Underfunding of German university-based high-performance medicine exemplified by the treatment of varices in cirrhosis

Facing increasing economization in the health care sector, clinicians have to adapt not only to the ever-growing economic challenges, but also to a patient-oriented health care. Treatment costs are the most important variable for optimizing success when facing scarce human resources, increasing material- and infrastructure costs in general, as well as low revenue flexibility due to flat rates per case in Germany, the so-called Diagnosis-Related Groups (DRG). University hospitals treat many patients with particularly serious illnesses. Therefore, their share of complex and expensive treatments, such as liver cirrhosis, is significantly higher. The resulting costs are not adequately reflected in the DRG flat rate per case, which is based on an average calculation across all hospitals, which increases this economic pressure. Thus, the aim of this manuscript is to review cost and revenue structures of the management of varices in patients with cirrhosis at a university center with a focus on hepatology. For this monocentric study, the data of 851 patients, treated at the Gastroenterology Department of a University Hospital between 2016 and 2020, were evaluated retrospectively and anonymously. Medical services (e.g., endoscopy, radiology, laboratory diagnostics) were analyzed within the framework of activity-based-costing. As part of the cost unit accounting, the individual steps of the treatment pathways of the 851 patients were monetarily evaluated with corresponding applicable service catalogs and compared with the revenue shares of the cost center and cost element matrix of the German (G-) DRG system. This study examines whether university-based high-performance medicine is efficient and cost-covering within the framework of the G-DRG system. We demonstrate a dramatic underfunding of the management of varicose veins in cirrhosis in our university center. It is therefore generally questionable whether and to what extent an adequate care for this patient collective is reflected in the G-DRG system.

[Use of summaries of product characteristics (SmPC) among family doctors and pharmacists in the context of the aut-idem regulation: Results of an exploratory cross-sectional survey]

INTRODUCTION

Summaries of product characteristics (SmPC) of same-substance medications may feature content-related differences. This may cause difficulties regarding informed consent in the case of prescriptions of drugs in the context of the aut-idem regulation. A survey among family doctors (FD) and pharmacists (PH) was conducted in order to evaluate the usage behaviour of SmPCs, sources used to obtain information about drugs and the awareness of the existence of differences between SmPCs of same-substance medications.

METHODS

An exploratory/non-representative, questionnaire- and telephone-based, semi-structured cross-sectional survey was performed (June to August 2018).

RESULTS

Participation rate of FD and PH was 29.8 % (34/114) and 73.0 % (73/100), respectively. In the previous month, all PH and 82.4 % of FD said that they had used a SmPC at least once (p=0.001). FD used SmPCs 6.4±4.9 and PH 65.0±52.5 times a month (p<0.001). In both occupational groups SmPCs were used most frequently to obtain information about dosing and/or type of application (FD: 97.1 %; PH: 98.6 %) and contraindications (97.1 % and 86.3 %, resp.). In both samples, the internet was the most frequently used drug information source (FD: 97.1 %; PH: 98.6 %), followed by the Rote/Gelbe Liste (97.1 % and 71.2 %, resp.) and the SmPCs of the original product (52.9 % and 65.8 %, resp.) or generic drug (52.9 % and 61.6 %, resp.). Only 32.4 % of the FD vs. 79.5 % of PH believed that differences might exist between SmPCs of same-substance medications (p<0.001). FD stated that they never (11.8 %) or rarely (85.3 %) use SmPCs for informed consent. It was indicated that the aut-idem substitution is excluded in 10.3 %±5.0 (FD) and 9.6 %±6,1 (PH) of issued or received prescriptions.

DISCUSSION

The results of the present survey indicate a low utilization rate of SmPCs by FD and little awareness of the existing differences of SmPCs of same-substance medications in this occupational group. Both aspects may impede proper information of patients, particularly in cases of aut-idem prescriptions of substances for which many same-substance medications with different SmPCs are available.

CONCLUSION

Physicians should use SmPCs regularly and keep themselves informed about differences between SmPCs of same-substance medications.

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Zusammenfassung. Rehabilitation wirkt auf individueller und volkswirtschaftlicher Ebene. Wichtig dafür ist in Zukunft, dass Rehabilitation gemacht und klar abgegrenzt wird von Pseudo-Anbietern aus dem Kur-, Hotel-/Resort- bzw. Langzeitpflege-Bereich. Sonst droht geringer bis gar kein Nutzen bei unnötigen Kosten.

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Zusammenfassung. Die soziale und ökonomische Bürde von jährlichen Influenza-Epidemien wird generell unterschätzt. Influenza-Epidemien verursachen neben direkten medizinischen Kosten vor allem indirekte Kosten durch Produktions- und Arbeitsausfall. Hinzu kommen makroökonomische Auswirkungen durch verändertes menschliches Verhalten und reduzierte ökonomische Nachfrage. Die Impfung ist eine einfache, effektive Massnahme mit der man sich und sein Umfeld gegen eine Infektion schützen kann. Viele Studien zeigten, dass die Impfung gegen Influenza kosteneffektiv und in gewissen Zielpopulationen sogar kostensparend ist.

Revolution then evolution: the advance of health economic evaluation in Australia

All governments face immense challenges in providing affordable healthcare for their citizens, and the diffusion of novel health technologies is a key driver of growth in expenditure for many. Although important methodological and process variations exist around the world, health economic evaluation is increasingly seen as an important tool to support decision-making around the introduction of new health technologies, interventions and programmes in countries of varying stages of economic development. In Australia, the assessment of the comparative cost-effectiveness of new medicines proposed for subsidy under the country's national drug subsidy programme, the Pharmaceutical Benefits Scheme, was introduced in the late 1980s and became mandatory in 1993, making Australia the first country to introduce such a requirement nationally. Since then the use of health economic evaluation has expanded and been applied to support decision-making across a broader range of health technologies, as well as to programmes in public health.

[Valuation of health-related quality of life and utilities in health economics]

Measuring health-related quality of life is an important aspect in economic evaluation of health programmes. The development of utility-based (preference-based) measures is advanced by the discipline of health economics. Different preference measures are applied for valuing health states to produce a weighted health state index. Those preference weights should be derived from a general population sample in case of resource allocation on a collective level (as in current valuation studies of the EuroQol group).