Health related quality of life in patients with bladder cancer: a cross-sectional survey and validation study of the Hungarian version of the Bladder Cancer Index

Health-related quality of life (HRQoL) is an important outcome in oncology care although an underexplored area in bladder cancer (BC). Our aims were to assess HRQoL of patients with BC, analyse relationships between diverse HRQoL measures and validate the Hungarian version of the Bladder Cancer Index (BCI) questionnaire. A cross-sectional survey was performed among patients with BC (N = 151). Validated Hungarian versions of the FACT-Bl, SF-36 and EQ-5D were applied and SF-6D was derived. Psychometric analysis of the Hungarian BCI was performed. Pearson correlations between the five measures were analysed. Deterioration in SF-36 Physical Functioning was detected among patients aged 45-64 years. The EQ-5D score did not differ significantly from the age-matched population norm. Correlations between the FACT-Bl, EQ-5D and SF-6D utility measures were strong (r > 0.6). Cronbach alpha coefficients of the Hungarian BCI ranged from 0.75 to 0.97 and factor analysis confirmed that data fit to the six predefined subdomains. Test-retest correlations (reliability, N = 50) ranged from 0.67 to 0.87 and interscale correlations between urinary, bowel and sexual BCI domains were weak or moderate (r = 0.29 to 0.49). Convergent validity revealed a stronger correlation with FACT-Bl (r = 0.126 to 0.719) than with generic health state scores (r = 0.096 to 0.584). Results of divergent validity of the Hungarian BCI by treatment groups by Kruskal Wallis test were promising although limited by low sample sizes in cystectomy subgroups. Generic health state measures have limited capacity to capture HRQoL impact of BC. Validity tests yielded favourable results for the Hungarian BCI. Mapping studies to estimate utility scores from FACT-Bl are encouraged but less recommendable with the BCI.

The link between past informal payments and willingness of the Hungarian population to pay formal fees for health care services: results from a contingent valuation study

We examine the willingness of health care consumers to pay formal fees for health care use and how this willingness to pay is associated with past informal payments. We use data from a survey carried out in Hungary in 2010 among a representative sample of 1,037 respondents. The contingent valuation method is used to elicit the willingness to pay official charges for health care services covered by the social health insurance if certain quality attributes (regarding the health care facility, access to the services and health care personnel) are guaranteed. A bivariate probit model is applied to examine the relationship between willingness to pay and past informal payments. We find that 66% of the respondents are willing to pay formal fees for specialist examinations and 56% are willing to pay for planned hospitalizations if these services are provided with certain quality and access attributes. The act of making past informal payments for health care services is positively associated with the willingness to pay formal charges. The probability that a respondent is willing to pay official charges for health care services is 22% points higher for specialist examinations and 45% points higher for hospitalization if the respondent paid informally during the last 12 months. The introduction of formal fees should be accompanied by adequate service provision to assure acceptance of the fees. Furthermore, our results suggest that the problem of informal patient payments may remain even after the implementation of user fees.

[Clinical efficacy and safety of enzalutamide in metastatic castration-resistant prostate cancer: systematic review and meta-analysis]

Enzalutamide, abiraterone-acetate, and cabazitaxel are licensed post-docetaxel treatments of metastatic castration-resistant prostate cancer (mCRPC) in Hungary. The objectives of the study were to assess the efficacy and safety of post-docetaxel enzalutamide treatment and to compare it with abiraterone and with cabazitaxel, using Medline-based systematic literature search, and meta-analysis of randomised controlled trials (RCT). Overall 3 RCTs were included, one for each substance. Compared to placebo, enzalutamide proved significant efficacy in each primary and secondary endpoint. Enzalutamide extended median overall survival by 4.8 months. Due to lack of a common comparator in the cabazitaxel trial, only enzalutamide and abiraterone were involved in an indirect comparison. No significant difference was identified either in the primary endpoint (overall survival) (HR: 0.97, 95% CI: 0.75-1.25) or in frequencies of adverse events between these two treatments. However, enzalutamide was significantly more efficacious than abiraterone in 3 secondary endpoints: time to prostate-specific antigen (PSA) progression (HR: 0.43, 95% CI: 0.31-0.59), radiographic progression-free survival (HR: 0.6, 95% CI: 0.5-0.72), and PSA response rate (RR: 7.48, 95% CI: 2.83-19.72). Enzalutamide therapy proved clinical efficacy and safety in patients with post-docetaxel mCRPC. In the indirect comparison, efficacy and safety of abiraterone and enzalutamide were found to be similar.

[The economic burden of prostate cancer. A systematic literature overview of registry-based studies]

INTRODUCTION

Prostate cancer, the most frequent malignant disease in males in Europe, accounts for a great proportion of health expenditures.

AIM

A systematic review of registry-based studies about the cost-of-illness and related factors of prostate cancer, published in the last 10 years.

METHOD

A MEDLINE-based literature review was carried out between January 1, 2003 and October 1, 2013.

RESULTS

Fifteen peer-reviewed articles met the criteria of interest. In developed countries radiotherapy, surgical treatment and hormone therapy account for the greatest per capita costs. In Europe early stage tumours (4-7000 €, 2006), while in the USA metastatic prostate cancer (19 900-25 500 $, 2004) was associated with highest per capita expenses. In Europe the greatest costs incurred within the initial treatment (6400 €/6 months, 2008), while in the USA within the end-of-life care (depending on age: 62 200-93 400 $, 2010).

CONCLUSIONS

Despite public health importance of prostate cancer, the cost-of-illness literature from Europe is relatively small.

Cost-of-illness in patients with moderate to severe psoriasis: a cross-sectional survey in Hungarian dermatological centres

BACKGROUND

Despite the widespread availability of biological drugs in psoriasis, there is a shortage of disease burden studies.

OBJECTIVES

To assess the cost-of-illness and quality of life of patients with moderate to severe psoriasis in Hungary.

METHODS

Consecutive patients with Psoriasis Area and Severity Index (PASI) > 10 and Dermatology Life Quality Index (DLQI) > 10, or treated with traditional systemic (TST) or biological systemic treatment (BST) were included. Demographic data, clinical characteristics, psoriasis related medication, health care utilizations and employment status in the previous 12 months were recorded. Costing was performed from the societal perspective applying the human capital approach. Quality of life was assessed using DLQI and EQ-5D measures.

RESULTS

Two-hundred patients were involved (females 32%) with a mean age of 51 (SD 13) years, 103 (52%) patients were on BST. Mean PASI, DLQI and EQ-5D scores were 8 (SD 10), 6 (SD 7) and 0.69 (SD 0.3), respectively. The mean total cost was €9,254/patient/year (SD 8,502) with direct costs accounting for 86%. The main cost driver was BST (mean €7,339/patient/year). Total costs differed significantly across treatment subgroups, mean (SD): no systemic therapy €2,186 (4,165), TST €2,388 (4,106) and BST €15,790 (6,016) (p < 0,001). Patients with BST had better PASI and DLQI scores (p < 0.01) than the other two subgroups.

CONCLUSIONS

Patients with biological treatment have a significantly better quality of life and higher total costs than patients with or without traditional systemic treatment. Our study is the largest in Europe and the first in the CEE region that provides cost-of-illness data in psoriasis involving patients with BST.

Efficacy and safety of infliximab-biosimilar compared to other biological drugs in rheumatoid arthritis: a mixed treatment comparison

OBJECTIVE

The aim of this meta-analysis was to compare the efficacy and safety of infliximab-biosimilar and other available biologicals for the treatment of rheumatoid arthritis (RA), namely abatacept, adalimumab, certolizumab pegol, etanercept, golimumab, infliximab, rituximab and tocilizumab.

METHODS

A systematic literature review of MEDLINE database until August 2013 was carried out to identify relevant randomized controlled trials (RCTs). Bayesian mixed treatment comparison method was applied for the pairwise comparison of treatments. Improvement rates by the American College of Rheumatology criteria (ACR20 and ACR50) at week 24 were used as efficacy endpoints, and the occurrence of serious adverse events was considered to assess the safety of the biologicals.

