Budget impact analysis on the introduction of a guideline based hepatitis B and C screening into a routine check-up in the German primary care setting.

OBJECTIVES: Systematic screening for chronic hepatitis B and C does not yet exist in Germany. Therefore, the implementation of a screening approach within a preventive medical examination performed by primary care physicians ('Check-Up 35+') was evaluated in a recent prospective multicenter study. The present analysis estimates the financial consequences for the statutory health insurance by budget impact analysis. MATERIALS AND METHODS: A Markov cohort model was developed consisting of 21 health states. Four different screening scenarios derived from the previous multicenter study were compared to usual care, a strategy without screening for hepatitis. Actual cost data for Germany were calculated and systematic literature searches for all input parameters were performed. RESULTS: The base case results in incremental costs for the screening strategies compared to no hepatitis screening of 165-227 € per patient in a 20-year horizon. Two main parameters influence the financial consequences: (A) detection and treatment increase the costs in the beginning. (B) Screening avoids hepatitis induced end-stage liver disease. The initial higher costs exceed the later savings. Sensitivity analyses demonstrate a strong impact of medication costs for the treatment of additionally detected hepatitis infections on the outcome. This finding is robust to sensitivity analysis. CONCLUSIONS: The screening strategy proposed here implies additional costs for the statutory health insurance, however, a decision regarding its usefulness must consider criteria other than cost. For example, the high burden of disease due to liver cirrhosis and liver carcinoma should be considered. Therefore, an additional cost-effectiveness-analysis should be conducted.

Effectiveness and cost-effectiveness of an integrated care program for schizophrenia: an analysis of routine data.

In Germany, a regional social health insurance fund provides an integrated care program for patients with schizophrenia (IVS). Based on routine data of the social health insurance, this evaluation examined the effectiveness and cost-effectiveness of the IVS compared to the standard care (control group, CG). The primary outcome was the reduction of psychiatric inpatient treatment (days in hospital), and secondary outcomes were schizophrenia-related inpatient treatment, readmission rates, and costs. To reduce selection bias, a propensity score matching was performed. The matched sample included 752 patients. Mean number of psychiatric and schizophrenia-related hospital days of patients receiving IVS (2.3 ± 6.5, 1.7 ± 5.0) per quarter was reduced, but did not differ statistically significantly from CG (2.7 ± 7.6, 1.9 ± 6.2; p = 0.772, p = 0.352). Statistically significant between-group differences were found in costs per quarter per person caused by outpatient treatment by office-based psychiatrists (IVS: €74.18 ± 42.30, CG: €53.20 ± 47.96; p < 0.001), by psychiatric institutional outpatient departments (IVS: €4.83 ± 29.57, CG: €27.35 ± 76.48; p < 0.001), by medication (IVS: €471.75 ± 493.09, CG: €429.45 ± 532.73; p = 0.015), and by psychiatric outpatient nursing (IVS: €3.52 ± 23.83, CG: €12.67 ± 57.86, p = 0.045). Mean total psychiatric costs per quarter per person in IVS (€1117.49 ± 1662.73) were not significantly lower than in CG (€1180.09 ± 1948.24; p = 0.150). No statistically significant differences in total schizophrenia-related costs per quarter per person were detected between IVS (€979.46 ± 1358.79) and CG (€989.45 ± 1611.47; p = 0.084). The cost-effectiveness analysis showed cost savings of €148.59 per reduced psychiatric and €305.40 per reduced schizophrenia-related hospital day. However, limitations, especially non-inclusion of costs related to management of the IVS and additional home treatment within the IVS, restrict the interpretation of the results. Therefore, the long-term impact of this IVS deserves further evaluation.

Course of respiratory allergy by treatment strategy based on German routine data.

