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      Variations in osteoporosis medication utilization. A population-based ecological cross-sectional study in the region of Valencia, Spain

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          Abstract

          Little is known about the contextual variability in osteoporosis medication utilization. Our aims were 1) to describe variations in utilization and spending on osteoporotic medication between the Primary Care Health Zones (PHZ) of the Valencia region, Spain, 2) to analyze observed variations using Small Area Variation Analysis methods, and 3) to quantify the influence of the specialized care level on variations in utilization. We conducted a population-based cross-sectional ecological study of expenditure and utilization of five therapeutic groups marketed as osteoporosis treatments in Spain in 2009. The unit of analysis was the PHZ (in total 240) nested in the 23 Hospital Healthcare Departments (HHD) of the region of Valencia, covering a population of about 4.9 million inhabitants. Drug utilization was measured by dispensed Defined Daily Dose per 1000 women aged 50 years old and over and day (DID) per PHZ and cost was measured by the annual osteoporosis drug cost per woman aged 50 and older as well as the average price of DDD (Defined Daily Dose) in each PHZ. We calculated Indirect Standardized Drug Utilization Ratios (ISR) and we used Spearman’s correlation to analyze associations between the ISRs of the different therapies. The average osteoporosis drug consumption was 119.1 DID, ranging from 77.6 to 171.3 DID (2.2 times higher) between PHZs in the 5th and 95th percentiles. Annual expenditure also showed a two-fold variation among PHZs. Average prices of the DDD by therapeutic group showed very low or no variation, although they differed substantially among therapeutic groups. Regarding the standardized consumption of osteoporotic drugs, HHDs explained a substantial part (39%) of the variance among PHZs. In conclusion, there is considerable variability in the volume and choice of anti-osteoporotic treatments between PHZs. with HHDs explaining an important proportion of the variation in utilization. Interventions aimed at reducing variation to improve appropriate care should take into account both the PHZ and HHD levels of care.

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          Is there much variation in variation? Revisiting statistics of small area variation in health services research

          Background The importance of Small Area Variation Analysis for policy-making contrasts with the scarcity of work on the validity of the statistics used in these studies. Our study aims at 1) determining whether variation in utilization rates between health areas is higher than would be expected by chance, 2) estimating the statistical power of the variation statistics; and 3) evaluating the ability of different statistics to compare the variability among different procedures regardless of their rates. Methods Parametric bootstrap techniques were used to derive the empirical distribution for each statistic under the hypothesis of homogeneity across areas. Non-parametric procedures were used to analyze the empirical distribution for the observed statistics and compare the results in six situations (low/medium/high utilization rates and low/high variability). A small scale simulation study was conducted to assess the capacity of each statistic to discriminate between different scenarios with different degrees of variation. Results Bootstrap techniques proved to be good at quantifying the difference between the null hypothesis and the variation observed in each situation, and to construct reliable tests and confidence intervals for each of the variation statistics analyzed. Although the good performance of Systematic Component of Variation (SCV), Empirical Bayes (EB) statistic shows better behaviour under the null hypothesis, it is able to detect variability if present, it is not influenced by the procedure rate and it is best able to discriminate between different degrees of heterogeneity. Conclusion The EB statistics seems to be a good alternative to more conventional statistics used in small-area variation analysis in health service research because of its robustness.
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            Comparing local and regional variation in health care spending.

            Wide geographic variation in health care spending has generated both concern about inefficiency and policy debate about geographic-based payment reform. Evidence regarding variation has focused on hospital referral regions (HRRs), which incorporate numerous local hospital service areas (HSAs). If there is substantial variation across local areas within HRRs, then policies focusing on HRRs may be poorly targeted. Using prescription drug and medical claims data from a 5% random sample of Medicare beneficiaries from 2006 through 2009, we compared variation in health care spending and utilization among 306 HRRs and 3436 HSAs. We adjusted for beneficiary-level demographic characteristics, insurance status, and clinical characteristics. There was substantial local variation in health care (drug and nondrug) utilization and spending. Furthermore, many of the low-spending HSAs were located in high-spending HRRs, and many of the high-spending HSAs were in low-spending HRRs. For drug spending, only 50.7% of the HSAs located within the borders of the highest-spending quintile of HRRs were in the highest-spending quintile of HSAs; conversely, only 51.5% of the highest-spending HSAs were located within the borders of the highest-spending HRRs. Similar patterns were observed for nondrug spending. The effectiveness of payment reforms in reducing overutilization while maintaining access to high-quality care depends on the effectiveness of targeting. Our analysis suggests that HRR-based policies may be too crudely targeted to promote the best use of health care resources. (Funded by the Institute of Medicine and others.).
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              Sources of regional variation in Medicare Part D drug spending.

              Sources of regional variation in spending for prescription drugs under Medicare Part D are poorly understood, and such variation may reflect differences in health status, use of effective treatments, or selection of branded drugs over lower-cost generics.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Formal analysisRole: Funding acquisitionRole: MethodologyRole: SupervisionRole: ValidationRole: Writing – original draftRole: Writing – review & editing
                Role: Data curationRole: Formal analysisRole: MethodologyRole: ValidationRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: MethodologyRole: Validation
                Role: ConceptualizationRole: Formal analysisRole: Funding acquisitionRole: MethodologyRole: Validation
                Role: MethodologyRole: ValidationRole: Writing – original draftRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                21 June 2018
                2018
                : 13
                : 6
                : e0199086
                Affiliations
                [1 ] Center for Public Health Research (CSISP-FISABIO), Valencia, Spain
                [2 ] Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
                [3 ] Navarrabiomed, Navarra Biomedical Centre, Pamplona, Navarra, Spain
                UiT The Arctic University of Norway, NORWAY
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Author information
                http://orcid.org/0000-0001-7098-4576
                http://orcid.org/0000-0002-4313-3976
                Article
                PONE-D-17-22089
                10.1371/journal.pone.0199086
                6013112
                29927952
                8e71bf75-42af-47a8-8c2e-6b89a5664c80
                © 2018 Sanfélix-Gimeno et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 9 June 2017
                : 31 May 2018
                Page count
                Figures: 0, Tables: 4, Pages: 12
                Funding
                Funded by: Department of Health of the Autonomous Government of Valencia
                Award ID: 047/2010
                Award Recipient :
                Funded by: funder-id http://dx.doi.org/10.13039/501100004587, Instituto de Salud Carlos III;
                Award ID: PI09/90882
                Funded by: funder-id http://dx.doi.org/10.13039/501100004587, Instituto de Salud Carlos III;
                Award ID: PI13/01721
                This project was partially funded by the Department of Health of the Autonomous Government of Valencia (Project 047/2010, www.san.gva.es) and the Instituto de Salud Carlos III from the Spanish Ministry of Health (Project PI09/90882 and PI13/01721, www.isciii.es). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article
                Medicine and Health Sciences
                Rheumatology
                Connective Tissue Diseases
                Osteoporosis
                Medicine and Health Sciences
                Women's Health
                People and places
                Geographical locations
                Europe
                European Union
                Spain
                Biology and Life Sciences
                Biochemistry
                Hormones
                Parathyroid Hormone
                Medicine and Health Sciences
                Pharmaceutics
                Drug Therapy
                Medicine and Health Sciences
                Health Care
                Health Care Policy
                Drug Policy
                Medicine and Health Sciences
                Public and Occupational Health
                Drug Policy
                Medicine and Health Sciences
                Pharmacology
                Drugs
                Physical Sciences
                Chemistry
                Chemical Elements
                Strontium
                Custom metadata
                All relevant data are within the paper and its Supporting Information files.

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