[Travel time to memory clinics in Bavaria: A geographical analyses within the framework of digiDEM Bayern]. / Räumliche Erreichbarkeit von Gedächtnisambulanzen ­ Eine geographische Analyse im Rahmen von digiDEM Bayern.

BACKGROUND: Memory clinics can contribute significantly to a qualified diagnosis of dementia. Since the accessibility of medical facilities is an important predictor for their utilisation, the aim of this study was to determine the accessibility of memory clinics for persons with dementia in Bavaria. METHODS: We used a Geographic Information System (GIS) to determine travel times to the nearest memory clinic for all Bavarian municipalities based on OpenStreetMap road network data. RESULTS: The majority of the modelled persons with dementia in Bavaria (40%; n = 93,950) live in communities with an average travel time of 20 to 40 minutes to the nearest memory clinic. Almost 7,000 (3%) require more than one hour. Especially persons from rural communities have to travel significantly longer distances than people from urban areas. CONCLUSION: In view of demographic developments, there is an urgent need for memory clinics to be accessible throughout the country for all persons with dementia, regardless of where they live. The systematic development of memory clinics in areas with long travel times or the establishment of mobile diagnostic services could help to improve dementia care.

Health Technology Assessment-Informed Decision Making by the Federal Joint Committee/Institute for Quality and Efficiency in Health Care in Germany and the National Institute for Health and Care Excellence in England: The Role of Budget Impact.

OBJECTIVES: This study aimed to test (official) evaluation criteria including the potential role of budget impact (BI) on health technology assessment (HTA) outcomes published by the Federal Joint Committee (Gemeinsamer Bundesausschuss [GBA]) and the Institute for Quality and Efficiency in Health Care (Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen [IQWiG]) in Germany as well as the National Institute for Health and Care Excellence (NICE) in England. METHODS: Data were extracted from all publicly available GBA decisions and IQWiG assessments as well as NICE single technology appraisals between January 2011 and June 2018, and information with regard to evaluation criteria used by these agencies was collected. Data were analyzed using logistic regression to estimate the effect of the BI on the HTA outcomes while controlling for criteria used by GBA/IQWiG and NICE. RESULTS: NICE recommendations are largely driven by the incremental cost-effectiveness ratio and, if applicable, by end-of-life criteria (P < .01). While IQWiG assessments are significantly affected by the availability of randomized controlled trials and patient-relevant endpoints (P < .01), GBA appraisals primarily focus on endpoints (P < .01). The BI correlated with NICE single technology appraisals (inverted-U relationship, P < .1) and IQWiG recommendations (increasing linear relationship, P < .05), but not with GBA decisions (P > .1). Nevertheless, given that IQWiG assessments seem to be more rigorous than GBA appraisals regarding the consideration of evidence-based evaluation criteria, decisions by GBA might be negatively associated with the BI. CONCLUSIONS: Results reveal that GBA/IQWiG and NICE follow their official evaluation criteria consistently. After controlling for all significant variables, the BI seems to have an (independent) effect on HTA outcomes as well.

[Advance Directives and Palliative Medical Care in Nursing Homes: A Study on Everyday Life and Relevance in Out-of-Hours Medical Care]. / Patientenverfügungen und palliative ärztliche Versorgung in Pflegeheimen ­ Studie zu Alltag und Relevanz außerhalb regulärer Praxiszeiten.

