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Every year, over 250,000 public authorities in the European Union (EU) spend about 14% of GDP on the purchase of services, works and supplies. Many are in the health sector, a sector in which public authorities are the main buyers in many countries. When these purchases exceed threshold values, EU public procurement rules apply. Public procurement is increasingly being promoted as a tool for improving efficiency and contributing to better health outcomes, and as a policy lever for achieving other government goals, such as innovation, the development of small and medium-sized enterprises, sustainable green growth and social objectives like public health and greater inclusiveness. In this paper, we describe the challenges that arise within health care systems with public procurement and identify potential solutions to them. We examined the tendering of pharmaceuticals, health technology, and e-health. In each case we identify a series of challenges relating to the complexity of the procurement process, imbalances in power on either side of transactions and the role of procurement in promoting broader public policy objectives. Finally, we recommend several actions that could stimulate better procurement, and suggest a few areas where further EU cooperation can be pursued.

Includes supplementary materials for the online appendix. Waiting times act as a non-price rationing mechanism to bring together the demand for and the supply of public healthcare services and ensure equal access independently of ability to pay. This study tests for the presence of socioeconomic inequalities in waiting times for ten publicly-funded planned and cancer surgeries in Catalonia (Spain) in 2015–2019. Socioeconomic status (SES), measured by four categories (very low, low, middle, high), is based on co-payment levels for medicines which depend on patient's income. Using administrative data, we estimate the association between SES and waiting times controlling for patient characteristics and hospital fixed effects. Compared to patients with low SES, patients with middle SES wait 2–6 fewer days for hip replacement, cataract surgery, and hysterectomy, and less than a day for breast cancer surgery. These inequalities arise within hospitals and are not explained by patient nor hospital characteristics. For some surgeries, the results also show that patients with higher SES are more likely to voluntarily exit the waiting list and have a lower probability of having a surgery canceled for medical reasons and dying while waiting.

Socioeconomic inequalities in health have been an issue in all European countries since the publication of the “Black Report” in the United Kingdom in 1980. However, data show that nowadays there are important socioeconomic health inequalities within EU countries. The purpose of this paper is to review EU-15 government reports that address socioeconomic inequalities in health. We reviewed 101 reports. The pioneer countries in analyzing this topic have a Beveridge-type health system, and they are the leaders over time. The top socioeconomic indicators used are education level, social class, deprivation level of the area, and nationality. Given the current COVID-19 pandemic situation and its economic consequences, EU governments need to continue monitoring the existing inequalities in health and to act transversely in all public policies. © 2021 The Authors. European Policy Analysis published by Wiley Periodicals LLC on behalf of Policy Studies Organization.

Background: Over the last two decades, the rise in opioid prescription has worsened health outcomes worldwide, increasing both levels of abuse and mortality rates. In order to reduce the scale of this public health problem, new policies have been implemented in many countries. In 2012, Spain adopted new legislation on opioid prescription (the ROE law), which meant that practitioners no longer needed to obtain extra authorisation in order to prescribe strong opioids. The objective of the paper is to assess the impact of this law on opioid use and abuse in Catalonia, Spain. Methods: We established two measures of the use of strong and weak opioids: DDDs, and abuse. We used benzodiazepines and antidepressants as controls, and adjusted for age, sex, drug co-payment level, death or near death, cancer diagnosis, morbidity group, and type of prescription. The data were obtained from administrative and dispensing drug databases in a population of 7.5 million inhabitants. We estimated two-way fixed effects using difference in difference models. Results: The ROE law impacted reducing the monthly use of strong opioids by 0.903 DDDs, representing a 3.15% decrease in the mean monthly use of strong opioids. However, abuse rose 1.86 times compared with the average pre-ROE value, which represents an increase of 11,190 months of opioid abuse (i.e., an 11.33% of all monthly opioids use). Conclusion: The abolition of the duplicate prescription programme for strong opioids led to a reduction in the average monthly use of strong opioids, but an increase in abuse. info:eu-repo/semantics/publishedVersion

