[Cost-Effectiveness of Pharmacological Smoking Cessation Therapies - A Systematic Literature Review]. / Kosteneffektivität von pharmakologischen Raucherentwöhnungsmaßnahmen ­ ein systematisches Literaturreview.

Aim of the Study: Through the promotion of smoking cessation premature mortality can be prevented. Therefore it is necessary to provide effective and cost-effective smoking cessation interventions. In Germany the cost of pharmacological smoking cessation measures are not yet reimbursed by the statutory health insurance. The aim of this study is to present the evidence on the cost-effectiveness of already approved pharmacological smoking cessation therapies and to evaluate their quality. Method: A systematic literature research was conducted in the databases by DIMDI (Medline, Embase, etc.) in April 2013 (update April 2014). The study research was focused on studies for cost effectiveness of nicotine replacement therapy (NRT), varenicline and bupropion. The assessment of study quality was performed using the "Quality of Health Economic Studies" (QHES) instrument. Results: 33 Of the original 10 340 identified studies were finally included. The majority of the studies show that an additional prescription of NRT or bupropion to a medical consultation is a cost-effective strategy. In addition, in most studies varenicline is a dominant strategy compared to bupropion. Overall, the study quality was found to be very heterogeneous between 45 and 80 points (Ø 63.7 points). Conclusion: The studies show that treatment with varenicline is the most cost effective strategy followed by bupropion and the NRT. However, the studies can only be compared inadequately due to different levels of age and country-specific intervention costs.

[Measures to improve the health situation of patients with rare diseases in Germany. A comparison with the National Action Plan]. / Maßnahmen zur Verbesserung der gesundheitlichen Situation von Menschen mit seltenen Erkrankungen in Deutschland. Ein Vergleich mit dem Nationalen Aktionsplan.

BACKGROUND: Approximately 4 million patients with a rare disease live in Germany. The medical care of these patients is problematic because of the rarity and heterogeneity of different clinical pictures. The Federal Ministry of Health has therefore published a research report on "Measures to improve the health situation of people with rare diseases in Germany" in 2009. OBJECTIVE: The aim of this paper is to present the main recommendations of this research report and relate it to current developments in the field of medical care for people with rare diseases. METHODOLOGY: The care situation of patients with rare diseases was determined using questionnaires, expert interviews and focus group discussions with representatives of patients, service providers and stakeholders from the health institutions. RESULTS: The main range of actions that have been identified in the research report were centre and network formation, specialized forms of medical care, diagnosis and treatment, information and experience exchange, performance fees and reimbursement of the costs, guidelines and patient pathways, the research, the implementation of a National Action Alliance and the development of a National Action Plan. DISCUSSION: In March 2010 a National Action League for People with Rare Diseases (NAMSE) was founded. The NAMSE created a national plan of action for people with rare diseases for improving medical care in the field of rare diseases which was approved by the Federal Government in August 2013. Thus, two important areas of the research report have already been implemented. In a comparison of the areas of activity of the research report with those of the National Action Plan it becomes clear that priorities will be in the context of health services research in rare diseases, for example the introduction of centres of reference for rare diseases, measures to accelerate the diagnostic process and the promotion of research and information management in the future.

[Calculation of disease-related costs in claims data analyses with the example of attention-deficit hyperactivity disorder. Comparison of methods]. / Die Berechnung indikationsspezifischer Kosten bei GKV-Routinedatenanalysen am Beispiel von ADHS. Ein Methodenvergleich.

Claims data have proven useful for carrying out cost-of-illness studies. To avoid overestimating disease-related costs, only those costs that are related to a specific disease should be considered. The present study demonstrates two basic approaches for identifying disease-related costs. Using the example of attention-deficit hyperactivity disorder (ADHD), the advantages and drawbacks of expert-based approaches and those based on control groups are compared. Anonymized data from the "Techniker Krankenkasse" for 2008 were available for the study. The study population encompassed all ADHD patients and a control group that was five times bigger. Additionally, a systematic literature review was carried out on 65 relevant studies. Compared with the control group, disease-related costs were EUR 2,902 per ADHD patient on average. However, using the expert-based approach, costs were established to be EUR 923 lower. This is mainly because a comparison with an appropriate control group incorporates all costs for possible comorbidities and concomitant diseases. Both approaches have specific advantages and drawbacks, and when planning studies the respective limitations need to be considered.

