Croatian Health Insurance Fund Research Articles

Antibiotics Prescribing Pattern and Quality of Prescribing in Croatian Dental Practices-5-Year National Study.

Antibiotic resistance is one of the biggest threats to global health today. The aim of this study was to analyze antibiotic prescribing patterns and quality of prescribing in Croatian dental practices over a 5-year period. This is a retrospective observational study based on the analysis of the electronic prescriptions (medicines in ATC groups J01 and P01) from dental practices in Croatia prescribed from 1 January 2015 to 31 December 2019. Prescriptions were retrieved from the Croatian Health Insurance Fund (HZZO). The analyses included the number of prescriptions, type and quantity of prescribed drugs, indication, and the patient's and prescriber's characteristics. The consumption increased from 1.98 DID in 2015, to 2.10 DID in 2019. The most prescribed antibiotic was Amoxicillin with clavulanic acid followed by Amoxicillin, Clindamycin, Metronidazole and Cefalexin. The analyses showed that 29.79% of antibiotics were not prescribed in accordance with the contemporary guidelines for the proper use of antibiotics. Additionally, 22% of antibiotics were prescribed in inconclusive indications. The research showed an increase in antibiotic consumption over five years along with unnecessary prescribing of antibiotics in cases with no indications for its use. The development of national guidelines for antibiotic use is necessary.

Impact of COVID-19 Pandemic on Cardiovascular Healthcare in Croatia: A Comprehensive Nationwide Survey.

The impact of the COVID-19 pandemic on cardiovascular healthcare in Croatia remains largely unexplored. This study aimed to compare the utilization and provision of cardiovascular services during the pre-pandemic (2017-2019) and pandemic (2020-2021) periods, leveraging nationwide data from the Croatian Health Insurance Fund, which covers 95% of all insurance claims in the country. Our findings reveal that while the use of coronary angiographies decreased during the pandemic, there was a notable increase in the utilization of advanced heart failure treatment modalities and percutaneous coronary interventions, particularly in the context of acute myocardial infarction. Additionally, transcatheter aortic valve implantations saw a significant rise during the pandemic period. Furthermore, laboratory diagnostic testing for troponin and natriuretic peptides experienced a marked increase, while the utilization of most other cardiovascular services remained stable or showed only minor declines compared to the pre-pandemic era. These observations suggest that the Croatian cardiovascular healthcare system displayed resilience during the COVID-19 pandemic, successfully maintaining and even expanding access to various diagnostic and interventional procedures despite facing widespread societal and logistical challenges.

Impact of the COVID-19 pandemic on acute mental health admissions in Croatia.

The pandemic of COVID-19 had a profound impact on our community and healthcare system. This study aims to assess the impact of COVID-19 on psychiatric care in Croatia by comparing the number of acute psychiatric cases before coronavirus disease (2017-2019) and during the pandemic (2020-2022). The paper is a retrospective, comparative analyzes of the hospital admission rate in Diagnosis Related Group (DRG) classes related to mental diseases, and organic mental disorders caused by alcohol and drug use. This study used DRG data from all acute hospitals in Croatia accredited to provide mental health care services and relevant publicly available data from the Croatian Institute of Public Health (CIPH) and the Croatian Health Insurance Fund (CHIF). All hospital admissions for acute psychiatric patients in Croatia were tracked during both periods under study. During the pandemic, the average number of all such cases decreased by 28% in secondary and tertiary hospitals, and by 11% in specialist psychiatric hospitals. It was also found that during COVID-19, there was a decrease in case numbers in DRG classes related to major affective disorders and anxiety, alcohol, and drug intoxication (31, 48, 34 and 45%, respectively). However, the same period saw an increase in hospital activity for eating disorders and for involuntary admissions related to schizophrenia and paranoia (30, 34 and 39% respectively). There were no changes in the admission rate for cases related to opioid use. The COVID-19 pandemic resulted in both a steep decrease in the overall number of psychiatric cases inpatient treatment at mental health facilities and their DRG casemix. Increasing our understanding of how pandemics and isolation affect demand for psychiatric care will help us better plan for future crises and provide more targeted care to this vulnerable group.

Effectiveness of Nusinersen in Type 1, 2 and 3 Spinal Muscular Atrophy: Croatian Real-World Data.

