Evaluating the decentralisation of the Spanish healthcare system: a data envelopment analysis approach.

OBJECTIVES: The aim of the study was to answer whether the central government has been more efficient than the regional governments or vice versa. Likewise, through the analysis of the data, the aim was to shed light on whether decentralisation has had a positive impact on the efficiency of the hospital sector or not. DESIGN: In this paper, we have used data envelopment analysis to analyse the evolution of efficiency in the last 10 Autonomous Regions to receive healthcare competences at the end of 2001. PARTICIPANTS: For this study, we have taken into account the number of beds and full-time workers as inputs and the calculation of basic care units as outputs to measure the efficiency of the Spanish public sector, private sector and jointly in the years 2002, 2007, 2012 and 2017 for the last Autonomous Regions receiving healthcare competences. RESULTS: Of the Autonomous Regions that received the transfers at the end of 2001, the following stand out for their higher efficiency growth: the Balearic Islands (81.44% improvement), the Madrid Autonomous Region, which practically reached absolute efficiency levels (having increased by 63.77%), and La Rioja which, together with the Balearic Islands which started from very low values, improved notably (46.13%). CONCLUSION: In general, it can be observed that the transfer of responsibilities in the health sector has improved efficiency in the National Health Service. JEL CLASSIFICATION: C14; I18; H21.

A pulmonary rehabilitation program reduces hospitalizations in chronic obstructive pulmonary disease patients: A cost-effectiveness study.

BACKGROUND: Although pulmonary rehabilitation (PR) is recommended in patients with chronic obstructive pulmonary disease (COPD), there is a scarcity of data demonstrating the cost-effectiveness and effectiveness of PR in reducing exacerbations. METHODS: A quasi-experimental study in 200 patients with COPD was conducted to determine the number of exacerbations 1 year before and after their participation in a PR program. Quality of life was measured using the COPD assessment test and EuroQol-5D. The costs of the program and exacerbations were assessed the year before and after participation in the PR program. The incremental cost-effectiveness ratio (ICER) was estimated in terms of quality-adjusted life years (QALYs). RESULTS: The number of admissions, length of hospital stay, and admissions to the emergency department decreased after participation in the PR program by 48.2%, 46.6%, and 42.5%, respectively (P < 0.001 for all). Results on quality of life tests improved significantly (P < 0.001 for the two tests). The cost of PR per patient and the cost of pre-PR and post-PR exacerbations were €1867.7 and €7895.2 and €4201.9, respectively. The PR resulted in a cost saving of €1826 (total, €365,200) per patient/year, and the gain in QALYs was+0.107. ICER was -€17,056. The total cost was <€20,000/QALY in 78% of patients. CONCLUSIONS: PR contributes to reducing the number of exacerbations in patients with COPD, thereby slowing clinical deterioration. In addition, it is cost-effective in terms of QALYs.

Forecasting emergency department arrivals using INGARCH models.

BACKGROUND: Forecasting patient arrivals to hospital emergency departments is critical to dealing with surges and to efficient planning, management and functioning of hospital emerency departments. OBJECTIVE: We explore whether past mean values and past observations are useful to forecast daily patient arrivals in an Emergency Department. MATERIAL AND METHODS: We examine whether an integer-valued generalized autoregressive conditional heteroscedastic (INGARCH) model can yield a better conditional distribution fit and forecast of patient arrivals by using past arrival information and taking into account the dynamics of the volatility of arrivals. RESULTS: We document that INGARCH models improve both in-sample and out-of-sample forecasts, particularly in the lower and upper quantiles of the distribution of arrivals. CONCLUSION: Our results suggest that INGARCH modelling is a useful model for short-term and tactical emergency department planning, e.g., to assign rotas or locate staff for unexpected surges in patient arrivals.

Estimated Technological Obsolescence of Computed Tomography Equipment.

RATIONALE AND OBJECTIVES: To evaluate a model for predicting technological obsolescence of computed tomography (CT) equipment. MATERIALS AND METHODS: Baseline data consisted of various models of CT scanners that have been on the market since 1974 and represent a technological leap in CT. In documenting the CT scans, a principal component analysis was performed to reduce the number of variables. A Cox regression model was used to calculate the probability of a technology leap. RESULTS: The CT parameters were divided into three main components: detection system, image resolution, and device performance. Cox regression odds ratios show that a technology leap can be expected as a function of the variables device power (1.457), detection system (0.818), and image resolution (0.964). CONCLUSION: Our results show that the variables that predict the technological leap in CT are device performance, image resolution, and detection system. The results provide a better understanding of the expected technological changes in CT, which will lead to advances in planning investments in this technology, purchasing and installing equipment in hospitals where this type of technology is not yet available, and renewing the technological base already installed.

