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PAIN MANAGEMENT IN THE VALENCIA
REGIONAL HEALTH SYSTEM
DR. ALFONSO BATALLER VICENT
Health Deputy Secretary
An outstanding Health system
Along the 20th century Spanish health system has achieved remarkable successes. Nowadays we can state that the Spanish health system is one of the top 10 best health systems worldwide.Universal Health Coverage is part of the guaranteed goods and services that make up the so-called Welfare State all Spanish citizens feel proud of for having guaranteed constitutionallyconsolidating an equitable, universal, free and high quality Health System.Our National Health System is similar to British or Swedish, offering a highly efficient and wide coverage since 1986 that we are extremely proud of.
Good outcomes in healthGood outcomes in health
Health outcomes in Spain are very good: life expectancy at birth is of 81 years. Worldwide, these results are only surpassed by Japan, 83 years, Switzerland and Australia, 82 years, followed by Spain, together with Sweden, France and Italy.Children's mortality rate is of 3.5/1000 born alive infants. Only 10 countries worldwide show these results.Our health system is modern, efficient, universal and of high quality although our concern since the beginning of the 21th century is over SUSTAINABILITY
Health services face similar challenges in all Health services face similar challenges in all developed countriesdeveloped countries
Patients better informed and more demanding
Health expenditure
increase (Health System's
Sustainability)
Introduction of Information and Communication Technologies
Population ageing and new immigration groups
Organization and management changes in
Health Institutions
Increasingly competitive environment
ORGANIZATIONSORGANIZATIONS
ENVIRONMENTENVIRONMENT
4
Valencia Health Agency
� Population SIP: 5.252.877February 2009
Source: INE (Statistics National Institute) andEUROSTAT, November 2006.
Valencia Autonomous Community Budget
Other
Health
5
Health Departments
Valencian Health System is organized in 24 Health Departments corresponding to the areas established in the Health General Law (LGS).
Maximum integration of health protection and promotion actions, and those of prevention, treatment and rehabilitation of health status will be the aim in the sphere of each department, by means of coordinating the existing resources, guaranteeing a HEALTH SYSTEM WITHOUT DIVISIONS…
TARGET.- To offer a dynamic medical and geriatric assistance, efficient and barrier free, that guarantees at all times the quality of assistance accomplishing the purposes stated in the LGS.
VALENCIA REGION HEALTH SYSTEMVALENCIA REGION HEALTH SYSTEM
7
POPULATION COVERED
5.029.601 Valencian citizens5.029.601 Valencian citizens are protected by the Valencia Region Public Health System.• 813,000 are over 65 years of age (16,2% of Valencian population).• 847,000 are foreign residents (16,1% of Valencian population).
HEALTH EXPENDITURE
In 2010, 5,720 million Euros were assigned to cover health needs and to improve our health care network.
• This means 39,74% of Regional Government total budget.• We will spend daily 15.6 million Euros in health care. •223 million Euros are invested in infrastructures and technological equipment.
UNITS, SERVICES, AND CENTRES• 484 medical transport units: 483 by land and one by air. • Over 1,250 centers and functional units make up our health care network.
- 33 are hospitals and 37 are centers giving specialized ambulatory care. - 842 are Primary care centers.
VALENCIA REGION HEALTH SYSTEM IN BIG NUMBERSVALENCIA REGION HEALTH SYSTEM IN BIG NUMBERS
8
HUMAN RESOURCES
•58,000 medical professionals working in our preventive and healthcare network.
•Over 11,000 are physicians.
•Over 14,000 are qualified in nursing.
MEDICAL CARE ASSISTANCE
•67 million medical procedures performed yearly by our health care network.
•Over 10,900 hospital beds.
•400,000 hospital admissions per year.
•300,000 hospital surgical procedures per year.
•Over 2,1 million emergencies assisted per year.
•7.5 million outpatient consultations per year.
PHARMACY
•Over 100 million prescriptions a year. This means over 1,500 million Euros assigned to medicines and health products.
OBSTETRIC PAIN CONTROL
We have increased in 50% analgesic protocols to control labor pain.
We offer Epidural Anesthesia for pain relief during labor in practically all the Hospitals of the Valencian Healthcare Network.
Home Care
Hospital Home Care (HHC) achieved to cover 91% of population in 2010.Services are organized according to activity lines:
Main activity lines:MedicalPost-surgeryPalliative care
Specific activity lines:Mental HealthPediatrics (at the Hospital La Fe, University Clinic Hospital of Valencia, and General Hospital of Alicante)Rehabilitation
HHC is the 1rst hospital of the VHS in number of beds (1,335 vacant hospital beds available/day)HHC is the 3rd hospital in the Valencian Community in number of hospital discharges per year (32,948).In 2009 2 new HHC opened (Torrevieja and Manises), adding up a total of 23 HHC units.With human resources equivalent to 331 full-time dedicated professionals In 2009, over 125,000 telephone consultations were provided by our health care personnel (medical and nursing).
