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International audience; OBJECTIVES: Patients waking up with stroke symptoms are often excluded from intravenous thrombolysis with alteplase (IV-tpa). The WAKE-UP trial, a European multicenter randomized controlled trial, proved the clinical effectiveness of magnetic resonance imaging-guided IV-tpa for these patients. This analysis aimed to assess the cost-effectiveness of the intervention compared to placebo. METHODS: A Markov model was designed to analyze the cost-effectiveness over a 25-year time horizon. The model consisted of an inpatient acute care phase and a rest-of-life phase. Health states were defined by the modified Rankin Scale (mRS). Initial transition probabilities to mRS scores were based on WAKE-UP data and health state utilities on literature search. Costs were based on data from the University Medical Center Hamburg-Eppendorf, literature, and expert opinion. Incremental costs and effects over the patients' lifetime were estimated. The analysis was conducted from a formal German healthcare perspective. Univariate and probabilistic sensitivity analyses were performed. RESULTS: Treatment with IV-tpa resulted in cost savings of €51 009 and 1.30 incremental gains in quality-adjusted life-years at a 5% discount rate. Univariate sensitivity analysis revealed incremental cost-effectiveness ratio being sensitive to the relative risk of favorable outcome on mRS for placebo patients after stroke, the costs of long-term care for patients with mRS 4, and patient age at initial stroke event. In all cases, IV-tpa remained cost-effective. Probabilistic sensitivity analysis proved IV-tpa cost-effective in \textgreater95% of the simulations results. CONCLUSIONS: Magnetic resonance imaging-guided IV-tpa compared to placebo is cost-effective in patients with ischemic stroke with unknown time of onset.

Zusammenfassung Ziel Die Depression ist eine weit verbreitete Erkrankung, die hohe Kosten verursacht. Ziel dieser Arbeit war es, eine systematische Übersicht über Krankheitskostenstudien der Depression in Deutschland zu erstellen. Methoden Es wurde eine systematische Literaturrecherche von Bottom-up-Krankheitskostenstudien der Depression in Deutschland durchgeführt. Die eingeschlossenen Studien berichteten Kosten der Versorgung von Erwachsenen in mindestens einem Versorgungssektor (ambulant, stationär) oder gesamte medizinische Kosten. Sie wurden nach der Art ihrer Kostenberechnung in 3 Gruppen (Gesamtkostenstudien, krankheitsspezifische Kostenstudien, Exzess-Kostenstudien) unterteilt. Ergebnisse Je nach Art der Kostenberechnung lagen die angegebenen durchschnittlichen jährlichen gesamten Kosten der medizinischen Versorgung pro Patient zwischen 400–3300 € bei krankheitsspezifischen Kostenstudien, ca. 3000 € bei Exzess-Kostenstudien und zwischen 3000–5000 € bei Gesamtkostenstudien. Angaben zu indirekten Kosten fehlten in fast allen Studien. Schlussfolgerung Depressionen in Deutschland sind mit hohen Kosten assoziiert, aber insbesondere die indirekten Kosten wurden in der Literatur bisher kaum untersucht und sollten eingehender bearbeitet werden.

ObjectiveTo determine patient-reported health-related quality of life (HRQOL) after stroke thrombectomy in clinical practice and to identify predictors of better HRQOL by analyzing data of 504 consecutive patients treated in a large university stroke center.MethodsAll patients with stroke treated by thrombectomy (June 2015–October 2018) were prospectively enrolled in this observational study. At 90 days, functional outcome was assessed by the modified Rankin Scale (mRS) and patient-reported HRQOL was assessed by the EuroQol Group 5-Dimension (EQ-5D) self-report questionnaire, consisting of 5 health domains. The EQ-5D utility index (EQ-5D-I) score (−0.594 to 1.00, with higher values indicating better HRQOL) was calculated. Linear regression analysis was applied to identify predictors of better HRQOL (higher EQ-5D-I score).ResultsOf 504 patients (median age 76 years, 51.8% female), the mean EQ-5D-I score was 0.39 (SD 0.44). The proportion of stroke survivors who reported complaints in the different domains decreased from 66% in Usual Activities to 57% in Mobility, 50.4% in Self-Care, 41.7% in Pain/Discomfort, and 40.8% Anxiety/Depression. Lower age, lower prestroke mRS score, lower baseline NIH Stroke Scale score, higher Alberta Stroke Program Early CT Score, concomitant thrombolysis therapy, and a successful recanalization were independent predictors of better HRQOL.ConclusionsPatient-reported HRQOL provides a more comprehensive assessment of stroke outcome than the mRS score. Health domains involving motor function most frequently showed complaints in HRQOL after stroke thrombectomy, while a large proportion of patients did not report any complaints across the different health domains. Predictors of better HRQOL closely match the predictors of better functional outcome measured by the mRS in other thrombectomy studies.

Background: Dementia is one of the costliest diseases for health care systems with growing importance for policy makers. Objective: The aim of this study is to systematically review the current literature of excess cost studies for dementia and to analyze excess costs in a meta-analysis. Methods: A systematic literature search was conducted in PubMed, EconLit, NHS-EED, and Cochrane Library. 22 studies were included and assigned to one of three subgroups according to the time period that they analyzed during disease progression: the time of diagnosis, the time between diagnosis and death, and the time prior to death. Excess costs were analyzed using the ratio of means (ROM) and meta-analysis was performed by pooling ROMs in a random effects model. Results: Total costs were significantly higher for demented persons compared to non-demented persons at the time of diagnosis (ROM: 2.08 [1.71, 2.54], p

Anxiety disorders (AD) are common mental disorders, for which several cost-of-illness (COI) studies have been conducted in the past. The aim of this review was to provide a systematic overview of these studies and an aggregation of their results. A systematic literature search limited to studies published after 1999 was conducted in PubMed/MEDLINE in November 2018. We included top-down COI studies reporting costs for AD, and bottom-up COI studies reporting costs for AD and a non-diseased control group, and extracted data manually. Results of the top-down COI studies were aggregated by calculating the mean percentage of costs on gross domestic product (GDP) and health expenditure, while the results of the bottom-up studies were analyzed meta-analytically using the ‘ratio of means’ method and inverse-variance pooling. In this review, the logarithm of the relative difference in a continuous outcome between two groups is calculated and aggregated over the studies. The results can be interpreted as the relative change in costs imposed by a specific disease compared with baseline costs. We identified 13 top-down and 11 bottom-up COI studies. All top-down COI studies and four bottom-up COI studies reported costs for AD as a diagnostic group, four for generalized anxiety disorder (GAD), four for social anxiety disorder (SAD), and one for panic disorder. In top-down COI studies, direct costs of AD, on average, corresponded to 2.08% of health care costs and 0.22% of GDP, whereas indirect costs, on average, corresponded to 0.23% of GDP. In bottom-up COI studies, direct costs of patients with AD were increased by factor 2.17 (1.29–3.67; p = 0.004) and indirect costs were increased by factor 1.92 (1.05–3.53; p = 0.04), whereas total costs increased by factor 2.52 (1.73–3.68; p

ObjectivesThe objectives of this study were to estimate the direct and indirect excess costs of type 2 diabetes mellitus (T2D) using data representative for the German adult population and to investigate the association of sociodemographic and clinical determinants with these excess costs.SettingWe calculated mean annual costs for individuals with T2D and a control group without diabetes, using data on healthcare utilisation and productivity losses from the cross-sectional German Health Interview and Examination Survey for Adults. We adjusted for group differences using entropy balancing and estimated excess costs for total, direct, indirect costs and additional cost categories using generalised linear models. We performed subgroup analyses to investigate the association of sociodemographic (age, sex and education) and clinical determinants (diabetes duration, glycaemic index and complications) with excess costs.ParticipantsThe final study sample included n=325 individuals with T2D and n=4490 individuals without diabetes in the age between 18 and 79 years.ResultsTotal excess costs amounted to €927, of which €719 were attributable to direct and €209 to indirect excess costs. Total costs were significantly increased by 28% for T2D compared with controls. Group differences in direct, outpatient and medication costs were statistically significant. Medication costs were 88% higher for T2D and had the highest share in direct excess costs. With respect to specific determinants, direct excess costs ranged from €203 for 4–10 years diabetes duration to €1405 for diabetes complications. Indirect excess costs ranged from €−544 for >10 years diabetes duration to €995 for high education.ConclusionsT2D was associated with high costs, mainly due to direct costs. As pointed out by our results, diabetes complications and comorbidities have a large impact on the costs, leaving medication costs as main contributor of T2D excess costs.

