Study protocol for the development, trial, and evaluation of a strategy for the implementation of qualification-oriented work organization in nursing homes.

BACKGROUND: Staffing ratios in nursing homes vary among the federal states of Germany, but there are no rational grounds for these variations. In a previous study, a new instrument for the standardized calculation of staffing requirements in nursing homes was developed (Algorithm 1.0). The development was based on a new empirical data collection method that derives actual and target values for the time and number of care interventions provided. Algorithm 1.0 found an increased requirement of 36% of staff in German nursing homes. Based on these results, the German legislature has commissioned a model program to trial and evaluate a complex intervention comprising increased staffing combined with strategies for organizational development. METHODS: The mixed-methods study consists of (i) developing a concept for restructuring the work organization, (ii) the application of this concept combined with increased staffing in 10 nursing homes (complex intervention), and the further development of the concept using a participatory and iterative formal evaluation process. The intervention consists of (a) quantitative measures of increased staffing based on a calculation using Algorithm 1.0 and (b) qualitative measures regarding organizational development. The intervention will be conducted over one year. The effects of the intervention on job satisfaction and quality of care will be evaluated in (iii) a comprehensive prospective, controlled summative evaluation. The results will be compared with ten matched nursing homes as a control group. Finally, (iv) prototypical concepts for qualification-oriented work organization, a strategy for the national rollout, and the further development of Algorithm 1.0 into Algorithm 2.0 will be derived. DISCUSSION: In Germany, there is an ongoing dynamic legislation process regarding further developing the long-term care sector. The study, which is the subject of the study protocol presented here, generates an evidence-based strategy for the staffing requirements for nursing homes. ETHICS AND DISSEMINATION: This study was approved by the Ethics Committee of the German Association of Nursing Science (Deutsche Gesellschaft für Pflegewissenschaft) on 02.08.2023 (amended on 20.09.2023). Research findings are disseminated through presentations at national and international conferences and publications in peer-reviewed scientific journals. TRIAL REGISTRATION NUMBER: German Clinical Trails Register DRKS00031773 (Date of registration 09.11.2023).

[Digital technologies in nursing-what can they achieve?] / Digitale Technologien in der Pflege ­ Was können sie leisten?

Digital care technologies are becoming increasingly important in long-term care. They encompass all technologies that change processes and products by means of networking and/or sensor technology and include artificial intelligence, that is, processes, methods, and algorithms for learning by means of data and enabling meaningful decisions based on this. Their application ranges from the promotion of professional collaboration, control and management, knowledge acquisition and transfer, interaction and relationships to physical caregiving.Digital care technologies have the potential to simultaneously increase the quality of care and improve working conditions in care. However, there are obstacles to this at various levels: The development of these technologies is often driven by technical possibilities, resulting in products that do not provide any concrete benefits in routine nursing care. During implementation, only the operator is trained; however, there is no organizational development for the systematic integration of these technologies into routine work. In addition, there is a lack of high-quality evaluations showing evidence of the actual benefits to routine work in order to attract potential users to these technologies. Finally, there is no sustainable financing, especially for the maintenance of these technologies.Successful digitization in long-term care therefore requires that technology developers and users, as well as policymakers and scientists, jointly overcome these obstacles. This implies that caregivers are involved in the development process from the outset (co-creation) but also that spaces are created where the effect of digital care technologies can be evaluated in routine caregiving.

Smartphone-assisted training with education for patients with hip and/or knee osteoarthritis (SmArt-E): study protocol for a multicentre pragmatic randomized controlled trial.

