Nadja Chernyak

Costs of dialysis—a regional population-based analysis

BACKGROUND Population-based estimates of costs of renal replacement therapy are scarce in the literature. The aim of our study was to calculate the costs of long-term dialysis in 2006 on the basis of patient-specific data from a well-defined population in a region in western Germany (n = 310,757). METHODS Cost estimation was performed from the perspective of the statutory health insurance. All dialysis patients from the study region (n = 344, 54% male, mean age (+/-SD) 69 +/- 13 years, 42% diabetic) were assessed for the costs of the dialysis procedures, dialysis-related hospital admissions, outpatient contacts outside of our dialysis center, dialysis-related medication, patient transportation and related costs (e.g. reimbursement fees on the basis of the German diagnosis-related group system, price scales). We estimated the cumulative cost per patient year in 2006 (in Euros), along with the 10th and 90th percentiles and the 95% confidence intervals (CI) by using bootstrapping procedures. RESULTS The mean total dialysis-related cost in 2006 was 54,777 Euros (95% CI, 51,445-65,705) per patient year. The largest part of the costs (55%) was caused by the dialysis procedures, followed by the costs of medication (22%), hospitalization (14%) and transportation (8%). The total cost increased significantly with increasing age. No significant association was found between total cost and sex, dialysis strategy, end-stage renal disease duration and diabetes. CONCLUSIONS We present for the first time a cost estimation of dialysis in Germany on the basis of patient-level data in a population-based sample. Except age, patient characteristics were not significantly associated with costs. The largest part of the costs was caused by the dialysis procedures themselves; however, other dialysis-specific health care utilization also strongly contributed to the total cost.

Cost-effectiveness analysis of cognitive behaviour therapy for treatment of minor or mild-major depression in elderly patients with type 2 diabetes: study protocol for the economic evaluation alongside the MIND-DIA randomized controlled trial (MIND-DIA CEA)

BackgroundDepression and elevated depression symptoms are more prevalent in patients with type 2 diabetes than in those without diabetes and are associated with adverse health outcomes and increased total healthcare utilization. This suggests that more effective depression treatment might not only improve health outcome, but also reduce costs. However, there is a lack of evidence on (cost-) effectiveness of treatment options for minor and mild-major depression in patients with type 2 diabetes. In this paper we describe the design and methods of the economic evaluation, which will be conducted alongside the MIND-DIA trial (Cognitive behaviour therapy in elderly type 2 diabetes patients with minor or mild-major depression). The objective of the economic evaluation (MIND-DIA CEA) is to examine incremental cost-effectiveness of a diabetes specific cognitive behaviour group therapy (CBT) as compared to intensified treatment as usual (TAU) and to a guided self-help group intervention (SH).Methods/DesignPatients will be followed for 15 months. During this period data on health sector costs, patient costs and societal productivity/time costs will be collected in addition to clinical data. Person-years free of moderate/severe major depression, quality adjusted life years (QALYs), and cumulative costs will be estimated for each arm of the trial (CBT, TAU and SH). To determine cost-effectiveness of the CBT, differences in costs and effects between the CBT group and TAU/SH group will be calculated.DiscussionCBT is a potentially effective treatment option to improve quality of life and to avoid the onset of a moderate/severe major depression in elderly patients with type 2 diabetes and minor or mild-major depression. This hypothesis will be evaluated in the MIND-DIA trial. Based on these results the associated economic evaluation will provide additional evidence on the cost-effectiveness of CBT in this target population. Methodological strengths and weaknesses of the planned economic evaluation are discussed.Trial registrationThe MIND-DIA study has been registered at the Current Controlled Trials Register (ISRCTN58007098).

A new prize system for drug innovation

We propose a new prize (reward) system for drug innovation which pays a price based on the value of health benefits accrued over time. Willingness to pay for a unit of health benefit is determined based on the cost-effectiveness ratio of palliative/nursing care. We solve the problem of limited information on the value of health benefits by mathematically relating reward size to the uncertainty of information including information on potential drug overuse. The proposed prize system offers optimal incentives to invest in research and development because it rewards the innovator for the social value of drug innovation. The proposal is envisaged as a non-voluntary alternative to the current patent system and reduces excessive marketing of innovators and generic drug producers.

