[Show abstract][Hide abstract] ABSTRACT: Cardiovascular diseases are the main cause of death worldwide, making their prevention a major health care challenge. In 2006, a German statutory health insurance company presented a novel individualised prevention programme (KardioPro), which focused on coronary heart disease (CHD) screening, risk factor assessment, early detection and secondary prevention. This study evaluates KardioPro in CHD risk subgroups, and analyses the cost-effectiveness of different individualised prevention strategies.
BMC Health Services Research 06/2014; 14(1):263. · 1.77 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Fractures are one of the most costly consequences of falls in elderly patients in nursing homes.
To compare the cost-effectiveness of a 'multifactorial fracture prevention program' provided by a multidisciplinary team with 'no prevention' in newly admitted nursing home residents.
We performed a cost-utility analysis using a Markov-based simulation model to establish the effectiveness of a multifaceted fall prevention program from the perspective of statutory health insurance (SHI) and long-term care insurance (LCI). The rate of falls was used to estimate the clinical and economic consequences resulting from hip and upper limb fractures. Robustness of the results was assessed using deterministic and probabilistic sensitivity analyses.
Compared to no prevention a multifactorial prevention program for nursing home residents resulted in a cost-effectiveness ratio of 21,353 per quality-adjusted life-year. The total costs for SHI/LCI would result in 1.7 million per year. Results proved to be robust following deterministic and probabilistic sensitivity analyses.
Multifactorial fracture prevention appears to be cost-effective in preventing fractures in nursing home residents. Since the results were based on the number of falls further research is required to confirm the results.
The European Journal of Health Economics 05/2014; · 2.10 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: There is an on-going debate about whether to perform surgery on early stage localised prostate cancer and risk the common long term side effects such as urinary incontinence and erectile dysfunction. Alternatively these patients could be closely monitored and treated only in case of disease progression (active surveillance). The aim of this paper is to develop a decision-analytic model comparing the cost-utility of active surveillance (AS) and radical prostatectomy (PE) for a cohort of 65 year old men with newly diagnosed low risk prostate cancer.
A Markov model comparing PE and AS over a lifetime horizon was programmed in TreeAge from a societal perspective. Comparative disease specific mortality was obtained from the Scandinavian Prostate Cancer Group trial. Direct costs were identified via national treatment guidelines and expert interviews covering in-patient, out-patient, medication, aids and remedies as well as out of pocket payments. Utility values were used as factor weights for age specific quality of life values of the German population. Uncertainty was assessed deterministically and probabilistically.
With quality adjustment, AS was the dominant strategy compared with initial treatment. In the base case, it was associated with an additional 0.04 quality adjusted life years (7.60 QALYs vs. 7.56 QALYs) and a cost reduction of [euro sign]6,883 per patient (2011 prices). Considering only life-years gained, PE was more effective with an incremental cost-effectiveness ratio of [euro sign]96,420/life year gained. Sensitivity analysis showed that the probability of developing metastases under AS, utility weights under AS are a major sources of uncertainty. A Monte Carlo simulation revealed that AS was more likely to be cost-effective even under very high willingness to pay thresholds.
AS is likely to be a cost-saving treatment strategy for some patients with early stage localised prostate cancer. However, cost-effectiveness is dependent on patients' valuation of health states. Better predictability of tumour progression and modified reimbursement practice would support widespread use of AS in the context of the German health care system. More research is necessary in order to reliably quantify the health benefits compared with initial treatment and account for patient preferences.
BMC Health Services Research 04/2014; 14(1):163. · 1.77 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Chronic illnesses, for which many patients are admitted to hospitals, substantially increase the risk of falling, and hence the likelihood of incurring a hip fracture. Hip fractures not only have devastating consequences on an individual's quality of life but may also affect a hospital's reputation in the community. In addition, hospitals may face litigation claims and increased costs for patients who fall and suffer a major injury as a consequence. External hip protectors are comparable to padded undergarments and shield the trochanter, reducing the detrimental effects and force impacting the bone during a fall. Screening for patients at high risk of falling and providing high-risk patients with hip protectors as a preventive measure to avoid hip fractures, not only improves public health, but can also save hospitals care and litigation costs.
[Show abstract][Hide abstract] ABSTRACT: Thrombosis inhibitors can be used to treat acute coronary syndromes (ACS). However, there are various alternative treatment strategies, of which some have been compared using health economic decision models.
To assess the quality of health economic decision models comparing thrombosis inhibitors in patients with ACS undergoing percutaneous coronary intervention, and to identify areas for quality improvement.