NEW TECHNOLOGIES USED IN PHARMACOLOGICAL TREATMENT OF PAIN
.
Electronic Prescription Service and Electronic Medical Record
• Reduction of bureaucracy in prescription/dispensing
• Improvement of patients access to pain treatments
• Development and introduction of the Electronic prescription for narcotic drugs
• Pharmacological Treatments for pain ⇒ NARCOTIC DRUGS
12VALENCIAN COMMUNITY – Electronic prescription
SIP: 5,348,163 Population covered
Electronic Health Records: 5,322,705 (99.87 %)
Pharmacy Expenditure:Hospital: 495 thousand EurosAmbulatory: 1,687 thousand Euros
Average users/day: 12,500 usersIn Abucasis
• 12,555 patients (8,782 women and 3,773
men) treated with narcotic drugs in July 2010
CRC Suministra Información Corporativa a todos los sistemasCRC Suministra Información Corporativa a todos los sistemas
VALENCIAN COMMUNITY INFORMATION SYSTEMS
GAIA-SICOMEPSAEMPS
CHANNELS
CRC
Corporate resources catalog
SIP
Population information system
E-firmaElectronic signature and access safety
DATA PROCESSING CENTER
PHYSICAL Infrastructure
LOGICAL Infrastructure
357,330,134
ELECTRONIC PRESCRIPTIONS
MILLIONS
20,416,173
MILLIONS
0
20.000.000
40.000.000
60.000.000
80.000.000
100.000.000
2003 2004 2005 2006 2007 2008 2009 sep-10
TOTAL DE RECETAS PRESCRITAS ELECTRONICAMENTE
0
200.000
400.000
600.000
800.000
1.000.000
1.200.000
mar-08
may-08
jul-08
sep-08
nov-08
ene-09
mar-09
may-09
jul-09
sep-09
nov-09
ene-10
mar-10
may-10
jul-10
sep-10
TOTAL DE RECETAS DISPENSADAS ELECTRONICAMENTE
ACTUAL ADVANTAGES OF ELECTRONIC PRESCRIPTION USE
ACCESS TO MEDICAL CARE
CARE QUALITY
ADMINISTRATIVE PROCEDURES
TIME DEDICATED TO DIAGNOSIS
CHRONIC PATIENTS VISITS
REAL-TIME INFORMATION
RATIONAL USE
INVOCING PROCESS
PHARMACIST-DOCTOR COMMUNICATION
Facilitates
Improves
Simplifies
Increases
Reduces
Offers
Helps
Integrates
Achieves
Time saving in medical consultation with electronic prescription ⇒ 20%
Example according to Pathogeny: NEUROPATHIC PAIN…
In the patient's Medical Electronic Record, from the start screen, doctor codifies (ICD-9) a TRIGEMINAL NEURALGIA diagnosis
Prescription module is requested
: NEUROPATHIC PAIN…Example according to Pathogeny :
This diagnosis shows a level of evidence A
INTERACTIVE GFT is selected showing the protocol of choice among other information
Information included for each active principle:
-Adverse effects
-Contraindications
-Recommendations and precautions
-Alerts to take into account during prescription…
Prescription module:
GFAR: Interactive Pharmacotherapeutic Guide
Pioneering System in Spain (until now the guides were not interactive)
Introduces Guides and Clinical Intervention Protocols with interactive and automatic access when prescribing treatments for the 350 more frequent pathologies.
