D Endrei

Multicriteria decision analysis in the reimbursement of new medical technologies: real-world experiences from Hungary.

We read with great interest the excellent article of Sussex et al. [1] on a pilot study of multicriteria decision analysis (MCDA) for valuing orphan medicines. MCDA seems to be more important in the past years, and many countries have tried to use it for evaluating new medical technologies [2,3]. We would like to give a short overview on the application of MCDA in Hungary. Hungary can be considered an upper-middle–income country [4]. We run a solidarity-based health insurance system with a single payer, where the National Health Insurance Fund Administration (in Hungarian: Országos Egészségbiztosítási Pénztár [OEP]) is the only health care financing agency [5,6]. All the hospitals—with the exception of church hospitals—are owned by the central government. On behalf of the central government, a governmental public agency, the National Institute for Qualityand Organizational Development in Healthcare and Medicines (in Hungarian: Gyógyszerészeti és Egészségügyi Minőségés Szervezetfejlesztési Intézet [GYEMSZI]) is responsible for the supervision of Hungarian hospitals [7]. The Hungarian health technology assessment (HTA) Office was established in 2004, and it also belongs to GYEMSZI [8,9]. Hungary adopted the directive 89/105/EEC of the Council of the European Communities on transparency for the evaluation of new drugs (2004) and medical devices (2007) applying for health insurance reimbursement [10]. We also have a formal guideline for conducting economic evaluation of health care interventions in Hungary [11]. More detailed description of the Hungarian health care system can be found elsewhere [12–17]. MDCA was introduced in Hungary by a ministerial decree in 2010 for the evaluation of new hospital medical technologies applied in hospital care [18]. In this term, medical technologies do include neither drugs nor medical devices. As a part of the application dossier, one must submit a formal HTA report (including a health-economics analysis), clinical evaluation, clinical expert opinion, and detailed cost calculation. Detailed cost calculation should demonstrate how the new hospital medical technology complies with the special financing methods of the Hungarian hospital care. It means that beyond the cost of new technology, its additional costs (e.g., implantation surgery, hospital stay, and nursing care) must be calculated according to the diagnosis-related groups such as hospital care financing [19,20]. The key players of the decision-making process are the health care financing agency (OEP), HTA office (within GYMESZI), Hungarian Medical College, and Scientific Council in Health Care.

Cost-effectiveness analysis of intensity-modulated radiation therapy with normal and hypofractionated schemes for the treatment of localised prostate cancer

The aim of our analysis was to compare the cost-effectiveness of high-dose intensity-modulated radiation therapy (IMRT) and hypofractionated intensity-modulated radiation therapy (HF-IMRT) versus conventional dose three-dimensional radiation therapy (3DCRT) for the treatment of localised prostate cancer. A Markov model was constructed to calculate the incremental quality-adjusted life years and costs. Transition probabilities, adverse events and utilities were derived from relevant systematic reviews. Microcosting in a large university hospital was applied to calculate cost vectors. The expected mean lifetime cost of patients undergoing 3DCRT, IMRT and HF-IMRT were 7,160 euros, 6,831 euros and 6,019 euros respectively. The expected quality-adjusted life years (QALYs) were 5.753 for 3DCRT, 5.956 for IMRT and 5.957 for HF-IMRT. Compared to 3DCRT, both IMRT and HF-IMRT resulted in more health gains at a lower cost. It can be concluded that high-dose IMRT is not only cost-effective compared to the conventional dose 3DCRT but, when used with a hypofractionation scheme, it has great cost-saving potential for the public payer and may improve access to radiation therapy for patients.

