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Costs of Inflammatory Bowel Disease in Germany

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Abstract

Introduction: Inflammatory bowel disease (IBD) is a chronic condition that afflicts young adults in their economically productive years. The goal of this study was to determine the costs of IBD in Germany from a societal perspective, using cost diaries.

Methods: Members of the German Crohn’s Disease and Ulcerative Colitis Association who had IBD were recruited by post, and those who agreed to participate documented their IBD-associated costs prospectively in a diary over 4 weeks. They documented their use of healthcare facilities, medications, sick leave and out-of-pocket expenditures, as well as general demographic information, the status and history of their IBD, and long-term disability. Item costs were calculated according to national sources. Cost data were calculated using non-parametric bootstrapping and presented as mean costs (year 2004) over 4 weeks.

Results: The cost diaries were returned by 483 subjects (Crohn’s disease: n = 241, ulcerative colitis: n = 242) with a mean age of 42 years and an average disease duration of 13 years (SD ± 8.09). The cost diaries were regarded as ‘easy to complete’ by 89% of participants. The mean 4-week costs per subject were €1425 (95% CI 1201, 1689) for Crohn’s disease and €1015 (95% CI 832, 1258) for ulcerative colitis. Of the total costs for Crohn’s disease, 64% were due to indirect costs such as early retirement or sick leave and 32% were due to direct medical costs. In contrast, of the total costs for ulcerative colitis, 41% were due to direct medical costs and 54% to indirect costs.

Conclusions: This is the first comprehensive cost study for Crohn’s disease and ulcerative colitis in Germany. The most important economic factors that influenced the cost profiles of both diseases were the long-term productivity losses due to an ongoing inability to work and the cost of medications. Results indicate significant cost differences between Crohn’s disease and ulcerative colitis. This data provides initial cost estimates that can be analysed further with respect to cost determinants and disease-specific costs in the future.

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Notes

  1. Patients were asked to specify costs per week for each of the ‘non-physician medical services’. For visits to a healer, physiotherapist or masseur, the costs documented by patients were compared with those available from the billing catalogue. If the costs were less than those of the billing catalogue, it was assumed that the patient had documented the co-payment, since patients insured with statutory health insurance must only pay a co-payment if a medical service has been prescribed by their physician (thus they would not know the real billing price). In this case, the price of the service according to the billing catalogue was taken. However, if the costs documented were higher than the billing catalogue, the value documented by the patient was used. Services that are not prescribed, and those used by privately insured patients, must be paid directly.

  2. Secondary general school, intermediate school and grammar school are the three types of school that can be attended after grade 4 in Germany, all starting at grade 5.[41] If a student only attends secondary general school without further qualifications, they can only go on to do an apprenticeship, whereas from intermediate school, a student can go on to further training for medium level occupations (e.g. bank employee) or obtain further qualifications for technical institutes. Only students attending grammar school can go on to study at university. Thus, table II provides only information regarding schooling up to grades 10–13 and the text provides some extra information regarding further training, such as trade school and university, which is comparable to other countries.

  3. Welfare payments, which are paid from taxes, differ from the pension received by 19% of patients with Crohn’s disease and 17% of patients with ulcerative colitis. These pensions are paid by the pension fund for long-term disability. Individuals can only receive such a disability pension if they have paid into the fund (i.e. were employed), are not eligible for the retirement pension and the courts have granted them the pension based on an expert medical report.

References

  1. Martins NB, Peppercorn MA. Inflammatory bowel disease. Am J Managed Care 2004; 10 (8): 544–52

    Google Scholar 

  2. Shivananda S, Lennard-Jones J, Logan R, et al. Incidence of inflammatory bowel disease across Europe: is there a difference between north and south? Results of the European Collaborative Study on Inflammatory Bowel Disease (EC-IBD). Gut 1996; 39 (5): 690–7

    Article  PubMed  CAS  Google Scholar 

  3. Bassi A, Dodd S, Williamson P, et al. Cost of illness of inflammatory bowel disease in the UK: a single centre retrospective study. Gut 2004; 53 (10): 1471–8