Background The Results Centre is the name of a project that, since 2012, has been openly publishing the results of each healthcare centre in Catalonia, with the idea of promoting benchmarking among centres and transparency toward society. As the project evolves, it has become increasingly necessary to adapt its contents and formats. The objective of this study is to identify the preferences and expectations of healthcare leaders regarding the Results Centre. Methods A qualitative study was conducted using the nominal group technique. Five nominal groups were created with the participation of 58 professionals (26 from hospital care, 16 from primary care, and 16 from long-term care centres). The areas of analysis were: (1) what the Results Centre of the future should be like; (2) what information needs should be addressed; and (3) what novelties should be incorporated to stimulate quality improvement. The spontaneity of ideas, intensity of recommendations, and intergroup consistency were analysed. The study was conducted in April 2019. Results The requirements reported by the participants to be met by the Results Centre included: being a tool for benchmarking and strategic decision-making; adjusted and segmented indicators; non-clinical information (patient experience, socio-economic status, etc.); and data accessible to all stakeholders, including citizens. The ideas were consistent across the different levels of care, although the intensity of recommendations varied depending on their content. Conclusions Regional agencies that are accountable for health outcomes should be consistently committed to adapting to the needs of different stakeholders in the health system. This project is an example of how this requirement has been addressed in Catalonia.

Background: In Spain, legislation was passed in 2012 excluding undocumented migrants from the public health-care system. Catalonia was one of the Spanish regions that did not implement this legislation, and continued to guarantee access to health care to the whole population. We aimed to analyse health-care use and health status among undocumented migrants in Catalonia, and compare health-care use and health status with legal residents classified according to their socioeconomic position (SEP). Methods: We did a population-based, cross-sectional study, with administrative individual data. The study included the resident population in Catalonia, Spain, in 2017, aged younger than 65 years and with a maximum annual income of less than €18 000 per year, and classified into three socioeconomic (SEP) groups—low SEP, very low SEP, and undocumented migrants. Indicators regarding health-care service use (primary care, emergency care, mental health care, acute care), drug prescriptions, and selected chronic and infectious diseases were analysed. Findings: Between Jan 1 and Dec 31, 2017, 4 071 988 residents of Catalonia were included in this study; undocumented migrants represented 2·8% (n=113 450) of this population. Of all undocumented migrants, 25 942 (61·0%) female participants aged 15–64 years and 19 819 (46·0%) male participants aged 15–64 years attended primary health-care centres: these rates were lower than in individuals with a very low SEP (84·8% in female participants and 72·1% in male participants). Hospital admission rates among male participants aged 15–64 years in the very low SEP group were more than three times as high as in undocumented migrants (111·6 vs 35·7). The highest tuberculosis rate was found in undocumented male migrants (incidence rate 4·35 [95% CI 3·55–5·16]). Interpretation: Undocumented migrants made less use of health-care services than those in the low and very low SEP groups, but for some infectious diseases, incidence was higher in undocumented migrants. These results constitute an additional argument to support the maintenance of universal health coverage for all citizens. Funding: None. © 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license

Se esquematiza la reciente evolución de la organización sanitaria en España analizando, e ilustrando con ejemplos, la innovación sanitaria. El énfasis del artículo se sitúa en la gestión sanitaria, tanto en la medida de su calidad como en la consideración del impacto de esta calidad en los resultados en salud. Se abordan las limitaciones de la gestión pública, que tanto influyen en las características de la gestión sanitaria, y se recuerda el deterioro institucional relativo de España para plantear las medidas que han de permitir mejorar la calidad de su gobierno. Se concluye con dos escogidas grandes vías de mejora de la gestión sanitaria: la centrada en la financiación pública y las que persiguen hacer individualmente atractivo lo socialmente conveniente. The recent evolution of the healthcare organization in Spain is outlined, analyzing and illustrating with examples, healthcare innovation. The emphasis of the article is placed on healthcare management, both in terms of its quality and in the consideration of the impact of this quality on health outcomes. The limitations of public management, which influence the characteristics of healthcare management, are addressed, and the relative institutional deterioration of Spain is recalled in order to propose the measures that will allow improving the quality of its government. It concludes with two chosen big ways of improvement of healthcare management: the one centered in the public financing and the ones that pursue to make individually attractive what is socially convenient. Vicente Ortún reconoce la financiación del Ministerio de Economía, Industria y Competitividad (Proyecto ECO2017-83771-C3-2-R, Encaje público-privado en sanidad, del Programa Estatal de I+D+i orientada a los retos de la sociedad). Vicente Ortún reconoce la financiación del Ministerio de Economía, Industria y Competitividad (Proyecto ECO2017-83771-C3-2-R, Encaje público-privado en sanidad, del Programa Estatal de I+D+i orientada a los retos de la sociedad).