PURPOSE: Allergic respiratory diseases represent a global health problem. The two major treatment strategies are symptom treatment and specific immunotherapy (SIT). SIT is considered the only causal treatment option available with the ability to alter the course of the disease. This study aims to describe the course of disease and medication of respiratory allergy across treatment strategies and disease groups. METHODS: The analysis is based on routine data from a German statutory health insurance. The patient cohort is observed from 2007-2012. For each year based on assured outpatient diagnoses patients are assigned to a disease group: rhinitis, asthma or both diseases. Additionally, prescribed medication is considered. Treatment comparisons are based on matched pairs. RESULTS: The study population comprises 165,446 patients with respiratory allergy. In 2007 the most frequent disease group is rhinitis (70%), followed by asthma (16%) and both diseases (14%). During the observation period a second allergic respiratory diagnosis occurs only in about 12% of rhinitis patients and 28% of asthma patients. In about 50% of patients with both diseases one of the diagnoses is omitted. These patients are more likely to no longer report their asthma diagnosis when receiving immunotherapy compared to symptom treatment. Furthermore immunotherapy reduces the frequency of asthma medication use. CONCLUSIONS: Results of detailed analysis of diagnoses reflect the alternating nature of allergic diseases. Although limited by accuracy of documentation and the lack of clinical information, the comparison of treatment strategies shows some advantages of immunotherapy regarding course of disease and asthma medication use.

[Dissemination of Patient Education in the Rehabilitation of Chronic Back Pain - Cost Analysis of a Program Implementation]. / Dissemination eines Schulungsprogramms bei chronischem Rückenschmerz ­ Kostenanalyse der Programmimplementierung.

The aim of the project is a cost analysis of 2 different strategies "train-the-trainer-seminar" (ttt-seminar) and "implementation guideline" (ig) in the implementation of a standardised patient education program in the inpatient rehabilitation of patients with chronic back pain. The implementation strategies were assigned by chance to 10 rehabilitation clinics. Expenditure of time was evaluated by questionnaire. Additionally materials and travel expenses were calculated. The total implementation costs accounted 4 582 € for the ttt-seminar and were about one third (35%) higher than the costs for the ig-strategy. The higher total implementation costs can basically be attributed to higher personnel costs due to the time-consuming seminar. However, in the ig-strategy postprocessing costs were 23.5% higher than in the ttt-strategy.

Depression management within GP-centered health care - A case-control study based on claims data.

OBJECTIVE: For most patients with depression, GPs are the first and long-term medical providers. GP-centered health care (GPc-HC) programs target patients with chronic diseases. What are the effects of GPc-HC on primary care depression management? METHOD: An observational retrospective case-control study was conducted using health insurance claims data of patients with depressive disorder from July 2011 to December 2012. RESULTS: From 40,298 patients insured with the largest health plan in Central Germany participating in the GPc-HC program (intervention group, IG), we observed 4645 patients with depression over 18months: 72.2% women; 66.6years (mean); multiple conditions (morbidity-weight 2.50 (mean), 86%>1.0). We compared them with 4013 patients who did not participate (control group). In participants we found lower number of incomplete/non-specified depression diagnoses (4.46vs.4.82;MD-0.36; p<0.01); lower rate of patients consulting more than one GP-practice (49.1%vs.58.0%;PP-8.9;p<0.01); more GP-contacts (18.19vs.15.59;MD+2.60;p<0.01); more GP-initiated referrals to specialists (82.9%vs.79.3%;PP+3.6;p<0.05), more antidepressant pharmacotherapy prescribed by a GP (37.9%vs.35.4%;PP+2.5;p<0.05), more frequent guideline-concordant therapy duration (19.2%vs.13.1%;PP+6.1;p<0.01) and more patients receiving "GP-psychosomatic basic care" (38.2%vs.30.2%;PP+8.0;p<0.01). CONCLUSION: Depressive patients participating in a GPc-HC program may be more often diagnosed by a GP, receive symptom-monitoring and appropriate depression treatment.

The Impact of GP-Centered Healthcare.

