Papers by Stephanie Stock
DMW - Deutsche Medizinische Wochenschrift, 2004
Hintergrund und Fragestellung: Hochschulambulanzen haben im deutschen Gesundheitswesen eine Sonde... more Hintergrund und Fragestellung: Hochschulambulanzen haben im deutschen Gesundheitswesen eine Sonderstellung. Dem Recht auf Zulassung von Kliniken an Universitätskrankenhäusern steht eine Begrenzung der Behandlung in dem für Forschung und Lehre erforderlichen Umfang gegenüber. In dieser Studie sollten der Stellenwert der Teilgebiete Versorgung, Lehre und Forschung in der Aufgabenwahrnehmung der Hochschulambulanzen und die dabei entstehenden Kosten für die einzelnen Teilgebiete abgeschätzt werden. Methode und Daten: Die Datendokumentation erfolgte an 6 deutschen Standorten. Insgesamt beteiligten sich 51 Ambulanzen an der prospektiven Dokumentation von jeweils bis zu 800 Konsultationen. 26312 Konsultationen mit rund 40000 Diagnosen und 150000 Einzelleistungen wurden erfasst. Daneben wurden retrospektiv übergreifende Daten zu Kosten, Lehre und Forschung erhoben. Ergebnisse: Innerhalb der Ambulanz betrug das durchschnittliche Verhältnis der Arbeitszeit zwischen Versorgung, Forschung und Lehre 81:11:8. Lehre und Forschung machten somit unter 20% des Arbeitszeitaufwandes aus. Bei rund jeder 4. Konsultation passte das Krankheitsbild der Patienten zum Forschungsschwerpunkt der Ambulanz. In 6,9% der Konsultationen wurden die Patienten auf eine Studienteilnahme angesprochen, 1,2% wurden neu aufgenommen, bei 3,7% der Konsultationen waren die Patienten bereits zuvor in eine Studie aufgenommen worden. Auf Lehrveranstaltungen wurden Patienten in 6,5% der Konsultationen angesprochen. Die durchschnittlichen Gesamtkosten betrugen 149 EUR pro Fall. Der Kostendeckungsgrad bei den über die Poliklinikspauschale abgerechneten Fällen lag durchschnittlich bei 31% (ohne Forschungs-und Lehrfälle). Folgerung: Die tatsächliche Aufgabenwahrnehmung und der vom Gesetzgeber vorgesehene Auftrag weichen in Hochschulambulanzen stark voneinander ab. Es scheint notwendig, die Öffnung für Versorgungsaufgaben stärker in den Vordergrund zu stellen und gleichzeitig die Vergütung unter Wahrung von Effizienzanreizen auf eine neue Basis zu stellen. Background: Outpatient clinics of university hospitals (Hochschulambulanzen) play a significant role in the German health care system. Universities have in contrast to other hospitals the right to implement an outpatient clinic, but the health care services they can render are restricted to clinical research and teaching activities. The university outpatient clinic study evaluates the intensity of medical care, teaching, research activities, and the related costs. Method and database: 6 university hospitals with 51 outpatient departments in Germany were included. The prospective documentation of consultations was restricted to 800 visits per department. A total of 26,312 consultations with approximately 40,000 diagnoses and 150,000 services were documented. Furthermore, data concerning costs, teaching activities and research facilities were documented. Results: Clinical treatment without any correlation to research or teaching activities amounted to about 81% of the working time in the outpatient department (research 11%; teaching 8%). The primary task of the university outpatient clinics takes up less than 20% of the working time. The physicians documented that the disease of every fourth visit was in accordance with their main field of research. 6.9% of the visits were asked to take part in clinical trials, of these 1.25% were included for the first time, 3.7% were already included. 6.5% of the visits were addressed to participate in specific teaching activities. The average total costs per case added up to 149 Euro. No outpatient clinic could cover the total per case costs with the lump sum payments. On the average 31% of these costs were covered by lump sum payments (without cases concerning research and teaching). Conclusion: Treatment in outpatient departments of university clinics is far beyond research and teaching activities required by law. However, the ability of outpatient departments of universities to provide excellent outpatient services should have a more dominant role in the health care system. Therefore access to care should be deregulated for the patients and reimbursement schemes should be adjusted to adjust for the present losses.
