Report EUR 25442 EN

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Authors: Maria Lluch, Francisco Lupiañez Villanueva Editors: Fabienne Abadie, Maria Lluch, Francisco Lupiañez Villanueva, Ioannis Maghiros, Elena Villalba Mora, Bernarda Zamora Talaya

Country Study: Spain

Strategic Intelligence Monitor on Personal Health Systems, Phase 2

European Commission Joint Research Centre Institute for Prospective Technological Studies Contact information Address: Edificio Expo, C/ Inca Garcilaso 3, E-41092 Seville (Spain) E-mail: jrc-ipts-secretariat@ec.europa.eu Tel.: +34 954488318 Fax: +34 954488300 http://ipts.jrc.ec.europa.eu/ http://www.jrc.ec.europa.eu/ This publication is a Scientific and Policy Report by the Joint Research Centre of the European Commission. Legal Notice Neither the European Commission nor any person acting on behalf of the Commission is responsible for the use which might be made of this publication. Europe Direct is a service to help you find answers to your questions about the European Union Freephone number (*): 00 800 6 7 8 9 10 11 (*) Certain mobile telephone operators do not allow access to 00 800 numbers or these calls may be billed. A great deal of additional information on the European Union is available on the Internet. It can be accessed through the Europa server http://europa.eu/. JRC71179 EUR 25442 EN ISBN 978-92-79-25740-7 (pdf) ISSN 1831-9424 (online) doi:10.2791/88631 Luxembourg: Publications Office of the European Union, 2013 © European Union, 2013 Reproduction is authorised provided the source is acknowledged. Printed in Spain

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TABLE OF CONTENTS 1 SIMPHS2 BACKGROUND AND RATIONALE FOR THIS REPORT ...................................................5

1.1 Research approach and objectives ....................................................................................................................... 5

2 INTRODUCTION TO SPAIN......................................................................................................................6

2.1 Socio-economic background .................................................................................................................................... 6

2.2 Healthcare costs ............................................................................................................................................................. 7

2.3 Chronic diseases prevalence and costs ............................................................................................................. 7

2.4 Social and Health care organisation................................................................................................................. 10

2.5 Disease management programmes and prevention............................................................................... 12

2.6 Role of ICT in promoting integrated care....................................................................................................... 13

3 ZOOMING INTO SELECTED REGIONS AND IPHS/RMT CASE STUDIES ................................... 17

3.1 Andalusia.......................................................................................................................................................................... 17

3.1.1 Population and health status........................................................................................................................... 17

3.1.2 Regional health and social care organisation ........................................................................................ 17

3.1.3 Chronic diseases and ageing ........................................................................................................................... 18

3.1.4 ICT for health in Andalusia................................................................................................................................ 18

3.1.5 ICT in Andalusia in cooperation with Plan Avanza............................................................................... 20

3.1.6 Telecare services in Andalusia ........................................................................................................................ 20

3.1.7 Integrated care in Andalusia ............................................................................................................................ 20

3.1.8 RMT in Andalusia – the case of hospital Virgen del Rocio .............................................................. 21

3.1.9 Conclusions of integrated care and ICT for health in Andalusia ................................................. 26

3.2 Basque Country ............................................................................................................................................................ 28

3.2.1 Population and health status........................................................................................................................... 28

3.2.2 Regional health and social care organisation ........................................................................................ 28

3.2.3 Chronic diseases and ageing ........................................................................................................................... 29

3.2.4 ICT for health in the Basque Country.......................................................................................................... 32

3.2.5 Telecare services in the Basque Country .................................................................................................. 32

3.2.6 Integrated care in the Basque Country ...................................................................................................... 33

3.2.7 RMT in the Basque country – Evidence Based Medicine Clinical Unit Hospital Donostia, San Sebastian........................................................................................................................................................... 35

3.2.8 Telemonitoring patients with chronic disease in Bilbao Primary Care Health Region: The TELBIL project........................................................................................................................................................... 39

3.2.9 Conclusions of integrated care and ICT for health in the Basque Country ........................... 43

3.3 Catalonia .......................................................................................................................................................................... 44

3.3.1 Population and health status........................................................................................................................... 44

3.3.2 Regional health and social care organisation ........................................................................................ 45

3.3.3 Chronic diseases and ageing ........................................................................................................................... 47

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3.3.4 ICT for health in Catalonia ................................................................................................................................ 48

3.3.5 ICT in Catalonia in cooperation with Plan Avanza................................................................................ 50

3.3.6 Telecare in Catalonia ............................................................................................................................................ 50

3.3.7 Integrated care in Catalonia............................................................................................................................. 51

3.3.8 RMT in Catalonia – Hospital Clinic COPD Trials ..................................................................................... 51

3.3.9 Conclusions of integrated care and ICT for health in Catalonia .................................................. 59

4 CONCLUSIONS AND LESSONS LEARNT .......................................................................................... 61

5 ANNEX I – STATISTICS AT NATIONAL AND REGIONAL LEVEL................................................. 65

6 REFERENCES ........................................................................................................................................... 83

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LIST OF FIGURES Figure 1 - Rates of hospital discharge for CHD, 1998-2008, selected countries............................................. 9 Figure 2 - The growth of the telecare public service in Spain from 2002-2011........................................... 15 Figure 3 - Related modules that comprise Diraya........................................................................................................... 19 Figure 4 - Health care expenditure Basque Country....................................................................................................... 29 Figure 5 - Distribution of patients according to the number of chronic illness by age .............................. 30 Figure 6 - Change in the percentage of persons with chronic problems between 1997 and 2007 according to their age ...................................................................................................................................................................... 30 Figure 7 - Number and prevalence of patients 18+ from selected chronic conditions as per primary care data.................................................................................................................................................................................................. 31 Figure 8 - Prevalence of the principal pathologies by age groups (according to diagnoses in Primary Care) ........................................................................................................................................................................................................... 31 Figure 9 - Towards a new model for the Basque Healthcare System.................................................................. 33 Figure 10 - General design of the randomised controlled trial ................................................................................ 40 Figure 11- Health care expenditure per inhabitant (2003-2009)........................................................................... 46 Figure 12 - Number of chronic health problems reported for males per age structure (2006) ........... 47 Figure 13 - Number of chronic health problems reported for females per age structure (2006)....... 48 Figure 14 - Study profile COPD Hospital Clinic (1999-2000) ................................................................................... 52 Figure 15 - Integrated care intervention with the support of ICT – Chronic Platform ................................ 54 Figure 16 - Integrated care intervention with the support of ICT – Chronic Platform – Barcelona subgroup .................................................................................................................................................................................................. 55 Figure 17 - Distribution of the Spanish population, Jan 2002- Jan 2011......................................................... 68 Figure 18 - Demographic forecast of the Spanish population per age range (2005-2050)................... 69 Figure 19 - Education levels of the population in Spain (%), years 1991-2009. .......................................... 70 Figure 20 - Unemployment in Spain (%) 2005-2010.................................................................................................... 70 Figure 21 - Morbidity of diabetes, cardiovascular diseases and COPD in Spain (2005-2009) ............. 75 Figure 22 - Morbidity of diabetes, cardiovascular diseases and COPD in Spain per region, year 2009........................................................................................................................................................................................................................ 76 Figure 23 - Evolution of chronic health problems reported in Catalonia 1994 – 2006............................. 82

LIST OF TABLES Table 1 - Number of deaths according to most frequent reason for death ........................................................ 7 Table 2 - Average length of stay (ALOS) in Spain for selected conditions, 2005-2009............................ 10 Table 3 - Number of telecare users, costs and coverage by region. Spain, December 2008................. 16 Table 4 - Inclusion and exclusion criteria.............................................................................................................................. 36 Table 5 - RCT Inclusion and exclusion criteria.................................................................................................................... 37 Table 6 - Inclusion and exclusion criteria.............................................................................................................................. 40 Table 7- Population of Spain total and per region, 2004-2010.............................................................................. 65 Table 8- Surface area and population density, EU27 (2009).................................................................................... 65 Table 9– Life expectancy in Spain (selected years) ........................................................................................................ 66 Table 10- Life expectancy (LE), disability-free life expectancy (DFLE) and expected years of disability (EYD) at birth, by region. Spain, 2000 and 2007......................................................................................... 66 Table 11 - Life expectancy (LE), life expectancy in good perceived health (LEGH) and expected years in poor perceived health (EYPH) at birth, by region. Spain, 2002 and 2007..................................................... 67 Table 12 - Life expectancy at birth, EU 27 (year 2006)............................................................................................... 67 Table 13 - Distribution of the population, EU 27, 1998 and 2008........................................................................ 68 Table 14 - Dependency ratio in total and per region, Spain....................................................................................... 69 Table 15 - Self-reported health status in persons aged 16 years and over. Percentage distribution by age and educational level. Spain, 2001 and 2006/07............................................................................................ 71 Table 16 - Self-reported health status in persons aged 16 years and over. Percentage distribution by region. Spain, 2001 and 2006/07....................................................................................................................................... 71 Table 17 - Average healthcare expenditure (€) per person covered in each region (1999-2008)...... 72 Table 18 - Hospital beds per 10,000 inhabitants, EU27. Selected years: 2000, 2005, 2007 ............... 72

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Table 19 - Health professionals resources per region, 2008 and 2009 data ................................................. 73 Table 20 - Population with some permanent disability, by region. Spain, 1999 and 2008..................... 73 Table 21 - COPD mortality rate per 100,000 inhabitants per age group (1998-2007)............................ 74 Table 22 - Diabetes mortality rate per 100,000 inhabitants per age group (1998-2007)..................... 74 Table 23 - Ischemic heart disease mortality rate per 100,000 inhabitants per age group (1998-2007) ......................................................................................................................................................................................................... 75 Table 24 - All causes of death. Crude mortality rate per 100,000 population, by region. Spain, 2000-2007........................................................................................................................................................................................................... 77 Table 25 - All causes of death. Age-adjusted mortality rate per 100,000 population, by region. Spain, 2000-2007.............................................................................................................................................................................. 78 Table 26 - Ischaemic heart disease. Crude mortality rate per 100,000 population, by region. Spain, 2000-2007............................................................................................................................................................................................. 78 Table 27 - Ischaemic heart disease. Age-adjusted mortality rate per 100,000 population, by region. Spain, 2000-2007.............................................................................................................................................................................. 79 Table 28 - Chronic obstructive pulmonary disease. Crude mortality rate per 100,000 population, by region. Spain, 2000-2007.............................................................................................................................................................. 79 Table 29 - Chronic obstructive pulmonary disease. Age adjusted mortality rate per 100,000 population, by region. Spain, 2000-2007 ............................................................................................................................. 80 Table 30 - Diabetes mellitus. Crude mortality rate per 100,000 population, by region. Spain, 2000-2007........................................................................................................................................................................................................... 80 Table 31 - Diabetes mellitus. Age-adjusted mortality rate per 100,000 population, by region. Spain, 2000-2007............................................................................................................................................................................................. 81 Table 32 - Average length stay (measured in days) per region in Spain. 2009............................................. 81 Table 33 - Evolution of Diraya implementation per module and population coverage ............................. 82

LIST OF BOXES Box 1 - Definition of key terms used in this document ................................................................................................... 7 Box 2 - Structure of a regional healthcare system in Spain ...................................................................................... 10 Box 3 - Delivery of long-term and social services in Spain........................................................................................ 11 Box 4 - Results at 3 months. TELBIL Project....................................................................................................................... 41 Box 5 - Results at 6 months. TELBIL Project....................................................................................................................... 42 Box 6 - General diagram of the Catalan Healthcare System.................................................................................... 46

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1. SIMPHS2 BACKGROUND AND RATIONALE FOR THIS REPORT

1.1 Research approach and objectives

This document presents an analysis of the data collected in relation to the integration of ICT, disease management and RMT at local/regional level (meso and micro level) in three different regions in Spain, in the framework of the SIMPHS2 project. Specifically, the regions targeted are Andalusia, the Basque country and Catalonia.

Data gathering on IPHS deployment in Spain has used a combination of desk research, and interviews. SIMPHS1 identified interesting initiatives in Andalusia and the Basque Country. Preliminary research and exposure of the team to the developments on IPHS in Spain concluded that including field work in Catalonia would also provide evidence relevant to SIMPHS2. Thus, it was concluded that these three regions would be included. Also, as will be later unveiled throughout this document, the approaches on integrated care and to promote RMT followed in Andalusia, the Basque country and Catalonia are somehow different, thus including these three regions would provide an enriched diversity of approaches.

Interviews in each setting have involved stakeholders at different levels: policy-makers, project managers, clinical champions and a health technology assessment agency. We have aimed at keeping the name of the interviewees anonymous. However, we are aware of the limitations as in certain cases they could be identifiable.

Six stakeholders were interviewed in Andalusia: at hospital level a clinical champion and an economist responsible for the evaluation of an RMT initiative; three members of the Service of Information and Statistics at the Department of Health including the head of the service; and the head of research and cooperation of the Andalusia Telecare Service.

In total in the Basque country six stakeholders were involved: at hospital level a clinical champion, at Primary care level a clinical champion, three members of The Basque Institute for Healthcare Innovation and a technological provider.

In Catalonia, five stakeholders were interviewed: at hospital level a clinical champion, two representatives of the Catalan Agency for Health Information, Assessment and Quality and two representatives ICT for Health Foundation.

In addition, and complementary to the qualitative data gathering, a survey of healthcare professionals was carried out in the three regions, results will be reported separately.

This document is structured as follows. First, an introduction to the Spanish health system context is provided including socio-economic data, statistics on healthcare, healthcare organisation and their approach to chronic diseases. This section also includes statistics on chronic diseases and details on the three diseases addressed in SIMPHS2 – diabetes, chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD). Areas that are common to all of Spain are covered here, where this is not the case it will be pointed out, emphasising different approaches in Andalusia, the Basque country, and Catalonia. Second, a section including the general eHealth strategy at central government and areas of cooperation between central and regional or local authorities are also reported with a specific focus on the three regions of interest. As part of this section, telecare is also covered nationwide and where appropriate at regional level.

Third, for each of the three selected regions (Andalusia, the Basque Country and Catalonia), telehealth experiences are reported together with additional background on regional eHealth developments and approaches to integrated care. This includes an analysis of governance, innovation diffusion and impact based on the data collected in each region. Finally, a concluding section presents lessons learnt drawing on the previous findings.

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2. INTRODUCTION TO SPAIN

2.1 Socio-economic background

As a result of the population increase over the last decade, today, Spain has an overall population of slightly over 47 Million inhabitants with variations across its 19 regions (see Table 7, Annex I): With 8.3 million inhabitants, Andalusia represents the highest population within the country, followed by Catalonia (7.5 million) and Madrid (6.4 million). The Basque Country which is included in this report has a population of 2.1 million and ranks 7th in terms of population size.

Life expectancy in Spain is one of the highest in the WHO European Region. In 2007, life expectancy at birth was 77.8 years in men and 84.3 years in women (see Table 9 to Table 12, Annex I). This difference in favour of women remains constant at all ages. However, the increase in life expectancy in recent years has been greater in men than in women, in line with trends in other OECD countries. In 2007, the Spanish regions with the highest life expectancy at birth were Navarra and Madrid — 82.5 years in both regions, followed by Castilla and Leon, with 82.1 years, while Ceuta and Melilla, with 79.5 years, and Andalusia, with 79.8 years, were the communities with the lowest life expectancy (Annex I, Table 10 and Table 11 provide details at regional level).

In January 2011, 17.07% of the population were aged 65 years and above, a trend that has remained quite stable over the last ten years (see Figure 17, Annex I).

In line with this, the dependency ratio - defined as the ratio of the population below 15 and above 65 over the population aged 16-64 - has decreased significantly between 1991 and 2009 from 53.33 to 48.17, but has remained rather stable showing similar values during the 2002 - 2009 period (see Table 14 - Dependency ratio in total and per region, Spain in Annex I).

Also, as detailed in Table 14 (Annex I), the dependency ratio varies per region, the Canary Islands displaying the lowest dependency ratio with 41.42% and Melilla the highest percentage (55.56%) in 2009. Both Catalonia and Andalusia lie below the national average (48.17) with a dependency ratio of 46.88 and 47.46 respectively while the Basque country lies above with a ratio of 49.42. Although the national ratio is relatively low when compared to other EU countries[1], when looking at the population forecast, the estimates are not so promising.

Indeed, a study carried out by the National Statistics Office (INE) [2] in 2006, forecasted a serious decrease of the population 25-65 from almost 46% in 2005 to 35% in 2050. Furthermore, the same forecast concluded that the percentage of 65+ over all the population would almost double during the 2005-2050 period (see Figure 18, Annex I).

In terms of education and economic situation, the picture shows some controversial results.

While education levels have seriously improved since 1991 and there has been a decrease in the population stopping their education at primary level in favour of an increase in secondary and tertiary level attainments, unemployment levels reached a dramatic historical peak in 2010.as a result of the economic crisis (see Figure 19 and Figure 20, Annex I). Thus, a serious risk of sustainability is threatening the country which has led to budget cuts in a set of areas including healthcare.

Most relevant for the purposes of SIMPHS2 are details on population health state related to education background. As much as the education level of the population has increased, the self-reported health state of the population seems to have worsened on average when compared to 2001: those considering being in very good, good and fair conditions represented 92.5% at the time, whilst the percentage for the period 2006/07 was 91.4% when considering the total population. Similar results are obtained when making the same calculations for the population with third level education, with the exception of those aged 16-24 years. Thus, the decrease in self-reported health status since 2001 may be the result of a combination of things including the ageing population. It could also be concluded that increasing education does not result in improved self-reported health

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status, which would defy any previous evidence on the topic and approaches to health inequalities. However, the relatively small difference in figures and the lack of a longer time series prevents more accuracy on the interpretation and the conclusions on this data. Details at regional level on health status are also provided (see Table 15 and Table 16, Annex I).

2.2 Healthcare costs

Like for most healthcare systems, current pressures to the system include spiralling costs and higher demand for health and social care services as a result of an ageing population. As detailed in Table 17 (Annex I), healthcare expenditure per person covered almost doubled during the period 1999-2008, from €721 to €1,381 per person at national level. This increase varies per region, but none of them have seen a decrease.

2.3 Chronic diseases prevalence and costs

Box 1 - Definition of key terms used in this document

Prevalence: the percentage of a population that is affected with a particular disease at a given time

Incidence: rate of occurrence or influence ; especially : the rate of occurrence of new cases of a particular disease in a population being studied

Morbidity: the incidence of disease, the rate of sickness (as in a specified community or group)

Mortality: (a) the number of deaths in a given time or place. (b) the proportion of deaths to population

Often prevalence is compared to incidence whilst mortality is compared to morbidity.

Source: MedlinePlus (U.S. National Library of Medicine)

According to the National Statistics Office (INE)[3], the three main causes of mortality in 2008 were cardiovascular diseases accounting for 31.7% of all deaths followed by tumours (26,9%) and by diseases of the respiratory system (11,4%). This trend was already initiated in the early 70s albeit with a steady decrease in the actual mortality rates from these diseases. Even though mortality rates for these diseases are among the lowest in the WHO European Region, when looking at the specific diseases in depth, deaths associated to diabetes, heart failure and COPD are prominent.

Table 1 - Number of deaths according to most frequent reason for death Total number of deaths 386,324 Ischemic heart disease 35,888 Stroke 31,714 Heart failure 20,211 Bronchi and lung cancer 20,195 Lower airways chronic diseases 14,857 Dementia 11,973 Colorectal cancer 10,602 Alzheimer 10,349 Diabetes mellitus 10,081 Pneumonia 9,165 Hypertensive disease 7,647 Kidney failure 6,621 Breast cancer 6,121 Stomach cancer 5,624 Prostate cancer 5,464

Source: INE (National Statistics Office)[2], 2011.

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When looking at deaths historically and per age structure, the mortality rate starts increasing dramatically from the age of 55 onwards. Mortality data at regional level is also available in annex I (Table 21 to Table 31).

In terms of morbidity, a picture of morbidity from diabetes, COPD and cardiovascular diseases is available in Annex I (Figure 21 and Figure 22), the latter being split into heart diseases and stroke. The data is obtained from the national hospital episodes statistics. As it is often the case, trends in the frequency of population health problems cannot be evaluated adequately using information on hospital discharges, since the frequency of hospital discharges is strongly influenced by variations in the availability of health resources over time and by changes in clinical practice. Hence, the statistics referred to here must be interpreted with caution. Nevertheless, it is still relevant to note that whilst for most of the diseases under study morbidity across years is similar or even decreases, morbidity for heart conditions has been increasing from 698,106 cases in 2005 to 721,868 in 2009 i.e. by 3,4%.

Although in general terms, morbidity per region is somehow proportional to the population in each region, there are also some differences. For instance, Catalonia has the highest morbidity for heart conditions in absolute numbers before Andalusia whilst the population of Andalusia is higher than that of Catalonia. However, as stated earlier data from hospital discharges shall be treated with caution and cannot be considered as conclusive.

In the case of COPD, serious inequalities also exist and persist across regions as found by the IBERPOC[4] and the EPI-SCAN studies[5] published in 2000 and 2010 respectively. The EPI-SCAN study conducted from May 2006 to July 2007, determined that the prevalence of COPD in Spain according to the GOLD criteria1 was 10.2% for the population aged between 40 to 80 years old. Geographical variations ranked from 16.9% in Asturias to 6.2% in Burgos (Castilla-León). Severe epidemiologic problems identified in the study were under-diagnosis (which also varied per region from 58.6% to 72.8%) and under-treatment (again varying regionally from 24.1% to 72.5%). In terms of impact, COPD generates high demand for hospital care. A small group of COPD patients (12.2%) accounts for nearly 60% of hospital visits for this disease. The group requiring greater care generally has a more severe form of the disease (older, more severe bronchial obstruction and hypoxemia)[6]. This high consumption is actually due to under-diagnosis often as a result of patients not being aware of their condition and reaching hospital in cases of serious exacerbation resulting in high resource consumption[7].

When it comes to diabetes, the Diabetes Atlas 2010 [8] estimated a total prevalence for diabetes in Spain at 8.7% with an associated healthcare cost at national level of USD 6,694 billion or €4,655 billion 2 during this year. Based on prevalence estimates of impaired glucose tolerance (IGT) and historical evolution on population and diabetes, the same source forecasted the cost of diabetes to the Spanish healthcare system for 2030 to reach USD 8,837 billion or €6,145 billion3.

2009 DRG4 data from the Spanish Ministry of Health and Social Policy provided an average cost for Diabetes treatment for patients 35+ of €3,222. The cost for those below 36 was € 2,179. However, this cost data is only indicative and again shall be treated with caution for several reasons. On the one hand they are DRG costs which may not reflect actual hospital costs. On the other hand, it shall be made clear that this is not the average hospital cost for treating diabetes and its complications

1 The GOLD COPD classifications are the main method doctors use to describe the severity of chronic

obstructive pulmonary disease (COPD). GOLD is short for the Global Initiative for Chronic Obstructive Lung Disease, a collaboration between the National Institutes of Health and the World Health Organization.

2 Exchange rate from the EIB on July 25th, 2011. 3 Id 4 DRG stands for Diagnostic Related Group. DRG refers to any of the payment categories that are used to

classify patients based on their condition and treatment received for the purpose of reimbursing hospitals for each case in a given category with a fixed fee regardless of the actual costs incurred. DRG is the most commonly used prospective payment mechanism.

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given that other conditions derived from diabetes have their own DRG tariff (e.g. pancreas transplant resulting from diabetes). Moreover, evidence in Spain shows that avoidable hospitalisations related to short-term diabetes complications can be as much as 12 times more frequent, depending on the treatment provided, and this variability has only increased over the years[9].

Regarding cardiovascular diseases, a 2008 European statistics report[10] revealed that in 2002, the age-standardized DALYs5 lost per 100,000 inhabitants was 368 for coronary heart disease (CHD), 294 for stroke and 274 for other cardio vascular diseases. The healthcare costs associated with cardiovascular diseases during 2006 were estimated at €5,694.6 billion divided as follows:

- €439.4 billion in primary care; - €579.5 billion in outpatient care; - €259.5 billion in Accidents & Emergencies (A&E); - €1,849.5 billion in inpatient care; and, - €2,566.6 billion in medication.

This resulted in a yearly cost per capita of €130 and a 7% of total healthcare expenditure. In addition, the same study found that non-healthcare costs for CHD resulted in €720.7 billion in productivity losses due to mortality; €120.9 billion in productivity losses due to morbidity; and, €264.3 in informal care. In the case of stroke the values obtained were: €103.7 billion in productivity losses due to mortality; €126.9 billion in productivity losses due to morbidity; and, €393.5 in informal care.

Although the above details for CHD come across as seriously concerning, when contextualising it with other countries (see Figure 1), Spain seems to be doing quite well when compared to Ukraine, Latvia, the United Kingdom and Greece. Nevertheless, the fact that the rate of hospitalisation discharge has been steadily increasing since 1998 remains an issue of concern.

Figure 1 - Rates of hospital discharge for CHD, 1998-2008, selected countries

Source: British Heart foundation, 2010 [11]

Regarding average length of stay (ALOS) in hospital associated with diabetes, CVD and COPD, a decline has been observed since 2005 (see Table 2) which is likely to be due to efficiency gains.

5 DALY stands for Disability Adjusted Life Years. One DALY can be thought of as one lost year of "healthy"

life. The sum of these DALYs across the population, or the burden of disease, can be thought of as a measurement of the gap between current health status and an ideal health situation where the entire population lives to an advanced age, free of disease and disability.

