Assessing oral health-related quality of life among older people in home-based care - survey results of the InSEMaP study in Germany.

BACKGROUND: Older people receiving home-based care (HBC) often face barriers to access preventive oral health care (OHC) and dental treatments. Leading to deterioration of their oral healthcare. It is further deteriorated by factors such as increasing burden of systemic diseases, medicinal side effects, limited mobility, financial constraints and lack of professional OHC at home. Older people also struggle to maintain necessary daily oral hygiene, leading to malnutrition, weight loss, and a risk of a further health degradation. This cross-sectional survey aimed to investigate the oral health-related quality of life (OHRQoL) and their associated factors in HBC recipients. METHODS: 5,280 older people (≥ 60 years) living in Hamburg, who were in need of care and insured with statutory health insurance DAK-Gesundheit received the questionnaire, which included the German version of the Oral Health Impact Profile (OHIP G-14) and, the EQ-5D health-related quality of life (HRQoL) measure as well as further questions regarding the extent of informal social support, subjective oral health status, oral health behaviour, subjective cognitive status, and socio-demographic variables. RESULTS: The participants (n = 1,622) had a median age of 83.2 years, with 72.0% of the sample being female. Nearly two thirds of the sample reported that their independence or abilities were significantly impaired (care level 2). Regarding oral health impacts, 40.0% of the participants reported experiencing at least one of the fourteen possible prevalent impacts of the OHIP-G14 fairly often or very often. A multivariate regression model on the severity of oral health impacts revealed, that a better HRQoL, a positive perception of one's own dental status, fewer visits to dental practices, and no need for support in OHC were associated with better OHRQoL. Conversely, respondents with a negative perception of their oral health status, more frequent visits to a dental practice, a need for support in OHC, and subjective memory impairment showed poorer OHRQoL. CONCLUSIONS: The results highlight the risk for poor oral health among older people in HBC. We conclude that there is an urgent need to prioritise oral health, especially as poor oral health can further compromise the systemic wellbeing of these already care dependent population.

[Updating standardized unit costs from a societal perspective for health economic evaluation]. / Aktualisierung der standardisierten Bewertungssätze aus gesellschaftlicher Perspektive für gesundheitsökonomische Evaluationen.

AIM OF THE STUDY: The aim of this work was to update the 2015 unit costs (UC) for the monetary valuation of health-related resource use from a societal perspective for the years 2019 and 2020 in Germany. METHODS: The update follows the methodology of Bock et al. 2015. Based on the newly established care levels, UC for care degree 1 to 5 are now provided. To account for change in price trends during the Covid-19 pandemic, average growth rates in UC are shown from 2011-2019 and compared to 2019-2020. RESULTS: Updates of UC for the outpatient medical sector, remedies and aids, hospitals, (in)formal care services, and rehabilitation for 2019 and 2020 are provided. CONCLUSION: The updated UC can be used as reference values for the monetary valuation of individual resource use in health economic evaluations in Germany.

The identification of economically relevant health and social care services for mental disorders in the PECUNIA project.

BACKGROUND: Health economic research is still facing significant problems regarding the standardization and international comparability of health care services. As a result, comparative effectiveness studies and cost-effectiveness analyses are often not comparable. This study is part of the PECUNIA project, which aimed to improve the comparability of economic evaluations by developing instruments for the internationally standardized measurement and valuation of health care services for mental disorders. The aim of this study was to identify internationally relevant services in the health and social care sectors relevant for health economic studies for mental disorders. METHODS: A systematic literature review on cost-of-illness studies and economic evaluations was conducted to identify relevant services, complemented by an additional grey literature search and a search of resource use measurement (RUM) questionnaires. A preliminary long-list of identified services was explored and reduced to a short-list by multiple consolidation rounds within the international research team and an external international expert survey in six European countries. RESULTS: After duplicate removal, the systematic search yielded 15,218 hits. From these 295 potential services could be identified. The grey literature search led to 368 and the RUM search to 36 additional potential services. The consolidation process resulted in a preliminary list of 186 health and social care services which underwent an external expert survey. A final consolidation step led to a basic list of 56 services grouped into residential care, daycare, outpatient care, information for care, accessibility to care, and self-help and voluntary care. CONCLUSIONS: The initial literature searches led to an extensive number of potential service items for health and social care. Many of these items turned out to be procedures, interventions or providing professionals rather than services and were removed from further analysis. The resulting list was used as a basis for typological coding, the development of RUM questionnaires and corresponding unit costs for international mental health economic studies in the PECUNIA project.

