Fernando Jesús Antoñanzas Villar

Guía Europea de Prevención Cardiovascular en la Práctica Clínica: adaptación Española del CEIPC 2008

espanolPresentamos la adaptacion espanola del Comite Espanol lnterdisciplinario para la Prevencion Cardiovascular (CEIPC) 2008 de la Guia Europea de Prevencion Cardiovascular (IV Cuarto Grupo de Trabajo Conjunto de la ESC y otras sociedades). Esta guia se centra en la prevencion de la enfermedad cardiovascular en su conjunto, incluyendo las distintas manifestaciones clinicas (coronaria, cerebrovascular, periferica y otras) y mantiene la recomendacion del modelo SCORE de bajo riesgo en la poblacion espanola para la valoracion del riesgo cardiovascular global, con un punto de corte en el 5% para definir alto riesgo. El objetivo es prevenir la mortalidad y morbilidad debidas a las ECV, mediante la prevencion y el manejo adecuado de sus factores de riesgo en la practica clinica. Se enfatiza la prevencion primaria basada en la modificacion de los habitos y estilos de vida, buscando o manteniendo el perfil de las personas sanas. Se requiere una intervencion profesional adecuada y duradera, generalmente multidisciplinar, para que la poblacion y los pacientes en riesgo incrementen su actividad fisica, sigan una alimentacion saludable y abandonen el tabaco si son fumadores. Respecto a las guias previas, se subraya el papel del medico y enfermeria de Atencion Primaria, por su proximidad y accesibilidad en los cuidados e intervenciones preventivas y en la promocion de un estilo de vida cardiosaludable. La decision de iniciar el tratamiento para reducir la presion arterial dependera de sus valores, del riesgo cardiovascular y de la existencia o no de lesiones de organos diana o ECV asociada. La meta terapeutica es, en general, PA EnglishWe are pleased to present the Spanish adaptation from the Spanish Committee for Cardiovascular Disease Prevention (CEIPC) of the European Guidelines on Cardiovascular Disease Prevention in Clinical Practice (IV Joint Task Force of the European Society of Cardiology and Other Societies). This guide is focused on the prevention of cardiovascular disease (CVD) as a whole, including coronary, cerebrovascular, periphery and others, recommending the SCORE model for risk assessment with a 5% threshold for the definition of high-risk. We empathize the need of primary prevention based on lifestyle changes included stop smoking, suitable nutrition and diary physical exercise, with the focus on the health people. The objective is to prevent premature mortality and morbidity due to CVD by means of dealing with its related risk factors in clinical practice. A maintained and multidisciplinary professional intervention is required in order to obtain an increase of physical activity, healthy alimentation and smoking cessation in smokers, to the general population and individuals at risk. The decision to start blood pressure treatment will depend upon the BP values, cardiovascular risk and possible damage to target organs or definite CVD. The treatment goal is to achieve BPThe present CEIPC Spanish adaptation of the European Guidelines on Cardiovascular Disease Prevention in Clinical Practice 2008. This guide recommends the SCORE model for risk evaluation. The aim is to prevent premature mortality and morbidity due to CVD by means of dealing with its related risk factors in clinical practice. The guide focuses on primary prevention and emphasizes the role of the nurses and primary care doctors in promoting a healthy life style, based on increasing physical activity, changing dietary habits, and not smoking. The therapeutic goal is to achieve a Blood Pressure < 140/90 mmHg, but in patients with diabetes, chronic kidney disease, or definite CVD, the objective is < 130/80 mmHg. Serum cholesterol should be < 200 mg/dl and cLDL < 130 mg/dl, although in patients with CVD or diabetes, the objective is < 100 mg/dl (80 mg/dl if feasible in very high-risk patients). Patients with type 2 diabetes and those with metabolic syndrome must lose weight and increase their physical activity, and drugs must be administered whenever applicable, with the objective guided by body mass index and waist circumference. In diabetic type 2 patients, the objective is glycated haemoglobin < 7%. Allowing people to know the guides and developing implementation programs, identifying barriers and seeking solutions for them, are priorities for the CEIPC in order to put the recommendations into practice.

Postoperative analgesia by infusion of local anesthetic into the surgical wound after modified radical mastectomy: a randomized clinical trial.

