Cost-of-illness and Economic Evaluation of Interventions in Children and Adolescents With Chronic Pain: A Systematic Review.

OBJECTIVES: Chronic pain in children and adolescents (CPCA) is widespread with an increasing prevalence. It is associated with a decreased quality of life and an increased parental work loss. Accordingly, CPCA may pose a substantial economic burden for patients, health care payers, and society. Therefore, this systematic review aimed to synthesize (1) the results of existing cost-of-illness studies (COIs) for CPCA and (2) the evidence of economic evaluations (EEs) of interventions for CPCA. METHODS: The systematic literature search was conducted in EMBASE, MEDLINE, PsycINFO, NHS EED, and HTA Database until February 2023. Title, abstract, and full-text screening were conducted by 2 researchers. Original articles reporting costs related to CPCA published in English or German were included. Study characteristics, cost components, and costs were extracted. The quality of studies was assessed using standardized tools. All costs were adjusted to 2020 purchasing power parity US dollars (PPP-USD). RESULTS: Fifteen COIs and 10 EEs were included. The mean annual direct costs of CPCA ranged from PPP-USD 603 to PPP-USD 16,271, with outpatient services accounting for the largest share. The mean annual indirect costs ranged from PPP-USD 92 to PPP-USD 12,721. All EEs reported a decrease in overall costs in treated patients. DISCUSSION: The methodology across studies was heterogeneous limiting the comparability. However, it is concluded that CPCA is associated with high overall costs, which were reduced in all EEs. From a health-economic perspective, efforts should address the prevention and early detection of CPCA followed by specialized pain treatment.

Evidence of the medical and economic benefits of implementing hygiene measures by a prevention link physician in trauma surgery: Study protocol for a biphasic multicenter prospective interventional pre-post cohort study using a structured intervention bundle development and tools of behavior change management.

INTRODUCTION: The German Commission for Hospital Hygiene and Infection Prevention recommends nominating one authorized medical specialist in every medical department as an infection prevention link physician (PLP). It has been roughly described that a PLP serves as a link between the infection prevention team and the respective clinical departments. No detailed evidence about the contribution made by PLPs to the decrease of infection rates is available in Germany. The "HygArzt" project aims to demonstrate the medical and economic benefits of the implementation of hygiene measures by PLP in trauma surgery/orthopedics. METHODS: A multicenter interventional pre/post cohort study design was chosen. The study will run for a three-year period, including a pre-, post-, and an intervention phase, in four different hospitals, one of which will serve as pilot. A complex intervention containing evidence-based infection control measures will be developed and implemented by a PLP to proof efficacy. After the successful implementation of the preventive measures in the pilot hospital, the concept will be transposed to the three remaining trauma and orthopedic departments to confirm the transferability and generalizability. To enable the PLPs of the non-pilot departments, a subject-specific training program will be developed based on the study results of the pilot hospital and offered to the PLPs. DISCUSSION: Data are intended to provide evidence that and, if so, to which extent the implementation of specific preventive measures by a medical department-specific PLP is possible and results in a reduction of nosocomial infections in orthopedic surgery and traumatology. CONTRIBUTION TO THE LITERATURE: The present study describes a novel complex study design to prove the effectiveness of intervention measures for infection prevention. The study design and newly developed methodological approach could serve as a model for similar studies on infection prevention in the future. For the first time, the presented research project "HygArzt" focuses on the implementation of hygiene measures by an infection prevention link physician (PLP) and investigates whether nosocomial infections, especially surgical site infections, can be reduced by the measures implemented. TRIAL REGISTRATION: German clinical Trials register DRKS-ID:00013,296. Registered on March 5, 2018, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00013296.

[Care planning for people with dementia on the margins of care between home care and nursing home: the balance of care approach in the RightTimePlaceCare project in Germany]. / Versorgungsplanung für Menschen mit Demenz am Übergang von der Häuslichkeit ins Pflegeheim: der "Balance-of-Care"-Ansatz im RightTimePlaceCare-Projekt in Deutschland.