Cost Analysis of Magnetic Resonance Imaging and Computed Tomography in Cardiology: A Case Study of a University Hospital Complex in the Euro Region.

INTRODUCTION: In recent years, several hospitals have incorporated MRI equipment managed directly by their cardiology departments. The aim of our work is to determine the total cost per test of both CT and MRI in the setting of a Cardiology Department of a tertiary hospital. MATERIALS AND METHODS: The process followed for estimating the costs of CT and MRI tests consists of three phases: (1) Identification of the phases of the testing process; (2) Identification of the resources consumed in carrying out the tests; (3) Quantification and assessment of inputs. RESULTS: MRI involves higher personnel (EUR 66.03 vs. EUR 49.17) and equipment (EUR 89.98 vs. EUR 33.73) costs, while CT consumes higher expenditures in consumables (EUR 93.28 vs. EUR 22.95) and overheads (EUR 1.64 vs. EUR 1.55). The total cost of performing each test is higher in MRI (EUR 180.60 vs. EUR 177.73). CONCLUSIONS: We can conclude that the unit cost of each CT and MRI performed in that unit are EUR 177.73 and EUR 180.60, respectively, attributable to consumables in the case of CT and to amortization of equipment and staff time in the case of MRI.

Patients With High Cardiovascular Risk as Candidates to Bempedoic Acid, After Treatment With Statins, Ezetimibe and PCSK9 Inhibitors: An Estimation and Cost-Effectiveness Analysis.

ABSTRACT: Low-density lipoprotein cholesterol (LDLc) is the lead effector of atherosclerosis and main treatment target. Bempedoic acid is a novel oral drug in the therapeutic armamentarium which is able to reduce LDLc. The objectives of this study were (1) to select the potential patients for administering bempedoic acid such as those with a very high cardiovascular risk in which objectives of LDLc were not achieved despite conventional treatment with PCSK9 inhibitors (PCSK9i) and/or statins and ezetimibe and (2) to estimate the cost-effectiveness of bempedoic acid in different scenarios. The methods used were a multicenter and retrospective study of 652 patients initiating treatment with any PCSK9 inhibitor in 17 different hospitals. Before and on-treatment LDLc cholesterol levels, medical treatments, clinical indication, and baseline characteristics were recorded. The results obtained from 443 subjects in secondary prevention were analyzed. The mean (±) LDLc level at baseline was 142.5 ± 46.4 mg/dL and 61.5 ± 40.5 mg/dL in the follow-up, with a reduction of 55.9% ( P < 0.0001); 71.6% of the patients reached the target of LDL < 55 mg/dL or >50% reduction. Of those patients treated with medium-intensity and low-intensity statins plus PCSK9 inhibitors (with or without ezetimibe), only 5.7% of them were able to reduce LDL below 55 mg/dL and the main LDLc reduction in this group was the lowest (42.9% on average). Patients with TG values >135 mg/dL represented 41.6% of the sample, of which approximately 10% of them were using fibrates. Assuming only LDLc reduction and the UK price, the incremental cost-effectiveness ratio was 88,359€; 83,117€; 82,378€; and 79,015€ for different discount rates. In conclusion, one-third of the patients could achieve the target LDL proposed in the 2019 ESC/EAS guidelines. Approximately 10% of them could also benefit from treating hypertriglyceridemia as indicated in the 2021 ESC guidelines on cardiovascular disease prevention. Patients with medium-intensity and low-intensity statins plus PCSK9i and ezetimibe would be the most benefited. Bempedoic acid could be a not cost-efficacy therapy in all the scenarios, but we need to wait for the CLEAR OUTCOMES Trial results.

Cost-Effectiveness of a New Outpatient Pulmonology Care Model Based on Physician-to-Physician Electronic Consultation.