INTRODUCTION: Hip and knee osteoarthritis are associated with functional limitations, pain and restrictions in quality of life and the ability to work. Furthermore, with growing prevalence, osteoarthritis is increasingly causing (in)direct costs. Guidelines recommend exercise therapy and education as primary treatment strategies. Available options for treatment based on physical activity promotion and lifestyle change are often insufficiently provided and used. In addition, the quality of current exercise programmes often does not meet the changing care needs of older people with comorbidities and exercise adherence is a challenge beyond personal physiotherapy. The main objective of this study is to investigate the short- and long-term (cost-)effectiveness of the SmArt-E programme in people with hip and/or knee osteoarthritis in terms of pain and physical functioning compared to usual care. METHODS: This study is designed as a multicentre randomized controlled trial with a target sample size of 330 patients. The intervention is based on the e-Exercise intervention from the Netherlands, consists of a training and education programme and is conducted as a blended care intervention over 12 months. We use an app to support independent training and the development of self-management skills. The primary and secondary hypotheses are that participants in the SmArt-E intervention will have less pain (numerical rating scale) and better physical functioning (Hip Disability and Osteoarthritis Outcome Score, Knee Injury and Osteoarthritis Outcome Score) compared to participants in the usual care group after 12 and 3 months. Other secondary outcomes are based on domains of the Osteoarthritis Research Society International (OARSI). The study will be accompanied by a process evaluation. DISCUSSION: After a positive evaluation, SmArt-E can be offered in usual care, flexibly addressing different care situations. The desired sustainability and the support of the participants' behavioural change are initiated via the app through audio-visual contact with their physiotherapists. Furthermore, the app supports the repetition and consolidation of learned training and educational content. For people with osteoarthritis, the new form of care with proven effectiveness can lead to a reduction in underuse and misuse of care as well as contribute to a reduction in (in)direct costs. TRIAL REGISTRATION: German Clinical Trials Register, DRKS00028477. Registered on August 10, 2022.

[On the need for financial and structural reform of long-term care insurance]. / Zur Notwendigkeit einer Finanz- und Strukturreform der Pflegeversicherung.

When long-term care insurance was introduced in 1994, a number of conceptual decisions were made that continue to shape the system today. This discussion article examines three of these decisions. In each case, an evaluation standard is formulated against which the current situation is assessed. In the case of a negative assessment, reform options are discussed.In combination with the lack of benefit adjustments, the design of long-term care insurance as a system with capped insurance benefits and unlimited co-payments has led to co-payment levels in nursing homes that the majority of residents cannot cover from their income. Therefore, in order to fulfill its original objectives, long-term care insurance would have be turned upside down - by imposing an absolute limit on the amount and duration of the individual co-payments.The "dual insurance system" consisting of a social insurance for the majority and a private mandatory plan for a minority of the population has also proved to be a "birth defect" of the system. Since the group of privately insured persons has a much more favorable risk structure and higher average incomes, the "equal distribution of burdens" in financing required by the Federal Constitutional Court does not exist. To remedy this inequality, the dual system must be transformed into an integrated long-term care insurance system, or at least a risk structure equalization scheme between the two branches must be implemented.The introduction of long-term care insurance as a separate branch of social insurance, however, can be justified. In order to overcome interface problems, it would nevertheless be necessary to place the financing competence for geriatric rehabilitation with long-term care insurance and that for medical treatment care in nursing homes with health insurance.

[Home-care services in the first two waves of the COVID-19 pandemic: challenges for staff and care recipients]. / Ambulante Pflege in den ersten beiden Wellen der COVID-19-Pandemie: Herausforderungen für Personal und Pflegebedürftige.

INTRODUCTION: During the COVID-19 pandemic, people in need of long-term care were among the most vulnerable population groups. Home-care services were under exceptional strain, especially at the beginning of the pandemic. The aim of this study is to examine the situation and problems of care services and the people in need of care during the first two waves of the pandemic in Germany. METHODS: Two cross-sectional studies were conducted during the first two COVID-19 waves (first survey 28 April to 12 May 2020, second survey 12 January to 7 February 2021). In total, data from N = 1029 outpatient care services were included in the analysis. Descriptive measures were used for the analysis. RESULTS: The clients of home-care services were severely burdened in the first two waves of the pandemic. This can be seen on the one hand in an increased risk of illness and increased mortality, and on the other in the loss of various care and support services. The latter also has negative effects on the psychosocial condition of those in need of care, for example. Care services were affected by high staff absenteeism and additional work due to protective measures. DISCUSSION: The COVID-19 pandemic led to immense burdens for people in need of care and home-care services and to a reduction in care services. The deterioration of care provision met with an already tense situation. It has become clear that the provision of care for those in need of care by outpatient care services is not crisis-proof, and that additional challenges such as a pandemic can have dramatic consequences. For the future, reliable structures and readily available emergency plans should be established with concrete instructions for action.

[The situation of informal caregivers of working age in the COVID-19 pandemic-results of an online survey in Germany]. / Die Situation pflegender Angehöriger im erwerbsfähigen Alter in der COVID-19-Pandemie ­ Ergebnisse einer Onlinebefragung in Deutschland.

