Cost-benefit analysis of a plant sterol containing low-fat margarine for cholesterol reduction.

For decreasing the risk of coronary heart disease (CHD) it has been proposed to enrich food such as margarine with plant sterol esters which have been shown to reduce total and LDL cholesterol concentrations, two of the major risk factors. A Markov model was developed to assess the costs and benefits of consuming a low-fat plant sterol containing margarine (PS margarine). A health insurer's perspective was taken with a time frame of 10 years. Transition probabilities for CHD and CHD-related death were calculated on the basis of the Framingham risk equations. These were applied to a representative sample of the German population. The alteration in cholesterol levels after intake of PS margarine was estimated based on a meta-analysis of ten randomized controlled trials with parallel or crossover design that found a reduction of 5.7% in total cholesterol. Average annual costs of CHD were assumed to be at 3,000 euro. Costs for "no CHD" and "CHD-related death" were set to 0 euro since the intervention would solely be paid by the consumers. Sensitivity analyses were performed with regard to annual costs, risk estimation, PS margarine reduction in total cholesterol, discount factor, and risk of CHD-related death. The 10-year CHD risks are 6.1% (PS margarine) vs. 6.5% (control). Thus expected 10-year CHD costs are 696 euro (PS margarine) vs. 748 euro (control). The cost savings of 52 euro varied between 32 euro and 74 euro in the sensitivity analysis. A projection at the level of the population for which evidence (randomized controlled trials) exists that plant sterols lower cholesterol (25.35 million) leads to a reduction of 117,000 CHD cases over 10 years and a cost reduction of 1.3 billion euro for this time period (sensitivity analysis 0.8-1.9 billion euro).

[Effects of tobacco tax increase on cigarette consumption and the impact on health policy]. / Auswirkungen der Tabaksteuererhöhungen in Deutschland auf den Tabakkonsum und Konsequenzen für die Gesundheitspolitik.

The purpose of this study is to analyse the recent development of tobacco taxes and demand for cigarettes in Germany and to describe consequences for health policy. A descriptive analysis of aggregated data of the Federal Statistical Office is used to show the development of tax income and consumer behaviour with regard to the degree of substitution between differently taxed tobacco products. From 1993 to 2002 the demand for cigarettes increased nearly continuously. In 2003 the demand for industrial cigarettes went down by 8.6% and in 2004 by 15.8%. The difference between taxes and prices of industrial cigarettes and substitutes increased over the time period and still continues to increase. Tax and price differences between tobacco products led to partial compensation of the decreasing demand for industrial cigarettes. Therefore a tax increase on substitute products like fine cut tobacco is recommended. There is still a lack of longitudinal epidemiological data on smoking behaviour in Germany that could affirm effects of tobacco taxation.

Diabetes--prevalence and cost of illness in Germany: a study evaluating data from the statutory health insurance in Germany.

OBJECTIVE: This population-based study assesses the prevalence and cost of illness as a result of diabetes mellitus in Germany by retrospectively analysing routine health insurance data. Prevalence and costs were analysed from statutory health insurance (GKV) and societal perspectives. RESEARCH DESIGN AND METHODS: The analysis comprises data of all insured persons of six large sickness funds. The insured with diabetes were identified via ICD-9 diagnosis and Anatomical Therapeutic Chemical Classification System (ATC) code for regular medication prescriptions. Costs for inpatient stay, medication and sickness benefits were taken from claims data. Costs for rehabilitation, premature death and early retirement were calculated using the human capital approach and data from national statistics. RESULTS: Overall diabetes prevalence in this age and sex standardized census of six large sickness funds was 6.45%. The cost of illness for sickness funds including hospital cost, medication and sickness benefits, and excluding ambulatory doctor care, were Euro 3.69bn . The total cost of diabetes from a societal perspective was calculated at Euro 5.71bn for the year 1999. CONCLUSION: In accordance with the results of recent studies using routinely collected health insurance data, our study suggests that the prevalence of diabetes mellitus has increased steadily in the past years. The prevalence in our population of 14.7 million insured was 6.45%. Total costs of diabetes mellitus amounted to Euro 5.71bn.

[Cost-effectiveness of prevention of coronary disease in Germany]. / Kosteneffektivität der Prävention der koronaren Herzkrankheit in Deutschland.

