Resource use of late-stage parkinsonism has not been sufficiently investigated; the CLaSP study provides the first detailed health economic insight. |
Resource use increases in the late stages compared to the earlier stages, while the duration of the disease and the age of the patients were independent predictors of costs. |
A large burden is placed on relatives in the form of informal care and only 25% of the patients receive professional care. |
1 Introduction
2 Patients and Methods
2.1 Study Design
2.2 Inclusion and Exclusion Criteria
2.3 Outcome Measures
2.3.1 Clinical Assessments
2.3.2 Health-Related Quality of Life
2.4 Cost Assessment
Parameter | Value | Unit | Year | References |
---|---|---|---|---|
General practitioner | 19.53 | €/visit | 2016 | Bock et al., 2015 [28] |
Neurologist | 66.62 | €/visit | 2016 | Bock et al., 2015 [28] |
Urologist | 27.17 | €/visit | 2016 | Bock et al., 2015 [28] |
Ear, nose, and throat specialist | 28.20 | €/visit | 2016 | Bock et al., 2015 [28] |
Dermatologist | 21.89 | €/visit | 2016 | Bock et al., 2015 [28] |
Radiologist | 217.51 | €/visit | 2016 | Bock et al., 2015 [28] |
Physician consultation average | 28.87 | €/visit | 2016 | Bock et al., 2015 [28] |
Multiplier outpatient medical sector (private and statutory health insurance) | 3.72 | Percent | 2016 | |
Physiotherapy | 18.09 | €/visit | 2016 | Bock et al., 2015 [28] |
Occupational therapy | 39.93 | €/visit | 2016 | Bock et al., 2015 [28] |
Speech training | 41.97 | €/visit | 2016 | Bock et al., 2015 [28] |
Ancillary therapy average | 20.92 | €/visit | 2016 | Bock et al., 2015 [28] |
Multiplier ancillary therapy (private and statutory health insurance) | 1.31 | Percent | 2016 | Bock et al., 2015 [28] |
Multiplier copayments ancillary therapy | 2.25 | Percent | 2016 | Bock et al., 2015 [28] |
Hospital stay (inpatient) | 692.77 | €/day | 2016 | |
Rehabilitation facility (inpatient) | 144.46 | €/day | 2016 | Bock et al., 2015 [28] |
Rehabilitation facility (outpatient) | 58.52 | €/day | 2016 | Bock et al., 2015 [28] |
Medical devices | BARMER, 2018 [31] | |||
Day care outside home | ||||
Care level 1 | 45.02 | €/day | 2016 | Bock et al., 2015 [28] |
Care level 2 | 52.51 | €/day | 2016 | Bock et al., 2015 [28] |
Care level 3 | 59.77 | €/day | 2016 | Bock et al., 2015 [28] |
Day care inside home | ||||
Compensation | 32.61 | €/hour | 2016 | Bock et al., 2015 [28] |
Travel flat-rate | 4.26 | €/visit | 2016 | Bock et al., 2015 [28] |
Average operation time (depending on care level) | ||||
Care level 1 | 0.36 | hours/visit | 2019 | Pflegebüro Bahrenberg Gruppe, 2019 [35] |
Care level 2 | 0.38 | hours/visit | 2019 | Pflegebüro Bahrenberg Gruppe, 2019 [35] |
