Health Economic Point Of View Research Articles

Center Hemodialysis Versus Peritoneal Dialysis: A Cost-Utility Analysis.

Introduction Kidney replacement therapy (KRT) is needed for patients with end-stage kidney disease. While it is clear that kidney transplantation remains the gold standard in KRT, data comparing the cost-utility of peritoneal dialysis (PD) and hemodialysis (HD) are scarce. No such analysis has been performed for German patients. Methods We used aggregated data generated by the Short Form 36 Health Survey (SF-36) for quality of life and insurance claims to evaluate mortality and economic impact. Quality-adjusted life years (QALY) and cost-utility were calculated accordingly. Results PD is superior to HD within all dimensions of the SF-36, both in terms of QALY and cost-utility. The difference in cost per QALY between the aggregated physical dimensions (€50,671.54 vs. €39,745.77) is greater than that of the aggregated mental dimensions (€31,638.75 vs. €25,287.63). However, there is considerable variability among patients. Conclusion From a health-economic point of view, PD should be preferred over HD when deciding on the KRT modality for the patient. This is not reflected in current practice, though. However, interindividual differences and patient preferences should be considered in the decision.

Development and validation of LightGBM algorithm for optimizing of Helicobacter pylori antibody during the minimum living guarantee crowd based gastric cancer screening program in Taizhou, China

Gastric cancer continues to be a significant health concern in China, with a high incidence rate. To mitigate its impact, early detection and treatment is key. However, conducting large-scale endoscopic gastric cancer screening is not feasible in China. Instead, a more appropriate approach would be to initially screen high-risk groups and follow up with endoscopic testing as needed. We conducted a study on 25,622 asymptomatic participants aged 45–70 years from a free gastric cancer screening program in the Taizhou city government's Minimum Living Guarantee Crowd (MLGC) initiative. Participants completed questionnaires, blood tests, and underwent gastrin-17 (G-17), pepsinogen I and II (PGI and PGII), and H. pylori IgG antibody (IgG) assessments. Using the light gradient boosting machine (lightGBM) algorithm, we developed a predictive model for gastric cancer risk. In the full model, F1 score was 2.66%, precision was 1.36%, and recall was 58.14%. In the high-risk model, F1 score was 2.51%, precision was 1.27%, and recall was 94.55%. Excluding IgG, the F1 score was 2.73%, precision was 1.40%, and recall was 68.62%. We conclude that H. pylori IgG appears to be able to be excluded from the prediction model without significantly affecting its performance, which is important from a health economic point of view. It suggests that screening indicators can be optimized, and expenditures reduced. These findings can have important implications for policymakers, as we can focus resources on other important aspects of gastric cancer prevention and control.

Comparison of Different Antibiotic Regimes for Preventive Tooth Extractions in Patients with Antiresorptive Intake-A Retrospective Cohort Study.

In the present study, the impacts on success rates between three different antibiotic regimes in patients receiving preventive tooth extraction during/after antiresorptive treatment were compared. For the retrospective analysis, we enrolled patients who had undergone tooth extraction from 2009 to 2019 according to the specified preventive conditions under antiresorptive therapy. Three antibiotic regimens were distinguished: (Group 1) intravenous for 7 days, (Group 2) oral for 14 days, and (Group 3) oral for 7 days of application. The primary endpoint was the occurrence of medication-related osteonecrosis of the jaw at 12 weeks after surgery. A total of 760 patients and 1143 extraction regions were evaluated (Group 1 n = 719; Group 2 n = 126; Group 3 n = 298). The primary endpoint showed no significant difference in the development of medication-related osteonecrosis of the jaw between the groups studied (Group 1 n = 50/669 (7%); Group 2 n = 9/117 (7%); Group 3 n = 17/281 (6%); p = 0.746). Overall, the success rate was 93% after intervention when preventive measures were followed. With the same success rate, a reduced, oral administration of antibiotics seems to be sufficient regarding the possible spectrum of side effects, the development of resistance and the health economic point of view.

