[Diagnostics and Eradication Therapy for MRSA Carriers in the Outpatient Sector: an Analysis of the Reimbursement Situation in the Light of Current Reimbursement Changes]. / Diagnostik und ambulante Eradikationstherapie von Trägern mit MRSA in der vertragsärztlichen Versorgung ­ Eine Analyse der Erstattungssituation im Kontext aktueller Vergütungsveränderungen.

Infection with methicillin-resistant Staphylococcus aureus (MRSA) occurs in both the inpatient and outpatient sector. The reimbursement for diagnostic services and eradication therapy in the outpatient sector was regulated for the first time on 01.04.2012 and after a 2-year test period, has been adopted into the standard range of care services. The aim of this retrospective study was to give an overview of the current situation in services and reimbursement in Germany and describe MRSA patients and their treatment in the outpatient sector. Secondary data, namely reimbursement data of the National Association of Statutory Health Insurance Physicians (KBV) und the Physicians' Association (KV) Mecklenburg-West Pomerania for the period 01/04/2012-31/03/2014 were analyzed. Results show that on the federal level, MRSA services amounting to € 3,235,870.18 have been reimbursed and that diagnostic costs exceed treatment costs. In Germany, 5,627 doctors invoiced services related to MRSA; 51,56% of these were general practitioners and 21,25% specialists in internal medicine working in general practice. In the KV Mecklenburg-Western Pomerania, patients were elderly (average age 69,13), cost for services were on average 27,76 €, and 76,85% of the patients were treated within one quarter. On the whole, there were regional differences in the identification and eradication of MRSA in the outpatient setting. In order to provide an extended base for a more efficient resource allocation in the health care sector, in addition to analysis of MRSA eradication from the medical point of view, attention needs to be paid to patient flow between the out- and inpatient sectors, as well as economic aspects.

[Financing Regional Dementia Networks in Germany: Determinants of Sustainable Healthcare Networks]. / Finanzierung regionaler Demenznetzwerke: Determinanten einer nachhaltigen Finanzierung am Beispiel spezialisierter Gesundheitsnetzwerke.

OBJECTIVES: Analysis of practice-based financing concepts in German dementia networks (DN); Provision of sustainable financing structures and their determinants in DN. MATERIALS AND METHODS: Qualitative expert interviews with leaders of 13 DN were conducted. A semi-structured interview guide was used to analyse four main topics: Finance-related organization, cost, sources of funding and financial sustainability. RESULTS: DN were primarily financed by membership fees, earnings of services provided, public funds and payments by municipalities or health care providers. 63% of the DN reported a financial sustainability. Funds to support the interpersonal expanding, a mix of internal and external financing sources and investments of the municipality were determinants of a sustainable financing. Overall, DN in rural areas seemed to be disadvantaged due to a lack of potential linkable service providers. CONCLUSION: DN in urban regions are more likely able to gather sustainable funding resources. A minimum funding of 50.000 €/year for human resources coordinating the DN, seems to be a threshold for a sustainable DN.

The impact of socioeconomic factors on the efficiency of voluntary toxoplasmosis screening during pregnancy: a population-based study.

BACKGROUND: Congenital toxoplasmosis is associated with severe complications. German state health insurance covers rubella, but not toxoplasmosis, immunity screening. We analysed the effect of socioeconomic factors on the efficiency of private toxoplasmosis screening during pregnancy. METHODS: Toxoplasmosis and rubella screening data (n = 5402 mothers) were collected within the population-based Survey of Neonates in Pomerania (SNiP). RESULTS: At the first-trimester screening, 34.4 % (88.1 %) of expecting mothers were immune to toxoplasmosis (rubella). Susceptibility for toxoplasmosis (rubella) was observed in 39.6 % (8.9 %) and 25.8 % (2.95 %) were not tested. Data on a 2(nd) screening were available in a subgroup of women with negative immunity showing less than 45 % participation rate. Active toxoplasmosis (no rubella) infection was observed in 0.3 % (n = 17) of pregnant women. A multiple logistic regression model (AIC = 719.67; AUC = 0.725) revealed that the likelihood of participating in a second toxoplasmosis screening increased among women with a good level of education and a steady partnership and decreased with paternal unemployment and the absence of breastfeeding. The highest probability of non-participation in toxoplasmosis screening was found among women with temporal burden and family responsibilities. A cost-benefit analysis showed that covering general screening for toxoplasmosis with health insurance saved costs. CONCLUSION: Toxoplasmosis carried a substantial risk of infection during pregnancy. Although increased socioeconomic status was positively associated with the participation in toxoplasmosis screening, this was not the case when pregnant women had strong temporal burden and family responsibilities. This data supports the need for toxoplasmosis screening among pregnant women as a general healthcare benefit covered by insurance.

