Diana Sonntag

Introduction: Participation is an important dimension of healthy child development and is associated with higher self-rated health, educational attainment and civic engagement. Many children with special healthcare needs (SHCN) experience limited participation and are thus at risk for adverse health and developmental outcomes. Despite this, interventions that promote participation in healthcare are scarce. We therefore evaluate the effectiveness of a complex age- and condition-generic intervention that strengthens participation-centred care involving parents and their children with SHCN by, inter alia, assessing preferences, specifying participation goals and facilitating shared decision-making in care. Methods and analysis: In this study protocol we describe the design and procedures for an unblinded, stepped wedge, cluster randomised trial conducted in 15 German interdisciplinary healthcare facilities providing services for children aged 0–18 years with SHCN. Sites are randomised to five periods in which they switch from control to intervention condition in blocks of three. The intervention includes: (1) team training focused on participation-centred care, (2) introduction of a new software facilitating participation-focused documentation and (3) implementation support promoting the transfer of training content into routine care. Study sites deliver routine care while in the control condition. As primary outcome, the degree of perceived shared decision-making with parents (CollaboRATE^pediatric parent scale), a potential antecedent of achieving participation goals in everyday life, is assessed on one randomly selected day per week during the entire study period, directly following care appointments. We aim to sample 70 parents per study site and period. Additionally, participation of children is assessed within a closed embedded cohort with three parent and patient surveys. Intervention effectiveness will be modelled with a marginal model for correlated binary outcomes using generalised estimation equations and complete cases. A comprehensive mixed-methods process evaluation complements the effectiveness analyses.

Background: Although there is a growing number of early childhood obesity prevention programs, only a few of them are effective in the long run. Even fewer reports exist on lifetime cost-effectiveness of early prevention strategies. This paper aimed to assess the lifetime cost-effectiveness of infant feeding modification aiming at reducing risk of later obesity. Methods: The simulation model consists of two parts: (a) Model I used data from the European Childhood Obesity Project (CHOP) trial (up to 6 years) and the German Interview and Examination Survey for Children (KiGGS) (6–17 years) to evaluate BMI trajectories of infants receiving either lower protein (LP) or higher protein (HP) content formula; and (b) Model II estimated lifetime cost-effectiveness based on Model I BMI trajectories. Compared to HP formula, LP formula feeding would incur lower costs that are attributable to childhood obesity across all decades of life. Results: Our analysis showed that LP formula would be cost-effective in terms of a positive net monetary benefit (discounted 3%) as an obesity prevention strategy. For the 19% of infants fed with formula in Germany, the LP strategy would result in cost savings of € 2.5 billion. Conclusions: Our study is one of the first efforts to provide much-needed cost-effectiveness evidence of infant feeding modification, thereby potentially motivating interventionists to reassess their resource allocation.

Summary: Background: Early childhood obesity prevention is gaining increasing importance, as the prevalence of children with overweight and obesity aged 5 years and under increases worldwide. Along with understanding the effectiveness of obesity interventions, it is important to understand the cost‐effectiveness of interventions over time.Objectives: To estimate the long‐term health benefits and health care cost‐savings of reductions in BMI for the Australian population of children aged between 2 and 5 years.Methods: A proportional multistate, multiple cohort lifetable model estimated the health benefits and health care cost‐savings related to hypothetical reductions in BMI, informed by a scoping review of systematic reviews reporting the effectiveness of obesity prevention interventions in preschool aged children.Results: Results suggest significant potential for cost‐effectiveness of obesity prevention interventions in preschool‐aged children if intervention effect can be maintained. A relatively small population level reduction in BMI z‐score (−0.13 BMIz) in children aged 2 to 5 years would result in 36 496 health‐adjusted life years saved (95% uncertainty interval [UI], 30 283‐42 945) and health care cost‐savings of approximately $301 million (95% UI $234 million‐$369 million) if modelled over the lifetime.Conclusions: Scenario results highlight the importance of obesity intervention in the early years of life.

Summary: System‐based interventions are of increasing interest as they seek to modify environments (e.g. socio‐cultural system, transport system or policy system) that promote development of conditions such as obesity and its related risk factors. In our commentary, we draw attention to features of the system‐based approach that may explain the relative absence of economic evaluations of the cost‐effectiveness of these interventions, needed to guide decision‐making on which to deploy. We present and discuss potentially applicable methods and alternative approaches based on our experiences in two major system‐based interventions currently underway (in Melbourne, Australia and Gaggenau, Germany) that begin to fill this gap. We feel the issues and potential solutions outlined in this commentary are important for a broad range of stakeholders (e.g. clinicians, interventionalists, policy makers) to consider as they seek to address the issue of obesity.