BACKGROUND: The consequences of the COVID-19 pandemic have posed major challenges to different groups. One of these are informal caregivers. This study investigates the changes the pandemic has caused for informal caregivers and the extent to which quality of life and burden of care have changed for specific subgroups. METHODS: Data for this cross-sectional study was gathered in the summer of 2020 in a convenient sample of informal caregivers (< 67 years of age, N = 1143). In addition to sociodemographic data, information on the care situation, compatibility of care and work, as well as stress and quality of life was collected in an online survey. The analysis of care situations and compatibility of care and work is done descriptively. Logistic regression models are used for a subgroup analysis of quality of life and care burden. RESULTS: The care situation has changed for 54.7% of participants and has become more time consuming. For 70.8% of respondents, the COVID-19 pandemic has made it even more difficult to balance care-giving and work. However, most respondents were satisfied with their employers' pandemic management (65.9%). A sharp decline in the quality of life and an increase in the burden of care for informal caregivers was ascertained. Both developments are stronger for young and female caregivers and for those caring for people with a greater need of support. DISCUSSION: The results indicate that living situations worsened for a substantial proportion of informal caregivers during the COVID-19 pandemic. Policymakers should recognize additional challenges that informal caregivers have faced since the outbreak of the COVID-19 pandemic and how they vary by subgroups. It is important to include home-based informal care as well as other care settings in future pandemic concepts.

Contacts with general practitioners, dentists, and medical specialists among nursing home residents: a cross-sectional study in 44 German nursing homes.

BACKGROUND: Nursing home residents have high medical care needs. Their medical care utilization is, however, lower compared to community-dwelling elderly and varies widely among nursing homes. This study quantified the utilization of general practitioners (GPs), dentists, and medical specialists among nursing homes and residents, and investigated whether dentist utilization is associated with individual and nursing home characteristics. METHODS: Forty-four nursing homes invited 2124 residents to participate in a cross-sectional study. For 10 medical specialties, data on contacts in nursing homes, practices, and by telephone in the last 12 months were assessed at individual and nursing home level. The proportion of nursing homes and residents with any form of contact, and the median number and interquartile range (IQR) of contacts among individuals with contact were determined. Using multilevel logistic regression, associations between the probability of individual dental care utilization and sex, age, LTC grade, years of residence, sponsorship, number of nursing home beds, and transport and medical escort services for consultations at a practice were investigated. RESULTS: The proportion of nursing homes with any form of contact with physicians ranged from 100% for GPs, dentists, and urologists to 76.7% for gynecologists and orthopedists. Among the nursing homes, 442 residents participated (20.8% response). The proportion of residents with any contact varied from 97.8% for GPs, 38.5% for neurologists/psychiatrists, and 32.3% for dentists to 3.0% for gynecologists. Only for GPs, neurologists/psychiatrists, dentists, otorhinolaryngologists, urologists, and dermatologists, the proportion was higher for nursing home contacts than for practice and telephone contacts. Among residents with any contact, the median number of contacts was highest for GPs (11.0 [IQR 7.0-16.0]), urologists (4.0 [IQR 2.0-7.0]), and neurologists/psychiatrists (3.0 [IQR 2.0-5.0]). Dentist utilization varied widely among nursing homes (median odds ratio 2.5) and was associated with higher age. CONCLUSIONS: Almost all residents had regular contact to GPs, but only one third had contact with dentists. Lower proportions with contact were found for medical specialists, except for neurologists/psychiatrists. Reasons for the large variations in dental care utilization among nursing homes should be identified. TRIAL REGISTRATION: DRKS00012383 [2017/12/06].

[Medical specialist undertreatment in nursing home residents-Prevalence and extrapolation]. / Fachärztliche Unterversorgung bei Heimbewohnern ­ Prävalenzstudie und Hochrechnung.