The patient, Oct 2, 2016
In this study, we tested the feasibility of an interviewer-assisted analytic hierarchy process (A... more In this study, we tested the feasibility of an interviewer-assisted analytic hierarchy process (AHP) in a special patient population with age-related macular degeneration (AMD). One aim was to generate preference weights regarding AMD treatment characteristics. A secondary aim was to explore the consistency of preference judgments and reasons for inconsistency. We generated quantitative importance weights for decision criteria using the matrix multiplication method. A qualitative study component in the form of asking patients to think aloud throughout their judgments was implemented to facilitate understanding of quantitative findings. Consistency ratios were calculated as a measure of logical judgment performance within AHP. If consistency ratios exceeded 0.2, we explored reasons for inconsistency. We interviewed 86 patients and generated preference weights for criteria. Patients rated the injection's effect on visual function the highest (0.44), followed by the frequency of mo...
International Journal of Public and Private Healthcare Management and Economics, 2012
Most people know what comprises a healthy lifestyle, but few actually exercise, follow a healthy ... more Most people know what comprises a healthy lifestyle, but few actually exercise, follow a healthy diet with low salt, fat, sugar, and avoid smoking and alcohol intake. It could be argued that society should incentivize prevention programs which lead to a healthy lifestyle instead of paying afterwards for the costly treatment of diabetes, cardiovascular diseases, and other preventable chronic diseases. The German experience shows that these programs might even work – however, they might work best for already healthy people. It’s still not clear, how prevention programs should be designed to initiate lasting behavior change in groups, which are deprived. It should be questioned whether it’s more cost-effective to simply raise taxes on unhealthy diet or pleasures.
Journal of Affective Disorders, 2016
Existing diverse bottom-up estimations of direct costs associated with depression in Germany moti... more Existing diverse bottom-up estimations of direct costs associated with depression in Germany motivated a detailed patient-level analysis of depression-related treatment (DRT), -costs (DRC) and Comorbidity. A large sickness fund's claims data was used to retrospectively identify patients aged 18-65 years with new-onset depression treatment between January 1st and February 15th 2010, and follow them until December 31st 2010, describe DRT, estimate associated DRC, and predict DRC with a generalised linear model. A total of 18,139 patients were analysed. Mean direct DRC were €783. Predictors of DRC regarding psychiatric comorbidities were: "Delusion, psychotic disorders and personality disorders" (DRC-ratio 1.72), "Alcohol/drug addiction" (1.82), "abuse of alcohol/drugs" (1.57). Predictors of DRC regarding medical comorbidities were: "Rheumatoid arthritis" (0.77), "atherosclerosis" (0.65), "pregnancy" (0.66), and "Osteoarthritis" (1.87). Of all patients, 60.8% received their most intense/specialised DRT from a general practitioner, a medical specialist (23.7%), a psychotherapist (8.0%), a medical specialist and psychotherapist (2.9%), or in hospital (4.6%). Serious psychiatric comorbidity nearly tripled depression-related hospitalisation rates. Seasonal affective disorder and missing psychiatric outpatient clinic data must be considered. Estimated DRC are significantly below the assessment of the German national guideline. Differing definitions of observation period and cost attribution might explain differing German DRC results. Signs of hospital psychiatric comorbidity bias indicate overestimation of hospital DRC. Identified associations of DRC with certain medical diseases in older adults warrant further research. Up to one quarter of patients with severe depression diagnosis might lack specialist treatment.