Cost-Effectiveness of Inter-Professional Collaboration to Reduce Hospitalisations in Nursing Home Residents: Results from the German Interprof ACT Trial.

Background: The German multi-centre cluster-randomised controlled trial interprof ACT investigated interventions to increase inter-professional collaboration between nursing home (NH) staff and local general practitioners to reduce hospitalisations and improve nursing homes residents' (NHRs) quality of life. The trial was funded by the German Health Care Innovation Fund. Methods: Cost-effectiveness of interprof ACT interventions was evaluated and compared to current standard of care (SOC) over 12 months, including 622 NHRs in 34 NHs in Germany. Multiplying resource use of healthcare services with German-specific unit costs generated costs. Health outcome was measured in quality-adjusted life-years QALYs), utility by multiplying EQ-5D-5L values with German-specific utility weights. Incremental cost-effectiveness analysis used an intention-to-treat approach and scenario analyses (SAs). Net-benefit-regression and cost-effectiveness acceptability curves addressed uncertainty. A German healthcare insurance perspective was assumed. Results: Base case results showed non-significant cost savings of 851.88€ and non-significant QALY loss of -0,056. Discussion: Dependency levels at baseline were non-significantly higher in IG compared to control group (CG). Lack of baseline costing data eliminated possibility to evaluate changes in costs due to the interprof ACT measures for both groups. Conclusion: Interprof ACT interventions are not cost-effective compared to current SOC.

Development of an Instrument for the Assessment of Health-Related Multi-sectoral Resource Use in Europe: The PECUNIA RUM.

BACKGROUND: Measuring objective resource-use quantities is important for generating valid cost estimates in economic evaluations. In the absence of acknowledged guidelines, measurement methods are often chosen based on practicality rather than methodological evidence. Furthermore, few resource-use measurement (RUM) instruments focus on the measurement of resource use in multiple societal sectors and their development process is rarely described. Thorn and colleagues proposed a stepwise approach to the development of RUM instruments, which has been used for developing cost questionnaires for specific trials. However, it remains unclear how this approach can be translated into practice and whether it is applicable to the development of generic self-reported RUM instruments and instruments measuring resource use in multiple sectors. This study provides a detailed description of the practical application of this stepwise approach to the development of a multi-sectoral RUM instrument developed within the ProgrammE in Costing, resource use measurement and outcome valuation for Use in multi-sectoral National and International health economic evaluAtions (PECUNIA) project. METHODS: For the development of the PECUNIA RUM, the methodological approach was based on best practice guidelines. The process included six steps, including the definition of the instrument attributes, identification of cost-driving elements in each sector, review of methodological literature and development of a harmonized cross-sectorial approach, development of questionnaire modules and their subsequent harmonization. RESULTS: The selected development approach was, overall, applicable to the development of the PECUNIA RUM. However, due to the complexity of the development of a multi-sectoral RUM instrument, additional steps such as establishing a uniform methodological basis, harmonization of questionnaire modules and involvement of a broader range of stakeholders (healthcare professionals, sector-specific experts, health economists) were needed. CONCLUSION: This is the first study that transparently describes the development process of a generic multi-sectoral RUM instrument in health economics and provides insights into the methodological aspects and overall validity of its development process.

Excess costs of mental disorders by level of severity.

