Análisis y desarrollo de un modelo predictivo del gasto farmacéutico ambulatorio ajustado a morbilidad y riesgo clínico

[EN] Introduction: Changes in population structure, including aging, have a significant impact on chronicity, comorbidity and polypharmacy. In the field of pharmaceutical services, problems with drugs and outpatient pharmaceutical expenditure of this aging, chronic and pluripathological population have a high clinical and economic impact. The risk adjustment systems based on morbidity are useful for monitoring health spending, setting provider payment systems and establishing proactive actions in the field of clinical and pharmaceutical management for chronic patients with polypharmacy. Objective: Analysis and adjustment of outpatient drug spending in Comunitat Valenciana (CV), applying a system of clinical risk population adjustment based on the patient classification called Clinical Risk Groups (CRG) for 2012-2013 and development of an indicator (FarmaIndex) for pharmaceutical expenditure prediction adjusted by morbidity according to the pharmaceutical budget. Methodology: Individual study, descriptive and analytical, based on population and focused on outpatient drug spending in the Valencia area. A first phase of the study was to develop a minimum data set using population information (CMDUP) and obtaining a database of 4.7 million patients containing demographic, clinical activity, clinical risk group assignment, annual pharmaceutical expenditure and other drug use variables. In the first phase of analysis, patients were described attending to the healthcare burden, the use of medicines and the pharmaceutical expenditure, and relating all this to the CRG. In the second phase, it was designed a model for pharmaceutical expenditure adjustment where the dependent variable was the natural logarithm of annual outpatient pharmaceutical expenditure and the independent variables were the main nine health status from the CRG classification in its third level of aggregation with the severity levels established for each of them. The weights of the adjustment model were estimated by least squares. With these weights it was built a case mix system useful in order to establish predictive budgets by health department, health center and physicians. Results: The stratification of patients through the CRG at an individual level is sensitive to the intensity of implementation and the quality of health information systems. It has been identified that 74% of outpatient pharmaceutical expenditure is consumed by patients with one or two dominant chronic diseases (health status 5 and 6), which represent 27% of the population. The average outpatient pharmaceutical expenditure by health status increases as does the comorbidity and severity of patients, finding its peak, in the health status 7 (three dominant chronic diseases). The risk adjustment system based on morbidity and clinical risk that has been developed has a very high predictive power for outpatient pharmaceutical expenditure (60%). The explicative power of the different models increases significantly if morbidity variables are added to demographic variables, increasing from 27.3% to 56.2% of explanation. The severity and clinical risk for the same health status, increases the explicative power by a 3.8%. The inclusion of hospital pharmacy in the model does not improve the degree of explanation achieved (55.9%). The model has not explicative capacity for the pediatric cohort (15.5%), which coincides with that reported by other risk adjustment systems based on chronic diseases. Conclusions: Risk adjustment systems based on morbidity are useful tools for rational drug use management, but they need a solid implementation of health information systems in order to be used for population applications and for the calculation of weights for budget assignment.[ES] Introducción: Los cambios en la estructura de la población tales como el envejecimiento, tienen una importante repercusión en la cronicidad, la pluripatología y la polimedicación. En el ámbito de la prestación farmacéutica, los problemas relacionados con los medicamentos y el gasto farmacéutico ambulatorio de esta población envejecida, crónica y pluripatológica, tiene un alto impacto clínico y económico. Los sistemas de ajuste de riegos, basados en morbilidad, son útiles para monitorizar el gasto sanitario, establecer sistemas de pago a proveedores y para establecer acciones proactivas en el ámbito de la gestión clínica y farmacéutica de los pacientes crónicos y polimedicados. Objetivo: Análisis y ajuste del gasto farmacéutico ambulatorio en la Comunidad Valenciana (CV), aplicando un sistema de ajuste de riesgo clínico poblacional basado en la clasificación de pacientes Clinical Risk Groups (CRG) para el periodo 2012-2013 y desarrollo de un indicador (FarmaIndex) para predecir el gasto farmacéutico ajustado a morbilidad en base al presupuesto de farmacia asignado. Metodología: Estudio individual, de ámbito poblacional, descriptivo y analítico del gasto farmacéutico ambulatorio en la CV. Una primera fase del estudio, ha sido desarrollar un conjunto mínimo de datos de utilización poblacional (CMDUP) obteniendo una base de datos de 4,7 millones de pacientes que contiene variables demográficas, de actividad asistencial, grupo de riesgo clínico asignado, gasto farmacéutico anual y otras variables de uso de medicamentos. En la primera fase, se describe a los pacientes atendiendo a la carga asistencial, uso de los medicamentos y gasto farmacéutico, relacionándolos con los CRG. En una segunda, se ha diseñado un modelo de ajuste de gasto farmacéutico que toma como variable dependiente el logaritmo neperiano del gasto farmacéutico ambulatorio anual y como variables independientes los 9 estados de salud principales de la clasificación de los CRG agregación 3 y los niveles de gravedad establecidos en cada uno de ellos. Los pesos del modelo de ajuste se han estimado por medido del ajuste mínimo