The cost of ischaemic stroke in Croatia.

Objective: The aim of this analysis was to estimate 1 year and long-term cost and quality of life of ischaemic stroke patients in Croatia. In addition, we aimed to identify and estimate key categories of costs and outcomes driving the burden of stroke in Croatian healthcare system. Methods: Data were derived from analysis of the RES-Q Registry for Croatia in 2018 and supplemented with clinical expert opinion and relevant medical, clinical and economic literature to estimate the course of the disease and treatment patterns in Croatian healthcare system. The health economic model was comprised of a one-year discrete event simulation (DES) mapping real life patient experience and a 10-year Markov model built on existing literature. Cost and health resources use were obtained using Croatian tariffs. Health utilities were mapped to EQ5D from the Barthel Index utilising previously published studies. Results: The key aspects determining costs and quality of life were rehabilitation, discharge to residential care (currently 13% of patients in Croatia) and recurrent stroke. Total 1 year cost per patient was 18,221 EUR having 0.372 QALYs. Conclusion: Direct costing structure of ischaemic stroke in Croatia is above the value of upper-middle income countries. Our study showed that post stroke rehabilitation seems to be a strong modifier of future post-stroke costs and further research into various models of post-stroke care and rehabilitation could be the answer into more successful rehabilitation that could increase QALY and reduce the economic burden of stroke. Further investment in rehabilitation research and provision might bring promising opportunities to improve long term patient outcomes.

Impact Assessment of an Innovative Integrated Care Model for Older Complex Patients with Multimorbidity: The CareWell Project.

OBJECTIVES: To evaluate the impact in terms of use of health services, clinical outcomes, functional status, and patient's satisfaction of an integrated care program, the CareWell program, for complex patients with multimorbidity, supported by information and communication technology platforms in six European regions. DATA SOURCES: Primary data were used and the follow-up period ranged between 8 and 12 months. STUDY DESIGN: A quasi-experimental study, targeting chronic patients aged 65 or older, with 2 or more conditions - one of them necessarily being diabetes, congestive heart failure or congestive obstructive pulmonary disease. The intervention group received the integrated care program and the control group received usual care. Generalized mixed regression models were used. DATA COLLECTION: Data were obtained from individual interviews and electronic clinical records. PRINCIPAL FINDINGS: Overall, 856 patients were recruited (475 intervention and 381 control). In the intervention group, the number of visits to emergency rooms was significantly lower, and the number of visits to the general practitioners and primary care nurses was higher than in the control group. CONCLUSION: The CareWell program resulted in improvements in the use of health services, strengthening the role of PC as the cornerstone of care provision for complex patients with multimorbidity.

Rationalizing the introduction and use of pharmaceutical products: The role of managed entry agreements in Central and Eastern European countries.

This paper aims to provide an overview of the rationalization strategies for the introduction and use of pharmaceuticals, focusing on the role of managed entry agreements (MEA) in Central and Eastern European (CEE) countries, namely Bulgaria, the Czech Republic, Croatia, Hungary, Poland and Romania. We developed a conceptual framework on MEAs that was used as the basis for a standardized assessment questionnaire sent to country experts to capture their perceptions on their countries' rationalization strategies and MEAs. Our study shows that the main role of MEAs and other related policies embedded in the health care system is to limit the budget impact of drugs in all examined 6 countries. Uncertainty about outcomes and appropriate utilization seem to be of lower priority. Finance-based MEAs are used by all countries. Performance-based MEAs are scarce and used to a limited extent by Hungary and Poland. The overall transparency of the existence and details of MEAs is limited. Expansion of the use and increased transparency of MEAs is recommended. Still, the informational infrastructure and competencies in implementing MEA's need to be developed further.

Health and Economic Burden of Skin Melanoma in Croatia - Cost-of-illness Study.

Melanoma incidence is increasing, especially in the younger population. The aim of this study was to investigate the cost of this disease in the Croatian population and to identify costs through types of care and types of costs. The secondary goal was to estimate the prevalence of certain types of melanoma (as well as staging distribution) and to connect each stage and its prevalence in Croatia to related costs. A cost-of-illness analysis was performed, mainly including direct costs (monitoring, drugs, primary health care services, hospitalizations, and diagnostics). The calculations were based on data collected from Sestre milosrdnice University Hospital Center in Zagreb and from Cancer Registry Data. The number of patients with melanoma was calculated using the Markov model for melanoma staging and 5-year survival. The estimated total prevalence of melanoma in 2011 in Croatia was 2,180. The total cost of melanoma was estimated to 1,063,488 EUR, with 46% used for hospitalization and chemotherapy, 10% for dermatoscopy, and the remaining 17% being monitoring costs. The average cost per patient was estimated to range between 98 and 4,333 EUR depending on the stage of the disease. The cost of melanoma in the adult population in Croatia in a one-year timeframe accounted for as much as 0.04% of the total Croatian national health care budget for 2011. Study findings indicate the need for a clear strategy to achieve regular screening in order to detect the disease at an early stage.

Nutritional Issues and Nutrition Support in Older Home Care Patients in the City of Zagreb.

