Catherine Kastanioti

Background: The COVID-19 pandemic disrupted healthcare systems, disproportionately affecting individuals with rare diseases. This study explores the health-related quality of life and financial burden in the post-pandemic context among children with Duchenne Muscular Dystrophy and their families in Greece, providing insights into health system performance. Methods: A multicenter, cross-sectional study was conducted in two neuromuscular clinics in Greece. Fifty families (response rate 67%) completed standardized quality of life instruments (PedsQL™ 4.0 Generic Core Scale; PedsQL™ 3.0 DMD Module) and a socioeconomic questionnaire. Descriptive and correlation analyses assessed associations between functional status, financial strain, and psychosocial indicators. Results: Children with Duchenne Muscular Dystrophy reported moderate-to-severe reductions in physical and emotional well-being, and substantial out-of-pocket expenditures. Families with greater financial strain or wheelchair-dependent children had significantly lower health-related quality of life scores. Insurance coverage was positively associated with emotional and psychosocial functioning. Conclusions: Greek families living with Duchenne Muscular Dystrophy continue to face significant financial and psychosocial challenges in the post-pandemic period. While the cross-sectional design does not allow causal attribute to COVID-19 pandemic, the results underscore the need to strengthen financial protection, coordinated multidisciplinary care, and equitable access to support services for rare disease management.

Background. The COVID-19 pandemic disrupted healthcare delivery systems worldwide, disproportionately affecting individuals with chronic and rare diseases. This study explores the status in the post-pandemic context on the quality of life and financial burden experienced by children with Duchenne Muscular Dystrophy and their families in Greece, a context that reflects broader challenges in healthcare system performance during crises. Methods. A multicenter, cross-sectional study was conducted across two neuromuscular clinics in Greece. Of 75 eligible families, 50 (response rate 67%) participated through structured interviews with patients and caregivers, using standardized instruments, the PedsQL™ 4.0 Generic Core Scale and the PedsQL™ 3.0 DMD Module to assess health-related quality of life, and a socioeconomic questionnaire to evaluate caregiving burden and out-of-pocket expenditures. Descriptive statistics and correlation analyses were applied to examine associations between functional status, financial strain, and psychosocial indicators. Results. Participants reported moderate-to-severe impacts on physical and emotional well-being, alongside significant caregiving and financial burdens. Households incurred substantial out-of-pocket costs related to home care and non-reimbursed services. Health-related quality of life outcomes were inversely associated with care-related financial stress and functional limitations. Conclusions. The findings highlight ongoing systemic challenges faced by families living with Duchenne Muscular Dystrophy in Greece during the post-pandemic period. While the cross-sectional design does not allow causal attribution to COVID-19 pandemic, the results provide valuable insights into current health system pressures and areas where financial protection and coordinated care pathways could be strengthened.

Objectives: To determine the prescribing prevalence of epidermal growth factor receptor (EGFR)- and anaplastic lymphoma kinase (ALK)-positive non-small cell lung cancer (NSCLC) patients in Greece and examine patterns of first-line tyrosine kinase inhibitor (TKI) utilization and associated treatment costs using nationwide real-world data. Methods: A retrospective analysis of the national e-prescription database was performed, identifying patients initiating first-line treatment (FLT) for EGFR- or ALK-positive NSCLC between 1 January 2020 and 31 December 2022. Demographic characteristics, prescribing prevalence data, drug utilization patterns, total annual drug expenditures, and per patient treatment costs were assessed. All statistical analyses were performed using the statistical software SPSS-v.29. Results: Overall, 1188 EGFR-positive (mean age of 70.93 ± 11.6) and 246 (mean age of 64.26 ± 12.6) ALK-positive NSCLC patients initiated FLT during the three-year study period. EGFR mutations were slightly more common in females (53%), peaking in the 70–79 age group (35%). ALK mutations were also more common among females (52%), particularly within the 60–79 age group. In EGFR-positive patients, osimertinib usage markedly increased from 41% in 2020 to 63% in 2022, primarily displacing afatinib (from 32% to 22%) and erlotinib (from 24% to 14%), with gefitinib prescriptions falling below 2%. Among ALK-positive patients, crizotinib utilization declined significantly from 60% to 16%, whereas alectinib increased to 59% by 2022. Annual EGFR-related total drug expenditures remained stable (€11.5 million in 2020 vs. €11.9 million in 2022), driven primarily by increasing osimertinib usage. Similarly, ALK-related annual drug expenditures showed stability, with costs predominantly attributed to rising alectinib utilization. Conclusions: This nationwide analysis highlights the rapid adoption of second- and third-generation TKIs for EGFR- and ALK-positive NSCLC in Greece, reflecting evolving clinical practice patterns. Although the target patient populations are relatively small, the associated economic burden is considerable. To ensure long-term sustainability of the Greek healthcare system, policymakers should critically assess the cost-effectiveness of these innovative therapies and align resource allocation with value-based care principles.

