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Research question: We analyzed two questions. First, the effectiveness of public Assisted Reproductive Technologies (ART) in Spain compared with private ones, measured by the time since initiating ART treatment until achieving pregnancy, accounting for age and socioeconomic factors. Second, socioeconomic determinants of access to ART, referring primarily to financial means derived by employment, income, and wealth. Design: We applied statistical models on data extracted from the national Spanish Fertility Survey from 2018. The first topic was analyzed by competing risk survival analysis conducted on a sample of 667 women who initiate ART treatment since 2000. The second, by a Bivariate Probit model conducted on a sample of 672 women older than 41 years who required ART services. Results: The first analysis raised that throughout the treatment, patients treated exclusively in private clinics had on average a higher cumulative incidence of becoming pregnant compared with patients who approached public clinics. The second analysis raised that both higher household equivalent income and higher education increase the likelihood of accessing ART in a private clinic and decrease the tendency of accessing public clinics or failing to access any service. Moreover, being single decreases the likelihood of accessing public clinics or ART services in general. Conclusions: Long waiting periods could be the main reason for the lower incidence of getting pregnant in public healthcare, explaining why patients choose private over public care. We develop a broader discussion over the extent of Spanish public funding of ART, the unequal medical outcome, and potential options for optimization. [ABSTRACT FROM AUTHOR]

Objective: To compare the differences in the use of healthcare services: visits to the doctor and hospitalisation, performance of routine tests, and preventive influenza vaccination, between users and non-users of homeopathic products. Methods: We used the microdata for adults over 15 years old from three waves of the Spanish National Health Survey, corresponding to the years 2011, 2014 and 2017. We proposed a comparative design of a quasi-experimental type, considering as the treatment group the respondents who said that they had used homeopathic products in the past two weeks; and another group, for control, comprising respondents who said that they had not used this type of products, but only conventional medicines, with observable characteristics similar to those of the treatment group. We used a model for rare events logistics regression (relogit) to estimate the probability of using homeopathy. From the propensity score and a vector of control variables, we used techniques of genetic matching to match individuals from the treatment group with similar individuals belonging to the control group. Results: There are no statistically significant differences between users and non-users of homeopathy in visits to the general practitioner (P>|z| 0.387), to the specialist (P>|z| 0.52), in hospitalisations (P>|z| 0.592) or in the use of emergency services (P>|z| 0.109). Nor were there any statistically significant differences in the performance of routine tests, except for the faecal occult blood test, which is more prevalent in users of homeopathic products. 20.9% of users of homeopathy had done this test compared with 15.3% of non-users (P>|z| 0.022). There are also significant differences in vaccination against influenza with 12.6% of homeopathy users stating that they had been vaccinated in the last influenza campaign, against 21.0% of non-users (P>|z| <0.001). The health conditions which homeopathy users reported were constipation (OR: 1.65 CI: 1.16–2.36), malignant tumour (OR: 1.60 CI: 1.09–2.36) osteoporosis (OR: 1.49 CI: 1.05–2.10), varicose veins (OR: 1.35 CI: 1.05–1.74) and allergy (OR: 1.35 CI: 1.06–1.72). Conclusions: Differences in the use of healthcare resources between users and non-users of homeopathic products have not been found to be statistically significant in Spain. It has been shown that most homeopathic products are used as a complement to treatment with conventional medicine. Nevertheless, our results highlight some warning signs which should raise the attention of healthcare authorities. The use of these therapies in patients with malignant tumours and the rejection of vaccines are warning signs of a possible health hazard in the long term. [ABSTRACT FROM AUTHOR]

