Technical ReportPDF Available

Abstract

Due to the recent economic environment and the accompanying financial pressure on public payers, European health systems are confronted to implement cost containment measures and simultaneously maintain the quality of health care services for the population. Fostering initiatives that promote patient involvement (“self-care”) is considered as a possible policy to achieve efficiency increases. As first step, a definition of self-care was developed based on a literature review and a two-stage Delphi process with the project’s expert panel. To determine the added value of self-care, a systematic literature review was conducted for five minor ailments (i.e. athlete’s foot, cold, cough, heartburn and urinary tract infection). As a next step, existing self-care initiatives in Europe have been identified and analysed according to the RE-AIM framework (i.e. reach, effectiveness, adoption, implementation and maintenance) in order to identify best-practices. For identified best-practice initiatives a cost benefit-analyis has been conducted from the patient’s, the supplier’s, the system’s and the societal perspective. Finally, a methodology of the transferability of best-practices was developed, which was based on a combination of literature search and expert interviews. Finally, a dissemination strategy for the results gained was developed. Concerning the added value of self care, good evidence is given for the effectiveness of topical treatments of athlete’s foot (i.e. allylamines and azoles), treatments of cold (i.e. Acetylsalicylic acid, nasal sprays/topical treatments, Echinacea), treatments against heartburn including lansoprazole and H2-receptor antagonists. No clear evidence could be found for the effectiveness of over-the counter (OTC) medicines against cough and also the evidence of self-care strategies for urinary tract infection (UCI) was unclear. Concerning the cost-benefit analysis, the results suggest that from the societal persective NHS Choices representing internet based information systems and MAS representing legislative change being favourable policy options, with different benefit levels regarding patient groups exempt/non-exempt of paying prescription charges. The impacts of NMP show no difference concerning the obligation of patients to pay prescription charges. Concerning the methodology of transferability of best-practice self-care initiatives, a four step approach was developed consisting of: 1.) identification of best-practices in selfcare, 2.) identification of key features of best-practice initiatives, 3.) assessment of the feasibility of transferring best-practice initiatives, 4.) deduction of policy options. The study offers added value to existing literature on self-care, which tends to focus on pharmaceutical treatments for the use in self-care. By assessing the effectiveness of selfcare treatments, assessing self-care initiatives in cost-benefit analysis and developing a methodlogy for transferability of best-practice self-care initiatives, scientific evidence could be supplemented by a practical guide for policy-makers for identifying and transferring best-practices in self-care. The results highlight that political commitment to self-care is essential for the implementation and uptake of self-care. Further, it shows that for successful self-care initiatives a change in “culture” is necessary, so that patients take responsibility for their own health. In this context, patient information and clear communication is of particular relevance. Also, successful self-care requires a re-thinking of health care professionals involved related to the definition of their professional identity. This may concern particularly the cooperation between physicians and pharmacists.
april - 2015
A cost/benefit analysis of self-care
systems in the European Union
Final report
A cost/benefit analysis of self-care systems in the European Union
April, 2015 2
Authors
Herwig Ostermann
Anna-Theresa Renner
Julia Bobek
Peter Schneider
Sabine Vogler
Supported by
Laurent Jacquet (Technical project coordinator, SOGETI)
Gwenaëlle Le Coroller (SOGETI)
Geoffroy Fisher (SOGETI)
Project assistant
Romana Landauer
A cost/benefit analysis of self-care systems in the European Union
April, 2015 3
© European Union, 2015
The information and views set out in this report are those of the author(s) and do not
necessarily reflect the official opinion of the Commission. The Commission does not
guarantee the accuracy of the data included in this study. Neither the Commission nor
any person acting on the Commissions behalf may be held responsible for the use
which may be made of the information contained therein.
ISBN
DOI
A cost/benefit analysis of self-care systems in the European Union
April, 2015 4
Acknowledgements
We would like to express our sincere thanks to the members of our expert panel who
contributed to this study through their commitment to taking the time for participating in
the Delphi process and the telephone interviews and sharing their knowledge about self
care with us.
We are grateful to Daiga Behmane and Ilaria Passarani who supported us in content
related questions through the whole run of the project and who helped us to improve the
methodology for the cost-benefit-analysis.
Finally, we are deeply grateful to the Europeon Commission for commissioning us and by
doing so giving us the opportunity to carry out an inspiring and challenging study. In
particular, we would like to thank Kari Steig (DG SANTE), Katja Neubauer (DG SANTE),
Agnieszka Daval-Cichon (DG SANTE), Federico Paoli (DG SANTE) and Artur Carvalho (DG
SANTE).
A cost/benefit analysis of self-care systems in the European Union
April, 2015 5
Abstract
Due to the recent economic environment and the accompanying financial pressure on
public payers, European health systems are confronted to implement cost containment
measures and simultaneously maintain the quality of health care services for the
population. Fostering initiatives that promote patient involvement (“self-care”) is
considered as a possible policy to achieve efficiency increases.
As first step, a definition of self-care was developed based on a literature review and a
two-stage Delphi process with the project’s expert panel. To determine the added value of
self-care, a systematic literature review was conducted for five minor ailments (i.e.
athlete’s foot, cold, cough, heartburn and urinary tract infection). As a next step, existing
self-care initiatives in Europe have been identified and analysed according to the RE-AIM
framework (i.e. reach, effectiveness, adoption, implementation and maintenance) in order
to identify best-practices. For identified best-practice initiatives a cost benefit-analyis has
been conducted from the patient’s, the supplier’s, the systems and the societal
perspective. Finally, a methodology of the transferability of best-practices was developed,
which was based on a combination of literature search and expert interviews. Finally, a
dissemination strategy for the results gained was developed.
Concerning the added value of self care, good evidence is given for the effectiveness of
topical treatments of athlete’s foot (i.e. allylamines and azoles), treatments of cold (i.e.
Acetylsalicylic acid, nasal sprays/topical treatments, Echinacea), treatments against
heartburn including lansoprazole and H2-receptor antagonists. No clear evidence could be
found for the effectiveness of over-the counter (OTC) medicines against cough and also
the evidence of self-care strategies for urinary tract infection (UCI) was unclear.
Concerning the cost-benefit analysis, the results suggest that from the societal persective
NHS Choices representing internet based information systems and MAS representing
legislative change being favourable policy options, with different benefit levels regarding
patient groups exempt/non-exempt of paying prescription charges. The impacts of NMP
show no difference concerning the obligation of patients to pay prescription charges.
Concerning the methodology of transferability of best-practice self-care initiatives, a four
step approach was developed consisting of: 1.) identification of best-practices in self-
care, 2.) identification of key features of best-practice initiatives, 3.) assessment of the
feasibility of transferring best-practice initiatives, 4.) deduction of policy options.
The study offers added value to existing literature on self-care, which tends to focus on
pharmaceutical treatments for the use in self-care. By assessing the effectiveness of self-
care treatments, assessing self-care initiatives in cost-benefit analysis and developing a
methodlogy for transferability of best-practice self-care initiatives, scientific evidence
could be supplemented by a practical guide for policy-makers for identifying and
transferring best-practices in self-care. The results highlight that political commitment to
self-care is essential for the implementation and uptake of self-care. Further, it shows
that for successful self-care initiatives a change in “culture” is necessary, so that patients
take responsibility for their own health. In this context, patient information and clear
communication is of particular relevance. Also, successful self-care requires a re-thinking
of health care professionals involved related to the definition of their professional identity.
This may concern particularly the cooperation between physicians and pharmacists.