Introduction The aim of this study was to estimate excess costs of depression in Germany and to examine the influence of sociodemographic and socioeconomic determinants. Methods Annual excess costs of depression per patient were estimated for the year 2019 by comparing survey data of individuals with and without self-reported medically diagnosed depression, representative for the German population aged 18–79 years. Differences between individuals with depression (n = 223) and without depression (n = 4540) were adjusted using entropy balancing. Excess costs were estimated using generalized linear model regression with a gamma distribution and log-link function. We estimated direct (inpatient, outpatient, medication) and indirect (sick leave, early retirement) excess costs. Subgroup analyses by social determinants were conducted for sex, age, socioeconomic status, first-generation or second-generation migrants, partnership, and social support. Results Total annual excess costs of depression amounted to €5047 (95% confidence interval [CI] 3214–6880) per patient. Indirect excess costs amounted to €2835 (1566–4103) and were higher than direct excess costs (€2212 [1083–3341]). Outpatient (€498), inpatient (€1345), early retirement (€1686), and sick leave (€1149) excess costs were statistically significant, while medication (€370) excess costs were not. Regarding social determinants, total excess costs were highest in the younger age groups (€7955 for 18–29-year-olds, €9560 for 30–44-year-olds), whereas total excess costs were lowest for the oldest age group (€2168 for 65+) and first-generation or second-generation migrants (€1820). Conclusions Depression was associated with high excess costs that varied by social determinants. Considerable differences between the socioeconomic and sociodemographic subgroups need further clarification as they point to specific treatment barriers as well as varying treatment needs. Supplementary Information The online version contains supplementary material available at 10.1007/s40273-021-01000-1.

IntroductionHealthcare systems around the world are looking for solutions to the growing problem of mental disorders. RECOVER is the synonym for an evidence-based, stepped and cross-sectoral coordinated care service model for mental disorders. RECOVER implements a cross-sectoral network with managed care, comprehensive psychological, somatic and social diagnostics, crisis resolution and a general structure of four severity levels, each with assigned evidence-based therapy models (eg, assertive community treatment) and therapies (eg, psychotherapy). The study rationale is the investigation of the effectiveness and efficiency of stepped and integrated care in comparison to standard care.Methods and analysisThe trial is conducted in accordance to the Standard Protocol Items: Recommendations for Interventional Trials Statement. The study aims to compare the RECOVER model with treatment as usual (TAU). The following questions are examined: Does RECOVER reduce healthcare costs compared with TAU? Does RECOVER improve patient-relevant outcomes? Is RECOVER cost-effective compared with TAU? A total sample of 890 patients with mental disorders will be assessed at baseline and individually randomised into RECOVER or TAU. Follow-up assessments are conducted after 6 and 12 months. As primary outcomes, cost reduction, improvement in symptoms, daily functioning and quality of life as well as cost-effectiveness ratios will be measured. In addition, several secondary outcomes will be assessed. Primary and secondary outcomes are evaluated according to the intention-to-treat principle. Mixed linear or logistic regression models are used with the direct maximum likelihood estimation procedure which results in unbiassed estimators under the missing-at-random assumption. Costs due to healthcare utilisation and productivity losses are evaluated using difference-in-difference regressions.Ethics and disseminationEthical approval from the ethics committee of the Hamburg Medical Association has been obtained (PV5672). The results will be disseminated to service users and their families via the media, to healthcare professionals via professional training and meetings and to researchers via conferences and publications.Trial registration number and registry nameClinicalTrials.gov (NCT03459664), RECOVERProtocol version19 March 2020 (V.3.0)

Cancer patients in Germany often face payments related to their disease or treatment which are not covered by their health insurance. The aim of this study was to analyze the amount of out-of-pocket payments (OOPPs) among cancer patients in Germany, to explore potential socioeconomic determinants of OOPPs, and to identify how cancer patients are burdened by these payments. Cancer ptients were consecutively enrolled in 16 clinics in Leipzig, Germany. Data on OOPPs for the past 3 months and on socioeconomic status were obtained at the end of their hospital stay (t0) and 3 (t1) and 15 months (t2) after t0. Financial burden was calculated by dividing the monthly OOPPs by the midpoint of the income category, and the perceived burden was assessed by using the financial difficulties scale of the EORTC QLQ-C30. A two-part regression model was used to estimate the determinants of OOPPs. At baseline (t0), 502 cancer patients participated in the study and provided data on OOPPs and socioeconomic status. The mean 3-month OOPPs were the following: €205.8 at baseline, €179.2 at t1, and €148.1 at t2. Compared to the lowest income group (

Zusammenfassung Ziel der Studie Entwicklung eines Instruments zur Erfassung der Leistungsinanspruchnahme bei psychischen Erkrankungen. Methodik Es wurde nach Leistungen zur Versorgung von Menschen mit psychischen Erkrankungen recherchiert. Häufig in Anspruch genommene Leistungen wurden zu Leistungskomplexen zusammengefasst. Ergebnisse Der FIMPsy ermöglicht die retrospektive Erfassung der Inanspruchnahme medizinischer und nicht medizinischer Leistungen bei Patienten mit psychischen Erkrankungen über einen Zeitraum von 6 Monaten. Schlussfolgerung Der FIMPsy deckt weite Bereiche der Versorgung von Menschen mit psychischen Erkrankungen ab und kann in ökonomischen Evaluationsstudien eingesetzt werden.

The Hamburg City Health Study (HCHS) is a large, prospective, long-term, population-based cohort study and a unique research platform and network to obtain substantial knowledge about several important risk and prognostic factors in major chronic diseases. A random sample of 45,000 participants between 45 and 74 years of age from the general population of Hamburg, Germany, are taking part in an extensive baseline assessment at one dedicated study center. Participants undergo 13 validated and 5 novel examinations primarily targeting major organ system function and structures including extensive imaging examinations. The protocol includes validate self-reports via questionnaires regarding lifestyle and environmental conditions, dietary habits, physical condition and activity, sexual dysfunction, professional life, psychosocial context and burden, quality of life, digital media use, occupational, medical and family history as well as healthcare utilization. The assessment is completed by genomic and proteomic characterization. Beyond the identification of classical risk factors for major chronic diseases and survivorship, the core intention is to gather valid prevalence and incidence, and to develop complex models predicting health outcomes based on a multitude of examination data, imaging, biomarker, psychosocial and behavioral assessments. Participants at risk for coronary artery disease, atrial fibrillation, heart failure, stroke and dementia are invited for a visit to conduct an additional MRI examination of either heart or brain. Endpoint assessment of the overall sample will be completed through repeated follow-up examinations and surveys as well as related individual routine data from involved health and pension insurances. The study is targeting the complex relationship between biologic and psychosocial risk and resilience factors, chronic disease, health care use, survivorship and health as well as favorable and bad prognosis within a unique, large-scale long-term assessment with the perspective of further examinations after 6 years in a representative European metropolitan population. Electronic supplementary material The online version of this article (10.1007/s10654-019-00577-4) contains supplementary material, which is available to authorized users.

