Health System In Spain Research Articles

Status of Private Rheumatology in Spain

IntroductionRheumatologic care is offered by the National Health System in Spain. However, more than a quarter of health spending is carried out in private medicine. Currently, there are no data about the number of rheumatologists with private activity in Spain. ObjectivesTo evaluate the number of rheumatologists with private activity in Spain and to describe the profile and location of these professionals. Material and methodsA survey was developed and sent from the SER Commission on Private Practice to all SER active members. Data collection ends in December 2014. A descriptive statistical analysis and comparison of results was done. Results759 answers from a total of 980 surveys sent (77.45%) were obtained; 38% of Spanish rheumatologists have private activity; 13% exclusively private practice and 25% private practice shared with his or her public activity. The private practice rheumatologist profile is: male, 49 years old with 19 years of experience after finishing the specialty and with a working day of 42h per week. There is a clear predominance of private practice in the Autonomous Community of Catalonia with 28% of the total, followed by Madrid 18%, Andalusia 12% and Valencia 8%. Conclusions38% of Spanish rheumatologists are working in private practice. The profile of professionals working in private practice is different from that of those who work exclusively in public health.Private rheumatology is located in all regions, although most private rheumatologists are located in the regions of Catalonia, Madrid, Valencia and Andalusia, representing more than 50% of the total.

The great challenge of the public health system in Spain.

Article 43 of the Spanish Constitution of 1978 establishes the right to health protection and healthcare for all citizens (1). The political organization of the Spanish state is made up of the central state and 17 highly decentralized regions (termed autonomous communities) with their respective governments and parliaments. In terms of health care, political devolution to regional governments has been incrementally implemented over the last 35 years. The taking-up of responsibilities in the field of health by the autonomous communities brings the management of healthcare closer to citizens and guarantees (2): Equity: access to benefits and right to health protection under conditions of effective equality throughout the country and free movement of all citizens. Quality: in the evaluation of the benefit delivered by clinical actions, incorporating only those which contribute added value to the improvement of health, implicating the healthcare system. Participation: public of citizens both in respect for the autonomy of their individual decisions as well as in the consideration of their expectations as users of the healthcare system. Spanish health system Over the last years, the establishment of health systems providing universal coverage in the most advanced European countries has contributed to a permanent improvement in many health indicators like population health status parameters, health care amenable outcomes, coverage, access and financial equity parameters, health care quality, users’ satisfaction and system legitimated by the population. According to the last OECD (Organisation for Economic Co-operation and Development) health statistics report, Spanish life expectancy is the highest in Europe (2.7 years above average) (3), clinical results are at the level of the most advanced countries (same cancer survival rates as in Sweden, France or Germany) (4) and its cost is on the average of the 35 OECD economies, in terms of total spending on gross domestic product (GDP), 9%, and below the average if we compare it in terms of per capita spending (5,6). In addition, it is an international benchmark for its universality and level of access compared to many other developed countries. This improvement in all these parameters has been associated to a continued increase in health spending. In all EU countries (including Spain), during most of the second half of the 20th century, health expenditure has been growing faster than national income. The same is happening in all member countries of the OECD, so this situation calls into question whether the economic sustainability of healthcare systems, most of which were created and developed in times of greater prosperity, will be guaranteed in the future (7). In the context of a worldwide economic crisis, the impact of financial difficulties of healthcare systems has become particularly evident in Spain, where unemployment rate is one of the highest in the European Union.

Transdiagnostic Cognitive Behavioral Therapy Versus Treatment as Usual in Adult Patients With Emotional Disorders in the Primary Care Setting (PsicAP Study): Protocol for a Randomized Controlled Trial.

