Gesundheitssysteme als epidemiologischer Gegenstand – oder: Wie wissen wir, wie effektiv Gesundheitssysteme sind?

The article looks at health systems -- especially their effectiveness in improving population health -- from an epidemiological perspective. It demonstrates that research questions and methodologies do not substantially differ from other areas of epidemiological research. Longitudinal designs are superior to the frequently conducted cross-sectional approaches; exposition and outcome parameters need to be carefully defined. A useful approach is "avoidable mortality" which separates medically amenable causes of death from other ones. The article demonstrates that the "exposition health system" has a clearly beneficial effect on population health.

Verhaltensänderung durch Einführung der Praxisgebühr und Ursachenforschung

As part of the Statutory Health Insurance Modernization Act a co-payment of 10 Euros per quarter for the first contact at a physician's or a dentist's office has been introduced with effect of January 1, 2004. Apart from contributing to the financial consolidation of the Statutory Health Insurance the co-payment aimed at changing the patients' behavior toward more self-responsibility. This article shows that physician contacts declined in the year 2004 compared to 2003. However, the share of those patients who had at least one physician contact in both years remained stable. Two Logit models point out that necessary physician contacts still take place, e. g., in case of disabled persons and persons with poor health. In addition, no discrimination of persons of low social status could be observed. The results are also approved by other studies. Therefore, it seems plausible, that the introduction of this co-payment has contributed to a reduction of unnecessary and redundant physician visits.

Macrophages in human visceral adipose tissue: increased accumulation in obesity and a source of resistin and visfatin

AIMS/HYPOTHESIS

Increased visceral white adipose tissue (WAT) is linked to the risk of developing diabetes.

METHODS/RESULTS

We showed by fluorescence activated cell sorting analysis that human visceral WAT contains macrophages, the proportion of which increased with obesity. Selective isolation of mature adipocytes and macrophages from human visceral WAT by CD14 immunoselection revealed that macrophages expressed higher levels of chemokines (monocyte chemotactic protein 1, macrophage inflammatory protein 1alpha, IL-8) and the adipokines resistin and visfatin than did mature adipocytes, as assessed by real-time PCR analysis. Moreover, resistin and visfatin proteins were found to be released predominantly by visceral WAT macrophages. Macrophage-derived secretory products stimulated phosphorylation of protein kinase B in human hepatocytes.

CONCLUSIONS/INTERPRETATION

Resistin and visfatin might be considered to be proinflammatory markers. The increased macrophage population in obese human visceral WAT might be responsible for the enhanced production of chemokines as well as resistin and visfatin.

[Health economics. Objectives, methodology, relevance]

The article briefly describes the development of health economics and defines its most important areas of research (e.g. subjective and objective valuation of health; demand for and supply of health services; health insurance; planning, regulation and management; evaluation of health systems; and microeconomic evaluation). Regarding economic evaluation, the article emphasises the choice of comparators, the assessment of costs and effects, the various types of economic analyses, average vs incremental cost-effectiveness, usage of trial data vs modelling as well as sensitivity analyses. It discusses the question of generalisability and introduces a checklist to assess quality and results of published studies.

Cost-effectiveness analysis of telemedical devices for pre-clinical traffic accident emergency rescue in Germany

OBJECTIVES

The purpose of this study is to assess the cost-effectiveness (net costs per life year gained) of telemedical devices for pre-clinical traffic accident emergency rescue in Germany.

METHODS

Two equipment versions of a telemedical device are compared from a societal perspective with the baseline in Germany, i.e. the non-application of telemedicine in emergency rescues. The analysis is based on retrospective statistical data covering a period of 10 years with discounted costs not adjusted for inflation. Due to the uncertainty of data, certain assumptions and estimates were necessary. The outcome is measured in terms of "life years gained" by reducing therapy-free intervals and improvements in first-aid provided by laypersons.

