Evaluation of costs, osteoporosis treatment, and re-fractures in German collaborative orthogeriatric care after fragility fractures.

Orthogeriatric co-management (OGCM) may provide benefits for geriatric fragility fracture patients in terms of more frequent osteoporosis treatment and fewer re-fractures. Yet, we did not find higher costs in OGCM hospitals for re-fractures or antiosteoporotic medication for most fracture sites within 12 months, although antiosteoporotic medication was more often prescribed. PURPOSE: Evidence suggests benefits of orthogeriatric co-management (OGCM) for hip fracture patients. Yet, evidence for other fractures is rare. The aim of our study was to conduct an evaluation of economic and health outcomes after the German OGCM for geriatric fragility fracture patients. METHODS: This retrospective cohort study was based on German health and long-term care insurance data. Individuals were 80 years and older, sustained a fragility fracture in 2014-2018, and were treated in hospitals certified for OGCM (ATZ group), providing OGCM without certification (OGCM group) or usual care (control group). Healthcare costs from payer perspective, prescribed medications, and re-fractures were investigated within 6 and 12 months. We used weighted gamma and two-part models and applied entropy balancing to account for the lack of randomization. All analyses were stratified per fracture site. RESULTS: We observed 206,273 patients within 12-month follow-up, of whom 14,100 were treated in ATZ, 133,353 in OGCM, and 58,820 in other hospitals. Total average inpatient costs per patient were significantly higher in the OGCM and particularly ATZ group for all fracture sites, compared to control group. We did not find significant differences in costs for re-fractures or antiosteoporotic medication for most fracture sites, although antiosteoporotic medication was significantly more often observed in the OGCM and particularly ATZ group for hip, pelvic, and humerus fractures. CONCLUSION: The observed healthcare costs were higher in ATZ and OGCM hospitals within 12 months. Antiosteoporotic medication was prescribed more often in both groups for most fracture sites, although the corresponding medication costs did not increase.

A flexible approach to measure care coordination based on patient-sharing networks.

BACKGROUND: Effective care coordination may increase clinical efficiency, but its measurement remains difficult. The established metric "care density" (CD) measures care coordination based on patient-sharing among physicians, but it may be too rigid to generalize across disorders and countries. Therefore, we propose an extension called fragmented care density (FCD), which allows varying weights for connections between different types of providers. We compare both metrics in their ability to predict hospitalizations due to schizophrenia. METHODS: We conducted a longitudinal cohort study based on German claims data from 2014 through 2017 to predict quarterly hospital admissions. 21,016 patients with schizophrenia from the federal state Baden-Württemberg were included. CD and FCD were calculated based on patient-sharing networks. The weights of FCD were optimized to predict hospital admissions during the first year of a 24-month follow-up. Subsequently, we employed likelihood ratio tests to assess whether adding either CD or FCD improved a baseline model with control variables for the second follow-up year. RESULTS: The inclusion of FCD significantly improved the baseline model, Χ2(1) = 53.30, p < 0.001. We found that patients with lower percentiles in FCD had an up to 21% lower hospitalization risk than those with median or higher values, whereas CD did not affect the risk. CONCLUSIONS: FCD is an adaptive metric that can weight provider relationships based on their relevance for predicting any outcome. We used it to better understand which medical specialties need to be involved to reduce hospitalization risk for patients with schizophrenia. As FCD can be modified for different health conditions and systems, it is broadly applicable and might help to identify barriers and promoting factors for effective collaboration.

Factors associated with institutionalization among the oldest old: Results based on the nationally representative study 'old age in Germany (D80+)'.