A cost/benefit analysis of self-care systems in the European Union
April, 2015 6
Table of Contents
Acknowledgements ..................................................................................................... 4
Abstract .................................................................................................................. 5
Table of Contents ................................................................................................... 6
List of Tables ......................................................................................................... 8
List of Figures ...................................................................................................... 13
List of Abbreviations ............................................................................................. 14
Executive summary .............................................................................................. 17
Résumé ............................................................................................................... 22
Zusammenfassung................................................................................................ 27
1 Introduction ................................................................................................... 32
1.1 Activities and deliverables ......................................................................... 32
1.2 Outline of this report ................................................................................ 32
2 Background and context .................................................................................. 33
2.1 Minor ailments ......................................................................................... 33
2.2 Relevance of self-care ............................................................................... 34
2.3 EU and international framework ................................................................. 35
2.4 Rationale and objectives ........................................................................... 37
3 Methodology ................................................................................................... 38
3.1 Definition of self-care (task 5).................................................................... 38
3.2 Added value of self- care (task 6) ............................................................... 39
3.3 Analysis of self-care initiatives (task 7) ....................................................... 40
3.4 Economic evaluation of self-care initiatives (task 8) ...................................... 41
3.4.1 Conceptualization and general assumptions ........................................... 41
3.4.2 Data collection ................................................................................... 44
3.4.3 Sensitivity analyses ............................................................................ 45
3.5 Definition and assessment criteria for the best-practice of self-care (task 9) .... 45
3.6 Transferability of best-practices (task 11) .................................................... 45
3.6.1 Methodology of transferability .............................................................. 45
3.6.2 SWOT and risk analysis ....................................................................... 46
3.7 Dissemination strategy of good practice initiatives (Task 14) ......................... 48
4 Results .......................................................................................................... 50
4.1 Definition of self-care (task 5).................................................................... 50
4.2 Added value of self-care (task 6) ................................................................ 50
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4.3 Analysis of self-care initiatives (task 7) ....................................................... 64
4.4 Economic evaluation of self-care initiatives (task 8) ...................................... 69
4.4.1 Costs and benefits from patient’s perspective ........................................ 70
4.4.2 Costs and benefits from the providers’ and system’s perspective .............. 77
4.4.3 Net benefits from patients’, providers’, system’s and societal perspective .. 85
4.4.4 Discussion of the results of the CBA ...................................................... 91
4.5 Definition and assessment criteria for the best-practice of self-care (task 9) .... 95
4.6 Transferability of best-practices (task 11) .................................................... 96
4.6.1 Methodology of transferability of best-practices...................................... 96
4.6.2 SWOT and risk analysis ..................................................................... 102
4.7 Dissemination strategy of good practice initiatives (task 14) ........................ 105
5 Conclusions and recommendations .................................................................. 113
References......................................................................................................... 116
Annex 1: List of Minor Ailments ............................................................................ 128
Annex 2: Definitions of self-care used for the Delphi process ................................... 129
Annex 3: Search Strategies ................................................................................. 130
Annex 4: Inclusion/Exclusion Criteria .................................................................... 166
Annex 5: Grade of Evidence ................................................................................. 168
Annex 6: List of Initiatives ................................................................................... 170
Annex 7: Quality tables ....................................................................................... 172
Annex 8: Extraction Tables .................................................................................. 195
Annex 9: Description and analysis of selected self-care initiatives ............................. 251
Annex 10: Economic Studies ................................................................................ 261
Annex 11: Pharmaceutical prices UK used for Cost/ benefit analysis ......................... 270
Annex 12: Costs and benefits from a patient’s perspective ....................................... 274
Annex 13: Telephone interview results .................................................................. 289
Annex 14: Stakeholder Analysis ........................................................................... 292
Annex 15: Assessment frameworks for initiatives ................................................... 294
Annex 16: Risk Analysis ...................................................................................... 299
A cost/benefit analysis of self-care systems in the European Union
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List of Tables
Table 1: Expert panel......................................................................................... 38
Table 2: Selected initiatives for economic evaluation ............................................. 40
Table 3: Operationalization of Criteria .................................................................. 41
Table 4: Conceptual framework for the cost/benefit-analysis of self-care initiatives ... 44
Table 5: Framework for SWOT analysis ................................................................ 47
Table 6: Results of the literature review about the added value of self-care for the
ailment of athlete’s foot ......................................................................... 51
Table 7: Results of the literature review about the added value of self-care for the
ailment of cold...................................................................................... 53
Table 8: Results of the literature review about the added value of self-care for the
ailment of cough ................................................................................... 56
Table 9: Results of the literature review about the added value of self-care for the
ailment of heartburn ............................................................................. 59
Table 10: Results of the literature review about the added value of self-care for the
ailment of Urinary tract infection ............................................................. 62
Table 11: Selected self-care initiatives ................................................................... 64
Table 12: Summary of analysis of initiatives ........................................................... 69
Table 13: Average time spent at encounter in minutes ............................................ 70
Table 14: Average pharmaceutical prices used in the CBA ........................................ 71
Table 15: Number and type of pharmaceuticals dispensed to patient ......................... 72
Table 16: MAS: Average patient’s savings who sees pharmacist instead of GP ............ 74
Table 17: NHS Choices: Average patient’s savings who sees pharmacist instead of GP. 75
Table 18: NMP/PIP: Average patient’s savings who sees pharmacist instead of GP ...... 76
Table 19: MAS: Summary of costs and benefits per shift case ................................... 80
Table 20: NHS Choices: Summary of costs and benefits per shift case ....................... 82
Table 21: NMP/PIP: Summary of costs and benefits per shift case ............................. 84
Table 22: MAS: Summary of net benefit per shift case ............................................. 86
Table 23: NMP/PIP: Summary of net benefit per shift case ....................................... 88
Table 24: NHS Choices: Summary of net benefit per shift case ................................. 90
Table 25: Matrix of best-practices identified ........................................................... 96
Table 26: Assessment framework for identification of initiative’s key features and
characteristics ...................................................................................... 98
Table 27: Assessment framework for the feasibility assessment of transferability ........ 99
Table 28: Results of the SWOT analysis ............................................................... 103
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Table 29: Selection of tools to be included the dissemination plan ........................... 108
Table 30: Dissemination plan Key features of dissemination activities and
proposed implementation..................................................................... 110
Table A 1: Shortlist of Minor Ailments ............................................................... 128
Table A 2: Proposed set of definitions found in the literature ................................ 129
Table A 3: First selection (abstracts) ................................................................. 166
Table A 4: Second selection (full texts) ............................................................. 167
Table A 5: Risk of bias - Definitions .................................................................. 168
Table A 6: Criteria for evaluation of external validity ........................................... 168
Table A 7: Evidence grade ............................................................................... 169
Table A 8: Overall evidence grade Definitions .................................................. 169
Table A 9: Crawford & Hollis, 2012 ................................................................... 172
Table A 10: Ortonne et al., 2006 ........................................................................ 172
Table A 11: AlBalawi ZH et al., 2013 .................................................................. 173
Table A 12: Karsch-Völk, 2014 .......................................................................... 174
Table A 13: Lanas et al., 2011 ........................................................................... 174
Table A 14: Chaudry et al., 2006 ....................................................................... 175
Table A 15: McNally et al., 2010 ........................................................................ 175
Table A 16: Wade et al., 2011 ........................................................................... 176
Table A 17: Yardley et. al, 2010 ......................................................................... 177
Table A 18: Häcker et al., 2010 ......................................................................... 178
Table A 19: Riebling and Unkauf, 2004 ............................................................... 179
Table A 20: Theurer and Gessner, 2011 .............................................................. 180
Table A 21: Conrad et al., 2007 ......................................................................... 181
Table A 22: Smith et al., 2012 ........................................................................... 181
Table A 23: Timmer et al., 2013 ........................................................................ 182
Table A 24: Schulz, 2007 .................................................................................. 182
Table A 25: Gonzales, 2005 ............................................................................... 183
Table A 26: Paul et. al., 2007 ............................................................................ 184
Table A 27: White et al., 2012 ........................................................................... 185
Table A 28: Bruley et al., 2010 .......................................................................... 186
Table A 29: Konturek et al.,2007 ....................................................................... 186
A cost/benefit analysis of self-care systems in the European Union
April, 2015 10
