Gesundheitsökonomische Evaluation von Rehabilitationsprogrammen im Förderschwerpunkt Rehabilitationswissenschaften

[Is rehabilitation worth it? : Review of economic evaluations of rehabilitation in Germany]

Because of demographic change, the rehabilitation sector in Germany is going to face increasing demands in the future. Limited budgets make the optimal allocation of resources a top priority. To support decisions about the optimal scope and design of rehabilitation, studies on health economics are of utmost importance. The aim of this article is to provide an overview of the evaluation of rehabilitation with regard to health economics in Germany.Based on a comprehensive literature research, 17 studies on the cost-effectiveness of rehabilitation in Germany were identified. The health economics evaluation focuses on four main topics: patient education (5 studies), the comparison of outpatient and inpatient rehabilitation (7 studies), medico-occupational rehabilitation programs (2 studies) and aftercare programs (3 studies). All four topics show that innovative rehabilitation technologies can be cost-effective. Significant potential savings in program costs of 25-35% are demonstrated in outpatient rehabilitation (with comparable effectiveness with inpatient care). Designated patient education programs often lead to significant savings with indirect costs, by reducing periods of unfitness to work and extending the long-term ability to work. This review article also points out that some relevant areas of rehabilitation, such as the flexibilization of rehabilitation programs or the efficient organization of access to rehabilitation, have not been evaluated sufficiently on the basis of health economics. This article ends with the requirement to carry out more economics-based rehabilitation studies.

Differences in the Time Course of Disease Progression, Quality of Life and Health Service Utilization in Women with Endometriosis

Introduction

This study aimed to identify different subgroups (clusters) of patients (n = 182) based on the previously defined variables “age” and “diagnostic delay” in order to identify varying needs of (socio-)medical care.

Methods

Five clusters were identified by two-step cluster analysis (SPSS 23.0). The mean values for parameters of quality of life, time course of disease progression and health service utilization were compared by chi-square and Kruskal-Wallis H test, and tested for correlations using Spearman's correlation coefficient.

Results

Clusters I and II patients recognized their endometriosis symptoms at a relatively late age. The results showed a short diagnostic delay and a low subjective disease burden, although cluster I was characterized by a high level of fatigue. Cluster III results indicated that a lack of social support and comparatively long diagnostic delay were major problems in this group. The women in cluster IV had the worst quality-of-life scores and a below-average utilization of services. Statistical analysis showed a significant association between an early age of onset of endometriosis symptoms and a very long delay in diagnosis. These women perceived their menstrual symptoms as “normal” or as “hypochondria”. Cluster V patients were mainly concerned about maintaining their work ability and employment.

Conclusions

In gynecological practice, special attention should be given to the very young women, as the early onset of endometriosis symptoms and a long delay in diagnosis may indicate the risk of an unfavorable course of the patient's medical and socio-medical history over time.

The Cost-Effectiveness of Screening for Hereditary Hemochromatosis in Germany: A Remodeling Study

Objective . Genetic tests for hereditary hemochromatosis (HH) are currently included in the German ambulatory care reimbursement scheme but only for symptomatic individuals and the offspring of HH patients. This study synthesizes the most current evidence to examine whether screening in the broader population is cost-effective and to identify the best choice of initial and follow-up screening tests. Methods . A probabilistic decision-analytic model was constructed to calculate cost per life year gained (LYG) for HH screening among male Caucasians aged 30. Three strategies were considered in both the general population and male offspring of HH patients: phenotypic (transferrin saturation, TS), genotypic (C282Y mutation), and sequential (genotype if TS is elevated) screening. Results . The incremental cost-effectiveness of sequential screening among male offspring, sequential population-wide screening, and genotypic screening is 41 000, 124 000, and 161 000 /LYG, respectively. All other strategies were subject to simple or extended dominance. The results are subject to high uncertainty. The most influential parameters in the deterministic one-way sensitivity analysis are discounting of life years gained and the adherence of patients to preventive phlebotomy. Discussion . The current German policy of only screening at-risk individuals is consistent with health economic decision making based on typically accepted thresholds. However, conducting the DNA test after the first elevated TS result is more cost-effective than waiting for a second TS result as recommended by the German guidelines. Further empirical work regarding adherence to long-term prevention recommendations and explicit and well-justified guidance for the choice of discount rates in German economic evaluation are needed.