Standard approach and future perspective for the management of benign prostatic hyperplasia from a health-economics point of view: the role of transperineal laser ablation

IntroductionBenign prostatic hyperplasia (BPH) is a common diagnosis among the ageing male population over 60 years and it is associated with the development of lower urinary tract symptoms (LUTS): dysuria, nocturia, increased frequency of urination, etc. LUTS negatively affect the patient’s daily activities and the quality of life. Patients with severe and persisting symptoms, not responding to pharmacological therapy, are candidates for surgical intervention. Transurethral resection of the prostate (TURP) has been the gold standard for surgical approach despite it can be associated with significant complications. Indeed, laser vaporization or enucleation are today the most broadly used surgical techniques and other minimally invasive surgical therapies (MISTs) have been introduced to reduce some complications during- and post-surgery. Moreover, a new micro-invasive approach for LUTS is represented by EchoLaser SoracteLite™ transperineal laser ablation (TPLA), an innovative, safe and feasible approach that can be performed under local anaesthesia and in an outpatient setting.ObjectiveThe paper aims to analyse and discuss the economic implications of standard surgical techniques and innovative approaches with a focus on TPLA thought a literature review.ResultsThe literature review highlights that at present there are few studies related to the economic implications of surgical therapies for LUTS. Preliminary results show that the TPLA is a promising technique in terms of clinical and economic benefit for the treatment of obstructive LUTS. Furthermore, TPLA can be performed in an outpatient setting implying an advantage from an economic and also organizational point of view, in particular in a health emergency situation.ConclusionsEconomic literature on minimally invasive techniques and surgical approaches for the treatment of BPH is still lacking. Multicentre and long-term economic studies are needed to assess the estimated disease burden. However, direct and indirect costs associated with TPLA are minimized vs TURP and laser vaporization/enucleation.

Economic Evaluation of the Community Benefit of the Australian Pregnancy Register of Antiseizure Medications.

The Raoul Wallenberg Australian Pregnancy Register (APR) was established to collect, analyze, and publish data on the risks to babies exposed to antiseizure medications (ASMs) and to facilitate quality improvements in management care over time. It is one of the seveal prospective observational pregnancy registers of ASMs that has been established around the world. Although the APR and other registries have contributed to knowledge gain that has been applied to decrease adverse pregnancy outcomes, their cost-effectiveness remains unknown. Here, we aimed to evaluate the economic impacts of the APR from both societal and health care system perspectives. Using decision analytic modeling, we estimated the effectiveness (prevention of adverse pregnancy outcomes) and costs (costs of adverse pregnancy outcomes and the register itself) of the APR over a 20-year time horizon (2000-2019). The comparator was set as the adverse pregnancy outcomes collected by the APR between 1998 and 2002 (i.e., no APR derived improvements in care). In the scenario analysis, we conservatively assumed a 2.5% and 5% contribution of the APR to the savings in health care and societal costs. Adverse pregnancy outcomes included stillbirth, birth defects, and induced abortion. All cost data were derived from published sources. Health and economic outcomes were extrapolated to the total target Australian epilepsy population. The primary outcomes of interest were the return of investment (ROI) for the APR and incremental cost-effectiveness ratio (ICER) for cost per adverse outcome avoided. Over the 20-year time horizon, the ROI from the APR from a societal perspective was Australian dollars (AUD) 2,250 (i.e., every dollar spent on the program resulted in a return of AUD2,250). Over this time, it was estimated that 9,609 adverse pregnancy outcomes were avoided, and health care and societal costs were reduced by AUD 191 million and AUD 9.0 billion, respectively. Hence, from a health economic point of view, the APR was dominant, providing cost saving ICERs from both perspectives. Following its inception 20+ years ago, the APR has represented excellent value for investment for Australia, being also health-saving and cost saving from a societal and a health care perspective. With the growing number of marketed ASMs, the APR is expected to continue to have a major impact in the foreseeable future.

Gene Therapy for Neuromuscular Diseases: Health Economic Challenges and Future Perspectives.

Highly efficacious, potentially curative gene therapies holds immense clinical promise, but also present complex challenges. At the time of regulatory approval and health technology assessment (HTA), evidence of efficacy and safety of gene therapies is often uncertain. In addition, research, development, and manufacturing costs, small pools of eligible patients, and the fact that many gene therapies are administered only once means that they frequently are associated with very high "one-off" price points. Although only a limited number of products have been brought to market globally, hundreds of clinical trials of gene therapies, including several of monogenetic neuromuscular diseases, are currently ongoing. Over time, as more and more conditions become amendable to gene therapy, the number of transformative, high-cost treatments is likely to increase considerably. For these reasons, concerns have been raised regarding the suitability of current health policy systems, including HTA frameworks, in ensuring appropriate access to these therapeutic innovations while simultaneously safeguarding value for taxpayers' money, as well as affordability and sustainability. This review provides a summary overview of current challenges and future perspectives of gene therapies for neuromuscular diseases from a health economic point of view.

