Use of removable support boot versus cast for early mobilisation after ankle fracture surgery: cost-effectiveness analysis and qualitative findings of the Ankle Recovery Trial (ART).

OBJECTIVES: To estimate the cost-effectiveness of using a removable boot versus a cast following ankle fracture from the National Health Service and Personal Social Services (NHS+PSS) payer and societal perspectives and explore the impact of both treatments on participants' activities of daily living. DESIGN: Cost-effectiveness analyses and qualitative interviews performed alongside a pragmatic multicentre randomised controlled trial. SETTING: Eight UK NHS secondary care trusts. PARTICIPANTS: 243 participants (60.5% female, on average 48.2 years of age (SD 16.4)) with ankle fracture. Qualitative interviews with 16 participants. Interventions removable air boot versus plaster cast 2 weeks after surgery weight bearing as able with group-specific exercises. PRIMARY AND SECONDARY OUTCOME MEASURES: Quality-adjusted life years (QALYs) estimated from the EQ-5D-5L questionnaire, costs and incremental net monetary benefit statistics measured 12 weeks after surgery, for a society willing-to-pay £20 000 per QALY. RESULTS: Care in the boot group cost, on average, £88 (95% CI £22 to £155) per patient more than in the plaster group from the NHS+PSS perspective. When including all societal costs, the boot saved, on average, £676 per patient (95% CI -£337 to £1689). Although there was no evidence of a QALY difference between the groups (-0.0020 (95% CI -0.0067 to 0.0026)), the qualitative findings suggest participants felt the boot enhanced their quality of life. Patients in the boot felt more independent and empowered to take on family responsibilities and social activities. CONCLUSIONS: While the removable boot is slightly more expensive than plaster cast for the NHS+PSS payer at 12 weeks after surgery, it reduces productivity losses and the need for informal care while empowering patients. Given that differences in QALYs and costs to the NHS are small, the decision to use a boot or plaster following ankle surgery could be left to patients' and clinicians' preferences. TRIAL REGISTRATION NUMBER: ISRCTN15497399, South Central-Hampshire A Research Ethics Committee (reference 14/SC/1409).

Organisational factors associated with hospital costs and patient mortality in the 365 days following hip fracture in England and Wales (REDUCE): a record-linkage cohort study.

BACKGROUND: Hip fracture care delivery varies between hospitals, which might explain variations in patient outcomes and health costs. The aim of this study was to identify hospital-level organisational factors associated with long-term patient outcomes and costs after hip fracture. METHODS: REDUCE was a record-linkage cohort study in which national databases for all patients aged 60 years and older who sustained a hip fracture in England and Wales were linked with hospital metrics from 18 organisational data sources. Multilevel models identified organisational factors associated with the case-mix adjusted primary outcomes: cumulative all-cause mortality, days spent in hospital, and inpatient costs over 365 days after hip fracture. FINDINGS: Between April 1, 2016, and March 31, 2019, 178 757 patients with an index hip fracture were identified from 172 hospitals in England and Wales. 126 278 (70·6%) were female, 52 479 (29·4%) were male, and median age was 84 years (IQR 77-89) in England and 83 years (77-89) in Wales. 365 days after hip fracture, 50 354 (28·2%) patients had died. Patients spent a median 21 days (IQR 11-41) in hospital, incurring costs of £14 642 (95% CI 14 600-14 683) per patient, ranging from £10 867 (SD 5880) to £23 188 (17 223) between hospitals. 11 organisational factors were independently associated with mortality, 24 with number of days in hospital, and 25 with inpatient costs. Having all patients assessed by an orthogeriatrician within 72 h of admission was associated with a mean cost saving of £529 (95% CI 148-910) per patient and a lower 365-day mortality (odds ratio 0·85 [95% CI 0·76-0·94]). Consultant orthogeriatrician attendance at clinical governance meetings was associated with cost savings of £356 (95% CI 188-525) and 1·47 fewer days (95% CI 0·89-2·05) in the hospital in the 365 days after hip fracture per patient. The provision of physiotherapy to patients on weekends was associated with a cost saving of £676 (95% CI 67-1285) per patient and with 2·32 fewer days (0·35-4·29) in hospital in the 365 days after hip fracture. INTERPRETATION: Multiple, potentially modifiable hospital-level organisational factors associated with important clinical outcomes and inpatient costs were identified that should inform initiatives to improve the effectiveness and efficiency of hip fracture services. FUNDING: Versus Arthritis.

