Maria Rubio-Valera

Aims: This study aimed to identify and prioritize key strategies for improving a psychiatric home‐based care programme, the Crisis Resolution and Home Treatment (CRHT) intervention in Catalonia, Spain. The objective was to incorporate the perspectives of service users, family caregivers and healthcare professionals to guide quality improvement efforts. Methods: A modified Delphi method was used to reach consensus among stakeholders previously involved in a qualitative evaluation of the CRHT programme. The expert panel included 130 participants: 31 CRHT service users/caregivers and 99 healthcare professionals. Over three rounds of online surveys, participants rated 18 pre‐identified improvement strategies across three dimensions: problem significance, change agency and feasibility of change. Service users and caregivers assessed only problem significance. Open‐ended responses were also collected and analysed. Findings: Consensus was reached in the third round, with five strategies prioritized: (1) training on CRHT referral and eligibility criteria, (2) standardized discharge and continuity of care protocols, (3) feedback loop between CRHT and referring professionals, (4) scheduling and communication of visiting hours, and (5) available updates for CRHT slots. These areas were rated highest in terms of feasibility and change agency, though not necessarily in problem significance. Notably, the same individuals who participated in the initial qualitative phase contributed to the prioritization process, ensuring continuity and relevance in stakeholder input. Conclusion: The study demonstrates the value of collaborative, consensus‐based approaches to quality improvement in mental health care. Prioritized strategies reflect feasible and actionable areas for enhancing CRHT services. Involving service users, caregivers and professionals in both evaluation and decision‐making processes strengthens the relevance, person‐centredness and effectiveness of care. Implementation of these strategies is underway, with further improvements planned based on stakeholder feedback and continuous assessment.

Objectives: Non-adherence to cardiovascular disease (CVD) treatments leads to suboptimal health outcomes and increased healthcare and societal costs. We assessed the long-term effects of adherence to CVD and diabetes medications using population data and microsimulation modelling. Methods: We developed a CVD microsimulation model using individual participant data from the SIDIAP database (2012–2021) for 152,117 adults who received new prescriptions for antihypertensive, lipid-lowering, oral glucose-lowering or antiplatelet treatments in Catalonia between January 2012 and December 2013. Model inputs included demographic and clinical characteristics, medication adherence and cardiovascular events. Costs (€, 2025) and treatment effects were sourced from the literature, and utilities were estimated using national population-based surveys. Model validity was assessed by comparing simulated and observed cumulative incidences over 8 years. The model simulated life-years (LYs), quality-adjusted life-years (QALYs) and healthcare and societal costs under three scenarios: non-adherent, observed adherence and full adherence. We estimated the maximum per-patient cost at which adherence-enhancing interventions would remain cost-effective. Results: Simulated cumulative incidences of cardiovascular events and all-cause death closely matched observed data. Improved adherence increased survival by 0.19–0.58 years and QALYs by 0.25–0.70, while increasing lifetime healthcare costs by €2,431–€8,093 per patient. The additional cost per QALY ranged from €8,946 to €12,614 per QALY, indicating that improving adherence is likely to be a cost-effective if achieved at additional cost of up to €4,041 to €10,098 per patient. Conclusions: Long-term extrapolation of real-world data using microsimulation modelling shows that optimising adherence to CVD and diabetes medications can enhance health outcomes cost-effectively.

