Intraindividual Comparisons to Determine Comparative Effectiveness: Their Relevance for G-BA's Health Technology Assessments

OBJECTIVES

Health technology assessments (HTA) rely on head-to-head comparisons. We searched for intraindividual comparisons (IIC) qualifying as head-to-head design to develop comparative evidence.

METHODS

Gemeinsamer Bundesausschuss (G-BA) appraisals between January 2011 and April 2020 were reviewed for inclusion of IIC. Identified IIC were grouped according to disease characteristics into nonprogressive, progressive, irregular, or symmetrical conditions. Evaluation of IIC by Institut für Qualität und Wirschaftlichkeit im Gesundheitswesen (IQWIG) and acceptance of IIC by G-BA were determined, and criteria for the usage and quality of IIC were developed.

RESULTS

A total of 483 appraisals finalized between January 2011 and April 2020 were reviewed. Eleven appraisals included IIC: nonacog beta (hemophilia B), turoctocog alpha (hemophilia A), emicizumab (2 appraisals: hemophilia A), pasireotide (unresectable pituitary tumor), lomitapid (homozygous familial hypercholesterolemia), glycerol phenylbutyrate (2 appraisals: urea cycle disorders), asfotase alfa (hypophosphatasia), lumacaftor (cystic fibrosis), and larotrectinib (NTRK⁺ solid tumors). All those appraisals related to rare genetic conditions with hemophilia and its bleeding rate are considered mainly a nonprogressive condition. All the other diseases show progressive disease characteristics. None of the identified IIC has been accepted by G-BA. Inconsistencies of before/after study design, lack of clarity on treatments prior to the switch, and different time intervals were among the most commonly cited methodological concerns.

CONCLUSIONS

IICs provide a rare opportunity to determine comparative effectiveness in distinct clinical settings that are not suitable or difficult to randomize into parallel groups. While manufacturers and researchers should aim for highest methodological standards when running an IIC, HTA bodies should accept IIC in distinct settings when determining relative effectiveness.

Type I Diabetes is the Main Cost Driver in Autoimmune Polyendocrinopathy

CONTEXT

Autoimmune polyendocrinopathy (AP), a chronic complex orphan disease, encompasses at least two autoimmune-induced endocrine diseases.

OBJECTIVE

To estimate for the first time total, indirect and direct costs for patients with AP, as well as cost drivers.

DESIGN

Cross-sectional cost of illness study.

SETTING

Academic tertiary referral center for AP.

PATIENTS

146 consecutive, unselected AP patients.

INTERVENTION

Interviews pertaining to patients' socioeconomic situation covered a recall period of 12 months. Both the human capital (HCA) and the friction cost approaches (FCAs) were applied as estimation methods.

MAIN OUTCOME MEASURES

Direct and indirect annual costs, and sick leave and medication costs.

RESULTS

AP markedly impacts healthcare expenses. Mean overall costs of AP in Germany ranged from €5 971 090 to €29 848 187 per year (HCA). Mean indirect costs ranged from €3 388 284 to €16 937 298 per year (HCA) while mean direct costs ranged from €2 582 247 to €12 908 095/year. Mean direct costs per year were €1851 in AP patients with type 1 diabetes (T1D, 76%) and €671 without T1D, which amounts to additional direct costs of €1209 for T1D when adjusting for concomitant autoimmune disease (95% CI = €1026-1393, P < 0.0001). Sick leave cost estimates for AP patients with T1D exceeded those without T1D by 70% (FCA) and 43% (HCA), respectively. In multiple regression analyses, T1D predicted total and direct costs, medication costs and costs for diabetic devices (all P < 0.001). Overall, AP patients with T1D were 54% (FCA) more expensive than those without T1D.

CONCLUSIONS

Public health socioeconomic relevance of AP was demonstrated, with T1D as main cost driver.

Pregnancy Related Health Care Needs in Refugees-A Current Three Center Experience in Europe

Background: Immigration into Europe has reached an all-time high. Provision of coordinated healthcare, especially to refugee women that are at increased risk for adverse pregnancy outcomes, is a challenge for receiving health care systems. Methods: We assessed pregnancy rates and associated primary healthcare needs in three refugee cohorts in Northern Germany during the current crisis. Results: Out of n = 2911 refugees, 18.0% were women of reproductive age, and 9.1% of these were pregnant. Pregnancy was associated with a significant, 3.7-fold increase in primary health care utilization. Language barrier and cultural customs impeded healthcare to some refugee pregnant women. The most common complaints were demand for pregnancy checkup without specific symptoms (48.6%), followed by abdominal pain or urinary tract infections (in 11.4% of cases each). In 4.2% of pregnancies, severe complications such as syphilis or suicide attempts occurred. Discussion: We present data on pregnancy rates and pregnancy associated medical need in three current refugee cohorts upon arrival in Germany. Healthcare providers should be particularly aware of the requirements of pregnant migrants and should adapt primary caretaking strategies accordingly.

[Instruments for Measuring the Effects of Early Intervention on Maintaining and Restoring Ability to Work in Germany: Opinion of an Interdisciplinary Working Group]

OBJECTIVE

In projects on early intervention, a wide variety of instruments is used for the measurement of intervention effects on preservation or restoration of ability to work. The aim of the present work was to propose an appropriate instrument or a range of appropriate instruments that enable diverse interventional approaches to be compared, and data quality to be improved.

METHODS

A systematic literature search was conducted to map the currently existing measuring instruments. In addition, based on structured interviews with leaders of existing early intervention projects or representatives of other interventional approaches, knowledge and application of the measuring instruments in Germany were determined. In the context of a working meeting, a recommendation was formulated based on the results of the literature search and interviews.

RESULTS AND COMMENTS

There is currently no instrument that could be recommended without reservation for the stated purpose. Based on the results of the literature search and the interviews, the working group recommends using, as a first step, the Work Ability Index (WAI, focus on work ability) and the Work Productivity and Activity Impairment Questionnaire (WPAI, focus on absenteeism and presenteeism). German-language versions of both questionnaires are freely available and offer a good compromise in terms of psychometric quality criteria, as well as of practicality and applicability. The measuring instruments should be developed further, with the goal of establishing an optimized instrument that combines the strengths of the two instruments.

CONCLUSION

In Germany, use of WAI and the WPAI in as many early intervention approaches as possible will help improve the database, allowing better comparability. However, the focus of further research must be to develop an optimized instrument from elements of WAI and WPAI, in order to be able to measure ability to work as well as the effects of an intervention on preservation or restoration of the ability to work, regardless of the setting.

Indikatoren für das Langzeitüberleben nach Anlage eines transjugulären intrahepatischen portosystemischen Shunts (TIPS)

INTRODUCTION

Complications of portal hypertension can be treated effectively by the transjugular intrahepatic portosystemic shunt procedure (TIPS). Indicators for long time survival after TIPS implantation are presented.

PATIENTS AND METHODS

From September 1992 until May 1995 forty-two consecutive patients (26 male, 16 female) with liver cirrhosis complicated by variceal bleeding (n = 27) or refractory ascites (n = 15) were treated by TIPS implantation and followed up clinically in a prospective, open study. The follow up period range was 5-3278 days. Univariate and multivariate regression analyses were applied to determine the correlation between patient characteristics and long term survival after TIPS implantation. The indicators were dichotomized at the median. The outcome variable was dichotomized. Positive outcome was defined as survival longer than three years without liver transplantation, all other outcomes were regarded as negative. Survival rates were determined for all patients and for subgroups according to results of the regression analyses.

RESULTS

During follow-up liver transplantation was performed in 8 of the 42 patients. 29 patients died. Mean survival was 1440 (+/-1060) days. Survival after one, two, three and six years was 76% (n = 32), 69%(n = 29), 62% (n = 26) and 38% (n = 16), respectively. The multivariate regression analysis revealed a significant better survival related to a prothrombine time >70%, MEGX synthesis >30 microgram/l, and ICG clearance <13 min. Patients with high ICG clearance (OR = 1.9), high MEGX synthesis (OR = 5.0) or high prothrombine time scores (OR = 5.2) had a significantly longer survival. This survival advantage increased with follow up time.

