Relationship between efficiency and clinical effectiveness indicators in an adjusted model of resource consumption: a cross-sectional study.

BACKGROUND: Adjusted clinical groups (ACG®) have been widely used to adjust resource distribution; however, the relationship with effectiveness has been questioned. The purpose of the study was to measure the relationship between efficiency assessed by ACG® and a clinical effectiveness indicator in adults attended in Primary Health Care Centres (PHCs). RESEARCH DESIGN: cross-sectional study. SUBJECTS: 196, 593 patients aged >14 years in 13 PHCs in Catalonia (Spain). MEASURES: Age, sex, PHC, basic care team (BCT), visits, episodes (diagnoses), and total direct costs of PHC care and co-morbidity as measured by ACG® indicators: Efficiency indices for costs, visits, and episodes (costs EI, visits EI, episodes EI); a complexity or risk index (RI); and effectiveness measured by a general synthetic index (SI). The relationship between EI, RI, and SI in each PHC and BCT was measured by multiple correlation coefficients (r). RESULTS: In total, 56 of the 106 defined ACG® were present in the study population, with five corresponding to 44.5% of the patients, 11 to 68.0% of patients, and 30 present in less than 0.5% of the sample. The RI in each PHC ranged from 0.9 to 1.1. Costs, visits, and episodes had similar trends for efficiency in six PHCs. There was moderate correlation between costs EI and visits EI (r = 0.59). SI correlation with episodes EI and costs EI was moderate (r = 0.48 and r = -0.34, respectively) and was r = -0.14 for visits EI. Correlation between RI and SI was r = 0.29. CONCLUSIONS: The Efficiency and Effectiveness ACG® indicators permit a comparison of primary care processes between PHCs. Acceptable correlation exists between effectiveness and indicators of efficiency in episodes and costs.

Obtaining the mean relative weights of the cost of care in Catalonia (Spain): retrospective application of the adjusted clinical groups case-mix system in primary health care.

OBJECTIVE: The study aims to obtain the mean relative weights (MRWs) of the cost of care through the retrospective application of the adjusted clinical groups (ACGs) in several primary health care (PHC) centres in Catalonia (Spain) in routine clinical practice. METHODS: This is a retrospective study based on computerized medical records. All patients attended by 13 PHC teams in 2008 were included. The principle measurements were: demographic variables (age and sex), dependent variables (number of diagnoses and total costs), and case-mix or co-morbidity variables (International Classification of Primary Care). The costs model for each patient was established by differentiating the fix costs from the variable costs. In the bivariate analysis, the Student's t, analysis of variance, chi-squared, Pearson's linear correlation and Mann-Whitney-Wilcoxon tests were used. In order to compare the MRW of the present study with those of the United States (US), the concordance [intraclass correlation coefficient (ICC) and concordance correlation coefficient (CCC)] and the correlation (coefficient of determination: R²) were measured. RESULTS: The total number of patients studied was 227,235, and the frequentation was 5.9 visits/habitant/year) and with a mean diagnoses number of 4.5 (3.2). The distribution of costs was €148.7 million, of which 29.1% were fixed costs. The mean total cost per patient/year was €654.2 (851.7), which was considered to be the reference MRW. Relationship between study-MRW and US-MRW: ICC was 0.40 [confidential interval (CI) 95%: 0.21-0.60] and the CCC was 0.42 (CI 95%: 0.35-0.49). The correlation between the US MRW and the MRW of the present study can be seen; the adjusted R² value is 0.691. The explanatory power of the ACG classification was 36.9% for the total costs. The R² of the total cost without considering outliers was 56.9%. CONCLUSIONS: The methodology has been shown appropriate for promoting the calculation of the MRW for each category of the classification. The results provide a possible practical application in PHC clinical management.

Adaptive capacity of the Adjusted Clinical Groups Case-Mix System to the cost of primary healthcare in Catalonia (Spain): a observational study.

