SARS-CoV-2 seroprevalence and determinants of infection in young adults: a population-based seroepidemiological study.

OBJECTIVES: Most SARS-CoV-2 seroprevalence studies have focussed on adults and high-risk populations, and little is known about young adults. The objective of the present study was to provide evidence on the SARS-CoV-2 seroprevalence among young adults in Germany and to explore determinants associated with seropositivity in general and, specifically, with previously undetected infections. STUDY DESIGN: This was a population-based SARS-CoV-2 seroprevalence study. METHODS: In November 2020, a population-based study on SARS-CoV-2 seroprevalence in young adults (aged 18-30 years) was conducted in a large German city. Serum samples were obtained to analyse the SARS-CoV-2 antibody status using the Elecsys Anti-SARS-CoV-2 immunoassay. Descriptive statistics and odds ratios (ORs) of seropositivity and of previously undetected infections in relation to different determinants were calculated. RESULTS: Among 2186 participants, SARS-CoV-2 antibodies were detected in 72 individuals, equalling a test performance-adjusted seroprevalence of 3.1% (95% confidence interval [CI]: 2.4-4.0). Based on reported COVID-19 cases to the public health authority, a moderate underascertainment rate of 1.7 was calculated. Seropositivity was higher among individuals who sought COVID-19-related information from social media (OR: 1.83, 95% CI: 1.2-3.1), and undetected COVID-19 infections were more prevalent among men and those not adhering to social distancing. CONCLUSIONS: The results show a substantial underascertainment of SARS-CoV-2 infections among young adults and indicate that seroprevalence is likely to be much higher than the reported COVID-19 prevalence based on confirmed COVID-19 cases in Germany. Preventive efforts should consider the heterogeneity of risk profiles among the young adult population.

Underascertainment of COVID-19 cases among first responders: a seroepidemiological study.

BACKGROUND: Providing frontline support places first responders at a high risk for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. AIMS: This study was aimed to determine the anti-SARS-CoV-2 seroprevalence in a cohort of first responders (i.e. firefighters/paramedics), to detect the underascertainment rate and to assess risk factors associated with seropositivity. METHODS: We conducted a serological survey among 745 first responders in Germany during 27 November and 4 December 2020 to determine the anti-SARS-CoV-2 seroprevalence using Elecsys® Anti-SARS-CoV-2 immunoassay (Roche Diagnostics, Mannheim, Germany). As part of the examination, participants were asked to provide information on coronavirus disease 2019 (COVID-19)-like-symptoms, information on sociodemographic characteristics and workplace risk factors for a SARS-CoV-2 infection and any prior COVID-19 infection. Descriptive statistics and logistic regression analysis were performed and seroprevalence estimates were adjusted for test sensitivity and specificity. RESULTS: The test-adjusted seroprevalence was 4% (95% CI 3.1-6.2) and the underascertainment rate was 2.3. Of those tested SARS-CoV-2 antibody positive, 41% were aware that they had been infected in the past. Seropositivity was elevated among paramedics who worked in the emergency rescue team providing first level of pre-hospital emergency care (6% [95% CI 3.4-8.6]) and those directly exposed to a COVID-19 case (5% [95% CI 3.5-8.1]). Overall, the seroprevalence and the underascertainment rate were higher among first responders than among the general population. CONCLUSIONS: The high seroprevalence and underascertainment rate highlight the need to mitigate potential transmission within and between first responders and patients. Workplace control measures such as increased and regular COVID-19-testing and the prompt vaccination of all personnel are necessary.

Torque Teno Virus plasma level as novel biomarker of retained immunocompetence in HIV-infected patients.

