Diseño de la Planta de Tratamiento de Agua Potable (PTAP)

COMMUNITY N. of Centres N. of Centres per

million population

N of implants N of implants per million population Andalucìa 12 1.5 474 60 Aragòn 2 1.6 78 61 Asturias 1 0.9 124 115 Baleares 2 2 33 33 Canarias 4 2 131 66 Cantabria 1 1.8 58 102 Castilla-La Mancha 3 1.6 88 46 Castilla y Leon 6 2.4 162 64 Cataluna 6 0.8 349 49 Comunidad Valenciana 7 1.5 224 47 Extremadura 1 0.9 26 24 Galicia 3 1.1 113 41 Madrid 12 2 503 84 Murcia 1 0.7 68 50 Navarra 1 1.7 70 116 Paìs Vasco 4 1.9 103 48 Total Espana 66 1.5 2679 60

Source : (Peinado, Torrecilla et al. 2007)

Similar to the situation found in Italy, available data highlights significant differences between ACs in terms of available resources and number of ICD implants per million of population: whereas some ACs like Asturias, Cantabria and Navarra reported more than 100 implants per million population, seven other ACs - Extremadura, Baleares, Castilla-La-Macha, Catalunia, Valencia, Galicia and Pais Vasco – reported less than 50 implants per million population (Table 18). Similar differences can also be found when analysing the rate of use of coronary stents in Spain (see the Section on Coronary Stents). It was argued that the reason for the existence of such a geographic variation in clinical practice may be found not only in the distribution of the disease burden and the characteristics of the patients and physicians but also - and mainly – to differences in regional wealth. In fact, the results of the Fitch-Warner study (2006)26 found no correlation between the number of procedures and the disease burden, whereas association was maintained between the former and supply variables – mainly the number of centres performing the procedures27. Strong positive correlation was found between the number of ICD per million inhabitants and regional wealth, measured by the per capita GDP, which accounted for 40% of the variability in the use of ICD28 : an increase of 2.5

26

The analysis was conducted on the basis of the data provided by a private company based on an estimation of the entire market

27

r = 0,679; P = .005

28

Results –ICD Spain 64 procedures in ICD was estimated per each 1000 euro increase in GDP in the given region29. The results suggest, as said before, that the number of ICD implantations is not related to the burden of ischemic disease in each region, but to its wealth (Fitch-Warner, de Yebenes et al. 2006).

Procurement

ICDs, as all devices implanted on an inpatient basis, are purchased by Spanish hospitals through public tender procedures at local level.

In some ACs, such as Castilla y Leon a so called two-round negotiation was introduced for specific technologies, including ICDs30. The measure consists of the following. First, the regional health authorities define the characteristics and the maximum prices corresponding to different categories of devices at AC level. Afterwards, hospitals publish their own individual tenders, and adjudicate the final price negotiating a reduction of the maximum price defined by the AC. Companies owning the requisites defined at central level are allowed to participate in all the tenders issued across the Region.

In general, tenders are adjudicated on the basis of the most advantageous economic offer; criteria for price and quality are explicitly indicated in the tender and generally the ratio between the two ranges from 40: 60 to 50:50, respectively.

The size of the single tender lot (no. of ICDs to be purchased) is usually defined on the basis of the volumes specified in the program-contract annually negotiated between the single healthcare provider and the regional health care authority.

A key role in the procurement process is played by clinicians who contribute to the definition of the characteristics of the ICDs31 and the ancillary services to be included in the tender. One of the approaches to introduce a new technique is to provide new clinical evidence: the clinicians agree to carry out a certain number of procedures in a defined temporal period (ie 6 months) and afterwards present the results to the Commission; in case of approval, the technology becomes part of the hospital carta de servicios. In some AC (mainly Catalunia), Health Technology Assessment activities have been introduced at the hospital level and start to play important part of the decision making process regarding the purchasing of new

29

Since high collinearity was found between the supply variables – number of centres and catheterisation specialists – and wealth – per capita GDP – linear regression was done exclusively with the latter.

30

Other devices are Insulin pumps.

31

devices, including ICDs32. Several ACs – such as Madrid, Valencia or Galicia - are developing official ICD registries to evaluate the effectiveness of the device on the basis of observational data and by taking a long term perspective

Prices – with some exceptions reported above - are negotiated at local level. The basis for tenders might be either based on historical trend or defined following specific criteria (in Hospital La Paz in Madrid, for instance, maximum prices are fixed also on the basis of the prices adjudicated in other ACs); variations between providers in the final price for same device might be also due to different bargaining powers of the hospitals determined by type of hospitals (eg. teaching clinic), nature (public/private) or the membership in a larger purchasing consortium (of several hospitals) (as in the case of Catalunia).

Reimbursement

ICDs are subjected to the same reimbursement mechanisms for medical devices provided in the hospitals, i.e global budgets.

Even though differences may be found in the negotiating process defining the global budgets across ACs, the reimbursement system doesn’t seem to explain the regional differences. More specifically, the Spanish clinicians we interviewed expressed their thoughts about potential drivers of the regional variability. According to them, the potential reasons include: i) differences in the culture and education of the professionals in different ACs, ii) differences in the belief for the usefulness of the therapy in the primary intervention, iii) the fact that in some secondary hospitals sending patient out for implants to other ACs hospitals is seen as resource consuming (in terms of time spent for bureaucratic procedures), if compared to the potential benefits deriving from the implantation so they opt for other treatment alternatives; and iv) differences in knowledge and perception of usefulness of HTA and economic evaluation analysis. Finally, our informants believe that the reimbursement mechanisms are probably one of the least important factors for the diffusion and uptake of the technology. At present, these hypotheses are only the assumptions that should be verified in the future empirical research.

32

Human resources, experts previously employed in regional HTA agencies began to work at the hospital level to support the manager for the development of policies that incorporate new technology within the hospital

Results –Cross country comparison ICD