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Introduction: Psychiatric home care provides a wide range of multidisciplinary, user-centered, high-intensity psychiatric interventions to manage mental health crises. Previous studies have found high satisfaction with care, but only assessed user and nurse perspectives. This study aimed to understand the experience of a psychiatric home hospitalization program in Spain from the perspective of all involved (users, families and healthcare professionals). Materials and methods: A qualitative study with a phenomenological approach was conducted to assess “Crisis Resolution and Home Treatment” (CRHT), a psychiatric home care program. Semi-structured individual and group interviews were held between 2021 and 2022. The final sample size was determined by saturation and data were analyzed thematically. Analyses were performed by a multidisciplinary team and externally reviewed by a mental health user and an experienced CRHT manager. Results: Four main themes summarizing CRHT experiences emerged: (1) Organizing and operating CRHT programs; (2) Receiving care at home; (3) Caregiver and family involvement and (4) Consequences of the home-based care model. CRHT allows individualized and contextualized treatment. Users and families valued home care and felt safe, although unprepared for the post-discharge situation, especially as care intensity decreases. While home care strengthens family bonds, some caregivers may need additional support to manage a crisis. Along with personalized care, CRHT allows for the development of a comprehensive lifelong treatment plan, although the care burden (for oneself and others) must be considered. Conclusion: CRHT was rated positively as a flexible intervention, facilitating person-centered care and strengthening trust between users, their families, and the CRHT team. It offers personalized treatment and connects individuals to further support, enabling better treatment experiences and strengthening family relationships.

Introduction Non-adherence to cardiovascular disease and diabetes treatments contributes to suboptimal clinical outcomes and higher cost. The initial medication adherence (IMA) intervention is a multidisciplinary primary care (PC) intervention based on shared decision-making (SDM). The IMA-cluster-randomised controlled trial (cRCT) study evaluated the impact of the IMA intervention on medication initiation, secondary adherence and clinical outcomes compared with usual care (UC). Methods This was a pragmatic cRCT with a hybrid effectiveness-implementation design which randomised 24 PC centres in Spain to intervention or UC. Patients receiving a new prescription of antihypertensive, lipid-lowering, antiplatelet and/or oral/injectable antidiabetic medication at the intervention centres (March 2022–September 2022) were attended by general practitioners (GPs), nurses and community pharmacists who had been trained in SDM and given decision aids (leaflets and website). Real-world data from prescription and dispensing records—used to assess medication initiation and secondary adherence (correct dosing and continued use)—and clinical outcome data from electronic health records were collected up to 18 months after initial prescription and analysed using multilevel regression models. Results Overall, 4910 prescriptions were issued to 3629 patients (Intervention=2148; UC=1481) by 150 GPs (Intervention=91; UC=59). No differences were detected between groups in medication initiation or secondary adherence. Among clinical outcomes, only blood pressure outcomes favoured the IMA intervention, reflecting a small but clinically meaningful improvement. Conclusions The IMA intervention had limited overall impact, with no effect on adherence, but showed potential benefits in blood pressure. However, SDM, as an ethically grounded approach, may enhance patients and professional experiences, supporting its consideration for broader implementation. Future efforts should prioritise these benefits by investing in professional training and patient support, addressing implementation challenges and deepening understanding of SDM effects, which would warrant further evaluation. Trial registration number NCT05026775.

Introduction The initial medication adherence (IMA) intervention aims to improve adherence to cardiovascular disease (CVD) and diabetes treatments in primary care (PC) through standardised shared decision-making (SDM) and healthcare professional (HCP) collaboration (general practitioners (GPs), nurses and pharmacists). This study assessed the intervention’s implementation (strategies, fidelity and integration into routine practice—based on the Normalisation Process Theory), mechanisms of action and the role of context. Methods The IMA-cRCT was an effectiveness-implementation cluster-Randomised Controlled Trial involving 24 Spanish PC centres (>300 HCP; >3000 patients) based on real-world evidence. This nested process evaluation used quantitative (monitoring data; HCP questionnaires) and qualitative methods (field diaries; 36 semistructured individual interviews and two focus groups (19 patients, 28 HCPs)). Quantitative data explored implementation and context and were analysed descriptively, while qualitative data examined implementation, mechanisms of action and context and were analysed using framework analysis. Both analyses were integrated for interpretation. Results Intervention implementation fidelity (6.5/10) and normalisation into clinical practice (7.6/10) were adequate, particularly regarding SDM and use of decision aids. HCPs recognised the importance of SDM, although some assumed it was already part of routine practice. The anticipated mechanisms of action were moderately supported. HCPs’ knowledge and attitudes towards SDM improved as they acknowledged its relevance to practice. Some patients reported participation in decision-making, while others preferred the GP to decide on their behalf. Patients found leaflets helpful for understanding information. Contextual factors influencing the intervention were mainly organisational, such as lack of time and familiarity with SDM. Conclusions The interprofessional SDM-based IMA intervention was considered beneficial for patients and HCPs, with adequate implementation fidelity and normalisation into practice. The intervention was important for HCPs, and patients accepted it. However, greater effort is needed to extend SDM throughout healthcare, moving towards patient-centred care. These results have enhanced understanding of SDM interventions and support their refinement for future implementation. Trial registration number ClinicalTrials.gov, NCT05026775.