Aims Major depressive disorders are highly prevalent in the world population, contribute substantially to the global disease burden and cause high health care expenditures. Information on the economic impact of depression, as provided by cost-of-illness (COI) studies, can support policymakers in the decision-making regarding resource allocation. Although the literature on COI studies of depression has already been reviewed, there is no quantitative estimation of depression excess costs across studies yet. Our aims were to systematically review COI studies of depression with comparison group worldwide and to assess the excess costs of depression in adolescents, adults, elderly, and depression as a comorbidity of a primary somatic disease quantitatively in a meta-analysis. Methods We followed the PRISMA reporting guidelines. PubMed, PsycINFO, NHS EED, and EconLit were searched without limitations until 27/04/2018. English or German full-text peer-reviewed articles that compared mean costs of depressed and non-depressed study participants from a bottom-up approach were included. We only included studies reporting costs for major depressive disorders. Data were pooled using a random-effects model and heterogeneity was assessed with I2 statistic. The primary outcome was ratio of means (RoM) of costs of depressed v. non-depressed study participants, interpretable as the percentage change in mean costs between the groups. Results We screened 12 760 articles by title/abstract, assessed 393 articles in full-text and included 48 articles. The included studies encompassed in total 55 898 depressed and 674 414 non-depressed study participants. Meta-analysis showed that depression was associated with higher direct costs in adolescents (RoM = 2.79 [1.69–4.59], p < 0.0001, I2 = 87%), in adults (RoM = 2.58 [2.01–3.31], p < 0.0001, I2 = 99%), in elderly (RoM = 1.73 [1.47–2.03], p < 0.0001, I2 = 73%) and in participants with comorbid depression (RoM = 1.39 [1.24–1.55], p < 0.0001, I2 = 42%). In addition, we conducted meta-analyses for inpatient, outpatient, medication and emergency costs and a cost category including all other direct cost categories. Meta-analysis of indirect costs showed that depression was associated with higher costs in adults (RoM = 2.28 [1.75–2.98], p < 0.0001, I2 = 74%). Conclusions This work is the first to provide a meta-analysis in a global systematic review of COI studies for depression. Depression was associated with higher costs in all age groups and as comorbidity. Pooled RoM was highest in adolescence and decreased with age. In the subgroup with depression as a comorbidity of a primary somatic disease, pooled RoM was lower as compared to the age subgroups. More evidence in COI studies for depression in adolescence and for indirect costs would be desirable.

Background: Placement matching guidelines are promising means to optimize patient-centered care and to match patients’ treatment needs. Despite considerable research regarding placement matching approaches to optimize alcohol abuse treatment, findings are inconclusive. Objectives: To investigate whether the use of patient-centered placement matching (PCPM) guidelines is more effective in reducing heavy drinking and costs 6 months after discharge from an inpatient alcohol withdrawal treatment compared to usual referral to aftercare. Secondary aims were to investigate whether age, gender, trial site or level of care (LOC) are moderators of efficacy and whether patients who were actually referred to the recommended LOC had better treatment outcomes compared to patients who were treated under- or overmatched. Methods: Design. Exploratory randomized controlled trial with measurements during withdrawal treatment and 6 months after initial assessment. Setting. Four German psychiatric clinics offering a 7–21 day inpatient qualified withdrawal program for patients suffering from alcohol dependence. Participants. From 1,927 patients who had a primary diagnosis of alcohol dependence and did not have organized aftercare when entering withdrawal treatment, 299 were invited to participate. Of those, 250 were randomized to the intervention group (IG, n = 123) or the control group (CG, n = 127). Intervention. The PCPM were applied to patients of the IG by feeding back a recommendation to a LOC for aftercare that was calculated from the Measurements in the Addictions for Triage and Evaluation (MATE) and discussed with the staff of the treatment unit. Patients of the CG received a general feedback regarding their MATE interview on request. Measurements. The MATE, the Client Socio-Demographic and Service Receipt Inventory-­European Version and the MATE-Outcomes were administered. Data were analyzed using generalized linear models. Results: In the intention-to-treat analysis, there were no significant differences between IG and CG regarding days of heavy drinking (incident risk ratio [IRR] 1.09; p = 0.640), direct (IRR 1.06; p = 0.779), indirect (IRR 0.77; p = 0.392) and total costs (IRR 0.89; p = 0.496). Furthermore, none of the investigated moderator variables affected statistically significant drinking or cost-related primary outcomes. Regardless of group allocation, patients who received matched aftercare reported significantly fewer days of heavy drinking than undermatched patients (IRR 2.09; p = 0.004). For patients who were overmatched, direct costs were significantly higher (IRR 1.79; p = 0.024), but with no additional effects on alcohol consumption compared to matched patients. Conclusions: While the use of PCPM failed to affect the actual referral to aftercare, our findings suggest that treating patients on the recommended LOC may have the potential to reduce days of heavy drinking compared to undertreatment and costs compared to overtreatment.

Zusammenfassung: In Deutschland ist mehr als die Hälfte der Erwachsenen übergewichtig, fast ein Viertel ist adipös. Als Risikofaktor für viele Erkrankungen geht Übergewicht mit einer hohen individuellen Krankheitslast und, infolge dessen, erhöhten Versorgungskosten und Produktivitätsverlusten einher. Aufgrund der hohen Krankheitslast und weiten Verbreitung gehört Übergewicht zu den relevantesten Risikofaktoren in Deutschland. Der Beitrag konzentriert sich auf die gesundheitsökonomischen Folgen des Übergewichtes.

Aim To elicit reference values of medical and non-medical health care utilisation and costs in Germany from a societal perspective. Methods 5007 telephone interviews were conducted in a representative sample of the German-speaking population above the age of 18. Participants were asked about medical and non-medical health care utilisation over the preceding six months. Participants were also asked about medical conditions, lifestyle, sociodemographic characteristics, employment status and sick leave. Resource utilisation was valued monetarily and analysed by means of descriptive and econometric tools (generalised linear models/two-part models). To obtain representative results, we weighted observations according to age, gender, education and state of residence. Results 95% of the respondents had at least one contact with an outpatient physician. 12% of the respondents were hospitalised and 3% received rehabilitative care. Direct costs per respondent were €1475 on average. The mean cost of physician visits was €278. We found differences in average costs for physician visits between men (€232) and women (€321). Indirect costs were €1554 on average per full-time employee. Multivariate analysis showed significant associations between direct costs and morbidity, age and gender. Indirect costs appeared to be significantly associated with morbidity and age, but not with gender. Conclusion Our reference values can be regarded as representative reference values for health care utilisation and costs, and can be used for the calculation of disease-specific excess costs.

ObjectivesHeavy alcohol use can cause somatic and mental diseases, affects patients’ social life and is associated with social isolation, unemployment and reduced quality of life. Therefore, societal costs of alcohol dependence are expected to be high. The aim of this study was to estimate excess costs of patients with alcohol dependence diagnosed using theDiagnostic and Statistical Manual of Mental Disorders, 4th Edition criteria compared with individuals without alcohol dependence in Germany.DesignIn a secondary analysis, baseline data of patients with alcohol dependence enrolled in a randomised controlled trial (German Clinical Trials Register DRS00005035) were compared with data collected via a telephone survey from individuals without alcohol dependence and that had been matched by entropy balancing. Health service use was evaluated retrospectively for a 6-month period.SettingsFour German psychiatric university clinics (patients with alcohol dependence) and the German general adult population (individuals without alcohol dependence).Participantsn=236 adult patients with alcohol dependence and n=4687 adult individuals without alcohol dependence.Primary and secondary outcome measuresThe excess costs of health service use, absenteeism and unemployment of patients with alcohol dependence were calculated and compared with individuals without alcohol dependence. In subgroup analyses, the associations between excess cost and gender, comorbidities and the duration of disease were investigated.ResultsTotal 6-month excess costs of €11 839 (95% CI €11 529 to €12 147) were caused by direct excess costs of €4349 (95% CI €4129 to €4566) and indirect costs of €7490 (95% CI €5124 to €9856). In particular, costs of inpatient treatment, formal long-term care, absenteeism and unemployment were high.ConclusionsAlcohol dependence causes substantial direct and indirect excess costs. Cost-effective interventions to prevent and treat alcohol dependence are urgently needed.Trial registration numberDRKS00005035.

