Association of two geriatric treatment systems with anti-osteoporotic drug treatment and second hip fracture in patients with an index hip fracture: retrospective cohort study.

BACKGROUND: In Germany, geriatricians deliver acute geriatric care during acute hospital stay and post-acute rehabilitation after transfer to a rehabilitation clinic. The rate patients receive acute geriatric care (AGC) or are transferred to post-acute rehabilitation (TPR) differs between hospitals. This study analyses the association between the two geriatric treatment systems (AGC, TPR) and second hip fracture in patients following an index hip fracture. METHODS: Nationwide health insurance data are used to identify the rate of AGC and TPR per hospital following hip fracture surgery in patients aged ≥ 80 years. Outcomes are a second hip fracture after surgery or after discharge within 180 or 360 days and new specific anti-osteoporotic drugs. Cox proportional hazard models and generalised linear models are applied. RESULTS: Data from 29,096 hip fracture patients from 652 hospitals were analysed. AGC and TPR are not associated with second hip fracture when follow-up started after surgery. However, during the first months after discharge patients from hospitals with no AGC or low rates of TPR have higher rates of second hip fracture than patients from hospitals with high rates of AGC or high rates of TPR (Hazard Ratio (95% CI) 1.35 (1.01-1.80) or 1.35 (1.03-1.79), respectively). Lower rates of AGC are associated with lower probabilities of new prescriptions of specific anti-osteoporotic drugs. CONCLUSIONS: Our study suggests beneficial relationships of geriatric treatment after hip fracture with a) the risk of second hip fractures during the first months after discharge and b) an improvement of anti-osteoporotic drug treatment.

Multimodal home-based rehabilitation intervention after discharge from inpatient geriatric rehabilitation (GeRas): study protocol for a multicenter randomized controlled trial.

BACKGROUND: Geriatric rehabilitation aims to maintain the functional reserves of older adults in order to optimize social participation and prevent disability. After discharge from inpatient geriatric rehabilitation, patients are at high risk for decreased physical capacity, increased vulnerability, and limitations in mobility. As a result, ageing in place becomes uncertain for a plethora of patients after discharge from geriatric rehabilitation and effective strategies to prevent physical decline are required. Collaboration between different health-care providers is essential to improve continuity of care after discharge from inpatient geriatric rehabilitation. The aim of this study is to evaluate the effectiveness of a multi-professional home-based intervention program (GeRas) to improve functional capacity and social participation in older persons after discharge from inpatient geriatric rehabilitation. METHODS: The study is a multicenter, three-arm, randomized controlled trial with a three-month intervention period. Two hundred and seventy community-dwelling older people receiving inpatient geriatric rehabilitation will be randomized with a 1:1:1 ratio to one of the parallel intervention groups (conventional IG or tablet IG) or the control group (CG). The participants of both IGs will receive a home-based physical exercise program supervised by physical therapists, a nutritional recommendation by a physician, and social counseling by social workers of the health insurance company. The collaboration between the health-care providers and management of participants will be realized within a cloud environment based on a telemedicine platform and supported by multi-professional case conferences. The CG will receive usual care, two short handouts on general health-related topics, and facultative lifestyle counseling with general recommendations for a healthy diet and active ageing. The primary outcomes will be the physical capacity measured by the Short Physical Performance Battery and social participation assessed by the modified Reintegration to Normal Living Index, three months after discharge. DISCUSSION: The GeRas program is designed to improve the collaboration between health-care providers in the transition from inpatient geriatric rehabilitation to outpatient settings. Compared to usual care, it is expected to improve physical capacity and participation in geriatric patients after discharge from inpatient geriatric rehabilitation. TRIAL REGISTRATION: German Clinical Trials Register (DRKS00029559). Registered on October 05, 2022.

[Cooperation of geriatrics and trauma surgery in certified geriatric trauma centers : Insights into different care models and the implementation of requirements resulting from certification]. / Zusammenarbeit von Geriatrie und Unfallchirurgie in zertifizierten alterstraumatologischen Zentren : Einblicke in unterschiedliche Versorgungsmodelle und in die Umsetzung von Anforderungen, die sich aus der Zertifizierung ergeben.

