Evolución temporal del gasto público hospitalario en el sistema nacional de salud

El gasto hospitalario es un foco creciente de atención en la evaluación de las políticas públicas en sanidad; es la partida más importante del gasto sanitario, su crecimiento es mayor que el experimentado por el gasto sanitario total, y crece proporcionalmente más que el PIB. Es importante analizar la evolución y variación del gasto hospitalario público y determinar cuantitativamente que impacto tiene en la variación de dicho gasto las variaciones de las tasas de utilización y las variaciones en el coste por ingreso ajustado a complejidad de las hospitalizaciones. HIPÓTESIS La hipótesis central de este trabajo es la hipótesis nula de no variabilidad entre áreas a lo largo del tiempo en el gasto hospitalario poblacional. OBJETIVOS Describir y cartografiar la variabilidad a lo largo del tiempo del gasto hospitalario poblacional, la tasa de utilización hospitalaria y el coste por ingreso ajustados a complejidad analizando además el impacto que tiene la variabilidad de las tasas de utilización hospitalarias y la variabilidad en los costes por ingreso ajustados por complejidad en la variación de dicho gasto. METODOLOGÍA Diseño: Estudio observacional, ecológico con un componente descriptivo del gasto hospitalario por habitante por área de salud en el periodo 2003-2011. Sujetos de estudio: Las 203 áreas geográficas de las 17 CCAA que participan en el Proyecto “Atlas de Variaciones en la Práctica Médica del Sistema Nacional de Salud”. Población: Todas las hospitalizaciones producidas por cualquier causa en hospitales de agudos del SNS. La asignación de cada alta hospitalaria se realizó a cada área geográfica. Variables: Dependiente: Gasto hospitalario poblacional (crudo y estandarizado) por habitante en cada área de salud. Independientes: - Edad y sexo. - Utilización hospitalaria cruda y estandarizada. - Coste por ingreso ajustado a complejidad. Estadísticos de Variabilidad: Razón de variación 5-95 (RV5-95), Componente sistemático de la variación (CSV)) y razones de utilización de gasto y de utilización y Coeficiente de Correlación Intraclase (CCI). Análisis de los factores subyacentes: utilización, precio y comunidad autónoma de residencia: Para valorar la importancia que sobre la variable dependiente tuvieron las variables independientes, se realizó un análisis de regresión múltiple. Para cuantificar la capacidad explicativa del factor CCAA de pertenencia se realizó para las mismas variables una regresión multinivel. Fuente de datos: El gasto hospitalario utilizado corresponde al gasto contable de los hospitales de agudos de la red pública conforme viene recogido en la Encuesta de Establecimientos Sanitarios con Régimen de internado. Los datos de actividad fueron extraídos del Conjunto Mínimo de Datos Básicos. La ponderación por severidad de cada una de las altas hospitalarias, se realizó utilizando el agrupador APR-DRG. Los datos de estructura poblacional provienen del Instituto Nacional de Estadística. RESULTADOS En el periodo 2003-2011 se realizaron más de 40 millones de hospitalizaciones en el SNS, con un gasto acumulado de 252.000 millones de euros. Entre el inicio y el final del periodo, la población creció en cerca de 4,5 millones de habitantes (10,5%) y el número de ingresos hospitalarios aumentó en 813.049 (20%). El gasto hospitalario público creció en 16.676 millones de euros (89%) –desde 18.670 millones en 2003 a 35.346 millones en 2011– mientras que el número de hospitales considerados en el análisis pasó de 244 a 284 (16,4%). Tasas utilización hospitalaria: La tasa creció un 6,5%, desde 9,72 hasta 10,36 por 100 habitantes con una variación atribuible a la CCAA del 40%, variabilidad no explicada por las diferencias demográficas. Coste por ingreso ajustado a complejidad: el coste por APR aumentó un 46%, desde 5.648 euros por APR en 2003 hasta 8.242 por APR en 2011. La variación atribuible a la CCAA explicaría más del 50% en todo el periodo. Gasto poblacional hospitalario estandarizado: gasto medio por habitante estandarizado creció un 71%, desde los 442 euros por habitante en el año 2003 hasta los 757 euros por habitante en 2011. La variación atribuible a la CCAA de residencia explicaría en torno al 10% hasta el año 2007, llegando a un 44% en el año 2011. Modelización multinivel: El modelo explicó año a año en torno al 80% de la varianza. La CCAA de residencia explicó alrededor del 40% de la varianza residual. La evolución de los coeficientes beta estandarizados muestran porcentualmente, que la importancia del peso relativo de la utilización en el gasto hospitalario por habitante desciende un 42%, mientras la importancia del coste por ingreso ajustado a complejidad aumenta ligeramente en un 12%. CONCLUSIONES - Gran crecimiento del gasto hospitalario por habitante entre 2003-2011, (del 70% en euros corrientes y del 38% en euros constantes) con dos periodos. El periodo 2003-2009, años de gran crecimiento, y a partir del 2009 se produce una notable reducción en el ritmo de crecimiento. - Una gran variabilidad en el gasto hospitalario por habitante entre áreas de salud que, además, es creciente en el periodo a estudio. El gasto hospitalario por habitante según área de residencia varió entre 337 y 566 euros (RV5-95=1,68) en 2003 y entre 573 y 1099 euros (RV5-95=1,92) al final del periodo. - El número de hospitalizaciones ha aumentado en un 6% manteniéndose la variabilidad entre áreas constante a lo largo de los años (RV5-95 en torno a 1,80). - El coste medio por ingreso (ajustado por APR) se ha incrementado en un 46% en el periodo (desde 5.648 euros/ingreso en 2003 a 8.242 euros/ingreso en 2011), aumentando también la variabilidad entre áreas (RV5-95=1,56 en 2003 y RV5-95=2,01 en 2011) en esta variable (así, y para 2011, el coste por ingreso en el área en el P5 fue de 6.368 euros, por 12.809 en el área en el P95). - La importancia relativa de la utilización hospitalaria sobre el gasto hospitalario por habitante se reduce en el periodo, mientras que la importancia del coste por ingreso ajustados a complejidad se mantiene e incluso aumenta. - La CCAA de residencia tiene un notable impacto sobre las tasas de utilización (en torno al 40%), que se mantiene relativamente constante durante el periodo, y también sobre el gasto hospitalario por habitante que se incrementa al inicio de la crisis económica (44% en 2011)

