Comorbidities in Patients with Rheumatoid Arthritis and Their Association with Patient-reported Outcomes: Results of Claims Data Linked to Questionnaire Survey.

OBJECTIVE: To investigate the prevalence of comorbidities in a population-based cohort of persons with rheumatoid arthritis (RA) compared to matched controls and to examine their association with patient-reported outcomes in a survey sample. METHODS: Data of 96,921 persons with RA [International Classification of Diseases, 10th ed (ICD-10) M05/M06] and 484,605 age- and sex-matched controls without RA of a German statutory health fund were studied regarding 26 selected comorbidities (ICD-10). A self-reported questionnaire, comprising joint counts [(tender joint count (TJC), swollen joint count (SJC)], functional status (Hannover Functional Ability Questionnaire), effect of the disease (Rheumatoid Arthritis Impact of Disease), and well-being (World Health Organization 5-item Well-Being Index; WHO-5) was sent to a random sample of 6193 persons with RA, of whom 3184 responded. For respondents who confirmed their RA (n = 2535), associations between comorbidities and patient-reported outcomes were analyzed by multivariable linear regression. RESULTS: Compared to controls, all investigated comorbidities were more frequent in persons with RA (mean age 63 yrs, 80% female). In addition to cardiovascular risk factors, the most common were osteoarthritis (44% vs 21%), depression (32% vs 20%), and osteoporosis (26% vs 9%). Among the survey respondents, 87% of those with 0-1 comorbidity but only 77% of those with ≥ 8 comorbidities were treated by rheumatologists. Increasing numbers of comorbidities were associated with poorer values for TJC, SJC, function, and WHO-5. CONCLUSION: Compared to a matched population, persons with RA present with increased prevalence of numerous comorbidities. Patients with RA and multimorbidity are at risk of insufficient rheumatological care and poorer patient-reported outcomes.

[Prescription frequency of physical therapy and analgesics before total hip and knee arthroplasy : An epidemiological analysis of routine health care data from Germany]. / Verordnungshäufigkeit physikalischer Therapien und Analgetika vor dem Einsatz einer Hüft- bzw. Kniegelenks-Endoprothese : Eine versorgungsepidemiologische Analyse basierend auf GKV-Routinedaten aus Deutschland.

BACKGROUND: Osteoarthritis of the hip or knee joint is a widespread disease with a strong influence on the quality of life. At present, the extent of conservative treatment with physical therapies and analgesics before the use of a total joint arthroplasty (TJA) of the hip or knee is largely unclear in Germany. OBJECTIVES: The aim was to analyze the prescription frequency according to regional and socio-demographic factors. MATERIALS AND METHODS: Based on routine health care data from BARMER insurance, patients who received a TJA of the hip or knee from 2011 to 2013 were analyzed. Included were consistently insured patients with the main discharge diagnosis of osteoarthritis who did not receive any further TJA for eight quarters before and after replacement. The prescription frequency of physical therapies and analgesics, stratified according to age groups, gender, number of comorbidities and federal state was analyzed. RESULTS: 40,242 persons with hip TJA and 35,652 persons with knee TJA were included. In the year prior to surgery, 49.4% of patients (hip TJA: 49.9%; knee TJA: 48.9%) received at least one physical therapy and 81.0% were prescribed analgesics. Regionally, the prescription frequency of physical therapies for hip TJA varied between 35.7% (Bremen) and 70.6% (Saxony) and for knee TJA between 37.6% (Saarland) and 66.9% (Saxony). CONCLUSION: The prescription frequency of physical therapy does not fully correspond to current treatment recommendations. The prescription of physical therapies in the year before the TEP shows regional differences, with fundamentally lower prescription frequencies in the former states of West Germany.

Waiting times in primary care depending on insurance scheme in Germany.

BACKGROUND: Waiting times for an outpatient appointment in Germany differ between insurants of the statutory and private health insurance schemes, especially for specialised care. The aim of this study was to uncover possible differences in waiting times depending on health insurance scheme and to identify predictors for excessive waiting times in primary care. METHODS: We used data of the Bertelsmann Foundation Healthcare Monitor, which is a repeated cross sectional study dealing with experiences in health care and attitudes towards current health policy themes. We analysed the surveys conducted from 2011 to 2013, with respondents assigned to their health insurance fund, namely AOK, BARMER GEK, BKK, DAK, TK, IKK, other statutory funds and private funds. The mean waiting times for an appointment and spent in a physician's waiting room, and the satisfaction with waiting times were evaluated with respect to different health insurance funds. A logistic regression model was used to calculate the chance of excessive waiting times with respect to health insurance fund, age, sex, health and socioeconomic status. The ninetieth percentile of the waiting time distribution (10 days) was chosen as the cut-off point between average and excessive. RESULTS: A total of 5618 respondents were analysed. Mean waiting times in primary care were low (4.0 days) and homogeneous (SHIs: 3.6-4.9 days), even though privately insured respondents reported shorter waiting times for appointments (3.3 days). They also reported a greater satisfaction with waiting times (77.5%) than SHI insurants (64.5%). However, we identified a group (10.1%), who experienced excessive waiting times in primary care. Compared to privately insured respondents, the chance of excessive waiting times was increased for SHI insurants (highest odds ratio for BKK: 2.17; 95%-CI: 1.38-3.42). Additionally, higher age and residence in East Germany were associated with higher chances of waiting times of 10 days or more. CONCLUSIONS: Primary care in Germany is readily accessible with generally short waiting times. However, barriers in access to the health care system affect a certain part of patients depending on insurance status, age and region of residence. Ways to improve the access need to be studied.

