Prävention und Kostenkontrolle im Gesundheitswesen

Hintergrund

Das deutsche Gesundheitswesen hat mit hohen Kosten zu kämpfen. Neben den aktuellen finanziellen Belastungen im Zusammenhang mit der Coronapandemie verfolgt die deutsche Bevölkerung mehrheitlich einen ungesunden Lebensstil der zukünftig zu weiteren Neuerkrankungen und assoziierten Kosten führen wird.

Ziel der Arbeit

Dieser Beitrag skizziert, wie mit Hilfe von Routinedatenanalysen der Gesetzlichen Krankenversicherung (GKV) Ansatzpunkte für Maßnahmen auf allen Ebenen der Prävention entwickelt werden können, die effektiv Krankheitsentstehungen verhindern, -progresse reduzieren und die Fähigkeit zur Beitragszahlung absichern können. Diese sollen durch effektives Gesundheitsmarketing Versicherte zu gesundheitsverbessernder Leistungsinanspruchnahme animieren.

Material und Methode

Es wird eine Idee entwickelt und diskutiert, in der ergänzend zu den bestehenden Möglichkeiten der GKV auf präventives Gesundheitsverhalten hinzuwirken, Ergebnisse der Sekundärdatenanalyse für Präventionsmaßnahmen und -verhalten nutzbar gemacht werden können.

Ergebnisse und Schlussfolgerung

Eine Machine-learning-gestützte Analyse bildet den Kern einer Klasse von Prädiktionsmodellen für die Prävention von Krankheiten. Diese Modelle setzen an unterschiedlichen Patientenmerkmalen in den Routinedaten der GKV an und liefern Empfehlungen für Präventionsmaßnahmen, die für eine zielgerichtete und kosteneffektive Ansprache beispielsweise mittels mHealth genutzt werden können. Die hohen Einsparungspotenziale im Gesundheitswesen sowie die Möglichkeiten der Gesetzlichen Krankenkassen diese datenanalytisch gestützt zu erschließen eröffnen eine sinnvolle Perspektive zu nachhaltiger Kostenkontrolle.

Notwendige Voraussetzungen einer kontrollierten Freigabe von Cannabis und anderer THC-haltiger Produkte

Zusammenfassung: Zielsetzung: Dieser Beitrag benennt notwendige Voraussetzungen der kontrollierten Abgabe von Cannabis an Erwachsene zur Begrenzung der mit der Freigabe verbundenen Schäden im Jugend- und Gesundheitsschutz. Ohne die vorgeschlagenen Maßnahmen würde lediglich ein weiterer Angebotskanal für THC-Produkte eröffnet, ohne die angestrebten Verbesserungen wie Stoffreinheit und Senkung der Drogenkriminalität zu erreichen. Methodik: Wir benennen die notwendigen legislativen Änderungen für eine schadensgeminderte kontrollierte Abgabe von Cannabis . Ergebnisse: Erforderlich für eine Abgabe von THC-haltigen Produkten ist eine THC-Steuer, die Behandlung von THC-Produkten als Arzneimittel gemäß Arzneimittelgesetz (AMG) und ihre Abgabe ausschließlich durch Apotheken. THC-Produkte dürfen nur von spezialisierten Unternehmen in Form der GmbH mit natürlichen Personen als Gesellschaftern hergestellt werden, die einer bankenanalogen Aufsicht und Wirtschaftsprüfung unterliegen. Ein Verbot jeglicher Werbung für THC-haltige Produkte ist unverzichtbar. Produkte dürfen eine Höchstmenge an THC Gehalt nicht überschreiten. Eine Beeinflussung der natürlichen THC-Aufnahme in den menschlichen Körper durch Zusatzstoffe oder besondere Zuführungstechniken etwa durch Verbindung mit Nikotin ist unzulässig. Nachfragern, die illegale Drogenanbieter im Markt halten, sind zur Erzwingung des Umschwenkens auf den neu eröffneten legalen Markt die Strafminderungen durch das Eigenverbrauchsprivileg ersatzlos zu streichen. Schlussfolgerungen: Eine kontrollierte Abgabe von Cannabis erfordert zwingend eine Reihe von gesetzlichen Vorschriften, um die bei einer Freigabe durch den Konsumanstieg anfallenden erheblichen medizinischen und ökonomischen Kosten zu mindern.