The literature databases MEDLINE, EMBASE, EconLit, National Health Service Economic Evaluation Database (NHS EED), Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment (HTA).
A review of the quality of health economic decision models was conducted by two independent reviewers, using the Philips checklist.
Twenty-one relevant studies were identified. Differences were apparent regarding the model type (six decision trees, four Markov models, eight combinations, three undefined models), the model structure (types of events, Markov states) and the incorporation of data (efficacy, cost and utility data). Critical issues were the absence of particular events (e.g. thrombocytopenia, stroke) and questionable usage of utility values within some studies.
As we restricted our search to health economic decision models comparing thrombosis inhibitors, interesting aspects related to the quality of studies of adjacent medical areas that compared stents or procedures could have been missed.
This review identified areas where recommendations are indicated regarding the quality of future ACS decision models. For example, all critical events and relevant treatment options should be included. Models also need to allow for changing event probabilities to correctly reflect ACS and to incorporate appropriate, age-specific utility values and decrements when conducting cost-utility analyses.
[Show abstract][Hide abstract] ABSTRACT: Transition from hospital to home is a critical period for older persons with acute myocardial infarction (AMI). Home-based secondary prevention programs led by nurses have been proposed to facilitate the patients' adjustment to AMI after discharge. The objective of this study was to evaluate the effects of a nurse-based case management for elderly patients discharged after an AMI from a tertiary care hospital.
In a single-centre randomized two-armed parallel group trial of patients aged 65 years and older hospitalized with an AMI between September 2008 and May 2010 in the Hospital of Augsburg, Germany, patients were randomly assigned to a case management or a control group receiving usual care. The case-management intervention consisted of a nurse-based follow-up for one year including home visits and telephone calls. Key elements of the intervention were to detect problems or risks and to give advice regarding a wide range of aspects of disease management (e.g. nutrition, medication). Primary study endpoint was time to first unplanned readmission or death. Block randomization per telephone call to a biostatistical center, where the randomization list was kept, was performed. Persons who assessed one-year outcomes and validated readmission data were blinded. Statistical analysis was based on the intention-to-treat approach and included Cox Proportional Hazards models.
Three hundred forty patients were allocated to receive case-management (n=168) or usual care (n=172). The analysis is based on 329 patients (intervention group: n=161; control group: n=168). Of these, 62% were men, mean age was 75.4 years, and 47.1% had at least either diabetes or chronic heart failure as a major comorbidity. The mean follow-up time for the intervention group was 273.6 days, and for the control group it was 320.6 days. During one year, in the intervention group there were 57 firs unplanned readmissions and 5 deaths, while the control group had 75 first unplanned readmissions and 3 deaths. With respect to the endpoint there was no significant effect of the case management program after one year (Hazard Ratio 1.01, 95% confidence interval 0.72-1.41). This was also the case among subgroups according to sex, diabetes, living alone, and comorbidities.
A nurse-based management among elderly patients with AMI had no significant influence on the rate of first unplanned readmissions or death during a one-year follow-up. A possible long-term influence should be investigated by further studies.Clinical trial registration: ISRCTN02893746.
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: To achieve fair-coverage decision making, both material criteria and criteria of procedural justice have been proposed. The relationship between these is still unclear. OBJECTIVE: . To analyze hypotheses underlying the assumption that more assessment, transparency, and participation have a positive impact on the reasonableness of coverage decisions. METHODS: . We developed a structural equation model in which the process components were considered latent constructs and operationalized by a set of observable indicators. The dependent variable "reasonableness" was defined by the relevance of clinical, economic, and other ethical criteria in technology appraisal (as opposed to appraisal based on stakeholder lobbying). We conducted an Internet survey among conference participants familiar with coverage decisions of third-party payers in industrialized countries between 2006 and 2011. Partial least squares path modeling (PLS-PM) was used, which allows analyzing small sample sizes without distributional assumptions. Data on 97 coverage decisions from 15 countries and 40 experts were used for model estimation. RESULTS: . Stakeholder participation (regression coefficient [RC] =0.289; P = 0.005) and scientific rigor of assessment (RC = 0.485; P < 0.001) had a significant influence on the construct of reasonableness. The path from transparency to reasonableness was not significant (RC = 0.289; P = 0.358). For the reasonableness construct, a considerable share of the variance was explained (R(2) = 0.44). Biases from missing data and nesting effects were assessed through sensitivity analyses. Limitations. The results are limited by a small sample size and the overrepresentation of some decision makers. CONCLUSIONS: . Rigorous assessment and intense stakeholder participation appeared effective in promoting reasonable decision making, whereas the influence of transparency was not significant. A sound evidence base seems most important as the degree of scientific rigor of assessment had the strongest effect.