Influenza vaccination rates before and after admission to nursing homes in Germany.

BACKGROUND: Influenza vaccination is highly recommended for nursing home residents. However, it is known that vaccination coverage is low in the general population. AIMS: We aim to find out whether influenza vaccination coverage differs for nursing home residents between the year before and after admission and factors determining the chance to receive vaccination. METHODS: Claims data of the health insurance fund DAK of at least 65-year-olds were used. The proportion of residents with influenza vaccination were compared in the year before and after the admission stratified by several covariates. A multivariate logistic regression analysis was conducted to obtain predictors for influenza vaccination after admission. RESULTS: Vaccination coverage was overall higher in the year after admission (53.0%) than before (38.3%). Differences in vaccination coverage between most covariates evened out after admission. Differences remained for region of residence and number of comorbidities. The strongest predictor for receiving a vaccination after admission was the vaccination status before admission (OR 3.5; 95% CI 3.3-3.6) followed by region and number of comorbidities. DISCUSSION: Overall, vaccination coverage of nursing home residents remains lower than recommended. Doctor-patient contacts whether due to care for comorbidities or as a continuation of the relation over the time of admission to the nursing home seem to assure vaccination for residents. CONCLUSION: Clear and unambiguous evidence of vaccine safety and efficacy for different subgroups within the same age group as well as organizational efforts to increase vaccination within nursing homes would be recommended.

High prevalence of diabetes in patients with rheumatoid arthritis: results from a questionnaire survey linked to claims data.

Objectives: To investigate the prevalence of diabetes in patients with RA and the impact of diabetes on self-reported outcomes and health care. Methods: RA patients between the ages of 18 and 79 years were randomly selected from a nationwide statutory health insurance fund and were surveyed about rheumatological care and disease burden. Comorbid diabetes (E10-14) was analysed regarding age, sex, BMI and socioeconomic status. Disease burden, comorbidity and prescriptions were compared in RA patients with and without diabetes. Predictors of rheumatological care were identified by multivariate regression. Results: Of the 2535 RA patients, 498 (20%) had diabetes. Diabetes was more frequent in males, in older patients, in patients with a higher BMI and in those with a lower socioeconomic status. All disease outcomes were poorer in RA-diabetes patients and were mainly attributable to a higher BMI. RA-diabetes patients received less DMARDs (40% vs 48%) and had more hospital stays (41% vs 30%) than patients without diabetes (all P < 0.05). Rates of cardiovascular disease (35% vs 15%), depression (39% vs 26%) and renal failure (23% vs 8%) were higher in RA-diabetes patients (all P < 0.0001). They were less frequently treated by rheumatology specialists: 57% vs 67%; odds ratio = 0.64 (95% CI: 0.45, 0.92), after controlling for confounders. Conclusion: The prevalence of diabetes in patients with RA is high and is associated with known sociodemographic factors. More than 40% of patients with RA and diabetes were not under rheumatological care even though they reported a high disease burden, were frequently hospitalized and often presented with further comorbidities.

[Outpatient emergency treatment of nursing home residents : Analysis of insurance claims data]. / Ambulante Notfallversorgung von Pflegeheimbewohnern : Auswertung von GKV-Routinedaten.

BACKGROUND: Utilization of outpatient emergency services by nursing home residents is increasing; however, out of hours medical care (OOHC) in Germany has not yet been studied. OBJECTIVE: In Bremen the used billing codes enabled a comparison between the use of outpatient emergency care in the year before and the year after admission to a nursing home stratified by emergency departments and OOHC. MATERIAL AND METHODS: In this retrospective cohort study we used insurance claims data of residents in Bremen, who were insured in a large German statutory health insurance (DAK-Gesundheit). We compared the use of emergency care in hospitals or OOHC practices in the year before and the year after admission to a nursing home. The incidence rates of visits, distribution on weekdays and coded diagnoses were investigated. RESULTS: We included 1175 nursing home residents (77% female) with a mean age of 85 years. After admission to a nursing home the incidence rate of visits in the OOHC practices increased from 30.4 up to 63.7 and in emergency departments (ED) from 27.4 up to 50.7 per 100 person years. A total of 59% of all visits in OOHC practices were on weekends. The most common diagnoses in ED were injuries and poisoning (75%) while a wide range of diagnoses were coded in the OOHC practices. CONCLUSION: There is a significant difference between diagnoses in the ED and OOHC practices. More research is needed to assess the appropriateness of care.

