Willingness to pay for a quality-adjusted life year: an evaluation of attitudes towards risk and preferences

BACKGROUND: This paper examines the Willingness to Pay (WTP) for a quality-adjusted life year (QALY) expressed by people who attended the healthcare system as well as the association of attitude towards risk and other personal characteristics with their response. METHODS: Health-state preferences, measured by EuroQol (EQ-5D-3L), were combined with WTP for recovering a perfect health state. WTP was assessed using close-ended, iterative bidding, contingent valuation method. Data on demographic and socioeconomic characteristics, as well as usage of health services by the subjects were collected. The attitude towards risk was evaluated by collecting risky behaviors data, by the subject’s self-evaluation, and through lottery games. RESULTS: Six hundred and sixty two subjects participated and 449 stated a utility inferior to 1. WTP/QALY ratios varied significantly when payments with personal money (mean €10,119; median €673) or through taxes (mean €28,187; median €915) were suggested. Family income, area income, higher education level, greater use of healthcare services, and the number of co-inhabitants were associated with greater WTP/QALY ratios. Age and female gender were associated with lower WTP/QALY ratios. Risk inclination was independently associated with a greater WTP/QALY when “out of pocket” payments were suggested. Clear discrepancies were demonstrated between linearity and neutrality towards risk assumptions and experimental results. CONCLUSIONS: WTP/QALY ratios vary noticeably based on demographic and socioeconomic characteristics of the subject, but also on their attitude towards risk. Knowing the expression of preferences by patients from this outcome measurement can be of interest for health service planning

Effectiveness of a strategy that uses educational games to implement clinical practice guidelines among Spanish residents of family and community medicine (e-EDUCAGUIA project):A clinical trial by clusters

This study was funded by the Fondo de Investigaciones Sanitarias FIS Grant Number PI11/0477 ISCIII.-REDISSEC Proyecto RD12/0001/0012 AND FEDER Funding.Background: Clinical practice guidelines (CPGs) have been developed with the aim of helping health professionals, patients, and caregivers make decisions about their health care, using the best available evidence. In many cases, incorporation of these recommendations into clinical practice also implies a need for changes in routine clinical practice. Using educational games as a strategy for implementing recommendations among health professionals has been demonstrated to be effective in some studies; however, evidence is still scarce. The primary objective of this study is to assess the effectiveness of a teaching strategy for the implementation of CPGs using educational games (e-learning EDUCAGUIA) to improve knowledge and skills related to clinical decision-making by residents in family medicine. The primary objective will be evaluated at 1 and 6months after the intervention. The secondary objectives are to identify barriers and facilitators for the use of guidelines by residents of family medicine and to describe the educational strategies used by Spanish teaching units of family and community medicine to encourage implementation of CPGs. Methods/design: We propose a multicenter clinical trial with randomized allocation by clusters of family and community medicine teaching units in Spain. The sample size will be 394 residents (197 in each group), with the teaching units as the randomization unit and the residents comprising the analysis unit. For the intervention, both groups will receive an initial 1-h session on clinical practice guideline use and the usual dissemination strategy by e-mail. The intervention group (e-learning EDUCAGUIA) strategy will consist of educational games with hypothetical clinical scenarios in a virtual environment. The primary outcome will be the score obtained by the residents on evaluation questionnaires for each clinical practice guideline. Other included variables will be the sociodemographic and training variables of the residents and the teaching unit characteristics. The statistical analysis will consist of a descriptive analysis of variables and a baseline comparison of both groups. For the primary outcome analysis, an average score comparison of hypothetical scenario questionnaires between the EDUCAGUIA intervention group and the control group will be performed at 1 and 6months post-intervention, using 95% confidence intervals. A linear multilevel regression will be used to adjust the model. Discussion: The identification of effective teaching strategies will facilitate the incorporation of available knowledge into clinical practice that could eventually improve patient outcomes. The inclusion of information technologies as teaching tools permits greater learning autonomy and allows deeper instructor participation in the monitoring and supervision of residents. The long-term impact of this strategy is unknown; however, because it is aimed at professionals undergoing training and it addresses prevalent health problems, a small effect can be of great relevance. Trial registration: ClinicalTrials.gov: NCT02210442.Publisher PDFPeer reviewe

Effectiveness of an intervention for improving drug prescription in primary care patients with multimorbidity and polypharmacy:Study protocol of a cluster randomized clinical trial (Multi-PAP project)

This study was funded by the Fondo de Investigaciones Sanitarias ISCIII (Grant Numbers PI15/00276, PI15/00572, PI15/00996), REDISSEC (Project Numbers RD12/0001/0012, RD16/0001/0005), and the European Regional Development Fund ("A way to build Europe").Background: Multimorbidity is associated with negative effects both on people's health and on healthcare systems. A key problem linked to multimorbidity is polypharmacy, which in turn is associated with increased risk of partly preventable adverse effects, including mortality. The Ariadne principles describe a model of care based on a thorough assessment of diseases, treatments (and potential interactions), clinical status, context and preferences of patients with multimorbidity, with the aim of prioritizing and sharing realistic treatment goals that guide an individualized management. The aim of this study is to evaluate the effectiveness of a complex intervention that implements the Ariadne principles in a population of young-old patients with multimorbidity and polypharmacy. The intervention seeks to improve the appropriateness of prescribing in primary care (PC), as measured by the medication appropriateness index (MAI) score at 6 and 12months, as compared with usual care. Methods/Design: Design:pragmatic cluster randomized clinical trial. Unit of randomization: family physician (FP). Unit of analysis: patient. Scope: PC health centres in three autonomous communities: Aragon, Madrid, and Andalusia (Spain). Population: patients aged 65-74years with multimorbidity (≥3 chronic diseases) and polypharmacy (≥5 drugs prescribed in ≥3months). Sample size: n=400 (200 per study arm). Intervention: complex intervention based on the implementation of the Ariadne principles with two components: (1) FP training and (2) FP-patient interview. Outcomes: MAI score, health services use, quality of life (Euroqol 5D-5L), pharmacotherapy and adherence to treatment (Morisky-Green, Haynes-Sackett), and clinical and socio-demographic variables. Statistical analysis: primary outcome is the difference in MAI score between T0 and T1 and corresponding 95% confidence interval. Adjustment for confounding factors will be performed by multilevel analysis. All analyses will be carried out in accordance with the intention-to-treat principle. Discussion: It is essential to provide evidence concerning interventions on PC patients with polypharmacy and multimorbidity, conducted in the context of routine clinical practice, and involving young-old patients with significant potential for preventing negative health outcomes. Trial registration: Clinicaltrials.gov, NCT02866799Publisher PDFPeer reviewe