ResumenEn los últimos años ha aumentado de forma notable el interés por la evaluación de las intervenciones en salud, especialmente en relación a su utilidad social y su eficiencia económica. Sin embargo, todavía estamos lejos de tener un grado suficiente de consenso en los aspectos básicos de la evaluación, como son la terminología, la finalidad y la metodología de trabajo. En este marco se revisan las principales definiciones y clasificaciones de la evaluación aplicada a los programas y políticas en salud pública. En relación a la evaluación de resultados, se presentan los principales diseños evaluativos y sus componentes, y se revisan las amenazas a la validez interna de los resultados de los diseños evaluativos débiles. Se analizan y discuten las características de las intervenciones de salud pública que limitan las opciones de evaluación con diseños tradicionales. Entre estas limitaciones destacan la complejidad de las intervenciones, que habitualmente tienen múltiples componentes, y la dificultad de establecer un grupo de comparación sin intervención, en especial mediante asignación aleatoria. Para finalizar, se describe una propuesta de evaluación a partir de diseños evaluativos débiles, consistente en la valoración de la adecuación y la plausibilidad. La adecuación estaría determinada por la existencia de un cambio observable en los indicadores de resultados, y podría ser suficiente para tomar decisiones bajo determinadas condiciones; otras veces sería necesario analizar la plausibilidad, o atribución de los resultados observados al programa.AbstractIn the last few years, interest has markedly increased in evaluating health programs, especially their social utility and economic efficiency. However, consensus on key issues in evaluation, such as terminology, goals and methods is still a long way off. In this context, we review the main definitions and classifications of evaluation applied to public health programs and policies. We describe the main evaluation designs and their components, focusing on outcome evaluation. Threats to the internal validity of the results of weak evaluation designs are also discussed. The characteristics of public health interventions that limit evaluation with traditional designs are also analyzed. These limitations include the complexity of interventions, usually with multiple components, and the difficulty of forming an equivalent control group with no intervention, especially through random assignment. Finally, a two-step approach to evaluation through weak designs, which takes into account adequacy and plausibility, is described. Adequacy consists of the observation of a change in the selected indicators after the intervention, and would be sufficient to take decisions under certain conditions; at other times, plausibility would need to be analyzed, defined as attribution of the results to the program or intervention.

El presente articulo pretende dar una vision actualizada de algunos de los aspectos metodologicos de la evaluacion economica de intervenciones preventivas. Concretamente, se ha intentado proporcionar informacion adicional para una mejor interpretacion de la evaluacion economica de intervenciones preventivas introduciendo conceptos como el de la utilidad anticipada y el de la tasa de descuento. En este sentido, para que pueda obtenerse una utilizacion eficiente de los recursos sanitarios, la metodologia de la evaluacion economica debe ser aplicada por parte de los profesionales sanitarios y otros agentes de manera transparente, comprensible y consistente, basandose en recomendaciones metodologicas consensuadas que incluyan criterios sobre la calidad y la validez de este tipo de evaluaciones. El conocimiento y la consideracion de algunas de las cuestiones mencionadas en este trabajo podrian ser de gran utilidad en futuras investigaciones sobre evaluacion economica de intervenciones preventivas.

