Health care and cost of medication for inflammatory bowel disease in the rhein-main region, germany: a multicenter, prospective, internet-based study

Health Care and Cost of Medication for Inflammatory BowelDisease in the Rhein-Main Region, Germany: A Multicenter,Prospective, Internet-based Study I. Blumenstein, MD,*† H. Bock, MD,†‡ C. Weber, MD,†‡ A. Rambow, MD,†‡ W. Tacke, MD,†‡ R. Kihn, MD,†‡R. Pfaff, MD,†‡ S. Orlemann, MD,†‡ R. Schaeffer, MD,†‡ O. Schro¨der, MD*† A. Dignaß, MD†PF. Hartmann, MD†§ J. Stein, MD, PhD*†¶ ⫾ 2897€/patient (median 960€) at the University Hospital.
Background: Studies examining the treatment reality of IBD
patients in Germany have been limited, as networking among de-
Conclusions: The registry provides the first detailed data about
liverers of care and reliable documentation of medical, demo- the reality of treatment of IBD patients in Germany and reveals the graphic, and economic data are lacking. The aim of the present study necessity for networking among attending physicians in order to was to establish an internet-based treatment registry in order to implement guidelines-conformed treatment.
evaluate treatment of IBD patients in Germany.
(Inflamm Bowel Dis 2008;14:53– 60) Methods: Between November 1st, 2005, and January 31, 2007,
Key Words: inflammatory bowel disase, healthcare, cost of med-
1024 outpatients with prevalent IBD from 10 gastroenterological private practices and 3 hospitals (UC ⫽ 439, CD ⫽ 567, ID ⫽ 18)were enrolled in the study. An internet-based registry was estab-lished that included data about medical history, disease status,diagnostic procedures, laboratory test results, and medical treatment.
In Germany, 380,000 patients suffer from inflammatory bowel diseases (IBDs) including Crohn's disease (CD), Data for private practices and hospitals were pooled in order tocompare treatment habits between these types of medical facilities.
ulcerative colitis (UC), and indeterminate colitis (IC). The The cost of medication was determined according to medications chronic recurrent course of the disease requires intensive and costly medical care. The costs of medical care for IBDpatients are estimated to be higher than those for other dis- Results: There was no significant difference between the 2 patient
eases, including cancer and heart disease,1,2 thus making up a groups in demographic and clinical characteristics. Marked differ- considerable part of health care expenses. Studies examining ences were observed in medical treatment. The most frequentlyprescribed medications in the private practices for patients in remis- the reality of treatment of IBD patients in Germany have been sion and those with active disease were aminosalicylates and corti- limited, as networking among care deliverers and reliable costeroids. Immunomodulators played a marginal role. In contrast, documentation of medical, sociodemographic, and economic in the hospitals azathioprine/6-MP was predominantly used for the data are lacking. Recently, the European Collaborative Study maintenance of remission. Patients with fistulizing CD were treated of Inflammatory Bowel Disease (EC-IBD) published a retro- with infliximab. The mean annual cost of medications was 1826 spective study on cost analysis and cost determinants in a ⫾ 1331€/patient (median 1353€) in the private practices and 1849€ large European inflammatory bowel disease inception cohort(1321 patients from 8 European countries and Israel).3 Apartfrom the EC-IBD study, studies of costs in IBD have been Received for publication April 27, 2007; accepted July 24, 2007.
limited to single centers with either hospitalized or ambula- From the *Division of Gastroenterology, J. W. Goethe-University, Frank- tory patients selected for study participation, recruitment of furt/Main, Germany; †Crohn-Colitis Center Rhein-Main, Frankfurt/Main,Germany; ‡Quality Management Group of Gastroenterologists in Hessia; prevalent cases, and short periods of follow-up evalua- §Division of Internal Medicine, St. Marien Hospital, Frankfurt am Main, tion.1,4–10 However, the EC-IBD study had a retrospective Germany; PDivision of Internal Medicine I, Marcus Hospital, Frankfurt/ design, and data from Germany were missing. Robust cost- Main, Germany; and ¶ZAFES (Center for Drug Research, Development and effectiveness data for IBD therapies are unavailable, as few Safety), Frankfurt/Main, Germany.
