Real-world data: a comprehensive literature review on the barriers, challenges, and opportunities associated with their inclusion in the health technology assessment process.

Objective: This review aimed to assess the current use and acceptance of real-world data (RWD) and real-world evidence (RWE) in health technology assessment (HTA) process. It additionally aimed to discern stakeholders' viewpoints concerning RWD and RWE in HTA and illuminate the obstacles, difficulties, prospects, and consequences associated with the incorporation of RWD and RWE into the realm of HTA. Methods: A comprehensive PRISMA-based systematic review was performed in July 2022 in PubMed/Medline, Scopus, IDEAS-RePEc, International HTA database, and Centre for Reviews and Dissemination with ad hoc supplementary search in Google Scholar and international organization websites. The review included pre-determined inclusion criteria while the selection of eligible studies, the data extraction process and quality assessment were carried out using standardized and transparent methods. Results: Twenty-nine (n = 29) studies were included in the review out of 2,115 studies identified by the search strategy. In various global contexts, disparities in RWD utilization were evident, with randomized controlled trials (RCTs) serving as the primary evidence source. RWD and RWE played pivotal roles, surpassing relative effectiveness assessments (REAs) and significantly influencing decision-making and cost-effectiveness analyses. Identified challenges impeding RWD integration into HTA encompassed limited local data access, complexities in non-randomized trial design, data quality, privacy, and fragmentation. Addressing these is imperative for optimal RWD utilization. Incorporating RWD/RWE in HTA yields multifaceted advantages, enhancing understanding of treatment efficacy, resource utilization, and cost analysis, particularly via patient registries. RWE complements assessments of advanced therapy medicinal products (ATMPs) and rare diseases. Local data utilization strengthens HTA, bridging gaps when RCT data is lacking. RWD aids medical device decision-making, cancer drug reassessment, and indirect treatment comparisons. Challenges include data availability, stakeholder acceptance, expertise, and privacy. However, standardization, training, collaboration, and guidance can surmount these barriers, fostering enhanced RWD utilization in HTA. Conclusion: This study highlights the intricate global landscape of RWD and RWE acceptance in HTA. Recognizing regional nuances, addressing methodological challenges, and promoting collaboration are pivotal, among others, for leveraging RWD and RWE effectively in healthcare decision-making.

Individuals' personal characteristics associated with private health insurance policy possession in Greece.

BACKGROUND: Possession of private health insurance has been associated with personal and socioeconomic characteristics, such as income and age. The objective of the present study is to assess the individuals' personal characteristics associated with private health insurance possession in Greece. METHODS: The data used in the present analysis derived from the 'Health and Welfare' survey conducted by the Hellenic National School of Public Health in Greece and refer to year 2017. The sample of the analysis consisted of 1,932 adults aged 18 years or older. Α binary logistic regression model was conducted, in order to investigate the factors associated with private health insurance possession. RESULTS: The factors that were found to be associated with private health insurance possession were: area of residence; Attica, family income level; 1,501€-2,000€, 2,001€+, absence of chronic condition, occupation; employer/self-employed, absence of public insurance, time since last health check-up; less than or equal to 5 and more than 1 years ago, more than 5 years or never and level of education; secondary, tertiary. CONCLUSIONS: Private health insurance covers a low percent of the Greek population and has a low contribution to private health spending, compared with other countries. The personal characteristics that were found to be associated with private health insurance possession in Greece by the present study are in line with previous studies in other countries. These results are expected to provide policy advice on how to enhance coverage in order to reduce out-of-pocket expenditure, which is considered high in Greece.

The impact of accessibility and service quality on the frequency of patient visits to the primary diabetes care provider: results from a cross-sectional survey performed in six European countries.