BACKGROUND: In Germany, enhanced primary care ('GP-centered health care') is being promoted in order to strengthen the role of GPs and improve the quality of primary care. The aim of this study was to evaluate the impact of a GPcentered healthcare program, established in 2011 in the German federal state of Thuringia, on healthcare costs, care coordination, and pharmacotherapy. METHODS: We conducted a retrospective case-control study based on insurance claims data. Participants were followed from 18 months before the start of the program to 18 months after its introduction. The intervention and control groups were matched via propensity scores. RESULTS: 40 298 participants enrolled in the program for a minimum of 18 months (between July 2011 and December 2012) were included in the intervention arm of the study. The mean age was 64.8 years. There was no significant difference in total direct costs (primary outcome) between cases and controls. Turning to secondary outcomes, the number of GP consultations rose sharply (+47%; p<0.001), there were less patients who consulted more than one GP (-41.4%; p<0.001), and less specialist consultations without referral (-5.8%; p<0.001) among patients in the intervention group. The number of patients who participated in Disease Management Programs (DMPs) increased (+17.7%; p<0.001), as did the number of GP home visits (+5.0%; p<0.001), specialist consultations (+4.1%; p<0.01), and the number of hospitalizations (+4.3%; p=0.006). The costs for pharmaceuticals were lowered by 3.9% (p<0.001). CONCLUSION: The study indicates that the GP-centered healthcare program does not lead to lower direct health care costs. However, it may lead to more intense and better coordinated healthcare in older, chronically ill patients with multiple conditions. Further studies are needed on long-term effects and clinical endpoints.

Evaluation of the short- and long-term safety and therapy outcomes of the everolimus-eluting bioresorbable vascular scaffold system in patients with coronary artery stenosis: Rationale and design of the German-Austrian ABSORB RegIstRy (GABI-R).

BACKGROUND: Third-generation drug-eluting metal stents are the gold standard for treatment of coronary artery disease. The permanent metallic caging of the vessel, however, can result in limited vasomotion, chronic inflammation, and late expansive remodeling, conditions that can lead to late and very late stent thrombosis. The development of bioresorbable scaffolds (BRSs) promises advantages over metal stents due to complete biodegradation within 2-4years. Theoretically, since vessel scaffolding is temporary and no permanent implant remains in the vessel, BRSs, as opposed to metal stents, once degraded would no longer be potential triggers for stent-related adverse events or side effects. METHODS/DESIGN: The short- and long-term outcome after implantation of an everolimus-eluting, poly-L-lactic acid-based bioresorbable scaffold system (ABSORB, Abbott Vascular, Santa Clara, CA, USA) in the world-wide greatest all-comers cohort will be evaluated in the prospective, non-interventional, multicenter German-Austrian ABSORB RegIstRy (GABI-R). GABI-R will include over 5000 patients from about 100 study sites in Austria and Germany. Safety endpoints such as cardiac death, myocardial infarction, and clinically driven percutaneous or surgical target lesion and vessel revascularization will be evaluated during hospitalization and in the follow-up period (minimum of 5years). CONCLUSION: Although two randomized controlled trials and several registries have documented safety and efficacy as well as non-inferiority of this everolimus-eluting ABSORB device compared with drug-eluting metal stents, the current knowledge regarding clinical application, treatment success, and long-term safety of using this BRS in daily routine is limited. Thus, the goal of GABI-R is to address this lack of information.

The impact of transcatheter aortic valve implantation on quality of life: results from the German transcatheter aortic valve interventions registry.

