Unravelling risk selection in Spanish general government employee mutual funds: evidence from cancer hospitalizations in the public health network.

Government employees in Spain are covered by public Mutual Funds that purchase a uniform basket of benefits, equal to the ones served to the general population, from private companies. Companies apply as private bidders for a fixed per capita premium hardly adjusted by age. Our hypothesis is that this premium does not cover risks, and companies have incentives for risk selection, which are more visible in high-cost patients. We focus on a particularly costly disease, cancer, whose prevalence is similar among government employees and the general population. We compare hospitalisations in the public hospitals of the government employees that have chosen public provision and the general population. We analysed a database of hospital discharges in the Valencian Community from 2010 to 2015 (3 million episodes). Using exact matching and logistic models, we find significant risk selection; thus, in hospitalised government employees, the likelihood for a solid metastatic carcinoma and non-metastatic cancer to appear in the registry is 31% higher than in the general population. Lymphoma shows the highest odds ratio of 2.64. We found quantitatively important effects. This research provides indirect evidence of risk selection within Spanish Mutual Funds for government employees, prompting action to reduce incentives for such a practice. More research is needed to figure out if what we have observed with cancer patients occurs in other conditions.

Assisted reproduction in Spain, outcome and socioeconomic determinants of access.

RESEARCH QUESTION: We analyzed two questions. First, the effectiveness of public Assisted Reproductive Technologies (ART) in Spain compared with private ones, measured by the time since initiating ART treatment until achieving pregnancy, accounting for age and socioeconomic factors. Second, socioeconomic determinants of access to ART, referring primarily to financial means derived by employment, income, and wealth. DESIGN: We applied statistical models on data extracted from the national Spanish Fertility Survey from 2018. The first topic was analyzed by competing risk survival analysis conducted on a sample of 667 women who initiate ART treatment since 2000. The second, by a Bivariate Probit model conducted on a sample of 672 women older than 41 years who required ART services. RESULTS: The first analysis raised that throughout the treatment, patients treated exclusively in private clinics had on average a higher cumulative incidence of becoming pregnant compared with patients who approached public clinics. The second analysis raised that both higher household equivalent income and higher education increase the likelihood of accessing ART in a private clinic and decrease the tendency of accessing public clinics or failing to access any service. Moreover, being single decreases the likelihood of accessing public clinics or ART services in general. CONCLUSIONS: Long waiting periods could be the main reason for the lower incidence of getting pregnant in public healthcare, explaining why patients choose private over public care. We develop a broader discussion over the extent of Spanish public funding of ART, the unequal medical outcome, and potential options for optimization.

The Economic Impact of the SARS-COV-2 (COVID-19) Pandemic in Spain.

BACKGROUND: The COVID-19 pandemic has hit both the Spanish economy and the population's health hard. The result is an unprecedented economic and social crisis due to uncertainty about the remedy and the socioeconomic effects on people's lives. METHODS: We performed a retrospective analysis of the macroeconomic impact of the COVID-19 pandemic in 2020 using key indicators of the Spanish economy for the 17 Autonomous Communities (ACs) of the country. National statistics were examined in the search for impacts or anomalies occurring since the beginning of the pandemic. To estimate the strength of the impact on each of the indicators analyzed, we used Bayesian structural time series. We also calculated the correlation between the rate of GDP decline during 2020 and the cumulative incidence of COVID-19 cases per 100,000 inhabitants in the ACs. RESULTS: In 2020, the cumulative impact on the gross domestic product was of -11.41% (95% credible interval: -13.46; -9.29). The indicator for business turnover changed by -9.37% (-12.71; -6.07). The Spanish employment market was strongly affected; our estimates showed a cumulative increase of 11.9% (4.27; 19.45) in the rate of unemployment during 2020. The worst indicators were recorded in the ACs most economically dependent on the services sector. There was no statistical association between the incidence of COVID-19 in 2020 and the fall in GDP in the ACs. CONCLUSIONS: Our estimates portray a dramatic situation in Spain, where the COVID-19 crisis has had more serious economic and health consequences than in other European countries. The productive system in Spain is too dependent on sectors vulnerable to the pandemic, and it is necessary to design and implement profound changes through the European Next Generation program.

The impact of taxing sugar-sweetened beverages on cola purchasing in Catalonia: an approach to causal inference with time series cross-sectional data.