Introduction: Assessing resource utilisation and costs for treating mental disorders in Germany is difficult. This pertains especially to the numerous non-medical services that are financed by a considerable number of payers. To standardise and simplify cost calculation, we created a database of unit costs for the most important services for mental disorders. Method: We performed a literature and internet search to identify services provided to persons with mental disorders. Unit costs were calculated either by means of public statistics or data directly obtained from payers. If data could not be obtained that way, health care providers were interviewed to collect data relevant for cost estimation. Results: Unit costs were calculated for medical and vocational rehabilitation, assisted living, sociopsychiatric services, counselling centres, daycare facilities, ambulant psychiatric nursing care, occupational therapy, sociotherapy, psychoeducation, caretaker, domestic help, creative therapies, physical therapy, and relaxation techniques. Discussion and Conclusion: Calculating unit costs for non-medical services was essential, since these services constitute a central element in the treatment of persons with mental disorders. Nevertheless, the large amount of different services and payers complicated a comprehensive assessment of costs. Thus, uncertainty associated with the calculation of costs should be taken into account.

To analyze the association between ceiling effects on the EQ-5D 5L and morbidity in a general population sample. We used a cross-sectional sample of the German general population (n = 5007) to describe the frequency of health state “11111” and “no problems”-answers on the five single dimensions stratified by the number of diseases for which participants utilized health care during the last 6 months. For the five single dimensions we also used specific criteria to analyze their discriminative ability. A logit-model was applied for a multivariate analysis of ceiling effects. 31% of participants reported the health state “11111.” This percentage strongly decreased with increasing morbidity, down to 4.9% if four or more diseases were present. The dimensions “mobility,” “usual activities,” and “pain/discomfort” showed good discriminative abilities. The dimensions “anxiety/depression” and “self -care” were able to discriminate between different levels of morbidity, but nevertheless showed strong ceiling effects, in particular “self-care.” When analyzing ceiling effects of the EQ-5D 5L, one has to draw attention to morbidity since high proportions of participants indicating the best health state might result from being healthy regarding the dimensions assessed by the EQ-5D, in particular in general population datasets.

Background Social anxiety disorder (SAD) is associated with low direct costs compared to other anxiety disorders while indirect costs tend to be high. Mental comorbidities have been identified to increase costs, but the role of symptom severity is still vague. The objective of this study was to determine the costs of SAD, and to explore the impact of symptoms and comorbidities on direct and indirect costs. Methods Baseline data, collected within the SOPHO-NET multi-centre treatment study ( N =495), were used. Costs were calculated based on health care utilization and lost productivity. Symptom severity was measured with the Liebowitz-Social-Anxiety-Scale; comorbidities were included as covariates. Results Total 6-month costs were accrued to € 4802; 23% being direct costs. While there was no significant association with SAD symptom severity for direct costs, costs of absenteeism increased with symptom severity in those with costs >0; comorbid affective disorders and eating disorders had an additional effect. Self-rated productivity was lower with more pronounced symptoms even after controlling for comorbidities. Limitations As the study was based on a clinical sample total costs were considered, rather than net costs of SAD and no population costs could be calculated. Discussion The burden associated with lost productivity was considerable while costs of healthcare utilization were rather low as most patients had not sought for treatment before. Efforts to identify patients with SAD earlier and to provide adequate treatment should be further increased. Mental comorbidities should be addressed as well, since they account for a large part of indirect costs associated with SAD.

Objective To estimate direct and indirect costs of anorexia nervosa (AN), and to identify cost determinants. Methods In a subsample (n = 225) of the ANTOP trial (Anorexia Nervosa Treatment of OutPatients) health care utilization and productivity losses were assessed at baseline for the previous 3 months and monetarily valued. Included were females aged 18 years and older diagnosed with AN or subsyndromal AN, and a body mass index (BMI) between 15 and 18.5 kg/m2. To account for missing data multiple imputation was employed. Cost determinants were derived from generalized linear models with gamma distribution and log link function. Results Mean 3-months costs per patient amounted to €5,866 (SE = €576). The largest share of costs (€3,374) resulted from hospitalizations. Determinants of direct costs were analyzed separately for those with hospitalizations for AN, and those without. In the group only treated as outpatients, participants with binge/purge subtype, and those diseased for more than 6 years had higher costs. Moreover, costs were increased in patients with a comorbid mental disorder. In the group with hospitalizations, direct costs increased with BMI. BMI was measured at the end of the observation period, indicating that longer duration of treatment yielded higher weight gain. Indirect costs were not significantly associated with any disease-related characteristic. Discussion Costs resulting from health care utilization and productivity loss are substantial, although the sample studied had not received sufficient treatment. Future research should analyze the development of costs over time. © 2014 Wiley Periodicals, Inc. (Int J Eat Disord 2015; 48:139–146)

Background Panic disorder is a mental disorder of high prevalence, which frequently co-occurs with agoraphobia. There is a lack of studies measuring excess costs of panic disorder patients with and without agoraphobia. We compared costs of panic disorder patients with or without agoraphobia with costs of the anxiety-free population in Germany. Methods Primary data from a cluster-randomized trial of adults suffering from panic disorder (n = 419) and from a representative survey of the German general population (N = 5005) were collected between 2012 and 2014. Missing data from the cluster-randomized trial were first imputed by multiple imputation using chained equations and subsequently balanced with the data from the survey by Entropy Balancing. The societal perspective was chosen. Excess costs were calculated by generalized linear models and two-part-models. Results Entropy Balancing led to an exact match between the groups. We found 6-month total excess costs of 3220€ (95% CI 1917€–4522€) for panic disorder patients without agoraphobia and of 3943€ (95% CI 2950€–4936€) for patient with agoraphobia. Panic disorder patients with or without agoraphobia had significantly higher costs for psychotherapy, general practitioners, general hospital stays and informal care Indirect costs accounted for approximately 60% of the total excess costs. Conclusions Panic disorder with or without agoraphobia is associated with significant excess costs. Agoraphobia changes the pattern of resource utilization. Especially indirect costs are relevant. Agoraphobia influences resource utilization in the inpatient sector. Trial registration ISRCTN64669297

In einer Vielzahl von Geburtskohortenstudien, epidemiologischen Studien und klinischen Beobachtungsstudien wurden psychische Erkrankungen bei Kindern, Jugendlichen und jungen Erwachsenen in Bezug auf Haufigkeit, Ersterkrankungsalter, Belastungsfaktoren, Storungspersistenz, Service-Inanspruchnahme, Behandlungsverzogerung und Krankheitsverlauf untersucht. Eine Vielzahl von Publikationen befasste sich daruber hinaus mit den Konsequenzen psychischer Erkrankungen hinsichtlich der Krankheitslast, der Versorgungsdefizite sowie der Effektivitat und Effizienz von „Early Intervention Services“. Die Ergebnisse zeigen, dass die Mehrzahl aller psychischen Erkrankungen bereits in der Kindheit, Jugend und im fruhen Erwachsenenalter erstmals auftreten. Es lassen sich dabei kombinierte und dauerhafte Belastungsfaktoren nachweisen, die das Risiko, (fruh und chronisch) psychisch zu erkranken, erhohen. In der Kindheit und Jugend erstmals aufgetretene psychische Storungen persistieren haufig bis in das Erwachsenenalter. Als wesentliche Ursachen hierfur wurden eine niedrigere Inanspruchnahme von Behandlung und eine lange Behandlungsverzogerung mit verschiedenen negativen Konsequenzen sowie eine allgemein unzureichende Behandlungsqualitat bei Kontakt zum Hilfesystem identifiziert. Zahlreiche andere Lander haben dementsprechend begonnen, an der Schnittstelle zwischen Kinder- und Jugend- und Erwachsenenpsychiatrie sog. „Early Intervention Services (EIS)“ zu implementieren. Das vorliegende Review Teil 1 befasst sich mit der Haufigkeit psychischer Erkrankungen, dem Ersterkrankungsalter, Belastungsfaktoren, der Storungspersistenz, Service-Inanspruchnahme und Behandlungsverzogerung und den Konsequenzen fur Kinder, Jugendliche und junge Erwachsene.

