La Agencia Estatal de Salud Pública: una oportunidad para el sistema de Salud Pública en España / Future National Public Health Agency: an opportunity for the public health system in Spain

La creación de un centro estatal de salud pública, con una dotación adecuada de recursos, permitirá afrontar los desafíos de la salud pública del presente y del futuro en España. Para ello, las funciones de esta futura institución, que se propone como Agencia Estatal, deben abordar, además de las necesidades habituales de organización de la salud pública, la conexión de estas con los Objetivos de Desarrollo Sostenible, coordinando una estrategia estatal que integre distintos actores de salud en una red generosa y cooperativa, y desarrollando una estrategia de comunicación en salud pública innovadora, referente y priorizada, entre otros aspectos. La falta de recursos, la relativa desconexión actual de las funciones esenciales de salud pública en el ámbito estatal y la inequidad en el desarrollo autonómico y municipal de estas propician el desarrollo del proyecto de la Agencia como una red de redes, tal como se defiende en este trabajo. Aportamos ideas para un proceso que confiamos en que será decisivo para la salud pública española del siglo XXI. (AU)

The creation of a national centre for public health, with adequate resources, will make it possible to face the public health challenges of the present and the future in our country. To this end, the proposed state agency, should hold functions based on advanced public health organizational schemes, while linking with the sustainable development goals. The coordination of a national public health strategy built on a collaborative network of networks would also be essential, as developing an innovative, benchmarked and prioritised public health communication strategy, among other tasks. The lack of resources, the current relative disconnection of essential public health functions at the state level, and the inequity in their development of these functions at the regional and municipal levels, favour the development of the agency project as a network of networks. In this paper we give ideas for a process that seems decisive for Spanish public health in the 21st century. (AU)

[Future National Public Health Agency: an opportunity for the public health system in Spain]. / La Agencia Estatal de Salud Pública: una oportunidad para el sistema de Salud Pública en España.

The creation of a national centre for public health, with adequate resources, will make it possible to face the public health challenges of the present and the future in our country. To this end, the proposed state agency, should hold functions based on advanced public health organizational schemes, while linking with the sustainable development goals. The coordination of a national public health strategy built on a collaborative network of networks would also be essential, as developing an innovative, benchmarked and prioritised public health communication strategy, among other tasks. The lack of resources, the current relative disconnection of essential public health functions at the state level, and the inequity in their development of these functions at the regional and municipal levels, favour the development of the agency project as a network of networks. In this paper we give ideas for a process that seems decisive for Spanish public health in the 21st century.

Postlaunch evidence-generation studies for medical devices in Spain: the RedETS approach to integrate real-world evidence into decision making.

The Monitoring Studies (MS) program, the approach developed by RedETS to generate postlaunch real-world evidence (RWE), is intended to complement and enhance the conventional health technology assessment process to support health policy decision making in Spain, besides informing other interested stakeholders, including clinicians and patients. The MS program is focused on specific uncertainties about the real effect, safety, costs, and routine use of new and insufficiently assessed relevant medical devices carefully selected to ensure the value of the additional research needed, by means of structured, controlled, participative, and transparent procedures. However, despite a clear political commitment and economic support from national and regional health authorities, several difficulties were identified along the development and implementation of the first wave of MS, delaying its execution and final reporting. Resolution of these difficulties at the regional and national levels and a greater collaborative impulse in the European Union, given the availability of an appropriate methodological framework already provided by EUnetHTA, might provide a faster and more efficient comparative RWE of improved quality and reliability at the national and international levels.

The Spanish Network of Agencies for Health Technology Assessment and Services of the National Health System (RedETS).

Earlier activities on health technology assessment (HTA) started in Spain around 1984, with the creation of a National Advisory Board on HTA, and the development of national and regional HTA organizations in the early 1990s. In 2012, the Spanish Health Ministry established the Spanish Network for Health Technology Assessment of the National Health System (RedETS); funded at national level and including all public HTA organizations at national and regional levels. RedETSis focused on the assessment of nondrug health technologies to inform the revision (approval and funding or disinvestment) of the Benefit Portfolio of the Spanish NHS. In parallel with European Network for Health Technology Assessment (EUnetHTA), RedETS has been setting-up and sharing common procedures and methodological guidelines to ensure effective cooperation and mutual recognition of the scientific and technical production in HTA. The output of RedETS is fifty to sixty annual reports, including the production of full HTA reports, Clinical Practice Guidelines, methodological guidance reports, relative effectiveness assessments, tools to support shared decision making between patients and healthcare professionals, and monitoring studies. The HTA assessments requested by the Regional Health Authorities are the biggest component of the annual RedETS working plan. These assessment needs are identified according to a yearly process and prioritized by a Commission composed of representatives from all Spanish regions with the aid of the PRITEC tool. The objectives of this study are to report and update the normative and organizational state of HTA in Spain; describing noteworthy advances witnessed over the past 10 years, as well as discussing existing challenges.

