Excess costs from functional somatic syndromes in Germany — An analysis using entropy balancing
Introduction
Functional somatic syndromes (FSS) are characterised by patterns of persistent or recurrent distressing bodily complaints for which even intensive diagnostic efforts do not reveal sufficient explanatory peripheral organ pathology [1]. Studies conducted in European countries estimated FSS to have a 12-month prevalence of about 5% [2]. The desire to find explanations for the experienced complaints leads to doctor hopping and inadequate health care use. Compared to persons without FSS, patients with FSS are assumed to have higher direct health care costs due to increased health seeking behaviour [3] and higher indirect costs due to absence from work or reduced productivity [4]. Associations between FSS and direct as well as indirect costs have been analysed in some studies, although evidence from Germany is rare [5], [6]. Two studies compared costs in FSS patients to costs in patients with different mental disorders as well as to average per capita expenditures of German public health insurance companies [4], [7]. In a previous study, we estimated overall costs of somatoform disorders in patients with mild, moderate and severe somatic symptom severity (SSS) according to the PHQ-15 [8]. Consequently, costs of patients with FSS have either been compared to patients with another disease or expenses of the general population. This is a methodological weakness, as the general population also includes patients with cancer or very costly diseases. Hence, the differences in costs cannot be completely attributed to FSS. Yet, to our knowledge, none of the studies conducted in Germany estimated costs solely attributable to FSS, i.e. disorder-specific excess costs. Our paper adds to the methodology of cost calculation in comparing patients with FSS to very similar persons that do not have FSS.
Thus, in this study, we took an alternative approach and estimated disorder-specific excess costs of FSS. The rationale behind this is as follows: Attributing all direct and indirect costs incurred in affected patients to FSS overestimates costs of the disorder, since the patient may have been treated for other diseases or injuries independent of the FSS, e.g. a flu or a broken leg. On the other hand, assessing only utilization of mental health care, such as visits to psychotherapists or stays in psychiatric hospitals, underestimates costs from FSS, since extensive use of somatic health care is a characteristic of these patients. For this reason, a comparison of costs between a group of persons with FSS and a group of similar persons without FSS is required. If persons of both groups differ only regarding the presence of a FSS, the excess in costs can be attributed to the FSS. Obviously, this works only on the theoretical level, since it is impossible to match a group with FSS to an identical group without FSS. Nevertheless, we tried to create this theoretical state in applying the method of entropy balancing to calculate disorder-specific excess costs in FSS patients.
Section snippets
Study design and samples
We combined two datasets from different samples to estimate excess costs. Data on FSS patients were obtained from a cluster randomized controlled trial to evaluate a specific psychosomatic short-term group intervention for adult patients with FSS in primary care (speciAL: ISRCTN55280791). For our study, we used the baseline data that contained information on 6-month health care utilization prior to the intervention collected between 2007 and 2009. Design, recruitment process, treatment manual
Results
Table 3 presents the first and second moment of all covariates that were included in the balancing process before and after conducting EB. In comparing the covariates of the control group to the covariates of the FSS group, both before and after EB, we can see that EB attained a good covariate balance.
Table 4 presents the estimated excess in costs between all FSS patients and the healthy control group. Furthermore, Table 4 presents the estimated excess in costs between FSS patients with mild,
Discussion
This study compared 6-month direct and indirect costs in FSS patients to a control group of the general adult population without FSS in Germany. FSS were of major importance in the outpatient sector, where costs in the patient group were significantly higher than costs in the control group. Further, we found significantly higher indirect costs due to absenteeism in FSS patients with severe SSS.
FSS patients differed significantly from the control group regarding 6-month costs of outpatient
Conclusion
We can conclude that FSS patients had significantly higher outpatient costs than the control group. Further, the excess in outpatient physician costs was significantly higher in FSS patients with a higher level of SSS. In analysing rehabilitation and hospital costs according to SSS, we did not find significant differences between FSS patients and the control group. Indirect costs proved to be significantly higher in FSS patients with severe SSS. These findings suggested that FSS were of major
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