With alerts to wran the doctor when:
1. An inadequate treatmentinadequate treatment has been prescribed for the diagnosis
2. Medicines without sufficient scientific evidence are used for the
pathology
3. Dose does not comply with the scientific societies recommendations
for each type of patient
Prescribes the most effective treatment with the lowest cost
Selected protocol
NEUROPHATIC PAIN …Example according to pathogeny:
Information over characteristics of the recommended medicines
NEUROPHATIC PAINExample according to pathogeny:
Once pharmacological treatment is selected
Dosage is established or checked when provided by the system
Prescription acceptance
SINGLE CONVENTION ON NARCOTIC DRUGS, 1961SINGLE CONVENTION ON NARCOTIC DRUGS, 1961
1.- Agreement Project
2.- Reunion of the Council to ratify the agreement project
3.-Resolution of the Valencia Regional Minister of Health, for the introduction of the narcotic drugs electronic prescription program
September 12th, 2008
December 11th, 2008
PROVISIO
NAL
December 11th, 2008
NARCOTIC DRUGS ELECTRONIC PRESCRIPTION ADMINISTRATIVE ACT
4.-Collaboration agreement between the Spanish Agency of Medicines and Healthcare Products (AEMPS) and the
Valencia Regional Council of Health (Consellería de
Sanidad)
December 22th, 2008
AGREEMENT BETWEEN THE
AEMPS AND THE COUNCIL OF
HEALTH PUBLICATION IN THE
OFFICIAL STATE GAZETTE
(BOE, JANUARY 29th, 2009)
NARCOTIC DRUGS ELECTRONIC
PRESCRIPTION
NARCOTIC DRUG ELECTRONIC PRESCRIPTION
1) At the Screen for Prescription: Select the medicines repository for the
narcotic drug
2) OPTIONAL search in the
interactive Pharmacotherapeutic
guide
3) Fill in dosage (system
calculates packages)
4) A current treatments report is
printed out for the patient (patient
receives more information about
treatments)
• Packages and cost of narcotic drugs consumed during the period between January 2000 and July 2010 (monthly)
• List of most widely used active ingredients during the first half of the year from 2006 to 2010 (six-monthly)
• Progress of Daily Dose per Inhabitant (DHD) for Narcotic Drugs in the Valencia Community, 2002-2010 (yearly)
• Patients on treatment with narcotic drugs: includes number of patients treated with narcotic drugs from January 2008 to July 2010 (monthly)
• Packages and cost of narcotic drugs per province, 2007-2009 (yearly)
• Cost per dose for narcotic drugs during the 2000 -2010 period (yearly)
DATA OF NARCOTIC DRUGS CONSUMPTION IN THE VALENCIA REGION
0
5000
10000
15000
20000
25000
30000
35000
40000
45000
ene-00may-00sep-00ene-01may-01sep-01ene-02may-02sep-02ene-03may-03sep-03ene-04may-04sep-04ene-05may-05sep-05ene-06may-06sep-06ene-07may-07sep-07ene-08may-08sep-08ene-09may-09sep-09ene-10may-10
Envases
In February 2009 the electronic prescription of narcotic drugs was introduced showing a 43% increase in packages consumed until June 2010.
Month/Year Packages Cost
feb-09 25.988 1.444.992,15
jul-10 37.151 1.467.853,82
Narcotic drugs packages dispensed in the CV. Period 2002-2010
43 %
Is this g
ood or b
ad?
0
200000
400000
600000
800000
1000000
1200000
1400000
1600000
1800000
ene-00may-00sep-00ene-01may-01sep-01ene-02may-02sep-02ene-03may-03sep-03ene-04may-04sep-04ene-05may-05sep-05ene-06may-06sep-06ene-07may-07sep-07ene-08may-08sep-08ene-09may-09sep-09ene-10may-10
Cost (€)
Narcotic drugs
electronic prescription
Price cut Regulation SCO/3803/2008 (RD. 1338/2006)
COST OF NARCOTIC DRUG PACKAGES DISPENSED IN THE CV. 2002-2010
A little o
r a lot o
f money
?
May 2010
0
0,5
1
1,5
2
2,5
3
DHD 0,8749 0,944 1,037 1,2976 1,4543 1,641 1,8817 2,2473 2,5648
2002 2003 2004 2005 2006 2007 2008 2009 2010
PROGRESS OF NARCOTIC DRUGS DHD IN THE CV. 2002-2010 PERIOD
A raise in the use of narcotic drugs is observed as shown by DHD (number of patients on daily treatment with narcotic drugs per each 1,000 inhabitants has
increased)
Up to September
0
2000
4000
6000
8000
10000
12000
14000
ene-08
feb-08
mar-08
abr-08
may-08
jun-08
jul-08
ago-08
sep-08
oct-08
nov-08
dic-08
ene-09
feb-09
mar-09
abr-09
may-09
jun-09
jul-09
ago-09
sep-09
oct-09
nov-09
dic-09
ene-10
feb-10
mar-10
abr-10
may-10
jun-10
jul-10
Hombre Mujer
PATIENTS ON TREATMENT WITH NARCOTIC DRUGS IN THE CV.
JANUARY 2008-JULY 2010 PERIOD (MONTHLY).