CONCLUSION

Longterm survival after TIPS implantation is influenced by the initial liver function. This survival advantage increases during follow up and is most pronounced after 6 years.

Cost-effectiveness simulation model of biologic strategies for treating to target rheumatoid arthritis in Germany

OBJECTIVES

The treatment of active rheumatoid arthritis (RA) usually requires different therapeutic options used sequentially in case of an insufficient response (IR) to previous agents. Since there is a lack of clinical trials comparing biologic treatment sequences, simulation models might add to the understanding of optimal treatment sequences and their cost-effectiveness. The objective of this study was to assess the cost-effectiveness of different biologic treatment strategies in patients with an IR to anti-TNF agents, based on levels of disease activity from the German public payer's perspective.

METHODS

A cost-effectiveness sequential model was developed in accordance with local RA treatment strategies, using DAS28 scores as dichotomous effectiveness endpoints: achieving remission/no remission (RS/no RS) or a state of low disease activity (LDAS/no LDAS). Costs were estimated using resource utilisation data obtained from a large observational German cohort. Advanced simulations were conducted to assess the cost-effectiveness over 2 years of four sequential biologic strategies composed of up to 3 biologic agents, namely anti-TNF agents, abatacept or rituximab, in patients with moderate-to-severe active RA and an IR to at least one anti-TNF agent.

RESULTS

Over two years, the biological sequence including abatacept after an IR to one anti-TNF agent appeared the most effective and cost-effective versus (vs.) use after two anti-TNF agents (€633 vs. €1,067/day in LDAS and €1,222 vs. €3,592/day in remission), and vs a similar sequence using rituximab (€633 vs. €728/day in LDAS and €1,222 vs. €1,812/day in remission). The sequence using a 3rd anti-TNF agent was less effective and cost-effective than the same sequence using abatacept (€2,000 vs. €1,067/day in LDAS and €6,623 vs. €3,592/day in remission). All differences were statistically significant (p<0.01).

CONCLUSIONS

The results suggest that in patients with an IR to at least one anti-TNF agent, biologic sequences including abatacept appear more efficacious and cost-effective than similar sequences including rituximab or only cycled anti-TNF agents.

Public health relevance of Graves' orbitopathy

CONTEXT

Disfiguring proptosis and functional impairment in patients with Graves' orbitopathy (GO) may lead to impaired earning capacity and to considerable indirect/direct costs.

OBJECTIVE

The aim of the study was to investigate the public health relevance of GO.

DESIGN AND SETTING

This cross-sectional study was performed between 2005 and 2009 at a multidisciplinary university orbital center.

PATIENTS

A total of 310 unselected patients with GO of various degrees of severity and activity participated in the study.

INTERVENTIONS

We conducted an observational study.

MAIN OUTCOME MEASURES

We measured work disability and sick leave as well as the resulting indirect/direct costs of GO-specific therapies.

RESULTS

Of 215 employed patients, 47 (21.9%) were temporarily work disabled, and 12 (5.6%) were permanently work disabled. Five (2.3%) had lost their jobs, and nine (4.2%) had retired early. The mean duration of sick leave was 22.3 d/yr. Compared with the German average of 11.6 d/yr, 32 (15%) patients had taken longer sick leaves. The duration of sick leave correlated with the disease severity (P = 0.015), and work disability correlated with diplopia (P < 0.001). Multivariable analysis identified diplopia as the principal predictor for work disability (odds ratio, 1.7; P < 0.001). The average costs due to sick leave and work disability ranged between 3,301€ (4,153$) and 6,683€ (8,407$) per patient per year. Direct costs were 388 ± 56€ (488 ± 70$) per patient per year and per year were higher in sight-threatening GO (1,185 ± 2,569€; 1,491 ± 3,232$) than in moderate-to-severe (373 ± 896€; 469 ± 1,127$; P = 0.013) or in mild GO (332 ± 857€; 418 ± 1,078$; P = 0.016). Total indirect costs ranged between 3,318€ (4,174$) (friction cost method) and 6,738€ (8,476$) (human capital approach). Work impairment as well as direct and indirect costs of GO significantly correlated with the scores of the internationally standardized and specific GO quality-of-life questionnaire.

CONCLUSIONS

Productivity loss and a prolonged therapy for GO incur great indirect and direct costs.

Interest of modelling in rheumatoid arthritis

Such as prospective studies can provide evidence-based information for clinicians and regulatory agencies, modelling studies provide useful information when experimental studies are to complex, too long, or too expensive to carry out. If modelling has been widely used in pharmacokinetics, it is in the field of pharmacoeconomics that numerous models have been published in recent years, including models relevant to the management of rheumatoid arthritis (RA). The most common modelling techniques published in RA are decision trees and Markov models which are used to perform cost-effectiveness and cost-utility analyses using real or simulated populations. This paper reviews the main types of modelling techniques used in pharmacoeconomic studies with the aim of clarifying their interest and limitations for the clinicians. Generating such evidence is highly relevant to assisting clinical recommendations and reimbursement decisions towards enabling the optimal management of RA and reducing its overall clinical and economic burden, for the benefits of patients and health systems.

Indirect medical costs in the first 3 years of rheumatoid arthritis: comparison of current methodological approaches

Indirect cost of chronic diseases have received increasing attention since recent diagnostic and therapeutic improvements have markedly raised costs of care. Relevant cost savings can be expected through the reduction of indirect costs. However, the assessment methods of indirect cost components still differ widely, leading to heterogeneous data that do not allow for a direct comparison. This prospective study of gainfully employed patients suffering from rheumatoid arthritis aims to compare indirect costs assessed by different current methodological approaches (human capital and friction cost method valued by either population or individual data), and compare the methods employed in order to provide a proposal for the standardization of indirect cost assessment. The finding of the present investigation underline the importance to define standardized assessment methods for a comparison of the results of cost evaluations comprising indirect costs. A recommendation for the assessment of productivity losses and their valuation is given. In a given specific economic investigation, the optimal assessment method might differ from these general statements. These recommendations are proposed to give an orientation in a field of heterogeneous strategies in order to improve comparability of indirect cost assessment.

Cost-effectiveness analysis of rituximab treatment in patients in Germany with rheumatoid arthritis after etanercept-failure

OBJECTIVE

The present health economic analysis investigated the cost-effectiveness-ratios of either (1) rituximab or (2) an alternative TNF-alpha-inhibiting agent as second line biological treatment in patients with active rheumatoid arthritis (RA) and an inadequate response to etanercept therapy.

METHODS

Incremental cost per quality-adjusted life-year (QALY) gained by rituximab treatment of RA is compared to TNF-inhibitor change (standard sequence) in a Markov-model (perspective: health care payer, full life-time approach). Direct cost components taken into account were treatment costs (medication-, administration- and monitoring costs) and resource utilisation (outpatient costs, inpatient costs). Indirect costs were estimated separately by the assessment of impaired work capacity due to RA (2008 Euro currency, discount rate 3.5%). Utility measures for the different treatment options were obtained from the ACR-response rates of published pivotal clinical trials.

RESULTS

Direct costs amount to euro 178,373 (standard sequence) and euro 192,295 (rituximab sequence), respectively, rendering incremental direct costs of euro 13,922. Incremental utilities yield 0.57 QALYs and the incremental cost-effectiveness-ratio (ICER) of rituximab compared to the standard sequence amounts to euro 24,517. Inclusion of indirect costs leads to less incremental costs and a lower ICER of euro 15,565/QALY. Thus, ICERs stay beneath the accepted threshold of euro 50,000/QALY.

CONCLUSION

Rituximab appears to be a cost-effective treatment alternative compared to the switch between TNF-inhibitors as second line biological treatment in patients with active RA having failed etanercept.