Background: In Spain, the Law 28/2005, which came into effect on January 2006, was a turning point in smoking regulation and prevention, serving as a guarantee for the progress of future strategies in the direction marked by international organizations. It is expected that this regulatory policy should benefit relatively more to lower socioeconomic groups, thus contributing to a reduction in socioeconomic health inequalities. This research analyzes the effect of tobacco regulation in Spain, under Law 28/2005, on the initiation and cessation of tobacco consumption, and whether this effect has been unequal across distinct socioeconomic levels. Methods: Micro-data from the National Health Survey in its 2006 and 2011 editions are used (study numbers: 4382 and 5389 respectively; inventory of statistical operations (ISO) code: 54009), with a sample size of approximately 24,000 households divided into 2,000 census areas. This allows individuals' tobacco consumption records to be reconstructed over five years before the initiation of each survey, as well as identifying those individuals that started or stopped smoking. The methodology is based on "time to event analysis".Cox's proportional hazard models are adapted to show the effects of a set of explanatory variables on the conditional probability of change in tobacco consumption: initiation as a daily smoker by young people or the cessation of daily smoking by adults. Results: Initiation rates among young people went from 25% (95% confidence interval (CI), 23-27) to 19% (95% CI, 17-21) following the implementation of the Law, and the change in cessation rates among smokers was even greater, with rates increasing from 12% (95% CI, 11-13) to 20% (95% CI, 19-21). However, this effect has not been equal by socioeconomic groups as shown by relative risks. Before the regulation policy, social class was not a statistically significant factor in the initiation of daily smoking (p > 0.05); however, following the implementation of the Law, young people belonging to social classes IV-V and VI had a relative risk of starting smoking 63% (p =0.03) and 82% (p = 0.02) higher than young people of higher social classes I-II. On the other hand, lower social class also means a lower probability of smoking cessation; however, the relative risk of cessation for a smoker belonging to a household of social class VI (compared to classes I-II) went from 24% (p < 0.001) lower before the Law to 33% (p < 0.001) lower following the law's implementation. Conclusion: Law 28/2005 has been effective, as after its promulgation there has been a decrease in the rate of smoking initiation among young people and an increase in the rate of cessation among adult smokers. However, this effect has not been equal by socioeconomic groups, favoring relatively more to those individuals belonging to higher social classes. [ABSTRACT FROM AUTHOR]

Background: Social health inequalities in adult population are partly due to socioeconomic circumstances in childhood. A better understanding of how those circumstances affect health during adulthood may improve the opportunities for reducing health disparities. The objective of this study is to investigate the effect of parental socioeconomic status, which is proxied by occupation, on adult Spaniards' health by birth cohort. The analysis will allow checking not only the direct impact of parental occupation on their offspring's health, but also whether inherited inequality has been reduced over time.Methods: We use data from the Bank of Spain's Survey of Household Finances on Spanish households from 2002 to 2008. Sequential models were used to estimate the influence of the father's and mother's occupation on their offspring's health, trying to disentangle direct from indirect effects. With a sample of 26,832 persons we consider effects for four different cohorts by birth periods ranging from 1916 to 1981.Results: The results show that parental occupation has a significant direct impact on individuals' health (p < 0.01). The effect of father's occupation exceeds that of mother's. For those born before 1936, the probability of reporting a good health status ranges from 0.31 (95% confidence interval (CI) 0.14-0.48), when fathers were classified as unskilled elementary workers, to 0.98 (95% CI 0.98-0.99) when they were managers or mid-level professionals. For those born during the period 1959-1975, those probabilities are 0.49 (95% CI 0.39-0.59) and 0.97 (95% CI 0.96-0.98), respectively. Therefore, health inequalities linked to parental socioeconomic status have been noticeably reduced, although discrimination against unskilled workers persists over time.Conclusions: Great progress has been made in the health area during the twentieth century, so that the impact of parental socioeconomic status on individuals' health has been significantly tempered for those at the bottom of the social scale. However, more efforts focused on the improvement of living conditions for most socioeconomically disadvantaged are needed in order to further reduce social inequalities in health. [ABSTRACT FROM AUTHOR]

