[Continuity of care between levels perceived by users of the health system in Catalonia, Spain]. / La continuidad asistencial entre niveles percibida por usuarios del sistema de salud en cataluña.

BACKGROUND: Rapid technological advances, organizational changes in health services and the rise of complex chronic diseases mean that users receive care from a wide variety of providers, threatening continuity of care (CC). The aim is to analyse users' perception of CC, as well as their experienced elements of (dis)continuity in the Catalonian health services. METHODS: Cross-sectional study by means ofa questionnaire survey to a sample of 200 healthcare users attended by more than one level of care for the same condition in the previous 3 months. The survey was conducted in Barcelona and Baix Empordà, between March and June 2009. The applied questionnaire collected first, the users' trajectories within health services and second, their perception of CC using a scale. A descriptive data analysis was conducted. RESULTS: Important elements of relational continuity were identified (86.4 and 83.5% of users were attended in the last year, respectively, by the same physician of primary and secondary care). However, potential elements of discontinuity were identified relating to transfer of clinical information (29.1% and 21.3% of users perceived that secondary care professionals were unaware of their comorbidities and the results of medical tests ordered by physicians of primary care, respectively), coherence of care (levels of referral to primary care of 51.2 %) and accessibility between levels of care (37.8 and 17.6% considered long or excessive waiting time for secondary and primary care, respectively). CONCLUSIONS: The results point to aspects of care, as accessibility and information transfer between professionals that could act as barriers for continuity and would require improvements in the coordination strategies of the health providers.

Evaluating management contracts.

The current medical environment is characterized by a rise in expenditure in excess of the general rise and an increase in the demands made by its users. Management contracts are a tool designed with the intention of sharing the responsibility of healthcare management with the medical profession without reducing quality. Although this is an attractive project, it also involves risks. It is for this reason that, aside from achieving the established objectives, it is necessary to carry out an evaluation of the project in itself and the impact that its implementation represents for the organization.

The relationship between effectiveness and costs measured by a risk-adjusted case-mix system: multicentre study of Catalonian population data bases.

BACKGROUND: The main objective of this study is to measure the relationship between morbidity, direct health care costs and the degree of clinical effectiveness (resolution) of health centres and health professionals by the retrospective application of Adjusted Clinical Groups in a Spanish population setting. The secondary objectives are to determine the factors determining inadequate correlations and the opinion of health professionals on these instruments. METHODS/DESIGN: We will carry out a multi-centre, retrospective study using patient records from 15 primary health care centres and population data bases. The main measurements will be: general variables (age and sex, centre, service [family medicine, paediatrics], and medical unit), dependent variables (mean number of visits, episodes and direct costs), co-morbidity (Johns Hopkins University Adjusted Clinical Groups Case-Mix System) and effectiveness.The totality of centres/patients will be considered as the standard for comparison. The efficiency index for visits, tests (laboratory, radiology, others), referrals, pharmaceutical prescriptions and total will be calculated as the ratio: observed variables/variables expected by indirect standardization.The model of cost/patient/year will differentiate fixed/semi-fixed (visits) costs of the variables for each patient attended/year (N = 350,000 inhabitants). The mean relative weights of the cost of care will be obtained. The effectiveness will be measured using a set of 50 indicators of process, efficiency and/or health results, and an adjusted synthetic index will be constructed (method: percentile 50).The correlation between the efficiency (relative-weights) and synthetic (by centre and physician) indices will be established using the coefficient of determination. The opinion/degree of acceptance of physicians (N = 1,000) will be measured using a structured questionnaire including various dimensions. STATISTICAL ANALYSIS: multiple regression analysis (procedure: enter), ANCOVA (method: Bonferroni's adjustment) and multilevel analysis will be carried out to correct models. The level of statistical significance will be p < 0.05.

[Relationship among the degree of control of arterial hypertension, comorbidity and costs in individuals over age 30 during 2006]. / Asociación entre el grado de control de la hipertensión arterial, la comorbilidad y los costes en personas de más de 30 años durante el año 2006.

