Vortragssitzung

Evaluationsstudien: Bewegungsapparat

Vorträge

Economic evaluation of collaborative orthogeriatric care for patients with hip fracture in Germany: A retrospective cohort study using health and long-term care insurance claims data
Claudia Schulz, Universitätsklinikum Hamburg-Eppendorf

Einleitung

Existing evidence suggests benefits of collaborative orthogeriatric care (COC) for geriatric hip fracture patients. Yet, COC may comprise different components, and evidence on cost-effectiveness is limited and based on rather small datasets. The aim of our study was to conduct an economic evaluation of the German COC for hip fracture patients compared to usual care. In Germany, COC due to a hip fracture is provided as a hospital treatment by a multidisciplinary team headed by a geriatrician and delivered on an orthopaedic or geriatric ward, including comprehensive geriatric assessments and inpatient rehabilitation starting few days after surgery.

Methode

This retrospective cohort study was based on German health and long-term care insurance claims data for the years 2012-2015. Patients were selected when aged 80 years or older, sustained a hip fracture in 2014 and treated in a hospital providing COC (intervention group) or usual care (control group). Health care costs from both payer and societal perspective, mortality, life years and quality-adjusted life years (QALYs) gained were investigated within one year follow-up. QALYs were estimated based on care dependency after hip fracture in terms of German care level. Due to the lack of randomization, we used entropy balancing to reweigh patient and hospital characteristics between groups during the two years before fracture. Weighted gamma, logistic and two-part models were applied. We calculated incremental cost-effectiveness ratios (ICER) and employed the net-benefit approach.

Ergebnisse

14,005 patients were treated in COC, and 10,512 in other hospitals. Total average health care costs per patient were higher in the COC group: EUR 951.72 (p<.001) from a payer perspective, and EUR 1,275.35 (p<.001) from societal perspective. Costs were mainly driven by inpatient treatment and long term care. Mortality was lower in the COC (33.10%) than in the control group (37.27%). The ICER equalled 22,910.20 EUR/life years gained or 43,592.46 EUR/QALY from a payer, and 30,701.22EUR/life years gained or 58,416.86 EUR/QALY from a societal perspective. The probability for cost-effectiveness would be 95% if the society’s willingness-to-pay (WTP) was at least 35,000 EUR/ life years gained or 65,000 EUR/QALY from a payer, and 40,000 EUR/ life years gained or 90,000 EUR/QALY from a societal perspective.

Zusammenfassung

Survival and QALYs can be improved if patients are treated in hospitals providing COC, compared to hospitals offering treatment in traditional orthopaedic trauma wards. Opposite to former studies, costs were found to increase due to COC, mainly driven by inpatient and long-term care. The cost-effectiveness of COC compared to usual care depends on the society’s WTP. The ICER is likely to improve with a follow-up period longer than one year.


Authors
Claudia Schulz, Universitätsklinikum Hamburg-Eppendorf
Christian Brettschneider, Universitätsklinikum Hamburg-Eppendorf
Hans-Helmut König, Universitätsklinikum Hamburg-Eppendorf
Health-economic evaluation of the German osteoporotic fracture prevention program in rural areas (OFRA)
Claudia Schulz, Universitätsklinikum Hamburg-Eppendorf

Einleitung

Osteoporotic fractures are one of the leading causes for disability in old people. Yet, evidence for effectiveness and cost-effectiveness of preventive approaches combining bone health and fall prevention is rare. The objective of this study was to conduct a health-economic evaluation of the German osteoporotic fracture prevention program in rural areas (OFRA, German name: Trittsicher). OFRA comprised mobility and falls prevention classes, examination of bone health by a DXA bone density measurement, and consultation on safety in the nearby living environment.

Methode

All districts in five federal states were cluster-randomized as intervention or control districts. OFRA was offered to community-living a) women aged 75 to <80 years or b) women and men aged 70 years and more with a prior fragility fracture in the intervention districts. Persons with these criteria in the control districts were assigned to the control group. We measured health care costs and effectiveness in terms of time to an osteoporotic fracture or death within one year after initial contact based on health insurance claims data. Implementation costs were recorded by the intervention performers. We calculated an incremental cost-effectiveness ratio (ICER) and employed the net-benefit approach to construct a cost-effectiveness acceptability curve (CEAC).

