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