Introduction: Improving the quality and transparency of the healthcare government has an impact on the health of the population through policies, management of organizations, and clinical practice. Moreover, the comparison between healthcare centres or territories on a population basis, and the transparent and open feedback of results to policy makers, managers, professionals and citizens contributes directly to improve results. Description of policy context and objective: The Results Centre of the Catalan healthcare system measures and disseminates the results achieved by the different healthcare centres in order to facilitate a co-responsible decision making process, to improve the quality of healthcare provided to the population of Catalonia. It favours the benchmarking between defined geographical local areas and healthcare centres and share best practices in a transparent way. As a result of the development of a chronic care and an integrated health and social care strategy in Catalonia, there is an increasing need to introduce a population based shared outcome framework with objectives and indicators which could act as drivers for integration with an increasing “triple aim” orientation Targeted population: For citizens, the Results Center promotes a wider and better understanding of the field of health, and allows them to interact with the healthcare system and participate in decisions that affect their health. For healthcare centres, it allows them to compare the results achieved, identify and share best practices, and look for opportunities for improvement and cooperation between institutions. For the health administration, the Results Centre respond to the demand for transparency in health policy decisions, as well as for accountability in the use of resources. Highlights: Since 2012, an annual report has been produced for hospitals, primary care, long-term care, mental healthcare, public health activities, and territory with population based indicators. For each topic, around 60 quality indicators are measured, identifying the provider and the territory. Some of the indicators are especially relevant for integrated care such as prevalence of people with complex healthcare needs or in advanced chronic disease condition, rate of avoidable emergency admissions related to a range of selected chronic conditions, readmission rates related to selected chronic conditions, and others. The experiences of centres with better results, and the opinion of experts are incorporated, and a version for citizens is published. The “territory report” offers a picture of population-based health, and a tool to monitor changes due to integrated care policies. All detailed results are available in tables, together with technical definitions (http://observatorisalut.gencat.cat), and in open data format. Comments on transferability: This project is possible due to the high level of development of health information systems in Catalonia, and to the maturity and compromise of the healthcare sector. The Chronic care Program and Integrated Health and Social care Plan is working in partnership with the Results Centre to continuously improve the project, incorporating new indicators significant for the evaluation of integrated care (i.e. “high needs, high cost”-) and spread this vision of integrated care with a population based orientation. Conclusions: Engaging healthcare professionals is essential to move towards better clinical practice by identifying and sharing best practices. These reports are used among managers and clinical and other professional leaders as a tool for benchmarking, and among commissioners to facilitate better understanding of the territorial performance. This is a pioneering initiative in Spain, and is aligned with the most advanced countries in terms of policies of transparency and accountability.

Objectives: The objective of this study was to assess the quality of economic analysis studies published in the medical and economical literature assessing the clinical management of functional dyspepsia.Methods: Bibliographic search in the main biomedical databases, in articles from bibliographic references, health technology assessment reports, and in gray literature. A specific protocol with economic and clinical items was designed for the evaluation.Results: Overall, 18 of 162 studies met the inclusion criteria for the assessment. The compared treatment options were very diverse. The main methodologic deficiencies were in perspective of analysis, inclusion of indirect costs, and sources of clinical information.Conclusions: Specific checklists with clinical and economical items may help to better assess the quality of economic analysis in the field of functional dyspepsia. The methodologic rigor in the application of economic analysis techniques, as well as the use of appropriate clinical outcome measures, is essential to guarantee the reproducibility of the studies.

The rising demand for health care, together with the scarce available resources, has increased the use of economic analysis as a support tool for policy making. The objective of this study was to make a description of economic evaluation studies carried out in Spain and published during the last 20 years, and to assess their quality. A systematic bibliographic search was made in the main biomedical databases. Full economic evaluation studies made in Spain comparing two or more health care alternatives were included. Statistical analyses included a descriptive analysis, the assessment of the association between pairs of variables, and a homogeneity analysis. A total of 87 studies were included in the review. According to the methodology, the technique most frequently used was cost-effectiveness analysis. In most cases, some weaknesses could be pointed out: absence of any objective directly linked to the decision-making process, a non-explicit perspective, no inclusion of indirect costs, or clinical and economical data not concurrently collected. A continuing challenge for health care economic analysis in Spain is to follow methodological guidelines and reporting conventions, to improve the dissemination of research, as well as to use more sophisticated economic analysis techniques, and to publish in international journals.

