Epidemiology, treatment and health care resource use of patients with severe asthma in Germany - a retrospective claims data analysis.

BACKGROUND: Asthma causes various clinical symptoms, including unpredictable severe exacerbations, and even though most patients can achieve a reasonable disease control due to adequate treatment, some patients do not. This study seeks to describe healthcare resource utilization (HCRU) and treatment of asthma and severe asthma patients in Germany. METHOD: A retrospective claims data analysis has been conducted on adult asthma patients and a subset of patients with severe asthma, identified during July 2017 - June 2018. A proxy was used to identify severe asthma patients based on therapy options recommended within the German treatment guideline for treating these patients. These include (i) biologics, (ii) medium/high-dose inhaled corticosteroids (ICS) in conjunction with LABA/montelukast and antibiotics/oral corticosteroids (OCS), and (iii) long-term OCS therapy. HCRU and treatment of patients were observed during a 1-year follow-up period (July 2018 - June 2019). RESULTS: The study included 388 932 adult asthma patients (prevalence: 7.90%), with 2.51%-12.88% affected by severe asthma (depending on the definition). 22.60% of all asthma patients experienced hospitalizations (severe asthma: 36.11%). Furthermore, 13.59% received OCS (severe asthma: 39.91%), but only 0.18% (severe asthma: 1.25%) received biologics. Only 23.95% (severe asthma: 41.17%) visited a pulmonologist. CONCLUSIONS: A considerable proportion of severe asthma patients receive long-term OCS therapy. However, less than 50% have seen a pulmonologist who would typically seek a change in treatment to avoid the long-term consequences of OCS. To optimize the treatment of severe asthma in Germany, better referral of these patients to specialists is needed and considering potential treatment alternatives.

Longitudinal evaluation of medication underuse in older outpatients and its association with quality of life.

PURPOSE: We investigated the factors promoting prescribing omissions (medication underuse) in long-term medical care and the impact of withholding indicated medications on quality of life. METHODS: In a population-based cohort study of older ambulatory patients (ESTHER), we collected data with sequential questionnaires from participants and from their GPs. Concurrently, in two consecutive home visits, trained study physicians performed comprehensive geriatric assessments and recorded all medicines currently taken. Each patient's medication was screened for underuse using the START-2 criteria. RESULTS: Medication underuse (absence of ≥1 indicated medication) was present in 70.3 and 73.2 % of 989 participants at two consecutive home visit assessments, respectively. Following variable selection accounting for subject-specific heterogeneity over time, multivariate results revealed that more drugs (odds ratio with 95 % confidence intervals: 0.83 [0.78;0.87] per drug) and better cognitive status (0.93 [0.87;0.99] per point on the MMSE scale) were preventive factors, while worse self-reported health status (1.33 [1.05;1.67] per point on an 5-point scale) and increasing frequency of GP consultations (1.07 [1.00;1.15] per visit within the preceding 3 months) were positively associated with medication underuse. An increase in omitted medications over time was associated with worse quality of life as determined on the EuroQuol EQ-Vas and EQ-5D scales. CONCLUSION: In addition to general and physician-related factors, also patient-related aspects, such as individual health appraisal, were associated with medication underuse. Because withholding indicated drugs was associated with substantially reduced quality of life, controlled intervention studies are necessary to confirm the notion that pharmacological appropriateness improves personal wellbeing.

Comparative evaluation of methods approximating drug prescription durations in claims data: modeling, simulation, and application to real data.

