Comparing outcomes of ILD patients managed in specialised versus non-specialised centres.

BACKGROUND: Early appropriate diagnosis and treatment of interstitial lung diseases (ILD) is crucial to slow disease progression and improve survival. Yet it is unknown whether initial management in an expert centre is associated with improved outcomes. Therefore, we assessed mortality, hospitalisations and health care costs of ILD patients initially diagnosed and managed in specialised ILD centres versus non-specialised centres and explored differences in pharmaceutical treatment patterns. METHODS: An epidemiological claims data analysis was performed, including patients with different ILD subtypes in Germany between 2013 and 2018. Classification of specialised centres was based on the number of ILD patients managed and procedures performed, as defined by the European Network on Rare Lung Diseases. Inverse probability of treatment weighting was used to adjust for covariates. Mortality and hospitalisations were examined via weighted Cox models, cost differences by weighted gamma regression models and differences in treatment patterns with weighted logistic regressions. RESULTS: We compared 2022 patients managed in seven specialised ILD centres with 28,771 patients managed in 1156 non-specialised centres. Specialised ILD centre management was associated with lower mortality (HR: 0.87, 95% CI 0.78; 0.96), lower all-cause hospitalisation (HR: 0.93, 95% CI 0.87; 0.98) and higher respiratory-related costs (€669, 95% CI €219; €1156). Although risk of respiratory-related hospitalisations (HR: 1.00, 95% CI 0.92; 1.10) and overall costs (€- 872, 95% CI €- 75; €1817) did not differ significantly, differences in treatment patterns were observed. CONCLUSION: Initial management in specialised ILD centres is associated with improved mortality and lower all-cause hospitalisations, potentially due to more differentiated diagnostic approaches linked with more appropriate ILD subtype-adjusted therapy.

Pirfenidone vs. nintedanib in patients with idiopathic pulmonary fibrosis: a retrospective cohort study.

BACKGROUND: Two antifibrotic drugs, pirfenidone and nintedanib, are licensed for the treatment of patients with idiopathic pulmonary fibrosis (IPF). However, there is neither evidence from prospective data nor a guideline recommendation, which drug should be preferred over the other. This study aimed to compare pirfenidone and nintedanib-treated patients regarding all-cause mortality, all-cause and respiratory-related hospitalizations, and overall as well as respiratory-related health care costs borne by the Statutory Health Insurance (SHI). METHODS: A retrospective cohort study with SHI data was performed, including IPF patients treated either with pirfenidone or nintedanib. Stabilized inverse probability of treatment weighting (IPTW) based on propensity scores was applied to adjust for observed covariates. Weighted Cox models were estimated to analyze mortality and hospitalization. Weighted cost differences with bootstrapped 95% confidence intervals (CI) were applied for cost analysis. RESULTS: We compared 840 patients treated with pirfenidone and 713 patients treated with nintedanib. Both groups were similar regarding two-year all-cause mortality (HR: 0.90 95% CI: 0.76; 1.07), one-year all cause (HR: 1.09, 95% CI: 0.95; 1.25) and respiratory-related hospitalization (HR: 0.89, 95% CI: 0.72; 1.08). No significant differences were observed regarding total (€- 807, 95% CI: €- 2977; €1220) and respiratory-related (€- 1282, 95% CI: €- 3423; €534) costs. CONCLUSION: Our analyses suggest that the patient-related outcomes mortality, hospitalization, and costs do not differ between the two currently available antifibrotic drugs pirfenidone and nintedanib. Hence, the decision on treatment with pirfenidone versus treatment with nintedanib ought to be made case-by-case taking clinical characteristics, comorbidities, comedications, individual risk of side effects, and patients' preferences into account.

Epidemiology of Pertussis and Pertussis-Related Complications in Adults: A German Claims Data Analysis.

INTRODUCTION: Pertussis is a highly contagious respiratory infection. It affects people of all ages, yet evidence of the impact of pertussis in adults with underlying conditions (UCs) is scarce. This study investigated the incidence and complication rate of pertussis in adult patients with and without UC. METHODS: A retrospective analysis was conducted using routinely collected German claims data between 2015 and 2019. Patients with and without different pneumological, cardiovascular, endocrinological, musculoskeletal, and psychological UCs were matched for incidence estimation. Logistic regression models were used to estimate the risk of pertussis depending on the presence of UCs. Negative binomial models were used to assess complication rates in patients with pertussis and with and without UC. RESULTS: In total, 4383 patients were diagnosed with pertussis during the study period. Patients with any UC had an increased risk for pertussis compared to matched patients without UC (odds ratio [OR] 1.72; 95% confidence interval [CI]1.60-1.84, p < 0.0001). Underlying asthma had the highest risk of pertussis (OR 2.70; 95% CI 2.50-2.91, p < 0.0001), followed by chronic obstructive pulmonary disease (OR 2.35; 95% CI 2.10-2.60, p < 0.0001) and depression (OR 2.08; 95% CI 1.95-2.22, p < 0.0001). Severe complications occurred in 10.8% of the pertussis cohort (13.4% with UC vs. 9.5% without UC). The UC-attributable effect on the risk of severe pertussis-related complications was significantly increased for any UC (incidence rate ratio [IRR] 1.29, 95% CI 1.19-1.39). The severe complication risk was also increased for patients aged 60+ (IRR 1.59, 95% CI 1.46-1.72). CONCLUSION: This study shows that adults with certain UCs have an increased risk for pertussis and are more likely to have complications. These results provide further evidence that pertussis is a relevant and impactful infectious disease in adults with and without certain UC, indicating that these patients need to be considered when developing vaccination recommendations to avoid pertussis and its associated complications. A graphical abstract is available with this article.