OBJECTIVES: To examine the factors associated with institutionalization among individuals aged 80 years and over in Germany (total sample and stratified by sex). METHODS/DESIGN: We used data from the nationally representative 'Old Age in Germany (D80+)' (analytic sample: n = 9572 individuals), including individuals aged 80 years and over in Germany. Institutionalization (private living vs. institutionalization) served as an outcome measure. For the written interview, data collection took place from November 2020 to April 2021. Multiple logistic regressions of the overall sample (also stratified by sex) were applied. RESULTS: In the analytic sample, 10.2% (95% CI: 9.2%-11.3%) of the participants were institutionalized. The odds of being institutionalized were positively associated with being female (OR: 2.02, 95% CI: 1.08 to 3.80), being 90 years and over (compared to 80-84 years, OR: 1.67, 95% CI: 1.17 to 2.40), not being married (e.g., being single compared to being married: OR: 14.06, 95% CI: 6.73 to 29.37), higher education (e.g., high education compared to low education: OR: 1.88, 95% CI: 1.25 to 2.84), more favorable self-rated health (OR: 1.32, 95% CI: 1.07 to 1.62) and greater functional impairment (OR: 15.34, 95% CI: 11.91 to 19.74). Sex-stratified regressions were also conducted, mostly yielding similar results. CONCLUSION: Our study highlighted the role of several sociodemographic factors (particularly marital status, e.g., being single) and functional impairment for the risk of institutionalization among the oldest old in Germany. This study confirms findings in studies in younger samples that functional decline is the main factor associated with institutionalization. As functional decline may be modifiable, efforts to maintain functional abilities may be important. This knowledge is important for relevant groups (such as clinicians and policy-makers) because it may guide early intervention and prevention efforts, can help allocate healthcare resources effectively and shape policies to support independent living. Further insights using longitudinal data is recommended.

Evaluating palliative care case conferences in primary care for patients with advanced non-malignant chronic conditions: a cluster-randomised controlled trial (KOPAL).

BACKGROUND: Patients with congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and dementia are underrepresented in specialist palliative home care (SPHC). However, the complexity of their conditions requires collaboration between general practitioners (GPs) and SPHC teams and timely integration into SPHC to effectively meet their needs. OBJECTIVE: To facilitate joint palliative care planning and the timely transfer of patients with advanced chronic non-malignant conditions to SPHC. METHODS: A two-arm, unblinded, cluster-randomised controlled trial. 49 GP practices in northern Germany were randomised using web-based block randomisation. We included patients with advanced CHF, COPD and/or dementia. The KOPAL intervention consisted of a SPHC nurse-patient consultation followed by an interprofessional telephone case conference between SPHC team and GP. The primary outcome was the number of hospital admissions 48 weeks after baseline. Secondary analyses examined the effects on health-related quality of life and self-rated health status, as measured by the EuroQol 5D scale. RESULTS: A total of 172 patients were included in the analyses. 80.4% of GP practices had worked with SHPC before, most of them exclusively for cancer patients. At baseline, patients reported a mean EQ-VAS of 48.4, a mean quality of life index (EQ-5D-5L) of 0.63 and an average of 0.80 hospital admissions in the previous year. The intervention did not significantly reduce hospital admissions (incidence rate ratio = 0.79, 95%CI: [0.49, 1.26], P = 0.31) or the number of days spent in hospital (incidence rate ratio = 0.65, 95%CI: [0.28, 1.49], P = 0.29). There was also no significant effect on quality of life (∆ = -0.02, 95%CI: [-0.09, 0.05], P = 0.53) or self-rated health (∆ = -2.48, 95%CI: [-9.95, 4.99], P = 0.51). CONCLUSIONS: The study did not show the hypothesised effect on hospitalisations and health-related quality of life. Future research should focus on refining this approach, with particular emphasis on optimising the timing of case conferences and implementing discussed changes to treatment plans, to improve collaboration between GPs and SPHC teams.

The effect of depressive symptoms on quality of life and its different facets in the oldest age population: evidence from the AgeQualiDe prospective cohort study.

