Pedro Gallo

Home palliative care as a cost-saving alternative: evidence from Catalonia

The aim of this study was to provide a comparative assessment of the health care resources consumed during the final month of life of patients undergoing palliative treatment and who died from cancer in the town of Mataró, Spain, in 1998, with respect to whether they benefited from home care teams or not. Relevant differences in the use of health care resources were found between the groups. Patients in the standard care group presented more hospital care admissions and longer length of stay, higher use of emergency and outpatient visits, and greater use of palliative care units within nursing homes than patients in the home care group. The monetary quantification of the use of the above-mentioned resources showed a 71% increase in the cost per patient in the standard care when compared to home care. According to the results of this study, home care teams for terminal cancer patients allow for savings to the health care system. A series of policy making and health services research implications are discussed.

Spanish health care cuts: Penny wise and pound foolish?

The purpose of this paper is to convey the specific health care actions and policies undertaken by the Spanish government, as well as by regional governments, as a result of the economic crisis. Throughout the last two years we have witnessed a number of actions in areas such as human capital, activity and processes, outsourcing and investment that, poorly coordinated, have shaped the nature of financial cuts on public services. This paper discloses the size and magnitude of these actions, the main actors involved and the major consequences for the health sector, citizens and patients. We further argue that there are a number of factors which have been neglected in the discourse and in the actions undertaken. First, the crisis situation is not being used as an opportunity for major reforms in the health care system. Further, the lay public and professionals have remained as observers in the process, with little to no participation at any point. Moreover, there is a general perception that the solution to the Spanish situation is either the proposed health care cuts or an increase in cost sharing for services which neglects alternative and/or complementary measures. Finally, there is a complete absence of any scientific component in the discourse and in the policies proposed.

Cuts drive health system reforms in Spain

The economic crisis is largely shaping health policy in Spain. This paper reports on major changes in the health care system, both nationally and regionally, as a consequence of sizable cutbacks and new pieces of legislation. The most relevant changes to the system introduced during the last year are having an impact on who is insured, which benefits are covered, and what share of the cost of service provision is contributed by the population, while at the same time reducing salaries and working conditions in the sector. We further report on the consequences these changes are having, and the roles played by key actors and organisations in the system.

DEVELOPMENT AND TEST OF A DECISION SUPPORT TOOL FOR HOSPITAL HEALTH TECHNOLOGY ASSESSMENT

OBJECTIVE To develop and test a decision-support tool for prioritizing new competing Health Technologies (HTs) after their assessment using the mini-HTA approach. METHODS A two layer value/risk tool was developed based on the mini-HTA. The first layer included 12 mini-HTA variables classified in two dimensions, namely value (safety, clinical benefit, patient impact, cost-effectiveness, quality of the evidence, innovativeness) and risk (staff, space and process of care impacts, incremental costs, net cost, investment effort). Weights given to these variables were obtained from a survey among decision-makers (at National/Regional level and hospital settings). A second layer included results from mini-HTA (scored as higher, equal or lower), which compares the performance of the new HT (in terms of the abovementioned 12 variables) with the available comparator. An algorithm combining the first (weights) and second (scores) layers was developed to obtain an overall score for each HT, which was then plotted in a value/risk matrix. The tool was tested using results from the mini-HTAs for three new HTs (Surgical Robot, Platelet Rich Plasma, Deep Brain Stimulation). RESULTS No significant differences among decision-makers were observed as regards the weights given to the 12 variables, therefore, the median aggregate weights from decision-makers were introduced in the first layer. The dot plot resulting from the mini-HTA presented good power to visually discriminate between the assessed HTs. CONCLUSION The decision-support tool developed here makes possible a robust and straightforward comparison of different competing HTs. This facilitates hospital decision-makers deliberations on the prioritization of competing investments under fixed budgets.