Development of Population Tariffs for the ICECAP-A Instrument for Hungary and their Comparison With the UK Tariffs.

OBJECTIVES: The ICEpop CAPability measure for Adults (ICECAP-A) was developed to assess the capability well-being of adults for use in economic evaluations. Currently, ICECAP-A tariffs are available only for the UK population. The objectives of this study were to develop a Hungarian tariff set for the ICECAP-A instrument and to explore intercountry differences between the Hungarian and the UK value sets. METHODS: A survey was conducted by computer-assisted personal interviews on a sample representative of the Hungarian adult population (N = 1000) to elicit their preferences regarding ICECAP-A attributes with the use of a best-worst scaling choice task. A latent class multinomial logit model with continuous variance scale was used to estimate the weights for each of the 4 capability levels of all 5 ICECAP-A attributes, namely, attachment, stability, achievement, enjoyment, and autonomy. RESULTS: The model identified 2 preference classes with approximately equal share. The first class had a stronger relative preference for autonomy and achievement, whereas the second class had a strong preference for attachment. Multivariate analysis of the classes revealed that women, pensioners, people who are married or living in a partnership, and people with poorer health status are characteristics associated with the latter class membership (preference for attachment). Population tariffs were estimated from the model. Overall, attachment was found to be the most important attribute, followed by stability, enjoyment, achievement, and autonomy. CONCLUSIONS: Hungarian tariffs are largely consistent with those found for the United Kingdom; nevertheless, autonomy seems to be less important in Hungary compared with the United Kingdom.

Self-Reported Waiting Times for Outpatient Health Care Services in Hungary: Results of a Cross-Sectional Survey on a National Representative Sample.

(1) Background: System-level data on waiting time in the outpatient setting in Hungary is scarce. The objective of the study was to explore self-reported waiting time for an appointment and at a doctor's office. (2) Methods: An online, cross-sectional, self-administered survey was carried out in 2019 in Hungary among a representative sample (n = 1000) of the general adult population. Chi-squared test and logistic regression analysis were carried out to explore if socioeconomic characteristics, health status, or residence were associated with waiting times and the perception of waiting time as a problem. (3) Results: Proportions of 90%, 41%, and 64% of respondents were seen within a week by family doctor, public specialist, and private specialist, respectively. One-third of respondents waited more than a month to get an appointment with a public specialist. Respondents in better health status reported shorter waiting times; those respondents were less likely to perceive a problem with: (1) waiting time to get an appointment (OR = 0.400) and (2) waiting time at a doctor's office (OR = 0.519). (4) Conclusions: Longest waiting times were reported for public specialist visits, but waiting times were favorable for family doctors and private specialists. Further investigation is needed to better understand potential inequities affecting people in worse health status.

Understanding the use of patient-reported data by health care insurers: A scoping review.

BACKGROUND: Patient-reported data are widely used for many purposes by different actors within a health system. However, little is known about the use of such data by health insurers. Our study aims to map the evidence on the use of patient-reported data by health insurers; to explore how collected patient-reported data are utilized; and to elucidate the motives of why patient-reported data are collected by health insurers. METHODS: The study design is that of a scoping review. In total, 11 databases were searched on. Relevant grey literature was identified through online searches, reference mining and recommendations from experts. Forty-two documents were included. We synthesized the evidence on the uses of patient-reported data by insurers following a structure-process-outcome approach; we also mapped the use and function of those data by a health insurer. RESULTS: Health insurers use patient-reported data for assurance and improvement of quality of care and value-based health care. The patient-reported data most often collected are those of outcomes, experiences and satisfaction measures; structure indicators are used to a lesser extent and often combined with process indicators. These data are mainly used for the purposes of procurement and purchasing of services, quality assurance, improvement and reporting, and strengthening the involvement of insured people. CONCLUSIONS: The breadth to which insurers use patient-reported data in their business models varies greatly. Some hindering factors to the uptake of such data are the varying and overlapping terminology in use in the field and the limited involvement of insured people in a health insurer's business. Health insurers are advised to be more explicit in regard to the role they want to play within the health system and society at large, and accommodate implications for the use of patient-reported data accordingly.

