Hippotherapy for patients with multiple sclerosis: A multicenter randomized controlled trial (MS-HIPPO).

BACKGROUND: Evidence-based complementary treatment options for multiple sclerosis (MS) are limited. OBJECTIVE: To investigate the effect of hippotherapy plus standard care versus standard care alone in MS patients. METHODS: A total of 70 adults with MS were recruited in five German centers and randomly allocated to the intervention group (12 weeks of hippotherapy) or the control group. Primary outcome was the change in the Berg Balance Scale (BBS) after 12 weeks, and further outcome measures included fatigue, pain, quality of life, and spasticity. RESULTS: Covariance analysis of the primary endpoint resulted in a mean difference in BBS change of 2.33 (95% confidence interval (CI): 0.03-4.63, p = 0.047) between intervention ( n = 32) and control ( n = 38) groups. Benefit on BBS was largest for the subgroup with an Expanded Disability Status Scale (EDSS) ⩾ 5 (5.1, p = 0.001). Fatigue (-6.8, p = 0.02) and spasticity (-0.9, p = 0.03) improved in the intervention group. The mean difference in change between groups was 12.0 ( p < 0.001) in physical health score and 14.4 ( p < 0.001) in mental health score of Multiple Sclerosis Quality of Life-54 (MSQoL-54). CONCLUSION: Hippotherapy plus standard care, while below the threshold of a minimal clinically important difference, significantly improved balance and also fatigue, spasticity, and quality of life in MS patients.

[Checklist for the Development and Assessment of Cost-of-Illness Studies]. / Checkliste zur Erstellung und Bewertung von Krankheitskostenstudien.

BACKGROUND: Cost-of-illness (CoI) studies are important instruments for estimating the socioeconomic burden of specified diseases. CoI studies provide important information about the cost structure of a disease, the resulting research need, approaches to improve aspects of care and, monetary consequences from different perspectives. This information can be useful for healthcare research and health policy. Due to heterogeneity of available Cost-of-Illness studies, the working group 'Health Economics' of the German Network for Healthcare Research (DNVF) in accordance with the German Society for Health Economics (DGGÖ) developed an instrument for the planning, conduct and assessment of CoI studies. METHODS: The checklist was developed based on a systematic literature search of published national and international checklists as well as guidelines and recommendations for development and assessment of CoI studies and health economic evaluations. Structure and subject matter of the generic checklist was designed, approved and, finally, examined in a pretest by the working group. RESULTS: Based on the results of the literature search (n=2 454), 58 articles were used for the identification of relevant criteria for the checklist. With respect to the results of the pretest, 6 dimensions were included in the checklist: (i) general aspects, (ii) identification of resources, (iii) description and quantification of resource consumption, (iv) valuation of resources (v) analysis and presentation of results and (vi) discussion and conclusion. In total, the 6 dimensions were operationalized through 37 items. CONCLUSION: This checklist is an initial approach to improve transparency and understanding of CoI studies in terms of the extent, structure and development of the socioeconomic burden of diseases. The checklist supports the comparability of different studies and facilitates study conception.

The Child Health Care System of Germany.

We describe the strengths and challenges of the child health care system in Germany and also provide an outlook on future health plans, focusing on making idiosyncrasies of national health care services in Europe understandable to those pediatricians working in other countries. The aim should be to avoid those unnecessary processes in child care which, unless abandoned, may be responsible for a poor outcome of child health. Larger countries, such as Germany, have many distinct regional differences. When it comes to problem-solving strategies, pediatricians must be aware of unavoidable cultural and historic differences that may influence the outcome of care. Even when assuming unlimited financial resources, different regional priorities might result in diverging goals.

Health Economics as Rhetoric: The Limited Impact of Health Economics on Funding Decisions in Four European Countries.

BACKGROUND: A response to the challenge of high-cost treatments in health care has been economic evaluation. Cost-effectiveness analysis presented as cost per quality-adjusted life-years gained has been controversial, raising heated support and opposition. OBJECTIVES: To assess the impact of economic evaluation in decisions on what to fund in four European countries and discuss the implications of our findings. METHODS: We used a protocol to review the key features of the application of economic evaluation in reimbursement decision making in England, Germany, the Netherlands, and Sweden, reporting country-specific highlights. RESULTS: Although the institutions and processes vary by country, health economic evaluation has had limited impact on restricting access of controversial high-cost drugs. Even in those countries that have gone the furthest, ways have been found to avoid refusing to fund high-cost drugs for particular diseases including cancer, multiple sclerosis, and orphan diseases. Economic evaluation may, however, have helped some countries to negotiate price reductions for some drugs. It has also extended to the discussion of clinical effectiveness to include cost. CONCLUSIONS: The differences in approaches but similarities in outcomes suggest that health economic evaluation be viewed largely as rhetoric (in D.N. McCloskey's terms in The Rhetoric of Economics, 1985). This is not to imply that economics had no impact: rather that it usually contributed to the discourse in ways that differed by country. The reasons for this no doubt vary by perspective, from political science to ethics. Economic evaluation may have less to do with rationing or denial of medical treatments than to do with expanding the discourse used to discuss such issues.