The cost-effectiveness of radial access percutaneous coronary intervention: A propensity-score matched analysis of Victorian data.

BackgroundDespite evidence of the comparative benefits of transradial access percutaneous coronary intervention (PCI) over transfemoral access, its uptake remains highly varied across Australia. Few studies have explored the implications of the choice of access site during PCI from the perspective of the Australian healthcare setting. We, therefore, performed a cost‐effectiveness analysis of radial versus femoral access PCI.MethodsData from the Victorian Cardiac Outcomes Registry (VCOR) were used to inform our economic analyses. Patients treated through either radial or femoral access PCI were propensity score‐matched using the inverse probability weighted (IPW) method, and the incidence of major bleeding and all‐cause mortality in the cohort was used to inform an economic model comprising a hypothetical sample of 1000 patients. Costs and utility data were drawn from published sources. The economic evaluation adopted the perspective of the Australian healthcare system.ResultsAmong a cohort of 1000 patients over 1 year, there were 19 fewer deaths, and six fewer episodes of nonfatal major bleeding in the radial group compared to the femoral group. Total cost savings attributed to radial access was AUD $1 214 688. Hence, from a health economic point of view, radial access PCI was dominant over femoral access PCI. Sensitivity analyses supported the robustness of these findings.ConclusionsRadial access is associated with improved patient outcomes and considerably lower costs relative to femoral access PCI. Our findings support radial access being the preferred approach for PCI across a variety of indications in Australia.

EU-CaRE study: Could exercise-based cardiac telerehabilitation also be cost-effective in elderly?

BackgroundThe role of cardiac rehabilitation (CR) is well established in the secondary prevention of ischemic heart disease. Unfortunately, the participation rates across Europe remain low, especially in elderly. The EU-CaRE RCT investigated the effectiveness of a home-based mobile CR programme in elderly patients that were not willing to participate in centre-based CR. The initial study concluded that a 6-month home-based mobile CR programme was safe and beneficial in improving VO2peak when compared with no CR. ObjectiveTo assess whether a 6-month guided mobile CR programme is a cost-effective therapy for elderly patients who decline participation in CR. MethodsPatients were enrolled in a multicentre randomised clinical trial from November 11, 2015, to January 3, 2018, and follow-up was completed on January 17, 2019, in a secondary care system with 6 cardiac institutions across 5 European countries. A total of 179 patients who declined participation in centre-based CR and met the inclusion criteria consented to participate in the European Study on Effectiveness and Sustainability of Current Cardiac Rehabilitation Programs in the Elderly trial. The data of patients (n = 17) that were lost in follow-up were excluded from this analysis.The intervention (n = 79) consisted of 6 months of mobile CR programme with telemonitoring, and coaching based on motivational interviewing to stimulate patients to reach exercise goals. Control patients did not receive any form of CR throughout the study period. The costs considered for the cost-effectiveness analysis of the RCT are direct costs 1) of the mobile CR programme, and 2) of the care utilisation recorded during the observation time from randomisation to the end of the study. Costs and outcomes (utilities) were compared by calculation of the incremental cost-effectiveness ratio. ResultsThe healthcare utilisation costs (P = 0.802) were not significantly different between the two groups. However, the total costs were significantly higher in the intervention group (P = 0.040). The incremental cost-effectiveness ratio for the primary endpoint VO2peak at 6 months was €1085 per 1-unit [ml/kg/min] improvement in change VO2peak and at 12 months it was €1103 per 1 unit [ml/kg/min] improvement in change VO2peak. Big differences in the incremental cost-effectiveness ratios for the primary endpoint VO2peak at 6 months and 12 months were present between the adherent participants and the non-adherent participants. ConclusionFrom a health-economic point of view the home-based mobile CR programme is an effective and cost-effective alternative for elderly cardiac patients who are not willing to participate in a regular rehabilitation programme to improve cardiorespiratory fitness. The change of QoL between the mobile CR was similar for both groups. Adherence to the mobile CR programme plays a significant role in the cost-effectiveness of the intervention. Future research should focus on the determinants of adherence, on increasing the adherence of patients and the implementation of comprehensive home-based mobile CR programmes in standard care.