PURPOSE: The purpose of this study was to compare the predictive accuracy of different methods suggested for approximation of drug prescription durations in claims data. METHODS: We expanded a well-established modeling and simulation framework to compare approximated drug prescription durations with 'true' (i.e., simulated) durations. Real claims data of persons aged ≥65 years insured by the German nationwide 'Statutory Health Insurance Fund' AOK between 2010 and 2012 provided empiric input parameters that were completed with missing information on actual dosing patterns from an observational cohort. The distinct approximation methods were based on crude measures (one tablet a day), population-averaged measures (defined daily doses), or individually-derived measures (longitudinal coverage approximation of the applied dose, COV). As a proof-of-principle, we assessed the methods' performance to predict the well-characterized bleeding risks of anticoagulant, antiplatelet, and/or non-steroidal anti-inflammatory drugs. RESULTS: When applied to modeling and simulation data sets, the closest, least biased, and thus most accurate approximation was observed using the COV approximation. In a real-data example, rather similar results to an external reference were obtained for all methods. However, some of the differences between methods were meaningful, and the most reasonable and consistent results were obtained with the COV approach. CONCLUSION: Based on theoretically most accurate approximations and practically reasonable estimates, the individual COV approach was preferable over the population-averaged defined daily dose technique, although the latter might be justified in certain situations. Advantages of the COV approach are expected to be even bigger for drug therapies with particularly large dosing heterogeneity. Copyright © 2016 John Wiley & Sons, Ltd.

Associations of frailty with health care costs--results of the ESTHER cohort study.

BACKGROUND: The concept of frailty is rapidly gaining attention as an independent syndrome with high prevalence in older adults. Thereby, frailty is often related to certain adverse outcomes like mortality or disability. Another adverse outcome discussed is increased health care utilization. However, only few studies examined the impact of frailty on health care utilization and corresponding costs. The aim of this study was therefore to investigate comprehensively the relationship between frailty, health care utilization and costs. METHODS: Cross sectional data from 2598 older participants (57-84 years) recruited in the Saarland, Germany, between 2008 and 2010 was used. Participants passed geriatric assessments that included Fried's five frailty criteria: weakness, slowness, exhaustion, unintentional weight loss, and physical inactivity. Health care utilization was recorded in the sectors of inpatient treatment, outpatient treatment, pharmaceuticals, and nursing care. RESULTS: Prevalence of frailty (≥3 symptoms) was 8.0%. Mean total 3-month costs of frail participants were €3659 (4 or 5 symptoms) and €1616 (3 symptoms) as compared to €642 of nonfrail participants (no symptom). Controlling for comorbidity and general socio-demographic characteristics in multiple regression models, the difference in total costs between frail and non-frail participants still amounted to €1917; p < .05 (4 or 5 symptoms) and €680; p < .05 (3 symptoms). Among the 5 symptoms of frailty, weight loss and exhaustion were significantly associated with total costs after controlling for comorbidity. CONCLUSIONS: The study provides evidence that frailty is associated with increased health care costs. The analyses furthermore indicate that frailty is an important factor for health care costs independent from pure age and comorbidity. Costs were rather attributable to frailty (and comorbidity) than to age. This stresses that the overlapping concepts of multimorbidity and frailty are both necessary to explain health care use and corresponding costs among older adults.

Characteristics of medication schedules used by elderly ambulatory patients.

PURPOSE: We investigated the prevalence and quality of medication schedules of elderly ambulatory patients and assessed factors associated with the availability of a medication schedule. In particular, we evaluated whether sending out a blank medication schedule template would increase the chances to use such a document. METHODS: Data originate from the ESTHER study, a cohort study conducted in Saarland, Germany, in which trained study physicians performed home visits. They scanned all medication schedules, recorded the participants' medication, and performed thorough geriatric assessments. As part of the intervention, a blank medication schedule template along with a brochure was mailed to half of the participants (intervention group) 4 weeks prior to the home visits. RESULTS: In total, 553 of 2470 participants (22.4 %) had a medication schedule. Almost two thirds of the schedules were issued by health care professionals (n = 353, 63.8 %). These schedules offered a higher quality, although important information such as over-the-counter (OTC) medication was regularly missing. Self-reported adherence was higher in participants who used self-issued medication schedules; however, self-reported medication adherence in patients with any medication schedule was poorer compared to those patients not using a schedule. Factors associated with the availability of a medication schedule were male sex, a higher number of medicines to take, and a more complex drug regimen. The intervention did not increase the number of patients having a medication schedule. CONCLUSION: Only a minority of elderly ambulatory patients had a medication schedule at home. Sending out a brochure along with a blank medication schedule template did not increase the prevalence of medication schedules.

