Heterogeneous Preferences for Colorectal Cancer Screening in Germany: Results of a Discrete Choice Experiment.

OBJECTIVES: Colorectal cancer (CRC) screening tests differ in benefits, harms, and processes, making individual informed decisions preference based. The objective was to analyze the preferences of insurees in Germany for characteristics of CRC screening modalities. METHODS: A generic discrete choice experiment with 2-alternative choice sets and 6 attributes (CRC mortality, CRC incidence, complications, preparation, need for transportation, and follow-up; 3 levels each) depicting characteristics of fecal testing, sigmoidoscopy, and colonoscopy was generated. Participants completed 8 choice tasks. Internal validity was tested using a within-set dominated pair. Between June and October 2020, written questionnaires were sent to a stratified random sample (n = 5000) of 50-, 55-, and 60-year-old insurees of the AOK (Allgemeine Ortskrankenkasse) Lower Saxony, who had previously received an invitation to participate in the organized screening program including evidence-based information. Preferences were analyzed using conditional logit, mixed logit, and latent-class model. RESULTS: From 1282 questionnaires received (26% [1282 of 4945]), 1142 were included in the analysis. Approximately 42% of the respondents chose the dominated alternative in the internal validity test. Three heterogeneous preference classes were identified. Most important attributes were preparation (class 1; n = 505, 44%), CRC mortality (class 2; n = 347, 30%), and CRC incidence (class 3; n = 290, 25%). Contrary to a priori expectations, a higher effort was preferred for bowel cleansing (class 1) and accompaniment home (classes 1 and 2). CONCLUSION: Internal validity issues of choice data need further research and warrant attention in future discrete choice experiment surveys. The observed preference heterogeneity suggests different informational needs, although the underlying reasons remained unclear.

The effectiveness of additional screening examinations for children and adolescents in Germany: a longitudinal retrospective cohort study.

BACKGROUND: Continuous medical care is particularly important in childhood and adolescence. Since there are gaps in regular care in Germany, various health insurance providers offer to cover additional examinations (e.g., U10, U11, J2) to ensure ongoing paediatrician visits. However, the question arises as to whether these examinations are effective. Thus, the main objective of this study is to determine whether participation in the U10, U11 or J2 examinations leads to more frequent and earlier diagnosis and treatment of age-specific diseases. METHODS: The analyses are based on administrative claims data from a statutory health insurance fund. For each examination, an intervention group (IG) is formed and matched with a corresponding control group (CG). Descriptive analyses include proportion with diagnosis and treatment, average age of diagnosis and treatment initiation. Hypothesis testing is performed using methods appropriate to each. In addition, subgroup analyses and binominal logistic regression models are conducted. RESULTS: More diagnoses are detected in IG, irrespective of subgroups. Additionally, diagnoses are made slightly earlier on average in IG. In the total samples, more therapies are initiated in IG, and slightly earlier. Considering only diagnosed cases, more therapies are initiated in CG but continue to be started earlier in IG. Regression models show that participation in the examinations has the highest predictive power for detecting a diagnosis. The presence of a chronic disease and sex - male at the U10 and U11 and female at the J2 - are also significantly associated. The models further show that nationality, unemployment of parents and region also have a significant influence in some cases, whereas school-leaving qualification, vocational qualification and income of parents do not. Considering the initiation of treatment in overall samples, the models show similar results, but here the presence of a chronic illness has the highest predictive power. CONCLUSION: The results indicate that participation in the examinations leads to significantly more diagnoses and, in the overall samples, significantly more treatments. In addition, diagnoses were made somewhat earlier and therapies were initiated somewhat earlier. In the future, it would be useful to investigate the U10, U11 and J2 examinations over a longer time horizon to determine whether the statistically significant difference found is also clinically relevant, i.e., earlier diagnosis and initiation of therapy lead to prevention of manifestation or progression of the diagnosed diseases and to avoidance of secondary diseases. TRIAL REGISTRATION: German Clinical Trials Register (DRKS), DRKS-ID: DRKS00015280. Prospectively registered on 18 March 2019.

Real-world experience for the outcomes and costs of treating hepatitis C patients: Results from the German Hepatitis C-Registry (DHC-R).

