Pay-for-performance programs effectiveness in healthcare: the case of the end-stage renal disease quality incentive program

This paper focuses on Medicare's End-Stage Renal Disease Quality Incentive Program (QIP). QIP aims to promote high-quality services in outpatient dialysis facilities by tying their payments to their performance on pre-specified quality measures. In this paper, employing principal-agent theory, we examine the effectiveness of QIP by exploring the changes in various clinical/operational measures when they become a part of the program as a performance measure. We study five QIP quality measures; two are operational: hospitalization and readmission. And three others are clinical: blood transfusion, hypercalcemia, and dialysis adequacy. Overall, we observe a significant improvement in all QIP quality measures after being included in the program, except for readmission. We recommend adjusting the weight and redesigning the readmission measure for Medicare to incentivize providers to reduce readmission. We also discuss establishing care coordination and employing data-driven clinical decision support systems as opportunities for dialysis facilities to improve the care delivery process.

Study protocol for a randomized, controlled, multicentre, pragmatic trial with Rehabkompassen®-a digital structured follow-up tool for facilitating patient-tailored rehabilitation in persons after stroke

BACKGROUND

Stroke is a leading cause of disability among adults worldwide. A timely structured follow-up tool to identify patients' rehabilitation needs and develop patient-tailored rehabilitation regimens to decrease disability is largely lacking in current stroke care. The overall purpose of this study is to evaluate the effectiveness of a novel digital follow-up tool, Rehabkompassen®, among persons discharged from acute care settings after a stroke.

METHODS

This multicentre, parallel, open-label, two-arm pragmatic randomized controlled trial with an allocation ratio of 1:1 will be conducted in Sweden. A total of 1106 adult stroke patients will have follow-up visits in usual care settings at 3 and 12 months after stroke onset. At the 3-month follow-up, participants will have a usual outpatient visit without (control group, n = 553) or with (intervention group, n = 553) the Rehabkompassen® tool. All participants will receive the intervention at the 12-month follow-up visit. Feedback from the end-users (patient and health care practitioners) will be collected after the visits. The primary outcomes will be the patients' independence and social participation at the 12-month visits. Secondary outcomes will include end-users' satisfaction, barriers and facilitators for adopting the instrument, other stroke impacts, health-related quality of life and the cost-effectiveness of the instrument, calculated by incremental cost per quality-adjusted life year (QALY).

DISCUSSION

The outcomes of this trial will inform clinical practice and health care policy on the role of the Rehabkompassen® digital follow-up tool in the post-acute continuum of care after stroke.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04915027. Registered on 4 June 2021. ISRCTN registry ISRCTN63166587. Registered on 21 August 2023.

Health care workers' perceptions of their hospitals' preparedness during the COVID-19 virus pandemic in three different world regions

Introduction

Pandemics are extraordinary circumstances that necessitate a multifaceted approach to getting the most out of healthcare systems. Health authorities should be aware of the beliefs and attitudes of healthcare professionals before adopting control measures and communication campaigns. We aimed to find out how hospital staff members in three economically diverse regions perceive their facility's preparedness for pandemics.

Methodology

A hospital-based cross sectional study was done in three separate world regions, classified according to the World Bank's economics, using a web-based questionnaire. A convenience sample of 450 healthcare workers was collected and analyzed using SPSS version 20.

Results

Physicians made up 94.4% of the 450 participants, with 50.3% from High-Income Foreign Countries (HIFC), 20.4% from High-Income Arab Countries (HIAC), and 29.3% from Lower Middle-Income Countries (LMIC). 81.5% of participants from HIAC had formal PPE training, compared to 22.7% and 64.4% of participants from LMIC and HIFC, respectively. Evidently, 39.4% of the HIFC's participants stated that the level of their hospital precautions during the pandemic was above average, as compared to 50% and 14.4% of participants from HIAC and LMIC, respectively. Compared to 42.4% of HIAC participants and 36.4% of LMIC participants, 44.6% of HIFC participants reported feeling at risk because of their clinical role.

Conclusion

In all three regions, hospital readiness was well viewed by healthcare professionals; nevertheless, more needs to be done to provide them with psychological and social support. This research may help health authorities put up a suitable preparedness plan to face emerging pandemics. Further research is needed to determine the best course of action to combat comparable pandemics at various economic levels.

Weighted blankets for sleep problems - prescription, use and cost analysis

BACKGROUND

Weighted blankets (WBs) have been suggested as a treatment option for insomnia and are commonly prescribed despite lack of evidence of efficacy.

AIM

To investigate prescription pattern, return rate and cost of WBs.

MATERIAL AND METHODS

This observational cohort register-based study in western Sweden included every individual who, in a 2.5-year period, was prescribed and received at least one WB (n = 4092). A cost evaluation was made by mapping prescription processes for WBs and sleep medication.

RESULTS

Individuals diagnosed with dementia, anxiety, autism or intellectual disability (ID) retained the WB longer than others. Individuals younger than six and older than 65 years had shorter use time. The cost evaluation showed that the prescription process for WBs was longer and resulted in a higher cost than for sleep medication.

CONCLUSIONS

Some individuals had longer use time, indicating a possible benefit from using a WB. Due to low risk of harm but high economic cost, a revision of the WBs prescription process could be recommended to identify those who might benefit from WB.