[Current aspects of cost effectiveness of TNF-alpha blocking agents in patients with rheumatoid arthritis]

Facing increasing health-related costs and limited health care resources, the assessment of cost effectiveness (CE) of medical procedures is also gaining considerable importance in the field of rheumatology. Since high annual therapy costs of 17,000-21,000 Euro are related to the employment of TNF-alpha blocking agents such as etanercept and infliximab (compared to annual costs of 350-5000 Euro of other disease modifying drugs (DMARDs) in the treatment of rheumatoid arthritis (RA)), their CE has become an important issue. The present investigation summarizes economic evaluations of cost and effectiveness of TNF-alpha blocking agents and compares the results to those of traditional DMARD therapies in patients with RA. The implications of these economic results on the further use of TNF-alpha blocking drugs and methodological improvements of their economic evaluation are discussed. The current literature provides evidence for the CE of the combination therapy with methotrexate (MTX), hydroxychloroquine (HCQ), and sulfasalazine (SASP). In comparison to this finding, the use of etanercept and MTX yields much higher costs, although the highest rate of ACR20 responses is achieved by this combination (additional costs of $42,000 per ACR20 response compared to combination of MTX, HCQ, and SASP). Two recent studies show more promising results of about $12,000/QUALY and even cost savings per QUALY administering etanercept and infliximab, respectively. The wide range of the CE ratios is mainly explained by different methodological approaches. Whether the wider employment of TNF-alpha blocking drugs (comprising not only selected patients) proves to be economically effective, remains to be investigated by further economic analyses. In contrast to the initial disappointing results of the comparison of established DMARD therapies and TNF-alpha blocking drugs in terms of CE, recently published data renders evidence that the CE of the TNF-alpha blocking drugs is comparable to other accepted therapies in internal medicine.

[Productivity costs of rheumatoid arthritis in Germany. Cost composition and prediction of main cost components]

OBJECTIVE

Identification of predictors for the productivity cost components: (1) sick leave, and (2) work disability in gainfully employed and (3) impaired household productivity in unemployed patients with rheumatoid arthritis (RA) from the societal perspective.

METHODS

Investigation of productivity costs was linked to a multicenter, randomized, controlled trial evaluating the effectiveness of clinical quality management in 338 patients with RA. The productivity losses were assessed according to the German Guidelines on Health Economic Evaluation. By means of multivariate logistic regression analyses, predictors of sick leave, work disability (employed patients, n=96), and for days confined to bed in unemployed patient (n=242) were determined.

RESULTS

Mean annual costs of 970 EUR arose per person taking into consideration all patients (453 EUR sick leave, 63 EUR work disability, 454 EUR impaired productivity of unemployed patients). Disease activity, disease severity, and impaired physical function were global predictors for all of the cost components investigated. Sick leave costs were predicted by prior sick leave periods and the vocational status blue collar worker, work disability costs by sociodemographic variables (marital status, schooling), and the productivity costs of unemployed patients by impaired mental health and impaired physical functions.

CONCLUSIONS

Interventions such as reduction in disease progression and control of disease activity, early vocational rehabilitation measures and vocational retraining in patients at risk of quitting working life, and self-management programs to learn coping strategies might decrease future RA-related productivity costs.

Transarterial chemoembolization using degradable starch microspheres and iodized oil in the treatment of advanced hepatocellular carcinoma: evaluation of tumor response, toxicity, and survival

BACKGROUND

In a multidisciplinary conference patients with advanced non-resectable hepatocellular carcinoma (HCC) were stratified according to their clinical status and tumor extent to different regional modalities or to best supportive care. The present study evaluated all patients who were stratified to repeated transarterial chemoembolization (TACE) from 1999 until 2003 in terms of tumor response, toxicity, and survival. A moderate embolizing approach was chosen using a combination of degradable starch microspheres (DSM) and iodized oil (Lipiodol) in order to combine anti-tumoral efficiency and low toxicity.

METHODS

Fourty-seven patients were followed up prospectively. TACE treatment consisted of cisplatin (50 mg/m(2)), doxorubicin (50 mg/m(2)), 450-900 mg DSM, and 5-30 ml Lipiodol. DSM and Lipiodol were administered according to tumor vascularization. Patient characteristics, toxicity, and complications were outlined. In multivariate regression analyses of pre-treatment variables from a prospective database, predictors for tumor response and survival after TACE were determined.

RESULTS

112 TACE courses were performed (2.4+/-1.5 courses per patient). Mean maximum tumor size was 75 (+/-43) mm, in 68% there was bilobar disease. Best response to TACE treatment was: progressive disease (PD) 9%, stable disease (SD) 55%, partial remission (PR) 36%, and complete remission (CR) 0%. Multivariate regression analyses identified tumor size <or=75 mm, tumor number <or=5, and tumor hypervascularization as predictors for PR. The overall 1-, 2-, and 3-year-survival rates were 75%, 59%, and 41%, respectively, and the median survival was 26 months. Low alpha-fetoprotein levels (<400 ng/ml) (Odds ratio=3.3) and PR as best response to TACE (Odds ratio=6.7) were significantly associated with long term survival (>30 months, R(2)=36%). Grade 3 toxicity occurred in 7.1% (n=8), and grade 4 toxicity in 3.6% (n=4) of all courses in terms of reversible leukopenia and thrombocytopenia. The incidence of major complications was 5.4% (n=6). All complications were managed conservatively. The mortality within 6 weeks after TACE was 2.1% (one patient).

CONCLUSIONS

DSM and Lipiodol were combined successfully in the palliative TACE treatment of advanced HCC resulting in high rates of tumor response and survival at limited toxicity. Favourable tumor response was associated with tumor extent and vascularization. TACE using DSM and Lipiodol can be considered a suitable palliative measure in patients who might not tolerate long acting embolizing agents.

Combination of repeated single-session percutaneous ethanol injection and transarterial chemoembolisation compared to repeated single-session percutaneous ethanol injection in patients with non-resectable hepatocellular carcinoma

AIM: To evaluate the treatment effect of percutaneous ethanol injection (PEI) for patients with advanced, non-resectable HCC compared with combination of transarterial chemoembolisation (TACE) and repeated single-session PEI, repeated single-session PEI alone, repeated TACE alone, or best supportive care.

METHODS: All patients who received PEI treatment during the study period were included and stratified to one of the following treatment modalities according to physical status and tumor extent: combination of TACE and repeated single-session PEI, repeated single-session PEI alone, repeated TACE alone, or best supportive care. Prognostic value of clinical parameters including Okuda-classification, presence of portal vein thrombosis, presence of ascites, number of tumors, maximum tumor diameter, and serum cholinesterase (CHE), as well as Child-Pugh stage, α-fetoprotein (AFP), fever, incidence of complications were assessed and compared between the groups. Survival was determined using Kaplan-Meier and multivariate regression analyses.

RESULTS: The 1- and 3-year survival of all patients was 73% and 47%. In the subgroup analyses, the combination of TACE and PEI (1) was associated with a longer survival (1-, 3-, 5-year survival: 90%, 52%, and 43%) compared to PEI treatment alone (2) (1-, 3-, 5-year survival: 65%, 50%, and 37%). Secondary PEI after initial stratification to TACE (3) yielded comparable results (1-, 3-, 5-year survival: 91%, 40%, and 30%) while PEI after stratification to best supportive care (4) was associated with decreased survival (1-, 3-, 5-year survival: 50%, 23%, 12%). Apart from the chosen treatment modalities, predictors for better survival were tumor number (n < 5), tumor size (< 5 cm), no ascites before PEI, and stable serum cholinesterase after PEI (P < 0.05). The mortality within 2 wk after PEI was 2.8% (n = 3). There were 24 (8.9%) major complications after PEI including segmental liver infarction, focal liver necrosis, and liver abscess. All complications could be managed non-surgically.