Care level 3 | 0.37 | hours/visit | 2019 | Pflegebüro Bahrenberg Gruppe, 2019 [35] |
Average number of operations (depending on care level) | ||||
Care level 1 | 2.00 | operations/day | 2019 | Pflegebüro Bahrenberg Gruppe, 2019 [35] |
Care level 2 | 2.14 | operations/day | 2019 | Pflegebüro Bahrenberg Gruppe, 2019 [35] |
Care level 3 | 3.17 | operations/day | 2019 | Pflegebüro Bahrenberg Gruppe, 2019 [35] |
Night care | ||||
Care level 1 | 65.80 | €/day | 2016 | Bock et al., 2015 [28] |
Care level 2 | 76.59 | €/day | 2016 | Bock et al., 2015 [28] |
Care level 3 | 89.67 | €/day | 2016 | Bock et al., 2015 [28] |
Respite or short-term care admission | ||||
Care level 1 | 67.49 | €/day | 2016 | Bock et al., 2015 [28] |
Care level 2 | 83.38 | €/day | 2016 | Bock et al., 2015 [28] |
Care level 3 | 99.57 | €/day | 2016 | Bock et al., 2015 [28] |
24-h care (minimum wage within care sector) | 12.33 | €/hour | 2016 | Bock et al., 2015 [28] |
Informal care (minimum wage within care sector) | 12.33 | €/hour | 2016 | Bock et al., 2015 [28] |
Unemployment due to illness | 121.74 | €/day | 2016 | Statistisches Bundesamt (Destatis), 2019 [37] |
Day of illness (based on 220 working days) | 201.98 | €/day | 2016 | Statistisches Bundesamt (Destatis), 2019 [37] |
Medication | 2016 | Rote Liste Service GmbH, 2016 [36] |
2.4.1 Direct Costs
2.4.1.1 Outpatient Medical Visits
2.4.1.2 Hospital and Rehabilitation
2.4.1.3 Ancillary Therapy
2.4.1.4 Medical Devices and Consumables
2.4.1.5 Formal Care and Informal Care
2.4.1.6 Medication
2.4.2 Indirect Costs
2.5 Missing Values
2.6 Statistical Analysis
3 Results
3.1 Patient Characteristics
Parameter | n | Missing | Mean | Standard deviation | Minimum | Maximum |
---|---|---|---|---|---|---|
Sex | ||||||
Female | 97 | – | – | – | – | – |
Male | 131 | – | – | – | – | |
Age | 227 | 1 | 74.06 | 8.39 | 46.00 | 95.00 |
UPDRS | ||||||
Hoehn and Yahr | ||||||
III | 14 | |||||
IV | 142 | – | – | – | – | – |
V | 72 | – | – | – | – | |
Schwab and England | ||||||
0.7 | 2 | – | – | – | – | – |
0.6 | 7 | – | – | – | – | |
0.5 | 56 | – | – | – | – | |
0.4 | 35 | – | – | – | – | |
0.3 | 55 | – | – | – | – | |
0.2 | 34 | – | – | – | – | |
0.1 | 24 | – | – | – | – | |
0 | 14 | – | – | – | – | |
Mentation, behavior, and mood | 228 | 0 | 5.14 | 3.00 | 0.00 | 13.00 |
Activities of daily living | 228 | 0 | 26.84 | 7.99 | 7.00 | 47.00 |
Motor examination | 228 | 0 | 48.98 | 17.36 | 10.00 | 92.00 |
Complications of therapy | 228 | 0 | 4.63 | 3.79 | 0.00 | 16.00 |
EQ–5D–3L | 227 | 1 | 0.45 | 0.27 | −0.21 | 0.90 |
Insurance status | ||||||
Private health insurance | 39 | 4 | – | – | – | – |