Loneliness in the elderly is associated with the use of psychotropic drugs.

OBJECTIVE: The aim of this study was to evaluate the association between loneliness in elderly people with the use of psychotropic drugs. METHODS: A subsample of 3111 participants (ages 55-85) of the large population-based German ESTHER study was included in the study. Loneliness was measured by using a three-item questionnaire. Two subgroups were defined according to their degrees of loneliness. Psychotropic drugs were categorized by study doctors. Logistic regression analyses were conducted to determine the association between loneliness subgroups and the use of psychotropic drugs adjusted for psychosocial variables, multimorbidity, depression, anxiety, and somatic symptom severity. RESULTS: Of the participants 14.1% (95%-CI = [12.9; 15.4]) were estimated to have a high degree of loneliness (women > men); 19% (95%-CI = [17.6; 20.4]) of the participants used psychotropic drugs, 8.4% (95%-CI = [7.5; 9.5]) antidepressants. Logistic regression analysis showed that more lonely participants had significantly higher odds for using psychotropic drugs (OR: 1.495; 95%-CI = [1.121; 1.993]). Depression severity, somatic symptom severity, and female gender were also positively associated with the use of psychotropic drugs. CONCLUSION: A high degree of subjective loneliness in the elderly is associated with the use of psychotropic drugs, even after adjustment for somatic and psychological comorbidities and psychosocial variables.

Health service use and costs associated with excess weight in older adults in Germany.

BACKGROUND: excess weight is a risk factor for numerous co-morbidities that predominantly occur in later life. This study's purpose was to analyse the association between excess weight and health service use/costs in the older population in Germany. METHODS: this cross-sectional analysis used data of n = 3,108 individuals aged 58-82 from a population-based prospective cohort study. Body mass index (BMI) and waist-to-height ratio (WHtR) were calculated based on clinical examinations. Health service use was measured by a questionnaire for a 3-month period. Corresponding costs were calculated applying a societal perspective. RESULTS: 21.8% of the sample were normal weight, 43.0% overweight, 25.5% obese class 1 and 9.6% obese class ≥2 according to BMI. In 42.6%, WHtR was ≥0.6. For normal weight, overweight, obese class 1 and obese class ≥2 individuals, mean costs (3-month period) of outpatient care were 384€, 435€, 475€ and 525€ (P < 0.001), mean costs of inpatient care were 284€, 408€, 333€ and 652€ (P = 0.070) and mean total costs 716€, 891€, 852€ and 1,244€ (P = 0.013). For individuals with WHtR <0.6 versus ≥0.6, outpatient costs were 401€ versus 499€ (P < 0.001), inpatient costs 315€ versus 480€ (P = 0.016) and total costs 755€ versus 1,041€ (P < 0.001). Multiple regression analyses controlling for sociodemographic variables showed a significant effect of obesity on costs of outpatient care (class 1: +72€; class ≥2: +153€) and total costs (class ≥2: +361€) while the effect of overweight was not significant. WHtR ≥0.6 significantly increased outpatient costs by +79€ and total costs by +189€. CONCLUSIONS: excess weight is associated with increased service use and cost in elderly individuals, in particular in obese class ≥2 individuals.

Swallowing Tablets and Capsules Increases the Risk of Penetration and Aspiration in Patients with Stroke-Induced Dysphagia.

