Anna Drabik

Financial incentives in the German statutory health insurance: new findings, new questions

OBJECTIVES This paper presents findings of a mandatory three-year evaluation of a prevention bonus scheme offered in the German Statutory Health Insurance (SHI). Its objective is to describe the rationale behind the programs, analyze their financial impact and discuss their implications on potentially conflicting goals on solidarity and competition. METHODS The analysis included 70,429 insured enrolled in a prevention bonus program in a cohort study. The intervention group and their matched controls were followed for a three-year period. Matching was performed as nearest neighbor matching. The economic analysis comprised all costs relevant for Sickness Funds (SF) in the SHI and was carried out from a SHI perspective. Differences in cost trends between the intervention and the control group were examined applying the paired t-test. RESULTS Regarding mean costs there was a significant difference between the two groups of euro177.48 (90% CI [euro149.73; euro205.24]) in favor of the intervention group. If program costs were considered cost reductions of euro100.88 (90% CI [euro73.12; euro128.63]) were obtained. CONCLUSIONS The uptake of a prevention bonus program led to cost reductions in the intervention group compared to the control group even when program costs were considered. However, the results must be interpreted with caution as in addition to financial aspects, socio-economic and health-status, selection bias and the function and use of bonus programs as marketing tools, as well as their long-term sustainability should be considered in future assessments.

Antibiotic prescribing for upper respiratory infections: European primary paediatricians' knowledge, attitudes and practice.

Aim:  Young children are the highest receivers of antibiotics in the European Union, with the majority of antibiotics given for children with minor upper respiratory infections (URIs). The study aims to examine paediatricians’ reported views influencing community antibiotic prescribing.

Patients with Type 2 Diabetes Benefit from Primary Care-Based Disease Management: A Propensity Score Matched Survival Time Analysis

This study aimed to assess the impact of a nationwide German diabetes mellitus disease management program (DMP) on survival time and costs in comparison to routine care. The authors conducted a retrospective observational cohort study using routine administration data from Germanys largest sickness fund to identify insured suffering from diabetes in 2002. A total of 95,443 insured with type 2 diabetes mellitus who were born before January 1, 1962 met the defined inclusion criteria, resulting in 19,888 pairs of DMP participants and nonparticipants matched for socioeconomic and health status using propensity score matching methods. This is the first time propensity score matching has been used to evaluate a survival benefit of DMPs. In the time frame analyzed (3 years), mean survival time for the DMP group was 1045 days vs. 985 days for the routine care group (P<0.001). Mean daily hospital and total costs (including DMP administration and medical costs) were lower for the DMP group in the case of deceased insureds (92€ vs. 139€ and 122€ vs. 169€, respectively) as well as for censored observations (6€ vs. 7€ and 12.9€ vs. 13.4€, respectively). Mean daily drug costs were slightly lower for deceased insured in the DMP group (difference 0.6€), while no identifiable difference was found for censored observations. In this study, insured who were enrolled in a DMP for diabetes mellitus in the German Statutory Health Insurance showed a significant benefit in survival time. They also incurred lower costs compared to propensity score matched insured in routine care.

Die Methoden der Evaluation von Disease Management Programmen im Kontrollgruppendesign am Beispiel Diabetes mellitus – Eine systematische Übersicht

BACKGROUND Disease management programmes (DMPs) were implemented in Germany in 2002. Their evaluation is required by law. Beyond the mandatory evaluation, a growing number of published studies evaluate the DMP for diabetes mellitus type 2 in a control-group design. As patients opt into the programme on a voluntary basis it is necessary to adjust the inherent selection bias between groups. The aim of this study is to review published studies which evaluate the diabetes DMP using a control-group design with respect to the methods used. METHODS A systematic literature review of electronic databases (PUBMED, Cochrane Library, EMBASE, MEDPILOT) and a hand search of reference lists of the relevant publications was conducted to identify studies evaluating the DMP diabetes mellitus in a control-group design. RESULTS 8 studies were included in the systematic literature review. 4 studies gathered retrospective claims data from sickness funds, one from physicians records, one study used prospective data from ambulatory care, and 2 studies were based on one patient survey. Methods used for adjustment of selection bias included exact matching, matching using propensity score methods, age-adjusted and sex-separated analysis, and adjustment in a regression model/analysis of covariance. One study did not apply adjustment methods. The intervention period ranged from 1 day to 4 years. Considered outcomes of studies (surrogate parameter, diabetes complications, mortality, quality of life, and claim data) depended on the database. CONCLUSION In the evaluation of the DMP diabetes mellitus based on a control-group design neither the database nor the methods used for selection bias adjustment were consistent in the available studies. Effectiveness of DMPs cannot be judged based on this review due to heterogeneity of study designs. To allow for a comprehensive programme evaluation standardised minimum requirements for the evaluation of DMPs in the control group design are required.

