Christian Krauth

How high are the costs of eating disorders - anorexia nervosa and bulimia nervosa - for German society?

Anorexia and bulimia are relatively rare psychogenic illnesses, which nevertheless are of great concern for society since they affect a mostly very young population and are accompanied by a significantly raised mortality risk. This cost-of-illness analysis for eating disorders in Germany considers hospitalization, rehabilitation services, and indirect costs through inability to work and premature death. The cost estimates are based on projections derived from benefit data as listed by health insurance schemes and pension insurance schemes and from epidemiological studies on the prevalence of eating disorders and mortality rates. For anorexia the cost of illness amounts to approximately 195 million euros (73 direct costs and 122 mortality costs, for bulimia it comes to around 124 million euros (12 direct costs and 112 mortality costs).The annual cost per anorexia and bulimia patient is approximately 5,300 and 1,300 euros, respectively. This cost-of-illness analysis underlines the significance of indirect costs due to premature death, but also highlights the extremely cost-intensive treatment. The hospitalization cost of 12,800 euros per anorexia patient is markedly higher than the average hospitalization cost of 3,600 euros.

Cystic fibrosis: cost of illness and considerations for the economic evaluation of potential therapies.

Cystic fibrosis (CF) is the most common life-shortening inherited disease of the Caucasian race, with a prevalence of around 1 in 2500 live births. Advances in the treatment and management of respiratory and pancreatic disorders have dramatically increased the life expectancy of patients with CF. This article presents an overview of cost-of-illness studies of CF, identifies deficits in the available health economic analyses of CF and discusses which specific factors are essential for the economic evaluation of potential therapies, based on a critical review of the health economic literature on two main therapeutic strategies.Cost-of-illness studies of CF have predominantly been restricted to direct costs. According to the literature, direct costs amount to between

A Stepwise Psychotherapy Intervention for Reducing Risk in Coronary Artery Disease (SPIRR-CAD) — Rationale and design of a multicenter, randomized trial in depressed patients with CAD

US6200–16 300 (1996 values) per patient per year. As most studies likely underestimated the actual costs (e.g. by disregarding provision of certain healthcare services), real healthcare costs tend to be at the upper end of the cost range. Healthcare costs depend on the patient’s age (for adults, costs are approximately twice as high as for children), the grade of severity (the cost relationship of severe to mild CF is between 4.5 and 7.1) and other factors. Lifetime direct costs of CF are estimated at

[Costs and benefits of an education program for patients with ankylosing spondylitis as part of an inpatient rehabilitation programs-study design and first results].

US200 000–300 000 (at 1996 values and a discount rate of 5%).Home intravenous (IV) antibacterial therapy and recombinant human DNase (rhDNase; dornase alfa) treatment are the two main therapeutic strategies most often evaluated in health economic studies of CF. While home IV antibacterial therapy (compared with inpatient IV antibacterial therapy) is assumed to be cost saving, rhDNase treatment is a very cost-intensive therapy intended to efficiently achieve health improvements.Health economic analyses of future CF therapeutic technologies should present explicit data regarding healthcare services provision, resource consumption and unit costs. Indirect costs and patient costs should be considered more often than they have to date, particularly when they are significantly influenced by novel CF technologies. The perspective of health economic studies should be stated explicitly and always include the societal perspective. More economic studies should be based on a controlled, and preferably randomised, design. The observation period must be long enough to identify long-term effects of interventions. A greater number of effectiveness studies should be performed to determine costs and outcomes of therapies applied under everyday life conditions for patients with CF. Finally, international comparison studies should identify the influence of different healthcare systems on the costs and outcomes of interventions.

Kostenvergleichsanalyse der stationären und ambulanten Intervalltherapie bei erwachsenen Mukoviszidosepatienten

OBJECTIVE Depressive symptoms are highly relevant for the quality of life, health behavior, and prognosis in patients with coronary artery disease (CAD). However, previous psychotherapy trials in depressed CAD patients produced small to moderate effects on depression, and null effects on cardiac events. In this multicentre psychotherapy trial, symptoms of depression are treated together with the Type D pattern (negative affectivity and social inhibition) in a stepwise approach. METHODS Men and women (N=569, age 18-75 years) with any manifestation of CAD and depression scores ≥ 8 on the Hospital Anxiety and Depression Scale (HADS), will be randomized (allocation ratio 1:1) into the intervention or control group. Patients with severe heart failure, acutely life-threatening conditions, chronic inflammatory disease, severe depressive episodes or other severe mental illness are excluded. Both groups receive usual medical care. Patients in the intervention group receive three initial sessions of supportive individual psychotherapy. After re-evaluation of depression (weeks 4-8), patients with persisting symptoms receive an additional 25 sessions of combined psychodynamic and cognitive-behavioral group therapy. The control group receives one psychosocial counseling session. Primary efficacy variable is the change of depressive symptoms (HADS) from baseline to 18 months. Secondary endpoints include cardiac events, remission of depressive disorder (SCID) and Type D pattern, health-related quality of life, cardiovascular risk profile, neuroendocrine and immunological activation, heart rate variability, and health care utilization, up to 24 months of follow-up (ISRCTN: 76240576; NCT00705965). Funded by the German Research Foundation.