Background: There is no consensus on the efficacy of postoperative infusion of local anesthetics after radical mastectomy. Methods: A randomized, double-blind, placebo-controlled, parallel-groups clinical trial was conducted in a tertiary hospital. Eighty consecutive women with operable breast cancer with indications for modified radical mastectomy without breast reconstruction were assigned randomly to receive infusion of levobupivacaine (0.5%) or saline at 2 ml/hour for 48 hours through a wound catheter. Seventy-three women finished the study (intervention group, n = 34; control group, n = 39). During surgery, all patients received 0.25% levobupivacaine (30 ml). Results: The levobupivacaine group reported less pain (p < 0.001) than controls in the postanesthesia care unit (1.6 ± 1.3 versus 6.7 ± 1.8) and on the ward at 24 (0.8 ± 0.9 versus 4.2 ± 1.9) and 48 (0.4 ± 0.7 versus 3.3 ± 2.3) hours. In the postanesthesia care unit, the levobupivacaine group consumed less metamizole (0.4 ± 0.5 versus 0.8 ± 0.4; p < 0.001) and dexketoprofen (0.1 ± 0.3 versus 0.7 ± 0.4; p < 0.001), with differences in paracetamol use being insignificant (0.8 ± 0.4 versus 0.9 ± 0.3; p = 0.140). On the ward, the levobupivacaine group used significantly less paracetamol (0.5 ± 0.7 versus 2.0 ± 2.0; p < 0.001) and metamizole (0.2 ± 0.4 versus 1.2 ± 1.4; p < 0.001), but differences in dexketoprofen were not significant (0.03 ± 0.2 versus 0.2 ± 0.6; p = 0.074). In the postanesthesia care unit, the levobupivacaine and control groups consumed 0 ± 0 and 0.7 ± 1.2 doses of opioids (p = 0.001), respectively. The authors observed no differences in nausea and vomiting at any stage in the postanesthesia care unit (0.2 ± 0.4 versus 0.4 ± 0.5; p = 0.081) or on the ward (0.3 ± 0.5 versus 0.4 ± 0.5; p = 0.563). All participants reported high levels of satisfaction. Conclusion: Continuous infusion of local anesthetic reduces pain and analgesic consumption, with high satisfaction, but does not affect rates of nausea and vomiting. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.

Guía Europea de Prevención Cardiovascular en la Práctica Clínica. Adaptación española del CEIPC 2008

Resumen Presentamos la adaptacion espanola realizada por el Comite Espanol Interdisciplinario para la Prevencion Cardiovascular (CEIPC) de la Guia Europea de Prevencion de las Enfermedades Cardiovasculares 2008. Esta guia recomienda el modelo SCORE de riesgo bajo para valorar el riesgo cardiovascular. El objetivo es prevenir la mortalidad y la morbilidad debidas a las enfermedades cardiovasculares (ECV) mediante el tratamiento de sus factores de riesgo en la practica clinica. La guia hace enfasis en la prevencion primaria y en el papel del medico y el personal de enfermeria de atencion primaria en la promocion de un estilo de vida cardiosaludable, basado en el incremento de los grados de actividad fisica, la adopcion de una alimentacion saludable y, en los fumadores, el abandono del tabaco. La meta terapeutica para la presion arterial es en general

Modelos matemáticos para la evaluación económica: los modelos dinámicos basados en ecuaciones diferenciales

The joint utilization of both decision trees and epidemiological models based on differential equations is an appropriate method for the economic evaluation of preventative interventions applied to infectious diseases. These models can combine the dynamic pattern of the disease together with health resource consumption. To illustrate this type of model, we adjusted a dynamic system of differential equations to the epidemic behavior of influenza in Spain, with a view to projecting the epidemiologic impact of influenza vaccination. The results of the epidemic model are implemented in a diagram with the structure of a decision tree so that health resource consumption and the economic implications can be calculated.

Healthcare Rationing in Spain: Framework, Descriptive Analysis and Consequences

This paper describes the main healthcare rationing policies implemented in Spain over the last 2 decades, and analyses the consequences of these policies on the healthcare system, patients, healthcare practitioners, the pharmaceutical industry and policymakers.The primary explicit healthcare rationing policies utilised in Spain include a catalogue that defines the healthcare rights of citizens. However, the existing system may lead to inequity between regions, and is not structured to direct resources towards the most cost-effective options. Health technology assessment requires further work before it can be utilised widely for the development of rationing strategies. Selective reimbursement of drugs and drug co-payments provide only short-term results and appear to have little long-term impact on expenditure. Implicit rationing instruments, especially waiting lists, have had a significant effect on healthcare quality and the welfare of citizens, and have contributed to keeping the Spanish healthcare budget under control.Newer regulations should integrate some form of economic evaluation within the policy-making processes associated with healthcare. Further research is needed to identify those efficient and equitable rationing instruments that are most likely to improve health interventions for an aging society that is increasingly demanding of health services.