Economic analysis of two-stage septic revision after total hip arthroplasty: What are the relevant costs for the hospital's orthopedic department?

BACKGROUND: The number of septic total hip arthroplasty (THA) revisions is increasing continuously, placing a growing financial burden on hospitals. Orthopedic departments performing septic THA revisions have no basis for decision making regarding resource allocation as the costs of this procedure for the departments are unknown. It is widely assumed that septic THA procedures can only be performed at a loss for the department. Therefore, the purpose of this study was to investigate whether this assumption is true by performing a detailed analysis of the costs and revenues for two-stage septic THA revision. METHODS: Patients who underwent revision THA for septic loosening in two sessions from January 2009 through March 2012 were included in this retrospective, consecutive cost study from the orthopedic department's point of view. We analyzed variable and case-fixed costs for septic revision THA with special regard to implantation and explantation stay. By using marginal costing approach we neglected hospital-fixed costs. Outcome measures include reimbursement and daily contribution margins. RESULTS: The average direct costs (reimbursement) incurred for septic two-stage revision THA was €10,828 (€24,201). The difference in cost and contribution margins per day was significant (p < .001 and p = 0.019) for ex- and implantation (€4147 vs. €6680 and €429 vs. €306) while length of stay and reimbursement were comparable. CONCLUSIONS: This is the first detailed analysis of the hospital department's cost for septic revision THA performed in two sessions. Disregarding hospital-fixed costs the included variable and case fixed-costs were covered by revenues. This study provides cost data, which will be guidance for health care decision makers.

[Cost Analysis of Cochlear Implantation in Adults]. / Kostenanalyse der unilateralen Cochlea-Implantatversorgung bei Erwachsenen.

OBJECTIVE: The number of implantation of cochlear implants has steadily risen in recent years. Reasons for this are an extension of indication criteria, demographic change, increased quality of life needs and greater acceptance. The consequences are rising expenditure for statutory health insurance (SHI) for cochlear implantation. A detailed calculation of lifetime costs from SHI's perspective for postlingually deafened adolescents and adults is essential in estimating future cost developments. METHODS: Calculations are based on accounting data from the Hannover Medical School. With regard to further life expectancy, average costs of preoperative diagnosis, surgery, rehabilitation, follow-ups, processor upgrades and electrical maintenance were discounted to their present value at age of implantation. RESULTS: There is an inverse relation between cost of unilateral cochlear implantation and age of initial implantation. From SHI's perspective, the intervention costs between 36,001 and 68,970 € ($ 42,504-$ 81,429). The largest cost components are initial implantation and processor upgrades. CONCLUSION: Compared to the UK the cost of cochlear implantation in Germany seems to be significantly lower. In particular the costs of, rehabilitation and maintenance in Germany cause only a small percentage of total costs. Also, the costs during the first year of treatment seem comparatively low. With regard to future spending of SHI due to implant innovations and associated extension of indication, increasing cost may be suspected.

[Psychiatric Nursing Internship and Promotion of Specialized Training Interest]. / Psychiatrisches Pflegepraktikum und die Förderung des fachspezifischen Ausbildungsinteresses.

Qualified personnel in the field of medical psychiatry are crucial to providing comprehensive care. The importance of a nursing internship as an access point to the psychiatric field is not considered by key players. A survey conducted across German medical schools in 2012 analyzed medical care internships as viewed by medical school students. From among students surveyed, those who participated in a nursing internship, and would consider taking part in further internships within the psychiatric department ("PFJ"), were separated from those who were not sure ("PFU") or who would not ("PFN") consider further study in the field of psychiatry. The survey's conclusion was that a comparably small number of students opted for a psychiatric nursing internship based upon practical aspects of content, satisfaction, and access to nursing internships. A potential solution to the low numbers of students selecting psychiatric internships is to restructure the initial contact program that psychiatric departments use to introduce prospective medical school students to the field of psychiatry.