BackgroundDemand for primary care (PC) services in Spain exceeds available resources. Part of this strong demand is due to the high prevalence of emotional disorders (EDs)—anxiety, depression, and somatic symptom disorders—and related comorbidities such as pain or chronic illnesses. EDs are often under- or misdiagnosed by general practitioners (GPs) and, consequently, treatment is frequently inadequate.ObjectiveWe aim to compare the short- and long-term effectiveness of group-delivered transdiagnostic cognitive behavioral therapy (TD-CBT) versus treatment as usual (TAU) in the treatment of EDs in the PC setting in Spain. We also aim to compare the effect of these treatments on disability, quality of life, cognitive-emotional factors, and treatment satisfaction.MethodsHere we present the study design of a two-arm, single-blind, randomized controlled trial (N=1126) to compare TAU to TD-CBT for EDs. TAU will consist primarily of pharmacological treatment and practical advice from the GP while TD-CBT will be administered in seven 90-minute group sessions held over a period ranging from 12 to 14 weeks. Psychological assessments are carried out at baseline (ie, pretreatment); posttreatment; and at 3-, 6-, and 12-month follow-up. The study is conducted in approximately 26 PC centers from the National Health System in Spain.ResultsThis study was initiated in December 2013 and will remain open to new participants until recruitment and follow-up has been completed. We expect all posttreatment evaluations to be completed by December 2017, and follow-up will end in December 2018.ConclusionsWe expect the TD-CBT group to have better results compared to TAU on all posttreatment measures and that this improvement will be maintained during follow-up. This project could serve as a model for use in other areas or services of the National Health System in Spain and even in other countries.ClinicalTrialInternational Standard Randomized Controlled Trial Number (ISRCTN): 58437086; http://www.isrctn.com/ISRCTN58437086 (Archived by WebCite at http://www.webcitation.org/6mbYjQSn3)

Estado de la reumatología privada en España

IntroductionRheumatologic care is offered by the National Health System in Spain. However, more than a quarter of health spending is carried out in private medicine. Currently, there are no data about the number of rheumatologists with private activity in Spain. ObjectivesTo evaluate the number of rheumatologists with private activity in Spain and to describe the profile and location of these professionals. Material and methodsA survey was developed and sent from the SER Commission on Private Practice to all SER active members. Data collection ends in December 2014. A descriptive statistical analysis and comparison of results was done. Results759 answers from a total of 980 surveys sent (77.45%) were obtained; 38% of Spanish rheumatologists have private activity; 13% exclusively private practice and 25% private practice shared with his or her public activity. The private practice rheumatologist profile is: male, 49 years old with 19 years of experience after finishing the specialty and with a working day of 42hours per week. There is a clear predominance of private practice in the Autonomous Community of Catalonia with 28% of the total, followed by Madrid 18%, Andalusia 12% and Valencia 8%. Conclusions38% of Spanish rheumatologists are working in private practice. The profile of professionals working in private practice is different from that of those who work exclusively in public health.Private rheumatology is located in all regions, although most private rheumatologists are located in the regions of Catalonia, Madrid, Valencia and Andalusia, representing more than 50% of the total.

What, who, when, where and how to inform patients after an adverse event: A qualitative study

ObjectiveTo explore suggestions and recommendations for conducting open disclosure with a patient after an adverse event in a setting without professionals’ legal privileges. MethodQualitative study conducting focus groups/Metaplan. This study was conducted with physicians and nurses from Primary Care and Hospitals working in the public health system in Spain. ResultsTwenty-seven professionals were involved 8–30 years of experience, 15 (56%) medical and 12 (44%) nurses, 13 (48%) worked in hospitals. Consensus was obtained on: how (honesty and open and direct language), where (avoid corridors, with privacy), and when to disclose (with agility but without precipitation, once information is obtained, and after reflecting on the most suitable according to the nature of the AE). There was controversy as to what to say to the patient when the AE had serious consequences and doubts about what type of incidents must be reported; who should be required to disclose (the professional involved in the AE or other professional related to the patient, the role of the staff and the management team); and in which cases an apology can be a problem. ConclusionsThe severity of the AE determines who should talk with the patient in both hospital and primary care. The most appropriate way to convey an apology to the patient depends of the AE. An early, direct, empathetic and proactive action accompanied by information about compensation for the harm suffered could reduce the litigation intention.

State of Training, Clinical Services, and Research on Dual Disorders Across France, India, Israel, and Spain