El canon de entrada en la cadena de franquicia

En el presente trabajo se pretende analizar las características del pago que realiza el franquiciado al franquiciador por su entrada en la cadena de franquicia. Este desembolso, conocido como canon de entrada, es un medio de cubrir los costes que soporta el franquiciador al abrirse un nuevo establecimiento de franquicia, que engloba, entre otros, asistencia técnica, objetos promocionales y diseño del establecimiento. El canon de entrada se encuadra en el contexto de los ingresos totales obtenidos por el franquiciador por parte del franquiciado, que incluyen los royalties en función de la facturación anual del negocio, que se conocen como canon de funcionamiento. A lo largo del artículo se discuten los elementos que influyen en la fijación del canon de entrada y se contrasta empíricamente el grado de influencia ejercido por cada una de estas variable

Evolución de las hospitalizaciones potencialmente evitables por condiciones crónicas en España

ResumenObjetivosAnalizar la evolución de las tasas de hospitalizaciones potencialmente evitables (HPE) que afectan a pacientes crónicos o frágiles en España durante el periodo 2002-2013.MétodosEstudio observacional, ecológico, sobre la evolución de las tasas estandarizadas de hospitalizaciones por seis condiciones clínicas, y su variación, en las 203 áreas sanitarias del Sistema Nacional de Salud.ResultadosEn el periodo estudiado hubo un descenso relativo del 35% en las tasas de HPE, pero la variación sistemática se mantuvo en cifras moderadas, alrededor de un 13% sobre lo esperado por azar. Las admisiones por angina experimentaron la mayor reducción, seguidas de las de asma y enfermedad pulmonar obstructiva crónica. Por el contrario, las hospitalizaciones por deshidratación doblaron su frecuencia.ConclusionesA pesar del descenso observado en las tasas de HPE, sigue existiendo una variación sistemática entre áreas, que apuntaría a un manejo diferencial de las condiciones crónicas que conduciría a resultados sanitarios distintos.AbstractObjectiveTo analyse the trend in potentially avoidable hospitalisations (PAH) in frail patients or those with chronic conditions in Spain during the period 2002-2013.MethodsAn 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.ResultsDuring the period 2002-2013, overall PAH standardised rates decreased by 35%, but systematic variation remained moderately high, around 13% above that expected by chance. Angina admissions showed the largest reduction, followed by those for asthma and chronic obstructive pulmonary disease. In contrast, the prevalence of admissions for dehydration doubled.ConclusionsDespite the decrease in PAH rates, systematic variation among areas remains, indicating differences in chronic care management that lead to distinct healthcare outcomes

