Office-based Oncologists Research Articles

Current treatment landscape of pancreatic cancer patients in a network of office-based oncologists in Germany.

Background: Pancreatic cancer is one of the most aggressive cancers, with comparatively poor outcomes despite the use of multiagent conventional chemotherapy regimens. Real-world data from clinical practice are still rare but are the basis for understanding and improving the current standard of care.Materials & methods: In this multi-institutional retrospective analysis of 24 office-based oncology practices in Germany,the authors documented 1786 pancreatic cancer patients who received systemic treatment between April 2017 and June 2021. Results:The authors' analysis showed that results from recent clinical studies are promptly incorporated into practice. Conclusion: It was striking that, during the analyzed period, the use of platinum-based therapy regimens in adjuvant and palliative first-line therapy increased predominantly in younger patients (<70 years).

Awareness and Availability of Routine Germline BRCA1/2 Mutation Testing in Patients with Advanced Breast Cancer in Germany

Introduction: Diagnostic testing of germline mutations in breast cancer susceptibility genes 1 or 2 (gBRCA1/2) in patients with human epidermal growth factor receptor 2 negative (HER2–) advanced breast cancer (ABC; locally advanced or metastatic breast cancer) is necessary to assess eligibility for poly(ADP-ribose) polymerase inhibitors (PARPi). We investigated awareness, clinical practice, and the availability of gBRCA1/2 mutation testing in the German outpatient oncology setting. Methods: Office-based oncologists completed a 23-item online survey. Responses were evaluated collectively and by center type. Results: Of 50 oncologists, 33 and 17 were medical and gynecological oncologists, respectively. Oncologists treated a median of 65 (range 14–350) patients with ABC per year. The strongest decision factors to initiate gBRCA1/2 mutation testing were: patient’s known family history of gBRCA1/2 mutation-related cancer(s), guideline recommendations, and triple-negative breast cancer (TNBC). In routine practice, 86% of oncologists tested for gBRCA1/2 mutations. Most oncologists (76–98%) reported testing patients with a known family history of gBRCA1/2 mutation-related cancer(s) irrespective of receptor status. For unknown family history, 92% of oncologists reported testing patients with advanced TNBC versus 30% for HR+/HER2– ABC. Oncologists (66%) rated the awareness of therapeutic relevance of gBRCA1/2 mutation testing for targeted treatment selection as good to satisfactory; 22% rated awareness as poor to in­sufficient. Conclusion: Diagnostic gBRCA1/2 mutation testing in patients with HER2– ABC is available and routinely performed in Germany’s outpatient oncology setting. However, specific patient subgroups were not routinely tested despite therapeutic indications. Given PARPi availability, opportunities exist to improve testing rates especially for patients with HR+/HER2– ABC without a known family history of gBRCA1/2 mutation-related cancer(s).

Effectiveness of a standardized patient education program on therapy-related side effects and unplanned therapy interruptions in oral cancer therapy: a cluster-randomized controlled trial.

Oral agents for cancer treatment are increasingly prescribed due to their benefits. However, oral cancer medications are difficult to handle and have a considerable potential for side effects. This type of therapy requires a high level of self-management competence by the patient. A standardized patient education program provided by physicians and oncology nurses may positively influence the handling of oral agents. The aim of the study was to evaluate the impact of a standardized patient education program provided by specially trained oncology nurses on therapy management regarding side effects and unplanned therapy interruptions. One hundred sixty-five patients from 28 office-based oncology practices from all over Germany participated in this cluster-randomized controlled study. Patients of both intervention (n=111) and standard care groups (n=54) received the usual oncologist counseling; in addition, the patients from the intervention group (k=17 practices) received an education from specially trained oncology nurses. The time of observation was 3months per patient. The patients of the intervention group reported fewer side effects (skin rash, pain, fatigue, nausea, vomiting). Patients in the standard care group interrupted the therapy more frequently without informing their oncologist, compared to the intervention group. Patients benefit from a standardized patient education program provided by specially trained oncology nurses. They tend to handle side effects and critical situations better.