PURPOSE: The present study aims to investigate the prospective effect of depressive symptoms on overall QoL in the oldest age group, taking into account its different facets. METHODS: Data were derived from the multicenter prospective AgeCoDe/AgeQualiDe cohort study, including data from follow-up 7-9 and n = 580 individuals 85 years of age and older. Overall QoL and its facets were assessed using the WHOQOL-OLD instrument. The short form of the geriatric depression scale (GDS-15) was applied to assess depressive symptoms. Cognitively impaired individuals were excluded. Linear mixed-effects models were used to assess the effect of depressive symptoms on QoL. RESULTS: Depressive symptoms were significantly associated with overall QoL and each of the different facets of WHOQOL-OLD, also after adjustment for time and sociodemographic characteristics such as age, gender, education, marital status, living situation, and cognitive status. Higher age and single as well as divorced marital status were also associated with a lower QoL. CONCLUSION: This work provides comprehensive longitudinal results on the relationship between depressive symptoms and QoL in the oldest age population. The results underscore the relevance of tailored and targeted care planning and the development of customized interventions.

Quality of life in a high-risk group of elderly primary care patients: characteristics and potential for improvement.

PURPOSE: Quality of Life (QoL) is associated with a bandwidth of lifestyle factors that can be subdivided into fixed and potentially modifiable ones. We know too little about the role of potentially modifiable factors in comparison to fixed ones. This study examines four aspects of QoL and its associations with 15 factors in a sample of elderly primary care patients with a high risk of dementia. The main objectives are (a) to determine the role of the factors in this particular group and (b) to assess the proportion of fixed and potentially modifiable factors. METHOD: A high-risk group of 1030 primary care patients aged between 60 and 77 years (52.1% females) were enrolled in "AgeWell.de," a cluster-randomized, controlled trial. This paper refers to the baseline data. The multi-component intervention targets to decrease the risk of dementia by optimization of associated lifestyle factors. 8 fixed and 7 modifiable factors potentially influencing QoL served as predictors in multiple linear regressions. RESULTS: The highest proportion of explained variance was found in psychological health and age-specific QoL. In comparison to health-related QoL and physical health, the modifiable predictors played a major role (corr. R2: 0.35/0.33 vs. 0.18), suggesting that they hold a greater potential for improving QoL. CONCLUSION: Social engagement, body weight, instrumental activities of daily living, and self-efficacy beliefs appeared as lifestyle factors eligible to be addressed in an intervention program for improving QoL. TRIAL REGISTRATION: German Clinical Trials Register, reference number: DRKS00013555. Date of registration: 07.12.2017.

Budget impact analysis of a Lifestyle-integrated Functional Exercise (LiFE) program for older people in Germany: a Markov model based on data from the LiFE-is-LiFE trial.

BACKGROUND: Fall prevention is important for healthy ageing, but the economic impact of fall prevention are scarcely investigated. A recent cost-effectiveness analysis compared a group-delivered Lifestyle-integrated Functional Exercise Program (gLiFE) with an individually-delivered program (LiFE) in community-dwelling people (aged ≥ 70 years) at risk of falling. In addition, the current study aimed to analyze the budget impact of LiFE and gLiFE, compared with standard care in Germany. METHODS: A Markov model was developed to reflect falls and associated care needs for community-dwelling persons over 5 years. The intervention effects of LiFE and gLiFE were shown to be equivalent in a non-inferiority trial, although the costs differed. Outpatient, inpatient, and intervention costs were assessed from a payer's perspective. The effect of parameter uncertainty was assessed in sensitivity analyses. RESULTS: The budget impact due to intervention costs was €510 million for LiFE and €186 million for gLiFE. Over five years, health care expenditures were €35,008 million for those receiving standard care, €35,416 million for those receiving LiFE, and €35,091 million for persons receiving gLiFE. Thereby, LiFE and gLiFE could prevent 2700 deaths and 648,000 falls over 5 years. Parameter uncertainties in the risk of falling, uptake of an intervention offer, and in the intervention effects had a major influence; thus cost savings for LiFE and gLiFE compared with standard care could be achieved for individuals with a high risk of falling. CONCLUSIONS: The results revealed that cost savings for LiFE and gLiFE compared with standard care could only be achieved for individuals at high risk of falling, with gLiFE being superior to LiFE. Future research should consider benefits and aspects of fall prevention beyond falls (e.g., physical activity, social aspects, and personal preferences of participants). TRIAL REGISTRATION: The study was preregistered under underclinicaltrials.gov (identifier: NCT03462654) on 12th March 2018; https://clinicaltrials.gov/ct2/show/NCT03462654 .