Background: The quality of decision-making processes is increasingly recognized as critical to public trust and policy sustainability. Objectives: This narrative review aims to identify and describe process-focused decision support models (DSMs) applied in pharmaceutical policy, and to examine their potential contributions to improving procedural quality in decisions related to pricing, reimbursement, and access to medicines. Methods: Relevant peer-reviewed and gray literature published between 2000 and 2025 was considered, drawing from key databases (e.g., PubMed and Scopus) and international policy reports (e.g., WHO, ISPOR, and HTA agencies). Studies were included if they provided insights into DSMs addressing at least one dimension of decision process quality. Results: Findings are synthesized narratively and organized by tool type, application context, and key quality dimensions. Frequently referenced tools included the Quality of Decision-Making Orientation Scheme (QoDoS), WHO-INTEGRATE, and AGREE II. QoDoS emerged as the only tool applied across regulatory, HTA, and industry settings, evaluating both individual- and organizational-level practices. WHO-INTEGRATE highlighted equity and legitimacy considerations but lacked a structured format. Overall, most tools demonstrated benefits in promoting internal consistency, transparency, and stakeholder engagement; however, their adoption remains limited, especially in low- and middle-income countries. Conclusions: Process-focused DSMs offer promising avenues for enhancing transparency, consistency, and legitimacy in pharmaceutical policy. Further exploration is needed to standardize evaluation approaches and expand the use of DSMs in diverse health systems.

The aim of this paper is to analyse the phenomenon of the shadow economy in the individual entrepreneurship sector of human-to-human services (H2H) during and after the period of the COVID-19 pandemic in Greece. The study demonstrates income concealment ranging from 41.46% to 59.14% in the individual entrepreneurship sector until 2017. In fact, until the emergence of the COVID-19 pandemic in 2019, the tax evasion rate reached 65%. However, since 2020, with the onset of the pandemic, there has been a reduction of 56% of the phenomenon in this sector After the end of the pandemic, tax evasion continues to decline, approaching 52% in 2022, showing a steady downward trend. This paper notes that individual entrepreneurship was not significantly affected in terms of income, which in 2020 reached €4.9 billion depicting an increase of 7% compared to 2019 (€4.6 billion), while in 2021 (€5.8 billion) and 2022 (€6.9 billion), when the economy starts to normalise after the end of the pandemic, the income increase from individual entrepreneurship soared to 19% and 17% respectively. The survey also showed a significant decrease in the consumption of clothing and household durables in 2020, by 27.43% and 15.81% respectively, a significant decrease in entertainment expenditure by 27.43% and a significant decrease in transport expenditure by 16.81%. Households significantly reduce the resources allocated to hotels and restaurants by 36.48% in 2020. Finally, expenditure on food, housing, water and energy recorded a small change, showing a stable trend that was not significantly affected by the health crisis. However, after the end of the pandemic, total household consumption expenditure increased by 9.11%.

Objective: This systematic literature review aimed to summarize the economic burden of lung cancer in Greece, identify current data gaps, and support the design of future real-world studies. Methods: A systematic search of studies published in English on the cost of lung cancer was performed in MEDLINE-(PubMed), Scopus, and ScienceDirect. The databases were searched until September 2024, and records were screened based on our eligibility criteria. After conducting the initial literature search, the abstracts and full texts of the identified studies were reviewed and evaluated for inclusion based on predefined criteria. Data from the selected studies were then extracted into a standardized form and subsequently synthesized. Results: Seven studies were included in this review. The reported burden was sourced from hospital data and categorized as direct and indirect costs. Most studies (n = 6) reported direct costs, with one study reporting both direct and indirect costs. The total direct medical cost per patient increased from approximately EUR 16,000 in 2015 to EUR 58,974 in 2023, with drug acquisition costs being the key driver of the total direct cost. Additionally, the cost of end-of-life care during the final six months of a patient’s life was estimated to range from EUR 6786 to EUR 7665 per patient, with pharmaceutical costs comprising the largest proportion of the total cost. One study also reported that indirect costs were considerably higher for patients than for family caregivers. Conclusion: The economic burden of lung cancer has increased substantially over the past decade in Greece. The present systematic review emphasizes the critical need for comprehensive real-world studies on the economic burden of lung cancer in Greece. Addressing the current gaps holistically will yield invaluable insights for policymakers and stakeholders.

