The European Journal of Health Economics

, Volume 15, Issue 2, pp 133–142 | Cite as

Cost-effectiveness of long-acting injectable risperidone versus flupentixol decanoate in the treatment of schizophrenia: a Markov model parameterized using administrative data

  • Simon FreyEmail author
  • Roland Linder
  • Georg Juckel
  • Tom Stargardt
Original Paper


We use longitudinal patient-level data from a German sickness fund with 7.26 million insured in a Markov-simulation model to assess the cost-effectiveness of long-acting injectable risperidone (LAI-RIS) compared with long-acting injectable flupentixol (LAI-FLX) in the long-term management of schizophrenia. We simulate treatment costs from the payer’s perspective, hospitalization, the probability to be prescribed co-medication, and treatment discontinuation over a 2-year time horizon. Model inputs were derived from 935 patients hospitalized with schizophrenia between 2005 and 2008 who received either LAI-RIS or LAI-FLX for at least 1 month. After 2 years, 89.4 % (95.8 %) of patients who were initiated on LAI-RIS (LAI-FLX) discontinued the initial regimen. The number of days spent in hospital per month and patient was slightly lower with LAI-RIS (1.08 vs. 1.28 days, p < 0.001). The proportion of patients receiving side-effect co-medication was lower with LAI-RIS (8.3 vs. 15.0 % per month, p < 0.001). Mean total costs of treatment per patient and month were 1,015 € under LAI-RIS and 395 € under LAI-FLX, resulting in an ICER of 3,088 € (95 % CI [−913 €; 3,551 €]) for an avoided hospital day per patient and month in the base case scenario with a 15.1 % probability of LAI-FLX being the dominant treatment strategy. Cost differences were mainly attributable to the higher drug costs of LAI-RIS. The effectiveness of LAI-RIS in preventing hospital days appears to be similar to LAI-FLX, with a slight superiority in side-effect and switching rates. This comes at the cost of substantially higher treatment expenses. From a decision-maker’s point of view, the use of health insurance data as a source of input for decision models appears to be a reasonable alternative to models driven by clinical data only.


Schizophrenia Long-acting injectable risperidone Flupentixol decanoate Markov model Cost-effectiveness Administrative data 

JEL Classification

I11 I19 



This study was kindly supported by an investigator-initiated grant from Bayer Vital GmbH. GJ has received grants or payments for lectures from manufacturers of antipsychotics (Astra Zeneca, Bayer, Bristol Meyers Squib, Eli Lilly, Janssen Cilag, Pfizer). TS has received grants from manufacturers of antipsychotics (Bayer, Lundbeck). RL is a health insurance employee.


  1. 1.
    McGrath, J., Saha, S., Chant, D., Welham, J.: Schizophrenia: a concise overview of incidence, prevalence, and mortality. Epidemiol. Rev. 30(1), 67–76 (2008)PubMedCrossRefGoogle Scholar
  2. 2.
    Federal Statistical Office. Gesundheitsberichterstattung des Bundes. Krankheitskostenrechnung. 2011Google Scholar
  3. 3.
    Rössler, W., Salize, H.J., Van Os, J., Riecher-Rössler, A.: Size of burden of schizophrenia and psychotic disorders. Eur. Neuropsychopharmacol. 15(4), 399–409 (2005)PubMedCrossRefGoogle Scholar
  4. 4.
    Davis, J.M.: Maintenance therapy and the natural course of schizophrenia. J. Clin. Psychiatry [Internet]. 1985 [cited 2012 Oct 31]; Available from:
  5. 5.
    Chakos, M., Lieberman, J., Hoffman, E., Bradford, D., Sheitman, B.: Effectiveness of second-generation antipsychotics in patients with treatment-resistant schizophrenia: a review and meta-analysis of randomized trials. Am. J. Psychiatry 158(4), 518–526 (2001)PubMedCrossRefGoogle Scholar
  6. 6.
    Kane, J.M.: Extrapyramidal side effects are unacceptable. Eur. Neuropsychopharmacol. 11(Suppl 4), S397–S403 (2001)PubMedCrossRefGoogle Scholar
  7. 7.
