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Background: Increasing cancer drug prices are a challenge for patients and health systems in the USA and Europe. By contrast with the USA, national authorities in European countries often directly negotiate drug prices with manufacturers. The American Society of Clinical Oncology (ASCO) and the European Society for Medical Oncology (ESMO) developed frameworks to evaluate the clinical value of cancer therapies: the ASCO-Value Framework (ASCO-VF) and the ESMO-Magnitude of Clinical Benefit Scale (ESMO-MCBS). We aimed to assess the association between the clinical benefit of approved cancer drugs based on these frameworks and their drug prices in the USA and four European countries (England, Switzerland, Germany, and France). Methods: For this cost–benefit analysis, we identified all new drugs with initial indications for adult cancers that were approved by the US Food and Drug Administration between Jan 1, 2009, and Dec 31, 2017, and by the European Medicines Agency up until Sept 1, 2019. For drugs indicated for solid tumours, we assessed clinical benefit using ASCO-VF and ESMO-MCBS. We compared monthly drug treatment costs between benefit levels using hierarchical linear regression models, and calculated Spearman's correlation coefficients between costs and benefit levels for individual countries. Findings: Our cohort included 65 drugs: 47 (72%) drugs were approved for solid tumours and 18 (28%) were approved for haematological malignancies. The monthly drug treatment costs in the USA were a median of 2·31 times (IQR 1·79–3·17) as high as in the assessed European countries. There were no significant associations between monthly treatment costs for solid tumours and clinical benefit in all assessed countries, using the ESMO-MCBS (p=0·16 for the USA, p=0·98 for England, p=0·54 for Switzerland, p=0·52 for Germany, and p=0·40 for France), and for all assessed countries except France using ASCO-VF (p=0·56 for the USA, p=0·47 for England, p=0·26 for Switzerland, p=0·23 for Germany, and p=0·037 for France). Interpretation: Cancer drugs with low or uncertain clinical benefit might be prioritised for price negotiations. Value frameworks could help identify therapies providing high clinical benefit that should be made rapidly available across countries. Funding: Swiss Cancer Research Foundation (Krebsforschung Schweiz). © 2020 Elsevier Ltd

Zunehmend etablieren sich minimal-invasive Verfahren in der Varizenbehandlung. Die kurz- bis mittelfristigen Ergebnisse der endovenösen Verfahren sind gut: Die Erfolgsraten sind vergleichbar mit dem chirurgischen Stripping, die Rehabilitationszeiten und Komplikationsraten sind jedoch besser. Die höchste Erfolgsrate verzeichnet bislang die endovenöse Lasertherapie (EVLT). Die endovenöse Radiofrequenzobilateration (RFO) hat jedoch grosse Fortschritte gemacht und erzielt mittlerweile ähnlich gute Kurzzeitergebnisse bei einem besseren Nebenwirkungsprofil. Die ultraschallgesteuerte Schaumsklerosierung hat die Sklerosierungsverfahren mit flüssigem Agenz verdrängt. Prinzipiell kann dieses Verfahren mit allen anderen kombiniert werden. Als Monotherapie verliert die Schaumsklerosierung gegenüber den thermoablativen Verfahren EVLT und RFO jedoch klar an Stellenwert, da die mittelfristigen Ergebnisse schlechter sind. Um eine evidenzbasierte Rangfolge festzulegen, sind prospektive randomisierte Vergleichsstudien notwendig. Die minimale Invasivität ermöglicht eine ambulante Behandlung. Ob sie damit auch kostengünstiger ist, bleibt abzuwarten.

Item does not contain fulltext BACKGROUND: Incidence of malignant skin lesions is rising in Switzerland. We wanted to assess the frequency of patients with suspicious skin lesions in daily practice. Furthermore, we asked for diagnostic certainty and the need of further education in skin cancer. METHODS: Survey with 1212 GPs in the canton of Zurich, descriptive analysis, regression analysis. RESULTS: Response rate 41,4%. 23,2% of the GPs saw daily/weekly patients with suspicious skin lesions, another 34,8% monthly. 79,0% reported need for further education in skin cancer. This need was lower in urban GPs and in GPs with higher diagnostic certainty. CONCLUSIONS: GPs saw relatively often patients with suspicious skin lesions. Despite high diagnostic certainty, there was a clear need for further education in skin cancer.

