Online Repository Measurement and Assessment of Cost Components

Online repository – Measurement and assessment of cost components

For monetary valuation of physician visits, we updated the prices per physician contact calculated for each medical speciality by the AG MEG to the base year 2007, using the percentage change in physician payment per case (National Association of Statutory Health Insurance Physicians) [53]. We calculated the valuation rates for physical therapy, physiotherapy in children, occupational and speech therapy analogously [54,55].To determine the costs of contacts with alternative practitioners, we used the rates suggested by the corresponding tariff for alternative practitioners [56]. In the rare cases where information on type of healthcare service and frequency of utilisation was missing, we applied a three-step approach of missing value imputation with single imputation using the MCMC and regression methods in SAS (PROC MI). We decided to use this imputation approach, as a complete case analysis would result in a disproportionate loss of information and an imprecise estimation of average utilisation and costs. As there was no information available on the reason for hospitalisation, we assessed the costs of inpatient hospital treatment by multiplying the number of days of the child’s stay by the mean costs per hospital day. The average values per day were updated following the AG MEG suggestions, which led to €488.37 [24,57,58]. If the number of days a child stayed in hospital was missing, we used the average length of stay. We assessed inpatient rehabilitation stays by multiplying the number of days of the child’s stay by the mean costs per inpatient rehabilitation day. We inflated the value proposed by the AG MEG [24] by the increase in per capita healthcare costs in Germany [57]. This leads to a value of €113.90 per day, which seems plausible for children as it is also in accordance with the results of an earlier German cost study [59].

References

53.Kassenaerztliche-Bundesvereinigung (2008). Grunddaten zur vertragsaerztlichen Versorgung in Deutschland.

54.Verband-der-Privaten-Krankenversicherung (2010). Beihilfevorschriften des Bundes nebst Durchfuehrungshinweisen. (Stand 01. January 2005).

55.Verband-der-Angestellten-Krankenkassen-eV-und-Arbeiter-Ersatzkassen-Verband-eV (2008). Verguetungslisten fuer Krankengymnastische/physiotherapeutische Leistungen, Massagen und medizinische Baeder.

56.Verband Freier Heilpraktiker e.V. Gebuehrenverzeichnis fuer Heilpraktiker (GeBueH) (2010).

57.Gesundheitsberichterstattung-des-Bundes. Gesundheitsausgaben in Deutschland als Anteil am BIP und in Mio. s (absolut und je Einwohner). Gliederungsmerkmale: Jahre. Jahre.

58.Statistisches-Bundesamt-Deutschland. Statistisches Jahrbuch fuer die Bundesrepublik Deutschland 2009. Wiesbaden: Statistisches Bundesamt; 2009.

59.Wolfenstetter SB. Adipositas und die Komorbiditat Diabetes mellitus Typ 2 bei Kindern und Jugendlichen in Deutschland: Entwicklung und Krankheitskostenanalyse. Gesundheitswesen. 2006;68:600-612.

Online repository Table 1: Adjusted odds of using medical services during the past 12 months by severity of behavior problems