Introduction: This study assesses the impact of an electronic physician-to-physician consultation program on the waiting list and the costs of a Pulmonology Unit. Materials and Methods: A prepost intervention study was conducted after a new ambulatory pulmonary care protocol was implemented and the capacity of the unit was adopted. In the new model, physicians at all levels of healthcare send electronic consultations to specialists. Results: In the preintervention year (2019), the Unit of Pulmonology attended 7,055 consultations (466 e-consultations and 6,589 first face-to-face visits), which decreased to 6,157 (3,934 e-consultations and 2,223 first face-to-face visits; 12.7% reduction) in the postintervention year (all were e-consultations). The mean wait time for the first appointment was 25.7 days in 2019 versus 3.2 days in 2021 (p < 0.001). In total, 43.5% of cases were solved via physician-to-physiciane-consultation. A total of 2,223 patients needed a face-to-face visit, with a mean wait time of 7.5 days. The mean of patients in the waiting listing decreased from 450.8 in 2019 to 44.8 in 2021 (90% reduction). The annual time devoted to e-consultations and first face-to-face visits following an e-consultation diminished significantly after the intervention (1,724 hours versus 2,312.8; 25.4% reduction). Each query solved via e-consultation represented a saving of €652.8, resulting in a total annual saving of €827,062. Conclusions: Physician-to-physiciane-consultations reduce waiting times, improve access of complex patients to specialty care, and ensure that cases are managed at the appropriate level. E-consultation reduces costs, which benefits both, society and the healthcare system.

Analysis of hospital costs by morbidity group for patients with severe mental illness.

OBJECTIVES: The goal of this study is to analyse hospital costs and length of stay of patients admitted to psychiatric units in hospitals in a European region of the Mediterranean Arc. The aim is to identify the effects of comorbidities and other variables in order to create an explanatory cost model. METHODS: In order to carry out the study, the Ministry of Health was asked to provide data on access to the mental health facilities of all hospitals in the region. Among other questions, this database identifies the most important diagnostic variables related to admission, like comorbidities, age and gender. The method used, based on the Manning-Mullahy algorithm, was linear regression. The results were measured by the statistical significance of the independent variables to determine which of them were valid to explain the cost of hospitalization. RESULTS: Psychiatric inpatients can be divided into three main groups (psychotic, organic and neurotic), which have statistically significant differences in costs. The independent variables that were statistically significant (p <.05) and their respective beta and confidence intervals were: psychotic group (19,833.0 ± 317.3), organic group (9,878.4 ± 276.6), neurotic group (11,060.1 ± 287.6), circulatory system diseases (19,170 ± 517.6), injuries and poisoning (21,101.6 ± 738.7), substance abuse (20,580.6 ± 514, 6) and readmission (19,150.9 ± 555.4). CONCLUSIONS: Unlike most health services, access to psychiatric facilities does not correlate with comorbidities due to the specific nature of this specialization. Patients admitted to psychosis had higher costs and a higher number of average staysKEY MESSAGESThe highest average hospital expenditure occurred in patients admitted for psychotic disorders.Due to the particularities of psychiatry units and unlike other medical specialties, the number of comorbidities did not influence the number of hospital stays or hospital expenditure.Apart from the main diagnostic group, the variables that were useful to explain hospital expenditure were the presence of poisoning and injuries as comorbidity, diseases of circulatory system as comorbidity, history of substance abuse and readmission.

Explaining the adoption and use of computed tomography and magnetic resonance image technologies in public hospitals.