cuadrados y con ellos se ha construido un sistema propio de case mix que sirve para establecer presupuestos predictivos por departamento, centro de salud y facultativo. Resultados: Se ha corroborado que la estratificación de pacientes a través de los CRG a nivel poblacional, es sensible al nivel de implantación y la calidad de los sistemas de información sanitaria. Se ha identificado que el 74 % gasto farmacéutico ambulatorio lo consumen los pacientes con una o dos enfermedades crónicas dominantes (estados de salud 5 y 6), que representan el 27% de la población. El gasto farmacéutico ambulatorio medio por estado de salud, aumenta a medida que lo hace la comorbilidad y la gravedad de los pacientes, encontrando su máximo, en el estado de salud 7 (tres enfermedades crónicas dominantes). El sistema de ajuste de riesgo basado en morbilidad y riesgo clínico desarrollado posee un poder predictivo muy elevado para el gasto farmacéutico ambulatorio (60%). La capacidad explicativa de los modelos se incrementa notablemente si se añaden variables sobre morbilidad a las variables demográficas, pasando de un 27,3% a un 56,2% de explicación. El nivel de gravedad y riesgo clínico para un mismo estado de salud, aumenta un 3,8% la capacidad explicativa. La inclusión de la farmacia hospitalaria en el modelo no mejora el grado de explicación conseguido (55,9%). El modelo no ha resultado ser explicativo para la cohorte pediátrica (15,5%), lo cual coincide con lo reportado por otros sistemas de ajuste de riesgo basados en enfermedades crónicas. Conclusiones: Los sistemas de ajuste de riesgos basados en morbilidad son una herramienta muy útil para gestión del uso racional de los medicamentos, pero requieren de una implantación sólida de los sistemas de información sanitaria para su aplicación poblaciona[CA] Introducció: Els canvis en l'estructura de la població, tals com l'envelliment, tenen una important repercussió en la cronicitat, la multimorbiditat i la polimedicació. En l'àmbit de la prestació farmacèutica, els problemes relacionats amb els medicaments i la despesa farmacèutica ambulatòria d'aquesta població envellida, crònica i multimòrbida tenen, en conseqüència, un alt impacte clínic i econòmic. Els sistemes d'ajust de riscos, basats en la morbiditat, són útils per monitoritzar la despesa sanitària, establir sistemes de pagament a proveïdors i per establir accions proactives en l'àmbit de la gestió clínica i farmacèutica dels pacients crònics i polimedicats. Objectiu: Analitzar i ajustar la despesa farmacèutica ambulatòria en la Comunitat Valenciana (CV) aplicant un sistema d'ajust de risc clínic poblacional en la classificació de pacients -Clinical Risk Groups (CRG)- per al període 2012-2013, i desenvolupar un indicador (Farmalndex) per predir la despesa farmacèutica ajustada a la morbiditat atenent al pressupost de farmàcia assignat. Metodologia: Estudi individual, d'àmbit poblacional, descriptiu i analític de la despesa farmacèutica ambulatòria en la Comunitat Valenciana. La primera fase de l'estudi ha estat desenvolupar una quantitat mínima de dades d'utilització poblacional (CMDUP) obtenint una base de dades de 4,7 milions de pacients que conté variables demogràfiques, d'activitat assistencial, grup de risc clínic assignat, despesa farmacèutica anual i d'altres variables d'ús de medicaments. En la primera fase d'anàlisi es descriu els pacients atenent a la càrrega assistencial, a l'ús de medicaments i a la despesa farmacèutica, relacionant-los amb els CRG. En la segona fase s'ha dissenyat un model d'ajust de la despesa farmacèutica prenent com a variable dependent el logaritme neperià de la despesa farmacèutica ambulatòria anual, i com a variables independents els nou estats de salut principals de la classificació dels CRG agregació 3 i els nivells de gravetat establerts en cadascun d'ells. El pes del model d'ajust s'ha estimat mitjançant l'ajust per mínims quadrats i amb ell s'ha construït un sistema propi de case mix que serveix per establir pressupostos predictius per departament, centre de salut i facultatiu. Resultats: S'ha corroborat que l'estratificació de pacients a través dels CRG a nivell poblacional és sensible al nivell d'implantació i a la qualitat dels sistemes d'informació sanitària. S'ha identificat que el 74 % de la despesa farmacèutica ambulatòria la consumeixen els pacients amb una o dues malalties cròniques dominants (estats de salut 5 i 6) que representen el 27% de la població. La despesa farmacèutica ambulatòria mitjana per estat de salut augmenta a mesura que ho fa la comorbiditat i la gravetat dels pacients, trobant el seu màxim en l'estat de salut 7 (tres malalties cròniques dominants). El sistema d'ajust de risc basat en la morbiditat i risc clínic desenvolupat posseix un poder predictiu molt elevat per a la despesa farmacèutica ambulatòria (60%). La capacitat explicativa dels models s'incrementa notablement si s'afegeixen variables sobre morbiditat a les variables demogràfiques, passant d'un 27,3% a un 56,2% d'explicació. El nivell de gravetat i risc clínic per a un mateix estat de salut augmenta un 3,8% la capacitat explicativa. La inclusió de la farmàcia hospitalària en el model no millora el grau d'explicació aconseguit (55,9%). El model no ha resultat ser explicatiu per a la cohort pediàtrica (15,5%), la qual cosa coincideix amb el que han reportat altres sistemes d'ajust de risc basats en malalties cròniques. Conclusions: Els sistemes d'ajust de riscos basats en la morbiditat són una eina molt útil per a la gestió de l'ús racional dels medicaments, però requereixen d'una implantació sòlida dels sistemes d'informació sanitària per a la seva aplicació poblacional i per al càlcul del pes prUsó Talamantes, R. (2015). Análisis y desarrollo de un modelo predictivo del gasto farmacéutico ambulatorio ajustado a morbilidad y riesgo clínico [Tesis doctoral]. Universitat Politècnica de València. https://doi.org/10.4995/Thesis/10251/56149TESISPremios Extraordinarios de tesis doctorale