SIGNIFICANCE

Our result points towards a need for revision of the prescription process, to implement standardized sleep assessments, and create a more efficient prescription process to lower the cost.

Efficacy of the antibacterial envelope to prevent cardiac implantable electronic device infection in a high-risk population

AIMS

Infection is a serious complication of cardiac implantable electronic device (CIED) therapy. An antibiotic-eluting absorbable envelope has been developed to reduce the infection rate, but studies investigating the efficacy and a reasonable number needed to treat in high-risk populations for infections are limited.

METHODS AND RESULTS

One hundred and forty-four patients undergoing CIED implantation who received the antibacterial envelope were compared with a matched cohort of 382 CIED patients from our institution. The primary outcome was the occurrence of local infection, and secondary outcomes were any CIED-related local or systemic infections, including endocarditis, and all-cause mortality. The results were stratified by a risk score for CIED infection, PADIT. The envelope group had a higher PADIT score, 5.9 ± 3.1 vs. 3.9 ± 3.0 (P < 0.0001). For the primary endpoint, no local infections occurred in the envelope group, compared with 2.6% in the control group (P = 0.04), with a more pronounced difference in the stratum with a high (>7 points) PADIT score, 0 vs. 9.9% (P = 0.01). The total CIED-related infections were similar between groups, 6.3% compared with 5.0% (P = 0.567). Mortality after 1600 days of follow-up did not differ between groups, 22.9 vs. 26.4%, P = 0.475.

CONCLUSION

Our study confirms the clinical efficacy of an antibacterial envelope in the prevention of local CIED infection in patients with a higher risk according to the PADIT score. In an effort to improve cost-benefit ratios, ration of use guided by the PADIT score is advocated. Further prospective randomized studies in high-risk populations are called for.

[Three-muscle surgery for large angle esotropia]

BACKGROUND

Bilateral medial rectus muscle recession with or without Cüppers' posterior fixation suture and recess and resect surgery are used to correct for large angle esotropia. There are only few reports on three muscle surgery (3MS). We analyzed the results of 3MS.

PATIENTS AND METHODS

Between June 2016 and May 2020, 61 patients received 3MS for esotropia ≥ 27° (50 PD) together with oblique muscle surgery, if needed. Angles of strabismus were measured by simultaneous prism and cover testing (SPCT) and alternating prism and cover testing (APCT) at 5 m and 0.3 m. Grading was around 0.51 mm/degree (at 5 m). Medium-term results of 57 patients were available.

RESULTS

Medians and ranges (min-max) were: age, 6 years (3-56 years). Preoperative APCT, far 34° (27-45°), near 36° (27-50°). Amount of surgery, 17 mm (15-21 mm), oblique muscle recession in 21 cases. The APCT after 5 months (3-24 months), far 2° (-10-18), near 2° (-8-18). Success rates (absolute deviation ≤ 6° [10 PD]), APCT far 68%, near 67%, SPCT far 79%, near 74%. Exotropia > 6° occurred in 4 cases (7%) at far and 3 (5%) at near, esotropia > 6° in 14 cases (25%) at far and 16 (28%) at near.

CONCLUSION

The use of 3MS is a suitable first step procedure to correct for large angle esotropia.

All around suboptimal health - a joint position paper of the Suboptimal Health Study Consortium and European Association for Predictive, Preventive and Personalised Medicine

First two decades of the twenty-first century are characterised by epidemics of non-communicable diseases such as many hundreds of millions of patients diagnosed with cardiovascular diseases and the type 2 diabetes mellitus, breast, lung, liver and prostate malignancies, neurological, sleep, mood and eye disorders, amongst others. Consequent socio-economic burden is tremendous. Unprecedented decrease in age of maladaptive individuals has been reported. The absolute majority of expanding non-communicable disorders carry a chronic character, over a couple of years progressing from reversible suboptimal health conditions to irreversible severe pathologies and cascading collateral complications. The time-frame between onset of SHS and clinical manifestation of associated disorders is the operational area for an application of reliable risk assessment tools and predictive diagnostics followed by the cost-effective targeted prevention and treatments tailored to the person. This article demonstrates advanced strategies in bio/medical sciences and healthcare focused on suboptimal health conditions in the frame-work of Predictive, Preventive and Personalised Medicine (3PM/PPPM). Potential benefits in healthcare systems and for society at large include but are not restricted to an improved life-quality of major populations and socio-economical groups, advanced professionalism of healthcare-givers and sustainable healthcare economy. Amongst others, following medical areas are proposed to strongly benefit from PPPM strategies applied to the identification and treatment of suboptimal health conditions:Stress overload associated pathologiesMale and female healthPlanned pregnanciesPeriodontal healthEye disordersInflammatory disorders, wound healing and pain management with associated complicationsMetabolic disorders and suboptimal body weightCardiovascular pathologiesCancersStroke, particularly of unknown aetiology and in young individualsSleep medicineSports medicineImproved individual outcomes under pandemic conditions such as COVID-19.

