Has Arthroscopic Meniscectomy Use Changed in Response to the Evidence? A Large-database Study From Spain.

BACKGROUND: Several randomized clinical trials on the treatment of meniscal tears have shown that surgery is not superior to nonoperative treatment in middle-aged and older adults. However, clinical practice has not changed consistently worldwide in response to this evidence, and arthroscopic meniscectomy remains one of the most frequently performed operations. QUESTIONS/PURPOSES: (1) How has the use of arthroscopic meniscectomy changed in Spain between 2003 and 2018, particularly in middle-aged (35 to 59 years) and older patients (over 60 years) relative to younger patients? (2) How have surgical volumes changed across different healthcare areas in the same health system? (3) How has the proportion of outpatient versus inpatient arthroscopic procedures changed over time? METHODS: Data on all 420,228 arthroscopic meniscectomies performed in Spain between 2003 and 2018 were obtained through the Atlas of Variations in Medical Practice project (these years were chosen because data in that atlas for 2002 and 2019 were incomplete). This database has been promoted by the Spanish Health Ministry since 2002, and it collects basic information on all admissions to public and public-private partnership hospitals. The Spanish population of 2003 was used to calculate age- and sex-standardized rates of interventions per 10,000 inhabitants and year. To assess the change in standardized rates among the age groups over the study period, a linear regression analysis was used. Standard small-area variation statistics were used to analyze variation among healthcare areas. Data on outpatient surgery and length of stay for inpatient procedures were also included. RESULTS: The standardized rate of arthroscopic meniscectomy in Spain in 2003 was 4.8 procedures per 10,000 population (95% CI 3.9 to 5.6), while in 2018, there were 6.3 procedures per 10,000 population (95% CI 5.4 to 7.3), which represents an increase of 33%. Standardized rates increased slightly in the age group < 35 years (0.06 interventions per 10,000 inhabitants per year [95% CI 0.05 to 0.08]), whereas they increased more markedly in the age groups of 35 to 59 years (0.14 interventions per 10,000 inhabitants per year [95% CI 0.11 to 0.17]) and in those 60 years and older (0.13 interventions per 10,000 inhabitants per year [95% CI 0.09 to 0.17]). The variability among healthcare areas in the meniscectomy rate progressively decreased from 2003 to 2018. In 2003, 32% (6544 of 20,384) of knee arthroscopies were performed on an outpatient basis, while in 2018, these accounted for 67% (19,573 of 29,430). CONCLUSION: We observed a progressive increase in arthroscopic meniscectomies in Spain; this procedure was more prevalent in older patients presumed to have degenerative pathologic findings. This increase occurred despite increasing high-level evidence of a lack of the additional benefit of meniscectomy over other less-invasive treatments in middle-aged and older people. Our study highlights the need for action in health systems with the use of financial, regulatory, or incentive strategies to reduce the use of low-value procedures, as well as interventions to disseminate the available evidence to clinicians and patients. Research is needed to identify the barriers that are preventing the reversal of interventions that high-quality evidence shows are ineffective. LEVEL OF EVIDENCE: Level III, therapeutic study.

Evolution of public hospitals expenditure by healthcare area in the Spanish National Health System: the determinants to pay attention to.

BACKGROUND: In Spain, hospital expenditure represents the biggest share of overall public healthcare expenditure, the most important welfare system directly run by the Autonomous Communities (ACs). Since 2001, public healthcare expenditure has increased well above the GDP growth, and public hospital expenditure increased at an even faster rate. This paper aims at assessing the evolution of need-adjusted public hospital expenditure at healthcare area level (HCA) and its association with utilisation and 'price' factors, identifying the relative contribution of ACs, as the main locus of health policy decisions. METHODS: Ecological study on public hospital expenditure incurred in 198 (HCAs) in 16 Spanish ACs, between 2003 and 2015. Aggregated and annual log-log multilevel models, considering ACs as a cluster, were modelled using administrative data. HCA expenditure was analysed according to differences in population need, utilization and price factors. Standardised coefficients were also estimated, as well as the variance partition coefficients. RESULTS: Between 2003 and 2015, over 59 million hospital episodes were produced in Spain for an overall expenditure of €384,200 million. Need-adjusted public hospital expenditure, at HCA level, was mainly associated to medical and surgical hospitalizations (standardized coefficients 0.32 and 0.28, respectively). The ACs explained 42% of the variance not explained by HCA utilization and 'price' factors. CONCLUSIONS: Utilization, rather than 'price' factors, may be explaining the difference in need-adjusted public hospital expenditure at HCA level in Spain. ACs, third-payers in the fully devolved Spanish National Health System, are responsible for a great deal of the variation in hospital expenditure.

