Barriers to accessing biologic treatment for rheumatoid arthritis in Greece: the unseen impact of the fiscal crisis--the Health Outcomes Patient Environment (HOPE) study

Patient Satisfaction With Public Pharmacy Services: Structural and Policy Implications From Greece

Objectives This study aimed at investigating patient satisfaction with services offered by a certain type of public pharmacies in Greece (National Organisation for Healthcare Provision (EOPYY) pharmacies), tasked with dispensing mostly high-cost drugs, in an effort to highlight the aspects to be optimized. Methods  The Patient Satisfaction with Pharmacist Services Questionnaire 2.0 (PSPSQ 2.0) questionnaire was the main instrument of our research. We received 201 full responses from patients themselves and patients' companions who had visited EOPYY pharmacies in Athens, the capital city of Greece, from October 2022 to January 2023. Results  Patients seem satisfied with public pharmacies in general. In fact, the professionalism of the pharmacists, the respect that patients have received from them, and the information and explanations that were given by pharmacists, received a very high score. On the other hand, the parameters referred to the information that patients received from pharmacists for the overall improvement of their health had the lowest score, revealing an apparent lag in the field of medicinal advice. Conclusion  Without any doubt, patients expect their pharmacists to be more guiding and to better communicate this role. This requires more time to be spent with patients, focused training, teamwork, layout, and other organizational interventions.

Factors influencing choice of b/ts DMARDs in managing inflammatory arthritis from a patient perspective: a systematic review of global evidence and a patient-based survey from Hong Kong

OBJECTIVES

To investigate factors concerning patients regarding biological/target synthetic disease-modifying antirheumatic drugs (b/ts DMARDs) in treating inflammatory arthritis (IA).

DESIGN

This study consists of a systematic review and a cross-sectional survey in Hong Kong. A systematic review of literature following Preferred Reporting Items for Systematic Reviews and Meta-Analyses was conducted on PubMed, Web of Science, Cochrane and Embase between 1 January 2000 and 1 January 2022. Content analysis was conducted to summarise factors grouped by four themes-social aspects (SA), clinical aspects (CA), medicine characteristics (MC) and financial aspects (FA) in the decision-making process. One cross-sectional survey among Hong Kong patients with IA was conducted to add to global evidence.

SETTING

A systematic review of global evidence and a patient-based survey in Hong Kong to complement scarce evidence in Asia regions.

RESULTS

The systematic review resulted in 34 studies. The four themes were presented in descending order consistently but varied with frequency throughout decision-making processes. During decision-making involving medication initiation, preference and discontinuation, MC (reported frequency: 83%, 86%, 78%), SA (56%, 43%, 78%) and FA (39%, 33%, 56%) were the three most frequently reported factors, whereas CA was less studied. Local survey also revealed that MC factors such as treatment efficacy and the probability of severe adverse events, and SA factors such as the availability of government or charity subsidy, influenced patients' initiation and preference for b/ts DMARDs. Meanwhile, self-estimated improvement in disease conditions (SA), drug side effects (MC) and drug costs (FA) were associated with treatment discontinuation.

CONCLUSIONS

Global and local evidence consistently indicate that MC and SA are important considerations in patients' decisions regarding novel DMARDs. Health policies that reduce patients' financial burden and enhances healthcare professionals' engagement in decision-making and treatment delivery should be in place with an efficient healthcare system for managing IA optimistically.

Impact of access to treatment on patient-reported outcomes among rheumatoid arthritis patients with tDMARDs and bDMARDS in two Latin-American countries: A prospective observational study

Background and Aims

A noninterventional prospective study was performed in Colombia and Peru. The aim was to describe the impact of access to treatment on Patient-reported outcomes (PRO) in patients with Rheumatoid arthritis (RA) after failure to conventional disease-modifying antirheumatic drugs (DMARDs) in real-life conditions.

Methods

The impact of access to treatment was measured by access barriers, time to supply (TtS) and interruption evaluating their effect in changes of PROs between baseline and 6-month follow-up between February 2017 and November 2019. The association of access to care with disease activity, functional status, health-related quality of life was assessed using bivariate and multivariable analysis. Results are expressed in least mean difference; TtS in mean number of days for delivery of treatment at baseline. Variability measures were standard deviation and standard error.

Results

One hundred seventy patients were recruited, 70 treated with tofacitinib and 100 with biological DMARDs. Thirty-nine patients reported access barriers. The mean of TtS was 23 ± 38.83 days. The difference from baseline to 6-month visit in PROs were affected by access barriers and interruptions. There was not statistically significant difference in the of PRO's score among visits in patients that reported delay of supply of more than 23 days compared to patients with less days of delay.

Conclusion

This study suggested the access to treatment can affect the response to the treatment at 6 months of follow-up. There seems to be no effect in the PROs for delay of TtS during the studied period.

