Marco Garrido-Cumbrera

Mental health systems in countries: where are we now?

More than 85% of the worlds population lives in 153 low-income and middle-income countries (LAMICs). Although country-level information on mental health systems has recently become available, it still has substantial gaps and inconsistencies. Most of these countries allocate very scarce financial resources and have grossly inadequate manpower and infrastructure for mental health. Many LAMICs also lack mental health policy and legislation to direct their mental health programmes and services, which is of particular concern in Africa and South East Asia. Different components of mental health systems seem to vary greatly, even in the same-income categories, with some countries having developed their mental health system despite their low-income levels. These examples need careful scrutiny to derive useful lessons. Furthermore, mental health resources in countries seem to be related as much to measures of general health as to economic and developmental indicators, arguing for improved prioritisation for mental health even in low-resource settings. Increased emphasis on mental health, improved resources, and enhanced monitoring of the situation in countries is called for to advance global mental health.

Social class inequalities in the utilization of health care and preventive services in Spain, a country with a national health system

In Spain, despite the existence of a National Health System (NHS), the utilization of some curative health services is related to social class. This study assesses (1) whether these inequalities are also observed for preventive health services and (2) the role of additional private health insurance for people of advantaged social classes. Using data from the Spanish National Health Survey of 2006, the authors analyze the relationships between social class and use of health services by means of Poisson regression models with robust variance, controlling for self-assessed health. Similar analyses were performed for waiting times for visits to a general practitioner (GP) and specialist. After controlling for self-perceived health, men and women from social classes IV-V had a higher probability of visiting the GP than other social classes, but a lower probability of visiting a specialist or dentist. No large class differences were observed in frequency of hospitalization or emergency services use, or in breast cancer screening or influenza vaccination; cervical cancer screening frequency was lower among women from social classes IV-V. The inequalities in specialist visits, dentist visits, and cervical cancer screening were larger among people with only NHS insurance than those with double health insurance. Social class differences in waiting times were observed for specialist visits, but not for GP visits. Men and women from social classes IV-V had longer waits for a specialist; this was most marked among people with only NHS insurance. Clearly, within the NHS, social class inequalities are still evident for some curative and preventive services. Further research is needed to identify the factors driving these inequalities and to tackle these factors from within the NHS. Priority areas include specialist services, dental care, and cervical cancer screening.

Development and spatial representation of synthetic indexes of outpatient mental health care in Andalusia (Spain).

INTRODUCTION There is a need to develop composite indicators to monitor mental health care in countries such as Spain, where there is wide variability of care systems in 17 different regions. The aim of this study is to generate and to test the usability of synthetic indexes in Andalusia (Southern Spain). METHOD Seven mental health indicators were selected by expert opinion from a previous list of simple indicators used to compare mental health care systems across Spain (Psicost-74). A Geographical Information Systems (GIS) was used to delineate 71 sectors based on the catchment areas of the mental health centers in Andalusia. Synthetic indexes were obtained through linear combinations of simple indicators via Principal Components Analysis (PCA), using activity data from the Mental Health Information System of Andalusia (SISMA). Maps of these indexes were drawn for 71 catchment areas. RESULTS Two synthetic indexes were obtained and showed high consistency in the PCA. The Care Load Index (component 1) related to population size and total outpatient care provided within the area. The Case Load Index (component 2) related to assisted morbidity in relation to the population size. The care load index was higher in populated urban areas, whereas the case load was higher in rural areas. DISCUSSION Care and case load indexes show a different pattern in urban and rural areas. This may be related to a different underlying model of care related to the degree of urbanisation. Geographical Information Systems (GIS) improved recognition and assessment of the spatial phenomena related to the mental health care system, and support policy decision making process in mental health.

Improving the Management of Psoriatic Arthritis and Axial Spondyloarthritis: Roundtable Discussions with Healthcare Professionals and Patients

Psoriatic arthritis (PsA) and axial spondyloarthritis (AxSpA) are both chronic, inflammatory conditions that result in a substantial burden of disease and reduced quality of life for patients. Patient involvement in developing optimal disease management strategies, including defining appropriate goals, therapies, and treatment options, as well as in setting policy priorities and agendas, is key. A working group of patient organization representatives and rheumatologists explored what patients consider to be unmet needs, important treatment gaps, and future priorities in PsA and AxSpA management. Reducing pain and fatigue, and improving physical and social functioning and work productivity were identified as important treatment goals for patients. Although the major treatment target for both PsA and AxSpA is remission, with low/minimal disease activity an alternative target for patients with established or long-standing disease, the meaning of remission from the patient’s perspective needs to be explored further as it may differ considerably from the physician’s perspective. Key recommendations from the working group to tackle unmet needs included reducing time to diagnosis, increasing patient and physician disease awareness, focusing on patients’ priorities for treatment goals, and improving patient–physician communication. By addressing these key action points moving forward, the hope is that outcomes will continue to improve for patients with PsA and AxSpA.