BACKGROUND & AIMS: With long-term consequences like the development of liver cirrhosis and hepatocellular carcinoma, chronic hepatitis C virus (HCV) infection is associated with a significant health burden. Information on HCV treatment outcomes and costs in routine care is still rare, especially for subgroups. The aim of this study was to analyse the treatment outcomes and costs of subgroups in routine care and to compare them over time with previous analyses. METHODS: Data were derived from a noninterventional study including a subset of 10298 patients receiving DAAs with genotypes 1 and 3. Sociodemographic, clinical parameters and costs were collected using a web-based data recording system. The total sample was subdivided according to treatment regimen, cirrhosis status as well as present HIV infection and opioid substitution treatment (OST). RESULTS: 95% of all patients achieved SVR. Currently used DAA showed higher SVR-rates and less adverse events (AE) compared to former treatments. Concerning subgroups, cirrhotic patients, HIV-coinfected patients and OST patients showed lower but still high SVR-rates. In comparison, cirrhotic had considerably longer treatment duration and more frequent (serious) AE. Overall, average treatment costs were €48470 and costs per SVR were €51129; for currently used DAAs costs amounted to €30330 and costs per SVR to €31692. After the end of treatment, physical health is similar to the general population in all patients except cirrhotic. Mental health remains far behind in all subgroups, even for currently used DAA. CONCLUSIONS: Over time, some relevant factors developed positively (SVR-rates, costs, treatment duration, adverse events, health-related quality of life (HRQoL)). Further research on HRQoL, especially on mental health, is necessary to evaluate the differences between subgroups and HRQoL over time and to identify influencing factors.

Study protocol: a non-randomised community trial to evaluate the effectiveness of the communities that care prevention system in Germany.

BACKGROUND: The Communities That Care (CTC) prevention planning and implementation system trains communities throughout a five-phase cycle to (1) build capacity for prevention, (2) adopt science-based prevention, (3) assess the prevention needs of adolescents living in the community, (4) select, and (5) implement evidence-based programs according to their needs. After CTC proved to be effective and cost-effective in the U.S., it is being used by an increasing number of communities in Germany. The aim of this study is to evaluate the effectiveness and cost-effectiveness of CTC in Germany. METHODS: Communities in CTC-phases 1 to 3 (n = 21) and individually-matched comparison communities (n = 21) were recruited for a non-randomised trial. To assess long-term outcomes, (1) a cohort of 5th Grade students will be surveyed biennially concerning behaviours (antisocial behaviour and substance use) and well-being as well as risk and protective factors. Additionally, (2) biennial cross-sectional surveys will be conducted in 6th, 8th, 10th, and 11th Grade in each community. To assess short-term outcomes, a cohort of ten key informants per community will be surveyed biennially concerning adoption of science-based prevention, collaboration, community support and community norms. (4) In a cross-sectional design, all ongoing prevention programs and activities in the communities will be assessed biennially and data will be collected about costs, implementation and other characteristics of the programs and activities. (5) To monitor the CTC implementation, the members of the local CTC-boards will be surveyed annually (cross-sectional design) about team functioning and coalition capacity. Data analysis will include general and generalised mixed models to assess the average treatment effect of CTC. Mediation analyses will be performed to test the logical model, e.g., adoption of science-based prevention as a mediator for the effectiveness of the CTC approach. DISCUSSION: This is the first controlled study to evaluate the effectiveness of a comprehensive community prevention approach in Germany. Evaluating the effectiveness of CTC in Germany is an important prerequisite for further diffusion of the CTC approach. TRIAL REGISTRATION: This study was registered with German Clinical Trial Register: DRKS00022819 on Aug 18, 2021.

Determinants of colorectal cancer screening in Germany: a claims data analysis.

