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The Role of the National Health Insurance Fund Administration in the Development of Health Economics and Health Technology Assessment in Hungary
VALUE IN HEALTH REGIONAL ISSUES 4C (2014) 6–7
Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/vhri
EDITORIAL
The Role of the National Health Insurance Fund Administration in the Development of Health Economics and Health Technology Assessment in Hungary We read with great pleasure ISPOR’s new journal, Value in Health Regional Issues, which had been devoted to the regions of Central and Eastern Europe, Western Asia, and Africa (CEEWAA) [1]. We do believe that ISPOR’s strategic decision on releasing this journal and providing space for scholars from less developed regions of the world for publishing their findings in the field of health economics and outcomes research is an excellent way for disseminating scientific outputs throughout these regions. The first CEEWAA issue of Value in Health Regional Issues provided a well-balanced overview of current research trends, capacity building, and health policy aspects of countries of the CEEWAA region. Kaló et al. [2] gave an excellent overview on the capacity building for health technology assessment (HTA) implementation in middle-income countries describing the case of Hungary. Our aim is to give a short overview on the role of the National Health Insurance Fund Administration (Országos Egészségbiztosítási Pénztár [OEP]) in the development of health economics and HTA in Hungary. A more detailed description of the Hungarian health care system can be found elsewhere [3–10]. The introduction of health economics and HTA into decision making started in Hungary in to 2001 when a nationwide public health program was developed. An important part of that complex public health initiative was the introduction of organized, nationwide cancer-screening programs for breast and cervical cancer. To explore the cost and benefits of such programs, a primary health economics analysis was performed by the working group of the National Health Insurance Fund Administration (OEP), the only health care financing agency in Hungary [11,12]. The cost-effectiveness analysis of breast cancer [13] and cervical cancer [14] found that both programs are cost-effective in Hungary from a purchaser’s point of view. After the evaluation of medical and economic considerations, an organized, nationwide breast and cervical cancer screening program was introduced in Hungary in 2002 and 2003, respectively [15,16]. These screening programs represent the first case in Hungary when the health care financing authority (OEP) performed a formal health-economics analysis for the assessment of costs and benefits of a new medical technology and the results of costeffectiveness analysis were considered during the decisionmaking process. After the introduction of the screening program, a monitoring process has been developed for continuous evaluation of the implementation of the program. The results of the monitoring process have also been published in international scientific literature and presented at ISPOR congresses [17–20].
The cost-effectiveness of colorectal cancer screening was also evaluated by the National Health Insurance Fund Administration (OEP): simultaneous application of both the guaiac-based test and the immunochemical fecal occult blood test detecting hemoglobin and albumin was compared with the no-screening strategy [21]. Colorectal cancer screening proved to be cost-effective in the Hungarian setting [22]. A small area pilot colorectal cancer screening project was introduced in the town of Ajka and surroundings in 2003 to 2004, and further monitoring was also conducted, but a nationwide colorectal screening program was still not introduced in Hungary [23–25]. Another important research topic of the Hungarian OEP is the analysis of hip fractures, including its epidemiology [26–28], burden of disease [29–32], outcomes research [33,34], and evaluation of biological therapies [35]. The OEP significantly contributed to the adoption of the directive 89/105/EEC of the Council of the European Communities on transparency in Hungary [36]. The OEP was also a facilitator for the development of guidelines for conducting economic evaluation of health care interventions in Hungary [37]. Two former board members of the National Health Insurance Fund Administration (OEP) played an important role in the development of health economics in Hungary: Csaba Dózsa, former deputy director general, and Imre Boncz, former department head. Both were the presidents of ISPOR Hungary Chapter. Andor Sebestyén, regional director of OEP, and his colleagues won the best poster presentation award at ISPOR’s Berlin congress in 2012 [38]. Hungarian researchers at universities and research institutes also prefer to conduct a detailed analysis of the nationwide data set of the National Health Insurance Fund Administration. Their research area covers pharmaceutical market analysis [39,40], cost-of- illness studies [41,42], and epidemiology [43,44]. In conclusion, we can emphasize that Hungarian National Health Insurance Fund Administration (OEP) had a significant contribution to the development of health economics and HTA in Hungary through the commitment of its staff members and leaders, by performing the first governmental health-economics evaluations in Hungary, to incorporate cost-effectiveness results into the decision-making process of new medical technologies. I am convinced that ISPOR’s new journal, Value in Health Regional Issues, will serve as a special forum for researchers from the CEEWAA region to increase their activity in scientific publications.
