Cost Effectiveness of Rivaroxaban for Stroke Prevention in German Patients with Atrial Fibrillation

Objective The aim of this study was to assess the cost effectiveness of the novel fixed-dose anticoagulant rivaroxaban compared with the current standard of care, warfarin, for the prevention of stroke in patients with atrial fibrillation (AF). Methods A Markov model was constructed to model the costs and health outcomes of both treatments, potential adverse events, and resulting health states over 35 years. Analyses were based on a hypothetical cohort of 65-year-old patients with non-valvular AF at moderate to high risk of stroke. The main outcome measure was cost per quality-adjusted life-year (QALY) gained over the lifetime, and was assessed from the German Statutory Health Insurance (SHI) perspective. Costs and utility data were drawn from public data and the literature, while event probabilities were derived from both the literature and rivaroxaban's pivotal ROCKET AF trial. Results Stroke prophylaxis with rivaroxaban offers health improvements over warfarin treatment at additional cost. From the SHI perspective, at baseline the incremental cost-effectiveness ratio of rivaroxaban was a,not sign15,207 per QALY gained in 2014. The results were robust to changes in the majority of variables; however, they were sensitive to the price of rivaroxaban, the hazard ratios for stroke and intracranial hemorrhage, the time horizon, and the discount rate. Conclusion Our results showed that the substantially higher medication costs of rivaroxaban were offset by mitigating the shortcomings of warfarin, most notably frequent dose regulation and bleeding risk. Future health economic studies on novel oral anticoagulants should evaluate the cost effectiveness for secondary stroke prevention and, as clinical data from direct head-to-head comparisons become available, new anticoagulation therapies should be compared against each other

Waiting times for elective treatments according to insurance status: A randomized empirical study in Germany

Abstract Background Health insurance coverage for all citizens is often considered a requisite for reducing disparities in health care accessibility. In Germany, health insurees are covered either by statutory health insurance (SHI) or private health insurance (PHI). Due to a 20%–35% higher reimbursement of physicians for patients with PHI, it is often claimed that patients with SHI are faced with longer waiting times when it comes to obtaining outpatient appointments. There is little empirical evidence regarding outpatient waiting times for patients with different health insurance status in Germany. Methods We called 189 specialist practices in the region of Cologne, Leverkusen, and Bonn. Practices were selected from publicly available telephone directories (Yellow Pages 2006/2007) for the specified region. Data were collected for all practices within each of five specialist fields. We requested an appointment for one of five different elective treatments (allergy test plus pulmonary function test, pupil dilation, gastroscopy, hearing test, MRT of the knee) by calling selected practices. The caller was randomly assigned the status of private or statutory health insuree. The total period of data collection amounted to 4.5 weeks in April and May 2006. Results Between 41.7% and 100% of the practices called were included according to specialist field. We excluded practices that did not offer the requested treatment, were closed for more than one week, did not answer the call, did not offer fixed appointments ("open consultation hour") or did not accept any newly registered patients. Waiting time difference between private and statutory policyholders was 17.6 working days (SHI 26.0; PHI 8.4) for allergy test plus pulmonary function test; 17.0 (25.2; 8.2) for pupil dilation; 24.8 (36.7; 11.9) for gastroscopy; 4.6 (6.8; 2.2) for hearing test and 9.5 (14.1; 4.6) for the MRT of the knee. In relative terms, the difference in working days amounted to 3.08 (95%-KI: 1,88 bis 5,04) and proved significant. Conclusion Even with comprehensive health insurance coverage for almost 100% of the population, Germany shows clear differences in access to care, with SHI patients waiting 3.08 times longer for an appointment than PHI patients. Wide-spread anecdotal reports of shorter waiting times for PHI patients were empirically supported. Discrepancies in access to care not only depend on accessibility to comprehensive health insurance cover, but also on the level of reimbursement for the physician. Higher reimbursements for the provider when it comes to comparable health problems and diagnostic treatments could lead to improved access to care. We conclude that incentives for adjusting access to care according to the necessity of treatment should be implemented.</p

Safety of Bevacizumab in Patients with Advanced Cancer: A Meta-Analysis of Randomized Controlled Trials

A meta-analysis of adverse events with bevacizumab in patients with advanced cancer is reported

Financial incentives in the German statutory health insurance: new findings, new questions

This paper presents findings of a mandatory three-year evaluation of a prevention bonus scheme offered in the German Statutory Health Insurance (SHI). Its objective is to describe the rationale behind the programs, analyze their financial impact and discuss their implications on potentially conflicting goals on solidarity and competition

Economic modeling of risk-adapted screen-and-treat strategies in women at high risk for breast or ovarian cancer

Background The 'German Consortium for Hereditary Breast and Ovarian Cancer' (GC-HBOC) offers women with a family history of breast and ovarian cancer genetic counseling. The aim of this modeling study was to evaluate the cost-effectiveness of genetic testing for BRCA 1/2 in women with a high familial risk followed by different preventive interventions (intensified surveillance, risk-reducing bilateral mastectomy, risk-reducing bilateral salpingo-oophorectomy, or both mastectomy and salpingo-oophorectomy) compared to no genetic test. Methods A Markov model with a lifelong time horizon was developed for a cohort of 35-year-old women with a BRCA 1/2 mutation probability of >= 10%. The perspective of the German statutory health insurance (SHI) was adopted. The model included the health states 'well' (women with increased risk), 'breast cancer without metastases', 'breast cancer with metastases', 'ovarian cancer', 'death', and two post (non-metastatic) breast or ovarian cancer states. Outcomes were costs, quality of life years gained (QALYs) and life years gained (LYG). Important data used for the model were obtained from 4380 women enrolled in the GC-HBOC. Results Compared with the no test strategy, genetic testing with subsequent surgical and non-surgical treatment options provided to women with deleterious BRCA 1 or 2 mutations resulted in additional costs of (sic)7256 and additional QALYs of 0,43 (incremental cost-effectiveness ratio of (sic)17,027 per QALY; cost per LYG: (sic)22,318). The results were robust in deterministic and probabilistic sensitivity analyses. Conclusion The provision of genetic testing to high-risk women with a BRCA1 and two mutation probability of >= 10% based on the individual family cancer history appears to be a cost-effective option for the SHI

