Post-discharge impact and cost-consequence analysis of prehabilitation in high-risk patients undergoing major abdominal surgery: secondary results from a randomised controlled trial.

BACKGROUND: Prehabilitation may reduce postoperative complications, but sustainability of its health benefits and impact on costs needs further evaluation. Our aim was to assess the midterm clinical impact and costs from a hospital perspective of an endurance-exercise-training-based prehabilitation programme in high-risk patients undergoing major digestive surgery. METHODS: A cost-consequence analysis was performed using secondary data from a randomised, blinded clinical trial. The main outcomes assessed were (i) 30-day hospital readmissions, (ii) endurance time (ET) during an exercise testing, and (iii) physical activity by the Yale Physical Activity Survey (YPAS). Healthcare use for the cost analysis included costs of the prehabilitation programme, hospitalisation, and 30-day emergency room visits and hospital readmissions. RESULTS: We included 125 patients in an intention-to-treat analysis. Prehabilitation showed a protective effect for 30-day hospital readmissions (relative risk: 6.4; 95% confidence interval [CI]: 1.4-30.0). Prehabilitation-induced enhancement of ET and YPAS remained statistically significant between groups at the end of the 3 and 6 month follow-up periods, respectively (ΔET 205 [151] s; P=0.048) (ΔYPAS 7 [2]; P=0.016). The mean cost of the programme was €389 per patient and did not increment the total costs of the surgical process (€812; CI: 95% -878 - 2642; P=0.365). CONCLUSIONS: Prehabilitation may result in health value generation. Moreover, it appears to be a protective intervention for 30-day hospital readmissions, and its effects on aerobic capacity and physical activity may show sustainability at midterm. CLINICAL TRIAL REGISTRATION: NCT02024776.

Review of the literature on reference pricing.

This paper reviews the literature on reference pricing (RP) in pharmaceutical markets. The RP strategy for cost containment of expenditure on drugs is analyzed as part of the procurement mechanism. We review the existing literature and the state-of-the-art regarding RP by focusing on its economic effects. In particular, we consider: (1) the institutional context and problem-related factors which appear to underline the need to implement an RP strategy; i.e. its nature, characteristics and the sort of health care problems commonly addressed; (2) how RP operates in practice; that is, how third party-payers (the insurers/buyers) have established the RP systems existing on the international scene (i.e. information methods, monitoring procedures and legislative provisions); (3) the range of effects resulting from particular RP strategies (including effects on choice of appropriate pharmaceuticals, insurer savings, total drug expenditures, prices of referenced and non-referenced products and dynamic efficiency; (4) the market failures which an RP policy is supposed to address and the main advantages and drawbacks which emerge from an analysis of its effects. Results suggest that RP systems achieve better their postulated goals (1) if cost inflation in pharmaceuticals is due to high prices rather than to the excess of prescription rates, (2) when the larger is the existing difference in prices among equivalent drugs, and (3) more important is the actual market for generics.

[Knowledge, values and politics in health economics]. / Conocimientos, valores y políticas en economía de la salud.

OBJECTIVE: To assess the level of agreement in positive questions, and policy-value questions in Health Economics of the members of the Spanish Health Economics Association (AES). METHODS: A survey was made among the members of the AES (42 academic health economists, 196 health managers, and 34 practising physicians). The survey included 20 positive questions, 11 policy questions, 4 value questions, and 5 socio-demographic questions. An analysis of the average absolute differences between percentage agreeing and percentage disagreeing by type of question was performed. RESULTS: Two main results can be identified. First, there are no significant differences in the level of agreement between health economists, health care managers and practising physicians with respect to positive and policy-value questions. Second, there is no significant difference in the level of agreement in the three identified groups between type of questions (positive versus policy-value questions). CONCLUSION: There are no significant differences in the agreement about the positive questions between the three identified groups in the AES (academic health economists, health care managers and practising physicians.

[Cost-effectiveness analysis of self-monitoring of blood glucose in type 2 diabetics]. / Análisis coste-efectividad de la automonitorización de la glucosa sanguínea en diabéticos tipo 2.