Cost-effectiveness of Radial Access Percutaneous Coronary Intervention in Acute Coronary Syndrome

Clinical trials have shown that radial access percutaneous coronary intervention (PCI) is associated with improved patient outcomes compared to femoral artery access. However, few studies have evaluated the cost-effectiveness of radial access PCI. This analysis sought to evaluate the cost-effectiveness of transradial versus transfemoral access PCI for patients with acute coronary syndrome (ACS) using data from the Minimizing Adverse Hemorrhagic Events by Transradial Access Site and Systemic Implementation of Angiox (MATRIX) trial. A decision analytic Markov model was constructed from an Australian health care perspective with a 2 year time horizon. The model simulated recurrent cardiovascular disease and death post PCI among a hypothetical cohort of 1000 individuals with ACS. Population and efficacy data were based on the MATRIX trial. Cost and utility data were drawn from published sources. Over a 2-year time horizon, radial access was predicted to save 12 (discounted) quality adjusted life years (QALYs) compared with femoral access PCI. Cost savings (discounted) amounted to AUD $51,305. Hence from a health economic point of view, radial access PCI was dominant over femoral access PCI. Sensitivity analyses supported the robustness of these findings. Radial access PCI is likely to be associated with both better outcomes and lower costs compared to femoral access PCI over 2 years post procedure. In conclusion, these findings support radial access being the preferred approach in PCI for ACS.

P190 Ileo-caecal Crohn’s Disease; medical or surgical management. Cost and outcomes

Abstract Background An ileo-caecectomy is known to be an effective treatment for Crohn’s disease limited to the terminal ileum that can lead to a long term remission. ECCO guidelines recommend that patients with active inflammation should be treated medically. However the LIR!C trial suggested there are QOL benefits and reduced costs to performing primary surgery. Methods We aimed to compare the outcomes of patients treated with primary medical treatment to primary surgery for patients with Crohn’s disease limited to the terminal ileum. We reviewed our database to identify all these patients and analysed outcome data. Results 49 patients were identified: Mean age was 50 yrs (range 22 - 93). 23 were male. Mean length of follow-up was 96 months (range 3 - 404). 1st line treatment was: medical; 33 (67.3%), surgery; 16 (32.6%). Outcomes after medical treatment: 27 of 33 patients failed primary medical treatment, they required surgery at a mean of 38 months (range 1–900) after initiating medical treatment. Colonoscopy after surgery to assess for disease recurrence: Colonoscopic assessment or calprotectin post was undertaken ileo-caecectomy in 4 of 16 patients at a mean of 6.2 months (range 1–10) who underwent primary surgery; and in 25 of 27 patients who underwent surgery following failure of medical treatment. Outcomes after surgery: 4 of 16 patients who had primary surgical treatment had endoscopic recurrence, requiring medical treatment after a mean of 4.4 months (range 0–10). 8 of 27 patients who had surgery post-failure of medical treatment developed disease recurrence, requiring medical treatment after a mean of 40 months (range 7–136) Bile acid malabsorption (BAM): BAM occurred after surgery in 10 of 43 patients. No medically managed patient developed BAM. Conclusion These data suggest that in our population the vast majority of patients with ileo-caecal Crohn’s disease will fail medical treatment and require surgery. 25% of those who undergo surgery will develop BAM (requiring medication), and 40% of those treated surgically will require immunosuppressant treatment in the medium term. These outcomes should be discussed with patients so that they appreciate that ileo-caecectomy is unlikely to lead to long term drug free treatment, and medical treatment is unlikely to lead to the avoidance of surgery. From a health-economics point of view it could be argued there is little point in offering primary medical therapy and ileo-caecectomy should be the initial treatment of choice for patients with limited ileo-caecal Crohn’s disease. Unfortunately endoscopic/calprotectin assessment following primary surgery was often not performed in the majority of patients, and changes in our local practice need to be undertaken to correct this.