BACKGROUND: The percentage of nursing home residents that have documented advance directives (AD) is increasing. However, there are no studies concerning the consideration of these directives within the out-of-hours primary care or the emergency service. There is also a lack of information on the differences in the attitudes of doctors on duty in various disciplines towards therapeutic options in palliative situations. METHODS: In the context of research about the medical care of nursing home residents outside regular practice hours, the existence of AD and their consideration by the doctors on duty or emergency doctors was investigated (n=101). Furthermore, the attitudes of the doctors on duty (n=60) and of a reference group of palliative doctors (n=19) towards experience in palliative medicine, asking for AD of the patients and the approach in a fictive palliative case were recorded. RESULTS: 71% of the 82 residents had documented a living will. In 54% of the 101 cases, the doctors on duty and emergency doctorsmade enquiries about AD. In 92% of cases, the doctors followed the given directives. Significant differences between doctors on duty and emergency doctors could not be confirmed. Given a fictive palliative case, 92% of the doctors on duty and 95% of the reference group stated they would enquire about an AD. In acute palliative situations, general practitioners, internists and palliative physicians were more likely to use rapid-acting opioids and anxiolytics, were less likely to call the emergency doctor and were less likely to admit patients to hospital. This distinguishes them from other disciplines. CONCLUSIONS: In only 54% of all contacts between patient and doctors on duty or emergency doctors, enquiries were about an AD. That is why doctors need to be further sensitized on the issue of making enquiries about AD from unknown. Additionally, the patient's will should be visible in short form in the respective patient file. Arrangements made with foresight, early involvement of doctors with palliative experience (AAPV, SAPV) as well as increased palliative medical training could improve the care of nursing home residents.

[Can nursing home placement of people with dementia be delayed by case management? A Systematic Review of Randomized Controlled Trials]. / Kann Case Management den Umzug von Menschen mit Demenz in eine Pflegeeinrichtung verzögern? ­ Ein systematisches Review randomisiert kontrollierter Studien.

BACKGROUND: Dementia is one of the main reasons for care dependency in old age. Demographic changes will lead to decreased formal and informal care potential in Germany. The promotion of structured home care arrangements therefore becomes increasingly significant. The concept of case management (CM) aims at the efficient coordination of health care services based on the needs and resources of patients with chronic health issues and their caregivers. The objective of this review was to evaluate current studies on the effectiveness of outpatient CM approaches on delaying long-term care placement or reducing the risk of long-term care placement in people with dementia. METHODS: A systematic literature review of randomized controlled trials (RCTs) was conducted. Relevant electronic databases (Pubmed, CINAHL, PsycINFO, Scopus, CENTRAL, Gerolit, ALOIS) were systematically searched. Reporting and study quality was assessed using the CONSORT checklist and Jadad scale. RESULTS: The search strategies identified 6 RCTs relating to 5 different health care systems (Germany, USA, Netherlands, France, China). Three of the RCTs showed significant delays of long-term care placements and/or significantly reduced rates of long-term care placement in favor of the intervention groups. CONCLUSION: The outcomes suggest that CM approaches have the potential of promoting the length of time that people with dementia remain in their own domestic environments. Further establishment and evaluation of CM approaches should therefore be strongly encouraged on the part of healthcare decision-makers. When planning and evaluating CM approaches, specific barriers, and resources for the sustainable implementation of CM in existing care chains should be assessed and taken into account.

[Current Evidence for Assessing Fitness to Drive of People with Cognitive Impairment: A Systematic Review]. / Aktuelle Evidenzlage zur Beurteilung der Fahrtauglichkeit von Menschen mit kognitiven Einschränkungen: Ein systematisches Review.

BACKGROUND: Assessment of driving ability in people with cognitive impairment is a topic of great social relevance due to the high prevalence of dementia. METHODS: A comprehensive systematic literature review was conducted on the research question, "Which evidence-based methods are suitable for assessing the fitness to drive of people with dementia or mild cognitive impairment?" for the period 2015-2020. The search was conducted in the Medline, PsycINFO, LIVIVO, PubPsych, Scopus, Cinahl, and CENTRAL databases. RESULTS: Thirty studies were included in the qualitative analysis. Driving ability can be assessed with practice-based testing procedures such as On-road Driving, Simulator, and Naturalistic Driving. Theory-based methods include neuropsychological testing, driving-specific testing, and self-assessment questionnaires. Studies show that single neuropsychological tests are not sufficient to determine fitness to drive. Practice-based test procedures, driving-specific tests, and combinations of evidence-based methods have a higher informative value. CONCLUSIONS: In view of the progressive course of dementia, the assessment of driving ability of people with cognitive impairment should be performed in a close-meshed way by a combination of theory- and practice-based methods.

Prediction of Recurrent Ischemic Stroke Using Registry Data and Machine Learning Methods: The Erlangen Stroke Registry.

