Medizinische Ökonomie in der Onkologie: Eine Einführung

Zusammenfassung: In der Onkologie gewinnen medizinisch-ökonomische Aspekte eine immer größere Bedeutung. In Anbetracht des Anstiegs der Gesundheitsausgaben und der immer teureren Interventionen müssen Wege aufgezeigt werden, wie mit den vorhandenen finanziellen Mitteln Prioritäten gesetzt werden können. Die medizinische Ökonomie, eine vergleichsweise junge Wissenschaft, beschäftigt sich unter anderem mit der ökonomischen Bewertung medizinischer Technologien mit dem Ziel der Verbesserung der gesundheitspolitischen Entscheidungsfindung. Dieser Artikel beleuchtet die Grundlagen dieser Wissenschaft, einschließlich der ökonomischen Evaluation, im Kontext der internistischen Onkologie. Zweifelsohne wird die medizinische Ökonomie in Zukunft in der ärztlichen Fort- und Weiterbildung eine ähnlich wichtige Rolle spielen wie klinische Epidemiologie und evidenzbasierte Medizi

Influenza Vaccination Coverage Rates in 5 European Countries: a Population-Based Cross-Sectional Analysis of the Seasons 02/03, 03/04 and 04/05

Introduction:: Influenza continues to be a considerable health problem in Europe. Vaccination is the only preventive measure, reducing mortality and morbidity of influenza in all age groups Objectives:: The objective of this survey was to assess and compare the level of influenza vaccination coverage during three consecutive influenza seasons (02/03, 03/04, 04/05) in the five European countries United Kingdom, France, Italy, Germany and Spain, understand the driving forces and barriers to vaccination now and 3 years ago and determine vaccination intentions for the following winter. Methods:: We conducted a random-sampling, telephone-based household survey among non-institutionalized individuals representative of the population aged 14 and over. The surveys used the same questionnaire for all three seasons. The data were subsequently pooled. Four target groups were determined for analysis: (1) persons aged 65 and over; (2) people working in the medical field; (3) persons suffering from chronic illness and (4) a group composed of persons aged 65 and over or working in the medical field or suffering from a chronic illness. Results:: The overall sample consisted of 28,021 people. The influenza vaccination coverage rate increased from 21.0% in season 02/03 to 23.6% in season 03/04 and then to 23.7% in season 04/05. The differences between the seasons are statistically significant (p = 0.01). The highest rate over all countries and seasons had Germany in season 04/05 with 26.5%, Spain had in season 02/03 with 19.3% the lowest rate totally. The coverage rate in the target group composed of person's aged 65 and over or working in the medical field or suffering from a chronic illness was 49.7% in season 02-04 and 50.0% in season 04/05. The driving forces and barriers to vaccination did not change over the years. The most frequent reasons for being vaccinated given by vaccines were: influenza, considered to be a serious illness which people wanted to avoid, having received advise from the family doctor or nurse to be vaccinated and not wanting to infect family and friends. Reasons for not being vaccinated mentioned by people who have never been vaccinated were: not expecting to catch influenza, not having considered vaccination before and not having received a recommendation from the family doctor to be vaccinated. Options encouraging influenza vaccination are: recommendation by the family doctor or nurse, more available information on the vaccine regarding efficacy and tolerance and more information available about the disease. The adjusted odds ratio of receiving influenza vaccine varied between 2.5 in Germany and 6.3 in the United Kingdom in any risk group. Conclusion:: The vaccination coverage rate increased from the first season (21.0%) to the third season (23.7%) by 2.6%. The family doctor is the most important source of encouragement for people to be vaccinated against influenza. It seems that the public would be more likely to be vaccinated if they had more information on the efficacy and tolerance of the vaccine, as well as the disease. We therefore suggest that family doctors be better informed on influenza vaccine and the disease itself, so that they can actively inform their patients on these topic

Disparities in influenza vaccination coverage rates by target group in five European countries: Trends over seven consecutive seasons

Abstract : Background: : The primary objective of this study was to measure influenza vaccination coverage rates in the general population, including children, and in high-risk groups of five European countries during the season 2007/2008. An additional aim was to analyze coverage trends over seven consecutive seasons and to gain an understanding of the primary drivers and barriers to immunization. Methods: : Community-based telephone and mail surveys have been conducted in the UK, Germany, Italy, France, and Spain, yearly, since 2001/2002. Approximately 2,000 individuals per country and season were interviewed who were considered to be representative of the adult population aged 14 years and older. Data on the vaccination status of children were obtained by proxy interviews. The questionnaire used was essentially the same for all seven seasons. Five target groups were identified for the study: (1) persons aged ≥ 65 years; (2) elderly suffering from a chronic illness; (3) patients suffering from a chronic illness; (4) persons working in the health care sector; (5) children. Results: : In the season 2007/2008, vaccination coverage rates in the general population remained stable in Germany. Compared to the coverage rates of the previous season, increases of 3.7%, 2.0%, and 1.8% were observed for the UK, Spain, and France, respectively, while a decrease of -1.5% was observed for Italy. Across all five countries, vaccination rates in the predefined target groups decreased to some extent (elderly) or increased slightly (chronically ill and health care workers). Vaccination rates among children varied strongly between countries and ranged from 6.1% in UK to 19.3% in Germany. The most powerful motivation for getting vaccinated in all countries was advice from a family doctor (58.6%) and the perception of influenza as a serious illness (51.9%). The major reasons why individuals did not become vaccinated were (1) the feeling of not being likely to catch influenza (39.5%) and (2) never having considered the option of being vaccinated (35.8%). Conclusions: : The change in general influenza vaccination coverage in the 2007/2008 season compared to the previous season was small, but decreases were seen in some target groups. The underlying motivations for and against vaccination did not substantially change. An effort to activate those driving forces that would encourage vaccination as well as dealing with barriers that tend to prevent it may help enhance coverage rates in Europe in the futur