Ergebnisse

There were 9,599 persons in the intervention and 27,768 persons in the control group. Mean time to osteoporotic fracture or death (difference: 0.13 days) and health care costs (difference: EUR 74.73, p<.05) were reduced, but mean intervention costs (difference: EUR 260.10) increased total costs (difference: EUR 185.37, p<.001) in the intervention group. The ICER per fracture-free year of survival was EUR 506,204.18. The CEAC showed no acceptable probability of cost-effectiveness at a reasonable willingness-to-pay.

Zusammenfassung

OFRA showed reduced rates of osteoporotic fractures. However, the high implementation costs for OFRA exceed the savings due to reduced health care utilization. We found an unfavorable ratio of incremental costs and effectiveness. We measured effectiveness in terms of fracture-free years of survival, although OFRA likely had further effects on physical and psychosocial level. For a further enrollment, ways to increase the effectiveness, e.g., by addressing particularly vulnerable risk groups, and to reduce the costs should be developed.


Authors
Claudia Schulz, Universitätsklinikum Hamburg-Eppendorf
Hans-Helmut König, Universitätsklinikum Hamburg-Eppendorf
Short-term cost-effectiveness of a group-based lifestyle-integrated functional exercise program: Results from the LiFE-is-LiFE trial
Sophie Gottschalk, Universitätsklinikum Hamburg-Eppendorf, Institut für Gesundheitsökonomie und Versorgungsforschung

Einleitung

The Lifestyle-Integrated Functional Exercise (LiFE) program has been shown to be effective in improving strength, balance, and physical activity while simultaneously reducing falls in older people. However, implementing the original, individually delivered LiFE program (iLiFE) would require substantial resources. A group format (gLiFE), on the other hand, requires fewer resources and could thereby reduce costs. Therefore, the aim of this study was to compare costs and effectiveness of gLiFE with iLiFE by conducting a cost-effectiveness analysis.

Methode

The analysis was conducted alongside a randomized controlled trial (LiFE-is-LiFE) testing gLiFE regarding its non-inferiority to iLiFE. Participants were randomly assigned to iLiFE (n=153) or gLiFE (n=156). Resource use from societal and health-insurance perspective was assessed retrospectively at baseline and at 6 months follow-up. Costs associated with inpatient and outpatient health care utilization, informal and formal service utilization as well as intervention costs were included. Quality-adjusted life years (QALY) were calculated based on the EQ-5D-5L. Incremental cost-effectiveness ratios (ICER) were determined and cost-effectiveness acceptability curves (CEAC) were constructed based on net-benefit regressions to account for statistical uncertainty. Different values for the society's willingness to pay (WTP) were assumed (€0 to €250,000).

Ergebnisse

From the societal perspective, gLiFE was associated with non-significantly lower mean total costs of €58 and effects (QALY) of -0.01. Accordingly the unadjusted ICER of €7,937 per QALY gained was located in the southwestern quadrant of a cost-effectiveness plane. The CEAC showed a high degree of uncertainty with probabilities of cost-effectiveness around 50%, even at high values of WTP. From the health insurance perspective, the difference in mean total costs became larger in favor of gLiFE (-€447), but remained non-significant. Thus, the ICER was €61,638 per QALY gained. The probability of being cost-effective was considerably higher (between 60% and 80%) compared to the societal perspective, but must still be interpreted as uncertain.

Zusammenfassung

Evidence for the cost-effectiveness of gLiFE compared to iLiFE seemed to be uncertain and depended on the cost perspective used. Furthermore, by considering a relatively short period of 6 months, long-term costs and effects of both interventions were not considered and should therefore be investigated in future economic evaluations.