Comparison of tools for assessing the methodological quality of primary and secondary studies in health technology assessment reports in Germany.

ZusammenfassungDie gesundheitsökonomische Evaluation eines Schulungsprogramms für Patienten mit Spondylitis ankylosans erfolgte in einem randomisiert kontrollierten, prospektiven, multizentrischen Studiendesign durch Vergleich von Schulungsprogrammkosten und Einsparungen bei den direkten und indirekten Folgekosten. Die Leistungsund Kostendaten wurden durch Befragung der Leistungserbringer (Schulungsprogramm) und der Patienten (Folgekosten) erhoben. Die bisherigen Auswertungen ergeben: Die Schulungsprogrammkosten je Patient betragen zwischen 117€ (bei 10 Kursteilnehmern) und 186€ (bei 6 Kursteilnehmern). Dem stehen Einsparungen bei den indirekten Folgekosten (Arbeitsunfähigkeitszeiten) von ca. 2500€ gegenüber. Aktuell werden [1] die Patientenangaben durch Kassendaten verifiziert und [2] direkte Folgekosten sowie Lebensqualität der Patienten bestimmt.SummaryThe economic evaluation of a patient education program ”ankylosing spondylitis”—based on a randomised controlled prospective multi-center study design—compares program costs and savings in direct and indirect follow-up costs. The collection of health services and cost data was conducted by questioning staff (education programme costs) and patients (follow-up costs). The present study results are: Program costs per patient range between 117€ (10 participants per course) and 186€ (6 participants per course). Savings in indirect costs (unfitness to work) amount to 2500€ and thus overcompensate program costs. Currently [1] patient data are verified by sickness fund data and [2] direct follow-up costs and qualitiy of life data are analysed.

Gesundheit und gesundheitliche Versorgung von Migranten unter besonderer Berücksichtigung von Sucht