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However, given that prevalence for these conditions is increasing, overall the improvement is not likely to result in a cost reduction. Details at regional level are also available in Annex I (Table 32).

Table 2 - Average length of stay (ALOS) in Spain for selected conditions, 2005-2009.

2005 2006 2007 2008 2009 ALL CAUSES 7 7 7.2 6.96 6.9 Diabetes mellitus 9 9 9.02 9.04 8.92 Heart conditions 9.08 9.08 8.93 9.07 8.68 Stroke 11 11 10.93 10.93 10.75 COPD & associated complications 9.5 9.5 9.17 9.17 8.63

Source: INE (National Statistics Office) [2]. 6

2.4 Social and health care organisation

The Spanish healthcare system is a National Health System (NHS) largely financed through taxation providing quasi-universal healthcare free of charge at the point of use [12], with very few copayments which mainly apply to pharmaceuticals to some of the population. Devolution of health competences to the regions was completed in 2002. This devolution resulted in 19 regional health ministries with full responsibilities and powers over the organisation, planning and delivery of health services within their jurisdiction. The regional financing scheme promotes regional autonomy both in expenditure and in revenue raising (especially after the 2009 revision)[9].

At central level, the Spanish Ministry of Health and Social Policy assumes responsibility for certain strategic areas, including general coordination and basic health legislation; definition of a benefits package guaranteed by the NHS and the SAAD (National System for Autonomy and Assistance for Situations of Dependency); international health; pharmaceutical policy; and education of healthcare professionals.

It was in 2009 that in an effort to improve integration of health and social services in long-term care provision the Ministry of Health and Consumer Protection became the Ministry of Health and Social Policy (MSPS), thus assuming additional competences and responsibilities for social care. Some regions are starting to mirror this new structure as well. This configuration is quite novel and the first measure addressing the integration of social and health policy reported at this stage is as recent as the Royal Decree dated August 19th 2011 which defines a new strategy coordinating health and social services nationwide jointly developed by MSPS, the regions, local stakeholders and care professionals to be delivered by February 2012. The strategy is also meant to include indicators on progress which will be reviewed on a two-year basis.

Box 2 - Structure of a regional healthcare system in Spain

The typical structure of regional health systems consists of a regional ministry (Consejería de Salud) holding health policy and health care regulation and planning responsibilities, and a regional health service performing as provider. The regional ministry of health is responsible for the territorial organization of health services within its jurisdiction: the design of the health care areas and basic health zones, and the degree of decentralization to the managerial structures in charge of each. The most frequent model consists of two separate executive organizations, one for primary and one for specialist care (ambulatory and hospitals), at the health area level. Nevertheless, regional health services are increasingly creating single-area management structures integrating primary care and specialist care. Basic health zones are the smallest units of the organizational structure of health care. They are usually organized around a single primary care team (PCT) which exercises the gatekeeper function.

Source: Spain: Health System Review 2010[9]

6 Note 1: Heart conditions have been selected according to guidelines of the Spanish Cardiology Association. Note 2: there are sampling biases given that only 87% of hospitals in Spain are included which results in

95% of overall hospital episodes completed.

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Although the structure of regional ministries of health and service delivery follow a common framework (as outlined in Box 2) in all cases healthcare delivery is heavily financed through taxation. Certain differences exist in the funding and purchasing of services. In most regions, the healthcare network is entirely public and most of the providers have a civil servant status with little room for third-party payers. Nevertheless, some regions (i.e.: Catalonia, Madrid or Valencia) have explicitly established regulations as a framework for purchaser-provider split and for the existence of a third-party payer in charge of purchasing services in their territory.

Across the country, with an average of 1,380 patients assigned to each general practitioner (GP), primary care plays a gatekeeping role. Except for the few regions where there is purchaser-provider split, GPs are civil servants. Roughly speaking, and with certain variations between regions, 2/3 of their salary is a fixed amount whilst the remaining is a combination of capitation, additional on-call shifts performed, experience and seniority[12]. Most recently, a portion related to performance quality indicators[9] including adherence to chronic disease management guidelines has also been included.

Regarding hospital care, a similar incentive structure for staff to that for primary care is used and prospective payment mechanisms such as the use of Diagnostic Related Groups (DRG) are being tested in some regions at institutional level.

Thus, in both primary and secondary care, incentives for health outcomes and promoting chronic disease management in place are becoming a trend. Nevertheless, it is not clear whether this financial incentive is effective enough to ensure healthcare professionals adherence to guidelines or whether it has resulted in an improvement in population outcomes.

From a patient perspective, although patients are allocated to a default GP and a default hospital within their catchment area, they have the right to change GP, hospital and to request a second opinion. This choice is not limited to another physician or hospital within the catchment area where they live but they are also eligible to choose a physician within the area where they work, instead.

Regarding social care, a range of services are available to the population in need (see details in Box 3). However, the extension of the basket of services only took place in 2006 and transition from hospital into the community still relies heavily on the support of the family.

Box 3 - Delivery of long-term and social services in Spain

Social services have been regulated only recently by Law 39/2006 on the Promotion of Personal Autonomy and Assistance for Persons in a Situation of Dependency, creating the brand new SAAD and coordinated at central level through the ICSAAD (Inter-territorial Council of the SAAD). Primary jurisdiction over services administration and delivery, and cash transfers within the SAAD is also held by regional governments; hence the role of the national administration in social services is similar to that performed regarding health; likewise, the existing governance structure contemplates an Inter-territorial Council of the SAAD, so far integrated by the regional Minister holding the social services portfolio in each region.

Since social care competences are totally devolved to the regions, SAAD only establishes a minimum level of protection financially supported by the national administration. The second level of protection is stipulated in the legislation, relying on bilateral collaboration and agreements between the central government and the regional administrations. In addition, regions could develop a wider set of benefits within their territory. Municipalities can also complement the basket within their constituency.

The benefits basket for long-term and social care comprises the following services: • promotion of personal autonomy and prevention of dependency • tele-assistance • home aids:

o house-keeping o personal care

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• day centre for elderly people, for those aged less than 65, and specialist care day centre and night centre

• residential services: • nursing home for dependent elderly people • residential centre for dependent people, adapted to the type of disability.

These services are provided by the network of social centres and services; it gathers all public institutions rely upon regions, municipalities, national reference centres for support of specific causes of disability, as well as accredited partner private centres. Regions have total freedom to articulate this network within their territory. NGOs and non-profit-making institutions are specially favoured in entering this network, acknowledging their expertise and long-standing status as key providers in many parts of the territory. Accreditation by the regional authority is also compulsory for non-partner private centres providing services in the regions.

The benefits basket also includes financial benefits, based on the degree of dependency and financial status; they can take three forms and are mainly linked to support services provision outside the social services network.

Source: Spain: Health System Review 2010 [9]

As outlined in Box 2, health services are provided and organised at regional level whilst social care services rely upon regions, municipalities or national reference centres. Thus, social care services suffer from a weaker coordination between the different parties involved than healthcare services. Such a weak coordination of social care hinders formal coordination between health and social care services. As stated above, a new bill dated August 2011 has been passed by the MSPS[13] according to which by early 2012 a set of strategies should be delivered aiming to improve coordination between these two tiers of care. It remains to be seen how strong and effective this push will be in the light of an ageing population and, in the context of this study, for large-scale development of IPHS.

2.5 Disease management programmes and prevention

Disease management, integrated care and prevention are all tackled through the Quality plan introduced by the 2003 Spanish Law 16/2003 on Cohesion and Quality in the National Health System. The Quality plan is delivered on a yearly basis and published by the Ministry of Health and Social policy (MSPS) at national level. Periodic reviews reporting progress, achievements, next steps and future strategies are also available. The most recent review available is for the period 2006-2010 [14]. The current Quality plan identifies six main pillars of activity including health prevention as well as the development of ICT for health. These areas of activity represent targets that regions are expected to achieve and the MSPS is meant to support them during the process.

In terms of health and prevention, most efforts are aimed at primary care based on the premise that proper disease management and prevention activities from GPs are likely to result in lower hospitalisations and hence better use of secondary care resources. In addition, complementary activities also tackle health education in schools to prevent the development of obesity and diabetes for instance.

Specific activities in health and prevention relate to the development of clinical guidelines in primary care promoting an integrated care approach and the coordination between primary and secondary care involving clinical pathways at each stage and in each tier of care. Clinical guidelines have been developed for over 100 conditions including COPD (published in 2010 and to be reviewed by 2013); diabetes (published in 2008 and to be reviewed by 2013); and for risks associated with coronary heart disease (first published in 2001, reviewed in 2009 and future review expected in 2014). All of the clinical guidelines lay in a portal which acts as a repository and where specific

13

versions adapted to patients are also available7. However, after careful review, it seems that in most cases regions which actively participate in the portal develop their own clinical guidelines and post them on the portal in case another region is interested in implementing them. Thus, the development of disease management programmes mainly remains within the regions whilst the web portal represents a platform for knowledge exchange in an attempt to consolidate and harmonise approaches at national level. Complementary to this, at national level the MSPS provides funding to specific projects promoting the implementation and dissemination of these guidelines such as projects at regional level, initiatives involving patient associations or the evaluation of the disease management programmes by the health technology assessment (HTA) agency at Carlos III Health Institute (ISCIII); more details on the role of ISCIII will be provided later in this document.

In addition, under the umbrella of the Quality plan, the MSPS is also responsible for the accreditation and audit of health centres that are part of or contracted by the NHS. University hospitals are also the object of these audits [14].

2.6 Role of ICT in promoting integrated care

Funding of ICT for health

ICT expenditure in healthcare represents about 1% of total healthcare expenditure in Spain[15]. The Plan Avanza, a programme under the Ministry of Trade and Tourism, funded with € 141 million for the 2006-2009 period was established with the aim of promoting the digital economy across sectors including healthcare and this funding was distributed to all regions. These funds were complemented during the same period by € 4.9 million from the MSPS targeting specific infrastructure issues such as IT infrastructures for healthcare and the development of health information and advancements on electronic health records (EHR)[14], which were also part of the Quality Plan. In order to pursue and provide continuity to the original Plan Avanza, a new strategy known as Plan Avanza 2 was developed for the 2011-2015 period. No funding was ring-fenced for Plan Avanza 2 for the overall period as it was designed based on needs and resources; however according to sources from the MSPS €101 million have already been ring-fenced for the period 2009-2012[14] to be allocated exclusively to healthcare. Progress towards interoperability is also supported by Plan Avanza 2.

All objectives defined are to be achieved through coordinated funding between Plan Avanza and MSPS, through specific funding from MSPS and through regional own sources.

In addition, through the Plan Avanza some activities have been developed at local level some of which will be duly reported in the chapters dedicated to the regions covered in this study.

Interoperability issues

Given that regions are responsible for financing, planning and organising healthcare delivery, there are differences in progress and developments of ICT for health as well as in systems in use amongst regions. As a result, there are serious interoperability issues across and within regions which would, so far, make any ICT application promoting integrated care only effective at regional level, thus, potentially, any IPHS application interoperable with current ICT systems may have a regional scope at best.

In the light of the above asymmetries on ICT development at regional level, ICT for health was addressed as one of the six main pillars of activity within the 2006-2010 Spanish Quality plan set by the MSPS at national level. One of the ten objectives set out in the Quality plan specifically involved "Spreading ICT in healthcare and for welfare" and the target for all regions in Spain to have an EHR and ePrescription by the end of 2012 was established[16]. The aforementioned Royal decree passed on August 2011 did not only address cooperation between health and social care but also issues related to ICT for health[13]. At national level, the bill does not only ratify the objective

7 They can be accessed at: http://portal.guiasalud.es/web/guest/catalogo-gpc

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of having EHR and ePrescription implemented in all regions by the end of 2012 but it also establishes interoperability as a target to be achieved by the same date. As a starting point for this, the bill establishes that by February 2012 all NHS cards would have a unified and common format, as opposed to the current ones which vary per region.

In sum, what so far looked like a highly atomised conglomerate of systems in terms of eHealth seems to be receiving the push required through the August 2011 bill[13]. It still remains to be seen whether the targets set in the bill will be met, in particular in light of current high levels of debt of both regions and central government.

Role of Carlos III Health Institute in ICT for health

With a view to fostering and structuring research within the NHS, the Carlos III Health Institute (ISCIII) - a public research institute established in 1986 - forms an association with the NHS research centres. Together they establish research networks, get involved in those and define priority areas for research. ISCIII carries out a variety of activities within the health arena through its different departments and initiatives, amongst which two are highlighted in this section.

The Healthcare Technology Evaluation Agency (HTA) created in 1994 as part of the ISCIII was established as a consulting body of the National Healthcare System with the aim to support Healthcare Policies focusing on socially advanced Healthcare Systems. This arm is often involved in carrying out systematic reviews on chronic disease management guidelines and programmes amongst others.

In parallel to the HTA agency, the Research Unit for Telemedicine and the Information Society (UITeS) was also established as part of the ISCIII. The goal of UITeS is to foster research, promote and diffuse the use of ICT in health as well as the development of standards alongside the initiatives of the MSPS8. The PITeS initiative is a good example of the type of initiatives pursued by UITeS.

PITeS9 stands for innovation platform for new telemedicine and eHealth services for chronic and dependent patients. PITeS is a three-year project coordinated by ISCII involving a network of different healthcare and research centres around the country such as Hospital Puerta de Hierro (Madrid), Hospital Clinic (Barcelona), the Technology Centre (Navarra), Hospital Virgen del Rocío (Seville), and the management team of primary care in Albacete. The private sector also participates in the network. The final aim of the project is to become a network of excellence in telemedicine and telehealth and through its capacity building role to diffuse experiences to other health and research centres. Although the project started as a very ambitious initiative, PITeS has suffered the consequences of the recent economic downturn and the associated cost cuts. Specific details about one of the experiences developed under the PITeS project will be covered in section 0 as part of the Andalusia case study in IPHS.

In sum, the HTA arm of ISCIII is involved in the evaluation of disease management programmes and other healthcare interventions while efforts to promote and diffuse telemedicine and telehealth are carried out within UITeS, another arm of ISCIII. However, so far, these two arms do not seem to be coordinated and there is room for further collaboration.

It is also important to point out that regions often have their own HTA body and the extent of their activities, their cooperation with ISCIII as well as their role in influencing health policy varies widely.

The case of Telecare in Spain

As detailed in Box 3, telecare is part of the basket of benefits for long-term and social care under the public system. This refers to the first generation telecare with the classic alarm button that

8 More details about UITeS are available at:

http://www.isciii.es/htdocs/servicios/telemedicina/telemedicina_presentacion.jsp 9 " Plataforma de innovación en nuevos servicios de telemedicina y e-salud para pacientes crónicos y

dependientes"

15

sends an alarm to a call-handler and action is taken where appropriate[15]. In recent years, the service has been enhanced with reminders about treatment adherence. The service was originally launched in 1992, since then, telecare has grown considerably in Spain as shown in Figure 2. In 2009 however there seems to be limited growth which is mainly due to methodological issues addressed that year including an update on actual users based on deaths and service reviews.

Figure 2 - The growth of the telecare public service in Spain from 2002-201110

104313 129937148905

208107

261433

330071

395917 431289

515305

622126

0

100000

200000

300000

400000

500000

600000

700000

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Number of Users of Telecare 2002-2011

Source: Imserso (reports and statistics), 2009-2011[17-20]

Although the service is coordinated at national level, municipalities (or groups of municipalities) are entitled to apply for the service and a minimum set of requirements needs to be fulfilled to be able to offer the service (e.g. minimum five call handlers).

The IMSERSO 2008 report on the ageing population[17], provided details of total users and costs per region as detailed in the table below.

10 2011 Data covers the 1 January to 1 June 2011 period.

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Table 3 - Number of telecare users, costs and coverage by region. Spain, December 2008.

Source: Imserso, 2009[17] (note: 2008 data)

The coverage index represents the number of telecare users as a percentage of the population aged 65+ in each region that year. The cost of the telecare public service represents the price published by each region when tendering (contracting) the service. There are significant differences in both coverage index and prices across regions. In addition, the average cost per user has also increased from 244,21 €/year in 2002 to 253,90 €/year in 2008[17].

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3. ZOOMING INTO SELECTED REGIONS AND IPHS/RMT CASE STUDIES

3.1 Andalusia

3.1.1 Population and health status

The largest Spanish region is Andalusia with 8 provinces covering the Southern part of the country, including areas in the Atlantic and in the Mediterranean coasts as well as non-coastal areas like Cordoba, Jaen and Seville. With a population of 8,370,975 people, it also represents the region with the largest population in Spain.

As detailed in Annex I (Table 9 to Table 11), life expectancy at birth was 79.8 for 2007 thus showing an increase and getting closer to the Spanish average compared to 2000. In 2007, this value was 76.7 years for males and 83 for females [21]. When comparing life expectancy per gender to the EU27 for 2008, the corresponding 2007 values for Andalusia are slightly above the EU average (see Table 12 in Annex I).

When looking at the population age structure, the dependency ratio in this region for 2009 was 47.46, slightly below the national average (see Table 14, Annex I)

The ratio of people with some permanent disability per 1,000 was much lower than the Spanish average, whilst the age-adjusted ratio falls well above the national average (see Table 20, Annex I). The same happens when looking at mortality rates and comparing them with age-adjusted mortality rates for all causes of death as well as for mortality rates related to diabetes and COPD. On the other hand, for cardiovascular diseases, the crude mortality rate in Andalusia is higher than the average in Spain and when adjusting per age group, Andalusia also represents the most concerning case of all regions (see Table 21 to Table 31, Annex I).

3.1.2 Regional health and social care organisation

As much as at central level in Spain health and social care have recently been integrated into the Ministry of Health and Social Policy (MSPS) at regional level, these two services are not yet coordinated.

The Andalusia Health Service (SAS) is the regional organisation responsible for the delivery of healthcare under the Ministry of Health of Andalusia. SAS is a universal service free at the point of service. All Andalusian GPs and primary healthcare centres (PHC), specialised outpatient clinics and physicians’ offices, as well as 75% of hospital care, are publicly owned and managed. There is therefore hardly any purchaser-provider split although some prospective payment mechanisms such as DRG are being introduced at hospital level in order to control costs and promote efficiencies within the system. Prior to the reform in 1985, the traditional system of primary care delivery consisted of a single practitioner working part-time, while the reformed model is based on a PHC team working full-time on a salary basis.

SAS involves 84,179 professionals out of which 22,244 are based in one of the 1,514 primary care health centres and 61,935 in one of the 29 hospital centres. For 2011, the SAS budget is set at € 8,601,566 million where 47.21% represent personnel costs, 26.14% pharmaceutical and research expenditure and the remaining running costs of health centres. Regarding expenditure in healthcare per population covered, as in most healthcare systems it has shown a steady increase over years. For instance in 1999, € 680 were spent by the SAS per person covered whilst the same value for 2008 was 1,331 (see Table 17, Annex I)

Andalusian citizens are all also free to select which hospital they would like to go to. They have guarantees in terms of how long they should wait for any treatment and specialised consultations.

As explained earlier, social care services, instead, are provided by the network of SAAD social centres and services involving regional and local facilities and resources. In particular, social care is

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delivered by the Andalusia government through their Ministry of Equity and Welfare and by the municipalities.

3.1.3 Chronic diseases and ageing

The dependency ratio (defined as the percentage of the population aged below 16 and 65+ over the population aged between 16 and 64) in Andalusia for 2009 was 47.46%, slightly below the national average, denoting a slightly higher amount of population in working age (see details in Table 14,Annex I).

In 2002, it was estimated that 450,000 patients suffered from Diabetes in Andalusia. Mortality data from 1975-1994 suggested that for females during the 70s mortality due to diabetes was 30 per 100,000. During the 80s, it first increased reaching 90 per 100,000 to then decrease again to 24 per 100,000 in 1994. For males it has remained constant throughout years around 18 per 100,000. In addition, a high level of mortality due to diabetes has been observed in the areas corresponding to west Andalusia when compared to other provinces in Spain. When adjusting for risk, there is great variability depending on the hospital or province concerned. This is partly due to lack of adherence to what is considered good clinical practice. Towards the end of the 90s, a high level of diabetic patients were hospitalised due to acute unbalances, leading to a high number of amputations, ophthalmologic complications, kidney complications or cardiovascular events[22].

In 2002, respiratory system diseases represented the third cause of death in Andalusia for the 65+ population. Out of these diseases, COPD is the first cause of death with a rate of 50.1 per 100,000 inhabitants for males and 10.6 for females, thus making it the 4th cause of death for males and the 10th for females. In the year 2000, the impact of COPD due to exacerbations resulted in over 10,000 hospitalisations generating over 117,000 hospital stays and 6,7% mortality. The costs associated with this (excluding intensive care) was € 27 million.

Currently it is estimated that by 2020 COPD will be the third cause of death worldwide. This increase in mortality is mainly due to smoking and to an ageing population. One of the main challenges associated with COPD is underdiagnosis [23]. The IBERPOC Multicentre Epidemiological study evidenced that in Spain 78% of patients suffering from COPD were not properly diagnosed and only 49% of those suffering from a severe form were diagnosed and receiving some sort of treatment. Moreover, only 61% of those diagnosed and under treatment were receiving the appropriate treatment according to guidelines[4].

Morbidity and mortality of Heart Failure (HF) in Andalusia are high. HF represents the most common cause of hospitalisation among the 65+ and rehospitalisation is increasing, mainly amongst high risk patients and the elderly. HF represents a great portion of hospital and pharmaceutical expenditure whilst clinical screening and follow-up of HF represents 1-2% of healthcare expenditure in most EU countries[24].

3.1.4 ICT for health in Andalusia

At the core of Andalusia‘s eHealth strategy is Diraya, a unified EHR system. It integrates patients’ health information and intervention details in primary care, emergency services, mental health services and ambulatory specialised care in the region. Diraya has been praised internationally as an example of a successful implementation of a region-wide EHR system[12, 25].

Diraya is the result of two political objectives: (i) reducing waiting lists for referral to health care specialists to a maximum of 1 month which in turn would improve patients' satisfaction and quality of care; and (ii) prescribing by active ingredient (or NIC) in order to contain health care expenditure. As these objectives were achieved, Diraya became an opportunity to support a process change that could be facilitated by ICT.

At the time interviews were carried out, roll-out was completed in primary care and in emergency departments whilst in hospital care it had only recently started, still being outspread with variability of integration depending on each individual hospital.

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Thus, broadly speaking integration of EHR in primary care has already been achieved whilst integration between primary and secondary care is limited to A&E services and specialised care, at this stage.

Diraya primarily consists of structured data with few free fields. The system has several interrelated modules that integrate as a pyramid (Figure 3) with four layers.

Figure 3 - Related modules that comprise Diraya

Source: SAS (Servicio Andaluz de Salud / Andalusian NHS)

Diraya started to be implemented in 2002 in Seville, a highly populated area, and mainstreaming throughout the rest of the region took over 8 years[25]. Currently Diraya's main applications are:

A centralised ebooking system (appointment module)

RECETA XXI, an ePrescribing module

EHR

• And the CPOE (Computer Physician Order Entry)11 system for lab and radiology tests which is still being rolled-out

The evolution of Diraya mainstreaming in primary care and its different applications is detailed in Annex I, Table 33.

Patients have a legal right of access to their records. Until recently, any patient could either have a print out, or consult it on GPs’ screens during the visit. A plan is in place to provide patients with on-line access to their records. Additionally, patients can choose to share confidential data only with their GPs. On request, their GP can block any other physician’s access to the EHR.

A specific module for diabetes was also introduced within the system, representing a very good example of ICT supporting chronic disease management. Ideally, additional modules for some of the most prevalent conditions could also be developed. Unfortunately, funding is currently one of the limitations to populate additional applications. Furthermore, interviews with stakeholders revealed that adherence to chronic disease management guidelines for diabetes is quite high whilst it is quite low for COPD for instance. It would be interesting to identify whether this is related to the 11 CPOE is the portion of a clinical information system that enables a patient’s care provider to enter an

order for a medication, clinical laboratory or radiology test, or procedure directly into the computer. The system then transmits the order to the appropriate department, or individuals, so it can be carried out. The most advanced implementations of such systems also provide real-time clinical decision support such as dosage and alternative medication suggestions, duplicate therapy warnings, and drug-drug and drug-allergy interaction checking. Source: HIMSS CPOE Wiki https://himsscpoewiki.pbworks.com/w/page/20831139/Def%20CPOE

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development of the diabetes module supporting this process or to other reasons, such as the incentives related to health outcomes or particularities related to each condition which may have an impact on the higher or lower feasibility of disease management at primary care level.

3.1.5 ICT in Andalusia in cooperation with Plan Avanza

As stated earlier, some activities have been developed at local level in cooperation with Plan Avanza. In particular, in Andalusia there are two initiatives targeting the elderly mainly focusing on promoting the use of ICT and bridging the digital divide gap, and four initiatives targeting the disabled population such as on the use of ICT to promote mobility amongst those with visual impairments and disabilities.

3.1.6 Telecare services in Andalusia

Andalusia ranks fifth in terms of regional penetration of telecare services and cost of service delivery with €9.74 per month per user, the second cheapest in Spain (see Table 3).

In 2006, the term "teleassistencia" (the equivalent to telecare) was included in the law at regional level through a bill promoting the quality of services delivered to the elderly and the fragile[26]. Resulting from it, the Home Observation Program was set up. The programme is a project for home care for Andalusian Telecare Service (SAT) users. It consists of monitoring the users and personal visits to them in order to increase the effectiveness of the service whilst promoting personal autonomy.