Reprints: Prof. Dr. Dr. J. Stein, Department of Gastroenterology, J. W.
therapeutic trials have incorporated the prospective collection Goethe-University, Theodor-Stern-Kai 7, Haus 11, 3. Stock, 60590 Frank- of resource data. So far, calculation of medication costs for furt/Main, Germany (e-mail: IBD patients has been based on subjective cost estimates or Copyright 2007 Crohn's & Colitis Foundation of America, Inc.
extrapolations for 1 year on a monthly basis. Furthermore, all DOI 10.1002/ibd.20257 published studies contain data on therapy costs from the Published online 31 October 2007 in Wiley InterScience (www.interscience.
Inflamm Bowel Dis Volume 14, Number 1, January 2008 Blumenstein et al Inflamm Bowel Dis Volume 14, Number 1, January 2008 Therefore, the aims of the present study were: (1) to other immunosuppressants (e.g., tacrolimus), antibiotics, and establish an internet-based treatment registry in order to pro- others (vitamins and minerals))].
spectively evaluate the reality of treatment of IBD patients in The average time needed by a trained study nurse or a region in central Germany; (2) to ascertain differences in physician to acquire data at the initial visit was about 30 treatment provided by physicians working in hospitals with minutes. To avoid mistakes in data entry, regular meetings of that provided by physicians in private practices; and (3) to all participating practices and hospitals were held, and a measure the cost of medications for IBD patients included in permanent telephone hotline was established. After data en- try, completeness and logic of data were checked electroni-cally. Incomplete data sets were highlighted and reported tothe particular person who entered the data.
The Rhein-Main region is a well-described geographi- Disease activity was determined according to the HBI cal region in central Germany with a population of approxi- for CD and the CAI for UC. Patients were assigned to 1 of 3 mately 2.8 million inhabitants. Using the estimated preva- groups according to disease activity. Patients were classified lence of IBD in Germany of 0.4%, it was calculated that as in remission if they had no disease activity (HBI ⬍ 5 about 11,000 patients suffering from IBD live in this region.
points and CAI ⱕ 5 points) and were pooled in the remission All patients with a confirmed diagnosis of IBD (meeting the group. Mild–moderate activity was defined as HBI 5–16 or diagnostic criteria of Lennard-Jones and Truelove and Witts) 6 –10 points, respectively. Patients were defined as having who were receiving secondary care for IBD in 1 of 10 high disease activity if they had an HBI ⬎ 16 or an CAI ⬎ 10.
gastroenterological private practices and 3 hospitals (1 uni-versity hospital and 2 municipal hospitals with a main focus Analysis of Medication Therapy
on IBD) in the Rhein-Main region were eligible for inclusion Analysis of medication therapy was based on the initial in the study. From November 1st, 2005, to January 31, 2007, visit medication therapy data sheet. Follow-up visits and 1024 patients with prevalent IBD were enrolled in the study consecutive changes in medication were not included. In (UC ⫽ 439, CD ⫽ 567, ID ⫽ 18).
total, 797 complete medication therapy data sets (78%) wereavailable for analysis.
Patient Data Acquisition Tools
All participating centers had access to 6 internet-based Determination of Medication Costs
data acquisition forms (demographic data at initial visit, CD As cost of medication is invariably skewed to the right, at initial visit, UC at initial visit, laboratory data sheet, median cost (rather than mean cost) was considered more diagnostic data sheet, and medication record sheet), which representative of the outlay for most cohort patients, avoiding were username- and password secured and firewall protected.
the bias that would result from the high costs incurred for a A file with a 10-digit code was created for each patient in the minority of patients. However, mean cost has the advantage study. At the initial visit, data sheets were used to collect of permitting calculation of overall expenditure in the cohort, demographic patient data [initials, date of birth, sex, practice which is important for planning future health care budgets.3 ID, first 3 digits of the zip code, insurance company, diag- In our cohort, data on 325 patients treated at 5 gastroenter- nosis, body mass index (BMI), smoking habits] as well as ological private practices were available. Medication cost clinical data about medical history [year of diagnosis, family was based on actual medications prescribed. The 5 private history, number of exacerbations, localization of disease, practices have an electronic system available that records not disease character, surgical procedures, extraintestinal mani- only prescriptions but also actual prices. For all 325 patients festations], actual disease status [including disease activity (46.8% of all patients treated at a private practice) complete scores Harvey-Bradshaw index (HBI), Colitis Activity Index data for the entire study period were available. These patients (CAI), and Vienna Classification], physical examination, di- obtained all their prescriptions exclusively in the at their agnostic procedures [ileocolonoscopy, gastroscopy, ultra- particular practice. Calculation of the cost of medications for sound], blood tests [infection parameters, blood count, liver patients treated at the University Hospital was done retro- and renal function parameters, lipase, anti–Saccharomyces spectively for the complete period of the study. Records of cerevisiae antibody (ASCA)] and stool tests [calprotectin and 198 patients (60%) in the study were available for analysis of detection of pathogens], and medications [route of applica- medication costs.
