Health Insurance Perspective Research Articles

Medical resource utilisation and cost of care for women seeking treatment for urinary incontinence in an outpatient setting: Examples from three countries participating in the PURE study

Objective To describe the medical resource use and direct costs of treatment for women with urinary incontinence (UI) in European countries. Design PURE is a non-interventional, observational study of patients seeking treatment for UI in an outpatient setting. Setting Investigators being either general practitioners (GPs) and/or specialists, i.e. urologists and gynaecologists, in 14 European countries participated in PURE. The results for medical resource use and cost of treatment in Germany, Spain and the UK/Ireland recorded retrospectively at the enrolment visit for the preceding 12 months are presented here. Subjects Treatment-seeking women aged over 18 years who were under treatment or seeking treatment for UI, and who presented within the normal course of care for UI were enrolled in the 6 months study. Measurements Information on the incontinence resource use was gathered on standard data collection forms. The direct medical costs were calculated by attaching the unit costs from the perspective of the relevant health insurance in each country to the country-specific resource use. Furthermore, the contribution of patients to the costs of pads, or any treatment for UI was assessed. Results Variation in medical resource use and cost of treatment between the three countries was observed, reflective of the differences in the healthcare systems and whether specialists and/or GPs provided the care. We found that women in Spain and Germany are more likely to have consulted a specialist for their UI symptoms, which had implications for utilisation of diagnostic procedures. Conservative treatment, particularly pelvis floor muscle exercises, was more common in patients in the UK/Ireland treated in primary care by GPs. In all three countries most of the women had used protective pads, which more than half the patients paying for them out-of-pocket, despite potential healthcare reimbursement schemes. Mean total UI-related costs per year ranged from 359€ in the UK/Ireland for patients predominantly treated in the GP setting to 515€ in Germany and 655€ in Spain for patients treated by specialists and GPs. Conclusions Our study provides an estimation of resource use and costs associated with UI in treatment-seeking European women, exemplified here in three countries.

Pharmacoeconomic evaluation of immunoglobulin treatment in patients with antibody deficiencies from the perspective of the German statutory health insurance

Pharmacoeconomic evaluation of immunoglobulin treatment in patients with antibody deficiencies from the perspective of the German statutory health insurance

Pharmacoeconomic evaluation of immunoglobulin treatment in patients with antibody deficiencies from the perspective of the German statutory health insurance.

Primary antibody deficiencies are the most common forms of primary immunodeficiencies. Substitution therapy with polyvalent immunoglobulins has been established as the standard therapy for antibody deficiencies for several decades. Until now mainly intravenous immunoglobulins (IVIG) have been used in Germany, and the majority of patients receive treatment in hospital outpatient clinics. In recent years subcutaneous administration of immunoglobulins (SCIG) has been developed which is administered as home self-infusion. Studies indicate no significant differences in immunoglobulin substitution therapy between SCIG and IVIG concerning outcome. We carried out a cost-minimization analysis to compare the two treatment alternatives in Germany. Under base case assumptions the treatment with SCIG is cost saving from the perspective of the German statutory health insurance. The main cost drivers are IVIG and SCIG; the incremental cost of SCIG compared to IVIG is most sensitive to changes in the immunoglobulin price and changes in the body weight of the patient.