BACKGROUND: Visits to the primary diabetes care provider play a central role in diabetes care. Therefore, patients should attend their primary diabetes care providers whenever a visit is necessary. Parameters that might affect whether this condition is fulfilled include accessibility (in terms of travel distance and travel time to the practice), as well as aspects of service quality (for example in-practice waiting time and quality of the provider's communication with the patient). The relationships of these variables with the frequency of visits to the primary diabetes care provider are investigated. METHODS: The investigation is performed with questionnaire data of 1086 type 2 diabetes patients from study regions in England (213), Finland (135), Germany (218), Greece (153), the Netherlands (296) and Spain (71). Data were collected between October 2011 and March 2012. Data were analysed using log-linear Poisson regression models with self-reported numbers of visits in a year to the primary diabetes care provider as the criterion variable. Predictor variables of the core model were: country; gender; age; education; stage of diabetes; heart problems; previous stroke; problems with lower extremities; problems with sight; kidney problems; travel distance and travel time; in-practice waiting time; and quality of communication. To test region-specific characteristics, the interaction between the latter four predictor variables and study region was also investigated. RESULTS: When study regions are merged, travel distance and in-practice waiting time have a negative effect, travel time no effect and quality of communication a positive effect on visit frequency (with the latter effect being by far largest). When region specific effects are considered, there are strong interaction effects shown for travel distance, in-practice waiting time and quality of communication. For travel distance, as well as for in-practice waiting time, there are region-specific effects in opposite directions. For quality of communication, there are only differences in the strength with which visit frequency increases with this variable. CONCLUSIONS: The impact of quality of communication on visit frequency is the largest and is stable across all study regions. Hence, increasing quality of communication seems to be the best approach for increasing visit frequency.

Investigating burden of informal caregivers in England, Finland and Greece: an analysis with the short form of the Burden Scale for Family Caregivers (BSFC-s).

OBJECTIVES: The burden of informal caregivers might show itself in different ways in different cultures. Understanding these differences is important for developing culture-specific measures aimed at alleviating caregiver burden. Hitherto, no findings regarding such cultural differences between different European countries were available. In this paper, differences between English, Finnish and Greek informal caregivers of people with dementia are investigated. METHODS: A secondary analysis was performed with data from 36 English, 42 Finnish and 46 Greek caregivers obtained with the short form of the Burden Scale for Family Caregivers (BSFC-s). The probabilities of endorsing the BSFC-s items were investigated by computing a logit model with items and countries as categorical factors. Statistically significant deviation of data from this model was taken as evidence for country-specific response patterns. RESULTS: The two-factorial logit model explains the responses to the items quite well (McFadden's pseudo-R-square: 0.77). There are, however, also statistically significant deviations (p < 0.05). English caregivers have a stronger tendency to endorse items addressing impairments in individual well-being; Finnish caregivers have a stronger tendency to endorse items addressing the conflict between the demands resulting from care and demands resulting from the remaining social life and Greek caregivers have a stronger tendency to endorse items addressing impairments in physical health. CONCLUSION: Caregiver burden shows itself differently in English, Finnish and Greek caregivers. Accordingly, measures for alleviating caregiver burden in these three countries should address different aspects of the caregivers' lives.

Subjective social status, social network and health disparities: empirical evidence from Greece.

BACKGROUND: Several studies suggest that socioeconomic status affects (SES) affects self-rated health (SRH), both in Greece and internationally. However, prior research mainly uses objective measures of SES, instead of subjective evaluations of individuals' social status. Based on this, this paper aims to examine (a) the impact of the economic dowturn on SRH in Greece and (b) the relationship between subjective social status (SSS), social network and SRH. METHODS: The descriptive analysis is based on four cross-sectional surveys conducted by the National School of Public Health, Athens, Greece (2002, 2006, 2011, 2015), while the data for the empirical investigation were derived from the 2015 survey (Health + Welfare Survey GR). The empirical strategy is based on an ordinal logistic regression model, aiming to examine how several variables affect SRH. Size of social network and SSS are among the independent variables employed for the empirical analysis RESULTS: According to our findings, average SRH has deteriorated, and the percentage of the population that reports very good/good SRH has also decreased. Moreover, our empirical analysis suggests that age, existence of a chronic disease, size of social network and SSS affect SRH in Greece. CONCLUSION: Our findings are consistent with the existing literature and confirm a social gradient in health. According to our analysis, health disparities can be largely attributed to socioeconomic inequalities. The adverse economic climate has impact on socioeconomic differences which in turn affect health disparities. Based on these, policy initiatives are necessasy in order to mitigate the negative impact on health and the disparities caused by economic dowturn and the occuring socioeconomic inequalities.