Who Smokes in Europe? Data From 12 European Countries in the TackSHS Survey (2017-2018)

BACKGROUND

Population data on tobacco use and its determinants require continuous monitoring and careful inter-country comparison. We aimed to provide the most up-to-date estimates on tobacco smoking from a large cross-sectional survey, conducted in selected European countries.

METHODS

Within the TackSHS Project, a face-to-face survey on smoking was conducted in 2017-2018 in 12 countries: Bulgaria, England, France, Germany, Greece, Ireland, Italy, Latvia, Poland, Portugal, Romania, and Spain, representing around 80% of the 432 million European Union (EU) adult population. In each country, a representative sample of around 1,000 subjects aged 15 years and older was interviewed, for a total of 11,902 participants.

RESULTS

Overall, 25.9% of participants were current smokers (31.0% of men and 21.2% of women, P < 0.001), while 16.5% were former smokers. Smoking prevalence ranged from 18.9% in Italy to 37.0% in Bulgaria. It decreased with increasing age (compared to <45, multivariable odds ratio [OR] for ≥65 year, 0.31; 95% confidence interval [CI], 0.27-0.36), level of education (OR for low vs high, 1.32; 95% CI, 1.17-1.48) and self-rated household economic level (OR for low vs high, 2.05; 95% CI, 1.74-2.42). The same patterns were found in both sexes.

CONCLUSIONS

These smoking prevalence estimates represent the most up-to-date evidence in Europe. From them, it can be derived that there are more than 112 million current smokers in the EU-28. Lower socio-economic status is a major determinant of smoking habit in both sexes.

The effect of online gambling on gambling problems and resulting economic health costs in Germany

Problematic and pathological gambling have emerged as substantial problems in many countries. One potential accelerating factor for this phenomenon during recent years is the Internet, which offers different kinds of games and online applications for gambling that are faster, more attractive due to a variety of design and marketing options, less costly and potentially more addictive than terrestrial gambling opportunities. However, the contributing role of the Internet for problematic gambling has not been analyzed sufficiently so far and remains inconclusive. The current study is based on a representative sample with 15,023 individuals from Germany. With a new concept of assessing online gambling with its relative fraction of total gambling activities and a control-function approach to account for possible endogeneity of online gambling, we estimate the impact of online gambling on gambling behavior while additionally controlling for a rich set of important covariates, like education, employment situation and family status. The results show that, on average, replacing 10% of offline gambling with online gambling increases the likelihood of being a problematic gambler by 8.8-12.6%. This increase is equivalent to 139,322 problematic gamblers and 27.24 million € per year of additional expenditures in the German health sector. Our findings underpin the necessity to keep online gambling restricted to prevent further developments of problematic and pathological gambling in Germany.

The costs of hazardous alcohol consumption in Germany

Hazardous alcohol consumption in Germany is a main threat to health. By using insurance claim data from the German Statutory Health Insurance and a classification strategy based on ICD10 diagnoses-codes we analyzed a sample of 146,000 subjects with more than 19,000 hazardous alcohol consumers. Employing different regression models with a control function approach, we calculate life years lost due to alcohol consumption, annual direct and indirect health costs, and the burden of pain and suffering measured by the Charlson-Index and assessed pain diagnoses. Additionally, we simulate the net accumulated premium payments over expenses in the German Statutory Health Insurance and the Statutory Pension Fund for hazardous alcohol consumers from a lifecycle perspective. In total, €39.3 billion each year result from hazardous alcohol consumption with an average loss of 7 years in life expectancy. Hazardous alcohol consumers clearly do not "pay their way" in the two main German social security systems and also display a higher intangible burden according to our definitions of pain and suffering.