[Improvement of cost allocation in gastroenterology by introduction of a novel service catalogue covering the complete spectrum of endoscopic procedures]. / Verbesserung der Kostenkalkulation in der Gastroenterologie durch Einführung eines neuen Leistungskatalogs für alle endoskopischen Prozeduren.

BACKGROUND: The German hospital reimbursement system (G-DRG) is incomplete for endoscopic interventions and fails to differentiate between complex and simple procedures. This is caused by outdated methods of personnel-cost allocation. METHODS: To establish an up-to-date service catalogue 50 hospitals made their anonymized expense-budget data available to the German-Society-of-Gastroenterology (DGVS). 2.499.900 patient-datasets (2011-2013) were used to classify operation-and-procedure codes (OPS) into procedure-tiers (e.g. colonoscopy with biopsy/colonoscopy with stent-insertion). An expert panel ranked these tiers according to complexity and assigned estimates of physician time. From June to November 2014 exact time tracking data for a total 38.288 individual procedures were collected in 119 hospitals to validate this service catalogue. RESULTS: In this three-step process a catalogue of 97 procedure-tiers was established that covers 99% of endoscopic interventions performed in German hospitals and assigned validated mean personnel-costs using gastroscopy as standard. Previously, diagnostic colonoscopy had a relative personnel-cost value of 1.13 (compared to gastroscopy 1.0) and rose to 2.16, whereas diagnostic ERCP increased from 1.7 to 3.62, more appropriately reflecting complexity. Complex procedures previously not catalogued were now included (e.g. gastric endoscopic submucosal dissection: 16.74). DISCUSSION: This novel service catalogue for GI-endoscopy almost completely covers all endoscopic procedures performed in German hospitals and assigns relative personnel-cost values based on actual physician time logs. It is to be included in the national coding recommendation and should replace all prior inventories for cost distribution. The catalogue will contribute to a more objective cost allocation and hospital reimbursement - at least until time tracking for endoscopy becomes mandatory.

[Additional Costs for Care of Patients with Multi-Resistant Pathogens--An Analysis from the Perspective of a Statutory Health Insurance]. / Mehrkosten bei der Versorgung von Patienten mit multiresistenten Erregern--Eine Analyse aus Sicht einer gesetzlichen Krankenversicherung.

Aim of this study was to determine the additional expenditures for a German statutory health insurance which are induced by patients with multi-resistant bacteria. Therefore a nationwide cross-sectional data analysis using routine data of the health insurance "Techniker Krankenkasse" was conducted. In the consideration of costs we included expenditures for inpatient and outpatient care and on drugs in a time period of 12 months. A control group was matched by age, gender, basic disease, quarterly period and region. On average additional costs of 17,500 Euro per insured were calculated due to the presence of multi-resistant bacteria. The hypothesis was corroborated in that the level of these costs differ widely by age, gender and basic disease.

[Outpatient Care of People with Dementia within Residential Communities in Germany--Care Potential and Cost]. / Ambulant betreute Demenz-Wohngemeinschaften in Deutschland--Pflegepotenzial und Kosten.

BACKGROUND: Since the 1980s dementia residential communities (DRC) have been established as part of the health-care landscape and as an alternative to inpatient long-term nursing care. Information about (a) the residents (b) the care potential and (c) the cost of DRCs are still lacking. METHODS: A nation-wide postal questionnaire was sent to n=332 DRCs managed by n=151 organizations. The sample was based on an internet search with various combinations of search terms such as "outpatient" and "residential care communities". The questionnaire contained questions about the resident's social-demography, nursing care level and the utilization, financing and cost structures of DRCs. RESULTS: In total 81 organizations with n=88 DRCs replied to the questionnaire. Overall n=794 persons were living in these communities, most of the residents were female (80%, n=522), and 67% of the residents were older than 80 years. The nursing care level was high, 27% of the DRC residents reached the highest stage. Only 5% of the DRCs capacity was vacant. 86% of the communities stated to be able to provide nursing care for the residents until the end of their life. Almost half (48%) of the residents received money from the social welfare. The total average amount of cost per place per month was 3,265.08€ (excluding costs of services related to health insurance). CONCLUSIONS: DRCs are caring for residents with high nursing care levels. Costs of these communities vary to a large extent but are in addition comparable to inpatient long-term nursing care. Thus, interested persons should obtain information about cost, financing and care concepts. The low level of vacant capacity demonstrates the demand for DRCs in Germany. Studies with the objective to evaluate quality of care, care concepts and suitable clients for those communities are needed to develop this living concept.