Source of financial support: The author has no other financial relationships to disclose.
VALUE IN HEALTH REGIONAL ISSUES 4C (2014) 6–7
Acknowledgment Dr. Ferenc Oberfrank was a former secretary of state (1999–2000) at the Ministry of Health and director general (2001–2002) of the National Health Insurance Fund Administration (OEP) in Hungary.
Ferenc Oberfrank, MD Hungarian Academy of Sciences (MTA), Institute of Experimental Medicine (IEM) Budapest, Hungary
2212-1099/$36.00 – see front matter Copyright & 2014, International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. http://dx.doi.org/10.1016/j.vhri.2014.02.011 R EF E R EN CE S
[1] Boncz I, Kalo Z, Mohamed Izham MI, Greenberg D. Further steps in the development of pharmaco-economics, outcomes research and health technology assessment in Central and Eastern Europe, Western Asia and Africa. Value Health Regional 2013;2:169–70. [2] Kaló Z, Bodrogi J, Boncz I, et al. Capacity building for HTA implementation in middle income countries: the case of Hungary. Value Health Regional 2013;2:264–6. [3] Gaal P, Szigeti S, Csere M, et al. Hungary health system review. Health Syst Transit 2011;13:1–266. [4] Boncz I, Nagy J, Sebestyen A, Korosi L. Financing of health care services in Hungary. Eur J Health Econ 2004;5:252–8. [5] Boncz I, Sebestyen A. Financial deficits in the health services of the UK and Hungary. Lancet 2006;368:917–8. [6] Boncz I, Dozsa C, Kalo Z, et al. Development of health economics in Hungary between 1990-2006. Eur J Health Econ 2006;7(S1):4–6. [7] Betlehem J, Boncz I, Kriszbacher I, et al. The export of nurses from Europe to the United States. Am J Public Health 2007;97:2119. [8] Szócska MK, Réthelyi JM, Normand C. Managing healthcare reform in Hungary: challenges and opportunities. BMJ 2005;331:231–3. [9] Kriszbacher I, Olah A, Bodis J, Boncz I. Health sciences research in Hungary. CMAJ 2007;176:809–12. [10] Boncz I, Sebestyen A. Health services research in Hungary. Med J Australia 2006;184:646–7. [11] Boncz I, Sebestyén A, Pál M, et al. Health economics analysis of cervical cancer screening. Orv Hetil 2003;144:713–7. [12] Boncz I, Sebestyén A, Gulácsi L, et al. Health economics analysis of breast cancer screening. Magy Onkol 2003;47:149–54. [13] Boncz I. Organized nationwide breast cancer screening programme was introduced in Hungary in 2002. Swiss Med Wkly 2006;136:328. [14] Boncz I. Prevention of cervical cancer in low-resource settings. JAMA 2006;295:1248. [15] Boncz I, Sebestyen A, Dobrossy L, et al. The organization and results of first screening round of the Hungarian nationwide organised breast cancer screening programme. Ann Oncol 2007;18:795–9. [16] Boncz I, Sebestyen A, Ember I. Organized, nationwide cervical cancer screening programme in Hungary. Gynecol Oncol 2007;106:272–3. [17] Vokó Z, Nagyjánosi L, Margitai B, et al. Modeling cost-effectiveness of cervical cancer screening in Hungary. Value Health 2012;15:39–45. [18] Kovács A, Döbrössy L, Budai A, et al. Cervical screening in Hungary: why does the “English model” work but the “Hungarian model” does not? Eur J Gynaecol Oncol 2008;29:5–9. [19] Boncz I, Sebestyen A, Pinter I, et al. The effect of an organized, nationwide breast cancer screening programme on non-organized mammography activities. J Med Screen 2008;15:14–7.