Comparing variation across European countries: building geographical areas to provide sounder estimates.

BACKGROUND: In geographical studies, population distribution is a key issue. An unequal distribution across units of analysis might entail extra-variation and produce misleading conclusions on healthcare performance variations. This article aims at assessing the impact of building more homogeneous units of analysis in the estimation of systematic variation in three countries. METHODS: Hospital discharges for six conditions (congestive heart failure, short-term complications of diabetes, hip fracture, knee replacement, prostatectomy in prostate cancer and percutaneous coronary intervention) produced in Denmark, England and Portugal in 2008 and 2009 were allocated to both original geographical units and new ad hoc areas. New areas were built using Ward's minimum variance methods. The impact of the new areas on variability was assessed using Kernel distribution curves and different statistic of variation such as Extremal Quotient, Interquartile Interval ratio, Systematic Component of Variation and Empirical Bayes statistic. RESULTS: Ward's method reduced the number of areas, allowing a more homogeneous population distribution, yet 20% of the areas in Portugal exhibited less than 100 000 inhabitants vs. 7% in Denmark and 5% in England. Point estimates for Extremal Quotient and Interquartile Interval Ratio were lower in the three countries, particularly in less prevalent conditions. In turn, the Systematic Component of Variation and Empirical Bayes statistic were slightly lower in more prevalent conditions. CONCLUSIONS: Building new geographical areas produced a reduction of the variation in hospitalization rates in several prevalent conditions mitigating random noise, particularly in the smallest areas and allowing a sounder interpretation of the variation across countries.

Delving into public-expenditure elasticity: Evidence from a National Health Service acute-care hospital network.

INTRODUCTION: The sustainability of public hospital financing in Spain is a recurring issue, given its representativeness in annual public healthcare budgets which must adapt to the macroeconomic challenges that influence the evolution of spending. Knowing whether the responsiveness of hospital expenditure to its determinants (need, utilisation, and quasi-prices) varies according to the type of hospital could help better design strategies aimed at optimising performance. METHODS: Using SARIMAX models, we dynamically assess unique nationwide monthly activity data over a 14-year period from 274 acute-care hospitals in the Spanish National Health Service network, clustering these providers according to the average severity of the episodes treated. RESULTS: All groups showed seasonal patterns and increasing trends in the evolution of expenditure. The fourth quartile of hospitals, treating the most severe episodes and accounting for more than 50% of expenditure, is the most sensitive to quasi-price factors, particularly the number of beds per hospital. Meanwhile, the first quartile of hospitals, which treat the least severe episodes and account for 10% of expenditure, is most sensitive to quantity factors, for which expenditure showed an elasticity above one, while factors of production were not affected. CONCLUSIONS: Belonging to one or another cluster of hospitals means that the determinants of expenditure have a different impact and intensity. The system should focus on these differences in order to optimally modulate expenditure not only according to the needs of the population, but also according to the macroeconomic situation, while leaving hospitals room for manoeuvre in case of unforeseen events. The findings suggest strengthening a network of smaller hospitals (Group 1)-closer to their reference population, focused on managing and responding to chronicity and stabilising acute events-prior to transfer to tertiary hospitals (Group 4)-larger but appropriately sized, specialising in solving acute and complex health problems-when needed.

Comparing Hospital Efficiency: An Illustrative Study of Knee and Hip Replacement Surgeries in Spain.