tion, side effects, medications ineffective in the past, medi-cation names (aminosalicylates, corticosteroids, budesonide, azathioprine/6-mercaptopurine (6-MP), cyclosporine (CSA), All electronic patient data were transmitted online to methotrexate (MTX), infliximab, other immunomodulators, the software company IOMTech in Berlin, Germany, for Inflamm Bowel Dis Volume 14, Number 1, January 2008 Care and Cost of Medication for IBD in Germany TABLE 1. Demographic and Clinical Characteristics
Patients treated in hospital outpatient Patients treated in private practice Patients, number (%) Patients with indeterminate colitis, number (%) Number of patients (%) Age (years), mean (SD) Weight (kg), mean (SD) Disease duration (years), mean (SD) Disease activity at initial visit, mean (SD)CAI (UC) Mild–moderate activity (%) High activity (%) quality assurance, storage, and analysis. Statistical analysis of hospital-treated patients. The proportions of patients suffer- data was done where applicable using Microsoft Excel 2003 ing from extensive UC were similar (Table 3).
and tools from Microsoft Excel XLSTAT.
It is remarkable that more UC patients treated in hos- pitals suffered from extraintestinal complications, mostly ar- thritis (18.2% versus 10.1%). The percentage of surgical The principle of internet-based, pseudonymized docu- procedures (proctocolectomies, bowel resections, and fistu- mentation was approved by the Hessian Bureau of Data lectomies) varied according to where treatment occurred (Ta- ble 4), such that more CD patients treated in hospitals hadpreviously had bowel resections (44% versus 29.4%), andtwice as many hospital-treated UC patients had undergone a proctocolectomy (8.3% versus 3.8%).
Demographic and Clinical Data
Demographic and clinical characteristics from 1024 TABLE 2. Distribution of CD Patients according to Vienna
patients treated at 1 of 10 private practices or in 1 of 3 hospitals were pooled and compared afterward (Table 1).
There was no significant difference between the 2 patient groups in sex, age, disease duration, and disease activity of UC patients. However, concerning disease activity in CD patients, more patients treated in hospitals are in remission Age at presentation (years) (69.5 versus 39.9) at the initial visit. Of patients treated in private practices, 58.0% showed mild–moderate disease ac- tivity at the first documented visit. The distribution of clinical forms in CD according to the Vienna Classification12 is B1 (inflammatory) shown in Table 2. There was no significant difference be- tween private practice–treated patients and hospital-treated patients, except that more patients with penetrating CD were treated in a hospital.
The extent of disease of UC patients differed according to where they were treated—more patients treated in private practices suffered from distal UC than did those treated in hospitals (37.4 versus 17.7), and 23.3% of private practice– gastrointestinal tract) treated patients had left-sided UC compared with 44.4% of Blumenstein et al Inflamm Bowel Dis Volume 14, Number 1, January 2008 TABLE 3. Extent of Disease in UC Patients according to
Montreal Classification for Ulcerative Colitis13
Extent of disease E1 (ulcerative proctitis) E2 (left-sided UC) Polypharmacy is defined as the use of 2 or more med- FIGURE 1. Percentage of patients on 0 or 1, ⱖ2, or ⬎5 IBD-
ications (minor) or the use of more than 5 medications (major specific medications including the antibiotics metronidazole polypharmacy).14 In our patient cohort, minor polypharmacy was present in about 40% of IBD patients treated in privatepractice and in about 35% of patients treated in a hospital. No CD, 45% of all patients were treated with 5-ASA alone patient in the study took more than 5 IBD-specific medica- (20.1%), corticosteroids (10.1%), or a combination of 5-ASA tions (Fig.1).
plus corticosteroids (14.8%). However, azathioprine/6-MP Medication prescribed during remission and active dis- (monotherapy 16.2%, combination with corticosteroids/5- ease by physicians in the private practices differs markedly ASA 11.5%) and other immunosuppressants/immunomodu- from that prescribed in the hospitals. Surprisingly, up to lators (3.9%) were given more frequently (Fig. 2a).