BACKGROUND: In Germany, different models of orthogeriatric co-management have been implemented in certified geriatric trauma centers. So far, it is not clear how the different models are implemented and what influence the certification has on the structures and processes within the centers. The present study examined the extent of cooperation between surgery and geriatrics and if the quality of care had changed since the certification of the centers. METHODS: In this study 4 guided focus group interviews (FGI) were conducted in different teams of certified geriatric trauma centers in 3 federal states with 16 participants. To specify the content of the FGI, two additional interviews were conducted with system auditors. Both types of interview were analyzed by content analysis. RESULTS: The certification supported the implementation of structures and processes in the different orthogeriatric models; however, the quality of care and cooperation between surgery and geriatrics depends on the spatial proximity and the orthogeriatric care model in the geriatric trauma centers. Simultaneously, challenges in the area of geriatric syndromes and the recruitment of skilled staff became relevant. DISCUSSION: The results can help to reflect processes in the certified geriatric trauma centers and to treat geriatric syndromes more effectively. In the future, the challenge will be to establish geriatric care under the existing shortage of skilled staff.

Health-Economic Evaluation of the German Osteoporotic Fracture Prevention Program in Rural Areas (OFRA): Mobility and Falls Prevention Classes, Examination of Bone Health, and Consultation on Safety in the Living Environment.

BACKGROUND: Fragility fractures are one of the leading causes of disability in older adults. Yet, evidence for effectiveness and cost-effectiveness of preventive approaches combining bone health and fall prevention is rare. OBJECTIVE: To conduct a health-economic evaluation of the German osteoporotic fracture prevention program in rural areas (OFRA). DESIGN: Secondary cluster-randomized intervention study based on routine data. PARTICIPANTS: All districts in five federal states in Germany were cluster-randomized as intervention or control districts. OFRA was offered to community-living (a) women aged 75-79 years or (b) women and men aged 70-84 years with a prior fragility fracture in the intervention districts. Individuals who meet these criteria in the control districts were assigned to the control group. INTERVENTION: OFRA comprised mobility and falls prevention classes, examination of bone health by bone density measurement, and consultation on safety in the home living environment. MAIN MEASURES: We measured health-care costs and effectiveness in terms of time to fragility fracture or death within 1 year after initial contact, based on health insurance claims data. Implementation costs were recorded by the intervention performers. We calculated an incremental cost-effectiveness ratio (ICER) and employed the net-benefit approach to construct a cost-effectiveness acceptability curve (CEAC). KEY RESULTS: There were 9408 individuals in the intervention group and 27,318 in the control group. Mean time to fragility fracture or death (difference: 0.82 days) and health-care costs (difference: 111.73€, p < .01) were reduced, but mean intervention costs (difference: 260.10€) increased total costs (difference: 148.37€, p < .001) in the intervention group. The ICER per fracture-free year of survival was 66,094.63€. The CEAC showed no acceptable probability of cost-effectiveness at a reasonable willingness to pay. CONCLUSION: OFRA showed reduced rates of fragility fractures, but had high implementation costs, resulting in an unfavorable ICER. The cost-effectiveness of OFRA may improve with a longer follow-up.

[Update of the recommendations of the Federal Falls Prevention Initiative-Identification and prevention of the risk of falling in older people living at home]. / Update der Empfehlungen der Bundesinitiative Sturzprävention ­ Identifizierung und Prävention des Sturzrisikos bei älteren zu Hause lebenden Menschen.

BACKGROUND: To reduce falls and their consequences, evidence-based and consensus-based recommendations are needed for risk stratification, screening, assessment, and fall prevention as well as treatment. In 2020, the Federal Falls Prevention Initiative (BIS) published recommendations for physical training for falls prevention as a group or individual intervention for older people living at home. In 2022, the world guidelines for falls prevention and management for older adults (WFG) were published. OBJECTIVE: To update the recommendations of the BIS. MATERIAL AND METHODS: The recommendations of the BIS were compared with those of the WFG and, if necessary, extended by methodological and subject-specific aspects. The following areas were considered: 1) screening and risk stratification, 2) interventions, 3) multifactorial assessment and interventions, and 4) specific target groups. RESULTS: The BIS recommendations are largely consistent with those of the WFG. The main reason for differences is the previous focus of the BIS recommendations on physical training. The multifactorial approach, which is described in detail by the WFG, has so far been mentioned in the recommendation paper on physical training in individual settings but not elaborated in detail. The BIS recommendations are supplemented or clarified in this respect. CONCLUSION: By updating the BIS recommendations, the establishment and promotion of fall prevention services for older people in Germany can be further advanced. The implementation can thus be carried out as consistently and scientifically proven as possible.