Depression-related treatment and costs in Germany: Do they change with comorbidity? A claims data analysis

Background: Existing diverse bottom-up estimations of direct costs associated with depression in Germany motivated a detailed patient-level analysis of depression-related treatment (DRT),-costs (DRC) and Comorbidity. Methods: A large sickness fund's claims data was used to retrospectively identify patients aged 18-65 years with new-onset depression treatment between January 1st and February 15th 2010, and follow them until December 31st 2010, describe DRT, estimate associated DRC, and predict DRC with a generalised linear model. Results: A total of 18,139 patients were analysed. Mean direct DRC were 783. Predictors of DRC regarding psychiatric comorbidities were: Delusion, psychotic disorders and personality disorders (DRCratio 1.72), Alcohol/drug addiction (1.82), abuse of alcohol/drugs (1.57). Predictors of DRC regarding medical comorbidities were: Rheumatoid arthritis (0.77), atherosclerosis (0.65), pregnancy (0.66), and Osteoarthritis (1.87). Of all patients, 60.8% received their most intense/specialised DRT from a general practitioner, a medical specialist (23.7%), a psychotherapist (8.0%), a medical specialist and psychotherapist (2.9%), or in hospital (4.6%). Serious psychiatric comorbidity nearly tripled depression related hospitalisation rates. Limitations: Seasonal affective disorder and missing psychiatric outpatient clinic data must be considered. Conclusions: Estimated DRC are significantly below the assessment of the German national guideline. Differing definitions of observation period and cost attribution might explain differing German DRC results. Signs of hospital psychiatric comorbidity bias indicate overestimation of hospital DRC. Identified associations of DRC with certain medical diseases in older adults warrant further research. Up to one quarter of patients with severe depression diagnosis might lack specialist treatment. (C) 2015 Elsevier B.V. All rights reserved

Longterm persistence and nonrecurrence of depression treatment in Germany: a four-year retrospective follow-up using linked claims data

ObjectivesTo measure persistence and nonrecurrence of depression treatment and investigate potential risk factors. MethodsWe retrospectively observed a closed cohort of insurees with new-onset depression treatment in 2007 and without most psychiatric comorbidity for 16 quarters (plus one to ascertain discontinuation). We linked inpatient/outpatient/drug-data per person and quarter. Person-quarters containing specified depression services were classified as depression-treatment-person-quarters (DTPQ). We defined longterm-DTPQ-persistence as 16+1 continuous DTPQ and longterm-DTPQ-nonrecurrence as 12 continuous quarters without DTPQ and used multivariate logistic regression to explore associations with these outcomes. ResultsWithin first 16 quarters, 28,348 patients' first period (total time) persisted for a mean/median 5.4/3 (8.7/8) quarters. Fourteen percent had longterm-DTPQ-persistence, associated (p<.05) with baseline hospital (odds ratio, OR=1.80), psychotherapy/specialist-interview and antidepressants (OR=1.81), age (years, OR=1.03), unemployment (OR=1.21), retirement (OR=1.31), and insured as a dependent (OR=1.32). Thirty-four percent had longterm-DTPQ-nonrecurrence, associated with psychotherapy/specialist-interview (OR=1.40), antidepressants (OR=0.54), female sex (OR=0.84), age (years, OR=0.99), retirement (OR=1.18), and insured as a dependent (OR=0.88). Women differed for episodic and not chronic treatment. ConclusionTreatment measures compared to survey's symptoms measures. We suggest further research on treatment-free-time. Antidepressants(-) and psychotherapy/specialist-interview(+) were significantly associated with longterm-DTPQ-nonrecurrence. This was presumably moderated by possible short-time/low-dosage antidepressants use(-) and selective therapy assignment(+). Sample selectivity limited data misclassification

Cost-effectiveness of different strategies to prevent breast and ovarian cancer in German women with a BRCA 1 or 2 mutation

Women with a BRCA1 or BRCA2 mutation are at increased risk of developing breast and/or ovarian cancer. This economic modeling study evaluated different preventive interventions for 30-year-old women with a confirmed BRCA (1 or 2) mutation. A Markov model was developed to estimate the costs and benefits [i.e., quality-adjusted life years (QALYs), and life years gained (LYG)] associated with prophylactic bilateral mastectomy (BM), prophylactic bilateral salpingo-oophorectomy (BSO), BM plus BSO, BM plus BSO at age 40, and intensified surveillance. Relevant input data was obtained from a large German database including 5902 women with BRCA 1 or 2, and from the literature. The analysis was performed from the German Statutory Health Insurance (SHI) perspective. In order to assess the robustness of the results, deterministic and probabilistic sensitivity analyses were performed. With costs of a,notsign29,434 and a gain in QALYs of 17.7 (LYG 19.9), BM plus BSO at age 30 was less expensive and more effective than the other strategies, followed by BM plus BSO at age 40. Women who were offered the surveillance strategy had the highest costs at the lowest gain in QALYs/LYS. In the probabilistic sensitivity analysis, the probability of cost-saving was 57% for BM plus BSO. At a WTP of 10,000 a,notsign per QALY, the probability of the intervention being cost-effective was 80%. From the SHI perspective, undergoing BM plus immediate BSO should be recommended to BRCA 1 or 2 mutation carriers due to its favorable comparative cost-effectiveness