It is generally accepted that the incidence of coronary heart disease can effectively be reduced by strengthening prevention. At the same time, it is still unclear how large the effects of life-style oriented preventive measurements such as diet and exercising are in everyday life. Furthermore, there is an ongoing debate on what measurements are effective. Thus, against the background of dwindling financial resources in health care the input of health economic evaluation is explicated. General issues of health economic evaluation are presented. After that, an overview on the current findings of cost-effectiveness in primary prevention of coronary heart disease is given. Risk factors are separately discussed. It is demonstrated that preventive measurements dealing especially with hypertension and hypercholesterolemia can be cost-effective.

Evidence-based medicine: why do opponents and proponents use the same arguments?

There is quite some ethical controversy on Evidence-based Medicine (EbM) with regard to issues of physician autonomy as well as its allocative implications. Yet, there are some shortcomings in the current debate. First of all, some of the arguments brought up against EbM are similarly defaults of "classical medicine" as well, for instance its negligence of social aspects of medicine. Second, it is often maintained that EbM is just a tool to attain cost containment. This argument is false in two regards for neither is there any idea of cutting costs in the roots of EbM nor does EbM once practiced necessarily lead to less costs as there can be underuse as well as overuse. Third, both opponents and proponents of EbM come up with the same arguments against each other. Both maintain that the other way of practicing medicine does not allow for physicians' autonomy and free judgment. Therefore, we are going to search for the different presuppositions on which these "reproaches" rely. In this way we can demonstrate that both opponents and proponents rely on different notions of autonomy and free judgment in their argument. Finally, we hope to show that some of the ethical criticism may be raised against classical medicine as well and that allocation in terms of costs is not primarily an aim of EbM.

Asthma: prevalence and cost of illness.

The purpose of this study was to estimate the prevalence and cost of illness of asthma in Germany by retrospectively analysing routine health insurance data. This analysis investigated claims data from all insured persons of six large sickness funds. Insurants with asthma were identified via the International Classification of Diseases (ninth revision) diagnosis and the Anatomical Therapeutic Chemical Classification System Code for regular medication prescriptions. Costs for hospital care, medication and sick benefit were taken from claims data. Costs for rehabilitation, premature death and early retirement were estimated using the human capital approach and data from national statistics. Prevalence of asthma in the German statutory health insurance was 6.34%. Total costs for asthma, including direct and indirect costs, were calculated at euro 2.74 billion during 1999. The prevalence of asthma in the German statutory health insurance has previously been estimated to be 4-6%. The results of this large study show the prevalence of asthma in the German social insurance system to be approximately 6%. The study also indicates that there is room for substantial savings in the German social insurance system, with indirect costs amounting to 74.8% of total costs and payment of sick benefits through the sickness funds amounting to 58.3% of indirect costs. These costs may be reduced with better asthma control in patients.

Appropriateness of invasive cardiovascular interventions in German hospitals (2000-2001): an evaluation using the RAND appropriateness criteria.

OBJECTIVE: Germany has the highest per capita rate of percutaneous transluminal coronary angioplasties (PTCAs) in Europe and the third highest per capita rate of heart surgeries requiring a heart-lung machine. The goal of this study was to evaluate the appropriateness of PTCA, coronary artery bypass graft (CABG), and carotid endarterectomy (CEA) in German hospitals using RAND appropriateness criteria. METHODS: A retrospective study in 121 randomly selected German hospitals (52 % of all hospitals contacted) was performed from December 2000 to August 2001. A total of 361 patients were enrolled providing information on the appropriateness of 128 PTCAs, 92 CABGs, and 141 CEAs. RESULTS: Inappropriateness rates were 2 % (95 % CI 0 - 5 %), 4 % (95 % CI 1 - 9 %), and 3 % (95 % CI 1 - 7 %) for PTCA, CABG, and CEA, respectively. The overall rate of uncertain procedures was 42 % (95 % CI 36 - 47 %). Only 38 % (95 % CI 32 - 45 %) of patients who received a coronary intervention had had a pre-interventional stress test. CONCLUSIONS: The study yielded little overt overuse in the performance of PTCAs, CABGs, and CEAs, but potentially large underuse of stress tests. Despite a high per capita rate of invasive cardiovascular interventions in Germany, the rate of inappropriate procedures was not larger than in other countries.

[Performance and costs of outpatient clinics of university hospitals for medical care, teaching, research activities]. / Leistungen und Kosten der Hochschulambulanzen in Forschung, Lehre und Versorgung -- Ergebnisse der Hochschulambulanzenstudie.