(1) Background: To investigate the real-world effectiveness and safety profile of nusinersen in Croatian paediatric and adult spinal muscular atrophy (SMA) patients. (2) Methods: A retrospective and anonymous collection of relevant demographic and clinical data for all Croatian SMA patients treated with nusinersen and reimbursed by the Croatian Health Insurance Fund (CHIF) between April 2018 and February 2022 was performed through searching the CHIF database and studying the associated reimbursement documentation. All patients who received at least one dose of nusinersen were included in the baseline clinical-demographic overview and safety analysis, whereas only subjects who had completed six doses were included in the effectiveness analysis. (3) Results: Fifty-two patients [61.5% male; median age 13.4 (0.1-51.1) yr.] received nusinersen treatment. In SMA type 1 and type 3 paediatric patients, statistically significant motor function improvement (CHOP INTEND 10.8 ± 10.3 vs. 20.0 ± 15.8, p = 0.003; HFMSE 49.6 ± 7.9 vs. 53.1 ± 7.7, p = 0.008; respectively) was achieved immediately after 4 loading doses of nusinersen and remained statistically significant onwards. Average improvements in HFMSE motor performance in SMA type 2 patients after four, five, and six doses of nusinersen were +6.0, +10.5, and +11.0 points, respectively. In SMA type 3 adult patients, no significant improvement in RHS motor performance or the 6-Minute Walk Test (MWT) was demonstrated. During the study period, 437 doses were administered without any new safety concerns appearing. (4) Conclusions: Our RWD findings indicate that nusinersen is an effective and safe treatment in a heterogeneous group of paediatric patients with all types of SMA; however, no significant benefit (but only RHS and 6MWT maintenance) was demonstrated in SMA type 3 patients who started nusinersen after >18 years of age.

Impact of COVID-19 on inpatient care related to skin conditions

The COVID-19 pandemic significantly affected our society and healthcare system. This study aims to evaluate the effects of COVID-19 on the number of hospitalized patients with dermatological diseases in Croatia, as well as the number of these patients treated surgically and conservatively, before (2017-2019) and during the pandemic (2020-2021). This is a retrospective, comparative study of the hospital admission rate for patients with skin, subcutaneous tissue, and breast disorders both before and during the pandemic. This study used data from the Croatian Institute of Public Health (CIPH) and the Croatian Health Insurance Fund (CHIF). Inpatient data for the CHIF data collection were categorized using the Australian Refined Diagnosis Related Groups (AR-DRGs). All hospital admissions for dermatology patients at all non-specialized hospitals in Croatia were tracked during two periods, before (2017-2019) and during the pandemic (2020-2021). The average number of dermatology patients in all hospitals fell by 29% during the pandemic. The overall number of dermatological patients admitted to hospitals fell by 32% in 2020 and by 26% in 2021 when compared to the number of patients admitted each year on average over the preceding 3 years. Additionally, there was an average 22% fall in surgical procedures performed during the pandemic. The only exception for surgical procedures is Major Breast Reconstruction for which is noted an increase, as also for Malignant Breast Disorders, Minor Complexity and Major Skin Disorders, Minor Complexity in a group of non-surgically treated patients. Examining the all consequences of the Croatian dermatological patient care interruption will require more investigation. Reduced access to medical care during the pandemic is anticipated to lead to later illness diagnosis, a later start to treatment, a poorer disease prognosis, as well as higher medical expenditures.

Legal Aspects of Recognizing COVID-19 As an Occupational Disease in The Republic of Croatia

Occupational diseases are diseases directly induced by work and working conditions. In the Republic of Croatia, according to the procedure set out by law, occupational diseases are reported and recognized by the Croatian Health Insurance Fund and registered and monitored in the Registry of Occupational Diseases kept by the Croatian Institute for Public Health – Department of Occupational Health. Diagnoses are under responsibility of occupational medicine specialists and are carried out according to modern occupational health criteria, which include determining the clinical picture of the disease and the damage caused by the work process. The recognition of COVID-19 as an occupational disease is extremely important for the worker considering the financial and pension benefits according to the applicable laws and regulations. Most workers who have had COVID-19 as a professional disease do not get the disease recognized as an occupational disease while they are sick. The length of the acute disease is shorter than the process of application and evaluation of occupational disease. However, the recognition of COVID-19 as an occupational disease may be important for the future. Should any of the complications (e.g. post COVID-19 syndrome) arise in the future, the worker holds their rights under health insurance. The scientific and healthcare community is still in the process of evaluating and recognizing complications of COVID-19 disease and their long-term impact on health and work ability. Key words: occupational disease, legislation, public health, occupational medicine