Treatment and pattern of bone metastases in 1094 patients with advanced breast cancer – Results from the prospective German Tumour Registry Breast Cancer cohort study

A high proportion of patients with breast cancer develop bone metastases, yet data on routine treatment with bone-targeted agents (BTA) are rare. We report real-life outcome data of patients with breast cancer metastasised to the bone treated by office-based oncologists in Germany.The ongoing, prospective, multicentre, population-based cohort study Tumour Registry Breast Cancer (TMK) was started in 2007 in 140 centres across Germany.This interim analysis of 1094 patients with bone metastases revealed differences among the tumour subtypes: at start of first-line therapy, 36% of the patients with hormone receptor (HR)-positive and only 20% of the patients with HR-negative tumours presented with bone-only metastasis. The majority of patients with bone metastases (89%, n = 976) received BTA therapy. In 2014–2015, 37% of the patients received the bisphosphonate zoledronic acid and 36% the antibody denosumab. Median duration of BTA therapy was 20 months (interquartile range 31.5 months), starting a median of 3 weeks after diagnosis of bone metastases, and ending a median of 7 weeks before death. The median overall survival (OS) also varied among the types of metastasis at start of first-line therapy ranging from 54 months (95% confidence interval [CI] 37.6–70.8), 38 months (95% CI 29.4–44.2) to 28 months (95% CI 24.2–31.0) for patients with bone-only metastases, non-visceral with or without bone metastases and visceral with or without bone metastases respectively.We show that choice and duration of BTA therapies are in conformity with guidelines applicable in Germany. To our knowledge, this is the first presentation of data on incidence, metastatic pattern, treatment and survival of patients with bone metastases in routine practice.

Adverse reactions in mRCC patients documented in routine practice by German office-based oncologists and uro-oncologists.

Background Signal transduction inhibitors (STIs) have considerably improved treatment of advanced/metastasized renal cell carcinoma (mRCC). Most safety data for these drugs are derived from clinical trials. The purpose of this study was to evaluate which adverse drug reactions are documented during first-line treatments in routine clinical practice. Patients and methods The ongoing prospective German mRCC clinical registry is recruiting patients in 110 oncology and urology outpatient centers. Data from the first 250 patients who had completed first-line treatment were analyzed regarding adverse drug reactions (ADRs) documented in patients' medical records. Results Patients were older than in clinical trials and had comorbidities. Patients were treated with the STIs sunitinib (61%), temsirolimus (14%), sorafenib (10%), or bevacizumab combined with interferon (6%). About 520 ADRs were documented, of which 29% resulted in treatment modifications. The most frequently affected organ system was the gastrointestinal system. The most frequently documented ADRs were mucositis/stomatitis (14%), fatigue (14%), diarrhea (12%), and nausea (12%). Conclusions In routine practice, mRCC first-line treatments using STIs frequently lead to ADRs partly necessitating treatment modifications. The pattern of reported ADRs is similar to that reported in clinical trials, but frequencies of events differ, especially for symptoms of multifactorial origin that are not immediately associated with the treatment. These results indicate that perception and documentation of adverse reactions is different between clinical trials and routine practice, and that reviews of patients' medical records might not be the best method to assess safety in routine practice.

Treatment of Venous Thromboembolism in Ambulatory Cancer Patients in Germany: A Prospective Non-Interventional Study

Background: Venous thromboembolism (VTE) is a serious threat for all cancer patients. This study was aimed to assess the VTE treatment of cancer patients in the ambulatory care setting. Patients and Methods: This is a prospective non-interventional study, which includes ambulatory cancer patients from office-based oncologists. A standardized case report form was used to obtain data on patient characteristics, treatment regimens, duration of treatment, and side effects. Results: Specialists from 34 centers included data from 76 patients. The median patient age was 62 years (range 33-81 years). The 4 most common cancer types were breast cancer (32%), colorectal cancer (18%), lymphoma and lung cancer (each 8%). 18% of the acute VTE cases were treated as inpatients, 80% as outpatients, and 99% with low-molecular-weight heparin (LMWH), unfractionated heparin (UFH), or fondaparinux. After the acute phase, secondary prophylaxis with LMWH/UFH/fondaparinux was planned in 61% of the patients, with oral anticoagulation in 39%. During acute-phase treatment and secondary prophylaxis, no patient had recurrent VTE. 4 patients (5%) experienced minor bleedings. Conclusions: This study shows that many ambulatory cancer patients with VTE have early tumors, no metastases, and an excellent performance score. Most patients receive LMWHs for secondary prophylaxis, as recommended by the national and international guidelines. Still, a relevant percentage is switched to oral anticoagulants.