Does uptake of specialty care affect HRQoL development in COPD patients beneficially? A difference-in-difference analysis linking claims and survey data.

BACKGROUND: There is an evidence gap on whether the choice of specialty care beneficially affects health-related quality of life (HRQoL) in patients with chronic obstructive pulmonary disease (COPD). This study analyzes how newly initiated pulmonologist care affects the generic and disease-specific HRQoL in COPD patients over a period of 1 year. METHODS: We linked claims data with data from two survey waves to investigate the longitudinal effect of specialty care on HRQoL using linear Difference-in-Difference models based on 1:3 propensity score matched data. Generic HRQoL was operationalized by EQ-5D-5L visual analog scale (VAS), and disease-specific HRQoL by COPD assessment test (CAT). Subgroup analyses examined COPD patients with low (GOLD AB) and high (GOLD CD) exacerbation risk. RESULTS: In contrast to routine care patients, pulmonologists' patients (n = 442) experienced no significant deterioration in HRQoL (VAS - 0.0, p = 0.9870; CAT + 0.5, p = 0.0804). Models unveiled a small comparative advantage of specialty care on HRQoL (mean change: CAT - 0.8, VAS + 2.9), which was especially pronounced for GOLD AB (CAT - 0.7; VAS + 3.1). CONCLUSION: The uptake of pulmonologist care had a statistically significant, but not clinically relevant, beneficial impact on the development of HRQoL by slowing down overall HRQoL deterioration within 1 year. Including specialty care more appropriately in COPD management, especially at lower disease stages (GOLD AB), could thus improve patients' health outcome.

Cost Effects of a Health Coaching in Children and Adolescents With Mental Health and Developmental Disorders.

OBJECTIVE: Health coaching (HC) aims to strengthen the role of primary care pediatricians in the treatment of children and adolescents with mental health and developmental disorders by extending consultation time and using disease-specific manuals. We evaluated the effect of HC on costs of specialized, pediatrician, and overall care. METHODS: In a retrospective cohort study based on German health insurance claims data, we identified children aged up to 17 years with a newly diagnosed mental health and/or developmental disorder between 2013 and 2015. Patients getting HC were matched to patients receiving usual care. Costs were calculated for 1 year following the start of the treatment and compared by 2-part and gamma models. Absolute costs and cost differences were calculated with bootstrapped 95% confidence intervals (CI). RESULTS: We compared 5597 patients receiving HC with 5597 control patients. The probability of incurring specialized care costs was similar between the groups (0.96, 95% CI: 0.88; 1.05). However, for those who did incur costs, specialized care costs were significantly lower for HC-treated patients (0.77, 95% CI: 0.63; 0.93). Accordingly, specialized care costs were lower by €-94 (95% CI: €-175; €-18), while pediatrician care costs were higher for HC-treated patients by €57 (95% CI: €49; €64). Hence, overall costs did not differ between the groups (€-59, 95% CI: €-191; €71). CONCLUSION: Provision of HC has the potential to lower the costs of specialized care, while increasing the costs of pediatrician care. Overall costs did not differ, suggesting that the additional costs incurred by the HC were offset.

Effects of Influenza Vaccination in Patients with Interstitial Lung Diseases: An Epidemiological Claims Data Analysis.