INTRODUCTION: Mental disorders are highly prevalent in Germany, and associated with decreased quality of life for those affected as well as high economic burden for the society. The purpose of this study was to determine the excess costs of mental disorders and to examine how these differ with respect to disease severity. METHODS: We analyzed mean 6-month costs using the baseline data from the RECOVER trial in Hamburg, Germany, which evaluates an innovative stepped-care model for mental disorders. Four severity levels were classified based on the current level of mental illness, loss of functioning, and psychiatric diagnosis. In this work, direct costs (outpatient, inpatient, and social/informal care) and indirect costs (sick leave, unemployment, and early retirement) were estimated using interview-based data on health care utilization and productivity losses. Excess costs were determined by matching a comparison group of the German general population without mental disorders. Group differences in sociodemographic covariates and somatic comorbidities were balanced using entropy balancing. Excess costs by severity levels were estimated using generalized linear models (GLM) with gamma distribution and log-link function. RESULTS: Overall, the RECOVER group included n = 816 and the comparison group included n = 3226 individuals. Mean total 6-month excess costs amounted to 19,075€, with higher indirect excess costs (13,331€) than direct excess costs (5744€) in total excess costs. The excess costs increased with increasing disease severity, ranging from 6,123€ with mild disease severity (level 1) to 31,883€ with severe mental illness (level 4). Indirect excess costs ranged from 5612€ in level 1 to 21,399€ in level 4, and were statistically significant for all disease severity levels. In contrast, direct excess costs were only statistically significant for the levels 2 to 4, and ranged from 511€ in level 1 to 10,485€ in level 4. The main cost drivers were hospital stays (level 2-4), sick leave and unemployment (all levels), and early retirement (level 3-4). DISCUSSION: Mental disorders are associated with high costs that increase with the level of disease severity, which was also shown for individual ICD-10 diagnosis groups. Due to their influence on costs, indirect costs and disease severity levels should be considered in future cost-of-illness studies of mental disorders. CLINICAL TRIAL REGISTRATION: clinicaltrials.gov, trial registration number NCT03459664.

Mixed-methods investigation of barriers and needs in mental healthcare of adults with autism and recommendations for future care (BarrierfreeASD): study protocol.

INTRODUCTION: Autism refers to an early-onset neurodevelopmental condition with characteristic impairments and difficulties in practical living skills, which persist across the lifespan such that adults with autism often require substantial support and comprehensive care. Yet, mental health and other services are frequently unavailable for adults with autism despite considerable need for mental healthcare and individual, familial and socioeconomic burdens. This study will (1) examine current needs, barriers and burdens related to ineffective healthcare of adults with autism in Germany, (2) develop specific recommendations for a need-oriented mental healthcare model and (3) evaluate its future implementation. METHODS AND ANALYSIS: A mixed-methods design with three phases will be conducted. In phase 1, current mental healthcare for adults with autism will be assessed at three levels (individual, structural and professional) and from three perspectives (adults with autism, relatives and healthcare providers) using (1) focus groups/interviews (qualitative data) and (2) large-scale online surveys (quantitative data). Furthermore, service utilisation and related costs will be estimated. In phase 2, recommendations for a future healthcare model will be derived based on phase 1, considering the heterogeneous and complex needs within the autism spectrum and specifying indications for recommended services. In phase 3, these will again be evaluated by the three stakeholder groups using mixed-methods and analysed regarding feasibility of implementation and cost-effectiveness. Our study will, thus, contribute to a better translation of recommendations into practice to reduce disability, burden and costs related to ineffective healthcare and improve mental health outcomes for adults with autism and those who support them. ETHICS AND DISSEMINATION: This study was approved by the Local Psychological Ethics Commission of the Center for Psychosocial Medicine at the University Medical Center Hamburg-Eppendorf (LPEK-0227). Findings will be disseminated via scientific meetings and peer-reviewed journals. Cooperating partners and associations will be informed about the study's course and findings by regular newsletters and meetings. TRIAL REGISTRATION NUMBER: This study protocol was preregistered at the Open Science Framework (osf.io/5x8pg).

In Search for Comparability: The PECUNIA Reference Unit Costs for Health and Social Care Services in Europe.