Identifying Health Economic Considerations to Include in the Research Protocol of a Randomized Controlled Trial (the REDUCE-RISK Trial): Systematic Literature Review and Assessment

BackgroundThe REDUCE-RISK trial was set up to compare the effectiveness of weekly subcutaneously administered methotrexate with daily oral azathioprine or 6-mercaptopurine in low-risk Crohn disease (CD) or subcutaneously administered adalimumab (ADA) in high-risk CD in a pediatric population (age 6-17 years).ObjectiveThe aim of this study is to perform a systematic review to provide input into the research protocol to gather the necessary information to improve the performance of an evidence-based economic evaluation when the trial is finished.MethodsThe Centre for Reviews and Dissemination (CRD) Health Technology Assessment (HTA) database, websites of HTA institutes, CRD’s National Health Service Economic Evaluation Database, MEDLINE (OVID), and Embase databases were consulted to retrieve (reviews of) relevant economic evaluations. Studies were eligible if they included a pediatric or adult population with inflammatory bowel diseases (CD and ulcerative colitis [UC]) treated with ADA (Humira). There were no restrictions on the comparator. Only economic evaluations expressing outcomes in life years gained or quality-adjusted life years gained were selected.ResultsA total of 12 primary studies were identified. None of these studies included a pediatric population because of a lack of supporting trials. The economic evaluations identified in our systematic review indicate that ADA is an appropriate intervention for inclusion in such a trial. From a health economic point of view, it is important to make an incremental analysis comparing such an intervention with standard care and not immediately versus another (expensive) biological treatment. Information on the impact of children’s school attendance and parents’ productivity is currently lacking in economic evaluations, and none of the underlying trials measured quality of life (QoL) using a generic utility instrument.ConclusionsThe review of the economic literature on ADA for the treatment of patients with CD supports the performance of a trial with biologicals in pediatric patients, including making a distinction according to disease severity. Conducting an economic literature review enabled us to decide which variables should be added to the research protocol from an economic point of view. Measurements for children’s and parents’ QoL (EuroQol 5-Dimension questionnaires), children’s school attendance, and parents’ productivity (WPAI-CD-CG questionnaire) were added to the research protocol. This will provide support for the calculation of the cost-effectiveness of the interventions evaluated in the REDUCE-RISK trial.Trial RegistrationClinicalTrials.gov NCT02852694; https://clinicaltrials.gov/ct2/show/NCT02852694

Cost assessment of health interventions and diseases.

Health resource use and identification of related costs are two essential steps in health economics assessment. The elicited costs will be balanced with health outcome improvement and enable the comparison of different diagnostic procedures or therapeutic strategies from a health economic point of view. The cost typology can be disentangled in three main components, that is, direct cost related to health resource use, indirect costs related to productivity loss and sometimes intangible costs (costs related to pain and suffering). These costs can be elicited from different perspectives depending on the general aim of the assessment: payer, societal perspective or patient perspective. Practically, the first step corresponds to the quantification of health resource use, that is, number of consultations, biological or imaging workups, hospitalisation, dispensed medication units or days on sick leave. It can be done by specific self-questionnaires or by access to insurance health databases. The second step is then to value each health resource use item, based on available public databases—either produced by insurance entities or statistics institute—providing the unit costs for each item. Importantly, substantial variability does exist in the costing exercise, requiring accepting a certain uncertainty around cost estimates. This can be taken into account by sensitivity analyses, which capture in what extent measurement error can impact cost assessment, depending on different hypotheses or assumptions. One essential element of health economic assessment is the identification of costs incurred by or associated with a specific health condition for a study on the economic burden of a disease—cost-of-illness study—or with a given diagnostic or therapeutic intervention in the context of health technology assessment in which these costs are compared with the alternative reference strategy—cost-effectiveness study.

The long and winding road to happiness: A randomized controlled trial and cost-effectiveness analysis of a positive psychology intervention for lonely people with health problems and a low socio-economic status