The effect of performance-volume limit on the DRG based acute care hospital financing in Hungary

OBJECTIVES The aim of our paper is to analyse the effect of the so-called performance volume limit (PVL) financing method on acute hospital care. DATA AND METHODS The data were derived from the nationwide administrative dataset of the National Health Insurance Fund Administration (OEP) covering the period 2003-2008. We analysed the trends in the DRG cost-weights, number of cases, case-mix, and average length of stay. We calculated the average annual reimbursement rate per DRG cost-weight with and without the application of PVL degression according to the hospital type and medical professions. RESULTS Our results showed that although the national case mix (i.e., the sum of all of the DRG cost-weights produced in one year) did not change between 2003-2006, the trend of the annual number of cases increased, and the average length of stay decreased. During 2007-2008, a significant decline was found in each indicator. The introduction of the PVL resulted in a health insurance budget saving of 1.9% in 2004, 2.6% in 2005, 3.4% in 2006, 5.6% in 2007, and 3.2% in 2008. We found the lowest reimbursement rate per DRG cost-weight at the university medical schools (HUF 138,200 or € 550) and childrens hospitals (HUF 132,547 or € 528), whereas the highest was at the county hospitals (HUF 143,451 or € 571) and city hospitals (HUF 142, 082 or € 565). CONCLUSIONS The implementation of the PVL reduced the acute care hospital activity and reimbursement. The effect of the PVL was different on the different types of hospitals, and it had a serious disadvantageous effect on the university medical schools and childrens hospitals.

Toe-brachial index and exercise test can improve the exploration of peripheral artery disease

BACKGROUND AND AIMS We assumed that hand-held Doppler ultrasound (DUS) at rest was insufficient to assess the severity of peripheral artery disease (PAD). Toe pressure and transcutaneous tissue oxygen pressure were studied to prove whether these could identify more patients with severe lower limb ischemia; exercise was applied to provoke ischemia. METHODS 120 patients with PAD and 30 volunteers without PAD were recruited. DUS, transcutaneous tissue oxygen pressure (tcpO2) and toe pressure measurements were performed at rest and after exercise. The differential power of these examinations for severe limb ischemia (SLI) was determined by receiver-operating curves (ROCs) and pattern recognition by independent multicategory analysis (PRIMA). RESULTS There was an obvious significant difference between the patient and control groups at rest; after exercise; the ratio of severely impaired values (ankle-brachial index - ABI, toe-brachial index - TBI, tcpO2 measured on index forefoot) increased significantly in the patient group (p < 0.05). TBI, tcpO2, ABI measured after exercise could differentiate SLI better than the values of these tests at rest (p < 0.001). In ROC analysis, the largest area under the curve (AUC) was covered by post- (AUC: 0.860) and pre-exercise TBI (AUC: 0.785), and post-exercise tcpO2 (AUC: 0.720) (p < 0.001). Post-exercise TBI gained the best discriminant score in PRIMA. CONCLUSIONS Pre- and post-exercise non-invasive vascular tests could reveal severe limb ischemia. Toe pressure measurement and TBI should become a basic part of the vascular workup.

The Hungarian Care Managing Organization Pilot Program

OBJECTIVES The aim of this article was to provide a description of the Hungarian care managing organization (CMO) pilot program and its environment, incentive structure, and preliminary outcomes. The need to change the behavior of doctors to increase the effectiveness and cost-effectiveness of the system was the key rationale for the Hungarian CMO pilot program. METHODS After an application process, nine CMOs were entitled to enter into the system in July 1999. By 2006, there were 14 CMOs covering 2.1 million people. The Hungarian CMO program tried to combine the advantages of both the US managed care programs and the UK general practitioner fundholding system, within the constraints and opportunities of a Central-European country committed to a single-payer health insurance system. RESULTS The revenue of CMOs derived from a risk-adjusted capitation. The capitation formula was weighted only by age and sex. The expenditures of the CMOs included all the health expenditures on their patients that occurred in any part of the health care system. The average savings rate for all CMOs for the fiscal years 1999 to 2007 was 4.94%. The highest rates of savings were realized in chronic and acute inpatient care and medical devices. The pilot was discontinued in 2008 without a comprehensive evaluation of the experience. CONCLUSIONS We can conclude that this pilot had a significant contribution to the modernization of the Hungarian health care system.