The validity of the EQ-5D-3L items: an investigation with type 2 diabetes patients from six European countries.

BACKGROUND: Most previous studies concerning the validity of the EQ-5D-3L items refer to applications of only a single language version of the EQ-5D-3L in only one country. Therefore, there is little information concerning the extent to which the results can be generalised across different language versions and/or different countries. Here the validity of the EQ-5D-3L items is investigated for six different language versions in six different countries. METHODS: Data came from 1341 type 2 diabetes patients (England: 289; Finland: 177; Germany: 255; Greece: 165; the Netherlands: 354; Spain: 101). The relationships of the five EQ-5D-3L items with seven different test variables (age, gender, education, previous stroke, problems with heart, problems with lower extremities, problems with eyes), were analysed for each combination of item and test variable. For each combination two logistic regression models with the dichotomised EQ-5D-3L item as dependent variable were computed. The first model contained the test variable and dummy coded countries as independent variables, the second model additionally the terms for the interaction between country and test variable. Statistically significant better fit of the second model was taken as evidence for country specific differences regarding the relationship. When such differences could be attributed mainly to one country the analyses were repeated without the data from this country. Validity was investigated with the remaining data using results of the first models. RESULTS: Due to lack of variation in the Spanish data only 31 of the originally intended 35 interaction tests could be performed. Only three of these yielded a significant result. In all three cases the Spanish data deviated most. Without the Spanish data only 1 of the 35 interaction tests yielded a significant result. With 3 exceptions, the tendency of reporting problems increased with age, female gender, lower education, previous stroke, heart problems, problems with lower extremities and problems with eyes for all EQ-5D-3L items. CONCLUSION: The results concerning the European Spanish version are ambiguous. However, the items of the English, Finnish, German, Greek and Dutch versions of the EQ-5D-3L relate in substantially the same way to the test variables. Mostly, these relationships indicate the items' validity.

Going up in ashes? Smoking-attributable morbidity, hospital admissions and expenditure in Greece.

Our aim was to calculate the morbidity, hospitalizations and subsequent hospital costs for the treatment of the smoking-attributable fraction of diseases in Greece using a prevalence-based annual cost approach. In 2011, smoking accounted for 199,028 hospital admissions (8.9% of the national total), with attributable hospital treatment costs calculated at more than €554 million, which represents 10.7% of the national hospital budget. These results pose a compelling reason for the European Union to champion tobacco control as a means of reducing the financial and social burden of disease in Greece and other countries currently facing a financial maelstrom.

Health technology assessment of medicines in Greece: pharmaceutical industry executives' views.

OBJECTIVES: The aim of this study was to investigate originator pharmaceutical companies' practices in relation to health technology assessment (HTA) and the views and perceptions of their executives on the importance of HTA in pricing and reimbursement of medicines in Greece. METHODS: A qualitative study was performed, using individual semi-structured interviews based on an interview schedule with open-ended questions. The target population was market access departments' executives of originator pharmaceutical companies. Our target sample consisted of sixteen executives, of whom ten agreed to participate. Saturation point was reached after eight interviews. Data were audio recorded, transcribed verbatim, and analyzed using content analysis. RESULTS: Participants considered HTA as a very important complementary tool for decision making in health policy, particularly in the field of pharmaceuticals and medical devices. They believed that, in Greece, HTA could be institutionalized for the reimbursement mechanism of medicines under certain conditions relating to current health policy-making attitudes and conditions pertaining in the country. They considered that there are many constraints which must be overcome as well as opportunities to be exploited. CONCLUSIONS: Decisions in pharmaceutical policy should be scientifically substantiated and HTA should be institutionalized primarily for reimbursement decisions. Development of guidelines for conducting pharmaco-economic evaluation, change in health policy goals, recording of cost and epidemiological data, and broader participation of all stakeholders in HTA decision-making processes are suggested as prerequisites for a successful implementation of HTA in Greece.