In einer Vielzahl von Geburtskohortenstudien, epidemiologischen Studien und klinischen Beobachtungsstudien wurden psychische Erkrankungen bei Kindern, Jugendlichen und jungen Erwachsenen in Bezug auf Haufigkeit, Ersterkrankungsalter, Belastungsfaktoren, Storungspersistenz, Service-Inanspruchnahme, Behandlungsverzogerung und Krankheitsverlauf untersucht. Eine Vielzahl von Publikationen befasste sich daruber hinaus mit den Konsequenzen psychischer Erkrankungen hinsichtlich der Krankheitslast, den Versorgungsdefiziten sowie der Effektivitat und Effizienz von „Early Intervention Services“. Die Ergebnisse zeigen, dass die Mehrzahl aller psychischen Erkrankungen bereits in der Kindheit, Jugend und im jungen Erwachsenenalter erstmals auftreten. Es lassen sich dabei kombinierte und dauerhafte Belastungsfaktoren nachweisen, die das Risiko, (fruh und chronisch) psychisch zu erkranken, erhohen. In der Kindheit und Jugend erstmals aufgetretene psychische Storungen persistieren haufig bis in das Erwachsenenalter. Als wesentliche Ursachen hierfur wurden eine niedrigere Inanspruchnahme von Behandlung und eine lange Behandlungsverzogerung mit verschiedenen negativen Konsequenzen sowie eine allgemein unzureichende Behandlungsqualitat bei Kontakt zum Hilfesystem identifiziert. Zahlreiche andere Lander haben dementsprechend begonnen, an der Schnittstelle zwischen Kinder- und Jugend- und Erwachsenenpsychiatrie sog. „Early Intervention Services (EIS)“ zu implementieren. Teil 2 des Reviews befasst sich mit der Krankheitslast inklusive der Kosten psychischer Erkrankungen, Versorgungsdefiziten in Deutschland sowie dem Stand der Forschung zur Effektivitat und Effizienz sogenannter „Early Intervention Services“ (EIS).

OBJECTIVE: To analyze direct costs and cost determinants in psychotic patients with persistent positive symptoms (PPS). METHODS: A total of 330 patients with PPS were recruited via 6 university clinics and interviewed about service utilization in the previous 3 months. After monetary valuation, costs were analyzed via generalized linear mixed models with gamma distribution and log-link function to identify determinants of direct costs. RESULTS: The mean costs were 7,065 € and resulted predominantly from psychiatric hospital care (63 %), assisted living (17 %) and complementary services (8 %). We found statistically significant associations between direct costs and an increasing score of the negative subscale of the Positive and Negative Syndrome Scale (+ 2,484 € per point, p < 0.001) and experiencing less than one social contact per week (- 2,272 €, p = 0.003). CONCLUSION: PPS incurred substantial direct costs which primarily resulted from hospital treatment, and were strongly associated with symptom severity.

Aim The aim of this study was to calculate disorder-specific excess costs in patients with functional somatic syndromes (FSS). Methods We compared 6-month direct and indirect costs in a patient group with FSS (n = 273) to a control group of the general adult population in Germany without FSS (n = 2914). Data on the patient group were collected between 2007 and 2009 in a randomized controlled trial (speciAL). Data on the control group were obtained from a telephone survey, representative for the general German population, conducted in 2014. Covariate balance between the patient group and the control group was achieved using entropy balancing. Excess costs were calculated by estimating generalized linear models and two-part models for direct costs and indirect costs. Further, we estimated excess costs according to the level of somatic symptom severity (SSS). Results FSS patients differed significantly from the control group regarding 6-month costs of outpatient physicians (+€280) and other outpatient providers (+€74). According to SSS, significantly higher outpatient physician costs were found for mild (+€151), moderate (+€306) and severe (+€376) SSS. We also found significantly higher costs of other outpatient providers in patients with mild, moderate and severe SSS. Regarding costs of rehabilitation and hospital treatments, FSS patients did not differ significantly from the control group for any level of SSS. Indirect costs were significantly higher in patients with severe SSS (+€760). Conclusion FSS were of major importance in the outpatient sector. Further, we found significantly higher indirect costs in patients with severe SSS.

BackgroundAnorexia nervosa (AN) is a serious illness leading to substantial morbidity and mortality. The treatment of AN very often is protracted; repeated hospitalizations and lost productivity generate substantial economic costs in the health care system. Therefore, this study aimed to determine the differential cost-effectiveness of out-patient focal psychodynamic psychotherapy (FPT), enhanced cognitive–behavioural therapy (CBT-E), and optimized treatment as usual (TAU-O) in the treatment of adult women with AN.MethodThe analysis was conducted alongside the randomized controlled Anorexia Nervosa Treatment of OutPatients (ANTOP) study. Cost-effectiveness was determined using direct costs per recovery at 22 months post-randomization (n = 156). Unadjusted incremental cost-effectiveness ratios (ICERs) were calculated. To derive cost-effectiveness acceptability curves (CEACs) adjusted net-benefit regressions were applied assuming different values for the maximum willingness to pay (WTP) per additional recovery. Cost–utility and assumptions underlying the base case were investigated in exploratory analyses.ResultsCosts of in-patient treatment and the percentage of patients who required in-patient treatment were considerably lower in both intervention groups. The unadjusted ICERs indicated FPT and CBT-E to be dominant compared with TAU-O. Moreover, FPT was dominant compared with CBT-E. CEACs showed that the probability for cost-effectiveness of FTP compared with TAU-O and CBT-E was ⩾95% if the WTP per recovery was ⩾€9825 and ⩾€24 550, respectively. Comparing CBT-E with TAU-O, the probability of being cost-effective remained ConclusionsDepending on the WTP, FPT proved cost-effective in the treatment of adult AN.

Background Collaborative group intervention (CGI) in patients with functional somatic syndromes (FSS) has been shown to improve mental quality of life. Objective To analyse incremental cost-utility of CGI compared to enhanced medical care in patients with FSS. Methods An economic evaluation alongside a cluster-randomised controlled trial was performed. 35 general practitioners (GPs) recruited 300 FSS patients. Patients in the CGI arm were offered 10 group sessions within 3 months and 2 booster sessions 6 and 12 months after baseline. Costs were assessed via questionnaire. Quality adjusted life years (QALYs) were calculated using the SF-6D index, derived from the 36-item short-form health survey (SF-36). We calculated patients' net-monetary-benefit (NMB), estimated the treatment effect via regression, and generated cost-effectiveness acceptability curves. Results Using intention-to-treat analysis, total costs during the 12-month study period were 5777EUR in the intervention, and 6858EUR in the control group. Controlling for possible confounders, we found a small, but significant positive intervention effect on QALYs (+ 0.017; p = 0.019) and an insignificant cost saving resulting from a cost-increase in the control group (− 10.5%; p = 0.278). NMB regression showed that the probability of CGI to be cost-effective was 69% for a willingness to pay (WTP) of 0EUR/QALY, increased to 92% for a WTP of 50,000EUR/QALY and reached the level of 95% at a WTP of 70,375EUR/QALY. Subgroup analyses yielded that CGI was only cost-effective in severe somatic symptom severity (PHQ-15 ≥ 15). Conclusion CGI has a high probability to be a cost-effective treatment for FSS, in particular for patients with severe somatic symptom severity.

Untersucht werden Berufsruckkehrer-Raten und Einflussfaktoren auf die Berufsruckkehr 3 Monate nach Bandscheiben-OP. In der Langsschnittstudie wurden 534 bandscheibenoperierte Patienten (18–55 Jahre) in personlichen Interviews im Akutkrankenhaus befragt. Eine telefonische Follow-up-Befragung fand 3 Monate spater mit 486 Patienten statt (Dropout-Rate: 9%). 3 Monate nach der Bandscheiben-OP arbeiten 40,9% der Patienten wieder. Als Risikofaktoren fur eine erschwerte berufliche Wiedereingliederung erwiesen sich u. a. psychische Beeintrachtigung, Schmerz, eine schlechtere gesundheitsbezogene Lebensqualitat, Berufsstatus und eine schlechtere subjektive Erwerbsprognose. Berufsruckkehrer nahmen signifikant haufiger an ambulanten Reha-Masnahmen teil als Nicht-Berufsruckkehrer. Das fruhzeitige Erkennen einer Risikogruppe fur eine erschwerte berufliche Wiedereingliederung nach Bandscheiben-OP kann Ausgangspunkt fur gezielte Masnahmen sein, um das Rehabilitationsergebnis zu verbessern und eine Berufsruckkehr zu unterstutzen.