BACKGROUND: The balance of care approach is a strategic planning framework that can be used to research the adequacy of care arrangements and the cost implications. It seeks to identify people who are on the margins of care, i. e. whose care and nursing needs could be met in more than one setting, and explores the relative costs of the possible alternatives. This article describes a balance of care application for people with dementia in a transitional phase between home and institutional care in Germany. METHODS: A sequential mixed-methods design was applied that combined empirical data, the decision of healthcare professionals (panels) and cost estimates in a structured way. Data were collected as part of the RightTimePlaceCare project from 235 people with dementia and their caregivers in 2 settings, in nursing homes and domestic care. RESULTS: Based on five key variables, case types of people with dementia with comparable needs were developed. In panels with healthcare professionals there was consensus that people represented by four of these case types could by cared for at home while the reference group of actual study participants was currently being cared for in nursing homes. For these four case types, exemplary home care arrangements were formulated, costs were estimated and compared to institutional care costs. CONCLUSION: There is a potential for home care for a significant group of people with dementia currently admitted to institutional care. Some of the alternative home care arrangements were cost-saving. Despite some limitations, the study demonstrated the utility of the balance of care approach to support the development of empirically based expert recommendations on care provision.

Costs of Care of Agitation Associated With Dementia in 8 European Countries: Results From the RightTimePlaceCare Study.

OBJECTIVE: To estimate the additional societal costs for people living with dementia (PwD) with agitation in home care (HC) and institutional long-term care (ILTC) settings in 8 European countries. DESIGN: Cross-sectional data from the RightTimePlaceCare cohort. SETTING: HC and ILTC settings from 8 European countries (Estonia, Finland, France, Germany, Netherlands, Spain, Sweden, and England). PARTICIPANTS: A total of 1997 PwD (1217 in HC group and 780 lived in an ILTC) and their caregivers. MAIN OUTCOME MEASURES: Medical care, community care, and informal care were recorded using the Resource Utilization in Dementia (RUD) questionnaire. Agitation was assessed based on the agitation symptoms cluster defined by the presence of agitation and/or irritability and/or disinhibition and/or aberrant motor behavior items of the Neuropsychiatric Inventory Questionnaire (NPI-Q). RESULTS: Total monthly mean cost differences due to agitation were 445€ in the HC setting and 561€ in the ILTC setting (P = .01 and .02, respectively). Informal care costs were the main driver in the HC group (73% of total costs) and institutional care costs were the main driver in the ILTC group (53% of total costs). After adjustments, the log link generalized linear mixed model showed an association between agitation symptoms and an increase of informal care costs by 17% per month in HC setting (P < .05). CONCLUSION: This study found that agitation symptoms have a substantial impact on informal care costs in the community care setting. Future research is needed to evaluate which strategies may be efficient by improving the cost-effectiveness ratio and reducing the burden associated with informal care in the management of agitation in PwD.

Informal and formal care: Substitutes or complements in care for people with dementia? Empirical evidence for 8 European countries.

BACKGROUND: In order to contain public health care spending, European countries attempt to promote informal caregiving. However, such a cost reducing strategy will only be successful if informal caregiving is a substitute for formal health care services. We therefore analyze the effect of informal caregiving for people with dementia on the use of several formal health care services. STUDY DESIGN: The empirical analysis is based on primary data generated by the EU-project 'RightTimePlaceCare' which is conducted in 8 European countries. 1223 people with dementia receiving informal care at home were included in the study. METHODS: Using a regression framework we analyze the relationship between informal care and three different formal health care services: the receipt of professional home care, the number of nurse visits and the number of outpatient visits. RESULTS: The relationship between formal and informal care depends on the specific type of formal care analyzed. For example, a higher amount of informal caregiving goes along with a lower demand for home care services and nurse visits but a higher number of outpatient visits. CONCLUSION: Increased informal caregiving effectively reduces public health care spending by reducing the amount of formal home care services. However, these effects differ between countries.

Health Care Utilization and Cost in Children and Adolescents With Chronic Pain: Analysis of Health Care Claims Data 1 Year Before and After Intensive Interdisciplinary Pain Treatment.