Cost of Illness and its Predictors for Parkinson??s Disease in Germany

To prospectively evaluate the health economic burden of patients with Parkinson's disease (PD) in Germany over a 6-month observation period and to identify the predictors of these costs. Direct and indirect costs were evaluated in 145 patients with PD (mean age 67.3 +/- 9.6 years). PD patients were recruited from an outpatient department for movement disorders, a specialised PD clinic, two office-based neurologists and general practitioners, all located in Germany, and were enrolled between January and June 2000. Relevant economic data were documented in a patient diary over the 6-month period. Clinical evaluations (Unified Parkinson's Disease Rating Scale [UPDRS]) were performed at baseline and at 3 and 6 months. Costs were derived from various German medical economic resources. Costs were calculated from the perspective of healthcare and transfer payment providers and the individual patient. Indirect costs for lost productivity were also calculated. Costs are presented as means +/- standard deviation (SD). Multivariate regression analyses were performed to identify independent cost predictors. Costs are in year 2000-02 values. We estimated average per patient direct, indirect and total costs for the 6-month observation period. The costs from the perspective of statutory health insurance (Gesetzliche Krankenkversicherung [GKV]) consisted of direct medical costs 1370 euro +/- 3240 euro, including rehabilitation (420 euro +/- 1630 euro), hospitalisation (710 euro +/-2520 euro), outpatient treatment (40 euro +/- 30 euro), ancillary treatment (190 euro +/- 280 euro) and ambulatory diagnostic procedures (10 euro +/-30 euro). In addition, parkinsonian drug costs were 1520 euro +/-euro1250. Non-medical direct costs calculated from the GKV perspective were estimated to be euro480 +/-euro1710, which included transportation (10 euro+/- 20 euro), special equipment (420 euro +/- 1640 euro), social/home-help services (10 euro +/-110 euro) and sickness benefit (40 euro +/- 540 euro). The total medical (including drug costs) and non-medical direct costs for the GKV were 3380 euro +/- 4230 euro. Univariate predictors for GKV direct costs included occurrence of motor complications and falls, disease severity, nightmares and dementia. However, multivariate analyses only suggested disease severity and health-related quality of life as significant predictors. For nursing insurance, payments of 1330 euro +/- 2890 euro were calculated. For retirement insurance, payments were 650 euro +/- 1510 euro and there were patient (or caregiver) costs of 1490 euro +/- 2730 euro. Total indirect costs amounted to 3180 euro +/-6480 euro. According to our study, PD puts a high financial burden on society and underscores the need for further economic and medical research to optimise treatment for PD.

Geriatric rehabilitation in Germany: service provision policy and structural aspects from a statutory health insurance perspective

The so-called shifting of paradigm in medicine has inevitably led to an increasing importance of medical rehabilitation, especially geriatric rehabilitation, within the system of medical care in the Federal Republic of Germany. Nationally valid guidelines for assessing the indication of geriatric rehabilitation and for recommending options for appropriate allocation have been elaborated within the framework of the German statutory health insurance system. In addition, manpower and equipment requirements for ambulatory geriatric rehabilitation facilities have been agreed on. These guidelines include clarifications concerning the following: definition of the geriatric patient; definition of the patient in need of geriatric rehabilitation; demarcation of geriatric rehabilitation from organ-specific rehabilitation; operationalization of assessment procedures and allocation recommendations concerning geriatric rehabilitation; requirements profiles for ambulatory geriatric rehabilitation facilities. Essential prerequisites for successful implementation of these national standards are among others: turning towards the bio-psycho-social model of health and disease advocated by the World Health Organization; overcoming the traditional deficit model of aging and old-age in favour of a resource-oriented approach in service-provision policies; rejecting the one-sided fiscal thinking in the current debate over service-provision policies in geriatric rehabilitation.

Cost-effectiveness analysis of different screening procedures for type 2 diabetes: the KORA Survey 2000.