We evaluated the prevalence of difficulties swallowing solid dosage forms in patients with stroke-induced dysphagia and whether swallowing tablets/capsules increases their risk of penetration and aspiration. Concurrently, we explored whether routinely performed assessment tests help identify patients at risk. Using video endoscopy, we evaluated how 52 patients swallowed four different placebos (round, oval, and oblong tablets and a capsule) with texture-modified water (TMW, pudding consistency) and milk and rated their swallowing performance according to the Penetration Aspiration Scale (PAS). Additionally, Daniels Test, Bogenhausener Dysphagiescore, Scandinavian Stroke Scale, Barthel Index, and Tinetti's Mobility Test were conducted. A substantial proportion of the patients experienced severe difficulties swallowing solid oral dosage forms (TMW: 40.4 %, milk: 43.5 %). Compared to the administration of TMW/milk alone, the placebos increased the PAS values in the majority of the patients (TMW: median PAS from 1.5 to 2.0; milk: median PAS from 1.5 to 2.5, each p value <0.0001) and residue values were significantly higher (p < 0.05). Whereas video-endoscopic examination reliably identified patients with difficulties swallowing medication, neither patients' self-evaluation nor one of the routinely performed bedside tests did. Therefore, before video-endoscopic evaluation, many drugs were modified unnecessarily and 20.8 % of these were crushed inadequately, although switching to another dosage form or drug would have been possible. Hence, safety and effectiveness of swallowing tablets and capsules should be evaluated routinely in video-endoscopic examinations, tablets/capsules should rather be provided with TMW than with milk, and the appropriateness of "non per os except medication" orders for dysphagic stroke patients should be questioned.

Two techniques to make swallowing pills easier.

To evaluate whether 2 techniques (the pop-bottle method for tablets and the lean-forward technique for capsules) ease swallowing of tablets and capsules, we conducted a cross-sectional study including 151 adults of the general German population. Participants swallowed 16 differently shaped placebos, rated their ease of swallowing on an 8-point Likert scale, and swallowed the 2 dosage forms that they had rated most difficult again using the appropriate technique. The pop-bottle method substantially improved swallowing of tablets in 59.7% (169/283) and the lean-forward technique for capsules in 88.6% (31/35). Both techniques were remarkably effective in participants with and without reported difficulties swallowing pills and should be recommended regularly.

Inequalities in out-of-pocket payments for health care services among elderly Germans--results of a population-based cross-sectional study.

INTRODUCTION: In order to limit rising publicly-financed health expenditure, out-of-pocket payments for health care services (OOPP) have been raised in many industrialized countries. However, higher health-related OOPP may burden social subgroups unequally. In Germany, inequalities in OOPP have rarely been analyzed. The aim of this study was to examine OOPP of the German elderly population in the different sectors of the health care system. Socio-economic and morbidity-related determinants of inequalities in OOPP were analyzed. METHODS: This cross-sectional analysis used data of N = 3,124 subjects aged 57 to 84 years from a population-based prospective cohort study (ESTHER study) collected in the Saarland, Germany, from 2008 to 2010. Subjects passed a geriatric assessment, including a questionnaire for health care utilization and OOPP covering a period of three months in the following sectors: inpatient care, outpatient physician and non-physician services, medical supplies, pharmaceuticals, dental prostheses and nursing care. Determinants of OOPP were analyzed by a two-part model. The financial burden of OOPP for certain social subgroups (measured by the OOPP-income-ratio) was investigated by a generalized linear model for the binomial family. RESULTS: Mean OOPP during three months amounted to €119, with 34% for medical supplies, 22% for dental prostheses, 21% for pharmaceuticals, 17% for outpatient physician and non-physician services, 5% for inpatient care and 1% for nursing care. The two-part model showed a significant positive association between income (square root equivalence scale) and total OOPP. Increasing morbidity was associated with significantly higher total OOPP, and in particular with higher OOPP for pharmaceuticals. Total OOPP amounted to about 3% of disposable income. The generalized linear model for the binomial family showed a significantly lower financial burden for the wealthiest quintile as compared to the poorest one. CONCLUSIONS: This is the first study providing evidence of inequalities in OOPP in the German elderly population. Socio-economic and morbidity-related inequalities in OOPP and the resulting financial burden could be identified. The results of this study may contribute to the discussion about the mechanisms causing the observed inequalities and can thus help decision makers to consider them when adapting future regulations on OOPP.