Objective: The objective of the study is to systematically analyze and summarize research literature regarding health service use and costs of depressive symptoms in late life. Design: Relevant articles were identified by systematically searching the databases MEDLINE, Web of Science, PSYNDEXplus, PsycINFO, and Cochrane Library. Keywords were ‘depression’ or ‘depressive*’, and ‘cost’ or ‘economic burden’ or ‘utilization’ or ‘use’ and ‘old age’ or ‘elderly’. Studies based on representative samples of elderly individuals aged 55 years and older were included. Results: 55 studies were found, 34 studies determined health service utilization, 10 studies reported costs, and 11 studies reported both. Studies of health service utilization and costs showed homogeneously that depressive elderly individuals have an increased service use compared to non-depressive, and a one-third increase of outpatient, inpatient, and total healthcare costs of depressive individuals. The majority of studies reported antidepressant (AD) use between 20 and 45% by depressive individuals. Mean annual costs for AD ranged from 108 to 305 US$ PPP (purchasing power parities). Increased service use and costs are only to a small proportion related to depression treatment. Conclusions: Depressive symptoms in late life lead to a high economic burden for nations which is not explained by costs for depressive symptom treatment. Strategies for improvement of diagnostic validity and treatment success of depressive symptoms in late life may have an effect on economic burden for societies.

To predict the burden of incident osteoporosis attributable fractures (OAF) in Germany, an economic simulation model was built. The burden of OAF will sharply increase until 2050. Future demand for hospital and long-term care can be expected to substantially rise and should be considered in future healthcare planning.The aim of this study was to develop an innovative simulation model to predict the burden of incident OAF occurring in the German population, aged50, in the time period of 2010 to 2050.A Markov state transition model based on five fracture states was developed to estimate costs and loss of quality adjusted life years (QALYs). Demographic change was modelled using individual generation life tables. Direct (inpatient, outpatient, long-term care) and indirect fracture costs attributable to osteoporosis were estimated by comparing Markov cohorts with and without osteoporosis.The number of OAF will rise from 115,248 in 2010 to 273,794 in 2050, cumulating to approximately 8.1 million fractures (78 % women, 22 % men) during the period between 2010 and 2050. Total undiscounted incident OAF costs will increase from around 1.0 billion Euros in 2010 to 6.1 billion Euros in 2050. Discounted (3 %) cumulated costs from 2010 to 2050 will amount to 88.5 billion Euros (168.5 undiscounted), with 76 % being direct and 24 % indirect costs. The discounted (undiscounted) cumulated loss of QALYs will amount to 2.5 (4.9) million.We found that incident OAF costs will sharply increase until the year 2050. As a consequence, a growing demand for long-term care as well as hospital care can be expected and should be considered in future healthcare planning. To support decision makers in managing the future burden of OAF, our model allows to economically evaluate population- and risk group-based interventions for fracture prevention in Germany.

Der medizinische Fortschritt in der Behandlung todlicher Erkrankungen fuhrte in den letzten Jahrzehnten zu einer erheblichen Verlangerung der Uberlebenszeit. Aus diesem Langzeituberleben erwachsen finanzielle Folgen fur das Gesundheitswesen und die Gesellschaft. Im vorliegenden Beitrag werden methodische Aspekte der Kostenmessung bei Krankheiten mit Langzeituberleben dargestellt. Dabei wird auf Kosten der Langzeittherapie, indirekte Kosten, nicht in Verbindung zur Erkrankung stehende Kosten (Unrelated Future Health Care Costs, UFHCC) und die Diskontierung der Kosten eingegangen, die anhand von Beispielen illustriert werden. Als besondere methodische Herausforderung fur die okonomische Evaluation von Therapien, die zu einem Langzeituberleben fuhren, kann die Berucksichtigung von UFHCC betrachtet werden. Die Frage nach der Berucksichtigung medizinischer Versorgungskosten in gewonnenen Lebensjahren, die nicht in Verbindung zur Erkrankung stehen, wird in der Literatur auf methodisch-theoretischer Basis intensiv diskutiert. Bei okonomischen Evaluationen der Therapie von Krankheiten mit Langzeituberleben wurden solche Kosten bisher jedoch kaum berucksichtigt – daraus kann eine Verzerrung der Ergebnisse resultieren. Fur die Vergleichbarkeit von Studienergebnissen ist eine Standardisierung der Methodik zur Kostenmessung dringend wunschenswert.

Objective: To review cost-of-illness studies (COIs) and cost-effectiveness analyses (CEAs) of eating disorders (EDs) and to describe their methodological quality. Method: A systematic literature search was done. Search results passed through a selection process, included studies were classified as COIs, CEAs, or “other cost studies” (OCS). Costs were inflated and converted to 2008 US$ purchasing power parities (PPP). Quality criteria were developed and applied to each study. Results: Five COI, two CEA, and eleven “OCS” were reviewed. Most studies focused on anorexia nervosa and bulimia nervosa. Annual costs per patient ranged from 1,288 to 8,042 US$-PPP. All interventions, investigated in CEA, were more effective and less costly than the alternative treatments. Discussion: The number of publications investigating costs in EDs has increased recently. However, no COI provided a comprehensive estimate of costs, and the comparability of CEA was limited. Nonetheless, the results indicate that the costs arising from EDs are substantial. © 2012 by Wiley Periodicals, Inc. (Int J Eat Disord 2012)

Obesity prevention provides a major opportunity to improve population health. As health improvements usually require additional and scarce resources, novel health technologies (interventions) should be economically evaluated. In the prevention of obesity, health benefits may slowly accumulate over time and it can take many years before an intervention has reached full effectiveness. Decision-analytic simulation models (DAMs), which combine evidence from diverse sources, can be utilized to evaluate the long-term cost-effectiveness of such interventions. This literature review summarizes long-term economic findings (defined as ≥ 40 years) for 41 obesity prevention interventions, which had been evaluated in 18 cost-utility analyses, using nine different DAMs. Interventions were grouped according to their method of delivery, setting and risk factors targeted into behavioural (n=21), community (n=12) and environmental interventions (n=8). The majority of interventions offered good value for money, while seven were cost-saving. Ten interventions were not cost-effective (defined as >50,000 US dollar), however. Interventions that modified a target population's environment, i.e. fiscal and regulatory measures, reported the most favourable cost-effectiveness. Economic findings were accompanied by a large uncertainty though, which complicates judgments about the comparative cost-effectiveness of interventions.

Objective To conduct a systematic literature review of cost-of-illness studies and economic evaluations for diabetic patients with comorbid depression. Methods Systematic literature search in PubMed and NHS EED in March 2011, complemented by a bibliographic search within all eligible articles. Results The search produced a total of 388 studies of which 16 were analysed in full text. Altogether, eleven studies were included into the review, all of which were conducted in the USA. The results from cost-of-illness studies (n = 8) indicate excess costs in between 35 % and 300 % for diabetics with comorbid depression, in comparison to those without depression. Three economic evaluations indicate that appropriate interventions can lead to improved health (i. e. more depression free days) at no extra cost. The results from two cost-effectiveness analyses indicate dominance (more depression free days and cost-savings compared to "usual care") for the evaluated interventions. Conclusions Depressive symptoms are associated with increased health care costs in diabetic patients. Part of these excess costs can be attributed to the treatment of diabetes. Appropriate interventions aimed at depression treatment can increase time free of depression at no greater cost than usual care.