OBJECTIVES: The aim of this study was to analyze changes in health care utilization and cost among a sample of highly impaired children and adolescents who sought a 3-week intensive interdisciplinary pain treatment (IIPT). MATERIALS AND METHODS: Claims data from 7 statutory health insurance companies were analyzed for 65 children and adolescents who sought IIPT at the German Paediatric Pain Centre. The annual health care utilization and cost were determined for the following 4 areas: outpatient care, inpatient care, medications, and remedies and aids. We analyzed the changes in resource utilization in the year before (pre_1 y) IIPT and in the subsequent year (post_1 y). RESULTS: Within the first year after IIPT, overall health care costs did not decrease significantly. However, the pattern of health care utilization changed. First, significantly more children and adolescents started outpatient psychotherapy (P=0.001). Second, the number of hospitalized children decreased significantly from 1-year pre to 1-year post (P=0.001). Accordingly, there were significantly fewer hospitalizations for primary chronic pain disorders at 1-year post (P<0.001). The prescription of nonopioids, co-analgesics and opioids was significantly reduced from 1-year pre to 1-year post (all P<0.013). DISCUSSION: The present results indicate that the health care costs of children and adolescents with severe chronic pain disorders do not significantly decrease 1 year after IIPT; however, the treatment becomes more goal-focused. Differential diagnosis measures and nonindicated therapeutic interventions decreased, and more indicated interventions, such as psychotherapy, were used. Future research is needed to investigate the economic long-term changes after IIPT.

Costs of care for people with dementia just before and after nursing home placement: primary data from eight European countries.

BACKGROUND: Dementia is the most common cause of functional decline among elderly people and is associated with high costs of national healthcare in European countries. With increasing functional and cognitive decline, it is likely that many people suffering from dementia will receive institutional care in their lifetime. To delay entry to institutional care, many European countries invest in home and community based care services. OBJECTIVES: This study aimed to compare costs for people with dementia (PwD) at risk for institutionalization receiving professional home care (HC) with cost for PwD recently admitted to institutional long-term nursing care (ILTC) in eight European countries. Special emphasis was placed on differences in cost patterns across settings and countries, on the main predictors of costs and on a comprehensive assessment of costs from a societal perspective. METHODS: Interviews using structured questionnaires were conducted with 2,014 people with dementia and their primary informal caregivers living at home or in an ILTC facility. Costs of care were assessed with the resource utilization in dementia instrument. Dementia severity was measured with the standardized mini mental state examination. ADL dependence was assessed using the Katz index, neuropsychiatric symptoms using the neuropsychiatric inventory (NPI) and comorbidities using the Charlson. Descriptive analysis and multivariate regression models were used to estimate mean costs in both settings. A log link generalized linear model assuming gamma distributed costs was applied to identify the most important cost drivers of dementia care. RESULTS: In all countries costs for PwD in the HC setting were significantly lower in comparison to ILTC costs. On average ILTC costs amounted to 4,491 Euro per month and were 1.8 fold higher than HC costs (2,491 Euro). The relation of costs between settings ranged from 2.4 (Sweden) to 1.4 (UK). Costs in the ILTC setting were dominated by nursing home costs (on average 94%). In the HC setting, informal care giving was the most important cost contributor (on average 52%). In all countries costs in the HC setting increased strongly with disease severity. The most important predictor of cost was ADL independence in all countries, except Spain and France where NPI severity was the most important cost driver. A standard deviation increase in ADL independence translated on average into a cost decrease of about 22%. CONCLUSION: Transition into ILTC seems to increase total costs of dementia care from a societal perspective. The prevention of long-term care placement might be cost reducing for European health systems. However, this conclusion depends on the country, on the valuation method for informal caregiving and on the degree of impairment.

A European study investigating patterns of transition from home care towards institutional dementia care: the protocol of a RightTimePlaceCare study.

BACKGROUND: Health care policies in many countries aim to enable people with dementia to live in their own homes as long as possible. However, at some point during the disease the needs of a significant number of people with dementia cannot be appropriately met at home and institutional care is required. Evidence as to best practice strategies enabling people with dementia to live at home as long as possible and also identifying the right time to trigger admission to a long-term nursing care facility is therefore urgently required. The current paper presents the rationale and methods of a study generating primary data for best-practice development in the transition from home towards institutional nursing care for people with dementia and their informal caregivers. The study has two main objectives: 1) investigate country-specific factors influencing institutionalization and 2) investigate the circumstances of people with dementia and their informal caregivers in eight European countries. Additionally, data for economic evaluation purposes are being collected. METHODS/DESIGN: This paper describes a prospective study, conducted in eight European countries (Estonia, Finland, France, Germany, Netherlands, Sweden, Spain, United Kingdom). A baseline assessment and follow-up measurement after 3 months will be performed. Two groups of people with dementia and their informal caregivers will be included: 1) newly admitted to institutional long-term nursing care facilities; and 2) receiving professional long-term home care, and being at risk for institutionalization. Data will be collected on outcomes for people with dementia (e.g. quality of life, quality of care), informal caregivers (e.g. caregiver burden, quality of life) and costs (e.g. resource utilization). Statistical analyses consist of descriptive and multivariate regression techniques and cross-country comparisons. DISCUSSION: The current study, which is part of a large European project 'RightTimePlaceCare', generates primary data on outcomes and costs of long-term nursing care for people with dementia and their informal caregivers, specifically focusing on the transition from home towards institutional care. Together with data collected in three other work packages, knowledge gathered in this study will be used to inform and empower patients, professionals, policy and related decision makers to manage and improve health and social dementia care services.