Drugs - Real World Outcomes, 2015
Background Multimorbidity and polypharmacy represent a major problem for elderly patients. Potent... more Background Multimorbidity and polypharmacy represent a major problem for elderly patients. Potentially inappropriate medication (PIM) use is highly prevalent among the elderly. PIMs are considered high-risk drugs and are suspected to be responsible for adverse drug events (ADEs) leading to hospitalization. Objective The objective of this study was to determine hospitalization rates related to selected ADEs in elderly patients with an incident prescription of a PIM as defined by the PRISCUS list. A second objective was to identify other factors independently associated with hospitalization. Methods We retrospectively analysed a full census of pharmaceutical claims, from one of the largest public sickness funds in Germany, for 647,073 patients aged C65 years in 2010, the year of publication of the PRISCUS list. Patients who received an incident PIM in 2010 were assigned to the intervention group. Propensity score matching was used to build a control group of patients at a comparable risk level who received an incident equivalent non-PIM. The risk of hospitalization due to PIM prescription was estimated via the odds ratio (OR). Risk factors were analysed via logistic regression models. Results The results showed significantly more ADEs in the PIM group. The OR for hospitalization was 1.54 [95 % confidence interval (CI) 1.23-1.93] for patients receiving any PIM compared with those who received a non-PIM. This trend remained stable [OR 1.46 (95 % CI 1.16-1.84)] after adjustment for relevant covariates in the logistic regression models showing ORs for each risk factor. Besides PIMs, common risk factors such as greater age, comorbidity and specific drug classes were significantly responsible for hospitalization. Conclusion PIMs (as defined by the PRISCUS list) are associated with high rates of ADEs associated with hospitalization. Our study suggests that PIM reduction may result in a lower risk of hospitalization in the elderly.
The patient, 2015
Patients suffering from age-related macular degeneration (AMD) are rarely actively involved in de... more Patients suffering from age-related macular degeneration (AMD) are rarely actively involved in decision-making, despite facing preference-sensitive treatment decisions. This paper presents a qualitative study to prepare quantitative preference elicitation in AMD patients. The aims of this study were (1) to gain familiarity with and learn about the special requirements of the AMD patient population for quantitative data collection; and (2) to select/refine patient-relevant treatment attributes and levels, and gain insights into preference structures. Semi-structured focus group interviews were performed. An interview guide including preselected categories in the form of seven potentially patient-relevant treatment attributes was followed. To identify the most patient-relevant treatment attributes, a ranking exercise was performed. Deductive content analyses were done by two independent reviewers for each attribute to derive subcategories (potential levels of attributes) and depict pr...
Population Health Management, 2012
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Zeitschrift für Evidenz, Fortbildung und Qualität im Gesundheitswesen, 2012
Disease management programs (DMPs) were implemented in the German Statutory Health Insurance (SHI... more Disease management programs (DMPs) were implemented in the German Statutory Health Insurance (SHI) in a nationwide rollout in 2002. The explicit goal of the programs is to improve coordination and quality of care for the chronically ill (Sect. 137f, SGB V). To reach this goal extensive quality assurance measures in the programs are mandatory, enrolment and coordination of care rests with the primary care or DMP physician, treatment is based on evidence-based care guidelines, and patients are offered diabetes education classes to support self-management. The present study evaluates the DMP diabetes mellitus type II, a nationwide program offered by the BARMER, a German health insurance company. To minimize selection bias we formed a control group of administrative data using a propensity score matching approach. In comparison to the control group DMP participants have a significantly lower mortality rate, and their average drug and hospital costs are reduced. Enrolled patients also ha...
Health Policy, 2015
This paper investigates the change in price elasticity of health insurance choice in Germany afte... more This paper investigates the change in price elasticity of health insurance choice in Germany after a reform of health insurance contributions. Using a comprehensive data set of all sickness funds between 2004 and 2013, price elasticities are calculated both before and after the reform for the entire market. The general price elasticity is found to be increased more than 4-fold from −0.81 prior to the reform to −3.53 after the reform. By introducing a new kind of health insurance contribution the reform seemingly increased the price elasticity of insured individuals to a more appropriate level under the given market parameters. However, further unintended consequences of the new contribution scheme were massive losses of market share for the more expensive sickness funds and therefore an undivided focus on pricing as the primary competitive element to the detriment of quality.