PURPOSE: To predict the course of immune recovery (IR) in HIV-1-infected patients after initiation of combined antiretroviral therapy (cART) by determination of the plasma concentration of Torque Teno Virus (TTV). TTV has been identified as marker for risk assessment in immunosuppressed patients after transplantation procedures. Here, TTV was analyzed in HIV-1-infected therapy-naïve patients to evaluate its use as predictor of the course of IR for guidance of individualized treatment. METHODS: TTV DNA was quantified in plasma samples of 301 therapy-naïve HIV-1-infected patients and correlated to CD4+ cell count, HIV viral load, presence of the herpes viruses CMV, EBV and HHV-8, age and sex. Patients were classified according to their initial CD4+ cell count and to the extent of CD4+ T-cell increase within the first year of cART. RESULTS: TTV DNA was detectable in 96% of the patients' plasma samples with a median TTV plasma concentration of 5.37 log10 cop/ml. The baseline CD4+ cell count was negatively correlated with TTV plasma concentration (p = 0.003). In patients with a CD4+ cell recovery < 50 cells/µl, the median TTV plasma concentration was significantly higher compared to patients with a CD4+ cell recovery of > 200 CD4+ cells/µl (5.68 log10 cop/ml versus 4.99 log10 cop/ml; p = 0.011). TTV plasma concentration in combination with baseline CD4+ cell count were significantly correlated to CD4+ cell recovery (p = 0.004). For all other parameters considered, no significant correlation for CD4+ cell recovery was found. CONCLUSION: Within the cohort, the significantly elevated TTV plasma concentration in patients with diminished CD4+ cell recovery indicates a more profound immune defect. Baseline TTV plasma concentrations and CD4+ cell count are predictive for the course of immune recovery in HIV-1-infected patients with severe immunodeficiency.

Hepatitis C virus (HCV) genotype 1 NS5A resistance-associated variants are associated with advanced liver fibrosis independently of HCV-transmission clusters.

OBJECTIVES: The aim of the study was to characterize the differences in the frequencies of NS3 and NS5A resistance-associated variants (RAVs) among Polish therapy-naive genotype 1 (G1) hepatitis C virus (HCV)-monoinfected and human immunodeficiency virus (HIV)/HCV-coinfected patients including clustering patterns and association of RAV frequency with liver fibrosis. METHODS: NS3/NS5A RAVs were identified by population sequencing in 387 directly acting antiviral treatment-naive G1-infected individuals (54 with genotype 1a (G1a) and 333 with genotype 1b (G1b)). Liver fibrosis was assessed based on histopathology or ultrasound elastography. Phylogenetic clusters were identified using maximum likelihood models. For statistics, chi-squared or two-sided Fisher's exact tests and multivariate logistic regression models were used, as appropriate. RESULTS: NS3 RAVs were found in 33.33% (18/54) for G1a and 2.62% (8/297) for G1b whereas NS5A variants were present in 5.55% (3/54) G1a and 9.31% (31/333) G1b sequences. Variations in NS5A 31 and 93 codon positions were found only in G1b (4.2% (14/333) for L31I/F/M and 5.39% (17/333) for Y93H). NS5A RAVs were more frequent among patients with advanced liver fibrosis (17.17% (17/99) for F3-F4 versus 6.94% (17/245) for F0-F2; p 0.004) or liver cirrhosis (20.34% (12/59) for F4 versus 7.72% (22/285) for F0-F3; p 0.003). Liver cirrhosis (F4) was associated with higher odds ratio of the NS5A RAVs among HCV-infected patients (odds ratio 2.34, 95% CI 1.004-5.291; p 0.049). NS5A RAVs were less frequent among sequences forming clusters and pairs (5.16% (8/155) versus 11.21% (26/232); p 0.039). CONCLUSIONS: Presence of NS5A RAVs correlated with progression of liver fibrosis and represents de novo selection of variants rather than transmission of drug resistance. Hence, the presence of NS5A RAVs may be a predictor for a long-lasting HCV infection.

[Future Trends in Medical Rehabilitation in the Context of Multimorbidity - Part II: Structural Requirements to Manage an Appropriate Rehabilitative Healthcare]. / Die Zukunft der medizinisch-rehabilitativen Versorgung im Kontext der Multimorbidität ­ Teil II: Strukturelle Voraussetzungen und Anforderungen an das rehabilitative Versorgungssystem.

BACKGROUND: Rehabilitative health care is paying increasing attention to multimorbid people with 2 and more coexistent chronic diseases of sociomedical relevance. METHODS: Terms, requirements, design, configuration, challenges and supply of sociomedical rehabilitation were described in part I. A project group of the Medical Advisory Board of the Federal Rehabilitation Council describes manifold fields of actions to be taken in the rehabilitation of persons with multimorbidity. RESULTS: The actions proposed range from reviewing existing forms of management to identifying rehabilitative needs and initiating accurately fitting interventions, sensitizing and enlarging competences of involved personnel, considering multimorbidity in guidelines and further research on questions still open.