WHO's Health Systems Performance Assessment framework suggests monitoring a set of dimensions. This study aims to jointly assess productivity and quality using a treatment-based approach, specifically analyzing knee and hip replacement, two prevalent surgical procedures performed with consolidated technology and run in most acute-care hospitals. Focusing on the analysis of these procedures sets out a novel approach providing clues for hospital management improvements, covering an existing gap in the literature. The Malmquist index under the metafrontier context was used to estimate the productivity in both procedures and its decomposition in terms of efficiency, technical and quality change. A multilevel logistic regression was specified to obtain the in-hospital mortality as a quality factor. All Spanish public acute-care hospitals were classified according to their average severity attended, dividing them into three groups. Our study revealed a decrease in productivity mainly due to a decrease in the technological change. Quality change remained constant during the period with highest variations observed between one period to the next according to the hospital classification. The improvement in the technological gap between different levels was due to an improvement in quality. These results provide new insights of operational efficiency after incorporating the quality dimension, specifically highlighting a decreasing operational performance, confirming that the technological heterogeneity is a critical question when measuring hospital performance.

Income level and regional policies, underlying factors associated with unwarranted variations in conservative breast cancer surgery in Spain.

BACKGROUND: Geographical variations in medical practice are expected to be small when the evidence about the effectiveness and safety of a particular technology is abundant. This would be the case of the prescription of conservative surgery in breast cancer patients. In these cases, when variation is larger than expected by need, socioeconomic factors have been argued as an explanation. OBJECTIVES: Using an ecologic design, our study aims at describing the variability in the use of surgical conservative versus non-conservative treatment. Additionally, it seeks to establish whether the socioeconomic status of the healthcare area influences the use of one or the other technique. METHODS: 81,868 mastectomies performed between 2002 and 2006 in 180 healthcare areas were studied. Standardized utilization rates of breast cancer conservative (CS) and non-conservative (NCS) procedures were estimated as well as the variation among areas, using small area statistics. Concentration curves and dominance tests were estimated to determine the impact of income and instruction levels in the healthcare area on surgery rates. Multilevel analyses were performed to determine the influence of regional policies. RESULTS: Variation in the use of CS was massive (4-fold factor between the highest and the lowest rate) and larger than in the case of NCS (2-fold), whichever the age group. Healthcare areas with higher economic and instruction levels showed highest rates of CS, regardless of the age group, while areas with lower economic and educational levels yielded higher rates of NCS interventions. Living in a particular Autonomous Community (AC), explained a substantial part of the CS residual variance (up to a 60.5% in women 50 to 70). CONCLUSION: The place where a woman lives -income level and regional policies- explain the unexpectedly high variation found in utilization rates of conservative breast cancer surgery.

Factors underlying the growth of hospital expenditure in Spain in a period of unexpected economic shocks: A dynamic analysis on administrative data.

AIMS: We sought to understand the evolution of Spanish public hospital expenditure by assessing its elasticity to volume versus price, controlling for need and case severity, from January 2003 to December 2015, a period of unexpected economic shocks. METHOD: Observational study of administrative data characterising hospitals in the Spanish National Health System. Public hospital expenditure was modelled using SARIMAX in a two-step approach aiming at: a) eliciting structural changes in the monthly time-series; and, b) analysing the reaction of expenditure to the behaviour of its direct underlying factors over the sub-periods identified in the first step. RESULTS: From January 2003 to December 2015, two structural changes were elicited, splitting this time-span into three sub-periods. The quantities of hospital services offered (mainly inpatient medical and surgical activity) were consistently shown as the main drivers of expenditure. Overall, hospital expenditure was inelastic to all the factors analysed, specially to quasi-prices; similar results were obtained across sub-periods of analysis. CONCLUSION: Factors associated to quantities (as compared to quasi-prices) were the main drivers of hospital expenditure in the period analysed, particularly after the economic shock. However, hospital expenditure was inelastic to both factors giving prominence to the economic cycle fluctuations as a strong inducer of the hospital expenditure trends in Spain.

Public-private partnerships in the Spanish National Health System: The reversion of the Alzira model.