Data Envelopment Analysis Applications on Primary Health Care Using Exogenous Variables and Health Outcomes

[EN] A data envelopment analysis was used to evaluate the efficiency of 18 primary healthcare centres in a health district of the Valencian Community, Spain. Factor analysis was used as a first step in order to identify the most explanatory variables to be incorporated in the models. Included as variable inputs were the ratios of general practitioners, nurses, and costs; as output variables, those included were consultations, emergencies, avoidable hospitalisations, and prescription efficiency; as exogenous variables, those included were the percentage of population over 65 and a multimorbidity index. Confidence intervals were calculated using bootstrapping to correct possible biases. Efficient organisations within the set were identified, although the results depend on the models used and the introduction of exogenous variables. Pharmaceutical expenditure showed the greatest slack and room for improvement in its management. Data envelopment analysis allows an evaluation of efficiency that is focussed on achieving better results and a proper distribution and use of healthcare resources, although it needs the desired goals of the healthcare managers to be clearly identified, as the perspective of the analysis influences the results, as does including variables that measure the achievements and outcomes of the healthcare services.This research was funded by "Conselleria de Hacienda y Modelo Economico de la Comunitat Valenciana (Spain)", file number HIECPU/2019/1, in the context of the Project "Desarrollo de un Modelo para el analisis de la eficiencia en las Unidades Basicas de Salud de atencion primaria en un departamento de Salud perteneciente al mapa sanitario de la Comunidad Valenciana".González-De Julián, S.; Barrachina Martínez, I.; Vivas-Consuelo, D.; Bonet-Pla, Á.; Usó-Talamantes, R. (2021). Data Envelopment Analysis Applications on Primary Health Care Using Exogenous Variables and Health Outcomes. Sustainability. 13(3):1-18. https://doi.org/10.3390/su1303133711813