    Lieberman, J.A., Tollefson, G., Tohen, M., Green, A.I., Gur, R.E., Kahn, R., et al.: Comparative efficacy and safety of atypical and conventional antipsychotic drugs in first-episode psychosis: a randomized, double-blind trial of olanzapine versus haloperidol. Am. J. Psychiatry 160(8), 1396–1404 (2003)PubMedCrossRefGoogle Scholar
  8. 8.
    Correll, C.U., Leucht, S., Kane, J.M.: Lower risk for tardive dyskinesia associated with second-generation antipsychotics: a systematic review of 1-year studies. Am. J. Psychiatry 161(3), 414–425 (2004)PubMedCrossRefGoogle Scholar
  9. 9.
    Gilmer, T., Dolder, C., Lacro, J., Folsom, D., Lindamer, L., Garcia, P., et al.: Adherence to treatment with antipsychotic medication and health care costs among Medicaid beneficiaries with schizophrenia. Am. J. Psychiatry 161(4), 692–699 (2004)PubMedCrossRefGoogle Scholar
  10. 10.
    Leucht, S., Arbter, D., Engel, R.R., Kissling, W., Davis, J.M.: How effective are second-generation antipsychotic drugs? A meta-analysis of placebo-controlled trials. Mol. Psychiatry 14(4), 429–447 (2008)PubMedCrossRefGoogle Scholar
  11. 11.
    Haddad, P.M., Taylor, M., Niaz, O.S.: First-generation antipsychotic long-acting injections v. oral antipsychotics in schizophrenia: systematic review of randomised controlled trials and observational studies. The. Br. J. Psychiatry 195(52), S20–S28 (2009)CrossRefGoogle Scholar
  12. 12.
    Kane, J., Aguglia, E., Altamura, A., Gutierrez, J., Brunello, N., Fleischhacker, W., et al.: Guidelines for depot antipsychotic treatment in schizophrenia. Eur. Neuropsychopharmacol. 8(1), 55–66 (1998)PubMedCrossRefGoogle Scholar
  13. 13.
    Johnson, D.A.W.: Historical perspective on antipsychotic long-acting injections. Br. J. Psychiatry 195(52), S7–S12 (2009)CrossRefGoogle Scholar
  14. 14.
    Kahn, R.S., Fleischhacker, W.W., Boter, H., Davidson, M., Vergouwe, Y., Keet, I.P., et al.: Effectiveness of antipsychotic drugs in first-episode schizophrenia and schizophreniform disorder: an open randomised clinical trial. The Lancet 371(9618), 1085–1097 (2008)CrossRefGoogle Scholar
  15. 15.
    Jones, P.B., Barnes, T.R.E., Davies, L., Dunn, G., Lloyd, H., Hayhurst, K.P., et al.: Randomized controlled trial of the effect on quality of life of second- vs first-generation antipsychotic drugs in schizophrenia: cost utility of the latest antipsychotic drugs in schizophrenia study (CUtLASS 1). Arch. Gen. Psychiatry 63(10), 1079–1087 (2006)PubMedCrossRefGoogle Scholar
  16. 16.
    Lieberman, J.A., Stroup, T.S., McEvoy, J.P., Swartz, M.S., Rosenheck, R.A., Perkins, D.O., et al.: Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. N. Engl. J. Med. 353, 1209–1223 (2005)PubMedCrossRefGoogle Scholar
  17. 17.
    Zhang, P.L., Santos, J.M., Newcomer, J., Pelfrey, B.A., Johnson, M.C., De Erausquin, G.A.: Impact of atypical antipsychotics on quality of life, self-report of symptom severity, and demand of services in chronically psychotic patients. Schizophr. Res. 71(1), 137–144 (2004)PubMedCrossRefGoogle Scholar
  18. 18.
    McEvoy, J., Lieberman, J., Perkins, D., Hamer, R., Gu, H., Lazarus, A., et al.: Efficacy and tolerability of olanzapine, quetiapine, and risperidone in the treatment of early psychosis: a randomized, double-blind 52-week comparison. Am. J. Psychiatry 164(7), 1050–1060 (2007)PubMedCrossRefGoogle Scholar
  19. 19.
    Robinson, D., Woerner, M., Napolitano, B., Patel, R., Sevy, S., Gunduz-Bruce, H., et al.: Randomized comparison of olanzapine versus risperidone for the treatment of first-episode schizophrenia: 4-month outcomes. Am. J. Psychiatry 163(12), 2096–2102 (2006)PubMedCrossRefGoogle Scholar
  20. 20.