The paper attempts to measure and report the extent and magnitude of Shadow Economy in Real Estate in Greece. The present research analyzed the sale prices of residential real estate for the years 2018 and 2022. In the first phase, the sale price per square meter was determined for the houses for sale, in particular apartments and detached houses, through websites of real estate ads for sale. In the second phase, the average sale price per square meter was determined for the same years, through the analysis of sales contracts as they are recorded in detail in the application of the Greek Ministry of Finance, the "Register of Real Estate Transfer Values". The comparison that followed showed that the percentage difference between these two figures is related to the shadow economy. From 2018 to 2022, the shadow economy in real estate shows a clear trend of decline, although it is still high. From 49.38% estimated to hide the real sale value in 2018, it decreased to 39.48% in 2022, not counting any discounts made. In 2018 the amount of the declaration of actual sales values was estimated at € 614.6 million and in 2022 at € 728.7 million. At the same time, a quantitative survey was conducted on a random sample of 715 people in order to estimate the percentage of achieving a discount between the buyer and seller with a period of the last five years. The conclusion is that the discount rate in the majority ranges up to 5% especially in recent years, while rates up to 10% are noted on old properties. The above amount of deduction must be taken into account for the final determination of the estimated shadow economy in the real estate market. Also identified were those properties that were sold with a significant difference from their objective value, i.e. over € 100,000.00 and over € 200,000.00, an important indication for "laundering" non-taxable and / or dirty money. In 2018, money laundering was estimated at €192.5 million to €231 million and in 2022 at €227 million to €303 million.

This study presents a novel statistical framework for evaluating the social and economic impact of delays in the reimbursement of innovative medicines. With the growing importance of timely access to advanced therapies, particularly in managing chronic diseases, we develop a model that quantifies social loss in terms of life years, productivity, productivity cost and overall well-being. The framework integrates several key factors, including years of life lost, years of potential productive life lost, deaths, delays in reimbursement, and cost of labor productivity losses. By providing a comprehensive assessment of the societal costs associated with delayed access, the model offers valuable insights for policymakers seeking to balance healthcare innovation with sustainability. The results emphasize the need for efficient pharmaceutical policies that reduce delays in access to innovative treatments, promote equity in healthcare, and ensure long-term system viability. This approach has broad implications for improving health outcomes and economic productivity, particularly in publicly funded healthcare systems.

Purpose: Duchenne Muscular Dystrophy (DMD) is a genetic disorder in boys’ early childhood that adversely affects the cardiac, respiratory, and skeletal muscle’s function and emotional and social functioning as aspects of health-related quality of life (HRQoL). The current study aimed to translate the disease-specific Pediatric Quality of Life Inventory™ (PedsQL™) 3.0 DMD Module into Greek to make it feasible to administer in patients with DMD for national and cross-national studies. Methods: Established guidelines, using forward-back translation were followed for the performance of the Greek translation of the PedsQL™ 3.0 DMD Module and approval was given by the creator of the instrument. The administration of the Greek version of the module took place at the patients’ organization MDA-Hellas, a non-profit association for neuromuscular disorders, to 28 participants, children with DMD (aged 8-18 years), and their caregivers. The inventory consists of a child self-report format for children aged 8 to 18 years and a caregiver proxy-report format for children ages 5 to 18 years. Results: The module encompasses four scales: 1) Daily activities (5 items), 2) Treatment (4 items), 3) Worry (6 items) and Communication (3 items). All the questions of the PedsQL™ 3.0 DMD module were translated without any major discrepancy. The results confirmed the feasibility of administering the Greek version of the PedsQL 3.0 DMD Module. It has a clear focus and is concise. The results showed that the quality of life of DMD patients from age 5 to 18 years is affected as reported by parents. Conclusion: The results showed that the translation of the Greek version of the PedsQL 3.0 Duchenne Muscular Dystrophy Module questionnaire was well perceived and accepted. It has a clear focus is comprehensive and can be used for health-related quality-of-life studies in Greek-speaking patients with Duchenne Muscular Dystrophy-DMD aged 5-18 years old.

Background & Aim: Diabetes is a chronic disease that affects nearly half a million people worldwide. Although advances in technology and medical science have made diabetes management easier today, self-care and adherence to treatment (medication, diet, exercise, etc.) remain a major challenge for diabetic patients. The purpose of this study is to study the quality of life of patients with type 2 diabetes, their levels of compliance with antidiabetic treatment, and the relationship between the two. Methods & Materials: The present work followed the quantitative approach. A well-structured and reliable questionnaire used in a previous study was distributed to patients with type 2 diabetes mellitus. The results were analysed in SPSS statistical program and the correlation between antidiabetic treatment and quality of life was examined using Pearson coefficient. Results: The study involved 165 patients with type 2 diabetes who were hospitalized at the General Hospital of Messinia. Among the dimensions of adherence to treatment, only personal care behaviour (p