RESULTS

Thirty-six RCTs were included in the meta-analysis. All the biological agents proved to be superior to placebo. For ACR20 response, certolizumab pegol showed the highest odds ratio (OR) compared to placebo, OR 7.69 [95% CI 3.69-14.26], followed by abatacept OR 3.7 [95% CI 2.17-6.06], tocilizumab OR 3.69 [95% CI 1.87-6.62] and infliximab-biosimilar OR 3.47 [95% CI 0.85-9.7]. For ACR50 response, certolizumab pegol showed the highest OR compared to placebo OR 8.46 [3.74-16.82], followed by tocilizumab OR 5.57 [95% CI 2.77-10.09], and infliximab-biosimilar OR 4.06 [95% CI 1.01-11.54]. Regarding the occurrence of serious adverse events, the results show no statistically significant difference between infliximab-biosimilar and placebo, OR 1.87 [95% CI 0.74-3.84]. No significant difference regarding efficacy and safety was found between infliximab-biosimilar and the other biological treatments.

CONCLUSION

This is the first indirect meta-analysis in RA that compares the efficacy and safety of biosimilar-infliximab to the other biologicals indicated in RA. We found no significant difference between infliximab-biosimilar and other biological agents in terms of clinical efficacy and safety.

Comparative efficacy and safety of biosimilar infliximab and other biological treatments in ankylosing spondylitis: systematic literature review and meta-analysis

OBJECTIVES

To compare the efficacy and safety of infliximab-biosimilar with other biological drugs for the treatment of active ankylosing spondylitis (AS).

METHODS

Systematic literature review for randomized controlled trials (RCTs) with adalimumab, etanercept, golimumab, infliximab and infliximab-biosimilar in AS was performed and indirect meta-analysis (Bayesian mixed treatment comparison) was carried out. The proportion of patients reaching 20% improvement by the assessment of Spondyloarthritis International Society response criteria (ASAS20) at weeks 12 and 24 was used as efficacy endpoints, and the occurrence of serious adverse events at week 24 was applied to compare the safety of the biologicals.

RESULTS

Altogether, 13 RCTs, identified by the systematic literature search, were included in the analysis. Results on the ASAS20 efficacy endpoint were reported for week 12 in 12 RCTs involving 2,395 patients, and for week 24 in 5 RCTs comprising 1,337 patients. All the five biological agents proved to be significantly superior to placebo. Infliximab showed the highest odds ratio (OR) of 7.2 (95% CI 3.68-13.19) compared to placebo, followed by infliximab-biosimilar with OR 6.25 (95% CI 2.55-13.14), both assessed at week 24. No significant difference was found between infliximab-biosimilar and other biological treatments regarding their efficacy and safety.

CONCLUSIONS

This is the first study which includes a biosimilar drug in the meta-analysis of biological treatments in AS. The results have proven the similar efficacy and safety profile of infliximab-biosimilar treatment compared to other biologicals.

Exploring the relationship between EQ-5D, DLQI and PASI, and mapping EQ-5D utilities: a cross-sectional study in psoriasis from Hungary

BACKGROUND

There is a growing interest in policy making for using utility measures and identifying algorithms to convert disease-specific measures into utilities.

OBJECTIVES

To analyse the relationship between EQ-5D, Dermatology Life Quality Index (DLQI) and Psoriasis Area and Severity Index (PASI) in psoriasis. To transform DLQI scores, and key clinical, demographic and health service utilisation variables into utilities.

METHODS

A cross-sectional questionnaire survey of 200 consecutive adult patients with moderate to severe psoriasis was carried out in two Hungarian university clinics. The relationship between the outcome measures were analysed with correlations and with the known-groups method. Bivariate and multivariate regression algorithms on EQ-5D scores were formulated.

RESULTS

The mean age of respondents was 51 years (SD = 12.9), 68.5% were male, and 51.5% received biological therapy. Median EQ-5D, DLQI, and PASI scores were 0.73, 3.0, and 3.45, respectively. EQ-5D showed a moderate correlation with the DLQI and with the PASI (r s = -0.48 and -0.43, p < 0.05). Strong correlation was found between DLQI and PASI (r s = 0.81, p < 0.05). DLQI and PASI discriminated better among groups categorised by the localisation of the lesions than EQ-5D. Presence of psoriasis on the neck and/or décolletage was associated with the greatest health related quality of life (HRQOL) impairment. Ten variables were incorporated in a multivariate algorithm that accounted for 48.8% of EQ-5D variance (ANOVA p < 0.001).

CONCLUSIONS

This study provided the first evidence that patients with visible psoriatic lesions have significantly worse HRQOL compared to those with non-visible lesions, measured not only with DLQI but also with EQ-5D. In addition to demographic and clinical variables, our model included health service utilisation variables related to psoriasis, and explained higher proportion of EQ-5D variance than any previous findings in the literature.

Subjective health expectations at biological therapy initiation: a survey of rheumatoid arthritis patients and rheumatologists

Subjective health expectations of patients with rheumatoid arthritis (RA) and rheumatologists remain understudied. We measured subjective expectations regarding treatment effects of biologicals as well as future length and quality of life. Moreover, we compared expectations regarding treatment effects to actual treatment effects. We recruited a sample of Hungarian RA patients initiating treatment with biologicals. Expectations regarding treatment effects and future health were obtained through a written questionnaire from patients and physicians, including functional impairment (HAQ-DI), health status (EQ-5D) and disease activity (DAS28). After three months, actual treatment effects were obtained. Ninety-two RA patients (females N = 81, 88%) with mean age of 51 (SD 12) and disease duration of 9 (SD 8) years with high average disease activity (DAS28: 6.1) were included. Patients expected significant and large health improvement within three months with mean changes on the HAQ-DI of -0.8 and on the EQ-5D of +0.4. Rheumatologists' estimates were similar, and they expected significant decrease of 2.3 on the DAS28. Actual scores after three months were obtained for 77 patients. The measured scores were significantly lower than expected scores for the HAQ-DI and EQ-5D. Rheumatologists' expectations for the DAS28 score were not significantly different from measured scores. Patients' average expectations regarding quality of life scores for ages 60, 70, 80 and 90 were 0.44, 0.24, 0.06 and -0.02, respectively. Our results suggest that both RA patients and rheumatologists expect quick and significant health improvements from biological drugs and tend to overestimate actual short term treatment effects. Nonetheless, RA patients expect a sharp deterioration of future health.

Transferability of results of cost utility analyses for biologicals in inflammatory conditions for Central and Eastern European countries

BACKGROUND

Several Central and Eastern European (CEE) countries require cost-utility analyses (CUAs) to support reimbursement formulary listing. However, CUAs informed by local evidence are often unavailable, and the cost-effectiveness of the several currently reimbursed biologicals is unclear.

AIM

To estimate the cost-effectiveness as multiples of per capita GDP/quality adjusted life years (QALY) of four biologicals (infliximab, etanercept, adalimumab, golimumab) currently reimbursed in six CEE countries in six inflammatory rheumatoid and bowel disease conditions.

METHODS

Systematic literature review of published cost-utility analyses in the selected conditions, using the United Kingdom (UK) as reference country and with study selection criteria set to optimize the transfer of results to the CEEs. Prices in each CEE country were pro-rated against UK prices using purchasing power parity (PPP)-adjusted per capita GDP, and local GDP per capita/QALY ratios estimated.

RESULTS

Central and Eastern European countries list prices were 144-333% higher than pro rata prices. Out of 85 CUAs identified by previous systematic literature reviews, 15 were selected as a convenience sample for estimating the cost-effectiveness of biologicals in the CEE countries in terms of per capita GDP/QALY. Per capita GDP/QALY values varied from 0.42 to 6.4 across countries and conditions (Bulgaria: 0.97-6.38; Czech Republic: 0.42-2.76; Hungary: 0.54-3.54; Poland: 0.59-3.90; Romania: 0.77-5.07; Slovakia: 0.55-3.61).

CONCLUSION

While results must be interpreted with caution, calculating pro rata (cost-effective) prices and per capita GDP/QALY ratios based on CUAs can aid reimbursement decision-making in the absence of analyses using local data.

Biological therapy in inflammatory rheumatic diseases: issues in Central and Eastern European countries

Biological drugs revolutionized the treatment of inflammatory rheumatic diseases. Access to treatment presents substantial variability across Europe. The economic level of a particular country as well as administrative restrictions have been proved as determining factors of biological drug uptake. The objective of this paper was to provide an overview of biological treatment in six selected Central and Eastern European (CEE) countries, namely in the Bulgaria, Czech Republic, Hungary, Poland, Romania and Slovakia. The literature is summarized with regard to the epidemiology, disease burden and use of biological agents in rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis. Moreover, an estimate is provided on the prevalence and number of patients with biological treatment based on international and local sources. In view of the limited availability of information and uncertainty in data, there is an urgent need for development of systematic and comprehensive data collection in inflammatory rheumatic diseases in CEE countries.