[Future Trends in Medical Rehabilitation in the Context of Multimorbidity - Part I: Definition of Terms, Issues and Challenges]. / Die Zukunft der medizinisch­rehabilitativen Versorgung im Kontext der Multimorbidität ­ Teil I: Begriffsbestimmung, Versorgungsfragen und Herausforderungen.

BACKGROUND: Rehabilitative health care is increasingly focusing its attention on multimorbid people with 2 and more coexistent chronic diseases of sociomedical relevance. METHODS: After defining the term "multimorbidity" in the context of rehabilitative health care, an exploratory overview of the prevalence and clinical implication of this condition as reported in the literature was drafted. Based on a case history, special attention was paid to general as well as special challenges regarding design, configuration and supply of sociomedical rehabilitative care. Consensus was achieved with the Health Advisory Board of the German Federal Rehabilitation Council. RESULTS: The proposed actions necessary for the healthcare of persons with multimorbidity include specific function-oriented individual assessment of needs via the distinctive allocation, selection and performance of rehabilitative procedures as well as post-rehabilitative care until the patient's reintegration into his social environment.

[Correction: Future Trends in Medical Rehabilitation in the Context of Multimorbidity - Part I: Definition of Terms, Issues and Challenges]. / Errata: Die Zukunft der medizinisch­rehabilitativen Versorgung im Kontext der Multimorbidität ­ Teil I: Begriffsbestimmung, Versorgungsfragen und Herausforderungen.

W. SEGER, W. CIBIS, A. DEVENTER, S. GROTKAMP, N. LüBKE, P.-W. SCHöNLE, M. SCHUBERT. DIE ZUKUNFT DER MEDIZINISCH-REHABILITATIVEN VERSORGUNG IM KONTEXT DER MULTIMORBIDITäT - TEIL I: BEGRIFFSBESTIMMUNG, VERSORGUNGSFRAGEN UND HERAUSFORDERUNGEN KüNSTLERISCHE THERAPEUTEN IM GESUNDHEITSWESEN. GESUNDHEITSWESEN 2016;: Bei diesem Beitrag fehlte ein Autor und die zugehörige Institutsangabe. Nachfolgend die ergänzten Autoren und Institute: AUTOREN:: W. Seger1, W. Cibis2, A. Deventer3, S. Grotkamp4, N. Lübke5, P.-W. Schönle6, M. Schmidt-Ohlemann7, M. Schubert2 INSTITUTE:: 1 MDK Niedersachsen, Hannover 2 Bundesarbeitsgemeinschaft für Rehabilitation (BAR), Frankfurt 3 Praxis für Physikalische und Rehabilitative Medizin, Hamburg 4 MDK Niedersachsen, SEG 1, Hannover 5 Kompetenz-Centrum Geriatrie (KCG), Hamburg 6 Maternus Kliniken, Bad Oeynhausen 7 Diakonie Bad Kreuznach, Rehabilitationsklinik, Bad Kreuznach.

[Mobile geriatric rehabilitation in nursing homes, in short-term care facilities and private homes : Setting-specific analysis of nationwide treatment documentation (Part 2)]. / Mobile geriatrische Rehabilitation in Pflegeheim, Kurzzeitpflege und Privathaushalt : Settingspezifische Auswertung der bundesweiten Basisdokumentation (Teil 2).

BACKGROUND: Mobile geriatric rehabilitation can be provided in the setting of nursing homes, short-term care (STC) facilities and exclusively in private homes. OBJECTIVE: This study analyzed the common features and differences of mobile rehabilitation interventions in various settings. MATERIAL AND METHODS: Stratified by setting 1,879 anonymized mobile geriatric rehabilitation treatments between 2011 and 2014 from 11 participating institutions were analyzed with respect to patient, process and outcome-related features. RESULTS: Significant differences between the settings nursing home (n = 514, 27 %), STC (n = 167, 9 %) and private homes (n = 1198, 64 %) were evident for mean age (83 years, 83 years and 80 years, respectively), percentage of women (72 %, 64 % and 55 %), degree of dependency on pre-existing care (92 %, 76 % and 64 %), total treatment sessions (TS, 38 TS, 42 TS and 41 TS), treatment duration (54 days, 61 days and 58 days) as well as the Barthel index at the start of rehabilitation (34 points, 39 points and 46 points) and the gain in the Barthel index (15 points, 21 points and 18 points), whereby the gain in the capacity for self-sufficiency was significant in all settings. CONCLUSION: The setting-specific evaluation of mobile geriatric rehabilitation showed differences for relevant patient, process and outcome-related features. Compared to inpatient rehabilitation mobile rehabilitation in all settings made an above average contribution to the rehabilitation of patients with pre-existing dependency on care. The gains in the capacity for self-sufficiency achieved in all settings support the efficacy of mobile geriatric rehabilitation under the current prerequisites for applicability.

