Anja Neumann

Heart Failure: the Commonest Reason for Hospital Admission in Germany: Medical and Economic Perspectives

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

Are HIV patients undertreated? Cardiovascular risk factors in HIV: results of the HIV-HEART study.

Background: Antiretroviral therapy improved the survival of patients with human immunodeficiency virus (HIV) infection. With increased life expectancy, HIV-infected patients increasingly are experiencing comorbidities, most notably cardiovascular risk factors (CRFs) and coronary heart disease (CHD). Design: This study utilized a prospective, cross-sectional multicentre long-term design. Methods: In 803 patients (82% male; mean age 44.2 ± 10.3 years) we evaluated the prevalence of CRFs and 10-year risk of CHD using the Framingham risk model. The presence of a risk factor was determined based on the guidelines of the National Cholesterol Education Program (NCEP ATP III), the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7), and the German Society of Cardiology. Results: The most common CRFs were smoking (51.2%), high triglycerides (39.0%), low high-density lipoprotein cholesterol (27.5 %) and high blood pressure (21.4%). In total, 60.3%, 21.6%, and 18.1% of patients were categorized as being at low (<10%), moderate (10–20%), and high (>20%) 10-year risk for CHD, respectively. In patients with hypertension, at least one antihypertensive drug was given in 91/163 (55.8%) patients. The percentage of patients on treatment with diabetes mellitus was 23/41 (56.1%). Anti-platelet therapy was prescribed to 42/102 (41.2%) patients with known CHD or CHD equivalent. In patients of moderate or high CHD risk there were more than 50% and 30% for LDL cholesterol and more than 60% and 40% for total cholesterol untreated. Conclusions: The prevalence of CRFs remains high in an HIV-infected population. CRF management of HIV-infected patients deserves further improvement.

Economic Evaluation of Treatment Options in Patients with Alzheimer’s Disease

AbstractIntroduction: Alzheimer’s disease (AD) is common among the elderly; it is responsible for 60–80% of all dementia cases. AD is characterized by cognitive decline, behavioural and psychological symptoms, and reductions in functioning and independence. Because of its progressive neurodegenerative nature and unknown aetiology, the burden of AD becomes increasingly significant in an aging population. Estimates indicate that 35.6 million people worldwide suffered from AD in 2010. By 2030 and 2050, this figure is predicted to increase to 65.7 million and 115.4 million, respectively. Costs will also rise along with the increase in the number of people diagnosed with AD. In 2010, the world-wide costs associated with dementia were estimated to be

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

US604 billion. Objective: The objective of this study was to conduct a systematic review of current publications dealing with the pharmacoeconomic factors associated with AD medications and to describe the decision-analytic models used to evaluate long-term outcomes. Methods: A systematic literature search was performed to identify articles published between 1 January 2007 and 15 July 2010. The search was also based on a previous systematic review, which included literature up to 2007. Articles were included if they were complete and original economic evaluations of AD and if they were comparative in nature. A quality assessment of the included publications was conducted and relevant information was extracted into tables. Results: Seven out of 2067 identified articles were included in this systematic review. Four articles evaluated treatment with donepezil, one with galantamine and two with memantine. The studies were conducted in America, Europe and Asia.Five different groups of medications were compared. The incremental cost-effectiveness ratios (ICERs) for the group of patients treated with donepezil versus no drug treatment ranged from a dominant value to h281416.13 per quality-adjusted life-year (QALY). Patients treated with donepezil versus placebo showed ICERs with a range from a dominant value (not specified) up to h20 866.77 per QALY. Treatment with memantine in addition to donepezil versus treatment with donepezil alone showed an ICER range from a dominant value to €6818.33 per QALY. In comparison with the memantine treatment as an add-on therapy, the ICER of memantine monotherapy versus standard care (without cholinesterase inhibitors [CEIs]) ranged from a dominant value to €63 087.20 per QALY. Finally, the economic evaluation of galantamine in comparison with usual care without any AD drugs showed ICERs ranging from h1894.70 to h6953 per QALY. Conclusion: The seven identified publications included in this review indicate that treatment with CEIs or memantine seems to be reasonable in terms of clinical effects and costs for patients with AD. Depending on different hypotheses, assumptions and variables (e.g. time horizon, discount rates, initial number of patients in different states, etc.) in the sensitivity analyses, treatment with these drugs seems to be primarily a cost-effective strategy or even a cost-saving strategy. Nevertheless, the results generally are associated with a degree of uncertainty. The comparability of the results from the different economic evaluations is limited because of the different assumptions made.