RESULTS

The introduction of the basic equipment version, "Automatic Accident Alert", is associated with net costs per life year gained of euro 247,977 (at baseline assumptions). The full equipment version of the telemedical device would lead to estimated net costs of euro 239,524 per life year gained. Multi-way sensitivity-analysis with best and worst case scenarios suggests that decreasing system costs would disproportionately reduce total costs, and that rapid market penetration would largely increase the system's benefit, while simultaneously reducing costs.

CONCLUSION

The net costs per life year gained in the application of the two versions of the telemedical device for pre-clinical emergency rescue of traffic accidents are estimated as quite high. However, the implementation of the device as part of a larger European co-ordinated initiative is more realistic.

Vascular endothelium and blood flow

Major advances have been made over the last decade towards the elucidation of the molecular mechanisms involved in the endothelium-dependent regulation of vascular tone and blood flow. While the primary endothelium-derived vasodilator autacoid is nitric oxide, it is clear that epoxyeicosatrienoic acids and other endothelium-derived hyperpolarising factors, as well as endothelin-1 and reactive oxygen species, play a significant role in the regulation of vascular tone and gene expression. This review is intended as an overview of the signalling mechanisms that link haemodynamic stimuli (such as shear stress and cyclic stretch) and endothelial cell perturbation to the activation of enzymes generating vasoactive autacoids.

[Attempt to exclude invasive cardiology services in Poland--rationing, national sovereignty and European Union law]

One of the guiding principles of health policy in many European countries is equitable access to health care services. One of the life saving procedures is percutaneous transluminal coronary angioplasty (PTCA) performed after coronary angiography. Introducing payment for these procedures would limit access for low-income patients. Fortunately, despite political debate, invasive cardiology develops well in Poland. It is important to notice that within the European Union Polish citizens would be able to receive this treatment in other member states and, according to a European Court of Justice ruling, the costs would have to be reimbursed by the National Health Fund. The wider implication is that the 10 new EU member states now have to realise that health care is no longer a matter of national sovereignty - a fact legislators and health care managers in the 15 member states of the pre-accession EU are still struggling with.

Hospitalisation costs of cystic fibrosis

OBJECTIVE

To calculate per-case hospital costs for patients with cystic fibrosis under routine conditions from a healthcare provider's perspective; identify the impact of different cost categories; investigate whether cases with cystic fibrosis can be grouped into homogenous cost groups according to defined severity levels; and determine the value of specific factors as predictors of hospital cost variations.

METHODS

All data were collected from cases (n = 131) admitted to an inpatient cystic fibrosis unit under routine conditions during a period of 6 months in 2004. All costs were calculated for the year 2004 and divided into categories with high and low impact on variation in hospitalisation costs between patients. Staff costs for patient care, laboratory costs and drug costs were defined as categories with high impact, thus the individual resource utilisation for each case was measured. Cost categories that were classified as having a low impact were measured as overhead costs. Cases were classified according to two different severity models; within each model, patients were classified according to three severity levels. The diagnosis-related model classifies patients with pulmonary hypertension and global respiratory insufficiency as having severe disease, patients with Pseudomonas aeruginosa as having moderate disease, and patients with no colonisation of the lungs as having mild disease. The lung-function-related model differentiates patients as having mild, moderate and severe disease when patients have forced expiratory volumes in 1 second (FEV(1)) that are > or =70%, between > or =40% and <70%, and <40%, respectively. Analysis of variance tests were performed to investigate the differences of mean costs between the groups. Ordinary least squares regression analysis was used to determine predictors for cost variation.

RESULTS

The mean total costs per case were 7326 euro. Almost one-third of the total mean costs were attributable to drug costs (28% of total costs), while shares of staff costs for patient care and laboratory costs (both 9% of total costs) were relatively small. Most of the difference in costs between severity levels was attributable to the variation in overhead costs and drug costs. For both severity models differences in mean total costs of mild and severe cases were statistically significant (p < 0.01 and p < 0.05, respectively) when compared with the mean costs of non-mild and non-severe cases. However, in moderate cases, significant differences compared with cases that were not of moderate severity were only seen for certain cost categories. In the multiple regression model the variables 'diagnosis-related severity' and 'FEV(1)' explained 31% of the variance of 'Ln (total costs per case)' between severity levels (p < or = 0.01).