Objective The increasingly high levels of overweight and obesity among the workforce are accompanied by a hidden cost burden due to losses in productivity. This study reviews the extent of indirect cost of overweight and obesity. Methods A systematic search was conducted in eight electronic databases (PubMed, Cochrane Library, Web of Science Core Collection, PsychInfo, Cinahl, EconLit and ClinicalTrial.gov). Additional studies were added from reference lists of original studies and reviews. Studies were eligible if they were published between January 2000 and June 2017 and included monetary estimates of indirect costs of overweight and obesity. The authors reviewed studies independently and assessed their quality. Results Of the 3626 search results, 50 studies met the inclusion criteria. A narrative synthesis of the reviewed studies revealed substantial costs due to lost productivity among workers with obesity. Especially absenteeism and presenteeism contribute to high indirect costs. However, the methodologies and results vary greatly, especially regarding the cost of overweight, which was even associated with lower indirect costs than normal weight in three studies. Conclusion The evidence predominantly confirms substantial short-term and long-term indirect costs of overweight and obesity in the absence of effective customised prevention programmes and thus demonstrates the extent of the burden of obesity beyond the healthcare sector.

This conceptual paper aims to illustrate the ways in which communities are able to advance health improvements on a population level. Outcome measures may include increased physical activity and healthier eating habits in particular, as well as an improved health-related quality of life and social cohesion as more generic outcomes. The paper begins by asking initial questions: Why did previous health-specific interventions only show moderate effects on an individual level and mixed effects on a population level? What is the added value of a community-based public health perspective compared to the traditional biomedical perspective when it comes to prevention? Why are we living the way we are living? Why do we eat what we eat? Why do we move the way we move? Subsequently, we illustrate the broad spectrum of contextual interventions available to communities. These can have geographical and technological as well as economic, political, normative and attitude-specific dimensions. It is shown that communities have a strong influence on health-related contexts and decision-making of adults, adolescents and children. In addition contextual characteristics, effects, mediators, moderators and consequences relevant for health can differ greatly between age groups. Both small-scale settings and overarching sectors possess physical, economic, political and sociocultural characteristics that can be proactively influenced by community decision-makers in the sense of a “health in all policies”-strategy. After presenting various interdisciplinary approaches to community-based health interventions, the manuscript closes with the following core message: Successful community-based health promotion strategies consist of multilevel – multicomponent interventions on the micro, meso and macro-level-environments.

Aim Despite the growing number of elderly cancer patients, health economic evaluations have not put enough attention on this patient group. We reflect on the current state of health economic evaluations for geriatric patients and present suggestions for improvements. Method We reviewed the scientific literature on health economic evaluations for geriatric patients in Germany and internationally. Additionally, we conducted a scoping review on cost-utility analyses on cancer treatment for older patients (> 60 years). Results The literature review resulted in eight relevant studies. Besides the paucity of economic evaluations for elderly patients, we also present quality limitations. From the literature, we identify four recommendations regarding cost calculation, geriatric assessment, patient decision-making and quality of life on how to design better economic evaluations for geriatric cancer treatment. Conclusion The demographic change requires more attention regarding elderly patients in health economics. Including patients above 70 years of age in health economic evaluations and improving cost-utility analyses will help to improve resource allocations and effective healthcare for the elderly.

The aim of this study was to quantify the magnitude of lifetime costs of overweight and obesity by socioeconomic status (SES).Differential Costs (DC)-Obesity is a new model that uses time-to-event simulation and the Markov modeling approach to compare lifetime excess costs of overweight and obesity among individuals with low, middle, and high SES. SES was measured by a multidimensional aggregated index based on level of education, occupational class, and income by using longitudinal data of the German Socioeconomic Panel (SOEP). Random-effects meta-analysis was applied to combine estimates of (in)direct costs of overweight and obesity.DC-Obesity brings attention to opposite socioeconomic gradients in lifetime costs due to obesity compared to overweight. Compared to individuals with obesity and high SES, individuals with obesity and low SES had lifetime excess costs that were two times higher (€8,526). In contrast, these costs were 20% higher in groups with overweight and high SES than in groups with overweight and low SES (€2,711).The results of this study indicate that SES may play a pivotal role in designing cost-effective and sustainable interventions to prevent and treat overweight and obesity. DC-Obesity may help public policy planners to make informed decisions about obesity programs targeted at vulnerable SES groups.

Aims: We compared predicted life‐time health‐care costs for current, never and ex‐smokers in Germany under the current set of tobacco control polices. We compared these economic consequences of the current situation with an alternative in which Germany were to implement more comprehensive tobacco control policies consistent with the World Health Organization (WHO) Framework Convention for Tobacco Control (FCTC) guidelines.Design: German EstSmoke, an adapted version of the UK EstSmoke simulation model, applies the Markov modelling approach. Transition probabilities for (re‐)currence of smoking‐related diseases were calculated from large German disease‐specific registries and the German Health Update (GEDA 2010). Estimations of both health‐care costs and effect sizes of smoking cessation policies were taken from recent German studies and discounted at 3.5%/year.Setting: Germany.Participants: German population of prevalent current, never and ex‐smokers in 2009.Measurement: Life‐time cost and outcomes in current, never and ex‐smokers.Findings: If tobacco control policies are not strengthened, the German smoking population will incur €41.56 billion life‐time excess costs compared with never smokers. Implementing tobacco control policies consistent with WHO FCTC guidelines would reduce the difference of life‐time costs between current smokers and ex‐smokers by at least €1.7 billion.Conclusions: Modelling suggests that the life‐time healthcare costs of people in Germany who smoke are substantially greater than those of people who have never smoked. However, more comprehensive tobacco control policies could reduce health‐care expenditures for current smokers by at least 4%.