Programme Costing of a Physical Activity Programme in Primary Prevention: Should the Costs of Health Asset Assessment and Participatory Programme Development Count?

This analysis aims to discuss the implications of the “health asset concept”, introduced by the WHO, and the “investment for health model” requiring a “participatory approach” of cooperative programme development applied on a physical activity programme for socially disadvantaged women and to demonstrate the related costing issues as well as the relevant decision context. The costs of programme implementation amounted to €48,700. Adding the costs for developing the programme design of €48,800 results in total costs of €97,500; adding on top of that the costs of asset assessment running to €35,600 would total €133,100. These four different cost figures match four different types of potentially relevant decisions contexts. Depending on the decision context the total costs, and hence the incremental cost-effectiveness ratio of a health promotion intervention, could differ considerably. Therefore, a detailed cost assessment and the identification of the decision context are of crucial importance

Wirtschaftlichkeit und Management in der Rehabilitation von Patienten mit chronischen Rückenschmerzen

Hintergrund: Die Trends stark steigender Ausgaben, innovativer medizinischer Verfahren und der Alterung der Gesellschaft machen eine stärkere Effizienzorientierung auch in der Rehabilitation unumgänglich. Die ökonomische Evaluation bietet einen Ansatz, diese Neuorientierung auf eine Evidenzbasis zu stellen. Ziel: In einem weit greifenden Ansatz sollte eine Intensivierung der stationären Rehabilitation von Patienten mit chronischen Rückenschmerzen auf ihre Wirksamkeit und Wirtschaftlichkeit untersucht und Ansatzpunkte einer Einbindung der Erkenntnisse in die Versorgung gesucht werden. Methoden: Die ökonomische Evaluation begleitete einen klinischen Versuch, in dem ein intensiviertes psychologisches Programm mit der herkömmlichen stationären Rehabilitation mit einer Nachverfolgung von einem halben Jahr verglichen wurde. Zuvor waren in Pilotstudien Instrumente zur Messung der poststationären Kosten mittels eines Kostenwochenbuchs und der Effekte – in Form gesundheitsbezogener Lebensqualität – mittels des Fragebogens des EuroQol 5D getestet worden. Die Einbindung von Studienergebnissen wurde durch konzeptionelle Analysen zur Entscheidungsfindung und zum Rehabilitationsmanagement untersucht. Ergebnisse: In jedem Studienarm nahmen etwa 200 Patienten teil. Die intensivierte psychologische Betreuung führte zu einer leichten Verbesserung der gesundheitsbezogenen Lebensqualität – gemessen auch in qualitätsbereinigten Lebensjahren (QALYs), die aber nicht statistisch signifikant war. Den leicht erhöhten Versorgungskosten standen deutliche Einsparungen durch eine Verbesserung der Erwerbsfähigkeit in der Nachbeobachtungszeit gegenüber. Auf Grund einer hohen Streuung der Resultate war die Verbesserung der Wirtschaftlichkeit aber statistisch nicht signifikant, was eine Empfehlung an Entscheidungsträger erschwert. Durch das Setzen von Anreizen, die an der Erwerbsfähigkeit und dem langfristigen Gesundheitszustand der behandelten Patientengruppen anknüpfen, könnte das Rehabilitationsmanagement stärker ökonomisch ausgerichtet werden. Diskussion: Die Untersuchung der Wirtschaftlichkeit von Rehabilitationsmaßnahmen kann in einem aufwändigen Verfahren begleitend zu einem klinischen Versuch durchgeführt werden. In der vorliegenden Studie gehörten die Prüfung der eingesetzten Instrumente, der Umgang mit fehlenden Werten an den verschiedenen Messzeitpunkten und die Interpretation der hohen Unsicherheit der Effekte und der Kosten-Effektivitätsrelation sowie zu den methodischen Herausforderungen. Schlussfolgerung: Bezogen auf die Kosten des Produktivitätsausfalls weist die Intensivierung der Rehabilitation in eine Erfolg versprechende Richtung. Hinsichtlich der Lebensqualitätseffekte ist weiter nach wirksameren Rehabilitationsmaßnahmen zu suchen. Grundsätzlich könnten Anreize zu beiden Teilendpunkte ein effizientes Rehabilitationsmanagement fördern