Total difficulties / Emotional symptoms / Hyperactivity/Inattention / Conduct problems
At risk / abnormal / At risk / abnormal / At risk / abnormal / At risk / abnormal
Total Group n= 3,477 / aORa
95%
CI / p / aOR
95%
CI / p / aOR
95%
CI / p / aOR
95% CI / p / aOR
95% CI / p / aOR
95% CI / p / aOR
95% CI / p / aOR
95% CI / p
Physiciansb (yes, n= 2939) / 2.04
1.29-3.24 / 0.0024 / 2.25
1.43-
3.52 / 0.0013 / 1.50
1.01-2.23 / 0.0024 / 1.85
1.27-
2.69 / 0.0013 / 1.47
0.91-
2.37 / 0.1153 / 1.58
1.06-
2.34 / 0.0245 / 1.54
1.02-
2.31 / 0.0388 / 1.60
0.94-
2.73 / 0.0804
Emergency room (yes, n= 463) / 1.12
0.77-
1.63 / 0.5497 / 1.0
0.69-
1.42 / 0.9564 / 1.10
0.76-
1.59 / 0.6042 / 0.85
0.60-
1.19 / 0.3374 / 1.53
1.03-
2.26 / 0.0338 / 1.02
0.71-
1.46 / 0.9325 / 1.04
0.72-
1.52 / 0.8278 / 1.50
0.99-
2.28 / 0.0577
Therapistsc (yes, n = 875) / 1.88
1.42-
2.50 / <0.0001 / 3.39
2.62-
4.39 / <0.0001 / 1.79
1.35-
2.38 / <0.0001 / 3.07
2.44
3.87 / <0.0001 / 2.23
1.62-
3.07 / <0.0001 / 2.49
1.92-
3.22 / <0.0001 / 1.48
1.11-
1.96 / 0.0067 / 2.00
1.43-
2.81 / <0.0001
Psychotherapists (yes, n= 185) / 4.23
2.75-
6.52 / <0.0001 / 7.43
5.14-
10.74 / <0.0001 / 2.59
1.60-
4.21 / 0.0001 / 4.34
3.04-
6.21 / <0.0001 / 3.65
2.25
5.95 / <0.0001 / 4.94
3.40-
7.17 / <0.0001 / 2.30
1.47-
3.59 / 0.0003 / 4.10
2.59-
6.50 / <0.0001
Hospital (yes, n= 186) / 0.80
0.43-
1.50 / 0.4895 / 1.07
0.64-1.81 / 0.7964 / 1.04
0.59-
1.84 / 0.8866 / 1.33
0.85-
2.07 / 0.2099 / 0.88
0.44-
1.76 / 0.7189 / 0.93
0.53-
1.61 / 0.7915 / 0.49
0.23-
1.05 / 0.0672 / 1.71
0.96-
3.04 / 0.0675
Inpatient rehabilitation (yes, n= 49) / 2.30
0.99
5.37 / 0.0536 / 2.33
1.07-
5.04 / 0.0323 / 3.43
1.55-
7.56 / 0.0023 / 3.70
1.88
7.28 / 0.0001 / 1.58
0.54-
4.61 / 0.4035 / 3.08
1.50-
6.34 / 0.0022 / 1.17
0.41-
3.36 / 0.7680 / 1.95
0.68-
5.63 / 0.2167
Total Direct Medical Services (yes, n= 3008)d / 2.21
1.33-
3.68 / 0.0021 / 4.06
2.19-
7.50 / <0.0001 / 1.62
1.05-
2.48 / 0.0277 / 2.76
1.73-
4.40 / <0.0001 / 1.75
1.02-
3.02 / 0.0427 / 2.13
1.33-
3.41 / 0.0017 / 1.62
1.04-
2.53 / 0.0330 / 2.05
1.10-
3.82 / 0.0248

p value calculated using logistic regressionsadjusted for gender, study centre, parental education, household income, chronic physical conditions

a= aOR for using medical services at age ten (0=no, 1=yes) by severity of behavior problems, reference category is the normal group

b= Physician visits (total= paediatrician, general practitioner, ophthalmologist, orthopaedist, ear, nose and throat specialist (ENT), dermatologist, pulmonologist, other physician, emergency room)

c= Therapists (total= alternative practitioner, physical therapy, speech therapy, psychotherapy, occupational therapy, homeopathy, other therapies)

d= Total=Physician, therapist, hospital, inpatient rehabilitation costs

Online Repository Table 2: Mean annual medical costs and cost differences by severity of total difficulties in children with chronic physical conditions (n=262) (in €, values of 2007)