CONCLUSION

This study shows that to a large extent hospitalisation costs for patients with cystic fibrosis vary according to the severity of their disease; drug costs play a major role in these differences. In the light of this variation it seems plausible to create separate reimbursement rates for two or three severity groups. Diagnoses as well as FEV(1) seem suitable criteria for such a classification.

Screening on urogenital Chlamydia trachomatis

INTRODUCTION

Around 92 million urogenital infections are caused yearly by Chlamydia trachomatis worldwide [1].The overall incidence of sexually transmitted diseases is increasing, as shown by the increases in the number of reported cases of syphilis and gonorrhea [2]. Chlamydia trachomatis infections are associated with various serious diseases in women, men and newborns, which could be, at least partially, avoided by means of early diagnosis and therapy. The Federal Joint Committee - responsible for decision-making concerning the benefit package of the German Social Health Insurance - has publicly announced the starting of deliberations on the issue of screening for Chlamydia trachomatis.

RESEARCH QUESTIONS

The leading question to be answered is whether screening for Chlamydia trachomatis should be included in the German benefit basket. The aim of this report is to provide a summary of the available evidence concerning the issue of screening for Chlamydia trachomatis.

METHODS

The summary of published scientific evidence, including HTA reports, systematic reviews, guidelines and primary research is represented. The synthesis follows the structure given by the criteria of Wilson and Jungner [3] for the introduction of screening in a population: relevance of the condition, availability of an adequate test, effectiveness of screening, acceptance of the programme, and economical issues. A literature search was conducted for each aspect of the synthesis and the evidence has been summarised in evidence tables.

RESULTS

We identified five HTA reports from three European agencies [4], [5], [6], [7] and one from the USA [8]. In addition, we identified four guidelines from Northamerica[9], [10], [11], [12] and one from Europe [13]. A total of 56 primary research publications were included: relevance of the disease (n=26), availability of test (n=1), effectiveness of screening (n=11), acceptance of the programme (n=11), economical issues (n=7).

DISCUSSION

The main limitation of this report is that we relied only on published results. Most of research has been conducted in countries other than Germany. The fulfilment of the criteria for introduction of screening depends on contextual factors. More data from Germany are needed in order to answer the main questions concerning acceptance, use of selection criteria to identify subgroups and economical aspects of screening for Chlamydia trachomatis in Germany.

CONCLUSIONS

The criteria for introduction of screening for Chlamydia trachomatis are partially fulfilled. The available evidence indicates that the success of a screening programme for Chlamydia trachomatis will depend on the implementation of strategies for uptake enhancement and probably on the participation of men as well. A pilot project should be conducted in order to assess cost-effectiveness, acceptance and feasibility of different screening strategies in Germany. On the light of the available evidence, the inclusion of screening for Chlamydia trachomatis in the benefit basket without embedding it in a multifaceted programme targeting primary prevention of sexually transmitted diseases and participation in screening cannot be recommende.

Determining the "Health Benefit Basket" of the Statutory Health Insurance scheme in Germany: methodologies and criteria

The issue of defining health benefit catalogues has recently gained new importance in Germany as a result of the creation of the new Institute for Quality and Efficiency. The Institute was designed to support the Federal Joint Committee conducting effectiveness studies for benefit coverage decisions. The Committee and the contractual partners (sickness funds and providers) define the benefit catalogues for the Statutory Health Insurance in the framework of Social Code Book V, Germany's most relevant health care scheme. Unlike other countries, the German federal government limits its regulatory role to defining procedures that determine the scope of Statutory Health Insurance services. The explicitness of the benefit catalogues varies greatly between different sectors. While benefits in outpatient care are rather explicitly defined, benefit definitions for inpatient care are vague. It is argued that the establishment of the new Institute and the development of the DRG system are initial steps towards a more effective and explicit benefit catalogue.

