Publikationen

Kasch R, Merk S, Kayser R, Lahm A, Drescher W, Schulz A.P, Wilke T, Flessa S. Kostenvergleichskalkulation der Schlitten- vs. bikondylären Oberflächenversorgung am Kniegelenk. Z Orthop Unfall. 2011;149(6): 646-652.

Abstract

BACKGROUND

The G-DRG system reimburses sledge endoprosthetic implantations (UKA) at a much lower rate than surface replacements (TKA), at significantly different cost weights (CW). Therefore, when only G-DRG payments are considered, the complete endoprosthesis implantation produces higher gains. An orientation on these revenues alone, however, does not provide the basis for an economically sound decision-making process. The aim of this study is to present a comparison of the variable costs of the two procedures.

MATERIAL AND METHODS

The mean cost and performance data of 28 Endo-Model UKA implantations and of 85 NexGen CR TKA replacements were compared with each other in 2007.

RESULTS

From the perspective of the hospital, when the correct medical indication is present, UKA treatment is of greater economic advantage. In this way the total unit contribution margin can be improved, and although the relative weighting is comparatively low, the costs are significantly lower than in a comparative analysis of the TKA.

CONCLUSION

For the desired maximisation of the unit contribution margin, assuming that it is the proper medical indication, the recommendation for the hospital would be implantation of the UKA. Considered from the economic perspective of gains and costs, the assumption that a TKA would be advantageous could not be confirmed in the present study.

Wilke T, Müller S, Neumann K, Loder T. Does the package design matter? The influence of OTC package design on patients’ drug knowledge. Pharmaceutical Medicine. 2011;25(5):307-317.

Abstract

INTRODUCTION

The objective of this study was to discover whether over-the-counter (OTC) package designs differ in their ability to transfer drug-safety-related information to pharmacy customers. The research was intended to answer two questions: (i) how well and quickly do customers comprehend, and what are the main characteristics of customers who have difficulty understanding relevant medical information on a package; and (ii) do alternative package designs provide for significantly different levels of comprehension? 

METHODS

We performed cross-sectional face-to-face interviews with 452 pharmacy customers in 17 German pharmacies. In each of three sequential experiments (one OTC brand per experiment), each participant was shown two packages of the same brand and was asked three drug-related questions per package. The different abilities of the three package designs to transfer information correctly and rapidly were compared by descriptive statistics; the significance of differences was tested by Wilcoxon tests. 

RESULTS

Older people, those with physical problems, people not in a receptive mood, and those with a poor doctor-patient relationship or a lack of trust in medicines in general, answered the questions with a significantly higher number of errors and/or required significantly more time to do so, than the remainder of the sample. When compared with two other package designs, one of the tested designs with special design characteristics proved superior. 

CONCLUSIONS

The design of a medication package can measurably influence the quality and speed of information transfer to pharmacy customers. Because drug safety and adherence are associated with drug knowledge, the design of packaging should be given more attention.

Wilke T, Müller S, K. Neumann K, Loder T. Does the package design matter? The influence of OTC package design on patients’ drug knowledge. Value and Health. 2010;13(7):A421.

Abstract

OBJECTIVES

Objective of this study is to discover whether OTC package designs
differ in their ability to transfer drug safety related information to pharmacy customers. The research was intended to answer two questions:

1) how well (in terms of speed and accuracy) do customers comprehend the relevant medical information on packages?

2) do alternative package designs cause significantly different levels of
comprehension?

METHODS

Face-to-face interviews with 452 customers of 17 German pharmacies were conducted. In each of three sequential experiments (one OTC brand per experiment), each of the participants was shown two packages of the same brand (Paracetamol/Bisacodyl) and asked three drug-related questions per package. Multivariate linear regression analysis was used to identify the factors capable of explaining the accuracy of the answers (first outcome; quality) and the speed with which the answers were made (second outcome; time). The different abilities of the three package designs to transfer information correctly and rapidly were compared by descriptive statistics. The significance of the differences was tested by Wilcoxon tests.