In the statutory Spanish National Health System (SNHS), the role of public provision is prominent. Nonetheless, since the inception of the SNHS, Regional Health Authorities have also purchased hospital care from private not-for-profit or for-profit providers, usually complementing public provision. Over the years, the autonomous community of Valencia has championed the use of Public Private Partnerships (PPP) in the form of administrative concessions (AC) awarded to private providers. In the La Ribera Health Department, which includes Alzira, the company Ribera Salud held the concession to provide hospital and primary care to the registered population since 1999 - and this became known as the Alzira model. In April 2018, when the administrative concession was expected to be renewed, Valencia's Health Authority decided to terminate the concession and to revert to direct public provision. While most stakeholders - and in particular the left-wing regional government - were in favour of reverting to public provision, advocates of the Alzira model argued that it was superior in terms of productivity, per capita expenditure and quality. The termination of the Alzira model led to further regulatory changes enacted in the Law for Health 8/2018, which clearly states that public provision is the preferred model of service delivery and new (tighter) requirements are defined for any future PPPs aiming to settle in the autonomous community of Valencia. This paper describes the process and provides background information to understand the underlying reasons of this policy development.

A comparative performance analysis of a renowned public private partnership for health care provision in Spain between 2003 and 2015.

BACKGROUND: Recently, the once archetype of the public private partnership (PPP) in the Spanish National Health System (SNHS), namely the Alzira's Model, has come to an end. Advocates defended the superiority of PPPs over public-tenured provision, in terms of quality and technical efficiency. This paper profiles and compares Alzira's life-cycle performance with similar public-tenured providers. METHODS: Observational study on secondary data from virtually all hospital care episodes produced in 51 integrated providers (i.e., administrative healthcare areas) and 67 hospitals, in 2003 and 2015. Alzira's 2015 performance (and its variation since 2003) was compared with all public-tenured peers in the SNHS, using 26 indicators analysing the differences in age-sex standardized rates of events or risk-adjusted mortality, severity-adjusted hospital expenditure and hospital technical efficiency. RESULTS: In comparison with the corresponding public-tenured peers, Alzira's 2015 performance was statistically worse than the benchmark in the majority of indicators (15 out of 26); yet, its performance was one of the best in the SNHS in adjusted-mortality after Percutaneous Coronary Intervention (PCI). Over time, Alzira showed a statistically greater 2003-2015 improvement than its peers' average in eleven of the indicators, and a lower improvement in nine. CONCLUSIONS: In this comprehensive comparative study on Alzira's performance, this PPP has not generally outperformed public-tenured providers, although in some areas of care its developments have been outstanding.

[Geographical bias in the inhospital mortality estimated by the Hospital Morbidity Survey]. / Sesgos territoriales en la mortalidad hospitalaria estimada por la encuesta de morbilidad hospitalaria.

BACKGROUND: The Hospital Morbidity Survey (EMH) includes, at the moment, 85% of hospitals and 90% of discharges, and is the only national data source that allows to deepen with information about diagnostics, gender or age, in the study of hospitals as place of death. This work aims to analyze the presence of inhospital mortality geographical biases in the EMH in relation to the sample universe represented by the Statistics of Health Establishments with Inpatient Regime (EESCRI). METHODS: We compared, for each province in 2004, the EMH estimations for discharges, deaths and the percent of mortality with the data from the EESCRI, and adjusting one linear regression model for the number of deaths and a second model for the percent of mortality. RESULTS: The EMH infraestimated the volume of discharges and deaths (-8.6% and -11.4%), but not the inhospital mortality rate (3.55% vs. 3.45%). In spite of the excellent correlation in the number of deaths, figures in the EMH are inferior to the EESCRI figures in most provinces, and in 13 provinces the discrepancies overcome the 20%. The percent of mortality showed discrepancies overcoming 20% in 9 provinces. CONCLUSION: In 2004, the EMH infraestimates the discharges and deaths figures but, except for 9 provinces, there are not evidence of important biases in the percent of mortality.

Quality and technical efficiency do not evolve hand in hand in Spanish hospitals: Observational study with administrative data.