Introduction: The potential of smoke-free bans to negatively impact the hospitality business has been an argument of the hospitality and tobacco industry against such legislation. A partial smoke-free legislation was introduced in Spain in 2006 allowing smoking in most bars and restaurants due to the pressure of the hospitality sector. However, this partial ban was later amended in 2011 to include all the hospitality premises without exceptions. The stepped Spanish process permits to evaluate whether the entry into force of the smoke-free legislation had any effect on the economic activity of the hospitality sector.Methods: We employed a pooled time series cross-sectional design, with national data over 6 years (2006-2011). The dependent variable used was the total number of bars and restaurants per 100,000 inhabitants. The explanatory variables used were the average amount of spending per household in bars and restaurants, and the total unemployment rate in Spain by regions.Results: For every 1% increase in the unemployment rate there was a 0.05% decrease in the number of bars and restaurants. In 2007, the number of bars and restaurants was significantly reduced by 13.06% (all others factors being held constant), 4.87% in 2008, and 10.42% in 2009. No statistically significant effect of the smoke-free legislation emerged from 2010 (6.76%) to 2011 (7.69%).Conclusion: The new Spanish smoke-free legislation had no effect on the number of bars and restaurants. [ABSTRACT FROM AUTHOR]

Introduction: Adult oral health is predicted by oral health in childhood. Prevention improves oral health in childhood and, consequently in adulthood, so substantial cost savings can be derived from prevention. The burden of oral disease is particularly high for disadvantaged and poor population groups in both developing and developed countries. Therefore, an appropriate and egalitarian access to dental care becomes a desirable objective if children's dental health is to be promoted irrespective of socioeconomic status. The aim of this research is to analyse inequalities in the lack of access to dental care services for children in the Spanish National Health System by socio-economic group over the period 1987-2011. Methods: Pooled data from eight editions of the Spanish National Health Survey for the years 1987-2011, as well as contextual data on state dental programmes are used. Logistic regressions are used to examine the related factors to the probability of not having ever visited the dentist among children between 6 and 14 years old. Our lack of access variable pays particular attention to the socioeconomic level of children's household. Results: The mean probability of having never been to the dentist falls considerably from 49.5% in 1987 to 8.4% in 2011. Analysis by socioeconomic level indicates that, in 1987, the probability of not having ever gone to the dentist is more than two times higher for children in the unskilled manual social class than for those in the upper non-manual social class (odds ratio 2.35). And this difference is not reduced significantly throughout the period analysed, rather it increases as in 1993 (odds of 2.39) and 2006 (odds of 3.03) to end in 2011 slightly below than in 1987 (odds ratio 1.80). Conclusion: There has been a reduction in children's lack of access to dentists in Spain over the period 1987-2011. However, this reduction has not corrected the socioeconomic inequalities in children's access to dentists in Spain. [ABSTRACT FROM AUTHOR]

Introduction Adult oral health is predicted by oral health in childhood. Prevention improves oral health in childhood and, consequently in adulthood, so substantial cost savings can be derived from prevention. The burden of oral disease is particularly high for disadvantaged and poor population groups in both developing and developed countries. Therefore, an appropriate and egalitarian access to dental care becomes a desirable objective if children's dental health is to be promoted irrespective of socioeconomic status. The aim of this research is to analyse inequalities in the lack of access to dental care services for children in the Spanish National Health System by socio-economic group over the period 1987-2011. Methods Pooled data from eight editions of the Spanish National Health Survey for the years 1987-2011, as well as contextual data on state dental programmes are used. Logistic regressions are used to examine the related factors to the probability of not having ever visited the dentist among children between 6 and 14 years old. Our lack of access variable pays particular attention to the socioeconomic level of children's household. Results The mean probability of having never been to the dentist falls considerably from 49.5% in 1987 to 8.4% in 2011. Analysis by socioeconomic level indicates that, in 1987, the probability of not having ever gone to the dentist is more than two times higher for children in the unskilled manual social class than for those in the upper non-manual social class (odds ratio 2.35). And this difference is not reduced significantly throughout the period analysed, rather it increases as in 1993 (odds of 2.39) and 2006 (odds of 3.03) to end in 2011 slightly below than in 1987 (odds ratio 1.80). Conclusion There has been a reduction in children's lack of access to dentists in Spain over the period 1987-2011. However, this reduction has not corrected the socioeconomic inequalities in children's access to dentists in Spain. [ABSTRACT FROM AUTHOR]

