Vicente Ortún

Widening social inequalities in mortality: the case of Barcelona, a southern European city.

OBJECTIVE: To analyse trends in mortality inequalities in Barcelona between 1983 and 1994 by comparing rates in those electoral wards with a low socioeconomic level and rates in the remaining wards. DESIGN: Mortality trends study. SETTING: The city of Barcelona (Spain). SUBJECTS: The study included all deaths among residents of the two groups of city wards. Details were obtained from death certificates. MAIN OUTCOME MEASURES: Age standardised mortality rates, age standardised rates of years of potential life lost, and age specific mortality rates in relation to cause of death, sex, and year were computed as well as the comparative mortality figure and the ratio of standardised rates of years of potential life lost. RESULTS: Rates of premature mortality increased from 5691.2 years of potential life lost per 100,000 inhabitants aged 1 to 70 years in 1983 to 7606.2 in 1994 in the low socioeconomic level wards, and from 3731.2 to 4236.9 in the other wards, showing an increase in inequalities over the 12 years, mostly due to AIDS and drug overdose as causes of death. Conversely, cerebrovascular disease showed a reduction in inequality over the same period. Overall mortality in the 15-44 age group widened the gap between both groups of wards. CONCLUSION: AIDS and drug overdose are emerging as the causes of death that are contributing to a substantial increase in social inequality in terms of premature mortality, an unreported observation in European urban areas.

The Black Box of Business Dynamics

This article highlights the contributions of business dynamics research to industrial policy design. Business creation support programs are widespread despite the fact that the optimal rate of business creation and destruction remains unknown. Economic analysis emphasizes heterogeneity as the most salient characteristic of industrial dynamics. A better knowledge of the different types of entrepreneurs, their behavior and their specific contribution to innovation and growth would allow to see into ‘black box’ of business dynamics and would facilitate the design of appropriate public policies. The empirical analysis performed shows that self-employment has a quite different economic nature than business with employees. Public programs should not promote indiscriminate entry but rather give priority to able entrants with survival capacities. Survival of entrants is positively related to their size at birth. Innovation and investment improve the survival of new manufacturing firms. Investment in R&D increases the risk of failure in new firms, although it improves the competitiveness of the incumbents.

A population-based study of the costs of care for community-acquired pneumonia

In a population-based study, the consumption of resources for treating adult patients with community-acquired pneumonia was determined. During a 2‐yr period, all cases with a clinical and radiological suspicion of community-acquired pneumonia that occurred in patients aged >14 yrs in a community of 74,610 inhabitants were investigated prospectively. Of 292 cases with a suspicion of community-acquired pneumonia, 224 were included (18.5% misdiagnoses). The mean number of visits per patient was 4.5 (72% in the primary care setting). Inpatient care was recommended in 59.8% of cases; after discharge, 44% of patients were managed in outpatient clinics. The mean direct cost of pneumonia treated in the hospital setting was (euros)1,553, whereas the mean cost of cases treated as outpatients was 196. A total of 15.7% of admissions were considered inappropriate and the length of stay could have been reduced by 3.5 days in the most severe cases. A reduction in inappropriate admissions and lengths of hospital stay would result in a decrease in cost of 17.4%. Community-acquired pneumonia in Maresme, Spain, occurs at a low incidence, although with a high percentage of hospitalisations (in part inappropriate), resulting in considerable costs.

Cost Efficiency in Primary Care Contracting: A Stochastic Frontier Cost Function Approach

The principal aim of this paper is to estimate a stochastic frontier cost function and an inefficiency effects model in the analysis of the primary health care services purchased by the public authority and supplied by 180 providers in 1996 in Catalonia. The evidence from our sample does not support the premise that contracting out has helped improve purchasing cost efficiency in primary care. Inefficient purchasing cost was observed in the component of this purchasing cost explicitly included in the contract between purchaser and provider. There are no observable incentives for the contracted-out primary health care teams to minimise prescription costs, which are not explicitly included in the present contracting system.

Specialty choice in times of economic crisis: a cross-sectional survey of Spanish medical students