Analysis of MRSA-attributed costs of hospitalized patients in Germany.

Infections with methicillin-resistant Staphylococcus aureus (MRSA) are assumed to have a high economic impact due to increased hygienic measures and prolonged hospital length of stay. However, surveys on the real expenditure for the prevention and treatment of MRSA are scarce, in particular with regard to the German Diagnosis-Related Groups (G-DRG) payment system. The aim of our study is to empirically assess the additional cost for MRSA management measures and to identify the main cost drivers in the whole process from the hospital's point of view. We conducted a one-year retrospective analysis of MRSA-positive cases in a German university hospital and determined the cost of hygienic measures, laboratory costs, and opportunity costs due to isolation time and extended lengths of stay. A total of 182 cases were included in the analysis. The mean length of hospital stay was 22.75 days and the mean time in isolation was 17.08 days, respectively. Overall, the calculated MRSA-attributable costs were 8,673.04 per case, with opportunity costs making up, by far, the largest share (77.45 %). Our study provides a detailed up-to-date analysis of MRSA-attributed costs in a hospital. It allows a current comparison to previous studies worldwide. Moreover, it offers the prerequisites to investigate the adequate reimbursement of MRSA burden in the DRG payment system and to assess the efficiency of targeted hygienic measures in the prevention of MRSA.

An economic analysis of aseptic revision hip arthroplasty: calculation of partial hospital costs in relation to reimbursement.

INTRODUCTION: Aseptic loosening is one of the most common intermediate and long-term complications after total hip replacement (THR). These complications cause suffering and require expensive revision surgery. Little concrete data on direct costs are available from the hospital's, moreover operating department's perspective. We here provide a detailed analysis of the costs of THR revision and relate them to reimbursement underlying the German diagnosis-related groups (DRG) system. MATERIALS AND METHODS: Major cost parameters were identified using for orientation the cost matrix of the German Institute for Hospital Reimbursement (InEK GmbH). We then retrospectively analysed the major direct costs of aseptic revision THR in terms of contribution margins I and II. The analysis included a total of 114 patients who underwent aseptic revision from 1 January 2009 to 31 March 2012. Data were retrieved from the hospital information system and patient records. All costs of surgery, diagnostic tests, and other treatments were calculated as purchase prices in EUR. The comparative analysis of direct costs and reimbursements was done for DRG I46A and I46B from the hospital's, especially treating department's rather than the society or healthcare insurance's perspective. RESULTS: The average direct cost incurred by the hospital for a THR revision was 4,380.0. The largest share was accounted for surgical costs (62.7 % of total). Implant and staff costs were identified as the most important factors that can be influenced. The proportion of the daily contribution margin that was left to cover the hospital's indirect cost decreased with the relative cost weight of the DRG to which a patient was assigned. CONCLUSION: Our study for the first time provides a detailed analysis of the major direct case costs of THR revision for aseptic loosening from the provider's perspective. Our findings suggest that these revision operations could be performed cost-beneficially by the operating unit. From an economic perspective, cases with higher cost weights are more favorable for a hospital. These results need to be confirmed in multicenter studies.

Cost-analysis of PCR-guided pre-emptive antibiotic treatment of Staphylococcus aureus infections: an analytic decision model.