Table A 30: Peura et al. 2009 ............................................................................ 187
Table A 31: Häcker and Morck, 2012 .................................................................. 188
Table A 32: Labenz & Schubert-Zsilavecz, 2012 ................................................... 189
Table A 33: Mehuys et al., 2009 ........................................................................ 189
Table A 34: Nähri, et al., 2005........................................................................... 190
Table A 35: Albert et al., 2004 ........................................................................... 191
Table A 36: Eells et al, 2014 .............................................................................. 191
Table A 37: Falagas, 2006 ................................................................................. 192
Table A 38: Hudson, 2006 ................................................................................. 192
Table A 39: Jepson et al., 2012 ......................................................................... 193
Table A 40: Ferry et al., 2004 ............................................................................ 193
Table A 41: Athlete’s foot: included publications second selection .......................... 195
Table A 42: Crawford and Hollis, 2003 ................................................................ 195
Table A 43: Ortonne et al., 2006 ........................................................................ 197
Table A 44: Cold: included publications second selection ....................................... 199
Table A 45: AlBalawi et al., 2013 ....................................................................... 200
Table A 46: Karsch-Völk et al., 2014 .................................................................. 201
Table A 47: Lanas et al., 2011 ........................................................................... 204
Table A 48: Chaudry et al., 2006 ....................................................................... 206
Table A 49: McNally et al., 2010 ........................................................................ 208
Table A 50: Wade et al., 2011 ........................................................................... 210
Table A 51: Yardley et al., 2010 ......................................................................... 212
Table A 52: Häcker et al., 2010 ......................................................................... 213
Table A 53: Riebeling and Unkauf, 2004 ............................................................. 215
Table A 54: Theurer and Gessner, 2011 .............................................................. 216
Table A 55: Cough: included publications second selection .................................... 218
Table A 56: Conrad et. al., 2007 ........................................................................ 219
Table A 57: Smith et. al., 2012 .......................................................................... 220
Table A 58: Timmer et. al., 2014 ....................................................................... 222
Table A 59: Schulz, 2007 .................................................................................. 223
Table A 60: Gonzales et al., 2005 ...................................................................... 224
Table A 61: Paul et. al., 2007 ............................................................................ 226
Table A 62: White et al., 2012 ........................................................................... 228
Table A 63: Heartburn: included publications second selection ............................... 230
A cost/benefit analysis of self-care systems in the European Union
April, 2015 11
Table A 64: Bruley et al., 2010 .......................................................................... 230
Table A 65: Konturek et al., 2007 ...................................................................... 232
Table A 66: Peura et al., 2009 ........................................................................... 234
Table A 67: Labenz and Willmer, 2012 ................................................................ 236
Table A 68: Mehuys et al., 2009 ........................................................................ 238
Table A 69: Närhi et al., 2005 ............................................................................ 239
Table A 70: Urinary Tract Infection (UTI): included publications second selection ..... 240
Table A 71: Albert et al., 2004 ........................................................................... 241
Table A 72: Eells et al., 2014 ............................................................................. 242
Table A 73: Falagas et al., 2006 ........................................................................ 244
Table A 74: Hudson, 2006 ................................................................................. 245
Table A 75: Jepson et al., 2012 ......................................................................... 246
Table A 76: Ferry et al., 2004 ............................................................................ 248
Table A 77: Rohrer et al., 2010, evidence table for economic studies ...................... 261
Table A 78: Svensson, 2012, evidence table for economic studies .......................... 262
Table A 79: Oppong et al., 2011, evidence table for economic studies .................... 263
Table A 80: Mason & Hungin, 2005, evidence table for economic studies ................ 265
Table A 81: Eells et al., 2014, evidence table for economic studies ......................... 267
Table A 82: Griebling, 2005, evidence table for economic studies ........................... 269
Table A 83: Pharmaceuticals for the treatment of athlete’s foot ............................. 270
Table A 84: Pharmaceuticals for the treatment of cold .......................................... 271
Table A 85: Pharmaceuticals for the treatment of cough ....................................... 272
Table A 86: Pharmaceuticals for the treatment of urinary tract infection ................. 272
Table A 87: Pharmaceuticals for the treatment of heartburn .................................. 273
Table A 88: Non-Medical Prescribing / Pharmacist independent prescribing
(NMP/PIP) for athlete's foot .............................................................. 274
Table A 89: Non-Medical Prescribing / Pharmacist independent prescribing
(NMP/PIP) for cold .......................................................................... 275
Table A 90: Non-Medical Prescribing / Pharmacist independent prescribing
(NMP/PIP) for cough ........................................................................ 276
Table A 91: Non-Medical Prescribing / Pharmacist independent prescribing
(NMP/PIP) for heartburn .................................................................. 277
Table A 92: Non-Medical Prescribing / Pharmacist independent prescribing
(NMP/PIP) for urinary tract infection .................................................. 278
Table A 93: Minor Ailment Scheme (MAS) for athlete's foot ................................... 279
Table A 94: Minor Ailment Scheme (MAS) for Cold ............................................... 280
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Table A 95: Minor Ailment Scheme (MAS) for Cough ............................................ 281
Table A 96: Minor Ailment Scheme (MAS) for Heartburn ....................................... 282
Table A 97: Minor Ailment Scheme (MAS) for urinary tract infection ....................... 283
Table A 98: NHS Choices for athlete’s foot .......................................................... 284
Table A 99: NHS Choices for cold ....................................................................... 285
Table A 100: NHS Choices for cough .................................................................... 286
Table A 101: NHS Choices for heartburn ............................................................... 287
Table A 102: NHS Choices for urinary tract infection .............................................. 288
Table A 103: Results of telephone interview on transferability of
best-practice initiatives .................................................................... 289
Table A 104: Different Stakeholder groups and the rationale for selecting them as
dissemination targets for this project ................................................ 292
Table A 105: Identification of key features and characteristics of
self care best-practice initiatives ....................................................... 294
Table A 106: Feasibility assessment of transferability of
self care best-practice initiatives ....................................................... 296
A cost/benefit analysis of self-care systems in the European Union
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List of Figures
Figure 1: Continuum of care ................................................................................ 33
Figure 2: Methodology for transferability ............................................................... 46
Figure 3: Framework for the risk analysis .............................................................. 47
Figure 4: Plan-Do-Study-Act (PDSA) process ......................................................... 49
Figure 5: Graphical illustration of the selection process for the ailment of
athlete’s foot ........................................................................................ 51
Figure 6: Graphical illustration of the selection process for the ailment of cold ........... 52
Figure 7: Graphical illustration of the selection process for the ailment of cough ......... 55
Figure 8: Graphical illustration of the selection process for the ailment of heartburn ... 58
Figure 9: Graphical illustration of the selection process for the ailment of
urinary tract infection ............................................................................ 61
Figure 10: Key features of best-practices ................................................................ 97
Figure 11: Strategic mapping of initiative-relevant conditions .................................. 101
Figure 12: Target groups addressed ..................................................................... 105
A cost/benefit analysis of self-care systems in the European Union
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List of Abbreviations
AMC/DCBA
Amylmetacrsol/2.4-dichlorobenzyl alcohol
ARI
Acute Respiratory Infection
AT
Austria
A&E
Accident & Emergency
BEUC
Bureau Européen des Unions de Consommateurs/The European
Consumer Organisation
BMI
Body Mass Index
CAP
Community-Acquired Pneumonia
CBA
Cost-Benefit Analysis
CHAFEA
Consumer, Health, Agriculture and Food Executive Agency
CNAMTS
Caisse Nationale de l’Assurance Maladie des Travailleurs salariés /
National Health Insurance Fund for Employees (France)
COPD
Chronic Obstructive Pulmonary Disease
CQC
Care Quality Commission (United Kingdom)
CRD
Centre for Reviews and Dissemination (United Kingdom)
CZ
Czech Republic
D
Deliverable
DE
Germany
DG SANTE
Direction générale de la santé et des consommateurs/Directorate-
General for Health and Food Safety
DIMDI
Deutsches Institut für medizinische Dokumentation und
Information/German Institut of Medical Documentation and
Information (Germany)
DK
Denmark
DoPHER
Database of Promoting Health Effectiveness Reviews (United
Kingdom)
DM
Dextromethorphan
ENT
Ear, Nose, Throat
EU
European Union
FR
France
GER / GOR
Gastro-Esophageal Reflux/Gastro-Oesophageal Reflux
GERD / GORD
Gastro-Esophageal Reflux Disease/Gastro-Oesophageal Reflux
Disease
GI
Gastro-Intestinal
GKV
Gesetzliche Krankenversicherung/National Health Insurance
(Germany)
A cost/benefit analysis of self-care systems in the European Union
April, 2015 15
GP
General Practitioner
H2RA
H2 Receptor Antagonists
HSCIC
Health & Social Care Information Centre (United Kingdom)
IDSA
Infectious Diseases Society of America (USA)
IQWIG
Institut für Qualität und Wirtschaftlichkeit im
Gesundheitswesen/Institute for quality and efficiency in
Healthcare (Germany)
LES / LOS
Lower Oesophageal Sphincter/Lower Esophageal Sphincter
LUTI
Lower Urinary Tract Infection
LV
Latvia
MAS
Minor Ailment Scheme
MeSH
Medical Subject Headings
NHS
National Health Service
NL
Netherlands
NMP/PIP
Non-Medical Prescribing / Pharmacist independent Prescribing
OECD
Organisation for Economic Co-operation and Development
ONB
Österreichische Nationalbibliothek/Austrian National Library
(Austria)
OTC
Over-the-counter
PCR
Polymerase Chain Reaction
PIP
Pharmacist Independent Prescribing
PMAS
Pharmacy Minor Ailment Scheme (England)
POM
Prescription Only Medicine
PPI
Proton Pump Inhibitors
PT
Portugal
QALY
Quality Adjusted Life Year
RCT
Randomised Controlled Trial
RE-AIM
Reach, Efficiecy, Adoption, Implementation, Maintenance
RSV
Respiratory Syncytial Virus
RTI
Respiratory Tract Infection
RUTI
Recurrent Urinary Tract Infection
Rx
Prescription
SARS
Severe Acute Respiratory Syndrome
SI
Slovenia
SMS
Short Message Service
UK
United Kingdom
URTI
Upper Respiratory Tract Infection
A cost/benefit analysis of self-care systems in the European Union
April, 2015 16
USA
United States of America
UTI
Urinary Tract Infection
VAT
Value Added Tax
WHO
World Health Organization
WP
Work package
WW
Watchful Waiting
A cost/benefit analysis of self-care systems in the European Union
April, 2015 17
Executive summary
Background
The traditional provider-centred structure within most European health care systems is
primarily designed for delivering acute care, and less targeted for the care of patients
with chronic, minor and/or self-limiting diseases. For these patients other concepts of
care may be more suitable and may also contribute to enhanced cost containment within
health care systems.