Communicating the parameter uncertainty in the IQWiG efficiency frontier to decision-makers.

The Institute for Quality and Efficiency in Health Care (IQWiG) developed-in a consultation process with an international expert panel-the efficiency frontier (EF) approach to satisfy a range of legal requirements for economic evaluation in Germany's statutory health insurance system. The EF approach is distinctly different from other health economic approaches. Here, we evaluate established tools for assessing and communicating parameter uncertainty in terms of their applicability to the EF approach. Among these are tools that perform the following: (i) graphically display overall uncertainty within the IQWiG EF (scatter plots, confidence bands, and contour plots) and (ii) communicate the uncertainty around the reimbursable price. We found that, within the EF approach, most established plots were not always easy to interpret. Hence, we propose the use of price reimbursement acceptability curves-a modification of the well-known cost-effectiveness acceptability curves. Furthermore, it emerges that the net monetary benefit allows an intuitive interpretation of parameter uncertainty within the EF approach. This research closes a gap for handling uncertainty in the economic evaluation approach of the IQWiG methods when using the EF. However, the precise consequences of uncertainty when determining prices are yet to be defined.

A New Model for Ranking Schools of Public Health: The Public Health Academic Ranking.

Objectives: As there is no ranking designed for schools of Public Health, the aim of this project was to create one. Methods: To design the Public Health Academic Ranking (PHAR), we used the InCites Benchmarking and Analytics™ software and the Web Of Science™ Core Collection database. We collected bibliometric data on 26 schools of Public Health from each continent, between August and September 2022. We included 11 research indicators/scores, covering four criteria (productivity, quality, accessibility for readers, international collaboration), for the period 2017-2021. For the Swiss School of Public Health (SSPH+), a network gathering faculties across different universities, a specific methodology was used, with member-specific research queries. Results: The five top schools of the PHAR were: London School of Hygiene and Tropical Medicine, Public Health Foundation of India, Harvard T.H. Chan School of Public Health, SSPH+, Johns Hopkins Bloomberg School of Public Health. Conclusion: The PHAR allows worldwide bibliometric ordering of schools of Public Health. As this is a pilot project, the results must be taken with caution. This article aims to critically discuss its methodology and future improvements.

Unconscious Bias among Health Professionals: A Scoping Review.

BACKGROUND: Unconscious biases are one of the causes of health disparities. Health professionals have prejudices against patients due to their race, gender, or other factors without their conscious knowledge. This review aimed to provide an overview of research on unconscious bias among health professionals and to investigate the biases that exist in different regions of the world, the health professions that are considered, and the research gaps that still exist. METHODS: We conducted a scoping review by systematically searching PubMed/MEDLINE, CINAHL, PsycINFO, PsycARTICLES, and AMED. All records were double-screened and included if they were published between 2011 and 2021. RESULTS: A total of 5186 records were found. After removing duplicates (n = 300), screening titles and abstracts (n = 4210), and full-text screening (n = 695), 87 articles from 81 studies remained. Studies originated from North America (n = 60), Europe (n = 13), and the rest of the world (n = 6), and two studies were of global scope. Racial bias was investigated most frequently (n = 46), followed by gender bias (n = 11), weight bias (n = 10), socio-economic status bias (n = 9), and mental illness bias (n = 7). Most of the studies were conducted by physicians (n = 51) and nurses (n = 20). Other health care professionals were rarely included in these studies. CONCLUSIONS: Most studies show that health professionals have an implicit bias. Racial biases among physicians and nurses in the USA are well confirmed. Research is missing on other biases from other regions and other health professions.

Interprofessional education day 2019 - a qualitative participant evaluation.

Objective: Interprofessional education (IPE) is when two or more students from different professions learn with, from, and about each other to improve collaboration and quality of healthcare. In October 2019, a first interprofessional education (IPE) day was held in the canton of Zurich with the aim of teaching interprofessional skills to participating students. Methodology: The IPE day was developed by an interprofessional team of students. After a short introduction, the roles and tasks of the professional groups involved were discussed. This was followed by two case studies with simulation persons and reflection rounds. For the evaluation of the day, 15 semi-structured interviews with students and lecturers were conducted and qualitatively evaluated by means of thematic analysis. Results: The students and lecturers had a very positive experience of the IPE day. Especially the participation of medical and pharmacy students, the practical case studies with simulation persons and the informal exchange during the breaks were appreciated. There was room for improvement in the development of role models. Through an open attitude and good communication, the students learned to know and appreciate the competencies of the other professional groups. All those interviewed wished for more interprofessional teaching opportunities and the students felt encouraged to apply what they had learned in their later professional practice. Conclusion: The IPE day could be carried out successfully and the didactic concept worked largely well. The evaluation provided subjective evidence that the students were able to improve the interprofessional competencies of teamwork, communication, openness, appreciation and reflectiveness. In the future, the IPE day should be anchored in the curricula.

