Jürgen Wasem

Impact of 4 different definitions used for the assessment of the prevalence of the Metabolic Syndrome in primary healthcare:The German Metabolic and Cardiovascular Risk Project (GEMCAS)

BackgroundThe metabolic syndrome (MetSyn) places individuals at increased risk for type 2 diabetes and cardiovascular disease. Prevalence rates of the population of the MetSyn are still scarce. Moreover, the impact of different definitions of the MetSyn on the prevalence is unclear. Aim here is to assess the prevalence of the MetSyn in primary health care and to investigate the impact of four different definitions of the MetSyn on the determined prevalence with regard to age, gender and socio-economic status.MethodsThe German-wide cross-sectional study was conducted during two weeks in October 2005 in 1.511 randomly selected general practices. Blood samples were analyzed, blood pressure and waist circumference assessed, data on lifestyle, medication, chronic disorders, and socio-demographic characteristics collected. MetSyn prevalence was estimated according to the definitions of NCEP ATP III (2001), AHA/NHLBI (2004, 2005), and IDF (2005). Descriptive statistics and prevalence rate ratios using the PROG GENMOD procedure, were calculated. Cohens kappa was used as measure for interreliability between the different prevalence estimates.ResultsData of 35,869 patients (age range: 18–99, women 61.1%) were included. The prevalence was lowest using the NCEP ATP III- (all: 19.8%, men 22.7%, women: 18.0%), highest according to the IDF-definition (32.7%, 40.3%, 28.0%). The increase in prevalence with recent definitions was more pronounced for men than for women, and was particularly high for men and women aged 60–79 years. The IDF-definition resulted in a higher prevalence especially in those with the highest educational status. Agreement (kappa) between the NCEP ATP III- and IDF-definition was 0.68 (men 0.61, women 0.74), between the updated the AHA/NHLBI- (2005) and IDF-definition 0.85 (men 0.79, women 0.89).ConclusionThe prevalence of metabolic syndrome is associated with age, gender, and educational status and increases considerably with each newly published definition. Our data highlight the need for a better evidence regarding thresholds of the components of the metabolic syndrome, especially with regard to the IDF-definition – according to which in some populations a majority of subjects are diagnosed with the metabolic syndrome.

Age- and sex-specific prevalence and ten-year risk for cardiovascular disease of all 16 risk factor combinations of the metabolic syndrome - A cross-sectional study

BackgroundBased on the AHA/NHLBI-definition three out of five cardiometabolic traits must be present for the diagnosis of the metabolic syndrome (MetS), resulting in 16 different combination types. The associated cardiovascular risk may however be different and specific combination may be indicative of an increased risk, furthermore little is known to which extent these 16 combinations contribute to the overall prevalence of MetS. Here we assessed the prevalence of all 16 combination types of MetS, analyzed the impact of age and gender on prevalence rates, and estimated the 10-year risk of fatal and non-fatal myocardial infarction (MI) of each MetS combination type.MethodsWe used data of the German Metabolic and Cardiovascular Risk Project (GEMCAS), a cross-sectional study, performed during October 2005, including 35,869 participants (aged 18-99 years, 61% women). Age-standardized prevalence and 10-year PROCAM and ESC risk scores for MI were calculated.ResultsIn both men and women the combination with elevated waist-circumference, blood pressure and glucose (WC-BP-GL) was the most frequent combination (28%), however a distinct unequal distribution was observed regarding age and sex. Any combination with GL was common in the elderly, whereas any combination with dyslipidemia and without GL was frequent in the younger. Men without MetS had an estimated mean 10-year risk of 4.7% (95%-CI: 4.5%-4.8%) for MI (PROCAM), whereas the mean 10-year risk of men with MetS was clearly higher (age-standardized 7.9%; 7.8-8.0%). In women without MetS the mean 10-year risk for MI was 1.1%, in those with MetS 2.3%. The highest impact on an estimated 10-year risk for MI (PROCAM) was observed with TG-HDL-GL-BP in both sexes (men 14.7%, women 3.9%). However, we could identify combinations with equal risks of non-fatal and fatal MI compared to participants without MetS.ConclusionsWe observed large variations in the prevalence of all 16 combination types and their association to cardiovascular risk. The importance of different combinations of MetS changes with age and between genders putting emphasis on a tailored approach towards very young or very old subjects. This knowledge may guide clinicians to effectively screen individuals and prioritize diagnostic procedures depending on age and gender.