Eliciting preferences for outpatient care experiences in Hungary: A discrete choice experiment with a national representative sample.

INTRODUCTION: Patient-reported experience measures (PREMs) are central to inform on the responsiveness of health systems to citizens' health care needs and expectations. At their current form, PREMs do not reflect the weights that patients assign to varying aspects of the care experience. We aimed to investigate patients' preferences and willingness to pay (WTP) for attributes of the care experience in outpatient settings. METHODS: A discrete choice experiment was conducted among a representative sample of the general adult population of Hungary (n = 1000). Choice set attributes and levels were defined based on OECD's standardized PREMs (e.g. a doctor spending enough time in consultation, providing easy to understand explanations, giving opportunity to ask questions, and involving in decision making) and a price attribute. Conditional and mixed logit analyses were conducted. WTP estimates were computed in preference and WTP space. RESULTS: The respondents most preferred attribute was that of a doctor spending enough time in consultation, followed by involvement in decision making. Moreover, waiting times had a less important effect on respondents' choice preference compared with aspects of the doctor-patient relationship. Estimates in the WTP space varied from €4.38 (2.85-5.90) for waiting an hour less at a doctor's office to €36.13 (32.07-40.18) for a consultation where a doctor spends enough time with a patient relative to a consultation where a doctor does not. CONCLUSIONS: A preference-based PREMs approach provide insight on the value patients assign to different aspects of their care experience. This can inform the decisions of policy-makers and other stakeholders to coordinate efforts and resource allocation in a more targeted manner, by acting on attributes of the care experience that have a greater impact on the implementation of patient-centered care.

Development of Population Tariffs for the CarerQol Instrument for Hungary, Poland and Slovenia: A Discrete Choice Experiment Study to Measure the Burden of Informal Caregiving.

BACKGROUND: The CarerQol instrument can be used in economic evaluations to measure the care-related quality of life of informal caregivers. Tariff sets are available for Australia, Germany, Sweden, the Netherlands, the UK, and the USA. OBJECTIVE: Our objective was to develop tariff sets for the CarerQol instrument for Hungary, Poland and Slovenia and to compare these with the existing value sets. METHODS: Discrete-choice experiments were carried out in Hungary, Poland and Slovenia. Data were collected through an online survey between November 2018 and January 2019, using representative samples of 1000 respondents per country. Tariffs were calculated from coefficient estimates from panel mixed multinomial logit models with random parameters. RESULTS: All seven CarerQol domains contributed significantly to the utility associated with different caregiving situations. Attributes valued highest were 'physical health' (tariffs for no problems were 15.6-21.8), 'mental health' (18.1-18.9) and 'fulfilment' (16.3-22.9). Value sets were comparable across the countries, although in Poland 'a lot of fulfilment' was valued higher (22.9) than in Hungary (16.3) and Slovenia (17.1). Compared with existing value sets, in the three Central European countries, 'fulfilment' was more important, whereas 'financial problems' were less important. CONCLUSION: For the first time in the Central and Eastern European region, country-specific tariffs are now available for the Hungarian, Polish and Slovenian versions of the CarerQol instrument. This facilitates inclusion of the impact of informal care in economic evaluations. Our results can be used to develop and evaluate country-specific health policy strategies to support informal caregivers. The differences found in informal care preferences highlight the limited transferability of CarerQol tariffs across European regions.

The burden of informal caregiving in Hungary, Poland and Slovenia: results from national representative surveys.