Background: The 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. Methods: Longitudinal 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. Results: Results 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. Conclusions: The 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 population's perceptions. [ABSTRACT FROM AUTHOR]

We investigate the main sources of heterogeneity in regional efficiency. We estimate a translog stochastic-frontier production function in the analysis of Spanish regions in the period 1964-96, to attempt to measure and explain changes in technical efficiency. Our results confirm that regional inefficiency is significantly and positively correlated with the ratio of public capital to private capital. The proportion of service industries in private capital, the proportion of public capital devoted to transport infrastructures, the industrial specialization, and spatial spillovers from transport infrastructures in neighbouring regions significantly contributed to improving regional efficiency. [ABSTRACT FROM AUTHOR]

Objectives: This article estimates the costs and benefits of changes in ischemic heart disease (IHD) care in Spain from 1980 to 2003. Methods: We use joinpoint regression to identify trends in the standardized rates of mortality and hospitalization for IHD in general and acute myocardial infarction (AMI) in particular. We estimate also logistic regression models for the probability of in-hospital death of patients admitted for AMI. To measure costs and benefits between 1980 and 2003 we use the microdata from Spanish Hospital Morbidity Survey, and the reports of the Cardiac Catheterization and Coronary Intervention Registry of the Spanish Society of Cardiology. Results: Mortality from IHD in Spain has been substantially reduced in the past 25 years. Medical advances have saved lives of many patients admitted to hospitals. If the patients with AMI admitted in 2003 had been treated with 1980 procedures the rate of hospital mortality for AMI would have doubled. The estimated benefits in 2003 are the lives of the 5326 patients saved. The unit real costs have increased from &U20AC;2143 to &U20AC;4550 per AMI admission. If this cost increase is applied to the 57,842 Spanish AMI inpatients admitted in 2003, one could say that advances in medical technology from 1980 to 2003 carry a cost of &U20AC;26,140 per life saved. Conclusions: In Spain advances in hospital technology for the treatment of IHD since 1980 are well worth the cost. [ABSTRACT FROM AUTHOR]

Focuses on a study which profiled smokers among Spanish men and women, based on subject characteristics, for the period 1993-1997. Materials and methods; Results; Discussion.

The interrupted time series analysis is a quasi-experimental design used to evaluate the effectiveness of an intervention. Segmented linear regression models have been the most used models to carry out this analysis. However, they assume a linear trend that may not be appropriate in many situations. In this paper, we show how generalized additive models (GAMs), a non-parametric regression-based method, can be useful to accommodate nonlinear trends. An analysis with simulated data is carried out to assess the performance of both models. Data were simulated from linear and non-linear (quadratic and cubic) functions. The results of this analysis show how GAMs improve on segmented linear regression models when the trend is non-linear, but they also show a good performance when the trend is linear. A real-life application where the impact of the 2012 Spanish cost-sharing reforms on pharmaceutical prescription is also analyzed. Seasonality and an indicator variable for the stockpiling effect are included as explanatory variables. The segmented linear regression model shows good fit of the data. However, the GAM concludes that the hypothesis of linear trend is rejected. The estimated level shift is similar for both models but the cumulative absolute effect on the number of prescriptions is lower in GAM. [ABSTRACT FROM AUTHOR]