17.6% of patients took no IBD-specific medication at all. In In contrast, physicians in hospitals prescribed azathio- general, physicians in private practice tended to prescribe prine/6-MP as a single treatment regimen to about 25% of UC corticosteroids as well as aminosalicylates as single-drug and CD patients. Azathioprine/6-MP combined with cortico- therapy or in combination with corticosteroids to treat both steroids was prescribed to 11.3% of UC patients, and aza- UC and CD patients. For 75.8% of UC patients, treatment thioprine/6-MP combined with 5-ASA was prescribed to was 5-ASA alone (41.7%), corticosteroids (7.1%), or both 5.1%. Corticosteroids as single-drug therapy were prescribed (27%). Azathioprine/6-MP (monotherapy 8.7%, in combina- to 9.3%. 5-ASA was given as monotherapy to 23.7% of UC tion with corticosteroids/5-ASA 5.9%) and other immuno- patients and in combination with corticosteroids to 9.3%. In suppressants/immunomodulators (1.2%) seemed to play a total, 5-ASA was at least partly involved in 38.1% of all UC marginal role in treatment (Fig. 2a). Even for patients with treatment regimens. CSA (2.1%) and MTX (1.0%) played a TABLE 4. Complications
Patients treated in hospital outpatient Patients treated in private practice Extraintestinal complications (%) Sclerosing cholangitis 1-2 Fistulectomies ⬎2 Fistulectomies 1-2 Bowel resections ⬎2 Bowel resections EN, erythema nodosum.
Inflamm Bowel Dis Volume 14, Number 1, January 2008 Care and Cost of Medication for IBD in Germany patients, 46.7% were in remission (HBI ⬍ 5), 51.7% hadmild–moderate disease activity (HBI 5–16), and 2.2% hadhigh disease activity. For CD patients treated in hospitals,5-ASA treatment varied significantly according to diseaseactivity: 80% were in remission, 20% had mild to moderatelyactive disease, and none had high disease activity (Fig. 3).
Treatment of penetrating CD varied significantly be- tween the private practices and the hospitals: 38.5% of pa-tients treated in private practice took 5-ASA as single-drugtherapy (20.8%) or in combination with corticosteroids. In thehospitals, only 4.5% of patients received 5-ASA alone, and13.6% received it in combination with corticosteroids. Cor-ticosteroid monodrug therapy was the treatment of choice for22.9% of patients treated in the private practices; in thehospitals only 9.1% were treated with this regimen. In privatepractices 28.1% of patients with penetrating CD were treatedwith azathioprine/6-MP (monotherapy, 17.7%; in combina-tion with corticosteroids, 10.4%); in the hospitals 36.4% ofsuch patients were treated with this regimen (monotherapy,27.3%; in combination with corticosteroids, 9.1%). In privatepractices 2.1% of patients received MTX as a single-drugregimen, and 1% received it in combination with corticoste-roids. However, in the hospitals MTX was prescribed morefrequently, as a single-treatment regimen to 20.5% of patientsand in combination with infliximab to 4.5% of patients.
Infliximab was of limited relevance in treating patients withpenetrating CD in private practices. Only 6.3% of patientswith penetrating CD were treated with infliximab (single-drug therapy, 2.1%; in combination with azathioprine/6-MP,4.2%). In the hospitals, 9.1% of patients were treated withinfliximab monotherapy and 6.8% with infliximab in combi-nation with azathioprine/6-MP (2.3%) or MTX (4.5%), asshown in Figure 4.