Modelling Deprivation Level and Multimorbidity in a Health District

[EN] Deprivation is associated with an increased risk of developing chronic health conditions and with worse outcomes in multimorbidity. The goal of our study was to develop an integrated population index of deprivation (IPID) to observe the influence of deprivation on morbidity and the subsequent use of healthcare resources in one health district, using the socioeconomic, clinical and geographical data from its administrative health records. Eight socioeconomic indicators were identified and weighted using the methodology of two-phase principal component analysis, providing an index that allowed each census section to be classified into seven deprivation groups. Secondly, the possible relation between the IPID and the variables for multimorbidity and healthcare resources was analysed using the theory of multiple comparisons. It was observed that places with a greater proportion of healthy people presented lower values of deprivation and that, at lower levels of deprivation, there were fewer hospital admissions. The results show that living in an area with a higher deprivation index is associated with greater consumption of healthcare resources and disease burden. Identifying areas of sociosanitary vulnerability can help to identify health inequalities and allow intervention by clinical practices and healthcare management to reduce them.Botija Yagüe, MP.; Sorbet-Santiago, S.; Díaz-Carnicero, J.; González-De Julián, S.; Usó-Talamantes, R. (2022). Modelling Deprivation Level and Multimorbidity in a Health District. Mathematics. 10(4):1-14. https://doi.org/10.3390/math1004065911410

Avaliação de modelo de predição de despesa farmacêutica em atenção primária à saúde baseado em variáveis demográficas

[EN] Problem: In the current context of budget constraints in the health sector management systems that allow allocating spending more efficiently are required. In the case of pharmaceutical expenditure, risk adjustment models are tools that help to improve the efficiency. Objectives: To evaluate the predictive power of a pharmaceutical expenditure adjustment model, Standardized Amount Indicator, using sociodemographic variables: Copayment, international coverage, age and sex. Methods: We included the population registered in Valencia (Spain) between 01/09/2009 and 31/08/2010. Population was standardized and linear regression analysis was performed in order to explain the variability of outpatient pharmaceutical expenditure. Results: The adjustment model evaluated improve the predictive power, reaching a R2 of 34%. Conclusions: This models valid to predict pharmaceutical costs and allocate prospective budgets to health districts and centers.[ES] Problema: en el actual contexto de restricciones presupuestarias en el sector salud, se precisade sistemas de gestión que permitan asignar el gasto de manera más eficiente. En el caso delgasto farmacéutico, los modelos de ajuste de riesgos en salud son herramientas que ayudan amejorar la eficiencia. Objetivos: evaluar la capacidad predictiva de un modelo de ajuste de gastofarmacéutico, Indicador de Importe Estandarizado (iie), según variables sociodemográficas:condición de farmacia, cobertura internacional, edad y sexo. Método: se incluyó la poblaciónempadronada en la Comunidad Valenciana (España) entre el 01/09/2009 y el 31/08/2010. Seestandarizó la población y se realizó un análisis de regresión lineal para explicar la variabilidaddel gasto farmacéutico ambulatorio. Resultados: el sistema de ajuste evaluado supone un avanceen relación con modelos anteriores, alcanzando un mayor poder predictivo (R2 = 34 %). Conclusiones:el iie es válido para predecir el gasto farmacéutico y asignar presupuestos prospectivosa departamentos y centros de salud.[PT] Questão: No atual contexto de restrições orçamentais no sector da saúde são precisos sistemas de gestão que permitan alocar os dispêndios de forma mais eficiente. No caso da despesa farmacêutica os modelos de ajuste de risco em saúde são ferramentas que ajudam no melhoramento da eficiência. Objetivos: avaliar a capacidade preditiva de um modelo de ajuste da despesa farmacêutica, Indicador de Importe Padronizado (iiP), de acordo com variáveis sociodemográficas: condição de farmácia, cobertura internacional, idade e gênero. Métodos: Foi incluída a população registrada em Valencia (Espanha) entre 01/09/2009 e 31/08/2010. A população foi padronizada e realizou-se análise de regressão linear para explicar a variabilidade dos dispêndios farmacêuticos ambulatórios. Resultados: O sistema de ajustamento avaliado supõe uma melhoria em relação aos modelos anteriores, alcançando maior poder preditivo (R2=34%). Conclusões: O iiP é válido para prever os custos farmacêuticos e alocar orçamentos prospectivos aos departamentos e centros de saúde.Artículo de investigación derivado del convenio de colaboración No.143/2011: “Gestión farmacoeconómica para el desarrollo de un modelo econométrico de ajuste del gasto farmacéutico según el riesgo clínico del paciente medido por crg’s”, celebrado entre la Consellería de Sanitat y la Universitat Politècnica de València, con fecha de inicio 28/10/2011 y fecha de finalización 28/10/2012, financiado por la Generalitat Valenciana por un importe de 50.532,27 euros.Santamargarita Pérez, S.; Sancho Mestre, C.; Vivas Consuelo, DJJ.; Usó Talamantes, R. (2013). Evaluación de un modelo de predicción del gasto farmacéutico en atención primaria de salud basado en variables demográficas. Revista Gerencia y Políticas de Salud. 12(25):55-65. http://hdl.handle.net/10251/60026S5565122