OBJECTIVES: To describe the adaptive capacity of the Adjusted Clinical Groups (ACG) system to the cost of care in primary healthcare centres in Catalonia (Spain). DESIGN: Retrospective study (multicentres) conducted using computerised medical records. SETTING: 13 primary care teams in 2008 were included. PARTICIPANTS: All patients registered in the study centres who required care between 1 January and 31 December 2008 were finally studied. Patients not registered in the study centres during the study period were excluded. OUTCOME MEASURES: Demographic (age and sex), dependent (cost of care) and case-mix variables were studied. The cost model for each patient was established by differentiating the fixed and variable costs. To evaluate the adaptive capacity of the ACG system, Pearson's coefficient of variation and the percentage of outliers were calculated. To evaluate the explanatory power of the ACG system, the authors used the coefficient of determination (R(2)). RESULTS: The number of patients studied was 227 235 (frequency: 5.9 visits per person per year), with a mean of 4.5 (3.2) episodes and 8.1 (8.2) visits per patient per year. The mean total cost was €654.2. The explanatory power of the ACG system was 36.9% for costs (56.5% without outliers). 10 ACG categories accounted for 60.1% of all cases and 19 for 80.9%. 5 categories represented 71% of poor performance (N=78 887, 34.7%), particularly category 0300-Acute Minor, Age 6+ (N=26 909, 11.8%), which had a coefficient of variation =139% and 6.6% of outliers. CONCLUSIONS: The ACG system is an appropriate manner of classifying patients in routine clinical practice in primary healthcare centres in Catalonia, although improvements to the adaptive capacity through disaggregation of some categories according to age groups and, especially, the number of acute episodes in paediatric patients would be necessary to reduce intra-group variation.

Comparación entre tres métodos de medida de la multimorbilidad en función del uso de recursos sanitarios en atención primaria / Comparison of three methods for measuring multiple morbidity according to the use of health resources in primary healthcare

Objetivo: Comparar 3 diferentes métodos de medida de la multimorbilidad en función del uso de recursos sanitarios (coste de la asistencia) en atención primaria (AP). Diseño: Estudio retrospectivo realizado a partir de registros médicos informatizados. Emplazamiento: En 13 equipos de AP de Cataluña. Participantes: Pacientes adscritos que demandaron atención durante el año 2008. Medidas principales: Variables sociodemográficas, de comorbilidad y de coste. Los métodos de comparación fueron: a) índice de comorbilidad combinado (ICC): se elaboró un índice propio a partir de las puntuaciones de episodios agudos y crónicos; b) índice de Charlson (iCh), y c) índices de casuística de los Adjusted Clinical Groups: bandas de utilización de recursos (BUR). El modelo de costes se estableció diferenciando los costes fijos (funcionamiento de los centros) y los variables. Análisis estadístico: se desarrollaron 3 modelos de regresión lineal para evaluar la capacidad explicativa de cada medida de comorbilidad; que se compararon a partir del coeficiente de determinación (R2), p<0,05. Resultados: Se seleccionaron 227.235 pacientes; el promedio/unitario del coste de la asistencia fue de 654,2 €. El ICC explica un R2=50,4%, el iCh un R2=29,2% y las BUR un R2=39,7% de la variabilidad del coste. El comportamiento del ICC es aceptable, no obstante con puntuaciones bajas (entre 1 y 3 puntos) no se consiguen resultados tan concluyentes. Conclusiones: El ICC se muestra como un sencillo y posible predictor del coste de la asistencia en AP en situación de práctica clínica habitual. De confirmarse estos resultados posibilitarían una mejora en la comparación de la casuística(AU)

Objective: To compare three methods of measuring multiple morbidity according to the use of health resources (cost of care) in primary healthcare (PHC). Design: Retrospective study using computerized medical records. Setting: Thirteen PHC teams in Catalonia (Spain). Participants: Assigned patients requiring care in 2008. Main measurements: The socio-demographic variables were co-morbidity and costs. Methods of comparison were: a) Combined Comorbidity Index (CCI): an index itself was developed from the scores of acute and chronic episodes, b) Charlson Index (ChI), and c) Adjusted Clinical Groups case-mix: resource use bands (RUB). The cost model was constructed by differentiating between fixed (operational) and variable costs. Statistical analysis: 3 multiple lineal regression models were developed to assess the explanatory power of each measurement of co-morbidity which were compared from the determination coefficient (R2), p< .05. Results: The study included 227,235 patients. The mean unit of cost was €654.2. The CCI explained an R2=50.4%, the ChI an R2=29.2% and BUR an R2=39.7% of the variability of the cost. The behaviour of the ICC is acceptable, albeit with low scores (1 to 3 points), showing inconclusive results. Conclusions: The CCI may be a simple method of predicting PHC costs in routine clinical practice. If confirmed, these results will allow improvements in the comparison of the case-mix(AU)

[Comparison of three methods for measuring multiple morbidity according to the use of health resources in primary healthcare]. / Comparación entre tres métodos de medida de la multimorbilidad en función del uso de recursos sanitarios en atención primaria.