Nursing economic$
Chronic illnesses, for which many patients are admitted to hospitals, substantially increase the ... more Chronic illnesses, for which many patients are admitted to hospitals, substantially increase the risk of falling, and hence the likelihood of incurring a hip fracture. Hip fractures not only have devastating consequences on an individual's quality of life but may also affect a hospital's reputation in the community. In addition, hospitals may face litigation claims and increased costs for patients who fall and suffer a major injury as a consequence. External hip protectors are comparable to padded undergarments and shield the trochanter, reducing the detrimental effects and force impacting the bone during a fall. Screening for patients at high risk of falling and providing high-risk patients with hip protectors as a preventive measure to avoid hip fractures, not only improves public health, but can also save hospitals care and litigation costs.
The European Journal of Health Economics, 2014
Fractures are one of the most costly consequences of falls in elderly patients in nursing homes. ... more Fractures are one of the most costly consequences of falls in elderly patients in nursing homes. To compare the cost-effectiveness of a 'multifactorial fracture prevention program' provided by a multidisciplinary team with 'no prevention' in newly admitted nursing home residents. We performed a cost-utility analysis using a Markov-based simulation model to establish the effectiveness of a multifaceted fall prevention program from the perspective of statutory health insurance (SHI) and long-term care insurance (LCI). The rate of falls was used to estimate the clinical and economic consequences resulting from hip and upper limb fractures. Robustness of the results was assessed using deterministic and probabilistic sensitivity analyses. Compared to no prevention a multifactorial prevention program for nursing home residents resulted in a cost-effectiveness ratio of <euro>21,353 per quality-adjusted life-year. The total costs for SHI/LCI would result in <euro>1.7 million per year. Results proved to be robust following deterministic and probabilistic sensitivity analyses. Multifactorial fracture prevention appears to be cost-effective in preventing fractures in nursing home residents. Since the results were based on the number of falls further research is required to confirm the results.
PharmacoEconomics, 2012
The monoclonal antibody rituximab has shown clinical effectiveness in combination with chemothera... more The monoclonal antibody rituximab has shown clinical effectiveness in combination with chemotherapy for the treatment of non-Hodgkin's lymphoma (NHL) in several randomized controlled studies. Rituximab maintenance therapy is associated with significant improvement in progression-free and overall survival in patients with NHL. However, treatment with rituximab causes considerable costs for healthcare systems. This article provides an overview of economic evaluations of rituximab and appraises their methodological quality. A systematic literature search of cost-effectiveness studies on rituximab was carried out in nine electronic databases: MEDLINE, EMBASE, Cochrane Database of Systematic Reviews (CDSR), the German Agency of Health Technology Assessment (DAHTA) database, German Institute for Quality Improvement (DIQ)-Literatur, DIQ-Projekte, Database of Abstracts of Reviews of Effects (DARE), Health Technology Assessments (HTA) database and Sozialmedizin (SOMED) [languages: English, German, Dutch, French, Spanish and Italian; publication period: 1998 to 2010]. Based on pre-specified inclusion criteria, cost-effectiveness studies were identified that compared standard chemotherapy with standard chemotherapy plus rituximab in patients with a subtype of NHL. The methodological quality of the studies was assessed using a quality checklist. Fourteen economic evaluations from seven different countries were included in the review. All economic evaluations reported incremental cost-effectiveness ratios (ICERs) for the add-on therapy with rituximab that were below the country-specific thresholds. The studies differed significantly in their characteristics and methodological rigour. Most studies lacked transparency regarding identification and justification of data. In several studies, the rationale for the model structure was not described appropriately. Adding rituximab to standard chemotherapy is considered a cost-effective treatment option for NHL. However, the results of the analyses should be interpreted with caution due to methodological limitations.