y = 186,1x + 3147,5
y = 75,771x + 1430,1
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
10000
0 10 20 30 40
Hombre
Mujer
Lineal (Mujer)
Lineal (Hombre)
Growth tendency is higher
in women than men
Men
Women
Linear (women)
Linear (men)
PATIENTS ON TREATMENT WITH NARCOTIC DRUGS BY SEX AND AGE RANGE
JULY 2010 DATA
Age range Total sip Total men Total women % men % women
11..14 AÑOS 1 1 0 100,00 0,00
15..20 AÑOS 7 3 4 42,86 57,14
21..25 AÑOS 24 12 12 50,00 50,00
26..30 AÑOS 60 25 35 41,67 58,33
31..35 AÑOS 143 75 68 52,45 47,55
36..40 AÑOS 260 126 134 48,46 51,54
41..45 AÑOS 403 190 213 47,15 52,85
46..50 AÑOS 593 264 329 44,52 55,48
51..55 AÑOS 741 311 430 41,97 58,03
56..60 AÑOS 869 355 514 40,85 59,15
61..65 AÑOS 1.190 424 766 35,63 64,37
66..70 AÑOS 1.391 457 934 32,85 67,15
71..75 AÑOS 1.678 452 1.226 26,94 73,06
76..80 AÑOS 2.106 508 1.598 24,12 75,88
81..85 AÑOS 1.834 362 1.472 19,74 80,26
86..90 AÑOS 974 165 809 16,94 83,06
MAYOR O IGUAL A 91 AÑOS 281 43 238 15,30 84,70
TOTAL 12.555 3.773 8.782 30,05 69,95
0
10
20
30
40
50
60
70
80
90
100
% mujeres
% hombres
From the age of 60
years, percentage of
women ranges
between 64-83%
FENTANYL
FENTANYL
FENTANYL FENTANYL
FENTANYL
MORPHINE MORPHINE MORPHINE MORPHINEMORPHINE
OXYCODONE OXYCODONE OXYCODONE
OXYCODONE OXYCODONE
0
20000
40000
60000
80000
100000
120000
140000
160000
Envases Enero-junio 2006 Envases Enero-junio 2007 Envases Enero-junio 2008 Envases Enero-junio 2009 Envases Enero-junio 2010
Packages
Narcotic drugs electronic
prescription introduction
The most widely used active ingredients before and after narcotic drugs electronic prescription continue being FENTANYL, MORPHINE and OXYCODONE
MOST WIDELY USED NARCOTIC DRUG ACTIVE INGREDIENTS IN THE CV.
Packages January-June 2006 Packages January-June 2007 Packages January-June 2008 Packages January-June 2009 Packages January-June 2010
0
20.000
40.000
60.000
80.000
100.000
120.000
140.000
160.000
180.000
200.000
Envases
CASTELLÓN 22.142 26.649 36.137
VALENCIA 131.438 150.271 189.429
ALICANTE 81.840 103.412 130.464
2007 2008 2009
PACKAGES AND COST OF NARCOTIC DRUGS DISPENSED BY PROVINCES.
2007-2009 PERIOD
0
1.000.000
2.000.000
3.000.000
4.000.000
5.000.000
6.000.000
7.000.000
8.000.000
9.000.000
10.000.000
Importe (€)
CASTELLÓN 1.281.143 1.511.013 1.714.500
VALENCIA 7.721.611 8.889.030 9.229.610
ALICANTE 4.612.138 5.725.036 6.070.239
2007 2008 2009
CostPackages
The growth tendency in packages and
costs is similar to total data tendency
0,00
5,00
10,00
15,00
20,00
25,00
30,00
35,00
40,00
Crecimiento08/07 Crecimiento09/08
% Increase
INCREASE PERCENTAGE OF NARCOTIC DRUG PACKAGES DISPENSED BY
PROVINCES. 2007/2008 AND 2008/2009 PERIOD
Increase percentage is higher following introduction of narcotic drugs electronic prescription, being more acute in the province of Castellon.
Castellon dispenses electronically “from all pharmacies” since November 2008.
CASTELLON
0,00
0,50
1,00
1,50
2,00
2,50
3,00
3,50
4,00
4,50
5,00
5,50
2002 2003 2004 2005 2006 2007 2008 2009 2010
Coste/Dosis
COST PER NARCOTIC DRUG DOSE. 2000 – 2010 PERIOD
We can observe a decrease in the cost per narcotic drug dose since year 2008, which indicates a tendency of CV prescribers to select more efficient medications
CONCLUSIONS FROM DATA ANALISED ON NARCOTIC DRUGS USE IN THE CV
1.- THE NARCOTIC DRUGS ELECTRONIC PRESCRIPTION has
decreased bureaucracy in medical consultation (up to 20%) facilitating
the prescription of narcotic drugs.
2.- One of the reasons for the increase in number of packages
prescribed is that a higher number of patients are being treated,
mainly women in the third stage of their life.
3.- The decrease in cost per dose since 2008 in the CV, shows a
tendency to select more efficient medications in prescription.
0
0,5
1
1,5
2
2,5
3
DHD 0,8749 0,944 1,037 1,2976 1,4543 1,641 1,8817 2,2473 2,5648
2002 2003 2004 2005 2006 2007 2008 2009 2010
NARCOTIC DRUGS DHD PROGRESS IN THE CV. 2002-2010 PERIOD
A raise in narcotic drugs use is observed, as shown by DHD progress (daily dose per
1,000 inhabitants). Number of patients treated on a daily basis with narcotic drugs has increased
Up to September
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