Caution, "normal" BMI: health risks associated with potentially masked individual underweight-EPMA Position Paper 2021

An increasing interest in a healthy lifestyle raises questions about optimal body weight. Evidently, it should be clearly discriminated between the standardised "normal" body weight and individually optimal weight. To this end, the basic principle of personalised medicine "one size does not fit all" has to be applied. Contextually, "normal" but e.g. borderline body mass index might be optimal for one person but apparently suboptimal for another one strongly depending on the individual genetic predisposition, geographic origin, cultural and nutritional habits and relevant lifestyle parameters-all included into comprehensive individual patient profile. Even if only slightly deviant, both overweight and underweight are acknowledged risk factors for a shifted metabolism which, if being not optimised, may strongly contribute to the development and progression of severe pathologies. Development of innovative screening programmes is essential to promote population health by application of health risks assessment, individualised patient profiling and multi-parametric analysis, further used for cost-effective targeted prevention and treatments tailored to the person. The following healthcare areas are considered to be potentially strongly benefiting from the above proposed measures: suboptimal health conditions, sports medicine, stress overload and associated complications, planned pregnancies, periodontal health and dentistry, sleep medicine, eye health and disorders, inflammatory disorders, healing and pain management, metabolic disorders, cardiovascular disease, cancers, psychiatric and neurologic disorders, stroke of known and unknown aetiology, improved individual and population outcomes under pandemic conditions such as COVID-19. In a long-term way, a significantly improved healthcare economy is one of benefits of the proposed paradigm shift from reactive to Predictive, Preventive and Personalised Medicine (PPPM/3PM). A tight collaboration between all stakeholders including scientific community, healthcare givers, patient organisations, policy-makers and educators is essential for the smooth implementation of 3PM concepts in daily practice.

The cost burden of Crohn's disease and ulcerative colitis depending on biologic treatment status - a Danish register-based study

Background

Patients diagnosed with inflammatory bowel disease may be treated with biologics, depending on several medical and non-medical factors. This study investigated healthcare costs and production values of patients treated with biologics.

Methods

This national register study included patients diagnosed with Crohn’s disease (CD) and ulcerative colitis (UC) between 2003 and 2015, identified in the Danish National Patient Register (DNPR). Average annual healthcare costs and production values were compared for patients receiving biologic treatment or not, and for patients initiating biologic treatment within a year after diagnosis or at a later stage. Cost estimates and production values were based on charges, fees and average gross wages.

Results

Twenty-six point one percent CD patients and ten point seven percent of UC patients were treated with biologics at some point in the study period. Of these, 46.4 and 45.5 % of patients initiated biologic treatment within the first year after diagnosis. CD and UC patients treated with biologics had higher average annual healthcare costs after diagnosis compared to patients not treated with biologics. CD patients receiving biologics early had lower production values both ten years before and eight years after treatment initiation, compared to patients receiving treatment later. UC patients receiving biologics early had lower average annual production values the first year after treatment initiation compared to UC patients receiving treatment later.

Conclusions

CD and UC patients receiving biologic treatment had higher average annual healthcare costs and lower average annual production values, compared to patients not receiving biologic treatment. The main healthcare costs drivers were outpatient visit costs and admission costs.

Flavonoids as an effective sensitizer for anti-cancer therapy: insights into multi-faceted mechanisms and applicability towards individualized patient profiles

Cost-efficacy of currently applied treatments is an issue in overall cancer management challenging healthcare and causing tremendous economic burden to societies around the world. Consequently, complex treatment models presenting concepts of predictive diagnostics followed by targeted prevention and treatments tailored to the personal patient profiles earn global appreciation as benefiting the patient, healthcare economy, and the society at large. In this context, application of flavonoids as a spectrum of compounds and their nano-technologically created derivatives is extensively under consideration, due to their multi-faceted anti-cancer effects applicable to the overall cost-effective cancer management, primary, secondary, and even tertiary prevention. This article analyzes most recently updated data focused on the potent capacity of flavonoids to promote anti-cancer therapeutic effects and interprets all the collected research achievements in the frame-work of predictive, preventive, and personalized (3P) medicine. Main pillars considered are: - Predictable anti-neoplastic, immune-modulating, drug-sensitizing effects; - Targeted molecular pathways to improve therapeutic outcomes by increasing sensitivity of cancer cells and reversing their resistance towards currently applied therapeutic modalities.

Feasibility of using ultrasound in ambulances in Saudi Arabia

BACKGROUND

In developed countries, the economic feasibility of using ultrasound in ambulances before arriving at the hospital has been achieved through comprehensive studies, and this of course does not apply to Arab countries, as there are no current studies to support this. Therefore, this study is a preliminary measure of the economic feasibility of using ultrasound in ambulances in Saudi Arabia.

AIM

To measure the demand for ultrasound equipment in ambulances in Saudi Arabia.

METHODS

A cross-sectional study of five different groups of participants including radiation technologists, emergency physicians, paramedics, Red Crescent managers and the public. Email and social media were used to deliver a questionnaire to these groups. The questionnaire included specific questions to measure the purpose of ultrasound use in each group of participants.