BACKGROUND: There have been multiple efforts toward individual prediction of recurrent strokes based on structured clinical and imaging data using machine learning algorithms. Some of these efforts resulted in relatively accurate prediction models. However, acquiring clinical and imaging data is typically possible at provider sites only and is associated with additional costs. Therefore, we developed recurrent stroke prediction models based solely on data easily obtained from the patient at home. METHODS: Data from 384 patients with ischemic stroke were obtained from the Erlangen Stroke Registry. Patients were followed at 3 and 12 months after first stroke and then annually, for about 2 years on average. Multiple machine learning algorithms were applied to train predictive models for estimating individual risk of recurrent stroke within 1 year. Double nested cross-validation was utilized for conservative performance estimation and models' learning capabilities were assessed by learning curves. Predicted probabilities were calibrated, and relative variable importance was assessed using explainable artificial intelligence techniques. RESULTS: The best model achieved the area under the curve of 0.70 (95% CI, 0.64-0.76) and relatively good probability calibration. The most predictive factors included patient's family and housing circumstances, rehabilitative measures, age, high calorie diet, systolic and diastolic blood pressures, percutaneous endoscopic gastrotomy, number of family doctor's home visits, and patient's mental state. CONCLUSIONS: Developing fairly accurate models for individual risk prediction of recurrent ischemic stroke within 1 year solely based on registry data is feasible. Such models could be applied in a home setting to provide an initial risk assessment and identify high-risk patients early.

Exploring physicians and patients' perspectives for current interventions on thyroid nodules using a MCDA method.

BACKGROUND: The detection of thyroid cancer has rapidly increased over last few decades without an increase in disease specific mortality. Several studies claim that the diagnose of thyroid nodules through routine ultrasound imaging is often the trigger for cascade effects leading to unnecessary follow-up over many years or to invasive treatment. The objective of this study was to explore physicians' and patients' insights and preferences regarding the current interventions on thyroid nodules. METHODS: An online survey was developed using a comprehensive multi-criteria decision analysis (MCDA) framework, the EVIdence based Decision-Making (EVIDEM). The EVIDEM core model used in this study encompassed 13 quantitative criteria and four qualitative criteria. Participants were asked to provide weights referring to what matters most important in general for each criterion, performance scores for appraising the interventions on thyroid nodules and their consideration of impact of contextual criteria. Normalized weights and standardized scores were combined to calculate a value contribution across all participants, additionally differences across physicians and patients' group were explored. RESULTS: 48 patients and 31 physicians were included in the analysis. The value estimate of the interventions on thyroid nodules reached 0.549 for patients' group and 0.5 was reported by the physicians' group, compared to 0.543 for all participants. The highest value contributor was 'Comparative effectiveness' (0.073 ± 0.020). For the physicians' group, 'Comparative safety' (0.050 ± 0.023) was given with higher value. And for the patients' group, 'Type of preventive benefits' (0.059 ± 0.022) contributed more positively to the value estimation. 51% participants considered 'Population priorities and access' having a negative impact on the interventions of nodules.66% participants thought that the 'system capacity' had a negative impact. CONCLUSION: Our study shows participants' preferences on each criterion, i.e., physician indicated keeping the interventions safe and effective more important, patients indicated quality of life after receiving interventions more important. Through comparison among participants, differences have been highlighted, which can make better communication between physicians and patients. This study provides a supportive decision-making for healthcare providers when they explored the interventions on thyroid nodules.

Predictors of the one-year-change in depressiveness in informal caregivers of community-dwelling people with dementia.