The coordinators of this Home Observation Program in each of the eight provinces in Andalusia are responsible for the maintenance, update of the services and the users' condition. SAT is also responsible for testing new solutions and innovations, such as third generation telecare technologies in coordination with other institutions. In line with it, the Andalusian Foundation of Social Services is involved in different projects, which aim to investigate and improve the social services provided nowadays, and the integration of the same in other interrelated sectors and services, such as healthcare.

They are involved in the following projects:

• CommonWell and Independent, which investigate new methods of research and piloting for the integration of social services and health care. The aim is to improve the efficiency, safety and resources management, together with sharing their experience with similar organizations of other European countries.

• Tests of improvements and investigations are made in the Telecare Service, with prototypes and applications in order to check their potential for future service provision, through projects such as We Care, CVN, Florence or Soprano, with relationships both with important technology providers and research entities.

These projects aim to develop new technologies in relation to social services, to transfer good practices between the participant regions, improve the users’ knowledge of telecare services and promote the creation of common standards between the partners.

Also as part of their research initiatives, SAT eventually tried to implement telehealth initiatives in a residential home for the elderly in order to avoid patients having to unnecessarily travel to hospital but it failed due to a variety of factors including their lack of competences in healthcare and high resistance from physicians. Thus, apart from this experiment, so far their activities have been limited to telecare and their coordination with healthcare services remains work in progress.

3.1.7 Integrated care in Andalusia

The Andalusia Ministry of Health has created clinical guidelines for over 40 of the most prevalent health issues, covering about 80% of the health problems treated in the region[25]. These exist for conditions such as chronic obstructive pulmonary disease (COPD), cancer and diabetes. Physicians who have patients in one of these clinical conditions have received appropriate training and are now

21

able to access guidelines easily. In addition, the clinical guidelines are gradually implemented into the ‘decision support system’ supported by Diraya, of particular interest for this study, the system includes a specific module for diabetes.

Thus, the approaches to integrated care in Andalusia are mainly driven by chronic disease management guidelines adherence which vary per condition and a set of incentives for healthcare professionals based on health outcomes. These incentives can represent around 15% of the overall yearly salary and they are negotiated on an annual basis in each district through the Clinical Management Units based on previous years' achievements and changes on population health status and conditions. In conjunction with this, the so-called inter-level or inter-centre teams have been implemented in most districts. These are teams that involve staff from primary and hospital care and are responsible for the coordination between these two as well as the coordination of processes behind each of them (i.e.: how often they will meet, what kind of specialties should be involved, which health conditions/diseases to prioritise). These teams are involved in the yearly negotiation at district level on financial incentives. Thus, they play a key role aligning incentives at different tiers of healthcare services promoting the delivery of integrated care. It is not clear however, whether the incentives for healthcare professionals at hospital level represent in some instances a clash towards institutional incentives based on DRG payments and how these are managed.

In addition, an EHR system in primary care involving also A&E and outpatient care currently being outspread to hospital care aims to support processes behind integrated care.

Finally, telecare is quite widespread in Andalusia whilst activities in cooperation with Plan Avanza are rather limited and do not seem to aim at promoting self-management of those with chronic conditions. However, there is still room for improvement when it comes to coordination of tiers of care in particular between primary and hospital care at institutional level as well as with social care services. This implies limitations to further deployment of IPHS promoted by social care services, an example of the limited coordination. It is expected however that based on the August 2011 Royal Decree and once the 2012 plan to coordinate health and social care at regional level is defined, this situation may improve.

3.1.8 RMT in Andalusia – the case of hospital Virgen del Rocio

Background

With over 1,200 beds and almost 5,200 healthcare professionals as part of their hospital staff, Hospital Virgen del Rocio (HUVR) is the biggest of the 5 regional hospitals in Andalusia. It is the hospital of reference for 13 districts (out of 24) at regional level which includes a population of 1,434,013 people and for 5 districts at provincial level covering 1,316,728 inhabitants. It is the main hospital for three districts in Seville – Seville, Aljarafe and Sevilla Sur – thus, being the default hospital to 550,502 inhabitants.

Being a university hospital, HUVR has traditionally been very innovative both in clinical and technology terms including ICT. Clinically, in 2010 they were awarded a set of prices for their successes in coordinating transplants, their good practices in cardiology or their advances in infectious diseases.

Their push for ICT started with the development of the EHR system through which currently 90% of their patients have an EHR. Their in-house EHR system was developed by their own IT team in cooperation with the different clinical departments which allows them to enter and mine data as per their needs. One of the drivers for HUVR to implement the EHR system was their need to mine data for Diagnostic Related Groups (DRG) purposes aiming to follow-up and compare costs against payments as well as to monitor any efficiency improvements. However, given that DRG represents 33% of HUVR income and the rest of the budget is calculated using other criteria (structural costs, R&D, etc), HUVR also felt the need to emphasise other aspects of the data mining beyond inpatient treatment but also for outpatient consultations and A&E, areas that are not reimbursed on a DRG basis.

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Furthermore, the hospital management also wanted to put more emphasis on clinical aspects and integrated care. With this ICT system, they have managed to get for each patient that has been hospitalised historical data on additional hospital contacts in different units of the hospital. The need for additional ICT applications beyond the EHR in the treatment of chronic diseases is obvious to HUVR staff. The hospital has 55,000 programmed hospital entries, 300,000 emergency medical entries and 1.2 million medical consultations per year. Of these, about 30% (from 20% to 50% depending on reason for entry) is a re-admission. These findings were reached by mining their database for a timeline of 30 days before a patient admission and 180 days after hospital discharge. In 60% of the cases, the re-admission is triggered by patient's lack of adherence to treatment after hospital discharge due to a variety of reasons including socio-economic background, usability of the technology or affordability. As a result hospital costs are spiralling and something had to be done about it without sacrificing quality of care.

In the light of the lack of promotion of telehealth initiatives at Ministerial level whilst HUVR needs and thirst for innovation, some ICT based initiatives were launched in the past to test if patients could be kept at home and some of these involved telemedicine applications.

One of them relates to TeleICTUS, a healthcare provider to healthcare provider solution. Given the positive results obtained, SAS endorsed it which is facilitating its roll-out and hospitals can now 'formally' apply for it and get involved. Each TeleICTUS activity is recorded both at patient EHR level and hospital activity follow-up level.

Another example relates to home dialysis, which does not involve telehealth but aims to keep patients at home. This initiative allows patients to be treated with dialysis at home instead of being hospitalised. The service has been outsourced to a provider from the private sector. A tool has been developed allowing healthcare professionals working for the contractor to also access the EHR of patients at HUVR and enter data in the EHR (i.e.: changes in patients data such as temperature, blood pressure, new symptoms/affections, or patients' adherence, etc). The interoperability they have achieved with the contractor for dialysis services has allowed them to exchange know-how. At some point, a difference in erythropoietin interpretation and the protocols to act upon it was detected. When this happened, the processes of the contractor were modified to match the standards of HUVR and much better results have been achieved as a result. Interviews with managers at HUVR revealed their wish to have the same level of data exchange at patient-level with other hospitals as it would allow them to develop joint protocols and clinical guidelines for processes to be standardised. When it comes to costs, it is interesting to note that in order to avoid additional costs to the patient which would result in lack of adherence and rehospitalisation12, the hospital covered all home dialysis costs including equipment, service costs paid to the contractor and an additional 15 €/month for patients to cover home costs incurred in terms of electricity and water used to carry-out the dialysis.

The third experience is an RMT application for heart failure so far being piloted with 10-20 patients under the project 'Health@home' co-funded by the Ambient Assisted Living Programme (AAL)13. The project plans to deliver a software system for the collection, transmission and recording of medical information (such as pathophysiological data relevant to HF conditions gathered through health technologies and applications) developed taking into account European standards. In addition, patient clinical data updated with available ”medical information” are processed by a monitor providing immediate visualisation of the level of criticality of the situation and alerting health care providers on such critical situations. In terms of costs, one hospital day at HUVR on average costs 600 €, an amount which is a bit higher for some pathologies and bit lower for others14. The average

12 As stated somewhere else in this document there is no co-payment for hospitalisation within the Spanish

NHS 13 More information of the project is available at: http://www.health-at-home.eu/index.php/home/results 14 Note that HUVR has high overheads due to their size and research activities so their bed-day cost is one of

the highest if not the highest in Andalucia

23

length of stay of HF patients in hospital is 10.39 days in HUVR whilst it is 11.72 days on average in Andalusia. The high hospital costs represented a driver to be part of this project.

Finally, another experience run by HUVR is an RMT pilot involving oxygen-therapy for COPD patients. The trial was completed at the end of July 2011 and it is the object of this study.

Pilot planning

Since 2009, HUVR has been part of the PITeS project coordinated by ISCIII alongside other hospitals across Spain. Within the framework of this project, HUVR applied for ISCIII funding to carry out RMT trials for COPD conditions, cephalalgia, apnoea and patients suffering from chronic conditions with co-morbidities. The conditions were selected after identifying that some of the needs of these patients could be monitored remotely and there was an opportunity to keep patients at home. As the original funding requested was about €1 million but the amount granted hardly reached €160,000, HUVR decided to carry out trials only for COPD, cephalalgia and patients suffering from chronic conditions with co-morbidities, complementing with other sources of funding. At the time of writing, the trials for cephalalgia and patients suffering from chronic conditions with co-morbidities were about to be launched whilst that for COPD was already concluded and the data collection for the evaluation was beginning.

The trial on COPD patients was to be performed on patients on home oxygen therapy for which HUVR already had a number of patients. The technology provider for these patients was Carburos Medica - CM - (part of the Air Products group). CM also became the technology provider for telehealth as will be explained later. From their side CM had already developed additional technologies related to monitoring adherence to oxygen-therapy in other pilots given that it was often observed that patients under this therapy did not follow the treatment as prescribed.

The hypothesis to be tested under the HUVR COPD trial was whether exacerbations for patients under home oxygen-therapy can be decreased by monitoring blood pressure, spirometry and oxygen levels in blood. CM was also interested in this initiative and decided to be involved as a technology partner sponsoring the RMT technology in use and part of the service delivery.

Between late August and December 2010, the study design phase took place. Three parties were involved in the design: the pneumology department and the technology innovation department at HUVR alongside the team from CM. During this phase it was decided that the trial would last for six months. The team defined jointly a protocol to be followed and set thresholds that would trigger an alert to healthcare professionals conducting the trial. The inclusion criteria were also defined as follows: patients under home oxygen-therapy, over 50 years old, and who would have been hospitalised at least once in the last two years. Given this inclusion criteria, it becomes clear that that eligible patients were suffering a severe or very severe form of COPD. Once the inclusion criteria were set, around 100 patients were identified as potential participants for the study and they were randomised in control and intervention groups. The staff at the HUVR pneumology department contacted them for recruitment and informed consent purposes. At that point, out of the 100 patients identified some of them had already died. In the end, 56 patients were included in the study.

Technology

In addition to the COPD drug treatments that patients are meant to routinely follow, two types of technologies were involved in the study: on the one hand the oxygen-therapy to all patients, on the other hand, the intervention group also used the RMT technology which allowed taking the measurements of blood pressure, spirometry and oxygen levels in blood. The RMT patient measurements data is sent via bluetooth to a pad and from there details are registered in the provider's platform through the patient phone line. At the back-end of the platform a healthcare professional is responsible for reading the data from each patient and follow the protocol when the alarm is triggered. After the triage, in case of a need to take action, healthcare professionals at the HUVR pneumology department were contacted to further assess the situation. When this happened, hospital staff could access the patient EHR through the hospital service and the patient readings

24

sent to the platform were remotely accessible through an iPhone. Thus, hospital nurses had to consult two different sources of data which were not interoperable.

CM sponsorship has consisted in providing all the technology (oxygen therapy, RMT technology for readings, platform providing the readings and iPhone for hospital staff). In addition, one healthcare professional (a nurse trained for this) responsible for the readings, detecting alarms, and carrying out the triage has also been provided by CM.

The RCT

The pilot was launched in February 2011 and finished end of July 2011. 56 patients were included in the pilot: 21 in the control group and 25 in the intervention group. Each patient was followed up for a three month period. Given the severity of their conditions two patients died during the trial, one in each group. The control group involved oxygen-therapy only whilst the intervention group is using both oxygen therapy and RMT applications taking the measurements on the three parameters outlined earlier.

The clinical data to be measured was hospital consumption during the pilot and patients' quality of life (QoL) measured at two points in time: at the beginning and at the end of the pilot for each patient in the two groups. Two different questionnaires were administered on self-reported QoL for all participants: EuroQoL and Saint George. The EuroQol questionnaire is a questionnaire on quality of life using five dimensions – mobility, self-care, ability to perform usual activities, pain/discomfort and anxiety/depression – thus, it is a questionnaire that can be used in any health condition. The Saint George questionnaire is specific to the COPD condition and it involves two parts: the first part includes 8 questions assessing the patient’s perception of their recent respiratory problems; the second part, including 8 sections, measure the patient’s disturbances to daily physical activity. In addition, questionnaires on the quality of the service and on technical quality were also administered. However, these would not be included for quantitative analysis purposes related to costs and outcomes of the RMT activity.

At the time of writing preliminary findings were made available as portrayed in the impact section.

Service organisation and stakeholders involved

Prior to starting the RCT, one training session to the HUVR pneumology department staff was given. The aim of this training was for staff to understand the platform and the RMT technology and to clarify expectations as well as actions to be taken in specific situations. Regarding participants, one person from CM would first visit the patient to install the equipment and would go through a first measurement together with the patient.

The service was mainly run by nurses. At the back-end of the platform where patient RMT data was registered there was a nurse that had received training on the protocol to follow in each situation depending on patients' results. This person was the first contact person for the patient. Thus, the whole patient triage was carried out by the same person regardless on whether the contact was initiated by the patient or by the providers. This nurse was contracted by CM, the technology provider. When the system triggered an alarm, this nurse would contact the patient and as part of the protocol they would go through a short questionnaire together with the patient on how he/she was feeling, whether the patient was coughing or on the presence and type of sputum. Interviews revealed that during the first weeks of the trial, phone contact with patients was almost on a daily basis.

In case the patient condition required intervention, the nurse at the end of the platform would contact the nurses at the HUVR pneumology department who were nurses with long-term experience in COPD. When hospital nurses were contacted they could assess the patient condition through the iPhone provided and also consult the patient EHR and finally would contact the patient directly where appropriate. It is relevant at this point to highlight that nurses in Spain have no competence to act on patients' prescriptions without the supervision of a doctor. Thus, in these cases, hospital nurses based on their experience could decide whether it was better to wait as the

25

patient was likely to recover or whether it was advisable for the patient to visit the doctor and adjust the patient treatment or even to be hospitalised.

Cost/funding

As stated earlier funding was obtained to a certain extent from the PITeS project. In addition, the project was co-sponsored by the technology provider.

Cost data resulting from the trial could not be provided at the time of writing given that evaluation was not yet completed.

Generalisation of the innovation

Regarding incentives in the long-run if this treatment was to be rolled-out, it is unclear how the study findings would influence the decision given the presence of perverse incentives within the system. Hospitals are reimbursed on a DRG basis but there is no DRG for home oxygen therapy on its own let alone combined with RMT. Thus, based exclusively on this very fact, hospitals would not have an incentive to roll-out these innovations since their income for treatment is based on DRG for hospitalised patients. Even if the technology proved to extend patients' lives, it could be argued that the innovation would result in higher hospitalisations which would be an incentive at hospital level. However, in the case of HUVR the demand they have for COPD treatments is already extremely high and beyond their ability to match it with their resources. Therefore, they would not be interested in having more COPD patients in need. In fact, even if RMT proved to reduce the number of hospitalisations, this would not refrain HUVR from mainstreaming given this high demand they have for these treatments.

Most interesting is the fact that patients in this pilot are already in a very severe condition and as described a few of them died during the trial. Given the severity of their condition, if RMT proves to improve or at least stabilise patients, even in case they needed to be rehospitalised, patients would not be in such a bad condition as they used to be without monitoring and thus length of stay would be reduced. This is where there is an incentive given that the DRG reimbursement is likely to exceed their hospital costs in patients with a more stable condition and lower length of stay as opposite to the current situation where patients showing up at hospital are extremely unstable resulting in longer length of stay which incur higher hospital costs than those reimbursed by the DRG. In addition, having shorter length of stay would free up resources to cater for the high demand, thus releasing pressure on the hospital which also comes at a cost, a non-quantified cost, but still a cost.

If the evaluation of the pilot proves to be positive, HUVR would like to roll-out. But before doing so, an evaluation needs to be carried out. In terms of the cost-effectiveness assessment (CEA), a higher sample of patients would have contributed to robustness of the results and potentially mainstreaming at regional level as it will be detailed in the impact section (see section 1.1.1.14). However, to mainstream at hospital level, this evaluation was meant to represent enough evidence for them to make a decision. Clinicians reckon that almost any patient with COPD would be clinically eligible for some form of RMT (with or without oxygen therapy) provided they had good social services that ensured patient adherence through RMT. Similar conclusions were reached for HF patients and for patients suffering from both COPD and HF.

It is also relevant to note that HUVR has in-house social services that are in contact with patients. Hence, their services as done in past experiments coordinate with external social services from other institutions that are taking care of their patients and any information that the external social care services may provide is entered in the EHR of the patient by the in-house social care services. Thus, the coordination with social care services takes place in an informal bottom-up way: social care professionals from the hospital cooperate with social care professional from other institutions, without involving authorities like the Department of Health or Social Affairs authorities at local or regional level. Hospital clinicians highlighted the need to carry out additional pilot studies on RMT applications involving different tiers of care and promoting integrated care in contrast with this experience which is focusing on a specific aspect of these patients and relying on the informal involvement of social care services.

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In addition, the EHR system at HUVR is quite independent from and not interoperable with that of primary care (Diraya) with the exception of records for A&E and some outpatient services. However, HUVR has managed to integrate their patient records with those of two primary care centres in the region, which has actually proven that they can work together with other tiers of care. Through interoperability with these two primary care centres, HUVR has been able to identify that such a good coordination results in lower numbers of re-hospitalisation.

Having made the above experience with social services and primary care, interviewees expressed the view that coordination with primary care and social care would result in "almost no limitations for telehealth eligibility". All patients suffering from a chronic condition would be eligible provided those who are in need of social care receive it and there is good coordination between hospital, primary and social care. However, whether RMT is mainly run by the hospital or by primary care may vary depending on the condition. For instance, for severe COPD patients, most of the RMT management is likely to be hospital based (after triage) as the complexity of these patients' conditions is likely to require the involvement of hospital specialists. In contrast, the trial that will be launched for cephalalgia conditions is based on a different service organisation given that it is a very different type of condition with different needs. It actually involves videoconferencing between hospital specialist and GP offices where the patient is also present. Thus, in this case, primary care involvement is key to delivering the pilot and eventually mainstreaming. The COPD trial actually implies little service re-organisation whilst the cephalalgia trial embeds some form of service reorganisation and coordination of tiers of care.

Furthermore, within the COPD trial it has been described that data systems were not made interoperable during the trial and hospital nurses accessed EHR and RMT data using two different applications. If HUVR was to mainstream, interoperability amongst those would be welcomed. Nevertheless, HUVR experience with home dialysis patients and their experience integrating data with two PHC points at the fact that interoperability would not be a major challenge and it would be duly addressed.

3.1.9 Conclusions of integrated care and ICT for health in Andalusia

ICT for health in Andalusia is being promoted through a set of very good initiatives which show some strengths and which would only require a final push to be crystallised and grow stronger together. After analysing the experiences described in Andalusia using three axes (diffusion of innovation, governance and health impact assessment), the following conclusions are drawn.

Innovation

Regarding IPHS applications and the experience reported in HUVR, this case reflects how at hospital level the diffusion of innovations is triggered by former positive ICT experiences supported by in-house IT services and by historical precedents of innovation both in clinical and technological terms. However, mainstreaming will very much depend on the results of the impact assessment.

In fact, as much as incentives to healthcare professionals portray an alignment between primary and hospital care, from a hospital revenue perspective if some of the existing perverse incentives within the system were addressed, there would be more room for generalisation of the innovation. Issues around incentives need further exploration and it is likely that additional policies around them are required if RMT innovations are to be sustainable in the long-run.

Furthermore, within the COPD trial as described data systems were not made interoperable during the trial and hospital nurses accessed EHR and RMT data using two different applications. If HUVR was to mainstream these applications, interoperability amongst those would be welcomed. Nevertheless, HUVR experience with home dialysis patients and their experience integrating data with two PHC points at the fact that interoperability would not be a major challenge and it would be duly addressed.

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Given the prestige of HUVR, if RMT proves to be cost-effective, it is likely to be mainstreamed for their patients but it remains to be seen whether endorsement by the Andalusian Ministry of Health is obtained, which would allow further diffusion of the innovation.

In addition, according to the stakeholders interviewed a set of conditions for wider diffusion and sustainability would need to be fulfilled:

• a cultural change from health care providers and their attitude towards telemedicine. It should be noted, however, that this aspect has already been addressed at HUVR by the IT department being very proactive and engaging with clinicians. For instance, the in-house team of developers approached the genomics department to identify their needs and develop an IT system that would support their processes and information needs;

• very good coordination/integration between hospital, primary and social care and interoperability of ICT applications supporting this coordination;

• affordable and reliable solutions provided by the industry. HUVR clinicians have often complained that off-the-shelf market products do not fit their actual needs as they often do not even involve product maintenance. Current solutions often involve many functionalities on top of those actually needed for the specific purpose of the treatment. Moreover, they do not offer a fully operational service, thus a shift from a product-centred to a service-centred approach would be needed. In addition affordable prices for the payers with minimum patient contribution are an issue of great importance as market prices today are too high and this is partly triggered by these unnecessary enhanced functionalities.

Governance

The HUVR initiative on COPD is very much a bottom-up initiative led by a team of clinical champions where coordination with tiers of care takes place at informal level. HUVR also provides additional examples of coordination with EHR systems with two PHC through dedicated platforms. This approach follows a different pattern from that of the implementation of ICT in primary care where the approach was very much top-down: from political agenda to implementation in primary health care settings.

Interviews with policy-makers highlight their willingness to develop IPHS at regional level and emphasise their limitations to do so mainly due to lack of funding. Thus, it is likely that in Andalusia IPHS deployment at scale would only take place after a few hospital led experiences provide evidence on savings which may encourage policy-makers to institutionalise these applications and make additional funding available for mainstreaming.

In addition, the current incentives system in Andalusia aligning healthcare professionals in primary and hospital care makes an interesting setting for IPHS deployment. Nevertheless, the DRG payment system to hospitals would need adjustments to align individual and institutional motivations. Similarly, incentives in social care would also need to be addressed.

Impact

Regarding the impact of the IPHS experience reported, the evaluation details aimed at assessing

• Healthcare resource utilisation including reduced (re)hospitalisation and/or lower length of stay due to RMT

• Health outcomes: better monitoring could be associated to improvements in quality of life (QoL). Every time a patient is re-hospitalised each acute episode results in a serious erosion of health state and lower QoL. HUVR is attempting to measure it for telehealth and it is becoming more challenging than planned given that so far, measuring health outcomes in terms of QoL had only been done for a limited number of telehealth interventions.

In terms of the cost-effectiveness assessment (CEA), preliminary results showed very weak evidence. Indeed, it was found that both groups (intervention and control group) showed an

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improvement in health status during the trial. This was due to a variety of limitations during the trial including the period of the trial being too short (three months), the low number of patients involved and the fragility of their condition which makes them vulnerable to weather changes. This represents a learning point for future impact assessments.

To sum up, telecare services are quite well widespread in Andalusia compared to other Spanish regions and applications beyond first generation telecare service are being explored and in some cases mainstreamed. However, when it comes to extending these services to telehealth, barriers become apparent mainly for lack of funding.

Moreover, even though the use of ICT in health and social care seems to be well spread in Andalusia, efforts promoting the coordination between tiers of care including primary, hospital and social care may further enhance integrated care. The lack of funding may also explain to a certain extent the limited use of telehealth as well as the scarce and scattered nature of these experiences which currently are mainly driven by a few entrepreneurs. Any initiatives promoting and strengthening IPHS deployment would need to consider and balance the needs of and subcultures present in each tier of care so as to provide enough flexibility to ensure initiatives from entrepreneurs are not hampered and contribute to spreading those that prove to be positive, instead. Potentially, the strategy to be launched in 2012 as mandated by the August 2011 Royal Decree[13] seeks to provide solutions to bridge the gap between health and social care tiers.

Additional barriers to the widespread use of IPHS are the lack of reimbursement or more generally the need to define the appropriate incentive scheme which is currently lacking at institutional level (mainly due to current hospital payment mechanisms) as well as the need to design technologies and services that suit the needs of those involved in delivering health and social care.

3.2 Basque Country

3.2.1 Population and health status

With 2,178,339 inhabitants in 2010, the Basque country represents 4.63% of the overall population in Spain.

Located in the North, the Basque Country is one of the 19 Spanish regions with a population density of 301 inhabitants per km2, in 2010. When comparing this population density with EU data from 2009, it is well above 117.8 inhabitants per Km2, the average of EU 27 (see Table 8, in annex I).

Life expectancy at birth for the overall population has increased from 79.9 in year 2000 to 81.6 in 2007, being both values above the Spanish average 2007 (Table 9 to Table 11, Annex I). In 2007, this value was 77.2 years for males and 84.3 for females. When comparing life expectancy per gender to the EU27 in 2008, the corresponding 2007 values for the Basque country are well above the EU average (see Table 12, in annex I).

People over 65 years represent 18.7% of the total population and the dependency ratio in this region for 2009 was 49.42, slightly above the national average (see Table 13 and Table 14; see also Figure 17 Annex I).