RESULTS

Each group had some knowledge on ultrasound and its benefits. More than 50% in each study group supported the availability of ultrasound in ambulances. Additionally, 60% of emergency physicians reported that they had difficulties in venous access, checking the presence of internal bleeding, recognizing pregnancy in trauma cases, and inserting endotracheal tubes, and the majority of them confirmed the effective role of ultrasound in achieving such tasks. Almost all paramedics (93.33%), physicians (98.89%), and Saudi Red Crescent managers (96.3%) emphasized the importance of communication between ambulance staff and emergency departments. Moreover, most physicians (77.78%), and technologists (82.73%) supported the presence of paramedics in ambulances to operate ultrasound in order to improve patient outcomes.

CONCLUSION

Most of the study groups evaluated had knowledge on ultrasound and supported the presence of ultrasound devices in ambulances.

[Biosimilar medicines: Regulatory issues and medico-economic impacts]

Le concept de médicament biosimilaire a été lancé par les directives européennes de 2001 et 2004 avec les premières autorisations européennes de mise sur le marché (AMM) délivrées en 2006. Ce sont des « copies » de médicaments biologiques, pour la plupart des protéines. Compte tenu de la variabilité inhérente aux processus de « synthèse biologique » quelques variations de la structure chimique du produit fini peuvent être observées sur les résidus glycosylés mais pas sur la séquence d’acides aminés pour les protéines. Pour cette raison, le dossier de demande d’AMM de ces produits, contrairement aux génériques, doit comporter une démonstration d’équivalence thérapeutique dans au moins l’une des indications thérapeutiques du princeps. C’est l’arrivée des biosimilaires des anticorps monoclonaux qui a vraiment marqué leur avènement avec les biosimilaires d’infliximab, d’étanercept et d’adalimumab dans les domaines de la rhumatologie, gastroentérologie et dermatologie, puis dans les domaines de la cancérologie avec les biosimilaires de rituximab, trastuzumab et enfin bévacizumab. Si l’arrivée des biosimilaires réduit le risque de ruptures d’approvisionnement des produits princeps, leur intérêt est principalement économique, permettant la réduction du prix des traitements face aux princeps biologiques coûteux. Avec l’expérience acquise, les réticences à l’interchangeabilité des produits se sont estompées.

Editorial. The Challenges of Orthopaedic Trauma in Spain

Spain is considered the healthiest nation in the world, due to lifepromoting aspects such as good diet, care facilities and a favourable family environment. However, although increased life expectancy is an indicator of development, it may have a negative impact on the other two variables of health service efficiency, namely health expenditure per capita and its relative weight in Gross Domestic Product.

Modelling long-term cost-effectiveness of health promotion for community-dwelling older people

The effectiveness of health promotion for community-dwelling older people is well documented; however, there is a general lack of health economic evaluations. The aim of the present study was to evaluate long-term cost-effectiveness over 4 years of two health promoting interventions: senior meetings and a preventive home visit, for community-dwelling older people in relation to no intervention. We applied a Markov model including five states defined in relation to level of dependency of home help and place of residency. The model included transitions between dependency states, scores for quality of life and societal costs for each state, intervention costs and intervention effects for two formats of health promoting interventions. For each intervention and a no-intervention control group, we calculated the accumulated quality-adjusted life years (QALYs) and societal costs over 4 years. Sensitivity analyses included higher intervention costs, lower intervention effects and additional intervention costs and effects related to booster sessions. The results of all analyses indicated that health promotion implemented for community-dwelling older people in the format of senior meetings or a preventive home visit was cost-effective. Both interventions lead to QALY gains and reduce societal costs at any follow-up over 4 years, and thus, resources can be used to implement other interventions. The most important factor for the magnitude of QALY gains and cost savings was the intervention effect. Yearly booster sessions implemented for those persons who maintained their level of functioning extended the intervention effects adding additional QALYs and further reducing societal costs.

Cost-effectiveness analysis of pulse oximetry screening for critical congenital heart defects following homebirth and early discharge

Pulse oximetry (PO) screening is used to screen newborns for critical congenital heart defects (CCHD). Analyses performed in hospital settings suggest that PO screening is cost-effective. We assessed the costs and cost-effectiveness of PO screening in the Dutch perinatal care setting, with home births and early postnatal discharge, compared to a situation without PO screening. Data from a prospective accuracy study with 23,959 infants in the Netherlands were combined with a time and motion study and supplemented data. Costs and effects of the situations with and without PO screening were compared for a cohort of 100,000 newborns. Mean screening time per newborn was 4.9 min per measurement and 3.8 min for informing parents. The additional costs of screening were in total €14.71 per screened newborn (€11.00 personnel, €3.71 equipment costs). Total additional costs of screening and referral were €1,670,000 per 100,000 infants. This resulted in an incremental cost-effectiveness ratio of €139,000 per additional newborn with CCHD detected with PO, when compared to a situation without PO screening. A willingness-to-pay threshold of €20,000 per gained QALY for screening in the Netherlands makes the screening likely to be cost-effective.Conclusion: PO screening in the Dutch care setting is likely to be cost-effective. What is Known: • Pulse oximetry is increasingly implemented as a screening tool for critical congenital heart defects in newborns. • Previous studies suggest that the screening in cost-effective and in the USA a reduction in infant mortality from critical congenital heart defects was demonstrated. What is New: • This is the first cost-effectiveness analysis for pulse oximetry screening in a setting with screening after home births, with screening at two moments. • Costs of pulse oximetry screening in a setting with hospital and homebirth deliveries were €14.71 and is likely to be cost-effective accordint to Dutch standards.