Improving the efficiency of mental healthcare service delivery by learning from international best-practice examples requires valid data, including robust unit costs, which currently often lack cross-country comparability. The European ProgrammE in Costing, resource use measurement and outcome valuation for Use in multi-sectoral National and International health economic evaluAtions (PECUNIA) aimed to harmonize the international unit cost development. This article presents the methodology and set of 36 externally validated, standardized reference unit costs (RUCs) for five health and social care services (general practitioner, dentist, help-line, day-care center, nursing home) in Austria, England, Germany, Hungary, The Netherlands, and Spain based on unambiguous service definitions using the extended DESDE PECUNIA coding framework. The resulting PECUNIA RUCs are largely comparable across countries, with any causes for deviations (e.g., country-specific scope of services) transparently documented. Even under standardized methods, notable limitations due to data-driven divergences in key costing parameters remain. Increased cross-country comparability by adopting a uniform methodology and definitions can advance the quality of evidence-based policy guidance derived from health economic evaluations. The PECUNIA RUCs are available free of charge and aim to significantly improve the quality and feasibility of future economic evaluations and their transferability across mental health systems.

Patient-centered placement matching of alcohol-dependent patients based on a standardized intake assessment: process evaluation within an exploratory randomized controlled trial.

BACKGROUND: In the implementation of placement matching guidelines, feasibility has been concerned in previous research. Objectives of this process evaluation were to investigate whether the patient-centered matching guidelines (PCPM) are consistently applied in referral decision-making from an inpatient qualified withdrawal program to a level of care in aftercare, which factors affect whether patients actually receive matched aftercare according to PCPM, and whether its use is feasible and accepted by clinic staff. METHODS: The study was conducted as process evaluation within an exploratory randomized controlled trial in four German psychiatric clinics offering a 7-to-21 day qualified withdrawal program for patients suffering from alcohol dependence, and with measurements taken during detoxification treatment and six months after the initial assessment. PCPM were used with patients in the intervention group by feeding back to them a recommendation for a level of care in aftercare that had been calculated from Measurements in the Addictions for Triage and Evaluation (MATE) and discussed with the staff on the treatment unit. As measurements, The MATE, the Client Socio-Demographic and Service Receipt Inventory-European Version, a documentation form, the Control Preference Scale, and the Motivation for Treatment Scale were administered. A workshop for the staff at the participating trial sites was conducted after data collection was finished. RESULTS: Among 250 patients participating in the study, 165 were interviewed at follow-up, and 125 had received aftercare. Although consistency in the application of PCPM was moderate to substantial within the qualified withdrawal program (Cohen's kappa ≥ .41), it was fair from discharge to follow-up. In multifactorial multinomial regression, the number of foregoing substance abuse treatments predicted whether patients received more likely undermatched (Odds Ratio=1.27; p=.018) or overmatched (Odds Ratio=0.78; p=.054) treatment. While the implementation process during the study was evaluated critically by the staff, they stated a potential of quality assurance, more transparency and patient-centeredness in the use of PCPM. CONCLUSIONS: While the use of PCPM has the potential to enhance the quality of referral decision making within treatment, it may not be sufficient to determine referral decisions for aftercare. TRIAL REGISTRATION: German Clinical Trials Register DRKS00005035 . Registered 03/06/2013.

Cost-Effectiveness of Magnetic Resonance Imaging-Guided Thrombolysis for Patients With Stroke With Unknown Time of Onset.

OBJECTIVES: Patients waking up with stroke symptoms are often excluded from intravenous thrombolysis with alteplase (IV-tpa). The WAKE-UP trial, a European multicenter randomized controlled trial, proved the clinical effectiveness of magnetic resonance imaging-guided IV-tpa for these patients. This analysis aimed to assess the cost-effectiveness of the intervention compared to placebo. METHODS: A Markov model was designed to analyze the cost-effectiveness over a 25-year time horizon. The model consisted of an inpatient acute care phase and a rest-of-life phase. Health states were defined by the modified Rankin Scale (mRS). Initial transition probabilities to mRS scores were based on WAKE-UP data and health state utilities on literature search. Costs were based on data from the University Medical Center Hamburg-Eppendorf, literature, and expert opinion. Incremental costs and effects over the patients' lifetime were estimated. The analysis was conducted from a formal German healthcare perspective. Univariate and probabilistic sensitivity analyses were performed. RESULTS: Treatment with IV-tpa resulted in cost savings of €51 009 and 1.30 incremental gains in quality-adjusted life-years at a 5% discount rate. Univariate sensitivity analysis revealed incremental cost-effectiveness ratio being sensitive to the relative risk of favorable outcome on mRS for placebo patients after stroke, the costs of long-term care for patients with mRS 4, and patient age at initial stroke event. In all cases, IV-tpa remained cost-effective. Probabilistic sensitivity analysis proved IV-tpa cost-effective in >95% of the simulations results. CONCLUSIONS: Magnetic resonance imaging-guided IV-tpa compared to placebo is cost-effective in patients with ischemic stroke with unknown time of onset.