Improving territorial accessibility of mental health services: The case of Spain

Background and Objectives: Citizens choose their health care services not only depending on their needs, but also on where they are located. The location of the services is especially important in the case of mental health due to the specific features of mental disorders. This article provides an analysis of temporal access by road to outpatient mental health centres in Andalusia (Spain) with a view to improving accessibility for the greatest volume of population possible. Methods: Firstly, accessibility by road to the outpatient mental health centres was calculated in terms of time by establishing journey times using the ArcGIS Geographical Information System�s (GIS) Network Analyst module. These journey times by road enabled travel times to be established for these sections, temporal accessibility areas to be plotted from each of the outpatient mental health centres and the number of people included in each accessibility area to be calculated. Results: The accessibility analysis enabled the sitting of the centres to be evaluated for 2006, a comparison to be made with 2011 (with six new facilities having been set up since 2006) and new locations for the siting of these six new facilities to be proposed. Conclusions: This study has enabled the optimum territorial locations to be proposed for the six mental health centres created between 2006 and 2011 that would allow travel times to be reduced for the greatest numbers of people possible. It can be stated on the basis of this study that, if territorial criteria had been taken into account, 97,720 inhabitants would have seen their travel times to their nearest mental health centres reduced using the same resources.

Atlas of Axial Spondyloarthritis in Spain 2017: Study Design and Population

OBJECTIVE Atlas of Axial Spondyloarthritis in Spain 2017 aims to better understand the reality of the patients suffering from this disease from an integrated approach. METHODS The Atlas 2017 based its results on an extensive cross-sectional patient survey conducted in Spain (2016), validated by a multidisciplinary group of experts on spondyloarthritis. RESULTS Data from 680 patients with axSpA were obtained, most of them suffered from AS, were HLA-B27 positive, older than 45 years, and live as part of a couple. A large percentage had university studies, were disabled and members of a patient association. Patients reported a diagnostic delay of 8.5 years, high disease activity (BASDAI 5.5±2.2), moderate-important stiffness (61.0%), medium-high functional limitation (74.9%), and psychological distress (GHQ 5.7±4.5). A total of 54.7% reported taking NSAIDs, 28.4% DMARDs, 36.3% biological therapy and 32.2% were not receiving pharmacological treatment. CONCLUSIONS The Atlas survey data reveals still a long diagnostic delay, high disease activity, psychological distress, while an important proportion could be undertreated.

Assessing the Impact of the 2008 Financial Crisis on the Labor Force, Employment, and Wages of Persons with Disabilities in Spain:

The financial crisis of 2008 has had a greater effect on people with disabilities than on those without disabilities in Spain. In recent years, the number of persons with disabilities registered as part of the labor force and having a higher educational level has increased. However, the unemployment rate among people with disabilities has grown at a faster pace, especially for women and young people. A similar situation has occurred with respect to the annual gross average wage; the gap between those with and without disabilities has increased in the years following the crisis. The present study reveals that Spanish public policies aimed at improving levels of employment for people with disabilities have not achieved the expected results. Here, we explore the possible causes and compare the results with those obtained in the United States.

AB0875 Quality of life improvement in patients with axial spondyloarthritis treated with nsaids and biological therapy from the patient’s perspective: results from the atlas-2017