OBJECTIVE: Recent evidence on the Spanish National Health System (SNHS) reveals a considerable margin for hospital efficiency and quality improvement. However, those studies do not consider both dimensions together. This study aims at jointly studying both technical efficiency (TE) and quality, classifying the public SNHS hospitals according to their joint performance. METHODS: Stochastic frontier analysis is used to estimate TE and multilevel logistic regressions to build a low-quality composite measure (LQ), which considers in-hospital mortality and safety events. All hospitalizations discharged in Spain in 2003 and 2013, in 179 acute-care general hospitals, were studied. Four scenarios of resulting performance were built setting yearly medians as thresholds for the overall sample, and according to hospital-complexity strata. RESULTS: Overall, since 2003, median TE improved and LQ reduced -from TE2003:0.89 to TE2013:0.93 and, from LQ2003:42.6 to LQ2013:27.7 per 1,000 treated patients. The time estimated coefficient showed technical progress over the period. TE across hospitals showed scarce variability (CV2003:0.08 vs. CV2013:0.07), not so the rates of LQ (CV2003:0.64 vs. CV2013:0.76). No correlation was found between TE values and LQ rates. When jointly considering technical efficiency and quality, hospitals dealing with the highest clinical complexity showed the highest chance to be placed in optimal scenarios, also showing lesser variability between hospitals. CONCLUSIONS: Efficiency and quality have improved in Spanish public hospitals. Not all hospitals experiencing improvements in efficiency equally improved their quality. The joint analysis of both dimensions allowed identifying those optimal hospitals according to this trade-off.

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.

Factors associated with hospitalisations in chronic conditions deemed avoidable: ecological study in the Spanish healthcare system.

OBJECTIVES: Potentially avoidable hospitalisations have been used as a proxy for primary care quality. We aimed to analyse the ecological association between contextual and systemic factors featured in the Spanish healthcare system and the variation in potentially avoidable hospitalisations for a number of chronic conditions. METHODS: A cross-section ecological study based on the linkage of administrative data sources from virtually all healthcare areas (n=202) and autonomous communities (n=16) composing the Spanish National Health System was performed. Potentially avoidable hospitalisations in chronic conditions were defined using the Spanish validation of the Agency for Health Research and Quality (AHRQ) preventable quality indicators. Using 2012 data, the ecological association between potentially avoidable hospitalisations and factors featuring healthcare areas and autonomous communities was tested using multilevel negative binomial regression. RESULTS: In 2012, 151 468 admissions were flagged as potentially avoidable in Spain. After adjusting for differences in age, sex and burden of disease, the only variable associated with the outcome was hospitalisation intensity for any cause in previous years (incidence risk ratio 1.19 (95% CI 1.13 to 1.26)). The autonomous community of residence explained a negligible part of the residual unexplained variation (variance 0.01 (SE 0.008)). Primary care supply and activity did not show any association. CONCLUSIONS: The findings suggest that the variation in potentially avoidable hospitalisations in chronic conditions at the healthcare area level is a reflection of how intensively hospitals are used in a healthcare area for any cause, rather than of primary care characteristics. Whether other non-studied features at the healthcare area level or primary care level could explain the observed variation remains uncertain.

[Trend in potentially avoidable hospitalisations for chronic conditions in Spain]. / Evolución de las hospitalizaciones potencialmente evitables por condiciones crónicas en España.

OBJECTIVE: To analyse the trend in potentially avoidable hospitalisations (PAH) in frail patients or those with chronic conditions in Spain during the period 2002-2013. METHODS: An observational, ecological study was conducted to analyse the trend in age-sex standardised rates of PAH affecting six clinical conditions, and their variation, in the 203 health care areas composing the publicly-funded health system in Spain. RESULTS: During the period 2002-2013, overall PAH standardised rates decreased by 35%, but systematic variation remained moderately high, around 13% above that expected by chance. Angina admissions showed the largest reduction, followed by those for asthma and chronic obstructive pulmonary disease. In contrast, the prevalence of admissions for dehydration doubled. CONCLUSIONS: Despite the decrease in PAH rates, systematic variation among areas remains, indicating differences in chronic care management that lead to distinct healthcare outcomes.

[Variability and opportunity costs among the surgical alternatives for breast cancer]. / Variabilidad y coste de oportunidad de las alternativas quirúrgicas en cáncer de mama.