Drug Costs in Prediabetes and Undetected Diabetes Compared With Diagnosed Diabetes and Normal Glucose Tolerance: Results From the Population-Based KORA Survey in Germany

Undetected diabetes and prediabetes are common (1–3). In decision analytic models of diabetes prevention and screening in particular, the differentiation in costs of detected, undetected, and prediabetic cases are important (4). To the best of our knowledge, no study has determined costs using population-based data with oral glucose tolerance test (OGTT)–based diabetes diagnosis. We used the population-based Cooperative Health Research in the Region of Augsburg (KORA) follow-up survey, conducted in 2006–2008 in southern Germany (2,3) ( n = 2,611, aged 40–82 years). By means of participants’ self report and an OGTT, we identified individuals with previously diagnosed diabetes ( n = 233, 57.9% male, mean age 67.8 ± 8.7), undetected diabetes ( n = 109, 56.9% male, mean age 65.3 ± 10.4), and prediabetes (i.e., impaired glucose tolerance and/or impaired fasting glucose) ( n = 489, 53.2% male, mean age 63.7 ± 10.4), and those with normal …

Studies analysing the need for health-related information in Germany - a systematic review

BackgroundExploring health-related information needs is necessary to better tailor information. However, there is a lack of systematic knowledge on how and in which groups information needs has been assessed, and which information needs have been identified. We aimed to assess the methodology of studies used to assess information needs, as well as the topics and extent of health-related information needs and associated factors in Germany.MethodsA systematic search was performed in Medline, Embase, Psycinfo, and all databases of the Cochrane Library. All studies investigating health-related information needs in patients, relatives, and the general population in Germany that were published between 2000 and 2012 in German or English were included. Descriptive content analysis was based on predefined categories.ResultsWe identified 19 studies. Most studies addressed cancer or rheumatic disease. Methods used were highly heterogeneous. Apart from common topics such as treatment, diagnosis, prevention and health promotion, etiology and prognosis, high interest ratings were also found in more specific topics such as complementary and alternative medicine or nutrition. Information needs were notable in all surveyed patient groups, relatives, and samples of the general population. Younger age, shorter duration of illness, poorer health status and higher anxiety and depression scores appeared to be associated with higher information needs.ConclusionKnowledge about information needs is still scarce. Assuming the importance of comprehensive information to enable people to participate in health-related decisions, further systematic research is required.

Economic evaluation of brief psychodynamic interpersonal therapy in patients with multisomatoform disorder.

Background A brief psychodynamic interpersonal therapy (PIT) in patients with multisomatoform disorder has been recently shown to improve health-related quality of life. Aims To assess cost-effectiveness of PIT compared to enhanced medical care in patients with multisomatoform disorder. Method An economic evaluation alongside a randomised controlled trial (International Standard Randomised Controlled Trial Number ISRCTN23215121) conducted in 6 German academic outpatient centres was performed. Incremental cost-effectiveness ratio (ICER) was calculated from the statutory health insurance perspective on the basis of quality adjusted life years (QALYs) gained at 12 months. Uncertainty surrounding the cost-effectiveness of PIT was presented by means of a cost-effectiveness acceptability curve. Results Based on the complete-case analysis ICER was 41840 Euro per QALY. The results did not change greatly with the use of multiple imputation (ICER = 44222) and last observation carried forward (LOCF) approach to missing data (ICER = 46663). The probability of PIT being cost-effective exceeded 50% for thresholds of willingness to pay over 35 thousand Euros per QALY. Conclusions Cost-effectiveness of PIT is highly uncertain for thresholds of willingness to pay under 35 thousand Euros per QALY.

Pre-test of questions on health-related resource use and expenditure, using behaviour coding and cognitive interviewing techniques

BackgroundValidated instruments collecting data on health-related resource use are lacking, but required, for example, to investigate predictors of healthcare use or for health economic evaluation.The objective of the study was to develop, test and refine a questionnaire collecting data on health-related resource use and expenditure in patients with diabetes.MethodsThe questionnaire was tested in 43 patients with diabetes mellitus types 1 and 2 in Germany. Response behaviour suggestive of problems with questions (item non-response, request for clarification, comments, inadequate answer, “don’t know”) was systematically registered. Cognitive interviews focusing on information retrieval and comprehension problems were carried out.ResultsMany participants had difficulties answering questions pertaining to frequency of visits to the general practitioner (26%), time spent receiving healthcare services (39%), regular medication currently taken (35%) and out of pocket expenditure on medication (42%). These difficulties seem to result mainly from poor memory. A number of comprehension problems were established and relevant questions were revised accordingly.ConclusionThe questionnaire on health-related resource use and expenditure for use in diabetes research in Germany was developed and refined after careful testing. Ideally, the questionnaire should be externally validated for different modes of administration and recall periods within a variety of populations.