BACKGROUND: Arterial hypertension is one of the main reasons for primary care consultations. This study is aimed at determining the relationship among the degree to which arterial hypertension is controlled, comorbidity and the direct costs in primary care. METHODS: Retrospective, multi-centre design. Subjects over 30 years of age pertaining to five primary care teams (2006) were included. CRITERIA: good control (<140/90 and <130/80 mmHg in diabetics and those with cardiovascular disease [CVD]. Main general measurements, CVD, Charlson index, casuistic/comorbidity (Adjusted Clinical Groups), clinical parameters and direct costs (fixed/semifixed and variable costs) [medications, tests and referrals]) Logic regression and ANCOVA for correcting the model, p<0.05. RESULTS: The prevalence of arterial hypertension was 26.5% (mean age: 67.1 years; males: 43.5%). Good control totalled 52.0% (CI: 51.2-52.8%). Poor control was independently related to diabetes (Odds Ratio=3.8), CVD (Odds Ratio=2.2) and males (Odds Ratio=1.2), p<0.001. The average/direct unit cost/year was 1,202.13 Euro vs. 1,183.55 Euro (p=0.032). CONCLUSIONS: Those individuals whose arterial hypertension was poorly controlled displayed a greater burden of morbidity and a similar healthcare cost in comparison to those under good control.

Asociación entre el grado de control de la hipertensión arterial, la comorbilidad y los costes en personas de más de 30 años durante el año 2006 / Relationship among the degree of control of arterial hypertension, comorbidity and costs in individuals over age 30 during 2006

Fundamento. La hipertensión arterial (HTA) es uno de los principales motivos de consulta de los centros de atención primaria (AP). El objetivo del estudio fue determinar la asociación entre el grado de control de la HTA, la comorbilidad y los costes directos en atención primaria. Métodos. Diseño retrospectivo-multicéntrico. Se incluyó a sujetos mayores de 30 años pertenecientes a cinco equipos de AP (año 2006). Criterios: buen control (<140/90, y <130/80 mmHg en personas diabéticas y presencia de enfermedad cardiovascular [ECV]). Principales medidas: generales, ECV, índice de Charlson, casuística/comorbilidad (Adjusted Clinical Groups), parámetros clínicos y costes directos (fijos/semifijos y variables [medicamentos, pruebas y derivaciones]). Análisis de regresión logística y de ANCOVA para la corrección del modelo, p<0,05. Resultados. La prevalencia de HTA fue del 26,5% (edad media: 67,1 años; varones: 43,5%). El buen control fue del 52,0% (IC: 51,2-52,8%). El mal control tuvo una relación independiente con la diabetes (OR=3,8), el ECV (OR=2,2) y los varones (OR=1,2), p<0,001. El promedio/unitario/año del coste directo corregido fue de 1.202,13 vs. 1.183,55 € (p=0,032). Conclusiones. Los pacientes en situación de mal control muestran una mayor carga de morbilidad y un similar coste sanitario (AU)

Background. Arterial hypertension is one of the main reasons for primary care consultations. This study is aimed at determining the relationship among the degree to which arterial hypertension is controlled, comorbidity and the direct costs in primary care. Methods. Retrospective, multi-centre design. Subjects over 30 years of age pertaining to five primary care teams (2006) were included. Criteria: good control (<140/90 and <130/80 mmHg in diabetics and those with cardiovascular disease [CVD]. Main general measurements, CVD, Charlson index, casuistic/comorbidity (Adjusted Clinical Groups), clinical parameters and direct costs (fixed/semifixed and variable costs) [medications, tests and referrals]) Logic regression and ANCOVA for correcting the model, p<0.05. Results: The prevalence of arterial hypertension was 26.5% (mean age: 67.1 years; males: 43.5%). Good control totalled 52.0% (CI: 51.2-52.8%). Poor control was independently related to diabetes (Odds Ratio=3.8), CVD (Odds Ratio=2.2) and males (Odds Ratio=1.2), p<0.001. The average/direct unit cost/year was 1,202.13 € vs. 1,183.55 € (p=0.032). Conclusions. Those individuals whose arterial hypertension was poorly controlled displayed a greater burden of morbidity and a similar healthcare cost in comparison to those under good control (AU)

[Calculation of morbidity, use of resources and costs of patients treated with tiotropium bromide for COPD in a Spanish population]. / Estimación de la morbilidad, el uso de recursos y los costes de los sujetos en tratamiento con bromuro de tiotropio para la enfermedad pulmonar obstructiva crónica en un ámbito poblacional español.

