Economic evaluation in health research: cohort simultation and applications

Currently, resources that may be spent in health care are limited so it is necessary to rationalize their consumption and prioritise their allocation to the options with higher health outcome and economic sustainability. It is for that reason that economic analyses are increasingly included in medicine research as an instrument for evaluating different therapeutic strategies. In this thesis, both cost and health outcome are separately and jointly evaluated to compare different therapeutic strategies to treat diseases in different and specific health areas. The challenge was adapting and implementing the methods to reflect the assessed health issue. The analyses require data, and the main sources to obtain them are clinical studies (prospective or retrospective), or simulation models. The use of simulations avoids to experiment directly to the system of interest, these methods imply a smaller time consumption and cost, and any danger can be caused by the experimentation performance. However, the simulated data always is going to be an approximation of real data. Real data of a clinical trial was used in the assessment of the adherence to antiretroviral treatment promotion program in HIV infected patients. A decision tree was used to study the cost per health gain, measured by means of clinical and health related quality of life outcomes. The simulation of a Spanish cohort of postmenopausal women and their possible osteoporotic fractures was done to assess the performance of two treatments for the prevention of vertebral and non-vertebral fractures in terms of cost-effectiveness. Simulation by means of a Markov model required that the disease evolution and the related events were simplified using a finite number of health states and the probabilities of moving from one state to another as the time go on. Markov models were adapted to reflect that the risk of suffering an event can change over time. This analytical model was applied to elucidate whether co-receptors testing is cost-effective to determine patient¿s suitability to benefit from the use of an antiretroviral treatment that includes maraviroc. All HIV strains require binding to CD4 plus at least one of the 2 co-receptors CCR5 or CXCR4 to enter human cells. Some HIV can use both co-receptors, and some individuals have a mixture of strains. Only patients with exclusively CCR5-tropic HIV are considered eligible to use the CCR5 antagonist maraviroc. A budget impact analyses to assess the economic effects of introducing eculizumab for treating the paroxysmal nocturnal hemoglobinuria was performed. Direct and indirect costs of this disease treatment were estimated and reported from the perspective of the health care system and from the societal perspective. Most of the published clinical studies are focused on measuring health in terms of efficacy and/or safety. But, sometimes the health and well-being quantification is not a direct measurement. Here, the calculation of the burden of disease for osteoporotic women who may suffer from fractures done at an individual level was presented in terms of disability adjusted life years (DALYs). Few studies of burden of diseases are available, and even less for Spanish population and performed using individual characteristics. The pharmacoeconomic studies can be useful in the health resources rationalization, and both budget impact analyses and new health measures are complementary tools. The work performed in this thesis constitutes a good example of methods application and adaptation to answer real clinical questions.Actualment, els recursos destinats a la salut són limitats i es fa necessari racionalitzar-ne el seu consum; cal prioritzar la despesa en opcions que reportin un major benestar i que siguin sostenibles econòmicament. És per aquest motiu, que cada cop hi ha més estudis clínics que inclouen paràmetres econòmics com a instrument per triar entre diferents estratègies terapèutiques. En aquesta tesi, tant el cost com la resposta de salut s'estudien per separat i conjuntament per a comparar diferents estratègies per al tractament de malalties de diferent àrees de salut. El repte es troba en adaptar i implementar la metodologia necessària per a dur a terme el seguiment d'aquests problemas de salut. Les anàlisis requereixen dades i la majoria d'elles provenen d'estudis clínics, ja siguin prospectius o retrospectius, o bé de models de simulació. L'ús de dades simulades evita experimentar directament amb el sistema d'interès, implicant un temps menor, un cost més econòmic i un decreixement del risc d'experimentació necessaris per a l'obtenció de resultats. Per contrapartida, la simulació és una aproximació de les dades reals. D'una banda, l'avaluació d'un programa de promoció de l'adherència al tractament antiretroviral per pacients VIH+ es du a terme amb dades reals recollides en el marc d'un assaig clínic. El cost per unitat de guany en salut, mesurat amb paràmetres clínics i en qualitat de vida, es representa mitjançant un arbre de decisió. A continuació, la simulació d'una cohort de dones espanyoles post menopàusiques i les seves possibles fractures òssies permet comparar, en termes de cost-efectivitat, dos tractaments usats en la prevenció de fractures vertebrals i no vertebrals. Els models de Markov permeten simular el curs de la malaltia fent servir un nombre finit d'esdeveniments que representen els possibles estats de salut i la probabilitat de que un pacient canviï d'estat amb l'adaptació dels models de Markov per permetre que el risc de patir un esdeveniment variï en el temps permet determinar si els tests de co-receptors del VIH són cost-efectius per decidir si un pacient es pot beneficiar del tractament antiretroviral amb maraviroc. Les cadenes de VIH s'han d'unir als CD4, com a mínim, en un dels dos co-receptors possibles, CCR5 o CXCR4, per entrar a la cèl.lula. Alguns virus VIH fan servir els dos co-receptors i alguns individus tenen una mixtura de cadenes de VIH. Els pacients que es poden beneficiar de l'ús de maraviroc son aquells que estan infectats únicament per virus amb el co-receptor CCR5. Per últim, una anàlisis d'impacte pressupostari permet quantificar la despesa econòmica d'introduir eculizumab per a tractar la hemoglobinúria paroxística nocturna. En aquest cas, s'ha fet una estimació de costos directes i indirectes i es reporten des de la perspectiva del sistema sanitari i des de la perspectiva de la societat. La major part d'estudis clínics publicats es centren en la mesura de la salut en termes d'eficàcia i/o de seguretat; però moltes vegades, la salut i el benestar no es poden quantificar de manera directa. En aquest cas, la càrrega de la malaltia de l'osteoporosi en dones post menopàusiques ha estat quantificada mitjançant anys de vida viscuts amb discapacitat (DALYs) calculats a partir de dades obtingudes a nivell d'individu. Actualment es disposa de pocs estudis de càrrega de malaltia, i menys encara per a població espanyola i amb dades individuals. Els estudis farmacoeconòmics són d'utilitat en l'assignació de recursos, i els estudis d'impacte pressupostari i la generació de noves mesures per a quantificar la salut i el benestar son eines complementàries. El treball realitzat en aquesta tesis és un bon exemple d'aplicació i adaptació de l'estadística per a respondre diferents qüestions de rellevància clínica actualment