Sugar-sweetened beverage (SSB) taxes related to the quantity of sugar have appeared as a popular regulatory tool around the world during the last decade showing important variations in their implementation and impact. We evaluated the impact of a new SSB tax implemented in Catalonia since May 1, 2017 on the purchased quantities and penetration rates of taxed and untaxed cola beverages. We use aggregate time series of cola beverages purchases in all 17 Spanish Autonomous Communities before and after the implementation of the SBB tax in Catalonia, from January 2013 to June 2019. A comparison between two different types of causal inference methods was conducted: a two-way fixed effects difference in differences model and a modified synthetic control model. Regular cola purchases decreased 12.1% and their penetration rate decreased by 1.27 points during the two post-intervention years using the preferred model. Diet cola purchases increased 17.0% and their penetration rate also increased by 1.65 points. Only regular cola results were robust to all placebo test checks. The SSB tax implemented in Catalonia in 2017 significantly reduced the volume and penetration rates of regular colas with no robust evidence for the substitution effect on diet colas.

Impact of sandstorm and carnival celebrations on SARS-CoV-2 spreading in Tenerife and Gran Canaria (Canary Islands, Spain).

OBJECTIVE: We address the hypothesis that the extraordinary sandstorm occurred on 22-24 February 2020 might have a role in the different cumulated incidence of COVID-19 cases between the islands of Tenerife and Gran Canaria, since it obliged to reduce significantly air traffic and forced to suspend all major carnival street events in all most locations. METHOD: We performed a retrospective analysis of COVID-19 cases as to 1 April 2020 according to symptoms onset, weather-related data and Carnival events in Tenerife and Gran Canaria. RESULTS: The sandstorm occurred on February 22-24, 2020, forced air traffic to close, reducing the influx of tourists to the Canary Islands and suspending carnival events in most places, except in Santa Cruz de Tenerife. Cumulated incidence as to 1 April was 132.81/100,000 in Tenerife, and 56.04/100,000 in Gran Canaria. CONCLUSIONS: The suspension of Carnival events due to the sandstorm in the Canary Islands contributed to reduce differently the SARS-CoV-2 spread in Tenerife and Gran Canaria.

Free prescriptions for low-income pensioners? The cost of returning to free-of-charge drugs in the Spanish National Health Service.

This study estimated the impact of reducing a capped low coinsurance rate for outpatient medicines to nil for low-income pensioners and disabled individuals in the Valencian Community (Spain). This reduction was implemented in January 2016 as a regional reform which modified the national cost-sharing reform adopted in July 2012. The impact of this intervention on the number of monthly prescriptions dispensed between July 2012 and December 2018 was estimated using two different approaches of the synthetic control method, the classical method and the method based on Bayesian structural time series. The estimates from both methods were similar, showing significant overall increases of 6.34% and 6.70% [95% credible interval: 4.05, 9.47], respectively in the number of prescriptions dispensed in this region. These results are similar to those of the previous studies indicating that reducing price from a small amount to zero discontinuously boosts demand. This evidence indicates that the impact of this intervention on the budget of the regional health service is far greater than the amount of the subsidy in the public budget. These results are useful for making accurate budgetary projections for similar eliminations of charges for low-income pensioners in the Spanish National Health Service.

Income and wealth as determinants of voluntary private health insurance: empirical evidence in Spain, 2008-2014.

BACKGROUND: Few studies have quantitatively estimated the income elasticity of demand of voluntary private health insurance (VPHI) in countries with a universal National Health Service. Most studies to date have uses cross-sectional data. METHODS: In this paper we used a longitudinal database from the Bank of Spain to analyse the financial behaviour of approximately six thousand families per wave. We used three waves (2008, 2011 and 2014). We estimated income and wealth semi-elasticities of VPHI in Spain considering personal and family characteristics (age, sex, level of health, education, composition of the household), i.e. changes in the probability of buying VPHI as result of 1% change in income or wealth. We estimated cross-sectional models for each wave and longitudinal models for families remaining for at least two waves, taking account of possible selection bias due to attrition. RESULTS: Cross-sectional models suggest that the income effect on the probability of buying a VPHI increased from 2008 to 2014. The positive impact was observed for, wealth. In 2008 a 1% increase in income is associated with an increase in the probability of having VPHI of 0.064 [95%-CI: 0.023; 0.104] - on the probability scale (0.1) - whereas in 2014, this effect is of 0.116 [95%-CI, 0.094; 0.139]. In 2011 and 2014 the wealth effect is not significant at 5%. The estimation of the longitudinal model leads to different results where both, income and wealth are associated with non- significant results. CONCLUSION: Our three main conclusions are: 1) Cross-sectional estimates of semi-elasticities of VPHI might be biased upwards; 2) Wealth is alongside income are economic determinants, of the decision to buy VPHI in high-income countries; 3) The effects of income and wealth on the probability of buying VHPI are neither linear nor log-linear. There are no significant differences among 60% of the most disadvantaged families, while the families of the two upper wealth quintiles show clearly differentiated behaviour with a higher probability of insurance.