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.

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.

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.

Drivers of poor medical care.

The global ubiquity of overuse and underuse of health-care resources and the gravity of resulting harms necessitate an investigation of drivers to inform potential solutions. We describe the network of influences that contribute to poor care and suggest that it is driven by factors that fall into three domains: money and finance; knowledge, bias, and uncertainty; and power and human relationships. In each domain the drivers operate at the global, national, regional, and individual level, and are modulated by the specific contexts within which they act. We discuss in detail drivers of poor care in each domain.

[Health reports as the centrepiece of public health services]. / Los informes de salud como eje de los servicios de salud pública.

The main objective of health reports is to contribute to the health improvement of a specific population. They are an essential support tool for the design and planning of health policies and can also be used for accountability and evaluation. This study assesses various types of health report, including that used by the City of Barcelona (Spain), with a focus on social determinants, as well as an international health report more centred on the impact of health services. Some suggestions are proposed about the appropriateness and best use of these documents, including: the need for effective communication between technical professionals and politicians through meetings and dialogue; commitment to transparency, both authors (by means of the declaration of interests) and in terms of the information reported and with the maximum level of participation; to promote the use of a conceptual framework of social determinants of health; a focus on health inequalities; the inclusion of information relevant to policy action; the organisation of information in such a way that it allows comparison or benchmarking with similar areas and prospectively; presenting the information in an attractive way using elements such as rankings, maps or other tools; and the design of communication strategies adapted to key stakeholders.

The Spanish long-term care system in transition: Ten years since the 2006 Dependency Act.

At the end of 2006, a new System for Promotion of Personal Autonomy and Assistance for Persons in a Situation of Dependency (SAAD) was established in Spain through the approval of the Act 39/2006 of 14th December (the Dependency Act, DA). The DA acknowledged the universal entitlement of Spanish citizens to social services. The recent economic crisis added degrees of uncertainty to several dimensions of the SAAD implementation process. Firstly, the political consensus on which its foundation rested upon has weakened. Secondly, implementation of the SAAD was hampered by several challenges that emerged in the context of the economic crisis. Thirdly, the so-called "dependency limbo" (i.e. the existence of a large number of people eligible for benefits but who do not receive them) has become a structural feature of the system. Finally, contrary to the spirit of the DA, monetary benefits have become the norm rather than a last resort. High heterogeneity across regions regarding the number of beneficiaries covered and services provided reveal the existence of regional inequity in access to long-term care services in the country. Broadly, the current evidence on the state of the SAAD suggests the need to improve the quality of governance, to enhance coordination between health and social systems, to increase the system's transparency, to foster citizens' participation in decision-making and to implement a systematic monitoring of the system.

The merry-go-round of approval, pricing and reimbursement of drugs against the Hepatitis C virus infection in Spain.

Given that drug innovation has been largely away from breakthroughs, arguing that a new drug recently approved and reaching the market is downright effective, safe and affordable is actually parlous. The soaring costs of an increasing number of new drugs (specially for cancer and rare diseases) threaten to supersede societal absorbing capacity, competing with other health and outside health sector resources. Some health systems are not making headways towards solving the current conundrum of keeping path with the state of the art regulatory mechanisms in delivering cost-effective, equitable and affordable treatments. The way pricing and reimbursement decisions have been made in Spain regarding the recent wave of new drugs against the hepatitis C virus could be one case in point. This paper analyses the path of decision-making and the positioning of the relevant actors in this case, that has set a cumbersome precedent (earmarked fund) for the Spanish National Health Service. It also stresses the need for current decision-making mechanisms on approval, pricing, coverage and reimbursement in Spain to move to a transparent regulatory system, avoiding improvisation and incorporating the highest regulatory standards that other countries have in place.

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)

[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.