The Excess Costs of Dementia: A Systematic Review and Meta-Analysis.

BACKGROUND: Dementia is one of the costliest diseases for health care systems with growing importance for policy makers. OBJECTIVE: The aim of this study is to systematically review the current literature of excess cost studies for dementia and to analyze excess costs in a meta-analysis. METHODS: A systematic literature search was conducted in PubMed, EconLit, NHS-EED, and Cochrane Library. 22 studies were included and assigned to one of three subgroups according to the time period that they analyzed during disease progression: the time of diagnosis, the time between diagnosis and death, and the time prior to death. Excess costs were analyzed using the ratio of means (ROM) and meta-analysis was performed by pooling ROMs in a random effects model. RESULTS: Total costs were significantly higher for demented persons compared to non-demented persons at the time of diagnosis (ROM: 2.08 [1.71, 2.54], p < 0.00001, I2 = 98%) and in the time period between diagnosis and death (ROM: 2.19 [1.97, 2.44], p < 0.00001, I2 = 100%). The ROM was highest for professional home care (ROM: 4.96 [2.62, 9.40], p < 0.0001, I2 = 88%) and for nursing facilities (ROM: 4.02 [2.53, 6.40], p < 0.00001, I2 = 100%) for the time period between diagnosis and death. CONCLUSION: This meta-analysis is the first to assess excess costs of dementia by the ROM method on a global scale. We conclude that our findings demonstrate that costs of dementia constitute a substantial economic burden.

Excess costs of type 2 diabetes and their sociodemographic and clinical determinants: a cross-sectional study using data from the German Health Interview and Examination Survey for Adults (DEGS1).

OBJECTIVES: The objectives of this study were to estimate the direct and indirect excess costs of type 2 diabetes mellitus (T2D) using data representative for the German adult population and to investigate the association of sociodemographic and clinical determinants with these excess costs. SETTING: We calculated mean annual costs for individuals with T2D and a control group without diabetes, using data on healthcare utilisation and productivity losses from the cross-sectional German Health Interview and Examination Survey for Adults. We adjusted for group differences using entropy balancing and estimated excess costs for total, direct, indirect costs and additional cost categories using generalised linear models. We performed subgroup analyses to investigate the association of sociodemographic (age, sex and education) and clinical determinants (diabetes duration, glycaemic index and complications) with excess costs. PARTICIPANTS: The final study sample included n=325 individuals with T2D and n=4490 individuals without diabetes in the age between 18 and 79 years. RESULTS: Total excess costs amounted to €927, of which €719 were attributable to direct and €209 to indirect excess costs. Total costs were significantly increased by 28% for T2D compared with controls. Group differences in direct, outpatient and medication costs were statistically significant. Medication costs were 88% higher for T2D and had the highest share in direct excess costs. With respect to specific determinants, direct excess costs ranged from €203 for 4-10 years diabetes duration to €1405 for diabetes complications. Indirect excess costs ranged from €-544 for >10 years diabetes duration to €995 for high education. CONCLUSIONS: T2D was associated with high costs, mainly due to direct costs. As pointed out by our results, diabetes complications and comorbidities have a large impact on the costs, leaving medication costs as main contributor of T2D excess costs.

[Costs of Depression in Germany - Systematic Review]. / Kosten der Depression in Deutschland.