    Article  PubMed  CAS  Google Scholar 

  4. de Boer AG, Sprangers MA, Bartelsman JF, et al. Predictors of health care utilization in patients with inflammatory bowel disease: a longitudinal study. Eur J Gastroenterol Hepatol 1998; 10 (9): 783–9

    Article  PubMed  Google Scholar 

  5. Carter MJ, Lobo AJ, Travis SP. Guidelines for the management of inflammatory bowel disease in adults. Gut 2004; 53 Suppl. 5: V1–16

    Article  PubMed  Google Scholar 

  6. Rubin GP, Hungin AP, Kelly PJ, et al. Inflammatory bowel disease: epidemiology and management in an English general practice population. Aliment Pharmacol Ther 2000; 14 (12): 1553–9

    Article  PubMed  CAS  Google Scholar 

  7. Ebinger M, Leidl R, Thomas S, et al. Cost of outpatient care in patients with inflammatory bowel disease in a German University Hospital. J Gastroenterol Hepatol 2004; 19 (2): 192–9

    Article  PubMed  Google Scholar 

  8. Beiche A, Konig HH, Ebinger M, et al. Costs of ambulant care for patients with inflammatory bowel disease in general practice [in German]. Z Gastroenterol 2003; 41 (6): 527–36

    Article  PubMed  CAS  Google Scholar 

  9. Rosch M, Leidl R, Tirpitz C, et al. Cost measurement based on a cost diary in patients with inflammatory bowel disease [in German]. Z Gastroenterol 2002; 40 (4): 217–28

    Article  PubMed  CAS  Google Scholar 

  10. Metge CJ, Blanchard JF, Peterson S, et al. Use of pharmaceuticals by inflammatory bowel disease patients: a population-based study. Am J Gastroenterol 2001; 96 (12): 3348–55

    Article  PubMed  CAS  Google Scholar 

  11. Jaisson-Hot I, Flourie B, Descos L, et al. Management for severe Crohn’s disease: a lifetime cost-utility analysis. Int J Technol Assess Health Care 2004; 20 (3): 274–9

    Article  PubMed  Google Scholar 

  12. Dubinsky MC, Reyes E, Ofman J, et al. A cost-effectiveness analysis of alternative disease management strategies in patients with Crohn’s disease treated with azathioprine or 6-mercaptopurine. Am J Gastroenterol 2005; 100 (10): 2239–47

    Article  PubMed  CAS  Google Scholar 

  13. Hansson L, Lloyd A, Anderson P, et al. Excess morbidity and cost of failure to achieve targets for blood pressure control in Europe. Blood Press 2002; 11 (1): 35–45

    Article  PubMed  Google Scholar 

  14. Hay JW, Hay AR. Inflammatory bowel disease: costs-of-illness. J Clin Gastroenterol 1992; 14 (4): 309–17

    Article  PubMed  CAS  Google Scholar 

  15. Sandler RS, Everhart JE, Donowitz M, et al. The burden of selected digestive diseases in the United States. Gastroenterol-ogy 2002; 122 (5): 1500–11

    Article  Google Scholar 

  16. Blomqvist P, Ekbom A. Inflammatory bowel diseases: health care and costs in Sweden in 1994. Scand J Gastroenterol 1997; 32 (11): 1134–9

    Article  PubMed  CAS  Google Scholar 

  17. Goossens ME, Rutten-van Molken MP, Vlaeyen JW, et al. The cost diary: a method to measure direct and indirect costs in cost-effectiveness research. J Clin Epidemiol 2000; 53 (7): 688–95

    Article  PubMed  CAS  Google Scholar 

  18. Becker A, Seitz R, Jacobi E, et al. Cost evaluation by a patient questionnaire: pilot study of a weekly cost diary [in German]. Rehabilitation (Stuttg) 2001; 40 (1): 12–20

    Article  CAS  Google Scholar 

  19. Verbrugge LM. Health diaries. Med Care 1980; 18 (1): 73–95

    Article  PubMed  CAS  Google Scholar 

  20. Mauskopf J, Schulman K, Bell L, et al. A strategy for collecting pharmacoeconomic data during phase II/III clinical trials. Pharmacoeconomics 1996; 9 (3): 264–77