CONCLUSION: Repeated single-session PEI is effective in patients with advanced HCC at an acceptable and manageable complication rate. Patients stratified to a combination of TACE and PEI can expect longer survival than those stratified to repeated PEI alone. Furthermore, patients with large or multiple tumors in good clinical status may also profit from a combination of TACE and reconsideration for secondary PEI.

Preoperative volume calculation of the hepatic venous draining areas with multi-detector row CT in adult living donor liver transplantation: impact on surgical procedure

OBJECTIVE

The purpose was to assess the volumes of the different hepatic territories and especially the drainage of the right paramedian sector in adult living donor liver transplantation (ALDLT).

METHODS

CT was performed in 40 potential donors of whom 28 underwent partial living donation. Data sets of all potential donors were postprocessed using dedicated software for segmentation, volumetric analysis and visualization of liver territories. During an initial period, volumes and shapes of liver parts were calculated based on the individual portal venous perfusion areas. After partial hepatic congestion occurring in three grafts, drainage territories with special regard to MHV tributaries from the right paramedian sector, and the IRHV were calculated additionally. Results were visualized three-dimensionally and compared to the intraoperative findings.

RESULTS

Calculated graft volumes based on hepatic venous drainage and graft weights correlated significantly (r = 0.86, P < 0.001). Mean virtual graft volume was 930 ml and drained as follows: RHV: 680 ml, IRHV: 170 ml (n = 11); segment 5 MHV tributaries: 100 ml (n = 16); segment 8 MHV tributaries: 110 ml (n = 20). When present, the mean aberrant venous drainage fraction of the right liver lobe was 28%.

CONCLUSION

The evaluated protocol allowed a reliable calculation of the hepatic venous draining areas and led to a change in the hepatic venous reconstruction strategy at our institution.

Cost of illness in rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis and systemic lupus erythematosus in Germany

OBJECTIVE

To estimate and compare the direct and indirect costs of illness in rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis (PsA) and systemic lupus erythematosus (SLE), and to evaluate the effect of sex, disease duration and functional status on the various cost domains.

METHODS

Data of outpatients, aged 18-65, with rheumatoid arthritis (n = 4351), ankylosing spondylitis (n = 827), PsA (n = 908) or SLE (n = 844), who were enrolled in the national database of the German collaborative arthritis centres in 2002, were analysed. Data on healthcare consumption, out-of-pocket expenses and productivity losses were derived from doctors and patients. For the calculation of indirect costs, the human capital approach (HCA) and the friction cost approach (FCA) were applied.

RESULTS

Mean direct costs amounted to 4737 euros a year in rheumatoid arthritis, 3676 euros in ankylosing spondylitis, 3156 euros in PsA and 3191 euros in SLE. By using the HCA, total costs were calculated at 15,637 euros in rheumatoid arthritis, 13,513 euros in ankylosing spondylitis, 11,075 euros in PsA and 14,411 euros in SLE, whereas with the FCA the numbers were 7899 euros, 7204 euros, 5570 euros and 6518 euros, respectively. Costs increased with disease duration and were strongly dependent on functional status. In patients with the highest disability (<50% of full function), the total costs on applying the HCA were 34,915 euros in rheumatoid arthritis, 29,647 euros in alkylosing spondylitis, 37,440 euros in PsA and 32,296 euros in SLE.

CONCLUSION

The costs of illness are high in all four diseases, with a strong effect of functional status on total costs. Indirect costs differ by the factor 3, based on whether the HCA or the FCA is used.

[Costs of ambulatory care for RA patients in Germany]

BACKGROUND

In 2000, the Regional Cooperative Center for Rheumatic Conditions in Hannover, Germany, initiated a project to introduce and evaluate a case-based clinical quality management system to enhance the quality of care for patients with rheumatoid arthritis. Building on that, it was possible to combine all resource uses, as paid by the sickness funds, including those in ambulatory care.

METHODS

The purpose of this study was to reach average "per-visit prices" for single physician visits, not only for rheumatologists, but also for other specialists as well as generalists. Those visits all had to be connected to the rheumatic condition of the patients. All ambulatory care visits for 1 year (2001) were evaluated.

RESULTS

Due to the high number of physician visits of the 338 patients with clinically assured rheumatoid arthritis included in the study (rheumatologist visits 4,488, generalist visits 3,901), statistically significant subgroups could be built. The average costs per visit associated with rheumatoid arthritis are: rheumatologist euro 22.71; generalist euro 8.02; as well as other specialties ranging from euro 5.81 to euro 19.48. The low price for generalists care is due to the selection of the cohort, as all patients are under constant specialist care. The prices were further broken down to certain subgroups of care.

CONCLUSION

The prices are calculated under the premises that no budgetary constraints apply to ambulatory care. This is not the reality in Germany. Hence, looking at the average frequency of rheumatologist visits in this cohort (13.2/year), the conclusion has to be that not all rheumatologic ambulatory care is being covered by the reimbursement system within the Statutory Health Insurance in Germany.

Prediction of costs-of-illness in patients with low back pain undergoing orthopedic outpatient rehabilitation

The objectives of this study were (1) to assess societal costs-of-illness and their changes in the year prior to and after outpatient rehabilitation (OPR) in initially gainfully employed persons with low back pain and (2) to identify predictors (cost drivers) for high overall costs in the year after the intervention. The health economical analysis is part of a prospective clinical trial investigating patients participating in orthopedic OPR. In all gainfully employed patients (n=244) resource consumption and productivity losses were assessed prior to OPR and 12 months afterwards. Overall annual medical costs per person were estimated. Parameters associated with high overall costs in the 12 months after OPR were predicted by multivariate logistic regression analysis. All sociodemographic, motivational, clinical, psychological, therapeutic and vocational variables were included as possible predictors. Costs due to sick leave periods represent the major component (83%/58%) of overall costs in both periods. The comparison of costs 12 months before and after OPR reveals a significant reduction from 8050 to 3200 per person, primarily caused by decreasing sick leave costs and the reduction of costs related to inpatient treatment. The prediction analysis reveals that patients with limited functional abilities, with problems due to strenuous labour, with low expectations in terms of possible improvement after OPR, with a high pain score or with limited satisfaction with working colleagues have a significantly higher risk for costs exceeding 2200 after OPR. The identified cost drivers can be used to develop multimodal therapeutic measures, which should be employed during the OPR intervention in order to prevent future costs.

Indirect cost assessment in patients with rheumatoid arthritis (RA): comparison of data from the health economic patient questionnaire HEQ-RA and insurance claims data

OBJECTIVE

To render information on the accuracy of patient-reported indirect cost data compared with payer-derived data of the real indirect costs on a patient-by-patient basis concerning disease-related productivity losses in rheumatoid arthritis (RA).

METHODS

The assessment of indirect cost data was part of a clinical, multicenter, randomized RA trial. A total of 234 patients of working age with a diagnosis of RA (according to 1987 American College of Rheumatology criteria) were recruited. Demographics of the cohort were mean age 53 years, mean disease duration 8 years, 76% were women, and all had membership in the regional statutory health insurance plan. Every 3 months corresponding indirect cost data were derived for the cohort from a health economic questionnaire for cost assessment in patients with RA and the payer's database over a period of 18 months. Comparative statistical analyses were performed between patient-reported and insurance claims data.

RESULTS

The mean annual productivity losses due to sick leave amounted to 14 and 17 days per patient (questionnaire versus payer data), and productivity losses due to work disability amounted to 3 days (both); monetary valuation renders overall costs of 1,240 and 1,590, respectively. The difference of 17% in overall productivity losses is not significant. Comparison of productivity losses reveals a strong correlation of r = 0.83 in those due to sick leave and of kappa = 0.84 in those due to work disability between questionnaire and payer data.

CONCLUSION

The comparison of questionnaire and payer data shows that RA patients report their productivity losses adequately. Indirect cost assessment should therefore be included in further RA trials and observational studies.