[How to bring quality into the focus of health care--results of a delphi and stakeholder survey]. / Wie rückt Qualität in den Fokus der Gesundheitsversorgung? Ergebnisse einer Delphi- und Akteurbefragung.

Although plenty of statutory requirements, concepts and tools to promote the quality of health care exist, Germany's health care system seems far from being pervaded by a vivid quality culture. In order to show ways how to succeed in developing and implementing such a quality culture in the German health care system, the Bertelsmann foundation conducted a delphi survey of seven quality of care experts and an online survey of 239 stakeholders, encompassing health care providers and representatives of the self administration of the health care system, politicians, the health care industry, and patient representatives. Based on the delphi results 31 theses within 12 subject areas have been formulated and assessed, which describe building blocks to put quality in the center of Germany's health care system. After dichotomizing the answers (school grades 1-6 into 1-2 = best, and 3-6 = worse) > 66% of the stakeholders rated 28 of 31 theses with grades 1-2. The ten most accepted theses received grades 1 or 2 from more than 85% of the stakeholders. Following the main results of the surveys, establishing a vivid quality culture requires outcome oriented quality goals and quality indicators to be defined, quality management to be embedded better into the education of all health care providers, and quality promotion to be introduced which is build on quality incentives and objective quality transparency. Since experts and stakeholders agree to such a high degree in the steps necessary to establish a quality culture in the German health care system, the realization of these steps seems to be possible.

The influence of insurance status on waiting times in German acute care hospitals: an empirical analysis of new data.

BACKGROUND: There is an ongoing debate in Germany about the assumption that patients with private health insurance (PHI) benefit from better access to medical care, including shorter waiting times (Lüngen et al. 2008), compared to patients with statutory health insurance (SHI). PROBLEM: Existing analyses of the determinants for waiting times in Germany are a) based on patient self-reports and b) do not cover the inpatient sector. This paper aims to fill both gaps by (i) generating new primary data and (ii) analyzing waiting times in German hospitals. METHODS: We requested individual appointments from 485 hospitals within an experimental study design, allowing us to analyze the impact of PHI versus SHI on waiting times (Asplin et al. 2005). RESULTS: In German acute care hospitals patients with PHI have significantly shorter waiting times than patients with SHI. CONCLUSION: Discrimination in waiting times by insurance status does occur in the German acute hospital sector. Since there is very little transparency in treatment quality in Germany, we do not know whether discrimination in waiting times leads to discrimination in the quality of treatment. This is an important issue for future research.

The legal framework for health care quality assurance in Germany.

Like most industrialized countries, Germany's health care system is facing two major challenges. The first is to find a sustainable financing system for increasing health care expenditures. The second is to ensure - and improve - the quality of care provided. This article describes the status quo in quality assurance in Germany and analyses the changes introduced into the SHI (Statutory Health Insurance) system with the Modernization Act of 2004. First, a theoretical framework for quality assurance that is consistent with the logic of the German social market economy is outlined. The analysis then describes new actors and their duties in the field of quality assurance, highlighting improvements in regulation and the regulatory instruments applied. Although the strategy for quality assurance is still dominated by regulation and corporatist bodies, the latest reform acts of 2004 and 2007 focus on more and better information about the quality of services provided - an important prerequisite for more competitive elements in the German health care system.

How to get the information needed to inform decision-makers - an economic perspective.

From an economic viewpoint, the amount of primary research conducted on a topic at any given point in time depends on grantmaker and researcher incentives. The potential addresses of research findings often set these incentives. Following this logic, there is an economic explanation provided for the availability of primary data in effcacy studies. This also explains the lack of data in other important fields of health care. This article evaluates why there are few studies on effectiveness and cost-effectiveness then discusses how research incentives might be changed to overcome this problem. As a result of cost containment efforts in some countries, this process has already been initialized.