[Mobile geriatric rehabilitation in statutory health insurance: Conceptual strategy and results of a nationwide treatment documentation (Part 1)]. / Mobile geriatrische Rehabilitation in der gesetzlichen Krankenversicherung: Konzeptionelle Ausrichtung und Ergebnisse der bundesweiten Basisdokumentation (Teil 1).

BACKGROUND: Insurants have a statutory right to mobile rehabilitation in which a multidisciplinary team carries out treatment in the familiar home environment. Framework recommendations in geriatric medicine were presented by the statutory health insurance (SHI) and a standardized treatment documentation was implemented nationwide. OBJECTIVE: This article presents the conceptual design and selected results from this treatment documentation and reports on the established practice. MATERIAL AND METHODS: A total of 1879 anonymized cases of mobile geriatric rehabilitation carried out between 2011 and 2014 from 11 participating institutions were analyzed with respect to patient and process-related features. RESULTS: The patients were on average 81 years old and 61 % were female. The mobile rehabilitation was provided on average over 22 treatment days over a period of 8 weeks and in 84 % of cases following hospital treatment. Of the rehabilitation patients 27 % lived in a care home prior to treatment and 73 % were already allocated to a care level. The statistically significant gain in capacity for self-sufficiency was 18 points on the Barthel index at the end of the rehabilitation. The majority of treatment was provided by physiotherapists and occupational therapists followed by speech therapists and nursing personnel. Relevant differences were detected between the institutions regarding the indications, access route, therapy combinations, treatment frequency, scope and duration. At the same time individual requirements from the framework recommendations were sometimes not met. CONCLUSION: Even though the treatment documentation does not replace any external mobile rehabilitation quality assurance, it provides transparency in a still very limited range of services that are sometimes differently implemented at institutions. It therefore provides the basis for further development of mobile out-patient rehabilitation in SHI.

[Ten years of early complex geriatric rehabilitation therapy in the DRG system]. / 10 Jahre geriatrische frührehabilitative Komplexbehandlung im DRG-System.

BACKGROUND: Geriatric medicine, as a specialized form of treatment for the elderly, is gaining in importance due to demographic changes. Especially important for geriatric medicine is combining acute care with the need to maintain functionality and participation. This includes prevention of dependency on structured care or chronic disability and handicap by means of rehabilitation. METHODS AND MATERIALS: Ten years ago, the German DRG system tried to incorporate procedures (e.g., "early rehabilitation in geriatric medicine") in the hospital reimbursement system. OPS 8-550.x, defined by structural quality, days of treatment, and number of therapeutic interventions, triggers 17 different geriatric DRGs, covering most of the fields of medicine. OPS 8-550.x had been revised continuously to give a clear structure to quality aspects of geriatric procedures. However, OPS 8-550.x is based on proven need of in-hospital treatment. In the last 10 years, no such definition has been produced taking aspects of the German hospital system into account as well as aspects of transparency and benefit in everyday work. RESULTS: The German DRG system covers just basic reimbursement aspects of geriatric medicine quite well; however, a practicable and patient-oriented definition of "hospital necessity" is still lacking, but is absolutely essential for proper compensation. A further problem concerning geriatric medicine reimbursement in the DRG system is due to the different structures of providing geriatric in-hospital care throughout Germany.

[Medical rehabilitation preventing long-term care for the elderly: analysis based on routine data]. / Rehabilitation vor Pflegebedürftigkeit im Alter: eine Analyse anhand von Routinedaten.