Prospective Survey of AntibioticUtilization in Pediatric Hospitalized Patients to IdentifyTargets for Improvement of Prescription

Abstract. : Background: : The rise in the use of antibiotics has resulted in increasing health care costs and the emergence of resistant bacteria. Little is known about the general misuse of antibiotics in hospitalized children. We evaluated the utilization of antibiotics in a pediatric teaching hospital aiming to identify targets for improvement of prescription. Patients and Methods: : Clinical, radiological, laboratory and treatment data of patients hospitalized in a pediatric medical and a pediatric surgery ward were prospectively collected during a 6-week period. A subsequent review of the collected data by a pediatric infectious diseases specialist, taking into consideration existing in-house treatment guidelines, was carried out. Results: : A total of 125 (36%) of 349 patients was prescribed 246 antibiotics. The median length of hospital stay for children prescribed antibiotics was 5 days (range, 2-30 days) and for those not prescribed 3 days (1-32 days; p < 0.001). Of 154 patients in the medical ward, 64 (42%) received antibiotics, compared to 61 (31%) of 195 patients in the surgical ward (p < 0.05). Empirical prescriptions were more frequent than prophylactic ones, which were more frequent than therapeutic prescriptions (136 [55%] vs 94 [38%] vs 16 [7%]; p < 0.001). Overall, 85% of the prescriptions were considered justified. The rates of inappropriate prescriptions were similar in the medical and surgical ward, and higher for therapeutic (19%) or prophylactic treatment (18%) than for empirical treatment (12%). Higher inappropriate prescription rates were noted for macrolides than for co-trimoxazole and β-lactams (50% vs 18% and 15%, respectively; p < 0.05). Conclusion: : Efforts need to be undertaken towards continuous education of medical staff on judicious antibiotic use, as well as ensuring compliance with existing guidelines. Improvement in the availability of rapid diagnostic methods to discern viral from bacterial infections may help reduce the numbers of empiric therapies in favor of pathogen-targeted therapeutic treatment

Kosten-Nutzen-Effektivität von Clopidogrel bei akutem Koronarsyndrom: Langzeitbehandlung, sekundäre Prophylaxe, Koronarintervention

Clopidogrel, a thienopyridine antiplatelet agent, is an adenosine diphosphate (ADP) receptor antagonist. Clopidogrel inhibits ADP binding to its platelet receptor and subsequent ADP-mediated activation of the glycoprotein IIb/IIIa complex, thus inhibiting platelet aggregation. Clopidogrel irreversibly modifies the ADP receptor so platelets are affected for the remainder of their life span. The treatment of acute coronary syndromes consists of an inpatient diagnosis and inpatient treatment usually done in an emergency room and intensive care unit and a long-term secondary prophylaxis of the underlying condition, coronary artery disease. Therefore, efficacy of different treatments and their implication on costs have to be examined over a long time period. The cost perspective (hospital, society, country) is another important point. In each country different charges for drugs, medical procedures and hospitalization are existing; varying drug costs may result in a more or less cost-effective ratio of a treatment. Furthermore, not only direct medical costs, but also implications on indirect costs should be taken into account when measuring cost-effectiveness of treatments. Worldwide, cardiovascular diseases account for a significant burden of hospital and societal costs. In particular for colleagues running their own private practice, cost-consciousness has become important in recent times. On the other hand, there has to be carried the duty to accord patients the best possible treatment. This – against the background of ethical responsibility, physicians can come into a conflict – continues to require cost-effectiveness studies in the future. By means of the set-forth results configurations can be seen in which clopidogrel has both, a benefit on the medical and on the economic side of view. From most of the quoted analyses application of clopidogrel was warrantable and the scope of costs within the amount of established cardiovascular therapies

Cost-effectiveness of trastuzumab in the adjuvant treatment of early breast cancer: a model-based analysis of the HERA and FinHer trial