Within-trial economic evaluation of diabetes-specific cognitive behaviour therapy in patients with type 2 diabetes and subthreshold depression

BackgroundDespite the high prevalence of subthreshold depression in patients with type 2 diabetes, evidence on cost-effectiveness of different therapy options for these patients is currently lacking.Methods/DesignWithin-trial economic evaluation of the diabetes-specific cognitive behaviour therapy for subthreshold depression. Patients with diabetes and subthreshold depression are randomly assigned to either 2 weeks of diabetes-specific cognitive behaviour group therapy (n = 104) or to standard diabetes education programme only (n = 104). Patients are followed for 12 months. During this period data on total health sector costs, patient costs and societal productivity costs are collected in addition to clinical data. Health related quality of life (the SF-36 and the EQ-5D) is measured at baseline, immediately after the intervention, at 6 and at 12 months after the intervention. Quality adjusted life years (QALYs), and cumulative costs will be estimated for each arm of the trial. Cost-effectiveness of the diabetes-specific cognitive behaviour group therapy will be analysed from the perspective of the German statutory health insurance and from the societal perspective. To this end, incremental cost-effectiveness ratio (ICER) in terms of cost per QALY gained will be calculated.DiscussionSome methodological issues of the described economic evaluation are discussed.Trial registrationThe trial has been registered at the Clinical Trials Register (NCT01009138).

Assessment of information needs in diabetes: Development and evaluation of a questionnaire

AIM To develop a questionnaire suitable for assessing the information needs of individuals with diabetes mellitus types 1 and 2 in diverse healthcare settings (e.g. primary care or long-term care) and at different time points during the course of the disease. METHODS The initial questionnaire was developed on the basis of literature search and analysis, reviewed by clinical experts, and evaluated in two focus groups. The revised version was pilot-tested on 39 individuals with diabetes type 2, type 1 and gestational diabetes. RESULTS The final questionnaire reveals the most important information needs in diabetes. A choice task, a rating task and open-ended questions are combined. First, participants have to choose three topics that interest them out of a list with 12 general topics and specify in their own words their particular information needs for the chosen topics. They are then asked how informed they feel with regard to all topics (4-point Likert-scale), and whether information is currently desired (yes/no). The questionnaire ends with an open-ended question asking for additional topics of interest. CONCLUSIONS Careful selection of topics and inclusion of open-ended questions seem to be essential prerequisites for the unbiased assessment of information needs. The questionnaire can be applied in surveys in order to examine patterns of information needs across various groups and changes during the course of the disease. Such knowledge would contribute to more patient-guided information, counselling and support.

Gesundheitsökonomische Evaluation von Interventionen bei Diabetes mellitus und komorbider Depression

ZusammenfassungKomorbide Depression bei Personen mit Diabetes ist im Vergleich zu diabetischen Patienten ohne Depression mit ungünstigen Erkrankungsereignissen, erhöhten medizinischen Kosten und Arbeitsunfähigkeit assoziiert. Die Betreuung dieser Patientengruppe erfordert integrierte Versorgungsmodelle. Um solche Modelle effizient zu implementieren, sind Kenntnisse über die Kosteneffektivität verschiedener Interventionen zur Behandlung von Depressionen bei Patienten mit Diabetes, möglichst unter Alltagsbedingungen, erforderlich. Bis jetzt haben nur wenige amerikanische Studien die Kosteneffektivität antidepressiver Interventionen bei diabetischen Patienten untersucht. Die Übertragbarkeit der Studienergebnisse aus den USA auf Deutschland ist jedoch fraglich. Erste Ergebnisse aus deutschen gesundheitsökonomischen Studien, die die Kosteneffektivität von Interventionen bei Diabetes und Depressivität evaluieren, sind Ende 2011 zu erwarten.AbstractCompared to patients with diabetes only, comorbid depression in patients with diabetes is associated with adverse health outcomes, higher total healthcare costs and work disability. Collaborative care models might improve treatment outcomes in these patients. To implement such models efficiently, evidence on cost-effectiveness of various treatment options for depression in patients with diabetes is needed. Until now only a few studies in the USA have evaluated cost-effectiveness of depression management strategies in patients with diabetes. Transferability of the study results from the USA to Germany is, however, problematic. The first results from the German trial-based economic evaluation of interventions for treatment of depression in patients with diabetes are to be expected at the end of 2011.