Two hundred and fifty seven male Caucasian ultraendurance athletes were recruited, pre-race, before different swimming, cycling, running and triathlon races. Fat mass and skeletal muscle mass were estimated using bioelectrical impedance analysis (BIA) and anthropometric methods in order to investigate whether the use of BIA or anthropometry would be useful under field conditions. Total body fat estimated using BIA was significantly high (P < 0.001) compared with anthropometry. When the results between BIA and anthropometry were compared, moderate to low levels of agreement were found. These results were in accordance with the differences found in the Bland-Altman analysis, indicating that the anthropometric equation of Ball et al. had the highest level of agreement (Bias = -3.0 ± 5.8 kg) with BIA, using Stewart et al. (Bias = -6.4 ± 6.3 kg), Faulkner (Bias = -4.7 ± 5.8 kg) and Wilmore-Siri (Bias = -4.8 ± 6.2 kg). The estimation of skeletal muscle mass using BIA was significantly (P < 0.001) above compared with anthropometry. The results of the ICC and Bland-Altman method showed that the anthropometric equation from Lee et al. (Bias = -5.4 ± 5.3 kg) produced the highest level of agreement. The combined method of Janssen et al. between anthropometry and BIA showed a lower level of agreement (Bias = -12.5 ± 5.7 kg). There was a statistically significant difference between the results derived from the equation of Lee et al. and Janssen et al. (P < 0.001). To summarise, the determination of body composition in ultra-endurance athletes using BIA reported significantly high values of fat and skeletal muscle mass when compared with anthropometric equations.

Die Arthrose ist die haufigste Gelenkaffektion des Menschen. Frauen sind in etwa doppelt so haufig betroffen wie Manner. Es wird erwartet dass die Inzidenz und Pravalenz in den nachsten Jahren weiter deutlich ansteigen wird. In der Therapie sollten zunachst alle allgemeinen Masnahmen ausgeschopft werden. Hierzu zahlen sowohl geeignete bzw. modifizierte Schuhe, Gehstocke sowie weitere orthopadietechnische Verfahren. Wichtigster beeinflussbarer Risikofaktor ist das Korpergewicht, hier muss ebenso an die Eigenverantwortlichkeit des Patienten fur die Progression seiner Erkrankung appelliert werden wie bei der korperlichen Aktivitat. Physikalische Masnahmen sollten die Therapie begleiten, obgleich fur viele haufig zum Einsatz kommende Masnahmen keine sehr gute Evidenz aus klinischen Studien vorliegt. Ahnliches gilt fur die Akupunktur, die bei der Kniegelenksarthrose zum Einsatz kommen sollte, obgleich die Frage des Wirkmechanismus nicht geklart ist. Die intraartikulare Applikation von Corticoiden kann in Einzelfallen beim akut entzundeten Kniegelenk unter streng aseptischen Bedingungen zum Einsatz kommen. Abzulehnen sind Ultraschallwellentherapien, Magnetfeldtherapien, Diathermie und Stoswellenbehandlungen. Umstellungsosteotomien kommen bei statischen Fehlbelastungen in Frage. Der definitive Gelenkersatz mittels Totalendoprothese ist eine im Hinblick auf Schmerzreduktion und Funktionsverbesserung gut belegte Intervention, sollte aber erst nach frustranem Ausschopfen aller anderen Optionen in Erwagung gezogen werden. Ob hier minimalinvasive oder roboterassistierte Verfahren uberlegen sind, lasst die derzeitige Datenlage nicht beantworten.

Hintergrund Fur Arthrosepatienten ist der Hausarzt primarer Ansprechpartner und „Lotse“ im Gesundheitssystem. Eine deutsche Leitlinie fur den hausarztlichen Sektor existiert bislang nicht. Ziel der vorliegenden Arbeit war es, das hausarztliche Vorgehen bezuglich Diagnostik, Therapie und Uberweisungen an Orthopaden zu untersuchen.