[Therapy of rheumatoid arthritis with methotrexate. Claims data analysis of treatment patterns]. / Therapie der rheumatoiden Arthritis mit Methotrexat. Analyse von Versorgungsaspekten anhand von GKV-Routinedaten.

Methotrexate (MTX) is the most important disease-modifying antirheumatic drug (DMARD) and is recommended by national and international guidelines as the first choice for treatment of rheumatoid arthritis (RA). Recent studies reporting prescription data of MTX captured only patients who were treated by rheumatologists. Therefore, the aim of the present study was to analyse several aspects of the prescription of MTX based on claims data. Outpatient and inpatient diagnoses as well as prescription data was available for 9579 RA patients for the years 2005-2008. Of the patients 45% were treated exclusively with parenteral MTX, 8% were treated exclusively with oral MTX and 48% switched between both forms of application. The average weekly dosage presribed in 70% of the patients was between 10 and 25 mg. The most common DMARD combination was MTX plus leflunomide with 16%. In 16% RA patients were treated with a combination of MTX and TNF-α inhibitors. Glucocorticoids were prescribed temporarily in 81% together with MTX and supplementation with folic acid was given only in 65%. The results of this study provide important insights into the drug supply of MTX to RA patients in the German statutory health care sector. In particular, the high frequency of prescriptions of parenteral MTX and the inadequate prescription of folic acid are different from the recently published multinational recommendations of the 3E initiative for the use of MTX.

[Decision support through economic evaluation from the perspective of science in Germany]. / Entscheidungsunterstützung durch gesundheitsökonomische Evaluation in Deutschland aus Perspektive der Wissenschaft.

For decades, economic evaluation studies, or cost-benefit analyses (CBA), have been a tool for decision support in the use of public funds. Despite this, in the last few years, debates on the inclusion of CBAs in the German health care system have paid little attention to the findings and practical experiences of scientific research. CBAs - especially the QALY - were instead represented a priori as "unfair" and "discriminatory." Today they have virtually no meaning when it comes to allocation and pricing decisions about publicly funded health services. Of course, CBAs are based on value judgments, which have to be communicated. They can lead to allocations that violate the minimum standards of justice. Here, distributive requirements and criteria are needed and must be developed in an interdisciplinary discourse. However, a general waiver of CBA does not make decisions about the allocation of resources easier, especially since its involvement can contribute to more openness and transparency in the system. Accordingly, for Germany a dual approach is recommended: an interdisciplinary exploration of the methodological foundations of economic evaluation and a consistent application of these in healthcare decision-making.

[Implementation of the new German job role code and its application in claims data analysis. Possibilities and limitations]. / Einführung des neuen Tätigkeitsschlüssels und seine Anwendung in GKV-Routinedatenauswertungen. Möglichkeiten und Limitationen.

In recent years, claims data analyses have become of increasing importance in several scientific disciplines in Germany. In specific research projects, it can be necessary to refine and to standardize the results by socioeconomic data. Information about graduation, social status, and occupation are provided by the German job role code for all people insured by statutory health insurance. During recent years, the working scheme has changed and new professions have appeared. Therefore, there has been a discussion about actualization and modification of the job role code. Since December 2011, an actualized job role code with an extensive set of new information is available. In addition, a new classification of professions is available in Germany which was considered in the design of the new job role code. The aim of this overview is to describe the structure of the new job role code as well as to discuss possible uses and limitations.

[Costs of illness and health-related quality of life for community-acquired pneumonia--a systematic review]. / Krankheitskosten sowie gesundheitsbezogene Lebensqualität (hrQoL) bei ambulant erworbener Pneumonie (CAP)--ein systematisches Review.

AIM: There are only very limited data available on the costs and health-related quality of life (hrQoL) of patients with community-acquired pneumonia (CAP) in Germany. The aim of this review was to identify studies in the international literature regarding the costs and hrQoL of CAP. METHOD: In March 2010, a systematic literature search was performed. The acquired literature was evaluated separately for costs of illness and/or hrQoL analyses followed by a structured discussion of the findings. RESULTS: A total of 172 references was identified. Sixteen publications on the cost of illness for CAP and five publications on hrQoL met the selection criteria and were included in the present review. CONCLUSION: There are only very limited and, furthermore, outdated data available on the costs and quality of life impacts of CAP. Hence, further research is urgently needed to fill this lack of evidence.