Health technology assessment in Poland, the Czech Republic, Hungary, Romania and Bulgaria

This paper describes and discusses the development and use of health technology assessment (HTA) in five Central and Eastern European countries (CEE): Poland, the Czech Republic, Hungary, Romania and Bulgaria. It provides a general snapshot of HTA policies in the selected CEE countries to date by focusing on country case-studies based on document analysis and expert opinion. It offers an overview of similarities and differences between the individual CEE countries and discusses in detail the role of HTA by assessing its formalization and institutionalization, standardization of methodology, the use of HTA in practice and the degree of professionalization of HTA in the region. It finds that HTA has been to some extent implemented in all five countries studied, with methodologies in accordance with international standards, but that challenges remain when it comes to the role of HTA in health care decision-making as well as to human resource capacities of the countries. This paper suggests that coming years will show whether CEE countries develop adequate national analytical capacity to assess and appraise technologies in the context of local need and affordability, instead of using HTA as a mere administrative procedure to fulfill (inter)national requirements. Finally, suggestions are provided to strengthen HTA in CEE countries through cooperation, mutual learning, a common accreditation of HTA bodies and increased network building among CEE HTA experts.

Acceptability of less than perfect health states in rheumatoid arthritis: the patients' perspective

Some health problems are considered by many individuals as a 'normal' part of ageing. Our aim was to investigate whether patients with rheumatoid arthritis (RA) consider different types and levels of health losses as acceptable beyond a certain age. A multicenter cross-sectional survey was performed involving RA patients at the initiation of the first biological therapy. The EQ-5D and the Health Assessment Questionnaire Disability Index (HAQ-DI) questionnaires were used to describe domain-specific health states. Patients were asked to indicate for each domain from what age and onward (between ages 30 and 80 years in 10 year intervals) they considered moderate and severe problems acceptable or alternatively never acceptable. Seventy-seven RA patients (females 86%, mean age 50.3, disease duration 9.1 years) completed the questionnaire. Disease activity (DAS28), EQ-5D and HAQ-DI scores were mean 6.00 (SD 0.85), 0.35 (SD 0.36), 1.48 (SD 0.66), respectively. The majority of the patients considered age 70 and beyond as acceptable to have some health problems (EQ-5D: self-care 42%, pain/discomfort 34%, mobility 33%, usual activities 33%, anxiety/depression 27%), whilst at ages 30 and 40 as not acceptable. Severe health problems were mostly (57-69%) considered never acceptable, except the 'Usual activities' domain (acceptable from age 80 by 50.6%). The great majority of the patients (77-96%) were younger than what they indicated as the acceptability age limit. Similar results were found for the HAQ-DI. This small experimental study suggests that RA patients consider some health problems acceptable. This acceptability is age related and varies by health areas. Further larger studies are needed to explore explanatory variables and to compare with other diseases. Owing to the impact acceptability might have on RA patients' self-evaluation of current health state and decision-making, the topic deserves methodological improvement and further investigation.

Work disability and productivity loss in patients with inflammatory bowel diseases in Hungary in the era of biologics

BACKGROUND AND AIMS

To assess work disability (WD) rates in an inflammatory bowel disease (IBD) cohort involving patients with Crohn's disease (CD) or ulcerative colitis (UC) cohort and to identify possible clinical or demographic factors associated with WD. To our knowledge, this is the first study from Eastern Europe that has estimated indirect costs in IBD.

METHODS

Data from 443 (M/F: 202/241, CD/UC: 260/183, mean age: 35.5 (CD) and 40.5 (UC) years, biological drug exposure 31.2/11.5%) consecutive patients were included. WD data were collected by questionnaire and the work productivity and activity impairment instrument. Disability pension (DP) rates in the general population were retrieved from public databases.

RESULTS

The overall DP rate in this IBD population was 32.3%, with partial disability in 24.2%. Of all DP events, 88.8% were directly related to IBD. Overall, full DP was more prevalent in IBD (RR: 1.51, p < 0.001) and CD (RR: 1.74, p < 0.001) but not in UC compared to the general population and also in CD compared to UC (OR 1.57, p = 0.03). RR for full DP was increased only in young CD patients (RR<35 year olds: 9.4; RR36-40 year olds: 9.4 and 5.6, p < 0.01 for both). In CD, age group, previous surgery, disease duration, frequent relapses, and the presence of arthritis/arthralgia were associated with an increased risk for DP. Among employed patients, absenteeism and presenteeism was reported in of 25.9 and 60.3% patients, respectively, leading to a 28% loss of work productivity and a 32% activity loss, and was associated with disease activity and age group. Average cost of productivity loss due to disability and sick leave with a human capital approach was 1,450 and 430 €/patient/year in IBD, respectively (total productivity loss 1,880 €/patient/year), the costs of presenteeism were 2,605 (SD = 2,770) and 2,410 (SD = 2,970) €/patient/year in CD and UC, respectively.

CONCLUSION

Risk of DP was highly increased in young CD patients (sixfold to ninefold). Previous surgery and presence of arthritis/arthralgia was identified as risk factors for DP. Work productivity is significantly impaired in IBD and is associated with high productivity loss.

[Survey of adults living with epilepsy in Hungary: health-related quality of life and costs]

BACKGROUND AND PURPOSE

Disease burden of epilepsy in Hungary is underexplored. The aim of our study was to assess the quality of life and costs of adults with epilepsy.

METHODS

Cross-sectional questionnaire survey was performed in two hospital based outpatient neurology centres involving consecutive patients with epilepsy. Demography, clinical characteristics, health status (EQ-5D) and health care utilisation in the past 12 months were surveyed. Cost calculation was performed from the societal perspective.

RESULTS

Altogether 100 patients (women 58%) were involved, their mean age was 37.6 (SD = 12.5) years. Disease duration was 15.0 (SD = 12.1) years on average and 22 (22%) patients were disability pensioners. The EQ-5D score was mean 0.83 (SD = 0.24) which is significantly lower than the age-matched population norm (p = 0.017). Pain/discomfort and anxiety/depression are the most problematic health dimensions. The annual cost per patient was mean 2421 (SD = 3249) Euros (679 397 SD = 911 783 HUF; conversion: 1 Euro = 280.6 HUF), distribution between direct medical, direct non-medical and indirect costs was 33%, 18% or 49%. Patients with seizure in the past 12 months have higher cost on avergare than the asymptomatic subsample (3119 vs. 988 Euros/patient/year; 935 481 vs. 277 209 HUF/patient/year).

CONCLUSION

Adults with epilepsy have significantly worse health status by the EQ-5D than the gender and age matched Hungarian general population. Disease related costs are significant especially in cases with seizure, productivity loss related costs are dominant. Our study provides basic data for clinical and sustainable health care financing decisions.

[Clostridium difficile infection: epidemiology, disease burden and therapy]

INTRODUCTION

C. difficile causes 25 percent of the antibiotic associated infectious nosocomial diarrhoeas. C. difficile infection is a high-priority problem of public health in each country. The available literature of C. difficile infection's epidemiology and disease burden is limited.

AIM

Review of the epidemiology, including seasonality and the risk of recurrences, of the disease burden and of the therapy of C. difficile infection.

METHOD

Review of the international and Hungarian literature in MEDLINE database using PubMed up to and including 20th of March, 2012.

RESULTS

The incidence of nosocomial C. difficile associated diarrhoea is 4.1/10 000 patient day. The seasonality of C. difficile infection is unproved. 20 percent of the patients have recurrence after metronidazole or vancomycin treatment, and each recurrence increases the chance of a further one. The cost of C. difficile infection is between 130 and 500 thousand HUF (430 € and 1665 €) in Hungary.

CONCLUSIONS

The importance of C. difficile infection in public health and the associated disease burden are significant. The available data in Hungary are limited, further studies in epidemiology and health economics are required.

[Antimicrobial therapy of Clostridium difficile infection. Systematic review and meta-analysis of the scientific evidence]

INTRODUCTION

Clostridium difficile is the leading cause of antibiotic associated infectious nosocomial diarrhoea. Limited number of new pharmaceutical products have been developed and registered in the past decades for the treatment of Clostridium difficile infection. The available scientific evidence is limited and hardly comparable.

AIM

To analyse the clinical efficacy and safety of metronidazole, vancomycin and fidaxomicin in the therapy of Clostridium difficile infection.

METHODS

Systematic review and meta-analysis of the literature data.