Defining the "Health Benefit Basket" in nine European countries. Evidence from the European Union Health BASKET Project

This article identifies and analyses a framework for "health baskets," the taxonomy of benefit catalogues for curative services, and the criteria for the in- or exclusion of benefits in nine EU member states (Denmark, England, France, Germany, Hungary, Italy, The Netherlands, Poland and Spain). Focusing on services of curative care, it is found that the explicitness of benefit catalogues varies largely between the countries. In the absence of explicitly defined benefit catalogues, in- and outpatient remuneration schemes have the character of benefit catalogues. The criteria for the in- or exclusion into benefit catalogues are often not transparent and (cost-)effectiveness is applied only for certain sectors. An EU-wide harmonization of benefit baskets does not seem realistic in the short or medium term as the variation in criteria and the taxonomies of benefit catalogues are large but not insurmountable. There may be scope for a European core basket.

Methods for the comparative evaluation of pharmaceuticals

POLITICAL BACKGROUND: As a German novelty, the Institute for Quality and Efficiency in Health Care (Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen; IGWiG) was established in 2004 to, among other tasks, evaluate the benefit of pharmaceuticals. In this context it is of importance that patented pharmaceuticals are only excluded from the reference pricing system if they offer a therapeutic improvement. The institute is commissioned by the Federal Joint Committee (Gemeinsamer Bundesausschuss, G-BA) or by the Ministry of Health and Social Security. The German policy objective expressed by the latest health care reform (Gesetz zur Modernisierung der Gesetzlichen Krankenversicherung, GMG) is to base decisions on a scientific assessment of pharmaceuticals in comparison to already available treatments. However, procedures and methods are still to be established.

RESEARCH QUESTIONS AND METHODS

This health technology assessment (HTA) report was commissioned by the German Agency for HTA at the Institute for Medical Documentation and Information (DAHTA@DIMDI). It analysed criteria, procedures, and methods of comparative drug assessment in other EU-/OECD-countries. The research question was the following: How do national public institutions compare medicines in connection with pharmaceutical regulation, i.e. licensing, reimbursement and pricing of drugs? Institutions as well as documents concerning comparative drug evaluation (e.g. regulations, guidelines) were identified through internet, systematic literature, and hand searches. Publications were selected according to pre-defined inclusion and exclusion criteria. Documents were analysed in a qualitative matter following an analytic framework that had been developed in advance. Results were summarised narratively and presented in evidence tables.