Results of a feasibility analysis of quality indicators for outpatient cancer care.

6623 Background: Quality indicators are increasingly used for measuring quality of care, for internal quality assurance, confidential benchmarking processes and anonymous quality reporting. The WINHO quality indicators project aims to develop and examine process quality measures for outpatient cancer care in Germany. This project is fully funded by the German Cancer Aid (Deutsche Krebshilfe). Currently, a set of 46 quality indicators exists. To gain better insights into what data can be retrieved from patient records and documentation systems in oncology practices, a feasibility analysis was conducted prior to data collection. Methods: 2176 questionnaires focusing on different aspects of the feasibility of quality indicators were sent to 295 doctors of WINHO partner practices. 1089 questionnaires were answered. Hence, for each of the 46 WINHO quality indicators 20 to 27 answers are available. Results: Although about 80% of the data required for the indicators are documented in patient charts, less than 30% of the data can be retrieved electronically. Particularly, data for indicators of the quality of pain management, holistic and palliative care often cannot be retrieved easily. By contrast, data on basal documentation, therapy planning and implementation are easier to obtain from patient charts. As a result, these indicators experience better evaluations by the office-based oncologists regarding frequency of occurrence, acceptance and reliability. However, high standard deviations show that documentation habits vary considerably within the group of office-based cancer specialists. Conclusions: Despite the large amount of data documented by oncologists in everyday practice, the information required to measure quality of care with indicators is complicated by low retrievability of data. Facilitating improved documentation and IT systems in oncology practices would ease the collection and examination of the rich information documented by office-based oncologists.

Association of PIK3CA mutations and age with the occurence of second primary lung cancer (SPLC).

1589 Background: The incidence of SPLC in Germany was reported to be 1.2 per 100,000 inhabitants in 2007 and the prevalence of second primary cancers reported by the US International Cancer Institute's Surveillance, Epidemiology and End Results Program has more than doubled over the last 25 years. Recently there has been tremendous progress in the ability to detect driver mutations in lung cancer and large studies presented the frequencies of driver mutations in unselected patient populations. We conducted an association study of known genetic driver events and clinical characteristics with the occurence of SPLC. Methods: Within the Network Genomic Medicine Lung Cancer, a local molecular screening network encompassing hospitals and office-based oncologists in the catchment area of the Center for Integrated Oncology Köln Bonn, we retrospectively reviewed the medical records of 375 molecularly annotated NSCLC patients for their SPLC status and clinical characteristics (age at diagnosis, histology, sex, smoking status). Molecular analysis for lung adenocarcinoma included the EGFR, ALK, BRAF, KRAS and PIK3CA status and for squamous cell lung cancer the FGFR1 and PIK3CA status. Results: 84 of 375 (22,4%) patients were SPLCs. The median age of SPLC diagnosis was 70 yrs. (Range 53 - 85 yrs.) and differed significantly from the rest of the population with a median age of 65 yrs. (Range 28 - 86 yrs.). The frequency of SPLCs was not significantly different between males and females (p = 0,259). In univariate logistic regression analysis active and former smoking, positive PIK3CA mutation and FGFR1 amplification status as well as age were significantly associated with the occurrence of SPLC. In a multivariate logistic regression analysis including the variables mentioned above only PIK3CA mutations (OR 9,48 95% CI 1,83 - 49,1) (p = 0,007) and age (OR 1,06 95% CI 1,03 - 1,1) (p = 0,015) could be confirmed to be independent prognosticators for the occurrence of SPLCs. Conclusions: The occurrence of SPLC was associated with age and PIK3CA mutations in our study population. Further comprehensive investigations on this topic are needed to confirm our findings and to further understand the association between mutation status and SPLCs.