What Influences Parents on Their Decision to Vaccinate Their Daughters Against HPV?

STUDY OBJECTIVE: To investigate and compare the attitudes of parents who initiated their daughters' HPV vaccination with parents who did not. METHODS: Data were collected through telephone interviews with a close-end questionnaire on parents' knowledge, attitudes towards the vaccine, and the reasons for vaccinating or not their daughters against HPV. The sample was random, stratified by geographic region and urbanization level, national, and representative of the general population of parents of girls aged 11-18 in Greece. Statistical analysis consisted of descriptives, an inferential analysis with hypothesis testing, and a logistic regression model. RESULTS: Overall, 996 parents were included in the analysis, 99.0% of which were women. Forty-seven percent of them initiated their daughters' HPV vaccination, with physician recommendation stated as the most important reason for this decision (50.2%). For those who had not initiated their daughters' HPV vaccination (53%), lack of information was the most important reason (25.6%). In the hypothesis testing, parents with unvaccinated daughters agreed more with the statements "I do not have enough information for the HPV vaccine to decide," and "My child is very young to be vaccinated for an STD" (P < .05), but no significant difference found for the statement "It's more possible for a vaccinated girl to begin sexual activities" (P > .05). CONCLUSIONS: Lack of information, young age of the daughter, and perceived effectiveness of the vaccine are the most important hesitation factors. Physician recommendation is the most important reason to initiate vaccination.

Impact of economic crisis and other demographic and socio-economic factors on self-rated health in Greece.

BACKGROUND: Financial crisis and worsened socio-economic conditions are associated with greater morbidity, less utilization of health services and deteriorated population's health status. The aim of the present study was to investigate the determinants of self-rated health in Greece. METHODS: Two national cross-sectional surveys conducted in 2006 and 2011 were combined, and their data were pooled giving information for 10 572 individuals. The sample in both studies was random and stratified by gender, age, degree of urbanization and geographic region. Logistic regression analysis was used to determine the impact of several factors on self-rated health. RESULTS: Poor self-rated health was most common in older people, unemployed, pensioners, housewives and those suffering from chronic disease. Men, individuals with higher education and those with higher income have higher probability to report better self-rated health. Furthermore, the probability of reporting poor self-rated health is higher at times of economic crisis. CONCLUSION: Our findings confirm the association of self-rated health with economic crisis and certain demographic and socio-economic factors. Given that the economic recession in Greece deepens, immediate and effective actions targeting health inequalities and improvements in health status are deemed necessary.

Protective behaviors during COVID-19 confinement measures in Greece: the role of anxiety, perceived risk and risky-choice framing.

Confinement measures at the beginning of the COVID-19 pandemic imposed major changes on the global population. The aim of this study was to explore the level to which the public adhered to protective guidelines by adopting the most appropriate behaviors at that time (such as hand washing with soap and using sanitizer gel) and to identify the determinants of these behaviors. A purposive sample of 1013 individuals was invited and voluntarily participated in the online survey. The questionnaire collected information on demographic data, hand washing, risk perception, anxiety (through the S = Anxiety scale of STAI) and risky-choice framing. Results showed increased levels of anxiety, a moderate perception of the risk of catching coronavirus and increased adoption of protective behaviors, such as handwashing and cleaning surfaces with disinfectant/antiseptic products. Multiple ordinal logistic regression models showed that being female, more educated and cleaning home with disinfectant / antiseptic products predicted handwashing with soap. Additionally, having an increased perception of getting the coronavirus, being older and cleaning the home with disinfectant / antiseptic products predicted handwashing with antiseptics. Public health interventions should take into consideration the unified cleaning pattern and the combined effect of sociodemographic variables and risk perception on the adoption of protective behaviour in the context of a health crisis which is out of people's control.

