José Jesús Martín

Factors associated with improvement in disability-adjusted life years in patients with HIV/AIDS

BackgroundThe epidemic of HIV/AIDS and treatments that have emerged to alleviate, have brought about a shift in the burden of disease from death to quality of life/disability. The aim was to determine which factors are associated with improvements in the level of health of male and female patients with HIV/AIDS in Andalusia, in terms of disability-adjusted life years.MethodsDescriptive study based on a sample group of 8800 people on the Andalusian AIDS register between 1983 and 2004. Dependent variables: Life lost due to premature mortality (YLL), years lost due to disability (YLD) and disability-adjusted life years (DALY). Independent variables: vital state, sex, age at the time of diagnosis, age at the time of death, transmission category, province of residence, AIDS-indicator disease and the period of diagnosis. A bivariate analysis was carried out to find out if the health level variables changed in accordance with the independent variables. Using the independent variables which had a statistically significant link with the level of health variables, a multivariate linear regression model, disaggregated by gender, was constructed.ResultsAmongst the women, we found a model which explained the level of health of 64.9%: a link was found between a higher level of health (lower DALYs) and not intravenous drug use, the province of residence, being diagnosed during the HAART era and older age at the time of diagnosis. Amongst the men, we found a model which explained the level of health of 64.4%: a link was found between a higher level of health (lower DALYs) and intravenous drug use, the province of residence, being diagnosed during the HAART era and older age at the time of diagnosis.ConclusionA higher level of health (lower DALY) amongst both men and women was found to be linked to not be intravenous drug user, the province of residence, being diagnosed during the HAART era and older age at the time of diagnosis.

Influencia de la renta, la desigualdad de renta y el capital social en la salud de los mayores de 65 años en España en 2007

The aim of this study is to evaluate the influence of personal income [absolute income hypothesis (AIH)], income inequality and welfare [relative income hypothesis (RIH)], and social capital on the health of older people. Multi-level, cross-sectional logit models are calculated separately for women and men. The database employed was the Spanish Life Conditions Survey for 2007. The population consists of 6,259 persons aged over 65 years living in the 17 autonomous regions of Spain. The results confirm the AIH hypothesis: higher personal income is associated with better health. Education is also associated with better self-perceived health. The RIH hypothesis is partially confirmed due to the association between the Gini coefficient, regional per capita welfare and self-perceived health in older people, but only for women. Two different measures of social capital are used: the value of services of social capital and the percentage of people aged over 65 belonging to an association. Both factors are statistically associated with better self-perceived health in women. This study is the first to contrast the associations among income, income inequalities, social capital and the health of elders in Spain.

Cost-effectiveness of percent free PSA for prostate cancer detection in men with a total PSA of 4-10 ng/ml.

Objective: To assess the cost-effectiveness of two diagnostic strategies for prostate cancer in men with prostate-specific antigen (PSA) levels of 4–10 ng/ml and normal digital rectal examination (DRE). Design: Cost-effectiveness analysis was performed using a decision tree model. Data collection and a systematic review of patients at the Urology Department (Carlos Haya Hospital) were made. 101 patients over the age of 40 with PSA levels of 4–10 ng/ml and normal DRE were selected. Transrectal ultrasound-guided prostate biopsy (TRUS-Bx) and percent free PSA testing prior to TRUS-Bx were performed. The outcome measures used were the incremental cost-effectiveness ratio, and costs were calculated through activity-based costing. The effectiveness was measured by means of the number of detected cases, test utility and actual cases (detected cases minus lost cases). Results: Using base-case analysis, the strategy of percent free PSA + TRUS-Bx was found to be the most cost-effective. The incremental cost-effectiveness ratio for free PSA + TRUS-Bx compared with TRUS-Bx was EUR 2,277.40. Strategy 2 (TRUS-Bx) would be more cost-effective if the cost of percent free PSA increased to EUR 21.64 or if prostate cancer prevalence increased to 26%. Conclusions: The use of percent free PSA prior to TRUS-Bx is the most cost-effective diagnostic strategy. However, this result is very sensitive and strategy 2 (TRUS-Bx) would be more cost-effective if the cost of the percent free PSA increased to EUR 21.64 or if the prevalence of prostate cancer increased to above 26%.