Coauthorship and Institutional Collaborations on Cost-Effectiveness Analyses: A Systematic Network Analysis

Background: Cost-Effectiveness Analysis (CEA) has been promoted as an important research methodology for determining the efficiency of healthcare technology and guiding medical decision-making. Our aim was to characterize the collaborative patterns of CEA conducted over the past two decades in Spain. Methods and Findings: A systematic analysis was carried out with the information obtained through an updated comprehensive literature review and from reports of health technology assessment agencies. We identified CEAs with outcomes expressed as a time-based summary measure of population health (e.g. quality-adjusted life-years or disabilityadjusted life-years), conducted in Spain and published between 1989 and 2011. Networks of coauthorship and institutional collaboration were produced using PAJEK software. One-hundred and thirty-one papers were analyzed, in which 526 authors and 230 institutions participated. The overall signatures per paper index was 5.4. Six major groups (one with 14 members, three with 7 members and two with 6 members) were identified. The most prolific authors were generally affiliated with the private-for-profit sector (e.g. consulting firms and the pharmaceutical industry). The private-for-profit sector mantains profuse collaborative networks including public hospitals and academia. Collaboration within the public sector (e.g. healthcare administration and primary care) was weak and fragmented. Conclusions: This empirical analysis reflects critical practices among collaborative networks that contributed substantially to the production of CEA, raises challenges for redesigning future policies and provides a framework for similar analyses in other regions

Transparency, openness, and reproducible research practices are frequently underused in health economic evaluations

Objectives: To investigate the extent to which articles of economic evaluations of healthcare interventions indexed in MEDLINE incorporate research practices that promote transparency, openness, and reproducibility. Study design and setting: We evaluated a random sample of health economic evaluations indexed in MEDLINE during 2019. We included articles written in English reporting an incremental cost-effectiveness ratio in terms of costs per life years gained, quality-adjusted life years, and/or disability-adjusted life years. Reproducible research practices, openness, and transparency in each article were extracted in duplicate. We explored whether reproducible research practices were associated with self-report use of a guideline. Results: We included 200 studies published in 147 journals. Almost half were published as open access articles (n = 93; 47%). Most studies (n = 150; 75%) were model-based economic evaluations. In 109 (55%) studies, authors self-reported use a guideline (e.g., for study conduct or reporting). Few studies (n = 31; 16%) reported working from a protocol. In 112 (56%) studies, authors reported the data needed to recreate the incremental cost-effectiveness ratio for the base case analysis. This percentage was higher in studies using a guideline than studies not using a guideline (72/109 [66%] with guideline vs. 40/91 [44%] without guideline; risk ratio 1.50, 95% confidence interval 1.15-1.97). Only 10 (5%) studies mentioned access to raw data and analytic code for reanalyses. Conclusion: Transparency, openness, and reproducible research practices are frequently underused in health economic evaluations. This study provides baseline data to compare future progress in the field.F.C-L. is supported by the Institute of Health Carlos III/CIBERSAM. D.M. is supported by a University Research Chair, University of Ottawa. The funders were not involved in the design of the study or de cision to submit the manuscript for publication, nor they were involved in aspect of the study conduct. The views expressed in this manuscript are those of the authors and may not be understood or quoted as being made on behalf of, or reflection of the position of, the funder(s) or any institution.S

The pharmacological and non-pharmacological treatment of attention deficit hyperactivity disorder in children and adolescents: protocol for a systematic review and network meta-analysis of randomized controlled trials