A scoping review on the impact of austerity on healthcare access in the European Union: rethinking austerity for the most vulnerable

BACKGROUND

There is consensus that the 2008 financial and economic crisis and related austerity measures adversely impacted access to healthcare. In light of the growing debt caused by the COVID-19 crisis, it is uncertain whether a period of austerity will return.

OBJECTIVE

This study aims to provide a structured overview of the impact of austerity policies in the EU-28 zone, applied in response to the Great Recession, on access to health care for the adult population, using the five access dimensions by Levesque et al. (2013).

METHODS

This study followed the PRISMA extension for Scoping Reviews guideline. Medline (PubMed) and Web of Science were searched between February 2021 and June 2021. Primary studies in the English language published after the 1st of January 2008 reporting on the possible change in access to the healthcare system for the adult population induced by austerity in an EU28 country were included.

RESULTS

The final search strategy resulted in 525 articles, of which 75 studies were reviewed for full-text analysis, and a total of 21 studies were included. Results revealed that austerity policy has been primarily associated with a reduction in access to healthcare, described through four main categories: i) Increase in rates of reported unmet needs (86%); ii) Affordability (38%); iii) Appropriateness (38%); iv) and Availability and Accommodation (19%). Vulnerable populations were more affected by austerity measures than the general population when specific safeguards were not in place. The main affected adult vulnerable population groups were: patients with chronic diseases, elderly people, (undocumented) migrants, unemployed, economically inactive people and individuals with lower levels of education or socioeconomic status.

CONCLUSION

Austerity measures have led to a deterioration in access to healthcare in the vast majority of the countries studied in the EU-28 zone. Findings should prompt policymakers to rethink the fiscal agenda across all policies in times of economic crisis and focus on the needs of the most vulnerable populations from the health perspective.

Access of People Living with HIV to Testing Services in Greece: A Challenge for Equity in Care

(1) Background: Access to laboratory testing services for HIV in Greece is persistently challenged and this impacts both the continuum of care and, potentially, equity in access. (2) Methods: A cross-sectional study with two parts (first part: HIV-positive people/PLWHIV; second part: HIV clinicians) was conducted in Greece to quantify challenges regarding access to laboratory testing for HIV. Data were collected through online surveys, during a one-month period, between 2019 and 2020. The total sample consisted of 153 PLWHIV and 26 HIV clinicians. (3) Results: Access to viral load testing varied significantly according to place of residence (p = 0.029) and year of diagnosis (p = 0.054). Patients diagnosed after 2015 reported worse access to viral load testing (72.7% vs. 85.9%). Over one third of respondents perceived viral load tests as being not at all accessible (11.4%) or somewhat accessible, only after facing multiple systemic obstacles (24.2%). Equally, most of HIV clinicians reported barriers or no access to baseline viral load testing (80%) and baseline genotype resistance tests (96%). (4) Conclusions: Access of people diagnosed with HIV to CD4 lymphocyte tests and genotype resistance screening is significantly challenged in Greece, especially after 2015. Addressing this challenge is critical in removing access barriers and achieving the UNAIDS 95-95-95 HIV elimination goals.

Drug Shortage: Causes, Impact, and Mitigation Strategies

Drug shortage is a global issue affecting low, middle, and high-income countries. Many countries have developed various strategies to overcome the problem, while the problem is accelerating, affecting the whole world. All types of drugs, such as essential life-saving drugs, oncology medicines, antimicrobial drugs, analgesics, opioids, cardiovascular drugs, radiopharmaceutical, and parenteral products, are liable to the shortage. Among all pharmaceutical dosage forms, sterile injectable products have a higher risk of shortage than other forms. The causes of shortage are multifactorial, including supply issues, demand issues, and regulatory issues. Supply issues consist of manufacturing problems, unavailability of raw materials, logistic problems, and business problems. In contrast, demand issues include just-in-time inventory, higher demand for a product, seasonal demand, and unpredictable demand. For regulatory issues, one important factor is the lack of a unified definition of drug shortage. Drug shortage affects all stakeholders from economic, clinical, and humanistic aspects. WHO established global mitigation strategies from four levels to overcome drug shortages globally. It includes a workaround to tackle the current shortage, operational improvements to reduce the shortage risk and achieve early warning, changes in governmental policies, and education and training of all health professionals about managing shortages.

Treatment Adherence in Patients with Lung Cancer from Prospects of Patients and Physicians

Purpose:

Adherence to treatment can be defined as the degree to which a patient’s behavior is consonant with medical or health advice he or she receive as part of his treatment regimen. The aim of this study was: 1) to measure the rate of treatment adherence to among patients with lung cancer from the prospect of both patients and physicians, 2) to measure the degree of concordance between the two prospect, and 3) to identify factors related to adherence for both prospect (patients and physicians).