BACKGROUND The importance of electronic medical records for the healthcare system is well documented. IT enables easy storage, communication and decision support and can provide important tools in the care of chronically ill patients in the form of a reminder system. METHODS A questionnaire was developed and send out to 1200 physicians extracted from the official data base. After four weeks the non-responders received a written reminder. Data collection started in December 2007 and was completed in February 2008. RESULTS 719 questionnaires were received back, representing a response rate of 59.9%. The data revealed a significant underuse of electronic medical records (EMRs) and IT compared to other European countries. Smaller practices, older physicians and especially primary care physicians tended to use less EMR. Only 10.2% of all physicians declared an interest in considering investment in IT in the next three years, 66.9% expressly denied wishing to do so. The most important barriers were the costs, the unclear benefit and a feared worsening of the doctor-patient-communication during consultation. CONCLUSION IT and especially EMRs are underused in daily ambulatory care in Switzerland. To increase the use of EMRs, several approaches could be helpful. First of all, the benefit of EMRs in daily routine care have to be increased as, for example, by decision support systems, tools to avoid pharmaceutical interactions and reminder systems to enable a proactive treatment of chronically ill patients. Furthermore, adequate approaches to offer appropriate reimbursement for the financial investments have to considered such as an additional payment for electronically generated, evidence based quality indicators.

Das Gesundheitsschiff (GS) bietet im Rahmen einer Kreuzfahrt die Möglichkeit medizinischer Check-ups. Gesundheitszustand und -verhalten in den vorangegangenen 12 Monaten wurden bei den Teilnehmern mittels Fragebogen erfasst und im Querschnitt mit den Teilnehmern der repräsentativen Schweizerischen Gesundheitsbefragung (SGB) verglichen. Die Teilnahmequote betrug 74.6% (n = 206). Alkohol- und Tabakkonsum waren geringer und die Nutzung medizinischer (Vorsorge-)Leistungen (Anzahl Arztkontakte, Messung von Blutzucker und Cholesterin, Mammographien bei Frauen) waren häufiger bei der GS-Population im Vergleich zu Teilnehmern der SGB. Diese Unterschiede geben Hinweise, dass es sich bei den GS-Teilnehmern um eine positive Selbstselektion von Personen mit niedrigem Gesundheitsrisiko handelt. Ein zusätzlicher Gesundheitsnutzen durch medizinische Check-ups erscheint in diesem Rahmen daher zumindest fragwürdig.

Contains fulltext : 81581.pdf (Publisher’s version ) (Closed access) BACKGROUND: Osteoarthritis (OA) has a high prevalence in primary care. Patient satisfaction is an important indicator for the quality of care provided to OA patients. Little is known about satisfaction of patients with this condition in a primary care setting in Germany. The aim of the study was to assess current satisfaction of patients and reveal possible disease and quality of life related predictors. METHODS/DESIGN: Seventy-five German GPs approached 1250 patients with OA consecutively. Sociodemographics, OA-specific quality of life (GERMAN-AIMS2-SF), co-morbidities and depression (using PHQ-9) were assessed. Patient satisfaction was measured by means of the European Task Force on Patient Evaluations of General Practice (EUROPEP) instrument. A stepwise linear regression analysis with the EUROPEP score as dependent variable controlled for the amount of GP visits was performed to assess predictors of satisfaction. RESULTS: A total of 1021 OA patients returned the questionnaire. The adjusted R(2) of the final model was 0.270 (P < 0.001). The main predictors were the PHQ-9 score (beta = -0.372; P < 0.001), age (beta = -0.185; P < 0.001), living alone (beta = -0.209; P < 0.001) and number of co-morbidities (beta = -0.152; P < 0.001). The only disease-related factor which remained as predictor of patient satisfaction was duration of OA (beta = -0.105; P = 0.008). DISCUSSION: The finding that depression and social factors are more important for patient satisfaction with provided care than disease-related aspects suggests that these factors need to be considered carefully in treatment. This represents a big challenge within an increasingly specialized health care system. The General Practitioner as the regular and first-choice provider of health care seems to be the most appropriate instance who can accomplish this.