OBJECTIVE: To compare three methods of measuring multiple morbidity according to the use of health resources (cost of care) in primary healthcare (PHC). DESIGN: Retrospective study using computerized medical records. SETTING: Thirteen PHC teams in Catalonia (Spain). PARTICIPANTS: Assigned patients requiring care in 2008. MAIN MEASUREMENTS: The socio-demographic variables were co-morbidity and costs. Methods of comparison were: a) Combined Comorbidity Index (CCI): an index itself was developed from the scores of acute and chronic episodes, b) Charlson Index (ChI), and c) Adjusted Clinical Groups case-mix: resource use bands (RUB). The cost model was constructed by differentiating between fixed (operational) and variable costs. STATISTICAL ANALYSIS: 3 multiple lineal regression models were developed to assess the explanatory power of each measurement of co-morbidity which were compared from the determination coefficient (R(2)), p< .05. RESULTS: The study included 227,235 patients. The mean unit of cost was €654.2. The CCI explained an R(2)=50.4%, the ChI an R(2)=29.2% and BUR an R(2)=39.7% of the variability of the cost. The behaviour of the ICC is acceptable, albeit with low scores (1 to 3 points), showing inconclusive results. CONCLUSIONS: The CCI may be a simple method of predicting PHC costs in routine clinical practice. If confirmed, these results will allow improvements in the comparison of the case-mix.

The relationship between effectiveness and costs measured by a risk-adjusted case-mix system: multicentre study of Catalonian population data bases.

BACKGROUND: The main objective of this study is to measure the relationship between morbidity, direct health care costs and the degree of clinical effectiveness (resolution) of health centres and health professionals by the retrospective application of Adjusted Clinical Groups in a Spanish population setting. The secondary objectives are to determine the factors determining inadequate correlations and the opinion of health professionals on these instruments. METHODS/DESIGN: We will carry out a multi-centre, retrospective study using patient records from 15 primary health care centres and population data bases. The main measurements will be: general variables (age and sex, centre, service [family medicine, paediatrics], and medical unit), dependent variables (mean number of visits, episodes and direct costs), co-morbidity (Johns Hopkins University Adjusted Clinical Groups Case-Mix System) and effectiveness.The totality of centres/patients will be considered as the standard for comparison. The efficiency index for visits, tests (laboratory, radiology, others), referrals, pharmaceutical prescriptions and total will be calculated as the ratio: observed variables/variables expected by indirect standardization.The model of cost/patient/year will differentiate fixed/semi-fixed (visits) costs of the variables for each patient attended/year (N = 350,000 inhabitants). The mean relative weights of the cost of care will be obtained. The effectiveness will be measured using a set of 50 indicators of process, efficiency and/or health results, and an adjusted synthetic index will be constructed (method: percentile 50).The correlation between the efficiency (relative-weights) and synthetic (by centre and physician) indices will be established using the coefficient of determination. The opinion/degree of acceptance of physicians (N = 1,000) will be measured using a structured questionnaire including various dimensions. STATISTICAL ANALYSIS: multiple regression analysis (procedure: enter), ANCOVA (method: Bonferroni's adjustment) and multilevel analysis will be carried out to correct models. The level of statistical significance will be p < 0.05.

[Influence of morbidity, metabolic control, and use of resources in subjects with cardiovascular risk in the primary care setting]. / Influencia de la morbilidad, control metabólico y uso de recursos de los sujetos en situación de riesgo cardiovascular en el ámbito de la atención primaria de salud.