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.

How do individuals rate their health compared to others? findings based on a nationally representative sample in Germany.

BACKGROUND: The aim of this study is to explore the determinants of health comparisons (i.e., how individuals rate their health compared to other individuals in their age bracket) in the general adult population (total sample and in different age groups). METHODS: Data were used from the general adult population in Germany (wave 46, n = 3,876 individuals; November 2021 to January 2022), based on the GESIS panel, which is a probability-based mixed-mode panel. Health comparisons were used as outcome measure. Socioeconomic, lifestyle-related and health-related determinants were included in regression analysis. Robustness checks were conducted. RESULTS: Regressions showed that more favorable health comparisons were associated with being male (among individuals up to 39 years), higher age (among the total sample), higher education (among the total sample and individuals up to 39 years), higher income (among the total sample and individuals aged 40 to 64 years), not "being married, and living together with a spouse" (among the total sample), never eating meat (among the total sample, individuals up to 39 years and particularly individuals aged 40 to 64 years), drinking alcohol (among the total sample, individuals aged 40 to 64 years and individuals aged 65 years and over), a higher frequency of sports activities (all groups) and a higher satisfaction with health (also in all groups). CONCLUSION: In addition to the evident link between health satisfaction and health comparisons, regression analysis revealed that certain socioeconomic factors, such as a higher income level, along with positive lifestyle-related factors - especially among middle-aged individuals - were significantly associated with more positive health comparisons. This knowledge is required in order to support individuals at risk for negative health comparisons. This is important because negative health comparisons can contribute to poor well-being and poor health outcomes.

Development and implementation of a treatment pathway to reduce coronary angiograms - lessons from a failure.

BACKGROUND: The rates of coronary angiograms (CA) and related procedures (percutaneous intervention [PCI]) are significantly higher in Germany than in other Organisation for Economic Co-ordination and Development (OECD) countries. The current guidelines recommend non-invasive diagnosis of coronary heart disease (CHD); CA should only have a limited role in choosing the appropriate revascularisation procedure. The aim of the present study was to explore whether improvements in guideline adherence can be achieved through the implementation of regional treatment pathways. We chose four regions of Germany with high utilisation of CAs for the study. Here we report the results of the concomitant qualitative study. METHODS: General practitioners and specialist physicians (cardiologists, hospital-based cardiologists, emergency physicians, radiologists and nuclear medicine specialists) caring for patients with suspected CHD were invited to develop regional treatment pathways. Four academic departments provided support for moderation, provision of materials, etc. The study team observed session discussions and took notes. After the development of the treatment pathways, 45 semi-structured interviews were conducted with the participating physicians. Interviews and field notes were transcribed verbatim and underwent qualitative content analysis. RESULTS: Pathway development received little support among the participants. Although consensus documents were produced, the results were unlikely to improve practice. The participants expressed very little commitment to change. Although this attempt clearly failed in all study regions, our experience provides relevant insights into the process of evidence appraisal and implementation. A lack of organisational skills, ignorance of current evidence and guidelines, and a lack of feedback regarding one's own clinical behaviour proved to be insurmountable. CA was still seen as the diagnostic gold standard by most interviewees. CONCLUSIONS: Oversupply and overutilisation can be assumed to be present in study regions but are not immediately perceived by clinicians. The problem is unlikely to be solved by regional collaborative initiatives; optimised resource planning within the health care system combined with appropriate economic incentives might best address these issues.

Pain: its prevalence and correlates among the oldest old.