Introduction: Children fail to initiate a high proportion of medications but little is known about motivations for non-initiation.Objective: To explore the factors affecting the decision to initiate a medication prescribed to children from caregivers’ and children’s perspectives.Methods: Qualitative study based on Grounded theory using a constructivist approach. Twenty-one caregivers and six children (<18 years old) were individually interviewed between 2021 and 2022 in Spain using a semi-structured thematic guide. Interviews were transcribed and analyzed by pharmacists, pediatricians and family physicians through a constant comparative analysis and results were internally audited.Results: Caregivers and healthcare professionals are the central figures involved in the decision-making process regarding treatment initiation; children were rarely involved. Caregivers, usually mothers, made a risk-benefit evaluation based on the perception of the disease and the medication, which was influenced by intrapersonal factors (emotional burden, health literacy and stigma); children-related factors (age, treatment and emotional burden); and factors related to the professionals (accessibility, discourse alignment, information, respect and emotional support, trust and specialty); healthcare system (trust and use of e-consultations) and context (media, peer pressure and social stigma).Conclusion: The decision to initiate medication in the pediatric population is multifactorial and influenced by perceptions on the disease and treatment, intrapersonal factors related to the caregivers and children, and interpersonal factors and factors related to the healthcare system and contexts. An informed, shared decision-making process that considers both the participation of children and the needs for support from caregivers when prescribing a treatment could promote initiation in the pediatric population.

Objectives: To perform a cost‐effectiveness analysis based on primary data from a cohort of patients with localized prostate cancer followed throughout 10 years, comparing radical prostatectomy, brachytherapy, and external beam radiotherapy (EBRT) and applying disease‐specific utilities, from a national health system’s perspective. Materials and Methods: Patients diagnosed with localized prostate cancer were consecutively recruited in 2003–2005 from 10 Spanish hospitals ( n = 674) (ClinicalTrials.gov number: NCT01492751). The expanded prostate cancer index composite (EPIC) and short‐form 36 (SF‐36) questionnaires were administered through telephone interviews before treatment and annually during follow‐up. The outcome measures to evaluate the incremental cost‐effectiveness ratio between treatments (ICER) were quality‐adjusted life‐years (QALYs), calculated by the patient‐oriented prostate utility scale (PORPUS) utility index, obtained with a mapping from the EPIC and the SF‐36, and survival data. Ten‐year medical activities were used to derive costs. Both unweighted and propensity score‐weighted analyses were performed. Results: The weighted mean of 10‐year QALYs was the highest for radical prostatectomy (8.53), followed by brachytherapy (8.49) and external radiotherapy (8.20), but the difference was only statistically significant with the latter. Costs were significantly higher for brachytherapy (€21,348) than radical prostatectomy (€12,281) and EBRT (€7,560). Compared to EBRT, the weighted ICER for radical prostatectomy was €14,169/QALY gained and €48,417/QALY for brachytherapy. Conclusion: Our findings support that radical prostatectomy was the most cost‐effective alternative, but the differences in effectiveness among the three treatments were small. The incremental cost of radical prostatectomy and brachytherapy compared to EBRT, however, does not justify restricting these alternatives. Trial Registration: ClinicalTrials.gov identifier: NCT01492751