A cost analysis of intensified vs conventional multifactorial therapy in individuals with type 2 diabetes: a post hoc analysis of the Steno-2 study

AIMS/HYPOTHESIS

Long-term follow-up of the Steno-2 study demonstrated that intensified multifactorial intervention increased median lifespan by 7.9 years and delayed incident cardiovascular disease by a median of 8.1 years compared with conventional multifactorial intervention during 21.2 years of follow-up. In this post hoc analysis of data from the Steno-2 study, we aimed to study the difference in direct medical costs associated with conventional vs intensified treatment.

METHODS

In 1993, 160 Danish individuals with type 2 diabetes and microalbuminuria were randomised to conventional or intensified multifactorial target-driven intervention for 7.8 years. Information on direct healthcare costs was retrieved from health registries, and the costs in the two groups of participants were compared by bootstrap t test analysis.

RESULTS

Over 21.2 years of follow-up, there was no difference in total direct medical costs between the intensified treatment group, €12,126,900, and the conventional treatment group, €11,181,700 (p = 0.48). The mean cost per person-year during 1996-2014 was significantly lower in the intensified treatment group (€8725 in the intensive group and €10,091 in the conventional group, p = 0.045). The main driver of this difference was reduced costs associated with inpatient admissions related to cardiovascular disease (p = 0.0024).

CONCLUSIONS/INTERPRETATION

Over a follow-up period of 21.2 years, we found no difference in total costs and reduced cost per person-year associated with intensified multifactorial treatment for 7.8 years compared with conventional multifactorial treatment. Considering the substantial gain in life-years and health benefits achieved with intensified treatment, we conclude that intensified multifaceted intervention in high-risk individuals with type 2 diabetes seems to be highly feasible when balancing healthcare costs and treatment benefits in a Danish healthcare setting.

The Prescription of Anticraving Medication and its Economic Consequences

IMPORTANCE

According to recent studies, only a small proportion of alcoholics in the system for addiction treatment receive expedited treatment [Rehm et al.: Sucht 2014;60:93-105] and that those who are untreated are at risk of harmful and dependent alcohol consumption. This is associated with significantly negative effects on morbidity, mortality, and quality of life [Kraus et al.: Sucht 2010;56:337-347]. As a result, not only individuals and their environment suffer but there is also a health economic impact.

OBJECTIVE

How often do patients with a primary or secondary diagnosis of alcohol dependence who have been discharged from inpatient treatment receive anticraving medication in the follow-up period of 6 months?

DESIGN, SETTING, AND PARTICIPANTS

Based on data from a statutory health insurance in Germany, 12,958 patients were investigated regarding alcohol dependence, rates for readmission to hospital, and prescription of anticraving drugs. In addition, outpatient and inpatient treatment costs were calculated. Main Outcomes and Measures: There will be an examination of how often anticraving medications are prescribed and what the economic consequences are.

RESULTS

Two hundred and eighty-eight (2.22%) patients received anticraving medication, 98 (0.76%) in the first 6 months after inpatient treatment. Fifty-nine of the 288 patients were monitored with a pre- and postcomparison over a 90-day period. Inpatient treatment fell from 0.83 times (±1.10) during the 3 months afterward to 0.79 (±1.01). On average, the duration of an inpatient stay before anticraving treatment (n = 29) was 17.34 days (±14.37), with an average cost of EUR 4,142.70 (±2,721.28). Among the anticraving treatment group, this fell to 14.03 days (±9.96) with an average cost of EUR 3,685.43 (±2,307.67). Overall, the average outpatient and inpatient treatment costs dropped from EUR 1,533.88 before treatment to EUR 1,462.76 after treatment. If this is extrapolated to the whole group, it leads to between EUR 921,500 and EUR 6.6 million saving for a health insurance company.

CONCLUSION

Anticraving medications are hardly ever prescribed. Their routine use could reduce hospital readmission rates and save on health-care costs.

[Study on outpatient utilization of an ENT-clinic in a rural region: elective patients]

BACKGROUND

In Germany medical care of outpatients is mainly provided by general practitioners and medical specialists in private practice. The outpatient departments of hospitals are available for patients under defined circumstances, such as by referral from a specialist or for oncological diseases (§ 116b). The aim of this investigation was the evaluation of the elective outpatient cases.

MATERIAL AND METHODS

The prospective study started in April 2013 and ended in March 2014. All elective outpatients were analyzed according to several items, such as personal and medical data, the reason, time and justification for presentation.

RESULTS

All in all 6463 elective patients were enrolled in this study. Children and the older patients were quantitatively more represented than the emergency patients. With respect to a defined score the majority of referrals were medically reasonable (87%), which correlated positively with the travelling distance to the patient's home.

DISCUSSION

This investigation emphasizes the usefulness of the German dual principle of specialist patient care that contributes to medically appropriate utilization of healthcare resources, which is not the case for emergency patients with a free choice of destination.