RESULTS

Meta-analysis of literature data showed no significant difference between these antibiotics in clinical cure endpoint (odss ratios: fidaxomicin vs. vancomycin 1.19; vancomycin vs. metronidazol 1.69 and fidaxomicin vs. metronidazol 2.00). However, fidaxomicin therapy was significantly more effective than vancomicin and metronidazol in endpoints of recurrence and global cure (odds ratios: fidaxomicin vs. vancomycin 0.47; vancomycin vs. metronidazol 0.91 és fidaxomicin vs. metronidazol 0.43). There was no significant difference between fidaxomicin, vancomycin and metronidazole in safety endpoints.

CONCLUSIONS

Each antibiotic similarly improved clinical cure. Fidaxomicin was the most effective therapeutic alternative in lowering the rate of recurrent Clostridium difficile infections.

[Quality of life and burden of disease in peripheral arterial disease: a study among Hungarian patients]

INTRODUCTION

Peripheral arterial disease may occur in about of 14% of patients with high blood pressure, of which 1-3% suffer from chronic critical limb ischemia. Literature data on the quality of life according to the Fontaine stages are very limited.

AIM

The aim of this study was to assess the quality of life of Hungarian patients with peripheral arterial disease regarding Fontaine stages II, III and IV.

METHODS

The study was based on a cross-sectional survey, which was carried out in four angiologic centres. One hundred and two respondents with peripheral arterial disease (43% woman) were evaluated. The average age of the patients was 70 years (SD-10).

RESULTS

Based on the EQ-5D index, the results of the quality of life assessment with respect to Fontaine stages II, III and IV were 0.66, 0.35 and 0.18, respectively. In each stage the EQ-5D values were lower than the values of the age-matched average population. The results of the Pain Visual Analogue Scale (0-100 mm) were 38, 65 and 71 mm in Fontaine stages II, III and IV, respectively, and this showed a strong correlation with the EQ-5D (R = -0.68). In stage Fontaine IV the quality of life of the patients was significantly lower among those who had pain at rest and ALSO ulcer on the leg.

CONCLUSIONS

Peripheral disease with clinical symptoms causes significant reduction in quality of life which can be measured with EQ-5D. It becomes worse as we move along the Fontaine stages. While measuring the health gain in stage Fontaine IV, the health gain from the reduction of pain in rest and partial recovery from ulcer should be taken into account.

Exploring consumers' attitudes towards informal patient payments using the combined method of cluster and multinomial regression analysis--the case of Hungary

BACKGROUND

Previous studies on informal patient payments have mostly focused on the magnitude and determinants of these payments while the attitudes of health care actors towards these payments are less well known. This study aims to reveal the attitudes of Hungarian health care consumers towards informal payments to provide a better understanding of this phenomenon.

METHODS

For the analysis, we use data from a survey carried out in 2010 in Hungary involving a representative sample of 1037 respondents. We use cluster analysis to identify the main attitude groups related to informal payments based on the respondents' perception of and behavior related to informal payments. Multinomial logistic regression is applied to examine the differences between these groups in terms of socio-demographic characteristics, as well as past utilization and informal payments paid for health care services.

RESULTS

We identified three main different attitudes towards informal payments: accepting informal payments, doubting about informal payments and opposing informal payments. Those who accept informal payments (mostly young or elderly people, living in the capital) consider these payments as an expression of gratitude and perceive them as inevitable due to the low funding of the health care system. Those who doubt about informal payments (mostly respondents outside the capital, with higher education and higher household income) are not certain whether these payments are inevitable, perceive them as similar to corruption rather than gratitude, and would rather use private services to avoid these payments. We find that the opposition to informal payments (mostly among men from small households and low income households) can be explained by their lower ability and willingness to pay.

CONCLUSIONS

A large share of Hungarian health care consumers has a rather positive attitude towards informal payments, perceiving them as "inevitable due to the low funding of the health care system". From a policy point-of-view, the change of this consumer attitude will be essential to deal with these payments in addition to other policy strategies.

Health status and costs of ambulatory patients with multiple sclerosis in Hungary

BACKGROUND AND PURPOSE

Data on disease burden of multiple sclerosis from Eastern-Central Europe are very limited. Our aim was to explore the quality of life, resource utilisation and costs of ambulating patients with multiple sclerosis in Hungary.

METHODS

Cross-sectional questionnaire survey was performed in two outpatient neurology centres in 2009. Clinical history, health care utilisation in the past 12 months were surveyed, the Expanded Disability Status Scale and the EQ-5D questionnaires were applied. Cost calculation was conducted from the societal perspective.

RESULTS

Sixty-eight patients (female 70.6%) aged 38.0 (SD 9.1) with disease duration of 7.8 (SD 6.7) years were involved. Fifty-five (80.9%) had relapsing-remitting form and 52 (76.5%) were taking immunomodulatory drug. The average scores were: Expanded Disability Status Scale 1.9 (SD 1.7), EQ-5D 0.67 (SD 0.28). Mean total cost amounted to 10 902 Euros/patient/year (direct medical 67%, direct nonmedical 13%, indirect costs 20%). Drugs, disability pension and informal care were the highest cost items. Costs of mild (Expanded Disability Status Scale 0-3.5) and moderate (Expanded Disability Status Scale 4.0-6.5) disease were 9 218 and 17 634 Euros/patient/year respectively (p<0.01), that is lower than results from Western European countries.

CONCLUSION

Our study provides current inputs for policy making and contributes to understanding variation of cost-of-illness of multiple sclerosis in Europe.

[Health related quality of life and productivity of women with overactive bladder]

The objective of the research was to assess the health related quality of life and productivity of women with overactive bladder.

METHODS

A cross-sectional survey was performed in 5 outpatient centers. General health status (EQ-5D), disease-specific quality of life (King's Health Questionnaire) and productivity (Work Productivity and Activity Impairment) were assessed.

RESULTS

Sixty-one women with mean age of 57.7 (SD = 11.6) years have had symptoms for 6.6 (SD = 6.2) years and 57 (93%) had incontinence. The EQ-5D (mean 0.668, SD = 0.314) was not significantly lower than that of the average population (p>0.05). The impact of incontinence and physical limitation (mean 70.5 and 68.9, respectively) were significant, the King's Health Questionnaire-utility was 0.932 (SD = 0.029). Productivity scores of involved patients were: absenteeism 0.04% (SD = 0.11), presenteeism 43.64% (SD = 28.54), overall work impairment 40.97% (SD = 26.91), and other activities 47.72% (SD = 27.24).

CONCLUSIONS

Applicability of the EQ-5D and King's Health Questionnaire as utility measures in overactive bladder deserve further research. Presenteeism should be considered in the evaluation of the therapy.

Subjective expectations regarding length and health-related quality of life in Hungary: results from an empirical investigation

BACKGROUND

Subjective expectations regarding future health are rarely studied, yet may have implications for medical decision making, health behaviour and health economic analysis.

OBJECTIVE

To study people's subjective expectations regarding length and future quality of life in Hungary and compare these with previous findings from the Netherlands.

METHODS

A cross-sectional survey was performed, using a questionnaire that was put on a highly frequented web journal during 1 day. Main socio-demographic variables and health status of the voluntary participants were registered using the EQ-5D questionnaire. People were asked about the age they expected to live and the health status they expected to have at ages 60, 70, 80 and 90, using the EQ-5D descriptive system. Responses were matched and compared to age- and gender-specific life expectancy data from the Hungarian National Statistics and to age- and gender-specific EQ-5D scores from a prior nationally representative survey in Hungary.

RESULTS

In total, 9407 people were included in the analysis with mean age of 36.1 (SD 10.6) years, mainly qualified (degree 74.0%), employed (86.0%) men (67.1%). People overestimated their life expectancy (women, 1.6; men, 8.2 years) and expected a sharp deterioration in health at the age 70. Age, current health status, perception of a healthy lifestyle and kins' age at death were important explanatory factors for subjective expectations. Subjective life expectancy correlates strongly with expected future health status.

CONCLUSIONS

The striking similarities between two surveys from distinct nations suggest that people's (mis)expectations regarding length and future quality of life are probably rather generalizable between jurisdictions within Europe.

[Effectiveness of prostanoids in patients with critical leg ischemia]

Prostanoids (alprostadil and iloprost) are used for the treatment of patients with critical limb ischemia in whom revascularization procedure is inadequate or proved to be unsuccessful. According to a Cochrane analysis (CD006544) prostanoids differ in their effects on rest-pain relief and ulcer healing.

OBJECTIVES

To study the efficacy and safety of prostanoids for critical limb ischemia.

METHODS

Systematic literature search and meta-analysis (mixed treatment comparison) was performed.