    Article  PubMed  CAS  Google Scholar 

  21. Johnston K, Buxton MJ, Jones DR, et al. Assessing the costs of healthcare technologies in clinical trials. Health Technol Assess 1999; 3 (6): 1–76

    PubMed  CAS  Google Scholar 

  22. Best BJ, Becktel JM, Singleton JW, et al. Development of a Crohn’s disease activity index. National Cooperative Crohn’s Disease Study. Gastroenterology 1976; 70: 439–44

    PubMed  CAS  Google Scholar 

  23. Rachmilewitz D. Coated mesalazine (5-aminosalicylic acid) versus sulphasalazine in the treatment of active ulcerative colitis: a randomised trial. BMJ 1989; 298: 82–6

    Article  PubMed  CAS  Google Scholar 

  24. Verband Deutscher Rentenversicherungsträger. Förderschwerpunkt “Rehabilitationswissenschaften”: Empfehlungen der Arbeitsgruppen “Generische Methoden”, “Routinedaten” und “Reha-Ökonomie”. Bad Homburg: WDV Wirtschaftsdienst, 1999

    Google Scholar 

  25. Krauth C, Hessel F, Hansmeier T, et al. Empirical standard costs for health economic evaluation in Germany: a proposal by the working group methods in health economic evaluation [in German]. Gesundheitswesen 2005; 67 (10): 736–46

    Article  PubMed  CAS  Google Scholar 

  26. Paracelsus heilpraktikerschulen. German billing guidelines for naturopaths [online]. Available from URL: http://www.paracelsus.de/recht/hp_geb.html [Accessed 2005 Jul 22]

  27. Federation of Public Health Insurance Companies of Employees (VDAK). Reimbursement of physiotherapy (west) [online]. Available from URL: http://www.vdak.de/heil_hilfsmittel/physio/verguetungsliste_physio_west.pdf [Accessed 2005 Jul 22]

  28. Federation of Public Health Insurance Companies of Employees (VDAK). Reimbursement of physiotherapy (east) [online]. Available from URL: http://www.vdak.de/heil_hilfsmittel/physio/verguetungsliste_physio_ost.pdf [Accessed 2005 Jul 22]

  29. Bundes-Angestelltentarifvertrag (BAT) [online]. Available from URL: http://www.huberlin.de/personalrat/battext/bat_0.htm [Accessed 2006 Mar 17]

  30. BAT payment system: Vergütungsordnung zum BAT (Bundes-Angestelltentarifvertrag) [online]. Available from URL: http://www.unituebingen.de/uni/qqp/mta-Angestellte.htm [Accessed 2006 Mar 20]

  31. Research Institute of the AOK [online]. Available from URL: http://wido.de/arzneimittel.html [Accessed 2006 Mar 20]

  32. EURO-MED-STAT: monitoring expenditure and utilization of medicinal products in the European Union countries. A public health approach. Eur J Public Health 2003; 13 (3 Suppl.): 95-100

    Google Scholar 

  33. Bundesministerium für Gesundheit. Daten des Gesundheitswesen 2001. Baden-Baden: Nomos Verlagsgesellschaft, 2001

    Google Scholar 

  34. Federal Statistical Office Germany. Reihe 6.3: account of hospi-tal costs in 2001 (in German) [online]. Available from URL: http://www.ec.destatis.de/csp/shop/sfg/bpm.html.cms.cBroker.cls?.cmspath=struktur,sfgsuchergebnis.csp&action=newsearch&op _EVASNr=startswith&search_EVASNr=2312 [Accessed 2006 Jan 26]

  35. Internet Pharmacy [online]. Available from URL: http://www.apondo.de/assura-basisplatten-10-35mm-m-guertelbef2884-2081971/ [Accessed 2005 May 4]

  36. Federal Statistical Office Germany. Press release regarding wages and salaries in 2001 (in German) [online]. Available from URL: http://www.destatis.de/presse/deutsch/pk/2003/loehne_gehaelter_2001_neu.pdf [Accessed 2005 Jul 28]