Aproximación a los costes de la no seguridad en el Sistema Nacional de Salud

BACKGROUND In the context of budgetary difficulties, the estimation of non safety costs is an additional tool that may be useful in the decision making process of the health system as well as to improve the health care management. Until now there is no study that has estimated the costs of non safety in Spain in an integral way. The objective of this article is to show a first approach to the calculation of the costs of non safety referred to the year 2011. METHOD The study updated from the year 2005 an estimation of the costs of non safety affecting inpatients. Those costs referred to medication errors, to nosocomial infections and to surgical complications. The costs derived from the non safety related to outpatients are estimated from data obtained from the National Health Survey combined with other information of medication errors and their treatment costs that other authors calculated. RESULTS Non safety costs were 2,474 million euros and 960 million euros for hospitalized and non hospitalized patients respectively. CONCLUSIONS This first estimation shows that non safety costs are about 6% of total public health expenditure.BACKGROUND In the context of budgetary difficulties, the estimation of non safety costs is an additional tool that may be useful in the decision making process of the health system as well as to improve the health care management. Until now there is no study that has estimated the costs of non safety in Spain in an integral way. The objective of this article is to show a first approach to the calculation of the costs of non safety referred to the year 2011. METHOD The study updated from the year 2005 an estimation of the costs of non safety affecting inpatients. Those costs referred to medication errors, to nosocomial infections and to surgical complications. The costs derived from the non safety related to outpatients are estimated from data obtained from the National Health Survey combined with other information of medication errors and their treatment costs that other authors calculated. RESULTS Non safety costs were 2,474 million euros and 960 million euros for hospitalized and non hospitalized patients respectively. CONCLUSIONS This first estimation shows that non safety costs are about 6% of total public health expenditure.Background: In the context of budgetary difficulties, the estimation of non safety costs is an additional tool that may be useful in the decision making process of the health system as well as to improve the health care management. Until now there is no study that has estimated the costs of non safety in Spain in an integral way. The objective of this article is to show a first approach to the calculation of the costs of non safety referred to the year 2011. Method: The study updated from the year 2005 an estimation of the costs of non safety affecting inpatients. Those costs referred to medication errors, to nosocomial infections and to surgical complications. The costs derived from the non safety related to outpatients are estimated from data obtained from the National Health Survey combined with other information of medication errors and their treatment costs that other authors calculated. Results: Non safety costs were 2,474 million euros and 960 million euros for hospitalized and non hospitalized patients respectively. Conclusions: This first estimation shows that non safety costs are about 6% of total public health expenditure.

Evaluación económica de eptifibatide

Introduccion y objetivos El objetivo de este estudio es realizar una evaluacion economica para Espana del ensayo PURSUIT, un estudio multicentrico y aleatorio sobre el tratamiento de la angina inestable o el infarto sin onda Q con eptifibatide frente a placebo, asi como medir el coste de cada ano de vida ganado en los pacientes tratados con dicho farmaco. Metodos Los datos que el PURSUIT proporciona sobre el consumo de recursos sanitarios se agruparon en distintas subpoblaciones segun criterios geograficos o de consumo de recursos. Los costes unitarios de estos se calcularon usando un enfoque «de abajo arriba» combinando costes individuales para conseguir los costes totales de distintos procesos y duraciones de la estancia hospitalaria. El analisis de costes compara los costes del ingreso inicial y de los 6 meses siguientes (coste total por paciente) entre los pacientes que recibieron placebo o eptifibatide. El analisis coste-efectividad se efectua con los costes totales y con los anos de vida ganados calculados segun las proyecciones hechas a partir de los resultados del ensayo para Europa Occidental. Resultados El coste medio de 6 meses para los pacientes que recibieron placebo varia entre 0,91 y 1,41 millones de pts., y entre 0,96 y 1,45 para los tratados con eptifibatide. La supervivencia fue de 16,07 anos en el grupo placebo frente a 16,11 anos en el de eptifibatide (se ganaron 2,9 anos por cada 100 pacientes tratados). El coste incremental de cada ano de vida ganado es de entre 1,3 y 3,3 millones de pts. Conclusion Los resultados varian segun los datos sobre consumo de recursos que se empleen. El coste por cada ano de vida ganado entra dentro de lo aceptable para una nueva tecnologia.