    Leucht, S., Komossa, K., Rummel-Kluge, C., Corves, C., Hunger, H., Schmid, F., et al.: A meta-analysis of head-to-head comparisons of second-generation antipsychotics in the treatment of schizophrenia. Am. J. Psychiatry 166, 152–163 (2009)PubMedCrossRefGoogle Scholar
  21. 21.
    Geddes, J., Freemantle, N., Harrison, P., Bebbington, P.: Atypical antipsychotics in the treatment of schizophrenia: systematic overview and meta-regression analysis. BMJ 321(7273), 1371–1376 (2000)PubMedCrossRefGoogle Scholar
  22. 22.
    Leucht, S., Heres, S., Hamann, J., Kane, J.M.: Methodological issues in current antipsychotic drug trials. Schizophr. Bull. 34(2), 275–285 (2008)PubMedCrossRefGoogle Scholar
  23. 23.
    Fleischhacker, W.W.: Second-generation antipsychotic long-acting injections: systematic review. Br. J. Psychiatry 195(52), S29–S36 (2009)CrossRefGoogle Scholar
  24. 24.
    Polsky, D., Doshi, J., Bauer, M., Glick, H.: Clinical trial-based cost-effectiveness analyses of antipsychotic use. Am. J. Psychiatry 163(12), 2047–2056 (2006)PubMedCrossRefGoogle Scholar
  25. 25.
    Rosenheck, R., Leslie, D., Sindelar, J., Miller, E., Lin, H., Stroup, T., et al.: Cost-effectiveness of second-generation antipsychotics and perphenazine in a randomized trial of treatment for chronic schizophrenia. Am. J. Psychiatry 163(12), 2080–2089 (2006)PubMedCrossRefGoogle Scholar
  26. 26.
    Davies, L.M., Lewis, S., Jones, P.B., Barnes, T.R.E., Gaughran, F., Hayhurst, K., et al.: Cost-effectiveness of first- v. second-generation antipsychotic drugs: results from a randomised controlled trial in schizophrenia responding poorly to previous therapy. Br. J. Psychiatry 191, 14–22 (2007)PubMedCrossRefGoogle Scholar
  27. 27.
    Taylor, D., Young, C., Mace, S., Patel, M.: Early clinical experience with risperidone long-acting injection: a prospective, 6-month follow-up of 100 patients. J. Clin. Psychiatry 65(8), 1076–1083 (2004)PubMedCrossRefGoogle Scholar
  28. 28.
    Patel, M.X., Young, C., Samele, C., Taylor, D.M., David, A.S.: Prognostic indicators for early discontinuation of risperidone long-acting injection. Int. Clin. Psychopharmacol. 19(4), 233–239 (2004)PubMedCrossRefGoogle Scholar
  29. 29.
    Taylor, D.M., Young, C., Patel, M.X.: Prospective 6-month follow-up of patients prescribed risperidone long-acting injection: factors predicting favourable outcome. Int. J. Neuropsychopharmacol. 9(06), 685–694 (2006)PubMedCrossRefGoogle Scholar
  30. 30.
    Niaz, O.S., Haddad, P.M.: Thirty-five months experience of risperidone long-acting injection in a UK psychiatric service including a mirror-image analysis of in-patient care. Acta Psychiatr. Scand. 116(1), 36–46 (2007)PubMedCrossRefGoogle Scholar
  31. 31.
    Taylor, M., Currie, A., Lloyd, K., Price, M., Peperell, K.: Impact of risperidone long acting injection on resource utilization in psychiatric secondary care. J. Psychopharmacol. 22(2), 128–131 (2008)PubMedCrossRefGoogle Scholar
  32. 32.
    Spill, B., Konoppa, S., Kissling, W., Maino, K., Messer, T., Heres, S.: Long-term observation of patients successfully switched to risperidone long-acting injectable: a retrospective, naturalistic 18-month mirror-image study of hospitalization rates and therapy costs. Int. J. Psychiatry Clin. Pract 14(1), 53–62 (2010)CrossRefGoogle Scholar
  33. 33.