One approach which promotes patient involvement and is expected to lead to savings in
health care budgets is the concept of self-care. The areas of action for self-care are
twofold: First, self-care is regarded as a suitable approach for dealing with chronic
conditions, as the day-to-day management is already carried out by patients and their
families. Second, there are also further, typically self-limiting and minor conditions which
can be handled with simple actions and low risk by the patients or other lay-persons
(such as relatives). These conditions are referred to as minor ailments.
At EU level, the issue of self-care was particularly addressed through processes related to
self-medication or non-prescription medication. In Commission Decision C(2013) 4940 of
2 August 2013 concerning the financial contribution by the Community towards a pilot
project in the field of self-care systems in EU, the Budget Authority asked the Commission
to fund initiatives which put in place a framework for action to enhance self-care at EU
level and develop strategies to support the broader implementation of effective self-care.
These objectives shall be achieved by:
1. A cost/benefit analysis of patient self-care oriented health care systems in the
European Union and the current frameworks in place to enhance self-care oriented
health care systems and patients’ empowerment;
2. Transferability of best-practices; and
3. The creation of a platform of experts in self-care and health care.
Objectives 1) and 2) are covered by this study at hand. Objective 3) will be addressed by
the ‘Pilot project on the promotion of self-care systems in the European Union: Platform
of experts’ (PISCE).
Rationale and objectives of the study
The general objective of the study was to explore the added value of self-care systems in
Europe. As such, this study aimed to provide a basis for assessing the economic and
societal impacts of self-care, as well as to offer guidance on how to transfer and
implement self-care initiatives that had proven to be effective on the grounds of existing
evidence. Accordingly, the specific objectives are:
to provide scientific evidence of the added value of self-care for five selected minor
ailments (i.e. athlete’s foot, cold, cough, heartburn, urinary tract infection);
to analyse potential costs and savings of self-care initiatives;
to develop a methodology of the transferability of best-practices in self-care and
assess it; and
to develop a strategy to disseminate the benefits of self-care.
A cost/benefit analysis of self-care systems in the European Union
April, 2015 18
Definition of self-care
For all activities undertaken in this project, such as the literature review of minor ailments
and the cost/benefit analysis, the following definition of self-care was applied:
“Self-care is what individuals, families and communities do with the intention to promote,
maintain, or restore health and to cope with illness and disability with or without the
support of health professionals such as pharmacists, doctors, dentists and nurses. It
includes but is not limited to self-prevention, self-diagnosis, self-medication and self-
management of illness and disability.”
This definition was developed based on a literature review and a two-stage Delphi process
with the project’s expert panel.
Added value of self-care
A systematic literature review was conducted for five selected minor ailments. Key results
were:
For the ailment of athletes’ foot, the included studies contained good evidence for the
effectiveness of almost all topical treatments of athlete’s foot which can be used by the
patient in self-care. Strong evidence was available for allylamines and azoles. For
butenafine, ciclopiroxolamine, tolciclate and tolnaftate as well as for terbinafine evidence
was less strong.
For cold, the included studies showed that there was sound evidence for the
effectiveness of treatments (e. g. Acetylsalicylic acid, nasal sprays/topical treatments,
Echinacea, etc.) against the symptoms of the common cold which can be used by patient.
However, some caution is required with regard to products where the effectiveness is not
proven, as the placebo effect together with the natural resolving of the common cold
might lead patients to misperceive the actual added value of these products.
With regard to cough, the systematic search revealed a lack of evidence for the
effectiveness of Over-the-Counter (OTC) medicines which can be used by patients in self-
care. Despite a high evidence grade of an included review, its results have to be
interpreted cautiously as it is based on too few studies with too many methodological
issues making generalisations difficult. Aligned with WHO recommendations, home
remedies like a spoon of buckwheat honey can be used as a first line treatment against
minor ailments, especially against nocturnal cough symptoms.
For the ailment of heartburn, there was good evidence for the effectiveness of some
treatments of heartburn, which can be used for self-care. Evidence found mostly referred
to products, which can usually be purchased over the counter and have little side-effects
such as lansoprazole and H2-receptor antagonists. However, future evaluations on self-
care for heartburn should pay more attention to clearly distinguish between heartburn,
gastroesophageal symptoms and Gastro-Esophageal Reflux Disease.
Referring to urinary tract infection (UTI), no clear evidence could be identified if and
how different preventive self-care strategies can reduce the risk of (recurrent) UTI. The
reasons are diverse: non-compliance with juice and syrup products, no statements about
how much of the active ingredient (if any) is inside non-juice products. Antibiotics are the
most effective treatment in the presence of UTI, but the added value for self-
management is limited, as it is not possible to draw inferences from symptoms to
bacteriuria or bacterial counts.
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Analysis of self-care initiatives
Initially, eight self-care initiatives were considered to be analysed according to the RE-
AIM+ framework. During the course of the project, one of these initially selected
initiatives (i.e. ‘Grünes Rezept’) was excluded in accordance with the project
commissioners. It did not target towards the avoidance/substitution of GP contacts by
self-care in first place, and thus did not completely comply with the definition of self-care
used in this project.
The following self-care initiatives were analysed:
Ameli santé (Health information website; France)
Latvian tele-helpline (Health information - telephone hotline; Latvia)
Zelfzorg.nl (Health information website; the Netherlands)
NHS Choices (Health information website; UK)
NHS 111 (NHS direct) (Health information - telephone hotline; UK)
Minor ailment scheme (Legislative change; UK)
Non-medical prescribing (Legislative change; UK)
According to the proposed framework the latter four UK-based initiatives were identified
as best-practice. A cost-benefit analysis was performed for NHS Choices, Minor ailment
scheme and Non-Medical Prescribing. For the case of NHS 111, sufficient cost data was
not available to undertake a cost-benefit analysis.
Economic evaluation of self-care initiatives
For the five selected minor ailments, costs and savings of the identified best-practice self-
care initiatives were analysed from four different perspectives: patient, provider, system,
society.