Effect of an osteoporotic fracture prevention program on fracture incidence in routine care: a cluster-randomized trial.

BACKGROUND: Fractures are a major health problem in aging societies. Preventive approaches combining bone health and fall prevention are rare. The osteoporotic fracture prevention program in rural areas (OFRA) is a health care fund-driven program for older people in randomly selected districts in Germany. The components of the program were falls prevention exercise classes, examination of bone health by a dual-energy X-ray absorptiometry (DXA) scan, and a consultation about "safety in the living environment." The aim of this study was to evaluate this complex preventive intervention in a routine health care setting. METHODS: This cluster-randomized trial was performed from October 2015 to October 2018 and took place in 186 administrative districts in five federal states, 47 districts served as intervention districts, and 139, as controls. Within these districts, we included (a) all community-living women and men aged 70-85 years with prior fragility fractures and (b) all community-living women aged 75-80 years. The analysis used routine data collected by a health insurance company. The primary endpoint was all fragility fractures combined. Fracture types, mortality, and nursing home admission were explorative endpoints. Cox frailty models were used for comparative analyses with a median follow-up time of 365 days (interquartile range: 0 days). RESULTS: Nine thousand four hundred eight individuals were approached to participate in one of the program components, 27,318 individuals served as controls. The mean age was 78.7 years. Of those approached to participate, nearly 30% joined the exercise classes. DXA measurement was reimbursed for 13.6%, and 51.8% received advice about measures to increase "safety in the living environment." The incidence of fragility fractures did not differ between the intervention and the control group (HR 0.94; 95% CI 0.80-1.11). However, femoral fractures, the most frequent fracture type, were reduced in the intervention group (HR 0.76; 95% CI 0.59-0.99). Mortality and nursing home admission did not differ between the intervention and the control group. CONCLUSIONS: A comprehensive fracture prevention program for older people living in rural areas was implemented. The program did not affect the primary endpoint of all fragility fractures combined. It has to be considered that we used a modified intention to treat approach based on geographic randomization and information about endpoints relied exclusively on routine data of the health care insurance. TRIAL REGISTRATION: German Clinical Trials Register DRKS-ID: 00009000.

Uptake of an exercise class and use of bone density measurement after advice by the health insurance fund: results from the osteoporotic fracture prevention program in rural areas (OFRA).

BACKGROUND: OFRA is a large health insurance fund-driven program which aims to reduce the risk of falls and fractures in older people living in rural areas. The programme offered specific mobility and falls prevention classes and bone density measurement by a DXA scan free of charge to more than 10,000 people, and was promoted by staff of the health insurance fund either by a visit at home, or a phone call, or a visit at home and a subsequent phone call. The aim of this study was to analyse the uptake of an exercise class and the use of a DXA scan after advice. METHODS: Telephone interviews were conducted in a randomly selected subgroup of 780 persons 9 months after first contact. Rates of uptake of an exercise class or use of a DXA scan were calculated. Predictors of uptake and use were analysed applying logistic regression models. RESULTS: The rate of uptake after advice for specific mobility and fall prevention class was 29.6%. For DXA scan, the rate of use after advice was 16.7%. Rates of uptake and use increased if the first contact by a visit at home or a phone call was followed by an additional subsequent phone call. CONCLUSION: A direct motivational approach in older people by a health insurance fund is feasible and results in relevant participation and utilization rates in exercise classes and DXA scans.

[Analysis of the effectiveness of urinary incontinence management in a geriatric rehabilitation]. / Analyse der Wirksamkeit des Harninkontinenzmanagements in einer geriatrischen Rehabilitationsklinik.