To compare the cost-effectiveness of different type 2 diabetes screening strategies using population-based data (KORA Survey; Augsburg, Germany; subjects aged 55-74 years), including participation data. The decision analytic model, which had a time horizon of 1 year, used the following screening strategies: fasting glucose testing, the oral glucose tolerance test (OGTT) following fasting glucose testing in impaired fasting glucose (IFG) (fasting glucose + OGTT), OGTT only, and OGTT if HbA(1c) was >5.6% (HbA(1c) + OGTT), all with or without first-step preselection (p). The main outcome measures were costs (in Euros), true-positive type 2 diabetic cases, incremental cost-effectiveness ratios (ICERs), third-party payers, and societal perspectives. After dominated strategies were excluded, the OGTT and HbA(1c) + OGTT from the perspective of the statutory health insurance remained, as did fasting glucose + OGTT and HbA(1c) + OGTT from the societal perspective. OGTTs (4.90 per patient) yielded the lowest costs from the perspective of the statutory health insurance and fasting glucose + OGTT (10.85) from the societal perspective. HbA(1c) + OGTT was the most expensive (21.44 and 31.77) but also the most effective (54% detected cases). ICERs, compared with the next less effective strategies, were 771 from the statutory health insurance and 831 from the societal perspective. In the Monte Carlo analysis, dominance relations remained unchanged in 100 and 68% (statutory health insurance and societal perspective, respectively) of simulated populations. The most effective screening strategy was HbA(1c) combined with OGTT because of high participation. However, costs were lower when screening with fasting glucose tests combined with OGTT or OGTT alone. The decision regarding which is the most favorable strategy depends on whether the goal is to identify a high number of cases or to incur lower costs at reasonable effectiveness.

Direct costs of pediatric diabetes care in Germany and their predictors.

Cost-of-illness study to evaluate diabetes-related direct costs for the care of diabetic children and adolescents in Germany from the perspective of the statutory health insurance. For all continuously treated patients < 20 years of age from 89 pediatric departments (n = 6437, 52 % male, mean age 12.5 [SD 3.8], diabetes duration 5.2 [3.3] years), diabetes-related hospitalization, ambulatory care, insulin management, glucose self measurement, and treatment with antihypertensive drugs in 2000 were ascertained, as well as metabolic control (HbA1c). Costs per patient-year were calculated in Euros (EUR) based on year 2000 prices. Using multivariate regression, the associations between costs and age, sex, diabetes duration, and metabolic control were evaluated. Mean total costs per patient-year were EUR 2611 (interquartile range 1665 - 2807). Blood glucose self measurement, hospitalization, and insulin accounted for 37 %, 26 %, and 21 % of the costs, respectively, followed by ambulatory care (9 %), injection equipment and glucagon sets (7 %), and treatment with antihypertensive drugs (0.1 %). The total costs were significantly increased for higher age, longer diabetes duration, and higher HbA1c (p < 0.01). The costs for hospitalization were significantly associated with pubertal age (10 - 14 years) and poor metabolic control (HbA1c SDS > 5) (p < 0.001). Based on the present estimations, the total direct costs for the care of all diabetic subjects in Germany < 20 years would be EUR 66.8 (95 % CI 65.4 - 68.1) million in 2000. Among the direct medical costs of childhood diabetes, the highest economic burden was due to glucose self measurement, hospitalization, and insulin. The costs were considerably higher in adolescents with poor metabolic control, especially the costs for hospitalization. Outpatient education programs in pediatric diabetes care, in particular targeting children with poor metabolic control, should be encouraged, including their evaluation with respect to cost and effectiveness.

Long-term medical costs of postmenopausal breast cancer therapy

Since the incidence of breast cancer is growing, prevention programs can be expected to have a large economic impact on the health care system. From a health economic point of view, one is interested in the costs saved by disease prevention. To predict 10-year cumulative incidence-based costs of postmenopausal breast cancer, a state transitional model was developed based on published clinical data. The model simulates disease progression and includes nine health states of 1 year: node-negative and node-positive early cancer; local relapse; metastasis, each with its follow-up states; and death. The cost per state was obtained from a chart review in 118 patients with different disease states. Costs were calculated from the health insurance perspective and discounted at 3%. The cumulative 10 year cost per patient was equal to 31,774 euro [95% confidence interval (CI) 30,536-33,012 euro] of which 30% was hospital costs, 28% systemic treatment, surgery and radiotherapy and 14% testing. Costs were at their highest following diagnosis and before death. This incidence-based approach identified the cost of postmenopausal breast cancer over time and may serve as a valid baseline for assessment of new interventions in prevention or early treatment.