3.2.2 Regional health and social care organisation

The Regional Government of the Basque Country is responsible for Health Planning, Financing and Regulation through its Department of Health while the provision of services is under the responsibility of the Osakidetza - Basque Health Service (BHS). Total healthcare expenditure in 2009 was 5.61% of GDP reflecting quite an increase when compared to the value in 2007, which was 4.5% (OECD 2007 average 6.4%).

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Figure 4 - Health care expenditure Basque Country

Source: Healthcare public expense statistic. Ministry of Healthcare and Social Policy (MSPS). Contribution to the Healthcare public expenditure, 2009.

Regarding expenditure in healthcare per population covered, as in most healthcare systems it has shown a steady increase over years. For instance in 1999, €791 were spent by the Basque healthcare system per person covered whilst the same value for 2008 was 1,557. the latter is well above 1,382 €/person, the Spanish average for this year (for further details see Figure 4 and Table 17 in Annex I).

Health service provision is organised in three geographical areas (Alava, Vizcaya and Guipuzcua) with the following public providers: 320 Primary Health Care centres grouped in 7 Health Areas; 11 acute hospitals (478 beds) and 3 medium and long stay hospitals (524 beds) and mental health services. Mental health services actually comprise 4 psychiatry services in acute hospitals; 4 psychiatric Hospitals (777 beds) and 3 Extra-hospitalary mental health Areas.

The number of hospital beds per 1,000 inhabitants is 3.75 (see Table 18, Annex I); and the ratio of registered physicians is 5.4; registered nurses 6.69; physicians practising specialists 1.63 and GPs 0.62 (see Table 19, annex I).

Furthermore, the 2009 BHS report[29] provided data on average costs as follows.

- Primary care: €184 per individual covered (without prescription costs)

- Acute hospital discharge: €4,262

- Medium and long stay hospitals discharge: €5,369;

- Inpatient in an acute hospital: €773 and in a medium and long stay hospital: €336;

- First specialist consultation within hospital: €199 and cost of consecutive specialist consultation within hospital: €99€

- Emergencies without hospitalization €144.

3.2.3 Chronic diseases and ageing

The last survey on health status carried out by the Basque Ministry of Health in 2007[30] reported that 41.5% of the Basque males and 46.3% of the Basque females suffered from at least one chronic condition. For the 65+, these values were well above 80% in both genders and co-morbidity

0

200

400

600

800

1000

1200

1400

1600

1800

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

EN MILES DE EUROS CORRIENTES EN MILES DE EUROS CONSTANTES

777

1.675111%

57%

1.219

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was very high within this group of population. In addition, in the next two decades, 26% of Basques – resulting from the baby boom that took place in the 1960s and early 1970s - will become part of the 65+.

The last Basque Country Health Survey carried out in 2007[30] revealed that 41.5% of men and 46.3% of women stated they were suffering from at least one chronic health problem. More than 70% of individuals aged 65+ reported this type of health problem. The number of chronic illnesses reported increased with age (see Figure 5). It has also shown a steady increase since 1997 (see Figure 6).

Figure 5 - Distribution of patients according to the number of chronic illness by age

Source: Osabide in "A strategy for tackling the challenge of chronicity in the Basque Country", 2010[31]

Figure 6 - Change in the percentage of persons with chronic problems between 1997 and 2007 according to their age

Source: Osabide in "A strategy for tackling the challenge of chronicity in the Basque Country", 2010[31]

Beyond self-reported health status, an analysis of Primary Care diagnosis in 2010 pointed out that Arterial Hypertension, Hypercholesterolemia, Osteoarticular Pathology, Diabetes, Asthma and Cardiovascular Diseases were the most common health problems among the Basque population

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(see Figure 7). The degree of prevalence increased considerably from the age of 65 onwards, especially in the case of Osteoarticular Pathology, Diabetes and Cardiovascular health problems (see Figure 8).

Figure 7 - Number and prevalence of patients 18+ from selected chronic conditions as per primary care data

Source: Osabide in "A strategy for tackling the challenge of chronicity in the Basque Country", 2010[31]

Although the values of prevalence are a concern, data accuracy is questionable given that in the Spanish version of the source, the values for diabetes, asthma, COPD and CVD are higher in terms of amounts and lower in terms of percentage. In addition, most of the diseases included in the graph such as diabetes, COPD and CVD also present main co-morbidities.

Figure 8 - Prevalence of the principal pathologies by age groups (according to diagnoses in Primary Care)

Source: : Osabide in "A strategy for tackling the challenge of chronicity in the Basque Country", 2010[31]

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3.2.4 ICT for health in the Basque Country

The ICT for Health strategy in the Basque Country is defined in "A Strategy to Tackle the Challenge of Chronic Diseases in the Basque Country"[31]. This document presents the main project directly related to ICT and the integration of health technologies within the health system:

• The utilisation of web 2.0 technologies to support a network of activated and connected patients through the development of a platform for all patients associations.

• Unified Medical Record (Osabide Global) which integrates the Basque Health service experience with EHR in Primary care (Osabide-AP) and EHR in hospitals (e-Osabide). The objective is to create and deploy Osabide Global, a single solution for medical records for all levels of care throughout the whole network of centres, enabling professionals to access patient data in the Basque Country and modify it when necessary.

• OSAREAN: a Multi-Channel Service Centre. The Department of Health and Consumer Affairs of the Basque Government, through the Basque Health Service (Osakidetza), is supporting the setting up of a Multi-channel Health Service Centre (MHSC) which will enhance the ways in which citizens can interact with the health system, offering them easier interaction with the system and improved efficiency in the provision of services and allocation of resources. This centre also deals with telemonitoring.

• Developing e-pharmacy and e-prescription. This involves the integration of the procedures of pharmaceutical supply (prescription, authorisation, dispensing and invoicing) based on information technologies. It enables an evolution from the concept of the pharmacist’s prescription to the establishment of integrated pharmacotherapy, particularly relevant from the point of view of chronic illnesses due to the existence of co-morbidity, complexity and long duration of the associated pharmacological treatments.

3.2.5 Telecare services in the Basque Country

With 14,333 telecare users (or a coverage index of 3.57), Telecare services in the Basque country have a lower penetration that the Spanish average. However, it is not clear whether this is due to an unmet need. Costing €20.10 per month per user, telecare costs in the Basque country are slightly below the nation average (at €21.16).

As it will be detailed in section 0, one of the projects launched under the Strategic plan in the Basque Country aims to strengthen the collaboration between Social care and Health care services. The Directorate General of Social care services15 which is under the Department of Employment and Social Affairs organises and provides social care services through a network of public institutions dependent upon regions and municipalities to cover all population, specially the elderly16. On 28 June 2011 a regional law17 was published to frame, define and regulate the provision of telecare in the Basque Country. The aim is to further develop telecare technology and services trough the intensive use of ICT. Therefore, a shift from traditional call-centre services and alarm systems (red-button) is planned aiming to move towards third generation telecare and telehealthcare services.

Cooperation initiatives in coordination with Plan Avanza targeting the elderly or the most vulnerable do not exist in this area of Spain.

15 Social Care Services http://www.gizartelan.ejgv.euskadi.net/r45-

contss/es/contenidos/informacion/servicios_sociales/es_servsoci/servicios_sociales.html 16 In 2010 this Directorate General has published "Analysis of well being of 60+ individuals in Basque

Country"" (Estudio sobre las condiciones de vida de las personas mayors de 60 años en la Comunidad Autónoma del País Vasco) http://www.gizartelan.ejgv.euskadi.net/r45-contss/es/contenidos/informacion/publicaciones_ss/es_publica/adjuntos/74_MAYORES%20cast%20MARCADORES.pdf

17 Decreto 144/2011 de 28 de junio http://www.gizartelan.ejgv.euskadi.net/bopv2/datos/2011/06/1103380a.pdf

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3.2.6 Integrated care in the Basque Country

Within this context in June 2010, the Basque Department of Health published "A Strategy to Tackle the Challenge of Chronic Diseases in the Basque Country"[31] with the aim to "improve the health and welfare of all people who are affected by chronic illnesses, as well as to reduce both the level and the impact of chronicity". It is relevant to point out that chronic illnesses currently represent 80% of the interactions with the Basque Health System and account for more than 77% of healthcare expenditure.

This Strategy has been developed in the framework of the revision of the main health indicators of the Basque Country, the review of the evidence about the various integrated care models and with the participation of all actors involved in the healthcare system. Figure 9 below shows the main elements of the strategy highlighting the expected characteristics of the new model as opposed to the current situation for a number of parameters like accessibility or care model. It is interesting to note that the "remote" vs "face to face" is one key element in the new strategy, which should support the deployment of remote monitoring type of solutions.

Figure 9 - Towards a new model for the Basque Healthcare System

Source: "A strategy for tackling the challenge of chronicity in the Basque Country", 2010[31]

The strategy consists of 5 main policies, expected to be implemented through 14 projects over the next 3 years[32] as follows:

• Focus on stratified population health status combined with a predictive risk approach

• Health promotion and prevention of chronic illnesses

• Greater responsibility and autonomy of patients

• Continuity of care for chronic patients

• Efficient interventions adapted to patient needs (patient-centred approach)

These projects and their main objectives address the following elements:

• Stratification and targeting of the population: To establish a predictive model of stratification of the population, according to care requirements and future demand for resources (considering demographic, diagnostic, utilisation and socioeconomic data), enabling the design of specific actions for each group, with particular emphasis on multi-pathology patients.

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• Interventions aimed at the principal risk factors: To construct a common framework of health promotion and early prevention, combining the strategic lines on the principal risk factors with innovative bottom-up pilot projects, such as, for example, the "De-Plan project" which deals with primary prevention of the progression to Type 2 diabetes in high risk subjects between 45 and 70 years of age, or the "Prescribe Vida Saludable" which aims at the efficient integration of the promotion of healthy lifestyles in primary care settings.

• Self-care and patient education: Launching of the "Chronic Disease Self-Management Program of the University of Stanford" (e.g. the Active Patient Program).

• Setting up a network of activated patients, connected through web 2.0 with patient associations: Support associations of chronic patients in the adoption and use of new communication technologies (web 2.0) in order to facilitate access to information and promote interactions and mutual support among their members.

• Integrated electronic health record: To create and deploy Osabide Global, an integrated solution for health records for all levels of care throughout the whole network of centres which will enable professionals to access patient data in the Basque Country and modify it when necessary.

• Integrated care: To explore through the experiences made in the pilot projects new ways of working and organising the delivery of healthcare, integrating primary care and specialised care.

• Development of sub-acute hospitals: Definition of a model of care for chronic patients, consolidating an intermediate level of care (focused on rehabilitation) between specialised and primary care for the care of these patients.

• Advanced nursing competencies: To define and develop advanced nursing competences in Osakidetza in relation to dealing with chronic patients, in particular complex chronic patients (care management approaches).

• Healthcare - Social Services collaboration: To develop a framework of socio-health collaboration involving all stakeholders from social serviced (Regional Government, Provincial Councils, Municipalities), which enables the definition of working master guidelines in order to be able to provide an integral response to chronic patients who have simultaneous need for social and health care.

• Financing and contracting: To adapt the mechanisms of financing health providers, moving progressively from an activity-focused to a risk-adjusted capitation scheme (considering also several quality of care parameters), aimed at providing care which fulfils the objectives of the chronic illness strategy

• Multi-channel centre: To design and implement a technology and organisation platform allowing multi-channel interaction (Internet, phone, mobile phones, etc) with the health system for the whole population of the Basque Country, facilitating easy access to health system and reducing the administrative workload of health professionals.

• E-prescription. To introduce an e-prescription system creating a single electronic pharmacotherapeutic record of the patient encompassing all care levels, making the necessary information available to each of the different actors involved and integrating prescribing and dispensing activities

• Chronic illness research centre: The creation of a research centre with the purpose of generating "glocal" knowledge for innovation in organisation and management and to improve healthcare systems with a focus on chronicity.

• Innovation from the medical professions: To design the process, the tools and the leaders with the aim of facilitating and promoting emerging innovations by means of pilot

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“bottom up” projects, and to ensure its sustainability and extension throughout the Basque Country, when positive outcomes are reached.

The specific focus of these projects highlights the role of ICT in implementing the strategy, together with the need to adopt a patient-centred approach and address the reorganisation and integration of care delivery, all of which are key for IPHS deployment.

To achieve these objectives a mix of top-down and bottom-up strategies has been planned to reach equilibrium in decision making. These strategies have been set up with several monitoring and evaluation process, however as most projects were launched in 2010, no results are available yet.

3.2.7 RMT in the Basque country – Evidence Based Medicine Clinical Unit Hospital Donostia, San Sebastian

Background

Hospital Donostia is located in San Sebastian, the capital of Gipuzkoa, one of the three regions of the Basque Country. This Hospital is part of Osakidetza and covers a population of 700,000 inhabitants with 1,150 beds; 400,000 inpatients approximately; 29 operating theatres; and 33,601 surgical procedures during 2009.[33]

On September 2003 an Evidence-Based Medicine Care Unit was launched at Hospital Donostia. The origin of this new unit dates back to 1996 when a group of health professionals from Hospital Aránzazu (currently Hospital Donostia) began to explore the possibilities of evidence -based medicine within their professional practice18.

This new unit tackles health problems from an evidence-based health care perspective defined as "the conscientious use of current best evidence in making decisions about the care of individual patients or the delivery of health services. Current best evidence is up-to-date information from relevant, valid research about the effects of different forms of health care, the potential for harm from exposure to particular agents, the accuracy of diagnostic tests, and the predictive power of prognostic factors".[34]

Following this approach, the Unit started to analyse the problem of hospital readmissions and chronic patients in the Internal Medicine Department. In 2003, 332 patients were readmitted three times (amounting to 996 hospitalisations), 122 patients were readmitted four times (i.e. 488 hospitalisations) and 130 patients were readmitted five or more times (650 hospitalisations, at least). The average hospital length of stay of these patients was eleven days (making up to a total of 23,694 days) and 40% of them were suffering from Chronic Obstructive Pulmonary Disease (COPD) or Chronic Heart Failure (CHF).

Furthermore, an analysis of a random sample of 800 inpatients from Internal Medicine revealed that 1 out of 4 patients was likely to be readmitted the following year for the same health problem. This vulnerability was associated with a continuous rotation of physicians, treatment changes, repetition of medical tests and negative patients' perception of the treatment process.

Projects undertaken by the Evidence-Based Health Care Unit

Based on the above analysis of the situation, the Evidence-Based Medicine Care Unit started a project to reduce CHF inpatients readmissions and visits to emergency (May 2006 – June 2007)[35]. The project was designed as a multifaceted intervention. On the one hand, the intervention consisted of a personalised Disease Management Programme for Chronic Heart Failure, using an application which was developed in collaboration with the Health Informatics Unit of San Sebastian Hospital. This application included an alert system to manage the provision of drugs and to identify possible drugs' adverse events during patients' hospitalisation as well as clinical parameters to monitor patients.

18 See the complete history of the group at https://10.ikere.net/mod/wiki/view.php?id=1170

36

On the other hand, a health promotion and prevention intervention based on physical exercises, diet and healthy lifestyle was launched. This program was managed by a nurse following a case management approach. In addition to this nurse, each patient had a referral doctor during his/her hospital stay.

Finally, a telephone line was open (8h – 15h) and planned follow-ups took place (on days 3 and 6, and every 15 days thereafter) between nurses, physicians and patients, once the latter were discharged from hospital. All these actions were developed in coordination with Primary Care.

Patients admitted to the Unit with Heart Failure between May 2006 – June 2007 were asked to participate in this programme following the eligibility criteria shown in Table 4 below. Finally, 40 patients were included in the intervention. It is worth pointing out that the Internal Medicine Department, where the Unit belongs, had registered 3,500 discharges with 320 hospital readmission (9.13%) during 2003 out of which 40% were related to Heart Failure or COPD.

Table 4 - Inclusion and exclusion criteria

Inclusion criteria

Exclusion criteria

1) Heart failure stage III - IV New York Heart Association (NYHA)

1) Severe dementia;

2) More than two co morbidities related with Heart Failure 2) Physical disability for aerobic activities

3) Heart failure stage IV New York Heart Association (NYHA) without improvements

Source: Artetxe et. al (2009)[35]

Patients involved in the intervention were treated as follow. Firstly, vital signs related with blood pressure, cardiac frequency, respiratory frequency and level of consciousness were gathered by a nurse trough a PDA and automatically sent via WIFI to the chronic management application within the clinical station. These vital signs were automatically processed to establish the risk score of the patient and set up an alarm system. All this information was also linked to the drug module of the applications. Secondly, when patients went from stage III-IV to stage II, a health promotion and prevention programme supervised by a nurse was launched. Finally, once the patients were discharged from the hospital all the planned telephone follow-ups were launched.

The impact of this multi-intervention programme was measured comparing the length of stay for inpatients readmissions in the hospital (0.3 days per month) and number of visits to emergency (0.1 visits per month) for this period with the same indicators from the previous year. Due to the absence of longitudinal data from all patients involved in the intervention, the average length of stay for inpatient readmissions (1.4 days per month) and the average number of visits to emergency (0.5 visits per month) were calculated for the year before the intervention.

As a result of this multiple-intervention a reduction of 1.1 days per stay for inpatients hospital readmissions was noted and 0.4 visits to emergency were avoided, thus representing a reduction of 80% of readmissions and visits to emergency.

Beyond these results as a practical implication, the Unit pointed out the importance of Primary Care, Home Care and Social Care intervention to tackle patients' care on the final period of their life when they are more fragile so the burden which otherwise would increase the pressure in the health system. Furthermore, they also noticed that most of the acute episodes occurred outside the unit and telephone support accessible hours (8h – 15h).

Following the results from this project, between February 2008 and December 2009, the Unit carried out a randomised controlled open clinical trial entitled "Evaluation of a strategy to diminish admissions in patients with heart failure"[36]. This intervention was designed to prove that "patients with heart failure may benefit from home telemonitoring of their condition plus

37

multifaceted personalised intervention compared with multifaceted personalised intervention alone". Table 5 shows the inclusion and exclusion criteria of the RCT:

Table 5 - RCT Inclusion and exclusion criteria

Inclusion criteria

Exclusion criteria

1) Patients of any gender, older than 65 ; 1) Moderate or severe dementia; 2) Heart failure stage III - IV New York Heart Association (NYHA) 2) Physical disability for aerobic activities

3) At least two admissions during the previous year 3) Refusal to participate Source: Emparanza J. Evaluation of a strategy to diminish admissions in patients with heart failure. In: Current Controlled Trials 2009. Available from: http://www.controlled-trials.com/ISRCTN62033748 Identifier: ISRCTN62033748.[36]

Building on the reported previous experience, the control group was supported with additional access to a telephone line and email address service (24 hours a day). In addition, an automated programme for opportunity/appropriateness of drug treatment with a personalised and monitored physical activity (fitness) program, a follow-up telephone call on day 3 and 6, and every 15 days thereafter by an appointed nurse, and the aforementioned telephone line and email address available 24 hours a day were designed for this control group.

The intervention group consisted of the same elements detailed above, plus the measurement at home twice a day of transdermal oxygen saturation, temperature, weight, blood pressure, cardiac and respiratory frequency, and in some cases, electrocardiogram (ECG). Patients sent these measurements via GSM to the hospital team.

Primary outcome measures were the number of admissions and number of emergency visits while secondary outcome measures were quality of life (a 36-item short form health survey – SF36) at the beginning and at the end of the study (20/02/2008 --31/12/2009) as well as perceived quality of medical attention, measured using the Spanish SERVQHOS questionnaire19, at the beginning and at the end of the study. The RCT was planned for 70 patients but during the whole period of the project only 38 patients were recruited (18 for the control group and 19 for the intervention group).

The results of the study showed a significant difference between both groups in terms of length of hospital stay (227 days for the control group vs. 83 days for intervention group) but no significant differences were found in terms of visits to emergency (36 days for the control group vs. days for the 22 intervention group) and admissions to the hospital (34 for the control group vs. 14 for the intervention group).

In parallel with this RCT, the Unit also launched a study to develop a clinical predictive model of severe acute episodes that caused mortality or transfer to Intensive Care Unit in the 24 hours following measurement. This predictive model was based on inpatients' vital signs gathered by a nurse trough a PDA every morning before the physicians visited the patients, and sent immediately to a centralized system via WIFI. Furthermore, in 2009 the Unit received funding from the Spanish Ministry of Health to carry out a clinical predictive model of readmissions.

Finally, in January 2010 the Unit launched a project related with telemonitoring of chronic patients care in geriatric centres to tackle dependent patients living in this type of centres. The aim of this project was to asses the efficacy of multidisciplinary and multifaceted personalised intervention, which includes tele-monitoring, to decrease patients' hospital admissions and to assess the appropriateness and acceptability of a common planning of care among all the stakeholders involved. Furthermore, this project assesses carers' and families' satisfaction with the multidisciplinary intervention as well as the efficacy of the intervention. The study has been designed as a centre-focused randomised controlled trial with 6 centres as control group and 6 centres as intervention group with 1,338 patients in total (573 in the intervention group and 765 in

19 This questionnaire addresses patients' perception of Hospital quality of care.

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the control group). All clinical data and questionnaires are being gathered with a PDA linked with a centralised dataset. In case of alarm, a SMS is sent automatically to the doctor in charge of the patient at the hospital who will react and decide in consensus with the Geriatric centre and the home care visiting unit (Primary care team) assigned to the Geriatric centre.

Service organisation

After all these experiences the Unit concluded that chronic health problems go through different stages (pre-frail patients, frail patients and terminal care), under different conditions (dependent patient and non-dependent patients) with each stage and condition requiring a different intervention approach.

In the case of admissions or pre-fragile patients, the intervention was implemented as follows: (1) access to a telephone line and email address (24 hours a day); (2) telephone consultation with a questionnaire adapted to each patient's health problem and stage; (3) coordination with Primary care with clear objectives; (4) each patient has an assigned unique doctor at the hospital; (5) patient monitoring system and (6) personalised health education programmes.

In the case of readmissions of non-dependent patients, the interventions consisted of: (1) patient identification and monitoring system; (2) personalised information; (3) unique doctor assigned; (4) nursing case managerial approach and (5) coordination with Primary Care with clear objectives.

In the case of dependent patients the Unit distinguishes between those staying at home and those living geriatric centres. The first group was tackled through home telemonitoring (see project on Evaluation of a strategy to decrease admissions of patients with heart failure mentioned earlier) and the second group is tackled by "Re acute chronic patients care in geriatric centres".

All the interventions are based on the interaction of clinical expertise, disease management, organisational change, medical informatics and ICT under the Evidence-Based Health Care approach. Therefore, these interventions required a high level of coordination and participation between health professionals, especially doctors and nurses. This coordination is facilitated by a clear referral system of nurses and doctors and a decision making process based on personalised patient information supported by disease management application and telemonitoring.

Technology

The Evidence-Based Medicine Care Unit has worked in close collaboration with the Health Informatics Unit of San Sebastian Hospital to develop a disease management application to store, retrieve and analyse vital sign data, clinical parameters and other information related to health questionnaires. This application included an alarm system and a drug treatment module with an adverse event and patient safety notification. Telephone follow-ups are also included in the application. The information is gathered by a nurse trough a PDA and sent to the system via WIFI. The reason for this collaboration was twofold. On the one hand, both units wanted to extend the capabilities of the existing IT system to avoid its obsolescence. On the other hand, this collaboration guaranteed the integration of the new functions within the system.

The equipment of home care and geriatric care telemonitoring consists of a touch screen PDA which runs a Microsoft’s Windows Mobile operating system, with wireless Bluetooth sensors to measure blood pressure, heart-rate and oxygen saturation, and manual input of body temperature, respiratory-rate, weight, questionnaires on the medical condition, any perceived changes and a record of compliance with medication and diet. Data are transferred via GPRS to a Web-based platform (Web data manager). The centralised Web management system allows different levels of access depending on the specific roles of the participating professionals (project leaders, GPs/nurses, hospital). The equipment and application have been provided by Saludnova, an SME from the Basque Country specialised in providing eHealth technology solutions. This company is well established in the Basque Country and wanted to collaborate with the Unit as part of its R&D activities without charging any costs in its first initiative.

39

Funding/costs

The Unit received initial funding to carry out its interventions from the hospital and the Basque Health Service (€18,890). It is worth pointing out that the disease management application was developed in-house while the RMT equipment and application were provided by Saludnova. None of the above mentioned initiatives received funding for human resources because the technological changes were always aligned with organizational aspects of the services provision so that no additional staff was needed.

A cost-effectiveness analysis of this intervention has been carried out by the Unit and the Health Technology Assessment Agency of the Basque Country[37] using direct cost of hospitalisation (including DRG), human resources and ICT costs. The quality-adjusted life year (QALY) was calculated using Health survey (SF-36) and Spanish SERVQHOS questionnaire. The results revealed that the intervention group led to cost savings, due to the reduced length of hospital stay but there were not statistical significance between the two groups regarding emergency visits and hospitals readmissions. The intervention was considered as cost-effective just in 37% of the cases. However, one should also bear in mind the fact that the control group was built on a previous experience which already showed 80% reduction of readmissions and visits to emergency, which may explain such incremental improvements.