OBJECTIVE: To determine the comorbidity, the therapeutic objectives, and economic impact in subjects with cardiovascular risk in primary care (PC). DESIGN: Multicentre, cross-sectional study. SETTING: Five urban PC centres, Spain. PARTICIPANTS: Patients over 55 years seen during the year 2006. Compared according to the presence/absence of a cardiovascular event (CVE). MEASUREMENTS: Demographics, cardiovascular/general comorbidity (adjusted clinical groups), Charlson index, clinical parameters, multiple drugs and semi-fixed direct costs (operational) and variables (tests, referrals, drugs). A logistical regression and ANCOVA analysis was performed to correct the models. SPSSWIN Program (P< .05). RESULTS: Of 24 410 patients, 15.4% (CI, 14.9-15.9) had a CVE. The subjects with a CVE showed a higher mortality (4.0% vs 1.8%) and general morbidity (8.1 vs 6.4 episodes) (P< .001). The CVE had an independent association in males (OR=2.7), Charlson index (OR=2.1), dyslipaemia (OR=1.5), depression (OR=1.4), age (OR=1.3), arterial hypertension (OR=1.2) and diabetes (OR=1.1) (P< .005). In primary prevention worse average cholesterols were obtained (211.6 vs 192.4 mg/dL), while in secondary prevention blood glucose was worse (111.3 vs 104.2 mg/dL; P< .001). The average corrected direct costs were euro1543.55 versus euro1027.65, respectively (P< .001). These differences were maintained in all the cost components. CONCLUSIONS: The presence of a CVE is associated with higher comorbidity, causing an increase in costs. The achievement of therapeutic control objectives could be improved, in primary prevention as well as in secondary. Intervention strategies should be increased to modify life styles in these patients.

Influencia de la morbilidad, control metabólico y uso de recursos de los sujetos en situación de riesgo cardiovascular en el ámbito de la atención primaria de salud / Influence of morbidity, metabolic control, and use of resources in subjects with cardiovascular risk in the primary care setting

Objetivo. Determinar la comorbilidad, los objetivos terapéuticos y el impacto económico de sujetos en situación de riesgo cardiovascular en atención primaria (AP). Diseño. Estudio multicéntrico y transversal. Emplazamiento. Cinco centros de AP urbanos. Participantes. Pacientes mayores de 55 años atendidos durante el año 2006, comparados en función de la presencia/ausencia de episodios cardiovasculares (ECV). Mediciones. Demográficas, comorbilidad cardiovascular/general (Adjusted Clinical Groups), índice de Charlson, parámetros clínicos, polifarmacia y costes directos semifijos (funcionamiento) y variables (pruebas, derivaciones, fármacos). Se efectuó un análisis de regresión logística y de ANCOVA para la corrección de los modelos con el programa SPSSWIN (p < 0,05). Resultados. Se incluyeron en el estudio 24.410 pacientes. Un 15,4% (intervalo de confianza [IC], 14,9-15,9) presentaron algún ECV. Los sujetos con ECV presentaron una mortalidad (el 4,0 frente al 1,8%) y una morbilidad general (8,1 frente a 6,4 episodios) superiores (p < 0,001). El ECV tuvo una relación independiente en varones (odds ratio [OR] = 2,7), índice de Charlson (OR = 2,1), dislipemia (OR = 1,5), depresión (OR = 1,4), edad (OR = 1,3), hipertensión arterial (OR = 1,2) y diabetes (OR = 1,1) (p < 0,005). En prevención primaria se obtuvieron unos peores promedios de colesterol (211,6 frente a 192,4 mg/dl), mientras que en prevención secundaria fueron los de glucemia (111,3 frente a 104,2 mg/dl; p < 0,001). El promedio de los costes directos corregidos fue de 1.543,55 frente a 1.027,65 €, respectivamente (p < 0,001). Estas diferencias se mantuvieron en todos los componentes del coste. Conclusiones. La presencia de ECV se asocia con una mayor comorbilidad, lo que ocasiona un incremento de los costes. La consecución de los objetivos terapéuticos de control debería mejorarse, tanto en el ámbito de la prevención primaria como en el de la secundaria. Se deberían potenciar estrategias de intervención sobre la modificación de los estilos de vida en estos pacientes