Total difficultiesa / Cost differenceb
Normal
n= 208 / At Risk
n= 27 / Abnormal
n= 27 / At Risk vs. Normal
n= 235 / Abnormal vs. Normal
n= 235 / Abnormal vs. At Risk
n= 54
Medical cost category / Mean
SD / (95% CIc) / Mean
SD / (95% CI) / Mean
SD / (95% CI) / Mean
SD / (95% CI) / p / Mean
SD / (95% CI) / p / Mean
SD / (95% CI) / p
Physician costsd / 174.9
185.6 / 150.7-200.6 / 152.2
120.5 / 110.5- 200.1 / 238.2
261.2 / 154.3- 343.6 / 22.7
179.5 / -55.9-87.2 / 0.9257 / 63.4
195.4 / -24.4-134.6 / 0.0482 / -86.0
203.4 / -23.8-192.7 / 0.1610
Emergency room costs / 8.6
30.7 / 5.0- 13.2 / 5.0
14.3 / 0-
9.9 / 11.6
23.5 / 3.3- 19.8 / 3.6
29.4 / -11.2-12.3 / 0.6672 / 3.0
30.0 / -12.0-11.9 / 0.2553 / 6.6
19.4 / -3.5-17.0 / 0.2669
Therapist costse / 96.7
284.9 / 61.5- 139.0 / 97.1
272.0 / 22.7- 216.6 / 511.4
829.0 / 227.4- 838.8 / 0.4
283.5 / -132.6-91.7 / 0.7796 / 414.7
385.7 / 238.3-541.5 / 0.0003 / 414.2
617.0 / 89.6-737.5 / 0.0228
Psychotherapy costs / 4.84
35.7 / 0.8- 10.5 / 26.9
84.1 / 0- 62.2 / 265.2
668.3 / 55.9- 553.2 / 22.1
43.9 / 0.20-35.0 / 0.0085 / 260.4
225.8 / 146.4-329.5 / <0.0001 / 238.3
476.3 / -16.6-491.8 / 0.3483
Hospital costs / 280.1
1047.8 / 152.3- 438.5 / 72.4
375.9 / 0- 217.1 / 307.5
1335.0 / 0-
868.2 / 207.8
995.6 / -272.0-519.4 / 0.2551 / 27.4
1083.7 / 494.1-360.0 / 0.6366 / 235.1
980.7 / -19.7-488.7 / 0.5217
Inpatient rehabilitation costs / 177.4
707.8 / 88.2- 278.2 / 185.6
695.1 / 0- 472.5 / 92.8
482.2 / 0-
278.4 / 8.2
706.4 / -323.1-235.4 / 0.9067 / 84.6
686.3 / -223.9-306.5 / 0.5508 / 185.6
92.8 / -236.1-399.8 / 0.5711
Total direct medical costsf / 729.1
1435.5 / 548.4- 943.2 / 507.3
850.1 / 225.3- 852.2 / 1149.9
1973.3 / 570.1- 1983.0 / 221.8
1382.5 / -392.3-700.0 / 0.9113 / 420.8
1505.1 / -261.9-935.1 / 0.0156 / 642.6
1519.3 / -159.6-1462.0 / 0.0559

p value calculated using Wilcoxon Mann Whitney test

a= SDQ Total difficulties score 13-15 borderline, score > 15= abnormal;

b= Cost difference between children with normalvs. at risk vs. abnormal total difficulties

c= To account for non-normality of the cost data 95% confidence intervals (CIs) for the means and for the difference of the means were estimated applying a non-parametric bootstrap approach (percentile method)

d= Physician visits (total= paediatrician, general practitioner, ophthalmologist, orthopaedist, ear, nose and throat specialist (ENT), dermatologist, pulmonologist, other physician, emergency room)

e= Therapists (total= alternative practitioner, physical therapy, speech therapy, psychotherapy, occupational therapy, homeopathy, other therapies)

f= Total=Physician, therapist, hospital, inpatient rehabilitation costs

Table 3:Stratified for gender: Comparison of costs among Boysusing medical services between at risk/abnormal vs. normal behavior problems