Materials and Methods:

A total of 250 patients were included in this study. Information about socio-economic characteristics, depressive and anxiety symptoms (Hospital Anxiety and Depression scale), nicotine dependence (Fagerstrom scale), barriers to accessing care, and the level of treatment adherence was collected through interview. Physicians were enquired about disease and treatment variables as well as patients’ level of adherence.

Results:

From the patient perspective, only 1.2% of patients displayed poor adherence; whereas the corresponding percentage among physicians was 12.4%. The concordance between the two was low: 0.244. The correlation of measurements made on the same individual was found to be equal to 0.14. Barriers to accessing medication (O.R.=2.82, 95% C.I.: 1.01-8.09) was the only risk factor when adherence was self-rated; barriers to accessing medication (O.R.=2.45, 95% C.I.: 1.03-5.86), education equal to 12 years (O.R.=0.33, 95% C.I.: 0.13-0.82) or higher than 12 years (O.R.=0.28, 95% C.I.: 0.08-0.96), nicotine dependence (O.R.=1.41, 95% C.I. 1.17-1.69) and HADS anxiety score (O.R.=1.15, 95% C.I. 1.03-1.30) were the predictors in physicians’ rating.

Conclusions:

Differences in rating adherence may underpin communication gaps between patients and physicians. Systemic determinants of poor adherence should not be overlooked. A concerted effort by researchers, physicians and policy makers in defining as well as communicating adherence, while removing its barriers should be made.

Economic Distress in Families with a Member Suffering from Severe Mental Illness: Illness Burden or Financial Crisis? Evidence from Greece

The present study aims to explore the economic distress and pertinent coping strategies in families with a member suffering from a severe mental illness. Furthermore it endeavors to gauge the impact of illness burden and that of the Greek recession on economic distress, while disentangling their contribution. In total, 190 key relatives of people with severe mental illness were recruited from community mental health services in the region of Attica. Relatives completed a self-reported questionnaire consisting of the Index of Personal Economic Distress, the Family Burden scale and the Family Rituals scale. Information on financial strategies for tackling recession and income loss due to the recession was also gleaned. Regarding economic distress, only 15% had frequent difficulty meeting routine financial demands in their household. The preponderant strategy was spending savings (56.8%). Income category and spending less on basic needs were the main predictors of economic distress. Objective poverty indices rather than burden predicted economic distress to a greater extent.

Accessibility to biologics and its impact on disease activity and quality of life in patients with rheumatoid arthritis in Kuwait

Objective

Biologics are indicated in rheumatoid arthritis (RA) in case of persistent high disease activity despite conventional disease-modifying anti-rheumatic drugs (cDMARDs) or patients with contraindications to cDMARDs or poor prognostic factors. The purpose of this study was to compare the prescription rates of biologics in Kuwaiti and non-Kuwaiti patients and to assess whether this had an impact on disease activity and quality of life in RA patients.

Methods

Data were extracted from the Kuwait Registry for Rheumatic Diseases. Adult patients who satisfied the ACR classification criteria for RA from four major hospitals in Kuwait were evaluated from February 2013 through May 2018. The treatment agents, disease activity, and quality of life of Kuwaiti patients were compared with non-Kuwaiti patients.

Results

A total of 1651 RA patients were included; 806 (48.8%) were Kuwaiti patients. Among Kuwaiti patients, 62.5% were on biologic drugs in comparison with 14% of non-Kuwaiti patients. In comparison with non-Kuwaiti patients, Kuwaiti patients had significantly lower numbers of swollen joints (p < 0.001) and disease activity score-28 scores (p = 0.02) and less steroid use (p < 0.001) yet a significantly higher health assessment questionnaire-disability index (p < 0.001). Regression analysis showed that DAS-28 scores were significantly associated with the treatment type (p < 0.001) and that nationality was significantly predictive of the treatment type (p < 0.001).

Conclusion

In the setting of easy accessibility to treatment for Kuwaiti patients, biologics were prescribed by rheumatologists at a higher rate than for non-Kuwaitis. This may explain the lower disease activity and the lower rate of steroid use in Kuwaiti patients than non-Kuwaitis.

Key points

• Significant discrepancies in the rates of prescribing biologic therapies between KP and NKP in Kuwait were observed.

• Several treatment outcomes were significantly better in the KP group than in the NKP group even after adjustment of confounding factors.

• The poor access to biologic therapies was suggested to limit the effectiveness of RA treatments in the NKP group.