BACKGROUND: Nursing home residents tend to have lower medical specialist utilization than other groups of older people; however, as yet there is little evidence whether nursing home residents obtain adequate medical specialist care. This study investigated whether nursing home residents receive adequate oral health care, ophthalmological care, otorhinolaryngologist care and neurological care. The unmet needs of the nursing home population in Germany was extrapolated. MATERIAL AND METHODS: Audiometry, eye examinations and oral visual inspection were performed in 409 residents from 44 nursing homes. Medical care in the previous 12 months as well as existing diagnoses were retrieved from the nursing documentation. Teams of physicians evaluated for each resident based on all collected data if the resident obtained specialist care that was adequate to the needs. RESULTS: Between 15% and 45% of the residents with need for medical specialist care did not receive adequate specialist care. Of all residents 27% had unmet need of specialist care in at least one of the investigated medical specialties. It is projected that up to 205,000 nursing home residents in Germany do not receive adequate medical specialist care. CONCLUSION: Given a considerable proportion of nursing home residents with unmet need of specialist care, interventions should be developed that help reduce the level of unmet needs.

Differences in medical specialist utilization among older people in need of long-term care - results from German health claims data.

BACKGROUND: Elderly in need of long-term care tend to have worse health and have higher need of medical care than elderly without need for long-term care. Yet, characteristics associated with long-term care need can impede health care access: Higher levels of long-term care need come with physical and cognitive decline such as frailty and memory loss. Yet, it has not been investigated whether level of long-term care need is related to medical care utilization. METHODS: We investigated the association between the level of long-term care and medical specialist utilization among nursing home residents and home care recipients. We applied zero-inflated Poisson regression with robust standard errors based on a sample of statutory health insurance members. The sample consisted of 100.000 elderly over age 60. We controlled for age, gender, morbidity and mortality, residential density, and general practitioner utilization. RESULTS: We found a strong gradient effect of the level of long-term care for 9 out of 12 medical specialties: A higher level of long-term care need was associated with a lower probability of having a medical specialist visit. Yet, we did not find clear effects of the level of long-term care need on the intensity of medical specialist care. These findings were similar for both the nursing home and home care setting. CONCLUSION: The findings indicate that inequalities in medical specialist utilization exist between elderly with differing levels of long-term care need because differences in morbidity were controlled for. Elderly with higher need of long-term care might face more access barriers to specialist medical care.

Claims data analysis of medical specialist utilization among nursing home residents and community-dwelling older people.

BACKGROUND: Most older people, and especially those in need of long-term care, suffer from one or more chronic diseases. Consequently, older people have an increased need of medical care, including specialist care. There is little evidence as yet whether older people with greater medical care needs obtain adequate medical care because existing studies do not sufficiently control for differences in morbidity. In this study we investigate whether differences in medical specialist utilization exist between older people with and without assessed long-term care need in line with Book XI of the German Social Code, while at the same time controlling for individual differences in morbidity. METHODS: We used data from the 11 German AOK Statutory Health and Long-term Care Insurance funds of 100,000 members aged 60 years or over. Zero-inflated Poisson regression analyses were applied to investigate whether the need for long-term care and the long-term care setting are associated with the probability and number of specialist visits. We controlled for age, gender, morbidity and mortality, residential density, and general practitioner (GP) utilization. RESULTS: Older people in need of long-term care are more likely to have no specialist visit than people without the need for long-term care. This applies to nearly all medical specialties and for both care settings. Yet, despite these differences in utilization probability the number of specialist medical care visits between older people with and without the need for long-term care is similar. CONCLUSION: Older people in need of long-term care might face access barriers to specialist care. Once a contact is established, however, utilization does not differ considerably between those who need long-term care and those who don't; this indicates the importance of securing an initial contact.

[Digitalization and Health Sciences - White Paper Digital Public Health]. / Digitalisierung und Gesundheitswissenschaften ­ White Paper Digital Public Health.

Potential limits and risk of digitalization in public health will be a core topic of the High profile Research Area Health Sciences at the University of Bremen in coming years. A white paper was developed to support positioning in this dynamic research. The paper describes the Health Sciences viewpoint on core evaluation criteria for digital public health, identifies interfaces and approaches for interdisciplinary cooperation and discusses cross-cutting themes as well as demarcations with respect to digitalization in medicine (digital health). An abbreviated version of the white paper is presented for discussion.

Linkage of Routine Data to Other Data Sources in Germany: A Practical Example Illustrating Challenges and Solutions.