Minor ailment schemes (MAS) have the potential to lead to a positive societal net
benefit if shift rates exceed 27.5 percent. As prescription charges are relatively high
(£ 8.05 or 10.87 per item) compared to the prices of OTC medicines, patients not
exempt from these charges tend to benefit to a larger extent than those exempt. Still, the
latter group of patients also tends to benefit from MAS, and even more than from merely
using an internet-based information service such as NHS Choices.
Concerning Non-medical prescribing (NMP), costs at providers’ level are too high to
allow for a positive net benefit at the societal level. Patients, however, regardless as to
whether they are exempt from prescription charges, tend to benefit from NMP, as they
are likely to save time due to the avoided GP encounter while the medication as well as
possible (co-)payments remain the same.
With regard to NHS Choices, a positive net societal benefit appears to exist despite
comparatively low rates of overall shift (break-even of the initiative at 4.4 percent shift
rate). Patients exempt from prescription charges benefit from time savings only, while
patients obliged to pay prescription charges additionally benefit from lower (co-)payments,
as they have to pay fully out-of-pocket for OTC medicines instead paying the prescription
fee of £ 8.05 per item for a similar prescription-only medicine.
In a nutshell, from a societal perspective the results suggest NHS Choices and MAS being
favourable policy options, with NHS Choices primarily benefiting patients obliged to pay
prescription charges, whereas MAS appears to be designed more towards patients exempt
from prescription charges.
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The impacts of NMP show no difference concerning the obligation of patients to pay
prescription charges. From a societal perspective, though, a widespread adoption of
pharmacist independent prescribing is very unlikely.
Transferability of best-practices
Based on the frameworks for policy transfer in health as well as in other settings
identified in literature, a four-step approach was developed, consisting of:
1. Identification of best-practices in self-care
2. Identification of key features of best-practice initiatives
3. Assessment of the feasibility of transferring best-practice initiatives
4. Deduction of policy options
The identification and selection of best-practices (step 1) in self-care was based on the
RE-AIM framework (i.e. criteria for reach, effectiveness, adoption, implementation and
maintenance). In order to identify the features and characteristics of best-practice self-
care initiatives in step 2, each best-practice initiative was assessed by a framework
consisting of four dimensions: 1) Population/Patient, 2) Providers, 3) Government/System
and 4) Technology.
Based on steps 1 and 2, the feasibility of best-practices’ transferability was assessed
(step 3). This step aims to examine the conditions that have to be met for a best-
practice initiative to function successfully in the importing setting. The assessment links
the above mentioned four dimensions to other works in that field and covers three
aspects:
1. Factors supporting policy success in the exporting setting (i.e. “favourable
conditions”).
2. Assessment of the success factors’ relevance in the exporting setting
(“relevance”).
3. Assessment of the situation in relation to the success factors in the importing
setting (“feasibility”).
Based on the assessment results gained by following the first three steps, policy-makers
decide in step 4 if, and how a best-practice initiative should be implemented in their
country.
In order to critically reflect the feasibility of the methodology for transferability a SWOT
and risk analysis was conducted.
Dissemination strategy of best-practice in self-care
In order to allow for learning and a transfer of best-practices in self-care, the findings of
the study about the benefits of self-care and the methodology for transferability should
be appropriately disseminated.
Major target groups include policy-makers and stakeholders at EU and national levels,
representatives of similar projects, in particular the PISCE (pilot project on the promotion
of self-care) consortium as well as the general public.
In addition to this report at hand, which comprises in a comprehensive way scientific
results and a practical tool of the methodology for transferability aimed at policy-makers,
further dissemination activities are recommended.
Highly recommended dissemination tools for this project include a press release and a
leaflet in order to raise awareness. Furthermore, the proposed dissemination plan for this
A cost/benefit analysis of self-care systems in the European Union
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report suggests making use of existing newsletters and websites of the consortium and of
other institutions to disseminate the results. The scientific community can be reached
through articles in peer-reviewed journals, presentations and posters at conferences.
A major dissemination activity would be the organisation of a large-scale conference
targeted at policy-makers and stakeholders, either as a stand-alone event or together
with similar projects, such as the PISCE project.
Conclusions and recommendations
The study at hand highlighted the increasing relevance of self-care, both in literature as
well as in practice, and, at the same time, the need for further evidence and knowledge,
and their dissemination.
Our study offers added value to existing literature that tends to be focused on the
effectiveness of the pharmaceutical treatments for self-care use. We explored the benefits
of self-care by critically assessing self-care initiatives in cost-benefit analyses. Scientific
evidence is supplemented by a practical guide for policy-makers that allows identifying
best-practices in self-care and transferring them to their own setting.
While several factors in the setting of the importing and exporting countries playing a role
to facilitate the implementation and uptake of self-care, our study has outlined that a
political commitment to self-care, such as in the UK, supports best-practices in self-
care.
A prerequisite for successful self-care initiatives is the change in “culture” so that
patients take responsibility for their own health. In order to do so, patients have to be
“empowered”, and they require access to reliable and understandable information about
how to engage in self-care. An inevitable part of patient information related to self-care
must be clear communication that self-care cannot substitute health care by
professionals. Patients have to be taught to distinguish minor ailments from serious
cases.
Self-care also requires re-thinking of the involved health care professionals related
to the definition of their professional identity. In particular, the cooperation between
physicians and pharmacists may need to be re-organised since these health care
professionals should engage more in collaborative care.
Our study is a basis for follow-up work in this field, especially for the development of a
guideline for the promotion of self-care and a guideline for the development and
production of communication tools as well as a proposal of policy actions on self-care at
EU level that will be done in the PISCE project. It is highly recommended that our results
are fed into the PISCE project and that the experts of the PISCE platform consider our
findings in their work.
A cost/benefit analysis of self-care systems in the European Union
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Résumé
Contexte
La structure traditionnelle centrée sur le fournisseur, au sein de la plupart des systèmes
de soins de santé européens, est principalement conçue pour la prestation de soins aigus
de courte durée, et moins ciblée sur le soin des patients atteints de maladies chroniques,
mineures et/ou spontanément résolutives. Pour ces patients, d'autres concepts de soins
peuvent être plus appropriés et peuvent également contribuer à la maîtrise des coûts
accrue dans les systèmes de soins de santé.
Une approche, qui favorise la participation des patients et peut conduire à des économies
dans les budgets de soins de santé est le concept des soins personnels («self care»). Les
domaines d'action pour les soins personnels sont de deux ordres: d'abord, les soins
personnels sont considérés comme une approche appropriée pour traiter des conditions
chroniques, étant donné que la gestion au jour le jour est déjà effectuée par les patients
et leurs familles. Deuxièmement, il y a aussi plus de maladies, spontanément résolutives
et mineures, qui peuvent être traitées avec des actions simples et à moindre risque par
les patients ou l’entourage. Ces conditions sont appelées maladies mineures («minor
ailments»).
Au niveau européen la question des soins personnels a été particulièrement abordée à
travers des processus liés à l'automédication ou à la médication sans ordonnance. La
décision C(2013) 4940 de la Commission, datant du 2 Août 2013, concerne la
contribution financière de la Communauté Européenne à un projet pilote dans le domaine
des systèmes de soins personnels dans l'UE. Dans cette décision l'autorité budgétaire a
demandé à la Commission de financer des initiatives qui mettent en place un cadre pour
des mesures d’amélioration des soins personnels au niveau de l'UE et pour velopper
des stratégies visant à soutenir la mise en œuvre plus large de soins personnels efficaces.
Ces objectifs seront atteints par:
1. Une analyse des coûts/avantages des systèmes de santé orientés sur les soins
personnels des patients dans l'Union européenne et les structures actuellement en
place pour améliorer ces systèmes ainsi que la responsabilisation des malades;
2. La transférabilité des meilleures pratiques; et
3. La création d'une plate-forme d'experts en soins personnels et en santé.
Les objectifs 1) et 2) sont couverts par cette étude. L’objectif 3) sera traité par le «Projet
pilote sur la promotion des systèmes de soins personnels dans l'Union européenne: plate-
forme d'experts» (PISCE).