3.2.8 Telemonitoring patients with chronic disease in Bilbao Primary Care Health Region: The TELBIL project

Background

The Bilbao Primary Care Health Region is one of the seven Health Regions within the Basque Country. This region covers a population of 390,000 inhabitants, out of which around 27% are over 60 years old. Primary care consists of 218 GPs, 269 nurses and 44 paediatricians located in 23 centres. This region also has two public referral centres: the Basurto Hospital and the Santa Maria Hospital. Within this context, a Primary care-based telemonitoring initiative for home care patients with heart failure and chronic lung disease was launched in 2011[38]. This initiative was launched by a GP who was aware of the Evidence-Based Medicine Care Unit initiatives and wanted to explore these initiatives from a Primary care perspective. The main objective of the study was "to evaluate the impact of a primary care-based telemonitoring intervention on the use of health care resources, specifically on the frequency of hospital admissions"[39]. Furthermore, this study aimed to: (1) analyse the impact of the intervention on mortality, length of hospital stay, use of emergency services, visits to primary care physicians and to specialists, home visits, and telephone calls; (2) evaluate the telemonitoring procedure in economic terms compared to usual care through a cost-effectiveness analysis and (3) assess the degree of satisfaction of the patients/caregivers and health care professionals with the telemonitoring intervention.

Study design

The TELBIL project addresses the evaluation of a primary care-based telemonitoring intervention for home care patients with heart failure and chronic lung disease. This study was designed as a randomised controlled open clinical trial to reach a number of objectives (see below) and test whether "home care patients with heart failure and chronic pulmonary disease may benefit from a primary care-based telemonitoring intervention which could result in a reduction of hospital admissions, duration of the hospitalisations and mortality", as well as whether "home telemonitoring may improve the quality of life of these patients in a way that is cost-effective and acceptable to patients and health care professionals". The total duration of intervention and follow-up for both intervention and control group is 12 months. The following figure summarises the general design of the study with 30 patients in the Control Group (CG) receiving usual care and 30 patients in the Intervention Group (IG) using telemonitoring in addition to usual care:

40

Figure 10 - General design of the randomised controlled trial

Source: Martín-Lesende et al. (2011)[39].

The telemonitoring system used was previously tested in the "Evaluation of a strategy to diminish admissions in patients with heart failure" study carried out by the Evidence-Based Health Care Unit, San Sebastian Hospital as described earlier.

Patients included in the TELBIL study were recruited from the Bilbao Primary Health Care Region. The following table summarises the inclusion and exclusion criteria.

Table 6 - Inclusion and exclusion criteria

Inclusion criteria Exclusion criteria

1) Home care patients over 70 years, male or female; 1) Residents in nursing homes

2) Heart failure and/or chronic pulmonary disease 2) Paediatric patients (younger than 14 years of age)

3) At least two hospital admissions during the previous year (with at least one of the admissions due to the above mentioned diseases)

3) Refusal to participate

4) Frequent users of specialist healthcare services (i.e. rehabilitation, haemodialysis, frequent visitors to hospital day-care centres, etc.)

5) Terminal illness with less than 6 month life expectancy

6) Cognitive impairment Source: Martín I. Primary care-based telemonitoring for home care patients with heart failure and chronic lung disease. . In: Current Controlled Trials 2010. Available from http://www.controlled-trials.com/ISRCTN89041993 Identifier: ISRCTN89041993, 2010.[38]

41

Preliminary results

The telemonitoring system gathers the following self-measured clinical parameters: respiratory-rate, heart-rate, blood pressure, blood oxygen saturation using pulse oxymetry, weight and body temperature. In addition to these patients complete a brief questionnaire using PDA to asses their perception of their medical and functional conditions.

The primary outcome measure analysed in the study is hospital admissions due to any cause, related to the use of health care resources. Moreover, as secondary outcomes measures, the study analysed variables related to duration of hospital stay, hospital admissions due to HF or chronic lung disease (CLD), mortality rate, use of health care resources, quality of life, cost-effectiveness, compliance and patient and health care professional satisfaction with the new technology.

The preliminary results of the 3 months and 6 months follow up were presented at the International Congress on Telehealth and Telecare organised by The King's Fund Conference, 2-3 March 2011 (see Box 4 and Box 5). The study revealed that hospital admissions decreased more than expected in both groups; no differences were identified in the number of hospitalisations, although the hospital stays tend to be shorter in the Intervention Group; there was a significant increase in telephone calls but home and health centres visits were reduced; only three people dropped out of the study due to technology difficulties.

Box 4 - Results at 3 months. TELBIL Project

Source: Martín-Lesende (2011). The King's Fund Conference, 2-3 March 2011.[40]

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Box 5 - Results at 6 months. TELBIL Project

Source: Martín-Lesende (2011). The King's Fund Conference, 2-3 March 2011.[40]

Service organisation

The TELBIL project was launched from Primary Care. Health professionals (nursing staff) checked patient data daily and contacted the patient by phone every two weeks. Other telephone contacts were carried out when the data received at the primary health care centre were out of the established limits. The telemonitoring system comprised personalised alerts set for each patient, with messages being sent when recorded parameters fall outside established limits (which may be adjusted over time).

The degree of satisfaction of the patients/caregivers and health care professionals with the telemonitoring intervention was assessed through qualitative focus groups with health professionals involved in the project. The main advantages identified by health professionals were: (1) avoidance of hospital admissions and increase in patients' quality of life; (2) facilitating the clinical decision process; (3) increasing patients' and caregivers' satisfaction and safety; (4) patients' participation in their care (i.e. self-care) and (5) new communication channels between primary and secondary care. On the other hand, health professionals involved in the study identified the following disadvantages: (1) unfairness related with the different resources applied to the Intervention Group and the Control Group; (2) doubts about the causal relationship between telemonitoring and its impact on hospital admission; (3) generating patients' dependency and additional patients' demand; (4) elderly patients having difficulties with the telemonitoring system; (5) information overload due to daily monitor of the system and (6) difficulties to coordinate primary and secondary care.

The qualitative study also tackled the usability and perception of use of the telemonitoring systems. Most of the professionals involved in the utilisation of this system stated that it was easy to use and understand the whole system and emphasized that it supported the clinical decision process.

43

Health professionals were also asked about the relationship of this intervention with their work practice. It is relevant to point out that most of the professionals stated that at the beginning of the intervention they had a work overload, but this overload had positive effects on their patients, although these positive effects did not compensate their work overload. Therefore, even though health professionals would like to introduce telemonitoring into their routine practice, they have identified lack of time as a main reason to avoid the adoption of this system within their daily clinical practice.

Finally, health professionals involved in the study have identified the following suggestions to improve the intervention: (1) patient education programmes related to drug and symptoms would facilitate patients' self-care; (2) patients eligibility criteria and clinical parameters have to be reviewed following the lessons learned during the study; (3) work routines have to be redesigned and integrated with usual care; and (5) communication between primary and secondary care have to be reinforced.

Technology

The equipment used as reported by authors of the study consists of "a touch screen PDA which runs the Microsoft’s Windows Mobile operating system, with wireless Bluetooth sensors to measure blood pressure, heart-rate and oxygen saturation, and manual input of body temperature, respiratory-rate, weight, questionnaires on the medical condition, any perceived changes and a record of compliance with medication and diet. Data will be transferred via GPRS to the Web-based platform (Web data manager). The centralised Web management system allows different levels of access depending on the specific roles of the participating professionals (project leaders, GPs/nurses, hospital)". Prior to the intervention, all GPs and nurses in charge of the care of the participants attended a four-hour workshop on management of HF and COPD. Additional training on telemonitoring was provided to health professionals involved in the IG. Same as in the San Sebastian project presented earlier, the technology was provided by Saludnova. This provider was chosen by the basque Department of Health based on a benchmarking exercise carried out by themselves and also based on the previous experience with San Sebastian Hospital.

Funding/costs

The intervention was funded by the Basque Health Service. A cost-effectiveness analysis will be carried out at the end of the project but as the study was only launched in 2011 no results were available at the time of writing.

The cost of the Project was €2,000 per patient. This budget included institution's membership access cost (€1,500), purchase of devices (€782), users' membership cost (€80 per user), health professionals' membership (€20 per professional) and software license/utilisation (€260 per institution and €65 per device).20

3.2.9 Conclusions of integrated care and ICT for health in the Basque Country

After having analysed two examples of chronic disease patients' telemonitoring initiatives and the strategy to tackle chronic health problems in the Basque Country launched by the Basque Department of Health, it is possible to draw some conclusions on the current scenarios of IPHS following our three axes: Innovation, Governance and Impact.

Innovation

Both initiatives reported are grounded in clinical expertise. This expertise and the systematic review of scientific literature supported the relevance of the innovation to tackle chronic patients. Prior to both interventions, an analysis of the situation of chronic patients within their services was carried out to justify the relative advantage of using ICT and telemonitoring instead of traditional care. The innovation component of the ICT solution was limited and the interventions were designed to avoid complexity and risk, and to achieve triability and observability of the initiatives. However the 20 These costs were reduced by Saludnova for 2011.

44

compatibility of the new IT systems with the electronic health record currently deployed within their institutions is still a challenge.

Beyond the innovation itself, both initiatives were launched by multidisciplinary teams with a strong leadership. The diffusion of innovation among the different health professionals and actors involved were achieved through formal and informal communication channels. Furthermore, the dissemination of awareness and education of all actors (health professionals, patients, IT staff and managers) facilitated the dissemination of the innovation.

It is worth pointing out that these initiatives were set up with an emphasis on Evidence Based Medicine by a multidisciplinary team led by a specialist (Hospital San Sebastian) and a general practitioner (Primary Care), both with experience in research and management and well considered within their fellows and in the institution. The characteristics of the "innovators" facilitated the implementation of the innovation process. Furthermore, both initiatives were supported by the Department of Health, which helped them involve all stakeholders not just within their institutions but also across organisations, especially in the case where all primary care centres were involved or for the coordination between the Hospital and the geriatric institution.

Finally, from a users perspective the main barriers were identified among professionals not among patients, who were keen on using this kind of technology (the number of drop-outs from both initiatives were low). Health professionals had to align ICT use with an organisational change and in some cases at the beginning they were overloaded with work (learning curve cost). The perfect integration and coordination between primary care units, Hospital and geriatric residence is still a challenge.

Governance

The current Strategy to Tackle the Challenge of Chronic Diseases in the Basque Country has been established as a middle-out approach for all health actors. Before this strategy was launched both initiatives were running with the support of the Basque Department of Health. It is worth pointing out that these initiatives were launched from Secondary and Primary care, both trying to achieve integrated care and the coordination between different levels, including geriatric residence in the case of San Sebastian Hospital.

The Basque Department of Health has been following up these initiatives as an example to push telemonitoring and IT systems, trying to develop a new integrated care paradigm. Nevertheless, integration between different levels of care and social care remains as a challenge for all the actors.

Impact

Impact evaluation is one of the strengths of both initiatives. Strong emphasis on monitoring and evaluation was established from the beginning in both experiments. Both initiatives perfectly understood the importance of impact as an outcome of the intervention as well as a learning process for health professionals to support their practice. Therefore both initiatives were designed as RCT to provide robust and comparable evidence as well as inputs for cost-effectiveness analysis, carried out in collaboration with the Basque Country Health Technology Assessment.

This impact evaluation exercise and its results will facilitate the deployment of this type of initiatives within the Strategy established by the Department of Health. It is important to emphasize the collaboration among all the stakeholders involved in the initiatives: health professionals, Department of Health and HTA.

3.3 Catalonia

3.3.1 Population and health status

Facing the Mediterranean Sea in the North-East of Spain and with 7,512,381 inhabitants in 2010, Catalonia represents the second most populated region in Spain representing almost 16% of all

45

national population. The population density of Catalonia in 2010 was 228.7 inhabitants per km2. This value is well above the average of EU27 in 2009 and along the same lines as Germany (see Table 8, Annex I).

Life expectancy at birth has increased in Catalonia from 79.1 in year 2000 to 81.6 in year 2007 (see Table 10 and Table 11). Although both values are above the Spanish average, this difference is higher for 2007. In 2007, life expectancy at birth was 78.4 years for males and 84.5 years for females [21]. When comparing life expectancy per gender to the EU27 in 2008, the corresponding 2007 values for Catalonia are well above the EU average (see table Table 12 in annex I).

Currently, around 17% of the population is over 65. This percentage has been altered in recent years by the arrival of a younger migrant population. Nevertheless, ageing continues to represent a relevant challenge for the health and social services, because of both increasing numbers of elderly and their dependency[41]. Indeed, whilst the average dependency ration in Spain has decreased from 53.33 in 1991 to 48.17 in 2009, the corresponding values for Catalonia were disappointing in comparison, with 50.64 in 1991 and 49.01 for 2009 (see table Table 14 in Annex I).

3.3.2 Regional health and social care organisation

Catalonia as a Regional Government is in charge of Health Planning, Financing and Regulation through its Department of Health while the responsibility for resource management and health services planning is held by the Catalonian Health Services (CatSalut), a single public insurer. Catalonia is divided into seven health regions based on geographic, socio-economic and demographic factors. Each region is organised into health sectors made up of a number of health areas.

Healthcare services are provided by a mixed health care system, where the main emphasis lies not in the nature of the ownership of facilities, but rather on public financing to meet the population's needs. In Catalonia 70% of acute hospital beds belong to contracted providers ; 20% to the Catalan Institute of Health (Institut Catalá de la Salut) and 10% to private centres. In contrast, for Primary Care, 80% of the Catalan population is covered by the Catalan Institute of Health (Institut Catalá de la Salut). This organisation manages 8 reference hospitals within the network of public use hospitals (32% of public hospital beds), 285 primary care units (including three established under strategic alliances), 38 out-of-hospital specialist centres, 24 territorial continuous care and emergency primary care (ACUT) units, which provide their services through 159 facilities, 35 sexual and reproductive healthcare services, 13 clinical laboratory services, 5 of which form part of territorial units coordinated by the local reference hospital, 31 diagnostic imaging services, 19 rehabilitation services, 14 PADES home care units, 8 mental health services, including 2 devoted to providing care for children and young people and 2 to drug dependency care and monitoring, and 3 occupational healthcare services. With a total budget of €3,069 million and total staff of over 41,000 professionals, the Catalan Health Institute (ICS) is the largest public healthcare provider in Catalonia. The ICS serves 5,774,142 users, i.e. 75.5% of all those insured in Catalonia.

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Box 6 - General diagram of the Catalan Healthcare System

Source: Guanyabens (2011). ECAB 2nd Partners' Meeting, 17th January 2011[42]

There are 362 Primary Care Centres and 65 Hospitals in Catalonia. The number of hospital beds per 1,000 inhabitants is 4.2, the ratio of registered physicians 5.02, that of registered nurses 6.34, of physicians practising specialists 2.13 and GPs 0.72. The health care expenditure per inhabitant rose from €860 in 2003 to €1,255 in 2009.

The total expenditure of the Catalonia Health System in 2007 amounted to 4.9% of GDP in 2003 and reached 5.3% of GDP in 2007. The public healthcare expenditure per inhabitant in Catalonia has risen from €1,119 per person in 2006 to €1,255 in 2009 (see Figure 11)

Figure 11- Health care expenditure per inhabitant (2003-2009)

Source: Health care budget 2003-2009. Catalonia Health Department[43]

Insurance Services

U

S

E

R

CATALAN HEALTHCARE

SERVICE

Suplementary

Private Insurers

CATALAN INSTITUTE OF

HEALTH

Private Centers

Contracted Providers

20%100%

20%

70%

10%

DEPARTMENT OF HEALTH: Draws up Health Plan and Transfers economic resources Plans

Governance

Fragmented Information System (IS) for most healthcare suppliers due to the healthcare system diversification ( 65 providers with different IS )

Multiple sources of information

ICT become an strategic component of the Catalan

Healthcare System

Key ICT projects in Catalonia

47

3.3.3 Chronic diseases and ageing

In 2006, self-reported quality of life using the EQ-5D measurement 21tool unveiled an average score of 0.95 and 0.92 in the 15 to 44 age group, for men and women respectively; 0.88 and 0.80, in the 45 to 64 age group; 0.83 and 0.66 in the 65 to 74 group; and 0.70 and 0.49 in the 75 + group.

In contrast, 77.4% of the population aged 15 and over declared they suffer one or more chronic disorders. The declaration of chronic disorders increases as the groups get older and is more frequent among women (83.0%) than among men (71.6%). The chronic disorders most frequently declared by the population aged 15 and over are bone and joint disorders (lumbar and cervical back pain, rheumatoid arthritis or rheumatism) and disorders of the circulation system (poor blood circulation, high blood pressure or varicose veins).

The last Catalonia Health Survey carried out in 2006[44] revealed that 68.8% of male and 78% of women stated that they were suffering from at least one chronic health problem. More than 97% of individuals over 65 year reported this type of health problem, while this percentage was 90.8% in 1994 (see Figure 12 and Figure 13)

The number of health problems reported by age shows that the burden of chronic illness increases with age (see Figure 12 and Figure 13). On the one hand, 67% of males and 87% of females older than 74 years stated that they suffer from four or more chronic health problems; 57% of males and 77% of females suffer from three chronic health problems. Furthermore, 10% of males and 24% females between 15-44 years declared four or more health problems. On the other hand, only 3% of males and 1% of females older than 74 reported having no chronic health problems and 41% of male and 28% of females between 15-44 reported not suffering from any of these health problems.

Figure 12 - Number of chronic health problems reported for males per age structure (2006)

Male

0

10

20

30

40

50

60

70

80

90

100

0-14 years 15-44 years 45-64 years 65-74 years 75 or more years

None 1 2 3 4 or more

Source: Catalonia Health Survey 2006[44]

21 EQ-5 is a standardised instrument for use as a measure of health outcome. Applicable to a wide range of

health conditions and treatments, it provides a simple descriptive profile and a single index value for health status. The EQ-5D values range from 0 (as the worst imaginary health state, often defined as "death") to 1 (often defined as "full health").

48

Figure 13 - Number of chronic health problems reported for females per age structure (2006)

Female

0

10

20

30

40

50

60

70

80

90

100

0-14 years 15-44 years 45-64 years 65-74 years 75 or more years

None 1 2 3 4 or more

Source: Catalonia Health Survey 2006[44]

The main causes of death for the overall population in Catalonia are tumours, circulatory system diseases, and respiratory system diseases. Their respective ranking varies per gender and age group and for those aged 65+ these remain the first three causes of deaths.

The number of cases of cancer in both men and women has been rising by nearly 1.5% per year. Over half of the cases diagnosed are in people aged over 65.

A reduction in deaths from diseases of coronary diseases has been observed in recent years (from 64.2 per 100,000 population in year 2000, to 59 per 100,000 population in year 2010) and a positive trend in monitoring levels for cardiovascular risk factors such as hypertension and high cholesterol levels has also taken place. In spite of this, coronary diseases are still among the main causes of sickness and death involving high social and healthcare costs.

The mortality rates due to COPD in the population aged 40+ show a 14.6% reduction during the period 2000-2004 and this trend reduction has remained steady in most recent years. Mortality rates in diabetic patients have also decreased in general, however, mortality caused by ischemic heart disease in patients with diabetes under the age of 75 rose between 2000 and 2005. In addition, the number of diabetic cases has been growing in recent years. For instance, between 1994 and 2006 the number of declared cases rose from 4.7% to 5.9% of those aged 15 and over.

3.3.4 ICT for health in Catalonia

The Department of Health launched a strategic plan focussing on ICT for Health (SITIC Strategic Plan 2008-2011) containing 6 strategic pillars:

1) Setting ICT as a strategic pillar within health system. This pillar aims to identify all ICT investment in collaboration with all health stakeholders and to plan investments for the strategic projects as well as new funding formulas to achieve the modernization of the ICT sector for health.

2) Facilitate and guide citizens' access to health information and health care services to support self-care. This pillar aims to develop a web services infrastructure for citizens to access health information, personal health data and virtual communities for health.

3) Develop ICT tools and applications for health professionals to support health care quality services. This pillar aims to develop the following: electronic identification system for all health professionals, shared electronic health record among all health centres, radiology digital imaging system across all health centres, electronic prescription system,

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telemedicine and telecare plan as well as virtual communities and teleconference system for health professionals.

4) Efficiency support to ICT information, management and security needs of the Catalonia health system. This pillar aims to develop IT systems and processes to support policy making and health planning, including security and regulation issues.

5) Provide adequately technological infrastructures and guarantee the interoperability among health actors. This pillars aims to develop a communication network with technological and interoperability standards to connect all health care centres.

6) Promote Catalonia as ICT for health innovative region.

Within this strategy the Catalonia Department of Health has carried out 5 main projects:

1) Shared Medical Record System. This system aggregates all the documents containing data, information and clinical assessments on the state and progress of a patient’s health throughout their clinical history. The Shared Medical Record System is based on a decentralised management model, connected via interoperable systems using common standards. It allows doctors to access all the relevant information available on their patients, irrespective of the healthcare service or geographical location involved, helping to ensure continuity of healthcare, to integrate information and avoid mistakes as well as the unnecessary repetition of examinations and/or procedures. Currently, there are 419 centres connected sharing 15,474,233 records relating to 7,217,789 people.

2) Personal Health Record Folder. The Personal Health Folder is a digital dossier which members of the public can consult, giving them secure, confidential access to their personal health information. The project is currently still being designed and implemented. In the first stage, members of the public will have access to the main details contained in the HC3: medication prescribed and vaccinations given, medical reports and test results, and complementary examinations carried out. The second stage will give the public personalised access to other information about their health and to all the e-services and administrative procedures that can be provided on-line: requesting a doctor's appointment, changing the details on their Health Card, following the progress of complaints and requests for health certificates.

3) Digitalise Medical Images. The aim of the Catalan Plan to Digitalise Medical Images is to digitalise x-ray images and to establish a basis for the digitalisation of other types of medical images. Through this Plan, the Catalan Ministry of Health has partially financed 12 digitalisation projects covering 24 hospitals and 39 primary healthcare centres, where 4 million examinations are annually performed, 50% of the total carried out in Catalonia. The roll-out of this infrastructure means that two-thirds of the over 7 million x-rays taken in Catalan healthcare centres each year are now available in digital form, while the objective of 100% was expected to be reached in 2010. The development of a Central Medical Images Repository, with an annual capacity of 150 terabytes, is in the final stages of completion. It will store the images generated in public healthcare centres, and will enable images to be distributed via the HC3 system.

4) Telemedicine and Telecare plan. The purpose is to accelerate the implementation of advanced technological applications that use telecommunications to optimise the quality and efficiency of the Catalan health services and to ensure equity of access to them. The plan prioritises real-time communication between healthcare centre professionals and the patient, promotes telemonitoring for patients with chronic diabetes, respiratory and cardiac disorders and facilitates communication between professionals in different parts of the

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service on the production of diagnostic reports. Within this plan, an application to map all innovative ICT for Health projects has been developed using Google maps22.

5) Electronic prescription system. Electronic prescription has now been implemented across the entire primary healthcare centre network in Catalonia. The number of patients using the system has passed 1.4 million with more than 32 million of dispensed prescriptions (May 2010). This system facilitates coordination among health professionals, physicians and pharmacists and provides a patient's medication plan, which improves the safety of drugs utilization and the accessibility of patients to pharmaceutical services.

The recently reformed Catalan Agency for Health Information, Assessment and Quality (CAHIAQ) has now the mission of generating relevant knowledge to contribute to the improvement of the quality, safety and sustainability of the Catalan Health Care System and thus easing the decision-making process for citizens and health care managers and professionals.

According to its extended mandate, the CAHIAQ will continue to perform its traditional responsibilities in health technology assessment (HTA) and the health care evaluation services area, as well as managing calls for research.

In addition to this, new responsibilities will be taken in quality assessment and, especially, assuming the strategic projects in Information and Communications Technologies (ICTs) led by the Catalan Health Ministry, such as the Shared Medical Record of Catalonia, the Personal Health Folder, Electronic Prescription, Telemedicine, and the Plan for Digital Medical Imaging.

In the light of this and other experiences, CAHIAQ spectrum of action has been broadened. It is expected that their new mandate involving the assessment of ICT in health will assist in diffusing these innovations. It is also relevant to point that the Head of ICT for health within the Catalan Health Ministry is also the CEO of CAHIAQ. This organisation is meant to strengthen the coordination between ICT for health and HTA evaluation.

3.3.5 ICT in Catalonia in cooperation with Plan Avanza

When it comes to ICT initiatives in Catalonia in cooperation with plan Avanza, a few initiatives have been identified many of which aim at promoting the use of ICT in society and developing the ICT infrastructure.

In particular, three initiatives targeting the elderly have been identified. Relevant for SIMPHS2 purposes is the SeniorLab 2.0 project exploring the feasibility of technological and social solutions aiming to increase the autonomy of those aged 55 + and/or with disabilities promoting their life within the community, their health and lifestyles, self-employment and new activities. Also of interest is another initiative targeting Alzheimer patients and their carers promoting the use of ICTs to organise events and obtain social and coordinated financial support for these patients and their relatives.

Five initiatives targeting the disabled population have also been launched under this framework. Amongst them, the "health networks" project aims at developing a Web 2.0 social network for a variety of health conditions where experiences, rehabilitation and self-caring programmes are exchanged and promoted.

3.3.6 Telecare in Catalonia

The telecare coverage index in Catalonia is 4.96 slightly above the national average. Costs of telecare services are quantified at €26.72 and represents the priciest nationwide. Of those aged 65+ who numbered nearly 1.2 million in 2006, it is estimated that 9.2%, approximately 105,000 individuals, are seriously dependent (including serious dependence and severe dependence)[45], however telecare users amounted to 59,339 which at first sight may reflect an unmet need.