    Chue, P., Heeg, B.M., Buskens, E., Van Hout, B.A.: Modelling the impact of compliance on the costs and effects of long-acting risperidone in Canada. PharmacoEconomics 23(Suppl 1), 62–74 (2005)PubMedCrossRefGoogle Scholar
  34. 34.
    Laux, G., Heeg, B., Van Hout, B.A., Mehnert, A.: Costs and effects of long-acting risperidone compared with oral atypical and conventional depot formulations in Germany. PharmacoEconomics 23(Suppl 1), 49–61 (2005)PubMedCrossRefGoogle Scholar
  35. 35.
    Heeg, B., Antunes, J., Figueira, M., Jara, J., Marques Teixeira, J., Palha, A., et al.: Cost-effectiveness and budget impact of long-acting risperidone in Portugal: a modeling exercise. Curr. Med. Res. Opin. 24(2), 349–358 (2008)PubMedCrossRefGoogle Scholar
  36. 36.
    De Graeve, D., Smet, A., Mehnert, A., Caleo, S., Miadi-Fargier, H., Mosqueda, G.J., et al.: Long-acting risperidone compared with oral olanzapine and haloperidol depot in schizophrenia: a Belgian cost-effectiveness analysis. PharmacoEconomics 23(Supplement 1), 35–47 (2005)PubMedGoogle Scholar
  37. 37.
    Edwards, N.C., Rupnow, M.F.T., Pashos, C.L., Botteman, M.F., Diamond, R.J.: Cost-effectiveness model of long-acting risperidone in schizophrenia in the US. PharmacoEconomics 23(3), 299–314 (2005)PubMedCrossRefGoogle Scholar
  38. 38.
    Hertling, I., Philipp, M., Dvorak, A., Glaser, T., Mast, O., Beneke, M., et al.: Flupenthixol versus risperidone: subjective quality of life as an important factor for compliance in chronic schizophrenic patients. Neuropsychobiology 47(1), 37–46 (2003)PubMedCrossRefGoogle Scholar
  39. 39.
    Ruhrmann, S., Kissling, W., Lesch, O.-M., Schmauss, M., Seemann, U., Philipp, M.: Efficacy of flupentixol and risperidone in chronic schizophrenia with predominantly negative symptoms. Prog. Neuropsychopharmacol. Biol. Psychiatry 31(5), 1012–1022 (2007)PubMedCrossRefGoogle Scholar
  40. 40.
    Stargardt, T., Weinbrenner, S., Busse, R., Juckel, G., Gericke, C.: Effectiveness and cost of atypical versus typical antipsychotic treatment for schizophrenia in routine care. J. Ment. Health Policy Econ. 11(2), 89–97 (2008)PubMedGoogle Scholar
  41. 41.
    Stargardt, T., Mavrogiorgou, P., Gericke, C.A., Juckel, G.: Effectiveness and costs of flupentixol compared to other first- and second-generation antipsychotics in the treatment of schizophrenia. Psychopharmacology 216, 579–587 (2011)PubMedCrossRefGoogle Scholar
  42. 42.
    Hansen, K., François, C., Toumi, M., Lançon, C.: A pharmacoeconomic evaluation of zuclopenthixol compared with haloperidol and risperidone in the treatment of schizophrenia. Eur. J. Health Econ. 3(3), 173–179 (2002)PubMedCrossRefGoogle Scholar
  43. 43.
    Langley-Hawthorne, C.: Modeling the lifetime costs of treating schizophrenia in Australia. Clin. Ther. 19(6), 1470–1495 (1997). (discussion 1424–1425)PubMedCrossRefGoogle Scholar
  44. 44.
    Lecomte, P., De Hert, M., Van Dijk, M., Nuijten, M., Nuyts, G., et al.: A 1-year cost-effectiveness model for the treatment of chronic schizophrenia with acute exacerbations in Belgium. Value Health 3(1), 1–11 (2000)PubMedCrossRefGoogle Scholar
  45. 45.
    Volz, H.-P., Sadre-Chirazi-Stark, M., Resch, A.: Die Effizienz der Behandlung der Schizophrenie mit Ziprasidon im Vergleich zu anderen Neuroleptika unter Berücksichtigung von Arzneimittelnebenwirkungen und Noncompliance. Gesundh ökon Qual Manag. 10, 96–101 (2005)CrossRefGoogle Scholar
  46. 46.