Direkte Kosten in der Diagnostik und Behandlung von Patienten mit symptomatischem Vorhofflimmern in Deutschland

IntroductionAtrial Fibrillation (AF) is a cardiac arrhythmia characterised by uncoordinated atrial activation. The public health relevance of AF will most likely increase in the future because of the aging population and the associated increased prevalence of age-related risk factors. Little is known about the economic burden associated with the treatment of AF patients in Germany. The aim of this study was to assess the costs of AF in the German health care system.MethodsWe considered annual direct medical costs of patients with paroxysmal, persistent and permanent AF from a payer’s perspective using 2008 prices. Resource items (e. g. laboratory tests) and quantity of resource use were identified by literature research and by consulting medical experts. Prices were drawn from standard reimbursement catalogues and appropriate discounts and rebates were taken into consideration.ResultsThe annual average costs of paroxysmal AF are € 1,394, of persistent AF are € 2,130 and of permanent AF are € 1,073. From a payer’s perspective, the first cost driver of AF was hospitalisation. The average costs for diagnostic investigations are € 250 for paroxysmal AF and € 311 for persistent AF.ConclusionsThis evaluation shows that hospital admissions, inpatient treatment and interventions represent the major cost driver in the treatment of AF patients. Efforts to reduce the economic burden of AF should focus on avoidance of hospital admissions. Nevertheless, hospitalisation for antiarrhythmic therapy initiation can be cost-effective. The developed cost database enables the adaption of costs data for future projects, especially when calculating the cost-effectiveness of innovative treatment options of AF.

Aktuelle Beispiele zur Fehlsteuerung von Kosten bei Therapien mit variabler Dauer durch die Verwendung von Defined Daily Doses

AbstractIntroductionThe control of drug costs within the statutory health system is not determined by pricing between manufacturer and final consumer but through negotiation with a variety of institutions. Defined Daily Doses (DDDs) are occasionally used for a comparison of prices. They are, however, explicitly not suitable for cost comparisons of different therapies. Amongst other aspects, price comparisons do not consider the treatment duration, which may lead to an unrealistic cost evaluation in cases of non-chronic or oncologic diseases.MethodsFor this overview, three examples of therapies with variable duration (tumor, antibiotic and anthelmintic therapy) were selected which illustrate potential faults in the use of DDDs to control costs in therapies of variable duration.ResultsThe presented examples enabled us to deduce the following requirements for the conduction of cost comparisons:nConsideration of therapy duration primarily for non-chronic disease or for cancer indicationsAs the prescribed dosages differ substantially due to clinical experiences or to available working strengths, Prescribed Daily Doses (PDDs) should be determined for cost comparisonsConsideration of costs per treatment case instead of per dayConsideration of cycle length, primarily in cancer indicationsn Furthermore, equivalent efficacy is a prerequisite for a comparison of costs. The costs beyond actual drug costs (repeated physician visits, morbidity, and inability for work) are usually difficult to determine: these considerations would, however, be desirable from a societal perspective.ConclusionsThe attempt to control drug costs is limited by a number of potential faults, particularly in therapies of variable durations. The method used in Germany may even lead to an increase in costs in some cases.

Kosteneffektivität der Nikotinersatz-therapie bei Patienten mit chronisch-obstruktiver Lungenerkrankung — ein entscheidungsanalytisches Modell