With an incidence of 58,000 cases per year, colorectal cancer (CRC) is the third most common type of cancer in Germany. Although guaiac-based fecal occult blood tests (gFOBT) and colonoscopy are accepted strategies for CRC screening offered for individuals aged 50 or 55 onwards, utilization rates remain low.This study examines various determinants for participation in CRC screening using claims data provided by the AOK Niedersachsen and covering the years 2014 to 2016. Using multivariate logistic regression models, we analyzed sociodemographic factors (sex, age, nationality, type of employment) associated with screening behavior, including individuals who underwent colonoscopy or gFOBT. The effect of school education and professional qualification was estimated using subgroups of employees with social insurance.The analysis consisted of 620,977 insured individuals in the study population for screening colonoscopy, while the gFOBT study population contained 845,191 individuals. With increasing age, individuals were less likely to participate in CRC screening. Participation rates for screening were higher for women than men in younger age groups. However, men in higher age groups showed increased participation rates in gFOBT screening. When compared with German citizens, Turkish citizens use the colonoscopy less often and the gFOBT more often. In contrast to employees with social insurance, unemployed individuals accept the prevention services less frequently, whereas pensioners and voluntarily insured individuals exhibit increased participation rates. In terms of education and professional qualification, we estimated a significantly lower participation rate exclusively for the least educated individuals. The results help to better understand patterns of utilization and can contribute to the development of information programs for specific groups.

[Frequency of diagnosed non-alcololic fatty liver disease (NAFLD) in the German population - An analysis based on health insurance data]. / Die Häufigkeit von diagnostizierten Fettlebererkrankungen (NAFLD) in der deutschen Bevölkerung ­ Eine Analyse auf der Basis von GKV-Routinedaten.

BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) is one of the most common chronic liver diseases in Germany. In the long term, there is an increased risk of developing liver cirrhosis and subsequent diseases. Epidemiologic studies on NAFLD prevalence in Germany are scarce. The aim of the study was to assess administrative incidence and prevalence or, more specifically, the number of patients diagnosed with NAFLD in the period from 2008 to 2018. METHODS: Analyses are based on administrative data of a large statutory health insurance fund. All individuals who were insured in the year of analysis and in the three-year pre-observation period were included (between 1.7-2 million insured per analysis year). NAFLD-patients were identified using relevant ICD-10 codes (K76.0 und K75.8). RESULTS: In 2018, 4.66 % of insured persons had a NAFLD diagnosis, 0.87 % were diagnosed first-time. Diagnoses of nonalcoholic steatohepatitis (NASH) were comparatively rare (0.09 %). Data show an uptake of NAFLD diagnoses over time. The number of incident cases per year has hardly changed. Patients with diseases of the metabolic syndrome had an increased chance of being diagnosed with NAFLD. CONCLUSION: It becomes evident that NAFLD is frequently diagnosed in everyday medical practice, although data from population-based studies suggest an even higher prevalence.

'As a surgeon, I am obliged to every single patient': evaluation of focus group discussions with transplantation physicians on the allocation of donor organs.

INTRODUCTION: Organ transplantation is the last resort for many patients. The ubiquitous shortage of suitable donor organs raises the question of best-justifiable allocation worldwide. This study investigates how physicians would allocate donor organs. METHODS: Focus group discussions with a total of 12 transplant surgeons and 2 other transplant-related physicians were held at the annual conference of the German Transplantation Society (Oct 2019). Three groups discussed aspects of 'egalitarianism', 'effectiveness/benefit', 'medical urgency', 'own fault', 'medical background' and 'socio-demographic status'. RESULTS AND DISCUSSION: It was observed that physicians often find themselves confronted with conflicts between (a) trying to advocate for their individual patients versus (b) seeing the systemic perspective and understanding the global impact of their decisions at the same time. The groups agreed that due to the current shortage of donor organs in the German allocation system, transplanted patients are often too sick at the point of transplantation and that a better balance between urgency and effectiveness is needed. The aspects of 'effectiveness' and 'urgency' were identified as the most challenging issues and thus were the main focus of debate. The dilemmas physicians find themselves in become increasingly severe, the larger the shortage of suitable donor organs is.

Public preferences for the allocation of donor organs for transplantation: Focus group discussions.