Socioeconomic inequality in hip replacement in four European countries from 2002 to 2009--area-level analysis of hospital data.

BACKGROUND: Cross-country comparisons of socioeconomic equity in health care typically use sample survey data on general services such as physician visits. This study uses comprehensive administrative data on a specific service: hip replacement. METHODS: We analyse 651 652 publicly funded hip replacements, excluding fractures and accidents, in adults over 35 in Denmark, England, Portugal and Spain from 2002 to 2009. Sub-national administrative areas are split into socioeconomic quintile groups comprising approximately one-fifth of the national population. Area-level Poisson regression with Huber-White standard errors is used to calculate age-sex standardised hip replacement rates by quintile group, together with gaps and ratios between richest and poorest groups (Q5 and Q1) and the middle group (Q3). RESULTS: We find pro-rich-area inequality in England (2009 Q5/Q1 ratio 1.35 [CI 1.25-1.45]) and Spain (2009 Q5/Q1 ratio 1.43 [CI 1.17-1.70]), pro-poor-area inequality in Portugal (2009 Q5/Q1 ratio 0.67 [CI 0.50-0.83]) and no significant inequality in Denmark. Pro-rich-area inequality increased over time in England and Spain but not significantly. Within-country differences between socioeconomic quintile groups are smaller than between-country differences in general population averages: hip replacement rates are substantially lower in Portugal and Spain (8.6 and 7.4 per 10 000 in 2009) than England and Denmark (20.2 and 27.8 per 10 000 in 2009). CONCLUSION: Despite limitations regarding individual-level inequality and area heterogeneity, analysis of area-level data on publicly funded hospital activity can provide useful cross-country comparisons and longitudinal monitoring of socioeconomic inequality in specific health services. Although this kind of analysis cannot provide definitive answers, it can raise important questions for decision makers.

Comparing hospital performance within and across countries: an illustrative study of coronary artery bypass graft surgery in England and Spain.

OBJECTIVE: To assess the feasibility, strengths and weaknesses of using administrative data to compare hospital performance across countries, using mortality after coronary artery bypass graft (CABG) surgery as an illustrative example. METHODS: Country specific and pooled models using individual-level data and logistic regression methods assess individual hospital performance using funnel plots accounting for multiple testing. Outcomes are adjusted for age, sex, comorbidities and indicators of patient severity. Data includes patients from all publicly funded hospitals delivering CABG surgery in England and Spain. Inpatient hospital-level standardized mortality rates within 30 days of CABG surgery are calculated for 83 999 CABG patients between 2007 and 2009. RESULTS: Unadjusted national mortality rates are 5% in Spain and 2.3% in England. Country-specific models identified similar patterns of excess mortality 'alerts' and 'alarms' in hospitals in Spain or England. Pooling data from both countries identifies larger numbers of alerts and alarms in Spanish hospitals, and risk-adjustment increased the already large national mortality difference. This was reduced but not eliminated by accounting for lower volume in Spanish hospitals. CONCLUSION: Cross-national comparisons potentially add value by providing international performance benchmarks. Hospital-level analysis across countries can illuminate differences in hospital performance, which might not be identified using country-specific data or incomplete registry data, and can test hypotheses that may explain national differences. Difficulties of making data comparable between countries, however, compound the usual within-country measurement problems.

Potentially avoidable hospitalizations in five European countries in 2009 and time trends from 2002 to 2009 based on administrative data.

INTRODUCTION: Potentially avoidable hospitalizations in chronic conditions are used to evaluate health-care performance. However, evidence comparing different countries at small geographical areas is still scarce. The aim of the present study is to describe and discuss differences in rates and time-trends across health-care areas from five European countries. METHODS: Observational, ecological study, on virtually all discharges produced in five European countries between 2002 and 2009. Potentially avoidable hospitalizations were operationally defined as a joint indicator composed of six chronic conditions. Episodes flagged as potentially avoidable were allocated to 913 geographical health-care areas. Age-sex standardized rates and standardized hospitalization ratios, as well as several statistics of variation, were estimated. RESULTS: Four hundred sixty-two thousand seven hundred and ninety-two episodes were flagged as potentially avoidable. Variation in rates across countries was notable, from 93.7 cases per 10,000 inhabitants in Denmark to 34.8 cases per 10,000 inhabitants in Portugal. Within-country variation was also noteworthy, from 3.12 times among extreme areas in Spain to a 1.46-fold difference in Denmark. The highest systematic variation was found in Denmark (empirical Bayes 0.45) and the lowest in England (empirical Bayes 0.08). Rates and systematic variation remained fairly stable over time, with Denmark and England experiencing a statistically significant decrease (20% and 10%, respectively). Income and educational level, hospital utilization propensity, and region of residence were found to be associated with avoidable admissions. CONCLUSION: The dramatic variation across countries, beyond age and sex differences, and its consistency over time, implies systemic, although differential, behaviour of the five health-care systems with regard to chronic care.