BACKGROUND: Medical rehabilitation of statutory health insurance (SHI) in Germany aims at prevention of (increasing) disability and thus the need for long-term care. The paper examines the inpatient rehabilitation care utilization in the elderly based on claims data, taking into account the need of pre-existing long-term care (LTC) in according to the German Long-Term Care Insurance and further changes (survival, LTC level). METHODS: Anonymous data from inpatient medical rehabilitation of AOK-insured patients ≥ 65 years (2008/2009) following different treatment pathways were evaluated: early rehabilitation while hospital treatment (FR), combined treatment with early and subsequent rehabilitation (F-/AR), subsequent rehabilitation after hospital treatment (AR); rehabilitation without previous hospital treatment (SR). Survival and LTC-Level (higher level=higher care demands) were tracked for 12 months after utilization of rehabilitation. RESULTS: The extent of pre-existing levels of LTC ≥ 1 was in FR 44.1%, in F-/AR 19.1%, in AR 10.1% and in SR 15.9%. Above-average shares of geriatric indications and below-average shares of orthopaedic indications were observed for all 4 groups. LTC levels remained unchanged for varying percentages of patients in the treatment groups (FR 57%, F-/AR 46%, AR 85%, SR 92%). Higher LTC-Levels were observed for 42% of cases in the FR group, 54% in the F-/AR group, and only 14% and 7% in the AR and the SR group respectively. Lower LTC-Levels could be found in less than 1% of the cases in all groups. Survival rates varied significantly (72% FR, F-/AR 84%, AR 92% and 96% SR). Cases with a pre-existing care level had significantly reduced survival rates. The results could be confirmed after standardization for age and gender. CONCLUSION: The current application of the legal principle "rehabilitation before LTC" for older insurants is in SHI mainly segmented afterwards or integrated into hospital treatment but rarely combined intersectoral or conducted without immediately preceding hospital-treatment.

[Geriatric multimorbidity in claims data: part 3: prevalence and predictive power of geriatric conditions in an age-specific systematic sample]. / Geriatrietypische Multimorbidität im Spiegel von Routinedaten : Teil 3: Prävalenz und prädiktiver Wert geriatrietypischer Merkmalskomplexe in einer systematischen Altersstichprobe.

BACKGROUND: In various contexts, the identification of insurants with geriatric conditions (GC) can offer new approaches for specific medical services. GC can be determined from diagnoses data of insurants retrieved from different care sectors, and supplemented with other relevant claims data, e.g., long-term care levels and pharmaceutical data. METHODS: Part 3 of this study is based on a systematic sample of 957,447 AOK insurants (age ≥ 60 years). Prevalence of 15 GC was investigated using anonymous claims data of diagnoses from physicians in the ambulant care setting and diagnoses from hospital settings in 2008. In addition the potential relationships of GC with mortality, nursing home admission, need for long-term care and hospital utilization in the following year were examined. All results were standardized by gender and age based on the general population aged ≥ 60 years in Germany. RESULTS: Pain and impairment of vision or hearing was the most common GC (> 25%) followed by high risk of complications, fall risk/dizziness, and cognitive deficit (8-14%). Delayed convalescence, frailty, medication problems, immobility and malnutrition occurred in < 1% of the insurants. Almost all GC occurred more often with increasing age. Only 37% insurants in the sample showed no GC, while for 31% exactly one, for 17% two, and for 15% three or more GC were observed. With the exception of pain and impairment of vision or hearing all of the GC had a significant positive association with mortality, nursing home admission, increasing need of care, and hospital utilization in the following year. CONCLUSIONS: The applied operational approach proved to be generally practicable and successful with few adaptations. The GC pain and impairment of vision or hearing, however, do not contribute sufficiently to the identification of geriatric multimorbidity based on claims data. These GC should be therefore disregarded from such identification processes. To enhance the reliability of an identified geriatric multimorbidity, the requirements on the specificity and number of individual GC (two, three, or more) can be adapted.

[Geriatric multimorbidity in claims data - part 1. Analysis of hospital data and long-term care insurance data]. / Geriatrietypische Multimorbidität im Spiegel von Routinedaten - Teil 1 : Auswertung von stationären Krankenhausdaten und Pflegedaten.