Cost-effectiveness of TNF-alpha-blocking agents in the treatment of rheumatoid arthritis

The current literature covering cost-effectiveness and cost-utility analyses of biological treatments in patients with rheumatoid arthritis (RA) are reviewed in order to discuss options and limitations for future application of these highly priced drugs in routine clinical practice. The cost-effectiveness and cost-utility ratios of the studies analysed are converted into the corresponding Euros of the publication year. Etanercept treatment achieved a cost-effectiveness ratio of 44,300 Euros (2002)/ACR 20 (20% response according to American College of Rheumatology criteria) and 43,100 Euros (2002)/ACR 70WR (ACR 70 weighted response) compared with sulfasalazine and methotrexate, respectively, in methotrexate-naive RA. In methotrexate-resistant RA, the combination of etanercept and methotrexate is compared to a combination therapy of methotrexate, sulfasalazine and hydroxychloroquine revealing costs of 46,100 Euros (2000)/ACR 20, and 37,700 Euros/ACR 70WR. The cost-utility ratios for infliximab treatment range from 16,000 Euros to almost 166,000/QALY (quality adjusted life-year) gained, the studies investigating etanercept treatment show a ratio of approximately 25,000 Euros and 120,000/QALY gained. No substantial differences of cost-utilities of infliximab and etanercept were found. The administration of these drugs as third-line therapy is regarded cost-effective compared to other well-accepted therapies with comparable cost-utility ratios of < 50,000 Euros/QALY gained. Still, data on economic outcomes of RA trials are sparse and further cost-effectiveness and cost-utility evaluations are needed.

Direct costs related to rheumatoid arthritis: the patient perspective

OBJECTIVE

To determine rheumatoid arthritis related out of pocket expenditure (OOPE) in Germany and to disaggregate the total OOPE into contributing cost domains.

METHODS

Data for the cost analysis were drawn from a multicentre randomised controlled prospective trial to assess the effectiveness of clinical quality management in patients with rheumatoid arthritis. Both payer sources and patient cost questionnaires were used to generate health care utilisation data. All cost domains of a recently published matrix were reviewed and potential sources of OOPE were determined. Health care utilisation data were developed throughout 2001. Co-payment regulations as per January 2004 were applied in order to indicate the most recent level of OOPE in Germany. Data were analysed in both physical and monetary units using descriptive statistics.

RESULTS

In all, 136 patients with rheumatoid arthritis were included. Mean total OOPE per patient and year was 417.20 Euro (SEM 38.8, median 271.2). OOPE accounted for 15.3% of the total direct costs of rheumatoid arthritis. Total OOPE were further subdivided into cost domains: "non-physician service utilisation"' (194.40 Euro per patient and year; SEM 24.2), "medication" (99.00 Euro; 6.1), "transportation" (56.20 Euro; 17.4), "visits to physicians" (38.40 Euro; 0.6), "hospital facilities" (24.00 Euro; 5.6), and "devices and aids" (5.10 Euro; 0.8).

CONCLUSIONS

Rheumatoid arthritis is associated with substantial OOPE, imposing a considerable economic burden for patients. OOPE contribute significantly to the total health care expenditure in rheumatoid arthritis. The patient perspective has to be taken into account when calculating the overall direct costs of rheumatoid arthritis from a societal point of view.

Initial experience from a combination of systemic and regional chemotherapy in the treatment of patients with nonresectable cholangiocellular carcinoma in the liver

AIM: In nonresectable cholangiocellular carcinoma (CCC) therapeutic options are limited. Recently, systemic chemotherapy has shown response rates of up to 30%. Additional regional therapy of the arterially hyper vascularized hepatic tumors might represent a rational approach in an attempt to further improve response and palliation. Hence, a protocol combining transarterial chemoembolization and systemic chemotherapy was applied in patients with CCC limited to the liver.

METHODS: Eight patients (6 women, 2 men, mean age 62 years) with nonresectable CCC received systemic chemotherapy (gemcitabine 1000 mg/m²) and additional transarterial chemoembolization procedures (50 mg/m² cisplatin, 50 mg/m² doxorubicin, up to 600 mg degradable starch microspheres). Clinical follow-up of patients, tumor markers, CT and ultrasound were performed to evaluate maximum response and toxicity.

RESULTS: Both systemic and regional therapies were tolerated well; no severe toxicity (WHO III/IV) was encountered. Nausea and fever were the most commonly observed side effects. A progressive rarefication of the intrahepatic arteries limited the maximum number of chemoembolization procedures in 4 patients. A median of 2 chemoembolization cycles (range, 1-3) and a median of 6.5 gemcitabine cycles (range, 4-11) were administered. Complete responses were not achieved. As maximum response, partial responses were achieved in 3 cases, stable diseases in 5 cases. Two patients died from progressive disease after 9 and 10 mo. Six patients are still alive. The current median survival is 12 mo (range, 9-18); the median time to tumor progression is 7 mo (range, 3-18). Seven patients suffered from tumor-related symptoms prior to therapy, 3 of these experienced a treatment-related clinical relief. In one patient the tumor became resectable under therapy and was successfully removed after 10 mo.

CONCLUSION: The present results indicate that a combination of systemic gemcitabine therapy and repeated regional chemoembolizations is well tolerated and may enhance the effect of palliation in a selected group of patients with intrahepatic nonresectable CCC.

Patient-reported health care utilization in rheumatoid arthritis: what level of detail is required?

OBJECTIVE

To investigate the level of detail required in self-reported health care utilization questionnaires for administration to patients with rheumatoid arthritis (RA).

METHODS

A preliminary questionnaire was developed on the basis of existing tools for use in rheumatic conditions and in-depth interviews with 10 RA patients. Data gathered over 1 year of administration in a clinical setting were then matched to a comprehensive database of payer-reported information. Kappa statistics were calculated for each health care utilization domain. For domains where disaggregation into metric data was potentially preferable, histograms of difference were assessed visually and the strength of association examined using Spearman's rank correlation coefficient.

RESULTS

Patients (n = 136) included in the base case analysis determined the preferred levels of detail for each domain. Physician visits: occurrence of physician visits (yes/no; kappa not applicable) and their number (r = 0.42, P < 0.001). Medication use of the following drug classes (yes/no): disease-modifying antirheumatic drug (DMARD; kappa = 0.68), nonsteroidal antiinflammatory drug (kappa = 0.64), osteoporosis medication (kappa = 0.56), analgesic (kappa = 0.38), and steroid (kappa = 0.83). Further disaggregation into different DMARD classes was recommended (kappa ranging between 1 [use of biologics: yes/no] and 0.67 [use of azathioprine: yes/no]. Imaging: imaging of bones and chest (yes/no; kappa = 0.20). Hospitalization: inpatient episodes (yes/no; kappa = 0.64) and number of inpatient days (r = 0.80, P < 0.001). Transport: costs incurred (yes/no; kappa = 0.13) and amount (r = 0.39, P < 0.001).

CONCLUSION

The use of highly aggregated items to assess health care utilization in RA is supported. Dichotomous assessment (yes/no) was the preferred level of detail for items in the domains covering medication and diagnostic procedures or tests. Metric data is appropriate in 3 areas: number of physician visits, number of inpatient days, and total expenditure on transportation.

Konzeptionelle und methodische Grundlagen von Krankheitskostenerhebungen in der Rheumatologie

Cost-of-illness studies in rheumatic conditions show an enormous variability in reported costs. Reasons are-among others-a lack of standardization with regards to relevant cost domains and the utilization of various insufficiently validated costing sources. A flow scheme is presented which may serve as a systematic basis for a valid costing analysis. The scheme includes: i) Selection of relevant cost domains. A comprehensive matrix of cost domains may be used as a framework. According to the specific aims of any costing study individual domains might be selected. ii) An adequate level of detail has to be determined taking into account factors such as the validity of the data collection and the feasibility. iii) Appropriate objective (i. e. usage of administrative data) or subjective (i. e. patient-derived) data sources have to be identified under consideration of respective strengths and weaknesses. While administrative sources provide a valid access to costing data accessibility and feasibility are important advantages of patient-derived costing procedures. iv) During data collection the potential bias due to protocol-driven costs and the differentiation of disease-related from other health care costs should be considered. v) The data analysis should support a transparent presentation of the costing data both in physical and monetary units. In summary, no 'gold standard' has been established for costing studies yet. However, valid costing approaches might follow the flow scheme presented in this analysis.