Objective. To determine the comorbidity, the therapeutic objectives, and economic impact in subjects with cardiovascular risk in primary care (PC). Design. Multicentre, cross-sectional study. Setting. Five urban PC centres, Spain. Participants. Patients over 55 years seen during the year 2006. Compared according to the presence/absence of a cardiovascular event (CVE). Measurements. Demographics, cardiovascular/general comorbidity (adjusted clinical groups), Charlson index, clinical parameters, multiple drugs and semi-fixed direct costs (operational) and variables (tests, referrals, drugs). A logistical regression and ANCOVA analysis was performed to correct the models. SPSSWIN Program (P<.05). Results. Of 24 410 patients, 15.4% (CI, 14.9-15.9) had a CVE. The subjects with a CVE showed a higher mortality (4.0% vs 1.8%) and general morbidity (8.1 vs 6.4 episodes) (P<.001). The CVE had an independent association in males (OR=2.7), Charlson index (OR=2.1), dyslipaemia (OR=1.5), depression (OR=1.4), age (OR=1.3), arterial hypertension (OR=1.2) and diabetes (OR=1.1) (P<.005). In primary prevention worse average cholesterols were obtained (211.6 vs 192.4 mg/dL), while in secondary prevention blood glucose was worse (111.3 vs 104.2 mg/dL; P<.001). The average corrected direct costs were €1543.55 versus €1027.65, respectively (P<.001). These differences were maintained in all the cost components. Conclusions. The presence of a CVE is associated with higher comorbidity, causing an increase in costs. The achievement of therapeutic control objectives could be improved, in primary prevention as well as in secondary. Intervention strategies should be increased to modify life styles in these patients

[Relationship among the degree of control of arterial hypertension, comorbidity and costs in individuals over age 30 during 2006]. / Asociación entre el grado de control de la hipertensión arterial, la comorbilidad y los costes en personas de más de 30 años durante el año 2006.

BACKGROUND: Arterial hypertension is one of the main reasons for primary care consultations. This study is aimed at determining the relationship among the degree to which arterial hypertension is controlled, comorbidity and the direct costs in primary care. METHODS: Retrospective, multi-centre design. Subjects over 30 years of age pertaining to five primary care teams (2006) were included. CRITERIA: good control (<140/90 and <130/80 mmHg in diabetics and those with cardiovascular disease [CVD]. Main general measurements, CVD, Charlson index, casuistic/comorbidity (Adjusted Clinical Groups), clinical parameters and direct costs (fixed/semifixed and variable costs) [medications, tests and referrals]) Logic regression and ANCOVA for correcting the model, p<0.05. RESULTS: The prevalence of arterial hypertension was 26.5% (mean age: 67.1 years; males: 43.5%). Good control totalled 52.0% (CI: 51.2-52.8%). Poor control was independently related to diabetes (Odds Ratio=3.8), CVD (Odds Ratio=2.2) and males (Odds Ratio=1.2), p<0.001. The average/direct unit cost/year was 1,202.13 Euro vs. 1,183.55 Euro (p=0.032). CONCLUSIONS: Those individuals whose arterial hypertension was poorly controlled displayed a greater burden of morbidity and a similar healthcare cost in comparison to those under good control.

Asociación entre el grado de control de la hipertensión arterial, la comorbilidad y los costes en personas de más de 30 años durante el año 2006 / Relationship among the degree of control of arterial hypertension, comorbidity and costs in individuals over age 30 during 2006

Fundamento. La hipertensión arterial (HTA) es uno de los principales motivos de consulta de los centros de atención primaria (AP). El objetivo del estudio fue determinar la asociación entre el grado de control de la HTA, la comorbilidad y los costes directos en atención primaria. Métodos. Diseño retrospectivo-multicéntrico. Se incluyó a sujetos mayores de 30 años pertenecientes a cinco equipos de AP (año 2006). Criterios: buen control (<140/90, y <130/80 mmHg en personas diabéticas y presencia de enfermedad cardiovascular [ECV]). Principales medidas: generales, ECV, índice de Charlson, casuística/comorbilidad (Adjusted Clinical Groups), parámetros clínicos y costes directos (fijos/semifijos y variables [medicamentos, pruebas y derivaciones]). Análisis de regresión logística y de ANCOVA para la corrección del modelo, p<0,05. Resultados. La prevalencia de HTA fue del 26,5% (edad media: 67,1 años; varones: 43,5%). El buen control fue del 52,0% (IC: 51,2-52,8%). El mal control tuvo una relación independiente con la diabetes (OR=3,8), el ECV (OR=2,2) y los varones (OR=1,2), p<0,001. El promedio/unitario/año del coste directo corregido fue de 1.202,13 vs. 1.183,55 € (p=0,032). Conclusiones. Los pacientes en situación de mal control muestran una mayor carga de morbilidad y un similar coste sanitario (AU)