The Evolution of Mental Health in the Context of Transitory Economic Changes.

BACKGROUND: Mental health disorders are highly prevalent across countries. They increase over time and impose a severe burden on individuals and societies. OBJECTIVE: This paper examines the evolution of mental health over a period of 15 years, paying special attention on the impact of the most recent economic downturn and subsequent recovery, in Spain. METHOD: We use data coming from the National Health Surveys of 2006/2007, 2011/2012 and 2016/2017. Mental health is proxied by two measures, doctor-diagnosed mental disorder and psychological distress (based on the 12-item General Health Questionnaire). To account for the relationship between the two mental health indicators, we estimate a bivariate probit model. The potential endogeneity of unemployment status is considered. RESULTS: We observe different patterns of the two mental health indicators over time. Psychological distress in men increased during recession years, but slightly decreased among women. Diagnosed mental disorders declined during the peak years of the crisis. Unemployment is a major risk factor for mental distress. Irrespective of the economic conditions, belonging to a higher social class acts as a buffer against psychological distress for women, but not for men. The remaining determinants acted as expected. Women declared worse psychological health than men, and were also more often diagnosed with mental disorders. Having a partner had a protective impact, while providing intensive care to a dependent relative exerted the opposite effect. Education acted as buffer against the onset of psychological distress in women. CONCLUSION: Even though the need for mental healthcare increased during the recession, the fact that fewer people were diagnosed suggests that barriers to accessing mental healthcare may be aggravated during the crisis. Policies aiming to tackle the challenges posed by the high prevalence of mental disorders have to be particularly attentive to changes in individuals' socioeconomic situation, including education, unemployment and social class.

Impact of sandstorm and carnival celebrations on SARS-CoV-2 spreading in Tenerife and Gran Canaria (Canary Islands, Spain) / Impacto de una tormenta de arena y de los carnavales en la diseminación del SARS-CoV-2 en Tenerife y Gran Canaria (Islas Canarias, España)

OBJECTIVE: We address the hypothesis that the extraordinary sandstorm occurred on 22-24 February 2020 might have a role in the different cumulated incidence of COVID-19 cases between the islands of Tenerife and Gran Canaria, since it obliged to reduce significantly air traffic and forced to suspend all major carnival street events in all most locations. METHOD: We performed a retrospective analysis of COVID-19 cases as to 1 April 2020 according to symptoms onset, weather-related data and Carnival events in Tenerife and Gran Canaria. RESULTS: The sandstorm occurred on February 22-24, 2020, forced air traffic to close, reducing the influx of tourists to the Canary Islands and suspending carnival events in most places, except in Santa Cruz de Tenerife. Cumulated incidence as to 1 April was 132.81/100,000 in Tenerife, and 56.04/100,000 in Gran Canaria. CONCLUSIONS: The suspension of Carnival events due to the sandstorm in the Canary Islands contributed to reduce differently the SARS-CoV-2 spread in Tenerife and Gran Canaria