BackgroundOur objective was to evaluate the effectiveness and cost-effectiveness of the positive psychology intervention ‘Happiness Route’ compared to an active control condition in a vulnerable population with an accumulation of health and psychosocial problems.MethodsWe conducted a randomized, single-blind, actively-controlled, parallel group study in seven municipalities in the Netherlands. To be eligible, participants had to experience loneliness, health problems and low socio-economic status. Each group received several home visits by a counsellor (two in the control condition, two to six in the experimental condition). In the Happiness Route, a happiness-based approach was used, whereas the control condition used a traditional problem-based approach. The primary outcome was well-being, measured with the Mental Health Continuum-Short Form (MHC-SF).ResultsFifty-eight participants were randomized to the Happiness Route, 50 to the control condition. Participants were severely lonely, had on average three health problems and less than 5% had paid work. The total MHC-SF score, emotional and social well-being, depression and loneliness improved significantly over the nine-month period in both conditions (p < .05), but there were no significant changes between the conditions across time. Languishing decreased significantly from 33% at baseline to 16% at follow-up among the Happiness Route participants but did not change significantly in the control condition. No significant improvement over time was found in psychological well-being, resilience, purpose in life, health-related quality of life and social participation. Cost-effectiveness analysis showed that expected saved costs per QALY lost was €219,948 for the Happiness Route, relative to the control condition. The probability was 83% that the Happiness Route was cost saving and 54% that the Happiness Route was cost-effective at a willingness to accept a threshold of €100,000.ConclusionsMental health status of both groups improved considerably. However, we could not demonstrate that the Happiness Route yielded better health outcomes compared to the control condition. Nevertheless, the results of the cost-effectiveness analysis suggested that the Happiness Route is an acceptable intervention from a health-economic point of view. Our results should be viewed in light of the fact that we could not include the planned number of participants.Trial registrationNetherlands Trial Register: NTR3377. Registered 2 Apr 2012.

Efficacy of Extracorporeal Irradiation in Primary Malignant Bone Tumours: A Tertiary Cancer Centre Experience

Background: Limb-sparing approaches involving a combination of surgery, chemotherapy, and radiotherapy are preferred in primary malignant bone tumours whenever possible. The limb function can be maintained by performing reconstruction either using a prosthesis or bone graft. Extracorporeal irradiation is a novel and exciting technique in which the restoration is done using the patient’s own tumour bone. In this article, we present the local control, complications, and functional outcome of 49 cases of primary malignant bone tumours treated using the technique of extracorporeal irradiation. Materials and methods: 49 patients with primary malignant bone tumours were treated with extracorporeal irradiation between the year 2007 to 2015.En-bloc resection of the tumour and the involved bone along with soft tissues was performed about four weeks after the completion of three to four cycles of neoadjuvant chemotherapy. The bone segment was irradiated with 6MV linear accelerator to a dose of 50Gy. After extracorporeal irradiation, the bone was re-implanted using fixation devices. Local control, relapse-free survival, complications and functional outcome were studied. Results: Out of 49 patients, there were 33 males and 16 females. The median age was 19 years. Femur and tibia were the most common tumour locations with osteosarcoma being the most common histology (74%). The local control rate was 94%. The 8 year local recurrence-free survival and distant metastasis-free survival were 89% and 84% respectively. The overall complication rate was 20%. Infection was the most frequent complication, observed in 46% of the patients who developed complications. Out of 49 patients, 40 had reported a good range of movements. Conclusion: Extracorporeal irradiation and re-implantation is a convenient alternative to prosthesis from a health economics point of view, provided severe complications are managed and avoided so that functional results can be achieved.&#x0D;

Lung cancer costs by treatment strategy and phase of care among patients enrolled in Medicare.

BackgroundWe studied trends in lung cancer treatment cost over time by phase of care, treatment strategy, age, stage at diagnosis, and histology.MethodsUsing the Surveillance, Epidemiology, and End Results (SEER)‐Medicare database for years 1998‐2013, we allocated total and patient‐liability costs into the following phases of care for 145 988 lung cancer patients: prediagnosis, staging, surgery, initial, continuing, and terminal. Patients served as self‐controls to determine cancer‐attributable costs based on individual precancer diagnosis healthcare costs. We fit linear regression models to determine cost by age and calendar year for each stage at diagnosis, histology, and treatment strategy and presented all costs in 2017 US dollars.ResultsMonthly healthcare costs prior to lung cancer diagnosis were $861 for a 70 years old in 2017 and rose by an average of $17 per year (P < 0.001). Surgery in 2017 cost $30 096, decreasing by $257 per year (P = 0.007). Chemotherapy and radiation costs remained stable or increased for most stage and histology groups, ranging from $4242 to $8287 per month during the initial six months of care. Costs during the final six months of life decreased for those who died of lung cancer or other causes.ConclusionsCost‐effectiveness analyses of lung cancer control interventions in the United States have been using outdated and incomplete treatment cost estimates. Our cost estimates enable updated cost‐effectiveness analyses to determine the benefit of lung cancer control from a health economics point of view.

