Gesundheitsökonomische Aspekte zur Gesundheitsförderung und Prävention von chronischen Lungenerkrankungen

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Applying the Analytic Hierarchy Process in healthcare research: A systematic literature review and evaluation of reporting

Background: The Analytic Hierarchy Process (AHP), developed by Saaty in the late 1970s, is one of the methods for multi-criteria decision making. The AHP disaggregates a complex decision problem into different hierarchical levels. The weight for each criterion and alternative are judged in pairwise comparisons and priorities are calculated by the Eigenvector method. The slowly increasing application of the AHP was the motivation for this study to explore the current state of its methodology in the healthcare context. Methods: A systematic literature review was conducted by searching the Pubmed and Web of Science databases for articles with the following keywords in their titles or abstracts: "Analytic Hierarchy Process," "Analytical Hierarchy Process," "multi-criteria decision analysis," "multiple criteria decision," "stated preference," and "pairwise comparison." In addition, we developed reporting criteria to indicate whether the authors reported important aspects and evaluated the resulting studies' reporting. Results: The systematic review resulted in 121 articles. The number of studies applying AHP has increased since 2005. Most studies were from Asia (almost 30 %), followed by the US (25.6 %). On average, the studies used 19.64 criteria throughout their hierarchical levels. Furthermore, we restricted a detailed analysis to those articles published within the last 5 years (n = 69). The mean of participants in these studies were 109, whereas we identified major differences in how the surveys were conducted. The evaluation of reporting showed that the mean of reported elements was about 6.75 out of 10. Thus, 12 out of 69 studies reported less than half of the criteria. Conclusion: The AHP has been applied inconsistently in healthcare research. A minority of studies described all the relevant aspects. Thus, the statements in this review may be biased, as they are restricted to the information available in the papers. Hence, further research is required to discover who should be interviewed and how, how inconsistent answers should be dealt with, and how the outcome and stability of the results should be presented. In addition, we need new insights to determine which target group can best handle the challenges of the AHP.CHER

Chapter 12 – Health Apps in Statutory and Private Health Insurance

Es wurde das Angebot und die Finanzierung von Apps im deutschen Krankenversicherungssystem untersucht. Hierbei wurden insbesondere Anwendungsbereiche, Zielgruppen, Kosten und Finanzierung beziehungsweise Kostenerstattung dieser Apps, Datensicherheit und -schutz sowie die Auswirkungen der (Nicht-)Nutzung dieser Applikationen analysiert. Als Methodik wurden eine systematische Literaturrecherche, eine Internetrecherche sowie eine quantitative Befragung von Krankenkassen und Krankenversicherungen genutzt. Wesentliche Ergebnisse waren, dass einige Krankenkassen und Krankenversicherungen derzeit bereits Apps mit unterschiedlichen Funktionalitäten anbieten. Zukünftig werden App-Angebote eine immer größere Bedeutung in der GKV und PKV erlangen. Serviceanwendungen sowie Apps zur Gesundheitsförderung oder Prävention haben aus wettbewerblichen Erwägungen eine besonders große Bedeutung. Apps zur Diagnostik oder Therapie spielen derzeit eine untergeordnete Rolle. Für die Versicherten können Service-Apps eine Erleichterung beim Zugang zu Informationen über Gesundheitsthemen, aber auch beim Versorgungszugang darstellen. Eine Unterstützung der Gesundheitsförderung oder Prävention über Apps ist ebenfalls möglich, allerdings ist derzeit noch ungeklärt, inwieweit sich hierüber tatsächlich gesundheitsförderliche Verhaltensänderungen erreichen lassen. Wesentliche Probleme bei der Nutzung der angebotenen Apps durch die Versicherten sind die unklaren qualitativen Eigenschaften der Applikationen sowie eine große Intransparenz im Hinblick auf datenschutzrechtliche Kriterien. In der GKV wird die Nutzung von Apps zur Gesundheitsförderung oder Prävention häufig mit Bonusprogrammen oder Gratifikationen verknüpft. Auch in der PKV gibt es ähnliche Tendenzen, eine Tarifierung über eine App-basierte gesundheitsbezogene Datenerfassung wird aktuell nicht verfolgt. Entsprechende Programme können über monetäre Anreize gesundheitsförderliches Verhalten unterstützen, es sollte allerdings kritisch beobachtet werden, ob zukünftig ein Zwang zur Teilnahme an entsprechenden Programmen und zur Datenübermittlung entsteht. Die wenigen vorhandenen Apps zur Diagnostik oder Therapie werden über besondere Versorgungsformen oder Selektivverträge einzelner Kassen angeboten. Es ist zu überprüfen, ob und gegebenenfalls wie die Kostenerstattungsprozesse für eine Implementierung in der Regelversorgung angepasst werden sollten. Eine wesentliche Limitation dieser Untersuchung ist die geringe Evidenz zu den unterschiedlichen Fragestellungen, so dass weitergehende wissenschaftliche Analysen dringend geboten scheinen.The supply and financing of apps in the German health insurance system were examined. Particular application areas, target groups, costs and financing or reimbursement of these apps, data security and protection, as well as the impact of the (non-) usage of these applications were analyzed. The methodology that was used was a systematic literature search as well as an Internet search and a quantitative survey of health insurance funds and health insurance companies. Some of the key findings were that currently, there are already a number of apps with various functions that are being offered by health insurance funds and companies. In the future, apps will continue to gain importance in statutory as well as private health insurance (SHI and PHI). Service applications and apps for health promotion or prevention are a very important factor in the context of competitive considerations. Apps for diagnosis or therapy currently play a minor role. Service apps for the insured cannot only facilitate access to information about health issues, but also information about treatments. Supporting health promotion or prevention via apps is a possibility; however, it is currently unclear whether beneficial changes in health related behavior can be achieved by using them. Major problems with the use of apps offered by the insurers are the unclear qualitative properties of applications as well as a profound lack of transparency with respect to data protection. In the SHI, the use of apps on health promotion or prevention is often associated with loyalty programs or gratuities. Even in the PHI, there are similar tendencies. However, there is currently no app supported tariffing that is based on the collection of health data. Such programs may support health-promoting behavior through monetary incentives. However, a critical observation is advised of whether participation in programs dealing with health related behavior and data transmissions becomes compulsory. The few existing apps for diagnosis or therapy are offered in the context of special forms of care or within selective contracts of individual funds. It remains to be seen whether – and how – reimbursement processes can be adapted to be able to integrate apps within regular health care. A major limitation of this study is the low evidence on the various issues. Therefore, further scientific analyses are strongly advised