Context : The aims of the Observatory of Innovation in Healthcare Management in Catalonia are to collect, validate, organize and value, the knowledge of the Catalan health system from many innovative experiences that are being developed today. The Observatory brings together the efforts made by the organisations in innovating in several spheres of management. It provides a forum for compiling innovative experiences and it offers an innovation community web page fostering interaction among 450 professionals who exchange their experiences. Methods : The process to register an innovative experience starts first with the signing up in the Innovation community. Innovative experiences should met criteria on implementation, bringing a change, impact on resources and scalability. Secondly, organisations may submit a self-assessment of their experiences. Then, the review and the self-assessment evaluation of the innovative management experiences constitutes the third context in which the Observatory operates, conducting a quality analysis done by the OIGS, to check that the experience meets with the established inclusion criteria. Experiences which pass the assessment phase are then awarded a certificate of quality issued by the AQuAS. Results : The Observatory compiles a total of 183 innovative experiences. The majority of these experiences are focused on improving strategic and care processes, handling patients with chronic illnesses, use of healthcare information technology and the consumption of pharmaceuticals in the area of primary and specialized care. A total of 49 out of the 183 experiences fall within the specialized care in coordination with primary care area of action; 45 experiences refer to the area of specialized care. In terms of key themes, 101 experiences deal with improvements in care procedures and strategies, followed by 26 experiences concerning management of chronic care patients, 25 regarding ICT and telemedicine, and 12 pharmaceutical experiences. Discussion : The Observatory of Innovation in Healthcare Management in Catalonia brings together the efforts made by the organisations in innovation in several spheres of management One of the main challenges however will be to support scalability and transferability of these innovative experiences (new care pathway, service or technology) that have the potential for wide scale spread in other areas to improve in the end outcomes and patient satisfaction. Conclusions : The identification of innovative experiences allows compiling some of the best practices observed in the system. The Observatory through the public and innovation community website constitutes a display cabinet for supporting transferability of good practices and it also forges ties among institutions creating synergies and joint projects. One of the main challenges in the future will be to identify barriers and drivers for the implementation, sharing problems, acknowledging failures and finding solutions in different contexts for the adoption and spread of good practices.

After a quarter century of annual health reports in the city of Barcelona, this study documents the experience and draws some elements that may be useful in other contexts, specifying the analysis on the Health Report of 2008. We show the conceptual framework, the process of preparing the report, sources of information used and the contents. We evaluate the dissemination of the health report, both at the political level, as well as the media, professionals and the public. Furthermore, we examine the impact of the report as a tool for social change and planning.

In the last few years, interest has markedly increased in evaluating health programs, especially their social utility and economic efficiency. However, consensus on key issues in evaluation, such as terminology, goals and methods is still a long way off. In this context, we review the main definitions and classifications of evaluation applied to public health programs and policies. We describe the main evaluation designs and their components, focusing on outcome evaluation. Threats to the internal validity of the results of weak evaluation designs are also discussed. The characteristics of public health interventions that limit evaluation with traditional designs are also analyzed. These limitations include the complexity of interventions, usually with multiple components, and the difficulty of forming an equivalent control group with no intervention, especially through random assignment. Finally, a two-step approach to evaluation through weak designs, which takes into account adequacy and plausibility, is described. Adequacy consists of the observation of a change in the selected indicators after the intervention, and would be sufficient to take decisions under certain conditions; at other times, plausibility would need to be analyzed, defined as attribution of the results to the program or intervention.

Although it has declined in recent decades, alcohol consumption in Spain is still high compared with other European countries. The consumption pattern shows a converging trend with Europe, with a decrease in consumption of wine and an increase in the consumption of beer. Likewise, mortality related to alcohol consumption has also declined in the last twenty years, but remains a major cause of death. The direct healthcare costs and indirect costs of diseases totally and partially attributable to alcohol consumption in 2007 was 2669.74 million. The effective tax regime in Spain gravel alcohol very little, so a substantial increase, in line with some European countries, could be an option to be considered for accelerating the reduction of the burden of morbidity and mortality associated with alcohol consumption.