The efficiency-frontier approach for health economic evaluation versus cost-effectiveness thresholds and internal reference pricing: combining the best of both worlds?

INTRODUCTION: The efficiency-frontier approach (EFA) to health economic evaluation aims to benchmark the relative efficiency of new drugs with the incremental cost-effectiveness ratios (ICERs) of non-dominated comparators. By explicitly considering any differences in health outcomes and costs, it enhances the internal reference pricing (IRP) policy that was officially endorsed by Germany as the first country worldwide in 1989. However, the EFA has been repeatedly criticized since its official endorsement in 2009. Areas covered: This perspective aims to stimulate the debate by discussing whether the main objections to the EFA are technically valid, irrespective of national contextual factors in Germany with reservations towards using cost-per-quality-adjusted life year (QALY) thresholds. Moreover, we comparatively assessed whether the objections are truly unique to the EFA or apply equally to IRP and cost-effectiveness thresholds. Expert commentary: The plethora of objections to the EFA (n = 20) has obscured that many objections are neither technically valid nor unique to the EFA. Compared with cost-effectiveness thresholds, only two objections apply uniquely to the EFA and concern intended key properties: (1) no external thresholds are needed and (2) the EFA is sensitive to price changes of comparators. Combining these policies and developing them further are under-utilized research areas.

Estimation of Input Costs for a Markov Model in a German Health Economic Evaluation of Newer Antidepressants.

Background: Estimating input costs for Markov models in health economic evaluations requires health state-specific costing. This is a challenge in mental illnesses such as depression, as interventions are not clearly related to health states. We present a hybrid approach to health state-specific cost estimation for a German health economic evaluation of antidepressants. Methods: Costs were determined from the perspective of the community of persons insured by statutory health insurance ("SHI insuree perspective") and included costs for outpatient care, inpatient care, drugs, and psychotherapy. In an additional step, costs for rehabilitation and productivity losses were calculated from the societal perspective. We collected resource use data in a stepwise hierarchical approach using SHI claims data, where available, followed by data from clinical guidelines and expert surveys. Bottom-up and top-down costing approaches were combined. Results: Depending on the drug strategy and health state, the average input costs varied per patient per 8-week Markov cycle. The highest costs occurred for agomelatine in the health state first-line treatment (FT) ("FT relapse") with €506 from the SHI insuree perspective and €724 from the societal perspective. From both perspectives, the lowest costs (excluding placebo) were €55 for selective serotonin reuptake inhibitors in the health state "FT remission." Conclusion: To estimate costs in health economic evaluations of treatments for depression, it can be necessary to link different data sources and costing approaches systematically to meet the requirements of the decision-analytic model. As this can increase complexity, the corresponding calculations should be presented transparently. The approach presented could provide useful input for future models.

No suitable precise or optimized epidemiologic search filters were available for bibliographic databases.

OBJECTIVES: To determine a suitable approach to a systematic search for epidemiologic publications in bibliographic databases. For this purpose, suitable sensitive, precise, and optimized filters were to be selected for MEDLINE searches. In addition, the relevance of bibliographic databases was determined. STUDY DESIGN AND SETTING: Epidemiologic systematic reviews (SRs) retrieved in a systematic search and company dossiers were screened to identify epidemiologic publications (primary studies and SRs) published since 2007. These publications were used to generate a test and validation set. Furthermore, each SR's search strategy was reviewed, and epidemiologic filters were extracted. The search syntaxes were validated using the relative recall method. RESULTS: The test set comprises 729 relevant epidemiologic publications, of which 566 were MEDLINE-indexed. About 27 epidemiologic filters were extracted. One suitable sensitive filter was identified (Larney et al. 2013: 95.94% sensitivity). Precision was presumably underestimated so that no precise or optimized filters can be recommended. About 77.64% of the publications were found in MEDLINE. CONCLUSION: There is currently no suitable approach to conducting efficient systematic searches for epidemiologic publications in bibliographic databases. The filter by Larney et al. (2013) can be used for sensitive MEDLINE searches. No robust conclusions can be drawn on precise or optimized filters. Additional search approaches should be considered.

Cost Recommendation under Uncertainty in IQWiG's Efficiency Frontier Framework.