BACKGROUND: We aimed to investigate the burden of informal care in Hungary (HU), Poland (PL) and Slovenia (SI). METHODS: A cross-sectional online survey was performed involving representative samples of 1000 respondents per country. Caregiving situations were explored; health status of informal caregivers/care recipients and care-related quality of life were assessed using the EQ-5D-5L and CarerQol-7D. RESULTS: The proportion of caregivers was (HU/PL/SI) 14.9, 15.0 and 9.6%, respectively. Their mean age was 56.1, 45.6 and 48.0, and the average time spent on informal care was 27.6, 35.5 and 28.8 h/week. Chronic care was dominant (> 1 year: 78.5%, 72.0%, 74.0%) and care recipients were mainly (own/in-law) parents. Average EQ-5D-5L scores of care recipients were 0.53, 0.49 and 0.52. For Poland and Slovenia, EQ-5D-5L scores of informal care providers were significantly lower than of other respondents. Average CarerQol-7D scores were (HU/PL/SI) 76.0, 69.6 and 70.9, and CarerQol-VAS was 6.8, 6.4 and 6.6, respectively. Overall, 89, 87, and 84% of caregivers felt some or a lot fulfilment related to caring. Problems with combining tasks with daily activities were most important in Hungary and Slovenia. Women had a higher probability of being a caregiver in Hungary. CarerQol-7D scores were significantly associated with caregivers' EQ-5D-5L scores. In Hungary and Poland, living in a larger household was positively, while caring for patients with mental health problems was negatively associated with CarerQol-7D scores. CONCLUSIONS: These first results from the Central and Eastern European region using preference-based measures for the evaluation of informal care can serve as a valuable input for health economic analyses.

Psychometric properties of the Hungarian version of the eHealth Literacy Scale.

BACKGROUND: We adapted the eHealth Literacy Scale (eHEALS) for Hungary and tested its psychometric properties on a large representative online sample of the general population. METHODS: The Hungarian version of eHEALS was developed using forward-backward translation. For the valuation study, 1000 respondents were recruited in early 2019 from a large online panel by a survey company. We tested internal consistency, test-retest reliability and construct and criterion validity using classical test theory, as well as item characteristics using an item-response theory (IRT) graded response model (GRM). RESULTS: 55% of respondents were female, and 22.1% were ≥ 65 years old. Mean eHEALS score was 29.2 (SD: 5.18). Internal consistency was good (Cronbach's α = 0.90), and test-retest reliability was moderate (intraclass correlation r = 0.64). We identified a single-factor structure by exploratory factor analysis, explaining 85% of test variance. Essential criteria for GRM analysis were met. Items 3 and 4 (search of health resources) were the least difficult, followed by items 5 and 8 (utilisation of health information), and then items 1 and 2 (awareness of health resources). Items 6 and 7 (appraisal of health resources) were most difficult. The measurement properties of eHEALS were not affected by gender, age, education or income levels. Female gender, older age, intensity of health information seeking, formal health education and visit at the electronic health-record website were associated with higher eHEALS scores, as well as best and worst self-perceived health states, BMI < 25 and participation at health screenings over the past year. CONCLUSIONS: The Hungarian eHEALS is a useful and valid tool for measuring subjective eHealth literacy.

Patient experiences with outpatient care in Hungary: results of an online population survey.

BACKGROUND: Health systems are undertaking efforts to make health care more patient centered and value based. To achieve this goal, the use of patient-reported experience measures (PREMs) is increasing, especially across OECD countries. However, in Hungary, data on patients' experiences are still lacking. Thus, our aim was twofold: first, to collect data on outpatient experience in Hungary on patient-doctor communication and patient involvement in decision making and compare it with that of other OECD countries; second, to assess associations of outpatient experience with patients' socioeconomic characteristics. METHODS: In early 2019, we conducted a cross-sectional, online, self-administered survey in a national representative sample of Hungary's population (n = 1000). The sample was weighted considering gender, age, highest education level attained, type of settlement, and region of residence. The survey questions were based on a set of recommended questions by the OECD. RESULTS: Our findings show that the proportion of reported positive experiences is as follows: doctors providing easy-to-understand explanations (93.1%) followed by time spent on the consultation (87.5%), opportunities to raise questions (85.8%), and doctors involving patients in decision making about care and treatment (80.1%). The share of positive experiences falls behind OECD's average regarding patient-doctor communication and patient involvement in decision making, which signals room for improvement in these areas. CONCLUSIONS: Women, younger people, people with a paid job, and patients with consultations with allied health professionals reported significant lesser positive care experiences and, hence, more targeted policies can be initiated based on our findings.