BMC public health, Jan 24, 2014
Health literacy (HL) is seen as an increasingly relevant issue for global public health and requi... more Health literacy (HL) is seen as an increasingly relevant issue for global public health and requires a reliable and comprehensive operationalization. By now, there is limited evidence on how the development of tools measuring HL proceeded in recent years and if scholars considered existing methodological guidance when developing an instrument. We performed a systematic review of generic measurement tools developed to assess HL by searching PubMed, ERIC, CINAHL and Web of Knowledge (2009 forward). Two reviewers independently reviewed abstracts/ full text articles for inclusion according to predefined criteria. Additionally we conducted a reporting quality appraisal according to the survey reporting guideline SURGE. We identified 17 articles reporting on the development and validation of 17 instruments measuring health literacy. More than two thirds of all instruments are based on a multidimensional construct of health literacy. Moreover, there is a trend towards a mixed measurement (...
PharmacoEconomics, 2011
Statutory health insurance (SHI) in Germany serves 90% of the population. Predicted SHI deficits ... more Statutory health insurance (SHI) in Germany serves 90% of the population. Predicted SHI deficits for 2010 and 2011, of h7 billion and h10–12 billion, respectively, resulted in a law freezing the prices of drugs already in the market (which came into effect on 1 August 2010). The subsequent ‘Act to Reorganize the Pharmaceuticals’ Market in the SHI System’ (Gesetz zur Neuordnung des Arzneimittelmarktes in der gesetzlichen Krankenversicherung [AMNOG]) passed through Federal Parliament on 11 November 2010 and came into effect on 1 January 2011. What implications does this have for the health economic evaluation of new drugs in Germany? We delineate where and how health economic evaluation will be tied in with decision making on drug prices, and also explore how close the new law will come to value-based pricing, a question verymuch in discussion in other healthcare systems.
Pediatric Research, 2010
Object of study: Assessing the current state-ofthe-art regarding the clinimetric properties and c... more Object of study: Assessing the current state-ofthe-art regarding the clinimetric properties and clinical possibilities of COMFORT-scale in the care of ill neonates. The COMFORT-scale is a multidimensional assessment tool, originally designed to measure distress in ventilated infants. Method: A review of the scientific literature was performed. Studies evaluating the COMFORTscale, a derived version of the COMFORT-scale or studies comparing the COMFORT-scale with other assessment methods and the presence of a recognizable group of newborns were included. Review articles were not included. The studies found were critically appraised, using the guidelines of Terwee, for its clinimetric properties; validity (content-, criterion-and construct validity and internal consistency), reproducibility, longitudinal validity, responsiveness, floor and ceiling effects and interpretability. Results: Nine studies (until October 2009) were included. The studies contained the original COMFORT-scale plus five derived versions; COMFORT plus 'crying', COMFORT-'behaviour', COMFORT-'modified', COMFORT-'adapted' and COMFORTneo. The scales have been studied for several concepts; pain, stress, distress and sedation and with neonates suffering from different disorders as well as during different (invasive) procedures. None of the studies had an overall positive judgement on all aspects of the methodological quality according to the guidelines of Terwee. Judgement was hampered by lack of information in the studies, lack of a golden standard and lack of clarity about the cutoff point of the different scales. Of all COMFORT-scale versions the COMFORT-'behaviour'-scale and the COMFORTneo-scale had the best clinimetric properties. Conclusion: For now the COMFORTneo-scale seems the best option to measure discomfort of ill neonates.
Pediatric Allergy and Immunology, 2012
Journal of Palliative Medicine, 2010
To face a terminal illness means to acknowledge that you are coming to the end of your life. You ... more To face a terminal illness means to acknowledge that you are coming to the end of your life. You might experience many different, even contradicting, emotions such as anxiety, fear, uncertainty, denial, hope, withdrawal, or a combination of these. If you, as a relative or ...