Rationale: Vaccination is the most effective protection against influenza. Patients with interstitial lung diseases (ILDs) represent a high-risk group for influenza complications. Thus, yearly influenza vaccination is recommended, but evidence on its effects is sparse. Objectives: This study aimed to compare all-cause mortality and all-cause and respiratory-related hospitalization between vaccinated and unvaccinated patients with ILD. Methods: Using data from the largest German statutory health insurance fund (about 27 million insurees in 2020), we analyzed four influenza seasons from 2014-2015 to 2017-2018 and compared vaccinated with unvaccinated patients with ILD. Starting from September 1 of each year, we matched vaccinated and unvaccinated patients in a 1:1 ratio using a rolling cohort design. Mortality and hospitalization were compared with Kaplan-Meier plots, and effects were calculated during the influenza season (in season) with risk ratios. Results: Both the vaccinated and the unvaccinated cohorts included 7,503 patients in 2014-2015, 10,318 in 2015-2016, 12,723 in 2016-2017, and 13,927 in 2017-2018. Vaccination rates were low at 43.2% in season 2014-2015 and decreased over time to 39.9% in season 2017-2018. The risk ratios for all-cause mortality were 0.79 (95% confidence interval [CI], 0.65-0.97; P = 0.02) in season 2014-2015, 0.66 (95% CI, 0.54-0.80; P < 0.001) in 2015-2016, 0.89 (95% CI, 0.76-1.04; P = 0.15) in 2016-2017, and 0.95 (95% CI, 0.81-1.12; P = 0.57) in 2017-2018. The effects on all-cause hospitalization and respiratory-related hospitalization were similar in all seasons. Conclusions: Although an unequivocally beneficial impact of influenza vaccination in patients with ILD could not be demonstrated, we observed promising results regarding avoidance of all-cause mortality in half of the seasons observed. Given the low vaccination rates, further efforts are necessary to improve vaccination rates in patients with ILD.

Mixed-methods evaluation of a structured primary care programme for children and adolescents with mental health problems (PrimA-QuO): a study protocol.

INTRODUCTION: More than 17% of German children and adolescents have clinically relevant mental health problems (MHP). Typically, general paediatricians are often the first contact for children with MHP, and referrals to specialised care tend to be the standard approach. A statutory health insurance fund developed a programme for children with MHP (Health Coaching (HC)) aiming to offer targeted but low-threshold services. However, little is known about whether HC has the potential for optimising patient care. The aim of the PrimA-QuO study is to examine the effectiveness and the acceptance, barriers and facilitators of all stakeholders of this structured primary care programme for children affected by the most frequently encountered MHP in paediatric practice. METHODS AND ANALYSIS: In this mixed-methods approach, children (n=800; aged 0-17 years) with MHP meeting all inclusion criteria will be identified in the health insurance database according to International Classification of Diseases, 10th Revision diagnoses between 2018 and 2019. The qualitative component uses a series of semistructured interviews with programme developers, paediatricians trained in HC, adolescents with MHP treated according to the programme guidelines and their parents. In addition, a prospective, pragmatic, parallel-group cohort study will be conducted using an online questionnaire to examine the effects of HC on health-related quality of life of affected children and their families as well as on change in MHP. Children treated according to the HC guidelines form the intervention group, whereas all others serve as controls. Primary data from the cohort study are linked to children's health insurance claims data to calculate the costs of care as proxies for healthcare utilisation. The hypothesis is that HC is an effective and efficient primary care programme with the potential to improve patients' and their families' health outcomes. ETHICS AND DISSEMINATION: The study was approved by the Ethical Committee of Ludwig-Maximilians-Universität München. Grant number 01VSF16032 (funded by the German Innovationsfonds).

Cost and survival of video-assisted thoracoscopic lobectomy versus open lobectomy in lung cancer patients: a propensity score-matched study.

OBJECTIVES: A video-assisted thoracoscopic surgery (VATS) is an accepted alternative to open thoracotomy (OT) in lung cancer patients undergoing lobectomy, but evidence of the benefits of VATS remains inconsistent. The aim of this study was to compare VATS and OT regarding survival, costs and length of hospital stay (LOS). METHODS: We identified lung cancer patients (incident 2013) undergoing VATS or OT from German insurance claims data and performed 1:2 propensity score matching. A 3-year survival was analysed using the Kaplan-Meier curves and a univariable Cox model. Group differences in the 3-year lung cancer-related costs and costs of hospital stay with lobectomy were compared via univariable generalized linear gamma models. LOS was compared using the Mann-Whitney-Wilcoxon test. RESULTS: After propensity score matching, we compared 294 patients undergoing VATS and 588 receiving OT. We found no differences in the 3-year survival (VATS: 73.8%, OT: 69.2%, P = 0.131) or costs for hospital stay with lobectomy (VATS: €11 921, OT: €12 281, P = 0.573). However, VATS patients had significantly lower lung cancer-related costs (VATS: €20 828, OT: €23 723, P = 0.028) and median postoperative LOS (VATS: 9 days, OT: 11 days, P < 0.001). CONCLUSIONS: From a payer's perspective, extending the use of VATS is beneficial, as it shows economic benefits without affecting survival. However, for a more comprehensive assessment of the benefits of VATS from a society's point of view, further aspects such as patient-reported outcomes and provider-related standby costs need to be investigated further.