Kosten und Lebensqualität bei ambulanter vs. stationärer kardiologischer Rehabilitation – ein gesundheitsökonomischer Ansatz

Hintergrund: Die ischämischen Herzerkrankungen wie der Myokardinfarkt gewinnen in Deutschland, unter anderem auf Grund des demographischen Wandels, zunehmend auch ökonomisch an Bedeutung. Die sich an die Phase der Akutversorgung anschließende kardiologische Rehabilitation wurde bisher in Deutschland überwiegend stationär durchgeführt. Ziel: Das Ziel der SARAH-Studie war es, basierend auf einem klinischen Versuch, die Kosten für die unterschiedlichen Rehabilitationsmaßnahmen sowie die erzielten Effekte hinsichtlich der Lebensqualität zu ermitteln und die Ergebnisse von ambulanter und stationärer Rehabilitation miteinander zu vergleichen. Methoden: Es wurde eine kontrollierte Beobachtungsstudie mit 163 Patienten durchgeführt, die einem comprehensive cohort design folgte. Die Beobachtung erstreckte sich über einen Zeitraum von 12 Monaten nach der Rehabilitation. Die Kosten wurden anhand der Kostenrechnung der Rehazentren und anhand der Patientenangaben zu einer retrospektiven Kostenbefragung ermittelt. Die gesundheitsbezogene Lebensqualität wurde mit dem EuroQol (EQ-5D) gemessen und bewertet. Ergebnisse: Über den gesamten Beobachtungszeitraum konnten die Daten von 140 Patienten ausgewertet werden, d.h. es wurde eine Rücklaufquote von 86% erreicht. Die Studie ergab einen deutlichen Lebensqualitätsgewinn, sowohl bei der stationären, als auch bei der ambulanten Rehabilitationsmaßnahme; diese Verbesserung der Lebensqualität bleibt bei beiden Settings größtenteils über den gesamten Nachbeobachtungszeitraum erhalten. Zwischen den Settings gab es allerdings keinen statistisch signifikanten Unterschied. Bei den direkten Kosten war das ambulante Setting auf Grund der niedrigeren tagesgleichen Kosten um 760€ günstiger als die stationäre Rehabilitation. Diskussion: Einschränkungen der Studie ergeben sich durch die geringe Bereitschaft der Patienten, sich wie vorgesehen randomisieren zu lassen, was eine entsprechende Analyse verhinderte und zu einer geringen Besetzung des ambulanten Arms führte; ferner konnten nur Kosten jeweils einer Angebotseinheit untersucht werden. Stärken sind im Einsatz vorab getesteter Messinstrumente, im hohen Rücklauf und in der Plausibilität der Angaben zu finden. Schlussfolgerung: Auch nach Betrachtung der indirekten Kosten und der statistischen Anpassung der Daten kann ein Kostenvorteil einer ambulanten Rehabilitationsmaßnahme gegenüber einer stationären Maßnahme nicht ausgeschlossen werden

Pathological Response in Resectable Non-small Cell Lung Cancer: A Systematic Literature Review and Meta-Analysis