BACKGROUND: There is very limited knowledge regarding pain among the oldest old. AIMS: To investigate the prevalence and correlates of pain among the oldest old. METHODS: Data were taken from the "Survey on quality of life and subjective well-being of the very old in North Rhine-Westphalia (NRW80+)", including individuals living in North Rhine-Westphalia aged 80 years and over. Pain was categorized as no pain, moderate pain and severe pain. Its prevalence was stratified by sex, age groups, marital status, place of residence and education. A multinomial logistic regression analysis was conducted. RESULTS: 28.50% of the participants reported no pain, 45.06% moderate pain and 26.44% severe pain. Regressions showed that being 85 years or older and a better self-rated health status decreased the likelihood of moderate pain. Being 85-89 years old, being male, highly educated and a better self-rated health status decreased the likelihood of severe pain. The likelihood of moderate and severe pain increased with a higher number of chronic diseases. DISCUSSION: Study findings showed a high prevalence of pain in the oldest old living in North Rhine-Westphalia, Germany. The likelihood of having moderate or severe pain was reduced among those who were older and presented with a better self-rated health but increased with a growing number of comorbidities. Severe pain was less likely among men and those with a higher education. CONCLUSION: This cross-sectional representative study adds first evidence of prevalence and correlations of pain among the oldest old. Longitudinal studies are required to further explore the determinants of pain in this age group.

A multidomain intervention against cognitive decline in an at-risk-population in Germany: Results from the cluster-randomized AgeWell.de trial.

INTRODUCTION: We investigated the effectiveness of a multidomain intervention to preserve cognitive function in older adults at risk for dementia in Germany in a cluster-randomized trial. METHODS: Individuals with a Cardiovascular Risk Factors, Aging, and Dementia (CAIDE) risk score ≥ 9 aged 60 to 77 years were recruited. After randomization of their general practitioner (GP), patients received a multidomain intervention (including optimization of nutrition and medication, and physical, social, and cognitive activity) or general health advice and GP treatment as usual over 24 months. Primary outcome was global cognitive performance (composite z score, based on domain-specific neuropsychological tests). RESULTS: Of 1030 participants at baseline, n = 819 completed the 24-month follow-up assessment. No differences regarding global cognitive performance (average marginal effect = 0.010, 95% confidence interval: -0.113, 0.133) were found between groups at follow-up. Perceived restrictions in intervention conduct by the COVID-19 pandemic did not impact intervention effectiveness. DISCUSSION: The intervention did not improve global cognitive performance. HIGHLIGHTS: Overall, no intervention effects on global cognitive performance were detected. The multidomain intervention improved health-related quality of life in the total sample. In women, the multidomain intervention reduced depressive symptoms. The intervention was completed during the COVID-19 pandemic.

[Updating standardized unit costs from a societal perspective for health economic evaluation]. / Aktualisierung der standardisierten Bewertungssätze aus gesellschaftlicher Perspektive für gesundheitsökonomische Evaluationen.

AIM OF THE STUDY: The aim of this work was to update the 2015 unit costs (UC) for the monetary valuation of health-related resource use from a societal perspective for the years 2019 and 2020 in Germany. METHODS: The update follows the methodology of Bock et al. 2015. Based on the newly established care levels, UC for care degree 1 to 5 are now provided. To account for change in price trends during the Covid-19 pandemic, average growth rates in UC are shown from 2011-2019 and compared to 2019-2020. RESULTS: Updates of UC for the outpatient medical sector, remedies and aids, hospitals, (in)formal care services, and rehabilitation for 2019 and 2020 are provided. CONCLUSION: The updated UC can be used as reference values for the monetary valuation of individual resource use in health economic evaluations in Germany.

Prevalence and factors associated with probable depression among the oldest old during the Covid-19 pandemic: evidence from the large, nationally representative 'Old Age in Germany (D80+)' study.