FIGURE 2. (a) Medication received by IBD patients treated in
private practice. (b) Medication received by IBD patients treated
in hospitals.
minor role in UC therapy. 5-ASA was given as monotherapyto only 7.0% of CD patients, in combination with corticoste-roids to 6.3% of patients, and in combination with cortico-steroids and azathioprine/6-MP to 0.7% of patients. Cortico-steroid monotherapy was recorded for 11.2% of CD patients,whereas other immunosuppressants (MTX) were used by7.0% of patients. Infliximab was infused as monotherapy for2.8%, in combination with azathioprine/6-MP for in 0.7%,and in combination with MTX for 6.3% (Fig. 2b).
As the prescription habits varied enormously between the 2 types of physician groups (Fig. 2a, b), we analyzed (1)5-ASA therapy prescribed to CD patients according to dis-ease activity, and (2) therapy prescribed patients with pene-trating CD. 5-ASA treatment of CD patients treated in privatepractice was as follows: 36.3% received 5-ASA either as FIGURE 3. 5-ASA medication prescribed to CD patients treated
single-drug therapy or in combination with either corticoste- in private practices and hospitals dependent on disease activ- roids or corticosteroids and immunosuppressants. Of these Blumenstein et al Inflamm Bowel Dis Volume 14, Number 1, January 2008 of system failure and loss of data, as was reported to occur inthe EC-IBD study.16 However, neither system failure norproblems with the data export facility occurred in our study.
(3) Our study was the first to compare the treatment reality ofIBD patients treated at private practices of gastroenterologistswith that of patients treated in outpatient services of hospitalswhose main focus is IBD. Major differences in therapy forboth UC and CD patients were detected. Most IBD patients inGermany are treated in private practices.17 Providing high-quality health care is a major concern of the expert network-ing group QGH (Quality Management Group of Gastroenter-ologists in Hessia), of which all participating private practicesare members. The present study showed the indispensablebasis of quality management—the investigation of treatmentreality. The reasons for the observed differences in the treat- FIGURE 4. Medications received by patients with penetrating
ment of IBD patients between private practices and hospitals CD treated in private practices and hospitals.
varied. First, treatment with azathioprine/6-MP was limitedby its late onset of action (3– 6 months) and its association Cost of Medication Therapy
with considerable toxicity.18–20 These data could explain the Median and mean (⫾ SD) medication costs for the 325 limited use of this drug by physicians in the private practices.
patients treated in 5 private practices as well as the 198 However, frequent monitoring of the blood count and begin- patients treated at the University Hospital of Frankfurt were ning with a low dose appear to be a safe option.21 Second, recorded. In total, the mean cost of medications including monetary reasons seem to be important (e.g., concerning infliximab was 1826€ ⫾ 1331€/patient-year in the private therapy with infliximab, a very costly medication). As shown practices and 1849€ ⫾ 2897€/patient-year at the University for the first time in our study, medication costs were cut in Hospital of Frankfurt. Median medication cost was 1352€ in half when infliximab use was restricted. However, financial the private practices and 960€ in the hospitals. In the private motives do not explain the extensive use of 5-ASA, espe- practices, the median cost not including infliximab was 720€/ cially in treating patients with Crohn's disease, for which the patient-year (median), and the mean (⫾ SD) cost was 827€ ⫾ drug should be of little or no importance according to national 374€/patient-year (mean ⫾ SD); at the University Hospital of and international guidelines. The annual costs of 5-ASA Frankfurt, the median cost not including infliximab was 960€/ medication such as for maintenance therapy are indeed equal patient-year, and the mean (⫾ SD) cost was 1091€ ⫾ 1352€/ to the price for azathioprine/6-MP therapy (920€ versus patient-year. 5-Aminosalicylates accounted for about 37% of 950€). If more than 2 g of 5-ASA is administered, annual the costs in both groups. These data show that a minority of costs can be as high as 1380€. Third, the treatment differ- patients receiving infliximab influenced the medication costsper year enormously (Fig. 5).
The present study provides the most comprehensive available record of the treatment reality and aligned costs ofIBD patients attending multiple centers in a central region ofGermany. It has several advantages over previous studies: (1)It was a prospective study, which has been proposed asnecessary to obtain complete data,3,15 with incomplete databeing a major problem in previously published retrospectivestudies.1,3,4,7 (2) It represents the first internet-based docu-mentation system for IBD patients in Germany. The datamanagement procedure promptly made available a reliableset of analyzable data after completion of the data acquisitionphase. So far, only the EC-IBD study has provided a similarlysuccessful data acquisition tool.16 In the present study, it was FIGURE 5. Mean cost of medication at 5 private practices and
shown that an internet-based documentation system can be a the University Hospital of Frankfurt compared with that from reliable tool for data entry and storage. There is a possibility previously published data for Europe.