7
[20] Boncz I, Sebestyen A, Pinter I, et al. Age-group specific gap between treatment cost of and mortality due to breast and colorectal cancer. J Clin Oncol 2007;25:4501–2. [21] Boncz I, Sebestyén A, Dózsa C, et al. Health economics analysis of colorectal screening. Magy Onkol 2004;48:111–5. [22] Boncz I, Sebestyen A, Dobrossy L, Otto S. The role of immunochemical testing for colorectal cancer. Lancet Oncol 2006;7:363–4. [23] Csonka C, Molnár C, Németh M, Ottó S. Results of and experinces with colorectal screening in town Ajka. Magy Onkol 2004;48(Suppl. 3):29. [24] Boncz I, Brodszky V, Péntek M, et al. The disease burden of colorectal cancer in Hungary. Eur J Health Econ 2010;10(Suppl.1): S35–40. [25] Boncz I, Németh M, Orosz E, et al. FIT performance in early-stage colorectal cancer–letter. Cancer Epidemiol Biomarkers Prev 2011;20:1562. [26] Sebestyén A, Tóth F, Sándor J, et al. Correlation between risk factors and subsequent surgical management following internal fixation of intracapsular femoral neck fractures in young adults. Eur J Trauma Emerg Surg 2011;37:503–10. [27] Péntek M, Horváth CS, Boncz I, et al. Epidemiology of osteoporosis related fractures in Hungary by the nationwide health insurance database, 1999-2003. Osteoporos Int 2008;19:243–9. [28] Sebestyén A, Boncz I, Tóth F, et al. Correlation between risk factors and mortality in elderly patients with femoral neck fracture with 5-year follow-up. Orv Hetil 2008;149:493–503. [29] Sebestyén A, Boncz I, Nyárády J. Analysis of health insurance costs in cases of patients under 60 years old with medial femoral neck fracture treated primarily with screw fixation or hip replacement. Orv Hetil 2006;147:1129–35. [30] Sebestyén A, Boncz I. The separate or combined evaluation of comorbidities have a different effect on the role of surgical delay on 1 year mortality. Ind J Orthop 2011;45:481–2. [31] Sebestyen A, Boncz I, Sandor J, Nyarady J. Response to an article in the June 2006 issue of Medical Care. Med Care 2006;44:1148. [32] Molics B, Kránicz J, Schmidt B, et al. Utilization of physiotherapy services in case of trauma disorders of the lower extremity in the outpatient care. Orv Hetil 2013;154:985–92. [33] Sebestyén A, Boncz I, Tóth F. Intra-operative femoral head vascularity assessment: an innovative and simple technique. Ind J Orthop 2012;46:114–5. [34] Sebestyen A, Boncz I, Sandor J, Nyarady J. Effect of surgical delay on early mortality in patients with femoral neck fracture. Int Orthop 2008;32:375–9. [35] Laki J, Mónok G, Pálosi M, Gajdácsi JZ. Economical aspect of biological therapy in inflammatory conditions in Hungary. Expert Opin Biol Ther 2013;13:327–37. [36] Dozsa C, Borcsek B, Boncz I, et al. Experiences of adoption of the directive 89/105/EEC of the council of the European communities on transparency in Hungary. Italian J Pub Health 2005;3(Suppl.1): 139. [37] Ministry of Health, Social and Family Affairs. Methodological guidelines for conducting economic evaluation of health care interventions in Hungary. J Ministry Health Soc Family Affairs 2002;52:1314. [38] Sebestyén A, Gajdácsi J, Patzai B, et al. Seasonal periodicity of secondary hip replacement after femoral neck fractures with reduction internal screw fixation. Value Health 2012;15:A403. [39] Kalo Z, Abonyi-Toth Z, Bartfai Z, Voko Z. Pitfalls associated with the therapeutic reference pricing practice of asthma medication. BMC Pulm Med 2012;12:35. [40] Kaló Z, Muszbek N, Bodrogi J, Bidló J. Does therapeutic reference pricing always result in cost-containment? The Hungarian evidence. Health Policy 2007;80:402–12. [41] Péntek M, Gulácsi L, Rózsa C, et al. Health status and costs of ambulatory patients with multiple sclerosis in Hungary. Ideggyogy Sz 2012;65(9–10):316–24. [42] Minier T, Péntek M, Brodszky V, et al. Cost-of-illness of patients with systemic sclerosis in a tertiary care centre. Rheumatology (Oxford) 2010;49:1920–8. [43] Csoboth I, Matyus A, Gabara K, Boncz I. Time of taking aspirin can have an effect on the frequency of occurrence of stroke. Chin Med J 2009;122:1119. [44] Kriszbacher I, Koppan M, Bodis J. Inflammation, atherosclerosis, and coronary artery disease. N Engl J Med 2005;353:429–30.
Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/vhri
EDITORIAL
The Role of the National Health Insurance Fund Administration in the Development of Health Economics and Health Technology Assessment in Hungary We read with great pleasure ISPOR’s new journal, Value in Health Regional Issues, which had been devoted to the regions of Central and Eastern Europe, Western Asia, and Africa (CEEWAA) [1]. We do believe that ISPOR’s strategic decision on releasing this journal and providing space for scholars from less developed regions of the world for publishing their findings in the field of health economics and outcomes research is an excellent way for disseminating scientific outputs throughout these regions. The first CEEWAA issue of Value in Health Regional Issues provided a well-balanced overview of current research trends, capacity building, and health policy aspects of countries of the CEEWAA region. Kaló et al. [2] gave an excellent overview on the capacity building for health technology assessment (HTA) implementation in middle-income countries describing the case of Hungary. Our aim is to give a short overview on the role of the National Health Insurance Fund Administration (Országos Egészségbiztosítási Pénztár [OEP]) in the development of health economics and HTA in Hungary. A more detailed description of the Hungarian health care system can be found elsewhere [3–10]. The introduction of health economics and HTA into decision making started in Hungary in to 2001 when a nationwide public health program was developed. An important part of that complex public health initiative was the introduction of organized, nationwide cancer-screening programs for breast and cervical cancer. To explore the cost and benefits of such programs, a primary health economics analysis was performed by the working group of the National Health Insurance Fund Administration (OEP), the only health care financing agency in Hungary [11,12]. The cost-effectiveness analysis of breast cancer [13] and cervical cancer [14] found that both programs are cost-effective in Hungary from a purchaser’s point of view. After the evaluation of medical and economic considerations, an organized, nationwide breast and cervical cancer screening program was introduced in Hungary in 2002 and 2003, respectively [15,16]. These screening programs represent the first case in Hungary when the health care financing authority (OEP) performed a formal health-economics analysis for the assessment of costs and benefits of a new medical technology and the results of costeffectiveness analysis were considered during the decisionmaking process. After the introduction of the screening program, a monitoring process has been developed for continuous evaluation of the implementation of the program. The results of the monitoring process have also been published in international scientific literature and presented at ISPOR congresses [17–20].
The cost-effectiveness of colorectal cancer screening was also evaluated by the National Health Insurance Fund Administration (OEP): simultaneous application of both the guaiac-based test and the immunochemical fecal occult blood test detecting hemoglobin and albumin was compared with the no-screening strategy [21]. Colorectal cancer screening proved to be cost-effective in the Hungarian setting [22]. A small area pilot colorectal cancer screening project was introduced in the town of Ajka and surroundings in 2003 to 2004, and further monitoring was also conducted, but a nationwide colorectal screening program was still not introduced in Hungary [23–25]. Another important research topic of the Hungarian OEP is the analysis of hip fractures, including its epidemiology [26–28], burden of disease [29–32], outcomes research [33,34], and evaluation of biological therapies [35]. The OEP significantly contributed to the adoption of the directive 89/105/EEC of the Council of the European Communities on transparency in Hungary [36]. The OEP was also a facilitator for the development of guidelines for conducting economic evaluation of health care interventions in Hungary [37]. Two former board members of the National Health Insurance Fund Administration (OEP) played an important role in the development of health economics in Hungary: Csaba Dózsa, former deputy director general, and Imre Boncz, former department head. Both were the presidents of ISPOR Hungary Chapter. Andor Sebestyén, regional director of OEP, and his colleagues won the best poster presentation award at ISPOR’s Berlin congress in 2012 [38]. Hungarian researchers at universities and research institutes also prefer to conduct a detailed analysis of the nationwide data set of the National Health Insurance Fund Administration. Their research area covers pharmaceutical market analysis [39,40], cost-of- illness studies [41,42], and epidemiology [43,44]. In conclusion, we can emphasize that Hungarian National Health Insurance Fund Administration (OEP) had a significant contribution to the development of health economics and HTA in Hungary through the commitment of its staff members and leaders, by performing the first governmental health-economics evaluations in Hungary, to incorporate cost-effectiveness results into the decision-making process of new medical technologies. I am convinced that ISPOR’s new journal, Value in Health Regional Issues, will serve as a special forum for researchers from the CEEWAA region to increase their activity in scientific publications.