Indirect evidence for proton pump inhibitor failure in patients taking them independent of meals.

PURPOSE: We investigated the association between conditions of proton pump inhibitor (PPI) treatment failure and food intake in an elderly ambulatory population. METHODS: Our data originate from a large population-based cohort study. During a home visit done by a trained study physician, patients were asked for each medication to state whether it was taken in relation to a meal (before, concurrently with, and after) or independent of a meal. This information was analyzed for all patients taking a PPI daily and correlated to markers of PPI failure. RESULTS: Out of 2717 patients participating in a home visit and taking at least one medication, 383 took a PPI daily (14.1%). A PPI intake independent of meals was defined as incorrect and was observed in 64 patients, whereas 319 patients took their PPI in relation to a meal, which was defined as the correct intake. Treatment failure was observed in 10 out of 64 (15.6%) PPI users with incorrect intake and in 18 out of 319 (5.6%) PPI users with correct intake. The risk of treatment failure was threefold higher in patients taking their PPI independent of meals (OR 3.35; 95%CI 1.44-7.76). CONCLUSION: The higher risk for PPI failure in patients taking PPIs independent of meals suggests that synchronized PPI administration with meals is indeed essential, and better counseling of patients is needed.

Health care costs in the elderly in Germany: an analysis applying Andersen's behavioral model of health care utilization.

BACKGROUND: To analyze the association of health care costs with predisposing, enabling, and need factors, as defined by Andersen's behavioral model of health care utilization, in the German elderly population. METHODS: Using a cross-sectional design, cost data of 3,124 participants aged 57-84 years in the 8-year-follow-up of the ESTHER cohort study were analyzed. Health care utilization in a 3-month period was assessed retrospectively through an interview conducted by trained study physicians at respondents' homes. Unit costs were applied to calculate health care costs from the societal perspective. Socio-demographic and health-related variables were categorized as predisposing, enabling, or need factors as defined by the Andersen model. Multimorbidity was measured by the Cumulative Illness Rating Scale for Geriatrics (CIRS-G). Mental health status was measured by the SF-12 mental component summary (MCS) score. Sector-specific costs were analyzed by means of multiple Tobit regression models. RESULTS: Mean total costs per respondent were 889 € for the 3-month period. The CIRS-G score and the SF-12 MCS score representing the need factor in the Andersen model were consistently associated with total, inpatient, outpatient and nursing costs. Among the predisposing factors, age was positively associated with outpatient costs, nursing costs, and total costs, and the BMI was associated with outpatient costs. CONCLUSIONS: Multimorbidity and mental health status, both reflecting the need factor in the Andersen model, were the dominant predictors of health care costs. Predisposing and enabling factors had comparatively little impact on health care costs, possibly due to the characteristics of the German social health insurance system. Overall, the variables used in the Andersen model explained only little of the total variance in health care costs.

Difficulties swallowing solid oral dosage forms in a general practice population: prevalence, causes, and relationship to dosage forms.

PURPOSE: We assessed the prevalence of difficulties in swallowing solid oral dosage forms in a general practice population. Reasons, nature, and characteristics of tablets and capsules causing such difficulties were investigated as well as general practitioners' (GP) awareness of these difficulties. METHODS: A questionnaire survey was conducted in 11 general practices and consecutive patients taking at least one solid oral dosage form for ≥4 weeks were invited to respond to a questionnaire at the practices and one at home. Physicians completed a short questionnaire for each included patient. RESULTS: Of all participants (N = 1,051), 37.4 % reported having had difficulties in swallowing tablets and capsules. The majority (70.4 %) of these patients was not identified by their GP. The occurrence of swallowing difficulties was related to gender (f>m), age (young>old), dysphagia [adjusted odds ratio (adOR): 7.9; p < 0.0001] and mental illness (adOR: 1.8; p < 0.05). By asking "Do you choke while eating or drinking?", affected patients could be identified with a sensitivity of 62.6 % and a specificity of 78.1 %. Because of these difficulties, 58.8 % of the affected patients had already modified their drugs in a way that may alter safety and efficacy and 9.4 % indicated to be non-adherent. CONCLUSIONS: One in 11 primary care patients had frequent difficulties in swallowing tablets and capsules while GPs grossly underestimated these problems. Therefore, physicians should rule out swallowing difficulties regularly to avoid non-adherence and inappropriate drug modifications. Special attention should be paid to specific patient groups (e.g. women and patients with dysphagia, dysphagia indicators, or mental illness).

