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BackgroundMultimorbidity is a major challenge for healthcare systems. However, currently, its magnitude and impact in healthcare expenditures is still mostly unknown.ObjectiveTo present an overview of the prevalence and costs of multimorbidity by socioeconomic levels in the whole Basque population.MethodsWe develop a cross-sectional analysis that includes all the inhabitants of the Basque Country (N = 2,262,698). We utilize data from primary health care electronic medical records, hospital admissions, and outpatient care databases, corresponding to a 4 year period. Multimorbidity was defined as the presence of two or more chronic diseases out of a list of 52 of the most important and common chronic conditions given in the literature. We also use socioeconomic and demographic variables such as age, sex, individual healthcare cost, and deprivation level. Predicted adjusted costs were obtained by log-gamma regression models.ResultsMultimorbidity of chronic diseases was found among 23.61% of the total Basque population and among 66.13% of those older than 65 years. Multimorbid patients account for 63.55% of total healthcare expenditures. Prevalence of multimorbidity is higher in the most deprived areas for all age and sex groups. The annual cost of healthcare per patient generated for any chronic disease depends on the number of coexisting comorbidities, and varies from 637 € for the first pathology in average to 1,657 € for the ninth one.ConclusionMultimorbidity is very common for the Basque population and its prevalence rises in age, and unfavourable socioeconomic environment. The costs of care for chronic patients with several conditions cannot be described as the sum of their individual pathologies in average. They usually increase dramatically according to the number of comorbidities. Given the ageing population, multimorbidity and its consequences should be taken into account in healthcare policy, the organization of care and medical research.

The COVID-19 outbreak has led to an unprecedented crisis in Spain This paper examines the spread of COVID-19 and the policies and technologies used A stringent confinement, paired with substantial reduction in mobility showed positive epidemiological results

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Background: Education leads to better health-related decisions and protective behaviors, being especially important for patients with chronic conditions. Self-management education programs have been shown to be beneficial for patients with different chronic conditions and to have a higher impact on health outcomes than does didactic education. Objective: To investigate improvements in glycemic control (measured by glycated hemoglobin A1c) in patients with type 2 diabetes mellitus. Methods: Our comparative trial involved one group of patients receiving patient-centered education and another receiving didactic education. We dealt with selection bias issues, estimated the different impact of both programs, and validated our analysis using quantile regression techniques. Results: We found evidence of better mean glycemic control in patients receiving the patientcentered program, which engaged better patients. Nevertheless, that differential impact is nonmonotonic. Patients initially at the healthy range at the patient-centered program maintained their condition better. Patients close to, but not within, the healthy range benefited equally from attending either program. Patients with very high glycemic level benefited significantly more from attending the patient-centered program. Finally, patients with the worst initial glycemic control (far from the healthy range) improved equally their diabetic condition, regardless of which program they attended. Conclusions: Different patients are sensitive to different categories of education programs. The optimal, cost-effective design of preventative programs for patients with chronic conditions needs to account for the different impact in different "patient categories." This implies stratifying patients and providing the appropriate preventative education program, or looking for alternative policy implementations for unresponsive patients who have the most severe condition and are the most costly.

The CRG grouping system aids analysis at different levels for clinical administration. Due to its composition, this system allows better understanding of the use, costs and quality of the set of services received by a population.

Patients with multimorbidity are responsible for more than half of all healthcare utilization, challenging the healthcare budgets of all European nations. Although the European Union is showing signs of a fragile economic recovery, achieving sustainable growth will depend on delivering a combination of fiscal responsibility, structural reforms, and improved efficiency. Addressing the challenges of multimorbidity and providing more effective, affordable, and sustainable care, has climbed the political agenda at a global, European, and national level. Current healthcare systems are poorly adapted to cope with the challenges of patients with multimorbidity. Little is known about the epidemiology and natural history of multimorbidity; the evidence base is weak; clinical guidelines are not always relevant to this population; and financing and delivery systems have not evolved to adequately measure and reward quality and performance. Pockets of innovation are, however, beginning to emerge. In Spain, for example, the ongoing economic crisis has forced regional governments to deliver substantial efficiency savings and, with this in mind, integrated care programmes have been introduced across the country for people with chronic disease and multimorbidity. Early results suggest that formalized integrated care for patients with multimorbidity improves their perceptions of care coordination, reduces hospital and emergency admissions and readmissions, and reduces average costs per capita. Such innovations require meaningful investments at a national level – something that is now supported within the framework of the European Union’s Stability and Growth Pact.

AcknowledgementsThe authors are thankful to Mauricio Avendano-Pabón, Anna Maresso and Marta TraperoBertran for helpful comments on a preliminary version of this work, and Jonathan Cylus for his data support. Manuel García-Goñi research was supported by the project "La innovación en servicios y las interacciones entre servicios públicos y privados: el caso de la sanidad", financed by the Spanish Ministry of Science and Innovation. Any errors are the authors' responsibility. 2 AbstractIncreasing health care expenditures is a matter of concern in many countries, particularly in relation to the underlying drivers of such escalation which include ageing, medical innovation, and changes in the burden of disease e.g. prevalence of chronic diseases. Most health care systems in developed countries have been designed to 'cure' acute episodes, rather than to 'manage' chronic conditions, and thereby they are not adequately and efficiently organized to respond to the changing needs and preferences of consumers. New models of chronic care provision have been developed to respond to the changing burden of disease and there are already practical experiences in different countries showing their advantages but also the difficulties in their implementation. In this paper, we focus on the Spanish experience in terms of policy changes and pilot studies directed at testing the viability of transiting towards chronic care models. In particular, we utilize a framework that identifies and analyses the 10 key pre-conditions of high performing chronic-care based healthcare systems and apply it to the current Spanish NHS. We find that the design of the Spanish National Health System already meets some of those pre-conditions. However, other features are still in their early stages of development or being applied in restricted geographical and clinical contexts. We propose a pathway to walk the crucial challenge of the transition towards an optimal health system focused on chronic care. Given the current evidence and trends, we expect that the pathway for developing a chronicity strategy for the Spanish NHS will significantly transform its current healthcare delivery model in the next few years.