Rheumatologic care of nursing home residents with rheumatoid arthritis: a comparison of the year before and after nursing home admission.

The purpose of this study was to investigate health care for patients with rheumatoid arthritis (RA) before and after admission to nursing homes. Data of a German health insurance fund from persons with diagnostic codes of RA, aged ≥65 years, admitted to a nursing home between 2010 and 2014 and continuously insured 1 year before and after admission were used. The proportion of patients with ≥1 rheumatologist visit and ≥1 prescription of biologic or conventional synthetic disease-modifying antirheumatic drugs (bDMARDs or csDMARDs), glucocorticoids and non-steroidal anti-inflammatory drugs (NSAIDs) in the year before and after admission were calculated. Predictors of rheumatologic care after admission were analyzed by multivariable logistic regression. Of 75,697 nursing home residents, 2485 (3.3%) had RA (90.5% female, mean age 83.8). Treatment by rheumatologists and prescription of antirheumatic drugs decreased significantly in the year after admission (rheumatologic visits: 17.6 to 9.1%, bDMARDs: 2.1 to 1.5%, csDMARDs: 22.5 to 16.5%, glucocorticoids: 46.5 to 43.1%, NSAIDs: 47.4 to 38.5%). 60.2% of patients in rheumatologic care received csDMARDs compared with 14.5% without rheumatologic care. Rheumatologic care before admission to a nursing home strongly predicted rheumatologic care thereafter (OR 33.8, 95%-CI 23.2-49.2). Younger age and lower care level (reflecting need of help) were also associated with a higher chance of rheumatologic care. Rheumatologic care is already infrequent in old patients with RA and further decreases after admission to a nursing home. Patients without rheumatologic care are at high risk of insufficient treatment for their RA. Admission to a nursing home further increases this risk.

Transition to adult rheumatology care is necessary to maintain DMARD therapy in young people with juvenile idiopathic arthritis.

OBJECTIVE: To evaluate the outpatient health service utilisation of young people (YP) with juvenile idiopathic arthritis (JIA) during transfer from paediatric to adult care in Germany. METHODS: Based on claims data of a large German statutory health fund (BARMER GEK) we conducted a cohort study of 2008-2014. Insured YP with diagnosis of JIA (ICD: M08 or M09.0) in two quarters at the age of 16 and continuous insurance until the age of 20 were included. Outpatient health care utilisation, prescribed antirheumatic drugs and diagnosis maintenance were analysed over four consecutive years for all YP with JIA and for the subgroup on disease-modifying antirheumatic drugs (DMARDs) at the age of 16. RESULTS: A total of 256 YP with JIA (67% female) were followed during the transfer period, 115 of them received (DMARDs) at the age of 16. At the age of 20, 30% of all 256 YP utilised adult specialty care, 59% still had a JIA diagnosis and 30% were treated with DMARDs. Of those 115 YP, treated with DMARDs at the age of 16 and in need of follow-up, 49% had visited an adult rheumatologist at the age of 20, 75% had a JIA diagnosis and 56% were on DMARDs. Those 49% YP with successful transfer to adult specialty care had a JIA diagnosis in 93% and were treated with DMARDs in 80%. YP, who were only seen by general practitioners, had a JIA diagnosis in 54% and received DMARDs in 27%. CONCLUSIONS: One in two YP with JIA and a clear need for ongoing follow-up do not utilise adult rheumatologic care. The maintenance of JIA diagnosis and DMARD therapy depend on the utilisation of specialised care services.

The Association of Low Income with Functional Status and Disease Burden in German Patients with Rheumatoid Arthritis: Results of a Cross-sectional Questionnaire Survey Based on Claims Data.