BACKGROUND: In Germany, typical geriatric multimorbidity is--next to age itself--of special significance for the identification of target groups for specific geriatric care offers. The present article primarily focuses on typical geriatric multimorbidity in the claims data of statutory health insurance and long-term care insurance in Germany. Using the definition of "the geriatric patient" that is agreed on by providers of services as well as by cost bearers, geriatric multimorbidity is defined as the coexistence of at least 2 of 15 typical geriatric conditions. A suggestion made by the German Geriatric Association was to assign ICD-10-GM codes to each of these 15 conditions. Thus, it becomes possible to identify the corresponding geriatric conditions in claims data. METHODS: The article investigates the frequency of geriatric conditions and, thus, of geriatric multimorbidity of patients aged ≥ 60 years admitted to a hospital with a geriatric ward. Patients treated in a geriatric ward were compared with those who did not receive geriatric care. In anticipation of a high correlation between typical geriatric conditions and specific features that are preconditions for receiving long-term care insurance benefits (such as care levels and status of a nursing home resident), claims data of the long-term care insurance were included for external validation. RESULTS: The analyses showed a distinctly higher proportion of insured people with typical geriatric multimorbidity or rather a certain care level among the geriatrically treated cases than among those patients not receiving geriatric treatment (68.5%/67.9% versus 24.2%/33.4%). The different proportions of typical geriatric multimorbidity coded among the patients with features of a certain care level in the two given groups give rise to the suspicion that typical geriatric multimorbidity is not always statistically recorded--especially in cases of treatment without provision of geriatric care. CONCLUSION: The frequency of cases of typical geriatric multimorbidity and a certain care level shows that--even when a specific geriatric offer exists--a considerable proportion of cases with typical geriatric conditions are treated in other medical departments.

[Geriatric multimorbidity in claims data - part 2 : diagnoses of hospitals and diagnoses from physicians in the ambulatory setting]. / Geriatrietypische Multimorbidität im Spiegel von Routinedaten - Teil 2 : Ambulante und stationäre Diagnosen bei geriatrisch versorgten und pflegebedürftigen Versicherten.

BACKGROUND: Due to demographics, characteristic multimorbidity in geriatric patients is resulting in increased social, medical, and healthcare challenges. Geriatric multimorbidity (GM) can be defined as the simultaneous occurrence of at least two diseases that require medical care with an interdisciplinary focus on independence in activities of daily living. Typical conditions of GM are, e.g., incontinence, cognitive impairment, frailty, and decubitus. MATERIAL AND METHODS: Part 2 of this study is based on claims data of 240,502 AOK insurants (AOK is one of the major health insurance companies of the German statutory health insurance system) aged ≥ 60 years with at least one admission to a hospital with a geriatric ward. Geriatric conditions (GCs) were ascertained in two ways: diagnoses from physicians in the ambulant care setting and diagnoses in a hospital setting in 2008. A total of 15 GC were assessed using diagnoses based on ICD-10 codes (as per suggestion from scientific geriatric societies). An insurant was defined as a person with GM, if he/she had at least two GCs. RESULTS: The proportion of GCs in ambulant or inpatient diagnoses of 240,502 insurants varied significantly in most cases. For specific GCs, considerably higher proportions of ambulant diagnoses (e.g., pain, impairment of vision, or hearing) or for inpatient diagnoses (e.g., electrolyte or fluid metabolism disorders, malnutrition, incontinence) were identified. Only on rare occasions were small differences observed comparing the proportions of specific GCs in the diagnoses of the two different care sectors. This finding reduces considerably the accordance between the two care sectors with reference to the presence or absence of a GC for ambulant or inpatient diagnoses. The main agreement was with the non-coding of specific GCs, not with ambulant or inpatient diagnoses. Insurants with a geriatric hospital admission or certain care level (level ≥ 1) generally had higher proportions for specific GCs for inpatient and ambulant diagnoses than non-geriatric treated insurants or insurants without a certain care level. Of the geriatric treated insurants and those with certain care levels, 90% were characterized by the presence of GM for both ambulant or inpatient diagnoses. This percentage is remarkably higher than for patients who featured no geriatric treatment or had no certain care level. CONCLUSION: The inclusion of ambulant diagnoses in addition to inpatient diagnosis offers comprehensive possibilities to identify insurants with GM in claims data. The contribution of the diagnoses of both care sectors for the identification of GC and GM varies with regard to attribute and insurant orientation. Furthermore, significant attribute-oriented overlap of insurants claiming geriatric treatments and insurants with certain care levels became visible, which can open new possibilities for simpler identification of a portion of patients with GM.

[Perspectives in rehabilitation. General position paper on future trends and challenges in rehabilitation by the Health Advisory Board of the German Federal Association for Rehabilitation]. / Perspektiven der Rehabilitation. Ein Positionspapier des Arztlichen Sachverständigenrates der Bundesarbeitsgemeinschaft f ü r Rehabilitation (BAR) zur Weiterentwicklung der Rehabilitation.