Inflamm Bowel Dis Volume 14, Number 1, January 2008 Care and Cost of Medication for IBD in Germany ences could be a result of variable implementation of treat- in therapy, the mean cost of medications of patients treated at ment guidelines. In our study, regular meetings of all partici- the University Hospital of Frankfurt was almost identical to pating parties were held. The implementation of treatment that of the patients treated in private practices in the Rhein- guidelines was promoted at each visit. In our patient cohort, Main region. Medication costs of IBD patients treated at the the differences observed in therapy may have resulted in a University Hospital of Ulm, Germany, have been pub- different outcome at least for CD patients, as 69.5% (hospi- lished.7,25 Medication costs accounted for 85% of the total tals) versus 39.9% (private practices) of these patients were in costs (mean total cost, 3171€; mean medication cost, 2687€).
remission at the initial visit. For UC patients, outcomes did 5-ASA accounted for 48.4% of the total medication costs not differ by patient group. A possible explanation for this (1301€/year). The authors speculated that the relatively high discrepancy is the therapeutic effectiveness of the substances costs of this medication, especially considering the data col- 5-aminosalicylates and corticosteroids frequently used in pri- lection period of 1997–2000, when infliximab was not a vate practices in treating CD and UC. These agents seem to routinely used medication, may be related to the fact that a be more effective in inducing and maintaining remission in university hospital may care for more severe cases of IBD.
UC patients than in CD patients. Analysis of the follow-up An analysis of medication costs by members of the German data of our study cohort is expected to bring more detailed Crohn's Disease and Ulcerative Colitis Association using information about the course of therapy during the study cost diaries revealed average medication costs over 4 weeks of €274 and €309 for patients with CD and UC, respectively.
Another important finding is the high prevalence of However, extrapolation of these data would overestimate polypharmacy in our study cohort. It has been shown that yearly costs of medication in comparison to our data.10 In polypharmacy correlates with adverse outcomes in other dis- general, in practices in Germany whose main focus is not ease processes. A cohort study of 30,397 Medicare enrollees IBD, the mean cost of medication is 613€ per year, with reported an overall rate of adverse drug reactions of 50.1/ 5-ASA accounting for 64% (263€) of this costs.11 1000 person-years, of which 25% were considered prevent- In a 6-month cohort of IBD patients receiving second- able.22 Veehof et al reported that adverse drug reactions in the ary care in a university hospital in the United Kingdom, mean elderly correlate with polypharmacy rates.23 Major polyphar- drug costs accounted for less than a quarter of total costs macy was identified in 50% of patients with CD reviewed by (548€ of 2195€ for 6 months), with 50% of drug costs Cross et al.24 In this study, it could be proven that clinical produced the use of oral 5-ASA preparations.4 In the EC-IBD disease activity increased and quality of life decreased with study,3 in which a cost analysis was done of IBD patients increasing polypharmacy. The authors discussed the possibil- treated in 8 European countries and Israel, the expense of ity that drug interactions occur with increasing use of medi- aminosalicylates exceeded the combined cost of all other cations, resulting in adverse clinical outcome. Furthermore, drugs (mean total cost of medication, 613€; 5-aminosalicy- they identified a group of patients who experienced decreased lates, 470€/patient-year). The percentage of time in the 10- clinical activity and improved quality of life with simple drug year follow-up period that patients were prescribed aminosa- withdrawal alone (9.7% of CD patients).
licylates was 81.3% (ulcerative colitis, 83.3%; Crohn's The economic evaluation of cost data in chronic ill- disease, 77.8%). The high expenditures for aminosalicylate nesses like IBD is based on estimating the market price of any formulations was a result of the frequent use and high price of resource, for example, medication costs. Thus far, the calcu- this medication. In our cost analysis, 5-ASA medication lation of medication costs has been based on subjective cost accounted for about 37% of total medication costs in private estimates or extrapolations of annual costs on the basis of practices as well as at the University Hospital of Frankfurt. At monthly or quarterly costs. In our opinion, these costs tend to least these costs can be reduced, especially for patients with be imprecise. Furthermore, all published studies contain data Crohn's disease, if treatment were to be adjusted to national on the costs of therapy during the preinfliximab era.3,4,7,10,11 and international treatment guidelines.
