Delving into public-expenditure elasticity: Evidence from a National Health Service acute-care hospital network.

Introduction: The sustainability of public hospital financing in Spain is a recurring issue, given its representativeness in annual public healthcare budgets which must adapt to the macroeconomic challenges that influence the evolution of spending. Knowing whether the responsiveness of hospital expenditure to its determinants (need, utilisation, and quasi-prices) varies according to the type of hospital could help better design strategies aimed at optimising performance.

Methods: Using SARIMAX models, we dynamically assess unique nationwide monthly activity data over a 14-year period from 274 acute-care hospitals in the Spanish National Health Service network, clustering these providers according to the average severity of the episodes treated.

Comparing Hospital Efficiency: An Illustrative Study of Knee and Hip Replacement Surgeries in Spain.

WHO's Health Systems Performance Assessment framework suggests monitoring a set of dimensions. This study aims to jointly assess productivity and quality using a treatment-based approach, specifically analyzing knee and hip replacement, two prevalent surgical procedures performed with consolidated technology and run in most acute-care hospitals. Focusing on the analysis of these procedures sets out a novel approach providing clues for hospital management improvements, covering an existing gap in the literature.

Has Arthroscopic Meniscectomy Use Changed in Response to the Evidence? A Large-database Study From Spain.

Background: Several randomized clinical trials on the treatment of meniscal tears have shown that surgery is not superior to nonoperative treatment in middle-aged and older adults. However, clinical practice has not changed consistently worldwide in response to this evidence, and arthroscopic meniscectomy remains one of the most frequently performed operations.

Questions/purposes: (1) How has the use of arthroscopic meniscectomy changed in Spain between 2003 and 2018, particularly in middle-aged (35 to 59 years) and older patients (over 60 years) relative to younger patients? (2) How have surgical volumes changed across different healthcare areas in the same health system? (3) How has the proportion of outpatient versus inpatient arthroscopic procedures changed over time?

Methods: Data on all 420,228 arthroscopic meniscectomies performed in Spain between 2003 and 2018 were obtained through the Atlas of Variations in Medical Practice project (these years were chosen because data in that atlas for 2002 and 2019 were incomplete).

Atlas VPM: two decades informing on unwarranted variations in health care in Spain.

Since the early 2000's, the Atlas of Variations in Medical Practice in the Spanish National Health System (namely, Atlas VPM) has been analysing and informing unwarranted variations in health care provision and outcomes in the Spanish Health System.Atlas VPM covers a two-fold perspective: a geographic one, where unwarranted variations would reflect the uneven exposure of the population to health care as a consequence of the place of residence; and, a provider-specific approach, where unwarranted variations would reflect differences in utilisation and outcomes that are at provider-level.Building on routine data (hospital and primary care electronic records, administrative data, geographic information, etc.

Factors underlying the growth of hospital expenditure in Spain in a period of unexpected economic shocks: A dynamic analysis on administrative data.

Aims: We sought to understand the evolution of Spanish public hospital expenditure by assessing its elasticity to volume versus price, controlling for need and case severity, from January 2003 to December 2015, a period of unexpected economic shocks.

Method: Observational study of administrative data characterising hospitals in the Spanish National Health System. Public hospital expenditure was modelled using SARIMAX in a two-step approach aiming at: a) eliciting structural changes in the monthly time-series; and, b) analysing the reaction of expenditure to the behaviour of its direct underlying factors over the sub-periods identified in the first step.

Public-private partnerships in the Spanish National Health System: The reversion of the Alzira model.

In the statutory Spanish National Health System (SNHS), the role of public provision is prominent. Nonetheless, since the inception of the SNHS, Regional Health Authorities have also purchased hospital care from private not-for-profit or for-profit providers, usually complementing public provision. Over the years, the autonomous community of Valencia has championed the use of Public Private Partnerships (PPP) in the form of administrative concessions (AC) awarded to private providers.

A comparative performance analysis of a renowned public private partnership for health care provision in Spain between 2003 and 2015.

Background: Recently, the once archetype of the public private partnership (PPP) in the Spanish National Health System (SNHS), namely the Alzira's Model, has come to an end. Advocates defended the superiority of PPPs over public-tenured provision, in terms of quality and technical efficiency. This paper profiles and compares Alzira's life-cycle performance with similar public-tenured providers.

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.

Evolution of public hospitals expenditure by healthcare area in the Spanish National Health System: the determinants to pay attention to.