RESULTS

Older people, those with physiological problems, people not in a good mood, and those with a poor doctor-patient relationship, or a lack of trust in medicines in general answered the questions with a significantly higher number of mistakes and/or needed significantly longer to do so. When compared to two other package designs, one of the tested designs proved itself to be superior in quality and time.

CONCLUSIONS

1) There exist significant differences between patient groups in their ability to comprehend medical information; specific patients do not understand medical information on packages in a sufficient way.

2) The design of a medication package can measurably influence the quality and speed of information transfer to pharmacy customers. An optimized package design is a source of added value from a drug safety point of view.

Wilke T, Müller S. Non-adherence in Outpatient Thromboprophylaxis after Major Orthopedic Surgery: a systematic Review. Pharmacoeconomics and Outcomes Research. 2010;(6):691-700

Abstract

The necessity for extended medication-based thromboprophylaxis after hip/knee-replacement surgery (major orthopedic surgery) has been acknowledged in international guidelines. In this article, we review and critically appraise the literature regarding patients' non-adherence (NA) in outpatient thromboprophylaxis after major orthopedic surgery. We conducted a systematic literature review. All studies published since 1990 and that were found to report research about NA in outpatient thrombosis prophylaxis after major orthopedic surgery were included. Only six relevant contributions could be identified. All these studies dealt with parenteral low-molecular-weight heparins or fondaparinux prophylaxis. The extent of NA (defined as existing when a patient fails to take the prescribed medication on at least 1 day) ranged from 13 to 37%. In one large German survey, patients who were non-adherent missed between 38 and 43% of their outpatient low-molecular-weight heparin injections. Subjective factors can play a role in increasing NA; such factors include a lack of knowledge of or having no fear concerning thrombosis in general and a lack of specific knowledge regarding measures to prevent it, as well as a negative evaluation of injections as the form of therapy application. Waiting times between acute in-hospital treatment and admission to rehabilitation clinics, as well as abstention from stationary rehabilitation programs, form objective adherence barriers. Therefore, NA is a phenomenon influenced by subjective patient-related factors as well as objective, care-provision structural factors. Current trends in patient care (e.g., shorter hospital stays and lengthened ambulant care) are likely to increase both the number of non-adherent patients and the extent of NA, if the current state of knowledge proves an accurate predictor of the future. At present, it appears that between one and two of every five patients are not adherent when parenteral prophylaxis is used. Whether or not new oral anticoagulation alternatives will be capable of improving the situation remains open for future research. 

Groth A, Müller S, Wilke T. The impact of medication switches induced by medication discount contracts on chronic patients’ adherence. Value in Health. 2010;13(7):A360

Abstract

OBJECTIVES

Switching of medications due to non-medical grounds may be a critical factor influencing patients’ medication-based adherence (NA). The aim of this analysis is to examine the effects of medication switching on NA for hypertonic/diabetic (type II) patients. Only switches between medications containing the same active ingredient were examined.

METHODS

Prescriptions filled at 5 German pharmacies over a period of 2 years were analyzed. Patients who had filled prescriptions for at least 3 medications to control hypertonia (focus on Moxonidin—ATC-Code C02AC05) and/ or diabetes type 2 (focus on Metformin—ATC-Code A10BA02) were included. The NA was calculated using the medication possession ratio (MPR); NA was defined as MPR < 80%. The average MPRs obtained while using the original and the discount products (before/after comparison) were compared using non-parametric tests for independent samples (Wilcoxon-Tests).

RESULTS

Of the 344 hypertonia sufferers, 253 received the active ingredient Moxonidin (NA patients’ percentage: 47.4%). In 68 cases, a switch to the discount product took place (NA percentage before switch: 46.4%). The percentage of NA patients was reduced to 39.1% after the switch. Of the 726 diabetic patients, 518 patients received Metformin (NA: 49.4%). a total of 136 patients received a discount article after the discount contract was in place (NA before switch: 42.7%). After the switch, the NA percentage increased to 66.2%. 

CONCLUSIONS

In the case of hypertonia, medication switches had no significant effect on the NA. By contrast, switchers receiving Metformin exhibited a substantial increase in medication-based NA. In future, the focus of research in this area should be to discover whether specific contracts concerning discount products (as, for example, in the case of Metformin) are related to particularly negative adherence effects and if so which factors influence such effects.