FIT performance in early-stage colorectal cancer-letter

See the Response, [p. 1563][1] We read with great interest the excellent article of Droste and colleagues on the assessment of the effect of higher cutoff levels of quantitative fecal immunochemical tests (FIT) on test positivity rate and detection rate of early-stage colorectal cancers (CRC; ref

Cancer screening policy in Hungary: Letter to the Editor

Dear Editor, Basu et al. published an excellent overview on the status of implementation and organization of cancer screening in the European Union Member States. This paper provides a valuable description of current cancer screening policies of the European countries. We would like to give some detailed information on the Hungarian screening programs. Mammography-based breast cancer screening has a long tradition in Hungary. Mammography-based opportunistic breast cancer screening started in Hungary as early as the late 1960s in the city of Bonyh ad. Even the first scientific evidences for the effectiveness of mammography screening in reducing the breast cancer mortality came from large randomized controlled trial performed by a Hungarian radiologist, Prof. L aszl o Tab ar, in two Swedish counties, Kopparberg and € Osterg€otland. Later several mammography screening pilot programs were performed in Hungary. Following the evaluation of pilot programs for mammography screening, a nationwide, organized population based breast cancer screening program was announced in 2001 and started in January 2002. Unlike the ones (45–64 years) given in table 2 of the paper by Basu and coworkers, women aged between 45 and 65 years old were invited for participating in the breast cancer screening program. Opportunistic cervical cancer screening started in Hungary during the 1970s. One should bear in mind that at that time Hungary was a socialist country, behind the “iron curtain” with limited access to the achievements of the developed countries. After the socialist system collapsed in 1990, Hungary initiated new pilot program for the early detection of cervical cancer. This program was financed by the World Bank. After three decades of opportunistic cervical cancer screening activities, an organized, nationwide cervical cancer screening was introduced in Hungary in July 2003 for women aged between 25 and 65 years old. Although in figure 2 of the paper mentioned that the Hungarian cervical cancer screening program’s rollout ongoing, we would like to emphasize that rollout was completed. However, we have several problems with the low participation rate of invited women: “The Hungarian organized, nationwide cervical screening program managed to moderately increase (13.7%) the screening coverage of the target population in the first screening round; therefore, it failed to attract women with high risk outside of the scope of both the previous opportunistic and the newly introduced organized cervical cancer screening program.” Between 2013 and 2015, a new element was added to the organized cervical cancer screening program, in order to increase the participation rate. A pilot program was introduced in 2013 for the involvement of health visitors. It meant that in addition to gynecologists, health visitors, having a B.Sc. degree in health sciences, were allowed to take the smears. The involvement of health visitors resulted in 8.3% increase in the participation rate. In Hungary, we had several pilot programs for colorectal cancer screening. In 1997–1998, the first Hungarian colorectal cancer screening pilot program was done in a well-defined administrative area of the Capital, Budapest, with support from the World Bank Close the gap public health programme. The next colorectal cancer screening pilot program was organized in a small city of Ajka, and the surrounding area in 2003– 2004. Later some other small scale pilot programs were organized in different Hungarian cities (Balatonf€ ured, B ek escsaba, Kecskem et, Nagyat ad). In 2015, we had a new colorectal cancer screening pilot program in County Csongr ad, financed from European Union’s funding (“Social Renewal Operational Programme: SROP-6.1.3A-13/1–2013-0001 To support the extension of pilot screening programs—cervical cancer screening by health visitor and colorectal cancer screening programs”). These pilot programs used immunochemical fecal occult blood test (FOBT) for the early detection of fecal blood. Following the evaluation of this pilot program, Hungarian health policy leaders committed to the introduction of a nationwide colorectal cancer screening program. We hope this program will be launched as soon as possible. Hungary can be considered as a pioneer with the application of immunochemical testing for colorectal cancer. But in Hungary we still did not have a nationwide colorectal cancer program, as it was stated in figure 3. The legal regulation of colorectal cancer screening was a bit confusing in Hungary. Since 1997, a ministerial decree regulates both the opportunistic and nationwide organized screening programs in Hungary. This decree defines breast and cervical cancer screening as an organized, nationwide screening program. Colorectal cancer screening program was mentioned as an organized, nationwide screening program in Hungary on a single day, the December 31, 2005! Never before or after this day colorectal cancer screening was not an organized, nationwide screening program, only opportunistic and/or pilot programs were carried out. We emphasize that the current Hungarian legal regulation (law) also does not mention colorectal cancer screening among the nationwide, organized cancer screening programs. Regarding cancer screening programs, we should mention their cost-effectiveness. In a country, with limited resources for healthcare, financial issues are important. In 2001–2002, Le tt er to th e E di to r