The aim of this study is to examine whether rapid polymerase chain reaction (PCR)-based screening is a cost-efficient tool to optimize pre-emptive antibiotic therapy of methicillin-resistant and methicillin-sensitive Staphylococcus aureus (MRSA and MSSA, respectively) infections. A decision analytic cost model was developed, based on data from the peer-reviewed literature. Sensitivity analyses were undertaken to investigate the impact of variation in the MRSA rate, cost ratio of the cost of inappropriate antibiotic therapy to the cost of appropriate antibiotic therapy, PCR test cost, and total hospital costs per case. At a current MRSA rate of 24.5 % in Germany, PCR-guided treatment regimens are cost-efficient compared to empirical strategies. The costs of alternative treatment strategies differ, on average, up to 1,780 per case. An empirical MRSA treatment strategy is least costly when the cost ratio is less than 1.06. When the total hospital cost per MRSA case is increased, pre-emptive MSSA treatment with PCR tests achieves the lowest average cost. Early verification and adaptation of an initial pre-emptive antibiotic treatment of S. aureus infections using PCR-based tests are advantageous in Germany and other European countries. PCR tests, accordingly, should be considered as elements in antimicrobial stewardship programs.

Transmission rates, screening methods and costs of MRSA--a systematic literature review related to the prevalence in Germany.

Methicillin-resistant Staphylococcus aureus (MRSA) infections represent a serious challenge for health care institutions, which is inherent in the combination of prevalence, transmission rates and costs. Furthermore, performing an MRSA screening requires information on the complex system of effectiveness, accuracy and costs of different screening methods. The purpose of this study was to give an overview of parameters with decisive significance for the burden of MRSA and the selection of a specific MRSA screening strategy. A systematic literature search for peer-reviewed health economic studies associated with MRSA was performed (from 1995 to the present). Eighty-seven different studies met all inclusion and exclusion criteria. Primary outcomes included the prevalence of MRSA, MRSA transmission rates, performance characteristics of MRSA screening methods, costs for pre-emptive isolation precautions and costs per MRSA case. The prevalence rates reported for all inpatients (1.2-5.3 %) as well as for inpatients with risk factors or patients in risk areas (3.85-20.6 %) vary greatly. The range of cross-transmission rates per day reported for patients with MRSA in isolation is 0.00081-0.009 and for carriers not in isolation is 0.00137-0.140, respectively. For polymerase chain reaction (PCR) methods, the mean sensitivity and specificity were 91.09 and 95.79 %, respectively. Culture methods show an average sensitivity of 89.01 % and an average specificity of 93.21 %. The turn-around time for PCR methods averages 15 h, while for the culture method, it can only be estimated as 48-72 h. This review filtered important parameters and cost drivers, and covered them with literature-based averages. These findings serve as an ideal evidence base for further health economic considerations of the cost-effectiveness of different MRSA screening methods.

[Quality features of German memory clinics: a cross-sectional study]. / Qualitätsmerkmale deutscher Memory-Kliniken : Eine Querschnittsuntersuchung.

BACKGROUND: Although memory clinics have become an established institution for diagnosing and treating dementia in Germany over the years, little is known about their quality features. Considering the increasing societal relevance of dementia, memory clinics will most likely gain in importance in the future. MATERIAL AND METHODS: Addresses of German memory clinics were obtained by an online search. All institutions were surveyed via questionnaire with items regarding structural characteristics (designation, affiliation, services offered, funding) and quality features (waiting times, disease severity at diagnosis). RESULTS: The results of the inquiry of all institutions (n=153, response: 48%) show memory clinics as specialised institutions that have a low degree of standardisation, but basically have a high structural quality for diagnostic and therapeutic care. CONCLUSION: The development of homogeneous structure and process standards could help to establish memory clinics in regular care and to establish sustainable funding. In order to achieve this, an even more intensive collaboration and consensus building of all German memory clinics would be needed as well as a coordinated representation of interests.

Prospective association of low serum total testosterone levels with health care utilization and costs in a population-based cohort of men.

Despite the burgeoning interest in the field of andrology, no studies have specifically addressed the impact of serum testosterone levels on healthcare utilization and costs. We analysed data from the population-based cohort Study of Health in Pomerania (SHIP), Germany, to assess the association of serum testosterone levels with self-reported health care utilization and costs at baseline and at 5 years follow up. Study sample comprised 2023 men at baseline, of whom 1530 men were repeatedly examined. Low and high serum testosterone levels, defined according to the age-specific 10th and 90th percentile, were compared with reference subjects with serum testosterone levels ≥10th -≤90th percentile. Two-part econometric models were applied adjusting for socio-economic and medical confounders. Cross-sectional models revealed higher numbers of outpatient visits and higher costs for both, men with low (+19.1 and +19.9%, respectively) and high serum testosterone levels (+25.3 and +30.2%, respectively), whereas number of inpatient days and costs were not associated with serum testosterone levels. Adjustment for age, educational level, income, waist circumference, smoking status, physical activity and alcohol consumption did not considerably alter the results. Longitudinal models revealed a significant association of low serum testosterone levels with increased number of follow-up outpatient visits (age-adjusted: +28.6%) and costs (+38.0%) only. Low and high serum testosterone levels were associated with increased short-term outpatient health care costs, whereas low serum testosterone levels appear to be predictive of long-term outpatient health care costs. Cost-effectiveness studies of available treatments are necessary to identify benefits for physicians, patients and health care system as a whole.