Medikament der ersten Wahl in der Therapie der Arthrose ist Paracetamol, da es das beste Nutzen/Risikoprofil besitzt. Nicht steroidale Antirheumatika (NSAR) sind etwas starker analgetisch wirksam und besitzen zudem eine antiphlogistische Komponente, ihr Einsatz sollte jedoch zeitlich immer eng begrenzt sein und im Wesentlichen der akut-entzundlichen Arthritis vorbehalten bleiben. Mittel der Wahl ist hierbei Diclofenac. Gemas der derzeitigen Datenlage sollte bei Patienten mit einem erhohten Gastrointestinalen Risiko eine Kombinationstherapie aus einem traditionellen NSAR und einem Protonenpumpenhemmer erfolgen. Alternativ konnen Coxibe zum Einsatz kommen, sofern keine Kontraindikationen vorliegen. Coxibe und traditionelle NSAR - auser dem ASS und eventuell dem Naproxen - sind mit einem erhohten kardiovaskularen Risiko assoziiert. Daher sollten diese Substanzen bei Patienten mit kardiovaskularen Risikofaktoren nicht oder nur nach strengster Indikationsstellung zum Einsatz kommen. Opiode haben bei kritischer Indikationsstellung ihre berechtige Stellung in der Arthrosetherapie. Sie sollten Bestandteil eines Schmerzregimes sein, das ein Schmerztagebuch und regelmasige Reevaluationen beinhaltet. Wichtig ist, dem Patienten das Ziel der medikamentosen Therapie, die Aufrechterhaltung der fur die Gelenkfunktion bedeutsamen korperlichen Aktivitat deutlich zu machen. Aufgrund der haufigen Selbstmedikation und der Inanspruchnahme von alternativmedizinischen Heilverfahren sollten auch diese Elemente im Therapiekonzept berucksichtigt werden. Ebenso wie eine begleitende Depression, die wie bei vielen chronischen Erkrankungen auch unter Arthrosepatienten gehauft auftritt.

Contains fulltext : 69029.pdf (Publisher’s version ) (Closed access) OBJECTIVE: Pain represents one of the most important predictors of quality of life in patients with osteoarthritis (OA). Prior studies were conducted in hospital settings and/or failed to control important factors such as depression, obesity, or physical activity. Therefore, the aim of the study was to determine factors associated with pain intensity in a large sample of OA patients in primary care. DESIGN: Cross-sectional survey with a questionnaire containing sociodemographic data, the short form of the Arthritis Impact Measurement Scale (AIMS2-SF), and the Patient Health questionnaire, to assess concomitant depression. A hierarchical stepwise multiple regression analysis with the AIMS2-SF dimension "symptom" reflecting patients' pain intensity as the dependent variable was performed. PATIENTS: 1,021 patients form 75 primary care practices. RESULTS: In the regression model four factors remained, explaining 46.5% of the variation in the dependent variable (P < 0.001): Severity of depression reflected in the PHQ-9 score showed the strongest association with pain intensity (beta = 0.459, P < 0.001). Functional disability of the lower limb achieved a beta of 0.427 (P = 0.003). A low educational level was associated with increased pain scores (beta = -0.321; P = 0.034), as well as a weak social network, (beta = 0.211; P = 0.042). CONCLUSIONS: A variety of physical and psychological factors were associated with pain intensity. Appropriate pain treatment of OA patients in primary care should consider as many of these factors as possible. Further research is needed to assess if a more comprehensive and proactive approach will result in less pain and in increased quality of life.

Item does not contain fulltext OBJECTIVE: In patients with osteoarthritis (OA), moderate physical activity (PA) can reduce the progress of joint damage. PA is therefore an important target of in the non-surgical treatment of OA. To know about factors associated with PA can increase the success of interventions aiming at increasing PA. The aim of the study was to determine predictors of PA in patients suffering from OA to the hip or to the knee. METHODS: In total, 1250 outpatients from 75 general practices were consecutively approached, 1021 returned questionnaires containing sociodemographic data, and short forms of the International Physical Activity Questionnaire (IPAQ), the Arthritis Impact Measurement Scale and the Patient Health Questionnaire to assess concomitant depression. A hierarchical stepwise multiple linear regression analysis with the IPAQ continuous score as dependent variable was performed. RESULTS: Comparison of our findings with General population suggests that the overall PA of OA patients is decreased. Main predictors of PA were physical limitation to the lower body (beta = -0.179; P = 0.001), social contacts (P = -0.134; P < 0.001), pain (beta =-0.120; P = 0.001), age (beta = -0.110; P = 0.004) and the body mass index (beta =-0.043; P < 0.001). CONCLUSION: The findings emphasize the influence of physical as well as psychosocial factors on PA of patients with OA and should help to tailor future interventions more appropriately. Further research is needed to determine if these tailored interventions will result in better compliance and in increased PA.