RESULTS

Seven randomized controlled trials including 964 patients were analyzed. Compared to placebo, both alprostadil (OR: 3.2 95% CI: 1.7-5.5 and OR: 1.8 95% CI: 0.6-4.3) and iloprost (OR: 2.7 95% CI: 1.7-4.2 and OR: 2.5 95% CI: 1.0-5.4) were more efficacious with regard to rest-pain relief and ulcer healing and the difference between the two prostanoids was not significant (OR: 1.2 95% CI: 0.7-1.9 and OR: 0.74 95% CI: 0.3-1.5). Adverse events occurred significantly more often with both drugs compared to placebo, however, they were less frequent with alprostadil than with iloprost (OR 0.2 95% CI: 0.1-0.3).

CONCLUSIONS

Prostanoids have favorable effect on rest-pain relief and ulcer healing in critical limb ischemia, without statistically significant difference between the two available drugs. The Cochrane study (CD006544) reported mistaken results due to defaults in the analysis.

[Health related quality of life and disease burden of patients with schizophrenia in Hungary]

INTRODUCTION

According to the international literature disease burden of schizophrenia is substantial, however data from Eastern Central Europe is scarce. Our aim was to assess the quality of life and costs of patients with schizophrenia in Hungary.

METHODS

A cross sectional questionnaire survey was performed in 3 hospital based psychiatry centres involving patients with schizophrenia. Demographics, disease severity (Clinical Global Impression, CGI), functional ability (Global Assessment of Functioning, GAF) and general health status (EQ-5D) was assessed. Health care utilisation and aids were surveyed for the past 12 months. Costing was performed from the societal perspective and human capital approach was applied.

RESULTS

Altogether 78 patients (female 43.6%) were involved with a mean age of 44.2 (SD=13.1) years, disease duration was >10 years at 49 (62.8%) cases, 66 (84.6%) patients were disability pensioners. Distribution between CGI 3-4-5-6 levels were 12 (16%), 33 (43%), 21 (28%), 10 (13%) patients, respectively, mean GAF was 52.6 (SD=13.9). The average EQ-5D score was 0.64 (SD=0.3) and it was significantly worse than the age-matched general population's score in Hungary (p < 0.01). Mean yearly cost was 13 878 Euros/patient (conversion 1 Euro=280.6 HUF), the rate of direct medical,direct non-medical and indirect costs was 28.5%, 5.4% and 66.1%, respectively. Among direct costs hospitalisation and drug costs were dominant. Total cost correlates with disease severity (CGI).

CONCLUSION

Schizophrenia leads to notable deterioration in health related quality of life and induce high costs to society, mainly due to the productivity loss of the patients. Nevertheless disease related costs in Hungary are lower than in economically more developed European countries. Our study offers basic data about disease burden of schizophrenia in Hungary to support clinical and health policy decision making.

The economic impact of dementia in Europe in 2008-cost estimates from the Eurocode project

OBJECTIVE

Care for demented people is very resource demanding, the prevalence is increasing and there is so far no cure. Cost of illness (CoI) studies are important by identifying the distribution of costs between different payers of care. The European Union (EU) funded the European Collaboration on Dementia (Eurocode) as part of the EU's 2005 work plan of the Community public health programme. Eurocode was administered by Alzheimer Europe. The aim was to describe the economic impact of dementia in Europe in 2008.

METHODS

Eurocode's new estimates for dementia prevalence were included in a cost model based on published European CoI papers. For countries where no CoI figures were available, imputation was used.

RESULTS

The total CoI of dementia in the EU27 in 2008 was estimated to be €160 billion (€22 000 per demented per year), of which 56% were costs of informal care. The corresponding costs for the whole Europe was €177 billion. In northern Europe, the direct costs are estimated to be considerabe, while the cost of informal care is the major cost component in southern Europe. The sensitivity analysis showed a range for total EU27 costs between €111 and 168 billion.

CONCLUSIONS

The estimated CoI in this study is higher than in previous studies. There are also large differences in different European regions. Notwithstanding the methodological challenges, the societal costs of dementia in Europe are very high which in turn have substantial resource impacts on the social and health care systems in Europe.

Disease burden of psoriatic arthritis compared to rheumatoid arthritis, Hungarian experiment

The objectives of this study were to assess the costs of psoriatic arthritis (PsA) in Hungary and to identify key cost drivers among demographic and clinical variables and to compare cost-of-illness of PsA and rheumatoid arthritis (RA). Cross-sectional retrospective survey of 183 consecutive patients from eight rheumatology centres was conducted. Mean direct medical, direct non medical, indirect and total costs were 1,876, 794, 2,904 and 5,574 euros/patient/year, respectively. Total costs were in significant linear relationship with health assessment questionnaire score and psoriatic area severity index. Costs of RA were higher in all domains than of PsA. Our study was the first from the Eastern European region that provides cost-of-illness data on PsA. Our study revealed that functional status and severity of skin symptoms were the key cost drivers. The costs of PsA in Hungary were lower than in the high-income European countries.

Costs of dementia in Hungary

OBJECTIVE

The main aim of this paper is to give an overview on the quality of life, health care utilisation and costs of dementia in Hungary.

METHOD

A cross-sectional non-population based study of 88 consecutive dementia patients and their caregivers was conducted in three GP practices and one outpatient setting in 2008. Resource Utilization in Dementia (RUD), Mini Mental State Examination (MMSE) and quality of life (EQ-5D) were surveyed and cost calculations were performed. Costs of patients living at home were estimated by the current bottom-up cost-of-illness calculations, while costs of nursing home patients were considered by official reimbursement to determine the disease burden from a societal viewpoint.

RESULTS

The mean age of the patients was 77.4 years (SD=9.2), 59% of them were female. The mean MMSE score was 16.70 (SD=7.24), and the mean EQ-5D score was 0.40 (SD=0.34). The average annual cost of dementia was 6,432 Euros per patient living at home and 6,086 Euros per patient living in nursing homes. For the whole demented population (based on EuroCoDe data) we estimated total annual costs of 846.8 million Euros; of which 55% are direct costs, 9% indirect costs and 36% informal care cost. Compared to acute myocardial infarction the total disease burden of dementia is 26.3 times greater.

CONCLUSIONS

This is the first study investigating resource utilisation, costs, and quality of life of dementia patients in the Central and Eastern European region. Compared to the general population of Hungary EQ-5D values of the demented patients are lower in all age groups. Dementia related costs are much lower in Hungary compared to Western European countries. There is no remarkable difference between the costs of demented patients living at home and in nursing homes, from the societal point of view.

Comparison of the Psoriatic Arthritis Quality of Life (PsAQoL) questionnaire, the functional status (HAQ) and utility (EQ-5D) measures in psoriatic arthritis: results from a cross-sectional survey

OBJECTIVES

To compare the Psoriatic Arthritis Quality of Life (PsAQoL) instrument, the Health Assessment Questionnaire (HAQ) as a measure of functional status, and the generic health status (utility) measure the EuroQoL (EQ-5D) in terms of ability to assess disease severity in psoriatic arthritis (PsA).

METHODS

The differences between known groups and correlations of the PsAQoL, the HAQ and the EQ-5D with clinical measures were analysed in a sample of 183 PsA patients.

RESULTS

Different severities of PsA determined by known groups were distinguished well by all three questionnaires; more severe disease was associated with significantly worse values of the instruments. The correlations revealed a strong relationship between each of the measures, and with the patients' pain on the visual analogue scale (VAS), the patient global VAS, and the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), and a weak relationship with the disease duration and the Psoriasis Area Severity Index (PASI). The PsAQoL also correlated strongly with the 28-joint Disease Activity Score (DAS28).

CONCLUSIONS

The PsAQoL, the HAQ, and the EQ-5D are able to distinguish well across levels of PsA severity.

Cost-of-illness of patients with systemic sclerosis in a tertiary care centre

OBJECTIVE

The aim of our study was to assess the costs of SSc and to analyse cost drivers.

METHODS

A cross-sectional survey of consecutive patients with SSc was performed in a rheumatology centre in Hungary. Clinical characteristics, the European Scleroderma Study Group activity index, disease severity scale (DSS), scleroderma HAQ (S-HAQ) and health care utilization were recorded. Cost calculation was performed and correlation with clinical variables was analysed. Results were compared with RA and PsA.