OBJECTIVE: To analyze medical practice variation in breast cancer surgery (either inpatient-based or day-case surgery), by comparing conservative surgery (CS) plus radiotherapy vs. non-conservative surgery (NCS). We also analyzed the opportunity costs associated with CS and NCS. METHODS: We performed an observational study of age- and sex-standardized rates of CS and NCS, performed in 199 Spanish healthcare areas in 2008-2009. Costs were calculated by using two techniques: indirectly, by using All-Patients Diagnosis Related Groups (AP-DRG) based on hospital admissions, and directly by using full costing from the Spanish Network of Hospital Costs (SNHC) data. RESULTS: Standardized surgery rates for CS and NCS were 6.84 and 4.35 per 10,000 women, with variation across areas ranging from 2.95 to 3.11 per 10,000 inhabitants. In 2009, 9% of CS was performed as day-case surgery, although a third of the health care areas did not perform this type of surgery. Taking the SNHC as a reference, the cost of CS was estimated at 7,078 € and that of NCS was 6,161 €. Using AP-DRG, costs amounted to 9,036 € and 8,526 €, respectively. However, CS had lower opportunity costs than NCS when day-case surgery was performed frequently-more than 46% of cases (following SNHC estimates) or 23% of cases (following AP-DRG estimates). CONCLUSIONS: Day-case CS for breast cancer was found to be the best option in terms of opportunity-costs beyond a specific threshold, when both CS and NCS are elective.

Carpal tunnel release surgery: small-area variation and impact of ambulatory surgery in the autonomous region of Valencia, Spain.

OBJECTIVE: This study aimed to analyze variability in rates of carpal tunnel release surgery among the healthcare areas of the autonomous region of Valencia, and to evaluate the contribution of ambulatory surgery and referrals to private hospitals to the variability found. METHODS: We carried out a cross-sectional, population-based study, describing the rates of carpal tunnel release surgery, standardized by age and sex, among areas in the region of Valencia in 2006. The observed variation was then analyzed using small-area analysis methods. Data from hospital admissions, referrals to private hospitals, population statistics and hospital resources were used to construct standardized rates, and Spearman's correlation was used to test the association with surgical setting and hospital resources. RESULTS: There were 8.2 carpal tunnel release surgeries per 10,000 inhabitants in the region of Valencia in 2006. Most (88.2%) of these interventions were performed as ambulatory surgery. After we excluded areas outside the 5th-95th percentiles, variation among areas was moderate and was similar for men and women. Variation was not associated with the proportion of the distinct surgical settings (admission to a public hospital, outpatient clinic, or referral to a private hospital) used in each area, or with the availability of resources. CONCLUSIONS: Variation in carpal tunnel release surgery among areas in the region of Valencia is moderate, but has a strong impact on the population because of the high prevalence of this disorder. This variation is not explained by the hospital resources available in each area or the surgical setting.

[Dabigatran versus acenocumarol for the prevention of stroke in atrial fibrillation: budget impact analysis in one health department in Spain]. / Dabigatrón versus acenocumarol para la prevención del ictus en la fibrilación atrial: análisis de impacto presupuestario en un departamento sanitario.

BACKGROUND: To Estimate, in the context of a Health Department of the Valencia Health Agency, the budgetary impact of the widespread use of dabigatran at doses of 110 and 150 mg in patients with non-valvular atrial fibrillation (AF), regarding the current scenario with acenocoumarol therapy. METHODS: Budget impact analysis of three scenarios of oral anticoagulation use in AF: a) current treatment with acenocoumarol, b) widespread replacement of acenocoumarol for Dabigatran 110 mg and, c) idem at doses of 150 mg. The analysis was conducted from the perspective of the Valencia Health Agency with a time horizon of one year (2009). The effectiveness and adverse effects were extrapolated from the RE-LY study, while prevalence and cost data correspond to the Health Department estimates in 2009. RESULTS: We included 5889 patients (2.4% of the population > 18 years) diagnosed with AF, of which 3726 (63.2%) were treated with acenocoumarol. The total costs of each scenario were € 1,119,412 (€ 300 patient/year) for acenocoumarol, € 4,985,095 (€ 1,337 patient/year) for dabigatran 110 and € 4,981,226 (€ 1,336 patient/year) for dabigatran 150, with a budget impact of 1,037 euros/year per patient shifted from acenocumarol to dabigatran-150. CONCLUSIONS: The high budgetary impact of moving to a scenario of widespread substitution of warfarin for Dabigatran supports the restriction of this therapeutic strategy to subgroups of patients at high risk or difficult control.