Ethics and HTA: Some lessons and challenges for the future

What have we learned? Is there in the contribution to this special theme a clue as to what is the best way of integrating ethical inquiry into health technology assessment (HTA)? Particularly, what is the significance of the social shaping perspective in this respect? In this concluding paper, we attempt to collect the lessons we have learnt and to answer these questions. Of course, our answer will not be the final one. It is difficult to find an appropriate and widely endorsed model of integrating ethical implications in HTA studies, if there is such a single appropriate model at all. But despite reserves, it is equally fair to claim that it is definitely possible to reach beyond what ethical inquiry in HTA too often concerns, namely to conclude that ‘‘the technology raises serious ethical concerns that must be dealt with.’’ This is truly a death sentence, for both HTA and medical ethics, just when their integration is called for. In the remainder of this paper, we address three questions. First, the main question of this issue is: How could ethical inquiry be integrated into HTA? Or in other words: What methods do we have to address moral aspects of technology in a valid and useful way? This question is addressed by discussing the following aspects: How can ethical issues be identified and addressed, and how could the perspective of social shaping of technology add to this? Second: Who is to face the challenge of ethical inquiry? Under this header, we discuss the role of researchers, policy-makers, laypersons, and ethicists. In addition, we address the issue of moral competence. Poiesis Prax (2004) 2: 247–256 DOI 10.1007/s10202-003-0054-1

Comparación de costes de tres tratamientos del cáncer de próstata localizado en España: prostatectomía radical, braquiterapia prostática y radioterapia conformacional externa 3D

OBJECTIVE To compare the initial costs of the three most established treatments for clinically localized prostate cancer according to risk, age and comorbidity groups, from the healthcare providers perspective. METHODS We carried out a cost comparison study in a sample of patients consecutively recruited between 2003 and 2005 from a functional unit for prostate cancer treatment in Catalonia (Spain). The use of services up to 6 months after the treatment start date was obtained from hospital databases and direct costs were estimated by micro-cost calculation. Information on the clinical characteristics of patients and treatments was collected prospectively. Costs were compared by using nonparametric tests comparing medians (Kruskall-Wallis) and a semi-logarithmic multiple regression model. RESULTS Among the 398 patients included, the cost difference among treatments was statistically significant: medians were € 3,229.10, € 5,369.00 and € 6,265.60, respectively, for the groups of patients treated with external 3D conformal radiotherapy, brachytherapy and radical retropublic prostatectomy, (p<0.001). In the multivariate analysis (adjusted R(2)=0.8), the average costs of brachytherapy and external radiotherapy were significantly lower than that of prostatectomy (coefficient -0.212 and -0.729, respectively). CONCLUSIONS Radical prostatectomy proved to be the most expensive treatment option. Overall, the estimated costs in our study were lower than those published elsewhere. Most of the costs were explained by the therapeutic option and neither comorbidity nor risk groups showed an effect on total costs independent of treatment.

Patrones de utilización de los servicios sanitarios en Cataluña

Resumen El objetivo de este articulo es conocer el uso de servicios sanitarios de la poblacion catalana segun necesidades de salud y analizar patrones de utilizacion por niveles asistenciales de atencion primaria, atencion especializada, atencion hospitalaria y atencion urgente. Con los datos de la Encuesta de Salud de Cataluna 2006 se construyeron modelos de regresion logistica de cada nivel asistencial para la poblacion general y la de hombres, mujeres, adultos y menores. Las variables explicativas fueron: necesidad de salud, estilos de vida, demograficas, nivel socioeconomico, pais de origen y lugar de residencia. Las mujeres utilizan mas los servicios en todas las lineas asistenciales. Los menores y los adultos mayores de 64 anos utilizan mas atencion primaria, que se asocia a clase social desfavorecida. Los jovenes, los adultos-jovenes y los inmigrantes infrautilizan todos los servicios excepto el de atencion urgente. La atencion especializada se asocia a la clase social acomodada, a personas con estudios universitarios, seguro sanitario privado y residencia en Barcelona, mientras que la atencion hospitalaria se asocia a necesidad de salud. Se concluye que la utilizacion de servicios sanitarios no solo se explica en funcion de la necesidad percibida, sino tambien por factores demograficos, socioeconomicos y territoriales.The purpose of this article is disclose services utilization patterns among the Catalan population with particular emphasis on primary care, specialised care, hospital care and emergency care. A number of logistic regression models were used to explain the utilization of the various types of services. Variables in the analysis included self-perceived need, lifestyles, and sociodemographic variables. Separate analyses were performed for male, female, adults, and children as well as for the general population. Women use all types of services more often than men. Children and people over 64 are more frequent users of primary care. Primary care is also associated to lower socioeconomic conditions. Young adults and the migrant population in general are found to be under users of services, except of emergency care services. The use of specialised care is associated to the better-off, to those with university level education attainment, individual private insurance, and those living in the city of Barcelona. Hospital care is largely associated to need variables. The use of health services is explained by self-perceived need as well as by demographic, socioeconomic and geographical factors.