[Background] Attention deficit hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders of children and adolescents, with a significant impact on health services and the community in terms of economic and social burdens. The objective of this systematic review will be to evaluate the comparative efficacy and safety of pharmacological and non-pharmacological treatments in children and adolescents with ADHD.[Methods] Searches involving PubMed/MEDLINE and the Cochrane Database of Systematic Reviews will be used to identify related systematic reviews and relevant randomized trials. Search results will be supplemented by reports from the regulatory and health technology agencies, clinical trials registers and by data requested from trialists and/or pharmaceutical companies. We will consider studies evaluating pharmacological interventions (e.g. stimulants, non-stimulants, antidepressants), psychological interventions (e.g. behavioural interventions, cognitive training and neurofeedback) and complementary and alternative medicine interventions (e.g. dietary interventions, supplement with fatty acids, vitamins, minerals, aminoacids, herbal treatment, homeopathy, and mind-body interventions including massage, chiropractic, acupuncture, yoga, meditation, Tai chi). Eligible control conditions will be placebo, waitlist, no treatment and usual care. Randomized controlled trials of a minimum of 3 weeks duration will be included. The primary outcomes of interest will be the proportion of patients who responded to treatment and who dropped out of the allocated treatment, respectively. Secondary outcomes will include treatment discontinuation due to adverse events, as well as the occurrences of serious adverse events and specific adverse events (decreased weight, anorexia, insomnia and sleep disturbances, anxiety, syncope and cardiovascular events). Two reviewers will independently screen references identified by the literature search, as well as potentially relevant full-text articles in duplicate. Data will be abstracted and risk of bias will be appraised by two team members independently. Conflicts at all levels of screening and abstraction will be resolved through discussion. Random-effects pairwise meta-analyses and Bayesian network meta-analyses will be conducted where appropriate. .[Discussion] This systematic review and network meta-analysis will compare the efficacy and safety of treatments used for ADHD in children and adolescents. The findings will assist patients, clinicians and healthcare providers to make evidence-based decisions regarding treatment selection.Specific funding is provided by the Alicia Koplowitz Foundation (2014 to 2016). RT-S is supported by the Spanish Psychiatric Research Network, Spanish Ministry of Science and Innovation (CIBERSAM). ADM is partially funded by grant number R24 AT001293 from the National Center for Complementary and Alternative Medicine (NCCAM) of the US National Institutes of Health. DM is funded by a University of Ottawa Research Chair

Marine ecosystems observation by a cooperative AUV in the PLOME project

To improve our understanding of how marine ecosystems function, it is crucial to quantify their processes using proper spatio-temporal multiparametric monitoring techniques. Science and innovative technologies must play a central role in developing the Blue Growth in a sustainable manner, where advances in enabling technologies such as remote sensing, modelling, AI and autonomous systems, will enhance our capacity to monitor and predict, assess and manage ecosystems. The PLOME project proposes a spatially adaptive, non-invasive, modular platform of independent and wirelessly connected benthic stations and AUVs to intelligently observe, monitor and map marine ecosystems, during long-lasting periods with real-time supervision. The monitoring solution has a simple deployment and is easy-to-move from an experimental site to another, without any cable installation, for coastal and deep water environments. Stations provide continuous and intensive temporal observation, while AUVs can provide such intensive measurement at spatial level, when they undock for a mission from a station in which they previously recharged batteries and transmitted information. The PLOME project will demonstrate the proposed concept in two scenarios. The first one, involves testing independent capabilities in a real deep-sea scenario, while the second one entails a oneweek demonstration in shallow water, where an AUV will be operated from a docking station. This paper describes the Girona 1000 AUV from the Universitat de Girona that will be used for the deep tests , conducted at depths ranging from 200 to 400 meters. The AUV will be used in cooperation with two fixed stations developed by the Universitat Politècnica de Catalunya. Acoustic communications and ranges between the AUV and the stations will be used to coordinate the AUV’s work and to improve its navigation. Optical communications will be used to transmit data to the stations gathered from the AUV observations. The AUV will integrate a multimodal sensor payload, including an optical camera and LED lighting system, a laser for microbathymetry and a forward-looking sonar for acoustic mapping. The AUV will also be able to process some of the data to transmit relevant information to the stations. Deep learning techniques will be used in real-time to detect species on the optical camera images, 3D point-clouds will be generated to describe the seabed’s profile, and onboard acoustic mosaicking will generate an acoustic map of the seabed.Peer Reviewe

Cancer and central nervous system disorders: protocol for an umbrella review of systematic reviews and updated meta-analyses of observational studies