1403 - Feasibility Analysis of the Winho Indicators for Outpatient Care in Oncology

ABSTRACT Background WINHO is an oncologist-led research department working on quality improvement and assurance and health care services research for out-patient care in Germany. A quality indicator project started in the middle of 2009. The project consists of 3 main parts: A) development of relevant measures, B) feasibility test, C) pilot study. QOPI is an important model for the scope of application and the methodological approach of the WINHO project. Taking into account the unique needs of the German health care system, a set of 46 relevant, evidence and consensus based quality measures has been developed. This was done with reference to internationally available indicator systems (QOPI, PQRSI and other sources). 13 measures were newly developed by WINHO. This presentation is about the feasibility test (part B) of the WINHO quality indicator project. Methods The feasibility analysis consists of 4 elements: 1. feasibility ratings of the expert panel (n = 15) in the RAND/UCLA procedure during part A of the project, 2. distribution of a feasibility questionnaire among office-based oncologists, 3. semi-structured depth interviews with 7 office-based oncologists, 4. randomized, retrospective chart abstraction from 59 charts for all 46 measures. Results 2176 feasibility questionnaires went into statistical analysis (response rate 50 %). Results from the questionnaire, interviews and trial chart abstraction show that the main problem lies within the retrieval of data from charts. Reasons for these findings may be the use of different electronic documentation systems, individual documentation habits and/or documentation of crucial information in running text. The estimated time to retrieve all data to calculate an indicator varies widely. A pilot study about the implementation of a routine data collection already started. (Supported by Deutsche Krebshilfe e. V.). Disclosure All authors have declared no conflicts of interest.

Early palliative care for patients with metastatic cancer

At present, clinicians and healthcare providers are increasingly urged to advance the provision of state-of-the-art palliative care for patients with incurable cancer. This review provides an overview about the recent findings and practical suggestions. In the last decade, the awareness about the logistic and personal resources needed to meet the somatic and psychological needs of patients with progressive and life-threatening diseases has increased and in parallel, palliative care concepts and expertise have evolved substantially. Care concepts for patients with metastatic cancer emphasized the potential of interdisciplinary care. For example, in 2010, a randomized trial reported a benefit for patients with lung cancer who received early palliative care in addition to routine care. It is discussed that this was because of increased quality of life and detailed exploration of patient preferences. Patients, families and physicians benefit from shared care concepts of oncology and specialized palliative care. Although this concept is already becoming increasingly implemented in tertiary (comprehensive cancer-) care settings, the potential of this approach should be explored for other clinical settings such as office-based oncology.

PCN13 Treatment of Patients with Multiple Myeloma (TLN-Registry): A “Real Life” Overview of Treatment by Office-Based Oncologists in Germany

PCN13 Treatment of Patients with Multiple Myeloma (TLN-Registry): A “Real Life” Overview of Treatment by Office-Based Oncologists in Germany

3630 POSTER Development of 46 Quality Indicators for Cancer Care in Office-based Medical Oncology

3630 POSTER Development of 46 Quality Indicators for Cancer Care in Office-based Medical Oncology

Identification of 46 quality indicators for cancer care in office-based oncology practices in Germany.

e16514 Background: The aim of the study is the identification of quality indicators for an indicator-based quality measurement in German office based oncology practices. They will be used by the WINHO department (collaboration of 210 medical oncology practices in Germany.) for quality improvement and peer to peer benchmarking. Special emphasis is on breast and colorectal cancer. The QOPI model was to some extent a paradigm for our study. Methods: Relevant indicators were collected through literature review. A two-step expert rating procedure with a modified RAND/UCLA method was done. The expert panel consisted of 25 experts from professional associations connected to ambulant oncology, members of the quality management group of the WINHO department and participants from patient support groups. The indicators were rated concerning 1) importance/relevance, 2) benefit for patients, 3) whether they lie within the responsibility of office based oncologists, 4) representation of high quality of care and 5) if the data is present in patient records. The indicators were rated on five stepped categorial rating scales. After discussion, a modified set of indicators was rated in the second session. Results: From literature review a preliminary set of 272 quality indicators was collected. Due to redundancy and/or low specification level, the set was reduced to 67. In the first rating session, 37 indicators were homogeneously rated as relevant and meaningful for high quality of care in oncology practices. The result of the second session is a first set of 46 (32 documentation and therapy, 5 colon, 9 mama) quality indicators for the process of care in German oncology practices. Currently we are running a feasibility study. Results will lead towards a pilot study about the implementation of a routine data collection. Conclusions: The results suggest that the QOPI indicators are to some extent adoptable for German practices as well. First results indicate that it will take a lot of time, effort and money to embed the data collection into a daily practices routine. Sponsored by the German Cancer Aid DKH.