Real world, big data cost of pharmaceutical treatment for rheumatoid arthritis in Greece

Introduction

Rheumatoid Arthritis (RA) is a highly prevalent autoimmune disease associated with joint inflammation and destruction. Treatment for RA, especially with biologic agents (biologics), improves patient functionality and quality of life and averts costly complications or disease progression. Cost of RA pharmaceutical treatment has rarely been reported on the basis of real-world, big data. This study reports on the real-world, big data RA pharmaceutical treatment cost in Greece.

Methods

The Business Intelligence database of the National Organization for Healthcare Services Provision (EOPYY) was used to identify and provide analytics on patients on treatment for RA. EOPYY is responsible for funding healthcare and pharmaceutical care services for approximately 95% of the population in the country. ICD-10 codes were applied to identify patients with RA and at least one reimbursed prescription between 1 June 2014 and 31 May 2015.

Results

35,873 unique patients were recorded as undergoing treatment for RA. Total reimbursed treatment cost for the study period was €81,206,363.70, of which €52,732,142.18 (64.94%) was for treatment with biologics. Of that cost, €39,724,489.71 (48.32%) accounted for treatment with anti-TNFs and/or methotrexate/corticosteroids.

Conclusion

Real world, big data analysis confirms that the major driver of RA pharmaceutical cost is, as expected, the cost of treatment with biologics. It is critical to be able to match this cost to the treatment outcome it produces to ensure an optimal, no-waste, evidence-based allocation of healthcare resources to need.

Association of Patient, Prescriber, and Region With the Initiation of First Prescription of Biologic Disease-Modifying Antirheumatic Drug Among Older Patients With Rheumatoid Arthritis and Identical Health Insurance Coverage

IMPORTANCE

Prescribing the first biologic treatment for rheumatoid arthritis (RA) is an important decision for patients, their physicians, and payers, with considerable costs and clinical implications. Conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) have known effectiveness and safety profiles and are less expensive; therefore, determining the variables contributing to csDMARD treatment duration is an essential question for patients, physicians, and payers.

OBJECTIVES

To describe access to the first biologic DMARD prescription in a population of patients with RA and identical comprehensive health insurance coverage in Ontario, Canada, and to explore the associations of patient, prescriber, and geographic region with differences in time to first biologic prescription.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study of incident patients with RA used administrative data with surveillance and patient-level data collected at yearly intervals. A total of 17 672 patients were included in the study; they were residents of Ontario, Canada, had an incident RA diagnosis at age 67 or older between 2002 and 2015, and received at least 1 csDMARD. Data were analyzed in November 2017.

EXPOSURE

Patient variables were age, sex, disease duration, socioeconomic status, distance to care, and supply of care in the patient's area of residence. Prescriber covariates were year of graduation, specialty of practice, and supply of rheumatologic care in the patient's geographic region.

MAIN OUTCOMES AND MEASURES

Time from first csDMARD prescription to receipt of first biologic medication.

RESULTS

Of 17 672 patients, 11 598 (65.6%) were women, and the mean (SD) age was 75.2 (5.8) years. Characteristics associated with longer time to receipt of a biologic prescription were older age (HR for every 5-year increase, 0.66; 95% CI, 0.62-0.71; P < .001), male sex (HR, 0.76; 95% CI, 0.66-0.89; P < .001), and distance to the nearest rheumatologist (HR per 10-km increase, 0.99; 95% CI, 0.98-0.99; P < .001). Prescribers were primarily rheumatologists (151 of 214 [70.6%]) and primary care physicians (26 of 214 [12.1%]). After adjusting for the number of patients eligible to receive biologic DMARDs, rheumatologists' preferences (ie, yearly prescription rates) for using biologic DMARDs increased over time, from 1.7% in 2001 to 4.9% in 2015. After adjusting for calendar year and patient-, prescriber-, and region-level characteristics, substantial variation between prescribers in rates of prescribing a first biologic DMARD were found (65% variance).

CONCLUSIONS AND RELEVANCE

This study found variation in time to receipt of first biologic DMARD after prescription of first csDMARD in a population with RA after adjustment for individual-level patient, prescriber, and geographic area covariates, despite identical universal health insurance coverage.

Persistence and Adherence during the First Six Months of Tocilizumab Treatment Among Rheumatoid Arthritis Patients in Routine Clinical Practice in Greece. Results from the Single Arm REMISSION II Study (NCT01649817)

OBJECTIVE/AIM

One of the most important factors that affect a treatment's performance in rheumatoid arthritis (RA) is adherence to medications. According to literature, there are several reasons for non-adherence in RA patients with some of them being related to a specific patient profile of the study population. In this study, we investigated persistence to intravenous tocilizumab (TCZ) therapy in RA during routine clinical practice in Greece and identified causes for non-adherence.

METHODS

183 RA patients who mostly attended private practice Rheumatologists and received intravenous TCZ treatment at a schedule of 1 infusion per 4-weeks in the first 6 months were recorded retrospectively.