Total difficulties / Emotional symptoms / Hyperactivity/Inattention / Conduct Problems
at risk / abnormal / at risk / abnormal / at risk / abnormal / at risk / abnormal
Medical cost categorya / N / (exp)Bb
Meanc / SE / N / (exp)B
Mean / SE / N / (exp)B
Mean / SE / N / (exp)B
Mean / SE / N / (exp)B
Mean / SE / N / (exp)B
Mean / SE / N / (exp)B
Mean / SE / N / (exp)B
Mean / SE
Physician costsd / 146 / 1.24
129.4 / 0.06 / 155 / 1.31
136.5
* / 0.07 / 119 / 1.09
112.5 / 0.07 / 159 / 1.48
151.9
* / 0.06 / 101 / 1.25
131.5 / 0.08 / 190 / 1.20
126.2 / 0.06 / 142 / 0.98
105.5 / 0.07 / 83 / 1.04
111.7 / 0.09
Emergency room costs / 21 / 0.88
44.5 / 0.09 / 18 / 1.21
61.1 / 0.10 / 23 / 1.03
47.9 / 0.09 / 17 / 1.14
56.0 / 0.10 / 19 / 1.31
62.8 / 0.09 / 27 / 1.12
54.0 / 0.08 / 17 / 1.10
53.9 / 0.10 / 12 / 1.05
52.0 / 0.11
Therapist costse / 66 / 1.21
370.5 / 0.15 / 88 / 1.90
582.7
* / 0.13 / 47 / 0.85
253.6 / 0.17 / 89 / 1.56
464.1
* / 0.13 / 46 / 1.63
483.7 / 0.17 / 93 / 1.66
491.2* / 0.13 / 60 / 1.06
334.0 / 0.16 / 39 / 1.26
397.4 / 0.19
Psychotherapist costs / 25 / 1.29
914.3 / 0.26 / 40 / 1.88
1326.8 / 0.21 / 14 / 1.13
753.3 / 0.32 / 35 / 1.60
1070.1 / 0.21 / 21 / 0.90
698.3 / 0.26 / 39 / 1.40
985.4 / 0.22 / 26 / 1.30
1016.9 / 0.25 / 19 / 1.05
821.7 / 0.28
Hospital costs / 3 / 1.18
1935.8 / 0.44 / 12 / 6.99
11462
* / 0.26 / 8 / 1.0
1295.4 / 0.28 / 11 / 6.85
8879.5
* / 0.25 / 4 / 0.81
1383.1 / 0.40 / 15 / 5.55
9500.5* / 0.26 / 4 / 0.73
1127.1 / 0.38 / 7 / 7.65
11867* / 0.31
Inpatient rehabilitation costs / 3 / 1.27
5458.4 / 0.50 / 5 / 3.67
15794 / 0.46 / 7 / 1.43
4486.4 / 0.43 / 5 / 2.82
8830.8 / 0.48 / 3 / 0.71
3490.5 / 0.59 / 7 / 2.34
11501 / 0.47 / 4 / 1.37
5469.3 / 0.49 / 2 / 6.67
26691 / 0.68
Total Direct Medical Costs f / 150 / 1.17
279.9 / 0.12 / 163 / 4.12
983.3
* / 0.12 / 122 / 1.44
301.5 / 0.13 / 168 / 3.83
800.9
* / 0.11 / 103 / 1.49
343.6 / 0.14 / 197 / 3.42
788.0* / 0.11 / 146 / 1.02
243.1 / 0.12 / 86 / 4.45
1059.6* / 0.16

p value calculated using generalised Linear Regression model, gamma distribution, log-link function

*p-value Bonferroni corrected <.0009

a=Number of children using that particular service

b= Adjusted exp(Beta) Estimates of the generalized Linear Regression model

c=Adjusted means of costs of medical services >0 for children with at risk and abnormal behavior problems (reference category=normal) controlled for study centre, parental education, household income, chronic physical conditions

d= Physician visits (total= paediatrician, general practitioner, ophthalmologist, orthopaedist, ear, nose and throat specialist (ENT), dermatologist, pulmonologist, other physician, emergency room)

e= Therapists (total= alternative practitioner, physical therapy, speech therapy, psychotherapy, occupational therapy, homeopathy, other therapies)

f= Total=Physician, therapist, hospital, inpatient rehabilitation costs

Table 4:Stratified for gender: Comparison of costs among Girlsusing medical services between at risk/abnormal vs. normal behavior problems

Total difficulties / Emotional symptoms / Hyperactivity/Inattention / Conduct Problems
at risk / abnormal / at risk / abnormal / at risk / abnormal / at risk / abnormal
Medical cost categorya / N / (exp)Bb
Meanc / SE / N / (exp)B
Mean / SE / N / (exp)B
Mean / SE / N / (exp)B
Mean / SE / N / (exp)B
Mean / SE / N / (exp)B
Mean / SE / N / (exp)B
Mean / SE / N / (exp)B
Mean / SE
Physician costsd / 80 / 1.42
126.5* / 0.09 / 105 / 1.26
112.9 / 0.08 / 110 / 1.15
103.0 / 0.08 / 169 / 1.31
117.4
* / 0.07 / 58 / 1.14
106.1 / 0.07 / 72 / 1.16
107.6 / 0.11 / 87 / 0.98
90.6 / 0.09 / 58 / 1.20
111.3 / 0.11
Emergency room costs / 17 / 1.17
50.0 / 0.09 / 20 / 0.94
39.91 / 0.08 / 16 / 0.92
40.1 / 0.09 / 25 / 1.17
51.1 / 0.07 / 15 / 1.01
44.0 / 0.09 / 14 / 0.93
40.5 / 0.10 / 18 / 0.93
41.1 / 0.09 / 17 / 0.95
42.1 / 0.09
Therapist costse / 21 / 2.27
485.4* / 0.23 / 50 / 2.19
466.9* / 0.16 / 37 / 1.30
292.9 / 0.19 / 78 / 1.38
312.6 / 0.14 / 24 / 0.87
226.6
* / 0.22 / 31 / 2.62
681.0* / 0.20 / 23 / 0.28
121.1 / 0.23 / 23 / 1.01
338.7 / 0.23
Psychotherapist costs / 8 / 1.24
524.3 / 0.37 / 18 / 1.78
750.3 / 0.29 / 8 / 0.48
256.0 / 0.37 / 18 / 1.37
730.3 / 0.31 / 2 / 0.39
190.1 / 0.67 / 13 / 1.71
833.8 / 0.32 / 1 / 0.28
122.5 / 0.96 / 8 / 1.01
448.7 / 0.38
Hospital costs / 8 / 1.81
9485.3 / 0.28 / 3 / 7.70
40332* / 0.35 / 7 / 1.50
6268.5 / 0.33 / 15 / 4.14
17287* / 0.23 / 5 / 5.93
31486* / 0.37 / 1 / 0.55
2916.1 / 0.82 / 3 / 8.48
42446* / 0.47 / 7 / 1.18
5905.8 / 0.37
Inpatient rehabilitation costs / 4 / 1.50
4323.1 / 0.41 / 4 / 1.46
4210.8 / 0.41 / 2 / 1.10
3195.2 / 0.46 / 9 / 1.48
4309.9 / 0.31 / 1 / 0.98
3447. 5 / 0.73 / 4 / 0.99
3473.4 / 0.40 / - / - / - / 1 / 1
3464.8 / 0.48
Total Direct Medical costs f / 80 / 2.83
974.7* / 0.15 / 108 / 3.99
1371.6
* / 0.14 / 112 / 1.39
440.5 / 0.13 / 173 / 3.88
1225.7
* / 0.11 / 61 / 4.43
1693.6* / 0.18 / 75 / 1.60
647.7 / 0.16 / 88 / 2.72
1126.9* / 0.16 / 60 / 1.55
641.6 / 0.18