OBJECTIVE: To determine the co-morbidity and economic impact of treatment with tiotropium bromide (TB) for COPD, in a population cared for by Spanish primary care teams (PCTs) and specialist physicians, in the context of routine clinical practice. DESIGN: Retrospective multi-centre study. SETTING: Four PCTs and 2 urban hospitals. PARTICIPANTS: Patients with COPD receiving regular treatment with TB, during 2004. MAIN MEASUREMENTS: Age and sex, episodes of co-morbidity, clinical parameters, resource use, and pharmacological groups. The costs model was established by differentiating semi-fixed from variable costs (pharmacy, tests, referrals) in the PCTs, as well as the visits, emergencies and hospital admissions occurring in the hospitals. A logistical regression analysis was made to correct the model. The costs were contrasted by analysis of covariance (ANCOVA), with the estimation of marginal means (Bonferroni adjustment). RESULTS: Of 900 patients with COPD, 14.3% (n=129) received treatment with TB (95% CI, 12.0%-16.6%). The mean episodes/patient/year was 2.1 (1.4) versus 1.8 (1.3) (NS), seriousness/severity 41.3% versus 26.3% (P =.001), defined daily dose (DDD) 5928.5 (9624.1) versus 6187.7 (12471.3) (NS) and number visits/patient/year 15.1 (9.4) versus 17.3(11.9) (P=.044). After adjustments for age and sex, TB use was associated with Diabetes Mellitus (OR=1.6; 95% CI, 1.0-2.5; P=.034) and severity of patients' illness (OR=1.8; 95% CI, 1.2-2.8; P=.004). Quantification of unit cost/year was 2793.16 (3166.30) euros (3359.27 [3423.25] euros versus 2703.09 [3113.75] euros; P=.001). The adjusted patient cost/year was 2831.23 euros (SE, 217.32) with TB versus 2786.86 euros (SE, 88.53) without TB (NS). CONCLUSIONS: TB is associated, as therapy complementing routine treatment, with the presence of Diabetes, and with the severity of the disease. The costs of COPD entail high resource consumption. The prescription of TB does not imply greater overall cost of the disease.

Estimación de la morbilidad, el uso de recursos y los costes de los sujetos en tratamiento con bromuro de tiotropio para la enfermedad pulmonar obstructiva crónica en un ámbito poblacional español / Calculation of morbidity, use of resources and costs of patients treated with tiotropium bromide for COPD in a spanish population

Objetivo. Medir la comorbilidad, así como el impacto económico que presentan los sujetos en tratamiento con bromuro de tiotropio (BT) en la enfermedad pulmonar obstructiva crónica (EPOC), en la población atendida por equipos de atención primaria (EAP) y especializada españoles, en situación de práctica clínica habitual. Diseño. Estudio retrospectivo y multicéntrico. Emplazamiento. Cuatro EAP y 2 centros hospitalarios urbanos. Participantes. Pacientes con EPOC que siguieron tratamiento regular con BT, durante el año 2004. Mediciones principales. Edad-sexo, episodios/comorbilidad, parámetros clínicos, utilización de recursos y grupos farmacológicos. El modelo de costes se estableció diferenciando los costes semifijos de los variables (farmacia, pruebas, derivaciones) en los EAP, así como las consultas, urgencias y hospitalizaciones acontecidas en los centros hospitalarios de referencia. Se efectuó un análisis de regresión logística para la corrección del modelo. Los costes fueron contrastados mediante análisis multivariable de ANCOVA, con estimación de medias marginales (ajuste de Bonferroni). Resultados. De 900 sujetos con EPOC, el 14,3% (n = 129) siguió tratamiento con BT (intervalo de confianza [IC] del 95%, 12,0-16,6%). El promedio de episodios/paciente/año fue de 2,1 ± 1,4 frente a 1,8 ± 1,3 (NS), la gravedad/severidad del 41,3 frente al 26,3% (p = 0,001), la dosis farmacológica (DDD) de 5.928,5 ± 9.624,1 frente a 6.187,7 ± 12.471,3 (NS) y el número de visitas/paciente/año de 15,1 ± 9,4 frente a 17,3 ± 11,9 (0,044). Los factores asociados con la utilización de BT, corregidos por edad-sexo, fueron diabetes mellitus (odds ratio [OR] = 1,6; IC del 95%, 1,0-2,5; p = 0,034) y gravedad de los pacientes (OR = 1,8; IC del 95%, 1,2-2,8; p = 0,004). La cuantificación del coste unitario/año fue de 2.793,16 ± 3.166,30 euros (3.359,27 ± 3.423,25 frente a 2.703,09 ± 3.113,75 euros; p = 0,001). El coste paciente/año ajustado fue de 2.831,23 euros (error estándar [EE] = 217,32) con BT, frente a 2.786,86 euros (EE = 88,53) sin BT (NS). Conclusiones. El BT se asocia, como tratamiento complementario al habitual, con la presencia de diabetes y con la severidad de la enfermedad. Los costes de la EPOC ocasionan un elevado consumo de recursos y la utilización de BT no conlleva un mayor coste global de la enfermedad