BACKGROUND: The National Institute for Quality and Efficiency in Health Care (IQWiG) employs an efficiency frontier (EF) framework to facilitate setting maximum reimbursable prices for new interventions. Probabilistic sensitivity analysis (PSA) is used when yes/no reimbursement decisions are sought based on a fixed threshold. In the IQWiG framework, an additional layer of complexity arises as the EF itself may vary its shape in each PSA iteration, and thus the willingness-to-pay, indicated by the EF segments, may vary. OBJECTIVES: To explore the practical problems arising when, within the EF approach, maximum reimbursable prices for new interventions are sought through PSA. METHODS: When the EF is varied in a PSA, cost recommendations for new interventions may be determined by the mean or the median of the distances between each intervention's point estimate and each EF. Implications of using these metrics were explored in a simulation study based on the model used by IQWiG to assess the cost-effectiveness of 4 antidepressants. RESULTS: Depending on the metric used, cost recommendations can be contradictory. Recommendations based on the mean can also be inconsistent. Results (median) suggested that costs of duloxetine, venlafaxine, mirtazapine, and bupropion should be decreased by €131, €29, €12, and €99, respectively. These recommendations were implemented and the analysis repeated. New results suggested keeping the costs as they were. The percentage of acceptable PSA outcomes increased 41% on average, and the uncertainty associated to the net health benefit was significantly reduced. CONCLUSIONS: The median of the distances between every intervention outcome and every EF is a good proxy for the cost recommendation that would be given should the EF be fixed. Adjusting costs according to the median increased the probability of acceptance and reduced the uncertainty around the net health benefit distribution, resulting in a reduced uncertainty for decision makers.

Preferences for antiviral therapy of chronic hepatitis C: a discrete choice experiment.

BACKGROUND: The German Institute for Quality and Efficiency in Health Care (IQWiG) uses patient-relevant outcomes to inform decision-makers. OBJECTIVE: IQWiG conducted a pilot study to examine whether discrete choice experiments (DCEs) can be applied in health economic evaluations in Germany to identify, weight, and prioritize multiple patient-relevant outcomes, using the example of antiviral therapy for chronic hepatitis C (HCV). A further objective was to contribute to a more structured approach towards eliciting and comparing preferences across key stakeholders. METHODS: In autumn 2010, a DCE questionnaire was sent to patients with chronic HCV to estimate preferences across seven outcomes ("attributes"), including treatment efficacy [sustained viral response (SVR) at 6 months], adverse effects (flu-like symptoms, gastrointestinal symptoms, psychiatric symptoms, and skin symptoms/alopecia), and measures of treatment burden (duration of therapy, frequency of injections). A linear model and an effects coded full model were applied to assess the relative importance of the attributes. RESULTS: In total N = 326 patients were included. A clear preference for SVR was shown; frequency of injections and duration of therapy shared the second rank, while psychiatric symptoms ranked third. The duration of flu-like symptoms was the least important attribute. CONCLUSION: Our findings indicate that it is possible to perform a DCE at the national level in a health technology assessment agency. The weighting of multiple outcomes allows an indication-specific and evidence-based measure to be used in health economic evaluations. In decision-making in health care, the approach generally allows for consideration of patient-relevant trade-offs regarding the benefits and harms of medical interventions.

Challenges in Cost-Effectiveness Analysis Modelling of HPV Vaccines in Low- and Middle-Income Countries: A Systematic Review and Practice Recommendations.

BACKGROUND: Low- and middle-income countries (LMICs) face a number of challenges in implementing cervical cancer prevention programmes that do not apply in high-income countries. OBJECTIVE: This review assessed how context-specific challenges of implementing cervical cancer prevention strategies in LMICs were accounted for in existing cost-effectiveness analysis (CEA) models of human papillomavirus (HPV) vaccination. METHODS: The databases of MEDLINE, EMBASE, NHS Economic Evaluation Database, EconLit, Web of Science, and the Center for the Evaluation of Value and Risk in Health (CEA) Registry were searched for studies published from 2006 to 2015. A descriptive, narrative, and interpretative synthesis of data was undertaken. RESULTS: Of the 33 studies included in the review, the majority acknowledged cost per vaccinated girl (CVG) (26 studies) and vaccine coverage rate (21 studies) as particular challenges for LMICs, while nine studies identified screening coverage rate as a challenge. Most of the studies estimated CVG as a composite of different cost items. However, the basis for the items within this composite cost was unclear. The majority used an assumption rather than an observed rate to represent screening and vaccination coverage rates. CVG, vaccine coverage and screening coverage were shown by some studies through sensitivity analyses to reverse the conclusions regarding cost-effectiveness, thereby significantly affecting policy recommendations. CONCLUSIONS: While many studies recognized aspects of the particular challenges of HPV vaccination in LMICs, greater efforts need to be made in adapting models to account for these challenges. These include adapting costings of HPV vaccine delivery from other countries, learning from the outcomes of cervical cancer screening programmes in the same geographical region, and taking into account the country's previous experience with other vaccination programmes.