BACKGROUND: The care of people with dementia is usually carried out by their family members, which can cause objective und subjective burden and raise their risk of depressiveness. Thus, the aim of this study is to identify predictors of the change in depressiveness of informal caregivers over 1 year in order to be able to derive hypotheses for interventions that promise success. METHODS: The Bavarian Dementia Survey (BayDem) is a multi-center, longitudinal study conducted at three different sites in Bavaria, Germany. Participants were people with dementia and their informal caregivers. Data was collected at baseline and after 12 months by standardized face-to-face interviews in cooperation with local players. The informal caregivers' depressiveness was assessed with the WHO-5. Data was also collected on the people with dementia's cognition (MMSE), behavioral symptoms (NPI) and comorbidities (Charlson Comorbidity Index) as well as caregivers' social inclusion (LSNS), time spent on care and care contribution (RUD). For statistical analysis, a multiple regression model was used. RESULTS: The data of 166 people with dementia and their informal caregivers was analyzed. Of the latter, 46% were categorized as "likely depressed". The change in depressiveness over a year was significantly predicted by baseline depressiveness as well as an increase in the time informal caregivers spent supervising the person with dementia. CONCLUSIONS: Informal caregivers of people with dementia are at high risk of depression. The time spent supervising the person with dementia has a significant impact on increasing depressiveness. This highlights the importance of support services to provide the informal caregiver with relief and possibly reduce depressiveness.

Twenty-Year Time Trends in Long-Term Case-Fatality and Recurrence Rates After Ischemic Stroke Stratified by Etiology.

BACKGROUND AND PURPOSE: Data on long-term survival and recurrence after stroke are lacking. We investigated time trends in ischemic stroke case-fatality and recurrence rates over 20-years stratified by etiological subtype according to the Trial of ORG 10172 in Acute Stroke Treatment classification within a population-based stroke register in Germany. METHODS: Data was collected within the Erlangen Stroke Project, a prospective, population-based stroke register covering a source population of 105 164 inhabitants (2010). Case fatality and recurrence rates for 3 months, 1 year, and 5 years were estimated with Kaplan-Meier estimates. Sex-specific time trends for case-fatality and recurrence rates were estimated with Cox regression. We adjusted for age, sex, and year of event and stratified for etiological subtypes. A sensitivity analysis with competing risk analysis for time trends in recurrence were performed. RESULTS: Between 1996 and 2015, 3346 patients with first ischemic stroke were included; age-standardized incidence per 100 000 was 75.8 in women and 131.6 in men (2015). Overall, 5-year survival probabilities were 50.4% (95% CI, 47.9-53.1) in women and 59.2% (95% CI, 56.4-62.0) in men; 5-year survival was highest in patients with first stroke due to small-artery occlusion (women, 71.8% [95% CI, 67.1-76.9]; men, 75.9% [95% CI, 71.3-80.9]) and lowest in cardioembolic stroke (women, 35.7% [95% CI, 31.0-41.1]; men, 47.8% [95% CI, 42.2-54.3]). Five-year recurrence rates were 20.1% (95% CI, 17.5-22.6) in women and 20.1% (95% CI, 17.5-22.7) in men; 5-year recurrence rate was lowest in women in stroke due to small artery occlusion 16.0% (95% CI, 11.7-20.1) and in men in large-artery atherosclerosis 16.6% (95% CI, 8.7-23.9); highest risk of recurrence was observed in undefined strokes (women, 22.3% [95% CI, 17.8-26.6]; men, 21.4% [95% CI, 16.7-25.9]). Cox regression revealed improvements in case-fatality rates over time with differences in stroke causes. No time trends in recurrence rates were observed. CONCLUSIONS: Long-term survival and recurrence varied substantially by first stroke cause. Survival probabilities improved over the past 2 decades; no major trends in stroke recurrence rates were observed.

[Impact of Sedating Drugs on Falls Resulting Injuries Among People with Dementia in a Nursing Home Setting]. / Einfluss zentralnervös dämpfender Arzneimittel auf Stürze mit Verletzungsfolgen bei Menschen mit Demenz in Pflegeheimen.