[Economic valuation of physician contacts in German outpatient care of COPD. Results from a survey of general practitioners and respiratory specialists]. / Ökonomische Bewertung ambulanter Arztkontakte von COPD-Patienten in Deutschland. Ergebnisse einer Befragung von Allgemeinmedizinern und Pneumologen.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is associated with considerable morbidity and mortality and features a substantial economic burden. METHODS: This article analyses the frequency of physician contacts and commonly provided services in the outpatient care of patients with COPD in Germany. Information on characteristic health care delivery in case of patients with COPD has been further used to construct basic scenarios of outpatient resource use. RESULTS: Altogether, 34 out of 150 respiratory specialists and 55 out of 350 general practitioners participated in the survey (response rates of 22.7 and 15.7%, respectively). Results point out, that the number of commonly provided services (a) is limited to a very basic set, (b) does not differ substantially according to severity of COPD, and (c) does not substantially vary between the stable phase of the disease and the presence of exacerbations. CONCLUSIONS: Despite its low level of evidence, the use of expert opinion can serve as a valuable and legitimate tool; especially when the literature does not provide any or only outdated information.

[Current status and perspectives of ambulatory rheumatologic health care in Germany : economic structural conditions and motivation of rheumatologists]. / Bestandsaufnahme und Perspektiven der ambulanten rheumatologischen Versorgung in Deutschland : Okonomische Rahmenbedingungen und Motivation der Rheumatologen.

AIM: To gather information about current structures in rheumatologic ambulatory health care in Germany. Based on the results recommendations on future structures will be evaluated. METHODS: Data collection and statistical analysis via a structured 10-page questionnaire answered by members of the German Association of Rheumatologists. Questions in this second part of the study related to two topics: economic factors and a subjective assessment of the health care structures by the participants. RESULTS: Data from 197 ambulatory rheumatologists who participated in health care could be included in the analyses. Extensive and detailed data on economic issues surrounding ambulatory patient treatment and practice management from the perspective of ambulatory rheumatologists are presented (e.g., revenue, income, income differences between regions or practice size). In addition, perceptions of participating rheumatologists on future perspectives of patient treatment, health policy, and their own economical survival are reported. CONCLUSIONS: As in other specialties there is a significant difference not only between the eastern and western regions in Germany but also between the north and the south looking at e.g., revenue, income, with rheumatologists in the east treating significantly more patients. Reasons for those differences are not only related to regional remuneration schemes or the number of patients with a private but statutory health insurance, but are also driven by the number of different services provided (e.g., own laboratory). Physicians perceptions towards their own future in rheumatology are generally positive. Scepticism was reported for the individual economic survival in ambulatory treatment and future changes in health policy.

[Current status of ambulatory rheumatologic health care in Germany. Structure of health care and range of services]. / Bestandsaufnahme der ambulanten rheumatologischen Versorgung in Deutschland. Versorgungsstruktur und Leistungsspektrum.

AIM: To gather information on current organizational structures in rheumatologic ambulatory health care in Germany. Based on the results recommendations on future structures will be discussed. METHODS: This study involved data collection and statistical analysis via a structured 10-page questionnaire among the members of the German Association of Rheumatologists. The questions concerned a variety of topics including information on office structures, patient structure, structure of services offered, co-operation with colleagues and hospitals, quality assurance measures, economic factors, and a subjective assessment of the health care structures in rheumatology by the participants. RESULTS: Data obtained from 197 rheumatologists who participate in health care were analyzed. In this paper results concerning the organizational as well as the medical ambulatory health care structure will be presented. Data on economic factors will be presented in part 2 of this study. CONCLUSIONS: The organization of ambulatory treatment regarding processes and treatment differences between office-based physicians and rheumatologic outpatient departments in hospitals was very homogeneous. However, physicians in the eastern regions treated significantly more patients compared with the western parts of Germany. This difference was also observed between the north and south. Differences in patient groups (e.g. underlying diseases) were reported between different sub-groups of rheumatologists (e.g. internal specialists vs. GP vs. orthopedic rheumatologists). Integrated health care, as promoted by German social law, did not play a major role. Overall there was a high level of self-initiated training of physicians and participation in education of patients and other physicians.

