Association between antibiotic resistance in intensive care unit (ICU)-acquired infections and excess resource utilization: Evidence from Spain, Italy, and Portugal.

BACKGROUND: Intensive care unit (ICU)-acquired infections with antibiotic-resistant bacteria have been associated with substantial health and economic costs. Moreover, southern Europe has historically reported high levels of antimicrobial resistance. OBJECTIVES: We estimated the attributable economic burden of ICU-acquired infections due to resistant bacteria based upon hospital excess length of stay (LOS) in a selected sample of southern European countries. METHODS: We studied a cohort of adult patients admitted to the ICU who developed an ICU-acquired infection related to an invasive procedure in a sample of Spanish, Italian, and Portuguese hospitals between 2008 and 2016, using data from The European Surveillance System (TESSy) released by the European Centers for Disease Control (ECDC). We analyzed the association between infections with selected antibiotic-resistant bacteria of public health importance and excess LOS using regression, matching, and time-to-event methods. We controlled for several confounding factors as well as time-dependent biases. We also computed the associated economic burden of excess resource utilization for each selected country. RESULTS: In total, 13,441 patients with at least 1 ICU-acquired infection were included in the analysis: 4,106 patients (30.5%) were infected with antimicrobial-resistant bacteria, whereas 9,335 patients (69.5%) were infected with susceptible bacteria. The unadjusted association between resistance status and excess LOS was 7 days (95% CI, 6.13-7.87; P < .001). Fully adjusted models yielded significantly lower estimates: 2.76 days (95% CI, 1.98-3.54; P < .001) in the regression model, 2.60 days (95% CI, 1.66-3.55; P < .001) in the genetic matching model, and a hazard ratio of 1.15 (95% CI, 1.11-1.19; P < .001) in the adjusted Cox regression model. These estimates, alongside the prevalence of resistance, translated into direct hospitalization attributable costs per ICU-acquired infection of 5,224€ (95% CI, 3,691-6,757) for Spain, 4,461€ (95% CI, 1,948-6,974) for Portugal, and 4,320€ (95% CI, 1,662-6,977) for Italy. CONCLUSIONS: ICU-acquired infections associated with antibiotic-resistant bacteria are substantially associated with a 15% increase in excess LOS and resource utilization in 3 southern European countries. However, failure to appropriately control for significant confounders inflates estimates by ∼2.5-fold.

Caesarean section trends in Catalonia between 2013 and 2017 based on the Robson classification system: A cross-sectional study.

INTRODUCTION: In Catalonia caesarean rates have always been analysed as a single percentage. The objective is to estimate caesarean section rates using the Robson classification in publicly funded hospitals in Catalonia between 2013 and 2017, considering sociodemographic, institutional and obstetric characteristics. MATERIALS AND METHODS: Cross-sectional population-based study in Catalonia including all women delivering within publicly funded hospitals between 2013-2017 (n = 210 020). The modified Robson classification distribution was estimated, the caesarean rate and the overall contribution, analysed for each year, and by confounders, through logistic regression models. RESULTS: CS rates decreased steadily between 2013 and 2017 in Catalonia within publicly funded hospitals from 24.3% to 22.8% (cOR 0.92, 95% CI; 0.89 to 0.95). Once adjusted for changes in sociodemographic, institutional and obstetric characteristics the observed decline was even more pronounced (aOR 0.87, 95% CI; 0.84 to 0.90). Within the different groups of Robson once adjusted for confounders, groups 1+2 (aOR 0.88, 95% CI; 0.83 to 0.93), 3+4 (aOR 0.83, 95% CI; 0.78 to 0.89) and 10 (aOR 0.78, 95% CI; 0.68 to 0.90) presented a reduction in caesarean section rates, whereas group 5 showed no significant decrease (aOR 0.95, 95% CI; 0.87 to 1.03%). CONCLUSIONS: The decrease in caesarean section rates in Catalonia is more pronounced when adjusted for known confounders, suggesting retrospective overutilization of caesarean section and percentages of (in)adequacy in the past. In any case, it remains above the recommended by experts. Further efforts should be made to achieve optimum rates, including improvement on obstetric data collection.

¿Qué es una intervención sanitaria eficiente en España en 2020? / What is an efficient health intervention in Spain in 2020?