Evaluation of the Quality of Life of Patients with Myasthenia Gravis in Greece.

Myasthenia Gravis (MG) patients often report an affected quality of life (QoL). The aim of the current study was to evaluate the QoL of patients with MG in Greece using a specific tool. A cross-sectional online survey was performed. Adult patients were invited to participate. A questionnaire incorporating the MG-QOL15r scale was distributed, following its translation and cultural adaptation into Greek. Overall, 99 valid responses were submitted. The median age (interquartile range) of the participants was 48.50 (13.50) years and 76.80% were females. One third of the patients mentioned that they could not work/changed jobs after their diagnosis (28.30%) and that they face severe restriction of their everyday activities (26.30%). The mean MG-QOL15r score was 13.50 ± 7.70. Patients with important restriction of everyday activities (p < 0.01), patients with more pronounced need of emotional support (p < 0.01), patients with generalized MG (p < 0.01) and patients with myasthenic crises (p < 0.01) reported lower QoL. This study is the first to report on the affected QoL of the Greek population with MG using the MG-QoL15r scale. Further work should be done to incorporate the routine evaluation of QoL in the care of patients with MG.

Knowledge, Perceptions and Attitudes Toward HPV Vaccination: A Survey on Parents of Girls Aged 11-18 Years Old in Greece.

Objective: To investigate knowledge, perceptions and practices of parents of girls aged 11-18 years old in Greece toward HPV vaccination, and determine which factors are associated with parents' decision to vaccinate their daughters. Methods: A close-end questionnaire was constructed and telephone interviews were conducted upon informed consent. The sample was random, national, stratified by geographic region and representative of the general population of parents of girls aged 11-18. The data collected include: general knowledge, attitudes and perceptions concerning HPV and HPV vaccine, information regarding their daughters' HPV vaccination, and sociodemographic characteristics. Statistical analysis included descriptives and a logistic regression model to investigate which factors are associated with HPV vaccination. Results: Overall, 1,000 parents participated in the study, 99.4% of which knew what HPV is and 98.8% knew there is a vaccine available against HPV. Furthermore, 47% of the parents stated that their daughters had been vaccinated against HPV, while further analysis revealed that only 35% had received all the recommended doses. In the logistic regression analysis, the following variables had a statistically significant association with HPV vaccination: perceived ease of contracting HPV (OR = 1.105), level of trust in medical profession regarding information on prevention (OR = 1.205), overall perception regarding importance of children's vaccination (OR = 0.618), internet/social media as a source of parent information regarding HPV (OR = 0.886), participant (parent) age (OR = 1.125), and daughter's treating physician's recommendation for HPV vaccination (OR = 7.319). Conclusions: HPV vaccination coverage is still suboptimal. Comprehension of the obstacles toward this goal is important and the role of healthcare professionals is crucial to increase acceptance.

Economic Evaluation of Digital Health Interventions in Palliative Care: A Systematic Review of the Literature.

Introduction: Digital health interventions can facilitate the provision of palliative care. However, the economic evaluation of such interventions has not yet been a standard practice. The present study aimed to identify the existing literature on the particular subject. Methods: A systematic search was conducted in six literature databases between 2010 and 2021: PubMed, Scopus, DARE, NHS EED, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials. Methodological quality was assessed with the Drummond Checklist. Results: The search identified 423 publications, 66 of which were removed as duplicates, resulting in 357 records to be screened by title and abstract. Ten studies were subjected to full-text review and 3 were included in the analysis. The interventions of these studies referred to video consultations and eHealth interventions for symptom management. Overall, the digital health interventions incurred lower costs compared with usual care or no intervention and were considered cost saving and cost-effective. The methodological quality of the studies was considered good. Conclusion: The results of this systematic review indicate that the use of digital health interventions has the potential to be cost-effective in palliative care. However, applicability and generalizability of the evidence is uncertain, mainly due to methodological heterogeneity and scarcity of research.

Survey of the curricula of public health training programs across Bulgaria and Greece: opportunities for future collaboration.