Statutory health insurance | 184 | – | – | – | – | |
Duration of the disease (years) | 222 | 6 | 12.64 | 8.14 | 1.00 | 51.00 |
3.2 Costs of Illness
Parameter | Original data set | Imputed data sets | ||||||
---|---|---|---|---|---|---|---|---|
n (%)b | Mean (€) | 95% CIa | Median (€) | Total costs (%) | Mean (€) | Total costs (%) | ||
Lower | Upper | |||||||
Direct costs | 100 | 8749 | 7332 | 10,400 | 6567 | 90.6 | 8033 | 89.3 |
Physicians | 88.6 | 177 | 153 | 203 | 124 | 1.8 | 179 | 2.0 |
Primary physician | 85.9 | 110 | 94 | 129 | 67 | 1.1 | 113 | 1.3 |
Further physicians | 48.1 | 62 | 47 | 79 | 0 | 0.6 | 66 | 0.7 |
Ancillary therapy | 78.2 | 639 | 566 | 711 | 434 | 6.7 | 641 | 7.1 |
Medical aids | 34.2 | 188 | 140 | 237 | 0 | 1.9 | 192 | 2.1 |
Hospital | 52.4 | 4964 | 4039 | 5955 | 1386 | 51.4 | 4992 | 55.5 |
Rehabilitation | 8.1 | 206 | 99 | 328 | 0 | 2.1 | 214 | 2.4 |
Inpatient | 5.8 | 203 | 103 | 324 | 0 | 2.1 | 213 | 2.4 |
Outpatient | 2.2 | 1 | 1 | 2 | 0 | 0 | 1 | 0.0 |
Professional care | 25.8 | 697 | 478 | 956 | 0 | 7.2 | 689 | 7.7 |
Medication | 100 | 1070 | 820 | 1321 | 545 | 11.1 | 1127 | 12.5 |
Levodopa | 86.9 | 478 | 239 | 754 | 73 | 5 | 507 | 5.6 |
Dopamine agonist | 53.3 | 239 | 161 | 337 | 46 | 2.5 | 242 | 2.7 |
MAO inhibitor | 7.5 | 30 | 18 | 45 | 0 | 0.3 | 31 | 0.3 |
COMT inhibitor | 7.9 | 20 | 10 | 29 | 0 | 0.2 | 20 | 0.2 |
Anticholinergic antiparkinsonian medication | 2.2 | 1 | 0 | 2 | 0 | 0 | 1 | 0.0 |
Amantadine | 2.5 | 6 | 5 | 8 | 0 | 0.1 | 6 | 0.1 |
Antidepressant | 31.9 | 9 | 7 | 11 | 0 | 0.1 | 9 | 0.1 |
Antipsychotics | 26.8 | 5 | 3 | 7 | 0 | 0 | 5 | 0.1 |
Drugs for dementia | 19.3 | 12 | 9 | 15 | 0 | 0.1 | 12 | 0.1 |
Antihypotensive agent | 0.4 | 0 | 0 | 1 | 0 | 0 | 0 | 0.0 |
Other medication | 95.5 | 249 | 193 | 318 | 132 | 2.6 | 295 | 3.3 |
Indirect costs | 9.2 | 962 | 606 | 1337 | 0 | 10 | 962 | 10.7 |
Early retirement or unemployment | 8.3 | 926 | 585 | 1267 | 0 | 9.6 | 926 | 10.3 |
Sick leave | 0.9 | 63 | 0 | 89 | 0 | 0.7 | 36 | 0.4 |
Total costs | 100 | 9657 | 8362 | 11,193 | 7453 | 100 | 8995 | 100 |
Informal care | 82.5 | 10,964 | 10,012 | 11,952 | 13,289 | 113.5 | 10,964 | 121.9 |
3.3 Direct Costs
3.3.1 Inpatient Stay
3.3.2 Drug Treatment
3.3.3 Professional Care
3.3.4 Further Direct Costs
3.4 Indirect Costs
3.5 Informal Care
3.6 Cost of Illness: Imputed Data Sets
3.7 Cost-Driving Factors: Univariate Analysis
3.8 Cost-Driving Factors: Multiple Regression Analysis
Parameter | Total costs | |||||||
---|---|---|---|---|---|---|---|---|
Original data | Imputed data | |||||||
βb | 95% CIa | P value | βb | 95% CIa | P value | |||
Lower | Upper | Lower | Upper | |||||