Background In patients with axial spondyloarthritis (axSpA), the main long-term outcome is quality of life. Clinical trials and observational studies have shown the efficacy of biological therapy (BT) on improving the signs and symptoms of the disease. However, data assessing the impact of BT on quality of life is scarce and mainly comes from clinical trials. Objectives To assess in clinical practice the improvement in quality of life from the patient’s perception as a result of pharmacological treatments in axSpA. Methods A sample of 680 patients diagnosed with axSpA was interviewed through an online survey as part of the Spanish Atlas-2017, which aimed to promote early referral, improve healthcare, and the use of effective treatments in patients with axSpA. For this study, self-reported data from patients who had received both NSAIDs and BT were analysed. Patients were asked about the improvement they had experienced on 7 different aspects of quality of life after starting treatment with NSAIDs or BT: independence, leisure and free time, social relations, sport and physical activity, and mood and sexual relations. Improvements were measured on a 0 to 10 Likert Scale and classified as low (≤5) and high (≥6). Non-parametric (Wilcoxon) tests were used to compare the degree of improvement between patients with biological therapy and those with NSAIDs. Results A total of 189 patients who had received both types of drugs were included. The mean (SD) age was 44.03 (±10.11) years, 50.3% were females, 70.9% married and 47.1% belong to a patients’ association. The mean (SD) disease duration was 21.3±10.7 years and 67.7% were HLA-B27+. A higher percentage of patients perceived a high level of improvement after receiving a BT than after receiving an NSAID, for both overall quality of life assessment (57% vs 22%, respectively) and the different quality of life-related aspects. Additionally, the mean degree of improvement for overall quality of life assessment and the different aspects related to this were reported to be significantly higher after receiving BT than after NSAIDs (overall improvement: 5.46±2.59 vs 3.19±2.45; p<0.001, respectively).Abstract AB0875 – Table 1 Mean improvement degree and percentage of patients who reported high improvement (≥6 in 0–10) in different aspects related to quality of life after receiving biological therapy and NSAIDs Conclusions In clinical practice, patients’ self-reported satisfaction overall and related to different aspects of quality of life is substantially greater after being treated with BT than with NSAIDs. However, these results need to be confirmed in a longitudinal study Acknowledgements The Atlas was promoted by CEADE and funded by Novartis Disclosure of Interest M. Garrido-Cumbrera: None declared, D. Gálvez-Ruiz: None declared, J. Gratacós: None declared, C. Blanch Mur Employee of: Novartis, V. Navarro-Compán: None declared

SAT0412 Association between smoking with spinal level of stiffness and functional limitation in patients with axial spondyloarthritis: results from the spanish atlas

Background Smoking has been associated with greater disease activity and radiographic progression in patients with Axial Spondyloarthritis (ax-SpA). In addition, radiographic damage has been linked to greater functional limitation. However, clarification is still being sought as to whether or not this association exists. Objectives To investigate the association between smoking and both the area of spinal stiffness and functional limitation in patients with ax-SpA. Methods A sample of 680 patients diagnosed with ax-SpA was interviewed during 2016 as part of the Spanish Atlas, which aims to promote early referral and improve healthcare and the use of effective treatments in patients with ax-SpA. Tobacco consumption was recorded as: Smoker (62.4%), Occasional Smoker (8.9%) and Non-Smoker (28.7%). Spinal stiffness was assessed in the three different vertebral areas: cervical, dorsal and lumbar. To determine de degree of functional limitation we used a composed index which includes the sum of the degree of limitation in the 18 daily activities well established (dressing, grooming, bathing, tying shoelaces, moving around the home, stairs, getting to/out of bed, toilet, shopping, preparing meals, eating, cleaning, walking, using public transportation, going to the doctor, driving, physical exercise, sexual relations) using an ordinal variable (0=none, 1=little, 2=some and 3=moderate). A descriptive analysis was used to compare the level of stiffness (chi-squared test) and the mean degree of limitation (Kruskal-Wallis test) in the different groups of smokers consumptions. Regression analysis was also used to assess the relation between smoking and degree of limitation (0–54). Results 53% were females, mean age 46 years and 77.1% were HLA-B27+. The percentage of patients with stiffness in the lumbar region was significantly higher in habitual/occasional smokers than in non-smokers (89.0%, 93.8%, 83.5% respectively; p<0.01) (Table). The mean degree of functional limitation increased with tobacco consumption, although this difference was not statistically significant (47.9±12.1 vs. 45.1±11.5 vs. 44.8±13.7 respectively; p=0.2). However, regression analysis showed a statistically significant correlation between smoking and functional limitation (r=0.096; p=0.02). Relationship between tobacco consumption and spinal stiffness levels in patients with ax-SpA Smoker Occasional smoker Non smoker P χ2 Cervical stiffness 84.2% 77.1% 73.1% 0.171 9.044 Dorsal stiffness 76.0% 76.6% 72.4% 0.408 6.141 Lumbar stiffness 89.0% 93.8% 83.5% 0.002 20.518 Source: Spanish Atlas. Conclusions Smoking in patients with ax SpA is associated to greater stiffness in the lumbar region, but is not related to stiffness in the cervical or dorsal regions. Additionally, smoking is associated to the degree of functional limitation in these patients. Acknowledgements This project has been supported by Novartis Disclosure of Interest None declared