  37. Federal Statistical Office Germany. Brochure regarding the development of labour costs [online]. Available from URL: http://www-ec.destatis.de/cps/shop/sfg/vollanzeige.csp?ID=1016383&CSPCHD=00000001000431s4f3M0003400713556 [Accessed 2005 Jul 28]

  38. Welte RJJ, Leidl R. MICE (Module for standardized Indirect Cost Estimation) increases the transferability of results [abstract]. Value Health 2001; 4 (6): 429

    Article  Google Scholar 

  39. Welte R, König HH, Jager J, et al. Assessment of indirect costs of injecting drug use: which methods should be employed? In: Jager J, Limburg W, Kretzschmar M, et al, editors. Hepatitis C and injecting drug use: impact, costs and policy options. Luxembourg: Office for Official Publications of the European Communities, 2004: 249–67

    Google Scholar 

  40. Bach H-U, Gaggermeier C, Kettner A, et al. IAB-Kurzbericht Nr. 17/2004; Deutschland: Entwicklung des Arbeitsmarktes im Jahr 2005 [online]. Available from URL: http://www.iab.de/asp/internet/dbdokShow.asp?.pkyDoku=k041112n01 [Accessed 2004 Jul 4]

    Google Scholar 

  41. Federal Ministry of Education and Research. Basic and structural data 2005 [online]. Available from URL: http://www.bmbf.de/pub/GuS_2005_ges_engl.pdf [Accessed 2006 Jan 26]

  42. Altman DG, Bland JM. Interaction revisited: the difference between two estimates. BMJ 2003; 326 (7382): 219

    Article  PubMed  Google Scholar 

  43. Wolfe R, Hanley J. If we’re so different, why do we keep overlapping? When 1 plus 1 doesn’t make 2. CMAJ 2002; 166 (1): 65–6

    PubMed  Google Scholar 

  44. Bland JM, Peacock J. Interpreting statistics with confidence. Obstet Gynaecol 2002; 4 (3): 176–80

    Google Scholar 

  45. Hay AR, Hay JW. Inflammatory bowel disease: medical cost algorithms. J Clin Gastroenterol 1992; 14 (4): 318–27

    Article  PubMed  CAS  Google Scholar 

  46. Statistics Sweden. Inflation in Sweden 1831–2004 [online]. Available from URL: http://www.scb.se/Statistik/PR/PR0101/2005M01/PR0101_2005M01_DI_06-07_EN.xls [Accessed 2005 Aug 19]

  47. National Statistics UK. Harmonised index of consumer prices (HICP) 1991–2005 [online]. Available from URL: http://www.statistics.gov.uk/STATBASE/tsdataset.asp?.vlnk=340 [Accessed 2005 Aug 19]

  48. GPEC Information Center. US inflation rate [online]. Available from URL: http://www.gpec.org/InfoCenter/Topics/Economy/USInflation.html [Accessed2005 Aug 19]

  49. OECD Health Data 2005: statistics and indicators for 30 coun-tries [CD]. Paris: OECD Publishing, 2005

  50. Timmer A. Health economic aspects of inflammatory bowel disease [in German]. Gesundh Ökon Qual Manag 2000; 5: 54–66

    Google Scholar 

  51. German guidelines for Crohn’s disease [online]. Available from URL: http://www.uni-duesseldorf.de/WWW/AWMF/ll/021004.htm [Accessed 2005 Jul 12]

  52. German guidelines for ulcerative colitis [online]. Available from URL: http://www.uni-duesseldorf.de/WWW/AWMF/ll/021-009.htm [Accessed 2005 Jul 12]

  53. Verband Deutscher Rentenversicherungsträger. VDR-Statistik Rentenzugang: des Jahres 2003 einschlieâlich Rentenwegfall, Rentenänderung/Änderung des Teilrentenanteils in der deutschen gesetzlichen Rentenversicherung. VDR: Frankfurt am Main, 2004

    Google Scholar 

  54. Longobardi T, Jacobs P, Bernstein CN. Work losses related to inflammatory bowel disease in the United States: results from the National Health Interview Survey. Am J Gastroenterol 2003; 98 (5): 1064–72