BACKGROUND: Surrogate endpoints for overall survival in patients with resectable non-small cell lung cancer receiving neoadjuvant therapy are needed to provide earlier treatment outcome indicators and accelerate drug approval. This study\u27s main objectives were to investigate the association among pathological complete response, major pathological response, event-free survival and overall survival and to determine whether treatment effects on pathological complete response and event-free survival correlate with treatment effects on overall survival. METHODS: A comprehensive systematic literature review was conducted to identify neoadjuvant studies in resectable non-small cell lung cancer. Analysis at the patient level using frequentist and Bayesian random effects (hazard ratio [HR] for overall survival or event-free survival by pathological complete response or major pathological response status, yes vs no) and at the trial level using weighted least squares regressions (hazard ratio for overall survival or event-free survival vs pathological complete response, by treatment arm) were performed. RESULTS: In both meta-analyses, pathological complete response yielded favorable overall survival compared with no pathological complete response (frequentist, 20 studies and 6530 patients: HR = 0.49, 95% confidence interval = 0.42 to 0.57; Bayesian, 19 studies and 5988 patients: HR = 0.48, 95% probability interval = 0.43 to 0.55) and similarly for major pathological response (frequentist, 12 studies and 1193 patients: HR = 0.36, 95% confidence interval = 0.29 to 0.44; Bayesian, 11 studies and 1018 patients: HR = 0.33, 95% probability interval = 0.26 to 0.42). Across subgroups, estimates consistently showed better overall survival or event-free survival in pathological complete response or major pathological response compared with no pathological complete response or no major pathological response. Trial-level analyses showed a moderate to strong correlation between event-free survival and overall survival hazard ratios (R2 = 0.7159) but did not show a correlation between treatment effects on pathological complete response and overall survival or event-free survival. CONCLUSION: There was a strong and consistent association between pathological response and survival and a moderate to strong correlation between event-free survival and overall survival following neoadjuvant therapy for patients with resectable non-small cell lung cancer

Assessing quality of life in a clinical study on heart rehabilitation patients: how well do value sets based on given or experienced health states reflect patients' valuations?

Background: Quality of life as an endpoint in a clinical study may be sensitive to the value set used to derive a single score. Focusing on patients' actual valuations in a clinical study, we compare different value sets for the EQ-5D-3L and assess how well they reproduce patients' reported results. Methods: A clinical study comparing inpatient (n = 98) and outpatient (n = 47) rehabilitation of patients after an acute coronary event is re-analyzed. Value sets include: 1. Given health states and time-trade-off valuation (GHS-TTO) rendering economic utilities;2. Experienced health states and valuation by visual analog scale (EHS-VAS). Valuations are compared with patient-reported VAS rating. Accuracy is assessed by mean absolute error (MAE) and by Pearson's correlation.. External validity is tested by correlation with established MacNew global scores. Drivers of differences between value sets and VAS are analyzed using repeated measures regression. Results: EHS-VAS had smaller MAEs and higher. in all patients and in the inpatient group, and correlated best with MacNew global score. Quality-adjusted survival was more accurately reflected by EHS-VAS. Younger, better educated patients reported lower VAS at admission than the EHS-based value set. EHS-based estimates were mostly able to reproduce patient-reported valuation. Economic utility measurement is conceptually different, produced results less strongly related to patients' reports, and resulted in about 20 % longer quality-adjusted survival. Conclusion: Decision makers should take into account the impact of choosing value sets on effectiveness results. For transferring the results of heart rehabilitation patients from another country or from another valuation method, the EHS-based value set offers a promising estimation option for those decision makers who prioritize patient-reported valuation. Yet, EHS-based estimates may not fully reflect patient-reported VAS in all situations

Development and first assessment of a questionnaire for health care utilization and costs for cardiac patients

<p>Abstract</p> <p>Background</p> <p>The valid and reliable measurement of health service utilization, productivity losses and consequently total disease-related costs is a prerequisite for health services research and for health economic analysis. Although administrative data sources are usually considered to be the most accurate, their use is limited as some components of utilization are not systematically captured and, especially in decentralized health care systems, no single source exists for comprehensive utilization and cost data. The aim of this study was to develop and test a questionnaire for the measurement of disease-related costs for patients after an acute cardiac event (ACE).</p> <p>Methods</p> <p>To design the questionnaire, the literature was searched for contributions to the assessment of utilization of health care resources by patient-administered questionnaires. Based on these findings, we developed a retrospective questionnaire appropriate for the measurement of disease-related costs over a period of 3 months in ACE patients. Items were generated by reviewing existing guidelines and by interviewing medical specialists and patients. In this study, the questionnaire was tested on 106 patients, aging 35–65 who were admitted for rehabilitation after ACE. It was compared with prospectively measured data; selected items were compared with administrative data from sickness funds.</p> <p>Results</p> <p>The questionnaire was accepted well (response rate = 88%), and respondents completed the questionnaire in an average time of 27 minutes. Concordance between retrospective and prospective data showed an intraclass correlation (ICC) ranging between 0.57 (cost of medical intake) and 0.9 (hospital days) with the other main items (physician visits, days off work, medication) clustering around 0.7. Comparison between self-reported and administrative data for days off work and hospitalized days were possible for n = 48. Respective ICCs ranged between 0.92 and 0.94, although differences in mean levels were observed.</p> <p>Conclusion</p> <p>The questionnaire was accepted favorably and correlated well with alternative measurement approaches. This first assessment showed promising characteristics of this questionnaire in different aspects of validity for patients with ACE. However, additional research and more extensive tests in other patient groups would be worthwhile.</p