Hace más de 15 años que en Gaceta Sanitaria se publicó el artículo titulado «¿Qué es una tecnología sanitaria eficiente en España?». El creciente interés por fijar el precio de las nuevas tecnologías en función del valor que estas proporcionan a los sistemas de salud y la experiencia acumulada por los países de nuestro entorno hacen oportuno revisar qué es una intervención sanitaria eficiente en España en el año 2020. El análisis de coste-efectividad sigue siendo el método de referencia para maximizar los resultados en salud de la sociedad con los recursos disponibles. La interpretación de sus resultados requiere establecer unos valores de referencia que sirvan de guía sobre lo que constituye un valor razonable para el sistema sanitario. Los umbrales de eficiencia deben ser flexibles y dinámicos, y actualizarse periódicamente. Su aplicación debe estar basada en la gradualidad y la transparencia, considerando, además, otros factores que reflejen las preferencias sociales. Aunque la fijación de los umbrales corresponde a los decisores políticos, en España puede ser razonable utilizar unos valores de referencia como punto de partida que podrían estar comprendidos entre los 25.000 y los 60.000 euros por año de vida ajustado por calidad. No obstante, en la actualidad, más que la determinación de las cifras exactas de dicho umbral, la cuestión clave es si el Sistema Nacional de Salud está preparado y dispuesto a implantar un modelo de pago basado en el valor, que contribuya a lograr la gradualidad en las decisiones de financiación y, sobre todo, a mejorar la previsibilidad, la consistencia y la transparencia del proceso

Fifteen years ago, Gaceta Sanitaria published the article entitled "What is an efficient health technology in Spain?" The growing interest in setting the price of new technologies based on the value they provide to health systems and the experience accumulated by the countries in our environment make it opportune to review what constitutes an efficient health intervention in Spain in 2020. Cost-effectiveness analysis continues to be the reference method to maximize social health outcomes with the available resources. The interpretation of its results requires establishing reference values that serve as a guide on what constitutes a reasonable value for the health care system. Efficiency thresholds must be flexible and dynamic, and they need to be updated periodically. Its application should be based on and transparency, and consider other factors that reflect social preferences. Although setting thresholds is down to political decision-makers, in Spain it could be reasonable to use thresholds of 25,000 and 60,000 Euros per QALY. However, currently, in addition to determining exact figures for the threshold, the key question is whether the Spanish National Health System is able and willing to implement a payment model based on value, towards achieving gradual financing decisions and, above all, to improve the predictability, consistency and transparency of the process

Impact of multi-drug resistant bacteria on economic and clinical outcomes of healthcare-associated infections in adults: Systematic review and meta-analysis.

BACKGROUND: Infections with multidrug resistant (MDR) bacteria in hospital settings have substantial implications in terms of clinical and economic outcomes. However, due to clinical and methodological heterogeneity, estimates about the attributable economic and clinical effects of healthcare-associated infections (HAI) due to MDR microorganisms (MDR HAI) remain unclear. The objective was to review and synthesize the evidence on the impact of MDR HAI in adults on hospital costs, length of stay, and mortality at discharge. METHODS AND FINDINGS: Literature searches were conducted in PubMed/MEDLINE, and Google Scholar databases to select studies that evaluated the impact of MDR HAI on economic and clinical outcomes. Eligible studies were conducted in adults, in order to ensure homogeneity of populations, used propensity score matched cohorts or included explicit confounding control, and had confirmed antibiotic susceptibility testing. Risk of bias was evaluated, and effects were measured with ratios of means (ROM) for cost and length of stay, and risk ratios (RR) for mortality. A systematic search was performed on 14th March 2019, re-run on the 10th of June 2019 and extended the 3rd of September 2019. Small effect sizes were assessed by examination of funnel plots. Sixteen articles (6,122 patients with MDR HAI and 8,326 patients with non-MDR HAI) were included in the systematic review of which 12 articles assessed cost, 19 articles length of stay, and 14 mortality. Compared to susceptible infections, MDR HAI were associated with increased cost (ROM 1.33, 95%CI [1.15; 1.54]), prolonged length of stay (ROM 1.27, 95%CI [1.18; 1.37]), and excess in-hospital mortality (RR 1.61, 95%CI [1.36; 1.90]) in the random effects models. Risk of publication bias was only found to be significant for mortality, and overall study quality good. CONCLUSIONS: MDR HAI appears to be strongly associated with increases in direct cost, prolonged length of stay and increased mortality. However, further comprehensive studies in this setting are warranted. TRIAL REGISTRATION: PROSPERO (CRD42019126288).