Online voluntary transparency in spanish retail firms. Measurement index and CSR-related factors as determinants

Information transparency is a key aspect of the Corporate Social Responsibility (CSR) strategy. The new information and communication technologies, such as the Internet, allow companies to disseminate relevant corporate information to different stakeholders and society, promoting voluntary online transparency. The analysis of social responsibility information published on corporate websites permits, among other issues, the development of disclosure and transparency indexes that facilitate comparisons between companies, and the assessment of potential drivers of the transparency strategy. In this sense, this study has two main objectives: (1) To develop a measurement index of voluntary online transparency, and (2) to identify relevant factors that influence on such transparency. The empirical research was carried out by analyzing the websites of a 176 large Spanish retail companies. Regression analysis was used to test the proposed hypotheses. The results obtained show that online voluntary transparency is encouraged by the implementation of CSR principles in store management and by the particular type of contributions in which the social commitment of the retail is materialized (monetary versus non-monetary), as well as by the fact that employees and/or society as a whole represent the main beneficiaries of CSR activities

NEU screen shows high accuracy in detecting cognitive impairment in older persons living with HIV

The NEUrocognitive (NEU) Screen is a practical tool proposed to screen for HIV-associated cognitive impairment in the clinical setting. This is a pencil-and-paper method that can be applied rapidly (<=10 minutes for administration) and has no copyright limitations. In this study, we aimed at investigating its diagnostic accuracy in an older population of persons living with HIV (PLWH), with cutoffs set at 30, 40, 50, and 60 years. Data were collected from a sample of 368 PLWH who underwent a comprehensive neuropsychological tests battery (gold standard). Results of statistical tests showed that accuracy of the NEU Screen increased with age of the participants. The highest degree of precision, with a sensitivity of 91% and specificity of 92%, was obtained for people ages 60 years or older (correct classification: 91%). These optimal results point to the great potential of the NEU Screen as a tool for detecting cognitive disorders in older PLWH

Methodology for ranking customer segments by their suitability for distributed energy resources applications