BACKGROUND: Urinary incontinence is a widespread health-related problem predominately occurring in older adults. The aim of the study was to evaluate the effectiveness of the management of urinary incontinence in routine care in a geriatric rehabilitation clinic. METHODS: A prospective observational study without a control group was conducted between 7 February 2018 and 7 June 2018. All patients included in the study (N = 32) received individualized guideline-conform measures to improve the symptoms of incontinence during the rehabilitation period. To assess the change in symptoms, the International Consultation on Incontinence Modular Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) was used at admission (T0) and discharge (T1). Assessment of patient satisfaction was conducted at T1 using the benefit, satisfaction, and willingness to continue treatment questionnaire (BSW). RESULTS: The total score of the ICIQ-UI SF improved by an average of 3.4 points (p = 0.004) due to a decrease in the frequency of incontinence episodes and in a reduction in the urine volume lost. Furthermore, there was a decrease in the number of patients who lost a large amount of urine from 9.4% at T0 to 3.1% at T1. The proportion of patients with incontinence several times a day, decreased from 68.6% to 31.3% during the intervention. Of the patients 80% received a guideline-conform treatment during the time of rehabilitation and 64% of the patients were satisfied with the treatment. CONCLUSION: The guideline-conform treatment of urinary incontinence in geriatric patients led to an improvement in the symptoms. A large number of patients benefited from the management of urinary incontinence during the rehabilitation period.

[The osteoporotic fracture prevention program in rural areas (OFRA): analysis of 1092 mobility courses in rural areas]. / Trittsicher durchs Leben: Analyse von 1092 Bewegungskursen im ländlichen Raum.

BACKGROUND: Specific training reduces the risk of falls and fall-related injuries in older persons. The availability of specific exercise programs in Germany, especially in rural areas is scarce. Therefore, a healthcare fund driven program osteoporotic fracture prevention program in rural areas (OFRA) (German name: "Trittsicher durchs Leben") was implemented in rural areas in 47 counties of 5 federal states. The most important components of the program are the "Trittsicher" mobility course and falls prevention classes organized by members of the German Association of Rural Women and executed by exercise instructors of the German Gymnastics Association or physiotherapists. Since the start of the program in October 2015 more than 2300 classes have been carried out. AIM: The study analyzed the structural characteristics of the first 1092 "Trittsicher" mobility courses and the characteristics of the 12,246 participants. METHOD: The analysis is based on data of a standardized course documentation sheet and information from an internal database of a health insurance company. Additionally, the distance between the location of the course and place of residence was determined for a subgroup of the participants. RESULTS: The classes were conducted in communal and confessional rooms, in sports associations, kindergartens and restaurants. The majority of the 12,246 participants were female (89.1%), the median age was 75 years. The average size of the classes was 11.2 participants per course. More than half of the participants attended all six sessions. Half of the participants of the courses had to travel less than 1.7 km between the place of residence and the location of the courses. CONCLUSION: "Trittsicher" mobility courses are a new specific offer to improve mobility and reduce the risk of falling. They contribute to a better care of older people in rural areas.

Long-term evaluation of the implementation of a large fall and fracture prevention program in long-term care facilities.

BACKGROUND: Falls and fractures are extremely frequent in long-term care facilities (LTCFs). Therefore, a fall and fracture prevention program was started in nearly 1000 LTCFs in Bavaria/Germany between 2007 and 2010. The components of the program were exercise classes, the documentation of falls, environmental adaptations, medication reviews, the recommendation to use hip protectors and education of staff. The present study aimed to provide a comprehensive evaluation of the implementation process of the program regarding results of the implementation phase and the follow-up of 3-9 years after start of implementation. METHODS: Data from numerous sources were used, including data from published studies, statistical data, health insurance claims data and unpublished data from an online questionnaire. To incorporate different aspects, time periods and results, the RE-AIM framework was applied. RESULTS: The program was adopted by 942 of the 1150 eligible LTCFs and reached about 62,000 residents. During the implementation phase exercise classes and recommendation about environmental adaptations were offered in nearly all LTCFs. 13.5% of the residents participated in exercise classes. Hip protectors were available for 9.2% of all residents. In the first implementation wave, femoral fracture rate was significantly reduced by 18% in the first year. At follow-up nearly 90% of all LTCFs still offered exercise classes, which were attended by about 11% of residents. However, only 10% of the exercise classes completely fulfilled the requirements of an effective strength and balance training. Individual advice about environmental adaptations was provided in 74.3% of the LTCFs and nearly all LTCFs claimed to offer hip protectors to their residents. A long-term effect of the program on femoral fractures could not be detected. CONCLUSIONS: The program did not affect the femoral fracture rate in the long run. Possible reasons could be a high turn-over of the staff, a reduced fidelity of training components or a shift in daily priorities among the staff.

The osteoporotic fracture prevention program in rural areas (OFRA): a protocol for a cluster-randomized health care fund driven intervention in a routine health care setting.