Experiences with Price Competition of Biosimilar Drugs In Hungary in Case of Colony-Stimulating Factor Products

value-based pricing, which reflects disease burden, therapeutic innovation, and social values, is suggested. This study attempts to measure the importance of costeffectiveness and other values for a new anticancer drug. Methods: Through literature reviews and experts’ advices, eight health insurance benefit criteria were selected: disease severity, size of population affected by disease, pediatric medicine, alternative drugs, innovativeness, clinical benefit, cost-effectiveness, and budget impact. Preference for the criteria was investigated by using Discrete Choice Experiments(DCE), Analytic Hierarchy Process (AHP), swing weighting (SWING), and direct point allocation (DIRECT). The survey was conducted in three hundred general population through face to face interview. Respondents were selected using stratified random sampling by age, sex and region. The conditional logistic regression for DCE was conducted with STATA ver.12. Results: In the preference investigation using DCE, people preferentially considered disease severity (OR: 1.837, 95% CI: 1.673 to 2.017), alternative drugs (OR: 1.556, 95% CI: 1.458 to 1.661), and size of population affected by disease (OR: 1.408, 95% CI: 1.285 to 1.543). According to the results by using AHP, respondents considered clinical benefit to be the most important, followed by cost-effectiveness and disease severity as the main evaluation items. As estimated by SWING and DIRECT, clinical benefit was also evaluated as the most important item. There was no difference in the first to third priority evaluation items between SWING and DIRECT. ConClusions: The priorities derived from all methodologies show that clinical benefit and disease severity were more important than cost-effectiveness in general terms. In the situation where decision-making is mostly centered on cost-effectiveness, our results may be seen as the social demand that clinical benefit and the influence of applicable disease should be reflected appropriately in the insurance coverage.

Az otthoni szakápolás egészségbiztosí tási vonatkozásainak elemzése Magyarországon