Abschlussbericht des Rehabilitationswissenschaftlichen Forschungsverbundes Ulm, Teilprojekt: Kosten-Effektivität stationäre versus ambulante Rehabilitation bei Patienten nach akutem koronaren Herzereignis (SARAH-Studie)

Background: With increasing cost pressure in the health care system interest in out-patient rehabilitative services rose, which in Germany have traditionally been predominantly provided in an in-patient setting. Aim: Aim of the SARAH-study was to compare out-patient versus in-patient cardiac rehabilitation in patients after an acute cardiac event. Method: A comprehensive cohort design was applied. Costs during rehabilitation were measured using the accounting systems of the rehabilitation centers. During 12 month follow-up questionnaires were applied for cost and effect measurement. Economic endpoints were quality of life (EQ-5D) and total health related direct and indirect cost. Results: As the randomization was chosen by a very small percentage of participants the design changed to a controlled observational study. Direct costs of in-patient rehabilitation were significantly higher while the outcomes in Qol were comparable. Considering the 12 month period and taking confounding into account no significant difference could be detected between groups. Point estimates of incremental cost effectiveness indicated dominance which could not be asserted statistically (CI 51.908, 12.168 €/QALY). Discussion: As a non-randomized controlled study the power of the study decreased. Consequently a considerable uncertainty in the health economic results, which tended to be in favor of out-patient rehabilitation, remained

Disease management programmes for patients with coronary heart disease--An empirical study of German programmes

Objective To evaluate healthcare and outcomes of disease management programmes (DMPs) for patients with coronary heart disease (CHD) in primary care, and to assess selection of enrolment for these programmes.Methods A cross-sectional survey of 2330 statutorily insured patients with a history of acute myocardial infarction (AMI) was performed in 2006 by the population-based KORA Myocardial Infarction Register from the region of Augsburg, Germany. Patients enrolled in DMP-CHDs receive evidence-based care, with patients not enrolled receiving standard care. To control for selection bias, a propensity score approach was used.Results Main factors influencing DMP participation were age (OR 0.98, 95% CI 0.96-0.99), diabetes (OR 1.56, CI 1.25-1.95) and time since last heart attack (OR 0.98, CI 0.95-0.99). Significantly more patients enrolled in DMP-CHDs stated that they received medical counselling for smoking (OR 3.77, CI 1.07-13.34), nutrition (OR 2.15, 1.69-2.74) and for physical activity (OR 2.58, 1.99-3.35). Furthermore, prescription of statins (OR 1.58, CI 1.24-2.00), antiplatelets (OR 1.96, CI 1.43-2.69) and beta-blockers (not significant) were higher in the DMP group. With respect to outcomes, we did not see relevant differences in quality of life and body mass index, and only a minor reduction in smoking.Conclusions Enrolment into DMPs for CHD exhibits systematic selection effects. Participants tend to experience - at least on a short to medium term and for AMI patients - better quality of healthcare services. However, since DMP-CHDs were initiated only 2 years ago, we were unable to identify significant improvements in health outcomes. Only the reduction in smoking provides a first indication of better quality outcomes following DMP-CHD. Thus, policy-makers must provide appropriate incentives to sickness funds and physicians in order to ensure initiation and continuation of high quality DMPs.Disease management programme Coronary heart disease Germany KORA Empirical study