ABSTRACTObjective: This article overviews training, clinical services, and research on dual disorders across four countries: France, India, Israel, and Spain. Methods: The current dual disorders systems in each of the four countries were reviewed, with a focus on strengths and limitations of each. Results: In France, psychiatric care occurs within the public health care system and involves little training of medical graduates for managing dual disorders. Special courses and forums for specialists have recently started to meet the growing interest of physicians in learning how to manage dual disorders. The Indian health care system grapples with a large treatment gap for mental disorders, and while some treatment services for dual disorders exist, specific research and training efforts on dual disorders are just beginning. Israel has both public- and private sector services for patients with dual disorders, with specialized inpatient and emergency care for the acutely ill as well as day care and therapeutic communities for long-term management. Interest by researchers is growing, but training and education efforts in dual disorders are, however, minimal. Similar to the other countries, addiction and psychiatry disciplines are governed by separate divisions within the National Health System in Spain. There are some dual disorders services available, but they are limited in scope. While medical professionals clearly recognize the importance of dual disorders, there is no such recognition by the national and regional governing bodies. Conclusions: The common thread in various aspects of dual disorder management in each of these four countries is that there is a lower-than-desirable level of attention to dual disorders in terms of care, policy, research, and training. There are growing opportunities for training and continuing education in dual disorders management. We suggest that nations could learn from each other's experiences on how to address the issue of dual disorders.

DEA-Like Efficiency Ranking of Regional Health Systems in Spain

The last decades have witnessed an increasing international concern in assessing how efficiently health care resources are used in producing health. At a country level, comparing the efficiency of regional health systems and ranking the regions accordingly promotes transparency policies and represents an important incentive for the design and implementation of specific programs aimed at improving the quality of health care services within the country. The use of data envelopment analysis (DEA) as a tool for efficiency analysis in the health sector is well-established, but its use with a ranking purpose is discouraged due to lack of discrimination and comparability issues. Using data from the competent health authority in Spain, the purpose of this study is to assess the efficiency of the regional health systems in Spain and identify those regions that are using their health care inputs more efficiently than others, given the observed level of health outcomes. To this aim, a DEA-based model that operates under a common weights basis is used in order to improve discrimination and establish a common scale for a proper comparison of the regional health systems in Spain that can be subsequently ranked by their efficiency score.

What, who, when, where and how to inform patients after an adverse event: a qualitative study.

To explore suggestions and recommendations for conducting open disclosure with a patient after an adverse event in a setting without professionals' legal privileges. Qualitative study conducting focus groups/Metaplan. This study was conducted with physicians and nurses from Primary Care and Hospitals working in the public health system in Spain. Twenty-seven professionals were involved 8-30 years of experience, 15 (56%) medical and 12 (44%) nurses, 13 (48%) worked in hospitals. Consensus was obtained on: how (honesty and open and direct language), where (avoid corridors, with privacy), and when to disclose (with agility but without precipitation, once information is obtained, and after reflecting on the most suitable according to the nature of the AE). There was controversy as to what to say to the patient when the AE had serious consequences and doubts about what type of incidents must be reported; who should be required to disclose (the professional involved in the AE or other professional related to the patient, the role of the staff and the management team); and in which cases an apology can be a problem. The severity of the AE determines who should talk with the patient in both hospital and primary care. The most appropriate way to convey an apology to the patient depends of the AE. An early, direct, empathetic and proactive action accompanied by information about compensation for the harm suffered could reduce the litigation intention.

Health-Sector Responses to Intimate Partner Violence: Fitting the Response Into the Biomedical Health System or Adapting the System to Meet the Response?

This study aims to analyze how middle-level health systems' managers understand the integration of a health care response to intimate partner violence (IPV) within the Spanish health system. Data were obtained through 26 individual interviews with professionals in charge of coordinating the health care response to IPV within the 17 regional health systems in Spain. The transcripts were analyzed following grounded theory in accordance with the constructivist approach described by Charmaz. Three categories emerged, showing the efforts and challenges to integrate a health care response to IPV within the Spanish health system: "IPV is a complex issue that generates activism and/or resistance," "The mandate to integrate a health sector response to IPV: a priority not always prioritized," and "The Spanish health system: respectful with professionals' autonomy and firmly biomedical." The core category, "Developing diverse responses to IPV integration," crosscut the three categories and encompassed the range of different responses that emerge when a strong mandate to integrate a health care response to IPV is enacted. Such responses ranged from refraining to deal with the issue to offering a women-centered response. Attempting to integrate a response to nonbiomedical health problems as IPV into health systems that remain strongly biomedicalized is challenging and strongly dependent both on the motivation of professionals and on organizational factors. Implementing and sustaining changes in the structure and culture of the health care system are needed if a health care response to IPV that fulfills the World Health Organization guidelines is to be ensured.