The costs and consequences of obesity in Germany: a new approach from a prevalence and life-cycle perspective

With the steadily growing health burden of obesity in Germany, the measuring and quantification of its costs and relevant economic consequences have become increasingly important. The usual quantifications via previous cost-of-illness approaches mostly have several weaknesses, e.g., applying "indirect methods" by using "population-attributable fractions" to identify parts of costs that can be accrued to obesity, second using highly aggregated data and third often only displaying part of the costs. This article presents a new approach and a new estimation of the cost and consequences of obesity in Germany using claims data from a German health insurance company. A sample of 146,000 individuals was analyzed with both a prevalence and a life-cycle focus on the cost and consequences of obesity. With additional data sets, we calculate the deaths per year due to obesity, the excess costs per year and several intangible consequences usually referred to as "pain and suffering". Our results show that the cost estimations of obesity in Germany so far have been largely underestimated. The annual direct costs of obesity in Germany amount to approximately €29.39 billion and the indirect costs to an additional €33.65 billion. A total of 102,000 subjects die prematurely each year because of obesity, and there is a significant excess of unemployment, long-term nursing care, and pain and suffering due to obesity. From a lifetime perspective, every obese man is equal to an additional burden of €166,911 and each woman of €206,526 for the social security system in Germany. Obesity due to unhealthy eating is thus about to replace tobacco consumption in terms of costs and consequences as the main hazardous lifestyle factor and thus should be more intensively focussed by public health policy.

Die medizinischen Kosten schädlichen Alkohol- und Tabakkonsums in Deutschland – eine Analyse mittels GKV-Routinedaten

Fragestellung: Der gesundheitsschädliche Konsum von Alkohol und Tabak ist mit hohen Kosten für das Gesundheitswesen verbunden. Aus Sicht politischer Entscheidungsträger und Gesundheitsbehörden ist es interessant, die durch Alkohol- und Tabakkonsum verursachten Kosten im Gesundheitsbereich sowie deren Entstehungszusammenhang genau zu kennen, um eine notwendige Priorisierung der Versorgung und Prävention zu erreichen. Bisher wurden Kostenquantifizierungen jedoch mit in der Tendenz eher unterschätzenden Methoden durchgeführt. Methodik: Mithilfe eines Paneldatensatzes aus Routinedaten der gesetzlichen Krankenversicherung wird das Ausmaß der durch Tabak- und Alkoholkonsum zusätzlich entstehenden Kosten im deutschen Gesundheitssektor mit statistischen Methoden geschätzt. Ergebnisse: Gemäß dem Prävalenzansatz belaufen sich die Kosten des schädlichen Tabakkonsums auf 400 – 500 € pro Quartal und des schädlichen Alkoholkonsums auf 660 – 800 € pro Quartal und gesetzlich Versichertem in Deutschland. Diese Ergebnisse sind robust gegenüber alternativen Modellspezifikationen und -annahmen. Schlussfolgerungen: Aufgrund der häufig gewählten Methoden der Krankheitskostenrechnung sind die Kosten durch Alkohol- und Tabakkonsum im deutschen Gesundheitswesen unterschätzt worden.

The burden and cost of disorders of the brain in Europe with the inclusion of harmful alcohol use and nicotine addiction