    AWMF S3-Leitlinie Psychiatrie: Schizophrenie [Internet]. AWMF online. 2005 [cited 2011 Mar 10]. Available from:
  47. 47.
    Hughes, D.A., Bagust, A., Haycox, A., Walley, T.: Accounting for noncompliance in Pharmacoeconomic evaluations. PharmacoEconomics 19(12), 1185–1197 (2001)Google Scholar
  48. 48.
    Kadambi, A., Leipold, R.J., Kansal, A.R., Sorensen, S., Getsios, D.: Inclusion of compliance and persistence in economic models: past, present and future. Appl. Health Econ. Health Policy 10(6), 365–379 (2012)PubMedCrossRefGoogle Scholar
  49. 49.
    Dezii, C.M.: Persistence with drug therapy: a practical approach using administrative claims data. Manag. Care 10(2), 42–45 (2001)PubMedGoogle Scholar
  50. 50.
    Sikka, R., Xia, F., Aubert, R.: Estimating medication persistency using administrative claims data. Am. J. Manag. Care 11(7), 449–457 (2005)PubMedGoogle Scholar
  51. 51.
    Andrade, S., Kahler, K., Frech, F., Chan, K.: Methods for evaluation of medication adherence and persistence using automated databases. Pharmacoepidemiol. Drug Saf. 15(8), 565–574 (2006)PubMedCrossRefGoogle Scholar
  52. 52.
    Elixhauser, A., Steiner, C., Harris, D.R., Coffey, R.M.: Comorbidity measures for use with administrative data. Med. Care 36(1), 8–27 (1998)PubMedCrossRefGoogle Scholar
  53. 53.
    Van Walraven, C., Austin, P.C., Jennings, A., Quan, H., Forster, A.J.: A modification of the Elixhauser comorbidity measures into a point system for hospital death using administrative data. Med. Care 47(6), 626–633 (2009)PubMedCrossRefGoogle Scholar
  54. 54.
    Bizzotto, R., Zamuner, S., Nicolao, G., Karlsson, M.O., Gomeni, R.: Multinomial logistic estimation of Markov-chain models for modeling sleep architecture in primary insomnia patients. J. Pharmacokinet Pharmacodyn. 37(2), 137–155 (2010)PubMedCrossRefGoogle Scholar
  55. 55.
    Hartzel, J., Agresti, A., Caffo, B.: Multinomial logit random effects models. Stat. Model. 1(2), 81 (2001)CrossRefGoogle Scholar
  56. 56.
    Tutz, G., Hennevogl, W.: Random effects in ordinal regression models. Comput. Stat. Data Anal. 22(5), 537–557 (1996)CrossRefGoogle Scholar
  57. 57.
    Daniels, M.J., Gatsonis, C.: Hierarchical polytomous regression models with applications to health services research. Stat. Med. 16(20), 2311–2325 (1997)PubMedCrossRefGoogle Scholar
  58. 58.
    Kuss, O., McLerran, D.: A note on the estimation of the multinomial logistic model with correlated responses in SAS. Comput. Methods Programs Biomed. 87(3), 262–269 (2007)PubMedCrossRefGoogle Scholar
  59. 59.
    Mihaylova, B., Briggs, A., O’Hagan, A., Thompson, S.G.: Review of statistical methods for analysing healthcare resources and costs. Health Econ. 20(8), 897–916 (2011)PubMedCentralPubMedCrossRefGoogle Scholar
  60. 60.
    Diehr, P., Yanez, D., Ash, A., Hornbrook, M., Lin, D.Y.: Methods for analyzing health care utilization and costs. Annu. Rev. Public Health 20(1), 125–144 (1999)PubMedCrossRefGoogle Scholar
  61. 61.
    Venables, W.N., Smith, D.M., et al.: R: A Language and Environment for Statistical Computing. R Foundation for Statistical Computing, Vienna (2010)Google Scholar
  62. 62.
    Zeileis, A., Kleiber, C., Jackman, S.: Regression models for count data in R. J. Stat. Softw. 27(8), 1–25 (2008)Google Scholar
  63. 63.
    Briggs, A., Sculpher, M.: An introduction to Markov modelling for economic evaluation. PharmacoEconomics 13(4), 397–409 (1998)PubMedCrossRefGoogle Scholar
  64. 64.
