Author response to “Comment on: Burden of coeliac disease in Germany: real world insights from a large retrospective health insurance claims database analysis”

Dear Editor,

We would like to express our sincere appreciation to the authors of the commentary for their interest in our study ¹ and their constructive critique. ² Their insights provide a valuable opportunity for further discussion on the healthcare costs associated with celiac disease (CeD) in Germany.

We agree with the commentary that distinguishing between incident and prevalent patients with CeD is important for understanding the disease’s economic implications. However, the limited timeframe of the available data restricts our ability to accurately identify adult CeD patients who are genuinely newly diagnosed, since most individuals with CeD are diagnosed during childhood or adolescence.^3,4 The available observation period for patients with CeD is not long enough to follow patients from childhood diagnosis until adulthood. Thus, there is a risk of misclassifying incident patients as prevalent cases, but it should be acceptable regarding the overall evaluation, since the probability of incident patients at older age groups is lower.^5,6 Given our interest in incident patients, we are currently preparing another publication focused specifically on newly diagnosed children with CeD.

Another important point raised relates to the causes of hospitalizations. Understanding whether admissions are directly related to CeD or to other conditions is important for the estimation of the financial burden of the disease. To achieve a robust assessment of CeD-related resource utilization and costs, we employed a case-control design that utilized matching based on variables such as age, sex, region of residence, and the Charlson Comorbidity Index. However, the high burden of inpatient stays may be related to specific comorbidities with a higher likelihood for diagnosing CeD (e.g., Crohn’s disease) and which were not accounted for in our matching process (as not included in the Charlson Comorbidity Index). This limitation suggests that some hospitalizations might be related to these underlying comorbidities. However, our study results indicated—though not detailed in the initial publication—that during the 5-year observation period, about 18% of patients were hospitalized with ICD-10-GM K90.0 (CeD) as a primary and about 11% as a secondary diagnosis.

The commentary also emphasizes the importance of tracking CeD-related medications. Our analysis showed that significantly more patients with CeD were prescribed selected drugs for functional gastrointestinal disorders compared to respective controls during the 5-year study period. Specifically, the prescription rates were as follows: metoclopramide (10.3% vs 7.0%), mesalazine (2.8% vs 1.0%), budesonide (2.2% vs 0.5%), mebeverine (2.1% vs 0.5%), butylscopolamine (0.7% vs 0.4%; all p < 0.01). These higher prescription rates may indicate the increased gastrointestinal symptoms and functional disorders that individuals with CeD often experience, suggesting a greater need for effective symptom management. This need for management is further evidenced by the increased number of visits to gastroenterologists (mean: 1.4 visits for CeD patients vs 0.4 visits for controls, p < 0.01).

The commentary also suggests categorizing costs by age. In our analysis, the additional mean costs for diagnosed CeD patients were as follows: €3524 (€9638 vs €6114, p = 0.02) for age group <6 years; €5381 (€10,426 vs €5045, p < 0.01) for age group 6–11 years; €5857 (€11,984 vs €6127, p < 0.01) for age group 12–17 years; €5303 (€16,989 vs €11,686, p < 0.01) for age group 18–67 years; and €5300 (€27,265 vs €21,965, p < 0.01) for age group >67 years. Detailed cost statistics can be found in Supplemental Table 1 of the publication.

Lastly, the commentary points out that examining patients’ out-of-pocket expenses, particularly for gluten-free foods, could provide a more comprehensive understanding of the economic challenges faced by individuals with CeD. We recognize that out-of-pocket expenditures play a significant additional role in the overall financial burden for patients with CeD. However, unlike in Italy, ⁷ where gluten-free foods are reimbursed by the health insurance, this is not the case in Germany. Claims data only include information on services reimbursable by the German statutory health insurance. Therefore, we cannot give exact numbers. There are valid estimates that the purchase of (strictly) gluten-free foods adds another €100–150 per person and month to these expenses. ⁷

In conclusion, we would like to thank the authors of the commentary once again for their thoughtful and constructive feedback. Their insights have highlighted several important areas for future research, particularly regarding the role of patients’ out-of-pocket expenses for gluten-free foods and their impact on the overall financial burden.

Yours sincerely

Supplemental Material

sj-docx-1-tag-10.1177_17562848251365852 – Supplemental material for Author response to “Comment on: Burden of coeliac disease in Germany: real world insights from a large retrospective health insurance claims database analysis”

Supplemental material, sj-docx-1-tag-10.1177_17562848251365852 for Author response to “Comment on: Burden of coeliac disease in Germany: real world insights from a large retrospective health insurance claims database analysis” by Bernd Bokemeyer, Leonarda Serdani-Neuhaus, Juliane Sünwoldt, Christina Dünweber, Svitlana Schnaidt and Detlef Schuppan in Therapeutic Advances in Gastroenterology