    PubMed  Google Scholar 

  55. Cohen RD. IBD indirect costs: the sleeping giant? Gastroenterology 2003; 125 (3): 982–4

    Article  PubMed  Google Scholar 

  56. John J, Holle R. Problems of building up and using statutory health insurance data for population-based economic evaluation studies: experiences from KORA [in German]. Informatik, Biometrie und Epidemiologie in Medizin und Biologie 2003; 34 (2): 96–111

    Google Scholar 

  57. Bernstein CN, Blanchard JF, Rawsthorne P, et al. Epidemiology of Crohn’s disease and ulcerative colitis in a central Canadian province: a population-based study. Am J Epidemiol 1999; 149 (10): 916–24

    Article  PubMed  CAS  Google Scholar 

  58. Roberts RO, Bergstralh EJ, Schmidt L, et al. Comparison of self-reported and medical record health care utilization measures. J Clin Epidemiol 1996; 49 (9): 989–95

    Article  PubMed  CAS  Google Scholar 

  59. Ritter PL, Stewart AL, Kaymaz H, et al. Self-reports of health care utilization compared to provider records. J Clin Epidemiol 2001; 54 (2): 136–41

    Article  PubMed  CAS  Google Scholar 

  60. Bodger K. Cost of illness of Crohn’s disease. Pharmacoeconomics 2002; 20 (10): 639–52

    Article  PubMed  Google Scholar 

  61. Deutsche Krankenhausgesellschaft. DKG-NT, Tarif der Deutschen Krankenhausgesellschaft für die Abrechnung erbrachter Leistungen und für die Kostenerstattung vom Arzt an das Krankenhaus. Stuttgart: Kohlhammer, 2002

    Google Scholar 

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Acknowledgements

This study was supported by a grant from the German Federal Ministry for Education and Research (BMBF grant no. 01-GI-0487).

The authors have no conflicts of interest that are relevant to the contents of the study. All authors contributed significantly to the intellectual content of the paper.

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Authors and Affiliations

  1. Institute for Health Economics and Health Care Management at the GSF - National Research Center for Environment and Health, Ingolstädter Landstraße 1, D-85764, Neuherberg, Germany

    Renee Stark & Reiner Leidl

  2. Department of Psychiatry, Health Economics Research Unit, University of Leipzig, Leipzig, Germany

    Hans-Helmut König

  3. Department of Health Economics and Health Care Management, Faculty of Business Administration, University of Munich, Munich, Germany

    Reiner Leidl

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  1. Renee Stark
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Correspondence to Renee Stark.

Appendices

Appendix 1

See table AI

Table AI
figure TabAI

Types of physician visits and services identified

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Appendix 2: Assumptions

Outpatient Medical Services

The following assumptions were made for the costs of some services.

  • Cost of an endoscopy procedure included a biopsy.

  • Costs of blood tests were calculated using full blood count and differential, erythrocyte sedimentation rate, C-reactive protein, blood glucose, liver function tests (bilirubin, alanine amino-transferase, aspartate aminotransferase, alkaline phosphatase, ?-glutamyl transferase), electrolytes (sodium, potassium), urea and creatinine as suggested by guidelines[5] and expert recommendations.[9]

  • For appointments in outpatient IBD specialty clinics, a standard service package was defined for the first visit[9] per month, which included a complete history and physical and rectal examination. Charges were based on the DKG-NT (Deutsche Krankenhaus Gesellschaft Tarif [German Hospital Association fee schedule]) 2002[61] (46.38). Charges for follow-up visits were only for consultation (6.87). Charges for other services were added to these basic charges (costs of blood tests were calculated on the basis of the blood tests above).

Acute Care Hospital Admissions

In addition to hospital-stay charges, it was assumed that a history, physical and blood tests (same blood tests as assumed for outpatient consultations) were performed for every patient and that, for every patient on the internal medicine ward, an ultrasound pracand colonoscopy were performed. Patients admitted for abscess operations were assumed to have had a CT scan for localisation.

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Stark, R., König, HH. & Leidl, R. Costs of Inflammatory Bowel Disease in Germany. Pharmacoeconomics 24, 797–814 (2006). https://doi.org/10.2165/00019053-200624080-00006

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