BACKGROUND: Deceased donor organs are scarce resources because of a large supply-and-demand mismatch. This scarcity leads to an ethical dilemma, forcing priority-setting of how these organs should be allocated and whom to leave behind. OBJECTIVE: To explore public preferences for the allocation of donor organs in regard to ethical aspects of distributive justice. METHODS: Focus groups were facilitated between November and December 2018 at Hannover Medical School. Participants were recruited locally. Transcripts were assessed with content analysis using the deductive framework method. All identified and discussed criteria were grouped according to the principles of distributive justice and reported following the COREQ statement. RESULTS: Six focus groups with 31 participants were conducted. Overall, no group made a final decision of how to allocate donor organ; however, we observed that not only a single criterion/principle but rather a combination of criteria/principles is relevant. Therefore, the public wants to allocate organs to save as many lives as possible by both maximizing success for and also giving priority to urgent patients considering the best compatibility. Age, waiting time, reciprocity and healthy lifestyles should be used as additional criteria, while sex, financial status and family responsibility should not, based on aspects of equality. CONCLUSIONS: All participants recognized the dilemma that prioritizing one patient might cause another one to die. They discussed mainly the unclear trade-offs between effectiveness/benefit and medical urgency and did not establish an agreement about their importance. The results suggest a need of preference studies to elucidate public preferences in organ allocation.

Evaluation of the pediatric-centered integrated care AOK Junior: protocol for a mixed-method study.

BACKGROUND: The "AOK-Junior" care program of the AOK Nordost (a German statutory health insurance) completes the primary care for children and adolescents (C&A) in the federal states of Berlin, Brandenburg and Mecklenburg-Vorpommern in Germany. The focus of this program is on prevention and early detection of illness on C&A. Furthermore, the aim is to maintain the health of C&A and to prevent, detect and treat illness on time. Elements of the program are not only the integrated care of C&A, but also, for example, weight reduction and additional medical checkups U10, U11 and J2. The evaluation of the complex intervention should provide information about the effectiveness of early disease detection and costs-effectiveness as well as of other parameters like satisfaction. METHODS: The evaluation is performed on the levels of structural-, process- and results-quality. The cost effectiveness is also assessed by means of a health economic evaluation. In addition to the collection of qualitative and quantitative primary data from participating and non-participating C&A and paediatricians, routine data from a statutory health insurance are used in the evaluation. Furthermore, a cross-sectional design is used to evaluate the structure and process quality. The effectiveness is evaluated in longitudinal section design on the basis of the secondary data. The quantitative surveys include net n = 1096 C&A and n = 340 pediatricians. For the focus groups, a sample of 72 to 96 parents as well as pediatricians will be sought by using the method of theoretical sampling. DISCUSSION: Around 560 pediatricians and 63,000 C&A currently participate in the AOK Nordost care program. The project provides information to what extent secondary preventive measures can lead to the early detection of diseases and on the associated cost-effectiveness. Furthermore, potentials and barriers of the program implementation are identified. The results of the evaluation study are expected not only to contribute to the further development of the care program, but also to derive recommendations for action. TRIAL REGISTRATION: German Clinical Trials Register (DRKS), DRKS-ID: DRKS00015280. Prospectively registered on 18 March 2019.

Implementation interventions in preventing surgical site infections in abdominal surgery: a systematic review.

BACKGROUND: Surgical site infections (SSIs) are highly prevalent in abdominal surgery despite evidence-based prevention measures. Since guidelines are not self-implementing and SSI-preventive compliance is often insufficient, implementation interventions have been developed to promote compliance. This systematic review aims to identify implementation interventions used in abdominal surgery to prevent SSIs and determine associations with SSI reductions. METHODS: Literature was searched in April 2018 (Medline/PubMed and Web of Science Core Collection). Implementation interventions were classified using the implementation subcategories of the EPOC Taxonomy (Cochrane Review Group Effective Practice and Organisation of Care, EPOC). Additionally, an effectiveness analysis was conducted on the association between the number of implementation interventions, specific compositions thereof, and absolute and relative SSI risk reductions. RESULTS: Forty studies were included. Implementation interventions used most frequently ("top five") were audit and feedback (80% of studies), organizational culture (70%), monitoring the performance of healthcare delivery (65%), reminders (53%), and educational meetings (45%). Twenty-nine studies (72.5%) used a multimodal strategy (≥3 interventions). An effectiveness analysis revealed significant absolute and relative SSI risk reductions. E.g., numerically, the largest absolute risk reduction of 10.8% pertained to thirteen studies using 3-5 interventions (p < .001); however, this was from a higher baseline rate than those with fewer or more interventions. The largest relative risk reduction was 52.4% for studies employing the top five interventions, compared to 43.1% for those not including these. Furthermore, neither the differences in risk reduction between studies with different numbers of implementation interventions (bundle size) nor between studies including the top five interventions (vs. not) were significant. CONCLUSION: In SSI prevention in abdominal surgery, mostly standard bundles of implementation interventions are applied. While an effectiveness analysis of differences in SSI risk reduction by number and type of interventions did not render conclusive results, use of standard interventions such as audit and feedback, organizational culture, monitoring, reminders, and education at least does not seem to represent preventive malpractice. Further research should determine implementation interventions, or bundles thereof, which are most effective in promoting compliance with SSI-preventive measures in abdominal surgery.

