Hospital-based nutrition-focused interventions have been found to alleviate the burden of malnutrition for inpatients due to improved health outcomes (i.e., reduced readmissions and hospital stays). Limited evidence exists on the economic impact of nutrition interventions across the care continuum and for community-based patients. We assessed the potential cost-savings associated with decreased 30-day healthcare resource utilization (i.e., admissions/readmissions, emergency room (ED) and outpatient clinic visits) employing a budget impact analysis of community-dwelling patients at malnutrition risk receiving healthcare services at home. The reduction observed in healthcare resource utilization rate for 1546 patients enrolled in the quality improvement program (QIP) was compared with that of the 7413 pre–QIP historical cohort patients to calculate potential cost-savings. The model calculates differences in the number of 30-day admission/readmissions, ED and outpatient clinic visits observed for QIP vs. pre-QIP historical group and associated total cost reductions. The fixed and variable QIP program costs including 30-day oral nutritional supplements (ONS) costs were included in the analysis. The cost of hospitalization of $17,985 was from the Healthcare Cost and Utilization Project (HCUP) which reported costs for malnourished adult patients using 2016 data for United States hospital admissions. The average costs of ED and outpatient visits of $1,252 and $510.95, respectively were from the 2013 Medical Expenditure Panel Survey (MEPS). Due to improved health outcomes and reduced healthcare resource utilization for the QIP patients over the 30-day timeframe, cost-savings of $2,353,237 total and per patient net-savings of $1,522 were calculated in favor of QIP group as compared to the pre-QIP/historical counterparts. The nutrition-focused QIP resulted in significant healthcare cost-savings by avoiding 30-day admissions/readmissions, ED and outpatient clinic visits. The observed economic improvement highlights the importance of implementing similar nutrition-focused QIPs for at-risk/malnourished patients across the care continuum, and in particular for community-dwelling adults receiving care in post-acute care settings.

Osteoporosis is characterized by the occurrence of fractures due to reduced bone stability. Annual direct costs of osteoporosis are estimated at € 5.4 billion in Germany. Without changes in policy, fractures – the main cost driver – are expected to double by the year 2050. While a high-quality evidence-based guideline on screening and preventive treatments exist, only 52% of general practitioners stated to have knowledge of the guideline, which is expected to result in low levels of guideline adherence and implementation. Therefore, the objective of this study is to investigate the economic impact of a 20% increase (from currently assumed ≈50% to a target 70%) of guideline adoption rate by German primary care physicians. A health economic model was developed to investigate the cost impact and cost-utility of extended guideline implementation. Screening was modeled using a decision tree, subsequent treatment was modelled in a Markov approach, with one-year cycles simulated over lifetime. The modelled cohort comprised 381,583 women eligible for screening at age 70. The perspective of the statutory health insurance was applied; accordingly, prices from official formularies and fee schedules were used. Sensitivity analyses were performed to test the robustness of results. Increasing implementation of the guideline by 20% resulted in an additional screening of 76,317 women and treatment of 19,079 women at high fracture risk. 1,668 fractures were avoided, as were 588 subsequent deaths. Over lifetime, higher implementation led to 5,214 additional QALYs and additional costs of € 59 million, resulting in € 11,383 per QALY gained. A conservative 20% increase in implementation of the evidence-based guideline could substantially reduce fractures and increase quality of life, while showing a limited impact on the healthcare budget. From a health economic point of view, a comprehensive implementation of the guideline, by increasing physicians’ guideline adherence, appears recommendable.

Reimbursement Pathways  Seventy-nine million Germans have either statutory health insurance (SHI ~ 90% of the German population) or private health insurance (PHI ~ 10% of the German population) coverage.  With a healthcare expenditure on medical devices of 25 billion euros in 2012 Germany remains the largest medical device market in the EU and the third ranked in the world, behind the USA and Japan.  Any medical device intended for the German market must bear a CE mark before it can be sold or put into service [1].  According to the German statutory rules in the inpatient care setting all (innovative) procedures are permitted with the reservation of prohibition (‚Verbotsvorbehalt‘) [2], and in the outpatient care setting all (innovative) procedures are prohibited until they have been officially approved (‚Erlaubnisvorbehalt‘) [3].  Hence hospitals are allowed to apply all innovative medical devices in an inpatient setting once they have received marketing approval for Germany (CE mark), whereas a positive voting from the federal joint committee (G-BA) is required for medical devices applied by physicians in the outpatient setting.  The reimbursement of inpatient services in Germany is based on a diagnosis-related group (DRG) system. Hence the reimbursement of a medical device in the inpatient setting depends on adequate coding options (procedural codes = OPS codes, medical indication coding = ICD-10 codes) on the DRG grouping systematic and on the adequate reimbursement value of the related DRG.  If all these preconditions are met a new medical device is already reimbursed adequately. If one or all preconditions are not met specific applications (OPS, DRG and/or NUB applications) can be made at the institutes responsible for the DRG coding and coverage, which are the German Institute of Medical Documentation and Information (DIMDI) and the Institute for the Hospital Remuneration System (InEK).  Whereas OPS and DRG application are focusing on the procedural coding and the DRG grouping, NUB applications are focusing on determining an extra rate, which will be reimbursed on top of an existing DRG fee. Such NUB applications can be prepared by the MD manufacturer but they can only be submitted by German hospitals that are also responsible for the NUB extra rate price negotiation. OPS=German Procedure Coding; DRG=Diagnoses Related Groups; ;MD = Medical Device; NUB=New Diagnosis & Therapy Methods; EBM=Statutory Health Insurance Physician Fee Schedule, GOA=Private Health Insurance Physician Fee Schedule; TAS = Therapeutic Appliance Schedule; IGeL=Individual Health Services Clinical and Health Economic Evidence Requirements