[EN] A massive implementation of distributed energy resources (DER) requires the development of innovative approaches to identify, based on the energy market requirements, fast track options for such implementation. These approaches should assess the potential for DER of the different customer segments and simulate DER adoption for those with highest potential in order to evaluate accurately the impact of this implementation on the different energy actors. This paper introduces a methodology to asses the DER implementation potential of customer segments based on a multi-criteria analysis, considering DER as including distributed generation (DG), distributed storage (DS) and local trading strategiest(1) (LTS). Application of the methodology to the commercial sector for DG installation, considering different motivations (cogeneration, renewable, emergency generator and peaking power) and the obtained results for five different segments in this sector are presented. (C) 2006 Elsevier Ltd. All rights reserved.This work was completed in the framework of the EUDEEP Integrated Project of the 6th EU RTD Framework Programme. The authors deeply thank all the participants in the projects for their help and support that made this work possible.Alfonso-Solar, D.; Pérez-Navarro, Á.; Encinas Redondo, N.; Álvarez, C.; Rodríguez-García, J.; Alcázar-Ortega, M. (2007). Methodology for ranking customer segments by their suitability for distributed energy resources applications. Energy Conversion and Management. 48(5):1615-1623. doi:10.1016/j.enconman.2006.11.006S1615162348

El periodismo de investigación y los nuevos formatos audiovisuales de las plataformas digitales: las docuseries

Con la crisis del periodismo escrito que amenaza el sector desde hace años, pero, sobre todo, con el cambio de modelo que ha supuesto el abandono del papel, el periodismo de investigación se encuentra en una encrucijada propiciada por su modelo de trabajo. Con el abandono del formato papel los dominicales, antaño vehículos propios para estos trabajos, carecen ya de rentabilidad como para financiar estos trabajos, que por su propia posología son caros y lentos de producir. Sin embargo, este tipo de productos se ha revelado como uno de los que, con la llegada de la era Netflix, mejor ha resistido el cambio de formato: solo en el 2020, de entre las propuestas de Netflix mas vistas destacan los siguientes documentales de investigación periodística: Jeffrey Epstein: asquerosamente rico (sobre los abusos del magnate americano), Examen de conciencia (del catalán Albert Solé, sobre los abusos en el seno de la iglesia católica española), La línea (sobre el narcotráfico en la bahía de Cádiz) o el estreno a bombo y platillo, justo en estos días, de Nevenka (una investigación sobre acoso sexual a través del testimonio de una concejala del PP que denunció el caso). Este trabajo pretende reflexionar sobre las particularidades en la adaptación de una investigación periodística tradicional, al nuevo lenguaje audiovisual en la era Netflix: un formato que debería permitir ampliar las pantallas de receptores del trabajo de un periodista de investigación, al tiempo que respeta el código deontológico del propio periodista

Protein and lipid fingerprinting of native-like membrane complexes by combining thin layer chromatography and protein electrophoresis: the example of lung surfactant

Traditionally, thin layer chromatography (TLC) has been used for the analysis of lipids isolated from membrane complexes. Here, we describe a method based on the combination of TLC and SDS-polyacrylamide gel electrophoresis (SDS-PAGE) for the qualitative analysis of the protein/lipid profile of membrane complexes such as those of lung surfactant. For this purpose, native lung surfactant was applied onto a silica TLC plate in the form of an aqueous suspension, preserving not only hydrophilic proteins associated to lipids, but also native protein-lipid interactions. Using native membrane complexes in a TLC allows the differential migration of lipids and their separation from the protein components. As a result, (partly) delipidated protein-enriched bands can be visualized and analysed by SDS-PAGE to identify proteins originally associated with lipids. Interestingly, the hydrophobic surfactant protein SP-C, which interact tightly with lipids in native membrane complexes, migrate through the TLC plate configuring specific bands that differ from those corresponding to lipids or proteins. This method therefore allows the detection and analysis of strong native-like protein-lipid interactions

Prospective study to assess progression of renal markers after interruption of tenofovir due to nephrotoxicity

Background. Prospective studies about the reversibility of tenofovir disoproxil fumarate- (TDF-) related renal impairment remain scarce. Methods. This is an observational prospective study including all patients that presented at our HIV Unit who interrupted TDF owing to nephrotoxicity. We assessed the evolution of renal parameters after discontinuation of this drug. Results. We included 59 patients, who were followed up for 72 weeks. Most were male (41, 69.5%), median (IQR) age was 53 (44; 58) years, and median time receiving TDF-containing regimens was 55.4 (28; 87.7) months. Most patients were receiving PI-based treatments (67%). At the final visit, most of the subjects showed complete recovery (35, 59.3%) or improvement (13 subjects, 22%). Significant improvements were observed in creatinine levels (from 84.9 [73.8; 97.5] to 78 [69.6; 91] mu mol/L, p = 0.013), estimated glomerular filtration rate (eGFR, CKD EPI equation, from 87.7 [67; 99] to 89.9 [73.6; 99.3] mL/min/1.73 m(2), p = 0.017), and number of patients with eGFR <60 mL/min/1.73 m(2) (from 9 [15.3%] to 1 [1.7%], p = 0.031). A trend toward significance was observed in abnormal urine proteinuria/creatinine ratio (from 22 [37%] to 8 [13.6%], p = 0.057). Conclusions. Our results corroborate the high frequency of complete or partial renal recovery in patients receiving TDF-containing regimens who discontinued therapy owing to nephrotoxicity.Peer ReviewedPostprint (published version