The effects of diagnosis-related groups payment on efficiency of the hospital health care in Croatia

AimTo assess the impact of Croatian reforms related to the funding of inpatient care on the efficiency of acute hospitals.MethodsBetween 2009 and 2018, the study analyzed resourcing, performance, and financing data for 33 acute hospitals. It used data from the Croatian Health Insurance Fund (CHIF) and the Croatian Institute of Public Health and included hospital activity and diagnosis-related grouping; average length of stay (ALOS); hospital staffing; CHIF revenue streams; and hospital incomes and expenditures.ResultsDuring the study period, the cost-efficiency of Croatian public hospitals did not meaningfully improve. While ALOS decreased by 14% and the number of beds decreased by 12%, bed occupancy rates decreased by 9%, acute inpatient admissions by 5%, and diagnosis-related group (DRG)-weighted output by 16%. Hospitals operated at higher costs, as the average cost per DRG-weighted case increased by 17%, from HRK 11 828 in 2016, to HRK 13 897 in 2018.ConclusionsIn this period, Croatian reforms failed to improve hospital efficiency. This may be explained by the failure of reformers to heed the experience of other countries, which showed that hospital payment reform of this nature calls for systematic and coordinated actions, inter-agency collaboration, and a strategic approach where the various interventions are in congruence and act to reinforce one another.

PRAVILA EUROPSKE UNIJE O TRŽIŠNOM NATJECANJU I DRŽAVNIM POTPORAMA I DOPUNSKO ZDRAVSTVENO OSIGURANJE U REPUBLICI HRVATSKOJ: KRIVO SRASTANJE?

Competition and state aid rules are not applicable to compulsory health insurance in the Republic of Croatia, since the latter does not constitute an economic activity as defined by EU law. On the other hand, complementary health insurance, as established in Croatia, constitutes an economic activity, due to the existence of real competition between undertakings. The illustrated situation with competition in complementary health insurance market allows for the statement that special rules applicable to Croatian Health Insurance Fund (HZZO) provide the latter with a privileged position when compared to its private competitors to whom these rules do not apply. Moreover, this privileged position is strengthened by the fact that HZZO, as a legal monopolist within the sphere of compulsory health insurance, utilizes respective infrastructure in the field of complementary health insurance, which enables it to reduce expenses to the detriment of its private competitors lacking such a privilege. A solution for the described situation could be for the state to establish a separate entity to provide complementary health insurance. This entity would have to provide open enrolment and community rating, regardless of age, sex or health of the insured persons. In order to prevent private competitors from jeopardising the exercise of service of general economic interest by taking over only the insured persons with a more favourable risk profile, a risk equalisation scheme would have to be set up. This would result in a transfer of funds from insurers with a favourable risk profile to those with an unfavourable risk profile on basis of objective and clear criteria, thereby making it possible for the latter to provide service to the higher-risk insured persons like the elderly and the ones with chronic illnesses. In this way, a balance between the necessity to provide a service of general economic interest to all insured persons, including those with a higher risk, and competition on the EU internal market, would be struck.

Cost effectiveness of antihypertensive drugs and treatment guidelines.

Arterial hypertension (AH) is associated with a high economic burden for the individual patient and for society in general. The study evaluates antihypertensives and their cost-effectiveness, comparing diuretics (D), beta-blockers (B), angiotensin converting enzyme inhibitors/angiotensin-II receptor blockers (A) and calcium channel blockers (C) with no intervention (NI). The study included five health states in a Markov model. Cost values included average cost of the drugs used, treatment in hospital and treatment in general practice (collected from Croatian Health Insurance Fund). The study was conducted separately for 65-year old men and women, with an initial probability of cardiovascular death risk of 2% and heart failure risk of 1%. The results were presented in terms of increase in QALYs and associated financial savings or costs in euros (€). Results for men (compared with NI): treatment with D resulted in a QALY increase of 0.76 and €886 in savings, treatment with C in an increase of 0.74 QALYs and €767 in savings, treatment with A in an increase of 0.69 QALYs and €834 in savings, treatment with B resulted in an increase of 0.40 QALYs, but with an additional cost of €41. Results for women (compared with NI): treatment with D resulted in an increase of 0.93 QALYs and €987 in savings, treatment with C in an increase of 0.89 QALYs and savings of €855, treatment with A in an increase of 0.86 QALYs and savings of €991, treatment with B in an increase of 0.48 QALYs, but with an additional cost of €148. Treatment of AH with D, C and A is cost effective compared with the no-intervention scenario. Diuretics are the most cost-effective first-line treatment. The scenario with beta-blockers resulted in additional QALY when compared with no intervention, but also additional costs; therefore, based on our results, this therapy would not be recommended as first-line treatment.