A standardized stepwise drug treatment algorithm for depression reduces direct treatment costs in depressed inpatients - Results from the German Algorithm Project (GAP3)

BACKGROUND

In a previous single center study we found that a standardized drug treatment algorithm (ALGO) was more cost effective than treatment as usual (TAU) for inpatients with major depression. This report aimed to determine whether this promising initial finding could be replicated in a multicenter study.

METHODS

Treatment costs were calculated for two time periods: the study period (from enrolment to exit from study) and time in hospital (from enrolment to hospital discharge) based on daily hospital charges. Cost per remitted patient during the study period was considered as primary outcome.

RESULTS

266 patients received ALGO and 84 received TAU. For the study period, ALGO costs were significantly lower than TAU (ALGO: 7 848 ± 6 065 €; TAU: 10 033 ± 7 696 €; p = 0.04). For time in hospital, costs were not different (ALGO: 14 734 ± 8 329 €; TAU: 14 244 ± 8 419 €; p = 0.617). Remission rates did not differ for the study period (ALGO: 57.9%, TAU: 50.0%; p=0.201). Remission rates were greater in ALGO (83.3%) than TAU (66.2%) for time in hospital (p = 0.002). Cost per remission was lower in ALGO (13 554 ± 10 476 €) than TAU (20 066 ± 15 391 €) for the study period (p < 0.001) and for time in hospital (ALGO: 17 582 ± 9 939 €; TAU: 21 516 ± 12 718 €; p = 0.036).

LIMITATIONS

Indirect costs were not assessed. Different dropout rates in TAU and ALGO complicated interpretation.

CONCLUSIONS

Treatment algorithms enhance the cost effectiveness of the care of depressed inpatients, which replicates our prior results in an independent sample.

Building on evidence to improve patient care

Evidence-based medicine (EBM) is gaining importance in the current paediatric healthcare landscape. Improvement of paediatric health status is its major aim. However, for EBM to be successful, all stakeholders involved should understand what EBM really is, why and how EBM should or should not be practiced, and have the necessary skills to distinguish methodologically sound papers from biased opinion papers, and understand how and why guidelines are different from systematic reviews. Improving patient outcome requires attention to high-quality evidence and understanding of the processes of medical decision-making. Rigorous methodology is the cornerstone of guideline production, but in cases where quality evidence cannot be produced, as is often the case in paediatric nephrology because of low patient numbers, consensus-based guidance may be suitable to assist the practitioner at the bedside, as long as the underlying process is transparent. Most importantly, EBM should support patient involvement in a shared decision-making process. The more consistent and accurately predictable the effect of certain interventions is, clinically relevant to patients rather than affecting surrogate outcomes, and a priority for patients and other stakeholders, the more likely it is that adherence to the guidance provided will improve the outcome of patients.

[Costs associated with multiresistant bacteria in neurorehabilitation]

BACKGROUND AND OBJECTIVES

The number of patients with multiresistant bacteria (MRB) in rehabilitation facilities is increasing. The increasing costs of hygienic isolation measures reduce resources available for core rehabilitation services. In addition to the existing lack of care, patients with MRB are at further risk of being given lower priority for admission to rehabilitation facilities. Therefore, the Hygiene Commission of the German Society for Neurorehabilitation (DGNR) attempted to quantify the overall risk for deterioration of rehabilitation care due to the financial burden of MRB.

MATERIALS AND METHODS

To analyze the added costs associated with the rehabilitation of patients with MBR, the DGNR Hygiene Commission identified criteria for a cost assessment. Direct (consumables, personnel and miscellaneous costs) and indirect costs of loss of opportunity were evaluated in seven neurorehabilitation centers in different states across Germany.

RESULTS

On average, hygienic isolation measures amounted to direct costs of 144 € per day (47 € consumables, 92 € personnel, 5 € for other costs such as extra transportation expenditure) and indirect costs of 274 €, totaling 418 € per patient with MRB per day. Given that approximately 10% of patients had MRB, the added costs of hygienic isolation measures equaled about one tenth of the overall budget of a rehabilitation center and can be expected to rise with the increasing numbers of patients with MRB.

CONCLUSIONS

Admission of patients carrying MRB to neurorehabilitation centers triggers added costs that critically diminish the overall capacity for centers to provide their core rehabilitation services.

Indirect costs related to caregivers' absence from work after paediatric tonsil surgery

Tonsillotomy has gradually replaced tonsillectomy as the surgical method of choice in children with upper airway obstruction during sleep, because of less postoperative pain and a shorter recovery time. The aim of this study was to examine the costs related to caregivers' absenteeism from work after tonsillectomy (TE) and tonsillotomy (TT). All tonsillectomies and tonsillotomies in Sweden due to upper airway obstruction during 1 year, reported to the National Tonsil Surgery Register in children aged 1-11 were included, n = 4534. The number of days the child needed analgesics after surgery was used as a proxy to estimate the number of work days lost for the caregiver. Data from the Social Insurance Agency (Försäkringskassan) regarding the days the parents received temporary parental benefits in the month following surgery were also analysed. The indirect costs due to the caregivers' absenteeism after tonsillectomy vs tonsillotomy were calculated, using the human capital method. The patient-reported use of postoperative analgesic use was 77% (n = 3510). Data from the Social Insurance Agency were gathered for all 4534 children. The mean duration of analgesic treatment was 4.6 days (indirect cost of EUR 747). The mean number of days with parental benefits was 2.9 (EUR 667). The indirect cost of tonsillectomy was 61% higher than that of tonsillotomy (EUR 1010 vs EUR 629). The results show that the choice of surgical method affects the indirect costs, favouring the use of tonsillotomy over tonsillectomy for the treatment of children with SDB, due to less postoperative pain.