Treatment-related experiences and preferences of patients with lung cancer: A qualitative analysis

Background: Lung cancer is one of the most common types of cancer worldwide, and it causes significant challenges for patients due to the poor survival rate and treatment-related side-effects. Because of lung cancer's great burden, identification and use of the patients' preferences can help to improve patients' quality of life. Objective: Interviews with patients who have lung cancer were used to ascertain a range of experiences and to make recommendations regarding the improvement of treatment based on these patients' preferences. Because chemotherapy is the common treatment option for lung cancer, we focused on this treatment. The interviews were audio-taped, verbally transcribed and evaluated via content analysis. Setting and Participants: A total of 18 participants (11 men and 7 women) with small or non-small-cell lung cancer who were receiving chemotherapy in one clinic were interviewed between June and July 2013. Results: Two main aspects with different subthemes were identified during the interviews. One main aspect focused on organizational context, such as the treatment day process, or experiences with different stakeholders, such as with the health insurance company or physicians. The other category referred to experiences that influenced psychosocial factors, including physical and mental experiences. Discussion and Conclusion: Patients reported different experiences concerning physical, psychological and organizational areas during chemotherapy. Nevertheless, some potential areas for improving care, and therefore the quality of life of patients with lung cancer, could be identified. These improvement measures highlighted that with small, non-time-consuming and inexpensive changes, the treatment for patients with lung cancer can be improved.BMB

Preferences of patients with asthma or COPD for treatments in pulmonary rehabilitation