Wilke T, Müller S, Groth A.  The methodological quality and effectiveness of adherence interventions: a review of diabetes type II interventions. Value in Health. 2010;13(7):A295–A296.

Abstract

OBJECTIVES

Adherence interventions (AI) are an important part of the health care
provision situation on the ground. For ethical, clinical and health economic reasons,
it is vital to identify methodological characteristics of successful AI. The aim of this
review is to do this for AI focused on oral anti-diabetics (Diabetes type II).

METHODS

A comprehensive review of Diabetes type II AI effectiveness studies was conducted
[Strings: (oral hypoglycemic agents; oral anti-diabetic medications; diabetes; hyperglycemia; Biguanide; Metformin; Potassium channel inhibitors; Dipeptidyl peptidase-4 inhibitors) and (improvement; enhancement; pharmacy, pharmacist; doctors; interventions; programs; reminder; prevention; patient education)]. Only interventions aiming to improve medication adherence/persistence were included.

RESULTS

A total of 6977 contributions were identified; after detailed examination by two reviewers 15 publications evaluating 19 different AI were included. 10 AI were able to improve the adherence/persistence and eight were able to improve the blood glucose levels of patients (double counting in three cases); five had no effect at all. Four dimensions of the methodological quality of AI programs were identified: 1) measurement of adherence/persistence/clinical outcomes, 2) measurement of NA/NP causes, 3) use of effective/validated intervention measures; and 4) effective program evaluation. The authors defined 5 detailed methodological requirements per dimension and, based on this, developed a corresponding scoring model (MIN Score 0, MAX score 20). All 19 AI programs were evaluated in the scoring model (average score 8.05):

• Score <5: 3 AI—no adherence/blood glucose level improvement;
• Score 5–9: 8 AI—6 with improvement in both adherence and/or blood glucose levels;
• Score >9: 8 AI—all improved adherence and/or blood glucose levels.

CONCLUSIONS

The scoring model provides a starting point for the methodical evaluation of AI. However, further development and testing of both the elements and construction is needed for medical indications other than diabetes type II.

Wilke T, Müller S. Why do patients not adhere to prescribed medication regimes? Results of two German surveys. Value in Health. 2010;13(7):A380.

Abstract

OBJECTIVES

The aim of this study is to answer the following questions: 1) How high is the self-reported nonadherence (NA) of German patients with the need to regularly take medication? and 2) Which factors capable of explaining this self-reported NA can be identified by multivariate analysis?

METHODS

Two cross-sectional surveys (phone survey with 1177 patients; face-to-face in-depth survey with 340 patients in 17 German pharmacies) were conducted. Self-reported NA was measured by the generic Morisky scale (either as 4 items or 8 item MMAS). Identification of explanatory factors was conducted on the basis of multivariate logistic regression analysis (including the calculation of additive risks by dichotomization of significant explanatory factors).

RESULTS

1) Approximately 35–40 % of the patients can be described as non-adherent (38.8 %/35.3 %); 2a) Survey 1: Only a few socio-demographic factors are able to explain the NA (chronic disease, some aspects of age, and low number of required medications to take); and 2b) Survey 2: Most results of the first survey can be replicated. However, intentional NA explanations have considerably
more influence: positive medication belief, a positive mood, and a good patient doctor relationship reduce the NA risk. Furthermore, patients who are easily able to
recognize the correct medication on the basis of the identification of the packaging
have a significantly reduced NA probability. When additive risk is considered, patients
who are chronically ill but display no other risk factors have an NA probability rate
of 10.4 %, for patients displaying all identified risk factors this rate increases to 93.9
%.

CONCLUSIONS

Our surveys are the largest and most detailed to have been
conducted in Germany concerned with the theme of medication-based NA. Our results show that approximately one-third of patients can be classified as non-adherent. Intentional NA factors explain the NA considerably better than do socio-economic factors.

Wilke T, Moock J, Müller S, Obert S, Pfannkuche M,  Kurth A. Non-Adherence in outpatient prophylaxis after major orthopedic surgery. 2010. Clin Orthop Relat Res. 2010;468(9):2437–2453.