Gegenüberstellung der Krankheitskosten im Jahr vor und nach stationärer und ambulanter Rehabilitation bei Personen mit Dorsopathien

The present economic analyses of orthopaedic inpatient and outpatient rehabilitation (IPR resp. OPR) focus but on the evaluation of the expenses from the cost carrier's perspective. Lower intervention costs were related to OPR, whereas comparable social and clinical outcome was achieved. Comprehensive assessment of the economic consequences (resource utilization and lost productivity) of low back pain have not been performed up to now. Therefore, as part of a prospective follow-up study (1) a comparison of overall cost-of-illness and cost components 12 months prior and after IPR and OPR, respectively, was carried out in patients with low back pain and (2) the relative changes of these cost components were compared in a full-cost-analysis from a societal perspective. A total of 150 matched pairs (SR and AR) were followed prospectively over 12 months. Disease related costs in the year prior to the intervention were evaluated retrospectively. Prior to IPR and OPR overall costs amounted to 7010 and 7710 Euro, respectively, per person and year in patients with low back pain. As the main cost component of overall costs, sick leave (SL) periods account for 74% (IPR) and 76% (OPR), respectively. Inpatient costs represent the main component of direct costs. In the year after the intervention the costs due to sick leave periods still represent the major cost component (46 and 52%, resp.) of overall costs (3370 and 3600 Euro, resp.). Disease related cessation of work including work disability accounts for about 10% of productivity costs after IPR and OPR. Indirect costs still make up for the major part of overall costs (58 and 62%, resp.). No differences of cost components and their relative changes can be seen between patients participating in IPR and OPR, respectively, within both time frames. The comparison of overall costs in the 12 months before and after IPR and OPR reveals a cost reduction of 52% (IPR) and 53% (OPR), resp. This decrease of costs is mainly related to the reduction of SL periods, though costs due to inpatient treatment decrease as well. Summarizing, the present full-cost-analysis from a societal perspective shows no differences of cost components and cost changes between orthopaedic IPR and OPR in the 12 months prior to and after the intervention. Comprehensive cost-analyses reveal no obstacles for further implementation of OPR in the treatment of low back pain. Future development and diversification of rehabilitation measures should aim at evaluating real resource consumption during the intervention in detail as a basis for further allocational decision making.

Comparison of estimated medical costs among patients who are defined as having rheumatoid arthritis using three different standards

Accurate estimation of medical care costs raises a host of challenging issues. We examined whether pure administrative claims data without clinical validation of diagnosis allow reasonable estimation of disease-related costs in rheumatoid arthritis (RA). Three patient groups were examined: patients with clinically confirmed RA (group A, n=338), patients with likely RA (administrative claims data reported the diagnosis of RA and patients were treated with disease modifying antirheumatic drugs, DMARDs; group B, n=303), and patients with possible RA (same as group B but patients had no DMARD treatment; group C, n=685). The payer's perspective was taken for this analysis. Only direct costs were included in the analysis. Cost data and data for several covariates were obtained from a major German statutory health insurance plan, the AOK Niedersachsen. A patient-per-patient microcosting approach was performed. A repeated measures, fixed effects model was applied to examine differences between the three study groups. Mean+/-SEM annual RA-related direct costs were euro 2,017+/-183 per patient-year in group A, euro 1,763+/-192 in group B, and euro 805+/-58 in group C. Outpatient (inpatient) costs were euro 1,636 (328) in group A, euro 1344 (340) in group B, and euro 546 (136) in group C. DMARD costs were by far the single most important cost driver in groups A and B. The difference in total RA-related direct cost between groups A and B was not significant whereas the differences between groups A and C (group B and C respectively), were significant. Pure administrative claims data allowed for an accurate estimate of disease-related costs in RA patients that received DMARD therapy. However, the high number of patients for whom administrative claims data listed the diagnosis RA, but no DMARD treatment was given poses a challenge for further research.

Diagnostic management of patients with SAPHO syndrome: use of MR imaging to guide bone biopsy at CT for microbiological and histological work-up

Propionibacterium acnes (P. acnes) is suspected to be involved in the pathophysiology of SAPHO syndrome, since it has been isolated repeatedly through open surgical bone biopsy. This study demonstrates the role of MRI in identifying inflamed bone areas in patients with SAPHO syndrome and the role of CT-guided bone biopsies in obtaining samples from these areas for microbiological and histopathological investigations, thus obviating open surgery. Fourteen consecutive patients with SAPHO syndrome were investigated by MRI to identify acute inflammatory changes in hyperostotic periarticular bone. The CT-guided biopsies for microbiological investigations were taken from the areas identified. Patients positive for P. acnes were started on long-term antibiotic therapy according to antibiotic susceptibility. On MRI the inflammatory changes appeared as hyperintense areas on fat-saturated T2 fast-spin-echo (FSE) images and showed signal increase on fat-saturated T1 SE images after Gd-DTPA. With MR localization CT-guided bone biopsies yielded P. acnes in 8 patients. No bacteria could be isolated from the remaining 6 patients. Acute inflammatory bone changes in SAPHO syndrome are well localized by MRI. With MR localization, CT-guided bone biopsies offer a minimally invasive alternative to open surgery in the detection of. P. acnes leading to the institution of a specific antibiotic therapy.

Early arthritis and rheumatoid arthritis in Germany

Early arthritis is challenging because the clinical picture often does not allow a distinction between rheumatoid arthritis (RA), self-limiting disease, and other forms of inflammatory arthritis. In Germany the first early synovitis clinic and several inception cohorts of patients with early RA were initiated and evaluated during the 1980s and 1990s to learn more about diagnostic classification, psycho-social problems and socio-economical status including sick-leave, work loss, and indirect costs of patients with early arthritis and early RA. Unclassified arthritis was described as the most frequent diagnosis and the term "undifferentiated arthritis" was chosen to underline the heterogeneity of theses arthritides and the preliminary state of this classification as a working diagnosis. A large National Databank of the German Regional Collaborative Arthritis Centres has been established over the last 10 years. In total, there are some 170,000 cases in the database. Moreover, a prospective multicentre inception cohort of early RA of less than 1 year's disease duration has been started recently to evaluate parameters of potential relevance for the pathogenesis of RA and eventually for the prediction of erosive disease. Studies are in progress to test the diagnostic performance of specific antibodies and antibody patterns for RA. Another topic of research addresses the identification of bacterial DNA in synovial fluid and synovial tissues to improve the differentiation of patients with reactive arthritis from those with early RA and to narrow the working diagnosis of undifferentiated arthritis.

Changes in quality of life according to the SF36 Health Survey of persons with back pain six months after orthopedic in- and outpatient rehabilitation

The objective of the current study was to compare changes of various aspects of quality of life according to the SF36 Health Survey after either inpatient rehabilitation (IPR) or outpatient rehabilitation (OPR) in patients with low back pain. To do this, a follow-up study (6 months) with a case-control design (n=150 matched pairs) of prospectively recruited patients suffering from low back pain and participating either in IPR or in OPR was carried out. To compare the effectiveness of IPR and OPR in terms of quality of life, the effect sizes (ES) of the changes in SF36 subscales 6 months after the rehabilitation programmes had ended were determined in those patients who had displayed abnormal values in the SF36 subscales before the intervention. The most important improvements in both IPR and OPR are found for "bodily pain" and "physical role". The improvement in "physical role" is higher after OPR (OPR 1.7; IPR 1.2), whereas the change in the subscale "mental health index" is lower after OPR (OPR 0.5; IPR 1.0). After adjusting for differing baseline values, improvements of psychosocial aspects such as "vitality" and "social function" tend to be more pronounced after IPR ("vitality": IPR 1.3; OPR 0.8; "social function": IPR 1.0; OPR 0.6). The outcome of IPR and OPR is similar in terms of several aspects of quality of life. However, the differences in psychosocial aspects result in the assumption that patients with impaired mental health, vitality or social abilities might receive a greater benefit from IPR whereas those with an impaired physical role might profit more from OPR. This needs to be studied in more detail in randomized controlled trials.