22 Mapping ICT for Health in Catalonia http://www.gencat.cat/salut/ticsalut/html/ca/dir1771/doc16731.html

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3.3.7 Integrated care in Catalonia

The Catalan Department of Health launched a Prevention and Chronic patients care programme in July 2011, which is due to start in November 2011. The aims of this program are to: (1) increase the quality of life of chronic patients and their families; (2) educate and promote patient self-care; (3) integrate social and health care services and adapt them to patients needs; (4) improve the efficiency of health systems; (5) tackle the different stages and conditions of chronic patients; (6) improve health professionals chronic disease management skills; (7) achieve better health outcomes; (8) improve the continuum of care through the different services; (8) decrease or delay patients institutional dependency and (9) avoid unnecessary hospitalizations.

To reach these objectives and facilitate the transition from an acute health care model to an integrated patient care model the programme has adopted the following strategies: (1) use of a stratification of health population approach; (2) promoting healthy behaviours and establishing health prevention programmes to tackle risks' factors; (3) encouraging patient autonomy and self-care through patient education and carers' training; (4) adapting health and social care services through integrated care services and health professionals' training; (5) adapting financial and purchasing models and (6) establishing new assessment models.

These strategies aim to facilitate an active and autonomous role of the patients during the evolution of their chronic health problems, adapting health and social care services to patients' need. Thus, the new integrated patient care model guarantees the continuum of care through the coordination and reorganization of primary and secondary care and social care. Furthermore, this model emphasises the importance of health promotion and prevention as well as the role of the community. It is worth pointing out the importance given to the assessment of health outcomes and quality of care services jointly.

3.3.8 RMT in Catalonia – Hospital Clinic COPD Trials

Background: the 1999-2000 COPD Trial

Hospital Clínic is a tertiary university hospital located in Barcelona. It is a public institution with a sound reputation for excellence in care provision, training and research at regional, national and international level. Hospital Clínic is the main specialised provider covering an area of approximately 540.000 inhabitants with 3,971 professionals (913 doctors; 2184 nurses and 874 managerial and support staff) and 900 beds. It is the main hospital for 18 health districts and works in close collaboration with 5 Primary Care centres and 4 secondary hospitals.

Hospital Clinic is a leading experimental institution, not only in Catalonia, but on the international stage, especially with regards to eHealth and integrated care. At local level, initiatives promoting integrated care have been launched involving other hospitals in cooperation with primary care centres within their catchment area (covering a population of 450,000 inhabitants in Barcelona) in order to better integrate the care patients receive. This cooperation implies regular visits from staff in these hospitals to primary care centres mainly from the following specialties: endocrinology, cardiology, neurology and dermatology. According to interviewees, one of the expected outcomes from this cooperation is that RMT experiences proving to be cost-effective will be rolled-out for patients in this area being primary care responsible for them.

At international level, Hospital Clinic has also been involved in a dozen European projects in the fields of eHealth and integrated care.

Its experience in those field dates back to 1999 with the launch of a clinical trial conducted on COPD exacerbations for patients admitted at the emergency room of two tertiary hospitals in the Barcelona area (Hospital Clinic and Hospital Bellvitge). The clinical trial was performed as a preliminary step prior to setting up a technological platform with a web-based call centre as one of its core elements. The hypothesis was that home hospitalisation with free patient phone access to a specialised nurse should generate a better outcome at lower direct cost than inpatient hospitalisation. As a consequence, there would be a lower rate of emergency room relapses, a

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greater improvement of health-related quality of life (HRQL) and better patient self management of the disease. From the 629 patients screened, 26% (n=165) required imperative hospitalisation while up to 35% (n=220) were not eligible. The remaining 244 patients (38.8%) were candidates for the study, but 22 of them (3.5%) did not sign the consent form. Eventually two-hundred and twenty-two patients were included (121 for home hospitalisation and 101 for conventional care: 101). Figure 14 below shows the profile of the study (COPD stands for chronic obstructive pulmonary disease and HH: home hospitalisation, n being the number of patients).

Figure 14 - Study profile COPD Hospital Clinic (1999-2000)

Source: Hernandez et al. (2003)[46]

Trial results reported revealed that "home hospitalisation generated better outcomes than conventional care of COPD exacerbations. Better outcomes with HH included: 1) lower hospitalisation rates; 2) lower rates of short-term relapses requiring emergency admissions; 3) clinically relevant improvement in Health-Related Quality of Life (HRQoL), as assessed by the St. George Respiratory Questionnaire (SGRQ); 4) a higher degree of patient satisfaction; and 5) an important positive impact on knowledge of the disease and on patient self-management of the chronic condition". It is worth pointing out that home hospitalisation is suitable only in a subset of exacerbations that must be selected at the hospital after proper assessment by a specialised team.

The study showed that home hospitalisation was less costly than conventional care. The average overall costs per home hospitalisation patient were substantially lower than in conventional care, essentially due to fewer days of inpatient hospitalisation. Slightly higher costs in the HH group were only observed in prescriptions that were due to both oxygen therapy and nebuliser treatment, because these two treatments were part of the inpatient hospitalisation costs in a substantial

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portion of the control group. This report clearly demonstrated the beneficial effects of the intervention compared with conventional care of COPD exacerbations. Furthermore, it also stated that improvement of the outcomes can be associated with a reduction of direct costs. However, the economic evaluation performed may be affected by two main limitations. First, the perspective of the evaluation was that of the public healthcare insurer excluding non-healthcare costs. In this study, formal (paid work) or informal (unpaid work and leisure time) care for exacerbated COPD patients were not evaluated. A second limitation of the economic evaluation was that average costs were used to evaluate hospital care. It has been argued that the existence of fixed hospital costs amplifies the value of any potential savings resulting from a reduction in bed days.

The authors of the study remarked that the study prompted the need for the deployment of this type of intervention as a regular healthcare service for exacerbated chronic obstructive pulmonary disease patients under the frame of a properly designed cost-effectiveness analysis.

ICT enabling integrated care in Hospital Clinic

Following the results of the trial reported above, another study was developed in coordination with University Hospital Gasthuisberg, Leuven, Belgium. In this case, the hypothesis made was that a simple, well defined integrated care (IC) intervention with the support of information and communication technologies may be effective to prevent hospitalisations for exacerbations in COPD patients. This intervention relied on shared-care arrangements between primary care teams and hospital teams, which aimed to avoid duplicates and to generate synergies among different levels of the healthcare system. A prospective controlled study was carried out in 155 COPD patients recruited in two tertiary hospitals immediately after the patients’ hospital discharge. All patients were admitted because of a previous episode of exacerbation requiring hospitalisation for 48 h. Up to 850 COPD patients were screened, but only 19% fulfilled the defined criteria and were finally included for randomisation.

Exclusion criteria for the study were: 1) not living in the healthcare area (39%); 2) severe comorbidity conditions, i.e. lung cancer or other advanced malignancies, and extremely severe neurological or cardiovascular disorders (25%); 3) logistical limitations due to extremely poor social conditions, such as illiteracy or no phone access at home (10%); and 4) being admitted to a nursing home (7%).[47]

The researchers reported that the intervention required customisation to country specificities, particularly regarding the interactions between hospital and primary care teams. While the general practitioners (GPs) played a key role in Leuven, the intervention in Barcelona was essentially carried out by specialised nurses.

The authors reported that integrated care intervention was standardised for both centres but slightly adapted to the two different healthcare systems and local geographical conditions with the following key features:

• A comprehensive assessment of the patient at discharge, including severity of the respiratory disease, evaluation of comorbidity conditions and analysis of requirements in terms of social support.

• An educational programme of 2 hours duration on self-management of the disease administered at discharge by a specialised respiratory nurse.

• Individually tailored care plan following international guidelines was shared across the system via interaction between the specialised nurse case manager and the primary care team.

• Accessibility of the specialised nurse to patients/carers and primary care professionals during the follow-up period was ensured through an ICT platform including a web-based call centre.

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A total of 155 COPD patients who were discharged from two tertiary hospitals were included in the analysis. Figure 15 shows a schematic representation of the study profile.

Figure 15 - Integrated care intervention with the support of ICT – Chronic Platform

Source: Casas et al. (2006)[47]

Results

Results reported revealed that Integrated care intervention presented a lower rate of readmissions (1.5 versus 2.1). Likewise, the percentage of patients without admissions among survivors was also greater in Integrated care (49%) than in usual care (31%). The difference in rate of admissions per patient between the follow-up and the previous year was also lower in Integrated care than in usual care. No significant differences regarding deaths were observed. In addition to this, no significant differences were observed between Integrated care and usual care in the number of visits. Therefore, the study demonstrated the effectiveness of a well-defined low-intensity Integrated care programme in COPD patients to prevent future exacerbation episodes triggering hospital admissions, considering that the intervention was customised to the organisational specificities of primary care in the two participating countries. The effectiveness of this program can be explained by its results in enhanced self-management of the disease together with a higher accessibility to healthcare professionals. Altogether the interventional impact may have prompted an early detection and better management of exacerbations in the Integrated care programme.

In the case of Hospital Clinic, a subgroup of patients were included in a Randomized controlled trial to assess the effectiveness of the intervention in terms of enhancing clinical status (dyspnoea, body mass index (BMI), health-related quality of life, lifestyle (smoking, physical activity), self-management (COPD knowledge, alarm knowledge and treatment, treatment adherence), medical treatment, and patients’ satisfaction, after a 1-year follow-up period, under the hypothesis that changes in these factors could explain the reduction in readmissions. Functional status (lung function and arterial blood gases) was also measured[47]. Figure 16 shows a flow chart of patients' participation in the study. At the beginning of the study 113 patients were identified and randomly assigned to the intervention group or the control group. Only 21 patients in the intervention group finished the study.

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Figure 16 - Integrated care intervention with the support of ICT – Chronic Platform – Barcelona subgroup

Source: Garcia-Aymerich et al. (2006)[48]

The study found no changes in lifestyle variables, medical treatment, lung function or quality of life. However, the intervention helped COPD patients enhance their knowledge about their condition and influenced their health behaviour with regard to treatment adherence after 1 year of intervention. The interpretation of these findings together with the previously reported reduction in admission risk, suggest that these factors play an important role in the treatment of COPD exacerbations at an early stage, and can reduce the need of hospital admission.

Transition to service provision: NEXES

Nowadays, Hospital Clinic is involved in a transitional phase from existing pilot experiences to extensive deployment of health and social services supported by NEXES, supporting Healthier and Independent Living for Chronic Patients and Elderly project funded by ICT Policy Support Programme Area (CIP-ICT-PSP-2007.2.2 – ICT for ageing well).

This transitional phase reflects the positive outcomes from the knowledge and experience acquired through small-scale controlled pilot studies, in terms of efficiency, user satisfaction and overall cost savings. The aim of NEXES is to evaluate the potential for generalisation of four specific services targeting people at risk and patients with chronic illnesses. NEXES mainly addresses patients with one or more of COPD, chronic heart failure and type II diabetes. To reach achieve this NEXES aims to: (1) develop an evolution from pilots to services; (2) carry out a controlled deployment, integration and validation of services and (3) identify suitable strategies for the success of extensive and sustainable deployment of services.

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The central hypotheses of the project are that integrated care based on standardised pathways supported by ICT may enhance clinical outcomes and generate satisfaction for patients, carers and health professionals. It may contain costs by preventing duplication and may also have a positive impact on disease progress and prognosis. NEXES is based on four initiatives. The first initiative is related to Wellbeing and physical training and it claims that a standardised programme for management of the illness and remote control, deferred, of the home physical training sessions will have a positive impact on: lifestyle, adherence to treatment and clinical results. The effects of long-term muscular training and the programme will be cost efficient. The objectives of this initiative are to evaluate the efficiency and sustainability of the programme and to demonstrate the maintenance of the effect of long-term muscular training. To reach these objectives, this initiative has adopted a two phases method. Phase I will use conventional supervised training (8 weeks) followed by home remote control monitoring with mobile equipment that includes a telephone with questionnaires about health behaviours and life style, and wireless sensors. The intervention group will have 100 patients with home monitoring for 18 months after the supervised training. Phase II will develop conventional supervised training (4 weeks) followed by remote control at home with mobile equipment that includes telephone with questionnaires and wireless sensors. The intervention group will have 100 patients with MPOC, chronic heart diseases and/or diabetes-obesity with home monitoring for 12 months after the supervised training. These deployments will be supported by mobile phone with questionnaires and sensors (pulse oximetry and physical activity) (200 patients - approximately 200 units); a call centre and a web application for professionals (physiotherapists, nurses, family doctors, degree holders in physical activity and sport sciences) and for patients with telecollaboration tools. Improvements of health status, assessed with standardised questionnaires; sustainability of the physiological effects of muscular training; increasing adherence to treatment; improvements of lifestyle; and reduction in healthcare expenses are the expected results.

The second initiative tackles Care for fragile patients. This initiative claims that coordination between Primary Care and preventive care specialists for fragile patients generates good clinical results (decrease in emergency service care and unscheduled hospitalisations), improved quality of life, and has a positive impact on the course of the disease and cost containment. Programme effectiveness will increase if good coordination is established with social support community services. Therefore, the objective is to evaluate the efficiency and sustainability of the widespread application of the programme for fragile patients with target pathologies. To reach this objective the following actions have been designed (minimum monitoring 12 months - Total patients 1200 (600 intervention and 700 control): a) joint visit of the primary teams, specialist and social worker with check-up for comorbidity treatment; b) educational session; c) access to the call centre; d) professional home visits with remote connection as a response to possible incidents; and, e) remote monitoring selectively and temporarily. These actions will be enabled by mobile phone with questionnaires (maximum peak 600 - approximately 600 units); sensors for remote monitoring (60 units); call centre; mobile application (laptop) per professionals with sensors (Primary Teams: 30 units and hospitals: 8 units) (total 38 units) and web application for professionals and for patients & caretakers with telecollaboration tools. The expected results are: improvements of health status, evaluated with standardised questionnaires; decrease visits to emergency room and unscheduled hospital admissions; decrease of admitted days; increased adherence to treatment; improve lifestyle; reduction in healthcare expenses and decrease mortality.

The third initiative is related to Home hospitalisation and early discharge. This initiative claims that the support of home hospitalisation with the tools provided by the technological platform must generate efficiencies by facilitating interaction with Primary Care and social support services. With these two conditions, healthcare continuity will improve (Primary) and exclusion causes will decrease (social support). Remote monitoring must also be facilitated for a group of selected patients. To prove this hypothesis, the initiative will evaluate the added value of the use of ICT in the widespread application of the home hospitalisation centre of the participating centres. The number of patients involves in this intervention is 2200 (1100 intervention and 1100 control). The

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inclusion criteria of these patients will be based on the previous experiences carried out at Hospital Clinic. This intervention is supported by mobile phone with questionnaires (1100 patients - approximately 300 units); sensors for remote monitoring (60 units); call centre; mobile application (laptop) per professionals with sensors (same as for fragile patients) and web application for professionals and for patients & caretakers with tele-collaboration tools. Reduction in hospitalisations and readmissions; improvement in mortality and satisfaction and cost reduction are the target variables and expected results.

The fourth initiative is related with Diagnostic and treatment support, claiming that the transfer of diagnostic and therapeutic support tools in the area of primary and home care with a certain degree of accessibility for the specialised professional will increase resolution potential and decrease pressures on the healthcare system. It is about a wide-range of possible services that are potentially quite diverse. One of the project activities will be the identification and validation of areas in which the application of ICT could be profitable for the health care system (forced spirometry in Primary care, sound studies, more out-patient surgeries, etc). Under these premises, the objective is to evaluate the added value of the use of ICT in the widespread application of the services in the Primary Care support programme. In this case, the methods will be designed according to areas of application and will use the same technologies of the other initiatives with the following expected results: increase resolution capacity of Primary Care; drop in test duplications and increase capacity for specific tests and/or treatments.

Service organisation

All the pilots carried out at Hospital Clinic emphasised the importance of a patient-centred approach, with special emphasis on shared care arrangements across the healthcare system (between specialised care at the hospital and primary care) and within the multidisciplinary primary care team.

One of the key features of the models is the development of innovative home-based services with involvement of patients (and caregivers) as partners in the management of the disease. In this new setting, there is an important role for the use of information technologies, facilitating the interactions between healthcare levels and the development of novel educational tools. However, ICT utilisation should be aligned with a redefinition of the roles and skills of the specialised nurses and doctors as well as an adequate standardisation of work procedures.

Indeed, the NEXES project emphasises the central position of Primary care and the transformation of traditional nurses into case managers. Furthermore, a patient-centred approach requires mandatory collaboration between healthcare services and community support services and the development of treatment which facilitates comorbidities' management, needs stratification needs and personalisation of healthcare.

The NEXES project outlines the need to consider three pivotal aspects for a successful deployment:

• Organisational issues, including workflow redesign and redefinition of the roles of the public and professionals;

• Legal and ethical implications associated with these changes; • Educational needs of professionals and the public.

Technology

The first system used to support the Chronic Disease Management Model at Hospital Clinic was developed by the CHRONIC Project: An Information Capture and Processing Environment for Chronic Patients in the Information Society (funded under 5th Fifth Framework Programme). The starting point of the CHRONIC project was the need to provide health care professionals with a technological solution that could facilitate the treatment of target populations of chronic patients, preserve the quality of the services, without increasing (if possible diminishing) the associated costs. The technological solution provided an effective management of chronic conditions through

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an integrated care platform conforming a reliable framework for a continuum of care model where different professionals and providers could interact and work together in a patient-centred model of care and a technical platform that could effectively support a wide range of services, from information sharing to remote monitoring of vital signs. Therefore the deployment of this system required the use of different IT components: 1) a call-centre that could provide an effective entry-level for the system; 2) an easy to use module for handling patient information; 3) patient units that could support monitoring and transmission of vital signs (wired or wireless sensors); and 4) portable equipment that could support home interventions.

This solution was based on two different parts:

- On the one hand, the Care Management Centre which is composed of two main modules - the Call-Centre and the Patient Management Module - was the core of the CHRONIC solution on the Hospital side. This centre can be located in a hospital or another healthcare structure, or it can be part of a service centre from which requests and/or clinical data can be transmitted to the clinical reference centre of the patient.

The Call-Centre module is based on a high-performance Web and Computer Telephony Integration (CTI) server that can be accessed using different communication links (PSTN, GSM, ISDN, LAN) and protocols (customised TCP/IP, POP, SMTP, http, etc). Users can access the call-centre in a variety of ways ranging from plain telephone to dedicated Patient’s Units (integrating different patient sensors with the home TV set). At the call-centre, incoming calls are handled by a dedicated application that provides for the two basic operational modes: 1) teleoperator mode and 2) Voice Response Unit (VRU) automatic mode.

The Patient Management Module is a web based application running on a Windows Internet Information Server, and implemented using ASP technology. It handles patients’ clinical information and serves as a tool for the co-operative work among professionals from different health care levels. The information regarding the patient is organised in folders to simplify its management, and includes items such as treatment, follow-up reports, test results and information regarding patient contacts with the call centre. The tools for the professional include a visits agenda, a list of pending tasks and other tools for awareness regarding the teams’ work.

- On the other hand, the home hub was the second part of the CHRONIC solution, which is based on a laptop computer linked to the Care Management Centre by mobile phone technology. Specifically designed for supporting home visit activities by health professionals, it includes the following basic features: access to patients’ clinical information (retrieve, update) in a format similar to that of the Patient Management Module and an agenda for scheduling nurse and team home visits. Security is achieved through the use of digital certificates and/or hardware tokens. These units are tailored PCs, with a look similar to a VCR, that feature videoconferencing, telemonitoring, messaging and educational material services. The telemonitoring functionality is provided in combination with a set of sensors (wireless or wired technology) developed within the project (Oxygen saturation, ECG, spirometry and accelerometer) or others available in the market (Sibel, Card-Guard are currently supported). The information gathered at the homes by the Patient Unit is accessible to the patient's care team through the web based Patient Management Module.

Hospital Clinic improved the CHRONC solution developing LINKCARE (Linking Health Professionals in Emerging Care Environments, funded by eTEN call). LINKCARE aimed to offer a viable, innovative, integrated health care service for chronic patients, providing appropriate support for information to health professionals in their activity (monitoring and management) and to pave the way for the implementation of new care models. This technological solution supported NEXES (see above 3.3.8.4).

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Funding/costs

The CHRONIC project 23 was funded under the Fifth Framework Programme within Personal health systems with a total cost of €3.47 million (EU contribution: €1.88 million). The duration of the project was 30 months from January 2000 to June 2002.

LINKCARE Linking Health Professionals in Emerging Care Environments24 was funded by eTen Market Validation with a total cost of €1.94m (EC Contribution: €0.76m). The duration of the project was 18 months from September 2005 to February 2007.

NEXES – Supporting Healthier and Independent Living for Chronic Patients and Elderly (Living Healthily at Home was funded under the ICT Policy Support Programme ICT for ageing well with a total cost of €4.76m (EU contribution: €2.38m). The duration of the project was 36 months from May 2008 to April 2011.

3.3.9 Conclusions of integrated care and ICT for health in Catalonia

After having analysed Hospital Clinic initiative and the Catalonia Department of Health Strategy in ICT and Chronic disease, it is possible to draw some conclusions on the current scenarios of IPHS following our three axes: Innovation, Governance and Impact.

Innovation

Since 1999 Hospital Clinic has been developing initiatives supported by ICT and integrated care to tackle COPD and other respiratory disease. This history of innovations is grounded in clinical expertise of their medical specialists who identified ICT utilisation and integrated care, as relative advantage with positive health outcomes and lower health care demands. The results obtained during a decade have proven the relevance of ICT to cope with the burden of these chronic health problems even though the evolution of these types of technologies during this decade has added complexity to innovation itself as well as to the implementation process.

The innovation process has been carried out by a multidisciplinary team led by renowned medical specialists who understand technology and organisational change, included integrated care paradigm. This mix of knowledge and skills facilitated the development of an innovative department within the Hospitals with a strong influence on other health actors related with COPD, included a Primary care centre of Barcelona and a network of researchers and practitioners around Europe. As reported in Basque Country and other regions, it was difficult to achieve compatibility between this initiative and usual care provided within other Departments of the Hospital and within the Hospital itself.

Governance

The clinical expertise and the amount of funding gathered facilitated the governance of the initiative through 'soft' interventions while the positive results achieved facilitated the collaboration with Primary Care centres to launch an integrated care services for COPD patients within a health area of Barcelona ('hard intervention') with the support of Hospital Clinic based on traditional reimbursement payments by Catalonia Department of Health. This goes beyond the traditional pilot projects and means a deployment initiative.

The NEXES project will face the challenge of spreading this innovation to other medical specialists and ensure the total compatibility of the innovation with other IT systems within the Hospital.

23 CHRONIC Project:

http://cordis.europa.eu/fetch?CALLER=PROJ_ICT&ACTION=D&DOC=6&CAT=PROJ&QUERY=01323ecef593:2cab:21d00c03&RCN=53659

24 LINKCARE http://ec.europa.eu/information_society/activities/eten/cf/opdb/cf/project/index.cfm?mode=detail&project_ref=ETEN_NM8

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Impact

Several RCT were carried out showing positive health outcomes and effectiveness of the interventions. A cost-effectiveness analysis is planned within the NEXES project.

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4. CONCLUSIONS AND LESSONS LEARNT This section aims to draw conclusions and lessons learnt from the three experiences zoomed in Spain: Andalusia, the Basque country and Catalonia. First, it will look into IPHS deployment in these three settings. Second, it will move from IPHS experiences to ICT deployment in each of these regions. Finally, and building on the above, it will look into the way forward at national level.

When it comes to IPHS deployment, all experiences explored have been initiated at hospital level: in Andalusia by Hospital Virgen del Rocio (HUVR); in Catalonia by Hospital Clinic, and in the Basque Country by Hospital Donostia or in the case of TELBIL based on the the experience of Hospital Donostia..

All of these have historically been hospitals with a culture of research (R&D) and innovation (i), thus they could be categorised as centres of reference for R&D&i. Hence, from the perspective of innovation diffusion the role played by these centres in spreading innovations is very relevant. A prominent example is that of TELBIL in the Basque Country. The TELBIL experience was primary-care led and it was launched by a GP influenced by the experiences made at Hospital Donostia..

Not only R&D&I centres play a key role, but also clinical champions do: their leadership, motivation and involvement represent strong catalysers for these experiences to take place. Indeed, the presence of clinical champions has been identified in both primary care and at hospital level.

The incentives at primary and hospital care level are diverse. In all three cases, hospital initiatives tackling chronic disease management have been the result of spiralling hospital re-admissions and higher number of bed-days associated with them. As a result, at hospital level, attempts to address patients holistically through the involvement of internists or multidisciplinary teams have taken place. A prominent example of this is the evidence based medicine clinical unit at Hospital Donostia.

Catalonia and the Basque country show more advanced levels of development when it comes to tackling chronic diseases supported by IPHS deployment. For instance, Hospital Clinic (Catalonia) started some trials with COPD patients as early as in 1999 treating patients at home rather than hospitalising them. The same applies in Hospital Donostia (Basque Country) where first trials were launched in 2006. The latter has actually reached quite a high level of sophistication identifying different care interventions depending on the severity of each patient (i.e.: pre-frail, frail, terminal, dependent or independent). In addition, from an impact perspective, these two settings (Catalonia and the Basque country) seem to work closely with the respective HTA agencies when it comes to evaluation of these trials.

Further, both Catalonia and the Basque Country have recently included patient autonomy and self-care as part of their recent strategies. In particular, Catalonia includes telemedicine and telecare as one of their main pillars and the Basque country specifically mentions remote access to healthcare. Thus, although the evidence on IPHS from the settings explored is limited in terms of generalisability of the results, two trends can be identified at policy level.