Background The allocation of limited available healthcare resources demands an agreed rational allocation principle and the consequent priority setting. We assessed the association between economic evaluations of healthcare interventions published in Spain (1983-2008) and the disease burden in the population. Methods Electronic databases (e.g., PubMed/MEDLINE, SCOPUS, ISI Web of Knowledge, CRD, IME, IBECS) and reports from health technology assessment agencies were systematically reviewed. For each article, multiple variables were recorded such as: year and journal of publication, type of study, health intervention targetted, perspective of analysis, type of costs and sources of information, first author's affiliation, explicit recommendations aimed at decision-making, and the main disease cause to which the intervention was addressed. The following disease burden measures were calculated: years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted life years (DALYs), and mortality by cause. Correlation and linear regression models were fitted. Results Four hundred and seventy-seven economic evaluations were identified. Cardiovascular diseases (15.7%), infectious diseases (15.3%), malignant neoplasms (13.2%), and neuropsychiatric diseases (9.6%) were the conditions most commonly addressed. Accidents and injuries, congenital anomalies, oral conditions, nutritional deficiencies and other neoplasms were the categories with a lowest number of studies (0.6% for each of them). For the main disease categories (n = 20), a correlation was seen with: mortality 0.67 (p = 0.001), DALYs 0.63 (p = 0.003), YLLs 0.54 (p = 0.014), and YLDs 0.51 (p = 0.018). By disease sub-categories (n = 51), the correlations were generally low and non statistically significant. Conclusions Examining discrepancies between economic evaluations in particular diseases and the overall burden of disease helps shed light on whether there are potentially over- and under-investigated areas. The approach taken could help policy-makers understand whether resources for economic evaluation are being allocated by using summary measures of population health.

Public policy evaluation is not always a mandatory task for administrations. A priori, the instruments for government intervention are chosen and calculated to maximize the social welfare function that should be implicit in the policies undertaken, or in the government's electoral program. However, it is surprising how the government sometimes acts without questioning whether institutional functioning and the corresponding public policies can effectively and efficiently achieve this objective. The absence of evaluation drains the scarce available resources towards ineffective and inefficient programs, which could be otherwise used in other initiatives with a greater impact on the population's welfare.

The economic evaluation of health technologies has become a major tool in health policy in Europe for prioritizing the allocation of health resources and the approval of new technologies. The objective of this proposal was to develop guidelines for the economic evaluation of health technologies in Spain. A group of researchers specialized in economic evaluation of health technologies developed the document reported here, following the initiative of other countries in this framework, to provide recommendations for the standardization of methodology applicable to economic evaluation of health technologies in Spain. Recommendations appear under 17 headings or sections. In each case, the recommended requirements to be satisfied by economic evaluation of health technologies are provided. Each recommendation is followed by a commentary providing justification and compares and contrasts the proposals with other available alternatives. The economic evaluation of health technologies should have a role in assessing health technologies, providing useful information for decision making regarding their adoption, and they should be transparent and based on scientific evidence.

Objectives:To compare methods and results among four health technology assessment organizations in different countries.Methods:All assessment reports published between 1999 and 2001 by VATAP (United States), NICE (United Kingdom), CCOHTA (Canada), and AETS (Spain), were reviewed. Detailed information about the organization, the technology assessed, the methods used, and the recommendations made were collected. A descriptive analysis of the variables, as well as comparisons of means and proportions, was performed.Results:Sixty-one reports assessing seventy-six technologies were published: nine (11.8 percent) by VATAP, thirty-nine (51.3 percent) by NICE, twenty (26.3 percent) by CCOHTA, and eight (10.5 percent) by AETS. A total of 64.5 percent of the technologies assessed were related to a high prevalence disease in the corresponding country. Most of the assessments addressed treatments (73.7 percent) and were mostly drugs (56.6 percent) and devices (23.7 percent). Most organizations used reviews of effectiveness and economic evaluations (64.5 percent), systematic reviews (21.1 percent), and original economic evaluations (36.7 percent). In 38.1 percent, the technology was recommended; the rest of the cases had no formal recommendations.Conclusions:Critical issues for future technology assessment efforts are making assessment processes more consistent, transparent, and evidence-based; formalizing the inclusion of economic and ethical considerations; and making more explicit the prioritization process for selecting technologies for assessment and reassessment.