Journal of Clinical Nursing, 2011
Objective. To examine the effect of pressure ulcers in older patients on the length of stay in ho... more Objective. To examine the effect of pressure ulcers in older patients on the length of stay in hospital. Background. Previous research on this topic did not focus solely on older people. A growing number of older people require hospital admission. Design. A retrospective observational study. Methods. Data of 3198 patients age 75 years and older were included. The setting was a 1350-bed German University Hospital. Data were drawn from quality indicator data recorded by nurses. The independent effect of pressure ulcers was analysed using a multivariate Poisson-Regression model. Results. Of the participants, 7AE1% had an ulcer during their hospitalisation. 87AE3% were classified as categories I and II. Mean age was 81AE6 years for all patients and 83AE2 years for pressure ulcer patients. Pressure ulcer patients had a longer overall hospital stay (19AE0 vs. 9AE9 days) and a higher excess length of stay (2AE6 vs. 0AE3 days). Pressure ulcers had a statistically significant effect (p = 0AE0011) on the increase in length of stay. The impact of hospital acquired pressure ulcers on length of stay was more pronounced compared to those ulcers being present on admission. The pressure ulcer category was not significant. Conclusions. Pressure ulcers during hospitalisation are an independent and significant predictor of a prolonged inpatient stay for elderly patients. This study indicates that besides complications and co-morbidities social factors, as well as the hospital's internal processes of patient care, also can play a significant role. Relevance to clinical practice. To evaluate the distinct role of hospital acquired pressure ulcers further research is needed. The elderly patients in this study were a heterogeneous group. The implementation of clinical and nursing processes for both the 'fit' and the 'sick' geriatric patients is an important challenge.
International Journal of Public Health, 2008
With the implementation of the Health Care Modernization Act in 2004 sickness funds in Germany we... more With the implementation of the Health Care Modernization Act in 2004 sickness funds in Germany were given the opportunity to award bonuses to their insured for health-promoting behavior. The aim of this study was to investigate the financial implications of a prevention bonus program from a sickness fund perspective. The investigation was designed as a controlled cohort study (matched pair study) comprising 70,429 members in each group. Matching criteria were sex, postal code, insurance status, and cost categories for health care utilization. Insured opted into the program on a voluntary basis. The program consisted of interventions featuring primary prevention, modest exercise and immunization. Differences in cost trends between the two groups were examined using the paired t-test. A reduction in mean costs of 241.11 Euro per active member for the year 2005 (90% CI = 348.70, 133.52; p-value < 0.001) could be achieved in the intervention group compared to the control group. When costs for the implementation of the program and the bonus payments were taken into account, there was a saving of 97.14 Euro per active member for the year 2005. Preliminary results of a prevention bonus program in the German Statutory Health Insurance suggest a decrease in mean health care spending per enrollee. These effects may increase with time as long term effects of prevention become effective. However, further research is needed to understand how much of these short-term cost reductions can be attributed to the program itself rather than to possible confounders or volunteer bias and how the short-term savings may be accrued.
International Journal of Public Health, 2012
This article examines whether the social health gradients in diabetes, hypertension and obesity f... more This article examines whether the social health gradients in diabetes, hypertension and obesity for men and women vary significantly across different age groups. We use a pooled sample of German survey data from the years 2002 and 2006 with a total of 87,601 observations. We employ a varying Wagstaff index derived from the class of Gini-type concentration indices to estimate age-specific income-related health inequalities. We find significant health disadvantages among poor women in mid-age, but no significant age-specific income-related health inequalities among men. Some leveling of inequalities in diabetes is observed. The results suggest that variations in age-specific inequalities are unlikely to be a purely artificial result of health-related selection into retirement or mortality.
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Papers by Stephanie Stock