Medical Decision Making 06/2013; · 2.89 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The aim of this study was to analyze influences of process- and technology-related characteristics on the outcomes of coverage decisions. Using survey data on 77 decisions from 13 countries, we examined whether outcomes differ by 14 variables that describe components of decision-making processes and the technology. We analyzed the likelihood of committees covering a technology, i.e. positive (including partial coverage) vs. negative coverage decisions. We performed non-parametric univariate tests and binomial logistic regression with a stepwise variable selection procedure. We identified a negative association between a positive decision and whether the technology is a prescribed medicine (p=0.0097). Other significant influences on a positive decision outcome included one disease area (p=0.0311) and whether a technology was judged to be (cost-)effective (p<0.0001). The first estimation of the logistic regression yielded a quasi-complete separation for technologies that were clearly judged (cost-)effective. In uncertain decisions, a higher number of stakeholders involved in voting (odds ratio=2.52; p=0.03) increased the likelihood of a positive outcome. The results suggest that decisions followed the lines of evidence-based decision-making. Despite claims for transparent and participative decision-making, the phase of evidence generation seemed most critical as decision-makers usually adopted the assessment recommendations. We identified little impact of process configurations.
[Show abstract][Hide abstract] ABSTRACT: Several risk factors for cardiovascular disease (CVD) have been identified in recent decades. However, the association between the health system and the burden of CVD has not yet been sufficiently researched. The objective of this study was to analyse the association between health system development and the burden of CVD, in particular CVD-related disability-adjusted life-years (DALYs).
Univariate and multivariate generalized linear mixed models were applied to country-level data collected by the World Bank and World Health Organization. Response variables were the age-standardized CVD mortality and age-standardized CVD DALY rates.
The amount of available health system resources, indicated by total health expenditures per capita, physician density, nurse density, dentistry density, pharmaceutical density and the density of hospital beds, was associated with reduced CVD DALY rates and CVD mortality. However, in the multivariate models, the density of nurses and midwives was positively associated with CVD. High out-of-pocket costs were associated with increased CVD mortality in both univariate and multivariate analyses.
A highly developed health system with a low level of out-of-pocket costs seems to be the most appropriate to reduce the burden of CVD. Furthermore, an efficient balance between human health resources and health technologies is essential.
PLoS ONE 01/2013; 8(4):e61718. · 3.53 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Positive screening results are often associated not only with target-disease-specific but also with non-target-disease-specific mortality. In general, this association is due to joint risk factors. Cost-effectiveness estimates based on decision-analytic models may be biased if this association is not reflected appropriately. OBJECTIVE: To develop a procedure for quantifying the degree of bias when an increase in non-target-disease-specific mortality is not considered. METHODS: We developed a family of parametric functions that generate hazard ratios (HRs) of non-target-disease-specific mortality between subjects screened positive and negative, with the HR of target-disease-specific mortality serving as the input variable. To demonstrate the efficacy of this procedure, we fitted a function within the context of coronary artery disease (CAD) risk screening, based on HRs related to different risk factors extracted from published studies. Estimates were embedded into a decision-analytic model, and the impact of 'modelling increased non-target-disease-specific mortality' was assessed. RESULTS: In 55-year-old German men, based on a risk screening with 5 % positively screened subjects, and a CAD risk ratio of 6 within the first year after screening, incremental quality-adjusted life-years were 19 % higher and incremental costs were 8 % lower if no adjustment was made. The effect varied depending on age, gender, the explanatory power of the screening test and other factors. CONCLUSION: Some bias can occur when an increase in non-target-disease-specific mortality is not considered when modelling the outcomes of screening tests.