BACKGROUND: To date, most studies examining the prevalence and determinants of depression among individuals aged 80 and over have used geographically limited samples that are not generalisable to the wider population. Thus, our aim was to identify the prevalence and the factors associated with probable depression among the oldest old in Germany based on nationally representative data. METHODS: Data were taken from the nationally representative 'Old Age in Germany (D80+)' study (n = 8386; November 2020 to April 2021) covering both community-dwelling and institutionalised individuals aged 80 and over. The Short Form of the Depression in Old Age Scale was used to quantify probable depression. RESULTS: Probable depression was found in 40.7% (95% CI: 39.5% to 42.0%) of the sample; 31.3% were men (95% CI: 29.7% to 32.9%) and 46.6% women (95% CI: 44.9% to 48.3%). The odds of probable depression were positively associated with being female (odds ratio (OR): 1.55, 95% CI: 1.30 to 1.84), being divorced (compared to being married, OR: 1.33, 95% CI: 1.01 to 1.76), being widowed (OR: 1.14, 95% CI: 1.00 to 1.30), having a low education (e.g., medium education compared to low education, OR: 0.86, 95% CI: 0.74 to 0.99), living in an institutionalised setting (OR: 2.36, 95% CI: 1.84 to 3.02), living in East Germany (OR: 1.21, 95% CI, 1.05 to 1.39), not having German citizenship (German citizenship compared to other citizenship, OR: 0.55, 95% CI: 0.31 to 0.95), poor self-rated health (OR: 0.31, 95% CI: 0.28 to 0.34), and the number of chronic conditions (OR: 1.12, 95% CI: 1.09 to 1.14). CONCLUSION: About four out of 10 individuals aged 80 and over in Germany had probable depression, underlining the importance of this challenge. Knowledge of specific risk factors for this age group may assist in addressing older adults at risk of probable depression.

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.

Cost-effectiveness of early rhythm control vs. usual care in atrial fibrillation care: an analysis based on data from the EAST-AFNET 4 trial.

AIMS: The randomized, controlled EAST-AFNET 4 trial showed that early rhythm control (ERC) reduces the rate of a composite primary outcome (cardiovascular death, stroke, or hospitalization for worsening heart failure or acute coronary syndrome) by ∼20%. The current study examined the cost-effectiveness of ERC compared to usual care. METHODS AND RESULTS: This within-trial cost-effectiveness analysis was based on data from the German subsample of the EAST-AFNET 4 trial (n = 1664/2789 patients). Over a 6-year time horizon and from a healthcare payer's perspective, ERC was compared to usual care regarding costs (hospitalization and medication) and effects (time to primary outcome; years survived). Incremental cost-effectiveness ratios (ICERs) were calculated. Cost-effectiveness acceptability curves were constructed to visualize uncertainty. Early rhythm control was associated with higher costs [+€1924, 95% CI (-€399, €4246)], resulting in ICERs of €10 638 per additional year without a primary outcome and €22 536 per life year gained. The probability of ERC being cost-effective compared to usual care was ≥95% or ≥80% at a willingness-to-pay value of ≥€55 000 per additional year without a primary outcome or life year gained, respectively. CONCLUSION: From a German healthcare payer's perspective, health benefits of ERC may come at reasonable costs as indicated by the ICER point estimates. Taking statistical uncertainty into account, cost-effectiveness of ERC is highly probable at a willingness-to-pay value of ≥€55 000 per additional life year or year without a primary outcome. Future studies examining the cost-effectiveness of ERC in other countries, subgroups with higher benefit from rhythm control therapy, or cost-effectiveness of different modes of ERC are warranted.

Community centers for older adults and psychosocial factors: Evidence from the German Ageing Survey.

INTRODUCTION: There is a dearth of studies examining the association between the use of community centers for older adults and psychosocial factors. Thus, our aim was to examine the association between the use of community centers for older adults and psychosocial factors (in terms of loneliness, perceived social isolation, and life satisfaction; also stratified by sex)-which is important for successful aging. METHODS/DESIGN: Data were taken from a nationally representative sample-the German Ageing Survey-including older community-dwelling individuals. The De Jong Gierveld tool was used to measure loneliness, the Bude and Lantermann tool was used to measure perceived social isolation, and the Satisfaction with Life Scale was used to quantify life satisfaction. Multiple linear regressions were used to evaluate the hypothesized associations. RESULTS: In the analytical sample, n equaled 3246 individuals (mean age was 75 years, 65-97 years). After adjusting for various socioeconomic, lifestyle-related, and health-related covariates, multiple linear regressions showed that the use of community centers was associated with higher life satisfaction among men (ß = 0.12, p < 0.01), but not women. The use of community centers was not associated with loneliness or perceived social isolation for either gender. CONCLUSIONS: The use of community centers was positively associated with satisfaction with one's own life among male older adults. Thus, encouraging older men to use such services may be beneficial. This quantitative study provides an initial basis for further research in this neglected area. For example, longitudinal studies are required to confirm our present findings.