Implementación de guías de práctica clínica en el entorno de la formación sanitaria especializada : un estudio de barreras, facilitadores y de la efectividad de una estrategia basada en juegos educativos

Las Guías de Práctica Clínica (GPC) son un conjunto de “recomendaciones desarrolladas de forma sistemática para ayudar a profesionales y pacientes a tomar decisiones sobre la atención sanitaria más apropiada, y a seleccionar las opciones diagnósticas o terapéuticas más adecuadas a la hora de abordar un problema de salud o una condición clínica específica”. Tienen la potencialidad de reducir la variabilidad y mejorar la práctica clínica, y pueden ser consideradas como instrumentos clave para la transferencia del conocimiento a la práctica clínica. Diferentes estudios han demostrado que el seguimiento de las recomendaciones de determinadas GPC mejora los resultados en salud de los pacientes, sin embargo, su publicación y difusión no conlleva necesariamente su utilización en la práctica, por lo que es necesario diseñar planes de implementación que faciliten este proceso utilizando estrategias de comunicación efectivas para promover el cambio. Lo que requiere un proceso de planificación donde hay que prestar especial atención al contexto -tanto institucional como social-, y a identificar las barreras y facilitadores que dificultarán o favorecerán el cambio en la práctica. Varios estudios han valorado la percepción y actitud de los médicos españoles hacia las GPC, pero en ninguno de ellos se ha centrado en los médicos residentes durante su formación especializada, momento crucial en el que puedan integrar en su práctica habitual el conocimiento de las GPC. En los últimos años los programas docentes de formación de especialistas están incorporando el uso de las GPC como herramientas para adquirir muchas de las competencias. El programa formativo de la especialidad de Medicina Familiar y Comunitaria (MFyC) en España ha sido pionero en este sentido no obstante existe evidencia del uso limitado que se hace de las GPC tanto por parte de los residentes como de los tutores en otros ámbitos. Se ha estudiado la efectividad de diferentes estrategias para aumentar la adherencia a las recomendaciones de las GPC, concluyendo que la mayoría de ellas mejoraban la adherencia y que la incorporación de programas educativos, casi siempre como componentes de intervenciones más complejas mejoraban estos resultados. Algunas de estas estrategias han sido dirigidas a médicos residentes. En los últimos años estamos asistiendo a la incorporación de los juegos en entornos de aprendizaje virtual como herramienta de apoyo docente en la formación de estudiantes y médicos residentes. Estos juegos permiten que el alumno adquiera nuevos conocimientos y habilidades de una manera interactiva y lúdica y cuentan con una elevada aceptación pero se precisan estudios adecuadamente diseñados ya que sigue siendo controvertida su eficacia didáctica. Varios grupos han evaluado su efectividad como estrategia de implementación de GPC mejorando la adherencia a sus recomendaciones a través de la mejora de sus conocimientos, habilidades y actitudes. Su uso permite desarrollar escenarios virtuales de toma de decisiones vinculados a las recomendaciones de las GPC. La revisión Cochrane que ha evaluado su efectividad concluye que es necesario realizar investigaciones de calidad que exploren el impacto de los juegos educativos en la formación de los profesionales de la salud.MadridES

Explicar las diferencias en cuanto a la calidad de vida percibida relacionada con la salud: estudio realizado en la población española

To assess the burden of several determinants on health-related quality of life (HRQOL) and to study its heterogeneity among the different Spanish regions. Cross-sectional study. Data were obtained from the Spanish National Health Survey (2012), and HRQOL was measured using the EQ-5D-5L questionnaire (utility and visual analogue scale -VAS- scores). Demographic variables, physical health condition, social variables, mental health status, and lifestyle were also analysed. Tobit regression models were employed to study the relationships between expressed HRQOL and personal characteristics. A total of 20,979 surveys were obtained. Of them, 62.4% expressed a utility score of 1, corresponding to perfect health (95%CI: 61.8%-63.2%), and 54.2% showed VAS scores ≥80 (95%CI: 53.5%-54.9%). HRQOL was mainly described as a function of age, chronic limitation in daily activities, and mental health status. Belonging to a higher-class strata and physical activity were related to better self-perceived HRQOL. Ageing worsened perceived HRQOL, but did not influence its determinants, and differences in HRQOL by regions were also not significant after model adjustment. HRQOL perception in the Spanish population varied slightly depending on the measure used (utilities index or VAS). Age, chronic limitations in daily life, and mental health status best explained the variability in perception, and no meaningful differences in HRQOL perception among regions were found after adjustment.This manuscript has been translated and edited with the support of ISCIII and FEDER Funds, Grant Number RD12/0001/0012. Publication charges have been supported by ISCIII, grant Number 1300648.S