Socio-economic impact of antiviral intervention.

In this paper we present a meta-analysis of the Cost-of-Illness of HIV/AIDS and the socio-economic impact of antiretroviral therapy. We distinguish between provider costs, direct household costs, and indirect costs. There is a growing number of publications on provider costs in different countries, but the methodology and the degree of precision between these papers make it difficult to give a good estimate of the current provider costs of treating HIV/AIDS cases. There seems to be a declining interest in health economic analysis of HIV/AIDS, and usually data is rather obsolete at the date of publication. In addition, we know hardly anything about household costs not covered by health insurances (e.g., transport to the provider, special diet). There are more studies on indirect costs, but even these studies are difficult to compare due to methodological differences. Even under these conditions we can state that in highly developed countries HAART is cost-effective. Because of an increase of life expectancy, the life-time provider costs increase under this drug regime. But, on the contrary, the indirect costs strongly decrease. In particular for employed and young HIV/AIDS cases in the USA and in Europe, HAART is an investment that pays back. In countries and in compartments of the population (e.g., unemployed, pensioners) where the loss of labor can be neglected, the positive effects of HAART on the indirect costs do not necessarily justify its costs. The cost-effectiveness analysis of antiviral therapy has to be seen under the precondition that no long-term effects, such as drug resistance, occur. Future analysis might show that we strongly underestimated the long-term costs of HIV/AIDS.

[Population density, age distribution and urbanisation as factors influencing the frequency of home visits--an analysis for Mecklenburg-West Pomerania]. / Bevölkerungsdichte, Altersverteilung und Urbanität als Einflussfaktoren der Hausbesuchshäufigkeit - eine Analyse für Mecklenburg-Vorpommern.

BACKGROUND: This study examines and compares the frequency of home visits by general practitioners in regions with a lower population density and regions with a higher population density. The discussion centres on the hypothesis whether the number of home visits in rural and remote areas with a low population density is, in fact, higher than in urbanised areas with a higher population density. The average age of the population has been considered in both cases. METHODOLOGY: The communities of Mecklenburg West-Pomerania were aggregated into postal code regions. The analysis is based on these postal code regions. The average frequency of home visits per 100 inhabitants/km2 has been calculated via a bivariate, linear regression model with the population density and the average age for the postal code region as independent variables. The results are based on billing data of the year 2006 as provided by the Association of Statutory Health Insurance Physicians of Mecklenburg-Western Pomerania. In a second step a variable which clustered the postal codes of urbanised areas was added to a multivariate model. RESULTS: The hypothesis of a negative correlation between the frequency of home visits and the population density of the areas examined cannot be confirmed for Mecklenburg-Western Pomerania. Following the dichotomisation of the postal code regions into sparsely and densely populated areas, only the very sparsely populated postal code regions (less than 100 inhabitants/km2) show a tendency towards a higher frequency of home visits. Overall, the frequency of home visits in sparsely populated postal code regions is 28.9% higher than in the densely populated postal code regions (more than 100 inhabitants/km2), although the number of general practitioners is approximately the same in both groups. In part this association seems to be confirmed by a positive correlation between the average age in the individual postal code regions and the number of home visits carried out in the area. As calculated on the basis of the data at hand, only the very sparsely populated areas with a still gradually decreasing population show a tendency towards a higher frequency of home visits. CONCLUSION: According to the data of 2006, the number of home visits remains high in sparsely populated areas. It may increase in the near future as the number of general practitioners in these areas will gradually decrease while the number of immobile and older inhabitants will increase.