Recent publications calculated an annual prevalence of 38% of the population within the European Union having a "disorder of the brain" including substance use disorders (SUD) (Wittchen et al., 2011). The overall economic burden was estimated at 789 billion € (Gustavsson et al., 2011). While these calculations included alcohol dependence, harmful use of alcohol, a common ICD-10 diagnosis, was not considered appropriately. Tobacco related figures were completely left out. We hence estimated burden and costs of these diagnoses for the European Union by extrapolating basic figures from Germany, which have average proportions of alcohol and tobacco related consumption and prevalence rates. Several German Data sets were used to estimate prevalence, disability adjusted life years (DALYs) and Cost-of-Illness for alcohol and tobacco use disorders in Germany. Results were obtained by focussing on the burden of SUD including well-known comorbidities. Results were then extrapolated to the European level. Compared with the earlier estimations DALYs increased from 2.8 million to over 6.6 million for SUDs. Costs augmented from 65.68 billion € PPP to about 350 billion € PPP. We discuss the robustness and validity of our findings under different assumptions and with regard to methodology. We further took into account that in the new DSM 5 alcohol abuse and alcohol dependence - and similar tobacco - will be collapsed into one category of "alcohol related disorder". If added to the burden and cost calculations the substance use disorders rank on top of all disorders of the brain in Europe. Regardless of the calculation procedure our figures represent lower estimates and have to be regarded as conservative approaches.

[Cigarette prices, tobacco taxes and the proportion of contraband cigarettes in Germany]

Taxes on tobacco products are among the most efficient instruments against tobacco consumption and the arising cost of illness associated with them. The main argument of the tobacco industry against increases of excise taxes on cigarettes is a presumed substitution effect of smokers turning from consumption of legal cigarettes to smuggled ones. Besides deriving this proposition from the tobacco industry's own funded research, it has never been tested empirically. This article analyses the interdependence between contraband cigarettes and cigarette prices in Germany. Using VAR-modelling on the time-series of the variables of interest, we find no empirically valid correlation or causation between prices and untaxed contraband cigarettes. Furthermore, we find a positive relationship between contraband and legal taxed cigarettes, i. e., when the demand for legal cigarettes decreased in amount, so did the quantity of untaxed cigarettes. We conclude that the proposed relationship between prices and smuggled cigarettes as well as an overall substitution effect among smokers is non-existent. This has important implications for public health policy. The proposition that higher taxes on tobacco products incur social costs from increased smuggling activity cannot be corroborated empirically. Furthermore, this finding should encourage public health policy to keep using tobacco taxes as an instrument for prevention.

[Excise taxes on tobacco and the problem of smuggling - concerning the credibility of the tobacco industry's "Discarded-Cigarette-Packages-Study"]

The consumption of tobacco products is one of the main causes of illnesses. An often neglected but highly effective instrument for fiscal and preventive purposes is higher taxes on tobacco products. The tobacco industry however claims that higher taxes have tremendous effects on smuggling activity with additional costs with regard to law enforcement. The claim appears to be substantiated by a study which collects and documents the amounts of discarded empty cigarette packs, and which is used to estimate the fraction of illegally imported cigarettes. We show that this study makes use of systematic misspecifications and impreciseness and thus seems to pursue the aim of showing an exaggerated high amount of illegally imported cigarettes. The industry's claim that two thirds of non-taxed cigarettes in Germany are imported illegally, thus lacks any sound, well-grounded empirical corroboration.

Television food advertising to children: a global perspective

OBJECTIVES

We compared television food advertising to children in several countries.

METHODS

We undertook a collaboration among 13 research groups in Australia, Asia, Western Europe, and North and South America. Each group recorded programming for 2 weekdays and 2 weekend days between 6:00 and 22:00, for the 3 channels most watched by children, between October 2007 and March 2008. We classified food advertisements as core (nutrient dense, low in energy), noncore (high in undesirable nutrients or energy, as defined by dietary standards), or miscellaneous. We also categorized thematic content (promotional characters and premiums).

RESULTS

Food advertisements composed 11% to 29% of advertisements. Noncore foods were featured in 53% to 87% of food advertisements, and the rate of noncore food advertising was higher during children's peak viewing times. Most food advertisements containing persuasive marketing were for noncore products.

CONCLUSIONS

Across all sampled countries, children were exposed to high volumes of television advertising for unhealthy foods, featuring child-oriented persuasive techniques. Because of the proven connections between food advertising, preferences, and consumption, our findings lend support to calls for regulation of food advertising during children's peak viewing times.