OBJECTIVES: Transcatheter aortic valve implantation (TAVI) has proven a survival benefit in patients with severe symptomatic aortic stenosis (AS). Recently published data from the German TAVI registry reported a 1-year mortality rate of 19.9 %. However, there are limited data for the effect of TAVI on quality of life (QoL), especially in real life settings. METHODS: The German TAVI registry was launched to evaluate safety, effectiveness and QoL of TAVI in daily clinical routine. We analyzed health-related QoL, using the EQ-5D questionnaire. RESULTS: Quality-of-life data were eligible for 460 patients who survived 12 months after TAVI (82.5 ± 6.0 years; 32.2 % men). At baseline, QoL (EQ-5D-index: 0.63 ± 0.26) was markedly depressed, but significantly improved 30 days and 12 months (0.67 ± 0.24; 0.70 ± 0.24; p < 0.0001) after TAVI procedure. In addition, the visual analogue health scale, recording the patient's self-rated health, significantly (p < 0.0001) increased from 42.0 ± 15.9 % at baseline to 57.0 ± 17.2 % (30 days) and 57.7 ± 19.6 % (12 months). A lower EQ-5D-index at baseline, a percutaneous transfemoral/transaxillar TAVI procedure, and indications other than frailty for TAVI were determinants for an improved QoL 1 year after TAVI. CONCLUSIONS: Among patients with AS, TAVI resulted in meaningful improvements in QoL. This benefit was present shortly after TAVI and maintained for at least 1 year. Different gains in QoL regarding patient-subgroups and determinants for improved QoL could give further impetus for patient selection.

Cost-effectiveness and cost-utility of a structured collaborative disease management in the Interdisciplinary Network for Heart Failure (INH) study.

BACKGROUND: Non-pharmacological treatment programmes are being developed, in which specialised nurses take care of heart failure (HF) patients. Such disease management programmes might increase survival and quality of life in HF patients, but evidence on their cost-effectiveness remains limited. METHODS AND RESULTS: A prospective economic evaluation piggy-backed onto the randomised controlled Interdisciplinary Network for Heart Failure (INH) Study weighted costs of the intervention HeartNetCare -HF™ (HNC) regarding effectiveness, mortality and quality-adjusted life years (QALYs). To consider uncertainty sensitivity analyses were performed. Compared to usual care (UC), HNC revealed 8,284 per death avoided within the 6 month study follow-up period. The cost-utility analysis showed additional costs of 49,335 per QALY. CONCLUSION: Although HNC did not reduce short-term re-admission rates of HF patients hospitalised for cardiac decompensation within the first 180 days after discharge, HNC might reduce mortality and increase quality of life in these patients at reasonable costs. Therefore, long-term HNC-effects deserve further evaluation.

Cost-effectiveness of 7-day-Holter monitoring alone or in combination with transthoracic echocardiography in patients with cerebral ischemia.

BACKGROUND AND PURPOSE: Prolonged Holter monitoring of patients with cerebral ischemia increases the detection rate of paroxysmal atrial fibrillation (PAF); this leads to improved antithrombotic regimens aimed at preventing recurrent ischemic strokes. The aim of this study was to compare a 7-day-Holter monitoring (7-d-Holter) alone or in combination with prior selection via transthoracic echocardiography (TTE) to a standard 24-h-Holter using a cost-utility analysis. METHODS: Lifetime cost, quality-adjusted life years (QALY), and incremental cost-effectiveness ratios (ICER) were estimated for a cohort of patients with acute cerebral ischemia and no contraindication to oral anticoagulation. A Markov model was developed to simulate the long-term course and progression of cerebral ischemia considering the different diagnostic algorithms (24-h-Holter, 7-d-Holter, 7-d-Holter after preselection by TTE). Clinical data for these algorithms were derived from the prospective observational Find-AF study (ISRCTN 46104198). RESULTS: Predicted lifelong discounted costs were 33,837 for patients diagnosed by the 7-d-Holter and 33,852 by the standard 24-h-Holter. Cumulated QALYs were 3.868 for the 7-d-Holter compared to 3.844 for the 24-h-Holter. The 7-d-Holter dominated the 24-h-Holter in the base-case scenario and remained cost-effective in extensive sensitivity analysis of key input parameter with a maximum of 8,354 /QALY gained. Preselecting patients for the 7-d-Holter had no positive effect on the cost-effectiveness. CONCLUSIONS: A 7-d-Holter to detect PAF in patients with cerebral ischemia is cost-effective. It increases the detection which leads to improved antithrombotic regimens; therefore, it avoids recurrent strokes, saves future costs, and decreases quality of life impairment. Preselecting patients by TTE does not improve cost-effectiveness.