OBJETIVO: Investigar la hipótesis de que la extraordinaria tormenta de arena ocurrida el 22-24 de febrero de 2020 pudo tener un papel en la diferente incidencia acumulada de casos de COVID-19 entre las islas de Tenerife y Gran Canaria, en cuanto conllevó una reducción significativa del tráfico aéreo y la cancelación de las mayores celebraciones del carnaval en muchas poblaciones. MÉTODO: Se realiza un análisis retrospectivo de los casos de COVID-19 hasta el 1 abril de 2020 según fecha de inicio de los síntomas, de los datos climáticos y de las celebraciones de carnaval en Tenerife y Gran Canaria. RESULTADOS: La tormenta de arena ocurrida el 22-24 de febrero de 2020 obligó a cerrar el tráfico aéreo, reduciendo la llegada de turistas a Canarias, y a suspender las celebraciones de los carnavales en muchas poblaciones, excepto en Santa Cruz de Tenerife. El 1 abril de 2020, la incidencia acumulada de casos era de 132,81/100.000 en Tenerife y de 56,04/100.000 en Gran Canaria. CONCLUSIONES: La cancelación de las celebraciones de carnaval debido a la tempestad de arena en las Islas Canarias parece que contribuyó de manera diferente a la reducción de la incidencia del SARS-CoV-2 en Tenerife y Gran Canaria

Trends in horizontal inequity in access to public health care services by immigrant condition in Spain (2006-2017).

BACKGROUND: The objective of this research is to analyse trends in horizontal inequity in access to public health services by immigration condition in Spain throughout the period 2006-2017. We focus on "economic immigrants" because they are potentially the most vulnerable group amongst immigrants. METHODS: Based on the National Health Surveys of 2006-07 (N = 29,478), 2011-12 (N = 20,884) and 2016-17 (N = 22,903), hierarchical logistic regressions with random effects in Spain's autonomous communities are estimated to explain the probability of using publicly-financed health care services by immigrant condition, controlling by health care need and other socioeconomic and demographic variables. RESULTS: Our results indicate that there are several horizontal inequities, though they changed throughout the decade studied. Regarding primary care services, the period starts (2006-07) with no global evidence of horizontal inequity in access (although the analysis by continent shows inequity that is detrimental to Eastern Europeans and Asians), giving way to inequity favouring economic immigrants (particularly Latin Americans and Africans) in 2011-12 and 2016-17. An opposite trend happens with specialist care, as the period starts (2006-07) with evidence of inequity that is detrimental to economic immigrants (particularly those from North of Africa) but this inequity disappears with the economic crisis and after it (with the only exception of Eastern Europeans in 2011-12, whose probability to visit a specialist is lower than for natives). Regarding emergency care, our evidence indicates horizontal inequity in access that favours economic immigrants (particularly Latin Americans and North Africans) that remains throughout the period. In general, there is no inequity in hospitalisations, with the exception of 2011-12, where inequity in favour of economic immigrants (particularly those from Latin America) takes place. CONCLUSIONS: The results obtained here may serve, firstly, to prevent alarm about negative discrimination of economic immigrants in their access to public health services, even after the implementation of the Royal Decree RD Law 16/2012. Conversely, our results suggest that the horizontal inequity in access to specialist care that was found to be detrimental to economic immigrants in 2006-07, disappeared in global terms in 2011-12 and also by continent of origin in 2016-17.

Dying at home for terminal cancer patients: differences by level of education and municipality of residence in Spain / Morir en casa pacientes terminales con cáncer: diferencias por nivel de educación y municipio de residencia en España

Objective: To measure and assess differences by educational level in the place of death for cancer patients, and to determine whether patterns of geographical disparities are associated with access to palliative care services in the municipality of residence. Method: We analysed the death certificates of adults (older than 24) who died of cancer (ICD-10 C00 to C97) in Spain during 2015, either at home, in hospital or in a long-term care centre. Of the 105,758 individuals included in the study population, 75.2% lived in one of the 746 identifiable municipalities (more than 10,000 inhabitants). This individual database was combined with three economic databases at municipal level and with a directory of palliative care resources published by the Sociedad Española de Cuidados Paliativos. Multilevel models were estimated to predict the place of death according to individual characteristics. Generalised least squares regression models were then applied to the municipal effects estimated in the first stage. Results: The probability of dying in long-term care centre decreases as levels of education increase; the probability of dying at home, rather than in hospital, is higher for patients with higher education. Dying in hospital is an urban phenomenon. There are large differences between Spanish regions. Access to palliative services is only of marginal significance in accounting for the systematic differences observed between municipalities. Conclusions: Developing specific plans for palliative care, with an active role being played by primary care teams, may help improve end-of-life care in Spain