Background. Arterial hypertension is one of the main reasons for primary care consultations. This study is aimed at determining the relationship among the degree to which arterial hypertension is controlled, comorbidity and the direct costs in primary care. Methods. Retrospective, multi-centre design. Subjects over 30 years of age pertaining to five primary care teams (2006) were included. Criteria: good control (<140/90 and <130/80 mmHg in diabetics and those with cardiovascular disease [CVD]. Main general measurements, CVD, Charlson index, casuistic/comorbidity (Adjusted Clinical Groups), clinical parameters and direct costs (fixed/semifixed and variable costs) [medications, tests and referrals]) Logic regression and ANCOVA for correcting the model, p<0.05. Results: The prevalence of arterial hypertension was 26.5% (mean age: 67.1 years; males: 43.5%). Good control totalled 52.0% (CI: 51.2-52.8%). Poor control was independently related to diabetes (Odds Ratio=3.8), CVD (Odds Ratio=2.2) and males (Odds Ratio=1.2), p<0.001. The average/direct unit cost/year was 1,202.13 € vs. 1,183.55 € (p=0.032). Conclusions. Those individuals whose arterial hypertension was poorly controlled displayed a greater burden of morbidity and a similar healthcare cost in comparison to those under good control (AU)

Evaluación clínica y económica según el grado de riesgo cardiovascular en sujetos pertenecientes a un ámbito poblacional español / No disponible

No disponible

[Calculation of morbidity, use of resources and costs of patients treated with tiotropium bromide for COPD in a Spanish population]. / Estimación de la morbilidad, el uso de recursos y los costes de los sujetos en tratamiento con bromuro de tiotropio para la enfermedad pulmonar obstructiva crónica en un ámbito poblacional español.

OBJECTIVE: To determine the co-morbidity and economic impact of treatment with tiotropium bromide (TB) for COPD, in a population cared for by Spanish primary care teams (PCTs) and specialist physicians, in the context of routine clinical practice. DESIGN: Retrospective multi-centre study. SETTING: Four PCTs and 2 urban hospitals. PARTICIPANTS: Patients with COPD receiving regular treatment with TB, during 2004. MAIN MEASUREMENTS: Age and sex, episodes of co-morbidity, clinical parameters, resource use, and pharmacological groups. The costs model was established by differentiating semi-fixed from variable costs (pharmacy, tests, referrals) in the PCTs, as well as the visits, emergencies and hospital admissions occurring in the hospitals. A logistical regression analysis was made to correct the model. The costs were contrasted by analysis of covariance (ANCOVA), with the estimation of marginal means (Bonferroni adjustment). RESULTS: Of 900 patients with COPD, 14.3% (n=129) received treatment with TB (95% CI, 12.0%-16.6%). The mean episodes/patient/year was 2.1 (1.4) versus 1.8 (1.3) (NS), seriousness/severity 41.3% versus 26.3% (P =.001), defined daily dose (DDD) 5928.5 (9624.1) versus 6187.7 (12471.3) (NS) and number visits/patient/year 15.1 (9.4) versus 17.3(11.9) (P=.044). After adjustments for age and sex, TB use was associated with Diabetes Mellitus (OR=1.6; 95% CI, 1.0-2.5; P=.034) and severity of patients' illness (OR=1.8; 95% CI, 1.2-2.8; P=.004). Quantification of unit cost/year was 2793.16 (3166.30) euros (3359.27 [3423.25] euros versus 2703.09 [3113.75] euros; P=.001). The adjusted patient cost/year was 2831.23 euros (SE, 217.32) with TB versus 2786.86 euros (SE, 88.53) without TB (NS). CONCLUSIONS: TB is associated, as therapy complementing routine treatment, with the presence of Diabetes, and with the severity of the disease. The costs of COPD entail high resource consumption. The prescription of TB does not imply greater overall cost of the disease.

Estimación de la morbilidad, el uso de recursos y los costes de los sujetos en tratamiento con bromuro de tiotropio para la enfermedad pulmonar obstructiva crónica en un ámbito poblacional español / Calculation of morbidity, use of resources and costs of patients treated with tiotropium bromide for COPD in a spanish population