Integrating Palliative Care Into the Outpatient, Private Practice Oncology Setting

Quality care for patients with cancer is a national priority-for those with noncurable cancer, the stakes are even higher. Strategies to promote integration of palliative care into oncology practice may enhance quality. We have developed a model in which palliative care services are integrated into the private, office-based oncology practice setting. We have evaluated the feasibility and assessed outcomes for both the oncologists and the patients they serve. To our knowledge, an embedded clinic in an outpatient, private practice oncology clinic has not been described previously. The primary outcomes assessed were 1) quality care outcomes through assessment of symptom burden and relief achieved through palliative care consultation, 2) provider satisfaction, 3) volume determined by number of palliative care consultations over time, and 4) time saved for the oncologist as a surrogate for the bottom line of the cancer practice. Measurement of: symptom burden and relief with the Edmonton Symptom Assessment System (ESAS), physician acceptance of palliative care services through a provider satisfaction survey and volume of referrals, and billing data to determine potential oncologists' time saved. Palliative care consultation was associated with a reduction in symptom burden by 21%, evidenced by decrease in average total ESAS score from 49.3 to 39. Median provider satisfaction scores rating components of palliative care ranged from 8.5 to 9/10, with an overall provider satisfaction of 9/10. Over the study period, the "embedded" oncology group consultation requests increased 87% (67-120), with each individual oncology provider nearly doubled. The total time saved for the oncology practice in Year 2 was just over four weeks (9720 minutes; 162 hours). An embedded palliative care clinic integrated into an office-based oncology practice is feasible and may improve the quality of care. Formal study of this service delivery model is warranted.

Patient satisfaction with care in office-based oncology practices.

The purpose of patient surveys is to measure the quality of health care from the patient's point of view. They are recommended as a way to detect the strengths and weaknesses of patient care and to locate areas of potential improvement. In the autumn of 2006, patients undergoing care in subspecialty oncology practices across Germany were given a questionnaire to be answered in writing. A total of 15 272 patients participated (response rate, 68.8%). The questionnaire addressed patient satisfaction with practice staff and organization as well as with the treating physicians themselves. The practices, their staffs, and the doctors were generally rated at least "good" in all aspects of patient care. Less highly rated aspects of practice organization, despite overall satisfaction, were waiting times and accessibility in emergencies. Appointment scheduling was considered good. Patients were particularly satisfied with the time their doctors devoted to them, but less satisfied with their advice about "alternative" treatments. The doctors involved them in the treatment process to differing extents and gave a variable degree of psychosocial care. The questionnaires documented high overall satisfaction with oncology practices with little variation among the individual items. There were a few specific areas that accounted for the differences between well and poorly rated practices and physicians; in these areas, there is a potential for improvement.

Key Practice Indicators in Office-Based Oncology Practices: 2007 Report on 2006 Data

As community-based oncology practices continue to adjust to changes made by payers, both government and private, the metrics needed to assess business changes become increasingly more important. A January 2007 Report to Congress by the Medicare Payment Advisory Commission (MedPAC) stated that “physicians reorganized their practices to become more efficient and control costs by obtaining lower prices on drugs,” and “all practices made at least some changes to lower their expenses, particularly their drug and staffing costs.”1 In 2006, Onmark, an Oncology Therapeutics Network (OTN) company, conducted the Office-Based Oncology Business Benchmarking Survey, and reported highlights of the results in the Journal of Oncology Practice.2 Recognizing that community-based oncology has a strong desire to monitor and trend the key practice indicators (KPIs) that were established last year, the company conducted the second annual Business Benchmarking Survey in Spring 2007. The oncology-specific business benchmarks contained in this article update these KPIs and also compare the 2007 survey results with those from 2006. Onmark is one of the largest group purchasing organizations in the community-based treatment setting, with more than 2,400 members representing more than 4,000 physicians and more than $6 billion in annual drug purchases. As with the 2006 survey, Oncology Metrics LLC was commissioned to conduct the survey and report the results to ensure that the identity of the participating oncology practices was kept confidential. To provide comparative results, the operational and financial benchmarks remained essentially the same as last year. One specific addition to this year's report is the metric of established patient visits per full-time equivalent (FTE) medical oncologist per year. This was included to help validate physician workload as it relates to new patients per FTE medical oncologist per year. An optional section was also added to the 2007 survey that included questions about staffing and staff compensation. This year's report in the Journal of Oncology Practice includes both business operational and financial benchmarks.