Ärztliches Handeln bei Mittelknappheit

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

Childhood Psoriasis—An Analysis of German Health Insurance Data

ZusammenfassungDie finanziellen Ressourcen im deutschen Gesundheitssystem sind begrenzt. Diese Mittelknappheit führt im Rahmen der ärztlichen Tätigkeit zu medizinischen, ökonomischen, juristischen und ethischen Problemen, welche sich in den kommenden Jahren weiter verschärfen dürften. Aus ethischer Perspektive sind die Probleme einer gerechten Verteilung knapper Ressourcen sowie mögliche Rollen- oder Gewissenskonflikte der ärztlichen Profession besonders relevant. Mit Hilfe von qualitativen Interviewstudien lässt sich der aktuelle ärztliche Umgang mit der Mittelknappheit in der klinischen Versorgung in seiner Komplexität und seinen ethisch relevanten Aspekten untersuchen. An fünf Kliniken mit unterschiedlichem Versorgungsauftrag wurden Tiefeninterviews mit fünfzehn leitenden Ärzten in den Bereichen Intensivmedizin und Kardiologie durchgeführt. Die auf Tonband aufgezeichneten Interviews wurden nach dem Verfahren der Grounded Theory ausgewertet. Die Ärzte berichten ein heterogenes Spektrum von Einflussfaktoren, Konsequenzen und Reaktionen im Zusammenhang mit ihrem Handeln bei Mittelknappheit. Zuteilungskriterien wie der medizinische Nutzen oder die Kosteneffektivität werden von den befragten Ärzten sehr unterschiedlich interpretiert und führen damit möglicherweise zu inkonsistenten Allokationsentscheidungen. Gleichzeitig bestätigen die Untersuchungen aber auch, dass die Ärzte nicht leichtfertig mit den Allokationsentscheidungen umgehen, im Gegenteil: Die Mittelknappheit und die dadurch hervorgerufenen Verteilungsprobleme können zu Gewissenskonflikten, emotionalem Stress und Gefühlen der Überforderung führen. Um Lösungskonzepte für ethische Probleme im Umgang mit der Mittelknappheit in der klinischen Praxis entwickeln und erfolgreich implementieren zu können, müssen die in dieser Arbeit systematisch zusammengestellten Verständnisweisen, Einflussfaktoren und Konsequenzen im Zusammenhang mit dem Kostendruck berücksichtigt werden.AbstractBackgroundFinancial resources in German and international health care systems are limited. Financial scarcity leads to medical, economical, judicial, and ethical problems in medical decision making. These problems will probably increase in the following years. From an ethical point of view the challenges of just allocation of scarce resources and moral conflicts of clinical decision makers are of special importance. Qualitative research allows the investigation of how different physicians deal with clinical decision making in the face of financial scarcity and what kind of ethical dilemmas occur.MethodWe conducted semi-structured in-depth interviews with fifteen senior and chief clinicians in the fields of intensive care and cardiology at five German primary, secondary, and tertiary care hospitals. All interviews were audio taped, transcribed verbatim and analysed using open and axial coding from the grounded theory approach.ResultsThe physicians reported a wide and heterogeneous range of influencing factors, strategies and consequences when explaining the daily practice of dealing with scarce resources. Prioritization criteria such as effectiveness or cost-effectiveness were interpreted differently between physicians and thus might lead to inconsistent allocation decisions. At the same time our research confirmed that physicians do not trifle with rationing decisions. In contrast, financial scarcity and the related practical and theoretical challenges of allocation can lead to moral conflicts, emotional distress and experiences of excessive demands.ConclusionPractical recommendations and ethical frameworks that aim to guide and change the clinical practice of decision making in the face of financial scarcity should acknowledge the influencing factors and consequences that are presented systematically in this article.

Schätzung der Ausgaben der öffentlichen Hand durch den Konsum illegaler Drogen in Deutschland

This study explored the epidemiology, treatment, and comorbidities of juvenile psoriasis in Germany using health insurance data. Psoriasis is a chronic inflammatory skin condition that affects approximately 2% to 3% of the worlds population. Data were obtained from a database of approximately 6.7 million individuals registered with health insurance organizations throughout Germany. The analysis considered all individuals age 18 years and younger with psoriasis who were registered in 2007. Comorbidities were identified using software based on a morbidity‐based risk adjustment model. A total of 138,338 patients with a diagnosis of psoriasis were identified in the database, yielding a prevalence of 2.1%. Within this group there were 4,499 children and adolescents (≤18 years of age), a prevalence of 0.4%. The prevalence ranged from 0.1% at the age of 1 year to 0.8% at the age of 18 years. Most of the patients were treated with topical corticosteroids (72.2%) and antipsoriatics (e.g., tars, psoralen; 20.0%). Immunosuppressants were used in 3.3% of the cases. Juvenile psoriasis was associated with numerous significant comorbidities such as rheumatoid arthritis and inflammation (2.1%); delirium, psychosis, and psychotic and dissociative disorder (1.1%); and heart disease (0.6%). Our study demonstrated that psoriasis is more prevalent in children and adolescents than some older international investigations have documented. Analysis of the health insurance data showed that juvenile psoriasis is associated with a range of comorbidities. The data also may suggest an unrecognized burden of mental health problems in young persons with psoriasis.