Unmet medical needs in ambulatory care in Hungary: forgone visits and medications from a representative population survey.

BACKGROUND: The objective of this paper is to explore unmet health care needs in Hungary in ambulatory care due to costs and difficulties in travelling, and to analyze how unmet needs relate to socio-demographic characteristics. METHODS: The quantitative analysis is based on a national, representative online survey carried out in Hungary on a sample of 1000 respondents in early 2019 using a proposed set of questions developed by the OECD. We present and compare unmet medical needs in different socio-demographic groups, and we use multivariate logistic regression analysis to identify the main determinants of unmet medical needs. RESULTS: Among responders who had medical problems in the last 12 months, 27.3% reported forgone medical visit due to difficulties in travelling, 24.2% had unfilled prescription for medicine due to costs, 21.4% reported forgone medical visit or follow-up visit due to costs and 16.6% reported skipped medical test, treatment or other follow-up due to costs. These shares are much higher than presented previously in international databases. The logistic model indicates that respondents were significantly more likely to report unmet needs if they were women, younger or belonged to first and second income quintiles. CONCLUSIONS: Policy makers need to address the issue of high prevalence of forgone medical care among the Hungarian population to avoid deterioration of population health and inequalities in access. As a first step, policies should try to decrease financial burden of vulnerable groups to improve access.

Cost-of-illness studies in nine Central and Eastern European countries.

BACKGROUND: To date, a multi-country review evaluating the cost-of-illness (COI) studies from the Central and Eastern European (CEE) region has not yet been published. Our main objective was to provide a general description about published COI studies from CEE. METHODS: A systematic search was performed between 1 January 2006 and 1 June 2017 in Medline, EMBASE, The Cochrane Library, CINAHL, and Web of Science to identify all relevant COI studies from nine CEE countries. COI studies reporting costs without any restrictions by age, co-morbidities, or treatment were included. Methodology, publication standards, and cost results were analysed. RESULTS: We identified 58 studies providing 83 country-specific COI results: Austria (n = 9), Bulgaria (n = 16), Croatia (n = 3), the Czech Republic (n = 10), Hungary (n = 24), Poland (n = 11), Romania (n = 3), Slovakia (n = 3), and Slovenia (n = 4). Endocrine, nutritional, and metabolic diseases (18%), neoplasms (12%), infections (11%), and neurological disorders (11%) were the most frequently studied clinical areas, and multiple sclerosis was the most commonly studied disease. Overall, 57 (98%) of the studies explicitly stated the source of resource use data, 45 (78%) the study perspective, 34 (64%) the costing method, and 24 (58%) reported at least one unit costs. Regardless of methodological differences, a positive relationship was observed between costs of diseases and countries' per capita GDP. CONCLUSIONS: Cost-of-illness studies varied considerably in terms of methodology, publication practice, and clinical areas. Due to these heterogeneities, transferability of the COI results is limited across Central and Eastern European countries.

Subjective expectations regarding ageing: a cross-sectional online population survey in Hungary.