Objetivo: Medir y evaluar las diferencias por nivel educativo respecto al lugar de muerte de pacientes con cáncer en España, y determinar si los patrones de desigualdad geográfica están asociados con el acceso a servicios de cuidados paliativos en el municipio de residencia. Método: Analizamos los certificados de defunción de mayores de 24 años que murieron de cáncer (CIE-10 C00-C97) en España durante 2015, en el hogar, en el hospital o en una residencia sociosanitaria. Sobre una población total de 105.758 personas, el 75,2% vivía en uno de los 746 municipios identificables (más de 10.000 habitantes). La base de datos individual se combina con datos económicos de ámbito municipal y con el directorio de recursos de cuidados paliativos publicado por la Sociedad Española de Cuidados Paliativos. Se estiman modelos multinivel para predecir el lugar de la muerte de acuerdo con las características individuales. A continuación, se estiman modelos de regresión por mínimos cuadrados generalizados sobre los efectos municipales estimados en el modelo anterior. Resultados: La probabilidad de morir en casa, frente al hospital, es mayor en los pacientes con educación superior. Morir en el hospital resulta un fenómeno urbano. Hay grandes diferencias entre regiones. El acceso a los servicios paliativos solo tiene una importancia marginal en la explicación de las diferencias entre municipios. Conclusión: El desarrollo de planes específicos para cuidados paliativos, con un papel más activo de los equipos de atención primaria, puede ayudar a mejorar la atención sanitaria al final de la vida en España

Differences in healthcare utilisation between users and non-users of homeopathic products in Spain: Results from three waves of the National Health Survey (2011-2017).

OBJECTIVE: To compare the differences in the use of healthcare services: visits to the doctor and hospitalisation, performance of routine tests, and preventive influenza vaccination, between users and non-users of homeopathic products. METHODS: We used the microdata for adults over 15 years old from three waves of the Spanish National Health Survey, corresponding to the years 2011, 2014 and 2017. We proposed a comparative design of a quasi-experimental type, considering as the treatment group the respondents who said that they had used homeopathic products in the past two weeks; and another group, for control, comprising respondents who said that they had not used this type of products, but only conventional medicines, with observable characteristics similar to those of the treatment group. We used a model for rare events logistics regression (relogit) to estimate the probability of using homeopathy. From the propensity score and a vector of control variables, we used techniques of genetic matching to match individuals from the treatment group with similar individuals belonging to the control group. RESULTS: There are no statistically significant differences between users and non-users of homeopathy in visits to the general practitioner (P>|z| 0.387), to the specialist (P>|z| 0.52), in hospitalisations (P>|z| 0.592) or in the use of emergency services (P>|z| 0.109). Nor were there any statistically significant differences in the performance of routine tests, except for the faecal occult blood test, which is more prevalent in users of homeopathic products. 20.9% of users of homeopathy had done this test compared with 15.3% of non-users (P>|z| 0.022). There are also significant differences in vaccination against influenza with 12.6% of homeopathy users stating that they had been vaccinated in the last influenza campaign, against 21.0% of non-users (P>|z| <0.001). The health conditions which homeopathy users reported were constipation (OR: 1.65 CI: 1.16-2.36), malignant tumour (OR: 1.60 CI: 1.09-2.36) osteoporosis (OR: 1.49 CI: 1.05-2.10), varicose veins (OR: 1.35 CI: 1.05-1.74) and allergy (OR: 1.35 CI: 1.06-1.72). CONCLUSIONS: Differences in the use of healthcare resources between users and non-users of homeopathic products have not been found to be statistically significant in Spain. It has been shown that most homeopathic products are used as a complement to treatment with conventional medicine. Nevertheless, our results highlight some warning signs which should raise the attention of healthcare authorities. The use of these therapies in patients with malignant tumours and the rejection of vaccines are warning signs of a possible health hazard in the long term.

Impact of the Spanish smoke-free laws on cigarette sales, 2000-2015: partial bans on smoking in public places failed and only a total tobacco ban worked.