RESULTS

Persistence estimated rate to TCZ therapy was 92.0% for patients that received 6 infusions and 83.4% for patients that received 7 infusions of TCZ. Potential factors that influence persistence to therapy were the occurrence of adverse events and response to the therapy. The main reasons for non-adherence to TCZ therapy were non-medically related with the most common being drug supply issues. The 6-month mean change from baseline in DAS28-ESR after initiation of TCZ therapy was -1.3, and the mean CDAI dropped from 29.6 at baseline to 16.7 at 6 months. Good/Moderate response was achieved by 89.1% of patients and remission by 23.5%. The safety profile was similar to that observed in other TCZ trials with the most common being infections, hematologic manifestations and musculoskeletal disorders.

CONCLUSION

Overall, persistence to therapy appeared to be high in the rheumatology private practice setting and non-adherence to the TCZ treatment schedule is attributed mainly to non-medical reasons.

An association of economic hardship with depression and suicidality in times of recession in Greece

The interplay between objective and subjective measures of economic hardship on influencing mental health has not been explored during a period of enduring recession. The present study aims to fill this gap by investigating the relationship between income and economic difficulties in evoking major depression and suicidality in Greece, while taking into consideration gender differences. A random and representative sample of 2188 adults participated in a telephone survey in 2013 (response rate = 81%). Major depression and suicidality were assessed with the pertinent modules of SCID-IV; while financial difficulties were measured by the Index of Personal Economic Distress. Information on confounder variables was also gleaned. Income exerted an independent effect on major depression (OR = 0.37, 95%CI = 0.22-0.63), which was more pronounced among men than women. On the contrary, financial difficulties exerted a strong and independent effect on depression (OR = 1.16, 95%CI = 1.13-1.2). Income was found to bear a strong association with suicidality only among men; whereas financial difficulties were unrelated in both genders. Subjective and objective indices of economic hardship exert a differential impact on mental health outcomes amid recession. Gender-sensitive policies and interventions should be geared towards softening the social effects of the recession in the country.

The impacts of medication shortages on patient outcomes: A scoping review

Background

In recent years, medication shortages have become a growing worldwide issue. This scoping review aimed to systematically synthesise the literature to report on the economic, clinical, and humanistic impacts of medication shortages on patient outcomes.

Methods

Medline, Embase, Global Health, PsycINFO and International Pharmaceutical Abstracts were searched using the two key concepts of medicine shortage and patient outcomes. Articles were limited to the English language, human studies and there were no limits to the year of publication. Manuscripts included contained information regarding the shortage of a scheduled medication and had gathered data regarding the economic, clinical, and/or humanistic outcomes of drug shortages on human patients.

Findings

We found that drug shortages were predominantly reported to have adverse economic, clinical and humanistic outcomes to patients. Patients were more commonly reported to have increased out of pocket costs, rates of drug errors, adverse events, mortality, and complaints during times of shortage. There were also reports of equivalent and improved patient outcomes in some cases.

Conclusions

The results of this review provide valuable insights into the impact drug shortages have on patient outcomes. The majority of studies reported medication shortages resulted in negative patient clinical, economic and humanistic outcomes.

Biosimilars in oncology and inflammatory diseases: current and future considerations for clinicians in Latin America

Biological therapies have revolutionized the treatment of several cancers and systemic immune-mediated inflammatory conditions. Expiry of patents protecting a number of biologics has provided the opportunity to commercialize highly similar versions, known as biosimilars. Biosimilars are approved by regulatory agencies via an independent pathway that requires extensive head-to-head comparison with the originator product. Biosimilars have the potential to provide savings to healthcare systems and expand patient access to biologics. In Latin American countries, regulatory frameworks for biosimilar approval have been introduced in recent years, and biosimilars of monoclonal antibody and fusion protein therapies are now emerging. However, the situation in this region is complicated by the presence of "non-comparable biotherapeutics" (also known as "intended copies"), which have not been rigorously compared with the originator product. We review the considerations for clinicians in Latin American countries, focusing on monoclonal antibody biosimilars relevant to oncology, rheumatology, gastroenterology, and dermatology.

Area of Residence and Socioeconomic Factors Reduce Access to Biologics for Rheumatoid Arthritis Patients in Romania

Introduction

The study aimed to evaluate the influence of socioeconomic factors on rheumatoid arthritis (RA) patients' access to biologics in Romania.

Method

Cross-sectional data were collected in January 2014 from the Romanian Registry of Rheumatic Diseases (RRRD) comprising all RA patients on biologics from 42 Romanian counties. “Territorial” access to biologics was defined by patients receiving biologics in their home county. A county was “equitable” if <25% of RA patients received biologics outside it.