Increased communication between neighboring countries may bring to the foreground the common health hazards of the populations but it also creates opportunities for joint actions, especially in the field of public health where knowledge and expertise are critical factors for effective collaboration. In this light, a questionnaire based survey on the curricula of public health training programs in Bulgaria and Greece was conducted in order to investigate any similarities and discrepancies. The survey focused on the various characteristics of the institutions that provide training in public health, e.g., the structure and duration of each course and the evaluation procedures. The results showed that the principal subjects such as public health, epidemiology, biostatistics and health promotion are present both in the Greek and Bulgarian curricula. Similarities are observed in other subjects as well, but differences exist as to whether these subjects are core or elective. The Greek curricula are more flexible (greater number of elective subjects) whereas Bulgarian curricula are structured around a wider core. Differences were observed in the duration of the programs, the teaching methodology and the issues of evaluation/accreditation. Collected data can serve as a basis for establishing a fruitful dialogue and contribute to the achievement of consensus in public health policy planning and actions for both neighbouring countries.

Comparison between two different measures of self-rated health: a single-question measure and a visual analogue scale.

INTRODUCTION: Self-rated health (SRH) is a useful concept for research and health planning, and an important indicator of population health. AIM: The present study aims to evaluate the appropriateness of two different measures used to assess SRH, a single question with a five-response Likert-type scale and a visual analogue scale (VAS), by studying the correlation between the two measures and the factors influencing response rates according to respondent characteristics. MATERIAL AND METHODS: A population-based postal survey was carried out within the framework of a World Health Organisation (WHO) project, with a national sample of randomly selected geographically stratified individuals. The factors influencing SRH using each measure were determined. The comparison of the two measures was also studied with respect to response frequencies and differences in association with potential determinants (age, sex, income, education). Answering to each measure depending upon answering to the other measure was also tested. RESULTS: The maximum correlation between the two measures was p = -0.78 (p < 0.001). Age, sex, income and education had an effect on SRH as measured using both measures. More people replies to the single question measure irrespective of any particular socio-economic characteristic. Generally, those completing the VAS were women of higher income. CONCLUSIONS: The two measures are moderately correlated, the structure of the questionnaire and sequence of questions seems to affect correlation, and the single question yields higher response rate than VAS does. Still, other factors may also play a significant explanatory role in SRH among the Greek population and in relation to which measure is used.

Factors influencing prescribing behaviour of physicians in Greece and Cyprus: results from a questionnaire based survey.

BACKGROUND: Over the past few decades, drug and overall healthcare expenditure have risen rapidly in most countries. The present study investigates the attitudes and the factors which influence physician prescribing decisions and practice in Greece and Cyprus. METHODS: A postal questionnaire was developed by researchers at the Department of Health Economics at the National School of Public Health in Greece, specifically for the purposes of the study. This was then administered to a sample of 1,463 physicians in Greece and 240 physicians in Cyprus, stratified by sex, specialty and geographic region. RESULTS: The response rate was 82.3% in Greece and 80.4% in Cyprus. There were similarities but also many differences between the countries. Clinical effectiveness is the most important factor considered in drug prescription choice in both countries. Greek physicians were significantly more likely to take additional criteria under consideration, such as the drug form and recommended daily dose and the individual patient preferences. The list of main sources of information for physicians includes: peer-reviewed medical journals, medical textbooks, proceedings of conferences and pharmaceutical sales representatives. Only half of prescribers considered the cost carried by their patients. The majority of doctors in both countries agreed that the effectiveness, safety and efficacy of generic drugs may not be excellent but it is acceptable. However, only Cypriot physicians actually prescribe them. Physicians believe that new drugs are not always better and their higher prices are not necessarily justified. Finally, doctors get information regarding adverse drug reactions primarily from the National Organisation for Medicines. However, it is notable that the majority of them do not inform the authorities on such reactions. CONCLUSION: The present study highlights the attitudes and the factors influencing physician behaviour in the two countries and may be used for developing policies to improve their choices and hence to increase clinical and economic effectiveness and efficiency.