Routine data have a high potential for epidemiological and health care research but lack information, for instance, on the cause of death. Often detailed information, such as on lifestyle factors is also missing. In Germany, obtaining the missing information by linkage to data sources is challenging, mainly due to strict data protection regulations. One key challenge arises from the fact that routine data users usually have no access to person identifiers which would be necessary for record linkage. A second key challenge is that sensitive information (i. e., the cause of death) should not be transferred to an institution that holds person identifiers. In this paper, we illustrate these key challenges and present corresponding solutions based on a practical example where claims data from statutory health insurance providers are linked to an epidemiological cancer registry to obtain cause of death information. We describe the approval procedures necessary for the record linkage, the dataflow between the involved institutions and explain the rationale of the dataflow in view of the key challenges. Finally, we generalize the questions that need to be addressed when a record linkage is planned and point to additional potential challenges. Overall, we illustrate that a linkage between routine data and other data sources in Germany is feasible, but specific restrictions and hurdles need to be taken into consideration.

[Needs of long-term nursing in the COVID-19 pandemic]. / Bedarfe der Langzeitpflege in der COVID-19-Pandemie.

The SARS-CoV­2 virus and the associated disease COVID-19 pose major challenges to healthcare systems worldwide. Especially the vulnerable group of people in need of long-term care is at risk of suffering a severe course of the disease or of dying from the infection.In a nationwide cross-sectional study the situation and needs of inpatient and outpatient long-term care facilities during the SARS-CoV­2 pandemic were assessed and analyzed using an online survey.Participants from 531 institutions postulated the need for uniform recommendations for action on SARS-CoV­2, adequate and affordable protective and hygiene materials, serial tests in the institutions, well-founded advice on the implementation of interventions, a specific pandemic plan and supporting public relations work by the media. This calls for higher nursing remuneration, better staffing levels and greater appreciation of the nursing profession.In order to protect the vulnerable group of people in need of nursing care from a SARS-CoV­2 infection, long-term care must be given a stronger focus in health policy measures during the pandemic.

Pflege in Zeiten von Corona: Zentrale Ergebnisse einer deutschlandweiten Querschnittsbefragung vollstationärer Pflegeheime.

Long-term care during the Corona pandemic - Main results from a nationwide online survey in nursing homes in Germany Abstract. Background: As a highly vulnerable group, people in need of long-term care are particularly affected by the COVID-19 pandemic. Due to their care-dependency, measures of social distancing can only be carried out to a very limited extent. In addition, the social and health consequences of reduced contacts are particularly high for nursing home residents. AIM: The study aims to describe the extent to which nursing homes are affected, the human and material resources of nursing homes, the organizational handling of the situation, and their requests for public support. METHODS: More than 7,000 nursing homes were invited to participate in an online survey with quantitative and qualitative elements. Data analysis applies descriptive statistics. RESULTS: 824 nursing homes participated in the survey. One in five nursing homes has at least one confirmed case of SARS-CoV-2 among its residents and / or employees. The initial lack of protective equipment has now decreased, but the facilities still have to cope with additional corona-related care needs with reduced staff. Nursing homes have banned contacts between residents and relative to an extent that now has to be reduced again. Nursing homes demand the provision and external financing of protective equipment as well as the systematic and regular testing of nursing staff and the provision of uniform guidelines for action throughout Germany. CONCLUSIONS: As about half of all deceased people with COVID-19 have been living in nursing homes, the support of nursing homes in their attempt to restrict the pandemic requires highest attention.

Pflege in Zeiten von Corona: Ergebnisse einer deutschlandweiten Querschnittbefragung von ambulanten Pflegediensten und teilstationären Einrichtungen.

Care in times of Corona: Results of a cross-sectional study in German home care services Abstract. Background: People in need of care are particularly affected by the COVID-19 pandemic due to their age and previous illnesses. At the same time, a large number of daily contacts between nursing staff and those in need of care increase the risk of transmission of the disease. AIM: The study aims to illustrate (I) to what extent home care services and semi-residential care facilities are affected by COVID-19, (II) human and material resources, (III) the care situation of those in need of care and (IV) the organizational handling of the situation and outline support requests to politicians. METHODS: More than 12,000 home-care nursing services and semi-residential care facilities were invited to participate in an online survey with quantitative and qualitative elements, 701 nursing services (response rate 7,3 %) and 96 semi-residential facilities (response rate 3,5 %) took part. RESULTS: Almost a third (30,1 %, 189 / 627) of the nursing services surveyed are affected by confirmed or suspected cases of COVID-19 among clients. About half of the services report a reduced use of SGB V (47,6 %, 288 / 605) or SGB XI services (59,7 %, 375 / 628). Two thirds of the semi-residential facilities (65,6 %, 63 / 96) say they are currently closed due to the pandemic. Likewise, half of the nursing services (45,8 %, 253 / 552) reported that care with reduced use of services was at risk / unstable or even not ensured. CONCLUSIONS: The results show that the situation of care-dependent people served by home-care services in the present pandemic - and also with a view to a possible second wave - should receive increased attention particularly with regard to unstable / risky care arrangements.