Costs of rheumatoid arthritis in Germany: a micro-costing approach based on healthcare payer's data sources

OBJECTIVE

To develop a systematic set of German cost data in rheumatoid arthritis (RA) based solely on valid healthcare payer's cost data sources.

METHODS

Retrospectively one year cost data of 338 patients with RA were generated and analysed. The cost data were derived from a major statutory health insurance plan ("Allgemeine Ortskrankenkasse Niedersachsen") and the regional physicians' association ("Kassenärztliche Vereinigung Niedersachsen"). The recently published matrix of cost domains in RA was applied to structure the analysis. Descriptive statistics were used to analyse the data.

RESULTS

The total direct costs for the 338 patients during one year (third quarter 2000 to second quarter 2001) were euro 3815 per patient-year. RA related direct costs were euro 2312 per patient-year. Outpatient costs accounted for 73.7%, inpatient costs for 24.0%, and other disease related costs for 2.3% of RA related direct costs. Outpatients cost drivers were RA related drugs (euro 1019 per patient-year), physician visits (euro 323 per patient-year), diagnostic and therapeutic procedures and tests (euro 185 per patient-year), and devices and aids (euro;168 per patient-year). 98 patients were retired prematurely owing to RA related work disability and incurred costs of euro;8358 per retired patient-year. 96 patients were gainfully employed and incurred sick leave costs of euro 2835 per employed patient-year.

CONCLUSION

Micro-costing based on healthcare payer's data provides a relatively conservative albeit highly accurate estimate of costs in RA. Both RA related and non-RA related costs must be taken into account. In gainfully employed patients and in patients who receive RA related retirement payments productivity costs exceed direct costs.

[Intraarterial calcium stimulation (ASVS) for pancreatic insulinoma: comparison of preoperative localization procedures]

PURPOSE

Evaluation of clinical relevance of the arterial stimulation procedure with venous sampling (ASVS) in the preoperative localization of insulinoma.

METHODS

Thirteen patients with endogenous hyperinsulinism underwent preoperative transabdominal ultrasound (US), helical CT (CT), MRI, endoscopic ultrasound (EUS), and angiography (DSA) in conjunction with the ASVS-test for the detection of insulinoma. The results were compared with intraoperative findings, intraoperative ultrasound (IOUS) and histology.

RESULTS

Sensitivity was as follows: US 8%, MRI 27%, CT 46%, EUS 50%,DSA 69%,and ASVS 92%. Intraoperative palpation and IOUS yielded a sensitivity of 77%. In 3 patients the tumors were neither palpable nor detectable by IOUS, the mode of resection was based on preoperative diagnostics. The ASVS procedure as a functional test was superior to all other modalities for the preoperative tumor detection.

CONCLUSION

The ASVS was the most sensitive diagnostic modality. It should especially be considered in terms of health economical aspects when CT or MRI do not yield conclusive results.

Implementing standardized cost categories within economic evaluations in musculoskeletal diseases

We present a matrix of relevant resource utilization domains for use in standardizing applied cost assessment in musculoskeletal conditions. In addition,we highlight the importance of selecting cost categories during the development of an economic evaluation. A set of four steps was applied: (a) literature search identifying economic evaluations in osteoarthritis and osteoporosis, (b) listing and aggregation of cost categories mentioned in the identified articles, (c) development of a matrix of resource utilization domains, and (d) qualitative discussion regarding the generalizability of the matrix to other musculoskeletal conditions such as rheumatoid arthritis. We examined 41 full-length articles (25 cost-of-illness studies or cost-comparisons, 14 cost-effectiveness analyses, and 2 cost-utility analyses), of which 16 studies focused on osteoarthritis and 25 on osteoporosis. The reviewed studies used a total of 151 different cost categories which, after adjustment for synonymous labeling, made up 34 cost categories. A matrix of 16 separate resource utilization domains was developed including seven outpatient, three inpatient, four other disease-related, and two productivity cost domains. We found that cost assessment in economic evaluation in the key musculo-skeletal diseases (osteoarthritis, osteoporosis, and rheumatoid arthritis) is performed rather inhomogeneously. A generalized matrix of applicable resource utilization domains and a flowchart facilitating the development of appropriate resource utilization data have been developed.

[Long-term follow-up and prognosis of work capacity in the early stage of chronic polyarthritis]

OBJECTIVES

Work disability (WD) in early rheumatoid arthritis (RA) has not been extensively evaluated in Germany. Therefore, the occurrence of WD pension within the first seven years of RA and prognostic indicators of the first year including the duration of sick leave (SL) were analyzed.

PATIENTS AND METHODS

Within the first year of RA according to the ACR 1987 criteria, 141 gainfully employed patients were entered into a prospective multicenter study (61% females, mean age 47 +/- 9 years, mean disease duration 6 +/- 3.5 months). One hundred and ten patients (78%) participated in a reevaluation (postal questionnaire) after a mean follow-up of 6.1 +/- 0.4 years. Predictors of WD pension were identified in univariate analyses and in backward multivariate Cox regression analyses (p < 0.05) with Hazard-ratios [H-R] as measures of WD risk.

RESULTS

Of 110 patients 53 (48%) were still employed at reexamination. WD due to RA occurred in 5% after one year disease duration, in 15% after 2 years, in 20% after 3 years, and in 28% after 6.5 years. Other reasons for leaving the labor force were found in 24%. High pain intensity, radiographic erosions, comorbidity and the pain behavior of avoidance were associated with WD only in univariate analyses. Age > 45 years [H-R 6.3] and the following job-related prognostic indicators were identified in the multivariate analyses: working under pressure of time [H-R 9.0], limited joint motion interferring with job tasks [H-R 5.9], feeling overworked [H-R 3.8] and work status (unskilled blue-collar workers vs white-collar professionals and self-employed persons) [H-R 3.4]. In an alternative final Cox-regression model the variables feeling overworked and work status were replaced by SL duration > 8 weeks within the first year of RA [H-R 7.1].

CONCLUSIONS

Since WD frequently occurs already within the first 3 years (20%) adequate interventions resulting from the prognostic indicators have to begin early in the course of RA. Apart from the rheumatological treatment and rehabilitation focusing on the reduction of pain, improved coping with pain, reduced joint destruction and improved mobility particularly working under pressure of time should be avoided and the work place has to be adjusted in case of limited joint motion interferring with job tasks. SL of several weeks duration already within the first year of RA is a red flag for impending WD.

[Prognosis of labour force participation after multidisciplinary outpatient and inpatient rehabilitation for chronic back pain]

In a one-year prospective study of patients participating in a multidisciplinary outpatient or inpatient rehabilitation program (OPR/IPR) for chronic back pain the following issues were investigated: (i) the frequency of low labour force participation (LFP), i. e., work loss due to the disease or total duration of sick leave (SL) of 6 weeks or more; (ii) prognostic indicators at the beginning of the rehabilitation program (T1) for low LFP after one year (T2); (iii) the significance of the type of rehabilitation IPR vs. OPR in relation to the identified prognostic indicators for LFP. A total of 413 patients participating in OPR (n = 299) or IPR (n = 114) for chronic back pain returned a postal questionnaire after one year. Low LFP was found in 30 % of all patients without significant differences between OPR (32 %) and IPR (25 %). Compared to the year before T1 the proportion of patients without SL between T1 and T2 increased from 12 % to 48 % after OPR, from 15 % to 47 % after IPR, respectively. In multivariate logistic regression analyses adjusted for type of rehabilitation the following prognostic indicators of T1 for low LFP were identified (p </= 0,05): SL of 6 weeks or more in the year before T1 with an odds ratio (OR) of 11.1; intended termination of employment (OR = 3.2), household income of less than 3300 DM per month (OR = 2.2); reduced social functioning (SF-36) (OR = 2.0). Regarding LFP no significance of the type of rehabilitation (IPR vs. OPR) was found in relation to the identified prognostic indicators or after adjustment for differences (i) in the characteristics of the patients at T1, and (ii) in the duration and number of single measures of the rehabilitation program.