Do Caregiver Characteristics Affect Caregiver Burden Differently in Different Countries?

The relationships between caregiver burden as measured with the Burden Scale for Family Caregivers-short form and 6 characteristics of caregivers caring for patients with dementia were investigated for caregivers from England (n = 36), Finland (n = 42), and Greece (n = 46) using survey data. In all 3 countries, caregiver burden increases with physical problems of the caregiver, emotional problems of the caregiver, and weekly hours of care. Hence, in all 3 countries, special support for informal care is required when these characteristics are at high levels. When the caregiver is a spouse or long-term partner of the person with dementia, lives in the same house as this person, or spends fewer than 20 h/wk for other duties than care, this is associated with less caregiver burden in England but with more caregiver burden in Greece. Accordingly, special support is required for Greek caregivers with these characteristics, but the opposite is true for English caregivers.

Development of a universal short patient satisfaction questionnaire on the basis of SERVQUAL: Psychometric analyses with data of diabetes and stroke patients from six different European countries.

OBJECTIVE: A short questionnaire which can be applied for assessing patient satisfaction in different contexts and different countries is to be developed. METHODS: Six items addressing tangibles, reliability, responsiveness, assurance, empathy, and communication were analysed. The first five items stem from SERVQUAL (SERVice QUALity), the last stems from the discussion about SERVQUAL. The analyses were performed with data from 12 surveys conducted in six different countries (England, Finland, Germany, Greece, the Netherlands, Spain) covering two different conditions (type 2 diabetes, stroke). Sample sizes for included participants are 247 in England, 160 in Finland, 231 in Germany, 152 in Greece, 316 in the Netherlands and 96 in Spain for the diabetes surveys; and 101 in England, 139 in Finland, 107 in Germany, 58 in Greece, 185 in the Netherlands, and 92 in Spain for the stroke surveys. The items were tested by (1) bivariate correlations between the items and an item addressing 'general satisfaction', (2) multivariate regression analyses with 'general satisfaction' as criterion and the items as predictors, and (3) bivariate correlations between sum scores and 'general satisfaction'. RESULTS: The correlations with 'general satisfaction' are 0.48 for tangibles, 0.56 for reliability, 0.58 for responsiveness, 0.47 for assurance, 0.53 for empathy, and 0.56 for communication. In the multivariate regression analysis, the regression coefficient for assurance is significantly negative while all other regression coefficients are significantly positive. In a multivariate regression analysis without the item 'assurance' all regression coefficients are positive. The correlation between the sum score and 'general satisfaction' is 0.608 for all six items and 0.618 for the finally remaining five items. The country specific results are similar. CONCLUSIONS: The five items which remain after removing 'assurance', i.e. the SERVQUAL-MOD-5, constitute a short patient satisfaction index which can usefully be applied for different medical conditions and in different countries.

Comparing Use of Health Technology Assessment in Pharmaceutical Policy among Earlier and More Recent Adopters in the European Union.

OBJECTIVES: To examine and compare the use of health technology assessment (HTA) for the reimbursement of new medicines in selected European Union member states with decades of experience in the use of HTA and in countries that have used it regularly since 2000. METHODS: The selected countries were categorized into "earlier" adopters (group A: England, Germany, France, and Sweden) and more "recent" adopters (group B: Poland, Bulgaria, Hungary, and Romania). A systematic review of published literature was performed. The analysis and comparison of HTA procedures were done by using an analytical framework. RESULTS: In all countries, the assessment criteria used include effectiveness, safety, relative effectiveness, and economic data. In group A countries, the main objectives are improving quality of care, ensuring equal access, and efficient use of resources. Group B countries have established HTA organizations with official guidelines but often seek the decisions of other developed countries. They place considerable emphasis on the budget impact of new therapies, and HTA is also used as a cost estimation tool for state budgets. CONCLUSIONS: HTA organizations have been developed dynamically not only in high-income countries but also in countries with limited resources. The experience and evolution of both can be used by countries that are in the dawn of creating an HTA organization.