Resource utilisation and cost of amblyopia treatment

The cost-effectiveness of screening for amblyopia is a controversial issue of international debate. The purpose of this study was to estimate the cost of amblyopia treatment to be used as a component for modelling the cost-effectiveness of prevention programmes. Cost was calculated from the perspective of the German social health insurance in the year 2002. A standardised detailed survey was conducted in writing among 13 experienced experts in amblyopia treatment from various offices and strabismological units in Germany. Average volumes of treatment items were estimated for a maximum treatment period of nine years. Cost was calculated using administrative prices (based on the social health insurance's uniform fee schedule for physician services and reference prices for therapeutic aids) and market prices. The questionnaires were fully completed by 12 of the 13 experts. The mean total cost of treatment was estimated at 2.472 Euro (95 %-CI: 1.171 - 3.774) for strabismic amblyopia and 2.051 Euro (95 %-CI: 426 - 3.675) for amblyopia of refractive origin. About 70 % of the total cost was caused by the therapeutic aids (e. g. glasses, patches). The price of the patches had a marked impact on the total treatment cost. The results may be used for modelling the cost-effectiveness of screening programmes for the prevention of amblyopia.

Cost of care and clinical condition in paediatric cystic fibrosis patients

Background: The clinical course of cystic fibrosis (CF) shows considerable variation resulting in differences in health care utilisation. We investigated important clinical parameters and their relation to costs. Methods: We collected clinical parameters together with health care utilisation of a representative paediatric CF population ( n=138 patients) attending Hanover Medical School over a period of 1 year. 49% of the patients were chronically infected with Pseudomonas aeruginosa. Costs were calculated on the basis of the annual individual health care utilisation from the perspective of health insurance. Results: Total annual expenditure per patient amounted to €23,989 (S.D. 18,026), with home drug treatment representing the most important single cost factor (47% of total costs). While costs rose with age and doubled in the first 18 years, they correlated foremost with P. aeruginosa airway colonisation status and lung function expressed as FEV 1. Costs of patients with chronic P. aeruginosa infection were more than three times higher than of uninfected patients. Conclusions: Health care expenditures for patients with CF vary with the clinical course. The variation can be explained to a large extend by clinical parameters.

Postmenopausal breast cancer: incidence-based cost of illness

SUMMARYA Markov state transition model was developed to predict 10-year cumulative incidence-based costs of postmenopausal breast cancer. Using published clinical data, the model simulates, during 10 periods of 1 year each, the disease progression through nine health states: node-negative and node-positive early cancer; local relapse; metastasis (each with its follow-up states); and death. The health insurance perspective was taken and a 3% annual discount rate on future costs was applied. The cost per health state was obtained from a chart review of 118 patients with different disease states. The average cumulative 10-year cost per patient was €31,774 (95% confidence interval €30,536 - 33,012), of which 30% was due to hospitalisation and 28% to systemic treatment and radiotherapy. The model provided a valid simulation of long-term breast cancer outcome. This model may serve as a valid baseline for economic assessment of new interventions in prevention or early treatment.

PDB3: THE BURDEN OF ILLNESS OF DIABETES MELLITUS TYPE 2 IN GERMANY— A PILOT STUDY

OBJECTIVES: A study was performed to assess the costs of diabetes mellitus type 2 considering costs for co-morbidities and diabetes related complications in Germany. The main objective of this cross-sectional study was to describe the cost structure of the treatment of diabetes mellitus type 2. The study focuses particularly on costs for oral antidiabetic treatment. METHODS: The resource utilization of a population of 201 diabetes mellitus patients with type 2 diabetes was retrospectively documented over a period of 2 years in a cross-sectional study. The documentation was performed by general practitioners (GPs) and diabetologists across Germany. Only direct costs were considered (perspective from statutory health insurances). Subgroups were analysed considering diabetes related macro- and microvascular complications. Costs were analysed taking the perspective of the statutory health insurance into consideration. RESULTS: Total costs of 201 patients suffering from diabetes mellitus type 2 amounted to DM 1,477,061 over a period of two years, which translates into DM 7,349 per patient. Costs per year were DM 3,674 with a maximum of DM 63,915. The largest cost-driving factor is the hospitalisation representing 34.1 % of the total costs followed by drug acquisition costs (20.4 %). Patients treated with insulin cause the 3,5 times higher costs than patients treated with oral drugs. The amount of costs also correlates with the complication status and the duration of diabetes. The lowest costs are caused by patients treated with oral antidiabetic drugs and/or diet and without complications. CONCLUSION: The highest costs were caused by patients with a high complication status, a long duration of diabetes and those treated with insulin. This result emphasises the necessity of an early treatment of diabetes mellitus type 2 preventing expensive diabetes related long-term complications e.g., myocardial infarction, stroke, diabetic foot lesion or dialysis.