El método de casos como recurso para el desarrollo de competencias en el Grado en Trabajo Social. Repertorio de casos sociales (RECAS-USAL)

Memoria ID-0245. Ayudas de la Universidad de Salamanca para la innovación docente, curso 2014-2015

Análisis de las competencias del orientador profesional: implicaciones para su formación

ABSTRACTThe present study is intended to analyze the competencies of the professional counselor in order to identify the key aspects that may allow the specific design of this professional training. This study was divided in two phases with the following goals: the first one focused on the description of the professional counselor profile, and the second one was dedicated to the identification of contents that need to be included in the specialized training in professional counseling. To carry out this research, we have applied a mixed methodology (quantitative and qualitative), and the data gathering was based on different types of data sources: an online questionnaire, personal interviews, review of specialized documents, and information from diverse audiences. The validation of the online questionnaire was developed through consultation with key informants. The samples selected for both phases was incidental and the statistical analysis were mainly quantitative and descriptive. From the results derived, we stand out the following: a) the recognition, need and demand of quality career guidance, b) the identification of key competencies for the professional counselor, and c) the consensus on core contents that allow to start with the design of specific postgraduate training. Conclusions in this study reveal the existence of a social interest in formal university training, as well as specialized vocational guidance, agreement on core contents, and the recognition of the contribution of a postgraduate proposal to cover this particular gap in the Spanish University academic offer.RESUMENEste estudio está dirigido a analizar las competencias del orientador profesional para identificar las claves que permitan diseñar una formación específica para ese perfil profesional. Para ello, se llevaron a cabo dos fases con los siguientes objetivos: I) Describir el perfil profesional del orientador profesional y, II) Delimitar los contenidos que deben integrar una formación especializada del orientador profesional. Se siguió una metodología mixta (cualitativa y cuantitativa) y se utilizaron diversas fuentes de recogida de datos (cuestionario en línea, entrevistas personales, consulta de documentos) y diversas muestras. La validación de contenido del cuestionario se realizó mediante consulta a informantes clave. La muestra utilizada para ambas fases es incidental y los análisis estadísticos realizados son de carácter cuantitativo y descriptivo. Los resultados obtenidos señalan: a) el reconocimiento y necesidad de sistemas de orientación profesional de calidad, b) la identificación de un conjunto de competencias clave para el desempeño laboral del orientador profesional y c) el acuerdo en un marco de contenidos a partir del cual diseñar planes de formación específica de postgrado. Las conclusiones del estudio confirman la existencia de un interés social en una formación universitaria oficial y especializada en Orientación Profesional, el consenso en los bloques de contenido y la contribución de esta propuesta formativa para llenar el vacío existente en la oferta universitaria española.ABSTRACTThe present study is intended to analyze the competencies of the professional counselor in order to identify the key aspects that may allow the specific design of this professional training. This study was divided in two phases with the following goals: the first one focused on the description of the professional counselor profile, and the second one was dedicated to the identification of contents that need to be included in the specialized training in professional counseling. To carry out this research, we have applied a mixed methodology (quantitative and qualitative), and the data gathering was based on different types of data sources: an online questionnaire, personal interviews, review of specialized documents, and information from diverse audiences. The validation of the online questionnaire was developed through consultation with key informants. The samples selected for both phases was incidental and the statistical analysis were mainly quantitative and descriptive. From the results derived, we stand out the following: a) the recognition, need and demand of quality career guidance, b) the identification of key competencies for the professional counselor, and c) the consensus on core contents that allow to start with the design of specific postgraduate training. Conclusions in this study reveal the existence of a social interest in formal university training, as well as specialized vocational guidance, agreement on core contents, and the recognition of the contribution of a postgraduate proposal to cover this particular gap in the Spanish University academic offer