p value calculated using generalised Linear Regression model, gamma distribution, log-link function

*p-value Bonferroni corrected <.0008

a=Number of children using that particular service

b= Adjusted exp(Beta) Estimates of the generalized Linear Regression model

d= Physician visits (total= paediatrician, general practitioner, ophthalmologist, orthopaedist, ear, nose and throat specialist (ENT), dermatologist, pulmonologist, other physician, emergency room)

e= Therapists (total= alternative practitioner, physical therapy, speech therapy, psychotherapy, occupational therapy, homeopathy, other therapies)

f= Total=Physician, therapist, hospital, inpatient rehabilitation costs

Appendix S1GINI-plus Study Group and LISA-plus Study Group:

§The GINI-plus Study Group comprises the Helmholtz Zentrum München, German Research Center for Environmental Health, Institute of Epidemiology, Munich (Heinrich J, Wichmann HE, Sausenthaler S, Zutavern A, Chen, Chih-Mei, Schnappinger M, Rzehak P); Department of Pediatrics, Marien-Hospital, Wesel (Berdel D, von Berg A, Beckmann C, Groß I); Department of Pediatrics, Ludwig Maximilians University, Munich (Koletzko S, Reinhardt D, Krauss-Etschmann S); Department of Pediatrics, Technical University, Munich (Bauer CP, Brockow I, Grübl A, Hoffmann U); IUF - Institut für Umweltmedizinische Forschung at the Heinrich-Heine-University, Düsseldorf (Krämer U, Link E, Cramer C); Centre for Allergy and Environment, Technical University, Munich (Behrendt H).

§§ The LISA-plus Study Group consists of the following: Helmholtz Zentrum München, German Research Center for Environmental Health, Institute of Epidemiology, Munich (Heinrich J, Wichmann HE, Sausenthaler S, Chen CM, Schnappinger M); Department of Pediatrics, Municipal Hospital “St.Georg”, Leipzig (Borte M, Diez U), Marien-Hospital Wesel, Department of Pediatrics, Wesel (von Berg A, Beckmann C, Groß I); Pediatric Practice, Bad Honnef (Schaaf B); Helmholtz Centre for Environmental Research – UFZ, Department of Environmental Immunology/Core Facility Studies, Leipzig (Lehmann I, Bauer M, Gräbsch C, Röder S, Schilde M); University of Leipzig, Institute of Hygiene and Environmental Medicine, Leipzig (Herbarth O, Dick C, Magnus J); IUF - Institut für Umweltmedizinische Forschung, Düsseldorf (Krämer U, Link E, Cramer C); Technical University Munich, Department of Pediatrics, Munich (Bauer CP, Hoffmann U); ZAUM - Center for Allergy and Environment, Technical University, Munich (Behrendt H, Grosch J, Martin F).