Cost comparison of three treatments for localized prostate cancer in Spain: radical prostatectomy, prostate brachytherapy and external 3D conformal radiotherapy

Objective: To compare the initial costs of the three most established treatments for clinically localized prostate cancer according to risk, age and comorbidity groups, from the healthcare provider’s perspective.Methods: Cost comparison study on a sample of patients recruited consecutively between 2003 and 2005 in a functional unit of treatment for prostate cancer in Catalonia. The use of services until 6 months after the treatment start date was obtained from hospital databases and direct costs were estimated by micro-cost calculation. The collection of information on clinical characteristics of patients and treatments was conducted prospectively. The costs were compared using nonparametric test comparing medians (Kruskal-Wallis) and a semi-logarithmic model of multiple regressions.Results: Among the 398 patients included, the cost difference among treatments was statistically significant: medians were €3,229.10, €5,369.00 and €6,265.60 respectively for the groups of patients treated with Radical Retropubic Prostatectomy, Brachytherapy and External 3D Conformal Radiotherapy (P Conclusions: Radical prostatectomy proved to be the most expensive treatment option. Overall, the estimated costs in our study are lower than those published elsewhere. Therapeutic option explains most of the costs, and neither comorbidity nor risk group showed an independent effect from treatment on total costs.

International Master's Program in health technology assessment and management: Assessment of the first edition (2001-2003)

BACKGROUND Despite a clear call for greater input from health technology assessment (HTA) in the areas of clinical practice and policy making, there are currently very few formal training programs. The objectives of our Consortium were to (i) develop a masters level program in HTA, (ii) test its content with a group of Canadian and European students, and (iii) evaluate the Programs strengths and weaknesses. OBJECTIVES This study presents the results of our evaluation of the first edition of the Masters Program (2001--2003). METHODS The evaluation relied on (i) a self-administered student questionnaire for each course (n = 142), (ii) interviews with students (n = 10), and (iii) interviews with internship supervisors (n = 5). RESULTS A vast majority of students were satisfied with the course content and particularly appreciated the exercises and materials presented in an intensive format. However, they needed more systematic feedback from faculty members and recommended increasing the methodology content. The six key characteristics of the program are (i) flexible format adapted to the needs of skilled professionals, (ii) continuous interaction between HTA users and producers, (iii) international academic and professional collaboration, (iv) partnership with HTA agencies, (v) global approach to evidence-based methods and practices, and (vi) multidisciplinary approach. CONCLUSIONS Despite the numerous organizational barriers inherent to creating an international program and several areas for improvement in the Program itself, the Ulysses Project was successful in attaining its objectives. Because there is a growing need for human resources with special training in HTA, further efforts need to be devoted to strengthening the international research capacity in HTA.

EDUCATION AND SUPPORT NETWORKS FOR ASSESSMENT OF HEALTH INTERVENTIONS

The aim of Working Group 5 is to develop and coordinate education and support networks for individuals and organizations undertaking or using assessment of health interventions and to identify needs in the field and assist in the establishment of new provisions.