Treatment duration (persistence) of basal insulin supported oral therapy (BOT) in Type-2 diabetic patients: comparison of insulin glargine with NPH insulin.

OBJECTIVE: To compare the persistence (treatment duration) of basal insulin supported oral therapy (BOT) using insulin glargine (GLA) or NPH insulin (NPH) in Type-2 diabetic patients. METHODS: This retrospective cohort study reports results from an analysis of claims data from prescriptions for ambulatory patients within the German Statutory Health Insurance scheme. The study is based on claims data from more than 80% of German community pharmacies. Treatment duration until switching to a basal bolus treatment regimen (intensified conventional insulin therapy: ICT) was determined in insulin-naïve patients who began treatment with BOT using GLA or NPH between 01/2003 and 12/2006. RESULTS: A total of 97,998 patients (61,070 GLA and 36,928 NPH) were included. Within the observation period, 23.5% of GLA patients and 28.0% of NPH patients switched from BOT to ICT. The upper quartile of probability of continuation of therapy (the 75th percentile) was reached after 769 days in GLA patients and after 517 days in NPH patients. Therefore, the risk of switching to ICT was significantly higher with NPH compared to GLA: hazard ratios were 1.34 (99% CI: 1.29-1.38; unadjusted) and 1.22 (99% CI: 1.18-1.27) after adjustment for predefined covariates. Various sensitivity analyses using modified inclusion criteria and endpoint definitions were applied and these confirmed the initial results. CONCLUSION: Type-2 diabetic patients under BOT with GLA stayed significantly longer on the initial therapy before switching to ICT than patients on BOT using NPH.

Use of Biologic Therapies in the Treatment of Asthma - A Comparative Real World Data Analysis on Healthcare Resource Utilization and Costs Before and After Therapy Initiation.

Background: Asthma is one of the most common chronic diseases in Germany. While many patients achieve asthma control under standard therapies, some patients still experience exacerbations and persistent airway obstructions. Thus, further pharmacological treatment is needed, and biologics could fill this gap, as they have shown clinical benefit in patients with severe asthma. Therefore, this real-world study aimed to compare healthcare resource utilization (HCRU) and associated costs before and after biologic therapy initiation. Methods: A retrospective claims data analysis has been conducted on adult asthma patients who initiated a long-term biologic therapy between January 2015 and June 2018. Patients were therapy-naïve to biologics for at least 12 months. HCRU and cost incurred by patients during 12 months before and after therapy initiation were compared. Results: Overall, 571 asthma patients initiated a biologic therapy during the observational period (316 omalizumab, 232 mepolizumab, 16 benralizumab, and 7 reslizumab). Patients had a mean age of 54.86 (62.70% female), and the majority (93.70%) received at least one follow-up prescription of their index-biologic agent within one year. During baseline, patients received on average 2.75 OCS prescriptions compared to 2.17 during follow-up. Most patients received less or the same amount of OCS after therapy initiation. Moreover, hospitalizations and asthma-related sick leave days decreased significantly. The average total costs per patient were €6618.90 during baseline and €22,832.33 during follow-up. Biologics mainly drove the increase; however, hospitalization costs were reduced significantly (€2443.37 vs €1941.93; p<0.001). Conclusion: Our study demonstrates an improved asthma control due to the initiation of a biologic therapy in terms of decreased hospitalization frequency, OCS consumption, and sick leave days. However, biologics are associated with high costs for healthcare providers during the first year after initiation. Therefore, short- and long-term clinical benefits and financial burden must be considered in the overall context of healthcare.