Ambulatory Pharmaceutical Spending Analysis Based on Risk Stratification in Patients with Chronic Conditions

Elsevier user license: Permitted: For non-commercial purposes: Read, print & download Text & data mine Translate the article Not Permitted: Reuse portions or extracts from the article in other works Redistribute or republish the final article Sell or re-use for commercial purposesRisk adjustment models allow stratifying the population, considering chronic disease as a predictor of drug costs. In this paper, we analyze outpatient drug spending using Clinical Risk Groups (CRG) to obtain patient risk stratification.Usó Talamantes, R.; Trillo Mata, JL.; Guadalajara Olmeda, MN.; Sancho Mestre, C.; Vivas Consuelo, DJJ. (2012). Ambulatory Pharmaceutical Spending Analysis Based on Risk Stratification in Patients with Chronic Conditions. Value in Health. 15(7):A297-A297. doi:10.1016/j.jval.2012.08.592SA297A29715

Electronic prescription and dispensation pharmaceutical system at the Health Valencian Agency, Spain

The electronic prescription and dispensation system is a breakthrough in the use of new technologies in the National Health System. It involves the improvement of processes of prescribing and dispensing pharmacotherapy and the coordination of health professionals. Also, for patients with long-term treatments, the system helps to reduce the frequency of primary care center visits and improves patient safety by reducing mistakes in prescriptions written by hand. The system requires the interconnection and functioning of many information systems to be integrated and work well together with the infrastructure of the data processing center that is responsible for distributing information to all healthcare centers. In this way, improvements of the electronic prescription system on healthcare will be analyzed (decrease of physician visits, reduction in medical errors, increase in therapeutic compliance by patients)

Pharmaceutical Expenditure for Diabetes Mellitus in a Region of Spain as Clinical Risk Group, 2012