Eficiencia técnica de los hospitales públicos y de las empresas públicas hospitalarias de Andalucía

OBJECTIVE To assess the technical efficiency of traditional public hospitals without their own legal identity and subject to administrative law, and that of public enterprise hospitals, with their own legal identities and partly governed by private law, all of them belonging to the taxypayer-funded health system of Andalusia during the period 2005 -2008. METHODS The study included the 32 publicly-owned hospitals in Andalusia during the period 2005-2008. The method consisted of two stages. In the first stage, the indices of technical efficiency of the hospitals were calculated using Data Envelopment Analysis, and the change in total factor productivity was estimated using the Malmquist index. The results were compared according to perceived quality, and a sensitivity analysis was conducted through an auxiliary model and bootstrapping. In the second stage, a bivariate analysis was performed between hospital efficiency and organization type. RESULTS Public enterprises were more efficient than traditional hospitals (on average by over 10%) in each of the study years. Nevertheless, a process of convergence was observed between the two types of organizations because, while the efficiency of traditional hospitals increased slightly (by 0.50%) over the study period, the performance of public enterprises declined by over 2%. DISCUSSION The possible reasons for the greater efficiency of public enterprises include their greater budgetary and employment flexibility. However, the convergence process observed points to a process of mutual learning that is not necessarily efficient.

La sostenibilidad del Sistema Nacional de Salud en España

El Sistema Nacional de Salud (SNS) espanol presenta problemas de sostenibilidad derivados de deficiencias en su diseno institucional y de gobierno, agravadas por la crisis economica que padece. La crisis economica mundial ha tenido una repercusion especialmente virulenta en Espana, caracterizada por altos niveles de desempleo y de deuda publica y privada. Las politicas de ajuste fiscal emprendidas pueden deteriorar el SNS significativamente. Junto a problemas de financiacion general, la fuerte descentralizacion territorial de competencias sanitarias en las Comunidades Autonomas no ha sido acompanada de un marco eficaz de coordinacion sanitaria a nivel de Estado. El SNS adolece de problemas en sus reglas de gobierno, su sistema de financiacion autonomica, las politicas de recursos humanos y la diversidad de formas de gestion directa e indirecta que funcionan en las distintas Comunidades Autonomas. Una estrategia de reformas en el gobierno de la sanidad espanola debe articularse en el marco de una revision mas amplia de las politicas publicas que permita estabilizar las lineas de defensa del Estado del Bienestar. En el ambito del sector sanitario se debe mejorar su sistema de financiacion y desarrollar cambios institucionales para aumentar la eficiencia.

The impact of the economic crisis on unmet dental care needs in Spain

Objectives To analyse the impact that the economic crisis and the evolution of socioeconomic inequality before (2007) and during (2011) the current crisis have had on unmet dental care needs in Spain. Methods The Living Conditions Surveys from the years 2007 and 2011 were used, including 44 138 adults aged under 65 years. A descriptive and stratified analysis was carried out along with the calculation of the concentration index and a multivariate logistic regression jointly and separately by gender. The dependent variable was unmet dental care needs and the independent variables were income, employment status, gender, age, education and chronic disease. A dummy variable was created for the year of survey completion as a proxy measure for the economic crisis. The SPSS V.20 software was used. Results During the period under analysis, the unmet needs for dental services increased (from 6.2% to 7.2%) along with the concentration index (from −0.1412 to −0.189). The main correlations with unmet needs were: unemployment (OR=1.46), lower income (OR=2.44 for the income quintile) and the year 2011 with respect to 2007 (OR 1.13). For women, the OR is greater according to income level (2.44 compared with 1.77 in men) and the year 2011 (1.21 compared with 1.06), while for men unemployment had a greater effect (OR=1.52 compared with 1.46). Conclusions There has been an increase in unmet dental care needs as well as in the social gradient for service access. The most vulnerable groups are those with less purchasing power and the unemployed. The economic crisis has also increased this unmet need.

El sistema nacional de salud español ante la gran recesión

El texto analiza el impacto de la crisis economica en algunos aspectos criticos del Sistema Nacional de Salud: resultados, gasto sanitario, politica retributiva y privatizaciones mediante los modelos de Colaboracion Publico Privado. Algunos resultados de salud vinculados a las desigualdades sociales son preocupantes. La reduccion del gasto sanitario publico ha aumentado la fragilidad del sistema sanitario, reducido las rentas salariales de los trabajadores del sector y aumentado la heterogeneidad entre Comunidades Autonomas. Finalmente, la evidencia senala que los procesos de privatizacion no suponen mas eficiencia ni mejor gobernanza. Son necesarias profundas reformas para reforzar el Sistema Nacional de Salud.