Background: Few studies have quantitatively estimated the income elasticity of demand of voluntary private health insurance (VPHI) in countries with a universal National Health Service. Most studies to date have uses cross-sectional data.Methods: In this paper we used a longitudinal database from the Bank of Spain to analyse the financial behaviour of approximately six thousand families per wave. We used three waves (2008, 2011 and 2014). We estimated income and wealth semi-elasticities of VPHI in Spain considering personal and family characteristics (age, sex, level of health, education, composition of the household), i.e. changes in the probability of buying VPHI as result of 1% change in income or wealth. We estimated cross-sectional models for each wave and longitudinal models for families remaining for at least two waves, taking account of possible selection bias due to attrition.Results: Cross-sectional models suggest that the income effect on the probability of buying a VPHI increased from 2008 to 2014. The positive impact was observed for, wealth. In 2008 a 1% increase in income is associated with an increase in the probability of having VPHI of 0.064 [95%-CI: 0.023; 0.104] - on the probability scale (0.1) - whereas in 2014, this effect is of 0.116 [95%-CI, 0.094; 0.139]. In 2011 and 2014 the wealth effect is not significant at 5%. The estimation of the longitudinal model leads to different results where both, income and wealth are associated with non- significant results.Conclusion: Our three main conclusions are: 1) Cross-sectional estimates of semi-elasticities of VPHI might be biased upwards; 2) Wealth is alongside income are economic determinants, of the decision to buy VPHI in high-income countries; 3) The effects of income and wealth on the probability of buying VHPI are neither linear nor log-linear. There are no significant differences among 60% of the most disadvantaged families, while the families of the two upper wealth quintiles show clearly differentiated behaviour with a higher probability of insurance. [ABSTRACT FROM AUTHOR]

Background: The objective of this research is to analyse trends in horizontal inequity in access to public health services by immigration condition in Spain throughout the period 2006–2017. We focus on "economic immigrants" because they are potentially the most vulnerable group amongst immigrants. Methods: Based on the National Health Surveys of 2006–07 (N = 29,478), 2011–12 (N = 20,884) and 2016–17 (N = 22,903), hierarchical logistic regressions with random effects in Spain's autonomous communities are estimated to explain the probability of using publicly-financed health care services by immigrant condition, controlling by health care need and other socioeconomic and demographic variables. Results: Our results indicate that there are several horizontal inequities, though they changed throughout the decade studied. Regarding primary care services, the period starts (2006–07) with no global evidence of horizontal inequity in access (although the analysis by continent shows inequity that is detrimental to Eastern Europeans and Asians), giving way to inequity favouring economic immigrants (particularly Latin Americans and Africans) in 2011–12 and 2016–17. An opposite trend happens with specialist care, as the period starts (2006–07) with evidence of inequity that is detrimental to economic immigrants (particularly those from North of Africa) but this inequity disappears with the economic crisis and after it (with the only exception of Eastern Europeans in 2011–12, whose probability to visit a specialist is lower than for natives). Regarding emergency care, our evidence indicates horizontal inequity in access that favours economic immigrants (particularly Latin Americans and North Africans) that remains throughout the period. In general, there is no inequity in hospitalisations, with the exception of 2011–12, where inequity in favour of economic immigrants (particularly those from Latin America) takes place. Conclusions: The results obtained here may serve, firstly, to prevent alarm about negative discrimination of economic immigrants in their access to public health services, even after the implementation of the Royal Decree RD Law 16/2012. Conversely, our results suggest that the horizontal inequity in access to specialist care that was found to be detrimental to economic immigrants in 2006–07, disappeared in global terms in 2011–12 and also by continent of origin in 2016–17. [ABSTRACT FROM AUTHOR]

Introduction: To assess the incidence and clinical significance of pneumoperitoneum after radiologic percutaneous gastrojejunostomy (PGJ) tube insertion. Methods: Sixteen subjects were prospectively assessed after imaging-guided PGJ tube insertion to discern the incidence of pneumoperitoneum related to specific clinical signs and symptoms. Computed tomography of the abdomen and the pelvis was performed immediately after PGJ insertion. A clinical evaluation, including history, general and abdominal physical examination, temperature, complete blood cell count, abdominal pain, and abdominal tension, was performed on days 1 and 3, and at the discretion of the nutritional support team on day 7 after PGJ insertion. Results: Fifteen of the 16 subjects demonstrated imaging findings of pneumoperitoneum after the PGJ-tube insertion. Only a small amount of pneumoperitoneum was demonstrated in 10 of the subjects, whereas a large volume of gas was detected in 2 of the subjects. The only altered clinical findings encountered were increased white blood cell count and fever. These abnormal clinical data were most frequently seen immediately after feeding-tube placement. Discussion: Pneumoperitoneum was a common finding after PGJ-tube placement in our study population. There were no statistically significant abnormal clinical parameters, in the presence or absence of pneumoperitoneum, for any of the subjects after PGJ-tube insertion. Conservative management of pneumoperitoneum after PGJ is warranted. [ABSTRACT FROM AUTHOR]