Source of financial support: The author has no other financial relationships to disclose.
VALUE IN HEALTH REGIONAL ISSUES 4C (2014) 6–7
Acknowledgment Dr. Ferenc Oberfrank was a former secretary of state (1999–2000) at the Ministry of Health and director general (2001–2002) of the National Health Insurance Fund Administration (OEP) in Hungary.
Ferenc Oberfrank, MD Hungarian Academy of Sciences (MTA), Institute of Experimental Medicine (IEM) Budapest, Hungary
2212-1099/$36.00 – see front matter Copyright & 2014, International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. http://dx.doi.org/10.1016/j.vhri.2014.02.011 R EF E R EN CE S
[1] Boncz I, Kalo Z, Mohamed Izham MI, Greenberg D. Further steps in the development of pharmaco-economics, outcomes research and health technology assessment in Central and Eastern Europe, Western Asia and Africa. Value Health Regional 2013;2:169–70. [2] Kaló Z, Bodrogi J, Boncz I, et al. Capacity building for HTA implementation in middle income countries: the case of Hungary. Value Health Regional 2013;2:264–6. [3] Gaal P, Szigeti S, Csere M, et al. Hungary health system review. Health Syst Transit 2011;13:1–266. [4] Boncz I, Nagy J, Sebestyen A, Korosi L. Financing of health care services in Hungary. Eur J Health Econ 2004;5:252–8. [5] Boncz I, Sebestyen A. Financial deficits in the health services of the UK and Hungary. Lancet 2006;368:917–8. [6] Boncz I, Dozsa C, Kalo Z, et al. Development of health economics in Hungary between 1990-2006. Eur J Health Econ 2006;7(S1):4–6. [7] Betlehem J, Boncz I, Kriszbacher I, et al. The export of nurses from Europe to the United States. Am J Public Health 2007;97:2119. [8] Szócska MK, Réthelyi JM, Normand C. Managing healthcare reform in Hungary: challenges and opportunities. BMJ 2005;331:231–3. [9] Kriszbacher I, Olah A, Bodis J, Boncz I. Health sciences research in Hungary. CMAJ 2007;176:809–12. [10] Boncz I, Sebestyen A. Health services research in Hungary. Med J Australia 2006;184:646–7. [11] Boncz I, Sebestyén A, Pál M, et al. Health economics analysis of cervical cancer screening. Orv Hetil 2003;144:713–7. [12] Boncz I, Sebestyén A, Gulácsi L, et al. Health economics analysis of breast cancer screening. Magy Onkol 2003;47:149–54. [13] Boncz I. Organized nationwide breast cancer screening programme was introduced in Hungary in 2002. Swiss Med Wkly 2006;136:328. [14] Boncz I. Prevention of cervical cancer in low-resource settings. JAMA 2006;295:1248. [15] Boncz I, Sebestyen A, Dobrossy L, et al. The organization and results of first screening round of the Hungarian nationwide organised breast cancer screening programme. Ann Oncol 2007;18:795–9. [16] Boncz I, Sebestyen A, Ember I. Organized, nationwide cervical cancer screening programme in Hungary. Gynecol Oncol 2007;106:272–3. [17] Vokó Z, Nagyjánosi L, Margitai B, et al. Modeling cost-effectiveness of cervical cancer screening in Hungary. Value Health 2012;15:39–45. [18] Kovács A, Döbrössy L, Budai A, et al. Cervical screening in Hungary: why does the “English model” work but the “Hungarian model” does not? Eur J Gynaecol Oncol 2008;29:5–9. [19] Boncz I, Sebestyen A, Pinter I, et al. The effect of an organized, nationwide breast cancer screening programme on non-organized mammography activities. J Med Screen 2008;15:14–7.