In January 2006, the Spanish government enacted a tobacco control law that banned smoking in bars and restaurants, with exceptions depending on the floor space of the premises. In January 2011, further legislation in this area was adopted, removing these exceptions. We analyse the effect produced on cigarette sales by these two bans. We approach this problem using an interrupted time series analysis while accounting for the potential effects of autocorrelation and seasonality. The data source used was the official data on legal sales of tobacco in Spain, from January 2000 to December 2015 (excluding the Canary Islands and the autonomous cities of Ceuta and Melilla). As confounder variables, we use the log-transformed average prices for manufactured and hand-rolled cigarettes (or the average minimum excise tax as a proxy), and log-transformed real-household disposable income. The implementation of a total smoke-free ban in Spain was associated with an immediate reduction in cigarette sales between 9% to 11%. In contrast, in the period immediately following the partial ban, no such reduction was detected, beyond the trend already present. Our results indicate that, in Spain, partial bans on smoking in public places failed, and that only a total tobacco ban worked.

Dying at home for terminal cancer patients: differences by level of education and municipality of residence in Spain.

OBJECTIVE: To measure and assess differences by educational level in the place of death for cancer patients, and to determine whether patterns of geographical disparities are associated with access to palliative care services in the municipality of residence. METHOD: We analysed the death certificates of adults (older than 24) who died of cancer (ICD-10 C00 to C97) in Spain during 2015, either at home, in hospital or in a long-term care centre. Of the 105,758 individuals included in the study population, 75.2% lived in one of the 746 identifiable municipalities (more than 10,000 inhabitants). This individual database was combined with three economic databases at municipal level and with a directory of palliative care resources published by the Sociedad Española de Cuidados Paliativos. Multilevel models were estimated to predict the place of death according to individual characteristics. Generalised least squares regression models were then applied to the municipal effects estimated in the first stage. RESULTS: The probability of dying in long-term care centre decreases as levels of education increase; the probability of dying at home, rather than in hospital, is higher for patients with higher education. Dying in hospital is an urban phenomenon. There are large differences between Spanish regions. Access to palliative services is only of marginal significance in accounting for the systematic differences observed between municipalities. CONCLUSIONS: Developing specific plans for palliative care, with an active role being played by primary care teams, may help improve end-of-life care in Spain.

Pinocchio testing in the forensic analysis of waiting lists: using public waiting list data from Finland and Spain for testing Newcomb-Benford's Law.

OBJECTIVE: Newcomb-Benford's Law (NBL) proposes a regular distribution for first digits, second digits and digit combinations applicable to many different naturally occurring sources of data. Testing deviations from NBL is used in many datasets as a screening tool for identifying data trustworthiness problems. This study aims to compare public available waiting lists (WL) data from Finland and Spain for testing NBL as an instrument to flag up potential manipulation in WLs. DESIGN: Analysis of the frequency of Finnish and Spanish WLs first digits to determine if their distribution is similar to the pattern documented by NBL. Deviations from the expected first digit frequency were analysed using Pearson's χ2, mean absolute deviation and Kuiper tests. SETTING/PARTICIPANTS: Publicly available WL data from Finland and Spain, two countries with universal health insurance and National Health Systems but characterised by different levels of transparency and good governance standards. MAIN OUTCOME MEASURES: Adjustment of the observed distribution of the numbers reported in Finnish and Spanish WL data to the expected distribution according to NBL. RESULTS: WL data reported by the Finnish health system fits first digit NBL according to all statistical tests used (p=0.6519 in χ2 test). For Spanish data, this hypothesis was rejected in all tests (p<0.0001 in χ2 test). CONCLUSIONS: Testing deviations from NBL distribution can be a useful tool to identify problems with WL data trustworthiness and signalling the need for further testing.

The effect of policies regulating tobacco consumption on smoking initiation and cessation in Spain: is it equal across socioeconomic groups?