OBJECTIVE: This article examines what the adoption and use of advanced medical technologies - computed tomography (CT) and magnetic resonance imaging (MRI) - by public hospitals depend on and to what extent. METHODS: From a sample of panel data for all public hospitals in the health service of Galicia (a subregion of the Galicia-North of Portugal Euroregion) for the 2010-2017 period, we grouped explanatory variables into inputs (resources), outputs (activities) and socio-demographic variables. Factor analysis was used to reduce as much as possible the number of analysed variables, discriminant analysis to examine the technologies adoption decision, and multiple regression analysis to investigate their use. RESULTS: Factor analysis identified motivators on adoption and use of CT and MRI medical technologies as follows: hospital inputs/outputs (Factor 1); radiology studies and adoption of CT by public hospitals (Factor 2); research/teaching role and big-ticket diagnostic and therapeutic (lithotripsy) technologies (Factor 3); number of transplants (Factor 4); cancer diagnosis/treatment (Factor 5); and catchment area geographical dispersion (Factor 6). Cronbach's alpha of 0.881 indicated an acceptable degree of reliability of the factor variables. Regarding adoption of these technologies, Factor 1 is the most influential, explaining 37% of the variance and showing adequate global internal consistency, whereas Factor 2 is limited to 13% of the variance. In the discriminant analysis, values for Box's M test and canonical correlations such as Wilks's lambda for the two technologies underpin the reliability and predictive capacity of the discriminant equations. Finally, and according to the regression analysis, the factor with the greatest influence on CT and MRI use is Factor 2, followed by Factors 1 and 3 in the case of CT use, and Factors 3 and 5 in the case of MRI use. CONCLUSION: CT and MRI adoption by public hospitals is mainly determined by hospital inputs and outputs. However, the use of both medical technologies is mainly influenced by conventional radiology studies and CT adoption. These results suggest that both choices - adoption and use of advanced medical technology - may be separate decisions as they are taken possibly by different people (the former by managers and policymakers and the latter by physicians).

[Does social mobility influence health status? A systematic review.] / ¿Influye la movilidad social en el estado de salud? Una revisión sistemática.

BACKGROUND: In the debate on the determinants of social class variation in health, it has been suggested that social mobility and associated factors play an important role in this variation. Social mobility describes changes or stability between social class positions. The aim of this paper was to identify studies on the association between social mobility and health. METHODS: The databases consulted were MEDLINE/PubMed, Cochrane, SciELO, CRD. The keywords used (in English), through the MeSH methodology, were: Health (MajorTerm), Class mobility, Vertical mobility, Social position, Socioeconomic factors, Social class, Social conditions, Social environment, Poverty and Social marginalisation (MeSHTerm). The search period was from January 2010 to December 2019. The STROBE statement has been used to develop the checklist. Finally, the evaluation of the studies has been carried out by means of a qualitative systematic review. RESULTS: The search identified 1,092 potentially relevant studies. After analysis, 376 studies were retained and their full texts were reviewed in depth, resulting in a final set of 42 studies. Of these, 2 studies were identified on Class Mobility and Health; 5 studies were also identified on Poverty and Health, showing evidence of effect on Health by Social Mobility; 9 studies on Social Class and Health, showing effect of Social Mobility on Health and 8 studies showing effect of Social Position on Health. CONCLUSIONS: Social mobility measures convey additional information to that of poverty indices. Using indices of social position and their impact on health inequalities could be empirically useful. More research is needed on this issue.

OBJETIVO: En el debate sobre los determinantes de la variación de la clase social en la salud, se ha sugerido que la movilidad social y los factores asociados a ella desempeñan un papel importante en esta variación. La movilidad social describe los cambios o la estabilidad entre las posiciones de clase social. El objetivo de este trabajo fue identificar estudios sobre la asociación entre movilidad social y salud. METODOS: Las bases de datos consultadas fueron MEDLINE/PubMed, Cochrane, SciELO, CRD. Las palabras clave utilizadas (en inglés), a través de la metodología MeSH, fueron: Salud (MajorTerm), Movilidad de clase, Movilidad vertical, Posición social, Factores socioeconómicos, Clase social, Condiciones sociales, Entorno social, Pobreza y Marginación social (MeSHTerm). El periodo de búsqueda fue de enero de 2010 a diciembre de 2019. La declaración de STROBE se ha utilizado para elaborar la lista de verificación. Finalmente, la evaluación de los estudios se ha realizado mediante una revisión sistemática cualitativa. RESULTADOS: La búsqueda identificó 1.092 estudios potencialmente relevantes. Tras el análisis, se retuvieron 376 estudios y se revisaron sus textos completos en profundidad, resultando un conjunto final de 42 estudios. De ellos, se identificaron 2 estudios sobre Movilidad de clase y Salud; también se identificaron 5 estudios sobre Pobreza y Salud, mostrando evidencia del efecto sobre la Salud por la Movilidad Social; 9 estudios sobre Clase Social y Salud, mostrando el efecto de la Movilidad Social sobre la Salud y 8 estudios que mostraron efecto de la Posición Social sobre la Salud. CONCLUSIONES: Las medidas de movilidad social transmiten información adicional a la de los índices de pobreza. Utilizar los índices de posición social y su impacto en las desigualdades en salud podría ser empíricamente útil. Se necesitan más estudios sobre esta cuestión.