Background context Back pain presents a significant cause of health care costs and lost productivity. In most cases, conservative treatment will be sufficient, but in the most severe cases, disc surgery is indicated. Purpose To analyze the effect of psychiatric comorbidity on health care costs and lost productivity in patients with back pain undergoing disc surgery. Study design A cross-sectional study design was used. Patient sample A sample of 305 disc surgery patients (lumbar, 239; cervical, 66). Outcome measures Patients were interviewed using the German version of the Composite International Diagnostic Interview to assess psychiatric comorbidity and a questionnaire to assess resource utilization and lost productivity for a 3-month period prior disc surgery. Health care resources were monetarily valued by unit costs, whereas productivity was valuated by labor costs. Methods Cost differences between patients with and without psychiatric comorbidity were analyzed using bootstrap regression techniques. Results Back pain was associated with mean 3-month direct health care costs ranging from €5,534 (lumbar disc herniation without psychiatric comorbidity) to €8,507 (cervical disc herniation with psychiatric comorbidity), of which between 51% and 79% were caused by disc surgery. Mean indirect costs ranged from €7,589 to €8,492. Psychiatric comorbidity was significantly associated with increased direct costs in lumbar disc herniation (€7,042 vs. €5,534). Regression analysis showed increments of €851 (p=.043) in direct costs and €1,636 (p=.058) in total costs for psychiatric comorbidity, which predominantly resulted from nonpsychiatric health care utilization. Conclusions Severe back pain is associated with high direct and indirect costs, which are influenced by the presence of psychiatric comorbidity. We found a lack of treatment for psychiatric comorbidity indicated by low mental health care utilization in affected individuals. More attention should be given to psychiatric comorbidity in the treatment of patients undergoing disc surgery. Clinicians should be aware of the high prevalence rates of psychiatric comorbidity in this patient group. They should consider the assessment of psychiatric distress and support of mental health professionals if applicable.

Physical-mental comorbidity is often associated with worse clinical and psychosocial outcomes, reduced health-related quality of life, and increased healthcare utilization. The following article is dedicated to the health economic aspects of physical-mental comorbidity. It presents basic theoretical and methodological aspects of cost-of-illness studies and economic evaluations related to physical-mental comorbidity, which are explained and discussed for the practical example of comorbid depression in diabetes mellitus. The results show that mental comorbidity in diabetes is associated with increased healthcare costs, which can in part be attributed to an increased somatic health service use. Appropriate interventions can lower these excess costs. Economic evaluations assessing the effectiveness of interventions for depressive diabetics have shown that overall health can be improved and costs saved. However, especially in health economics, mental comorbidity in somatic diseases has not been comprehensively investigated and further research is warranted.

OBJECTIVE: The aim of this study was a systematic literature review of cost-of-illness studies for schizophrenia in Germany. METHODS: We conducted a database search in Pubmed and PsychINFO. Cost data were inflated to the year 2007. RESULTS: We finally included 11 studies in our review which show that schizophrenia causes societal cost of several billion Euros per year. After adjustment for inflation, costs per patient and year estimated between 1980 and 2002 tended to be relatively stable at around 14,000 to 18,000 Euro. Additionally, relatives are confronted with spending of 950 to 1,700 Euro due to the patients' disorder. Indirect costs are mainly due to early retirement or unemployment and amount to 25,000 to 30,000 Euro per patient when using the human capital approach. We found that changes in treatment settings and increasing costs of drug treatment seem to be reflected in published cost-of-illness studies. CONCLUSIONS: When corrected for inflation, treatment cost per patient for schizophrenia show changes in their distribution over different cost sectors in the health care system but no substantial increases between 1980 and 2002.

The health and economic burden of osteopenia- and osteoporosis-attributable hip fractures (OHF) in Germany was estimated for 2002 and projected until 2050. We found 108,341 OHF resulting in 2,998 million Euros cost, which will more than double by the year 2050, calling for improvement and development of prevention strategies for OHF. This study aimed to estimate the health impact and the societal costs of OHF in Germany in the year 2002 and to extrapolate these estimates to the years 2020 and 2050. We estimated OHF-attributable deaths, years of potential life lost (YPLL) and quality-adjusted life years lost (QALYs) using attributable fractions. Direct costs for acute treatment, rehabilitation, nursing care, non-medical costs and indirect costs for sickness absence, early retirement and mortality were estimated. All estimates were extrapolated to 2020 and 2050 using an estimation of future population composition and life expectancy. We found 108,341 OHF resulting in 3,485 deaths, 22,724 YPLL, 114,058 QALYs, 2,736 millions of Euros direct cost and 262 millions of Euros indirect costs. Projection to 2020 showed corresponding increases of 44%, 62%, 56%, 49%, 47% and 33%, whereas the projection to 2050 resulted in changes of 128%, 215%, 196%, 152%, 138% and 90%, respectively. OHF have considerable impact on health and direct costs in the elderly. Both may strongly increase in future decades due to demographic changes, calling for improvement and development of effective strategies for preventing and dealing with OHF.

Objective: To estimate the incremental cost-effectiveness ratio (ICER) of antibodies against cyclic citrullinated peptides (aCCP) in the early diagnosis of rheumatoid arthritis (RA). Methods: A Markov model was used to model 10-year progression of RA in patients first diagnosed with undifferentiated arthritis (UA) and to estimate the incremental costs and quality-adjusted life years (QALYs) of using aCCP additionally to American College of Rheumatology (ACR) criteria. The impact of later diagnosis and treatment due to non-use of aCCP was modelled as increased Health Assessment Questionnaire (HAQ) progression. Utilities were assigned to HAQ states for calculating QALYs. Uncertainty was analysed using univariate and probabilistic sensitivity analyses (Monte Carlo simulation). Results: Baseline ICER was €930/QALY. Univariate sensitivity analyses identified the impact of later diagnosis on HAQ progression as a major source of uncertainty, resulting in an ICER range from “dominance” to €153 092/QALY, compared with a maximum ICER of €4870/QALY for other variables. Monte Carlo simulation resulted in a 95% uncertainty interval from –€3537/QALY (dominance) to €5429/QALY; when indirect costs were considered, Monte Carlo simulation resulted in a 95% uncertainty interval from –€78 115/QALY (dominance) to –€23 444/QALY (dominance). Conclusions: Using aCCP in the diagnosis of RA in patients with UA is likely to be cost effective compared with using ACR criteria alone. When indirect costs are incorporated, aCCP seems to save costs. Clearly, more research is needed relating the effects of diagnosis and treatment on the long-term course and the resulting functional impairment of RA as measured by the HAQ.

Osteoporosis is a frequent complication in patients with inflammatory bowel disease. Recent studies have shown bisphosphonates to considerably reduce fracture risk in patients with osteoporosis, and preventing fractures with bisphosphonates has been reported to be cost effective in older populations. However, no studies of the cost effectiveness of these agents in preventing fractures in patients with inflammatory bowel disease are available.To investigate the cost effectiveness of the bisphosphonate ibandronate combined with calcium/colecalciferol ('ibandronate') in patients with osteopenia or osteoporosis due to inflammatory bowel disease in Germany. Treatment strategies used for comparison were sodium fluoride combined with calcium/colecalciferol ('fluoride') and calcium/colecalciferol ('calcium') alone.A cost-utility analysis was conducted using data from a randomized controlled trial (RCT). Changes in bone mineral density (BMD) were adjusted and predicted for a standardized population receiving each respective treatment. A Markov model was developed, with probabilities of transition to fracture states consisting of BMD-dependent and -independent components. The BMD-dependent component was assessed using predicted change in BMD from the RCT. The independent component captured differences in bone quality and micro-architecture resulting from prevalent fractures or treatment with anti-resorptive drugs. The analysis was conducted for a population with a mean age of the RCT patients (women aged 36 years, men aged 38 years) with osteopenia (T-score about -2.0 at baseline), a population of the same age with osteoporosis (T-score of -3.0 at baseline) and for an older population (both sexes aged 65 years) with osteoporosis (T-score of -3.0). Outcomes were measured as costs per QALY gained from a societal perspective. The treatment duration in the RCT was 42 months. A 5-year period was assumed to follow, during which the treatment effects linearly declined to 0. The simulation time was 10 years. Prices for medication and treatment were presented as year 2004 values; costs and effects were discounted at 5%. To test the robustness of the results, univariate and probabilistic sensitivity analyses (Monte Carlo simulation) were conducted.The calcium strategy dominated the fluoride strategy. When the ibandronate strategy was compared with the calcium strategy, the base-case cost-effectiveness ratios (costs per QALY gained) were between euro 407 375 for an older female population with osteoporosis and euro 6 516 345 for a younger female population with osteopenia. Univariate sensitivity analyses resulted in variations between 4% of base-case results and dominance of calcium. In Monte Carlo simulations, conducted for the various populations, the probability of an ICER of ibandronate below euro 50 000 per QALY was never greater than 20.2%.The ibandronate strategy is unlikely to be considered cost effective by decision makers in men or women with characteristics of those in the target population of the RCT, or in older populations with osteoporosis.