Indirect costs related to caregivers' absence from work after paediatric tonsil surgery

Tonsillotomy has gradually replaced tonsillectomy as the surgical method of choice in children with upper airway obstruction during sleep, because of less postoperative pain and a shorter recovery time. The aim of this study was to examine the costs related to caregivers' absenteeism from work after tonsillectomy (TE) and tonsillotomy (TT). All tonsillectomies and tonsillotomies in Sweden due to upper airway obstruction during 1 year, reported to the National Tonsil Surgery Register in children aged 1-11 were included, n = 4534. The number of days the child needed analgesics after surgery was used as a proxy to estimate the number of work days lost for the caregiver. Data from the Social Insurance Agency (Försäkringskassan) regarding the days the parents received temporary parental benefits in the month following surgery were also analysed. The indirect costs due to the caregivers' absenteeism after tonsillectomy vs tonsillotomy were calculated, using the human capital method. The patient-reported use of postoperative analgesic use was 77% (n = 3510). Data from the Social Insurance Agency were gathered for all 4534 children. The mean duration of analgesic treatment was 4.6 days (indirect cost of EUR 747). The mean number of days with parental benefits was 2.9 (EUR 667). The indirect cost of tonsillectomy was 61% higher than that of tonsillotomy (EUR 1010 vs EUR 629). The results show that the choice of surgical method affects the indirect costs, favouring the use of tonsillotomy over tonsillectomy for the treatment of children with SDB, due to less postoperative pain.

Catastrophic expenditure due to out-of-pocket health payments and its determinants in Colombian households

BACKGROUND

Out-of-pocket expenditure to pay for health services could result in financial catastrophe. The purpose of this study was to identify the incidence and determinants of catastrophic out-of-pocket payments for healthcare in Colombia. The underlying hypotheses are that low-income and non-insured population in Colombia, and households living in isolated and high level of rurality regions, are more likely to incur catastrophic healthcare expenses.

METHODS

This study used data from the Quality of Life National Survey conducted in Colombia in 2011. The presence of catastrophic healthcare spending was calculated using the methodology proposed by the World Health Organization in 2005. Households were classified as having catastrophic health spending when their out-of-pocket health payments were over 20 % of their payment capacity. All other households were classified as not having catastrophic health spending. A probit model was estimated aimed at determining what factors influence the probability of catastrophic healthcare spending.

RESULTS

Study findings show that 9.6 % of Colombian households had catastrophic expenditure. The incidence was higher in households in the Pacífica and Atlántica regions, extended and nuclear families, households with children or elderly adults, located in rural areas, and not insured under the healthcare system. The ratio of household members who work seems to reduce the risk of catastrophic healthcare spending, but the occurrence of any in-patient event increases it. So, there is no statistical evidence for rejecting the hypotheses under study.

CONCLUSIONS

Results indicate the importance of establishing intervention mechanisms in order to improve equity in access and payment for health care, protect vulnerable groups against financial risk, and, consequently, reduce the incidence of catastrophic healthcare spending. For this, it is essential to achieve universal health coverage through standardized and improved health services packages for vulnerable age groups and implement healthcare campaigns for households in rural areas where the incidence of out-of-pocket payments is higher.

[Biosimilars versus original biologics. Similarities and differences from development to approval]

BACKGROUND

Due to the expiry of patents for biological pharmaceuticals, in forthcoming years there will be an increase in the approval of biosimilars by the international health authorities. This will bring potential savings in the range of 11.8-33.4 billion euros in the European Union (EU) in the year 2020.

OBJECTIVES

The aims are an understanding of the natural variability of biological substances and the clinical relevance of the diverse product attributes, proof of comparability (similarity) as a self-contained concept in the development and approval of biosimilars and importance of extrapolation to other indications when comparability is demonstrated by comprehensive analytical and functional studies.

MATERIAL AND METHODS

This study involved an assessment of the regulations of the European licensing authority, the European Medicines Agency (EMA), with respect to the approval of biosimilars, analytical, physicochemical and biological procedures for determination of comparability and the permissible deviation from the reference product

RESULTS

Approved biological pharmaceuticals have a natural intrinsic variability, e.g. with respect to glycosylation. Furthermore, different batches in the manufacturing process can be different or the manufacturing process itself can be subject to change. Biosimilars are subject to specific and strict approval criteria with the aim of restricting the product attributes to lie within the variability range of the original biologics, can only show deviations from the original preparations within very narrow limits and must show proven safety, quality and effectiveness comparable to them.

DISCUSSION

The development and approval concept of biosimilars has been proven for nearly 10 years. Strict requirements by the EMA guarantee the highest quality standards, which have led to significant savings in the healthcare system and an expansion of access to biological pharmaceuticals in many countries and for many patients.