Cost-utility model of brivaracetam in the adjunctive treatment of patients with epilepsy in Spain.

OBJECTIVE: This study aims to assess the cost utility of Brivaracetam compared with the third-generation anti-epileptic drugs used as standard care. METHODS: A cost utility analysis of Brivaracetam was carried out with other third-generation comparators. The treatment pathway of a hypothetical cohort over a period of 2 years was simulated using the Markov model. Data for effectiveness and the QALYs of each health status for epilepsy, as well as for the disutilities of adverse events of treatments, were analyzed through a studies review. The cost of the anti-epileptics and the use of medical resources linked to the different health statuses were taken into consideration. A probabilistic sensitivity analysis was performed using a Monte Carlo simulation. RESULTS: Brivaracetam was shown to be the dominant alternative, with Incremental Cost Utility Ratio (ICUR) values from -11,318 for Lacosamide to -128,482 for Zonisamide. The probabilistic sensitivity analysis validates these results. The ICUR sensitivity is greater for increases in the price of Brivaracetam than for decreases, and for Eslicarbizapine over the other adjunctives considered in the analysis. CONCLUSIONS: Treatment with Brivaracetam resulted in cost effective and incremental quality adjusted life years come at an acceptable cost.

Using flexible regression models for calculating hospital's production functions.

BACKGROUND: The relative lack of flexibility of parametric models has led to the development of nonparametric regression techniques based on the family of generalized additive models. However, despite the potential advantages of using Generalized Additive Model (GAM) in practice many models have, until now, not been sufficiently explored in health economics problems. It could be interesting to calculate a new flexible hospital production function by means of a GAM including interactions and to compare it with the classic model Cobb-Douglas in the prediction of the behavior of productive factors. METHOD: The flexible model considered has been the AM including the beds-facultative interaction. The covariates "Hospital", being a categorical variable and "Year" being a continuous variable, have also been included in the model. Based on the estimation of the model penalized thin plate splines will be used to represent smoothed functions. In this configuration, the smoothed parameters will be estimated via REML. RESULTS: Cobb-douglas model fits well for the production functions of the more general clinical and surgical services, while the GAM adjusts better in the case of more specialized medical services. CONCLUSIONS: Generalized Additive Models are more flexible than parametric models, providing a better fit in the presence of non-linear relationships and thus allowing more accurate prediction values. The results of this study suggest that AM is a promising technique for the areas of research and application in health economics.

Comparing Some Production Functions for Inpatient Health Services in Selected Public Hospitals in Spain.

To investigate the adequacy of the widely used Cobb-Douglas and transcendental logarithmic (translog) models of the production functions of hospital inpatient services, the authors fitted these and additive models to data for the four most productive health services of 10 public hospitals in Galicia, Spain (the same four in each). Production, measured as admissions weighted in accordance with their diagnosis-related groups (DRGs), was treated as a function of physician full-time equivalents as surrogate labor factor and number of beds as surrogate capital factor. The results suggest that while the Cobb-Douglas and translog models suffice to represent the production functions of services with low average DRG weight, the greater flexibility of additive models is required for services with higher average DRG weight when only these two inputs are considered.

El sistema de salud como dinamizador de la economía: el caso del Servicio Galego da Saúde / No disponible

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Algunas consideraciones sobre el futuro del Sistema Nacional de Salud / Some considerations on the future of the National Health Care System

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Servicios de asistencia médica en el sector privado del Reino Unido y el nuevo contrato de especialistas: estadísticas y tendencias clave / Healthcare services in the U.K. private sector and the new consultant contract: key statistics and trends

El sector de los hospitales privados en el Reino Unido es pequeño comparado con la provisión ofertada por el National Health Service. En términos per cápita, en el bienio 1997-1998, había 20 camas hospitalarias de agudos por 100.000 habitantes, comparado con las 219 camas de agudos por 100.000 habitantes ofertadas por el NHS.

Experiencia de la inversión privada en los hospitales públicos del Reino Unido. Una visión crítica del PFI (Private Finance Initiative) / The experience of private investment in public hospitals in the United Kingdom. A critical view of the PFI (Private Finance Initiative)

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