Evaluating Support Services in Office-Based Oncology Practice: A Collaboration Between ASCO and AOHA

The complex nature of cancer and symptom management is no secret to oncologists and their support staff members. Cancer patients need extensive support services, which are not often required in other physician practices. Precise measures of these services and the associated cost is lacking.

Financial benchmarking: results from a survey of office-based oncology practices, part 2

Financial benchmarking: results from a survey of office-based oncology practices, part 2

Benchmarking Practice Operations: Results From a Survey of Office-Based Oncology Practices.

The Medicare Modernization Act of 20031 brought with it sweeping changes to community-based oncology practices. As Medicare payment for both drugs and drug administration services have changed, oncology practices have become more aware of their business practices and have responded by closely evaluating and monitoring operations. In a January 2006 report to the Centers for Medicare & Medicaid Services and Congress, titled “The Effects of Medicare Payment Changes on Oncology Services,”2 the Medicare Payment Advisory Commission stated that “oncologists responded by cutting costs and increasing efficiency.” As oncology practices continue to strive to further improve practice efficiency, they will need to develop metrics to measure current performance and trend improvements. They also will need to benchmark key practice business indicators specific to oncology. The Medical Group Management Association (MGMA), a professional association that includes medical practice managers and administrators throughout the United States, conducts a comprehensive annual cost survey that reports key practice business indicators and related benchmarks. However, the resulting benchmarks lack specificity for the oncology specialty. In the late 1990s, the Assembly of Oncology and Hematology Administrators, an MGMA specialty assembly, developed additional survey questions to report benchmarks specifically for oncology. MGMA published an oncology-hematology survey for several years. However, because of low participation and high administrative burden, the collection of oncology-specific data was discontinued. The last MGMA oncology-specific report was published in 2003 and was based on 2002 data. More recently, MGMA published its Cost Survey for Single Specialty Practices 2006 Report, which was based on 2005 data. The survey contained 138 questions and had participation from only 12 oncology practices nationwide.3 To meet the growing demand for oncology-specific business benchmarks, Onmark created a user-friendly survey tool to collect data on business operations from its member practices. Onmark Inc, an OTN company in South San Francisco, California, is one of the largest group purchasing organizations in the community-based treatment setting, with more than 2,100 members representing more than 3,600 physicians and more than $4 billion in annual drug purchases. To ensure confidentiality, Oncology Metrics LP, was commissioned to conduct the survey and report the results. The goal was to develop a number of key practice business indicators, or benchmarks, by which to measure and trend changes in oncology practice efficiency. To simplify the survey process, the 34-question survey was offered as a Web-based survey tool. A total of 178 oncology practices participated in this First Annual Onmark Office-Based Oncology Business Benchmarking Survey.

Health Economic Analysis of Fluoropyrimidine-Based Therapies of Colorectal Cancer from the Perspective of Statutory Sickness Funds

1) to identify the treatment costs of different standard fluoropyrimidine-based therapies, i. e., the Mayo-Clinic and AIO/Ardalan regimens, under real-life conditions in settings routinely used for chemotherapy administration in Germany (inpatient, day-clinic or office-based oncologists) and 2) to investigate the cost implications of the routine use of capecitabine, an oral alternative for the treatment of metastatic colorectal cancer. We analysed the actual fee-listings of office based oncologists and projected the results to several hospital-based treatment settings and to oral treatment with capecitabine from the perspective of statutory sickness funds. Office-based setting: the highest quarterly treatment costs of 9.874 were found for the AIO/Ardalan-regimen, followed by the Mayo-Clinic regimen, which incurred costs of 2.497. The cheapest treatment option was capecitabine with quarterly costs of 1.610. Day-clinic setting: the costs of the Mayo-Clinic protocol amounted to 2.036 in a municipal hospital and 8.455 in a university hospital. The respective costs for the AIO/Ardalan regime were 1.294 and 5.374. In-patient setting: the Mayo-Clinic protocol costs were 3.143 in a municipal hospital and 10.5609 in a university hospital. The respective costs found for the AIO/Ardalan-regimen were 1.998 and 6.717. From a health economic perspective, substantial cost savings for health insurance may be realised if patients with colorectal carcinoma were treated in the office-based setting with capecitabine instead of a hospital-based treatment. Economic consequences would be positive for municipal hospitals (avoided losses) and negative for university hospitals. Further savings could be realised if drug prices in hospital and retail pharmacies were harmonized.