BACKGROUND: We aimed to investigate individuals' subjective expectations regarding health and happiness alongside their provisions on life circumstances for older ages. METHODS: A cross-sectional online survey was performed involving a representative sample (N = 1000; mean age 50.9, SD = 15.4; female 54.5%) in Hungary. Subjective expectations on health status (EQ-5D-3L/-5L, GALI, WHO-5), happiness (0-10 VAS), employment status, care time, and forms of care for ages 60, 70, 80, and 90 were surveyed. RESULTS: Current mean EQ-5D-5L was 0.869 (SD = 0.164) and happiness was 6.7 (SD = 2.4). Subjective life expectancy was 80.9 (SD = 11.1), and median expected retirement age was 65. Mean expected EQ-5D-5L for ages 60/70/80/90 was 0.761/0.684/0.554/0.402, and no activity limitations (GALI) were expected by 64%/40%/18%/14%, respectively. Expected happiness score was 6.8/6.7/6.2/5.7, and a decrease in mental well-being (WHO-5) was provisioned. A substantial increase in drug expenses and care time was anticipated, but only 52% thought to have extra income besides pension. The great majority expected to be helped by the family (77%/72%/53%/40%) if needed. Educational level, GALI, and longevity expectations were significant predictors of EQ-5D-5L expectations using a standard 5% significance level of decision. Current happiness was major determinant of expected future happiness. CONCLUSIONS: Individuals expect a significant deterioration of health with age but only a moderate decrease in happiness. Overestimation of future activity limitations suggests a gap between statistical and subjective healthy life expectancy. The majority expects to rely on informal care in the elderly. Raise in retirement age is underestimated. Our results can be used as inputs for economic modelling of labor force participation and ageing.

Biosimilars for the Management of Inflammatory Bowel Diseases: Economic Considerations.

Biological drugs revolutionized the treatment of inflammatory bowel diseases (IBD) such as Crohn's disease and ulcerative colitis. However, not all clinically eligible patients have access to biologicals due to significant costs and budget impact. Biosimilars are highly comparable to their originator product in terms of clinical efficacy and safety. Biosimilars are priced 15-75% lower than their reference product, which makes them a less costly alternative and is expected to offer better patients access to biologicals. The total projected cost savings are significant. If the achieved budget savings were used to cover more biological therapy, several additional IBD patients could be treated. Currently, the main barriers to the increasing uptake of biosimilars are the few incentives of the key stakeholders, while physicians' and patients' skepticism towards biosimilars seems to be changing. Over the coming years, biosimilars are expected to gain a growing importance in the treatment of IBD, contributing to a better access to treatment, improving population-level health gain and sustainability of health systems. This review summarizes the results of the literature on the economic considerations of biosimilars in IBD and the role of biosimilar infliximab in the treatment of IBD.

Cost-effectiveness of biological treatment sequences for fistulising Crohn's disease across Europe.

BACKGROUND: In clinical practice, treatment sequences of biologicals are applied for active fistulising Crohn's disease, however underlying health economic analyses are lacking. OBJECTIVE: The purpose of this study was to analyse the cost-effectiveness of different biological sequences including infliximab, biosimilar-infliximab, adalimumab and vedolizumab in nine European countries. METHODS: A Markov model was developed to compare treatment sequences of one, two and three biologicals from the payer's perspective on a five-year time horizon. Data on effectiveness and health state utilities were obtained from the literature. Country-specific costs were considered. Calculations were performed with both official list prices and estimated real prices of biologicals. RESULTS: Biosimilar-infliximab is the most cost-effective treatment against standard care across the countries (with list prices: €34684-€72551/quality adjusted life year; with estimated real prices: €24364-€56086/quality adjusted life year). The most cost-effective two-agent sequence, except for Germany, is the biosimilar-infliximab-adalimumab therapy compared with single biosimilar-infliximab (with list prices: €58533-€133831/quality adjusted life year; with estimated prices: €45513-€105875/quality adjusted life year). The cost-effectiveness of the biosimilar-infliximab-adalimumab-vedolizumab three-agent sequence compared wit biosimilar-infliximab -adalimumab is €87214-€152901/quality adjusted life year. CONCLUSIONS: The suggested first-choice biological treatment is biosimilar-infliximab. In case of treatment failure, switching to adalimumab then to vedolizumab provides meaningful additional health gains but at increased costs. Inter-country differences in cost-effectiveness are remarkable due to significant differences in costs.

Assessing quality of maternity care in Hungary: expert validation and testing of the mother-centered prenatal care (MCPC) survey instrument.