[No abstract available]

Objectives: The objectives of the study were to identify the current standards of clinical practice regarding prostate cancer screening in western Europe, Canada, and the United States, and to highlight major characteristics of current prostate cancer screening programs or patterns of practice.Methods: We performed a semi-structured interview by means of a self-administered questionnaire sent by fax to 26 institutes pertaining to the International Network of Agencies for Health Technology Assessment.Results: None of the countries surveyed had a formal national screening policy. Despite that, all the countries answering the questionnaire had discretionary, public-financed screening practices. Moreover, some scientific and professional organizations recommended population screening for prostate cancer, and few of the surveyed countries offered it as experimental practice within a randomized controlled trial. Survey results showed variation regarding screening policies, in particular test of choice, age cut-off points, and treatment prescribed for positive test results.Conclusions: Despite the lack of conclusive evidence on the benefits of prostate cancer screening, the availability of simple and easy-to-administer tests has lead to an enormous variation on screening policies around the world. Practice variations also affect prostate cancer therapy.

ResumenLa evaluación económica de tecnologías sanitarias se ha convertido en los últimos años en Europa en una herramienta de primer orden para los gestores sanitarios en sus estrategias de asignación de recursos sanitarios y de adopción de nuevas tecnologías. España fue uno de los países pioneros en realizar propuestas de estandarización metodológica aplicable a estudios de evaluación económica. No obstante, la falta de decisión política y de apoyo de los gestores sanitarios a este tipo de herramientas hizo que las propuestas cayeran en desuso. Sin embargo, lo esperable es que a medio plazo sea cada vez más habitual que las nuevas tecnologías sanitarias financiadas por el Sistema Nacional de Salud deban aportar una adecuada evidencia de su valor terapéutico y social en comparación con su coste. Llegado ese momento, los actores del sistema requerirán una serie de reglas claras y consensuadas por parte de los agentes del sistema sobre las cuestiones técnicas o metodológicas que deben respetar los estudios de evaluación de tecnologías sanitarias. Por este motivo, las presentes recomendaciones orientan sobre cómo realizar y analizar los estudios de evaluación económica de calidad. Las recomendaciones aparecen bajo 17 encabezamientos o dominios, y bajo cada recomendación hay además un comentario, en el cual se justifican y discuten las propuestas en relación con otras opciones posibles.AbstractOver the last few years, economic evaluation of health technologies has become a major tool used by European health policy decision-makers to create strategies for prioritizing the allocation of health resources and the approval of new technologies. Spain was a pioneer in proposing the standardization of methodology applicable to economic evaluation studies. However, because health policy decision-makers refused to support the initiative, the methodology was never put into practice.In the medium term, evidence of the economic value of new health technologies financed by the national health system will probably be increasingly required. At that time, stakeholders and decision-makers will have to agree upon a clear and concise set of rules on the technical and methodological issues that must be followed by economic evaluations of health technologies. Consequently, we have provided guidelines and recommendations for producing first-rate economic evaluations. The recommendations appear under seventeen headings or sections. In each case, the recommended requirements to be satisfied by an economic evaluation of health technologies are provided and each recommendation is followed by a commentary, providing a justification and comparing and contrasting the proposal with other available alternatives.

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./n/nResults: 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. The authors are grateful the Agència de Salut Pública de Barcelona (ASPB) for providing the data, to Maarten Lindeboom (Department of General and Development Economics, Free University, Amsterdam) for his valuable suggestions on the statistical analysis, and all the members of the Centre for Health Economics (CHE), and the Health, Econometrics and Data Group (HEDG) of the University of York, for their comments on a previous version of this paper.