    Daniels, M.J., Zhao, Y.D.: Modelling the random effects covariance matrix in longitudinal data. Stat. Med. 22(10), 1631–1647 (2003)PubMedCentralPubMedCrossRefGoogle Scholar
  65. 65.
    Briggs, A., Sculpher, M., Claxton, K.: Decision Modelling for Health Economic Evaluation. Oxford University Press, Oxford (2006)Google Scholar
  66. 66.
    Polsky, D., Glick, H.A., Willke, R., Schulman, K.: Confidence intervals for cost-effectiveness ratios: a comparison of four methods. Health Econ. 6(3), 243–252 (1997)PubMedCrossRefGoogle Scholar
  67. 67.
    Weiden, P., Olfson, M.: Cost of relapse in schizophrenia. Schizophr. Bull. 21(3), 419–429 (1995)PubMedCrossRefGoogle Scholar
  68. 68.
    Haycox, A.: Pharmacoeconomics of long-acting risperidone: results and validity of cost-effectiveness models. PharmacoEconomics 23(Supplement 1), 3–16 (2005)PubMedGoogle Scholar
  69. 69.
    Revicki, D.A., Frank, L.: Pharmacoeconomic evaluation in the real world: effectiveness versus efficacy studies. PharmacoEconomics 15(5), 423–434 (1999)Google Scholar
  70. 70.
    Konnopka, A., Klingberg, S., Wittorf, A., König, H.H.: Die Kosten der Schizophrenie in Deutschland: Ein systematischer Literaturüberblick. Psychiatrische Praxis 36(5), 211–218 (2009)Google Scholar
  71. 71.
    Knapp, M., Mangalore, R., Simon, J.: The global costs of schizophrenia. Schizophr. Bull. 30(2), 279–293 (2004)PubMedCrossRefGoogle Scholar
  72. 72.
    Buxton, M.J., Drummond, M.F., Van Hout, B.A., Prince, R.L., Sheldon, T.A., Szucs, T., et al.: Modelling in ecomomic evaluation: an unavoidable fact of life. Health Econ. 6(3), 217–227 (1997)PubMedCrossRefGoogle Scholar
  73. 73.
    Marshall, A., Vasilakis, C., El-Darzi, E.: Length of stay-based patient flow models: recent developments and future directions. Health Care Manag. Sci. 8, 213–220 (2005)PubMedCrossRefGoogle Scholar
  74. 74.
    Lacro, J.P., Dunn, L.B., Dolder, C.R., Leckband, S.G., Jeste, D.V.: Prevalence of and risk factors for medication nonadherence in patients with schizophrenia: a comprehensive review of recent literature. J. Clin. Psychiatry 63(10), 892–909 (2002)PubMedCrossRefGoogle Scholar
  75. 75.
    Sonnenberg, F.A., Beck, J.R.: Markov models in medical decision making: a practical guide. Med. Decis. Making 13(4), 322 (1993)PubMedCrossRefGoogle Scholar
  76. 76.
    Beck, J.R., Pauker, S.G.: The Markov process in medical prognosis. Med. Decis. Making 3(4), 419 (1983)PubMedCrossRefGoogle Scholar
  77. 77.
    Kelin, K., Lambert Jr, T., Brnabic, A.J., Newton, R., Ye, W., Escamilla, R.I., et al.: Treatment discontinuation and clinical outcomes in the 1-year naturalistic treatment of patients with schizophrenia at risk of treatment nonadherence. Patient Prefer. Adherence 5, 213–222 (2011)PubMedCentralPubMedCrossRefGoogle Scholar
  78. 78.
    Sernyak, M.J., Rosenheck, R.: Risk adjustment in studies using administrative data. Schizophr. Bull. 29(2), 267 (2003)PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  • Simon Frey
    • 1
    Email author
  • Roland Linder
    • 2
  • Georg Juckel
    • 3
  • Tom Stargardt
    • 1
  1. 1.Hamburg Center for Health Economics (HCHE)University of HamburgHamburgGermany
  2. 2.Scientific Institute of TK for Benefit and Efficiency in Health Care (WINEG)HamburgGermany
  3. 3.Department of Psychiatry, Psychotherapy and Preventive MedicineRuhr University BochumBochumGermany

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