Objective To investigate the determinants of specialty choice among graduating medical students in Spain, a country that entered into a severe, ongoing economic crisis in 2008. Setting Since 2008, the percentage of Spanish medical school graduates electing Family and Community Medicine (FCM) has experienced a reversal after more than a decade of decline. Design A nationwide cross-sectional survey conducted online in April 2011. Participants We invited all students in their final year before graduation from each of Spains 27 public and private medical schools to participate. Main outcome measures Respondents’ preferred specialty in relation to their perceptions of: (1) the probability of obtaining employment; (2) lifestyle and work hours; (3) recognition by patients; (4) prestige among colleagues; (5) opportunity for professional development; (6) annual remuneration and (7) the proportion of the physicians compensation from private practice. Results 978 medical students (25% of the nationwide population of students in their final year) participated. Perceived job availability had the largest impact on specialty preference. Each 10% increment in the probability of obtaining employment increased the odds of preferring a specialty by 33.7% (95% CI 27.2% to 40.5%). Job availability was four times as important as compensation from private practice in determining specialty choice (95% CI 1.7 to 6.8). We observed considerable heterogeneity in the influence of lifestyle and work hours, with students who preferred such specialties as Cardiovascular Surgery and Obstetrics and Gynaecology valuing longer rather than shorter workdays. Conclusions In the midst of an ongoing economic crisis, job availability has assumed critical importance as a determinant of specialty preference among Spanish medical students. In view of the shortage of practitioners of FCM, public policies that take advantage of the enhanced perceived job availability of FCM may help steer medical school graduates into this specialty.

Cost-effectiveness Analysis: Why and How

Para que el acceso a los servicios sanitarios dependa de la necesidad clinica y sanitaria, la practica totalidad de los paises desarrollados del mundo optan por darles financiacion publica. Lo que parece manifestar unos valores de equidad tiene tambien una justificacion en terminos de eficiencia, dado que, si se quiere obtener la maxima cantidad y calidad de vida con los recursos disponibles, hay que dejar de lado las extravagancias para centrarse en lo clinicamente efectivo. Siempre cabra satisfacer caprichos segun la capacidad y la voluntad de pagar individualmente por ellos. Por otra parte, cuando la forma de abordar tanto la innovacion como el envejecimiento continuara modulando el ritmo de crecimiento del porcentaje de la riqueza producida por un pais que se dedica a servicios sanitarios, ya no basta el criterio de efectividad. Hay que incorporar la consideracion de los costes sociales para optar por los servicios menos costosos entre los efectivos. Y no es una cuestion de ahorrar dinero, sino de evitar muertes y sufrimientos innecesarios. Por ejemplo, si en Espana el lapatinib + capecitabina, en segunda linea para el cancer de mama, supone 732.000 euros anuales, del orden de 1,5 a 2 millones de euros por ano de vida ajustado por calidad (AVAC), el problema no es que 2 millones sean mucho dinero, sino que se estan perdiendo unos 150-200 AVAC en el mejor uso alternativo de esos recursos (lo que se llama coste de oportunidad). Como escribe Salvador Espriu, «a veces es necesario y forzoso que un hombre muera por un pueblo, pero nunca un pueblo entero debe morir por un hombre. . .». Y se pierden 150-200 suponiendo simplemente que el mejor uso alternativo es aproximadamente el coste promedio que supone obtener 1 AVAC en Espana o en Reino Unido. Tambien en clinica, hace mucho que Cochrane escribio que no se trata de manejar cada caso individual hasta el limite de lo imposible, pues, como sentencio Donabedian, la eficiencia es la marca del virtuosismo en Medicina. En Espana, y en todo el Mezzogiorno europeo, la situacion refuerza el clamor por la sensatez. Los datos del Ministerio de Sanidad senalan que entre 2009 y 2013 el gasto sanitario publico tuvo una caida del 13%, a lo que debe anadirse que toca devolver lo que se debe (incluido lo despilfarrado en aeropuertos sin aviones,

Incentivos en atención primaria: de la contención del gasto a la salud de la población

Este texto se elaboro a partir del debate en el segundo taller presencial de los Seminarios de Innovacion en Atencion Primaria, que en 2007 se dedican a la organizacion de los servicios en atencion primaria. Se celebro en Madrid, el 22 de junio de 2007, y fue ponente Vicente Ortun, contrapuntos Luis Palomo y Miguel Angel Ripoll, y coordinador Juan Gervas. Los Seminarios de Innovacion en Atencion Primaria estan organizados por la Fundacion Ciencias de la Salud y la Fundacion para la Formacion de la Organizacion Medica Colegial, y cuentan con el patrocinio de GSK. A los participantes en los debates previos y posteriores del segundo Seminario de Innovacion 2007, que tambien generaron ideas durante el debate presencial. Fueron participantes en dicho seminario: Abarca B, Amengual M, Ayala V, Bonis J, Casajuana J, Coll Benejam JM, Dominguez Velazquez J, Ezquerra M, Garcia Marco CM, Garcia Olmos LM, Gomez Moreno N, Martinez T, Minue S, Morera R, Otero A, de Pablo R, Palacin JC, Pastor-Sanchez R, Perez Artigues JA, Perez Fernandez M, Rico A, Redondo J, Rivas Costa G, Rodriguez Ledo P, Rodriguez Sendin JJ, Ruiz Tellez A, Simo J, Timoner J, Vazquez Diaz JR, Saffron JP, Solla JM, Vela Cordon P, Vicente Molinero A, Violan C.