Elimination of hepatitis C virus in Germany: modelling the cost-effectiveness of HCV screening strategies.

BACKGROUND: Chronic hepatitis C is a major public health burden. With new interferon-free direct-acting agents (showing sustained viral response rates of more than 98%), elimination of HCV seems feasible for the first time. However, as HCV infection often remains undiagnosed, screening is crucial for improving health outcomes of HCV-patients. Our aim was to assess the long-term cost-effectiveness of a nationwide screening strategy in Germany. METHODS: We used a Markov cohort model to simulate disease progression and examine long-term population outcomes, HCV associated costs and cost-effectiveness of HCV screening. The model divides the total population into three subpopulations: general population (GEP), people who inject drugs (PWID) and HIV-infected men who have sex with men (MSM), with total infection numbers being highest in GEP, but new infections occurring only in PWIDs and MSM. The model compares four alternative screening strategies (no/basic/advanced/total screening) differing in participation and treatment rates. RESULTS: Total number of HCV-infected patients declined from 275,000 in 2015 to between 125,000 (no screening) and 14,000 (total screening) in 2040. Similarly, lost quality adjusted life years (QALYs) were 320,000 QALYs lower, while costs were 2.4 billion EUR higher in total screening compared to no screening. While incremental cost-effectiveness ratio (ICER) increased sharply in GEP and MSM with more comprehensive strategies (30,000 EUR per QALY for total vs. advanced screening), ICER decreased in PWIDs (30 EUR per QALY for total vs. advanced screening). CONCLUSIONS: Screening is key to have an efficient decline of the HCV-infected population in Germany. Recommendation for an overall population screening is to screen the total PWID subpopulation, and to apply less comprehensive advanced screening for MSM and GEP.

Public preferences for primary care provision in Germany - a discrete choice experiment.

BACKGROUND: Primary care is a central element of healthcare and addresses the main health problems of the population. While primary care gains in importance due to an aging population, there is an ongoing debate on physician shortages in German rural regions. The study aims on analyzing the population's preferences on primary healthcare and, therefore, on helping policy makers to make care delivery more responsive to patients' needs when planning political reforms of primary care. METHODS: A paper-based discrete choice experiment (DCE) was used to assess preferences of the population of eight rural regions in Germany. Based on literature search and qualitative research, six attributes were selected and included in the choice experiment. The survey presented participants with eight choice sets in which they had to choose between two possible scenarios of care. A conditional logistic regression as well as a latent class model (LCM) were used to analyze preferences for primary healthcare. RESULTS: Nine hundred four participants completed the survey (response rate 46.1%). The conditional logistic regression showed significant impact of the attributes "home visits", "distance to practice", "number of healthcare providers", "opening hours of the practice", and "diagnostic facilities" on the respondents' choices of primary healthcare alternatives. Moreover, the LCM identified four classes that can be characterized by preference homogeneity within and heterogeneity between the classes. CONCLUSION: Although the study revealed heterogeneous preferences among the latent classes, several similarities in preferences for primary care could be detected. The knowledge on these public preferences may help policy makers when implementing new models of primary care and, thus, raise the populations' acceptance of future primary care provision and innovative care models.

[Primary Healthcare Provision and Introduction of New Models of Care in Hard to Serve Regions: A Population Survey]. / Hausärztliche Versorgungssituation und Einführung neuer Versorgungsformen in schwer zu versorgenden Regionen: Eine Befragung der Bevölkerung.