[Health economic research in rheumatic diseases]. / Gesundheitsökonomie am Beispiel rheumatischer Erkrankungen.

Thorough health economic research of budget-relevant diseases should be one of the major tasks in the German health care system. Up to now cost studies were only performed for special research questions and/or with very limited focuses, e.g. the patients' view. Hence, federal programmes, like competence networks for certain diseases, which were introduced by the German Ministry for Research and Education in the late 1990s, should give a broader focus on health services research. With such an approach health politicians may obtain a deeper insight into areas of the health care sector which are likely to be more efficient after reorganisation. The process of a structured analysis of certain diseases will be demonstrated using the example of rheumatoid arthritis (RA). To this end, the results of a research programme sponsored within the Competence Network for Musculoskeletal Diseases will be presented. Direct costs, indirect costs as well as values for health-related quality of life of German RA patients in routine care by generalists and specialists will be discussed.

Direct costs for the treatment of HIV-infection in a German cohort after the introduction of HAART.

BACKGROUND: Highly active antiretroviral combination therapy (HAART) has become the standard of care for HIV infection. The reduction of morbidity by HAART has been proven to be cost-effective despite high expenditures for regular use of antiretrovirals. We examined direct costs in a German monocentric cohort of HIV-infected patients after introduction of HAART. SUBJECTS/METHODS: In 1997 recruitment started and 201 patients gave informed consent. They underwent structurized interviews. Additional data were taken from the patients records. Later on follow-ups were performed for the same cohort in the years 2000 and 2001 respectively. Direct costs have been calculated per patient and year for each period. RESULTS: The proportion of HAART treated patients rised in the cohort from 86% to 93%. The mean of antiretrovirals used per case increased from 2.4 to 3.4. Nevertheless mean direct costs for HAART decreased significantly from Euro 17,746 to Euro 16,007. Reduction of expenditures for additional drugs, hospitalisation and diagnostics led to about one third decrease of mean total direct cost from Euro 35,865 in 1997 to Euro 24,482 in 2001. For surviving patients expenditures remained higher in advanced stage of disease for HAART, hospitalisation, diagnostics and total costs. CONCLUSION: Expenditures for HAART remained on a high level. Despite rising drug prices and increased use of antiretrovirals a decrease of mean costs of HAART by about 10% resulted from more frequent use of less expensive drug combinations. The continuous decrease of expenditures for non-HAART drugs, diagnostics and hospitalisation predominated and therefore HAART caused about a half of total direct costs in 1997 and two third in 2001 respectively. Higher expenditures in advanced stages of disease continued over the follow up period and raise the question of an economic impact of earlier initiation of treatment. More extensive use of standardized evaluation of direct costs could be an important tool towards a more rational allocation of resources in health care.

[The cost of an HIV patient. Lack of funds for optimal treatment?]. / Was ein HIV-Patient kostet. Scheitert die optimale Behandlung am Geld?

Many patients with HIV--a group in urgent need of effective health care measures--are extremely worried by current discussions on budgeting, fearing, as daily practice shows, restrictions on vitally indicated services. The present article describes the results of a recent health economics study of the direct and indirect costs generated by HIV infection.

[Using the excimer laser in refractive eye surgery. Results of a survey of German ophthalmologists]. / Verwendung des Excimer-Lasers in der refraktiven Augenchirurgie. Ergebnisse einer Umfrage unter deutschen Augenärzten.

BACKGROUND: Little information about the cost-effectiveness of excimer laser operations is available. As the number and structure of providers of these services in Germany are relatively unknown, only rough estimations can be made about the number of operations. PURPOSE: In this study the market for excimer laser operations is defined, structured from an economic view and examined according to medium-term demand and supply trends. The aim of the study is an applicable estimation of the current level of dissemination and of existing economic conditions for providers of excimer laser operations. METHODS: In a postal survey 219 ophthalmologists in Germany were asked to provide the number of excimer laser operations they had carried out and the organizational and financial details of these services. The questionnaire was answered anonymously. RESULTS: One can conclude that the annual number of interventions is increasing, although less significantly than in the United States. In most cases, providers of German health insurance have rejected inclusion of this service in their reimbursement catalogue. CONCLUSIONS: As of yet, excimer-laser-related turnover has frequently not met expectations. However, because of modifications of technological, health-economic and demand conditions an increase in the number of operations within this area is expected in the future.