AIM: The aims of this study were to create a scale for measuring the sedating and activating effects of drugs and to analyse if the total value of this scale correlates significantly with falls requiring medical treatment in dementia patients. Furthermore, prescription of drugs in nursing homes included in the PRISCUS-List, Anticholinergic Cognitive Burden List (ACB-List) and usage of psychotropic drugs were investigated. METHOD: This is a data analysis of a randomized controlled trial which tested the effects of a non-pharmacological multimodal activation therapy (MAKS®) in 139 patients with degenerative dementia in 5 nursing homes. At the beginning of the study, all prescribed drugs were rated on a five-tier scale by 2 pharmacologists based on the drugs' sedating or activating effects. The scale ranged from severely activating (+2) to severely sedating (- 2). The "central nervous system (CNS) depressant score" of each patient was calculated by summing up the scale value of all the medications they were taking. The correlation between CNS-depressant score and falls resulting in injuries within an observation period of 12 months was investigated by binary logistic regression analysis. RESULTS: Nearly 30% of the nursing home residents received drugs listed in the PRISCUS-list, 50% received drugs on the ACB-List, 55% took psychotropic drugs and 66% received at least 5 drugs. Sedating drugs were prescribed to 62% of patients. During the observation period, 36 out of 139 nursing home residents suffered falls and medical treatment was necessary. In multivariate analysis, the CNS-depressant score was associated significantly (p=0.045) with falls with resulting injuries. Increased sedation resulted in a higher number of fall incidents. CONCLUSIONS: The CNS-depressant score is a useful tool to describe the degree of sedation. Due to the significant association between sedation and falls resulting in injuries, the sedating medication of people suffering from dementia should be minimised as much as possible to reduce the risk of undesirable side effects.

[Predictors of Caregiver Burden in Dementia: Results of the Bavarian Dementia Survey (BayDem)]. / Einflussfaktoren auf die Pflegebelastung der Angehörigen von Menschen mit Demenz: der Bayerische Demenz Survey (BayDem).

BACKGROUND: Dementia is an age-specific disease with increasing care needs over the course of the disease. Care is predominantly conducted by caregivers. Caregiver burden is a core criterion for the evaluation of the care situation. The aims of this examination are to identify predictors of caregiver burden and to analyze the course of the caregiver burden over a 12 months period. METHODS: The Bavarian Dementia Survey (BayDem) is a supra-regional, longitudinal study carried out at 3 different sites in Bavaria, Germany. Participants were people with dementia (pwd) as defined by ICD-10 and their informal caregivers. Data was collected by standardized face-to-face interviews in cooperation with local actors. For statistical analysis, a multiple regression as well as a mixed ANOVA (Analysis of Variance) and repeated measures ANOVAs were used. RESULTS: In this analysis, 295 pwd and 276 caregivers were studied. Key factors influencing caregiver burden were gender of the pwd, behavioral and psychological symptoms and a decline of everyday functioning of the pwd as well as gender of the informal caregivers, their relation to the pwd and if they live at the same household as the pwd. Analysis showed a significant main effect of time over the course of the caregiver burden. CONCLUSION: A permanent high caregiver burden can cause health problems for the caregivers. However, caregivers can be supported according to the specific factors of the caregiver burden. One approach in order to support caregivers could be a combination of pharmacological and non-pharmacological interventions for the treatment of disease-specific symptoms and an empowerment as well as the provision of support services for the caregivers. Furthermore, tailored services for specific target groups can be meaningful.

[Use of Outpatient Care Services by People with Dementia: Results of the Bavarian Dementia Survey (BayDem)]. / Wenn es nicht mehr alleine geht ­ Inanspruchnahme ambulanter Unterstützungsangebote von Menschen mit Demenz: der Bayerische Demenz Survey (BayDem).

BACKGROUND: The increasing prevalence of dementia raises challenges concerning the care of people with dementia (pwd). The care of pwd is mainly conducted by informal caregivers who are faced with several burdens; however, use of care services is generally low. The aim of this study was to identify predictors of the use of outpatient care services. METHODS: The Bavarian Dementia Survey (BayDem) is a multi-centre, longitudinal study that was conducted at 3 different sites in Bavaria, Germany. Participants were people with dementia (pwd) (according to ICD-10) and their informal caregivers. Data were collected by standardised face-to-face interviews using well-designed instruments in cooperation with local partners. Logistic regression analysis was carried out in order to identify predictors of the use of outpatient care services. RESULTS: In total, 364 pwd and 339 informal caregivers were included at the beginning of the study BayDem. The use of supportive care services was generally low. One-third of all participants used outpatient care services. In the logistic regression analysis, the following significant predictors for the use of outpatient care services 6 months after baseline were identified: severity of cognitive impairment of the pwd; use of outpatient care at the beginning of the study. CONCLUSION: The low use of outpatient care services is a well-known paradoxical phenomenon. Such services can help give relief to informal caregivers. In order to enhance the use of supportive outpatient care services, there should be more focus on innovative health service delivery models with a low access threshold barrier. Besides more public campaigns, more guidance for existing offers is needed.