OBJECTIVE: Compare the cost-effectiveness of self-monitoring of blood glucose (MBG) with your non-use. DESIGN: Descriptive and retrospective study covering the period 1995-97 in the 597 type-2 diabetes patients: 286 practicing MBG on a stable basis and 311 not doing so. All are registered in seven health districts in the territorial ambit of Tortosa Primary Care. Were quantified the direct costs in relation to consumption of reagent strips for the practice of MBG, outpatients visits in your primary care center, derivations to specialist of reference and complementary test according to recommendations of the European NIDDM Policy Group in the population user of MBG and no-user; the annual cost increment, the average annual cost and the total annual cost in the population user of MBG and in the application of a ideal model of quantitative and qualitative cover according to clinical recommendations of the Gedaps; and the cost-effectiveness. RESULTS: While the 78% of the total diabetic population satisfy some clinical indication for prescribing MBG, only the 42.5% practice the MBG. The consumption of reagent strips rising of 8% to 15% of the global cost of the diabetic population. In the application of the ideal model of cover, this cost increase up the 30% of global cost. The effectiveness obtained, an 27%, not are significantly different in the population user of MBG and no user. The cost-effectiveness in the user of MBG increased of 210.789 ptes/year to 213.148 ptes/year; and no-user of 162.019 ptes/year to 162.051 ptes/year. The application of ideal model of cover and the gain of an effectiveness near to possible level of efficiency imply an descent average of cost-effectiveness of approximately 60%: 78.904 ptes/year in user MBG and 54.682 ptes/year in no-user. CONCLUSIONS: 1. We choose in the presents conditions the option of no-user MBG. 2. The average cost-effectiveness per diabetic patient will increase by the needs of accommodate the therapy to new standards of metabolic control. 3. Are clear opportunity for the improve the management and to motivate an efficient use of technology associate to defects of public sanitary market. 4. The model of ideal cover associated to greater effectiveness are necessary for to unify the economic and clinic efficiency.

[Efficiency in primary health care: a critical review of frontier measures]. / Eficiencia en la atención primaria de salud: una revisión crítica de las medidas de frontera.

The object of this paper is to review applied research on primary care efficiency in Spain performed using parametric and nonparametric production and cost frontiers. A review of the most important bibliographic databases showed 12 applied papers that used frontier approach to measure primary care efficiency in Spain. The most part of these papers only used Data Envelopment Approach to measure technical efficiency scores. There is only one study that has employed a stochastic and nonparametric approach to obtain cost efficiency estimates. Activity measures such as number of visits are a usual measure of output and inefficiency sources are rarely analysed in this literature. Important methodological problems observed in this literature severely limit their practical utility. Future research should consider more accurate output measures, use available methods more appropriately, and shed light on the sources of inefficiency.

[Review of the economic evidence on the use of deep brain stimulation in late stage Parkinson's disease]. / Revisión de la evidencia económica sobre el uso de la estimulación cerebral profunda en la enfermedad de Parkinson avanzada.

INTRODUCTION: The purpose of this article is to present the results of a systematic review on the costs and the efficiency of Deep Brain Stimulation (DBS) on patients suffering advanced Parkinson's disease. MATERIAL AND METHOD: A systematic review is performed using databases such as Medline, NHS EED and HTA del Centre for Reviews and Dissemination and Google Scholar from January 2001-2008. RESULTS: Ten articles meet the criteria; one cost description, four cost analyses and five economic evaluations. The scientific evidence shows a reduction in the pharmaceutical costs of those patients treated with DBS. Regarding the direct medical costs, the same statement cannot be made. While some studies estimate the equivalent annual cost of DBS is 54,7% higher than that of traditional therapy, other studies, which include indirect costs such as productivity losses or informal care, claim DBS costs 34,7% less. The incremental cost-effectiveness ratio per QALY is slightly above euro30.000 in 1998 in both the cost-utility analyses where the time horizon was 5 years or more. In the third cost-utility analysis, DBS is the dominant option when the equivalent annual cost was computed. CONCLUSIONS: The available evidence is not strong enough to conclude whether DBS' direct medical costs are higher or lower than the costs of traditional therapy. Key words: Parkinson's disease. Deep brain stimulation. Subthalamic stimulation. Cost analysis. Economic evaluation.

Managing risk selection incentives in health sector reforms.

The object of the paper is to review theoretical and empirical contributions to the optimal management of risk selection incentives ('cream skimming') in health sector reforms. The trade-off between efficiency and risk selection is fostered in health sector reforms by the introduction of competitive mechanisms such as price competition or prospective payment systems. The effects of two main forms of competition in health sector reforms are observed when health insurance is mandatory: competition in the market for health insurance, and in the market for health services. Market and government failures contribute to the assessment of the different forms of risk selection employed by insurers and providers, as the effects of selection incentives on efficiency and their proposed remedies to reduce the impact of these perverse incentives. Two European (Netherlands and Spain) and two Latin American (Chile and Colombia) case studies of health sector reforms are examined in order to observe selection incentives, their effects on efficiency and costs in the health system, and regulation policies implemented in each country to mitigate incentives to 'cream skim' good risks.