Authors
Sophie Gottschalk, Universitätsklinikum Hamburg-Eppendorf, Institut für Gesundheitsökonomie und Versorgungsforschung
Hans-Helmut König
Michael Schwenk
Corinna Nerz
Clemens Becker
Jochen Klenk
Carl-Philipp Jansen
Judith Dams
Rise-uP: Ein integriertes eHealth-Programm zur Prävention der Chronifizerung von Rückenschmerzen – eine ökonomische Evaluation
Katharina Achtert, inav GmbH – private Institut für angewandte Versorgungsforschung GmbH

Einleitung

Unbehandelte (sub)akute Rückenschmerzen können zu einer Chronifizierung und damit zu einer hohen Krankheitslast führen. Innovative Technologien haben das Potenzial Rückenschmerzen wirksam zu behandeln. Die Effizienz solcher Programme ist jedoch noch nicht ausreichend evaluiert worden. Das Ziel dieser Studie ist es daher, die Kosteneffektivität eines innovativen, integrierten Behandlungsansatzes in Bayern zu evaluieren.

Methode

In einer cluster-randomisiert kontrollierten Studie soll die Kosteneffektivität der Rise-uP-Intervention mit der Standardversorgung von Rückenschmerzen verglichen werden. Die Intervention umfasst ein Instrument zur Chronifizierungsrisikobewertung (STarT Back), die Kaia-Rückenschmerz-App mit Elementen der multimodalen Schmerztherapie und den telemedizinischen Austausch zwischen Hausarzt und Schmerzspezialist über eine gemeinsame elektronische Patientenakte. Primäre und sekundäre Endpunkte sind Schmerzintensität, Lebensqualität, schmerzbedingte Beeinträchtigung, Depression und Angstsymptome sowie Versorgungskosten. Die Daten werden einerseits mit Hilfe standardisierter Fragebögen zur Baseline, nach 6 und 12 Monaten und andererseits mittels Routinedaten von drei gesetzlichen Krankenkassen erhoben. Es wird eine Kosteneffektivitätsanalyse unter Verwendung einer Kostenträgerperspektive durchgeführt.

Ergebnisse

Die Rekrutierung und der Follow-up der Studie sind abgeschlossen. Insgesamt wurden 1.291 Erwachsene mit unspezifischen Rückenschmerzen eingeschlossen. Dabei erhielten 971 Patienten die Rise-uP-Intervention und 320 Patienten wurden in der Kontrollgruppe anhand der Standardversorgung behandelt. Wir erwarten, dass die Rise-uP-Intervention einen wesentlichen Einfluss auf die Verbesserung der krankheitsbezogenen Symptome und das Nachfragen von Gesundheitsleistungen haben wird, indem sie die Inanspruchnahme von z.B. bildgebenden Verfahren reduziert. Um die Kosteneffektivität zu untersuchen, werden die zusätzlichen Kosten für die Intervention zur Gewinnung einer zusätzlichen Einheit verringerter Schmerzintensität mit der Standardversorgung verglichen. Es wird erwartet, dass die Rise-uP-Intervention der Standardversorgung überlegen sein wird. Erste Ergebnisse konnten für die Interventionsgruppe überlegene Ergebnisse hinsichtlich der Schmerzintensität und weiterer sekundärer Endpunkte zeigen. Die vollständige gesundheitsökonomische Bewertung wird Ende 2020 durchgeführt.

Zusammenfassung

Diese Studie untersucht erstmalig in Deutschland die Kostenwirksamkeit eines innovativen, integrierten Behandlungsansatzes für Rückenschmerzen. Die Ergebnisse der Kosteneffektivitätsanalyse werden eine wichtige Rolle spielen, wenn es um die Frage der Überführung in die Regelversorgung geht.


Authors
Katharina Achtert, inav GmbH – private Institut für angewandte Versorgungsforschung GmbH
Thomas R. Tölle, Zentrum für Interdisziplinäre Schmerzmedizin, MRI, Technische Universität München
Janosch A. Priebe, Zentrum für Interdisziplinäre Schmerzmedizin, MRI, Technische Universität München
Katharina Haas, Zentrum für Interdisziplinäre Schmerzmedizin, MRI, Technische Universität München
Fernanda Moreno Sánchez, Zentrum für Interdisziplinäre Schmerzmedizin, MRI, Technische Universität München
Reinhard Thoma, Algesiologikum MVZ GmbH
Siegfried Jedamzik , Bayerische Telemedallianz
Jan Reichmann, StatConsult
Volker E. Amelung, inav GmbH – private Institut für angewandte Versorgungsforschung GmbH
Linda Kerkemeyer, inav GmbH – private Institut für angewandte Versorgungsforschung GmbH