To estimate the direct and indirect costs of morbidity and mortality attributable to alcohol consumption in Germany from a societal perspective in 2002.Using the concept of attributable risks and the prevalence-based approach, age- and gender-specific alcohol-attributable fractions for morbidity and mortality were calculated for alcoholic disorder, neoplasms, endocrinological, nervous, circulatory, digestive, skin and perinatal disorders, and injuries and poisonings. The literature provided data on alcohol consumption in Germany by age, gender and dose amount, and relative risks. Direct costs were calculated based on routine resource utilisation and expenditure statistics. Indirect costs were calculated based on the human capital approach using a discount rate of 5%.Alcohol consumption accounted for 5.5% of all deaths and 970,000 years of potential life lost. Total costs were euro24,398 million, amounting to 1.16% of Germany's GDP, or euro296 per person. Direct medical and non-medical costs were euro8441 million. Indirect costs were euro15,957 million (69% mortality and 31% morbidity costs). In contrast, protective health effects of alcohol consumption saved euro4839 million.The magnitude of alcohol-attributable morbidity and mortality and associated costs demands more preventive efforts.

In 2011, Konnopka et al. (Eur J Health Econ 12:345-352, 2011) published a top-down cost of illness study on the health burden, and direct and indirect costs of morbidity and mortality attributable to excess weight (BMI ≥25 kg/m(2)) in Germany in 2002. The objective of the current study was to update the 2002 estimates to the year 2008. To simplify comparisons, we closely followed the methods and assumptions of the original study, using 2008 data for most input parameters (e.g. prevalence, mortality, resource use, costs). Excess weight related deaths increased by 31% (from 36,653 to 47,964) and associated years of potential life lost (from 428,093 to 588,237) and quality adjusted life years lost (from 367,722 to 505,748) by about 37%, respectively. Excess weight caused €16,797 million in total costs in 2008 (+70%), of which €8,647 million were direct costs (corresponding to 3.27% of total German health care expenditures in 2008). About 73% (€12,235 million) of total excess weight related costs were attributable to obesity (BMI ≥30 kg/m(2)). The main drivers of direct costs were endocrinological (44%) and cardiovascular (38%) diseases. Indirect costs amounted to €8,150 million in 2008 (+62%), of which about two-thirds were indirect costs from unpaid work. The great majority of indirect costs were due to premature mortality (€5,669 million). The variation of input parameters (univariate sensitivity analyses) resulted in attributable costs between €8,978 million (-47% compared to base case) and €25,060 million (+49%). The marked increase in excess weight related costs can largely be explained by increases in the prevalence of overweight and obesity, and to a lesser extent from increases in resource consumption, as well as increases in (unit) costs and wages (comprising 5.5% inflation).

Objective To examine rehabilitation preferences, participation and determinants for the choice of a certain rehabilitation setting (inpatient vs. outpatient) and setting-specific rehabilitation outcomes. Methods The longitudinal observational study referred to 534 consecutive disc surgery patients (18–55 years). Face-to-face baseline interviews took place about 3.6 days after disc surgery during acute hospital stay. 486 patients also participated in a follow-up interview via telephone three months later (dropout-rate: 9%). The following instruments were used: depression and anxiety (Hospital Anxiety and Depression Scale), pain intensity (numeric analog scale), health-related quality of life (Short Form 36 Health Survey), subjective prognosis of gainful employment (SPE-scale) as well as questions on rehabilitation attendance, return to work, and amount of sick leave days. Results The vast majority of patients undergoing surgery for a herniated disc attended a post-hospital rehabilitation treatment program (93%). Thereby two-thirds of these patients took part in an inpatient rehabilitation program (67.9%). Physical, psychological, vocational and health-related quality of life characteristics differed widely before as well as after rehabilitation depending on the setting. Inpatient rehabilitees were significantly older, reported more pain, worse physical quality of life, more anxiety and depression and a worse subjective prognosis of gainful employment before rehabilitation. Pre-rehabilitation differences remained significant after rehabilitation. More than half of the outpatient rehabilitees (56%) compared to only one third of the inpatient rehabilitees (33%) returned to work three months after disc surgery (p

Obesity has substantially increased in recent decades and is now one of the major global health problems. The large obesity-related health burden negatively impacts many relevant health outcomes (e.g. quality of life, disability, mortality) and leads to increased healthcare utilization. This excess service use is the main driver behind high healthcare costs of obese individuals. Findings indicate that costs rise curvilinearly with increasing body mass index, especially among the obese. As more individuals of a country's population become obese, a larger share of total annual national healthcare expenditure is spent on obesity and obesity-related health problems. In addition to escalating healthcare costs, obesity goes along with indirect costs through decreases in workforce productivity. The empirical evidence has shown beyond doubt that obesity negatively impacts individuals, healthcare systems, employers, and the economy as a whole. This article provides a brief overview of selected economic consequences associated with excess-weight.

article i nfo Objective: To analyse the association of direct and indirect costs in patients with medically unexplained symptoms (MUS) with somatic symptom severity (SSS). Methods:A cross-sectional cost analysis forretrospective 6 monthswas conducted in 294primary care patients with MUS. Health care utilisation and loss of productivity were measured by questionnaires. SSS was measured using the "Patient Health Questionnaire 15" (PHQ-15). Direct and indirect costs and the association of costs with SSS were analysed via multiple linear regression analysis. Results: Patients with MUS had average 6-month direct costs of 1098 EUR and indirect costs of 7645 EUR. For direct costs, outpatient physician visits were the most expensive single cost category (36%), followed by pharmaceuticals (25%) and hospital stays (19%). Indirect costs were predominantly caused by productivity reduction at work (56%) followed by early retirement (29%) and acute sickness absence (14%). As compared to mild SSS, moderate SSS was not significantly associated with direct, but with indirect costs (+2948 EUR; p b .001); severe SSS was associated with increased direct cost (+658 EUR; p = .001) and increased indirect costs (+4630 EUR; p b .001). Age was positively associated with direct cost (+15 EUR for each additional year; p = .015) as well as indirect cost (+104 EUR for each additional year; p b .001). Conclusions: MUS are associated with relevant direct and even much higher indirect costs that strongly depend on SSS.

Background The EQ-5D is a generic questionnaire providing a preference-based index score applicable to cost-utility analysis. This is the first study to validate the EQ-5D in patients with somatoform disorders. Methods Data of the EQ-5D descriptive system, the British and the German EQ-5D index and the EQ Visual Analogue Scale, the Patient Health Questionnaire 15, the Patient Health Questionnaire 9, the Whiteley Index 7 and the Short Form 36 were collected from 294 patients at baseline, 244 at 6 months and 256 at 12 months after baseline. The discriminative ability of the EQ-5D was evaluated by comparison with a general population sample and by the ability to distinguish between different symptom severities. Convergent validity was analysed by assessing associations between the EQ-5D and the other instruments. Responsiveness was evaluated by analysing the effects on scores between two measurements in groups of patients reporting worse, same or better health. The Bonferroni correction was employed. Results For all items of the EQ-5D except ‘self-care’, patients with somatoform disorders reported more problems than the general population. The EQ-5D showed discriminative ability in patients with different symptom severities. For nearly all reference instruments there were significant differences in mean scores between respondents with and without problems in the various EQ-5D items and strong correlations with the EQ Visual Analogue Scale and the EQ-5D index scores. Evidence for the responsiveness of the EQ-5D could only be found for patients with better health; effects were medium at the utmost. Conclusions The EQ-5D showed a considerable validity and a limited responsiveness in patients with somatoform disorders. Trial registration Current Controlled Trials ISRCTN55280791