Introduction: Pulmonary rehabilitation (PR) aims to improve disease control in patients with chronic obstructive pulmonary disease (COPD) and asthma. However, the success of PR-programs depends on the patients’ participation and willingness to cooperate. Taking the patients’ preferences into consideration might improve both of these factors. Accordingly, our study aims to analyze patients’ preferences regarding current rehabilitation approaches in order to deduce and discuss possibilities to further optimize pulmonary rehabilitation. Methods and analysis: At the end of a 3 weeks in-house PR, patients’ preferences concerning the proposed therapies were assessed during two different time slots (summer 2015 and winter 2015/2016) in three clinics using a choice-based conjoint analysis (CA). Relevant therapy attributes and their levels were identified through literature search and expert interviews. Inclusion criteria were as follows: PR-inpatient with asthma and/or COPD, confirmed diagnosis, age over 18 years, capability to write and read German, written informed consent obtained. The CA analyses comprised a generalized linear mixed-effects model and a latent class mixed logit model. Results: A total of 542 persons participated in the survey. The most important attribute was sport and exercise therapy. Rehabilitation preferences hardly differed between asthma and COPD patients. Health-related quality of life (HRQoL) as well as time since diagnosis were found to have a significant influence on patients’ rehabilitation preferences. Conclusions: Patients in pulmonary rehabilitation have preferences regarding specific program components. To increase the adherence to, and thus, the effectiveness of rehabilitation programs, these results must be considered when developing or optimizing PR-programs.Introduction: Pulmonary rehabilitation (PR) aims to improve disease control in patients with chronic obstructive pulmonary disease (COPD) and asthma. However, the success of PR-programs depends on the patients’ participation and willingness to cooperate. Taking the patients’ preferences into consideration might improve both of these factors. Accordingly, our study aims to analyze patients’ preferences regarding current rehabilitation approaches in order to deduce and discuss possibilities to further optimize pulmonary rehabilitation. Methods and analysis: At the end of a 3 weeks in-house PR, patients’ preferences concerning the proposed therapies were assessed during two different time slots (summer 2015 and winter 2015/2016) in three clinics using a choice-based conjoint analysis (CA). Relevant therapy attributes and their levels were identified through literature search and expert interviews. Inclusion criteria were as follows: PR-inpatient with asthma and/or COPD, confirmed diagnosis, age over 18 years, capability to write and read German, written informed consent obtained. The CA analyses comprised a generalized linear mixed-effects model and a latent class mixed logit model. Results: A total of 542 persons participated in the survey. The most important attribute was sport and exercise therapy. Rehabilitation preferences hardly differed between asthma and COPD patients. Health-related quality of life (HRQoL) as well as time since diagnosis were found to have a significant influence on patients’ rehabilitation preferences. Conclusions: Patients in pulmonary rehabilitation have preferences regarding specific program components. To increase the adherence to, and thus, the effectiveness of rehabilitation programs, these results must be considered when developing or optimizing PR-programs

Trade-off between benefits, harms and economic efficiency of low-dose CT lung cancer screening: a microsimulation analysis of nodule management strategies in a population-based setting

Abstract Background In lung cancer screening, a nodule management protocol describes nodule assessment and thresholds for nodule size and growth rate to identify patients who require immediate diagnostic evaluation or additional imaging exams. The Netherlands-Leuvens Screening Trial and the National Lung Screening Trial used different selection criteria and nodule management protocols. Several modelling studies have reported variations in screening outcomes and cost-effectiveness across selection criteria and screening intervals; however, the effect of variations in the nodule management protocol remains uncertain. This study evaluated the effects of the eligibility criteria and nodule management protocols on the benefits, harms and cost-effectiveness of lung screening scenarios in a population-based setting in Germany. Methods We developed a modular microsimulation model: a biological module simulated individual histories of lung cancer development from carcinogenesis onset to death; a screening module simulated patient selection, screening-detection, nodule management protocols, diagnostic evaluation and screening outcomes. Benefits included mortality reduction, life years gained and averted lung cancer deaths. Harms were costs, false positives and overdiagnosis. The comparator was no screening. The evaluated 76 screening scenarios included variations in selection criteria and thresholds for nodule size and growth rate. Results Five years of annual screening resulted in a 9.7–12.8% lung cancer mortality reduction in the screened population. The efficient scenarios included volumetric assessment of nodule size, a threshold for a volume of 300 mm3 and a threshold for a volume doubling time of 400 days. Assessment of volume doubling time is essential for reducing overdiagnosis and false positives. Incremental cost-effectiveness ratios of the efficient scenarios were 16,754–23,847 euro per life year gained and 155,287–285,630 euro per averted lung cancer death. Conclusions Lung cancer screening can be cost-effective in Germany. Along with the eligibility criteria, the nodule management protocol influences screening performance and cost-effectiveness. Definition of the thresholds for nodule size and nodule growth in the nodule management protocol should be considered in detail when defining optimal screening strategies

Terrorist targeting, information and secret coalitions

We consider a game played by a state sponsor of terrorism, a terrorist group, and the target of terrorist attacks. The sponsoring state wishes to see as much damage inflicted on the target of attack as possible, but wishes to avoid retaliation. To do so, his relationship with the terrorist group must remain ambiguous. The target of attack, for his part, wishes to bring these attacks to an end as quickly as possible and will consider the option of retaliating against the sponsor to do so. We approach the problem by introducing an �evidence� variable in a dynamic setting. We show that the interplay of different strategic and non-strategic effects boils down to three qualitatively different scenarios, determined by key parameters. Based on this result, two alternative instruments to retaliation are identified in order to resist terrorist activities. First, assuming that the target is able to change some parameters by monetary investments, the paper provides an economic analysis of how to invest optimally in order to make the sponsor lose incentives to support the terrorist group. Second, we propose changing the structure of the game. Here, the key insight is that the target country can make a unilateral statement as to his strategy. The sponsor cannot do so as he is in fact claiming that there is no cooperation with terrorist groups. While our discussion, in this article, is motivated by an important problem in contemporary counterterrorism policy, it applies more generally to the study of secret coalitions. Keywords: Secret Coalitions, Security Economics, Noncooperative Games Classification-JEL: C72, D8