The European Journal of Health Economics 12/2012; · 2.10 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Patients undergoing major orthopaedic surgery (MOS), such as total hip (THR) or total knee replacement (TKR), are at high risk of developing venous thromboembolism (VTE). For thromboembolism prophylaxis, the oral anticoagulant rivaroxaban has recently been included in the German diagnosis related group (DRG) system. However, the cost-effectiveness of rivaroxaban is still unclear from both the German statutory health insurance (SHI) and the German hospital perspective. Objectives To assess the cost-effectiveness of rivaroxaban from the German statutory health insurance (SHI) perspective and to analyse financial incentives from the German hospital perspective. METHODS: Based on data from the RECORD trials and German cost data, a decision tree was built. The model was run for two settings (THR and TKR) and two perspectives (SHI and hospital) per setting. RESULTS: Prophylaxis with rivaroxaban reduces VTE events (0.02 events per person treated after TKR; 0.007 after THR) compared with enoxaparin. From the SHI perspective, prophylaxis with rivaroxaban after TKR is cost saving (E27.3 saving per patient treated). However, the costeffectiveness after THR (E17.8 cost per person) remains unclear because of stochastic uncertainty. From the hospital perspective, for given DRGs, the hospital profit will decrease through the use of rivaroxaban by E20.6 (TKR) and E31.8 (THR) per case respectively. CONCLUSIONS: Based on our findings, including rivaroxaban for reimbursement in the German DRG system seems reasonable. Yet, adequate incentives for German hospitals to use rivaroxaban are still lacking.
BMC Health Services Research 07/2012; 12(1):192. · 1.77 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Aim As a consequence of the demonstrated efficacy in clinical studies, statins have increasingly been used in the secondary prevention
of cardiovascular diseases (CVD). We aim to analyse whether expected health gains based on efficacy data can be confirmed
by epidemiological trends in the Austrian population.
Subjects and methods A Markov model that estimates clinical outcomes from statin treatment in secondary prevention was linked with Austrian data
on statin prescription to estimate expected population health gains from 1997 to 2007. Model results are contrasted with epidemiological
data on CVD mortality and morbidity.
Results Among approximately 600,000 persons who took statins between 1996 and 2006, it was estimated that 860 fewer cases of unstable
angina, 26,000 fewer myocardial infarcts (MIs), 1,100 fewer strokes, and roughly 25,000 more cases of stable angina occurred
compared to non-medical prevention. In contrast, observed epidemiological trends indicate an increase in CVD morbidity. Furthermore,
the model demonstrated 10,300 avoided/postponed fatal CVD events in Austria. Decreasing coronary heart disease (CHD) and MI
mortality rates in the model are congruent with the observed epidemiology.
Conclusion Tentative evidence exists that statins may have contributed to decreasing CHD mortality in Austria, whereas the expected benefits
with respect to CHD morbidity and related revascularisation interventions could not be verified.
Journal of Public Health 01/2012; · 2.06 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Breast cancer is the leading cause of death from cancer among women in Germany. Despite its clinical and economic relevance, no attributable costs for breast cancer have been reported for Germany so far. The objective of this study is to estimate age-specific breast cancer attributable health expenditures for Germany.
Sickness fund data from 1999 representing about 26 million insured (i.e. 32% of the total German population) have been analysed using generalized additive models and the error propagation law. Costs have been inflated to 2010.
Breast cancer attributable costs decreased with age. Among breast cancer patients aged 30-45 years, about 90% of all health expenditures were due to breast cancer, whereas in breast cancer patients aged 80-90 years, about 50% were due to breast cancer. Breast cancer attributable costs amounted to about €9,000 annually for patients below 55 years of age and declined to about €3,000 in 90-year-old breast cancer patients.
This analysis provides estimates of attributable breast cancer costs in Germany. Compared with the international literature, the estimates were plausible but had a tendency to underestimate breast cancer attributable costs.
PLoS ONE 01/2012; 7(12):e51312. · 3.53 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To analyse the psychometric properties of the EQ-5D in German stroke survivors undergoing neurological rehabilitation.
The EQ-5D, the Hospital Anxiety and Depression Scale (HADS) and the Stroke Impact Scale (SIS) were completed before (210 subjects) and after (183 subjects) a patient education programme in seven rehabilitation clinics in Bavaria, Germany. A postal follow-up was conducted after 6 months. Acceptance, validity, reliability and responsiveness of the EQ-5D were tested. The SIS subscales were used as external anchors to classify the patients into change groups between the measurements.
The proportion of missing answers ranged from 4.7 to 8.6%. Between 16 and 19% reported no problems in any EQ-5D dimension. At baseline, correlations between EQ-5D index and the SIS subscales ranged from 0.15 (communication) to 0.60 (mobility). Correlations with the EQ VAS were slightly smaller. All scores were reliable in test-retest with intraclass correlations ranging from 0.67 to 0.81. EQ-5D index and EQ VAS were consistently responsive only to improvements in health, showing small- to medium effect sizes (0.27-0.42).