Technical efficiency in the clinical management of critically ill patients.

The purpose of this paper is to obtain empirical measures of performance in the management of critical patients treated in intensive care units (ICUs) and to evaluate the factors associated with performance, in a two stage approach. In the first stage, this paper uses an extended version of Data Envelopment Analysis (non-discretionary and categorical variables, and weight constraints under consideration) to obtain measures of technical efficiency in the treatment of 993 critical care patients in intensive care units in Catalonia (Spain) in 1991-92. The model incorporates accurate individual measures of illness severity from Mortality Probability Models (MPM II0) and quality outcome measures in the input-output set to obtain non-biased efficiency measures. In the second stage, a loglinear regression model is applied to test a number of hypothesis about the role of different environmental factors--such as ownership, market structure, dimension, internal organization, diagnostic, mortality risk, etc.--to explain differences in the efficiency scores.

[Vertical integration and contracting-out in generic hospital services in Spain]. / Integración vertical y contratación externa en los servicios generales de los hospitales españoles.

OBJECTIVES: This study examines the factors that influence make or buy decisions corresponding to four generic services (housekeeping, laundry, food services, and maintenance and security) in Spanish hospitals (3,160 transactions in 790 hospitals). METHODS: The empirical estimation of a logistic model based on hospital utility maximization is presented. Factors included in the model are not only those related to transaction costs, but also those related to public intervention and the political dimension. RESULTS: A total of 55.7% of hospitals contracted-out at least one of the generic services. The services most frequently contracted-out were housekeeping and maintenance and security(45.1 and 32.5%, respectively). In contrast, the services (94.3% and 80.1%, respectively). Hospital size (economies of scale), measured by the number of beds, was one of the most important factors influencing make or buy decisions. CONCLUSIONS: We find evidence that economies of scale are related to a higher level of vertical integration, while specialization and for-profit objectives favor the decision to contract-out. The choice of organizational model for laundry services presents a different pattern from that of the other three services. Empirical results show that some asset specificity could be present in laundry services.

Why do patients prefer hospital emergency visits? A nested multinomial logit analysis for patient-initiated contacts.

This paper analyzes the nature of health care provider choice in the case of patient-initiated contacts, with special reference to a National Health Service setting, where monetary prices are zero and general practitioners act as gatekeepers to publicly financed specialized care. We focus our attention on the factors that may explain the continuously increasing use of hospital emergency visits as opposed to other provider alternatives. An extended version of a discrete choice model of demand for patient-initiated contacts is presented, allowing for individual and town residence size differences in perceived quality (preferences) between alternative providers and including travel and waiting time as non-monetary costs. Results of a nested multinomial logit model of provider choice are presented. Individual choice between alternatives considers, in a repeated nested structure, self-care, primary care, hospital and clinic emergency services. Welfare implications and income effects are analyzed by computing compensating variations, and by simulating the effects of user fees by levels of income. Results indicate that compensating variation per visit is higher than the direct marginal cost of emergency visits, and consequently, emergency visits do not appear as an inefficient alternative even for non-urgent conditions.

Home hospitalisation of exacerbated chronic obstructive pulmonary disease patients.

It was postulated that home hospitalisation (HH) of selected chronic obstructive pulmonary disease (COPD) exacerbations admitted at the emergency room (ER) could facilitate a better outcome than conventional hospitalisation. To this end, 222 COPD patients (3.2% female; 71+/-10 yrs (mean+/-SD)) were randomly assigned to HH (n=121) or conventional care (n=101). During HH, integrated care was delivered by a specialised nurse with the patient's free-phone access to the nurse ensured for an 8-week follow-up period. Mortality (HH: 4.1%; controls: 6.9%) and hospital readmissions (HH: 0.24+/-0.57 controls: 0.38+/-0.70) were similar in both groups. However, at the end of the follow-up period, HH patients showed: 1) a lower rate of ER visits (0.13+/-0.43 versus 0.31+/-0.62); and 2) a noticeable improvement of quality of life (delta St George's Respiratory Questionnaire (SGRQ), -6.9 versus -2.4). Furthermore, a higher percentage of patients had a better knowledge of the disease (58% versus 27%), a better self-management of their condition (81% versus 48%), and the patient's satisfaction was greater. The average overall direct cost per HH patient was 62% of the costs of conventional care, essentially due to fewer days of inpatient hospitalisation (1.7+/-2.3 versus 4.2+/-4.1 days). A comprehensive home care intervention in selected chronic obstructive pulmonary disease exacerbations appears as cost effective. The home hospitalisation intervention generates better outcomes at lower costs than conventional care.

