaluation studies carried out in Spain and published during the last 20 years, and to assess their quality. A systematic bibliographic search was made in the main biomedical databases. Full economic evaluation studies made in Spain comparing two or more health care alternatives were included. Statistical analyses included a descriptive analysis, the assessment of the association between pairs of variables, and a homogeneity analysis. A total of 87 studies were included in the review. According to the methodology, the technique most frequently used was cost-effectiveness analysis. In most cases, some weaknesses could be pointed out: absence of any objective directly linked to the decision-making process, a non-explicit perspective, no inclusion of indirect costs, or clinical and economical data not concurrently collected. A continuing challenge for health care economic analysis in Spain is to follow methodological guidelines and reporting conventions, to improve the dissemination of research, as well as to use more sophisticated economic analysis techniques, and to publish in international journals.

Could we measure the efficiency of prostate cancer treatment? A critical appraisal of economic evaluation studies.

The objective of this paper is to introduce the methodology of economic analysis in health care, and its application to the measurement of the efficiency analysis of prostate cancer treatment. We presented the methodology of economic analysis. To review its application in prostate cancer treatment, we performed a bibliographic search in the main biomedical databases (February 1988-January 2001) to identify economic evaluation studies that compared both costs and effects of prostate cancer treatments. The lack of economic studies for localized prostate cancer and the diversity of treatments for advanced prostate cancer make it difficult to make comparisons across studies and to make therapeutic recommendations.Prostate Cancer and Prostatic Diseases (2001) 4, 217-220.

Economic analysis of treatment of functional dyspepsia. An assessment of the quality of published studies.

OBJECTIVES: The objective of this study was to assess the quality of economic analysis studies published in the medical and economical literature assessing the clinical management of functional dyspepsia. METHODS: Bibliographic search in the main biomedical databases, in articles from bibliographic references, health technology assessment reports, and in gray literature. A specific protocol with economic and clinical items was designed for the evaluation. RESULTS: Overall, 18 of 162 studies met the inclusion criteria for the assessment. The compared treatment options were very diverse. The main methodologic deficiencies were in perspective of analysis, inclusion of indirect costs, and sources of clinical information. CONCLUSIONS: Specific checklists with clinical and economical items may help to better assess the quality of economic analysis in the field of functional dyspepsia. The methodologic rigor in the application of economic analysis techniques, as well as the use of appropriate clinical outcome measures, is essential to guarantee the reproducibility of the studies.