Age | − 0.029 | − 0.047 | − 0.010 | 0.003 | − 0.025 | − 0.042 | − 0.009 | 0.003 |
UPDRS | ||||||||
Hoehn and Yahr | ||||||||
III | 0.493 | − 0.287 | 1.273 | 0.215 | 0.368 | − 0.298 | 1.034 | 0.279 |
IV | − 0.113 | − 0.533 | 0.308 | 0.599 | − 0.065 | − 0.423 | 0.293 | 0.723 |
V | – | – | – | – | – | – | – | – |
Schwab and England | ||||||||
0.7 | – | – | – | – | – | – | – | – |
0.6 | − 0.030 | − 2.038 | 1.979 | 0.977 | 0.102 | − 1.355 | 1.559 | 0.891 |
0.5 | 0.360 | − 1.417 | 2.136 | 0.692 | − 0.057 | − 1.398 | 1.285 | 0.934 |
0.4 | 0.271 | − 1.516 | 2.057 | 0.766 | − 0.092 | − 1.459 | 1.275 | 0.895 |
0.3 | 0.157 | − 1.623 | 1.938 | 0.863 | − 0.152 | − 1.518 | 1.213 | 0.827 |
0.2 | 0.244 | − 1.654 | 2.143 | 0.801 | − 0.162 | − 1.617 | 1.292 | 0.827 |
0.1 | − 0.136 | − 2.048 | 1.775 | 0.889 | − 0.671 | − 2.168 | 0.827 | 0.380 |
0 | 0.263 | − 1.784 | 2.311 | 0.801 | 0.101 | − 1.501 | 1.703 | 0.901 |
Mentation, behavior, and mood | − 0.021 | − 0.082 | 0.041 | 0.512 | –0.007 | − 0.057 | 0.044 | 0.791 |
Activities of daily living | 0.018 | − 0.015 | 0.052 | 0.285 | 0.018 | − 0.012 | 0.047 | 0.243 |
Motor examination | 0.003 | − 0.012 | 0.018 | 0.677 | 0.000 | − 0.012 | 0.013 | 0.949 |
Complications of therapy | − 0.022 | − 0.070 | 0.026 | 0.361 | − 0.009 | − 0.053 | 0.034 | 0.669 |
EQ-5D-3L | − 0.337 | − 1.047 | 0.374 | 0.353 | − 0.310 | − 0.919 | 0.299 | 0.318 |
Duration of the disease (years) | 0.030 | 0.010 | 0.049 | 0.003 | 0.018 | 0.001 | 0.036 | 0.039 |
Goodness of fit: deviance [value/df] = 0.928 for original data; between 0.979 and 1.010 for imputed datasets | Pearson Chi-square [value/df]: 0.731 for original data; between 0.857 and 0.875 for imputed datasets | ||||||||
Direct costs | ||||||||
Age | − 0.006 | − 0.027 | 0.015 | 0.571 | − 0.003 | − 0.022 | 0.015 | 0.715 |
UPDRS | ||||||||
Hoehn and Yahr | ||||||||
III | 0.333 | − 0.480 | 1.145 | 0.422 | 0.183 | − 0.510 | 0.876 | 0.604 |
IV | − 0.210 | − 0.640 | 0.219 | 0.337 | − 0.130 | − 0.493 | 0.233 | 0.483 |
V | – | – | – | – | – | – | – | – |
Schwab and England | ||||||||
0.7 | – | – | – | – | – | – | – | – |
0.6 | − 0.478 | − 2.552 | 1.597 | 0.652 | 0.425 | − 1.096 | 1.947 | 0.584 |
0.5 | 0.404 | − 1.446 | 2.255 | 0.668 | 0.508 | − 0.883 | 1.899 | 0.474 |
0.4 | 0.243 | − 1.619 | 2.106 | 0.798 | 0.420 | − 0.988 | 1.827 | 0.559 |
0.3 | 0.166 | − 1.687 | 2.019 | 0.860 | 0.369 | − 1.033 | 1.770 | 0.606 |
0.2 | 0.272 | − 1.701 | 2.246 | 0.787 | 0.400 | − 1.090 | 1.891 | 0.599 |
0.1 | − 0.152 | − 2.142 | 1.837 | 0.881 | − 0.149 | − 1.682 | 1.385 | 0.849 |
0 | 0.339 | − 1.790 | 2.468 | 0.755 | 0.630 | − 1.012 | 2.273 | 0.452 |
Mentation, behavior, and mood | − 0.031 | − 0.096 | 0.034 | 0.348 | − 0.015 | − 0.067 | 0.038 | 0.586 |