The present study aimed to quantitate the true costs of med- It should be kept in mind that the presented data cannot ication prescribed in the study patient cohort. Thus, the costs be generalized for the whole of Germany, as the Rhein-Main of electronically prescribed medications were calculated. The region has specific features compared with those of rural most important prerequisites for being included in calculation areas in northern or eastern Germany. However, the present of patients' prescriptions were (1) that prescriptions for an study could provide a basis for further nationwide studies.
individual patient came exclusively from one practice and (2) In summary, the present study is the first to show the that there was available a complete data set for the study treatment reality of IBD patients in central Germany. The period. However, electronic prescription software is not in presented user-friendly, internet-based documentation sys- use in either of the participating hospitals. Thus, the data on tem, which provides the possibility of daily updates and patients treated at the University Hospital of Frankfurt were exchange of information, makes an important contribution to recorded retrospectively. Surprisingly, despite the differences the networking of private practices and hospitals and facili- Blumenstein et al Inflamm Bowel Dis Volume 14, Number 1, January 2008 tates efficient, successful, and satisfactory therapy for IBD Costs of ambulant care for patients with inflammatory bowel disease in patients. In addition to including more IBD patients treated in general practice. Z Gastroenterol. 2003;41:527–536.
12. Gasche C, Scholmerich J, Brynskov J, et al. A simple classification of the Rhein-Main region in our study, we aim to further im- Crohn's disease: report of the Working Party for the World Congresses plement national and international treatment guidelines in our of Gastroenterology, Vienna 1998. Inflamm Bowel Dis. 2000;6:8 –15.
system in order to level the differences in treatment habits so 13. Satsangi J, Silverberg MS, Vermeire S, Colombel JF. The Montreal classification of inflammatory bowel disease: controversies, consensus, far detected and to assure a high-quality standard of practice.
and implications. Gut. 2006;55:749 –753.
14. Bjerrum L, Sogaard J, Hallas J, Kragstrup J. Polypharmacy: correlations with sex, age and drug regimen. A prescription database study. EurJ Clin Pharmacol. 1998;54:197–202.
The authors thank the study nurses P. Altmann, D.
15. Goossens ME, Rutten-van Molken MP, Vlaeyen JW, van der Linden Bratic, L. Fouta, E. Kretzschmar, M. Paterakis, D. Rompel, SM. The cost diary: a method to measure direct and indirect costs in N. Schieferdecker, S. Spielberg, S. Steckhan, and S. Weber cost-effectiveness research. J Clin Epidemiol. 2000;53:688 – 695.
16. Wolters FL, Van Zeijl G, Sijbrandij J, et al. Internet-based data inclusion for excellent data entry and cooperation.
in a population-based European collaborative follow-up study of inflam-matory bowel disease patients: description of methods used and analysis of factors influencing response rates. World J Gastroenterol. 2005;11:7152–7158.
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the loss of smell in a visual culture susana cámara leret the loss of smell in a visual culture susana cámara leret Fig. 1 smell can provide a new understanding of nature I would like to thank the following people for their support and guidance throughout the project: Rodrigo Camara Leret; Maria Luisa Leret Verdu from the Department of Physiology (Animal Physiology II) University Complutense of Madrid, Spain; Jan Frits Veldkamp PhD from the National Herbarium of the Netherlands; Frans Krens PhD and Maarten A. Jongsma PhD from Plant Breeding International, Wageningen University and Research Center, The Netherlands; Yehuda Shoenfeld, Head of Department of Medicine B and Center for Autoimmune Diseases, Sheba Medical Center, Tel-Aviv, Israel; Professor Fabrizio Benedetti from the Department of Neuroscience, University of Turin Medical School, Italy; Andrea Evers, Investigator Clinical Psychology at the Medisch Centrum Radboud Universiteit Nijmegen, The Netherlands; Dirk Hermans from the Center for the Psychology of Learning and Experimental Psychopathology, University of Leuven, Belgium; Professor Berry M. Spruijt, Ethology and Welfare, Department of Biology, Faculty of Beta Sciences, University of Utrecht, The Netherlands.

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