Medication Prescribing Practices in Croatian Dental Offices and Their Contribution to National Consumption

ObjectivesThe objective of this study was to analyse the pattern of medication prescribing among dental practitioners in the Republic of Croatia and to compare it with general medical practice patterns at the national level. MethodsData on drug prescriptions were obtained from the Croatian Health Insurance Fund. The number of dentist prescriptions, the cost of medicine denominated in the national currency (Croatian Kuna [HRK]), and the number of packages and days prescribed have been included in the analysis. ResultsResults indicate that there was an increase in medication prescribing(+5.7%) by dentists, with antimicrobials comprising the majority, whereas national medical antimicrobial prescribing had slightly decreased. Antibiotics accounted for 80% of all dentists’ prescriptions, with penicillins being the most commonly prescribed. In particular, amoxicillin with clavulanic acid accounted for 56.4% of all antibiotics prescribed. Such broad-spectrum antibiotics were prescribed more frequently than those of narrow-spectrum. Antibiotics were followed by nonsteroidal anti-inflammatory drugs, with prescribing frequency for ibuprofen increasing by 75%. ConclusionCurrent trends show an increase in the overall prescription rate for all medications prescribed by dentists. The largest increase was observed for the broad-spectrum amoxicillin with clavulanic acid, and ibuprofen. As the apparent widespread use of broad-spectrum antibiotics by dentists in Croatia is in contrast to national and international recommendations for antibiotic stewardship, there is a need for further prospective investigation and possible provider education and guidelines.

Private health care sector in Croatia

This paper investigates the trends in business activity of the private health care sector in Croatia from 2011 to 2018. Databases of Croatian provider of financial and electronic services - Financial Agency (FINA) - have been employed to explore key performance indicators of private health care sector companies, in particular trends in total employment, business revenues and operating profits. In addition, the most important features of voluntary health insurance (VHI) provided by private health insurance companies and the Croatian Health Insurance Fund (HZZO) have been presented. Furthermore, this paper provides both a relevant analysis of the private health care sector as well as private spending on health care in Croatia. The results indicate that users of health care services are willing to pay more to gain faster access and higher quality services. In 2018, expenditures for private health care services reached almost HRK 5 billion. Nearly 60% were out-of-pocket (OOP) payments and 40% were paid through the VHI. Despite the persistent recession, the private health care sector in Croatia experienced an average annual growth rate of 10% in the analysed period. More recently, the trend of introduction of more complex services within private providers can be observed indicating the rise in investments, and competitiveness. In conclusion, private health care sector’s presence in Croatia is a reality that should be addressed adequately. Original findings in this paper might serve as starting point for future discussions regarding the private health care sector role in the overall health care system financing. The paper brings a deeper insight into Croatian private health care sector market using original and most recent microdata thus shedding the light on important part of our health economy. Nevertheless, paper has certain limitations that are mainly reflected in relatively narrow set of indicators used in private health care sector business analysis. This though might be addressed properly in future research.