Digital technology and nursing care: a scoping review on acceptance, effectiveness and efficiency studies of informal and formal care technologies.

BACKGROUND: The existence, usage and benefits of digital technologies in nursing care are relevant topics in the light of the current discussion on technologies as possible solutions to problems such as the shortage of skilled workers and the increasing demand for long-term care. A lack of good empirical overviews of existing technologies in the present literature prompted us to conduct this review. Its purpose was to map the field of digital technologies for informal and formal care that have already been explored in terms of acceptance, effectiveness and efficiency (AEE), and to show the scope of the used methods, target settings, target groups and fields of support. METHODS: A systematic literature search was conducted using Medline, Scopus, CINAHL, Cochrane Library, ACM Digital Library, IEEE Xplore, the Collection of Computer Science Bibliographies, GeroLit and CareLit. In addition, project websites were manually screened for relevant publications. RESULTS: Seven hundred fifteen papers were included in the review. Effectiveness studies have been most frequently performed for ICT, robots and sensors. Acceptance studies often focussed on ICT, robots and EHR/EMR. Efficiency studies were generally rare. Many studies were found to have a low level of evidence. Experimental designs with small numbers and without control groups were the most common methods used to evaluate acceptance and effectiveness. Study designs with high evidence levels were most commonly found for ICT, robots and e-learning. Technologies evaluated for informal caregivers and children or indicated for formal care at home or in cross-sectoral care were rare. CONCLUSION: We recommend producing high-quality evaluations on existing digital technologies for AEE in real-life settings rather than systematic reviews with low-quality studies. More focus should be placed on research into efficiency. Future research should be devoted to a closer examination of the applied AEE evaluation methods. Policymakers should provide funding to enable large-scale, long-term evaluations of technologies in the practice of care, filling the research gaps for technologies, target settings and target groups identified in this review.

Economic evaluation of health promotion interventions for older people: do applied economic studies meet the methodological challenges?

BACKGROUND: In the light of demographic developments health promotion interventions for older people are gaining importance. In addition to methodological challenges arising from the economic evaluation of health promotion interventions in general, there are specific methodological problems for the particular target group of older people. There are especially four main methodological challenges that are discussed in the literature. They concern measurement and valuation of informal caregiving, accounting for productivity costs, effects of unrelated cost in added life years and the inclusion of 'beyond-health' benefits. This paper focuses on the question whether and to what extent specific methodological requirements are actually met in applied health economic evaluations. METHODS: Following a systematic review of pertinent health economic evaluations, the included studies are analysed on the basis of four assessment criteria that are derived from methodological debates on the economic evaluation of health promotion interventions in general and economic evaluations targeting older people in particular. RESULTS: Of the 37 studies included in the systematic review, only very few include cost and outcome categories discussed as being of specific relevance to the assessment of health promotion interventions for older people. The few studies that consider these aspects use very heterogeneous methods, thus there is no common methodological standard. CONCLUSION: There is a strong need for the development of guidelines to achieve better comparability and to include cost categories and outcomes that are relevant for older people. Disregarding these methodological obstacles could implicitly lead to discrimination against the elderly in terms of health promotion and disease prevention and, hence, an age-based rationing of public health care.

Economic evaluation of health promotion and primary prevention actions for older people-a systematic review.