Evolución de las hospitalizaciones potencialmente evitables por condiciones crónicas en España

ObjectiveTo analyse the trend in potentially avoidable hospitalisations (PAH) in frail patients or those with chronic conditions in Spain during the period 2002-2013. MethodsAn observational, ecological study was conducted to analyse the trend in age-sex standardised rates of PAH affecting six clinical conditions, and their variation, in the 203 health care areas composing the publicly-funded health system in Spain. ResultsDuring the period 2002-2013, overall PAH standardised rates decreased by 35%, but systematic variation remained moderately high, around 13% above that expected by chance. Angina admissions showed the largest reduction, followed by those for asthma and chronic obstructive pulmonary disease. In contrast, the prevalence of admissions for dehydration doubled. ConclusionsDespite the decrease in PAH rates, systematic variation among areas remains, indicating differences in chronic care management that lead to distinct healthcare outcomes.

The State of the Art of Group Psychotherapy in Spain

(1) What is the history and the theoretical orientation of group therapy in Spain? (2) How is training organized? (3) What role does group psychotherapy play in the health system in Spain? (4) What is the relationship between group psychotherapy research and clinical practice in Spain? (5) What topics can be identified as unique to therapy groups in Spain? (6) How are group-related issues important within the social background of Spain? and (7) What does group work hold for the future? Although not even a century has passed since the birth of this discipline, there have already been many events associated with the management of power and knowledge, the development of a sense of community, and the evolution of the political and social life of our country. Group therapy training is still evolving and is properly supported and accredited by prestigious institutions. In the 2013 Symposium of the Spanish Society of Group Psychotherapy and Group Techniques (SEPTG), the need for joint group theories and techniques within the profession’s activities was clearly highlighted. Further, the enthusiasm of group psychotherapists to open themselves to specific social perspectives (health, education, community prevention, organizations) is a way of encouraging society to untangle conscious and unconscious knots that are created in social interaction.

Gasto económico del tratamiento del dolor irruptivo

This article presents two pharmacoeconomic studies comparing the compressedfentanyl lozengewith an integral oromucosalapplicator (Actiq®); fentanyl sublingual tablets(Abstral®); effervescent fentanyl buccal tablets(Effentora®) and nasal fentanyl with two technologies: a formulation that contains pectin in a gel-based nasal spray (PecFent®) and another formulation in an aqueous solution without pectin (Instanyl®). The first of these studies aimed to analyze the potential savings due to the progressive introduction of fentanyl pectin nasal spray for the treatment of adult patients with breakthrough cancer pain. The second study aimed to determine the effectiveness and efficiency of fentanyl pectin nasal spray compared with the other tansmucosal treatments currently on the market. The first study showed a reduction in healthcare costs with the progressive introduction of fentanyl pectin nasal spray for the treatment of breakthrough pain in the publicly-funded health system in Spain. The second study showed that the most efficient option (greatest effectiveness and lowest cost) in all the cases analyzed was the fentanyl-pectin nasal spray.

Health care circuit for patients with soft tissue sarcomas of the extremities. A tortuous and slow road to referral units

ObjectiveTo analyze the waiting periods elapsed since soft tissue sarcomas become symptomatic until their specific treatment in our unit, and to determine new strategies for the improvement of referral circuits. Material and methodsThis is an ambispective observational study of a cohort of 61 patients, with previously untreated soft tissue sarcomas, obtained from our musculoskeletal tumors database. Several variables related to the patient, tumor, and health care circuit were analyzed, as well as the different periods between the initial symptoms of the disease and the first consultation in our unit. The significance level was α=0.05. ResultsThe mean size of the sarcomas was 11.3cm. Thirty-six patients (59%) followed the usual circuit of the National Health System in Spain. The time elapsed since the disease became symptomatic until the first medical consultation was greater than 9.5 months, and nearly another 8.5 months to the consultation in our specific unit. Statistically significant relationships were found between the independent and dependent variables. DiscussionThe study shows that the care of patients with soft tissue sarcomas in our environment is far away from the times of care in our neighboring countries. ConclusionsIt is essential to make the population and health professionals aware of this disease, as well as to remember that there is a referral circuit that must be used.