GIS Analysis of Accessibility and Spatial Distribution of Health Care Institutions on the Example of Zadar City, Croatia

The accessibility of health care organizations plays a key role in promoting health equality and quality of life. The main objective of this paper is to analyze the accessibility of health care organizations in the city of Zadar. Data on the locations of general practitioners’ clinics, dental care clinics, pediatric clinics, pharmacies, private practice offices and general hospitals were used in the GIS analysis. The addresses of health care organizations were taken from the website of the Croatian Health Insurance Fund (HZZO) and then geocoded. Data on the transport network of the settlement of Zadar were taken from the Geofabrika website. Topological verification and data correction were performed. Healthcare accessibility zones were derived in the ArcMap 10.1 Network Analyst extension. Accessibility zones were derived according to the travel time criterion and classified with respect to minutes on foot (5-10-15). Data on statistical circles and population were taken from the Central Bureau of Statistics. It has been found that there are significant differences in statistical circles regarding the accessibility of health care organizations in the city of Zadar. The highest concentration of health care organizations has been marked in the statistical circles of Poluotok, while the scarcity of institutions was noted in the statistical circles of the eastern part of the city.

A single-payer health care system in Croatia: problem or solution?

Abstract Background Andrija Štampar implemented innovative healthcare solutions in Croatia at the beginning of the 20th century, advocating principles of comprehensiveness, continuity, and availability. These principles are globally challenged at ideological, social and policy levels, reflecting discussions in the USA and EU on whether a single-payer, mandatory health insurance (MHI) system and universal health coverage (UHC) are optimal solutions for the sustainable health system of the 21st century? Methods Analyzing the impact of the Croatian Health Insurance Fund (CHIF) as a single-payer on the performance of Croatia's health care system through the analysis of the financial and health outcomes for the 2000-2020 period to assess allocative efficiency, organizational effectiveness, and economic sustainability. Results The CHIF is the single purchaser of all publicly financed individual health services, delivered through both public and private providers. Although the broad scope of the MHI scheme, patients must pay towards the costs of many goods and services, and the right to free health care services has been systematically reduced in the last twenty years. The financial sustainability of the system is decreasing mainly caused by the model focusing on the tertiary care and payment scheme based on monthly hospital limits. However, the incidence of catastrophic and impoverishing payments is lower in Croatia than in many other EU13 countries. Conclusions The solution might be in the development of integrated health services, implementation of health promotion, education, and awareness, diseases prevention, and focus on the outcomes. The funding should follow the population needs in accordance with public health priorities and not only the structural demand of the existing system. The alternative is to face additional financial burden and impoverishment of the population in need of healthcare services. Key messages Modern universal health coverage strives to integrate health care and focuses on the outcomes. Single-payer system is not an obstacle for integration or source of fragmentation.

THE CROATIAN HEALTH INSURANCE FUND DOES NOT RECOGNIZE DIFFERENCES IN THE COST OF DIFFERENT TREATMENTS FOR REVISION TOTAL HIP ARTHROPLASTY.

SUMMARYIn recent years, there has been increased interest in the cost of treatment for revision interventions for hip and knee prostheses. In all publications so far, the authors note the high cost of treatment for revision interventions, especially if infection is present. The aim of this study was to compare the cost of treatment and health insurance reimbursements between revision total hip arthroplasty (THA) for infection and revision for aseptic indications (aseptic instability and periprosthetic fracture). Hospital data on 168 patients having undergone revision THA between 2010 and 2018 at the Department of Traumatology, Sestre milosrdnice University Hospital Centre from Zagreb were analyzed. Financial data were collected from the Hospital Information System. Financial analysis included total cost per patient, Croatian Health Insurance Fund reimbursements, cost of implants, and length of hospital stay. The difference between the mean total cost per patient and the mean Croatian Health Insurance Fund reimbursements was -262.83 € (-6.08%) for aseptic instability, -1694.94 € (-17.25%) for infection and -916.49 € (-17.33%) for periprosthetic fracture. The Croatian Health Insurance Fund does not recognize differences in the cost of revision THA for aseptic instability, infection and periprosthetic fracture. Health insurance reimbursement is inadequate for centers that offer revision hip surgery.

Outpatient benzodiazepine utilization in Croatia: drug use or misuse.