7
[20] Boncz I, Sebestyen A, Pinter I, et al. Age-group specific gap between treatment cost of and mortality due to breast and colorectal cancer. J Clin Oncol 2007;25:4501–2. [21] Boncz I, Sebestyén A, Dózsa C, et al. Health economics analysis of colorectal screening. Magy Onkol 2004;48:111–5. [22] Boncz I, Sebestyen A, Dobrossy L, Otto S. The role of immunochemical testing for colorectal cancer. Lancet Oncol 2006;7:363–4. [23] Csonka C, Molnár C, Németh M, Ottó S. Results of and experinces with colorectal screening in town Ajka. Magy Onkol 2004;48(Suppl. 3):29. [24] Boncz I, Brodszky V, Péntek M, et al. The disease burden of colorectal cancer in Hungary. Eur J Health Econ 2010;10(Suppl.1): S35–40. [25] Boncz I, Németh M, Orosz E, et al. FIT performance in early-stage colorectal cancer–letter. Cancer Epidemiol Biomarkers Prev 2011;20:1562. [26] Sebestyén A, Tóth F, Sándor J, et al. Correlation between risk factors and subsequent surgical management following internal fixation of intracapsular femoral neck fractures in young adults. Eur J Trauma Emerg Surg 2011;37:503–10. [27] Péntek M, Horváth CS, Boncz I, et al. Epidemiology of osteoporosis related fractures in Hungary by the nationwide health insurance database, 1999-2003. Osteoporos Int 2008;19:243–9. [28] Sebestyén A, Boncz I, Tóth F, et al. Correlation between risk factors and mortality in elderly patients with femoral neck fracture with 5-year follow-up. Orv Hetil 2008;149:493–503. [29] Sebestyén A, Boncz I, Nyárády J. Analysis of health insurance costs in cases of patients under 60 years old with medial femoral neck fracture treated primarily with screw fixation or hip replacement. Orv Hetil 2006;147:1129–35. [30] Sebestyén A, Boncz I. The separate or combined evaluation of comorbidities have a different effect on the role of surgical delay on 1 year mortality. Ind J Orthop 2011;45:481–2. [31] Sebestyen A, Boncz I, Sandor J, Nyarady J. Response to an article in the June 2006 issue of Medical Care. Med Care 2006;44:1148. [32] Molics B, Kránicz J, Schmidt B, et al. Utilization of physiotherapy services in case of trauma disorders of the lower extremity in the outpatient care. Orv Hetil 2013;154:985–92. [33] Sebestyén A, Boncz I, Tóth F. Intra-operative femoral head vascularity assessment: an innovative and simple technique. Ind J Orthop 2012;46:114–5. [34] Sebestyen A, Boncz I, Sandor J, Nyarady J. Effect of surgical delay on early mortality in patients with femoral neck fracture. Int Orthop 2008;32:375–9. [35] Laki J, Mónok G, Pálosi M, Gajdácsi JZ. Economical aspect of biological therapy in inflammatory conditions in Hungary. Expert Opin Biol Ther 2013;13:327–37. [36] Dozsa C, Borcsek B, Boncz I, et al. Experiences of adoption of the directive 89/105/EEC of the council of the European communities on transparency in Hungary. Italian J Pub Health 2005;3(Suppl.1): 139. [37] Ministry of Health, Social and Family Affairs. Methodological guidelines for conducting economic evaluation of health care interventions in Hungary. J Ministry Health Soc Family Affairs 2002;52:1314. [38] Sebestyén A, Gajdácsi J, Patzai B, et al. Seasonal periodicity of secondary hip replacement after femoral neck fractures with reduction internal screw fixation. Value Health 2012;15:A403. [39] Kalo Z, Abonyi-Toth Z, Bartfai Z, Voko Z. Pitfalls associated with the therapeutic reference pricing practice of asthma medication. BMC Pulm Med 2012;12:35. [40] Kaló Z, Muszbek N, Bodrogi J, Bidló J. Does therapeutic reference pricing always result in cost-containment? The Hungarian evidence. Health Policy 2007;80:402–12. [41] Péntek M, Gulácsi L, Rózsa C, et al. Health status and costs of ambulatory patients with multiple sclerosis in Hungary. Ideggyogy Sz 2012;65(9–10):316–24. [42] Minier T, Péntek M, Brodszky V, et al. Cost-of-illness of patients with systemic sclerosis in a tertiary care centre. Rheumatology (Oxford) 2010;49:1920–8. [43] Csoboth I, Matyus A, Gabara K, Boncz I. Time of taking aspirin can have an effect on the frequency of occurrence of stroke. Chin Med J 2009;122:1119. [44] Kriszbacher I, Koppan M, Bodis J. Inflammation, atherosclerosis, and coronary artery disease. N Engl J Med 2005;353:429–30.