RESULTS AND DISCUSSION

Currently licensing agencies do not systematically assess a new drug's added value for patients and society. This is why many countries made post-licensing evaluation of pharmaceuticals a requirement for reimbursement or pricing decisions. Typically an explicitly designated drug review body is involved. In all eleven countries included (Austria, Australia, Canada, Switzerland, Finland, France, the Netherlands, Norway, New Zealand, Sweden, and the United Kingdom) a drug's therapeutic benefit in comparison to treatment alternatives is leading the evaluation. A medicine is classified as a therapeutic improvement if it demonstrates an improved benefit-/risk-profile compared to treatment alternatives. However, evidence of superiority to a relevant degree is requested. Health related quality of life is considered as the most appropriate criterion for a drug's added value from patients' perspective. Review bodies in Australia, New Zealand, and the United Kingdom have committed themselves to include this outcome measure whenever possible. Pharmacological or innovative characteristics (e.g. administration route, dosage regime, new acting principle) and other advantages (e.g. taste, appearance) are considered in about half of the countries. However, in most cases these aspects rank as second line criteria for a drug's added value. All countries except France and Switzerland perform a comparative pharmacoeconomic evaluation to analyse costs caused by a drug intervention in relation to its benefit (preferably by cost utility analysis). However, the question if a medicine is cost effective in relation to treatment alternatives is answered in a political and social context. A range of remarkably varying criteria are considered. Countries agree that randomised controlled head-to-head trials (head-to-head RCT) with a high degree of internal and external validity provide the most reliable and least biased evidence of a drug's relative treatment effects (as do systematic reviews and meta-analyses of these RCT). Final outcome parameters reflecting long-term treatment objectives (mortality, morbidity, quality of life) are preferred to surrogate parameters. Following the concept of community effectiveness, drug review institutions also explicitly favour RCT in a "natural" design, i.e. in daily routine and country specific care settings. The countries' requirements for pharmacoeconomic studies are similar despite some methodological inconsistencies, e.g. concerning cost calculation. Outcomes of clinical and pharmacoeconomic analyses are largely determined by the choice of comparator. Selecting an appropriate comparative treatment is therefore crucial. In theory, the best or most cost effective therapy is regarded as appropriate comparator for clinical and economic studies. Pragmatically however, institutions accept that the drug is compared to the treatment of daily routine or to the least expensive therapy. If a pharmaceutical offers several approved indications, in some countries all of them are assessed. Others only evaluate a drug's main indication. Canada is the only country which also considers a medicine's off-label use. It is well known that clinical trials and pharmacoeconomic studies directly comparing a drug with adequate competitors are lacking - in quantitative as well as in qualitative terms. This is specifically the case before or shortly after marketing authorisation. Yet there is the need to support reimbursement or pricing decisions by scientific evidence. In this situation review bodies are often forced to rely on observational studies or on other internally less valid data (including expert and consensus opinions). As a second option they use statistical approaches like indirect adjusted comparisons (in Australia and the United Kingdom) and, commonly, economic modelling. However, there is consensus that results provided by these techniques need to be verified by valid head-to-head comparisons as soon as possible.

CONCLUSIONS

In the majority of countries reimbursement and pricing decisions are based on systematic and evidence-based evaluation comparing a drug's clinical and economic characteristics to daily treatment routine. However, further evaluation criteria, requirements and specific methodological issues still lack internationally consented standards.

[Pharmaceutical reference pricing in Germany: definition of therapeutic groups, price setting through regression procedure and effects]

The German reference pricing system defines a reimbursement threshold for groups of pharmaceuticals. Pharmaceuticals are grouped according to certain criteria by the Federal Joint Committee. To make different active ingredients comparable, so called reference values are defined. Subsequently, the federal association of sickness funds sets reference prices using a regression procedure. However, the impact of the reference price system is limited. On the one hand there is a strong incentive for pharmaceutical companies to decrease prices to the reference price. On the other hand there is no incentive for further price reductions. Additionally, only one part of the pharmaceutical market is affected by reference pricing. Therefore the instrument has only managed to lower pharmaceutical expenditure in the short run. For sustainable long-term cost containment the use of other regulatory instruments is necessary. Nevertheless, compared to other instruments of price-regulation, reference pricing seems to be a good alternative to control pharmaceutical prices, since rationing is kept as little as possible.

Regulation of pharmaceutical markets in Germany: improving efficiency and controlling expenditures?

Rising pharmaceutical expenditure has become a major concern for policy makers in Germany over recent years. Therefore, the pharmaceutical market has been increasingly targeted by different kinds of regulation, focussing on both the supply and the demand side, using price, volume and spending controls. Specific regulations include price reductions, reference pricing, pharmacy rebates for sickness funds, increasing co-payments, an 'autidem' substitution, parallel imports, a negative list, directives, and finally, spending caps for pharmaceutical expenditure per physicians' association. Although it is difficult to attribute certain effects to single measures, some measures like reference pricing and physician spending caps are more effective and long-lasting than others. In spite of being opposed by physicians, the spending caps applied between 1993 and 2001 have limited pharmaceutical expenditure for an entire decade. However, while some measures do effectively control expenditures, their effect on allocative efficiency may be detrimental.