Results

The RRRD included 4507 RA patients aged 56.7 ± 12.1 years, with a disease duration of 12.1 ± 8.3 years. Urban dwellers (67.8%) had a significantly higher prevalence of territorial biologic access than rural dwellers (83.1% compared to 74.1%; p < 0.001). Gross domestic product (GDP) in 1000 €/capita/county (odds ratio (OR) = 1.224) and number of physicians/1000 inhabitants/county (OR = 2.198) predict territorial access to biologics and also predict the number of territorially treated RA patients. Inequitable counties exhibited significantly lower socioeconomic indicators than equitable counties.

Conclusion

In Romania, RA patients' access to biologics varies significantly between counties. Urban dwellers and patients living in counties/regions with high living standards are more likely to receive biologics locally than those living in more deprived areas.

The impact of the long-lasting socioeconomic crisis in Greece

Since 2009, Greece has experienced a long-lasting socioeconomic crisis that has had substantial consequences on the health and mental health of the population. Unemployment, financial hardship and income loss constitute the hallmarks of the socioeconomic landscape. Consequently, a substantial decline in health and mental health has been documented. Converging evidence corroborates a deterioration of self-rated health, an alarming rise in suicide rates and a gradual increase in the prevalence of major depression. Concomitantly, the healthcare system is on the verge of collapse and the mental healthcare system is incapable of addressing the emerging needs. Therefore, a multifaceted and concerted effort is urgently needed to mitigate the mental health effects of the recession.

Access to treatment for Hepatitis C among injection drug users: results from the cross-sectional HOPE IV study

Background

Evidence suggests that Greece is among the European countries with increased trend in HCV prevalence among injecting drug users (IDUs) from 2008 to 2014. Nonetheless, the access of IDUs to treatment for Hepatitis C Virus (HCV) is very limited while the risk of co-infection and transmission remains high. In an effort to better understand the inhibitors to HCV treatment, the present study aimed to investigate the main barriers to access in a sample of IDUs.

Methods

The cross-sectional study was carried out between July and September 2015 using a 23-items questionnaire. Participants were recruited from urban primary services, mobile health vans, community health services, day-care centers as well as during street work, located in Athens, Greece. Inclusion criteria were age above 18 years, understanding and speaking Greek sufficiently, HCV diagnosis, intravenous drug use. Data collection was carried out by health professionals of Praksis, a non-governmental organization. For the comparisons of proportions chi-square and Fisher’s exact tests were used.

Results

The study sample consisted of 101 HCV patients, 68% male. More than 80% of study participants experienced barriers in accessing their doctor and medication during the past 12 months. The most common obstacles in accessing a doctor were “delay in making the appointment and “difficulties in going to the doctor due to health condition or lack of means of transport”. Access to physician or medication was not differed according to gender, but significant differences were found according to economic status and health insurance coverage. 56.1% of participants reported loss or treatment delay due to barriers to treatment. The majority of participants had deteriorated financial status, health status, access to health services and medication, higher financial burden for health services, worse mental health and lower adherence to medical instructions in 2015 compared to 2009.

Conclusions

The findings from the present study revealed that the vast majority of IDUs experience significant barriers in seeking HCV care in Greece, thus highlighting the need for immediate action in this particular area due to the high risk of co-infection and transmission.

Telemedicine for patients with rheumatic diseases: Systematic review and proposal for research agenda

OBJECTIVE

To systematically review the scientific literature regarding tele-rheumatology and draw conclusions about feasibility, effectiveness, and patient satisfaction.

METHODS

PubMed, Scopus, and Cochrane database searches were performed (April 2016) using relevant MeSH and keyword terms for telemedicine and rheumatic diseases. Articles were selected if reporting outcomes for feasibility, effectiveness, and patient satisfaction and methodologically appraised using the Cochrane Collaboration's tool for assessing risk of bias and a modified version of CONSORT 2010 Statement.

RESULTS

A total of 177 articles were screened, 23 were selected for the present review but only 9 were RCTs. Five studies reported on feasibility, 14 effectiveness, and 9 satisfaction rates for different tele-rheumatology interventions grouped in synchronous (remotely delivered consultation) and asynchronous (remote disease activity assessment; tele-monitoring of treatment strategies or rehabilitation; and remotely delivered self-management programs). Seven studies (30.4%) were on rheumatoid arthritis, 2 (8.7%) were on systemic sclerosis (1 including also rheumatoid arthritis patients), 5 (21.7%) on fibromyalgia, 2 (8.7%) on osteoarthritis, 3 (13.0%) on juvenile idiopathic arthritis and 4 (17.4%) on mixed disease cohorts. Interventions and outcomes heterogeneity prevented meta-analysis of results. Overall, feasibility and patient satisfaction rates were high or very high across intervention types. Effectiveness was equal or higher than standard face-to-face approach in controlled trials which, however, were affected by small sample size and lack of blinding participants according to appraisal tools.