BACKGROUND: Instruments to assess quality of maternity care in Central and Eastern European (CEE) region are scarce, despite reports of poor doctor-patient communication, non-evidence-based care, and informal cash payments. We validated and tested an online questionnaire to study maternity care experiences among Hungarian women. METHODS: Following literature review, we collated validated items and scales from two previous English-language surveys and adapted them to the Hungarian context. An expert panel assessed items for clarity and relevance on a 4-point ordinal scale. We calculated item-level Content Validation Index (CVI) scores. We designed 9 new items concerning informal cash payments, as well as 7 new "model of care" categories based on mode of payment. The final questionnaire (N = 111 items) was tested in two samples of Hungarian women, representative (N = 600) and convenience (N = 657). We conducted bivariate analysis and thematic analysis of open-ended responses. RESULTS: Experts rated pre-existing English-language items as clear and relevant to Hungarian women's maternity care experiences with an average CVI for included questions of 0.97. Significant differences emerged across the model of care categories in terms of informal payments, informed consent practices, and women's perceptions of autonomy. Thematic analysis (N = 1015) of women's responses identified 13 priority areas of the maternity care experience, 9 of which were addressed by the questionnaire. CONCLUSIONS: We developed and validated a comprehensive questionnaire that can be used to evaluate respectful maternity care, evidence-based practice, and informal cash payments in CEE region and beyond.

Access to biologicals in Crohn's disease in ten European countries.

AIM: To analyze access (availability, affordability and acceptability) to biologicals for Crohn's disease (CD) in ten European countries and to explore the associations between these dimensions, the uptake of biologicals and economic development. METHODS: A questionnaire-based survey combined with desk research was carried out in May 2016. Gastroenterologists from the Czech Republic, France, Germany, Hungary, Latvia, Poland, Romania, Slovakia, Spain and Sweden were invited to participate and provide data on the availability of biologicals/biosimilars, reimbursement criteria, clinical practice and prices, and use of biologicals. An availability score was developed to evaluate the restrictiveness of eligibility and administrative criteria applied in the countries. Affordability was defined as the annual cost of treatment as a share of gross domestic product (GDP) per capita. Correlations with the uptake of biologicals, dimensions of access and GDP per capita were calculated. RESULTS: At the time of the survey, infliximab and adalimumab were reimbursed in all ten countries, and vedolizumab was reimbursed in five countries (France, Germany, Latvia, Slovakia, Sweden). Reimbursement criteria were the least strict in Sweden and Germany, and the strictest in Hungary, Poland and Slovakia. Between countries, the annual cost of different biological treatments differed 1.6-3.3-fold. Treatments were the most affordable in Sweden (13%-37% of the GDP per capita) and the least affordable in the Central and Eastern European countries, especially in Hungary (87%-124%) and Romania (141%-277%). Biosimilars made treatments more affordable by driving down the annual costs. The number of patients with CD on biologicals per 100000 population was strongly correlated with GDP per capita (0.91), although substantial differences were found in the uptake among countries with similar economic development. Correlation between the number of patients with CD on biologicals per 100000 population and the availability and affordability was also strong (-0.75, -0.69 respectively). CONCLUSION: Substantial inequalities in access to biologicals were largely associated with GDP. To explain differences in access among countries with similar development needs further research on acceptance.

Informal cash payments for birth in Hungary: Are women paying to secure a known provider, respect, or quality of care?

BACKGROUND: In Central and Eastern Europe, many women make informal cash payments to ensure continuity of provider, i.e., to have a "chosen" doctor who provided their prenatal care, be present for birth. High rates of obstetric interventions and disrespectful maternity care are also common to the region. No previous study has examined the associations among informal payments, intervention rates, and quality of maternity care. METHODS: We distributed an online cross-sectional survey in 2014 to a nationally representative sample of Hungarian internet-using women (N = 600) who had given birth in the last 5 years. The survey included items related to socio-demographics, type of provider, obstetric interventions, and experiences of care. Women reported if they paid informally, and how much. We built a two-part model, where a bivariate probit model was used to estimate conditional probabilities of women paying informally, and a GLM model to explore the amount of payments. We calculated marginal effects of the covariates (provider choice, interventions, respectful care). RESULTS: Many more women (79%) with a chosen doctor paid informally (191 euros on average) compared to 17% of women without a chosen doctor (86 euros). Based on regression analysis, the chosen doctor's presence at birth was the principal determinant of payment. Intervention and procedure rates were significantly higher for women with a chosen doctor versus without (cesareans 45% vs. 33%; inductions 32% vs. 19%; episiotomy 75% vs. 62%; epidural 13% vs. 5%), but had no direct effect on payments. Half of the sample (42% with a chosen doctor, 62% without) reported some form of disrespectful care, but this did not reduce payments. CONCLUSION: Despite reporting disrespect and higher rates of interventions, women rewarded the presence of a chosen doctor with informal payments. They may be unaware of evidence-based standards, and trust that their chosen doctor provided high quality maternity care.

