PURPOSE:Economic assessment of an additional psychological intervention in the rehabilitation of patients with chronic low-back pain and evaluation of results by decision makers.METHODS:Piggy-back cost-utility analysis of a randomised clinical trial, including a bootstrap analysis. Costs were measured by using the cost accounting systems of the rehabilitation clinics and by surveying patients. Health-related quality of life was measured using the EQ-5D. Implications of different representations of the decision problem and corresponding decision rules concerning the cost-effectiveness plane are discussed.RESULTS:As compared with the 126 patients of the control arm, the 98 patients in the intervention arm gained 3.5 days in perfect health on average as well as 1219 euro cost saving. However, because of the uncertainty involved, the results of a bootstrap analysis cover all quadrants of the cost-effectiveness plane. Using maximum willingness-to-pay per effect unit gained, decision rules can be defined for parts of the cost-effectiveness plane. These have to be aggregated in a further valuation step.CONCLUSIONS:Study results show that decisions on stochastic economic evaluation results may require an additional valuation step aggregating the various parts of the cost-effectiveness plane.

Ziel: Analyse der Wirtschaftlichkeit einer zusätzlichen psychologischen Intervention bei der Rehabilitation von Patienten mit chronischen Rückenschmerzen und Beurteilung der Resultate durch Entscheidungsträger. Methoden: Begleitung eines randomisierten klinischen Versuches mit einer Kostennutzwertstudie mit Bootstrapanalyse. Die Kosten wurden über betriebliche Kostenrechnung und Patientenbefragungen erhoben, die gesundheitsbezogene Lebensqualität über den EQ-5D. Die Implikationen unterschiedlicher Darstellungen des Entscheidungsproblems und korrespondierender Entscheidungsregeln innerhalb der Kosteneffektivitätsebene werden diskutiert. Ergebnis: Im Durchschnitt wiesen die 98 Patienten der Interventionsgruppe im Vergleich zu den 126 Patienten der Kontrollgruppe einen Gewinn von 3,5 Lebenstagen bei voller Gesundheit und Kosteneinsparungen von 1219 € auf. Aufgrund der Unsicherheit in den Ergebnissen kann jedoch durch die Bootstrapanalyse keiner der Quadranten der Kosteneffektivitätsebene ausgeschlossen werden. Mit der Formulierung einer maximalen Zahlungsbereitschaft je Effekteinheit können Entscheidungsprinzipien für die Teilbereiche der Kosteneffektivitätsebene definiert werden, die in einem weiteren, wertenden Schritt aggregiert werden müssen. Schlussfolgerung: Das Beispiel der Studienresultate zeigt, dass Entscheidungen zur Wirtschaftlichkeit von Maßnahmen unter stochastischen Bedingungen eine zusätzliche, aggregierende Wertung der Beurteilungen der Teilbereiche der Kosteneffektivitätsebene erfordern können.

Ziel des Beitrags ist die Entwicklung eines Konzepts für ökonomisches Rehabilitationsmanagement auf der Grundlage des Managed-Care-Ansatzes.

Background and study purpose. Back pain causes high costs to society. In Germany, these amount to an estimated total of 5 billion euro of direct costs per year and 13 billion euro of indirect costs, the latter being caused by incapacity to work. The purpose of this study is to develop a concept for economic rehabilitation management. This concept is based on the managed care approach and aims at improving efficiency of care.Methods. The concept development consists of a theoretical and an empirical part. The method of the theoretical part is based on a systematic literature review on managed care (not included in this article), health systems research and the analysis of economic incentives. For the empirical investigation, long term effects and costs were calculated. For the evaluation of effects, we psychometrically tested and used the Euro-Qol (EQ-5D) as a measure of health-related quality of life (HRQL). The calculation of costs (both direct and indirect) is based on routine data of payers, a cost diary and the internal cost accounting systems of rehabilitation clinics. We statistically analysed the cost distribution and identified predictors of the management targets (e.g., costs of care) by means of regression analyses.Results. The market-driven managed care approach is based on three tools: (1) a primary care system with case management and gatekeeping, (2) direct influence on providers by utilisation review and setting guidelines, and (3) indirect influence by setting supply-side economic incentives via the remuneration mode. The third managed care toot is most important when managing the rehabilitation of working age patients with chronic low back pain from an economic point of view. This concept consists of three components: (1) a case-based budget for direct costs;this is a prospective remuneration mode for an integrated primary care network including a rehabilitation facility, (2) retrospective bonus payments which are related to savings of indirect costs, and (3) retrospective bonus payments which are related to the effectiveness of rehabilitation, i.e. gains in HRQL. Common features of the three management components are a long-term perspective (e.g.,from admission to a rehabilitation clinic until six months after discharge) and risk-adjustment of the three management targets (i.e., direct and indirect costs and gains in HRQL) in order to avoid selection and to limit the financial risk for providers. The EuroQol instrument shows acceptable psychometric properties in the rehabilitation setting for back pain patients. This instrument may yield two kinds of preference-based index values, one reflecting the preferences of the general population and one those of the patient. The Pearson correlation of these two approaches is fair, but there is a systematic difference. Empirical investigation shows that the distribution of both direct and indirect costs is skewed to the right. Statistically relevant predictors of the management targets are incapacity to work and HRQL at admission.Conclusions. Economic rehabilitation management might help to save money and to improve health outcomes, thus increasing the efficiency of care. The results of our empirical studies show the feasibility of tools for the economic management of rehabilitation. Risk adjustment of the management components is of paramount importance.

Weekly cost diaries are instruments to measure direct and indirect costs prospectively by using patient data. First we searched MEDLINE for information concerning the use of diaries in health care and their methodological evaluation. Based on a Dutch weekly cost diary we developed an instrument for patients with acute or chronic back pain to be completed following participation in an inpatient rehabilitation measure. Its use was tested in an explorative pilot study. We asked for all costs and resource use due to back pain (all direct medical and non medical costs as well as indirect costs) occurring in a 4-week follow-up period, irrespective of the cost carrier. The total response rate was 58%. Patients spent an average 13 minutes a week for completing the questionnaire, without reporting any major methodological difficulties. Some 30% percent of overall costs were direct costs, the majority being non-recurring costs for assistive devices such as mattresses and mattress frames. Excluding these, monthly direct costs per patient were 270 DM on average. Indirect costs, mainly due to absence from salaried work, amounted to an average 1634 DM per patient, with marked variation. Our study results show that this instrument is basically useful and feasible in this indication. Further studies with larger and representative samples are needed to evaluate data quality. It is suggested that weekly cost diaries can be useful tools in particular in decentralized health care systems to measure costs from the societal perspective.