OBJECTIVE: Depression is a common mental disorder associated with a high economic burden. Aim of this study was to review cost-of-illness studies of depression in Germany. METHODS: We conducted a systematic literature search of bottom-up cost-of-illness-studies of depression in adults in Germany. Included studies were classified into three groups depending on their costing approach (total health care cost studies, disease-specific health care cost studies, excess cost studies). RESULTS: Depending on the type of cost calculation the average total costs per patient and year varied between 400-3,300 € for disease-specific costs, 3,000 € for excess costs and 3,000-5,000 € for total health care costs. There were no results for indirect costs in most studies. CONCLUSION: Depression in Germany is associated with high costs, but especially indirect costs are missing in the current literature and should be examined more intensively.

The Excess Costs of Depression and the Influence of Sociodemographic and Socioeconomic Factors: Results from the German Health Interview and Examination Survey for Adults (DEGS).

INTRODUCTION: The aim of this study was to estimate excess costs of depression in Germany and to examine the influence of sociodemographic and socioeconomic determinants. METHODS: Annual excess costs of depression per patient were estimated for the year 2019 by comparing survey data of individuals with and without self-reported medically diagnosed depression, representative for the German population aged 18-79 years. Differences between individuals with depression (n = 223) and without depression (n = 4540) were adjusted using entropy balancing. Excess costs were estimated using generalized linear model regression with a gamma distribution and log-link function. We estimated direct (inpatient, outpatient, medication) and indirect (sick leave, early retirement) excess costs. Subgroup analyses by social determinants were conducted for sex, age, socioeconomic status, first-generation or second-generation migrants, partnership, and social support. RESULTS: Total annual excess costs of depression amounted to €5047 (95% confidence interval [CI] 3214-6880) per patient. Indirect excess costs amounted to €2835 (1566-4103) and were higher than direct excess costs (€2212 [1083-3341]). Outpatient (€498), inpatient (€1345), early retirement (€1686), and sick leave (€1149) excess costs were statistically significant, while medication (€370) excess costs were not. Regarding social determinants, total excess costs were highest in the younger age groups (€7955 for 18-29-year-olds, €9560 for 30-44-year-olds), whereas total excess costs were lowest for the oldest age group (€2168 for 65+) and first-generation or second-generation migrants (€1820). CONCLUSIONS: Depression was associated with high excess costs that varied by social determinants. Considerable differences between the socioeconomic and sociodemographic subgroups need further clarification as they point to specific treatment barriers as well as varying treatment needs.

Patient-Centered Placement Matching of Alcohol-Dependent Patients Based on a Standardized Intake Assessment: Primary Outcomes of an Exploratory Randomized Controlled Trial.

BACKGROUND: Placement matching guidelines are promising means to optimize patient-centered care and to match patients' treatment needs. Despite considerable research regarding placement matching approaches to optimize alcohol abuse treatment, findings are inconclusive. OBJECTIVES: To investigate whether the use of patient-centered placement matching (PCPM) guidelines is more effective in reducing heavy drinking and costs 6 months after discharge from an inpatient alcohol withdrawal treatment compared to usual referral to aftercare. Secondary aims were to investigate whether age, gender, trial site or level of care (LOC) are moderators of efficacy and whether patients who were actually referred to the recommended LOC had better treatment outcomes compared to patients who were treated under- or overmatched. METHODS: Design. Exploratory randomized controlled trial with measurements during withdrawal treatment and 6 months after initial assessment. SETTING: Four German psychiatric clinics offering a 7-21 day inpatient qualified withdrawal program for patients suffering from alcohol dependence. PARTICIPANTS: From 1,927 patients who had a primary diagnosis of alcohol dependence and did not have organized aftercare when entering withdrawal treatment, 299 were invited to participate. Of those, 250 were randomized to the intervention group (IG, n = 123) or the control group (CG, n = 127). INTERVENTION: The PCPM were applied to patients of the IG by feeding back a recommendation to a LOC for aftercare that was calculated from the Measurements in the Addictions for Triage and Evaluation (MATE) and discussed with the staff of the treatment unit. Patients of the CG received a general feedback regarding their MATE interview on request. MEASUREMENTS: The MATE, the Client Socio-Demographic and Service Receipt Inventory--European Version and the MATE-Outcomes were administered. Data were analyzed using generalized linear models. RESULTS: In the intention-to-treat analysis, there were no significant differences between IG and CG regarding days of heavy drinking (incident risk ratio [IRR] 1.09; p = 0.640), direct (IRR 1.06; p = 0.779), indirect (IRR 0.77; p = 0.392) and total costs (IRR 0.89; p = 0.496). Furthermore, none of the investigated moderator variables affected statistically significant drinking or cost-related primary outcomes. Regardless of group allocation, patients who received matched aftercare reported significantly fewer days of heavy drinking than undermatched patients (IRR 2.09; p = 0.004). For patients who were overmatched, direct costs were significantly higher (IRR 1.79; p = 0.024), but with no additional effects on alcohol consumption compared to matched patients. CONCLUSIONS: While the use of PCPM failed to affect the actual referral to aftercare, our findings suggest that treating patients on the recommended LOC may have the potential to reduce days of heavy drinking compared to undertreatment and costs compared to overtreatment.