Objective. To determine the co-morbidity and economic impact of treatment with tiotropium bromide (TB) for COPD, in a population cared for by Spanish primary care teams (PCTs) and specialist physicians, in the context of routine clinical practice. Design. Retrospective multi-centre study. Setting. Four PCTs and 2 urban hospitals. Participants. Patients with COPD receiving regular treatment with TB, during 2004. Main measurements. Age and sex, episodes of co-morbidity, clinical parameters, resource use, and pharmacological groups. The costs model was established by differentiating semi-fixed from variable costs (pharmacy, tests, referrals) in the PCTs, as well as the visits, emergencies and hospital admissions occurring in the hospitals. A logistical regression analysis was made to correct the model. The costs were contrasted by analysis of covariance (ANCOVA), with the estimation of marginal means (Bonferroni adjustment). Results. Of 900 patients with COPD, 14.3% (n=129) received treatment with TB (95% CI, 12.0%-16.6%). The mean episodes/patient/year was 2.1 (1.4) versus 1.8 (1.3) (NS), seriousness/severity 41.3% versus 26.3% (P =.001), defined daily dose (DDD) 5928.5 (9624.1) versus 6187.7 (12471.3) (NS) and number visits/patient/year 15.1 (9.4) versus 17.3(11.9) (P=.044). After adjustments for age and sex, TB use was associated with Diabetes Mellitus (OR=1.6; 95% CI, 1.0-2.5; P=.034) and severity of patients' illness (OR=1.8; 95% CI, 1.2-2.8; P=.004). Quantification of unit cost/year was 2793.16 (3166.30) euros (3359.27 [3423.25] euros versus 2703.09 [3113.75] euros; P=.001). The adjusted patient cost/year was 2831.23 euros (SE, 217.32) with TB versus 2786.86 euros (SE, 88.53) without TB (NS). Conclusions. TB is associated, as therapy complementing routine treatment, with the presence of Diabetes, and with the severity of the disease. The costs of COPD entail high resource consumption. The prescription of TB does not imply greater overall cost of the disease

[Comparative study at 4 health centres of efficiency, measured on the basis of ambulatory care groups]. / Estudio comparativo de la eficiencia, medida a partir de los Ambulatory Care Groups, entre 4 centros de salud.