[Symptom Burden, Health Services Utilization and Places and Causes of Death in People with Dementia at the End of Life: the Bavarian Dementia Survey (BayDem)]. / Symptombelastung, Inanspruchnahme des Gesundheitssystems und Todesumstände von Menschen mit Demenz in der letzten Lebensphase: der Bayerische Demenz Survey (BayDem).

BACKGROUND: Dementia is usually a life-limiting disease. However, evidence-based guidelines for palliative care for people with dementia (PwD) are currently lacking. One reason for this is the dearth of reliable empirical data on PwD at the end of life. The aim of this study is to describe the symptom burden, causes of death, places of death and the use of various health services for PwD at the end of life. METHODS: The Bavarian Dementia Survey (BayDem) was a multi-center, longitudinal study at 3 different sites in Bavaria, Germany (Dachau, Kronach, Erlangen). Participants were PwD defined by ICD-10 and their informal caregivers. Data were collected in standardized face-to-face interviews in cooperation with local actors. In order to obtain comparable groups, deceased and non-deceased PwD were matched using 1:1 propensity score matching. For the statistical analyses, McNemar tests as well as paired t-tests were used. RESULTS: In this analysis, 58 deceased and 58 non-deceased PwD were studied (n=116). In most cases, PwD died at home (36.2%), in hospital (25.9%) or in a nursing home (19.0%), but no one in palliative care. The most common causes of death were respiratory (13.8%) and cardiovascular complications (12.1%) as well as stroke (12.1%). PwD at the end of life showed more pronounced physical comorbidities than the other PwD (Charlson-Index: M=2.75 vs. M=1.80; p=0.030, Cohen's d=0.425) and were therefore admitted to hospital (46.6 vs. 12.1%, p<0.001, OR=6.250) or emergency departments (22.4 vs. 3.4%, p=0.007, OR=6.500) more frequently. Behavioral and psychological symptoms were very pronounced (NPI Score: M=31.67 vs. M=24.77, p=0.118, Cohen's d=0.303). Nevertheless, the utilization of outpatient health services was low. CONCLUSION: The results underline the need to develop evidence-based guidelines to provide palliative care specifically adapted to the needs of PwD at the end of life. In this context, the high incidence of behavioral and psychological symptoms should be taken into account, as should the high incidence of physical comorbidities. Considering the frequent hospital admissions, special attention should also be paid to the development of recommendations for the inpatient sector (acute hospital and palliative care unit).

[Timely Diagnosis of Dementia: Results of the Bavarian Dementia Survey (BayDem)]. / Zeitgerechte Diagnosestellung bei Menschen mit Demenz: der Bayerische Demenz Survey (BayDem).

BACKGROUND: In many cases, people with dementia (PWD) receive their first diagnosis at an advanced stage of the disease. A timely diagnosis, however, is crucial for the utilization of therapies and support services for PWD and their caregivers. So far, only a few international studies have analysed predictors of the time lapse between the first perceived symptoms and diagnosis. The aim of this study was to assess the time span from the first symptoms of dementia until the first dementia diagnosis and to identify predictors of a timely diagnosis. METHODS: The Bavarian Dementia Survey (BayDem) is a multi-centre, longitudinal study at 3 different sites in Bavaria, Germany. Participants were PWD as defined by ICD-10 and their informal caregivers. Data was collected by standardized face-to-face interviews in cooperation with local actors. For the analysis of potential sociodemographic predictors of a timely diagnosis within 9 months after the perception of the first symptoms, binary logistic regressions were used. RESULTS: The median length from the perception of the first symptoms until diagnosis was 16 months. Predictors of a timely diagnosis for male PWD were age at the time of the first perceived symptoms and education. There was no association between a timely diagnosis and the place of residence or living situation of the PWD. CONCLUSIONS: Diagnosis of dementia is often made with a huge delay. Therefore, it is necessary to enhance structured access routes to a timely diagnosis in primary care.