BACKGROUND: In Spain, the Law 28/2005, which came into effect on January 2006, was a turning point in smoking regulation and prevention, serving as a guarantee for the progress of future strategies in the direction marked by international organizations. It is expected that this regulatory policy should benefit relatively more to lower socioeconomic groups, thus contributing to a reduction in socioeconomic health inequalities. This research analyzes the effect of tobacco regulation in Spain, under Law 28/2005, on the initiation and cessation of tobacco consumption, and whether this effect has been unequal across distinct socioeconomic levels. METHODS: Micro-data from the National Health Survey in its 2006 and 2011 editions are used (study numbers: 4382 and 5389 respectively; inventory of statistical operations (ISO) code: 54009), with a sample size of approximately 24,000 households divided into 2,000 census areas. This allows individuals' tobacco consumption records to be reconstructed over five years before the initiation of each survey, as well as identifying those individuals that started or stopped smoking. The methodology is based on "time to event analysis". Cox's proportional hazard models are adapted to show the effects of a set of explanatory variables on the conditional probability of change in tobacco consumption: initiation as a daily smoker by young people or the cessation of daily smoking by adults. RESULTS: Initiation rates among young people went from 25% (95% confidence interval (CI), 23-27) to 19% (95% CI, 17-21) following the implementation of the Law, and the change in cessation rates among smokers was even greater, with rates increasing from 12% (95% CI, 11-13) to 20% (95% CI, 19-21). However, this effect has not been equal by socioeconomic groups as shown by relative risks. Before the regulation policy, social class was not a statistically significant factor in the initiation of daily smoking (p > 0.05); however, following the implementation of the Law, young people belonging to social classes IV-V and VI had a relative risk of starting smoking 63% (p = 0.03) and 82% (p = 0.02) higher than young people of higher social classes I-II. On the other hand, lower social class also means a lower probability of smoking cessation; however, the relative risk of cessation for a smoker belonging to a household of social class VI (compared to classes I-II) went from 24% (p < 0.001) lower before the Law to 33% (p < 0.001) lower following the law's implementation. CONCLUSION: Law 28/2005 has been effective, as after its promulgation there has been a decrease in the rate of smoking initiation among young people and an increase in the rate of cessation among adult smokers. However, this effect has not been equal by socioeconomic groups, favoring relatively more to those individuals belonging to higher social classes.

Estimating direct effects of parental occupation on Spaniards' health by birth cohort.

BACKGROUND: Social health inequalities in adult population are partly due to socioeconomic circumstances in childhood. A better understanding of how those circumstances affect health during adulthood may improve the opportunities for reducing health disparities. The objective of this study is to investigate the effect of parental socioeconomic status, which is proxied by occupation, on adult Spaniards' health by birth cohort. The analysis will allow checking not only the direct impact of parental occupation on their offspring's health, but also whether inherited inequality has been reduced over time. METHODS: We use data from the Bank of Spain's Survey of Household Finances on Spanish households from 2002 to 2008. Sequential models were used to estimate the influence of the father's and mother's occupation on their offspring's health, trying to disentangle direct from indirect effects. With a sample of 26,832 persons we consider effects for four different cohorts by birth periods ranging from 1916 to 1981. RESULTS: The results show that parental occupation has a significant direct impact on individuals' health (p < 0.01). The effect of father's occupation exceeds that of mother's. For those born before 1936, the probability of reporting a good health status ranges from 0.31 (95% confidence interval (CI) 0.14-0.48), when fathers were classified as unskilled elementary workers, to 0.98 (95% CI 0.98-0.99) when they were managers or mid-level professionals. For those born during the period 1959-1975, those probabilities are 0.49 (95% CI 0.39-0.59) and 0.97 (95% CI 0.96-0.98), respectively. Therefore, health inequalities linked to parental socioeconomic status have been noticeably reduced, although discrimination against unskilled workers persists over time. CONCLUSIONS: Great progress has been made in the health area during the twentieth century, so that the impact of parental socioeconomic status on individuals' health has been significantly tempered for those at the bottom of the social scale. However, more efforts focused on the improvement of living conditions for most socioeconomically disadvantaged are needed in order to further reduce social inequalities in health.

Tax on sugar sweetened beverages in Spain. / El impuesto sobre bebidas azucaradas en España.

This article provides a critical review about the challenges that taxes on sugary drinks as an instrument of health policy must face to reverse the trend of the current epidemics of obesity. We analyzed the experiences of the leading countries, particularly Mexico, and reflect on the counterweight exerted by the industry against obesity policies, and on the power of lobbyists. Those tax policies for public health have to overcome the enormous strength of the industry, which is exerted in several-science and research, brand reputation, influence on regulators-levels. We suggest that a specific tax on sugary drinks has enough potential to reduce noncommunicable diseases and risk -diabetes, Hypertriglyceridemia, hyperholesterolemia LDL, hypertension- via reduced consumption thanks to the high price elasticity of those drinks. Furthermore, the effects are amplified even in the medium term, once established new habits to healthier eating. These taxes could encourage business innovation without inflicting costs of lost jobs and contribute to reducing the social gradient in obesity.