BACKGROUND: Fragility fractures are one of the leading causes for disability in old people. The main underlying mechanisms are osteoporosis and falls. Evidence-based measures to prevent either falls or fractures are available. However, coordinated preventive approaches combining bone health and fall prevention are rare. The objective of the study is to evaluate a health care fund driven program, which encourages insured persons to adhere to national guidelines regarding bone health and physical activity and falls prevention. The health care fund cooperates with the 'German Association of Rural Women' and the 'German Gymnastics Association'. The program consists of mobility and falls prevention classes, the examination of bone health by a DXA scan, and a consultation about 'safety in the living environment'. METHODS: Cluster-randomized study in 47 intervention and 143 control districts in 5 federal states of Germany. The program is offered to a) community-living women and men aged 70 to <85 years with a prior fragility fracture or b) community-living women aged 75 to <80 years. Within two years more than 10,000 persons will be directly contacted and motivated to make use of the components of the program. The primary outcome is a combined measure of incident osteoporotic fractures. Secondary outcomes include the rate of referrals to a mobility and falls prevention class or a bone mass density measurement. An economic evaluation will be conducted. DISCUSSION: The study evaluates a complex preventive intervention in a routine health care setting which may serve as model for similar approaches in other areas or countries. TRIAL REGISTRATION: DRKS-ID: DRKS00009000 ; date of registration: 06.08.2015.

Regional variation of care dependency after hip fracture in Germany: A retrospective cohort study using health insurance claims data.

OBJECTIVE: To investigate variation of care dependency after hip fracture across German regions based on the assessment by the German statutory long-term care insurance. DATA SOURCES/STUDY SETTING: Patient-level statutory health and long-term care insurance claims data from 2009-2011 and official statistical data from Germany. STUDY DESIGN: We performed a retrospective cohort study. Investigated multinomial outcome categories were increase in care dependency (new onset or a higher care dependency than pre-fracture), no change as reference and death as competing risk in the quarterly period following hip fracture (follow-up 3 months). Regional variation was operationalized with the variance of regional-level random intercepts based on generalized linear mixed models. We adjusted for patient and regional characteristics. PRINCIPAL FINDINGS: The study included 122,887 hip fracture patients in 95 German postal code regions. Crude outcomes were 30.87% increase in care dependency and 14.35% death. Results indicated modest variation on regional level. Male sex, increasing age, increasing comorbidity, pertrochanteric and subtrochanteric fracture site compared to femoral neck, time from hospital admission to surgery of 3 or more days, as well as increasing inpatient length of stay, non-participation in rehabilitation and regions with lower hospital density were positively associated with an increase in care dependency. CONCLUSIONS: Several characteristics on patient and regional level associated with the outcome were identified. Variation in the increase in care dependency after hip fracture appeared to be attributable primarily to patient characteristics. Variation on regional level was only modest.

Patient Characteristics as Indicator for Care Dependence after Hip Fracture: A Retrospective Cohort Study Using Health Insurance Claims Data From Germany.

OBJECTIVES: Hip fractures are common consequences of falls in older adults and, among other negative health outcomes, often lead to care dependence in the long term. Until 2016, the German long-term care insurance classified care recipients according to a standardized classification system consisting of 3 care levels. It was based on required assistance in performing activities of daily living and assessed by a qualified physician or nurse. Thus, care level reflects the degree of care dependence. The aim of this study was to determine relevant patient characteristics, which are related to the likelihood of increasing care dependence in terms of worsening care level after hip fracture. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: Statutory health insurance claims data including 122,922 insured individuals living in Germany and aged 65 years or older, who sustained a hip fracture from 2009 through 2011. MEASURES: The association of patient characteristics with worsening care level in the quarterly period after hip fracture was investigated by means of multinomial logit regression analysis. Death constitutes a competing risk and was modeled as additional nominal outcome. RESULTS: Among all patients, crude rates were 30.9% for worsening care level, 54.8% for unchanged care level, and 14.4% for death after hip fracture. The multivariate analysis revealed that patient factors male sex, increasing age, increasing comorbidity, increasing inpatient length of stay, and a lack of inpatient rehabilitation were significantly associated with a worsening care level. CONCLUSIONS/IMPLICATIONS: This study uses the German standardized measurement of care dependence in terms of worsening care level after hip fracture and finds various related patient characteristics. Knowledge of these characteristics helps to identify possible risk groups for care dependence after hip fracture, for which special attention can be provided regarding treatment and prevention of hip fractures.