Background: In Spain, hospital expenditure represents the biggest share of overall public healthcare expenditure, the most important welfare system directly run by the Autonomous Communities (ACs). Since 2001, public healthcare expenditure has increased well above the GDP growth, and public hospital expenditure increased at an even faster rate. This paper aims at assessing the evolution of need-adjusted public hospital expenditure at healthcare area level (HCA) and its association with utilisation and 'price' factors, identifying the relative contribution of ACs, as the main locus of health policy decisions.

Quality and technical efficiency do not evolve hand in hand in Spanish hospitals: Observational study with administrative data.

Objective: Recent evidence on the Spanish National Health System (SNHS) reveals a considerable margin for hospital efficiency and quality improvement. However, those studies do not consider both dimensions together. This study aims at jointly studying both technical efficiency (TE) and quality, classifying the public SNHS hospitals according to their joint performance.

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.

[Trend in potentially avoidable hospitalisations for chronic conditions in Spain].

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.

Comparing variation across European countries: building geographical areas to provide sounder estimates.

Background: In geographical studies, population distribution is a key issue. An unequal distribution across units of analysis might entail extra-variation and produce misleading conclusions on healthcare performance variations. This article aims at assessing the impact of building more homogeneous units of analysis in the estimation of systematic variation in three countries.

[Variability and opportunity costs among the surgical alternatives for breast cancer].

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.

[Dabigatran versus acenocumarol for the prevention of stroke in atrial fibrillation: budget impact analysis in one health department in Spain].

Background: To Estimate, in the context of a Health Department of the Valencia Health Agency, the budgetary impact of the widespread use of dabigatran at doses of 110 and 150 mg in patients with non-valvular atrial fibrillation (AF), regarding the current scenario with acenocoumarol therapy.

Methods: Budget impact analysis of three scenarios of oral anticoagulation use in AF: a) current treatment with acenocoumarol, b) widespread replacement of acenocoumarol for Dabigatran 110 mg and, c) idem at doses of 150 mg. The analysis was conducted from the perspective of the Valencia Health Agency with a time horizon of one year (2009).

Carpal tunnel release surgery: small-area variation and impact of ambulatory surgery in the autonomous region of Valencia, Spain.

Objective: This study aimed to analyze variability in rates of carpal tunnel release surgery among the healthcare areas of the autonomous region of Valencia, and to evaluate the contribution of ambulatory surgery and referrals to private hospitals to the variability found.

Methods: We carried out a cross-sectional, population-based study, describing the rates of carpal tunnel release surgery, standardized by age and sex, among areas in the region of Valencia in 2006. The observed variation was then analyzed using small-area analysis methods.

Pharmacoeconomic assessment of implementing a universal PCV-13 vaccination programme in the Valencian public health system (Spain).

Background: Heptavalent pneumococcal conjugate vaccine (PCV-7) was licensed to provide immunity against pneumococcal disease caused by seven serotypes of S. pneumoniae. Thirteen-valent pneumococcal conjugate vaccine (PCV-13) includes 6 additional serotypes for preventing invasive pneumococcal disease.

Income level and regional policies, underlying factors associated with unwarranted variations in conservative breast cancer surgery in Spain.

Background: Geographical variations in medical practice are expected to be small when the evidence about the effectiveness and safety of a particular technology is abundant. This would be the case of the prescription of conservative surgery in breast cancer patients. In these cases, when variation is larger than expected by need, socioeconomic factors have been argued as an explanation.

[Geographical bias in the inhospital mortality estimated by the Hospital Morbidity Survey].

Background: The Hospital Morbidity Survey (EMH) includes, at the moment, 85% of hospitals and 90% of discharges, and is the only national data source that allows to deepen with information about diagnostics, gender or age, in the study of hospitals as place of death. This work aims to analyze the presence of inhospital mortality geographical biases in the EMH in relation to the sample universe represented by the Statistics of Health Establishments with Inpatient Regime (EESCRI).

Methods: We compared, for each province in 2004, the EMH estimations for discharges, deaths and the percent of mortality with the data from the EESCRI, and adjusting one linear regression model for the number of deaths and a second model for the percent of mortality.

Using clopidogrel in non-ST-segment elevation acute coronary syndrome patients: a cost-utility analysis in Spain.

Objective: The objective of this study was to estimate the cost-effectiveness of clopidogrel, administered for 1 year after hospital admission for non-ST-segment elevation acute coronary syndrome in the Spanish public health network.

Methods: A cost-utility analysis was conducted from the societal perspective. A Markov decision tree was constructed for modeling the long-term cardiovascular events according to the probabilities of the CURE study, the Framingham study, and the Spanish age-sex-specific mortality rates.