Motifs et objectifs de l'étude
L'objectif général était d'explorer la valeur ajoutée des systèmes de soins personnels en
Europe. Cette étude vise à fournir une base pour évaluer les impacts économiques et
sociaux de soins personnels, ainsi que d’offrir des conseils sur la façon de mettre en
œuvre des initiatives de soins personnels qui se sont montrées efficaces selon les preuves
existantes. Les objectifs spécifiques sont:
de fournir des preuves scientifiques de la valeur ajoutée des soins personnels pour
cinq maladies mineures sélectionnés (pied d'athlète, le rhume, la toux, les brûlures
d'estomac, l’infection des voies urinaires);
d'analyser les coûts potentiels et les économies des initiatives de soins personnels;
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de développer une méthodologie de transmission des meilleures pratiques en soins
personnels et de l'évaluer; et
de développer une stratégie visant à diffuser les avantages des soins personnels.
Définition des soins personnels
Dans ce projet la définition suivante des soins personnels a été appliquée:
«Les soins personnels sont ce que les individus, les familles et les communautés font avec
l'intention de promouvoir, maintenir ou rétablir la santé et de faire face à la maladie et
l'invalidité avec ou sans le soutien des professionnels de santé tels que les pharmaciens,
les médecins, les dentistes et les infirmières. Il inclut, mais n’est pas limitée à, l'auto-
prévention, l’autodiagnostic, l'automédication et l'autogestion de la maladie et du
handicap.»
Cette définition a été élaborée sur la base d'une revue de la littérature et d’un processus
Delphi en deux étapes avec un panel d'experts.
Valeur ajoutée des soins personnels
Une revue systématique de la littérature a été réalisée pour cinq maladies mineures:
Pour la maladie du pied d'athlète (mycose des pieds), les études considerées
contenaient une forte indication de l'efficacité de presque tous les traitements topiques du
pied d'athlète qui peuvent être utilisés par le patient en soins personnels. Des preuves
solides étaient disponibles pour les allylamines et azoles. Pour la buténafine,
ciclopiroxolamine, tolciclate et tolnaftate ainsi que pour la terbinafine, les indications
étaient moins fortes.
Pour le rhume, les études ont montrés qu'il y avait de fortes indications de l'efficacité des
traitements (par exemple de l'acide acétylsalicylique) contre les symptômes du rhume qui
peuvent être appliqués par le patient. Toutefois, une certaine prudence est nécessaire en
ce qui concerne les produits pour lesquels l'efficacité n’est pas prouvée. L'effet placebo lié
à la guérison naturelle du rhume pourrait conduire les patients à mal percevoir la valeur
ajoutée réelle de ces produits.
En ce qui concerne la toux, la recherche systématique a révélé un manque de preuves en
ce qui concerne l'efficacides médicaments sans ordonnances qui peuvent être utilisés
par les patients en termes de soins personnels. Malgré de fortes indications, ses résultats
doivent être interprétés avec prudence, car ils sont basés sur trop peu d'études avec trop
de problèmes méthodologiques rendant les conclusions difficiles. En accord avec les
recommandations de l'OMS, les remèdes maison comme une cuillère de miel de sarrasin
peuvent être utilisés comme un traitement de première intention contre les maladies
mineures.
Pour les brûlures d'estomac, il y avait une forte indication de l'efficacité de certains
traitements, qui peuvent être utilisés pour les soins personnels. Les éléments trouvés font
souvent référence à des produits qui peuvent généralement être achetés sans ordonnance
et qui ont peu d'effets secondaires tels que le lansoprazole et les antagonistes récepteurs
H2. Toutefois, les évaluations futures devront accorder plus d'importance au fait de
distinguer clairement les brûlures d'estomac des symptômes de la gastro et de la maladie
de reflux gastro-oesophagien.
En ce qui concerne l'infection des voies urinaires (IVU), aucune indication claire n'a
pu être identifiée pour savoir si et comment les différentes stratégies de soins personnels
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préventifs peuvent réduire le risque (récurrent) d’IVU. Les raisons sont diverses: non-
respect des produits de type jus et sirop, aucune déclaration sur le nombre d'ingrédient
actif (le cas échéant) à l'intérieur des produits de type non-jus. Les antibiotiques sont le
traitement le plus efficace en présence de l'IVU, mais la valeur ajoutée pour les soins
personnels est limitée, car il n’est pas possible de tirer des conclusions à partir de
symptômes à bactériurie ou à numération bactérienne.
Analyse des initiatives de soins personnels
Initialement, huit initiatives de soins personnels ont été considérées pour être analysées
selon le cadre RE-AIM+ (l'efficacité, l'adoption, la mise en œuvre et la maintenance). Au
cours du projet, l'une de ces initiatives initialement sélectionnée (en l’occurrence «Grünes
Rezept») a été exclue en accord avec les commissaires du projet parce qu'elle ne visait
pas à éviter/substituer les contacts avec les médecins dans le cadre des soins personnels,
et n'est donc pas complètement conforme avec la définition des soins personnels utilisée
dans ce projet.
Les initiatives de soins personnels suivants ont été analysées:
Ameli santé (information sur la santé - site; FR)
lé-assistance téléphonique Lettone (information sur la santé - ligne téléphonique; LV)
Zelfzorg.nl (information sur la santé - site; NL)
NHS Choices (information santé - site; RU)
111 NHS (NHS Direct) (information sur la santé - ligneléphonique; RU)
Minor ailment scheme (changement législatif; RU)
Non-medical prescribing (changement législatif; RU)
Les quatre dernières initiatives basées au Royaume-Uni ont été identifiées comme les
meilleures pratiques. Une analyse des coûts-avantages a été effectuée pour NHS Choices,
Minor Ailment Scheme (le service des maladies mineures) et Non-medical-prescribing (la
prescription sans ordonnance). Pour le cas de NHS 111, les données sur les coûts n'ont
pas été suffisantes pour entreprendre une analyse des coûts-avantages.
L'évaluation économique des initiatives de soins personnels
Pour les cinq maladies mineures sélectionnées, les coûts et les économies des meilleures
pratiques identifiés ont été analysés à partir de quatre points de vue différents: celui du
patient, du fournisseur, du système et de la société.
Minor ailment scheme (MAS) a le potentiel d´apporter une contribution avantageuse
dans la société (avantage net) si les taux de changement dépassent 27,5%. Comme les
frais d'ordonnance sont relativement élevés dans le Royaume-Uni (£ 8,05 ou 10,87 par
article) par rapport aux prix des médicaments en vente libre, les patients non exemptés
de ces frais ont tendance à en profiter plus largement. Pourtant, ce dernier groupe a
également tendance à bénéficier de services de maladies mineures, et même plus que de
la simple utilisation d'un service d'information sur Internet tels que NHS Choices.
En ce qui concerne la Non-medical prescribing (NMP), les coûts au niveau des
fournisseurs sont trop élevés pour permettre une contribution avantageuse pour la
société. Les patients, cependant, indépendamment de savoir s’ils sont exemptés de frais
d'ordonnance, ont tendance à bénéficier de NMP, car ils sont susceptibles de gagner du
temps en raison de la non-consultation de médecin tandis que la médication ainsi que les
(co)paiements possibles restent les mêmes.
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En ce qui concerne NHS Choices, une contribution avantageuse dans la société semble
exister en dépit des taux de changement relativement faibles (seuil de rentabilité de
l'initiative taux de changement de 4,4%). Les patients bénéficiant de la franchise de
prescription ne bénéficient que d’un gain de temps, alors que les patients tenus de payer
les frais d'ordonnance supplémentaires bénéficient de (co)paiements plus bas, car ils
doivent payer intégralement de leur poche les médicaments en vente libre, au lieu de
payer les frais de prescription de £ 8,05 par article pour un médicament similaire
uniquement sur ordonnance.
En un mot, pour la société les résultats suggèrent NHS Choices et MAS comme étant des
options politiques favorables, avec NHS Choices bénéficiant principalement aux patients
qui sont obligés de payer des frais d'ordonnance, alors que MAS semble être plutôt conçu
pour des patients exemptés de frais d'ordonnance.
Les impacts des NMP ne montrent aucune différence concernant l'obligation des patients à
payer les frais d'ordonnance. Pour la société cependant, une adoption généralisée d’une
prescription indépendante du pharmacien est très peu probable.