A Bayesian stochastic SIRS model with a vaccination strategy for the analysis of respiratory syncytial virus

Our objective in this paper is to model the dynamics of respiratory syncytial virus in the region of Valencia (Spain) and analyse the effect of vaccination strategies from a health-economic point of view. Compartmental mathematical models based on differential equations are commonly used in epidemiology to both understand the underlying mechanisms that influence disease transmission and analyse the impact of vaccination programs. However, a recently proposed Bayesian stochastic susceptible-infected-recovered-susceptible model in discrete-time provided an improved and more natural description of disease dynamics. In this work, we propose an extension of that stochastic model that allows us to simulate and assess the effect of a vaccination strategy that consists on vaccinating a proportion of newborns.

Cost-Utility Analysis of Physicians' Guideline Adherence for Osteoporosis In Germany

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.

The clinical practice and related reflections of staged step-up approach in the treatment of patients with severe acute pancreatitis

Both new insights in the pathophysiology of severe acute pancreatitis (SAP) and upspringing related evidence-based supports prompt the staged step-up approach, which stress emphasis on minimal invasiveness and damage control, to be accepted and advocated by the majority of guidelines. For documented or suspected patients with infected pancreatic necrosis, an imaging-guided percutaneous catheter drainage or an endoscopic transluminal drainage should be initially performed followed by, if necessary, a minimal access retroperitoneal necrosectomy, or a video-assisted retroperitoneal debridement, or an endoscopic transluminal necrosectomy, or an even an open access necrosectomy. The outstanding performance of staged step-up approach in patients with SAP has been justified from both a clinical and a health economic point of view, meanwhile, there are some issues remained to be further elucidated and optimized.

Ärztemangel im ländlichen Raum – Neue Anreizstrukturen und innovative Versorgungsmodelle als Ausweg? Zur Bedeutung einer patientenorientierten Steuerung

Abstract In Germany there is an ongoing debate on the adequate distribution of physicians that are obliged to guarantee the overall access to health care. Especially in rural regions the number of general practioners will decline in the next years. From a health economics point of view it has to be discussed which role physicians have to play within different forms of organizing care and cure. In the paper, a standardized utility function that depicts physicians’ interest helps to figure out the range in which physicians have an interest to choose an engagement in rural environments contingent of aspects of risk sharing between caretaker und cost payers. In consequence, patient driven care models will enforce new organizational and institutional arrangements of division of labour between medical practitioners as well as new needs to reorganize regional medical facilities.

Ärztemangel im ländlichen Raum – Neue Anreizstrukturen und innovative Versorgungsmodelle als Ausweg?

Abstract General practitioner (GP) care in Germany is characterized by a disparate distribution of GPs, explain Stefan Greß und Klaus Stegmüller. There is considerable oversupply in many urban areas while there is undersupply in many rural regions. Centralized planning of GP capacities so far has not been able to ameliorate this unequal distribution. What is more, several health policy reforms have not been able to make capacity planning more effective. The authors suggest a framework for more effective allocation of GP resources by decentralizing capacity planning to the level of local municipalities. Juergen Zerth refers to the ongoing debate on the adequate distribution of physicians that are obliged to guarantee the overall access to health care in Germany. Especially in rural regions, the number of general practioners will decline in the next years, he states. From a health economics point of view it has to be discussed which role physicians have to play within different forms of organizing care and cure. In the paper, a standardized utility function that depicts physicians’ interest helps to figure out the range in which physicians have an interest to choose an engagement in rural environments contingent of aspects of risk sharing between caretaker und cost payers. In consequence, patient driven care models will enforce new organizational and institutional arrangements of division of labour between medical practitioners as well as new needs to reorganize regional medical facilities. Hans-Joachim Helming presents a possible solution approach to ensure the ambulatory care in economically underdeveloped, rural areas. Some regions of Brandenburg in in the northeast of Germany face a shortage of medical care that is primarily caused by the change of generations, the lack of young people and the little existing infrastructure. In these parts of Brandenburg one also sees the consequences of the demographic change: the population is older, less mobile, and the proportion of multi-morbid patients comparatively increased. In addition, the practicing physicians tend to be older and young doctors are becoming less willing to settle in their own surgery. To cope with these challenges the Regional Associations of Statutory Health Insurance Physicians in Brandenburg (Kassenärztliche Vereinigung Brandenburg) invented the KV RegioMed Program. KV RegioMed is a modular concept with regionally tailored solutions that can be combined as needed. The concept meshes medical and non-medical capacities. Competencies and resources can be bundled by outpatient and inpatient areas and intertwined across different sectors.