El impuesto sobre bebidas azucaradas en España / Tax on sugar sweetned beverages in Spain

Este artículo aporta una revisión crítica acerca de los retos a los que se enfrentan los impuestos sobre las bebidas azucaradas como instrumento de políticas de salud, para revertir la tendencia epidémica de la obesidad. Se valoran las experiencias de los países más significados, en particular México, y se reflexiona sobre el contrapeso que ejerce la industria a las políticas antiobesidad y el poder de los lobbies. Esas políticas impositivas en pro de la salud pública han de sobreponerse a la enorme fuerza de la industria, que es ejercida en varios niveles-ciencia e investigación, reputación de marca, influencia en reguladores-. Se sugiere que un impuesto específico sobre bebidas azucaradas tiene bastante potencial para reducir enfermedades no transmisibles y riesgos -diabetes mellitus, hipertrigliceridemia, lipoproteínas de baja densidad, hipetensión diastólica-, a través de la reducción del consumo, al ser alta la elasticidad del precio de estas bebidas. Además, los efectos incluso se amplifican a medio plazo, una vez establecidos nuevos hábitos de consumo más saludable. Los impuestos podrían fomentar la innovación empresarial sin infligir costes de pérdida de empleos y contribuirían a reducir el gradiente social de la obesidad (AU)

This article provides a critical review about the challenges that taxes on sugary drinks as an instrument of health policy must face to reverse the trend of the current epidemics of obesity. We analyzed the experiences of the leading countries, particularly Mexico, and reflect on the counterweight exerted by the industry against obesity policies, and on the power of lobbyists. Those tax policies for public health have to overcome the enormous strength of the industry, which is exerted in several-science and research, brand reputation, influence on regulators-levels. We suggest that a specific tax on sugary drinks has enough potential to reduce noncommunicable diseases and risk -diabetes mellitus, hypertriglyceridemia, lipoproteins, LDL, blood pressure- via reduced consumption thanks to the high price elasticity of those drinks. Furthermore, the effects are amplified even in the medium term, once established new habits to healthier eating. These taxes could encourage business innovation without inflicting costs of lost jobs and contribute to reducing the social gradient in obesity (AU)

The importance of leadership and management skills in dental practices to attract and retain patients in periods of economic recession / La importancia de la gestión directiva y liderazgo en la práctica de la odontología para atraer y conservar pacientes en periodos de recesión económica

To test the hypothesis that leadership and management skills protect dental practices against the effects of an economic recession. Methods: This was a cross-sectional exploratory study. Dentists (n= 232)were randomly selected to participate in an online survey in which they were asked about their practice activity. Results: A total of 162 questionnaires were returned (response rate 70 percent). Results indicated that improved leadership and management skills are positively related to the probability that a practice remained stable or increased its productivity during the economic recession: OR=2.39 (95 percent CI; 1.08-5.3). Conclusions: Our findings suggest that dental practices applying leadership and management skills are related to attract and retain patients, as measured by increased numbers of both initial consultations and continued patronage (return visits); and keep the economic crisis’ impact on revenue manageable...

Contrastar la hipótesis de que las habilidades en liderazgo y gestión directiva de los odontólogosproporcionan una ventaja comparativa en el manejo de la actividad profesional en periodos de recesión económica. Material y método: Estudio exploratorio de corte transversal. Utilizamos los datos procedentes de una encuesta sobre actividad en el consultorio realizada a 232 odontólogos seleccionados aleatoriamente. Resultados: Se obtuvieron un total de 162 cuestionarios válidos (tasa derespuesta del 70 por ciento). Los resultados sugieren que la mejorade las habilidades de liderazgo y de gestión se relacionan positivamente con la probabilidad de aumentar o mantenerestable la facturación del consultorio en tiempos de recesión económica: OR=2.39 (IC del 95 por ciento, 1.08-5.3). Conclusiones: Nuestros resultados sugieren que las habilidadesde liderazgo y gestión aplicadas a la práctica de la odontología están relacionadas con la capacidad de atraernuevos pacientes y conservar los actuales, en términos tanto del número de primeras visitas como del retorno depacientes; lo que permite atenuar el impacto de la crisis sobre la facturación del consultorio...