Transférabilité des meilleures pratiques
Une approche en quatre étapes a été élaborée, comprenant:
1. Identification des meilleures pratiques en soins personnels
2. Identification des caractéristiques clés des initiatives de meilleures pratiques
3. Évaluation de la faisabilité du transfert des initiatives de bonnes pratiques
4. Déduction des options politiques
L'identification et la sélection des meilleures pratiques (étape 1) dans les soins
personnels a été basée sur le cadre RE-AIM. Afin d'identifier les spécificités et les
caractéristiques des initiatives de meilleures pratiques dans l'étape 2, chaque initiative a
été évaluée par un cadre composé de quatre dimensions: 1) Population/Patient, 2)
Fournisseurs, 3) Gouvernement/système et 4) la Technologie.
Basé sur les étapes 1 et 2, la faisabilité de la transmission et réalisation des meilleures
pratiques a été évaluée (étape 3). Cette étape vise à examiner les conditions qui doivent
être remplies pour qu’une initiative des meilleures pratiques puisse fonctionner avec
succès dans le cadre de l'importation. L'évaluation relie les quatre dimensions
mentionnées ci-dessus à d'autres travaux dans ce domaine et couvre trois aspects:
1. Facteurs soutenant la réussite de la politique pour l’exportation («conditions
favorables»).
2. L'évaluation de la pertinence des facteurs de succès dans l'exportation (la
«pertinence»).
3. Évaluation de la situation par rapport aux facteurs de succès dans l'importation
faisabilité»).
Basé sur les résultats de l'évaluation obtenus en suivant les trois premières étapes, les
décideurs politiques décident à l'étape 4 si, et comment une initiative de meilleures
pratiques devrait être mise en œuvre dans leur pays. Afin de réfléchir de manière critique
à la faisabilité de la méthodologie pour la transmission et réalisation, une analyse SWOT
et une analyse des risques ont été menées.
Stratégie de diffusion des meilleures pratiques en matière de soins personnels
Afin de permettre l'apprentissage et le transfert des meilleures pratiques, les résultats de
l'étude sur les avantages des soins personnels et la méthodologie de transmission
A cost/benefit analysis of self-care systems in the European Union
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devraient être diffusés de manière appropriée.
Les principaux groupes cibles sont les décideurs politiques et les parties prenantes au
niveau européen et nationaux, des représentants de projets similaires, en particulier le
projet PISCE ainsi que le grand public.
Les Outils de diffusion fortement recommandés comprennent un communiqué de
presse et un dépliant pour sensibiliser le public. En outre, le plan de diffusion proposé
pour ce rapport suggère de faire usage de bulletins d'information et des sites Web
existants du consortium et d'autres institutions pour diffuser les résultats. La
communauté scientifique peut être atteinte par des articles dans des revues évaluées par
des pairs, des présentations et des affiches à des conférences.
Une des principales activités de diffusion serait l'organisation d'une grande conférence
destinée aux décideurs politiques et aux parties prenantes, que ce soit comme un
événement autonome ou avec des projets similaires, tels que le projet PISCE.
Conclusions et recommandations
Cette étude a souligné l'importance croissante des soins personnels, à la fois dans la
littérature ainsi que dans la pratique, le besoin de plus d’indications, de connaissances et
de leur diffusion.
Notre étude apporte une valeur ajoutée à la littérature existante qui se concentre sur
l'efficacité des traitements pharmaceutiques pour un usage personnel. Nous avons
exploré les avantages des soins personnels par une évaluation critique des initiatives de
soins personnels dans les analyses de coûts-avantages. Les preuves scientifiques sont
complétées par un guide pratique pour les décideurs politiques. Notre étude permet
d'identifier les meilleures pratiques dans les soins personnels et de les transférer vers leur
propre milieu.
Bien que plusieurs facteurs dans le cadre des pays importateurs et exportateurs jouent un
rôle pour faciliter la mise en œuvre et l'utilisation des soins personnels, notre étude a
souligné qu'un engagement politique aux soins auto-administrés, comme en
Royaume-Uni, soutient les meilleures pratiques dans les soins personnels.
Une condition préalable pour le succès des initiatives de soins personnels est le
changement de «culture» afin que les patients prennent en charge leur propre santé.
Pour ce faire, les patients doivent être «habilités», et doivent avoir accès à une
information fiable et compréhensible sur la façon de s’engager dans l'autogestion. Une
communication claire sur ce type de soins ne peut se substituer aux soins de santé
délivrés par des professionnels. Les patients doivent apprendre à distinguer les maladies
mineures des cas graves.
Prendre soin de soi nécessite également une réflexion des professionnels de santé
impliqués, liée à la définition de leur identité professionnelle. Une coopération entre les
médecins et les pharmaciens doit permettre de tendre vers une collaboration au niveau
des soins.
Notre étude est une base de travail qui doit être suivie dans ce domaine, en particulier
pour l'élaboration de recommandations pour la promotion des soins personnels et pour le
développement et la production d'outils de communication; ainsi que d'une proposition de
mesures politiques sur les soins personnels au niveau de l'UE qui sera faite dans le projet
PISCE. Il est fortement recommandé que nos résultats soient introduits dans le projet
PISCE.
A cost/benefit analysis of self-care systems in the European Union
April, 2015 27
Zusammenfassung
Hintergrund
Die traditionell Anbieter-zentrierte Struktur der meisten europäischen
Gesundheitssysteme ist in erster Linie auf Akutversorgung ausgelegt und zielt weniger auf
die Betreuung von Patienten/innen mit chronischen, minderschweren und/oder
selbstlimitierenden Erkrankungen ab. Für diese wären andere Konzepte der Versorgung
besser geeignet. Ein Ansatz, der Patientenbeteiligung fördert und voraussichtlich auch zu
Einsparungen bei den Gesundheitskosten führen wird, ist das Konzept der
Selbstbehandlung („Self Care“). Es gibt zwei Handlungsfelder für Selbstbehandlung: Zum
einen chronischen Erkrankungen, deren tägliches Management ohnehin bereits jetzt von
den Erkrankten und ihren Familien durchgeführt wird. Zum anderen selbstlimitierende
kleinere Erkrankungen, die mit einfachen Maßnahmen und mit geringem Risiko von den
Patienten/innen selbst. Diese werden als minderschwere Beschwerden (minor ailments)
bezeichnet.
Auf EU-Ebene wurde die Frage der Selbstbehandlung bisher vor allem mit Prozessen der
Selbstmedikation in Zusammenhang gebracht. In der Entscheidung C(2013)4940 vom
2. August 2013 über die finanzielle Beteiligung der Gemeinschaft an einem Pilotprojekt im
Bereich von Selbstbehandlungssystemen in der EU forderte die Haushaltsbehörde die
Kommission auf, Initiativen zu finanzieren, die einen Handlungsrahmen für Maßnahmen in
diesem Bereich auf EU-Ebene einrichten, und Strategien für eine umfassende Umsetzung
wirksamer Selbstbehandlung zu entwickeln.
Diese Ziele sollen erreicht werden durch:
1. eine Kosten-Nutzen-Analyse von patienten- und selbstbehandlungsorientierten
Gesundheitssystemen in der EU sowie einer Analyse der bestehenden
Rahmenbedingungen, um selbstbehandlungsorientierte Pflegesysteme zu stärken
und Patientenbefähigung zu erhöhen;
2. die Übertragbarkeit von Best Practices;
3. die Schaffung einer Experten-Plattform zum Thema ‚Selbstbehandlung und
Gesundheit‘.
Die vorliegende Studie beschäftigt sich mit den Zielen 1 und 2. Das Ziel 3 wird von dem
Pilotprojekt Pilot project on the promotion of self-care systems in the European Union:
Platform of experts’ (PISCE) adressiert.