Inpatient Palliative Care: A nationwide analysis

OBJECTIVE The implementation of palliative care (PC) is an important challenge for health policy makers. The primary aim of this study was to analyze the effects of inpatient PC for cancer patients in the last six months of life. METHODS Based on routine data of a nationwide sickness fund, a retrospective matched-pair analysis was performed to assess the care of cancer patients who were treated at least once on an inpatient PC unit and compare the results to cancer patients who where not treated on an inpatient PC unit. The main categories that were assessed included place of death, cost of health care and surrogates for quality of symptom control, aggressiveness of care, and end of life decisions. RESULTS Of 11,355 patients, 841 received PC. Compared with other patients they were more likely to receive opioids (66.8% vs. 55.3%; p<0.0001) and chemotherapy in an outpatient setting (25.5% vs. 19.9%; p=0.004). Provision of artificial nutrition and surgery was similar in both groups. Total costs were higher for PC patients compared to routine care (21,879€ (±14,351€) vs. 17,885€ (±14,326€); difference 3994€ (95%-CI: [2648€; 18,973€]; p<0.0001) and PC patients were more likely to die in hospital (69.9% vs. 55.3%; p<0.0001). CONCLUSION Cancer patients treated on a PC inpatient unit where more likely to receive opioids (a surrogate for quality of end-of-life care) but where less likely to die at home and the cost of care for these patients was higher. The results can be interpreted both from (i) a methodological standpoint that assumes confounding due to the fact that the PC patients might have been suffering from more complex symptoms and (ii) a health policy view. For the latter it is important to recognize that the whole potential of PC can only be achieved if PC (a) is provided as a cross-sectoral network, (b) is integrated early in the disease (c) assures specialized PC expertise.

Substitution of theophylline slow-release formulations according to the rebate contracts in the German statutory health insurance.

On the basis of the rebate contracts between individual statutory health insurance funds and pharmaceutical enterprises, the generic substitution of prescribed medications is economically attractive and is advocated for statutory health insurees in Germany. In addition to the drugs whose substitution can be considered to be uncritical, rebate contracts also include controversial substances such as the bronchodilator theophylline (CAS 58-55-9), which has a narrow therapeutic range and should only be substituted under certain conditions. The objective of this article was to check the safety of the substitution of theophylline by means of a comparative evaluation of bioequivalence studies carried out on theophylline slow-release preparations. A systematic literature search was carried out in the MEDLINE database. The search terms used were combinations of the following key words: theophylline, generics, bioequivalence, substitution, brand and non-brand. In addition, a manual search was performed in the reference lists of the relevant articles. Only articles that were published between January 1, 1988 and August 30, 2008 were to be included. Five studies conformed to the inclusion and exclusion criteria. Two of the studies came to the conclusion that the preparations analysed were bioequivalent. In the remaining three studies there was no bioequivalence found between the preparations and the reference product. Because of the heterogeneity of study outcomes no metanalysis could be performed. On the basis of the studies analysed the conclusion can be drawn that a theophylline slow-release preparation should only be substituted under close monitoring by a physician because of the many factors which can adversely affect serum levels, such as the narrow therapeutic range of the active ingredient, the patients metabolisation rate or the different galenics of the preparations. Nevertheless, the question remains as to whether the costs saved by the rebate contracts would not be significantly outweighed.

Correspondence (letter to the editor): Matching should take place before the start of the study.

Linder et al criticize the evaluation of DMPs in Germany and present their own study (1). Their study has methodological limitations that put in question the validity of their results. Firstly, we wish to point out the incomprehensible formation of groups. Matching has to be done before starting an intervention. In the Linder et al study, patients registered before 2007 were not excluded, however, and paired in 2006, which already partly eliminates the effect of the intervention. What is not clear either is why the researchers did not pair each DMP participant with a control from the sufficiently large pool. Patients who participated in more than one DMP were also excluded. This means that seriously ill people were excluded who would have benefited particularly from an improved healthcare structure. Patients who were registered very recently were included, in whom no effect has had time to manifest. Furthermore we cannot follow how subjects can be paired according to the variable “Education”, if pertinent data were lacking in almost 70% of identified diabetes patients. It is not permissible to use “missing” as a valid pairing variable. The authors have therefore missed their own objective, namely that of considering more carefully selection effects in evaluating the DMPs. A study published in December 2010 that showed a positive trend in the quality of care and efficiency in participants in the DMP diabetes compared with a group of non-registered diabetes patients was not discussed (2). This is surprising as this was the first study in Germany that evaluated the T2DM by means of propensity score matching.