Potential of geographical variation analysis for realigning providers to value-based care. ECHO case study on lower-value indications of C-section in five European countries.

BACKGROUND: Although C-section is a highly effective procedure, literature abounds with evidence of overuse and particularly misuse, in lower-value indications such as low-risk deliveries. This study aims to quantify utilization of C-section in low-risk cases, mapping out areas showing excess-usage in each country and to estimate excess-expenditure as a proxy of the opportunity cost borne by healthcare systems. METHODS: Observational, ecologic study on deliveries in 913 sub-national administrative areas of five European countries (Denmark, England, Portugal, Slovenia and Spain) from 2002 to 2009. The study includes a cross-section analysis with 2009 data and a time-trend analysis for the whole period. Main endpoints: age-standardized utilization rates of C-section in low-risk pregnancies and deliveries per 100 deliveries. Secondary endpoints: Estimated excess-cases per geographical unit of analysis in two scenarios of minimized utilization. RESULTS: C-section is widely used in all examined countries (ranging from 19% of Slovenian deliveries to 33% of deliveries in Portugal). With the exception of Portugal, there are no systematic variations in intensity of use across areas in the same country. Cross-country comparison of lower-value C-section leaves Denmark with 10% and Portugal with 2%, the highest and lowest. Such behaviour was stable over the period of analysis. Within each country, the scattered geographical patterns of use intensity speak for local drivers playing a major role within the national trend. CONCLUSION: The analysis conducted suggests plenty of room for enhancing value in obstetric care and equity in women's access to such within the countries studied. The analysis of geographical variations in lower-value care can constitute a powerful screening tool.

Joint spatial modeling to identify shared patterns among chronic related potentially preventable hospitalizations.

BACKGROUND: Rates of Potentially Preventable Hospitalizations (PPH) are used to evaluate access of territorially delimited populations to high quality ambulatory care. A common geographic pattern of several PPH would reflect the performance of healthcare providers. This study is aimed at modeling jointly the geographical variation in six chronic PPH conditions in one Spanish Autonomous Community for describing common and discrepant patterns, and to assess the relative weight of the common pattern on each condition. METHODS: Data on the 39,970 PPH hospital admissions for diabetes short term complications, chronic obstructive pulmonary disease (COPD), congestive heart failure, dehydration, angina admission and adult asthma, between 2007 and 2009 were extracted from the Hospital Discharge Administrative Databases and assigned to one of the 240 Basic Health Zones. Rates and Standardized Hospitalization Ratios per geographic unit were estimated. The spatial analysis was carried out jointly for PPH conditions using Shared Component Models (SCM). RESULTS: The component shared by the six PPH conditions explained about the 36% of the variability of each PPH condition, ranging from the 25.9 for dehydration to 58.7 for COPD. The geographical pattern found in the latent common component identifies territorial clusters with particularly high risk. The specific risk pattern that each isolated PPH does not share with the common pattern for all six conditions show many non-significant areas for most PPH, but with some exceptions. CONCLUSIONS: The geographical distribution of the risk of the PPH conditions is captured in a 36% by a unique latent pattern. The SCM modeling may be useful to evaluate healthcare system performance.