Background Benzodiazepines are commonly prescribed medications, especially among elderly, despite known risks and guidelines focused on short term usage. There is an increased trend of benzodiazepine consumption in Croatia. Consumption of anxiolytics in 2015 and 2016 in Croatia can almost entirely be ascribed to benzodiazepines, with diazepam being the most commonly prescribed drug, followed by alprazolam. Objective The aim of this study was to examine benzodiazepine utilization habits among the Croatian population. Setting This study was conducted on the national level, based on digital prescribing data. Method Data regarding the prescription of anxiolytics in Croatia was sourced and analyzed from the Croatian Health Insurance Fund database for the years 2015 and 2016. Drugs included in the study were classified according to The Anatomical and Therapeutic Classification of Medicines System, and consist of several chemical therapeutic subgroups (N05BA, N05BC,N05CD, N05CF). Main outcome measures The prescribing frequency of the most often prescribed benzodiazepines in Croatia. Results The total number of benzodiazepine prescriptions was 5,085,695 in 2015, and 5,294,075 in 2016; this represents a 208,380 increase in prescriptions, or 4.1% more than the previous year. The number of patients who utilized benzodiazepines showed an increase from 860,664 (8.67%) in 2015 to 876,046 (8.76%) in 2016. In relation to gender, benzodiazepine consumption was higher among female patients in all age groups, with the number of utilized benzodiazepine prescriptions per patient being highest in the oldest age group (80 +), comprising 7 prescriptions per patient in a 12months period. Conclusion Increased utilization and long-term treatment with benzodiazepines remains a serious challenge for the health care system in Croatia. National prescription guidelines, improved control of benzodiazepine usage and prescriptions, along with restricted release drug lists, should all be considered as potential measures to rationalize benzodiazepine prescription, control unnecessary expenditure in the country and improve the well-being of the patients.

Resource utilisation and cost of cervical cancer and dysplasia in Croatia

Purpose of investigation: To analyse resource utilisation and costs due to cervical cancer and dysplasia in Croatia. Materials and Methods: Patients diagnosed with cervical cancer were identified from the Croatian National Cancer Registry. Resource utilisation and costs of cervical cancer treatment for the period of five years after the date of diagnosis were retrieved from the Croatian Health Insurance Fund Claims Database. Patients diagnosed with cervical dysplasia were identified and their resource utilisation and treatment costs during one year following diagnosis were obtained from the Croatian Health Insurance Fund Claims Database. Results were calculated for different healthcare services and disease stages. Results: There were 346 patients diagnosed with cervical cancer in 2008. Total costs of treatment in the five-year period were 2, 177, 071 Euros, while average cost of treatment per patient was 6, 403 Euros. The largest shares of total costs were costs for hospitalisations (73%), followed by outpatient healthcare (17%), and personal sick leave (7%). There were also 14, 913 patients with cervical dysplasia diagnosed in 2012. Total costs of their treatment during one year after the diagnosis were 1, 609, 073 Euros, with average costs per patient of 108 Euros. Outpatient care (48%), followed by hospitalisations (45%), and prescribed medicines (6%) had the greatest share of total costs. Conclusion: Treatment of cervical cancer and dysplasia in Croatia is associated with significant costs and healthcare resource utilisation.

Integrated Care Platforms to support Mental Health Patients

Integrated Care improve outcomes for both patients and their caregivers; creating access to better integrated socio-sanitary care e-Services (integration of health care, social care, long-term and self-care in any kind of health/living conditions) outside of hospitals; reducing unnecessary hospital admissions and enabling effective working of professionals. They can be considered as organizers of care around the needs of people with the aim of improving the health services through better coordination across different levels of socio-sanitary care and from different providers within each level. The introduction of integrated care programmes could undeniably improve the quality of life of both patient suffering from mental health but also for their home care-givers. As a result, the Croatian Health Insurance Fund and the Rijeka City Department of Health and Social Welfare in collaboration with the Psychiatric Hospital "Lopača" (founded by the City of Rijeka), participated in the CIP-ICT-PSP Project “INclusive INtroduction of INtegrated CAre (INCA)” trials to evaluate how the use of such platform would affect the health and quality of life of the people suffering from mental health problems or other mental health disorders, their caregivers, their doctors and social services.