Modulation of the Ca2 permeable cation channel TRPV4 by cytochrome P450 epoxygenases in vascular endothelium

TRPV4 is a broadly expressed Ca2+-permeable cation channel in the vanilloid subfamily of transient receptor potential channels. TRPV4 gates in response to a large variety of stimuli, including cell swelling, warm temperatures, the synthetic phorbol ester 4alpha-phorbol 12,13-didecanoate (4alpha-PDD), and the endogenous lipid arachidonic acid (AA). Activation by cell swelling and AA requires cytochrome P450 (CYP) epoxygenase activity to convert AA to epoxyeicosatrienoic acids (EETs) such as 5,6-EET, 8,9-EET, which both act as direct TRPV4 agonists. To evaluate the role of TRPV4 and its modulation by the CYP pathway in vascular endothelial cells, we performed Ca2+ imaging and patch-clamp measurements on mouse aortic endothelial cells (MAECs) isolated from wild-type and TRPV4(-/-) mice. All TRPV4-activating stimuli induced robust Ca2+ responses in wild-type MAECs but not in MAECs isolated from TRPV4(-/-) mice. Upregulation of CYP2C expression by preincubation with nifedipine enhanced the responses to AA and cell swelling in wild-type MAECs, whereas responses to other stimuli remained unaffected. Conversely, inhibition of CYP2C9 activity with sulfaphenazole abolished the responses to AA and hypotonic solution (HTS). Moreover, suppression of EET hydrolysis using 1-adamantyl-3-cyclo-hexylurea or indomethacin, inhibitors of soluble epoxide hydrolases (sEHs), and cyclooxygenases, respectively, enhanced the TRPV4-dependent responses to AA, HTS, and EETs but not those to 4alpha-PDD or heat. Together, our data establish that CYP-derived EETs modulate the activity of TRPV4 channels in endothelial cells and shows the unraveling of novel modulatory pathways via CYP2C modulation and sEH inhibition.

Analysing the impact of health-care system change in the EU member states--Germany

The core of the German health-care system is the statutory health insurance (SHI). Coverage of the SHI has remained fairly constant at about 90% whereas the rest of the population is insured for the most part with private health insurance. The primary goal of health-care reforms since the 1990s has been to contain the expenditure of the SHI. The primary measures to do this have been the introduction of budgets and a shift of expenditure towards private households mainly in the form of benefit exclusions and increased co-payments. So far these measures did not have a negative effect on broad outcome measures such as life expectancy, which continued to rise, and self-assessed health of the population, which remained stable in the period 1992--2002. Besides cost containment another leitmotif of reform have been attempts to increase competition both between sickness funds and providers of care. These two strands of reforms also affected the incentive structures for both insurers and providers in various ways which this article describes. The immediate future of health-care reform will concern the mode of financing of the SHI which centres on the question if contributions proportional to income shall be maintained or if there shall be a radical shift towards flat-rate health premiums.

Ärztliche Einstellungen gegenüber Leitlinien

BACKGROUND

Guidelines gain importance for medical services. Their perception and use by physicians does not only rely on their attitudes towards guidelines, but also on other parameters of influence.

PURPOSE

to assess hospital physicians's attitudes concerning clinical guidelines and physician- and hospital- related factors of influence.

METHODS

multicenter survey with 99 junior and senior registrars from 30 departments of neurology (taking regional random samples).

RESULTS

A majority of physicians regarded guidelines as a means of quality improvement and medical education. However, there were no generally positive or negative attitudes, but the physicians differentiated between the individual and the health system level. These patterns of attitudes did not depend upon aspects of the respective departments (such as size, internal guidelines, access to sources of information) and did not vary significantly between hospitals. Instead, there was a marked influence of personality traits on individual opinions concerning guideline utility. Senior registrars, less team-oriented physicians, younger physicians and the more prestige-motivated expressed positive attitudes. On the other hand, a sceptical and more negative attitude was found with professionals who expressed strong team orientation and scientific interest.

CONCLUSIONS

The overall positive attitude is probably related to the identification of guideline users with their authors and also to the their present status as non-binding recommendations. The independence of attitudes from hospital characteristics, especially the existence of internal guidelines, may indicate either voluntary guideline use or rather a low impact of guidelines as management instruments or frequently used tools. The potential of guidelines for medical education does not seem to be fully utilised.