RESULTS

Eighty patients were involved: 72 (90%) women, mean age (s.d.) 57.4 (9.6) years and disease duration of 6.2 (6.6) years and 25% of the cases had dcSSc. Mean total cost was 9619 (s.d. 6444) euros/patient/year with rate of indirect cost being 56%. Disability-related productivity loss (55.2%) and hospitalization (28.3%) were the highest among the cost items. Patients with dcSSc had significantly higher direct costs (P = 0.005) compared with the lcSSc subset. Disease activity showed significant correlation with total costs, DSS and S-HAQ with direct costs. SSc-related costs were higher than in matched RA and PsA cases.

CONCLUSIONS

The cost-of-illness of SSc is high with a dominance of productivity loss related costs. Moreover, the disease activity is an important cost driver.

[Epidemiology of dementia in Hungary]

OBJECTIVE

To estimate the epidemiology and the distribution of disease severity of dementia in Hungary, using published data. To estimate the demented population of 2008 and to make a projection for 2050.

METHODOLOGY

With an outlook for the international professional literature and the available Hungarian information we examine the epidemiology of dementia in Hungary by age-groups and disease severity (according to MMSE categories), then make our estimation for the entire population.

RESULTS

Based on the estimation of the number of demented people in Hungary there is a noticeable difference between the domestic and the internationally published data. According to previous Hungarian studies, the number of the demented subjects vary between 530 and 917 thousand patients. Multiplying the elderly age-group's populations by the global prevalence data it results in 101 thousand of demented patients. Estimation by the domestic published data we remarkably overestimate the presumed value, whereas by using the global prevalence figures we underestimate.

CONCLUSIONS

There is a strong need for a representative study to obtain exact figures on the prevalence of dementia in Hungary. Getting exact figures of the Hungarian prevalence of dementia it is a strong need an overall representative study. With the lack of it the health and social care systems are not able to prepare for providing the increasing number of patients.

The disease burden of colorectal cancer in Hungary

The aim of the paper is to give an overview of the epidemiology, treatment pattern and quality, as well as policy issues and disease burden of colorectal cancer (CRC) in Hungary. Colorectal cancer is the second most common cause of cancer-related death in both males and females in Hungary. The Hungarian Cancer Registry collects data on the epidemiological characteristics of CRC. Two pilot programmes (1997/1998 and 2003/2004) were conducted for population-based screening of CRC using both immunological and guaiac faecal occult blood testing (FOBT). The National Health Insurance Fund Administration (NHIFA) spends altogether <euro> 38.9 million a year on the treatment of CRC. It is hoped that the introduction of an accepted and cost-effective screening programme for CRC can reduce the high CRC burden in Hungary.

Impact of disease progression on health status, quality of life and costs in rheumatoid arthritis in Hungary

A rheumatoid arthritis (RA) krónikus, progresszív, szimmetrikus sokízületi gyulladás. A betegek hosszú távú gondozásához és a költséghatékonysági modellekhez alapvető ismerni és standardizáltan mérni a betegség lefolyását és annak következményeit. Célkitűzés: A betegségprogresszió és az egészségi állapot, életminőség és költségek kapcsolatainak vizsgálata magyarországi RA-s betegeken. Módszer: 2004. április–augusztus között keresztmetszeti kérdőíves vizsgálatot végeztek RA-s betegek bevonásával hat fekvőbeteg-osztályos háttérrel rendelkező járóbeteg-szakambulancián. Standardizált kérdőívekkel vizsgálták a betegség progresszióját kifejező funkcionális állapotot (HAQ), az egészségi állapotot (EQ-5D), a betegségspecifikus életminőséget (RAQoL), felmérték a betegségaktivitást (DAS) és a betegséggel összefüggő költségeket, elemezték e paraméterek kapcsolatát. Eredmények: 255 beteg adatait elemezték [átlagos életkor: 55,5 ± 12,3 év; a betegség fennállása: 9,0 ± 9,3 év; HAQ: 1,38 ± 0,76; EQ-5D: 0,46 ± 0,33; RAQoL: 16,2 ± 8,1; DAS: 5,09 ± 1,42; költség: 1 043 163 (± 844 750) Ft/beteg/év]. Szignifikáns korrelációt találtak az összes esetben ( p < 0,01), függvénykapcsolat volt kimutatható: EQ-5D index = 1,014–0,25 × HAQ–0,041 × DAS és HAQ = 0,314 + 0,065 × RAQoL. Betegségsúlyossági csoportonként (0,5 HAQ-léptékkel) vizsgálva, az egészségi állapot átlaga rosszabbodott (EQ-5D: 0,784; 0,576; 0,504; 0,367; 0,211; 0,022), és az átlagos költség emelkedett (628 280; 888 187; 953 759; 1 291 218; 1 346 112; 1 371 674 Ft/beteg/év) a betegség előrehaladásával. Minimális klinikailag szignifikáns funkciócsökkenés (0,25 HAQ-változás) 0,0705 EQ-5D-csökkenésnek és 1,884 RAQoL-emelkedésnek felelt meg, nem súlyosan aktív (DAS < 5,1) esetekben kisebb a változás (EQ-5D: 0,05725). Következtetések: A betegségprogresszió és az általános egészségi állapot, életminőség és a költségek kapcsolata nem tér el jelentősen a nemzetközi eredményektől. A betegségköltségek nagysága azonban jelentősen kisebb Magyarországon, mint a fejlett országokban. A vizsgálat adatokkal szolgál a hazai egészség-gazdaságtani elemzésekhez.

Epidemiology of osteoporosis related fractures in Hungary from the nationwide health insurance database, 1999-2003

The Hungarian national health insurance database was screened for fractures of patients aged 50-100, 1999-2003. On average, there were 343 hip, 1,579 forearm, 342 proximal humerus, 48 inpatient vertebral and 2,459 other fractures/100,000 inhabitants/year.

INTRODUCTION

The incidence of fractures differs among populations. Our aim was to study the incidence of fractures in Hungary, focusing on classical osteoporotic sites and to compare the results with those of other European countries.

METHODS

The Hungarian National Health Insurance Fund database, covering 100% of the population, was screened for fractures of patients aged 50-100, 1999-2003. The search of vertebral fractures was restricted to those admitted to hospital. A gender and age-matched comparison was performed with available data from Europe.

RESULTS

There were mean 343 hip, 1,579 forearm, 342 proximal humerus, 48 inpatient vertebral and 2,459 other fractures/100,000 inhabitants/year; the female/male ratio was between 1.2-2.4. Multiple fractures occurred in 23.1% of the cases. Hip fracture incidence in Hungary lies between the rates of northern and southern countries of Europe.

CONCLUSIONS

Our study offers nationwide epidemiological data on fractures in Hungary. The incidence of fractures increased by age, regardless of the type of fracture. Incidence of hip fractures in Hungary fits in the previously established geographic trends in Europe. Our results fulfil a need for fracture data from Central Europe.

Rituximab in patients with rheumatoid arthritis: systematic review

A rheumatoid arthritis terápiájában legújabban alkalmazott gyógyszerek a biológiai szerek. Legutóbb a B-lymphocyta-gátló rituximabot törzskönyvezték rheumatoid arthritis indikációjában. A rituximabot eddig a non-Hodgkin-lymphoma kezelésében alkalmazták. Európai és a magyar reumatológusok ajánlása szerint a rituximab rheumatoid arthritisben azoknak a betegeknek javasolható, akiknél a kórtörténetben eredménytelenség vagy toxicitás miatt sikertelen TNF-α-gátló kezelés szerepel. Célkitűzés: A rituximabkezelés klinikai hatásosságáról rheumatoid arthritisben rendelkezésre álló szakirodalom áttekintése. A rituximabkezelés hatásosságának és biztonságának értékelése. Módszer: A szerzők a MEDLINE- és Cochrane-adatbázisokban megkeresték az összes randomizált, kontrollált rituximabvizsgálatot rheumatoid arthritisben. Elvégezték az adatok metaanalízisét. Eredmények: Az irodalomkeresés során 3 randomizált kontrollált klinikai vizsgálatot azonosítottak a szerzők, amelyekben összesen 1145 beteget követtek. A TNF-α-gátló kezelésre nem reagáló, súlyos gyulladásos tüneteket mutató betegeknél rituximabkezelés mellett 33%-kal több betegnek (95%; KI: 25–41%) javulnak a tünetei az American College of Rheumatology 20 kritérium szerint, mint ha nem kezelnék őket. Majdnem 5-ször nagyobb (relatív kockázat = 4,77; 95%; KI, 3,12–7,31) esélyük van a javulásra, mint kezelés nélkül. A funkcionális állapotot jelző Health Assessment Questionnaire pontszám is szignifikánsan nagyobb mértékben ( p < 0,001) javult a rituximabcsoportban (–0,4 pont), mint a kontrollcsoportban (–0,1 pont). Rituximabkezelés hatására a mérsékelt vagy jó választ adó betegek aránya 38%-kal nagyobb (95% KI, 32–44%) a rituximabkezelési ágon, mint a kontrollcsoportban, a különbség szignifikáns ( p < 0,00001). A rituximab a radiológiai progressziót is javítja a TNF-α-gátló kezelésre nem reagáló betegek között. Következtetések: A rituximab új, hatásos terápiás lehetőség a rheumatoid arthritis terápiájában. A TNF-α-gátló kezelésre nem reagáló vagy azt nem toleráló betegeknél is javulás érhető el.