BACKGROUND: Routine adjuvant administration of trastuzumab (T) has been implemented in most centers, but its economic impact has not yet been well examined. METHODS: A Markov model was constructed based on clinical data of the Herceptin Adjuvant (HERA) and the Finland Herceptin (FinHer) trials. Costs from the perspective of a Swiss health care provider were calculated based on resource use. RESULTS: On the basis of HERA data, our model yielded an overall survival rate of 71.8% for the T group versus 62.8% for the control group [risk ratio (RR) = 0.87) after 10 years and 62.9% versus 52.7% (RR = 0.84) after 15 years. Cost-effectiveness resulted in 40505 Euros (EUR) per life years gained (LYG) after 10 years and 19673 EUR per LYG after 15 years. For the FinHer regimen, overall survival after 10 and 15 years resulted in 81.8% versus 66.1% (RR = 0.81) and 73.6% versus 57.0% (RR = 0.77). Costs of 8497 EUR per patient could be saved after 10 years and 9256 EUR after 15 years compared with the control group. CONCLUSION: In a long-term perspective, adjuvant T based on the HERA regimen can be considered cost-effective. The regimen used in the FinHer trial is even cost saving, but estimations are based on a single small tria

Addition of cetuximab to first-line chemotherapy in patients with advanced non-small-cell lung cancer: a cost-utility analysis

Background: Adding cetuximab to standard chemotherapy results in a moderate increase of overall survival in patients with advanced non-small-cell lung cancer (NSCLC), but the cost-effectiveness is unknown. Materials and methods: A Markov model was constructed based on the results of the First-Line ErbituX in lung cancer randomized trial, adding cetuximab to cisplatin-vinorelbine first-line chemotherapy in patients with advanced NSCLC. The primary outcome was the incremental cost-effectiveness ratio (ICER) of adding cetuximab, expressed as cost per quality-adjusted life year (QALY) gained, and relative to a willingness-to-pay threshold of €60 000/QALY. The impact of cetuximab intermittent dosing schedules on the ICER was also evaluated. Results: Adding cetuximab to standard chemotherapy leads to a gain of 0.07 QALYs per patient at an additional cost of €26 088. The ICER for adding cetuximab to chemotherapy was €376 205 per QALY gained. Intermittent cetuximab dosing schedules resulted in ICERs per QALY gained between €31 300 and €83 100, under the assumption of equal efficacy. Conclusions: From a health economic perspective, the addition of cetuximab to standard first-line chemotherapy in patients with epidermal growth factor receptor-expressing advanced NSCLC cannot be recommended to date, due to a high ICER compared with other health care interventions. Treatment schedules resulting in more favorable cost-utility ratios should be evaluate

Trastuzumab beyond progression: a cost-utility analysis

Background: The continuation of trastuzumab beyond progression in combination with capecitabine as secondary chemotherapy for HER2-positive metastatic breast cancer (MBC) prolongs progression-free survival without a substantial increase in toxicity. Patients and methods: A Markov cohort simulation was used to follow the clinical course of typical patients with MBC. Information on response rates and major adverse effects was derived, and transition probabilities were estimated, based on the results of the Breast International Group 03-05 clinical trial. Direct costs were assessed from the perspective of the Swiss health care system. Results: The addition of trastuzumab to capecitabine is estimated to cost on average an additional of €33 980 and to yield a gain of 0.35 quality-adjusted life years (QALYs), resulting in an incremental cost-effectiveness ratio of €98 329/QALYs gained. Probabilistic sensitivity analysis showed that the willingness-to-pay threshold of €60 000/QALY was reached in 12% of cases. Conclusion: The addition of trastuzumab to capecitabine in MBC patients is more expensive than what is typically regarded as cost-effective but falls within the value ranges found for established regimens in the treatment of MB

Risk factors for chemotherapy-induced neutropenia occurrence in breast cancer patients: data from the INC-EU Prospective Observational European Neutropenia Study

BACKGROUND: Chemotherapy-induced neutropenia (CIN) places patients at risk of life-threatening infections. While reduction of chemotherapy dose or delay of the subsequent treatment cycle and, consequently, reduction of relative dose intensity (RDI) may limit myelotoxicity, these actions can also impact adversely on treatment outcome and should be avoided in adjuvant settings. PATIENTS AND METHODS: Based on data from 444 breast cancer patients in the INC-EU Prospective Observational European Neutropenia Study, we have evaluated patient-specific and treatment-specific factors that impact on the incidence of grade 4 CIN (absolute neutrophil count <0.5 x 10(9)/L), either during the first or in any cycle of (neo)adjuvant chemotherapy, across a range of regimens and doses. RESULTS: Using multivariate logistic regression analysis, risk factors for grade 4 CIN were identified as older age, lower weight, higher planned dose intensity of doxorubicin, epirubicin, or docetaxel, higher number of planned cycles, vascular comorbidity, lower baseline white blood cell count, and higher baseline bilirubin. Use of colony-stimulating factor before a neutropenic event occurred, dose delays, and dose reductions were protective against grade 4 CIN. CONCLUSIONS: By identifying risk factors for grade 4 CIN, CSF prophylaxis may be appropriately targeted to prevent low RDI in patients treated with curative intent