[Blood glucose self-monitoring (BGSM): an evaluation of its prescription and results in type-2 diabetes. The Research Group in Primary Care of Tortosa]. / Automonitorización de la glucosa sanguínea (MGS): evaluación de su prescripción y resultados en la diabetes tipo 2. Grup de Recerca en Atenció Primària Tortosa.

OBJECTIVES: To investigate the results of metabolic control among type-2 diabetics who practise self-monitoring of their blood glucose (MBG) and compare them with those who do not; the adequacy of MBG prescription according to clinical criteria and frequency of use; and to analyse the presence of factors predicting metabolic control. DESIGN: Descriptive and retrospective study covering 1995, 1996 and 1997. SETTING: The seven health districts in the territorial ambit of Tortosa Primary Care. PATIENTS: 597 type-2 diabetes patients were evaluated: 286 practising MBG, and 311 not doing so. All of them belonged to the health districts reference population. The sample was systematized and stratified by health districts in order to obtain data through a pre-designed data collection form. MEASUREMENTS AND MAIN RESULTS: 41.06% of diabetics practised MBG on a stable basis, without any significant differences showing in either HbA1c percentage, in any of the biological variables defining metabolic control in relation to the practice or otherwise of MBG, or in its frequency. An inverse relationship (p = 0.012) between the frequency of MBG and age was shown. Some clinical indication for prescribing MBG existed in 78.22% of the total diabetic population. In the diabetic population using MBG, inappropriate use of quantity was 54.89% (84.07% by too little, 15.92% in excess). Only 37.9% displayed quantitative and qualitative concordance simultaneously. The logistic model applied to the total diabetic population predicted 73.19% metabolic control with the variables of BMI (OR = 1.0542). Karnofsky index (OR = 0.9768) and presence of macroangiopathy (OR = 0.4249). CONCLUSIONS: 1. The practice of MBG is questionable, since the effectiveness found was not superior. 2. There is an imbalance between the real practice of MBG according to the clinical recommendations and consumption, which tends to be deficient. 3. The results do not seem to depend so much on MBG practice as on other linked circumstances which cannot be modified by MBG practice.

Integración vertical y contratación externa en los servicios generales de los hospitales españoles / Vertical integration and contracting-out in generic hospital services in Spain

Objetivos: Este estudio analiza los factores que influyen en las decisiones de integración vertical/contratación externa de cuatro servicios generales (limpieza, lavandería, alimentación y seguridad y mantenimiento) en los hospitales españoles (3.160 transacciones que corresponden a 790 hospitales). Métodos: Se presenta la estimación empírica de un modelo logístico de maximización de la utilidad de los hospitales, en el que intervienen no sólo factores relacionados con los costes de transacción, sino también otros relacionados con la intervención pública y la dimensión política. Resultados: El 55,7% de los hospitales contrata al menos uno de los servicios generales analizados. El servicio de limpieza es el que presenta un mayor grado de contratación externa (45,1%), seguido del servicio de seguridad y mantenimiento (32,5%). En cambio, el servicio de lavandería es el que presenta un mayor grado de integración vertical (94,3%) junto con el de alimentación (..) (AU)

Objectives: This study examines the factors that influence make or buy decisions corresponding to four generic services (housekeeping, laundry, food services, and maintenance and security) in Spanish hospitals (3,160 transactions in 790 hospitals). Methods: The empirical estimation of a logistic model based on hospital utility maximization is presented. Factors included in the model are not only those related to transaction costs, but also those related to public intervention and the political dimension. Results: A total of 55.7% of hospitals contracted-out at least one of the generic services. The services most frequently contracted-out were housekeeping and maintenance and security(45.1 and 32.5%, respectively). In contrast, the services (94.3% and 80.1%, respectively). Hospital size (economies of scale), measured by the number of beds, was one of the most important factors (..) (AU)