Price Models for Multi-indication Drugs: A Systematic Review.

BACKGROUND: Marketing of new and existing drugs with new indications used alone or in combination is increasing. OBJECTIVE: To identify the advantages and disadvantages of indication-based pricing (IBP) systems for such drugs from the standpoint of economic theory, practical applications and international experiences. METHODS: We conducted a systematic review of published articles and reports using six bibliographic databases: PubMed, ASCO, Scopus, DARE, HTA and NHS EED. We also conducted a search of gray literature in Google Scholar. The same search terms were used as in Towse et al. (The debate on indication-based pricing in the U.S. and five major European countries. OHE Consulting Report, London, 2018). Articles and reports published from 1 January 2000 to 30 September 2018 were included. RESULTS: A total of 26 studies met the inclusion criteria. There are three main types of IBP: different brands with different prices for each indication, an averaged single price for all indications and a single price with differential discounts. The studies indicate that IBP systems are premised on the idea that charging a different price for different indications reflects the differences in their value and in social willingness to pay for each one and for the investment in R&D based on the indication's incremental clinical benefit. Some argue that a uniform price reduces access and increases the price for lower-value indications, while others contend that if IBP sets prices at the maximum threshold of social willingness to pay for each indication, all surplus is transferred to the producer and consumer surplus is reduced to zero. No practical applications of pure IBP were found. Single pricing for drugs is the most prevalent approach. The system that most closely approximates an IBP model consists of agreements that are generally confidential and linked to risk-sharing agreements. CONCLUSIONS: There are no applications of pure IBP systems and their practical consequences are therefore unknown. More economic theory-based assessments of the pros and cons of IBP and studies different from reviews are needed to capture their intricacies and specificities.

[What is an efficient health intervention in Spain in 2020?] / ¿Qué es una intervención sanitaria eficiente en España en 2020?

Fifteen years ago, Gaceta Sanitaria published the article entitled "What is an efficient health technology in Spain?" The growing interest in setting the price of new technologies based on the value they provide to health systems and the experience accumulated by the countries in our environment make it opportune to review what constitutes an efficient health intervention in Spain in 2020. Cost-effectiveness analysis continues to be the reference method to maximize social health outcomes with the available resources. The interpretation of its results requires establishing reference values that serve as a guide on what constitutes a reasonable value for the health care system. Efficiency thresholds must be flexible and dynamic, and they need to be updated periodically. Its application should be based on and transparency, and consider other factors that reflect social preferences. Although setting thresholds is down to political decision-makers, in Spain it could be reasonable to use thresholds of 25,000 and 60,000 Euros per QALY. However, currently, in addition to determining exact figures for the threshold, the key question is whether the Spanish National Health System is able and willing to implement a payment model based on value, towards achieving gradual financing decisions and, above all, to improve the predictability, consistency and transparency of the process.

A multifaceted model for improving the appropriateness of indications for cesarean delivery / Un modelo multifacético para mejorar la adecuación de las indicaciones de cesárea

Background: We evaluated the effectiveness of a multifaceted strategy to improve the appropriateness of the indications for cesarean delivery in 41 hospitals belonging to the Spanish National Health Service. Methods: We implemented indications for emergency and elective cesareans and analyzed their appropriateness prospectively. We provided staff with feedback and training courses and allocated the necessary resources. The results were published. A pre-post design without a control group was used. Results: The total number of deliveries in both periods was 23,711 and 29,627; of these, 5,380 and 6,371, respectively, were cesarean deliveries. The general cesarean rate decreased by 1.19 percentage points, and the overall appropriateness rate increased by 15.45% (95%CI, 13.78-17.13): 8.65% (95%CI, 6.24-11.07) for elective cesarean and 20.15% (95%CI, 17.93-22.36) for emergency cesareans. Appropriateness improved across all 5 indications for emergency cesarean, ranging from 10.87% (95%CI, 6.85-14.89) for fetal distress to 29.97% (95%CI, 24.49-35.45) for cephalopelvic disproportion. Conclusion: This strategy appears to be effective for increasing the appropriateness of the indications for cesarean delivery and reducing the complications and costs associated with the cesarean deliveries avoided