Determinants of psychosocial factors amongst the oldest old: Longitudinal evidence based on the representative "survey on quality of life and subjective well-being of the very old in North Rhine-Westphalia".

OBJECTIVES: There are few studies investigating the determinants of psychosocial outcomes using data exclusively from the oldest old; and even fewer that use longitudinal data. Thus, our aim was to explore the determinants of psychosocial factors (in terms of life satisfaction, loneliness, and depressive symptoms) amongst the oldest old (also stratified by sex) based on representative, longitudinal data from Germany. METHODS/DESIGN: Data from "Survey on quality of life and subjective well-being of the very old in North Rhine-Westphalia (NRW80+)" were used. This study includes community-dwelling and institutionalized individuals aged 80 years and above (n = 1760 observations in the analytical sample) located in North Rhine-Westphalia (the most populous state in Germany). The mean age was 86.6 years (SD: 4.3 years). Established instruments were used to quantify life satisfaction, loneliness, and depressive symptoms. Linear FE regressions were used in this study to mitigate the challenge of unobserved heterogeneity. Sex-stratified regressions were also conducted. RESULTS: Regressions showed that the loss of a spouse was significantly associated with worsening psychosocial factors (in terms of increases in depressive symptoms and loneliness). Furthermore, regressions revealed that increases in functional impairment were significantly associated with poorer psychosocial outcomes. CONCLUSIONS: This longitudinal study enhanced our understanding of the factors contributing to poorer psychosocial outcomes among the oldest old. Efforts to avoid or postpone functional impairment may contribute to more favorable psychosocial outcomes. Moreover, our current study underlines the importance of spousal relationships for psychosocial outcomes in the oldest age group.

Comparison of falls and cost-effectiveness of the group versus individually delivered Lifestyle-integrated Functional Exercise (LiFE) program: final results from the LiFE-is-LiFE non-inferiority trial.

BACKGROUND: the individually delivered Lifestyle-integrated Functional Exercise (LiFE) was shown to improve physical activity (PA) and reduce fall incidence, however being rather resource-consuming due to one-to-one delivery. A potentially less resource-intensive group format (gLiFE) was developed and compared against the original program, considering higher risk of falling due to possible PA enhancement. OBJECTIVE: to investigate non-inferiority in terms of PA-adjusted fall risk and cost-effectiveness of gLiFE at 12-month follow-up. DESIGN: single-blinded, randomised, multi-centre non-inferiority trial. SETTING: community. SUBJECTS: in total, 309 adults aged 70+ years at risk of or with history of falling; n = 153 in gLiFE, n = 156 in LiFE. METHODS: LiFE was delivered one-to-one at the participants' homes, gLiFE in a group. PA-adjusted fall risk was analysed using negative binomial regression to compare incidence rate ratios (IRR). Cost-effectiveness was presented by incremental cost-effectiveness ratios and cost-effectiveness acceptability curves, considering quality-adjusted life years, PA and falls as effect measures. Secondary analyses included PA (steps/day) and fall outcomes. RESULTS: non-inferiority was inconclusive (IRR 0.96; 95% confidence interval, CI 0.67; 1.37); intervention costs were lower for gLiFE, but cost-effectiveness was uncertain. gLiFE participants significantly increased PA (+1,090 steps/day; 95% CI 345 and 1.835) versus insignificant increase in LiFE (+569, 95% CI -31; 1,168). Number of falls and fallers were reduced in both formats. CONCLUSION: non-inferiority of gLiFE compared with LiFE was inconclusive after 12 months. Increases in PA were clinically relevant in both groups, although nearly twice as high in gLiFE. Despite lower intervention costs of gLiFE, it was not clearly superior in terms of cost-effectiveness.