Pharmacoeconomic Analysis of Different Biologic Therapies in Inflammatory Bowel Disease Patients in 1 Tertiary Center in Croatia

Table: Table. Results of pharmacoeconomic analysis of different biologic therapiesIntroduction: Biologics are used in patients with inflammatory bowel disease (IBD) usually after failure of conventional therapy, or, sometimes, instead of it early in the disease course. In Croatia, in the treatment of IBD, anti-tumor necrosis factor alpha (anti-TNF) agents infliximab, adalimumab and golimumab, and anti-integrin antibody vedolizumab are available. In patients achieving remission with anti-TNFs, loss of response should be treated firstly by dose optimization (dose increase or interval shortening). Our aim was to compare costs of different biologic therapies considering the costs of dose optimization. Methods: During March of 2017, we collected data of 91 patients with Crohn's disease and ulcerative colitis currently receiving biologic therapy at the Department of Gastroenterology and Hepatology of Clinical Hospital Center Osijek, Croatia. Data of our interest were: diagnosis, drug used, date of first and last drug application, projected date of next application, drug dosage of last application, and data of whether patient is receiving induction or maintenance therapy. We calculated the projected yearly cost of maintenance therapy with each biologic drug including costs of dose optimization. Projected yearly costs of maintenance therapy with different biologics were then compared. Drug prices were obtained from currently active list of medications of Croatian Health Insurance Fund. Results: 19% of our patients on infliximab and 26% of our patients on adalimumab had dose optimization due to loss of response. Projected average yearly dose per patient for infliximab considering dose optimization is 3053 mg/y compared to yearly dose recommended in summary of product characteristics (SmPC), which is 2600 mg/y. For adalimumab, projected average yearly dose per patient considering dose optimization is 1337 mg/y compared to 1040 mg/y recommended in SmPC. Projected cost of maintenance therapy per year after dose optimization is 1.2 times higher (13937 vs. 11868 USD) for infliximab and 1.3 times higher (17449 vs. 13571 USD) for adalimumab when comparing to costs of maintenance therapy in doses recommended in SmPC. Results are presented in table 1. Conclusion: As our results show, costs of maintenance therapy for certain biologics are higher when considering dose optimization. Inclusion of costs of dose optimization would give more accurate calculation of different biologic therapy costs and would help in understanding of pharmacoeconomic justification of use of different biologic therapies.

Drug Policy in Croatia

We presented a general overview of the health care system as well as the pricing and reimbursement environment in Croatia. In Croatia, most of the public funding for health care is collected from employers, through mandatory health care contributions for all the employed citizens. This contribution is a dedicated tax reserved for the health care system derived from employees’ salaries. The rest of the public funds is mainly from taxes used by the Ministry of Finance to complement the overall health budget each year. The population is covered by a basic health insurance plan provided by statute and optional insurance, administered by the Croatian Health Insurance Fund. Reimbursement decisions are based on the Ordinance of Ministry of Health issued in 2013, which is an ordinance establishing the criteria for inclusion of medicinal products in the Croatian Health Insurance Fund basic and supplementary drug lists. A health technology assessment agency was established in 2007 as a legal, public, independent, nonprofit institution under the Act on Quality of Health Care. Budget impact analysis is obligatory, and cost-effectiveness analysis is beneficial. Two reimbursement lists exist: the basic (100% drug coverage) and the supplementary (co-payment from 10% to 90%) lists. The basic list covers both hospital and retail drugs. There is also a special drug list for expensive drugs (mainly hospital drugs). International reference pricing is also in place. List updates are done on an yearly basis. Real-world evidence can be required for health technology assessment as evidence for the budget impact models and cost-effective analysis; it is, however, not mandatory.

Costs of occupational injuries and illnesses in Croatia.

Apart from influencing the quality of life, occupational injuries and illnesses can pose a large economic burden to a society. There are many studies that estimate the costs of occupational injuries and illnesses in highly developed economies, but the evidence for other countries is scarce. This study aimed to estimate the financial costs of occupational injuries and illnesses to Croatian government and employers in 2015. Workers were excluded due to the lack of data. Costs were estimated by analysing available data sources on occupational health and safety. Financial costs were grouped in several categories: medical costs, productivity losses, disability pensions, compensation for physical impairment, administrative costs, and legal costs. Unlike in other studies, the costs of compliance with occupational safety and health regulations were also investigated. In 2015, financial costs to employers were twice higher than costs to the government (HRK 604.6 m vs HRK 297 m). Employers additionally covered around HRK 300 m of compliance costs. Taking into account that financial costs of occupational injuries and illnesses are significant, even without including the costs to workers, policy makers should put additional efforts into their prevention. A prerequisite is transparency in Croatian Health Insurance Fund's expenditures, as well as more detailed data on lost days from work by industries, causes of injury etc. Organisations in charge of occupational health and safety and policy makers should observe relevant statistics in monetary terms too.