Secular trend in the incidence of hip fracture in Catalonia, Spain, 2003–2014

Objectives to describe the secular trend and seasonal variation in the incidence of hip fracture (HF) over 12 years (2003-2014) in Catalonia, the community with the highest incidence of HF in Spain. Methods data about age, gender, type of fracture and month of hospitalisation among patients aged 65 years and older discharged with a diagnosis of HF were collected. Crude and age-standardised annual incidence rate were reckoned. To analyse HF trend, the age/sex-adjusted average annual change in incidence (incidence rate ratio, IRR) was calculated. Results we identified 100,110 HF in the period, with an increase of 16.9% (women 13.4%; men 28.4%). Trochanteric fractures were the most frequent (55.8%). The crude incidence rate (per 100,000 population) decreased from 677.2 (95% confidence interval (95% CI) 662.0-692.7) to 657.6 (95% CI 644.0-671.5). The standardised incidence rate decreased from 754.0 (95% CI 738.6-769.3) to 641.5 (95% CI 627.7-655.3), with a sharp decrease in women (-16.8%) while it was stable in men. The incidence by type of fracture was stable. The trend throughout the period showed a slight decrease with IRR 0.99 (95% CI 0.98-0.99; P = 0.025). The incidence was stable in the oldest group (+85 years), while there was a downward trend in the younger groups. A significant seasonal pattern was observed, with more cases in winter and less in summer (spring as reference). Conclusions the secular trend reveals a decreasing incidence of HF although the absolute number has increased in the last 12 years in Catalonia. Trochanteric fractures were the most prevalent and a seasonal pattern was observed, with more cases in winter.

Obstetric interventions in two groups of hospitals in Catalonia: a cross-sectional study

BackgroundChildbirth assistance in highly technological settings and existing variability in the interventions performed are cause for concern. In recent years, numerous recommendations have been made concerning the importance of the physiological process during birth. In Spain and Catalonia, work has been carried out to implement evidence-based practices for childbirth and to reduce unnecessary interventions.To identify obstetric intervention rates among all births, determine whether there are differences in interventions among full-term single births taking place in different hospitals according to type of funding and volume of births attended to, and to ascertain whether there is an association between caesarean section or instrumental birth rates and type of funding, the volume of births attended to and women’s age.MethodsCross-sectional study, taking the hospital as the unit of analysis, obstetric interventions as dependent variables, and type of funding, volume of births attended to and maternal age as explanatory variables. The analysis was performed in three phases considering all births reported in the MBDS Catalonia 2011 (7,8570 births), full-term single births and births coded as normal.ResultsThe overall caesarean section rate in Catalonia is 27.55% (CI 27.23 to 27.86). There is a significant difference in caesarean section rates between public and private hospitals in all strata. Both public and private hospitals with a lower volume of births have higher obstetric intervention rates than other hospitals (49.43%, CI 48.04 to 50.81).ConclusionsIn hospitals in Catalonia, both the type of funding and volume of births attended to have a significant effect on the incidence of caesarean section, and type of funding is associated with the use of instruments during delivery.

The evolution of health status and chronic conditions in Catalonia, 1994-2006: the paradox of health revisited using the Blinder - Oaxaca decomposition

BackgroundThe paradox of health refers to the improvement in objective measures of health and the increase in the reported prevalence of chronic conditions. The objective of this paper is to test the paradox of health in Catalonia from 1994 to 2006.MethodsLongitudinal cross-sectional study using the Catalonia Health Interview Survey of 1994 and 2006. The approach used was the three-fold Blinder - Oaxaca decomposition, separating the part of the differential in mean visual analogue scale value (VAS) due to group differences in the predictors (prevalence effect), due to differences in the coefficients (severity effect), and an interaction term. Variables included were the VAS value, education level, labour status, marital status, all common chronic conditions over the two cross-sections, and a variable for non-common chronic conditions and other conditions. Sample weights have been applied.ResultsResults show that there is an increase in mean VAS for men aged 15-44, and a decrease in mean VAS for women aged 65-74 and 75 and more. The increase in mean VAS for men aged 15-44 could be explained by a decrease in the severity effect, which offsets the increase in the prevalence effect. The decrease in mean VAS for women aged 65-74 and 75 and more could be explained by an increase in the prevalence effect, which does not offset the decrease in the severity effect.ConclusionsThe results of the present analysis corroborate the paradox of health hypothesis for the population of Catalonia, and highlight the need to be careful when measuring population health over time, as well as their usefulness to detect populations perceptions.