Zusammenfassung□ HintergrundDie stationäre Intervalltherapie (SIT) bei erwachsenen Mukoviszidosepatienten gilt als teuer. Es wird vermutet, daß eine ambulante Therapie deutlich kostengünstiger wäre. Im Rahmen einer prospektiven kontrollierten Studie zum Vergleich der SIT mit einem neuen häuslichen Therapiekonzept (HIT) hinsichtlich medizinischer, psychosozialer und ökonomischer Erfolgsparameter wurden daher auch die erbrachten Gesundheitsleistungen und Kosten unter deutschen Systembedingungen vergleichend evaluiert.□ Patienten und MethodeWährend des Studienzeitraums April 1995 bis September 1996 wurden 45 Patienten mit insgesamt 56 stationären und 40 ambulanten Therapiekursen aufgenommen. Wesentliches Instrument zur Erhebung des Ressourcenverbrauchs waren Dokumentationsbögen, die vom medizinischen Personal und den Patienten geführt wurden. Darüber hinaus wurden bei HIT Apothekenrechnungen und bei SIT Patientenakten und Daten der Finanzbuchhaltung genutzt.□ ErgebnisseDie durchschnittlichen Kosten je Therapiekurs betrugen bei der SIT 14038, — DM, bei der HIT 18702, — DM. Auffallend waren die hohen Medikationskostenunterschiede (17280, — DM bei HIT gegenüber 4847, — DM bei SIT), die in zwei Unterschieden gründen: dem Einsatz mobiler Pumpinfusionssysteme und deutlich höheren Abgabepreisen für Medikamente bei HIT, wobei Übergewinne der Befüller und/oder Apotheke zu vermuten sind. Die gesellschaftlich relevanten Kosten der HIT (unter Herausrechnung von Übergewinnen) liegen bei geschätzt unter 10500, — DM. Aus gesellschaftlicher Perspektive ist damit die ambulante Therapie kostengünstiger, aus Kassenperspektive die stationäre Therapie.□ Schlußfolgerungen1. Die weithin akzeptierte Annahme, daß die ambulante Versorgung kostengünstiger als die stationäre ist, gilt nicht durchgängig. 2. Es liegt ein Steuerungsdefekt vor, der zu unnötigen und vermeidbaren Krankenhausaufenthalten führen kann, wenn die Kassenperspektive dominiert. 3. Änderungen der Systembedingungen, wie die Zulassung von Versandapotheken, sollten ernsthaft erwogen und evaluiert werden.Abstract□ BackgroundThe regular i.v.-therapy of adults with cystic fibrosis (CF) on an in-patient basis is regarded as expensive. Home treatment is supposed to be cheaper. During a prospective controlled study to compare in-patient treatment (SIT) with home i.v.-treatment (HIT) in regard to clinical, psychosocial and economic parameters, delivered health services and costs in the German setting were evaluated in a comparatable manner.□ Patients and MethodsDuring the study period 4/95 to 9/96 45 patients with altogether 56 hospital and 40 home i.v.-courses of approximately 14 days were included in the study. Principal instruments to record the resource consumption were documentation sheets kept by the medical staff and the patients. In addition, pharmacy accounts in HIT and patient records and hospital controlling data in SIT were used.□ ResultsThe average costs of a course were 14,038 DM for HIT and 18,702 DM for SIT. Striking are the large differences in medication costs. Two main reasons could be identified for the cost difference: 1. the use of a mobile infusion system in HIT and 2. the much higher prices of pharmaceuticals in the ambulatory care sector compared to the hospital sector, where extremely high profits of the home care service firms or the pharmacy can be supposed. The social costs of HIT (when antibiotics are valued to opportunity costs) are estimated at less than 10,500 DM. From a societal perspective HIT is preferable, from the perspective of the statutory health insurance funds hospital therapy is preferable.□ Conclusions1. The widely accepted hypothesis that ambulatory care is cheaper than hospital care is — at least in the German setting — not a-priori true. 2. In the treatment of CF patients incentive failures exist which induce unnecessary and avoidable hospital stays if the perspective of the statutory sickness funds is dominant. 3. Changes in system conditions as e. g. the permission of mail-order pharmacies might help to implement a more rational allocation of resources.BACKGROUND The regular i.v.-therapy of adults with cystic fibrosis (CF) on an in-patient basis is regarded as expensive. Home treatment is supposed to be cheaper. During a prospective controlled study to compare in-patient treatment (SIT) with home i.v.-treatment (HIT) in regard to clinical, psychosocial and economic parameters, delivered health services and costs in the German setting were evaluated in a comparable manner. PATIENTS AND METHODS During the study period 4/95 to 9/96 45 patients with altogether 56 hospital and 40 home i.v.-courses of approximately 14 days were included in the study. Principal instruments to record the resource consumption were documentation sheets kept by the medical staff and the patients. In addition, pharmacy accounts in HIT and patient records and hospital controlling data in SIT were used. RESULTS The average costs of a course were 14,038 DM for HIT and 18,702 DM for SIT. Striking are the large differences in medication costs. Two main reasons could be identified for the cost difference: 1, the use of a mobile infusion system in HIT and 2, the much higher prices of pharmaceuticals in the ambulatory care sector compared to the hospital sector, where extremely high profits of the home care service firms or the pharmacy can be supposed. The social costs of HIT (when antibiotics are valued to opportunity costs) are estimated at less than 10,500 DM. From a societal perspective HIT is preferable, from the perspective of the statutory health insurance funds hospital therapy is preferable. CONCLUSIONS 1. The widely accepted hypothesis that ambulatory care is cheaper than hospital care is--at least in the German setting--not a-priori true. 2. In the treatment of CF patients incentive failures exist which induce unnecessary and avoidable hospital stays if the perspective of the statutory sickness funds is dominant. 3. Changes in system conditions as e.g. the permission of mail-order pharmacies might help to implement a more rational allocation of resources.

Cost of treating hepatitis C in Germany: a retrospective multicenter analysis.