[Health care costs of acute myocardial infarction in Hungary, 2003-2005]

BACKGROUND

The morbidity of acute myocardial infarction (AMI) is remarkable in Hungary, therefore understanding the disease burden more accurately is inevitable.

AIM

We assessed the hospitalized AMI patient's burden on the financer both in active and chronic hospital care as well as outpatient visits and we estimated the size of indirect social costs.

METHODS

We assessed the active and chronic hospital care costs of 'new' AMI patients having the event in May 2003. The costs were assessed in the subsequent 12 and 24 months to the event in the population over 25 with the morbidity from the database of the National Health Insurance Fund Administration (NHIFA). Data were collected by gender and age (age groups 25-44, 45-64, 65 and over). Costs of GPs, specialist visits, transportation and productivity losses were taken into account as other costs.

RESULTS

Average health insurance costs of AMI's active hospital care in the first 12 months are generally higher in females as in males; 476.3 thousand HUF vs 391.1 thousand HUF (65 and over), 429.1 thousand HUF vs 389.4 thousand HUF (45-64) and 229.5 thousand HUF vs 240.6 thousand HUF (25-44). The burden in the chronic care is 15-40 thousand HUF per patient in the first year, which is similar to the active care costs in the 13-24th months after the AMI (22-54 thousand HUF).

CONCLUSION

NHIFA was estimated to spend 4.4 billion HUF on direct health care on behalf of the nearly 12 thousand annual AMI patients in the first 12 months, 3.6 billion HUF on the active and 370 million on the chronic hospital care. Avoiding one AMI could save 345-565 thousand HUF (depending on gender and age) direct health care cost in the first 12 months. In our estimation the annual indirect costs of AMI exceed 840 million HUF (177 829 HUF/patient) in the working age group.

[Mortality of hospitalized stroke patients in Hungary; 2003-2005]

The aim of our research was to assess the incidence and the 12- and 24-month mortality of hospitalized stroke in Hungary. We analyzed the rate of mortality after stroke and compared it to the standard mortality rate of the population. To assess the incidence we extracted the data of "new" stroke patients (ICD-10 diagnoses: 160-64) hospitalized in May 2003 from the database of the National Health Insurance Fund Administration. We regarded those as "new" patients who had not been treated with these primary or secondary diagnoses in the previous 24 months. Data were collected by sex and age (age groups: 25-44, 45-64, 65 and over). We analyzed the patients' survival on the basis of their April 2004 and April 2005 data. The incidence of the "new" hospitalized stroke patients was higher in men than in women; the incidence in the age group of 65 and over was 2112/100.000 in males and 1582/100.000 in females, the corresponding values in the 45-64 age group were 623 vs. 366 per 100.000, respectively. In 2003 more than 42 thousand "new" stroke patients were hospitalized in Hungary of whom over 10 thousand died in the first year, followed by a further 2 thousand in the second year. Women's survival is more favourable than men's: in the first year it is 71.47% vs. 69.24% (65+ group), and 88.18% vs. 83.16% (45-64 group); in the second year the corresponding values are 66.95% vs. 61.62% (65+), and 85.45% vs. 80.90% (45-64), respectively. The risk of death in the first year after stroke, compared to the standard population, is 5.17-fold in women and 4.70-fold in men in the total sample, and 10-15-fold in the 45-64 group. There are large differences by gender, particularly in men of the working age groups (25-44, 45-64), whose mortality is twice as high as that of women of the same age.

[Social insurance costs of hospital treatment of stroke in Hungary, 2003-2005]

Our aim was to assess the social insurance costs of hospital treatments for acute stroke in Hungary between 2003 and 2005. We studied how much burden stroke patients impose on the financer (National Health Insurance Fund Administration) in acute and chronic hospital admissions. We extracted the data of "new" stroke patients (ICD-10: 160-64 diagnosis) hospitalized in May 2003 from the database of the financer. We analyzed active and chronic hospital treatment costs of these patients in the period of 12 months before the stroke and in the following first and second 12 months. Data were collected by sex and age (age groups: 25-44, 45-64, over 65). We studied patients hospitalized in May 2003 with the ICD-10: 160-64 main diagnosis but not being treated with the same diagnosis in the previous 24 months. In the first 12 months of the active care the burden of the disease was (male vs. female) 65+: 254.6 vs. 205.8; 45-64: 341.4 vs. 280.5; 25-44: 370.1 vs. 306.1 thousand HUF per patient. In the second 12 months the costs were 50.6 vs. 36.2; 24.2 vs. 32.6; 27.6 vs. 24.8 thousand HUF respectively. In the first year following the episode the costs of the chronic hospital treatment were (age groups as above) 23.3 vs. 31.3; 28.9 vs. 22.2; 22.8 vs. 22.5 thousand HUF A year later the chronic hospital costs were 9.0 vs. 10.9; 6.7 vs. 12.2; 1.4 vs. 38.1 thousand HUF respectively. Average costs of stroke are higher in the case of males as are in the case of females, 364.8 vs. 303.0 thousand HUF in the first 24 months. The remarkable difference results from active hospital treatment costs (331.5 vs. 262.1 thousand HUF), while the discrepancy is smaller in the chronic hospital care (33.3 vs. 40.9 thousand HUF).

The efficacy of indapamid in different cardiovascular outcome – Meta-analysis

Bevezetés: Az első vonalba tartozó vérnyomáscsökkentőktől elvárható, hogy csökkentsék a cardiovascularis morbiditást és mortalitást. A thiazid vízhajtók ez irányú hatékonyságát több metaanalízisben leírták. Az indapamid hatásosságát bár számos tanulmány vizsgálja, eddig nem készült az összes adatot összefoglaló elemzés. Célkitűzés: az indapamid hatásosságát vizsgáló összes randomizált kontrollált vizsgálat adatainak szintézise. A tanulmányok eredményeit a különböző cardiovascularis és biztonsági végpontok szerint elemezzük. Módszer: A MEDLINE adatbázisban megkerestük az összes randomizált kontrollált indapamidvizsgálatot 1995 és 2005 között. Csak a kettős vak-, párhuzamos lebonyolítású vizsgálatokat vontuk be. Az adatok metaanalízisét állandó és véletlen hatású modellekben is elvégeztük, az eredményeket Mantel–Haenzel-próbával, inverz varianciapróbával teszteltük. Eredmények: 9 vizsgálat és 10 108 beteg adatait elemeztük. 48, stroke-on átesett beteg indapamidkezelésével megelőzhető egy újabb stroke-esemény (NNT = 47,8; 95%; KI: 29,6–126,6). 5 vizsgálatban 7085 beteg adatai alapján az indapamid a szisztolés vérnyomást 7,28 (95%; KI: 6,37–8,19), a diasztolés vérnyomást 3,50 Hgmm-rel (95%; KI 2,99–4,01) nagyobb mértékben csökkentette, mint a placebo. 5 vizsgálatban 2856 beteg szisztolés vérnyomását az indapamid 1,30 Hgmm-rel (95%; KI: 0,28–2,31) nagyobb mértékben csökkentette, mint az aktív kontroll, a diasztolés vérnyomáscsökkentés esetében nem volt szignifikáns különbség. 505 beteg adatai alapján az indapamid 6,50 g/m 2 -rel (95%; KI: 0,81–12,9) nagyobb mértékben csökkenti a bal kamrai izomtömegindexet, mint az enalapril. 6206 beteg követése során a gyógyszerhez köthető mellékhatások előfordulásának gyakorisága hasonló a placebóéhoz (rr = 0,97; 95%; KI: 0,76–1,22). Következtetések: Az indapamid hatásos az újabb stroke megelőzésében, hatékonyan csökkenti a vérnyomást és a bal kamrai izomtömegindexet. A kezelés biztonságosan alkalmazható.