Activities of daily living | 0.019 | − 0.016 | 0.054 | 0.284 | 0.022 | − 0.009 | 0.053 | 0.166 |
Motor examination | 0.004 | − 0.012 | 0.019 | 0.621 | 0.000 | − 0.013 | 0.012 | 0.962 |
Complications of therapy | − 0.035 | − 0.084 | 0.013 | 0.154 | − 0.020 | − 0.064 | 0.024 | 0.370 |
EQ-5D-3L | − 0.185 | − 0.920 | 0.549 | 0.621 | − 0.173 | − 0.809 | 0.464 | 0.595 |
Duration of the disease (years) | 0.030 | 0.009 | 0.050 | 0.005 | 0.017 | 0.001 | 0.035 | 0.068 |
Goodness of fit: deviance [value/df] = 1.017 for original data; between 1.051 and 1.095 for imputed datasets | Pearson Chi-square [value/df]: 0.830 for original data; between 1.021 and 1.045 for imputed datasets | ||||||||
Indirect costs | ||||||||
Age | − 0.218 | − 0.305 | − 0.132 | < 0.001 | ||||
UPDRS | ||||||||
Hoehn and Yahr | ||||||||
III | 1.080 | − 2.117 | 4.278 | 0.508 | ||||
IV | 0.255 | − 1.512 | 2.022 | 0.777 | ||||
V | – | – | – | – | ||||
Schwab and England | ||||||||
0.7 | – | – | – | – | ||||
0.6 | − 0.371 | − 3.488 | 2.746 | 0.815 | ||||
0.5 | − 2.520 | − 5.581 | 0.542 | 0.107 | ||||
0.4 | − 2.646 | − 5.994 | 0.701 | 0.121 | ||||
0.3 | − 2.917 | − 6.266 | 0.431 | 0.088 | ||||
0.2–0.0 | − 4.230 | − 8.574 | 0.114 | 0.056 | ||||
Mentation, behavior, and mood | 0.204 | − 0.025 | 0.432 | 0.080 | ||||
Activities of daily living | − 0.041 | − 0.135 | 0.053 | 0.389 | ||||
Motor examination | 0.038 | − 0.013 | 0.089 | 0.143 | ||||
Complications of therapy | 0.049 | − 0.107 | 0.204 | 0.541 | ||||
EQ-5D-3L | − 0.940 | − 3.053 | 1.173 | 0.383 | ||||
Duration of the disease (years) | 0.064 | − 0.002 | 0.130 | 0.058 |
Parameter | Total costs | |||
---|---|---|---|---|
Imputed data | ||||
βb | 95% CIa | P value | ||
Lower | Upper | |||
Sex | ||||
Female | − 0.083 | − 0.247 | 0.081 | 0.321 |
Male | – | – | – | – |
Age | − 0.014 | − 0.026 | − 0.002 | 0.018 |
UPDRS | ||||
Hoehn and Yahr | ||||
III | − 0.207 | − 0.651 | 0.238 | 0.362 |
IV | − 0.108 | − 0.338 | 0.122 | 0.358 |
V | ||||
Schwab and England | ||||
0.7 | ||||
0.6 | 0.033 | − 0.897 | 0.963 | 0.944 |
0.5 | 0.303 | − 0.524 | 1.131 | 0.472 |
0.4 | 0.191 | − 0.659 | 1.042 | 0.660 |
0.3 | 0.287 | − 0.564 | 1.138 | 0.509 |
0.2 | 0.319 | − 0.587 | 1.225 | 0.491 |
0.1 | 0.146 | − 0.803 | 1.095 | 0.763 |
0 | 0.373 | − 0.647 | 1.394 | 0.474 |
Mentation, behavior, and mood | 0.015 | − 0.018 | 0.048 | 0.381 |
Activities of daily living | 0.020 | 0.002 | 0.039 | 0.030 |
Motor examination | − 0.006 | − 0.014 | 0.002 | 0.134 |
Complications of therapy | − 0.008 | − 0.035 | 0.020 | 0.587 |
EQ-5D-3L | − 0.185 | − 0.570 | 0.200 | 0.346 |
Duration of the disease (years) | 0.015 | 0.003 | 0.027 | 0.011 |