BACKGROUND: Outpatient clinics of university hospitals (Hochschulambulanzen) play a significant role in the German health care system. Universities have in contrast to other hospitals the right to implement an outpatient clinic, but the health care services they can render are restricted to clinical research and teaching activities. The university outpatient clinic study evaluates the intensity of medical care, teaching, research activities, and the related costs. METHOD AND DATABASE: 6 university hospitals with 51 outpatient departments in Germany were included. The prospective documentation of consultations was restricted to 800 visits per department. A total of 26,312 consultations with approximately 40,000 diagnoses and 150,000 services were documented. Furthermore, data concerning costs, teaching activities and research facilities were documented. RESULTS: Clinical treatment without any correlation to research or teaching activities amounted to about 81 % of the working time in the outpatient department (research 11 %; teaching 8 %). The primary task of the university outpatient clinics takes up less than 20 % of the working time. The physicians documented that the disease of every fourth visit was in accordance with their main field of research. 6.9 % of the visits were asked to take part in clinical trials, of these 1.25 % were included for the first time, 3.7 % were already included. 6.5 % of the visits were addressed to participate in specific teaching activities. The average total costs per case added up to 149 Euro. No outpatient clinic could cover the total per case costs with the lump sum payments. On the average 31 % of these costs were covered by lump sum payments (without cases concerning research and teaching). CONCLUSION: Treatment in outpatient departments of university clinics is far beyond research and teaching activities required by law. However, the ability of outpatient departments of universities to provide excellent outpatient services should have a more dominant role in the health care system. Therefore access to care should be deregulated for the patients and reimbursement schemes should be adjusted to adjust for the present losses.

Evidence-based medical quality management in dialysis--Part I: Routine implementation of QiN, a German quality management system.

Increasing medical complexity, centrifugal forces of medical subspecialization and growing economic constraints are the key reasons for the introduction of quality management into routine care processes such as dialysis. Adequate quality assurance and improvement must be implemented in order to supply medical staff, care providers, and patients with the necessary information on critical issues of clinical management of dialysis patients. QiN (Quality in Nephrology), the quality management program of the largest German dialysis provider, is outlined here as a practicable example. The first of 2 parts provides information on the structure, implementation of QiN and achieved clinical improvement in routine care. The second part (quotation) analyzes longitudinal data in order to differentiate whether observed improvements during more than 5 years of QiN can be ascribed to the intervention (application of QiN) or whether they are due to other factors such as generally improved medical knowledge.

[Health policy guidelines for ambulatory and brief inpatient surgery. Backgrounds, facts and possible future solutions]. / Gesundheitspolitischer Rahmen für die ambulante und kurzzeitstationäre Chirurgie. Hintergründe, Fakten und zukünftige Lösungsansätze.

Ambulatory and short-stay surgery in Germany are regulated by two different political committees with different members. Currently, hospitals are permitted to practice ambulatory surgery on the basis of a mere notification sent to the health insurance companies. The details for access, reimbursement, and quality assurance are negotiated between the hospitals' association, the health insurance companies, and the association of the physicians. Compared to other fields of ambulatory care, the legislation for ambulatory surgery is rather loose concerning hospitals' access to this field of health care provision. Short-stay surgery is designated under inpatient care. With the introduction of so-called diagnosis-related groups (DRG) in 2003, a steep decline in length of stay is expected. Further efforts of the government and health insurance companies to extend ambulatory surgery to further indications are expected, too. However, the hurdle of transferring services from the inpatient sector to the ambulatory sector is a major challenge in Germany. We recommend lowering the legislative hurdle hindering hospitals and physicians from entering the area of ambulatory surgery for specific diagnoses. Same-day treatment should also be encouraged.

[Relevance of medical rehabilitation in disease management programmes]. / Bedeutung der medizinischen Rehabilitation in Disease-Management-Programmen.

Disease management programmes will increasingly be introduced in Germany due to the new risk adjustment scheme. The first disease management programmes started in 2003 for breast cancer and diabetes mellitus type II. German rehabilitation will have to face several challenges. Disease management programmes are strongly based on the notion of Evidence so that proof of the efficacy of a care giving task should be present. Verification of the evidence of the specifically German rehabilitation treatments must therefore be given. However, integration of rehabilitation in disease management programmes could lead to changes in the alignment of German rehabilitation. The essence of German rehabilitation, notably its holistic approach, could get lost with integration in disease management programmes.