Bedside dressing changes for open abdomen in the intensive care unit is safe and time and staff efficient

Background

Patients with an open abdomen (OA) treated with temporary abdominal closure (TAC) need multiple surgical procedures throughout the hospital stay with repeated changes of the vacuum-assisted closure device (VAC changes). The aim of this study was to examine if using the intensive care unit (ICU) for dressing changes in OA patients was safe regarding bloodstream infections (BSI) and survival. Secondary aims were to evaluate saved time, personnel, and costs.

Methods

All patients treated with OA in the ICU from October 2006 to June 2014 were included. Data were retrospectively obtained from registered procedure codes, clinical and administrative patients’ records and the OR, ICU, anesthesia and microbiology databases. Outcomes were 30-, 60- and 90-day survival, BSI, time used and saved personnel costs.

Results

A total of 113 patients underwent 960 surgical procedures including 443 VAC changes as a single procedure, of which 165 (37 %) were performed in the ICU. Nine patients died before the first scheduled dressing change and six patients were closed at the first scheduled surgery after established OA, leaving 98 patients for further analysis. The mean duration for the surgical team performing a VAC change in the ICU was 63.4 (60.4–66.4) minutes and in the OR 98.2 (94.6–101.8) minutes (p < 0.001). The mean duration for the anesthesia team in the OR was 115.5 minutes, while this team was not used in the ICU. Personnel costs were reduced by €682 per procedure when using the ICU. Forty-two patients had all the VAC changes done in the OR (VAC-OR), 22 in the ICU (VAC-ICU) and 34 in both OR and ICU (VAC-OR/ICU). BSI was diagnosed in eight (19 %) of the VAC-OR patients, seven (32 %) of the VAC-ICU and eight (24 %) of the VAC-OR/ICU (p = 0.509). Thirty-five patients (83 %) survived 30 days in the VAC-OR group, 17 in the VAC-ICU group (77 %) and 28 (82 %) in the VAC-OR/ICU group (p = 0.844).

Conclusions

VAC change for OA in the ICU saved time for the OR team and the anesthesia team compared to using the OR, and it reduced personnel costs. Importantly, the use of ICU for OA dressing change seemed to be as safe as using the OR.

Cost-effectiveness of providing patients with information on managing mild low-back symptoms in an occupational health setting

BACKGROUND

Evidence shows that low back specific patient information is effective in sub-acute low back pain (LBP), but effectiveness and cost-effectiveness (CE) of information in early phase symptoms is not clear. We assessed effectiveness and CE of patient information in mild LBP in the occupational health (OH) setting in a quasi-experimental study.

METHODS

A cohort of employees (N = 312, aged <57) with non-specific, mild LBP (Visual Analogue Scale between 10-34 mm) was selected from the respondents of an employee survey (N = 2480; response rate 71 %). A random sample, representing the natural course of LBP (NC, N = 83; no intervention), was extracted as a control group. Remaining employees were invited (181 included, 47 declined, one excluded) into a randomised controlled study with two 1:1 allocated parallel intervention arms ("Booklet", N = 92; "Combined", N = 89). All participants received the "Back Book" patient information booklet and the Combined also an individual verbal review of the booklet. Physical impairment (PHI), LBP, health care (HC) utilisation, and all-cause sickness absence (SA) were assessed at two years. CE of the interventions on SA days was analysed by using direct HC costs in one year, two years from baseline. Multiple imputation was used for missing values.

RESULTS

Compared to NC, the Booklet reduced HC costs by 196€ and SA by 3.5 days per year. In 81 % of the bootstrapped cases the Booklet was both cost saving and effective on SA. Compared to NC, in the Combined arm, the figures were 107€, 0.4 days, and 54 %, respectively. PHI decreased in both interventions.

CONCLUSIONS

Booklet information alone was cost-effective in comparison to natural course of mild LBP. Combined information reduced HC costs. Both interventions reduced physical impairment. Mere booklet information is beneficial for employees who report mild LBP in the OH setting, and is also cost saving for the health care system.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00908102.

Current evidence and future research needs for FeNO measurement in respiratory diseases

Although not yet widely implemented, fraction of exhaled nitric oxide (FeNO) has emerged in recent years as a potentially useful biomarker for the assessment of airway inflammation both in undiagnosed patients with non-specific respiratory symptoms and in those with established airway disease. Research to date essentially suggests that FeNO measurement facilitates the identification of patients exhibiting T-helper cell type 2 (Th2)-mediated airway inflammation, and effectively those in whom anti-inflammatory therapy, particularly inhaled corticosteroids (ICS), is beneficial. In some studies, FeNO-guided management of patients with established airway disease is associated with lower exacerbation rates, improvements in adherence to anti-inflammatory therapy, and the ability to predict risk of future exacerbations or decline in lung function. Despite these data, concerns regarding the applicability and utility of FeNO in clinical practice still remain. This article reviews the current evidence, both supportive and critical of FeNO measurement, in the diagnosis and management of asthma and other inflammatory airway diseases. It additionally provides suggestions regarding the practical application of FeNO measurement: how it could be integrated into routine clinical practice, how its utility could be assessed and its true value to both clinicians and patients could be established. Although some unanswered questions remain, current evidence suggests that FeNO is potentially a valuable tool for improving the personalised management of inflammatory airway diseases.