CONCLUSION

Telemedicine may provide a well-accepted way to remotely deliver consultation, treatment and monitoring disease activity in rheumatology. Higher quality RCTs demonstrating effectiveness of different tele-rheumatology interventions are needed.

Knowledge and attitudes of women regarding gynaecological cancer prevention in an urban area of Greece in financial crisis

INTRODUCTION

Preventive gynaecological examinations (PGEs) are the main means of monitoring gynaecological cancers across the developed world. The purpose of this study was to investigate the perceptions and attitudes of women of a regional municipality of Greece, regarding preventive gynaecological examinations amid economic crisis.

MATERIAL AND METHODS

The study included 360 women aged 20-70 years, who lived in an urban area of Greece. A specialised, valid and anonymous questionnaire that included questions about perceptions and attitudes regarding preventive gynaecological examinations was used. The data analysis was performed using the statistical package spss 21.

RESULTS

It was found that women who lived in less developed areas had had lower educational levels and higher abstinence rates from medical examinations. The main source of information about sexually transmitted diseases was their social circle (48%), but the gynaecologist is the one preferred (54.8) to inform about preventive gynaecological examinations. Thirty per cent of the participants had never have a mammogram, while 33.9% of the sample did not show the same result, although considered the Pap test necessary. The main cause of women's abstention of preventive gynaecological examinations is the financial crisis.

CONCLUSIONS

The current financial crisis has negatively affected the women's ability to afford gynaecological examinations. Therefore, it is necessary to inform the population about the necessity of preventive gynaecological examinations starting from school age and at the same time, health information and promotion campaigns should be launched at a national level.

Protective effect of taraxasterol against rheumatoid arthritis by the modulation of inflammatory responses in mice

Taraxasterol is an effective component of dandelion that has anti-inflammatory effects in vivo and in vitro. The present study was performed to explore whether taraxasterol exhibits a protective effect against rheumatoid arthritis through the modulation of inflammatory responses in mice. Eight-week-old CCR9-deficient mice were injected with a collagen II monoclonal antibody cocktail to create a rheumatoid arthritis model. In the experimental group, arthritic model mice were treated with 10 mg/kg taraxasterol once per day for 5 days. Treatment with taraxasterol significantly increased the pain thresholds and reduced the clinical arthritic scores of the mice in the experimental group compared with those of the model group. Furthermore, treatment with taraxasterol significantly suppressed tumor necrosis factor-α, interleukin (IL)-1β, IL-6 and nuclear factor-κB protein expression levels compared with those in the rheumatoid arthritis model mice. Taraxasterol treatment also significantly reduced nitric oxide, prostaglandin E2 and cyclooxygenase-2 levels compared with those in the rheumatoid arthritis model group. These observations indicate that the protective effect of taraxasterol against rheumatoid arthritis is mediated via the modulation of inflammatory responses in mice.

Enduring financial crisis in Greece: prevalence and correlates of major depression and suicidality

PURPOSE

A series of repeated cross-sectional surveys conducted in 2008, 2009, 2011 and 2013 were conducted with the aim of estimating the prevalence of major depression and suicidality as well as of investigating its risk factors. The present report concentrates on the 2013 survey.

METHODS

A random and representative sample of 2.188 people was telephone interviewed with regard to various socio-economic indicators and the presence of major depression and suicidality, which were assessed with the germane module of the Structured Clinical Interview.

RESULTS

Findings suggest a rise in 1-month prevalence of major depression (12.3 %) and a decline in prevalence of suicidality (2.8 %). Female gender, residence in rural area, low educational attainment, unemployment and economic hardship were found to increase the odds of suffering from major depression. The influence of economic hardship and unemployment on suicidality was also substantial and independent of major depression.

CONCLUSIONS

Results stress the imperative need for the design and implementation of social policies and interventions that would offset the dire impact of the sustained recession in Greece.

Access to Care for Multiple Sclerosis in Times of Economic Crisis in Greece--the HOPE II Study

BACKGROUND

While there is currently no cure for multiple sclerosis (MS), treatment with biologic disease-modifying drugs (bDMDs) can reduce the impact of the condition on the lives of patients. In Greece, the regulatory change in the distribution system of bDMDs, limited their administration through the designated pharmacies of the National Organization for Healthcare Services Provision (EOPYY) or the National Health System (ESY) hospitals, thus potentially impacting access to MS treatment. In this context, the aim of this paper was to assess the barriers to bDMDs, by recording MS patients' experiences.