Substantial reduction of inappropriate tablet splitting with computerised decision support: a prospective intervention study assessing potential benefit and harm.

BACKGROUND: Currently ambulatory patients break one in four tablets before ingestion. Roughly 10% of them are not suitable for splitting because they lack score lines or because enteric or modified release coating is destroyed impairing safety and effectiveness of the medication. We assessed impact and safety of computerised decision support on the inappropriate prescription of split tablets. METHODS: We performed a prospective intervention study in a 1680-bed university hospital. Over a 15-week period we evaluated all electronically composed medication regimens and determined the fraction of tablets and capsules that demanded inappropriate splitting. In a subsequent intervention phase of 15 weeks duration for 10553 oral drugs divisibility characteristics were indicated in the system. In addition, an alert was generated and displayed during the prescription process whenever the entered dosage regimen demanded inappropriate splitting (splitting of capsules, unscored tablets, or scored tablets unsuitable for the intended fragmentation). RESULTS: During the baseline period 12.5% of all drugs required splitting and 2.7% of all drugs (257/9545) required inappropriate splitting. During the intervention period the frequency of inappropriate splitting was significantly reduced (1.4% of all drugs (146/10486); p = 0.0008). In response to half of the alerts (69/136) physicians adjusted the medication regimen. In the other half (67/136) no corrections were made although a switch to more suitable drugs (scored tablets, tablets with lower strength, liquid formulation) was possible in 82% (55/67). CONCLUSION: This study revealed that computerised decision support can immediately reduce the frequency of inappropriate splitting without introducing new safety hazards.

A novel superior medication-based chronic disease score predicted all-cause mortality in independent geriatric cohorts.

OBJECTIVES: On the basis of current treatment guidelines, we developed and validated a medication-based chronic disease score (medCDS) and tested its association with all-cause mortality of older outpatients. STUDY DESIGN AND SETTING: Considering the most prevalent chronic diseases in the elderly German population, we compiled a list of evidence-based medicines used to treat these disorders. Based on this list, a score (medCDS) was developed to predict mortality using data of a large longitudinal cohort of older outpatients (training sample; MultiCare Cohort Study). By assessing receiver-operating characteristics (ROC) curves, the performance of medCDS was then confirmed in independent cohorts (ESTHER, KORA-Age) of community-dwelling older patients and compared with already existing medication-based scores and a score using selected anatomical-therapeutic-chemical (ATC) codes. RESULTS: The final medCDS score had an ROC area under the curve (AUC) of 0.73 (95% CI 0.70-0.76). In the validation cohorts, its ROC AUCs were 0.79 (0.76-0.82, KORA-Age) and 0.74 (0.71-0.78, ESTHER), which were superior to already existing medication-based scores (RxRisk, CDS) and scores based on pharmacological ATC code subgroups (ATC3) or age and sex alone (Age&Sex). CONCLUSIONS: A new medCDS, which is based on actual treatment standards, predicts mortality of older outpatients significantly better than already existing scores.

[Tablet splitting: do discount contracts influence prescribing quality?]. / Teilung von Tabletten: Welchen Einfluss haben die Rabattverträge auf die Verordnungsqualität?