Abstract

BACKGROUND

According to some current guidelines, extended thromboprophylaxis after hip and knee arthroplasties is recommended. Outpatient prophylaxis with low molecular weight heparins (LMWH) is an important part of this prophylaxis, although the rates of adherence to these regimens is not known.

QUESTIONS/PURPOSES

We determined (1) the degree of nonadherence (NA) of patients with LMWH outpatient prophylaxis, and (2) whether specific independent factors explain NA.

METHODS

NA was determined by syringe count and by indirect and direct questions to patients. We defined six different NA indicators. To identify factors explaining LMWH NA, we used three different logistic regression models.

RESULTS

NA rates ranged between 13% and 21% depending on the indicator used for measurement. Patients who were nonadherent missed between 38% and 53% of their outpatient LMWH injections. If patients attended an outpatient rehabilitation program, the probability for their NA increased substantially. Moreover, the NA probability increased with each additional day between acute hospitalization and start of rehabilitation (linking days). NA was lower for patients who feared thrombosis or who believed antithrombotic drugs to be the most important measure in thromboprophylaxis.

Wilke T, Tesch S, Scholz A, Kohlmann T, Greinacher A. The costs of heparin-induced thrombocytopenia: a patient-based cost of illness analysis. Journal of Thrombosis and heamostasis. 2009;7(5):766–773.

Abstract

BACKGROUND AND OBJECTIVES

Due to the complexity of heparin-induced thrombocytopenia (HIT), currently available cost analyses are rough estimates. The objectives of this study were quantification of costs involved in HIT and identification of main cost drivers based on a patient-oriented approach. Methods: Patients diagnosed with HIT (1995–2004, University-hospital Greifswald, Germany) based on a positive functional assay (HIPA test) were retrieved from the laboratory records and scored (4T-score) by two medical experts using the patient file. For cost of illness analysis, predefined HIT-relevant cost parameters (medication costs, prolonged in-hospital stay, diagnostic and therapeutic interventions, laboratory tests, blood transfusions) were retrieved from the patient files. The data were analysed by linear regression estimates with the log of costs and a gamma regression model. Mean length of stay data of non-HIT patients were obtained from the German Federal Statistical Office, adjusted for patient characteristics, comorbidities and year of treatment. Hospital costs were provided by the controlling department. Results and conclusions: One hundred and thirty HIT cases with a 4T-score ≥4 and a positive HIPA test were analyzed. Mean additional costs of a HIT case were 9008 €. The main cost drivers were prolonged in-hospital stay (70.3%) and costs of alternative anticoagulants (19.7%). HIT was more costly in surgical patients compared with medical patients and in patients with thrombosis. Early start of alternative anticoagulation did not increase HIT costs despite the high medication costs indicating prevention of costly complications. An HIT cost calculator is provided, allowing online calculation of HIT costs based on local cost structures and different 

Wilke T. Patient preferences for an oral anticoagulant after major orthopedic surgery: results of a German survey. The Patient. 2009;2(1):39-49.

Abstract

BACKGROUND
Since 2008, the availability of the oral direct thrombin inhibitor dabigatran etexilate provides a further therapeutic alternative to injectable low-molecular-weight heparin (LMWH) for thromboprophylaxis following hip or knee replacement surgery. The intention of this study is to analyze patient preferences for this new oral thromboprophylaxis agent.

METHODS
Face-to-face interviews were conducted with 73 doctors and nurses in 12 German hospitals, 195 current hip and knee replacement patients in six German rehabilitation hospitals, and 202 former thromboprophylaxis patients. Qualitative questions were complemented by a full-profile ranking-based conjoint analysis regarding alternative thromboprophylaxis regimens.

RESULTS
Nearly 100% of the interviewed medical staff viewed the daily subcutaneous LMWH injection as a source of inconvenience for patients. However, both current and former patients perceived their discomfort to be much less intense. In contrast, the conjoint estimates of preferences showed that older and male patients in particular understated their levels of discomfort in a face-to-face interview situation and had a strong preference for oral anticoagulation.

CONCLUSIONS
Patients in Germany appear to have a positive preference for oral thromboprophylaxis after major orthopedic surgery.