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

Objetivos Analizar la variabilidad poblacional del tratamiento quirúrgico del cáncer de mama, tanto en régimen de ingreso como ambulatorio, mediante cirugía conservadora más radioterapia y cirugía no conservadora, y estimar el coste de oportunidad asociado a la utilización de una u otra. Métodos Estudio observacional de las variaciones geográficas en las tasas estandarizadas de cirugía conservadora y no conservadora realizadas en 199 áreas de salud españolas durante 2008-2009. Los costes se calcularon de manera indirecta, mediante All-Patients Diagnosis Related Groups (AP-DRG) y de manera directa a partir de costes registrados por la Red Española de Costes Hospitalarios (RECH). Resultados Las tasas estandarizadas de cirugía conservadora y no conservadora por cada 10.000 mujeres fueron 6,84 y 4,35, respectivamente, con un rango de variación entre áreas de 2,95 y 3,11. En el año 2009, el 9% de la cirugía conservadora se realizó mediante cirugía mayor ambulatoria, pero más de un tercio de las áreas no registraron ninguna intervención de este tipo. Según RECH, el coste medio de la cirugía conservadora fue de 7078 Euros, y el de la cirugía no conservadora fue de 6161Euros. Utilizando AP-DRG, estos costes fueron de 9036 Euros y 8526 Euros, respectivamente. Sin embargo, el coste de oportunidad de la cirugía conservadora resultó inferior al coste de la cirugía no conservadora, a partir de un 46% de utilización de cirugía mayor ambulatoria según RECH o un 23% según AP-DRG. Conclusiones La cirugía conservadora realizada mediante cirugía mayor ambulatoria se perfila como la opción con menor coste de oportunidad en el tratamiento quirúrgico del cáncer de mama, a partir de cierto umbral, cuando ambas, conservadora y no conservadora, son de elección (AU)

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 Euros and that of NCS was 6,161 Euros. Using AP-DRG, costs amounted to 9,036 Euros and 8,526 Euros, 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 (AU)

Oferta sanitaria y crisis: financiamos los bienes y servicios según su valor o caemos en la insolvencia. Informe SESPAS 2014 / Health services supply and the economic crisis: either we fund goods and services according to their value or we become bankrupt. SESPAS report 2014

La reacción de la política sanitaria a la crisis financiera ha puesto excesivo énfasis en medidas orientadas a disminuir precios unitarios, aumentar barreras (lista de espera) o cerrar dispositivos. Aún es pronto para saber con fundamento científico si estos cambios en la oferta tienen correlato en la equidad de acceso o en la calidad y la seguridad de los servicios, y a la postre en la salud de los pacientes y la población. En cualquier caso, la urgencia en conseguir la estabilización fiscal ha movido el foco hacia la resolución de los problemas de liquidez presupuestaria, y ha relegado a un segundo plano medidas de mayor calado orientadas a decidir, con trazo fino, qué debe financiarse y cómo. En este trabajo se aboga por una política fundamentada en la financiación selectiva de las prestaciones sobre la base de su valor. Las experiencias de otros países pueden servirnos de orientación: métodos robustos para identificar tecnologías (o sus usos) de valor cuestionable, criterios de priorización y una cuidadosa consideración de las limitaciones asociadas a la eliminación de una cierta prestación, en especial si afecta a los valores esenciales del sistema. España cuenta con los mimbres necesarios: regulación, legislación y organismos con capacidad técnica para identificar tecnologías de bajo valor, guiar las decisiones y evaluar oportunamente los efectos de estas últimas. Los obstáculos son numerosos, pero mantener el statu quo es la peor opción, dado el coste de oportunidad en pérdidas de efectividad y seguridad, equidad y eficiencia económica del Sistema Nacional de Salud, y su eventual traducción en el empeoramiento del estado de salud de la población (AU)

Health policy has reacted to the financial crisis by overemphasising measures targeted at reducing unit costs, increasing barriers to access (waiting lists) or closing premises. It is too soon for scientific assessment of the impact of this reshaping of supply on equity, quality and safety, and on individual and population health. Nevertheless, the emergency measures taken to achieve fiscal stabilization have shifted the focus to resolving budget problems at the expenses of sounder and deeper initiatives aimed at deciding what must be funded and how. This article advocates a policy based on selective funding of services and benefits on the basis of their value. Other countries’ experiences can serve as a useful guide, including robust methods to identify technologies (or their uses) of questionable value, prioritization criteria, and careful consideration of limitations associated with the elimination of a certain benefit, especially if it affects the founding values of the system. The necessary tools are available to the Spanish health system: the regulatory framework and technical bodies able to identify lower value care, support for decision-making, and timely evaluation of such decisions. Despite the numerous hurdles, maintaining the status quo is too expensive a choice, given the opportunity costs of effectiveness and safety losses, measured in terms of equity and the economic efficiency of the Spanish health system, which may ultimately translate into worsening of the population's health status (AU)