The EQ-5D has shown reasonable validity, reliability and, more limited, responsiveness in stroke patients with mild to moderate limitations of functional status, allowing it to be used in clinical trials in rehabilitation.
Quality of Life Research 10/2011; 21(7):1205-16. · 2.41 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Zusammenfassung Die gesundheitsökonomische Evaluation hat in den letzten Jahren auch im Bereich Diabetes mellitus erheblich an Bedeutung gewonnen.
Es existiert eine große Anzahl entscheidungsanalytischer Modelle, mit denen die Konsequenzen von verschiedenen Interventionsstrategien
abgeschätzt werden können. Ziel dieses Artikels ist es, grundlegende Aspekte von Diabetesmodellen verständlich zu machen.
Dazu werden Grundzüge der entscheidungsanalytischen Modellierung und deren Anwendung im Bereich Diabetes mellitus dargestellt.
Die grundlegendsten Modelltypen Entscheidungsbaum, Markov-Modell und diskrete Ereignissimulation werden vorgestellt und die
Unterschiede zwischen Kohortensimulation und Mikrosimulation erläutert. Ferner werden die Formen und der Umgang mit Unsicherheit
in entscheidungsanalytischen Modellen dargestellt sowie wichtige Besonderheiten der komplexen Diabetesmodellierung aufgezeigt.
Die Zusammenarbeit zwischen Klinikern und Modellierern ist eine wichtige Voraussetzung für eine adäquate Konstruktion und
Nutzung von Modellansätzen.
Der Diabetologe 01/2011; 7(2):99-104. · 0.25 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We performed a meta-analysis on adverse events seen with bevacizumab to combine the existing evidence about its safety in patients with advanced cancer.
A systematic literature search was conducted to identify published, randomized controlled trials of bevacizumab in cancer patients with data on adverse events available. The primary endpoint was "severe adverse event," a composite of grade 3 and 4 adverse events. Secondary endpoints for the exploratory analysis were individual adverse events. We used random-effects meta-analysis to combine data.
Thirteen eligible publications were identified and eight trials reported the primary endpoint. Compared with the control group, the bevacizumab group had a slightly higher risk for any severe adverse event (pooled relative risk, 1.10; 95% confidence interval [95% CI], 1.01-1.19). The pooled risk difference was 7% (95% CI, 1%-13%), with a number needed to harm of 14 treated patients. Exploratory analyses showed a statistically significant higher risk for eight of the 15 evaluated secondary endpoints: bevacizumab was associated with a fourfold higher risk for hypertension, epistaxis, and gastrointestinal hemorrhage/perforation; a threefold higher risk for any bleeding events; and a lower, but elevated risk for proteinuria, leukopenia, diarrhea, and asthenia. No statistically significant differences were found for any thrombotic event (arterial or venous), hemoptysis, cardiac event, thrombocytopenia, neutropenia, impaired wound healing, or death related to an adverse event.
Treatment with bevacizumab was associated with a slightly higher risk for any severe (grade 3 or 4) adverse event in patients with cancer. The result may impact individual benefit-risk assessments and policy guidelines.
The Oncologist 11/2010; 15(11):1179-91. · 4.10 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This paper presents findings of a mandatory three-year evaluation of a prevention bonus scheme offered in the German Statutory Health Insurance (SHI). Its objective is to describe the rationale behind the programs, analyze their financial impact and discuss their implications on potentially conflicting goals on solidarity and competition.
The analysis included 70,429 insured enrolled in a prevention bonus program in a cohort study. The intervention group and their matched controls were followed for a three-year period. Matching was performed as nearest neighbor matching. The economic analysis comprised all costs relevant for Sickness Funds (SF) in the SHI and was carried out from a SHI perspective. Differences in cost trends between the intervention and the control group were examined applying the paired t-test.
Regarding mean costs there was a significant difference between the two groups of euro177.48 (90% CI [euro149.73; euro205.24]) in favor of the intervention group. If program costs were considered cost reductions of euro100.88 (90% CI [euro73.12; euro128.63]) were obtained.
The uptake of a prevention bonus program led to cost reductions in the intervention group compared to the control group even when program costs were considered. However, the results must be interpreted with caution as in addition to financial aspects, socio-economic and health-status, selection bias and the function and use of bonus programs as marketing tools, as well as their long-term sustainability should be considered in future assessments.
Health Policy 06/2010; 96(1):51-6. · 1.51 Impact Factor