The trend from Catalonia and the Basque country following a middle-out governance approach which may be more likely to promote initiatives at local level to expand and increase the number of patients involved. Also, these two settings often involve local HTA agencies during the evaluation which has translated into the promotion of IPHS in the current health strategy region wide. Hence, there is evidence of deployment at scale involving over 1,000 in these two regions. In contrast, in Andalusia which follows a top-down governance approach deployment at scale is still not taking place. Even though the HUVR initiative is very much a bottom-up approach, it is likely to require government endorsement to deploy IPHS at scale. This is a common trend in top-down approaches, where entrepreneurial behaviour reaches limitations at an earlier stage before deployment at scale can be tested and it is instead government intervention promoting widespread deployment that defines the initiatives to be mainstreamed.

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Common features have also been identified in the three settings. Both, hospital and primary-care led experiences heavily rely on the role of nurses to such extent that the Basque country is currently promoting the role of specialist nurses as part of their chronic disease management strategy. Also, in all these initiatives the need for cooperation among tiers of care (primary, secondary, tertiary and social care) becomes an issue which in some cases is addressed through system re-organisation to a certain degree. Indeed, it has been described how the hospitals leading IPHS initiatives have also attempted to better coordinate with primary care services. Such is the case of Hospital Clinic in Barcelona organising routine meetings between hospital consultants and primary care. The same applies to HUVR in Andalusia where a platform to exchange EHR data with primary care centres has also been developed in order to better coordinate the care patients receive. Nevertheless, in all of them the need for further cooperation and coordination is identified as an area for further improvement.

Moreover, and in line with the above, system interoperability has also been identified as an important enabler. If different tiers of care are to coordinate in order to deliver patient-centred care, their information systems should also be interoperable allowing the exchange of information amongst them. The interoperability gap equally applies to IPHS technologies. Often the data generated by these systems is not interoperable with the rest of systems in place for clinical use which makes integration of IPHS into care pathways more difficult. It is worth pointing out that in the case of Hospital Donostia interoperability was achieved due to the participation of Medical Informatics Unit from the beginning, which shows that IPHS deployment should benefit from coordinated approaches with IT departments. Thus, lack of interoperability does not only hamper coordination between tiers of care but also widespread adoption of IPHS.

The technology providers vary in each case: from a multinational provider such as CM in Andalusia, to a unique local provider in the experiences reported in the Basque Country or even a specific application developed at Hospital Clinic. However, it is relevant to point that in all cases a close cooperation between clinical staff and technology providers has taken place to adapt the technology and the service to the clinical needs of patients and healthcare staff.

Also, in most cases the trials involve a relatively low number of patients which limits generalisability of their results. However the trial coordinated by Hospital Donostia with geriatric centres involving 1,338 patients in total and the NEXES project carried out by Hospital Clinic where one of the four initiatives involves 2,200 patients (half in the control group) show that after small scale experiments decisions to scale up are being taken. While this is an encouraging trend, there is still a long way to go for IPHS to spread out even at the level of a regional.

While results from the different trials differ somehow, it is important to note that in all cases properly supported home care (with or without ICT) results in shorter length of stay when patients require hospitalisation. Moreover, the number of hospitalisations often decreases as a consequence of implementing home care strategies, which in turn results in lower costs. Furthermore, an improvement in quality of life has also been identified in some of the evaluations (i.e.: COPD trial in hospital clinic with free phone access). Finally, interventions promoting patients treatment at home often improve patients' knowledge about their condition and self-management. This shows the benefits of promoting patient self-management. The overarching aim is to promote their autonomy through self-management rather than enhance their dependency on the technology. Thus, providing sufficient self-management training to patients is important to avoid their overreliance on the technologies. This should be taken into account in any IPHS deployment initiatives.

Regarding sources of funding, these vary widely. The cases reported from the Basque country seem to rely on funding from their own Health service, whilst the experience in Andalusia relied on funding at national level (from ISCIII) and the industry. The Catalonia approach instead has relied heavily on EC funding all along. This is another encouraging trend, which shows that a variety of funding options may be available which have led to successful IPHS experiences. Greater awareness on the various approaches could encourage further hospitals or primary care centres to follow suit.

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In contrast, when it comes to incentives trends seem to converge. On the one hand, incentives based on health outcomes are already in place in Andalusia whilst in the Basque country a shift from activity focused to a risk-adjusted capitation scheme is taking place. Catalonia is aiming at adapting their financing and purchasing models aiming to stimulate integrated care and coordination between tiers of care. As seen in the case of Andalusia and HUVR, current incentives at hospital level can be spurious, in particular for widespread IPHS deployment. This effect is likely to occur in other regions than those studied given that few regions are currently combining outcome incentives at hospital level and DRG payments, and the latter do not exist for IPHS deployment. It would be interesting to see how new financing mechanisms take current incentive schemes a step-forward and hopefully unintended consequences from current purchasing schemes are eliminated.

In relationship to telecare applications, Andalusia leads the way in terms of penetration of telecare services. The Basque country with a lower penetration than that of Andalusia is currently focusing on more sophisticated telecare services paving the way to telehealthcare. Catalonia seems to follow a similar path to that of the Basque country.

To sum up, middle-out approaches such as those promoted in Catalonia and the Basque Country seem to enable IPHS deployment although there is still a long way to go before widespread adoption becomes a reality. The bottom-up approach described in Andalusia on the other hand does not seem to benefit IPHS development to the same extent. However since the experiment is still under evaluation and only one case was investigated, one should be cautious with generalising. It will be interesting to see whether further steps towards wider deployment are being taken following the pilot at HUVR and how far the bottom-up approach yields different results compared with the middle-out approach of the other cases. Ideally a balance between generalisation through institutionalisation and promotion of entrepreneurial behaviour would be desirable to better succeed in delivering ICT-supported integrating care.

Although healthcare in Spain is highly decentralised, national policies have set a framework for eHealth and ICT for health to develop. First, intensive ICT deployment in healthcare was promoted through the National Quality Plan. In line with it, Plan Avanza was designed to support this process with funding and it was left to the regions to proceed their own way in promoting ICT. However it should be noted that the ambitions of Plan Avanza have been lowered significantly and limited to 10% of the original plan as a consequence of the economic crisis. While some of the regions have achieved a "reasonable" level of ICT deployment in health, the recent law passed in August 2011 stipulates for all regions to have an EHR and an ePrescribing system in place. In addition, interoperability among regions is also a requirement by the end of 2012. In this context, some regions like Andalusia may only have to work on interoperability, whilst others may have to start by developing a proper ePrescribing system for instance. Thus, it seems that in a decentralised context the policies adopted by the central government in order to promote eHealth and ICT for health have a limited impact. A way to foster further uptake would be for instance to promote know-how exchange from front-runners regions to laggards in order to achieve the national targets recently established.

Another area where great impact could be achieved would be the funding from Plan Avanza. As described, some local initiatives have been developed in cooperation and financed through Plan Avanza. However, these initiatives are often too local and they seem to operate independently with regional strategies. Therefore, there would be room for better coordination of initiatives launched at regional level with those funded through Plan Avanza rather than working in uncoordinated silos.

A third example of loose coordination between central and regional level is that related to HTA agencies. It has been described how regions like Catalonia and the Basque country involve their regional HTA agencies in their evaluations when it comes to ICT applications in healthcare. In particular Catalonia represents a good example of how the CAHIAQ (the Catalan HTA agency) plays an increasingly important role in the diffusion of ICT for health. Greater coordination at national level could be helpful to promote knowledge exchange, consolidate evidence on IPHS experiences and promote further involvement of HTA agencies when assessing ICT applications in healthcare.

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Besides addressing interoperability the August 2011 law also seeks to tackle the lack of coordination between health and social care services. Again, this issue represented a common barrier to deliver better quality of care supported by ICT. Thus, through this law some of the main barriers identified seem to be addressed. However additional initiatives would also be welcomed, such as those described above.

It remains to be seen whether the targets established at national level are achieved by the regions as planned. In addition, should those targets be achieved, the context may be more favourable to wider telehealthcare services diffusion. Still, it remains to be seen whether IPHS definitely find their place within the Spanish healthcare system as a routine form of care delivery.

To sum up, as illustrated in the first part of this report Spain is no exception to other OECD countries when it comes to an ageing population and the threat that chronic diseases pose to the sustainability of healthcare systems. Objective data presented shows how chronic diseases represent a high cause of mortality, morbidity and hospitalisations with the associated costs and consumption of health resources (not to mention the associated indirect economic impact through loss of activity). Subjective data on self-reported health status of the population corroborates this very fact.

There are clear differences amongst regions both, in terms of the impact of chronic diseases and in terms of health delivery which is not surprising given the decentralised nature of health and social care delivery in Spain.

These regional differences are also reflected in the policies addressing chronic disease management and in the strategies to develop ICT for health, as illustrated through the approaches from three regions – Andalusia, the Basque Country, and Catalonia. The picture that emerges is one of successful IPHS experiments whose initial results have led in most cases to further deployment. While progress is incremental and there is a long way to go for IPHS to become a routine form of care delivery in these Spanish regions, in combination with recent policies adopted by the central government, the case for IPHS in Spain looks promising. Further, given the diversity of approaches towards integrated care identified across these regions there is also room for know-how exchange amongst them.

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ANNEX I – STATISTICS AT NATIONAL AND REGIONAL LEVEL Table 7- Population of Spain total and per region, 2004-2010

2008 2007 2006 2005 2004Total 46,157,822 44,708,964 45,200,737 43,197,684 44,108,530 Andalusia 8,202,220 7,975,672 8,059,461 7,687,518 7,849,799 Aragon 1,326,918 1,277,471 1,296,655 1,249,584 1,269,027 Asturias 1,080,138 1,076,896 1,074,862 1,073,761 1,076,635 Balearic Islands 1,072,844 1,001,062 1,030,650 955,045 983,131 Canary islands 2,075,968 1,995,833 2,025,951 1,915,540 1,968,280 Cantabria 582,138 568,091 572,824 554,784 562,309 Castilla & Leon 2,557,330 2,523,020 2,528,417 2,493,918 2,510,849 Castilla-La Mancha 2,043,100 1,932,261 1,977,304 1,848,881 1,894,667 Catalonia 7,364,078 7,134,697 7,210,508 6,813,319 6,995,206

Valencian Community 5,029,601 4,806,908 4,885,029 4,543,304 4,692,449 Extremadura 1,097,744 1,086,373 1,089,990 1,075,286 1,083,879 Galicia 2,784,169 2,767,524 2,772,533 2,750,985 2,762,198 Madrid 6,271,638 6,008,183 6,081,689 5,804,829 5,964,143 Murcia 1,426,109 1,370,306 1,392,117 1,294,694 1,335,792 Navarre 620,377 601,874 605,876 584,734 593,472 Basque Country 2,157,112 2,133,684 2,141,860 2,115,279 2,124,846 La Rioja 317,501 306,377 308,968 293,553 301,084 Ceuta 77,389 75,861 76,603 74,654 75,276 Melilla 71,448 66,871 69,440 68,016 65,488

2009201046,745,807 47,021,031 8,302,923 8,370,975 1,345,473 1,347,095 1,085,289 1,084,341 1,095,426 1,106,049 2,103,992 2,118,519

589,235 592,250 2,563,521 2,559,515 2,081,313 2,098,373 7,475,420 7,512,381 5,094,675 5,111,706 1,102,410 1,107,220 2,796,089 2,797,653 6,386,932 6,458,684 1,446,520 1,461,979

630,578 636,924 2,172,175 2,178,339

321,702 322,415 78,674 80,579 73,460 76,034

Source: INE (National Statistics Office), 2011[2]

Table 8- Surface area and population density, EU27 (2009)

Source: Instituto Vasco de Estadística 2010

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Table 9 – Life expectancy in Spain (selected years)

1986 1991 1995 2002 2007 Life expectancy

at birth 76.4 76.9 77.9 79.7 81.1 at 1 year 76.1 76.5 77.4 79.0 80.4

at 15 years 62.5 62.8 63.7 65.2 66.5 at 45 years 33.9 34.5 35.4 36.4 37.5 at 65 years 16.9 17.5 18.2 19.0 20.0

Life expectancy in full health

at birth 52.6 53.9 54.6 55.1 55.3 at 1 year 52.1 53.3 54.0 54.4 54.6

at 15 years 39.8 41.0 41.6 42.1 42.3 at 45 years 16.1 17.5 18.0 18.0 18.5 at 65 years 6.1 7.0 7.6 7.0 7.9

Life expectancy with some form of disability

at birth 23.8 23.0 23.3 24.6 25.7 at 1 year 24.0 23.2 23.4 24.6 25.8

at 15 years 22.7 21.8 22.1 23.1 24.2 at 45 years 17.8 17.0 17.4 18.4 19.1 at 65 years 10.8 10.5 10.6 12.0 12.1

Source: Ministry of Health and Social Policy (MSPS), 2010 [50]

Table 10 - Life expectancy (LE), disability-free life expectancy (DFLE) and expected years of disability (EYD) at birth, by region. Spain, 2000 and 2007

2000 2007

LE DFLE EYD LE DFLE EYD Total 79.4 70.7 8.7 81.1 72.6 8.5

Andalusia 78.3 67.9 10.4 79.8 70.6 9.2 Aragon 80.1 72.8 7.3 81.7 73.9 7.8 Asturias 79.2 71.1 8.1 80.4 72.5 7.9 Balearic Islands 78.7 71.3 7.4 81.6 74.1 7.6 Canary islands 77.7 70.4 7.3 80.4 72.5 7.9 Cantabria 79.8 71.1 8.7 81.1 74.8 6.3 Castilla-La Mancha 80.1 71 9.1 81.5 72.4 9.2 Castilla & Leon 80.8 70.7 10.1 82.1 73.1 9 Catalonia 79.1 70.7 8.4 81.6 74.3 7.3 Valencian Community 78.8 70.9 7.9 80.6 71.1 9.5 Extremadura 79 70 9 80.6 71.1 9.5 Galicia 79.5 70.6 8.9 81 71.9 9.1 Madrid 80.4 73.1 7.3 82.5 74 8.5 Murcia 78.6 67.7 10.9 80.5 70.3 10.2 Navarre 80.7 72.8 7.9 82.5 75 7.5 Basque Country 79.9 72.8 7.1 81.6 73.9 7.8 La Rioja 80.5 75.1 5.4 81.8 76 5.8 Ceuta and Melilla 78 68 10 79.5 67.2 12.2

Source: Ministry of Health and Social Policy (MSPS), 2010 [50]

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Table 11 - Life expectancy (LE), life expectancy in good perceived health (LEGH) and expected years in poor perceived health (EYPH) at birth, by region. Spain, 2002 and 2007

2002 2007

LE LEGH EYPH LE LEGH EYPH Total 79.7 55.1 24.6 81.1 55.3 25.8

Andalusia 78.4 51.2 27.2 79.8 54.8 25 Aragon 80.2 60.3 19.9 81.7 59.1 22.6 Asturias 79.5 50.9 28.6 80.4 53.8 26.6 Balearic Islands 79.4 51.4 28 81.6 57.8 23.8 Canary islands 78.6 47.5 31.1 80.4 54.5 25.9 Cantabria 80.2 54.7 25.5 81.1 59.6 21.5 Castilla-La Mancha 80.2 51.3 28.9 81.5 55.2 26.3 Castilla & Leon 80.9 59.5 21.4 82.1 61.3 20.8 Catalonia 79.9 56 23.9 81.6 55.2 26.4 Valencian Community 78.9 59.3 19.6 80.6 52.5 28.1 Extremadura 79.3 52.9 26.4 80.6 52.6 28 Galicia 79.9 48.6 31.3 81 47.8 33.2 Madrid 80.6 57.7 22.9 82.5 58.6 23.9 Murcia 78.9 54 24.9 80.5 50.7 29.8 Navarre 80.9 60.2 20.7 82.5 57.6 24.9 Basque Country 80.1 59.5 20.6 81.6 59.8 21.8 La Rioja 80.5 62.3 18.2 81.8 62.8 19

Ceuta and Melilla

78.2/78.0 51.2 27/26.8 79.5 52.8 26.7 Source: Ministry of Health and Social Policy (MSPS), 2010 [50]

Table 12 - Life expectancy at birth, EU 27 (year 2006)

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Source: Instituto Vasco de Estadística/ Basque Statistics Office, 2010

Figure 17 - Distribution of the Spanish population, Jan 2002- Jan 2011

0%

20%

40%

60%

80%

100%

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

65+15-64 years0-14 years

Source: INE (National Statistics Office), 2011[2].

Table 13 - Distribution of the population, EU 27, 1998 and 2008

Source: Instituto Vasco de Estadística/ Basque Statistics Office 2010

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Table 14 - Dependency ratio in total and per region, Spain

Dependency ratio 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Total 53.33 52.44 51.62 50.88 50.24 49.74 49.38 49.13 48.96 48.77 48.53 48.29 48.09 47.88 47.62 47.48 47.43 47.62 48.17Andalusia 56.84 55.75 54.75 53.81 52.96 52.23 51.61 51.09 50.66 50.25 49.85 49.40 48.93 48.46 47.89 47.45 47.12 47.12 47.46Aragon 54.94 54.53 54.15 53.83 53.59 53.45 53.44 53.50 53.62 53.77 53.81 53.63 53.31 52.93 52.44 52.08 51.76 51.62 51.88Asturias 52.47 51.73 51.03 50.42 49.96 49.63 49.46 49.40 49.42 49.41 49.32 49.17 48.93 48.68 48.44 48.32 48.35 48.65 49.28Balearic Islands 54.21 53.27 52.29 51.27 50.25 49.32 48.54 47.77 46.98 46.13 45.37 44.89 44.59 44.36 44.10 43.97 43.81 43.68 43.95Canary islands 50.54 49.21 48.02 46.92 45.94 45.10 44.40 43.82 43.35 42.69 42.10 41.81 41.53 41.27 41.09 41.08 41.08 41.14 41.42Cantabria 54.31 53.37 52.44 51.49 50.59 49.84 49.26 48.78 48.41 48.14 47.88 47.57 47.27 46.93 46.56 46.32 46.27 46.51 47.04Castilla & Leon 56.32 55.89 55.50 55.16 54.90 54.76 54.75 54.82 54.96 55.13 55.13 54.93 54.65 54.30 53.89 53.62 53.44 53.44 53.76Castilla-La Mancha 60.86 60.53 60.24 59.97 59.71 59.51 59.36 59.21 59.07 58.91 58.59 57.79 56.65 55.47 54.17 52.98 51.90 51.00 50.60Catalonia 50.64 49.80 49.04 48.37 47.84 47.47 47.27 47.22 47.25 47.29 47.35 47.39 47.42 47.42 47.27 47.26 47.36 48.00 49.08Valencian Community 53.94 52.93 51.99 51.09 50.27 49.61 49.12 48.75 48.44 48.09 47.71 47.33 47.03 46.74 46.43 46.29 46.24 46.35 46.88Extremadura 60.12 59.70 59.30 58.90 58.60 58.40 58.24 58.12 58.08 57.94 57.66 57.12 56.34 55.49 54.64 53.91 53.26 52.84 52.64Galicia 56.33 55.20 54.15 53.20 52.40 51.79 51.39 51.20 51.19 51.15 51.10 51.04 50.88 50.71 50.53 50.48 50.58 50.91 51.56Madrid 48.03 47.02 46.14 45.36 44.73 44.24 43.91 43.68 43.50 43.27 42.93 42.83 43.11 43.44 43.72 44.14 44.61 45.00 45.79Murcia 57.01 56.05 55.08 54.06 53.07 52.18 51.44 50.82 50.28 49.79 49.29 48.82 48.49 48.15 47.67 47.28 46.82 46.61 46.95Navarre 51.83 51.02 50.25 49.57 49.00 48.59 48.36 48.26 48.28 48.37 48.56 48.72 48.80 48.90 48.98 49.20 49.44 49.77 50.41Basque Country 45.11 44.29 43.61 43.09 42.75 42.64 42.73 42.99 43.35 43.74 44.12 44.53 45.02 45.52 45.98 46.53 47.21 48.15 49.42La Rioja 54.37 53.70 53.05 52.46 51.94 51.54 51.34 51.28 51.21 51.03 50.64 50.13 49.73 49.31 48.78 48.48 48.38 48.77 49.52Ceuta 56.44 55.76 55.19 54.58 53.75 52.86 52.01 51.24 50.56 49.96 49.41 49.23 49.52 49.78 49.98 50.25 50.59 51.01 51.52Melilla 58.67 58.94 59.00 58.59 58.01 57.25 56.32 55.41 54.50 53.72 52.90 52.42 52.75 53.19 53.53 53.94 54.40 54.96 55.56 Source: INE (National Statistics office), 2011[2].

Figure 18 - Demographic forecast of the Spanish population per age range (2005-2050)

% population per age - forecast

0

5

10

15

20

25

30

35

40

45

50

2005 2010 2020 2030 2040 2050

year

%

0-1818-2525-65total 65+

Source: INE (National Statistics Office), 2011[2].

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Figure 19 - Education levels of the population in Spain (%), years 1991-2009.

0

5

10

15

20

25

30

35

40

45

50

1991

1993

1995

1997

1999

2001

2003

2005

2007

2009

Illiterate

Literate with noeducationfirst level education

second level

third level

Source: INE (National Statistics Office), 2011[2].

Figure 20 - Unemployment in Spain (%) 2005-2010

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

2005 2006 2007 2008 2009 2010

Source: INE (National Statistics Office), 2011[2].

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Table 15 - Self-reported health status in persons aged 16 years and over. Percentage distribution by age and educational level. Spain, 2001 and 2006/07

Source: Ministry of Health and Social Policy (MSPS), 2010 [50]

Table 16 - Self-reported health status in persons aged 16 years and over. Percentage distribution by region. Spain, 2001 and 2006/07

Source: Ministry of Health and Social Policy (MSPS), 2010 [50]

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Table 17 - Average healthcare expenditure (€) per person covered in each region (1999-2008)

Region 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Average SPAIN 721 776 818 876 956 1,023 1,091 1,189 1,272 1,382 Andalusia 680 766 791 837 903 973 1,020 1,113 1,167 1,331 Aragon 776 824 899 955 1,069 1,168 1,209 1,321 1,420 1,512 Asturias 757 810 872 946 1,061 1,136 1,205 1,284 1,367 1,481 Balearic islands 614 635 679 786 877 950 1,121 1,118 1,216 1,265 Canary islands 770 820 840 910 999 1,046 1,147 1,227 1,311 1,446 Cantabria 773 833 921 1,014 1,163 1,243 1,331 1,403 1,496 1,378 Castilla & Leon 726 787 840 898 1,029 1,093 1,177 1,342 1,298 1,510 Castilla-La Mancha 675 721 774 879 936 923 1,157 1,287 1,288 1,304 Catalonia 722 777 817 869 958 998 1,058 1,170 1,287 1,380 Valencian community 689 750 790 846 934 989 1,029 1,113 1,196 1,273 Extremadura 725 786 826 969 1,060 1,122 1,199 1,332 1,499 1,616 Galicia 754 797 864 902 980 1,088 1,122 1,232 1,316 1,442 Madrid 725 752 788 830 870 980 1,026 1,092 1,188 1,261 Murcia 709 768 806 861 951 1,037 1,114 1,218 1,326 1,582 Navarra 878 933 961 1,014 1,089 1,167 1,204 1,285 1,400 1,514 Basque country 791 836 894 957 1,028 1,095 1,195 1,293 1,437 1,577 Rioja 720 791 834 910 994 1,112 1,228 1,557 1,884 1,549 Ceuta 763 800 839 909 1,019 1,124 1,182 1,247 1,310 1,516 Melilla 1,004 956 1,011 1,049 1,131 1,278 1,465 1,497 1,594 1,730

Source: Key indicators, Ministry of Health and Social Policy (MSPS), 2010 [51]

Table 18 - Hospital beds per 10,000 inhabitants, EU27. Selected years: 2000, 2005, 2007

Source: Instituto Vasco de Estadística 2010

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Table 19 - Health professionals resources per region, 2008 and 2009 data

Physicians registered per 1000 inhabitants (2009)

Nurses registered per 1000

inhabitants (2009)

Physicians Practising

specialists per 1000 inhabitants

(2008)

Physicians Practising

specialists per 1000 inhabitants

(% National health services, 2008)

GPs Practising per 1000 covered

individuals (2009)

Andalusía 3,99 4,26 1,43 90,91 0,72 Aragón 5,96 6,15 2,18 92,1 0,86 Asturias 5,41 6,12 2,08 92,93 0,74 Baleares 4,4 5,2 1,86 84,55 0,64 Canarias 4,12 4,73 1,62 82,11 0,72 Cantabria 5,47 6,8 1,81 94,62 0,76 Castilla y León 5,32 6,41 1,67 95,66 1,08 Castilla - La Mancha 3,96 5,51 1,76 97,16 0,81 Cataluña 5,02 6,34 2,13 91,31 0,72 Comunidad Valenciana

4,28 4,77 1,59 91,04 0,7

Extremadura 4,45 5,95 1,69 96,72 0,87 Galicia 4,48 5,03 1,77 93,3 0,8 Madrid 5,82 6,47 1,9 91,35 0,69 Murcia 3,99 3,35 1,56 94,36 0,73 Navarra 5,79 9,54 2,27 72,67 0,75 Basque Country 5,4 6,69 1,63 90,86 0,62 La Rioja 4,6 6,12 1,76 97,47 0,83 Ceuta 3,84 6,12 1,81 100 0,63 Melilla 3,31 6,77 1,23 100 0,74 Spain 4,76 5,55 1,76 91,33 0,74 Source: Key indicators, Ministry of Health and Social Policy (MSPS), 2010 [51]