Diagnosis of cognitive decline and dementia in rural areas - A scoping review.

OBJECTIVES: Due to the demographic change, the global prevalence of dementia will continually rise. Barriers to diagnosis and care are still high. But timely diagnosis is associated with valuable benefits and can promote timely and optimal management. Receiving an early diagnosis is especially in rural areas a problem due to the limited access to assessments. Therefore, the aim of our scoping review is to investigate different interventions targeted at rural living elderly to screen and diagnose cognitive decline and dementia. METHODS: A scoping review was conducted in line with the framework of Arksey and O'Malley. The following databases were systematically searched: PubMed, PsycINFO, Cochrane Library, and ScienceDirect. The interventions were categorized in four main categories (interventions for general practitioners/institutions; online/mobile offers; telehealth applications; telephone-based screenings). RESULTS: Thirty studies were included. The four categories show different scopes of application. Telehealth applications show that it is feasible and valid to diagnose dementia via videoconference. Assessments described in three other categories show that remotely used tools are appropriate to screen for mild cognitive impairment or cognitive decline, but are not valid to establish a dementia diagnosis. CONCLUSIONS: Telehealth applications can appropriately be used to diagnose dementia. However, most of the studies included only small sample sizes and did not test the applications explicitly in rural or remote populations. Therefore, studies taking these limitations into account are needed. On top, only two RCTs are included in this review indicating that more high quality studies in this field are needed.

Cost-of-illness studies in heart failure: a systematic review 2004-2016.

BACKGROUND: Heart failure is a major and growing medical and economic problem worldwide as 1-2% of the healthcare budget are spent for heart failure. The prevalence of heart failure has increased over the past decades and it is expected that there will be further raise due to the higher proportion of elderly in the western societies. In this context cost-of-illness studies can significantly contribute to a better understanding of the drivers and problems which lead to the increasing costs in heart failure. The aim of this study was to perform a systematic review of published cost-of-illness studies related to heart failure to highlight the increasing cost impact of heart failure. METHODS: A systematic review was conducted from 2004 to 2016 to identify cost-of-illness studies related to heart failure, searching PubMed (Medline), Cochrane, Science Direct (Embase), Scopus and CRD York Database. RESULTS: Of the total of 16 studies identified, 11 studies reported prevalence-based estimates, 2 studies focused on incidence-based data and 3 articles presented both types of cost data. A large variation concerning cost components and estimates can be noted. Only three studies estimated indirect costs. Most of the included studies have shown that the costs for hospital admission are the most expensive cost element. Estimates for annual prevalence-based costs for heart failure patients range from $868 for South Korea to $25,532 for Germany. The lifetime costs for heart failure patients have been estimated to $126.819 per patient. CONCLUSIONS: Our review highlights the considerable and growing economic burden of heart failure on the health care systems. The cost-of-illness studies included in this review show large variations in methodology used and the cost results vary consequently. High quality data from cost-of-illness studies with a robust methodology applied can inform policy makers about the major cost drivers of heart failure and can be used as the basis of further economic evaluations.

Health economic evaluations of non-pharmacological interventions for persons with dementia and their informal caregivers: a systematic review.

BACKGROUND: This systematic review aims to review the literature on trial-based economic evaluations of non-pharmacological interventions directly targeted at persons with dementia as well as persons with mild cognitive impairment and their respective caregivers. METHODS: A systematic literature research was conducted for the timeframe from 2010 to 2016 in the following databases: Centre for Reviews and Dissemination, EconLit, Embase, Cochrane Library, PsycINFO and PubMed. Study quality was assessed according to the Drummond criteria. RESULTS: In total sixteen publications were identified. Health economic evaluations indicated the cost-effectiveness of physical exercise interventions and occupational therapy. There was also evidence to suggest that psychological and behavioral therapies are cost-effective. Health economic studies investigating psychosocial interventions mainly targeted towards informal caregivers showed inconsistent results. CONCLUSIONS: Due to the increasing prevalence of dementia non-pharmacological interventions and their health economic impact are of increasing importance for health care decision-makers and HTA agencies.