OBJECTIVE: To measure efficiency in the use of resources for the care lists of four primary care centres (PCC), by using ambulatory care Groups (ACGs). DESIGN: Retrospective, observational study. SETTING: Four PC teams. PARTICIPANTS: All patients attended during 2003. MEASUREMENTS: Dependent variables (costs per patient, between medical lists [family medicine, paediatrics] and PCCs) and case load variables. The model of costs for each patient was set by differentiating the semi-fixed and variable costs. The efficiency index (EI) was set as the quotient between the observed real cost and the expected cost on the basis of ACG distribution, by indirect standardization. The study population was 62,311 patients seen, with an average of 4.8+/-3.2 episodes/patient/year. MAIN RESULTS: The total health care cost reached 24,135,236.62 euro, of which 65.2% was for prescription, 28.9% for semi-fixed costs, and 2.9% for cost of specialist referrals. The average total cost per patient/year was 387.34 euro+/-145.87 euro (average relative weight). The EI for each centre was: 0.93 (95% CI, 0.85-1.01), 0.97 (95% CI, 0.89-1.05), 1.04 (95% CI, 0.96-1.12), and 1.05 (95% CI, 0.97-1.13), P < .0001. In addition, differences between the medical lists (rank, 0.63-1.56) and between the paediatrics lists (rank, 0.73-1.26) were found (P = .005). CONCLUSIONS: The ACGs enabled us to estimate the efficiency of our PCCs and care lists. Efficiency cannot be isolated from other dimensions of the quality of health care delivery. Study of the EI improved our understanding of the profile of professionals and health centres.

Estudio comparativo de la eficiencia, medida a partir de los Ambulatory Care Groups, entre 4 centros de salud / Comparative study at 4 health centres of efficiency, measured on the basis of ambulatory care groups

Objetivo. Medir la eficiencia en el uso de recursos entre los cupos asistenciales de 4 centros de atención primaria de salud (APS), a partir de la utilización de los Ambulatory Care Groups (ACG). Diseño. Estudio observacional retrospectivo. Emplazamiento. Cuatro equipos de atención primaria. Participantes. Todos los pacientes atendidos durante el año 2003. Mediciones. Variables dependientes (costes por paciente, entre cupos médicos [medicina de familia, pediatría] y centros asistenciales) y de casuística. El modelo de costes para cada paciente se estableció diferenciando los costes semifijos y los variables. El índice de eficiencia (IE) se estableció entre el cociente entre el coste real observado y el coste esperado en función de la distribución ACG, por estandarización indirecta. Resultados principales. La población de estudio fue de 62.311 pacientes atendidos, con una media de 4,8 ± 3,2 episodios/paciente/año. El coste total de la atención sanitaria ascendió a 24.135.236,62 €, de los cuales el 65,2% correspondió a la prescripción de farmacia, el 28,9% a los costes semifijos y el 2,9% al coste de las derivaciones a especialistas. El promedio de coste total por paciente/año fue de 387,34 ± 145,87 € (peso relativo medio). El IE por centro fue de 0,93 (intervalo de confianza [IC] del 95% 0,85-1,01), 0,97 (IC del 95% del 95% 0,89-1,05), 1,04 (IC del 95% 0,96-1,12) y 1,05 (IC del 95%, 0,97-1,13), respectivamente (p < 0,0001). Además, se observan diferencias entre los cupos médicos (rango, 0,63-1,56) y entre los cupos pediátricos (rango, 0,73-1,26) (p = 0,005). Conclusiones. Los ACG permiten realizar una aproximación a la medida de la eficiencia de centros y cupos asistenciales de APS de nuestro entorno. La eficiencia no puede ser considerada de manera aislada de otras dimensiones de la calidad asistencial. El estudio del IE permite profundizar en el conocimiento del perfil de los profesionales y de los centros de salud

Objective. To measure efficiency in the use of resources for the care lists of four primary care centres (PCC), by using ambulatory care Groups (ACGs). Design. Retrospective, observational study. Setting. Four PC teams. Participants. All patients attended during 2003. Measurements. Dependent variables (costs per patient, between medical lists [family medicine, paediatrics] and PCCs) and case load variables. The model of costs for each patient was set by differentiating the semi-fixed and variable costs. The efficiency index (EI) was set as the quotient between the observed real cost and the expected cost on the basis of ACG distribution, by indirect standardization. The study population was 62 311 patients seen, with an average of 4.8±3.2 episodes/patient/year. Main results. The total health care cost reached €24 135 236.62, of which 65.2% was for prescription, 28.9% for semi-fixed costs, and 2.9% for cost of specialist referrals. The average total cost per patient/year was €387.34±€145.87 (average relative weight). The EI for each centre was: 0.93 (95% CI, 0.85-1.01), 0.97 (95% CI, 0.89-1.05), 1.04 (95% CI, 0.96-1.12), and 1.05 (95% CI, 0.97-1.13), P<.0001. In addition, differences between the medical lists (rank, 0.63-1.56) and between the paediatrics lists (rank, 0.73-1.26) were found (P=.005). Conclusions. The ACGs enabled us to estimate the efficiency of our PCCs and care lists. Efficiency cannot be isolated from other dimensions of the quality of health care delivery. Study of the EI improved our understanding of the profile of professionals and health centres