BACKGROUND: In Germany, about one fourth of all tablets are split before ingestion. Since April 2007, by German law, pharmacists are legally obligated to substitute a prescribed drug for a generic drug, provided the patients' health insurance company has made corresponding contracts with pharmaceutical companies (discount contracts). However, generic drugs may differ substantially in their splitting properties. Until now it is unknown how generic substitutions due to discount contracts will influence the prescribing quality with regard to tablet splitting. METHODS: The prescription data of 425 ambulatory patients with polymedication insured at the Allgemeine Ortskrankenkasse (AOK) were analyzed and their drugs switched according to current discount contracts. RESULTS: Altogether 24% of all tablets were split before ingestion. For 54% of these split tablets (182 of 335) existing discount contracts mandated generic substitution. In about 10% of the substitutions there was a chance of substituting a scored tablet for a dosage form not suitable for splitting (unscored tablet or capsule). BACKGROUND: Therefore, current legislation should not only aim at reducing medication cost but also safeguard both effectiveness of the drugs and handling by the patients.

The impact of potentially inappropriate medication on the development of health care costs and its moderation by the number of prescribed substances. Results of a retrospective matched cohort study.

BACKGROUND: In the growing population of the elderly, drug-related problems are considered an important health care safety issue. One aspect of this is the prescription of potentially inappropriate medication (PIM) which is considered to increase health care costs. OBJECTIVE: Using data from the Health Economics of Potentially Inappropriate Medication (HEPIME) study, we aimed to analyze how the number of prescribed substances moderates the association of PIM use as defined by the German PRISCUS list and health care costs applying a longitudinal perspective. METHODS: An initial number of 6,849,622 insurants aged 65+ of a large German health insurance company were included in a retrospective matched cohort study. Based on longitudinal claims data from the four separate quarters of a 12-month pre-period, 3,860,842 individuals with no exposure to PIM in 2011 were matched to 508,212 exposed individuals. Exposure effects of PIM use on health care costs and the number of prescribed substances were measured based on longitudinal claims data from the four separate quarters of the 12-month post-period. RESULTS: After successful balancing for the development of numerous matching variables during the four quarters of the pre-period, exposed individuals consumed 2.1 additional prescribed substances and had higher total health care costs of 1,237 € when compared to non-exposed individuals in the 1st quarter of the post-period. Controlling for the number of prescribed substances, the difference in total health care costs between both study groups was 401 €. The average effect of one additionally prescribed substance (other than PIM) on total health care costs was increased by an amount of 137 € for those being exposed to a PIM. In quarters 2-4 of the post-period, the differences between both study groups tended to decrease sequentially. CONCLUSIONS: PIM use has an increasing effect on the development of health care costs. This cost-increasing effect of PIM use is moderated by the number of prescribed substances.

Higher preference for participation in treatment decisions is associated with lower medication adherence in asthma patients.

OBJECTIVE: To investigate the interrelations between medication adherence, self-management, preference for involvement in treatment decisions and preference for information in asthma patients in primary care. METHODS: One hundred and eighty-five patients from 43 practices completed a series of questionnaires, which included the 'Autonomy Preference Index' (API) [range=0-100], the four-item Morisky self-report medication adherence questionnaire and structured questions about asthma severity, medication and self-management. RESULTS: The mean (S.D.) for participation preference was 34.5 (15.3) whereas the mean (S.D.) for information preference was 91.1 (9.7). Higher participation preference was associated with stopping medication when feeling better (OR 1.03; 95%CI 1.01-1.06) or feeling worse (OR 1.02; 95%CI 1.0-1.05) but it was not related to asthma severity. Higher information preference was associated with non-adherence to medication (Spearman correlation coefficient 0.166; p=0.035) as well as the wish to receive asthma education (p=0.04) and usage of peak flow meter (p=0.05). CONCLUSION: Participation preference was low in general. Higher preference for involvement may entail more motivation for self-management but also lower medication adherence. This may be explained by a continuous internal negotiation process to accept the potentially lifelong demands of the disease. PRACTICE IMPLICATIONS: Patients with lower medication adherence may possibly be addressed and empowered by their enhanced preference for participation in treatment decisions. Physicians offering to share treatment decisions may utilise the patients' participation preference to enhance medication adherence. Due to varying participation preferences, optimal patient preference matching, which involves more flexible use of different communication styles, may be necessary to improve outcomes.