Health Economic Impact of a Pulmonary Artery Pressure Sensor for Heart Failure Telemonitoring: A Dynamic Simulation.

AIMS: Recently, a permanently implantable wireless system, designed to monitor and manage pulmonary artery (PA) pressures remotely, demonstrated significant reductions in heart failure (HF) hospitalizations in high-risk symptomatic patients, regardless of ejection fraction. The objectives of this study were to simulate the estimated clinical and economic impact in Germany of generalized use of this PA pressure monitoring system considering reductions of HF hospitalizations and the improvement in Quality of Life. MATERIALS AND METHODS: Based on the Prospective Health Technology Assessment approach, we simulated the potential of the widespread application of PA pressure monitoring on the German healthcare system for the period 2009-2021. RESULTS: This healthcare economic simulation formulated input assumptions based on results from the CHAMPION Trial, a multicenter, prospective, randomized controlled U.S. trial that demonstrated a 37% reduction of hospitalizations in persistently symptomatic previous HF patients. Based on these results, an estimated 114,800 hospitalizations would expected to be avoided. This effect would potentially save an estimated €522 million, an equivalent of $575 million, during the entire simulation period. CONCLUSION: This healthcare economic modeling of the PA pressure monitoring system's impact demonstrates substantial clinical and economic benefits in the German healthcare system.

Time trends in incidence of pathological and etiological stroke subtypes during 16 years: the Erlangen Stroke Project.

BACKGROUND: Population-based data, which continuously monitors time trends in stroke epidemiology are limited. We investigated the incidence of pathological and etiological stroke subtypes over a 16 year time period. METHODS: Data were collected within the Erlangen Stroke Project (ESPro), a prospective, population-based stroke register in Germany covering a total study population of 105,164 inhabitants (2010). Etiology of ischemic stroke was classified according to the Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria. RESULTS: Between January 1995 and December 2010, 3,243 patients with first-ever stroke were documented. The median age was 75 and 55% were females. The total stroke incidence decreased over the 16 year study period in men (Incidence Rate Ratio 1995-1996 vs. 2009-2010 (IRR) 0.78; 95% CI 0.58-0.90) but not in women. Among stroke subtypes, a decrease in ischemic stroke incidence (IRR 0.73; 95% CI 0.57-0.93) and of large artery atherosclerotic stroke (IRR 0.27; 95% CI 0.12-0.59) was found in men and an increase of stroke due to small artery occlusion in women (IRR 2.33; 95% CI 1.39-3.90). CONCLUSIONS: Variations in time trends of pathological and etiological stroke subtypes were found between men and women that might be linked to gender differences in the development of major vascular risk factors in the study population.

The main cost drivers in dementia: a systematic review.

OBJECTIVES: Because of the increasing prevalence of dementia worldwide, combined with limited healthcare expenditures, a better understanding of the main cost drivers of dementia in different care settings is needed. METHODS: A systematic review of cost-of-illness (COI) studies in dementia was conducted from 2003 to 2012, searching the following databases: PubMed (Medline), Cochrane Library, ScienceDirect (Embase) and National Health Service Economic Evaluations Database. Costs (per patient) by care setting were analyzed for total, direct, indirect and informal costs and related to the following: (1) cost perspective and (2) disease severity. RESULTS: In total, 27 studies from 14 different healthcare systems were evaluated. In the included studies, total annual costs for dementia of up to $70,911 per patient (mixed setting) were estimated (average estimate of total costs = $30,554). The shares of cost categories in the total costs for dementia indicate significant differences for different care settings. Overall main cost drivers of dementia are informal costs due to home based long term care and nursing home expenditures rather than direct medical costs (inpatient and outpatient services, medication). CONCLUSIONS: The results of this review highlight the significant economic burden of dementia for patients, families and healthcare systems and thus are important for future health policy planning. The significant variation of cost estimates for different care settings underlines the need to understand and address the financial burden of dementia from both perspectives. For health policy planning in dementia, future COI studies should follow a quality standard protocol with clearly defined cost components and separate estimates by care setting and disease severity.