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.

Pharmacoeconomic assessment of implementing a universal PCV-13 vaccination programme in the Valencian public health system (Spain).

BACKGROUND: Heptavalent pneumococcal conjugate vaccine (PCV-7) was licensed to provide immunity against pneumococcal disease caused by seven serotypes of S. pneumoniae. Thirteen-valent pneumococcal conjugate vaccine (PCV-13) includes 6 additional serotypes for preventing invasive pneumococcal disease. OBJECTIVE: The objective of this study was to estimate the potential health benefits, costs, and cost-effectiveness of vaccination with PCV-13 in the Community of Valencia and to generate valuable information for policy makers at regional and country levels. METHODS: A decision tree was designed to determine the health and economic outcomes in hypothetical cohorts of vaccinated and unvaccinated children followed over their lifetime. Information about disease incidence and serotype distribution were gathered from local databases and from published and unpublished local records. PCV-13 effectiveness was extrapolated from PCV-7 efficacy data. A 5% of herd effect and a serotype replacement of 25% were considered for the base case scenario. Only direct costs were taken into account and results were expressed in terms of life-years gained (LYG) and quality adjusted life years (QALY). RESULTS: Implementing a universal PCV-13 vaccination program in the Community of Valencia would decrease the number of hospital admitted pneumonia to less than 4571 cases while avoiding 310 cases of IPD and 82,596 cases of AOM throughout the cohort lifetime. A total of 190 S. pneumoniae related deaths would be averted over the same period. Total medical costs of non-vaccinating the cohort of newborns would reach up to 403,850.859€ compared to 438,762.712€ that would represent vaccinating the cohort. The incremental cost of vaccinating the children was estimated in 12,794€/LYG and 10,407€/QALY, respectively. CONCLUSIONS: A universal PCV-13 vaccination program in the Community of Valencia would be a cost-effective intervention from the payer perspective after preventing for pneumococcal infections and for decreasing its associated mortality and morbidity.

Evolución de las hospitalizaciones potencialmente evitables por condiciones crónicas en España / Trend in potentially avoidable hospitalisations for chronic conditions in Spain

Objetivos: Analizar la evolución de las tasas de hospitalizaciones potencialmente evitables (HPE) que afectan a pacientes crónicos o frágiles en España durante el periodo 2002-2013. Métodos: Estudio observacional, ecológico, sobre la evolución de las tasas estandarizadas de hospitalizaciones por seis condiciones clínicas, y su variación, en las 203 áreas sanitarias del Sistema Nacional de Salud. Resultados: En el periodo estudiado hubo un descenso relativo del 35% en las tasas de HPE, pero la variación sistemática se mantuvo en cifras moderadas, alrededor de un 13% sobre lo esperado por azar. Las admisiones por angina experimentaron la mayor reducción, seguidas de las de asma y enfermedad pulmonar obstructiva crónica. Por el contrario, las hospitalizaciones por deshidratación doblaron su frecuencia. Conclusiones: A pesar del descenso observado en las tasas de HPE, sigue existiendo una variación sistemática entre áreas, que apuntaría a un manejo diferencial de las condiciones crónicas que conduciría a resultados sanitarios distintos (AU)

Objective: To analyse the trend in potentially avoidable hospitalisations (PAH) in frail patients or those with chronic conditions in Spain during the period 2002-2013. Methods: An observational, ecological study was conducted to analyse the trend in age-sex standardised rates of PAH affecting six clinical conditions, and their variation, in the 203 health care areas composing the publicly-funded health system in Spain. Results: During the period 2002-2013, overall PAH standardised rates decreased by 35%, but systematic variation remained moderately high, around 13% above that expected by chance. Angina admissions showed the largest reduction, followed by those for asthma and chronic obstructive pulmonary disease. In contrast, the prevalence of admissions for dehydration doubled. Conclusions: Despite the decrease in PAH rates, systematic variation among areas remains, indicating differences in chronic care management that lead to distinct healthcare outcomes (AU)