[Deficits in socioeconomic and psychosocial support of HIV-positive women]. / Defizite der sozioökonomischen und psychosozialen Unterstützung HIV-positiver Frauen.

Despite increasing numbers of heterosexually transmitted HIV-infected women and high numbers of female i.v.-drug users within HIV-infected population the subject of HIV-infection in women has been of low interest during the past years in Germany. This prospective study investigated the economic, social and psychological situation with regard to the special situation of this group. While there was no difference in clinical parameters we found a worse economic situation of HIV-positivity in women. Concerning the psychosocial situation there were few differences, but HIV-infected women sought help by voluntary workers more often. Specific education and socioeconomic support of HIV-infected women are conditions for the success of antiretroviral therapy of HIV-infection which has recently become more demanding and complex.

[Health economics and evaluation of schizophrenic psychoses in Germany]. / Gesundheitsökonomische Evaluationen schizophrener Psychosen in Deutschland.

This paper presents a survey of economic analyses of schizophrenia in Germany. A recently published cost-of-illness study demonstrates the high financial burden to society caused by the disease. Ambulatory care and medication were remarkably less costly than in-patient treatment. Several other studies show that continuous in-patient treatment is less cost-effective than complementary care in the community. Two pharmaco-economic models evaluate drugs with special focus on long-term treatment. Drugs with better compliance rates seem to produce savings in the health care system by less hospital admissions, even if the drug is more expensive than other medication. In addition to the survey the problems of economic analysis of psychiatric disorders in Germany are discussed. There are difficulties caused by the structure of the German health care system. Other problems emerge from the measurement of outcomes, effectiveness, utilities and quality of life in psychiatric disorders.

The influence of economic evaluation studies on decision making. A European survey. The EUROMET group.

Despite the growing activity in the field of health economics very little is known about the influence of economic evaluation studies on health care decision making in the EU member states. Several investigations about the impact of health economic studies on decision making have been performed, but most of them did not involve decision makers themselves. In this paper the results of the EUROMET survey are reported and discussed. Different types of decision makers in nine European countries were surveyed by postal questionnaires, semi-structured interviews and focus group discussions. Questions include issues about the extent of knowledge about economic evaluation, the actual and potential use of study results as well as barriers and incentives in the use of studies. It is concluded that despite the general positive attitude knowledge about the formal methodology is rather limited. Accordingly, results of economic evaluation studies are not widely used in decision making. The results show that institutional dimensions, such as difficulties in transferring budgets, are viewed as important barriers. Also, the lack of credibility of studies is assigned a high relevance. Moreover, decision makers wish for a better explanation of the practical relevance of studies and feel that there is a need for more training in health economics. Considering these requirements a number of recommendations for enhancing the value of health economic studies are given.

[Direct and indirect costs of schizophrenia]. / Die direkten und indirekten Kosten der Schizophrenie.

In the present study the costs of schizophrenia in Germany were studied using the "bottom up" prevalence-based method. In a random sample of 180 schizophrenic patients stratified according to the most important care institutions, direct and indirect costs were retrospectively documented for a 12-month period. Depending on the place of recruitment and the extent of care provided, total yearly costs result between about DM 33,000 for a patient treated predominantly on an outpatient basis and about DM 126,000 for a patient requiring hospital care and about DM 135,000 for a patient in job rehabilitation. The direct yearly treatment costs were, as expected, lowest for patients recruited in the private practice of a psychiatrist and predominantly treated on an outpatient basis (DM 5,788), and were the highest in the psychiatric hospital (DM 64,661) and in job rehabilitation (DM 79,996). In the patients recruited in the outpatient domain, doctors' fees and medication together were responsible for only 4.5% of the total costs, whereas the indirect costs (e.g., through work incapacity) were responsible for 87% of the total yearly costs. For methodological reasons the total costs caused by schizophrenic psychoses in Germany per year can at present be estimated only roughly. A conservative estimate is between 8.5 and 18 billion DM per year. The study shows that schizophrenia is a very expensive illness, the direct and indirect costs of which are on the whole comparable to those of the common somatic illnesses. Therefore, also for economical reasons, sufficient financial means should be invested in the research and treatment of this severe illness.