El Consumo de Medicamentos: Políticas y Pacto Social

E l consumo de medicamentos genera un alivio en los pacientes pero tiene su contrapartida en la carga económica que ha de soportarse, principalmente desde los presupuestos públicos. Estas características, junto con otras derivadas de su seguridad, han llevado a que tales bienes sean objeto de numerosas regulaciones administrativas y a que la sociedad esté muy sensibilizada por las políticas públicas que afecten a su consumo. En primer lugar, y dado que desde diferentes foros se ha venido mencionando con cierta insistencia que el consumo de medicamentos en España es excesivo, merece la pena presentar las cifras referentes a este mercado y valorar si tales aseveraciones están fundadas. Seguidamente, tras reseñar algunos datos que enmarcan la situación desde una perspectiva económica, se comentarán las políticas o medidas de regulación que pueden implicar un cambio cultural importante al modificar las reglas del juego de las últimas décadas.

Las bebidas alcohólicas en España: salud y economía

Desde diversos foros de la salud publica se insiste en las consecuencias negativas para la salud derivadas del consumo de alcohol, asi como en otras consecuencias sociales tambien del mismo signo; sin embargo, en los medios de comunicacion observamos como se potencia su consumo y como una buena parte de la industria y del sector turistico pivota sobre la oferta de estos bienes. Desconocemos si, como en muchas ocasiones, en el termino medio esta la virtud; lo que desde luego esta claro, por los resultados presentados mas adelante, es que la virtud no reside en el termino en que se situa el actual consumo. Seguidamente se describiran la estructura del sector productivo del alcohol, algunas pautas de su consumo y las consecuencias que acarrea, para luego pasar a citar las politicas publicas, haciendo especial hincapie en las de caracter fiscal, y a efectuar una evaluacion en cuanto a su capacidad para reducir el consumo. Finalmente, se presentan algunas conclusiones y vias de avance orientadas a fomentar la investigacion para conocer mejor los aspectos economicos y de salud publica relacionados con el alcohol, y asi disenar politicas de salud publica mas eficaces

Impacto del Real Decreto-Ley 16/2012 sobre el copago farmacéutico en el número de recetas y en el gasto farmacéutico

Fundamentos: el objetivo del trabajo es es conocer si el impacto del Real Decreto-Ley 16/2012 en el numero de recetas y el gasto farmaceutico, evaluadas por el Ministerio de Sanidad, Servicios Sociales e Igualdad (MSSSI), se corresponden con las obtenidas por otros metodos estadisticos habitualmente empleados. Asimismo, se han elaborado unos modelos para predecir la evolucion de ambas variables entre septiembre de 2013 y diciembre de 2014. Metodos: se aplico la metodologia Box-Jenkins conjuntamente con el analisis de intervencion de Box-Tiao a datos del periodo 2003-13 para predecir mensualmente los valores de las series de recetas y gasto farmaceutico. Las predicciones se emplearon en un analisis contrafactico para compararlas con las series de recetas y gasto real. Tambien se efectuaron predicciones para el periodo de septiembre de 2013 a diciembre de 2014 para observar el impacto de la medida en un horizonte superior al real. Resultados: el analisis contrafactico estimo el descenso en el numero de recetas en un 12,18% y el del gasto farmaceutico en un 12,83%, mientras que al calcularse mediante el analisis de intervencion fueron 12,75% y 14,03%, respectivamente. Conclusiones: la reduccion estimada del numero de recetas para el periodo de junio de 2012 hasta agosto de 2013 es similar a la ofrecida por el MSSSI, mientras que para la serie del gasto farmaceutico fue inferior a la ofrecida por el MSSSI. La metodologia de Box-Jenkins genera errores de prediccion menores al 3% por lo que se considera util para anticipar fiablemente los consumos futuros.BACKGROUND this research aims to understand if the consequences on drug expenditures and number of prescriptions of Royal Decree-Law 16/2012 as estimated by the Ministry of Health, Social Services and Equality (MHSSE) are similar to those found by using common statistical approaches. In addition, several models have been built to forecast the evolution of both variables for the period September 2013-December 2014. METHODS the Box-Jenkins methodology and the Box-Tiao intervention analysis were applied to data of the period 2003-13 to forecast the monthly values of the number of prescriptions and pharmaceutical expenditures. Forecasts were used in a counter-factual analysis to be compared to the actual values of prescriptions and drug expenditures. Moreover, forecasts for the period September 2013 to December 2014 were obtained to observe the impact of the policy in the future. RESULTS the counterfactual analysis estimated a decrease in the number of prescriptions of 12.18% and 12.83% in the pharmaceutical expenditure; these figures were 12,75% and 14,03% respectively, when the intervention analysis was used. CONCLUSION the estimated reduction in the number of prescriptions for the period June 2012-August 2013 was similar to the figure offered by the MHSSE, while the reduction in the drug expenditure series was smaller. The Box-Jenkins methodology generated low forecast errors (less than 3%) what makes this procedure useful to reliably anticipate future consumptions.