Population aging is a global demographic trend showing continuous growth and among its consequences is a rise in malnutrition that is characteristic for the elderly. The objective of this study was to evaluate nutritional status of elderly home care patients immediately after hospital discharge and to determine factors that affect nutritional status using questionnaires based on validated tools (NRS-2002, DETERMINE checklist) and basic medical history data. The study involved 76 elderly individuals (51.3% of them older than 70) living in the City of Zagreb. The nutritional status assessment using the NRS-2002 tool showed that 57.6% of the subjects were at nutritional risk. The findings of the assessment by use of the DETERMINE tool were also unfavorable, indicating that 82.1% of persons older than 70 were categorized as being at a high nutritional risk, while 17.9% were at moderate risk. The DETERMINE checklist elements (illness; reduced intake of fruits, vegetables or dairy products; alcohol consumption; oral health problems; and weight loss) were linked to a higher NRS score. The mean number of hospital days in subjects at nutritional risk was 14.27 (the mean number in the Republic of Croatia is 8.56 days). Although the study involved a small number of subjects, the results showed a substantial presence of malnutrition among the elderly. A timely -intervention by the healthcare system and training of healthcare personnel can be a step towards achieving a better nutritional status.

The economic burden of disease-related undernutrition in selected chronic diseases.

BACKGROUND & AIMS: Undernutrition is a common and aggravating problem in people suffering from various chronic diseases as well as a source of material costs. The aim of this study was to investigate the prevalence of disease-related undernutrition among adults in Croatia in the year 2012, as well as the cost of undernutrition associated with tumour cachexia, chronic pancreatitis, inflammatory bowel disease, hepatic encephalopathy, chronic obstructive pulmonary disease, chronic renal insufficiency requiring dialysis, cerebrovascular insult, pressure ulcers, and femoral fractures in the elderly. METHODS: A cost-of-illness analysis was conducted, including direct costs only. The study employed the dominant cost-of-illness method, which restricts the summation of medical expenditure to the disease of interest. The bottom-up, prevalence-based approach was used. The budget holder perspective was employed, and data sources include the list of reimbursed drugs, clinical opinions, and literature. RESULTS: The prevalence of disease-related undernutrition in people over the age of 20 in Croatia in the year 2012 was estimated to be 33.7/1000. The total cost of adult malnutrition for selected diagnoses was 97.35 million EUR, accounting for 3.38% of the total Croatian national health care budget. The largest share was used for medications (43%), followed by 34% for hospitalizations, 13% for community health nursing, while parenteral and enteral nutrition contributed with 6% and 1% respectively. The average cost per patient was estimated at 1640.48 EUR. CONCLUSIONS: The cost of malnutrition for the selected diagnoses in Croatia was substantial. These health costs will increase due to population ageing, which calls for undernutrition screening in people at risk as well as for effective approaches in nutrition supplementation.

Health care issues in Croatian elections 2005-2010: series of public opinion surveys.

AIM: To compare the results of a series of public opinion surveys on experiences with the health care sector in Croatia conducted in the time of elections and to analyze whether political party affiliation had any influence on issues of priority ranking. METHODS: The surveys were conducted during 2005, 2007, and 2009. They were administered through a Computer Assisted Telephone Interviewing method to representative samples of Croatian population and were statistically weighted according to sex, age, level of education, and political party affiliation. The random sampling of the person within the household was done using the table of random numbers. RESULT: Health and health care system was the most important issue (58%) during the 2007 parliamentary election and the second most important issue during the 2005 and 2009 elections (46% and 28%). In the 2007 election, health care was viewed as most important by women, respondents with lower education levels, and respondents with lower income. In 2005, the most important health care issues were corruption and lack of funding (45% and 43%, respectively), in 2007 poor organization and lack of funding (43% and 42%, respectively), and in 2009 lack of funding and corruption (51% and 45%, respectively). CONCLUSION: Health and health care system were consistently among the top two issues in all elections from 2005 to 2009. The top three most important health care sector issues were corruption, poor organization, and lack of funding. This indicates that political parties should include solutions to these issues in their health care policymaking.

Quality of life in Croatian Homeland war (1991-1995) veterans who suffer from post-traumatic stress disorder and chronic pain.

BACKGROUND: The aim of this study was to investigate the quality of life in Croatian homeland war veterans who suffer from post-traumatic stress disorder and chronic low back pain (LBP). METHODS: A total of 369 participants were included, classified in four study groups: those with post-traumatic stress disorder (PTSD; N = 59), those with both PTSD and lower back pain (PTSD+LBP; N = 80), those with isolated LBP (N = 95) and controls (N = 135). WHOQOL-BREF survey was used in the estimation of quality of life. The data were analysed using statistical methods and hierarchical clustering. RESULTS: The results indicated a general pattern of lowering quality of life in participants with both psychological (PTSD) and physical (LBP) burden. The average overall quality of life was 2.82 ± 1.14 for the PTSD+LBP group, 3.29 ± 1.28 for the PTSD group, 4.04 ± 1.25 for the LBP group and 4.48 ± 0.80 for the controls (notably, all the pair-wise comparisons were significantly different at the level of P < 0.001, except for the pair LBP-controls, which was insignificant). This result indicated that quality of life was reduced for 9.9% in patients with LBP, 26.6% in patients with PTSD and 37.1% in PTSD+LBP, suggesting strong synergistic effect of PTSD and LBP. The analysis also identified several clusters of participants with different pattern of quality of life related outcomes, reflecting the complex nature of this indicator. CONCLUSIONS: The results of this study reiterate strong impact of PTSD on quality of life, which is additionally reduced if the patient also suffers from LBP. PTSD remains a substantial problem in Croatia, nearly two decades after the beginning of the 1991-1996 Homeland war.