Objetivo. Medir la comorbilidad, así como el impacto económico que presentan los sujetos en tratamiento con bromuro de tiotropio (BT) en la enfermedad pulmonar obstructiva crónica (EPOC), en la población atendida por equipos de atención primaria (EAP) y especializada españoles, en situación de práctica clínica habitual. Diseño. Estudio retrospectivo y multicéntrico. Emplazamiento. Cuatro EAP y 2 centros hospitalarios urbanos. Participantes. Pacientes con EPOC que siguieron tratamiento regular con BT, durante el año 2004. Mediciones principales. Edad-sexo, episodios/comorbilidad, parámetros clínicos, utilización de recursos y grupos farmacológicos. El modelo de costes se estableció diferenciando los costes semifijos de los variables (farmacia, pruebas, derivaciones) en los EAP, así como las consultas, urgencias y hospitalizaciones acontecidas en los centros hospitalarios de referencia. Se efectuó un análisis de regresión logística para la corrección del modelo. Los costes fueron contrastados mediante análisis multivariable de ANCOVA, con estimación de medias marginales (ajuste de Bonferroni). Resultados. De 900 sujetos con EPOC, el 14,3% (n = 129) siguió tratamiento con BT (intervalo de confianza [IC] del 95%, 12,0-16,6%). El promedio de episodios/paciente/año fue de 2,1 ± 1,4 frente a 1,8 ± 1,3 (NS), la gravedad/severidad del 41,3 frente al 26,3% (p = 0,001), la dosis farmacológica (DDD) de 5.928,5 ± 9.624,1 frente a 6.187,7 ± 12.471,3 (NS) y el número de visitas/paciente/año de 15,1 ± 9,4 frente a 17,3 ± 11,9 (0,044). Los factores asociados con la utilización de BT, corregidos por edad-sexo, fueron diabetes mellitus (odds ratio [OR] = 1,6; IC del 95%, 1,0-2,5; p = 0,034) y gravedad de los pacientes (OR = 1,8; IC del 95%, 1,2-2,8; p = 0,004). La cuantificación del coste unitario/año fue de 2.793,16 ± 3.166,30 euros (3.359,27 ± 3.423,25 frente a 2.703,09 ± 3.113,75 euros; p = 0,001). El coste paciente/año ajustado fue de 2.831,23 euros (error estándar [EE] = 217,32) con BT, frente a 2.786,86 euros (EE = 88,53) sin BT (NS). Conclusiones. El BT se asocia, como tratamiento complementario al habitual, con la presencia de diabetes y con la severidad de la enfermedad. Los costes de la EPOC ocasionan un elevado consumo de recursos y la utilización de BT no conlleva un mayor coste global de la enfermedad

Objective. To determine the co-morbidity and economic impact of treatment with tiotropium bromide (TB) for COPD, in a population cared for by Spanish primary care teams (PCTs) and specialist physicians, in the context of routine clinical practice. Design. Retrospective multi-centre study. Setting. Four PCTs and 2 urban hospitals. Participants. Patients with COPD receiving regular treatment with TB, during 2004. Main measurements. Age and sex, episodes of co-morbidity, clinical parameters, resource use, and pharmacological groups. The costs model was established by differentiating semi-fixed from variable costs (pharmacy, tests, referrals) in the PCTs, as well as the visits, emergencies and hospital admissions occurring in the hospitals. A logistical regression analysis was made to correct the model. The costs were contrasted by analysis of covariance (ANCOVA), with the estimation of marginal means (Bonferroni adjustment). Results. Of 900 patients with COPD, 14.3% (n=129) received treatment with TB (95% CI, 12.0%-16.6%). The mean episodes/patient/year was 2.1 (1.4) versus 1.8 (1.3) (NS), seriousness/severity 41.3% versus 26.3% (P =.001), defined daily dose (DDD) 5928.5 (9624.1) versus 6187.7 (12471.3) (NS) and number visits/patient/year 15.1 (9.4) versus 17.3(11.9) (P=.044). After adjustments for age and sex, TB use was associated with Diabetes Mellitus (OR=1.6; 95% CI, 1.0-2.5; P=.034) and severity of patients' illness (OR=1.8; 95% CI, 1.2-2.8; P=.004). Quantification of unit cost/year was 2793.16 (3166.30) euros (3359.27 [3423.25] euros versus 2703.09 [3113.75] euros; P=.001). The adjusted patient cost/year was 2831.23 euros (SE, 217.32) with TB versus 2786.86 euros (SE, 88.53) without TB (NS). Conclusions. TB is associated, as therapy complementing routine treatment, with the presence of Diabetes, and with the severity of the disease. The costs of COPD entail high resource consumption. The prescription of TB does not imply greater overall cost of the disease