El contenido de los artículos es de exclusiva responsabilidad de los autores. Los textos pueden reproducirse total o parcialmente citando la fuente.[ES] Se pretende estimar la multimorbilidad asociada con diabetes mellitus tipo 2 y su relación con el gasto farmacéutico, para lo cual se realizó un estudio de corte transversal durante el año 2012. Se identificó a 350 015 individuos diabéticos, a través de códigos clínicos, usando la Clasificación Internacional de Enfermedades y el software 3M Clinical Risk Groups. Todos los pacientes fueron clasificados en cuatro grupos de morbilidad. El primer grupo corresponde al estadio inicial, el segundo grupo incluye el núcleo de multimorbilidad de pacientes en fases intermedia y avanzada, el tercer grupo incluye pacientes con diabetes y enfermedades malignas, y el último grupo es de pacientes en estado catastrófico, principalmente enfermos renales crónicos. La prevalencia bruta de diabetes fue de 6,7 %. El gasto promedio total fue de € 1257,1. La diabetes se caracteriza por una fuerte presencia de otras condiciones crónicas y tiene un gran impacto en el gasto farmacéutico[EN] Estimations of multimorbidity associated with Type 2 Diabetes Mellitus and its relationship to pharmaceutical expenditure. Cross-sectional study during 2012. 350,015 diabetic individuals, identified through clinical codes using the International Statistical Classification of Diseases and Related Health Problem and the 3M Clinical Risk Groups software. The raw prevalence of diabetes was 6.7 %. All patients were stratified into four morbidity groups. The first group corresponds to the initial state; the second group includes the core multimorbidity patients in the intermediate and advanced stages; the third group includes patients with diabetes and malignancies; the last group patients with catastrophic statuses, manly chronic renal patients. The raw prevalence of diabetes was 6.7 %. The average total cost was € 1257.1. Diabetes is characterized by a strong presence of other chronic conditions have a great impact on pharmaceutical spending.Alvis, L.; Vivas-Consuelo, D.; Caballer Tarazona, V.; Usó Talamantes, R.; Sancho Mestre, C.; Buigues Pastor, L. (2016). Gasto farmacéutico en diabetes mellitus en una región de España según el Clinical Risk Group, 2012. Revista Gerencia y Políticas de Salud. 15(30):68-78. doi:10.11144/Javeriana.rgyps15-30.gfdmS6878153

Cost of Type 2 Diabetes Patients with Chronic Kidney Disease Based on Real-World Data: An Observational Population-Based Study in Spain

[EN] This study analyzed the prevalence, costs and economic impact of chronic kidney disease CKD in patients with T2D in a Spanish Health District using real-world data. Observational cross-sectional study in adult patients with T2D was through data extracted from the information systems of the Valencia Clinico-La Malvarrosa Health District in the year 2015. Patients were stratified with the KDIGO classification for CKD. Additionally, patients were assigned to Clinical Risk Groups (CRGs) according to multimorbidity. Direct costs of primary and specialized care, and medication were estimated. The prevalence of T2D in the database population (n = 28,345) was 10.8% (mean age (SD) = 67.8 years (13.9); 51.5% male). Up to 14.935 patients (52.6%) had data on kidney function. According to the KDIGO classification, 66.2% of the patients were at low risk of CKD, 20.6% at moderately increased risk, 7.9% at high risk, and 5.2% at very high risk. The average healthcare costs associated with these four risk groups were EUR 3437, EUR 4936, EUR 5899 and EUR 7389, respectively. The large number of T2D patients with CKD in the early stages of the disease generated a significant increase in direct healthcare costs. The economic impact could be mitigated by early and comprehensive therapeutic approaches.This research was funded by Boehringer-Ingelheim Espana, S.A.Usó-Talamantes, R.; González-De Julián, S.; Díaz-Carnicero, J.; Saurí-Ferrer, I.; Trillo-Mata, JL.; Carrasco-Pérez, M.; Navarro-Pérez, J.... (2021). Cost of Type 2 Diabetes Patients with Chronic Kidney Disease Based on Real-World Data: An Observational Population-Based Study in Spain. International Journal of Environmental research and Public Health (Online). 18(18):1-14. https://doi.org/10.3390/ijerph18189853S114181

Predictability of pharmaceutical spending using Clinical Risk Groups in the Valencian Community, Valencia

Elsevier user license: Permitted: For non-commercial purposes: Read, print & download Text & data mine Translate the article Not Permitted: Reuse portions or extracts from the article in other works Redistribute or republish the final article Sell or re-use for commercial purposesThe Valencian Community, with 5,000,000 inhabitants, is implementing a system of pharmaceutical management to reduce costs. This system is based on classifying patients in groups using the case mix system, Clinical Risk Groups. An electronic tool has been developed based on www to manage patients with chronic conditions and monitor pharmaceutical expenditure in primary health care. GPs receive a report on the real pharmaceutical cost that is being incurred and the optimum cost adjusted by CRG.Usó Talamantes, R.; Caballer Tarazona, M.; Buigues Pastor, L.; Trillo Mata, JL.; Guadalajara Olmeda, MN.; Vivas Consuelo, DJJ. (2011). Predictability of pharmaceutical spending using Clinical Risk Groups in the Valencian Community, Valencia. Value in Health. 14(7):A341-A341. doi:10.1016/j.jval.2011.08.596SA341A34114