IntroductionChronic-obstructive pulmonary disease (COPD) is a respiratory disorder characterised by progressive airway obstruction followed by a decrease in lung function. Tobacco smoking is considered as the most important avoidable risk factor. COPD is currently the fourth leading cause of death in the world with a predicted future increase in prevalence and mortality. The presented decision-analytic model aims to analyse the incremental cost-effectiveness ratio (ICER) of smoking cessation with Nicotine Replacement Therapy (NRT) compared to smoking cessation without NRT in COPD patients.MethodsA Markov model simulates the long-term natural course of the disease considering the effect of smoking cessation with NRT versus no intervention, from the perspective of the German Statutory Health System. The input data, such as transition probabilities between COPD severity levels, costs (base year 2008) and NRT effectiveness, are based on several systematic literature researches and internal calculations. As an outcome the incremental costs per life-year gained (LYG) are calculated.ResultsWithin a simulated time horizon of 55 years, smoking cessation with NRT is the dominant strategy with € 26,207 and 17.06 LYG (discounted). Comparatively, smoking cessation without NRT results in € 2,095 additional costs and a loss of 0.61 LYG. NRT remains the dominant strategy in most of the performed sensitivity analyses.ConclusionsNRT is the dominant strategy compared to no intervention for smoking cessation in patients with COPD. The results of this analysis are robust to the variation of numerous model parameters and assumptions.

Behandlungskosten bei Myokardinfarkt, Schlaganfall und Diabetes mellitus Typ 2 unter Berücksichtigung kardiovaskulärer Risikofaktoren aus Sicht der Gesetzlichen Krankenversicherung in Deutschland

AbstractIntroductionCoronary heart disease (CHD), myocardial infarction (MI), stroke and diabetes mellitus are among the leading causes of morbidity and mortality in Germany. The aim of this study was to determine the costs of myocardial infarction, coronary heart disease, stroke and diabetes mellitus type 2 with its micro and macro vascular complications.MethodsWe considered annual direct medical costs from a payer’s perspective assuming 2005 prices. A representative number of disease states, risk factors and combinations thereof were identified a priori and the average annual costs were calculated of those listed below:nDiabetes mellitus without complicationsDiabetes mellitus with one additional risk factorDiabetes mellitus with 2–4 risk factorsDiabetes with micro vascular complicationsDiabetes with macro vascular complicationsCombination of risk factors (obesity, elevation of triglycerides and LDL-cholesterol, hypertension)Cardiovascular diseases (MI and stroke)n Since events like MI and stroke incur costs due to acute hospitalisation, the annual costs comprised acute care costs for a defined time horizon and post-event treatment costs for the remainder of the initial year. Resource utilisation was based on published data and expert interviews. Prices were drawn from standard reimbursement catalogues and appropriate discounts and rebates were taken into consideration.ResultsThe annual average costs of cardiovascular and metabolic diseases and risk factors vary from € 336 (combinations of risk factors) to € 6,276 (diabetes mellitus type 2 with micro vascular complications). These costs increase with the severity of the disease and the number of additional risk factors. The costs of hospitalisation for acute MI or acute stroke are € 4,560 and € 4,780 respectively.ConclusionsThe micro and macro vascular complications of diabetes mellitus and cardiovascular diseases cause considerable costs within the health care system in Germany. The results of this study demonstrate that costs increase as the number of cardiovascular risk factors and co-morbidities increase. Based on this evidence, premature therapy and prevention could lead to a reduction in morbidity and mortality and thereby decrease disease-specific costs.

Kosten der stationären Versorgung von Patienten mit akuter Dekompensation einer chronischen Lebererkrankung unter Verwendung des artifiziellen Leberunterstützungssystems MARS

ObjectiveArtificial liver support systems are seen as a promising innovative approach in the treatment of liver failure. Currently the most widespread technology used in the treatment of patients with acute-on-chronic liver failure (ACLF) is the Molecular Adsorbent Recirculating System MARS. The purpose of this study is to describe the distribution of the cost of ACLF-patients from the perspective of a hospital and to identify relevant indicators for cost to the hospital with a particular focus on MARS.MethodsBased on a bottom-up data acquisition of 149 ACLF-patients treated in a large German university hospital, the costs from the hospital’s point of view were calculated. In a regression analysis relevant indicators were identified.ResultsIn addition to the intervention cost, the treatment costs of patients with ACLF significantly increase if MARS is used. Further indicators were identified, including: a severe grade of hepatic encephalopathy, a high creatinine and a low platelet count at hospital admission.ConclusionsThe cost for inpatient care of ACLF-patients varies significantly due to the use of technical procedures such as artificial liver support systems, as well as clinical parameter. This variation of costs is currently not sufficiently reflected in the calculation of public payers’ package reimbursement rates.