OBJECTIVE OF THE STUDY: One of the central challenges in health policy is to ensure nationwide provision of primary healthcare services. However, it is not clear how the general public rates the current primary healthcare provision in their region. Furthermore, there is very little information on whether people are willing to make use of new models of care that could contribute to ensuring a nationwide provision of healthcare services. Thus, the objective of this study was to analyse the general public's ratings of the local primary healthcare provision as well as their acceptance of selected new models of care. Furthermore, potential differences in the ratings of the population between hard to serve regions and normal regions will be analysed. METHODOLOGY: Focus group discussions and a literature review were conducted in order to develop a questionnaire to elicit the expectations of the population concerning the local provision of primary healthcare as well as their acceptance of new models of care. A postal questionnaire was sent to a random sample of 2,000 persons in 8 regions in Lower Saxony. RESULTS: The adjusted response rate of the postal survey was 51% (n=996). 97% of respondents saw a general practitioner regularly, with 5.4 visits per year on average. Patients could reach the practice in 13 min on average. Respondents predominantly rated the current healthcare provision as being good. However, the majority of respondents expected the local primary healthcare provision to deteriorate in the future. New models of care most preferred by the respondents were the delegation of medical tasks to non-medical professionals and mobility-oriented models. On the other hand, the provision of healthcare via telemedicine was rejected. DISCUSSION: According to the results of this study, respondents believe that new models of care can play an important role in ensuring the nationwide provision of healthcare services. Introducing, at an early stage, those new models of care that people accept could contribute to ensuring a sustainable provision of primary healthcare services. Furthermore, the introduction of these new models of care could reduce the public's concerns regarding a worsening provision of primary healthcare services in their regions. Additionally, pilot projects with those new models of care that are rather rejected might increase acceptance with these models of care if they prove to be successful.

Prognostic factors for long-term survival after adult liver transplantation.

PURPOSE: Prognostic factors for survival ≥ 15 years and life years lost after liver transplantation are largely unknown. METHODS: One thousand six hundred thirty primary adult liver transplants between 1983 and 2014 were analyzed. Risk factors for survival were identified with multivariable Cox regression and subsequently tested for their relevance as prognostic factors for observed 15-year survival using multivariable logistic regression and c statistics. The difference of life expectancy between a matched national reference population and survival in patients with post-transplant survival ≥ 15 years was calculated. RESULTS: Survival of ≥ 15 years was observed in 361 patients (22%). Sixty-nine adults died after more than 15 years losing a median of 15 years of life expectancy. One of those patients lived longer while 292 patients still have the chance to survive longer than their normal life expectancy. The indication primary sclerosing cholangitis (PSC) and later eras of transplantation were identified as significant independent protective factors while recipient age > 36.8 years, graft loss due to initial non-function or thrombosis, the indications hepatocellular carcinoma (HCC), hepatitis-C-virus-related cirrhosis (HCV-cirrhosis) and all other indications, donor age > 53 years, the number of surgical complications, and operative durations > 4.5 h were identified as significant independent risk factors limiting survival. All of these factors except the duration of operation had also a significant independent influence on observed 15-year survival (AUROC = 0.739). CONCLUSIONS: Recipients can exceptionally live longer than their normal life expectancy. Older recipients and patients with the indications HCC, HCV-cirrhosis, or other indications except PSC, should be transplanted with younger donor organs.

Hangzhou criteria are more accurate than Milan criteria in predicting long-term survival after liver transplantation for HCC in Germany.