The long-term cost-effectiveness of improving alcohol abstinence with adjuvant acamprosate.

A computer model was developed with decision analysis software to explore the long-term clinical and economic outcomes of alcohol abstinence maintenance with either standard counselling therapy or standard therapy plus 48 weeks of adjuvant acamprosate in detoxified alcoholic patients. Important complications of alcoholism were modelled using Markov processes, and included relapse (return to drinking), alcohol-related hepatic disease, acute and chronic pancreatitis, acute and chronic gastritis, oropharyngeal carcinoma, oesophageal carcinoma, alcoholic cardiomyopathy, alcohol-related peripheral neuropathy, alcoholic psychosis, accidental death, and suicide. Probabilities of developing complications were dependent on whether the patients within the cohort remained abstinent or had relapsed. Relapse rates, probabilities, and costs for acamprosate therapy and treatment of complications were taken from published literature. The analysis was performed from the German health insurance perspective. Life expectancy and total lifetime costs (costs of initial abstinence maintenance therapy plus costs of complications) were calculated for a typical male cohort with average age of 41 years, 80% with fatty liver, 15% with cirrhosis, 22% with chronic pancreatitis, and 1% with alcoholic cardiomyopathy at baseline. Life expectancy with and without acamprosate therapy was 15.90 and 14.70 years respectively, and discounted (5% per annum) average total lifetime costs per patient were DEM 46 448 and DEM 49 549 respectively. We conclude that, despite the acquisition costs of DEM 2177, adjuvant acamprosate therapy was both clinically and economically attractive under conservative assumptions.

Economic Evaluation of Campral® (Acamprosate) Compared to Placebo in Maintaining Abstinence in Alcohol-Dependent Patients

We compared the costs of acamprosate in maintaining abstinence in weaned alcoholic patients, to no pharmaceutical treatment over a 24-month period. A controlled trial (n=448) involving a 12-month treatment with acamprosate and a 12-month follow-up showed a significant advantage of acamprosate over placebo in the prevention of relapse. For the economic analysis, the average costs of relapses from the health insurance perspective were calculated based on a Belgian survey among general practitioners and on an observational prospective Belgian trial among specialists. Calculations resulted in net cost savings of 21,301 BEF (528 Euro) per patient over a 24-month period for acamprosate compared to no pharmaceutical treatment, explained by fewer acute hospitalisations for detoxification and less institutionalised rehabilitation. A global anticipated net saving of 70 million BEF (1.74 million Euro) over 2 years was estimated for the Belgian health insurance.

Diagnosis related group costs in a regulated environment. A note about their economic interpretation.