Posibilidades de los grupos clínicos ajustados (ajusted clinical groups-acgs) en el ajuste de riesgos de pago capitativo / Prospects of adjusted clinical groups (ACG´s) in capitated payment risk adjustment

Fundamento: La mayoría de los sistemas de clasificación depacientes han sido diseñados en Estados Unidos con la finalidad dedisponer de una herramienta que facilite una medida en la utilizaciónde los recursos. El objeto del estudio fue obtener los pesos relativos(PR) medios del coste de la asistencia en varios equipos de atenciónprimaria de salud, en comparación con los americanos, mediante laaplicación de los Grupos Clínicos Ajustados (ACGs), como un posibleajuste de riesgos de pago capitativo.Métodos: Estudio descriptivo. Se incluyeron todas las historiasclínicas generadas por cuatro equipos de atención primaria durante elaño 2003. Las principales mediciones fueron: edad y sexo, recursos(visitas y costes) y casuística. El modelo de costes para cada pacientese estableció diferenciando los costes fijos y variables. Se efectuóun análisis de regresión para la corrección del modelo. El coste relativode cada ACG se obtuvo dividiendo el coste medio de cada categoríaentre el coste medio de toda la población de referencia.Resultados: El número total de historias estudiadas fue de62.311, con una media de 4,8±3,2 diagnósticos y 7,8±7,5visitas/paciente/año. El gasto total fue de 24,1 millones de euros, loscostes fijos o semifijos representan el 28,9% y los variables el71,1%. El promedio de coste total por paciente/año fue de387,34±145,87? (referencia). El poder explicativo corregido delcoste de la asistencia entre las dos clasificaciones (estadounidenserespecto a la estudiada) fue del 64,3%; p=0,000).Conclusiones: La generalización de los resultados debe de interpretarsecon prudencia. Los ACGs se muestran como un instrumentoadecuado y podrían utilizarse los PR medios estadounidenses parael ajuste del riesgo en el pago capitativo, ante la dificultad de tenerbases de datos amplias y consistentes en nuestro medio. Sería necesarioesperar nuevas investigaciones que refuercen la consistencia delos resultados

Background: Most patient classification systems have beendesigned in the United States for the purpose of availing of a toolproviding a means of gauging the use of resources. This study wasaimed at calculating the mean relative weights (MRW´s) for thecost of care at several primary care health facilities as compared tothose in the U.S. by using the Adjusted Clinical Groups (ACG´s) asa possible capitated payment risk adjustment.Methods: Descriptive study. All of the clinical records generatedby four primary care facilities throughout 2003 were included.The main measurements were: age and gender, resources (visits andcosts) and casuistics. The cost model was determined for each individualpatient by differentiating the fixed and variable costs. Aregression analysis was made for model adjustment purposes. Therelative cost of each ACG was calculated by dividing the mean costof each category by the mean cost of the population as a whole.Results: A total of 62,311 records were studied, revealing anaverage of 4.8±3.2 diagnoses and 7.8±7.5 visits/patient/year. Thetotal expense was 24.1 million euros, the fixed and semi-fixed coststotaling 28.9% and the variable costs 71.1%. The mean totalcost/patient/year was 387.34±145.87? (reference). The adjustedexplicative power of the cost of care between the two classifications(U.S. classification vs. the one studied) was 64.3%; p=0,000).Conclusions: The generalization of the results must be carefullyconstrued. ACG´s show themselves to be a suitable tool, and themean U.S. RW´s could be used for adjusting capitated payment riskadjustments in view of the difficulty of availing of full, consistentdatabases in our environment. Further research would be required toback up the consistency of the results