Bevezetes: Az otthoni szakapolas 1996 vegen indult meg Magyarorszagon. Celkitűzes: A szerzők celja a magyar otthoni szakapolasi rendszer egeszsegbiztositasi es igenybeveteli mutatoinak bemutatasa. Modszer: Az elemzesben szereplő adatok az Orszagos Egeszsegbiztositasi Penztar finanszirozasi adatbazisabol (2001–2012) szarmaznak. Elemeztek a betegszamokat, a vizitszamokat, a szakapolasi es szakiranyu terapias tevekenysegek (gyogytorna, fizioterapia, logopedia) aranyat. Eredmenyek: Az ellatott betegek szama a 2001. evi 36 560-rol 2012-re 51 647-re nőtt, 41,3%-kal emelkedett. A teljesitett vizitek szama ugyanezen időszak alatt 841 715-ről 1 194 670-re, 41,9%-kal nőtt. A szakapolasi es szakiranyu terapias tevekenysegek, valamint az apolasi fokozatok vonatkozasaban jelentős megyek kozotti eltereseket figyeltek meg. A szakapolasra kifizetett osszegek aranya a legmagasabb volt Nograd (80,4%), Szabolcs-Szatmar-Bereg (79,7%) es Komarom-Esztergom (74,6%) megyekben, mig a legalacsonyabb Zala (53,0%) es Csongrad (52,7%...INTRODUCTION Home nursing care was introduced in Hungary in 1996. AIM The aim of this study was to analyse health insurance data and utilization indicators of the Hungarian home nursing care. METHOD Data derived from the database of the National Health Insurance Fund Administration (2001-2012). The number of patients and visits, and the ratio of special nursing and special therapy (physiotherapy, speech therapy) were analysed. RESULTS The number of patients increased by 41.3% from 36.560 (2001) to 51.647 (2012). The number of visits also increased by 41.9% from 841.715 (2011) to 1.194.670 (2012). Significant geographical inequalities were found in the ratio of special nursing and special therapy as well as nursing needs. The ratio of reimbursement for special nursing was the highest in county Nógrád (80.4%), Szabolcs-Szatmár-Bereg (79.7%) and Komárom-Esztergom (74.6%), while the lowest in county Zala (53.0%), Csongrád (52.7%) and Budapest (47.9%). CONCLUSIONS There are significant inequalities in the home nursing care in Hungary. In order to decrease these inequalities, specific guidelines should be developed for home nursing care.

Health insurance data analysis on home nursing care in Hungary

Bevezetes: Az otthoni szakapolas 1996 vegen indult meg Magyarorszagon. Celkitűzes: A szerzők celja a magyar otthoni szakapolasi rendszer egeszsegbiztositasi es igenybeveteli mutatoinak bemutatasa. Modszer: Az elemzesben szereplő adatok az Orszagos Egeszsegbiztositasi Penztar finanszirozasi adatbazisabol (2001–2012) szarmaznak. Elemeztek a betegszamokat, a vizitszamokat, a szakapolasi es szakiranyu terapias tevekenysegek (gyogytorna, fizioterapia, logopedia) aranyat. Eredmenyek: Az ellatott betegek szama a 2001. evi 36 560-rol 2012-re 51 647-re nőtt, 41,3%-kal emelkedett. A teljesitett vizitek szama ugyanezen időszak alatt 841 715-ről 1 194 670-re, 41,9%-kal nőtt. A szakapolasi es szakiranyu terapias tevekenysegek, valamint az apolasi fokozatok vonatkozasaban jelentős megyek kozotti eltereseket figyeltek meg. A szakapolasra kifizetett osszegek aranya a legmagasabb volt Nograd (80,4%), Szabolcs-Szatmar-Bereg (79,7%) es Komarom-Esztergom (74,6%) megyekben, mig a legalacsonyabb Zala (53,0%) es Csongrad (52,7%...INTRODUCTION Home nursing care was introduced in Hungary in 1996. AIM The aim of this study was to analyse health insurance data and utilization indicators of the Hungarian home nursing care. METHOD Data derived from the database of the National Health Insurance Fund Administration (2001-2012). The number of patients and visits, and the ratio of special nursing and special therapy (physiotherapy, speech therapy) were analysed. RESULTS The number of patients increased by 41.3% from 36.560 (2001) to 51.647 (2012). The number of visits also increased by 41.9% from 841.715 (2011) to 1.194.670 (2012). Significant geographical inequalities were found in the ratio of special nursing and special therapy as well as nursing needs. The ratio of reimbursement for special nursing was the highest in county Nógrád (80.4%), Szabolcs-Szatmár-Bereg (79.7%) and Komárom-Esztergom (74.6%), while the lowest in county Zala (53.0%), Csongrád (52.7%) and Budapest (47.9%). CONCLUSIONS There are significant inequalities in the home nursing care in Hungary. In order to decrease these inequalities, specific guidelines should be developed for home nursing care.