Long-term costs and survival of prostate cancer: a population-based study.

PURPOSE: There is a rising interest in measuring the societal burden of malignancies including prostate cancer. However, population-based studies reporting incidence costs of prostate cancer in the long term are lacking in Europe. The objectives of the study are to analyse the long-term costs and survival of prostate cancer patients treated by radical prostatectomy (RP) or conservative management (nRP). METHODS: A retrospective claims data analysis of the National Health Insurance Found Administration of Hungary between 01.01.2002 and 31.10.2013 was carried out. Annual incidence costs related to prostate cancer and overall survival were calculated for a cohort of patients diagnosed between 2002 and 2005. RESULTS: Altogether 17,642 patients were selected; 2185 (12%) of them have undergone RP. The annual incidence rate ranged between 4177 and 4736 cases. Mean age of RP and nRP patients was 59.4 (SD 5.9) and 71.0 (8.4) years, respectively. The mean survival time of the RP patients was significantly longer compared to nRP patients both in the total sample (11.2 vs. 7.4 years; p < 0.001) and in the subgroup <70 years (11.3 vs. 8.8 years; p < 0.001). At the end of the 12-year follow-up, RP patients had a higher (0.83 vs. 0.68), while nRP patients had a slightly lower (0.35 vs. 38) probability of being alive compared with the age-matched general male population. The long-term cumulative costs of the RP and nRP patients amounted to €4448 and €8616. The main driver of the cost difference was the high drug costs in the nRP group. CONCLUSIONS: To our knowledge, this study applied the longest time-window in reporting population-based incidence costs in Europe. We found that not only RP patients lived longer but they had significantly lower total long-term costs than nRP patients. Therefore, radical prostatectomy is a cost-effective strategy in prostate cancer.

EQ-5D studies in musculoskeletal and connective tissue diseases in eight Central and Eastern European countries: a systematic literature review and meta-analysis.

EQ-5D is becoming the preferred instrument to measure health-state utilities involved in health technology assessment. The objective of this study is to assess the state of EQ-5D research in musculoskeletal disorders in 8 Central and Eastern European countries and to provide a meta-analysis of EQ-5D index scores. Original research articles published in any language between Jan 2000 and Sept 2016 were included, if they reported any EQ-5D outcome from at least two musculoskeletal patients from Austria, Bulgaria, the Czech Republic, Hungary, Poland, Romania, Slovakia, or Slovenia. Risk of bias was assessed with the Cochrane Collaboration's tool. Twenty-nine articles (5992 patients) were included on rheumatoid arthritis (n = 7), osteoporosis (n = 5), chronic pain (n = 5), osteoarthritis (n = 4), ankylosing spondylitis (n = 2), psoriatic arthritis (n = 2), total hip replacement (n = 2), and scleroderma (n = 2). Low back pain was under-represented, while studies in neck pain, systemic lupus erythematosus, gout, and childhood disorders were lacking. EQ-5D index scores were reported in 24 studies, while the version of the instrument and the value-set was not specified in 41% and 46% of the articles, respectively. Meta-analysis was performed on 24 disease states involving 6876 observation points. Intervention effect was reported in 22 subgroups, out of which risk of bias was low in 41%. This review provides recommendations to improve reporting standards of EQ-5D results and highlights potential areas for future research. Coordinated research in conditions with greatest public health impact as well as a development of a regional value-set could provide locally relevant health-state utilities that are transferable among countries within the region.