Table 20 - Population with some permanent disability, by region. Spain, 1999 and 2008

Source: Ministry of Health and Social Policy (MSPS), 2010 [50]

74

Table 21 - COPD mortality rate per 100,000 inhabitants per age group (1998-2007)

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

all ages 44.73 47.71 41.27 37.38 40.76 40.66 36.35 40.59 32.53 34.98 < 1 1.37 0.54 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.21 1-4 0.07 0.07 0.07 0.07 0.19 0.06 0.12 0.00 0.06 0.05 5-14 0.12 0.10 0.02 0.07 0.12 0.10 0.05 0.02 0.07 0.0715-24 0.31 0.33 0.26 0.25 0.11 0.33 0.13 0.34 0.19 0.2025-34 0.32 0.44 0.21 0.37 0.44 0.31 0.33 0.28 0.32 0.1835-44 0.89 0.95 0.98 0.82 0.68 0.91 0.66 0.56 0.46 0.5545-54 4.29 4.84 3.32 3.26 4.06 3.78 3.30 3.43 2.57 3.1555-64 23.54 24.62 18.62 16.54 16.44 16.09 14.10 16.36 12.59 13.9665-74 100.36 106.85 88.49 77.99 85.93 80.74 70.16 80.16 60.73 66.7875 y + 470.22 485.92 419.95 374.78 402.89 402.73 357.95 392.24 314.20 332.01

Age adjusted

rate 28.97 30.31 25.51 22.76 24.52 24.05 21.09 23.26 18.34 19.53

Source: Ministry of Health and Social Policy (MSPS), 2010 [50]

Table 22 - Diabetes mortality rate per 100,000 inhabitants per age group (1998-2007)

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

all ages 24.00 24.34 22.98 23.53 23.61 24.04 23.34 23.82 21.95 22.62 < 1 0.00 0.00 0.26 0.00 0.00 0.23 0.00 0.00 0.00 0.00 1-4 0.07 0.07 0.00 0.07 0.00 0.06 0.06 0.00 0.00 0.00 5-14 0.02 0.05 0.00 0.02 0.00 0.00 0.00 0.00 0.02 0.0215-24 0.11 0.08 0.03 0.07 0.00 0.00 0.07 0.04 0.00 0.0025-34 0.34 0.35 0.39 0.35 0.24 0.21 0.15 0.15 0.20 0.1335-44 0.77 1.06 0.94 0.79 0.78 0.74 0.66 0.75 0.64 0.6145-54 2.66 2.89 2.57 2.74 3.17 2.99 2.73 2.72 2.93 2.4355-64 13.50 11.75 12.71 11.49 10.83 10.61 10.68 11.21 9.98 10.4565-74 55.76 52.70 47.27 48.55 45.82 47.36 42.57 44.26 38.10 39.8975 y + 246.95 249.61 230.79 233.35 234.69 235.74 229.34 229.46 210.84 215.26

Age-adjusted rate 15.65 15.48 14.41 14.48 14.30 14.36 13.71 13.82 12.52 12.69

Source: Ministry of Health and Social Policy (MSPS), 2010 [50]

75

Table 23 - Ischemic heart disease mortality rate per 100,000 inhabitants per age group (1998-2007)

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

all ages 101.20 101.97 97.64 95.25 95.37 96.07 90.98 90.59 84.17 82.95 < 1 0.55 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.21 1-4 0.07 0.00 0.14 0.00 0.00 0.00 0.00 0.00 0.00 0.00 5-14 0.09 0.02 0.02 0.00 0.05 0.02 0.00 0.02 0.00 0.0015-24 0.34 0.33 0.29 0.40 0.41 0.27 0.32 0.46 0.18 0.3525-34 1.79 1.83 1.71 1.48 1.46 1.49 1.34 1.26 1.02 1.2335-44 10.55 10.08 10.10 8.17 8.93 8.56 7.95 7.17 8.29 6.8945-54 33.56 33.06 32.92 30.72 30.49 29.07 28.49 27.33 26.98 24.6455-64 91.15 89.19 82.34 79.28 74.28 74.66 68.29 67.78 64.16 63.4965-74 249.17 249.98 236.70 221.72 211.05 211.28 192.45 191.54 173.03 168.8175 y + 915.62 899.86 842.98 824.19 831.21 831.01 786.13 775.25 707.99 696.70Age-adjusted

rate 70.0 69.2 65.4 62.6 61.7 61.5 57.3 56.3 51.9 50.4

Source: Ministry of Health and Social Policy (MSPS), 2010 [50]

Figure 21 - Morbidity of diabetes, cardiovascular diseases and COPD in Spain (2005-2009)

0

100000

200000

300000

400000

500000

600000

700000

800000

2005 2006 2007 2008 2009

Diabetes mellitus

Heart conditions

Stroke

COPD & complicationsassociated to it

Source: INE (National Statistics Office), 2011[2]. 25

25 Note 1: Heart conditions have been selected according to guidelines of the Spanish Cardiology Association. Note 2: there are sampling biases given that only 87% of hospitals in Spain are included which results in

95% of overall hospital episodes completed

76

Figure 22 - Morbidity of diabetes, cardiovascular diseases and COPD in Spain per region, year 2009.

0

20000

40000

60000

80000

100000

120000

140000

Andalu

sia

Aragon

Asturia

s

Baleari

c Isla

nds

Canary

islan

ds

Cantab

ria

Castilla

& Leon

Castilla

-La M

anch

a

Catalon

ia

Valenc

ian C

ommun

ity

Extrem

adura

Galicia

Madrid

Murcia

Navarr

e

Basqu

e cou

ntry

RiojaCeu

taMeli

lla

Diabetes mellitus Heart conditions Stroke COPD & complications associated to it

Source: INE (National Statistics Office), 2011[2]. 26

26 Note 1: Heart conditions have been selected according to guidelines of the Spanish Cardiology Association. Note 2: there are sampling biases given that only 87% of hospitals in Spain are included which results in

95% of overall hospital episodes completed

77

Table 24 - All causes of death. Crude mortality rate per 100,000 population, by region. Spain, 2000-2007

Crude rate 2000 2001 2002 2003 2004 2005 2006 2007

Total 895.1 884.4 892.2 916.2 871.2 892.6 843 858.8

Andalusia 830 817.8 833.6 864.2 828.1 852.3 795.4 816.4 Aragon 1,050.40 1,060.80 1,073.20 1,120.20 1,065.80 1,093.50 1,026.10 1,032.40 Asturias 1,165.60 1,122.30 1,170.90 1,202.90 1,184.40 1,199.80 1,166.70 1,196.40 Balearic Islands 874.2 814.9 799.7 800.3 746.1 757.5 726.4 703.2 Canary islands 704.9 679 658.6 669.2 663.4 662.8 643.4 650.8 Cantabria 1,002.70 950.8 982.4 995.5 951.3 969.1 972.7 990.1 Castilla-La Mancha 965.7 985.8 990.1 987 948 961.6 905 929.9 Castilla & Leon 1,043.10 1,032.10 1,072.60 1,097.50 1,068.30 1,110.60 1,054.40 1,097.60 Catalonia 894.7 893.7 901.5 924.9 860 900.5 826.6 837.4 Valencian Community 904.7 904.7 900.3 924.1 860.7 878.7 821.8 828.5 Extremadura 978.7 976.1 995.4 1,055.40 976.3 1,044.00 965.9 999.3 Galicia 1,072.40 1,049.90 1,051.30 1,102.70 1,053.50 1,082.10 1,080.30 1,105.20 Madrid 723.5 720.7 714.2 734.6 699.1 694.6 666.1 677.2 Murcia 794.4 772.5 776.5 776.6 747.8 754.5 718.6 723.4 Navarre 898.7 869.2 890.5 922.4 867.3 889 836.7 859.6 Basque Country 879.9 869.8 893.3 923.1 889.8 921 873.8 903.6 La Rioja 944 922.3 942.9 956.4 915 961.8 874.8 920 Ceuta 632.8 639.1 712.1 693.1 687.6 696.2 669.6 747.9 Melilla 420.8 391.9 437 443.8 443.7 404.7 442.2 415.5

Source: Ministry of Health and Social Policy (MSPS), 2010 [50]

78

Table 25 - All causes of death. Age-adjusted mortality rate per 100,000 population, by region. Spain, 2000-2007

Adjusted rate 2000 2001 2002 2003 2004 2005 2006 2007

Total 611.5 595.8 592.7 600.1 565.2 568.5 532.3 534

Andalusia 679.7 660.4 662.1 675.3 637.5 642.8 593.4 598.4 Aragon 565.9 558.4 554.7 570.1 546.2 540.4 504.3 505.8 Asturias 638.1 599.7 605.4 617.9 588.8 587 565.9 561.9 Balearic Islands 651.7 602.2 592.8 587 548.5 553.1 528.8 511 Canary islands 681.2 653.8 628.2 630.1 614.6 602.2 575.2 568.9 Cantabria 603.6 559 568.4 561 533 529.4 529.3 531.5 Castilla-La Mancha 565.3 569.6 560.6 555.2 532.6 536.7 497.3 509.9 Castilla & Leon 535.7 516.9 529 527.7 502.3 512.6 481.8 489 Catalonia 588.6 580 576.3 584.7 543.9 559 512.3 512 Valencian Community 644.9 637.2 631.7 643.7 596.9 602.4 558.2 557.1 Extremadura 630.7 616.4 614.5 639.3 581.8 603.4 553.7 557.8 Galicia 599.7 574.6 564.7 578.8 542.9 547.9 537.6 536.8 Madrid 549.4 543.1 533.6 543.7 510.3 499.3 472.1 472.6 Murcia 658.2 633.2 629.7 626.5 596.2 591.6 561.1 559.1 Navarre 547.1 522.6 529.3 530.3 497.5 495.3 467.6 471.3 Basque Country 588.7 564.7 566.3 568.5 535.4 536.6 500.7 508 La Rioja 549.4 538.9 546.5 544.1 513.1 526 479.8 498.9 Ceuta 663 660.9 733.5 691.1 665.3 657.1 608 644.6 Melilla 711 645.9 704.2 691.8 671.7 583.9 619.5 578 Source: Ministry of Health and Social Policy (MSPS), 2010 [50]

Table 26 - Ischaemic heart disease. Crude mortality rate per 100,000 population, by region. Spain, 2000-2007

Crude rate 2000 2001 2002 2003 2004 2005 2006 2007

Total 97.6 95.3 95.4 96.1 91 90.6 84.2 82.9

Andalusia 102.2 97.6 100 102.6 97.5 95.8 86.8 85.6 Aragon 101.30 99.20 103.20 102.70 98.00 96.20 93.10 97.80 Asturias 133.20 132.00 146.70 149.10 141.80 140.20 135.10 136.60 Balearic Islands 86.1 80.2 80.2 83.5 75.1 79.2 66.7 66 Canary islands 103.4 102.5 95.8 97.5 89.6 88.9 82.7 86.1 Cantabria 84 64 92 81.3 73 76.5 76.2 79 Castilla-La Mancha 95 98.8 90.7 88.5 82.8 84.4 83.3 79.5 Castilla & Leon 109.60 101.80 103.50 105.50 103.80 103.90 96.90 96.40 Catalonia 87.8 86.8 87.6 87.1 79 79.7 72.3 69 Valencian Community 112.8 112.1 108.3 113 105.5 108.1 99.8 96.7 Extremadura 112.9 109.2 108.7 117.70 104.3 109.60 102.6 104.1 Galicia 108.50 110.60 106.00 104.80 102.00 104.50 102.80 101.80 Madrid 70.5 70.3 70.8 69.3 70.1 64.4 61.6 60.6 Murcia 86.7 79.8 77.8 78.4 76.5 77.9 70 70.6 Navarre 91.2 96.3 92.6 86.5 81.1 80.9 73 70.9 Basque Country 80.9 74.8 75.2 78.1 74 73.8 68.6 69.4 La Rioja 87.9 86.9 87.7 81.3 84.1 83.3 79.5 76.6 Ceuta 68.7 89.5 93.7 71.4 60.2 93.9 62.9 78 Melilla 34.7 36.3 44.1 45 30.2 34.2 49.7 34.5 Source: Ministry of Health and Social Policy (MSPS), 2010 [50]

79

Table 27 - Ischaemic heart disease. Age-adjusted mortality rate per 100,000 population, by region. Spain, 2000-2007

Adjusted rate 2000 2001 2002 2003 2004 2005 2006 2007

Total 65.4 62.6 61.7 61.5 57.3 56.3 51.9 50.4

Andalusia 82.2 77.4 77.9 78.8 73.1 71.1 63.2 61.8 Aragon 54.9 52.2 51.7 50.5 50 46.8 46.6 47.9 Asturias 71.4 67 74.4 73 66.4 64.4 64 61.7 Balearic Islands 62.4 57.7 57.8 58.6 54.1 55 46.4 46.2 Canary islands 99.6 98.2 91.1 91.3 82.2 80.5 73.7 74.5 Cantabria 50.3 35.2 49.7 43.5 38.7 39.9 38.6 39.8 Castilla-La Mancha 55.2 56.1 49.9 49 46.4 46.7 45.5 42.5 Castilla & Leon 54.2 48.9 47.8 48.6 46.3 46.5 42.2 42.1 Catalonia 56 54.5 54 53.3 48.1 47.6 43.7 40.8 Valencian Community 79 76.9 74.2 76.8 71.1 72.1 66.4 63.5 Extremadura 71.1 66.8 65.4 70.4 59.9 60.2 56.8 56.1 Galicia 58.9 58.1 54.6 52.8 50.6 51.5 48.7 47.4 Madrid 52.1 51.6 51.3 50.1 49.5 44.9 42.1 40.9 Murcia 70.1 63.8 61.2 62.6 59.1 60 54.3 54.2 Navarre 55.2 56.5 55.7 50.2 46.4 44.7 40.1 38.9 Basque Country 53.3 47.6 46.9 47.4 43.5 42 38.4 38.5 La Rioja 51.2 49.5 48.4 46.2 46.8 43.6 42.5 41.1 Ceuta 73.9 95.2 95.5 70.7 58.5 88.1 58.8 66.7 Melilla 59.8 62.1 71 70.8 46.1 50.9 66.9 48 Source: Ministry of Health and Social Policy (MSPS), 2010 [50]

Table 28 - Chronic obstructive pulmonary disease. Crude mortality rate per 100,000 population, by region. Spain, 2000-2007

Crude rate 2000 2001 2002 2003 2004 2005 2006 2007

Total 41.3 37.4 40.8 40.7 36.3 40.6 32.5 35

Andalusia 37.3 34.4 38.3 37.4 33.5 39.1 29.6 33.4 Aragon 45.7 39.4 43.1 45 41.3 42.9 35.5 39 Asturias 67.4 55.1 68.8 65.8 61.6 64.5 59.7 62.3 Balearic Islands 38.1 29 31.1 32.3 25.8 31 23.3 23.8 Canary islands 24 22.1 19.5 18.8 20.6 20.4 18.6 21.6 Cantabria 44 35.4 38.5 36.5 31.9 36.6 29.3 34.6 Castilla-La Mancha 45.9 45.2 49.6 50.1 43.7 49.2 39.8 43.8 Castilla & Leon 49.6 45.4 48.4 45.9 43 49.2 40.5 42.6 Catalonia 44.5 40.7 44.8 46.1 39.6 45.7 34.9 36.6 Valencian Community 42 40.4 44.8 42.6 38.4 41.9 34.8 35.2 Extremadura 36.3 35.1 40 42.6 31.8 43.7 29.2 34.2 Galicia 55 49 50.9 54.1 49 53.4 45.8 49 Madrid 28.5 26.4 27.9 27.3 23.8 24.8 20.6 22.5 Murcia 43.2 36.8 42.4 39.2 40.5 36 30.8 35.6 Navarre 40.6 34.9 31.1 41 37.4 39 32.9 35.5 Basque Country 44.2 36.5 42.1 43.9 39.1 47.1 35.7 37.7 La Rioja 38.2 34 35.4 32.6 32.3 40 33 27.5 Ceuta 37.9 28 23.8 35 30.8 36.4 32.2 30.6 Melilla 14.9 12.8 13.7 14.7 11.7 16.6 10.7 16.3 Source: Ministry of Health and Social Policy (MSPS), 2010 [50]

80

Table 29 - Chronic obstructive pulmonary disease. Age adjusted mortality rate per 100,000 population, by region. Spain, 2000-2007

Adjusted rate 2000 2001 2002 2003 2004 2005 2006 2007

Total 25.5 22.8 24.5 24 21.1 23.3 18.3 19.5

Andalusia 28.6 26.1 28.6 27.3 24 27.7 20.4 22.9 Aragon 21.5 18.5 19.3 19.9 18 18.3 15.8 16.9 Asturias 32.2 25.8 31 29.2 25.9 27.7 24.7 25.1 Balearic Islands 26.4 19.5 21.6 22.8 17.9 21.3 16.1 16.4 Canary islands 22.3 20.7 18.1 16.8 18.1 17.5 15.8 17.7 Cantabria 23 18 18.9 18.8 15.6 17.9 13.9 16.2 Castilla-La Mancha 23.8 23.4 25.7 25 21.5 24.6 18.7 21.1 Castilla & Leon 22 19.1 20.5 18.7 17.2 19.2 15.7 16 Catalonia 26.4 23.8 26 26.6 22.6 25.6 19.2 20.2 Valencian Community 27.5 25.9 28.6 27.1 24 26.1 21.4 21.4 Extremadura 21.5 19.8 22.7 23.3 16.6 23.7 15.4 17.5 Galicia 26.4 23.2 23.3 24.1 21.3 22.4 18.9 19.8 Madrid 20.1 18.4 19.1 18.8 16 16.3 13.4 14.3 Murcia 33.2 28.1 32.2 29.2 29.8 26.1 22.2 25 Navarre 21.7 18.1 16.2 20.6 19.1 19.1 16.3 18.2 Basque Country 26.8 21.3 24 23.8 20.8 24.4 18.1 18.8 La Rioja 18.4 16.6 18.6 16.3 15.6 19.1 15.8 13.1 Ceuta 38.9 27.2 23 33.7 27.1 34.3 26.6 26.4 Melilla 27 22.2 20.5 22.9 16.4 24.8 12.6 22.4 Source: Ministry of Health and Social Policy (MSPS), 2010 [50]

Table 30 - Diabetes mellitus. Crude mortality rate per 100,000 population, by region. Spain, 2000-2007

Crude rate 2000 2001 2002 2003 2004 2005 2006 2007

Total 23 23.5 23.6 24 23.3 23.8 22 22.6

Andalusia 24.2 24.5 25.1 24.7 23.1 23.4 22.8 21.5 Aragon 26.2 25.6 29.3 28 27.7 27.9 28.3 28.6 Asturias 33.3 32.1 33.2 30.3 31 31.7 30.3 31.9 Balearic Islands 21.5 20.4 17.4 23.1 21.2 18.7 18.5 19.2 Canary islands 28.4 28.4 28.2 30.4 32.8 36.8 36.2 46 Cantabria 22.4 19.1 19.7 21.8 24.1 28 25.5 22.7 Castilla-La Mancha 30.7 32 31.3 31.8 30.2 31.6 27.1 30.3 Castilla & Leon 25.6 28.2 28.1 27.3 27.9 28.9 28.7 28.1 Catalonia 21.6 22.6 22.8 24.9 24.3 24.9 20.6 22.7 Valencian Community 25 26.2 25.9 25.8 25.6 25.7 23.8 23.4 Extremadura 27.3 30 31.8 29.8 29.7 27.6 27.6 26.7 Galicia 22.9 23.2 21.8 23.5 21.8 22.3 21.8 21 Madrid 13.2 12.8 13.1 12.7 11.6 11.5 9.7 9.9 Murcia 23 23.7 21.8 21.9 19.5 18.7 16.4 15.7 Navarre 18.8 20 19.3 24.6 22.5 23.8 20.8 22.8 Basque Country 21.1 21.3 21.4 22.5 22.3 23.7 21.1 22.6 La Rioja 21.9 28.1 29 24.9 25.4 23.2 19.1 23 Ceuta 30.9 28 28 28 33.6 40.6 28 27.9 Melilla 9.9 13.8 20.6 21.5 26.3 17.6 23.4 15.4 Source: Ministry of Health and Social Policy (MSPS), 2010 [50]

81

Table 31 - Diabetes mellitus. Age-adjusted mortality rate per 100,000 population, by region. Spain, 2000-2007

Adjusted rate 2000 2001 2002 2003 2004 2005 2006 2007

Total 14.4 14.5 14.3 14.4 13.7 13.8 12.5 12.7

Andalusia 18.7 18.6 18.7 18.1 16.7 16.7 15.8 14.9 Aragon 12.9 12.1 13.1 12.1 12.4 11.9 11.6 11.7 Asturias 16.3 15.5 14.9 13.3 13.2 13.8 12.9 12.9 Balearic Islands 14.9 14.1 11.7 16.2 14.4 12.4 12.3 12.8 Canary islands 26.8 26.7 26.3 27.6 29.3 31.9 30.7 38.2 Cantabria 12.1 9.8 9.8 11.3 12 13 12.3 10.8 Castilla-La Mancha 16.3 16.4 16 16.1 14.9 16.2 13.3 14.7 Castilla & Leon 11.3 12.2 11.7 11.1 10.8 11.2 10.9 10.1 Catalonia 13.2 13.4 13.2 14.5 13.8 14.1 11.6 12.6 Valencian Community 16.3 17 16.8 16.6 16.4 16 14.6 14.4 Extremadura 15.8 16.9 17.9 15.9 16.2 14.2 14.5 12.9 Galicia 11.5 11.2 10.4 10.9 9.8 9.6 9.5 8.7 Madrid 9.3 8.9 9.1 8.6 7.8 7.6 6.4 6.2 Murcia 18.2 18.3 16.9 16.6 14.3 14 12.1 11.3 Navarre 11 11.2 10.2 13.1 11.7 12 10.4 11.8 Basque Country 12.7 12.2 12.4 12.4 12 12.6 10.8 11.1 La Rioja 11.6 14.2 15.4 13 12.5 11.3 9.1 10.6 Ceuta 30.6 29.5 27.6 27.2 31.9 37.8 23.1 25.6 Melilla 16.8 24.9 33.3 33.9 41.6 24 29.4 21.8 Source: Ministry of Health and Social Policy (MSPS), 2010 [50]

Table 32 - Average length stay (measured in days) per region in Spain. 2009

all causes Diabetes mellitus

Heart conditions Stroke

COPD & complications

Total 6.9 8.92 8.68 10.75 8.63

Andalusia 6.64 9.65 8.84 10.42 9.515Aragon 7.21 9.76 8.95 12.06 8.65Asturias 7.71 9.32 8.00 11.29 8.66Balearic Islands 5.7 8.89 7.60 10.49 10.12Canary islands 7.2 11.05 10.04 12.97 8.53Cantabria 7.94 11.92 7.52 10.18 8.985Castilla-La Mancha 6.61 8.27 8.18 9.39 7.415Castilla & Leon 7.61 9.32 8.13 10.94 8.93Catalonia 7.3 7.97 8.85 12.58 7.8Valencian Community 5.78 7.09 7.51 9.14 7.57Extremadura 7.27 8.36 8.19 8.39 5.565Galicia 7.92 10.46 8.61 11.78 9.9Madrid 0 0 0.00 0 0Murcia 0 0 0.00 0 0Navarre 6.73 10.99 8.28 11.42 9.4Basque Country 7.09 8.06 7.56 8 7.31La Rioja 6.85 9.25 7.40 8.7 9.55Ceuta 6.35 9.15 9.26 11.81 7.58Melilla 5.92 13.74 9.54 15.97 11.74Source: INE (National Statistics Office), 2011.[2]

82

Table 33 - Evolution of Diraya implementation per module and population coverage

Source: data provided by SAS (Servicio Andaluz de Salud / Andalusian NHS)

Figure 23 - Evolution of chronic health problems reported in Catalonia 1994 – 2006

44,2

57,2

65,5

75,4

83,4 86,690,8

94,7 97,5

0

10

20

30

40

50

60

70

80

90

100

1994 2002 2006

15-44 years 45-64 years 65 or more years

Source: Catalonia Health Survey 2006Error! Bookmark not defined.

83

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European Commission EUR 25442 – Joint Research Centre – Institute for Prospective Technological Studies Title: Strategic Intelligence Monitor on Personal Health Systems, Phase 2. Country Study: Spain Authors: Maria Lluch, Francisco Lupiañez Villanueva Luxembourg: Publications Office of the European Union 2013 – 85 pp. – 21.0 x 29.7 cm EUR – Scientific and Technical Research series –ISSN 1831-9424 (online) ISBN 978-92-79-25740-7(pdf) doi:10.2791/88631 Abstract This study presents and discusses the status for integrated personal health systems (IPHS) in Spain. It aims to illustrate through case studies the patient and health monitoring systems that are available, the level of implementation of these systems, the impact they have on the general socio-economic context, as well as their cost-effectiveness where applicable. The analysis presented in this report is based on interviews with key experts and stakeholders from Spain and a substantial secondary data collection.

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As the Commission’s in-house science service, the Joint Research Centre’s mission is to provide EU policies with independent, evidence-based scientific and technical support throughout the whole policy cycle. Working in close cooperation with policy Directorates-General, the JRC addresses key societal challenges while stimulating innovation through developing new standards, methods and tools, and sharing and transferring its know-how to the Member States and international community. Key policy areas include: environment and climate change; energy and transport; agriculture and food security; health and consumer protection; information society and digital agenda; safety and security including nuclear; all supported through a cross-cutting and multi-disciplinary approach.

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