The availability of the Diagnosis Related Group (DRG) system for determining hospital costs in some European countries has encouraged its use in pharmacoeconomic evaluations. The DRG system was developed in the US to provide data for prospective payments for hospitals. However, the financing of hospitals in some European countries is still based on the so-called 'global budget' approach. Therefore, results of pharmacoeconomic studies involving hospitals financed by the 'global-budget' approach in which DRG costs have been used require careful consideration. The main points to consider are: (i) that most of the cost components constituting the DRGs are in fact charges fixed by the government. This cost-charge ratio varies significantly across different DRGs, altering economic consequences when cost-shifting between DRGs; (ii) that there is rarely a perfect concordance between attributable cost (as proposed by the DRGs) and the definition of variable cost (as defined in economic evaluations); (iii) from the Sickness Fund's point of view, the way DRGs could be interpreted is rather unclear: financing or bench-marking?; and (iv) the perspective of DRG cost is a mixed patient-hospital perspective which is neither the societal nor the health insurance perspective generally used in pharmacoeconomic evaluations. In conclusion, the use of DRG costs is a major improvement for pharmacoeconomic evaluation. However, many hypotheses still need to be made in these studies, depending on the economic perspective of the study. Therefore, the results of pharmacoeconomic studies should be considered and discussed in line with the national financing system of the hospitals involved.

PCV7 Economic Evaluation of Torasimide in Congestive Heart Failure in Germany

Studies with classical clinical endpoints indicated comparable efficacy and tolerability of the two loop diureties torasemide and furosemide in congestive heart failure (CHF). However, differences in the pharmacological profiles suggested potentially different quality of disease control under real life conditions. OBJECTIVE: The present study aimed at collecting data in a naturalistic setting and comparing overall cost and cost-effectiveness of torasemide and furosemide. METHODS: Data on the course of the disease and on related resource utilization were collected retrospectively from a one-year treatment period of 200 torasemidetreated and 200 furosemide-treated patients. High comparability of the two patient groups was achieved by using the matched-pair method with nine demographic and medical matching criteria. RESULTS: Disease control was better in the torasemide patients, as reflected by fewer hospital days due to CHF (324 vs. 62) and more patients with improvement of NYHA class (torasemide: 38.0% [31.25%–45.11%]; furosemide: 24.5% [18.71%–31.06%]) during the observation period. Comparing overall cost from the statutory health insurance's perspective, torasemide treatment is less costly by 361 DEM per patient and year (1502 vs. 1863 DEM). Moreover, torasemide is clearly more cost-effective: The cost per patient with improved NYHA class is 3954 DEM for torasemide versus 7605 DEM for furosemide. Analyses from the societal perspective yielded similar results. CONCLUSIONS: The data reveal substantial improvement of disease control and reduction of treatment cost with torasemide compared to furosemide. Furthermore, this study highlights the value of collecting naturalistic data from balanced populations to improve our understanding of drug effects on disease courses and health care cost.

Economic Evaluation of Multiple Sclerosis in the UK, Germany and France

A cross-sectional cost-of-care study was performed to assess the economic burden of multiple sclerosis (MS) in France, Germany and the UK. Patients were stratified into 3 groups according to the Expanded Disability Severity Scale (EDSS): stages I, II and III, corresponding to mild (EDSS 1.0 to 3.5), moderate (EDSS 4.0 to 6.0) and severe (EDSS 6.5 to 8.0) MS, respectively. 90 patients with MS and 30 non-MS control patients were recruited in each country. Control patients were matched to the patients with MS on the basis of age and gender. Demographic, clinical and economic data during the 3-month period prior to entry were collected in patient interviews. Total costs included actual expenditures, such as direct medical and non-medical costs, as well as indirect costs. From the societal perspective, the total cost of MS for 3 months was estimated at 1,928 US dollars, 3,941 US dollars and 5,678 US dollars in France, 2,772 US dollars, 2,056 dollars and 5701dollars in Germany, and 5,125 US dollars, 6,751 US dollars and 14, 622 US dollars in the UK, for stage I, II and III patients, respectively. The major medical cost driver in the UK was outpatient consultations, whereas hospitalisations were the major component in Germany and France. The major cost in the UK arose from the dependence of patients with MS on caregivers, which caused high non-medical, societal costs compared with France and Germany. From both the societal and health insurance perspectives in each country, costs for control patients were lower than those for stage I MS patients. MS represents a major financial burden on the individual, the family, health services and society, and these costs increase with MS progression.