OBJECTIVE: To assess the influence of income on self-reported disease and work productivity outcomes. METHODS: Persons with rheumatoid arthritis (RA) diagnosis (International Classification of Diseases, 10th ed. codes M05/M06) on health insurance claims data in at least 2 quarters of 2013 were randomly selected. They were mailed questionnaires covering RA diagnosis, household income, functional capacity [Hannover functional status questionnaire (FFbH), 0-100], RA Impact of Disease questionnaire (RAID; 0-10), self-reported swollen joint count (SJC; 0-48), tender joint count (TJC; 0-50), and effect of RA on work productivity (change of work, fewer working hours, sick leave, application for disability pension, and others). Weighted multivariable linear regression models were used to assess the association between income and disease outcomes. RESULTS: A total of 1492 persons of working age who confirmed RA diagnosis were available for analysis. The mean age was 55 years, 82% were women, and 74% were under rheumatologic care. A total of 27%, 52%, and 21% had a low (< €1500), medium (€1500-3200), and high monthly income (> €3200), respectively. Respondents with low income had the worst mean FFbH, RAID, SJC, and TJC values. This was confirmed in the regression model: mean FFbH low versus high income -8.65 (95% CI -9.72 to -7.58), RAID 0.73 (0.59-0.86), and SJC 3.47 (2.86-4.08). Sick leave (8.7%/3.5%/1.8%) and disability pension (18.1%/9.6%/6.9%) were more frequent in patients with low versus medium versus high income (p < 0.05). CONCLUSION: The association of low income with a higher disease burden, more functional disability, and higher rates of work loss emphasizes the need to focus on these outcomes when choosing treatment strategies for patients in the lower income groups.

Pain, depressive symptoms and medication in German patients with rheumatoid arthritis-results from the linking patient-reported outcomes with claims data for health services research in rheumatology (PROCLAIR) study.

PURPOSE: Pain and depressive symptoms are common in patients with rheumatoid arthritis (RA). Information on the prevalence and treatment of both conditions in German RA patients is scarce. METHODS: Using data from a nationwide statutory health insurance fund (BARMER GEK), 6193 RA patients aged 18 to 79 years were provided with a questionnaire covering a variety of items such as demographics, medical condition and quality of life in 2015. Pain caused by the joint disorder (11-point scale) was classified as none existent/mild, moderate or severe. Depressive symptoms were determined using the World Health Organization's five-item Well-being Index and categorized as none existent, mild or moderate/severe. Another item covered additional use of over-the-counter drugs. Data were linked to dispensation records. RESULTS: A total of 3140 RA patients were included. Median age was 66 years (79% female). About 70% of patients were classified as having moderate or severe pain. Depressive symptoms were found in 52% and were far more common among patients with higher pain levels. Analgesic treatment ranged from 45% to 76% (non-opioid analgesics) and from 6% to 33% (opioids) in patients with no/mild pain and those reporting severe pain, respectively. In patients reporting moderate or severe pain, substantially higher prevalences of opioid use were observed among those with depressive symptoms. Depending on depressive symptoms, antidepressant use ranged from 7% to 37%. Overall, over-the-counter drug use varied between 30% and 59%. CONCLUSIONS: Pain and depressive symptoms are highly prevalent in German RA patients, often present together and influence each other's treatment. Copyright © 2017 John Wiley & Sons, Ltd.

Initiation and duration of dual antiplatelet therapy after inpatient percutaneous coronary intervention with stent implantation in Germany: An electronic healthcare database cohort study.

BACKGROUND: Studies assessing the routine outpatient dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) in Germany are scarce. The aim of this study was (i) to investigate the initiation and duration of DAPT after inpatient PCI with stent implantation in Germany, and (ii) to identify factors associated with DAPT discontinuation during the recommended treatment period. METHODS: This retrospective cohort study was based on data from a large German electronic healthcare database of the years 2004 to 2009. The study population comprised four groups of patients with acute coronary syndrome (ACS) or stable angina pectoris undergoing inpatient PCI with either bare metal stent (BMS) or drug eluting stent (DES) implantation between 2005 and 2008. Initiation of outpatient DAPT within a period from 100 days before the PCI to 60 days after the PCI was ascertained. Time until end of treatment was analysed using the Kaplan-Meier method. Factors potentially associated with DAPT discontinuation, like sex, age, cardiovascular comorbidity, contraindications, and other antithrombotic drugs were analysed in a Cox proportional hazard model. RESULTS: The cohort comprised 37,001 patients. Depending on the type of stent and the indication for the PCI, DAPT was initiated in 85 % (ACS/BMS) and 95 % (AP/DES) of all patients. Of those, 12 % (AP/DES) and 64 % (ACS/BMS) discontinued DAPT during the recommended treatment duration. An age of over 80 years (OR 1.2-1.5 compared to patients aged 0-49 years) and the use of phenprocoumon (OR 2.7-5.0 compared to no phenprocoumon) were associated with an increased risk of DAPT discontinuation. CONCLUSIONS: A high proportion of patients with coronary artery disease undergoing inpatient PCI with stent implantation received DAPT. However, DAPT discontinuation during the recommended time span was frequent, particularly in patients suffering from ACS. On the other hand, especially patients with AP and DES were often treated longer than recommended.