Economic Burden of Anxiety Disorders: A Systematic Review and Meta-Analysis.

BACKGROUND: Anxiety disorders (AD) are common mental disorders, for which several cost-of-illness (COI) studies have been conducted in the past. OBJECTIVE: The aim of this review was to provide a systematic overview of these studies and an aggregation of their results. METHODS: A systematic literature search limited to studies published after 1999 was conducted in PubMed/MEDLINE in November 2018. We included top-down COI studies reporting costs for AD, and bottom-up COI studies reporting costs for AD and a non-diseased control group, and extracted data manually. Results of the top-down COI studies were aggregated by calculating the mean percentage of costs on gross domestic product (GDP) and health expenditure, while the results of the bottom-up studies were analyzed meta-analytically using the 'ratio of means' method and inverse-variance pooling. In this review, the logarithm of the relative difference in a continuous outcome between two groups is calculated and aggregated over the studies. The results can be interpreted as the relative change in costs imposed by a specific disease compared with baseline costs. RESULTS: We identified 13 top-down and 11 bottom-up COI studies. All top-down COI studies and four bottom-up COI studies reported costs for AD as a diagnostic group, four for generalized anxiety disorder (GAD), four for social anxiety disorder (SAD), and one for panic disorder. In top-down COI studies, direct costs of AD, on average, corresponded to 2.08% of health care costs and 0.22% of GDP, whereas indirect costs, on average, corresponded to 0.23% of GDP. In bottom-up COI studies, direct costs of patients with AD were increased by factor 2.17 (1.29-3.67; p = 0.004) and indirect costs were increased by factor 1.92 (1.05-3.53; p = 0.04), whereas total costs increased by factor 2.52 (1.73-3.68; p < 0.001). Subgroup analysis revealed an increase in direct costs by 1.60 (1.16-2.22; p = 0.005) for SAD and 2.60 (2.01-3.36; p < 0.001) for GAD. Measures of heterogeneity indicated high heterogeneity when pooling studies for direct costs, indirect costs, and total costs, but low to moderate heterogeneity when pooling studies for SAD or GAD. CONCLUSIONS: Using methods that focused on relative rather than absolute costs, we were able to aggregate costs reported in different COI studies for ADs. We found that ADs were associated with a low proportion of health care costs on a population level, but significantly increased health care costs on an individual level compared with healthy controls. Our disorder-specific subgroup analysis showed that study findings are most homogeneous within specific ADs. Therefore, to get a more detailed picture of the costs of ADs, more studies for currently under researched ADs, such as panic disorder, are needed.

The allocation of resources in the care for patients with panic disorder in Germany: an excess cost analysis informing policy and science.