Objetivo: evaluar la efectividad de una estrategia dirigida a mejorar la adecuación de las indicaciones de cesáreas en 41 hospitales del Sistema Nacional de Salud. Métodos: implantación de un protocolo de las indicaciones de cesáreas urgentes y programadas, el análisis prospectivo de su adecuación, retroalimentar a los profesionales, impartir cursos de formación, asignar recursos necesarios y difundir los resultados. Se utilizó un diseño pre-post sin grupo control. Resultados: el número de partos en los periodos pre y post fue 23.711 y 29.627, y el de cesáreas, 5.380 y 6.371, respectivamente. El porcentaje global de cesáreas descendió 1,19, y el de adecuación global aumentó 15,45 (IC 95%: 13,78-17,13); 8,65 (IC 95%: 6,24-11,07) en el conjunto de programadas y, 20,15 (IC 95%:17,93-22,36) en el conjunto de las urgentes. La mejora en la adecuación se observó en las cinco indicaciones de cesáreas urgentes y osciló entre 10,87 (IC 95%: 6,85-14,89) en el grupo de riesgo de pérdida de bienestar fetal y 29,97 (IC 95%: 24,49-35,45) en el de desproporción pelvifetal. Conclusión: esta estrategia parece ser efectiva para aumentar la adecuación de las indicaciones de cesáreas y reducir las complicaciones y los costes asociados con las cesáreas evitadas

La decisión clínica: clave de los resultados de los servicios de salud en cualquier país / The clinical decision: a clue to health services outcomes everywhere

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Profesionales, organizaciones y sistema sanitario: haciendo individualmente atractivo lo socialmente conveniente / Health professionals, organizations and the health system: making what is socially advisable individually attractive

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It's about time: Cesarean sections and neonatal health.

Cesarean sections have been associated in the literature with poorer newborn health, particularly with a higher incidence of respiratory morbidity. Most studies suffer, however, from potential omitted variable bias, as they are based on simple comparisons of mothers who give birth vaginally and those who give birth by cesarean section. We try to overcome this limitation and provide credible causal evidence by using variation in the probability of having a c-section that is arguably unrelated to maternal and fetal characteristics: variation by time of day. Previous literature documents that, while nature distributes births and associated problems uniformly, time-dependent variables related to physicians' demand for leisure are significant predictors of unplanned c-sections. Using a sample of public hospitals in Spain, we show that the rate of c-sections is higher during the early hours of the night compared to the rest of the day, while mothers giving birth at the different times are similar in observable characteristics. This exogenous variation provides us with a new instrument for type of birth: time of delivery. Our results suggest that non-medically indicated c-sections have a negative and significant impact on newborn health, as measured by Apgar scores, but that the effect is not severe enough to translate into more extreme outcomes.

Predictive modeling of emergency cesarean delivery.

OBJECTIVE: To increase discriminatory accuracy (DA) for emergency cesarean sections (ECSs). STUDY DESIGN: We prospectively collected data on and studied all 6,157 births occurring in 2014 at four public hospitals located in three different autonomous communities of Spain. To identify risk factors (RFs) for ECS, we used likelihood ratios and logistic regression, fitted a classification tree (CTREE), and analyzed a random forest model (RFM). We used the areas under the receiver-operating-characteristic (ROC) curves (AUCs) to assess their DA. RESULTS: The magnitude of the LR+ for all putative individual RFs and ORs in the logistic regression models was low to moderate. Except for parity, all putative RFs were positively associated with ECS, including hospital fixed-effects and night-shift delivery. The DA of all logistic models ranged from 0.74 to 0.81. The most relevant RFs (pH, induction, and previous C-section) in the CTREEs showed the highest ORs in the logistic models. The DA of the RFM and its most relevant interaction terms was even higher (AUC = 0.94; 95% CI: 0.93-0.95). CONCLUSION: Putative fetal, maternal, and contextual RFs alone fail to achieve reasonable DA for ECS. It is the combination of these RFs and the interactions between them at each hospital that make it possible to improve the DA for the type of delivery and tailor interventions through prediction to improve the appropriateness of ECS indications.

Documento del grupo de trabajo SESPAS-OMC sobre iatrogenia / No disponible

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Consumo de fármacos teratogénicos en gestantes en atención primaria / Consumption of teratogenic drugs in pregnant women in the primary care clinic

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La prevención y el control de la iatrogenia requieren varios frentes y alianzas. SESPAS llama a la colaboración / The prevention and control of iatrogenesis require various fronts and alliances. The Spanish Society for Public Health and Health Administration (SESPAS) calls for collaboration

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