[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.

[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.

[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.

[Ambulatory geriatric rehabilitation and its legal classification within the statutory health insurance system]. / Ambulante geriatrische Rehabilitation und ihre leistungsrechtliche Einordnung in die gesetzliche Krankenversicherung.

In Germany, the number and proportion of elderly people will continue to increase. Only few hospitals and rehabilitation units are currently providing inpatient geriatric services. Concepts for graded geriatric care see ambulatory geriatric rehabilitation (AGR) as an independent service und as a complement to pre-existing structures in geriatric care. In 2004, the national association of statutory health insurance funds established recommendations for AGR, which include criteria of structural and process quality of ambulant geriatric rehabilitation. This article describes various aspects of these framework recommendations (target groups, rehabilitation indicators, and equipment of services). In addition, the classification of AGR within the legislation of the statutory health insurance system is evaluated. The financing of AGR by the statutory health insurance system and the preconditions for accreditation of AGR-services within this system are discussed. The authors conclude that discrimination between existing partially-inpatient day clinics and AGR services is not appropriate. Furthermore, there is no legal basis for such a discrimination; on the contrary, the terms partially-inpatient and ambulatory rehabilitation services can be seen as a uniform benefit according to book 5 of the German social code, SGB V. Therefore there is no differentiation between AGR and partially-inpatient rehabilitation in the statutory health insurance system.

[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.

[Outpatient geriatric rehabilitation: an evaluation of two models assessing trends of medical outcomes]. / Wohnortnahe geriatrische Rehabilitation: Evaluation zweier Modelle anhand medizinischer Verlaufskriterien.

In Germany, complex and intensified outpatient geriatric rehabilitation is currently scarcely practised, mainly in model projects. The evaluation of these projects is exclusively conducted in uncontrolled studies. In our project "AMBRA", two different organisational models of geriatric rehabilitation are compared: a mobile rehabilitation team based at a geriatric hospital department and an outpatient rehabilitation centre run by GPs trained in geriatrics. Outcomes were assessed in terms of capability of self-care (Barthel-Index), mobility (Tinetti-Test, Timed "Up & Go"-Test, TUG), and depression (Geriatric Depression Scale, GDS). They were documented at three points in time (start of rehabilitation, end of rehabilitation, 6 months after end of rehabilitation) and analysed by multivariate analyses of variance (repeated measurements). 162 complete patients histories were taken in the first 18 months of the project. They show significant improvements in capability of self-care and mobility (both Tinetti-Test and TUG) between the beginning and the end of rehabilitation (adjusted for age, sex, cognitive function, diagnosis, rehabilitation model). On a medium-term basis, these results remained stable (TUG declined, however). Average GDS values did not change significantly. There were no significant sex- or age-related effects. The patients' cognitive function influenced changes in the results of the Barthel-Index and the Tinetti-Test. Patients with skeletal diseases showed less favourable trends in the Barthel-Index as did patients with cognitive impairments caused by vascular disease in the TUG, but these patients also benefited in the course of the model rehabilitation procedures. Differences in trends between patient groups of the two models were observed in the Barthel-Index. 96 % of patients previously living at home were still living there at the end of rehabilitation, 91 % were still living there 6 months after the end of rehabilitation. At the end of rehabilitation, 67 % of patients described an improvement of their personal situation associated with the rehabilitation procedure. Six months later, 82 % described an improvement or a stabilisation of their personal situation. Our results show positive medium-term rehabilitation trends concerning medical and subjective outcomes. In order to analyse effectiveness, we will have to wait for the results of a regional control group which is being recruited.

[Outpatient geriatric rehabilitation - the structural and process quality of a geriatric mobile service team and a community-based outpatient center]. / Wohnortnahe geriatrische Rehabilitation - Zur Struktur- und Prozessqualität eines mobilen und eines ambulanten Rehabilitationsmodells.

The trial "Outpatient Geriatric Rehabilitation (AMBRA)" has been launched to compare two outpatient rehabilitation models close to their place of residence or at home: a mobile rehabilitation team based at a geriatric hospital department and a community-based outpatient rehabilitation center run by GPs. Primary analyses concerning structural and process quality of the models are presented in this paper. They refer to medical features and factors associated with care which were assessed at the beginning of the rehabilitation procedures and during intervention. The models include 60 patients attended by the mobile rehabilitation team and 76 patients attended by the outpatient rehabilitation centre. The patients are suffering from multiple illnesses and are limited in their daily activities. Both teams co-ordinate interdisciplinary rehabilitation programs with an average of 50 therapeutic units per patient under medical supervision. The programs' focus is on physiotherapy and occupational therapy and, if indicated, on logotherapy. Psychosocial and health promotional offers are hardly integrated into the procedures. The mobile rehabilitation team on average cares for patients with better cognitive functions (Mini-Mental State Examination) but worse abilities to cope in daily life (Barthel index) than the outpatient rehabilitation team. These differences between rehabilitation groups remain significant after multivariate consideration of sociodemographic, morbidity and process factors. However, differences in mobility (Tinetti Test) can be explained by these variables. The future comparison of results of the rehabilitation programs must therefore consider the different baseline levels and determinants between both groups.

[Cardiomyopathy in female carriers of the Duchenne gene]. / Kardiomyopathie bei Trägerinnen des Duchenne-Gens.

The present report describes a family with X-linked recessive muscular dystrophy. In two female carriers a myocardial involvement could be demonstrated, which dominated the clinical picture in one patient. Obviously a congestive cardiomyopathy may develop in female carriers of X-linked recessive muscular dystrophy of the Duchenne-type.