The Health Advisory Board of the German Federal Association for Rehabilitation (BAR) describes future trends and challenges in rehabilitation as deriving from the socio-demographic development in Germany and the structural characteristics of its Social and Health Care Insurance System. The focus is on elder employees to sustain and regenerate their capacity for employment, on people which are no longer employed to activate their autonomy and ability for self-support, and on rehabilitation as a holistic and integrative process extending through the social security and health insurances. There is an urgent need and a real chance to benefit from already existing scientific findings more frequently and to integrate them effectively into adequate further education and training programmes for professionals. Finally the conclusion summarises 8 theses to facilitate rehabilitation as an integral and essential part of the German social security and health sector. This paper was fully accredited by the members of the BAR Managing Board.

[Current appraisal of external quality assurance procedures in geriatric rehabilitation]. / Aktuelle Bestandsaufnahme externer Qualitätssicherungsverfahren im Bereich geriatrischer Rehabilitation.

Seven standardized external quality assurance (QA) procedures are currently being applied in geriatric rehabilitation in Germany. Five of these procedures are case-based (Gemidas, GiB-DAT, KODAS, EVA-Reha, Evaluation Procedures of the Medical Review Board of Saxony), and two are institution-based (Quality Seal for Geriatric Rehabilitation in Rhineland-Palatinate, Quality Seal for Geriatrics BAG KGE). The institution-based procedures focus on the quality dimensions "structure" and "process", whereas the case-based procedures mainly focus on the collection of administrative data, and to a limited extent on the quality dimensions "outcomes" and "patient satisfaction". The outcome quality parameters used in the case-based QA procedures are usually the "place of discharge" versus the "place of residence", the "improvement in coping with daily activities" (mostly based on the Barthel Index), and the "improvement in mobility and gait" (based on the Timed Up & Go). So far, outcomes to be specified at the beginning of rehabilitation measures have only been defined in few procedures, and only to a basic degree or on a trial basis. In the institution-based procedures, the data are mainly collected by external data collectors, whereas in the case-based procedures, they are collected by the service providers themselves. In most procedures, data processing and analysis are performed independently of the participating service providers but only partly independently of the agency responsible for the procedure and the whole group of service providers. In the case-based procedures, risk adjustment techniques are not routinely applied in comparisons between institutions. Attempts to implement standardised QA procedures in geriatric rehabilitation may be based on existing procedures and should use this appraisal for developing them further, however taking more into account QA aspects specific to geriatrics.

[Expansion or reduction of geriatric care structures in Germany? A critical analysis on the significance of the official statistics and other surveys]. / Auf- oder Abbau geriatrischer Versorgungsstrukturen in Deutschland? Kritische Analyse zur Aussagekraft der amtlichen Statistik und anderweitiger Erhebungen.

The legal survey basis for the hospital statistics of the Statistisches Bundesamt (German Federal Statistical Office) affecting the recording of data starting in the year 2002 has been also adjusted to improve the quality of information on geriatric care structures. The basic hospital statistics data for the year 2003 published in April 2005 report 171 geriatric hospital facilities for in-house treatment and 97 for partial in-house treatment as well as 74 geriatric rehabilitation facilities for inpatient treatment. In an additional internal investigation, another 46 geriatric rehabilitation facilities for outpatient treatment were ascertained for the year 2003. Compared to other, earlier surveys, the Statistisches Bundesamt reports an almost equal number of geriatric care facilities in the hospital sector, but a far lower number of such facilities in the sector of rehabilitation facilities for inpatient treatment, and therefore is highly incomplete. Hence, despite modified recording conditions, the official statistics do not provide a realistic representation of geriatric care structures. Under consideration of these limitations and corresponding corrections, the average geriatric care ratio (inpatient and partial inpatient or out-patient geriatric treatment places in hospitals and rehabilitation facilities per 10,000 persons aged 65 and above) amounted to 10.2 geriatric treatment units in 1997, 12.2 in 2000, and 12.3 in 2003. There were significant differences regarding the total capacity and the shares of different kinds of geriatric care structures in the individual federal states. All in all, that means that the expansion of geriatrics that had taken place until the year 2000 has slowed down significantly over recent years and has largely been limited to demographic adjustments. As far as the relevance of reliable numbers on the existence of geriatric care structures for requirement planning, secondary statistics, and state-related comparative analyses is concerned, the ongoing weaknesses of the hospital statistics must be taken into account when developing corresponding interpretations. They call for examining further improvements of the procedure of recording geriatric facilities for the official statistics. So far, they are no reliable basis for cross-sectional analysis.