BACKGROUND: Milan criteria are used for patient selection in liver transplantation for hepatocellular carcinoma (HCC). Hangzhou criteria have been shown in China to enable access to liver transplantation for more patients when compared to Milan criteria without negative effects on long-term survival. The purpose of this study was to evaluate the Hangzhou criteria in a German cohort. METHODS: One hundred fifty-nine patients transplanted for HCC between 1975 and 2010 were investigated. Patients were categorized into four groups depending on the fulfillment of Milan and Hangzhou criteria. General and tumor baseline characteristics were compared. Overall and tumor-free survival rates were investigated with the Kaplan-Meier analysis. RESULTS: One-, 3-, 5-, and 10-year survival rates for patients fulfilling Milan criteria (n = 68) were 89.7, 83.7, 75.8, and 62.1%, respectively, versus 89.8, 82.2, 75.2, and 62.6% for patients fulfilling Hangzhou criteria (n = 109) (p = 0.833). When comparing patients exceeding Milan or Hangzhou criteria, survival rates were 75.3, 53.2, 48.1, and 41.1% versus 63.3, 31.4, 26.9, and 22.1%, respectively (p = 0.019). The comparison of tumor-free survival rates in patients fulfilling Milan or Hangzhou criteria was statistically not significant (p = 0.785), whereas the comparison of the groups exceeding the criteria showed significantly worse survival for patients outside Hangzhou criteria (p = 0.007). The proportion of patients fulfilling Hangzhou criteria (68.6%) was significantly larger as compared to the proportion fulfilling Milan criteria (42.8%) (p < 0.001). CONCLUSION: Hangzhou criteria are more accurate in predicting long-term survival after liver transplantation for HCC in Germany. Deployment of the Hangzhou criteria for patient selection could enlarge the pool of transplantable patients.

High resource utilization in liver transplantation-how strongly differ costs between the care sectors and what are the main cost drivers?: a retrospective study.

To control treatment pathways of transplant patients across healthcare sectors, a profound knowledge of the underlying cost structure is necessary. The aim of this study was to analyze the resource utilization of patients undergoing liver transplantation. Data on resource utilization for 182 liver-transplanted patients was investigated retrospectively. The observational period started with the entry on the waiting list and ended up to 3 years after transplantation. Median treatment cost was 144 424€. During waiting time, median costs amounted to 9466€; 72% of costs were attributed to inpatient care, 3% to outpatient care, and 26% to pharmaceuticals. During the first year after transplantation, median costs of 105 566€ were calculated; 83% were allocated for inpatient and 1% outpatient care, 14% for drugs, and 1% for rehabilitative care. During follow-up after the first year of transplantation, median costs amounted to 20 115€; 75% of these were caused by pharmaceuticals, 21% by inpatient, 4% by outpatient, and <1% by rehabilitative services. Subgroup analyses (e.g., for labMELD scores) were done. Costs incurred by inpatient care and pharmaceuticals are the dominating cost factors. These findings encourage a debate on challenges and improvements for cost-efficient clinical management between different healthcare sectors.

Patients' preferences for primary health care - a systematic literature review of discrete choice experiments.

BACKGROUND: Primary care is a key element of health care systems and addresses the main health problems of the population. Due to the demographic change, primary care even gains in importance. The knowledge of the patients' preferences can help policy makers as well as physicians to set priorities in their effort to make health care delivery more responsive to patients' needs. Our objective was to describe which aspects of primary care were included in preference studies and which of them were the most preferred aspects. METHODS: In order to elicit the preferences for primary care, a systematic literature search was conducted. Two researchers searched three electronic databases (PubMed, Scopus, and PsycINFO) and conducted a narrative synthesis. Inclusion criteria were: focus on primary health care delivery, discrete choice experiment as elicitation method, and studies published between 2006 and 2015 in English language. RESULTS: We identified 18 studies that elicited either the patients' or the population's preferences for primary care based on a discrete choice experiment. Altogether the studies used 16 structure attributes, ten process attributes and four outcome attributes. The most commonly applied structure attribute was "Waiting time till appointment", the most frequently used process attribute was "Shared decision making / professional's attention paid to your views". "Receiving the 'best' treatment" was the most commonly applied outcome attribute. Process attributes were most often the ones of highest importance for patients or the population. The attributes and attribute levels used in the discrete choice experiments were identified by literature research, qualitative research, expert interviews, or the analysis of policy documents. CONCLUSIONS: The results of the DCE studies show different preferences for primary health care. The diversity of the results may have several reasons, such as the method of analysis, the selection procedure of the attributes and their levels or the specific research question of the study. As the results of discrete choice experiments depend on many different factors, it is important for a better comprehensibility of the studies to transparently report the steps undertaken in a study as well as the interim results regarding the identification of attributes and levels.

[Laboratory requirements to diagnose viral hepatitis under the development of guidelines]. / Veränderungen der Laboranforderungen zur Diagnostik von Virushepatitiden unter Fortentwicklung von Leitlinien.