Treatment costs and indirect costs of cluster headache: A health economics analysis.

BACKGROUND: Cluster headache (CH) is the most frequent trigemino-autonomic cephalgia. CH can manifest as episodic (eCH) or chronic cluster headache (cCH) causing significant burden of disease and requiring attack therapy and prophylactic treatment. METHODS: Treatment costs (direct costs) due to healthcare utilisation, as well as costs caused by disability and reduction in earning capacity (indirect costs), were obtained using a questionnaire in CH patients treated in a tertiary headache centre based at the University Duisburg-Essen over a 6-month period. RESULTS: A total 179 patients (72 cCH, 107 eCH) were included. Mean attack frequency was 3.5 ± 2.5 per day. Mean direct and indirect costs for one person were €5963 in the 6-month period. Direct costs were positively correlated with attack frequency (r = 0.467, p < 0.001). Burden of disease measured with HIT-6 showed a significant correlation with attack frequency (r = 0.467, p < 0.001). Twenty-four (13.4%) of the participants were disabled and not able to work. CONCLUSION: CH leads to major socioeconomic impact on patients as well as society due to direct healthcare costs and indirect costs caused by loss of working capacity.

[Influence of the demographic change on hospital admissions and costs in Germany]. / Einfluss der demographischen Entwicklung auf die stationären Fallzahlen und Kosten deutscher Krankenhäuser.

BACKGROUND: In the next years the population of most western countries will age rapidly. Beside socioeconomic and social problems sustainable consequences on the health care system are expected. Ageing of the population will place a corresponding growth in demand of health care services and relating expenditures. The following analysis assesses the impact of demographic factors on hospital admissions and related costs over the next 30 years. METHOD: German Federal Statistical Office 12th coordinated population projection, diagnosis statistics and cost of illness data were used to develop a projection of future hospital admissions and associated economic burden. The model considers age- and sex-specific differences. RESULTS: Ageing will increase all-cause hospital admissions by 12% between 2010 and 2040. Diseases of the circulatory system will have one of the most tremendous increases with an expected rise of 34% until 2040. In contrast, hospital stays because of mental and behavioural disorders will decrease by 9%. As hospital admissions rise we expect a further increase in overall expenditures for hospitalisations. DISCUSSION: Ageing of the population will further increase the demand for inpatient hospital services during the coming years. Nevertheless, the increase of hospital admissions will differ concerning single illness groups. The development of new care strategies should take these aspects into consideration.

Heart failure: the commonest reason for hospital admission in Germany: medical and economic perspectives.

BACKGROUND: Heart failure is now the commonest reason for hospitalization in Germany (German Federal Statistical Office, 2008). Heart failure will continue to be a central public health issue in the future as the population ages. This article focuses on regional differences, the costs of the disease, and the expected rate of increase in cases in the near future. METHODS: This analysis is based on diagnosis statistics, cause-of-death statistics, and cost of illness data, as reported by the German Federal Statistical Office. Age- and sex-specific differences are taken into account. RESULTS: 2006 was the first year in which heart failure led to more hospital admissions in Germany (317 000) than any other diagnosis. At present, about 141 000 persons in Germany aged 80 and over have heart failure; by the year 2050, it is predicted that more than 350 000 persons in this age group will be affected. The rate of diagnosis of heart failure, its frequency as a cause of death, and the costs associated with it all vary across the individual states of the Federal Republic of Germany. The nationwide cost of heart failure in 2006 was estimated at 2.9 billion euros. CONCLUSIONS: These findings reveal that heart failure has become more common as an admission diagnosis of hospitalized patients in Germany. Because the population is aging, new concepts for prevention and treatment will be needed in the near future so that the affected patients can continue to receive adequate care.