Circuito de asistencia a pacientes con sarcomas de partes blandas de las extremidades: un tortuoso y lento camino hasta las unidades de referencia

ObjectiveTo analyse the waiting periods elapsed since soft tissue sarcomas become symptomatic until their specific treatment in our unit, and to determine new strategies for the improvement of referral circuits. Material and methodsThis is an ambispective observational study of a cohort of 61 patients, with previously untreated soft tissue sarcomas, obtained from our Musculoskeletal Tumors Database. Several variables related to the patient, tumour, and health care circuit were analysed, as well as the different periods between the initial symptoms of the disease and the first consultation in our unit. The significance level was α=0.05. ResultsThe mean size of the sarcomas was 11.3cm. Thirty-six patients (59%) followed the usual circuit of the National Health System in Spain. The time elapsed since the disease became symptomatic until the first medical consultation was greater than 9.5 months, and nearly another 8.5 months to the consultation in our specific unit. Statistically significant relationships were found between the independent and dependent variables. DiscussionThe study shows that the care of patients with soft tissue sarcomas in our environment is far away from the times of care in our neighbouring countries. ConclusionsIt is essential to make the population and health professionals aware of this disease, as well as to remember that there is a referral circuit that must be used.

EPA-1394 – Spain health system performance

Health is considered a right in the Spanish constitution and is financed through a very strict tax system. Health care covers 100% of the population and 100% of the needs, including even illegal immigrants. The main problem of Spanish Health Care is that it has been transferred to the 17 different Autonomous Communities existing in Spain (regions with high administrative and political autonomy) which are the providers. In order to offer better services (and have more chances to be reelected) the autonomous communities have in the years before the crisis overspent circa 30% of their budget every year in health care, education and other services. The present economic crisis is forcing to better management and more standardization of the system having on the other hand significantly reduced the budget allocated to health care. There is more control on the expenses and no room for overspending via loans. At present there is no agreement on a common portfolio of services yet. There are also limitations such as charging for prescription and the reduction of the number of facilities and professionals.

Bronchopulmonary complications associated to enteral nutrition devices in patients admitted to Internal Medicine Departments

Background and aimsEnteral nutrition using feeding devices such as nasogastric (NG) tube or percutaneous endoscopic gastrostomy (PEG) is an effective feeding method subject that may give rise to complications. We have studied the relationship between enteral nutrition feeding devices in patients admitted to the Internal Medicine Departments and the development of pulmonary complications (bronchial aspiration and aspiration pneumonia). Patients and methodsAll of the patients discharge between 2005 and 2009 from the Internal Medicine (IM) Departments of the public hospitals of the National Health System in Spain were analyzed. The data of patients with bronchial aspiration or aspiration pneumonia who also were carriers of NG tubes or PEG, were obtained from the Minimum Basic Data Set (MBDS). ResultsFrom a total of 2,767,259 discharges, 26,066 (0.92%) patients with nasogastric tube (NG tube) or percutaneous gastrostomy (PEG) were identified. A total of 21.5% of patients with NG tube and 25.9% of patients with PEG had coding for a bronchopulmonary aspiration on their discharge report versus 1.2% of patients without an enteral feeding tube. In the multivariate analysis, the likelihood of suffering bronchoaspiration was 9 times greater in patients with SNG (OR 9.1; 95% CI 8.7–9.4) and 15 greater in subjects with PEG (OR 15.2; 95% CI 14.5–15.9) than in subjects without SNG or PEG. Mean stay (9.2 and 12.7 more days), diagnostic complexity and costs were much higher in patients with SNG or PEG compared to patients in hospital who did not require these devices. ConclusionsAn association was found between SNG and PEG for enteral feeding and pulmonary complications. Mean stay, diagnostic complexity and cost per admission of these patients were higher in patients who did not require enteral nutrition.

Effects of health care decentralization in Spain from a citizens’ perspective

The aim of this article is to analyze the impact of the decentralization of the public national health system in Spain on citizens' satisfaction with different dimensions of primary and hospital care. Using micro-data from the Health Barometer 1996-2009 and taking advantage of the exogeneity of the different pace of decentralization across Spain using a difference-in-differences strategy, we find that, in general, decentralization has not improved citizens' satisfaction with different features of the health services. In our base model, we find that there are even some small negative effects on a subset of variables. Sensitivity analysis confirms that there is no empirical evidence for supporting that decentralization has had a positive impact on citizens' satisfaction with health care. We outline several possible reasons for this.