Infections with hepatitis B-, C- and D- viruses have a significant health burden. In Germany, the seroprevalence of HBs-Ag is calculated with 0.6 % and of HCV-antibodies with 0.3 %. However, most patients are not diagnosed. Sequelae are liver-cirrhosis and hepatocellular carcinoma. Several S3-guidelines for the diagnosis and treatment of viral hepatitis have been established. However, implementation of guidelines is not easy to evaluate. To estimate the changes of medical knowledge and diagnostic procedures about viral hepatitis, 7 parameters of liver-diagnostics were elected to analyze the requirements profile in the years 2005 - 2011 in 4 German federal states. GPT/ALT showed no important change except the influence of the laboratory-reformation. HBs-Ag and HCV-Ab show only a minor increase in adults. The molecular differentiation of HBV-DNA and HCV-RNA showed changes up to 200 % in some regions; however, this might not be explained by more screening but rather increased treatment monitoring or new region-specific regulations. The most significant increase was observed for HDV-antibodies, but the amount of testing is still at a low level. The development and update of guidelines, the World-Hepatitis-Awareness-Day, and other specific nationwide activities did not result in a major increase in the screening of viral hepatitis with the exception of HDV. The results and the new treatment options against hepatitis C should motivate to continue the education in the field of viral hepatitis in an intensified manor.

[HBV-infections in Germany - health care costs in a real-life-setting]. / HBV-Infektionen in Deutschland ­ Versorgungskosten in einem Real-life-Setting.

Background An estimated 500 000 people are infected with hepatitis B in Germany, inducing an enormous burden on infected patients and the health care system. The aim of our study was to estimate the real-life costs of treating hepatitis B and to analyze sociodemographic factors. Methods We conducted a retrospective, non-interventional, single-center study from 07/2009 to 12/2012. Information on health care delivery was extracted from patient records. Besides that, a questionnaire survey regarding sociodemographic parameters and quality of life of HBV-infected patients was performed. Results A total of 117 patients were included in our study and grouped in six different disease stages. The response rate of our survey was 80 %. We determined annual total costs of €â€Š3509. The different groups altered between €â€Š221 and €â€Š5618. The main costs (80 %) were caused by the antiviral therapy. Costs of co-medication and hospitalizations were of minor importance. Laboratory costs were primarily caused by determination of virological parameters. Route of transmission of HBV-infection was unknown in 2/3 of all cases. Restrictions in quality of life due to the HBV-infection were reported by 60 % of the patients. Patients receiving interferon treatment reported highest restrictions. In an extrapolation, we estimated total annual hepatitis B treatment costs of 430 million € in Germany. Conclusion This is the first study estimating real-life treatment costs of hepatitis B infections in Germany. Further research should follow in the context of newly introduced generic antivirals.

[Is rehabilitation worth it? : Review of economic evaluations of rehabilitation in Germany]. / Lohnt sich Rehabilitation? : Überblick über gesundheitsökonomische Analysen der Rehabilitation in Deutschland.

Because of demographic change, the rehabilitation sector in Germany is going to face increasing demands in the future. Limited budgets make the optimal allocation of resources a top priority. To support decisions about the optimal scope and design of rehabilitation, studies on health economics are of utmost importance. The aim of this article is to provide an overview of the evaluation of rehabilitation with regard to health economics in Germany.Based on a comprehensive literature research, 17 studies on the cost-effectiveness of rehabilitation in Germany were identified. The health economics evaluation focuses on four main topics: patient education (5 studies), the comparison of outpatient and inpatient rehabilitation (7 studies), medico-occupational rehabilitation programs (2 studies) and aftercare programs (3 studies). All four topics show that innovative rehabilitation technologies can be cost-effective. Significant potential savings in program costs of 25-35% are demonstrated in outpatient rehabilitation (with comparable effectiveness with inpatient care). Designated patient education programs often lead to significant savings with indirect costs, by reducing periods of unfitness to work and extending the long-term ability to work. This review article also points out that some relevant areas of rehabilitation, such as the flexibilization of rehabilitation programs or the efficient organization of access to rehabilitation, have not been evaluated sufficiently on the basis of health economics. This article ends with the requirement to carry out more economics-based rehabilitation studies.