Effectiveness of the glycoprotein IIb/IIIa antagonist abciximab during percutaneous coronary interventions (PCI) in clinical practice at a single high-volume center.

OBJECTIVE: Randomized controlled trials (RCTs) showed that the glycoprotein (GP) IIb/IIIa antagonist abciximab is able to reduce ischemic complications during percutaneous transluminal coronary interventions (PCIs). Its effectiveness in daily clinical practice in unselected patients remains to be determined. DESIGN, SETTING AND PATIENTS: From 7/1997 until 12/2000, 3310 PCIs were performed at the Heart Center Ludwigshafen. Out of them, 1076 (32.5%) patients were nonrandomly treated with a GP IIb/ IIa antagonist. Patients who were treated with abciximab were matched with patients not treated with abciximab. The matching procedure resulted in 590 pairs of patients. RESULTS: Patients treated with abciximab were more likely to have a history of former PCI (13.7% versus 8.8%, p=0.008) or coronary artery bypass surgery (19.2% versus 12.8%, p=0.003). There were no differences in concomitant diseases, left ventricular function, number of vessels diseased or target vessel. However, patients treated with abciximab had a higher rate of more complex stenosis (> or =B2; 94.4% versus 80.7%, p<0.001) and a longer x-ray exposition (median 486 s versus 422 s, p<0.001). Treatment with abciximab was associated with a significantly lower incidence of the combined endpoint of death, reinfarction or stroke during the hospital stay (2.4% versus 4.4%, p=0.039). This was confirmed after adjustment for confounding parameters (p=0.034). There was no increase in the rate of severe bleeding in the abciximab group (p=0.347). After one year the rates for the combined endpoint were 8.5% in the control group and 6.2% in the abciximab group (univariate analysis, p=0.134; multivariate analysis, p=0.143). CONCLUSION: Treatment with abciximab during PCI in daily clinical practice at a high volume center in patients with a high rate of acute coronary syndromes seems to be as effective as shown in RCTs.

[Prospective payment in medical rehabilitation]. / Pauschalierte Vergütung in der medizinischen Rehabilitation.

After introducing DRGs (Diagnosis-Related Groups) in the prospective payment system for German hospitals, the use of per-case reimbursement for medical rehabilitation as well is being discussed. In particular two systems have already been tested internationally. FIM-FRG were especially developed for a prospective payment system for inpatient rehabilitation facilities. RUG-III are used for reimbursing long-term care in nursing homes and are based on a per-day payment. It is recommended to test the FIM-FRG or one of the refined systems in Germany in a pilot project.

[Quality control of outpatient imaging examinations in North Rhine-Westphalia, Part II]. / Qualitätskontrolle der ambulanten bildgebenden Diagnostik in Nordrhein-Westfalen, Teil II.

PURPOSE: In the state of North Rhine-Westphalia (NRW), Germany, a survey was conducted on radiologic examinations ordered by general practitioners (GPs). Part II of this study aims to determine the quality of the process and outcome. The reference standard is the assessment of both radiologists and physicians without board certification in radiology working at a university hospital and in outpatient facilities. MATERIALS AND METHODS: AllGPs in NRW were asked to cooperate. Participating GPs filled out a questionnaire for each patient. The patients recorded the symptoms prompting the imaging examinations. The radiologists or other physicians performing the examinations were asked to provide the images and written reports and to complete a questionnaire. A file was created for each of the 394 patients with image documentation of at least one examination. Each file, which included medical history, physical findings, imaging documentation and written report, was sequentially forwarded to a board-certified radiologist and to a physician without board certification in radiology working in a university hospital and in an outpatient facility. All physicians were requested to complete a structured questionnaire for each file. RESULTS: The referral diagnoses were rated as medically plausible in 81%, the indications for imaging found correct in 76%, the examination techniques considered appropriate in 69%, the clinical question answered in 63%, the interpretation judged medically correct in 50% and all incidental findings documented in 49%. In retrospect, 32 % of the examinations were judged superfluous. The sequence of multiple examinations performed on a particular patient was rated as appropriate in 51%. The interpretation revealed specialty-related differences. The plausibility of the referral diagnoses had a significant impact on the appropriateness of subsequent diagnostic investigations. Marked deficits showed sonography, performance by non-radiologists, self-referrals by GPs, gastroenterologic radiology and the ICD-10 coding (suspicion of cardiovascular disease). CONCLUSION: In the "best-case" scenario, the process quality proved to have moderate deficiencies and the outcome quality severe deficiencies. In consequence, GPs and radiologists should be more communicative by sharing information and exchanging opinions. GP self-referrals should be restricted. Sonography and examinations performed by physicians without board certification in radiology should undergo stricter quality controls. A more intensive interdisciplinary collaboration is needed to determine the optimum implementation of diagnostic imaging of gastroenterologic and cardiovascular diseases.