Begründung und Ziele der Studie
Das allgemeine Ziel der Studie ist, den Mehrwert von etablierten
Selbstbehandlungssystemen in Europa zu erkunden. Sie soll eine Grundlage für die
Beurteilung der wirtschaftlichen und gesellschaftlichen Auswirkungen von
Selbstbehandlung schaffen sowie eine Anleitung zur Übertragung und Umsetzung von
Selbstbehandlungsmaßnahmen entwickeln. Die spezifischen Ziele sind daher:
wissenschaftliche Evidenz für den Mehrwert von Selbstbehandlung für fünf
ausgewählte minderschwere Erkrankungen (Fußpilz, Schnupfen, Husten,
Sodbrennen, Harnwegsinfektion) zu liefern;
potenzielle Kosten und Einsparungen von Selbstbehandlungsinitiativen zu
analysieren;
eine Methodik für die Übertragbarkeit von Best Practices im Bereich
‚Selbstbehandlung‘ zu entwickeln und zu bewerten; und
eine Strategie zur Verbreitung von erfolgreicher Selbstbehandlung zu entwickeln.
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Definition von Selbstbehandlung
Für alle Aktivitäten, die im Zuge dieses Projekts durchgeführt wurden wurde folgende
Definition von Selbstbehandlung angewendet:
"Selbstbehandlung ist, was Einzelpersonen, Familien und Gemeinschaften mit der Absicht
tun, Gesundheit zu fördern, zu erhalten oder wiederherzustellen und Krankheit und
Behinderung zu bewältigen. Dies kann mit der oder ohne die Unterstützung durch
Gesundheitsberufe, wie etwa Apotheker, Ärzte, Zahnärzte und Pflegepersonal erfolgen.
Der Begriff Selbstbehandlung beinhaltet, ist aber nicht beschränkt auf Selbstprävention,
Selbstdiagnose, Selbstmedikation und Selbstmanagement von Krankheit und
Behinderung."
Diese Definition wurde entwickelt auf Basis einer Literaturrecherche in Kombination mit
einem zweistufigen Delphi-Prozess, welcher mit Hilfe eines Expertengremiums
durchgeführt wurde.
Mehrwert von Selbstbehandlung
Für fünf ausgewählte minderschwere Beschwerden wurde eine systematische
Literaturrecherche durchgeführt. Die wichtigsten Ergebnisse waren:
Hinsichtlich Fußpilz zeigen die eingeschlossenen Studien eine gute Evidenz für die
Wirksamkeit von fast allen topischen Behandlungen, die von Patienten/innen in
Selbstbehandlung angewendet werden können. Starke Evidenz liegt für Allylamine und
Azole vor. Für Butenafin, Ciclopiroxolamin, Tolciclat und Tolnaftat sowie Terbinafin war
der Evidenzgrad niedriger.
In Bezug auf Erkältungen liefern die eingeschlossenen Studien klare Evidenz für die
Wirksamkeit von Selbstbehandlungen bei Erkältungssymptomen (z. B. Acetylsalicylsäure,
Nasensprays / topische Behandlungen, Echinacea etc.). Eine gewisse Skepsis ist in Bezug
auf Produkte angebracht, bei denen die Wirksamkeit nicht erwiesen ist, da der Placebo-
Effekt zusammen mit dem natürlichen Abklingen der Erkältung dazu führen kann, dass
der tatsächliche Mehrwert dieser Produkte falsch wahrgenommen wird.
In Bezug auf Husten zeigt die systematische Literatursuche einen Mangel an Evidenz für
die Wirksamkeit rezeptfreier Arzneimittel. Trotz des hohen Evidenzgrades einer
inkludierten Übersichtsarbeit sind die Ergebnisse mit Vorsicht zu interpretieren, da die
wenigen eingeschlossenen Studien methodische Ungenauigkeiten aufweisen, was die
Verallgemeinerbarkeit der Ergebnisse schmälert. Den Empfehlungen der WHO folgend
können Hausmittel wie ein Löffel Buchweizenhonig als First-Line-Behandlung,
insbesondere gegen die Symptome nächtlichen Hustens, eingesetzt werden.
Zu Sodbrennen gibt es Evidenz für die Wirksamkeit einiger Selbstbehandlungsmethoden
(z. B. Lansoprazol und H2-Rezeptorantagonisten). Bei künftigen Untersuchungen zum
Thema Selbstbehandlung bei Sodbrennen sollte zwischen Sodbrennen,
gastroösophagealen Symptomen und gastroösophagealer Reflux-Krankheit genauer
unterschieden werden.
Keine Evidenz konnte identifiziert werden hinsichtlich präventiver
Selbstbehandlungsstrategien, die das Risiko einer (wiederkehrenden)
Harnwegsinfektion reduzieren. Die Gründe dafür sind vielfältig und können z. B.
mangelnde Einnahmetreue bei Saft- und Sirup-Produkten oder mangelnde Klarheit
hinsichtlich der aktiven Wirkstoffmenge (falls vorhanden) in Nicht-Saft-Produkten sein.
Antibiotika sind die effektivste Behandlung, jedoch ist der Mehrwert in Hinblick auf
A cost/benefit analysis of self-care systems in the European Union
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Selbstbehandlung limitiert, da es Patienten/innen nur bedingt Rückschlüsse von den
Symptomen auf eine Bakteriurie oder die Bakterienanzahl ziehen können.
Analyse der Selbstbehandlungsinitiativen
Zunächst sollten acht Selbstbehandlungsinitiativen anhand der RE-AIM+ Kriterien
(Reichweite, Wirksamkeit, Übernahme, Implementierung, Aufrechterhaltung, Zugang,
Gerechtigkeit und Einsparungspotenzial) analysiert werden. In Abstimmung mit den
Projektauftraggebern wurde im Projektverlauf eine der ursprünglich ausgewählten
Initiativen („Grünes Rezept") aufgrund der mangelnden Übereinsprechung mit der in
diesem Projekt verwendeten Definition von Selbstbehandlung ausgeschlossen. Folgende
Initiativen wurden untersucht:
Ameli santé (Gesundheitsinformation - Website; FR)
Lettische Tele-Helpline (Gesundheitsinformation - Telefon-Hotline, LV)
Zelfzorg.nl (Gesundheitsinformation - Website, NL)
NHS Choices (Gesundheitsinformation - Website; UK)
NHS 111 (NHS Direct) (Gesundheitsinformation - Telefon-Hotline, UK)
Minor Ailment Scheme (Gesetzesänderung, UK)
Non-Medical Prescribing (Gesetzesänderung, UK)
Die vier in Großbritannien ansässigen Initiativen wurden als Best Practices identifiziert.
Eine Kosten-Nutzen-Analyse wurde für NHS Choices, Minor Ailment Scheme und Non-
Medical Prescribing durchgeführt. Für NHS 111 standen nicht genügend Kostendaten zur
Verfügung, um eine Kosten-Nutzen-Analyse durchführen zu können.
Ökonomische Bewertung von Selbstbehandlungsinitiativen
Für die fünf ausgewählten minderschweren Beschwerden wurden Kosten und
Einsparungen durch die identifizierten Best-Practice-Selbstbehandlungsinitiativen
analysiert. Die Bewertung erfolgte aus vier unterschiedlichen Perspektiven: Patient,
Anbieter, öffentlicher Zahler und Gesellschaft.
Minor Ailment Schemes (MAS) führen aus gesellschaftlicher Sicht potenziell zu einem
positiven Nettonutzen, wenn die Verschiebungsrate 27,5 Prozent überschreitet. Aufgrund
der relativen Höhe von Rezeptgebühren (£ 8,05 oder 10,87 pro Stück in GB) im
Vergleich zu den Preisen von OTC-Arzneimitteln profitieren Patienten/innen ohne
Rezeptgebührbefreiung in einem größeren Umfang als jene, die befreit sind. Dennoch
profitiert auch die letztere Patientengruppe tendenziell von MAS, mehr sogar als durch die
alleinige Nutzung eines internetbasierten Informationsdiensts (wie NHS Choices).
Für Non-Medical-Prescribing (NMP) sind die Kosten auf Anbieterebene zu hoch, um
einen positiven Nettonutzen aus gesellschaftlicher Sicht zu ermöglichen. Der tendentielle
Nutzen von NMP für Patienten/innen ist unabhängig von der Rezeptgebührenpflicht, da sie
aufgrund der vermiedenen ärztlichen Konsultationen Zeit eingesparen, während die
Kosten für Medikamente sowie mögliche Selbstbehalte gleich bleiben.
Im Hinblick auf NHS Choices wurde trotz vergleichsweise niedriger Verschiebungsraten
(Break-even der Initiative bei 4,4 Prozent Verschiebu