BACKGROUND: Panic disorder is a mental disorder of high prevalence, which frequently co-occurs with agoraphobia. There is a lack of studies measuring excess costs of panic disorder patients with and without agoraphobia. We compared costs of panic disorder patients with or without agoraphobia with costs of the anxiety-free population in Germany. METHODS: Primary data from a cluster-randomized trial of adults suffering from panic disorder (n = 419) and from a representative survey of the German general population (N = 5005) were collected between 2012 and 2014. Missing data from the cluster-randomized trial were first imputed by multiple imputation using chained equations and subsequently balanced with the data from the survey by Entropy Balancing. The societal perspective was chosen. Excess costs were calculated by generalized linear models and two-part-models. RESULTS: Entropy Balancing led to an exact match between the groups. We found 6-month total excess costs of 3220€ (95% CI 1917€-4522€) for panic disorder patients without agoraphobia and of 3943€ (95% CI 2950€-4936€) for patient with agoraphobia. Panic disorder patients with or without agoraphobia had significantly higher costs for psychotherapy, general practitioners, general hospital stays and informal care Indirect costs accounted for approximately 60% of the total excess costs. CONCLUSIONS: Panic disorder with or without agoraphobia is associated with significant excess costs. Agoraphobia changes the pattern of resource utilization. Especially indirect costs are relevant. Agoraphobia influences resource utilization in the inpatient sector.Trial registration ISRCTN64669297.

Health-related quality of life measured with the EQ-5D-5L: estimation of normative index values based on a representative German population sample and value set.

BACKGROUND: The generic and preference-based instrument EQ-5D is available in a five-response levels version (EQ-5D-5L). A value set for the EQ-5D-5L based on a representative sample of the German population has recently been developed. The aim of this study was to estimate normative values of the EQ-5D-5L index for Germany, and to examine associations between the EQ-5D-5L and selected sociodemographic factors. METHODS: The analysis was based on a representative sample (n = 4998) of the German general adult population in 2014. Participants had to rate their health-related quality of life on the EQ-5D-5L descriptive system as well as on a visual analogue scale (EQ-VAS). Normative values of the EQ-5D-5L index were estimated for selected sociodemographic characteristics. For the examination of associations between EQ-5D-5L index scores and selected sociodemographic factors, multivariate regression analyses were used. RESULTS: The mean EQ-5D-5L index score of the total sample was 0.88 (SD 0.18), corresponding to an overall mean EQ-VAS score of 71.59 (SD 21.36). Female gender and increasing age were associated with a lower EQ-5D-5L index score (p < 0.001). Higher education, full-time employment and private health insurance were associated with a higher EQ-5D-5L index score (p < 0.001). CONCLUSION: This was the first study to estimate normative values of the EQ-5D-5L index for Germany based on a representative sample. The German normative values of the EQ-5D-5L are comparable to those reported for other countries. However, the mean EQ-5D-5L index score of the total sample was worse than those of the samples of studies from other countries.

Out-of-pocket-payments and the financial burden of 502 cancer patients of working age in Germany: results from a longitudinal study.

PURPOSE: Cancer patients in Germany often face payments related to their disease or treatment which are not covered by their health insurance. The aim of this study was to analyze the amount of out-of-pocket payments (OOPPs) among cancer patients in Germany, to explore potential socioeconomic determinants of OOPPs, and to identify how cancer patients are burdened by these payments. METHODS: Cancer ptients were consecutively enrolled in 16 clinics in Leipzig, Germany. Data on OOPPs for the past 3 months and on socioeconomic status were obtained at the end of their hospital stay (t0) and 3 (t1) and 15 months (t2) after t0. Financial burden was calculated by dividing the monthly OOPPs by the midpoint of the income category, and the perceived burden was assessed by using the financial difficulties scale of the EORTC QLQ-C30. A two-part regression model was used to estimate the determinants of OOPPs. RESULTS: At baseline (t0), 502 cancer patients participated in the study and provided data on OOPPs and socioeconomic status. The mean 3-month OOPPs were the following: €205.8 at baseline, €179.2 at t1, and €148.1 at t2. Compared to the lowest income group (< €500 monthly), all other income groups (€500-999, €1000-1499, and ≥ €1500) had higher 3-month OOPPs of €52.3 (p = 0.241), €90.2 (p = 0.059), or €62.2 (p = 0.176). Financial burden at t0 was 6.4% (SD 9.2%) on average, 5.4% (SD 9.9%) at t1, and to 3.9% (SD 7.0%) of monthly income at t2. CONCLUSION: German cancer patients face relatively high OOPPs during their cancer journey. These payments may burden cancer patients, especially certain subgroups like low-income groups.