Complicaciones broncopulmonares asociadas a dispositivos de nutrición enteral en los pacientes ingresados en Servicios de Medicina Interna

Background and aimsEnteral nutrition using feeding devices such as nasogastric (NG) tube or percutaneous endoscopic gastrostomy (PEG) is an effective feeding method subject that may give rise to complications. We have studied the relationship between enteral nutrition feeding devices in patients admitted to the Internal Medicine Departments and the development of pulmonary complications (bronchial aspiration and aspiration pneumonia). Patients and methodsAll of the patients discharge between 2005 and 2009 from the Internal Medicine (IM) Departments of the public hospitals of the National Health System in Spain were analyzed. The data of patients with bronchial aspiration or aspiration pneumonia who also were carriers of NG tubes or PEG, were obtained from the Minimum Basic Data Set (MBDS). ResultsFrom a total of 2,767,259 discharges, 26,066 (0.92%) patients with nasogastric tube (NG tube) or percutaneous gastrostomy (PEG) were identified. A total of 21.5% of patients with NG tube and 25.9% of patients with PEG had coding for a bronchopulmonary aspiration on their discharge report versus 1.2% of patients without an enteral feeding tube. In the multivariate analysis, the likelihood of suffering bronchoaspiration was 9 times greater in patients with SNG (OR: 9.1; 95% CI: 8.7-9.4) and 15 greater in subjects with PEG (OR: 15.2; 95% CI: 14.5-15.9) than in subjects without SNG or PEG. Mean stay (9.2 and 12.7 more days), diagnostic complexity and costs were much higher in patients with SNG or PEG compared to patients in hospital who did not require these devices. ConclusionsAn association was found between SNG and PEG for enteral feeding and pulmonary complications. Mean stay, diagnostic complexity and cost per admission of these patients was higher in patients who did not require enteral nutrition.

Citizens participation in South European countries health systems: Italy, Portugal and Spain

The purpose of this study was to analyse the health systems in Spain, Italy and Portugal from the perspective of the Southern European countries Social Protection. Through a review of the sanitary regulations, health plans and literature on specific health experiences, published in recent years in Spain, Italy and Portugal, the practices of participation, in these three countries, were studied. Some of the research results are noteworthy: a) Citizens' participation in the decision making process on health has become the focus of attention of the public policies only after the 1990; b) there has been a significant progress in the regulatory framework and in the acknowledgement of users' rights; c) the development and implementation of participatory mechanisms were insufficient and limited to certain regions.

Cost-effectiveness analysis per life-year gained based on predictors of response for first-line metastatic colorectal cancer therapy in Spain.

3601 Background: Economic crisis, increasing prevalence and cost of mCRC management endanger availability of biological therapies for public health systems due to budget limitations. We performed a cost-effectiveness analysis based on markers of response/resistance including biological therapies available in Spain for mCRC. Methods: We aimed to calculate incremental cost-effectiveness ratio (ICER) per life-year gained (LYG) and progression-free year gained based on predictive markers for mCRC. Efficacy data include randomized trials (RT) that guided on-label uses of bevacizumab and cetuximab. Control arms from these trials were used as reference to calculate ICERs. Markers of clinical benefit (biological and radiological) were included in this model. Toxicity as predictor of efficacy was excluded for any therapy. Prices for drugs in Spain were assumed to represent the best-value for each drug including all possibilities to reduce pharmacy costs. For 1st line, median duration of therapy reported by RT was used to calculate the final budget. 70kg and 1.7 m were used as reference for patients dose calculations. If accessible, HR for PFS and OS were used instead of medians. Results: K-Ras status and early response measured by CT at 8 weeks were used as predictors of resistance and increased efficacy for cetuximab-based combinations. We have not identified any predictor marker for other drugs from RT. In this regard, FOLFIRI+cetuximab combination obtained an ICER below the widely-proposed Spanish threshold of 30,000 € per LYG if patients harbored wt K-Ras tumors and evidenced an objective response at 8 weeks. Other ICERs for different schedules were too distant from this limit, they will be presented at the meeting. Multivariate analysis confirmed the robustness of results. Conclusions: 1st line FOLFIRI+cetuximab therapy for wt K-Ras patients that get an objective response measured by CT at 8 weeks is the only cost-effective therapy option for mCRC below usual health-economic thresholds for Spain. Our results are critical to design cost-effectiveness based clinical guidelines for mCRC that will contribute to financial sustainability of public health system in Spain.