This paper contributes to the empirical knowledge of determinants of smoking initiation in adolescents. The instrument we used was a structural equation model, which is a powerful tool to analyze causal relationships in nonexperimental studies. We used a school-based sample of 1198 teenagers from Spain. We measured the attitude of the adolescents towards tobacco. Attitudes and smoking status are related. Attitudes become more favorable to smoking, as experimentation with cigarettes progresses and pupils become older. Teenagers who have tried at least one cigarette are on average more favorable to smoking than those who had never smoked. The study's limitations were noted. [ABSTRACT FROM AUTHOR]

Objective: Nutritional support is part of the standard of care for the critically ill adult patient. In the average patient in the intensive care unit who has no contraindications to enteral nutrition (EN) or parenteral nutrition (PN), the choice of route for nutritional support may be influenced by several factors. Because EN and PN are associated with risks and benefits, we systematically reviewed and critically appraised the literature to compare EN with PN the critically ill patient.Methods: We searched computerized bibliographic databases, personal files, and relevant reference lists to identify potentially eligible studies. Only randomized clinical trials that compared EN with PN in critically ill patients with respect to clinically important outcomes were included in this review. In an independent fashion, relevant data on the methodology and outcomes of primary studies were abstracted in duplicate. The studies were subsequently aggregated statistically.Results: There were 13 studies that met the inclusion criteria and, hence, were included in our meta-analysis. The use of EN as opposed to PN was associated with a significant decrease in infectious complications (relative risk = 0.64, 95% confidence interval = 0.47 to 0.87, P = 0.004) but not with any difference in mortality rate (relative risk = 1.08, 95% confidence interval = 0.70 to 1.65, P = 0.7). There was no difference in the number of days on a ventilator or length of stay in the hospital between groups receiving EN or PN (Standardized Mean Difference [SMD] = 0.07, 95% confidence interval = -0.2 to 0.33, P = 0.6). PN was associated with a higher incidence of hyperglycemia. Data that compared days on a ventilator and the development of diarrhea in patients who received EN versus PN were inconclusive. In the EN and PN groups, complications with enteral and parenteral access were seen. Four studies documented cost savings with EN as opposed to PN.Conclusion: The use of EN as opposed to PN results in an important decrease in the incidence of infectious complications in the critically ill and may be less costly. EN should be the first choice for nutritional support in the critically ill. [Copyright &y& Elsevier]

Purpose: To determine if design modifications to the Gray-St. Louis gastrojejunostomy catheter would improve its deployment and utilization characteristics. Methods: A modified catheter and the Gray-St. Louis catheter were alternately inserted in consecutive patients requiring gastrojejunostomy. At the time of insertion, the anatomic locations of the fenestrated end of the catheter and the Cope retention loop were recorded. At the time of removal or exchange, catheters were assessed for the position of the fenestrated end and the retention loop, the presence of catheter tears, leakage of injected contrast medium and evidence of catheter blockage. Results: Of the 250 catheters we assessed in a 3year period, 141 (56%) were modified catheters and 109 (44%) were Gray-St. Louis catheters. At insertion, the retention loop of the modified catheter was in the duodenum in 132 (94%) patients, whereas the retention loop of the Gray-St. Louis catheter reached the duodenum in 29 (27%) (p < 0.05). At the time of catheter removal or exchange, the retention loop of the modified catheter was in the duodenum in 72 (60%) patients, whereas the retention loop of the GraySt. Louis catheter was in the duodenum in 13 (14%) (p < 0.05). Conclusion: The design modifications to the Gray-St. Louis catheter improved the likelihood of the retention loop residing in the duodenum, while continuing to allow the fenestrated portion of the catheter to reside in the jejunum. [ABSTRACT FROM AUTHOR]