Background: Healthy ageing and health promotion (HP) actions for older people have become an important health sector priority. At the same time, the application of economic evaluation methods in the field of health interventions in order to support allocative decision processes is of growing importance. The aims of the review were to analyze what the existing evidence is on cost-effectiveness of HP and/or primary prevention (PP) programmes for older people whilst providing deeper insight into methodological aspects of such studies, their overall quality and issues related to practical implementation of results. Methods: Systematic review of contemporary evidence (2000-15). Studies' eligibility criteria included target population 65 years old or older; interventions classified as HP or PP; a full economic evaluation conducted. The search strategy included five electronic databases and Internet websites of institutions or projects related to the topic. Quality assessment of the studies was based on the 'Drummond checklist'. Results: After screening 6450 records, 29 papers were included, the vast majority of which (22) focus on fall prevention strategies. In this area, there are examples of good and moderate quality studies which confirm the cost-effectiveness of diverse physical activity interventions in fall prevention. The existing studies are characterized by huge differences in the methods applied as well as overall quality which limits the comparability and generalizability of the results. Conclusions: There is a need for development and implementation of economically driven studies, with methods adjusted to particular character of HP and/or PP strategies for older population.

Promoting community readiness for physical activity among older adults in Germany--protocol of the ready to change intervention trial.

BACKGROUND: Healthy ageing is an important concern for many societies facing the challenge of an ageing population. Physical activity (PA) is a major contributor to healthy ageing; however insufficient PA levels are prevalent in old age in Germany. Community capacity building and community involvement are often recommended as key strategies to improve equitable access to prevention and health promotion. However, evidence for the effectiveness of these strategies is scarce. This study aims to assess the community readiness for PA promotion in local environments and to analyse the utility of strategies to increase community readiness for reaching vulnerable groups. METHODS/DESIGN: We designed a mixed method intervention trial comprising three study modules. The first module includes an assessment of community readiness for PA interventions in older adults. The assessment is carried out in a sample of 24 municipalities in the Northwest of Germany using structured key informant interviews. In the second module, eight municipalities with the low community readiness are selected from the sample and randomly assigned to one of two study groups: active enhancement of community readiness (intervention) versus no enhancement (control). After enhancing community readiness in the active enhancement group, older adults in both study groups will be recruited for participation in a PA intervention. Participation rates are compared between the study groups to evaluate the effects of the intervention. In addition, a cost-effectiveness analysis is carried out calculating recruitment costs per person reached in the two study groups. In the third module, qualitative interviews are conducted with participants and non-participants of the PA intervention exploring reasons for participation or non-participation. DISCUSSION: This study offers the potential to contribute to the evidence base of reaching vulnerable older adults for PA interventions and provide ideas on how to reduce participation barriers. Its findings will inform governmental authorities, professionals, academics, and NGOs with an estimate of resources necessary to achieve equitable access to physical activity programs for vulnerable older adults. TRIAL REGISTRATION: German Clinical Trials Register DRKS00009564 (Date of registration 03-11-2015).

Economic evaluation of health promotion for older people-methodological problems and challenges.

BACKGROUND: The support of health promotion activities for older people gains societal relevance in terms of enhancing the health and well-being of older people with a view to the efficient use of financial resources in the healthcare sector. Health economic evaluations have become an important instrument to support decision-making processes in many countries. Sound evidence on the cost-effectiveness of health promotion activities would encourage support for the implementation of health promotion activities for older people. This debate article discusses to what extent economic evaluation techniques are appropriate to support decision makers in the allocation of resources regarding health promotion activities for older people. We address the problem that the economic evaluation of these interventions is hampered by methodological obstacles that limit comparability, e.g. with economic evaluations of curative measures. Our central objective is to describe and discuss the specific problems and challenges entailed in the economic evaluation of health promotion activities especially for older people with regard to their usefulness for informing decision making processes. DISCUSSION: Beyond general problems concerning the economic evaluation of health promotion, our discussion focusses on problems that pertain to the analysis of cost and outcomes of health promotion interventions for older people. With regard to costs these are general problems of economic evaluations, namely the actual implementation of a societal perspective, the appropriate measurement and valuation of informal caregiver time, the measurement and valuation of productivity costs and costs incurred in added years of life. The main problems concerning the identification and measurement of outcomes are related to the identification of outcome parameters that, firstly, adequately reflect the broad effects of health promotion interventions, especially social benefits that gain importance for older people, and secondly, ensure a comparability of effects across different age groups. In particular, the limitations of the widely used QALY for older people are discussed and recently developed alternatives are presented. CONCLUSIONS: The key conclusion of the article is that a comparison of the effects of different health promotion initiatives between different age groups by means of economic evaluation is not recommendable. Taking into account the complex outcomes of health promotion interventions it has to be accepted that the outcomes of these interventions will often not be comparable with clinical interventions and have to be assessed differently.