The time for cost-effectiveness in the new European Union member states: the development and role of health economics and technology assessment in the mirror of the Hungarian experience

Sophisticated methodology and research centres of health economics and health technology assessment were established in the developed countries over the past 30 years, releasing more and more studies of better and better quality every year. A crucial factor in health policy and reimbursement decisions in these countries is cost-effectiveness results. Due to methodological diversification, results of locally performed health economics studies are constrained in international utility. This fact encourages us to set the current goal of greatest importance, i.e. to standardise country-specific methods, thereby promoting transferability and adaptability of results, being backed by each important health care organisation all over Europe. The situation in the new member states [European Union (EU)12] is profoundly different compared with EU15. In these countries, neither the necessary research institutions nor professionals are in place in sufficient numbers; even in most EU12 countries, the importance of cost-effectiveness has not yet been realised. The present study focuses mainly on the EU12. These countries are absolutely dependent on cost-effectiveness results from abroad, and this seems to persist in the long-term. Transferability and adaptability of the results of health economics studies carried out elsewhere through European collaboration is vital for these countries.

[The role of biological agents in the treatment of psoriatic arthritis, literature review]

INTRODUCTION

The recognition of the key pathogenetic role of TNF-alpha in psoriatic arthritis has made it possible to introduce new drugs in the treatment. TNF-alpha inhibitors available in Hungary (infliximab, etanercept, adalimumab) are potential therapies for patients who have not adequately responded to traditional disease-modifying antirheumatic drugs.

OBJECTIVE

The aim of the study was to present the epidemiology and progression of psoriatic arthritis in Hungary based on national and international data, to assess the target population for biological therapy and to analyze their effectiveness, reviewing the available literature of randomized controlled trials.

METHODS

The prevalence of psoriatic arthritis in Hungary was estimated using international data. Characteristics of psoriatic arthritis population were studied using the database of a rheumatology ward. A systematic literature search was performed to identify each relevant trial. A synthesis and comparison of the results from the 5 identified trials was performed and the average effect of biological agents was calculated. Both the fixed and the random effect model were used for the data synthesis; the results were probed with Mantel-Haenzel test.

RESULTS

The prevalence of psoriatic arthritis is about 10.000-20.000 in Hungary. Average disease-duration was 10 years in the sample (n = 189), the most frequent was polyarticular form (51%). Regarding functional status the mean HAQ score was 1.46, with an average progression of 0.05 points/year. The trial data confirmed that biological agents are superior to placebo in improving symptoms (achieving ACR20); risk difference between biological treatments and placebo is 47% (RD = 0.47, 95% CI: 0.42-0.53). The biological treatment of 2 patients improves the status of 1 patient (NNT = 2.1 95% CI 1.9-2.4). There is no significant difference in efficacy between the three biological agents.

CONCLUSIONS

TNF-alpha inhibitors are effective treatments of psoriatic arthritis and are safe under strict medical control. The principles of indications, contraindications, administration and control have been worked out by the Rheumatology and Physical Medicine Board.

[The effectiveness of carvedilol in heart failure]

BACKGROUND

The third generation beta-blocker (carvedilol) is effective in reduction of hypertension, and of mortality and morbidity as a supplement to conventional drugs of heart failure therapies (diuretics, ACE inhibitors), based on randomized controlled trials and retrospective analysis.

OBJECTIVE

To analyse the efficacy of carvedilol in the treatment of heart failure with special focused on morbidity, mortality endpoints.

METHODS

We assessed the multicenter, randomised, double-blind studies involving more than 150 patients (1995-2005) from MEDLINE database, in which carvedilol was used in the case of moderate to severe heart failure. We also present the results of health-economic publications (2000-2005).

RESULTS

In U.S. Carvedilol Heart Failure Study (n 1096) the mortality declined by 65% (3.2% vs. 7.8%; p <0.001) with carvedilol vs. placebo, while the cardiovascular hospitalization decline was 27% (14.1% vs. 19.6%; p = 0.036) in heart failure (LVEF < or = 5%) applied together with the basic therapy (diuretic and ACE-inhibitor). In the COPERNICUS trial the efficacy of carvedilol was compared to placebo in the case of severe HF patients (LVEF < 25%, n = 2889). The annual mortality risk declined by 35% (19.7% vs. 12.8%, 95% CI 19-48%, p = 0.00013) while the risk of mortality or any risk of hospitalisation by 24% (p = 0.00004) in the active group. The CAPRICORN study (LVEF < or = 0%, n=1959) showed that carvedilol is efficacious in reduction of total (HR: 0.77; 95% CI 0.60-0.98; p = 0.031) and cardiovascular mortality (HR: 0.75; 95% CI 0.58-0.96; p = 0.024) as far as high-risk patients are concerned.

CONCLUSION

The effectiveness of carvedilol is certified in reduction of mortality and hospitalization in the treatment of moderate-severe heart-failure as part of the combination therapy. The benefits of use of the drug are well measurable not only on the level of patients but on the suppliers and the financer as well, thanks to the decline of resource utilization.

[The role of biologic agents in the therapy of ankylosing spondylitis]

Ankylosing spondylitis is a chronic, inflammatory rheumatic disease which etiology and pathogenesis are not yet fully understood. The inflammation involves the spine and also the peripheral joints might be affected in some cases resulting in a progressive ankylosis, restricted mobility, significant disability, loss of productivity and decreased quality of life. Gene technology based new drugs of the past decade, the biologic agents, offer an alternative opportunity for the treatment of ankylosing spondylitis in comparison with the previous drugs with doubtful efficiency. In Hungary infliximab and etanercept has been registered for ankylosing spondylitis. The aim of this study was to evaluate the efficacy of infliximab and etanercept by the available randomised controlled trials. A systematic search of the literature was performed from 01. 01. 2000 to 08. 31. 2005. and the relevant publications were analysed following the concepts of evidence based medicine. 7 double blind, randomised, placebo controlled trials were identified, three for infliximab (n = 389) and four for etanercept (n = 431). Although the inclusion criteria, the duration of the trials and the primary endpoints were different, the results confirm that both drugs significantly decrease symptoms and disease activity, and this effect is sustained during the therapy, nevertheless half of the patients did not achieve the standardised criteria of 50% decrease in disease activity. Both agents are well tolerated by patients. The outcomes of long-term therapy are reassuring by open extension studies of three years. Guidelines for biologic therapy has been developed in Hungary determining the target patient group, the conditions of the therapy and also an arthritis centre network has been established. Though individual admission is feasible, biologic drugs are not under reimbursement in Hungary. High drug costs makes the implementation of this new therapeutic opportunity difficult in the daily medical practice.

[The role of biological drugs in the treatment of psoriasis, results from 9 randomized placebo-controlled trials]

BACKGROUND

Recognition the key role of TNF-alpha in the pathogenesis of psoriasis makes possible to use new and efficacious drugs in the treatment. In the years past more trials were published, which are examining the efficacy of different biological drugs. There is no analysis which is including all the trials with biological drugs.

OBJECTIVE

The authors compared the efficacy of biological drugs - efalizumab, etanercept, infliximab - in the treatment of psoriasis. The evidences on effect of biological drugs were synthesized. The safety of drugs also was examined.

METHODS

The authors searched the MEDLINE database for all trials with TNF-alpha in the treatment of psoriasis. The authors conducted a meta-analysis with the results of trials. The random effect model were used for the data synthesis, the results were probed with Mantel-Haenszel test.

RESULTS

Data were combined from 13 trials included 4165 patients. All the three examined biological drugs are significantly superior to placebo treatment in improving the symptoms of psoriasis. Data from 3 trials included 1242 patients prove, that using 1 mg/kg etanercept the proportion of patients whom skin response improved at least 75% is greater with 25% than using placebo (RD = 0.25 95% Cl 0.21-0.29). Data from 5 trials included 995 patients show, that using 2 x 25 mg etanercept the proportion of patients whom skin response improved at least 75% is greater with 29% than using placebo (RD = 0.29 95% Cl 0.24-0.33). Data from 5 trials included 759 patients prove, that using 5 mg/kg infliximab the proportion of patients whom skin response improved at least 75% is greater with 73% than using placebo (RD = 0.73 95% Cl 0.68-0.78). Biological treatment of 3 patients improves 1 patient's skin-symptoms at least with 75% (NNT = 2.7 95% Cl 2.6-2.9).

CONCLUSIONS

According to the available data the TNF-alpha inhibitors are effective in improving the symptoms of psoriasis non-responding to the conventional treatment. After the meta-analysis of data infliximab seems to be the most effective biological treatment.