Economic burden of patients with various etiologies of chronic systolic heart failure analyzed by resource use and costs

AIM A scientifically based overview of public expenditures related to illicit drugs was lacking for Germany. The aim of the present project is to carry out for the first time a comprehensive estimation of direct (labelled and non-labelled) expenditures of the government and the social insurance funds related to the use of illicit drugs in Germany for the year 2006. METHODS Depending on the respective financing bodies, different ways of data collection were required. Data on drug-related expenditure were searched in publically available budget documents and statistical reports; moreover written requests were sent to the relevant public authorities. Information on the expenditures of social insurance funds was collected through standardised questionnaires, which were sent to the Statutory Pension Insurance Scheme (Rentenversicherung Bund) and the 40 biggest statutory health insurance companies. The collected data were extrapolated for the total statutory health insurance. RESULTS All in all, on the government side an amount of 3.7-4.6 billion Euro spent on the task of tackling illicit drugs (i. e., for prevention, intervention and law enforcement measures) was identified. The expenditures of the pension funds related to illegal drug use amount to 171.7 million Euro. For the statutory health insurances a total expenditure of 1.4 billion Euro was estimated. CONCLUSION The aim of the project - a first estimation of the public expenditures concerning illicit drugs in Germany - has been achieved. Nevertheless, there remains some degree of uncertainty regarding the overall result because of the heterogeneous data quality. The approximation of the amount of public expenditures concerning illegal drug use still gives no information about adequate spending or actual benefits. However, it provides the indispensable basis for such an assessment and contributes to a more objective discussion.

Cost-effectiveness analysis of coronary artery disease screening in HIV-infected men:

analyzed by resource use and costs Janine Biermann , Till Neumann ⁎, Christiane E. Angermann , Raimund Erbel , Bernhard Maisch , David Pittrow , Vera Regitz-Zagrosek , Thomas Scheffold , Rolf Wachter , Gotz Gelbrich , Jurgen Wasem , Anja Neumann b and on behalf of the German Competence Network Heart Failure a Clinic of Cardiology, University Hospital Essen, Germany b Institute for Health Care Management and Research, University of Duisburg-Essen, Essen, Germany c Department of Internal Medicine I and Comprehensive Heart Failure Center, University Hospital Wurzburg, Germany d Department of Internal Medicine, Cardiology, University Hospital Giessen and Marburg, Marburg, Germany e Department for Clinical Pharmacology, Medical Faculty, Carl Gustav Carus, Technical University of Dresden, Germany f Department of Cardiovascular Diseases in Women, Charite University Medicine, Berlin, Germany g Institute for Heart and Circulation Research, University of Witten/Herdecke, Dortmund, Germany h Department of Cardiology and Pneumology, Georg-August University Gottingen, Germany i Clinical Trial Centre Leipzig, University of Leipzig, Germany

Lipodystrophy - a sign for metabolic syndrome in patients of the HIV-HEART study.

Background HIV-infected patients are at increased risk of coronary artery disease (CAD). We evaluated the cost-effectiveness of cardiac screening for HIV-positive men at intermediate or greater CAD risk. Design We developed a lifetime microsimulation model of CAD incidence and progression in HIV-infected men. Methods Input parameters were derived from two HIV cohort studies and the literature. We compared no CAD screening with stress testing and coronary computed tomography angiography (CCTA)-based strategies. Patients with test results indicating 3-vessel/left main CAD underwent invasive coronary angiography (ICA) and received coronary artery bypass graft surgery. In the stress testing + medication and CCTA + medication strategies, patients with 1–2-vessel CAD results received lifetime medical treatment without further diagnostics whereas in the stress testing + intervention and CCTA + intervention strategies, patients with these results underwent ICA and received percutaneous coronary intervention. Results Compared to no screening, the stress testing + medication, stress testing + intervention, CCTA + medication, and CCTA + intervention strategies resulted in 14, 11, 19, and 14 quality-adjusted life days per patient and incremental cost-effectiveness ratios of 49,261, 57,817, 34,887 and 56,518 Euros per quality-adjusted life year (QALY), respectively. Screening only at higher CAD risk thresholds was more cost-effective. Repeated screening was clinically beneficial compared to one-time screening, but only stress testing + medication every 5 years remained cost-effective. At a willingness-to-pay threshold of 83,000 €/QALY (∼100,000 US