Health care policy background Findings from scientific studies form the basis for evidence-based health policy decisions. Scientific background Quality assessments to evaluate the credibility of study results are an essential part of health technology assessment reports and systematic reviews. Quality assessment tools (QAT) for assessing the study quality examine to what extent study results are systematically distorted by confounding or bias (internal validity). The tools can be divided into checklists, scales and component ratings. Research questions What QAT are available to assess the quality of interventional studies or studies in the field of health economics, how do they differ from each other and what conclusions can be drawn from these results for quality assessments? Methods A systematic search of relevant databases from 1988 onwards is done, supplemented by screening of the references, of the HTA reports of the German Agency for Health Technology Assessment (DAHTA) and an internet search. The selection of relevant literature, the data extraction and the quality assessment are carried out by two independent reviewers. The substantive elements of the QAT are extracted using a modified criteria list consisting of items and domains specific to randomized trials, observational studies, diagnostic studies, systematic reviews and health economic studies. Based on the number of covered items and domains, more and less comprehensive QAT are distinguished. In order to exchange experiences regarding problems in the practical application of tools, a workshop is hosted. Results A total of eight systematic methodological reviews is identified as well as 147 QAT: 15 for systematic reviews, 80 for randomized trials, 30 for observational studies, 17 for diagnostic studies and 22 for health economic studies. The tools vary considerably with regard to the content, the performance and quality of operationalisation. Some tools do not only include the items of internal validity but also the items of quality of reporting and external validity. No tool covers all elements or domains. Design-specific generic tools are presented, which cover most of the content criteria. Discussion The evaluation of QAT by using content criteria is difficult, because there is no scientific consensus on the necessary elements of internal validity, and not all of the generally accepted elements are based on empirical evidence. Comparing QAT with regard to contents neglects the operationalisation of the respective parameters, for which the quality and precision are important for transparency, replicability, the correct assessment and interrater reliability. QAT, which mix items on the quality of reporting and internal validity, should be avoided. Conclusions There are different, design-specific tools available which can be preferred for quality assessment, because of its wider coverage of substantive elements of internal validity. To minimise the subjectivity of the assessment, tools with a detailed and precise operationalisation of the individual elements should be applied. For health economic studies, tools should be developed and complemented with instructions, which define the appropriateness of the criteria. Further research is needed to identify study characteristics that influence the internal validity of studies.

Cost-Effectiveness of Treating Hepatitis C with Sofosbuvir/Ledipasvir in Germany.

Adequate knowledge about the target group is essential for user-focused health care. Little differentiated information on the health and health care of migrants is available in Germany, and focused research on migrant groups hardly exists. The burden of the migration itself, the change in the socioeconomic status (compared to the home country) and - compared with the locals - a more restricted access to the health care system affect the health of migrants. A major health problem with this group is addiction. Characteristics of health and health behaviour of Turkish- and Russian-speaking migrants in Germany are examined by a study supported by the German Federal Ministry of Education and Research.ZusammenfassungWesentlich für eine nutzerorientierte Gesundheitsversorgung sind hinreichende Kenntnisse über die Zielgruppe. Über Migranten liegen in Deutschland bislang nur wenig differenzierte Daten zur Gesundheit und Versorgung vor, eine singuläre Beforschung von Migrantengruppen erfolgte kaum. Die Belastungen durch die Migration selbst, der im Vergleich zum Heimatland veränderte sozioökonomische Status sowie die im Vergleich zu Einheimischen häufig erhöhten Zugangsbarrieren zum Gesundheitssystem bestimmen die Gesundheit der Migranten mit. Ein wichtiges Gesundheitsproblem ist Sucht. Welche Charakteristika die Gesundheit und das Gesundheitsverhalten von türkisch- und russischsprachigen Migranten aufweist geht eine vom Bundesforschungsministerium geförderte Studie nach.SummaryAdequate knowledge about the target group is essential for user-focused health care. Little differentiated information on the health and health care of migrants is available in Germany, and focused research on migrant groups hardly exists. The burden of the migration itself, the change in the socioeconomic status (compared to the home country) and – compared with the locals – a more restricted access to the health care system affect the health of migrants. A major health problem with this group is addiction. Characteristics of health and health behaviour of Turkish- and Russian-speaking migrants in Germany are examined by a study supported by the German Federal Ministry of Education and Research.

Outcomes, costs and cost-effectiveness of treating hepatitis C with direct acting antivirals

Background Viral hepatitis is major a public health problem affecting millions of people worldwide. Estimates assume 400 000–500 000 people chronically infected with hepatitis C virus (HCV) in Germany. Long-term consequences are the development of liver cirrhosis and hepatocellular carcinoma. The aim of the study was to assess the costs for treating patients with chronic HCV in Germany. Methods We conducted a retrospective multicenter observational study. The design was approved by an ethics committee, and patients were asked for their informed consent. Patients were grouped in four different health states. Healthcare utilization data were extracted from doctor files of six medical centers in Germany. Results Data of 315 patients with chronic HCV were analyzed. The mean age was 49.4 years, 57.5% were male and 67.9% had a genotype 1 infection. The most common routes of transmission were injection drug use (39.0%) and infection through blood products (15.9%). The average total cost was &OV0556;19 147 including ambulatory care and diagnostics (&OV0556;1686), pharmaceuticals (&OV0556;14 875), inpatient care (&OV0556;1293), and sick leave (&OV0556;1293). For patients in stable health states (mild and moderate HCV, compensated cirrhosis), costs did not differ significantly and were mainly influenced by antiviral treatment. For patients with decompensated cirrhosis, inpatient care accounted for the largest part of the costs. Conclusion Treatment of HCV patients involves high costs, mainly associated with the length of antiviral therapy. Viral eradication can prevent severe disease stages, which are associated with high costs. It is necessary to follow current guidelines and monitor patients closely to avoid unnecessary costs.