METHODS

A survey research was conducted between January and February 2014 in Athens and 5 other major Greek cities with the methods of personal and telephone interview. A structured questionnaire was used to elicit socio-economic and medical information, information related to obstacles in accessing bDMDs and medical treatment, from MS patients that visited EOPYY pharmacies during the study period.

RESULTS

During the last year 69% of 179 participants reported that the distribution system of bDMDs has improved. Thirteen percent of participants encountered problems in accessing their medication, and 16.9% of participants in accessing their physician, with the obstacles being more pronounced for non-Athens residents. Frequent obstacles to bDMDs were the distance from EOPYY pharmacies and difficulties in obtaining a diagnosis from an EOPYY/ESY physician, while obstacles to medical care were delays in appointment booking and travel difficulties.

CONCLUSION

Even though the major weaknesses of the distribution system of bDMDs have improved, further amelioration of the system could be achieved through the home delivery of medicines to patients living in remote areas, and through the development of a national MS registry.

Estimating the Fiscal Effects of Public Pharmaceutical Expenditure Reduction in Greece

The purpose of the present study is to estimate the impact of pharmaceutical spending reduction on public revenue, based on data from the national health accounts as well as on reports of Greece’s organizations. The methodology of the analysis is structured in two basic parts. The first part presents the urgency for rapid cutbacks on public pharmaceutical costs due to the financial crisis and provides a conceptual framework for the contribution of the Greek pharmaceutical branch to the country’s economy. In the second part, we perform a quantitative analysis for the estimation of multiplier effects of public pharmaceutical expenditure reduction on main revenue sources, such as taxes and social contributions. We also fit projection models with multipliers as regressands for the evaluation of the efficiency of the particular fiscal measure in the short run. According to the results, nearly half of the gains from the measure’s application is offset by financially equivalent decreases in the government’s revenue, i.e., losses in tax revenues and social security contributions alone, not considering any other direct or indirect costs. The findings of multipliers’ high value and increasing short-term trend imply the measure’s inefficiency henceforward and signal the risk of vicious circles that will provoke the economy’s deprivation of useful resources.

Access to an optimal treatment. Current situation

Access to an optimal treatment is determined by several factors, like availability, pricing/funding, and acceptability. In Latin America (LA), one of the regions with more disparities particularly on healthcare in the world, access is affected by other factors, including socio-demographic factors like poverty, living in rural regions, and/or health coverage. Regarding rheumatoid arthritis (RA), an inadequate access to specialists leads to diagnosis and treatment delays diminishing the probability of remission or control. Unfortunately, in almost every LA country, there are cities with more than 100,000 inhabitants without rheumatologists; furthermore, a primary care reference system is present in only about half the countries. In the public health system, coverage of biologic disease-modifying antirheumatic drugs occurs for less than 10 % of the patients in about half of the countries. Also, as healthcare providers based their funding decisions mainly in direct costs instead of on patient-centered healthcare quality indicators, access to new drugs is more complicated in this region than in high-income countries. More accurate epidemiological data from LA need to be obtained in order to improve the management of patients with rheumatic diseases in general and RA in particular.

Economic evaluation of anti-TNF agents for patients with rheumatoid arthritis in Greece

Objectives

We aimed to estimate the total mean annual treatment cost of different therapy options for patients with moderate-to-severe rheumatoid arthritis (RA) in Greece.

Methods

A cost-minimization approach was adopted. An economic model was developed to estimate the direct costs of the three widely used treatments within a 1-year time horizon, from a health care payer perspective, either for new or for existing patients. Data on resource use, dose escalation, and frequency of therapy were based on a nationwide field survey of rheumatologists. Other analyses were also undertaken based on evidence from the literature. Total cost comprised the cost of drugs, administration, and hospital day care visits. Unit cost data were obtained from the price bulletin and the government gazettes issued by the Ministry of Health. Due to the short time horizon of the study, the cost was not discounted.

Results

The mean annual total cost per new (or per existing) responder patient on etanercept was estimated at €9,845 (€9,840), and the total cost on etanercept/methotrexate (MTX) was estimated at €9,857 (€9,852). Therapy with etanercept had lower annual cost relative to adalimumab and infliximab. On an annual basis, it was estimated that the difference between etanercept monotherapy and adalimumab monotherapy was €544 (€1,323). Similarly, the difference between etanercept/MTX and infliximab/MTX was €1,871 (€1,490) and €543 (€1,323), respectively, relative to adalimumab/MTX. Results remained constant under other scenario analyses undertaken.

Conclusion

In the real-life practice setting in Greece, where dose intensity and frequency differences occur, etanercept alone or in combination with MTX, if prescribed as per label, represents the option with lower annual cost per patient when compared with adalimumab or infliximab in patients with RA. These results hold true as long as the assumptions and data used in the analysis remain stable and may alter if any of the underlying parameters, such as drug price, change.