[Required competence in geriatrics in the view of the Competence Center for Geriatrics]. / Erforderliche Kompetenzen der Geriatrie aus Sicht des Kompetenz-Centrums Geriatrie.

The geriatric patient is defined by a high specific risk that is taken into account by the special geriatric treatment concept. This risk relates to suffering from the permanent and significant loss of earlier functional independence caused by relatively trivial accessory conditions or other changes to the personal situation or falling in need of or increasing the need for care. It results from the geriatric patient's limited reserve capacities that are caused by physiological age-related limitations of organ and organ system reserves and/or manifested or at least latent functional impairments. A rather narrow definition of the geriatric patient based on this specific risk is a key criterion for the future systematic integration of geriatric care into the health service. In such a definition, use of the age component alone is adequate only from a very old age on. The high-risk group of geriatric patients narrowly defined in such a way also calls for primary medical geriatric case management: from commencement of a treatment throughout its entire course, from therapy to rehabilitation to longterm and outpatient care. This comprises first and foremost an comprehensive geriatric assessment and a treatment oriented primarily towards achieving quality of life and independence, medical treatment control including a systematic risk management system, continuous patient support, even in case of other temporary, specific treatments, the individual use of early rehabilitative treatments and the coordination of secondary treatment initiatives. Positioning geriatrics in the health care system in such a way means that the required skills extend beyond a general knowledge of geriatric medicine. Above all, high generic treatment expertise and experience in geriatric rehabilitation are also needed. Additionally, the guide and support function of the geriatrician demands a willingness to take special medical and ethical responsibility and an abundant ability to integrate and communicate. The education, training and development initiatives for attaining geriatric qualifications must satisfy these requirements. Lasting efficient geriatric care concepts also call for the appropriate skills in primary medical outpatient care.

[Preventive home visits to the elderly: systematic review of available evidence]. / Präventive Hausbesuche im Alter: eine systematische Bewertung der vorliegenden Evidenz.

The aim of preventive home visits to elderly persons is to reduce mortality, to avoid admissions to nursing homes and hospitals and to improve the functional status and general wellbeing of the elderly. Preventive home visits are rarely a standard service in national health care systems. For over 20 years, controlled randomized studies have been carried out to test their effectiveness. This systematic review evaluates the evidence available on preventive home visits for elderly persons in the context of considerations relating to the incorporation of such a service into the German health care system. Three current systematic reviews (two of them meta-analyses) were identified in a systematic literature survey. They consider a total of 26 studies, most of them RCTs. A further three original controlled studies were identified and evaluated. The original studies were very heterogeneous with respect to goals, target groups, intensity and duration of the home visit programme and with respect to the individuals performing the study (number, profession, qualifications and cooperation). This makes it more difficult to perform a pooled overall evaluation. It was possible to consider mortality, admissions to nursing homes, functional status and psychosocial status as relevant target parameters. The systematic reviews arrive at different assessments of effectiveness. A quantitative, across-studies evaluation demonstrated that preventive home visits to elderly persons were effective both in studies with selected and with unselected inclusion of participants. The second meta-analysis did not confirm this result. Effectiveness here was only demonstrated using stratified analyses which investigated a large number of home visits, the performance of a multidimensional assessment with follow-up visits and the average age and morbidity of participants as relevant influencing factors. However no factor exerted an influence over more than one of the investigated target parameters. The findings thus constitute very unspecific evidence of effectiveness with largely unclear determinants of success. Preventive home visit programmes have been tested in various health systems. Results from controlled (randomised) German studies have not been published to date. The results of studies from other countries have only limited applicability to the conditions in the German health care system because the opportunities for, and extent of, economical and effective improvement in the preventive care of the elderly depend on the standard of care existing in the individual country. The additional value of screening depends on the empirical level of care and not on a given standard. At present the introduction of home visits in Germany cannot be recommended beyond studies. However there appear to be sufficient reasons for controlled studies in Germany which should be carried out in a coordinated way with mutual agreement on concepts.