CONCLUSIONS

One year after IPR or OPR the rate of return to work is similar (about seven out of ten patients). The identified prognostic indicators may stimulate further research of the improvement of the rehabilitation processes. No evidence was found against the expansion of OPR.

[Health economics research in the area of chronic polyarthritis]

Costs of illness are of major economic relevance in rheumatoid arthritis (RA) as in other chronic diseases. Overall costs of 15,000 Euro/year: 10,000 Euro indirect costs, and 5000 Euro direct costs are estimated, respectively. A further detailed analysis of direct costs underlines that inpatient care (50%) is the most prominent cost driver. Medication costs are also evaluated in detail since they are expected to gain importance with the introduction of the more expensive biologicals. While annual costs for regular disease modifying drugs (DMARDs) vary from 160 to 5000 Euro per patient, costs for the new biologicals amount up to 20,000 Euro (100-125% of the current estimated overall costs). For a comparison of different therapeutic strategies, costs are related to effectiveness in cost-effectiveness analyses. Based on present clinical trials, the ratios of medication costs and response according to the ACR 20-criteria of various DMARDs and biologicals are compared. The most cost-effective medication is sulfasalzine, followed by methotrexate, and leflunomide. Combining etanercept and methotrexate is preferable to methotrexate monotherapy and the combination of infliximab and methotrexate. This review shows that important economic issues in RA have already been addressed by applying cost-of-illness analyses and cost-effectiveness analyses. However, the knowledge about cost-effective therapeutic options is still scarce. Thus, primary data will have to be obtained using standardized approaches. These economic findings can be taken into account in the development of disease-management recommendations for RA-therapy.

[Association of disease severity in the early course of rheumatoid arthritis and locus of control]

This study examines the applicability of the questionnaire "Fragebogen zur Erhebung von Kontrollüberzeugungen zu Krankheit und Gesundheit - KKG" to patients with early course of rheumatoid arthritis (RA) or undifferentiated Arthritis (uA), and the relationship between the severity of the disease and locus of control by controlling for socio-demographic variables and personality characteristics. 326 patients with early RA or uA with a disease duration of less than 12 months (mean disease duration 6 months +/- 3.5, mean age 53 +/- 14) were assessed. Full clinical investigations were performed and patients questionnaires were administered at the outset of the study (T1), after 12 months (T2) and after 24 months (T3). The factor-solution of the KKG-questionnaire in patients with early course of RA/uA is not different from healthy controls. A marked influence on coping types can be demonstrated for the covariates sex, age, cognitive components of anxiety and the severity of RA. These results should be considered in education programs for RA applying special techniques of behaviour therapy. Such interventions in the early phase of RA might lead to a reduction of cognitive anxiety and thus to more active coping in patients with RA.

Development of a matrix of cost domains in economic evaluation of rheumatoid arthritis

The aim of our study was to comprehensively review and critically appraise the cost domains used in economic evaluations of the rheumatic diseases and to use this information to propose standardization of cost domains. The literature search identified 210 abstracts, 32 of which included original cost data. The listed cost categories were grouped into 3 major areas: (direct) health care costs, other (direct) disease related costs, and productivity costs (indirect costs). The number of individual cost categories was reduced by considering the following criteria: (1) inclusion of all relevant cost domains; (2) avoidance of double counting; (3) summarizing of related categories under one representative heading; (4) feasibility of level of aggregation. After adjustment for synonymous labeling, 38 cost categories remained. The subsequent development of a classification scheme of cost categories led to a set of 19 separate cost domains including 7 outpatient, 3 inpatient, 6 other disease related, and 3 productivity cost domains. This literature review indicates that cost assessment in economic evaluations in rheumatoid arthritis lacks standardization. A preliminary scheme to categorize cost assessment in rheumatic conditions is presented. The adoption of standards for economic evaluation would greatly facilitate national and international comparisons.

Indirect medical costs in early rheumatoid arthritis: composition of and changes in indirect costs within the first three years of disease

OBJECTIVE

To investigate 1) the magnitude of indirect costs, 2) changes in cost components, and 3) correlations between changes in cost and social, clinical, and occupational variables within the first 3 years of rheumatoid arthritis (RA).

METHODS

We evaluated the indirect costs per person-year in 133 consecutive gainfully employed out-patients with early RA, in a prospective multicenter followup study. Costs due to RA-related sick leave, work disability, and other work loss were assessed using the human capital approach. Variables associated with reduction in lost productivity were tested by multivariate logistic regression analysis.

RESULTS

Mean +/- SEM annual indirect costs were $11,750 +/- 1,120 per person. During the 3-year period of observation, a marked reduction in the costs associated with sick leave was seen, which exceeded the increase in costs due to work disability and other work loss. This phenomenon resulted in an overall reduction in indirect costs of 21%. The final logistic regression model of reduced loss of productivity included 3 variables: no problems with standing (odds ratio [OR] 7.1), no problems with working speed (OR 4.1), and no problems with outdoor work (OR 3.1).

CONCLUSION

High indirect costs in early RA were demonstrated. An overall decrease of costs can be seen in the first 3 years, due to the reduction in sick leave. Since the absence of problems due to strenuous working conditions was found to be associated with a reduction in indirect costs, it is assumed that early intensified vocational rehabilitation, apart from controlling disease activity by adequate treatment, might help to reduce indirect costs.

Cost assessment instrument in rheumatology: evaluation of applied instrument characteristics

We compared the major characteristics of internationally applied cost assessment instruments (CAI) in rheumatic conditions. Fifteen utilization questionnaires were identified and assessed using a structured approach. The forms differed considerably with respect to applied characteristics: length (3-113 items), recall period (between 1 week and 1 year), format (2 interview, 13 self-administered), response categories, cost units (physical vs monetary), and cost domains covered. While all included a gross assessment of outpatient and inpatient costs, the level of disaggregation differed. Only a few CAI included an assessment of other direct disease related costs (e.g., home remodeling or home health care services) and out-of-pocket expenditure. Productivity costs were included in all but 2 CAI. Efforts to further standardize the applied CAI should (1) be based on sound psychometric data, (2) define a required core set of cost domains covered, (3) discriminate between generic and relevant disease related cost components, and (4) examine the feasibility of developing international standards for cost data.

[Goal-oriented outcome measurement in inpatient or day care orthopedic-rheumatologic rehabilitation of patients with back pain]

The comparison of patient characteristics and effectiveness of inpatient rehabilitation (IPR) and outpatient rehabilitation (OPR) is of growing importance in terms of flexible and cost-effective structures in rehabilitation. The effectiveness of the treatment is measured applying a goaloriented approach based on the individual rehabilitation goals and the attainment of these goals at the end of the programme. The frequencies of rehabilitation goals chosen by patients in IPR and OPR are similar. Decrease of pain, improvement of muscular strength and improvement of the range of motion are the main goals of patients in IPR and OPR (92-56%). No relevant differences can be seen considering the effectiveness of IPR and OPR, except for the markedly higher improvement of vitality in IPR. Patients in need of rehabilitation whose primary rehabilitation goal is improvement of vitality should therefore preferentially be referred to an inpatient rehabilitation programme.