BACKGROUND: The objective of this study will be to synthesize the epidemiological evidence and evaluate the validity of the associations between central nervous system disorders and the risk of developing or dying from cancer. METHODS/DESIGN: We will perform an umbrella review of systematic reviews and conduct updated meta-analyses of observational studies (cohort and case-control) investigating the association between central nervous system disorders and the risk of developing or dying from any cancer or specific types of cancer. Searches involving PubMed/MEDLINE, EMBASE, SCOPUS and Web of Science will be used to identify systematic reviews and meta-analyses of observational studies. In addition, online databases will be checked for observational studies published outside the time frames of previous reviews. Eligible central nervous system disorders will be Alzheimer's disease, anorexia nervosa, amyotrophic lateral sclerosis, autism spectrum disorders, bipolar disorder, depression, Down's syndrome, epilepsy, Huntington's disease, multiple sclerosis, Parkinson's disease and schizophrenia. The primary outcomes will be cancer incidence and cancer mortality in association with a central nervous system disorder. Secondary outcome measures will be site-specific cancer incidence and mortality, respectively. Two reviewers will independently screen references identified by the literature search, as well as potentially relevant full-text articles. Data will be abstracted, and study quality/risk of bias will be appraised by two reviewers independently. Conflicts at all levels of screening and abstraction will be resolved through discussion. Random-effects meta-analyses of primary observational studies will be conducted where appropriate. Parameters for exploring statistical heterogeneity are pre-specified. The World Cancer Research Fund (WCRF)/American Institute for Cancer Research (AICR) criteria and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach will be used for determining the quality of evidence for cancer outcomes. DISCUSSION: Our study will establish the extent of the epidemiological evidence underlying the associations between central nervous system disorders and cancer and will provide a rigorous and updated synthesis of a range of important site-specific cancer outcomes. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42016052762

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

<p>Abstract</p> <p>Background</p> <p>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. Objectives: Using an ecologic design, our study aims at describing the variability in the use of surgical conservative versus non-conservative treatment. Additionally, it seeks to establish whether the socioeconomic status of the healthcare area influences the use of one or the other technique.</p> <p>Methods</p> <p>81,868 mastectomies performed between 2002 and 2006 in 180 healthcare areas were studied. Standardized utilization rates of breast cancer conservative (CS) and non-conservative (NCS) procedures were estimated as well as the variation among areas, using small area statistics. Concentration curves and dominance tests were estimated to determine the impact of income and instruction levels in the healthcare area on surgery rates. Multilevel analyses were performed to determine the influence of regional policies.</p> <p>Results</p> <p>Variation in the use of CS was massive (4-fold factor between the highest and the lowest rate) and larger than in the case of NCS (2-fold), whichever the age group. Healthcare areas with higher economic and instruction levels showed highest rates of CS, regardless of the age group, while areas with lower economic and educational levels yielded higher rates of NCS interventions. Living in a particular Autonomous Community (AC), explained a substantial part of the CS residual variance (up to a 60.5% in women 50 to 70).</p> <p>Conclusion</p> <p>The place where a woman lives -income level and regional policies- explain the unexpectedly high variation found in utilization rates of conservative breast cancer surgery.</p

A new approach to use marine robotic networks for ecosystem monitoring and management: The PLOME Project

4th Marine Imaging Workshop, 3-6 October 2022, Brest, FranceOur understanding of marine ecosystem functioning and processes relies on adequate spatio-temporal multiparametric monitoring procedures. Over the next 3 years, the Project PLOME (Platforms for Long-lasting Observation of Marine Ecosystems) will implement a spatially adaptive and autonomous network of easy-to-use benthic landers with dockable Autonomous Underwater Vehicles (AUVs)ñ This network will be used to intelligently video-monitor and map marine ecosystems and their environment from coastal to deep-sea areas. All platforms will be connected via acoustic or optical communication and will operate over periods of weeks to months with real-time supervision. Stations will provide continuous and intensive temporal observations, while dockable AUVs (with battery recharge and data downloading capability) will provide intensive measurements at various spatial scales, using intelligent and adaptive trajectories to explore surrounding areas. Biological, geochemical and oceanographic data will be generated by an array of sensors including acoustic receivers and cameras. Images will be processed in real-time for species classification and tracking, using advanced data analysis and Deep Learning techniques. Metadata will be communicated between landers and AUVs and transmitted opportunistically whenever an Unmanned Surface Vehicle (USV) connects the platform via aerial communications (i.e. GSM and satellite communications, depending on form distance to shore). The unattended operation will also be possible with an innovation of pop-up buoys that will allow data transfer to the surface from landers and UAVs to be relayed once the pop-up buoys reach the surface. Complex ecological indicators for ecosystem management will be computed from the collected data, by applying advanced computer vision techniques to classify, count and size individuals in video images and to generate multimodal maps of the seabed. A pipeline for automated data treatment will be tailored for multiparametric analyses to derive cause-effect relationships between biological variables and the physical habitatsPeer reviewe