[Quality control of outpatient imaging examinations in North Rhine-Westphalia, part I]. / Qualitätskontrolle der ambulanten bildgebenden Diagnostik in Nordrhein-Westfalen, Teil I.

PURPOSE: In the state of North-Rhine Westphalia (NRW), Germany, a survey was conducted on radiologic examinations ordered by general practitioners (GPs). Part I of this study aims to collect characteristic epidemiological data and to assess structural quality. MATERIALS AND METHODS: All GPs in NRW were asked to cooperate. Participating GPs filled out a questionnaire for each patient. The patients recorded the symptoms prompting the imaging examinations. The radiologists or other physicians performing the examinations were asked to provide the images and written reports and to complete a questionnaire. Two university radiologists documented the pertinent test data from the submitted images and written records. Independently of each other, five university radiologists anonymously reviewed the image quality of each examination using structured questionnaires. RESULTS: A total of 920 patients gave their informed consent and participated. Questionnaires from 787 patients, 852 GPs and 611 radiologists or other interpreting physicians as well as the complete survey data from 530 examinations were available. Of 1503 examinations, conventional radiography made up 52 %, sonography 17 %, computed tomography (CT) 13 % and magnetic resonance imaging (MRI) 5 %. Most indications involved the musculoskeletal (37 %) and respiratory systems (24 %). Physicians without board certification in radiology interpreted 1 % of the CT examinations, 26 % of the radiographic examinations and 71 % of the sonographic examinations. Of the 174 self-referrals, 1 % involved CT, 33 % conventional radiography and 66 % sonography. Written reports were available for 95 % of all 469 examinations performed by radiologists and 74 % of all 127 examinations conducted by non-radiologists. Only 44 % of the 23 sonographic studies were self-referrals by the patient's GP. On average, the radiographic techniques were acceptable in terms of diagnostic information and radiation hygiene. Conventional radiographs were better exposed when obtained by radiologists than by non-radiologists (p = 0.038). The delineation of anatomical structures was rated as good to acceptable for MRI, CT and conventional radiography, while the image quality was rated as diagnostically insufficient for sonography (p < 0.0001). The image quality of radiographic and sonographic examinations performed by radiologists was superior in comparison to examinations performed by physicians without board certification in radiology (p < 0.0001). CONCLUSION: Examination technique and imaging quality of MRI, CT and conventional radiography performed on outpatients were in an acceptable diagnostic range, whereas the quality of sonography was inadequate.

European comparison of costs and quality in the prevention of secondary complications in Type 2 diabetes mellitus (2000-2001).

AIMS: To compare the out-patient costs and process quality of preventing secondary complications in patients with Type 2 diabetes mellitus in France, Germany, Italy, The Netherlands, Sweden, Switzerland, and the UK. METHODS: A total of 188 European physician practices assessed annual services for one hypothetical average patient (cost evaluation) and 178 practices reported retrospective data on one or two real patients (quality evaluation) in 2000/2001. In countries with a detailed fee-for-service schedule (Germany, Italy, and Switzerland) reimbursement fees were used to approximate costs. These fee-for-service schedules were also used to develop index (average) fees for all countries, in order to measure resource utilization. The following process quality indicators were evaluated: control of HbA1c; control of lipids; urine test for (micro)albuminuria; control of blood pressure; foot examination; neurological examination; eye examination; and patient education. For each country an average quality rating was calculated by weighting the response to each quality indicator with the level of scientific evidence. RESULTS: Average quality ratings ranged from 0.40 in The Netherlands to 0.62 in the UK (0 = lowest rating; 1 = highest rating). Total annual costs for secondary prevention were higher in Switzerland than in Germany and Italy (EUR475, EUR381, and EUR283, respectively). Resource utilization was highest in Germany and lowest in the UK. CONCLUSIONS: The overall quality of preventive services documented was found to be poor in the seven European countries studied. The UK rated as both the most effective and the most efficient country in providing secondary prevention in Type 2 diabetes.