Apart from the Medical Complaints, Why do Patients Use Emergency Medical Services? Results of a Patient Survey.

INTRODUCTION: Many countries face an increased use of emergency medical services (EMS) with a decreasing percentage of life-threatening complaints. Though there is a broad discussion among experts about the cause, patients' self-perceived, non-medical reasons for using EMS remain largely unknown. METHODS: The written survey included EMS patients who had≥1 case of prehospital emergency care in 2016. Four German health insurance companies sent out postal questionnaires to 1312 insured patients. The response rate was 20%; 254 questionnaires were eligible for descriptive and interferential analyses (t-tests, chi2-tests, logistic models). RESULTS: The majority of respondents indicated that their EMS use was due to an emergency or someone else's decision (≥84%; multiple checks allowed); 56% gave need for a quick transport as a reason. Other frequently stated reasons addressed the health care system (e. g., complaints outside of physicians' opening hours) and insecurity/anxiety about one's state of health (>45% of the respondents). "Social factors" were similarly important (e. g., 42% affirming, "No one could give me a ride to the emergency department or doctor's office."). Every fifth person had contact with other emergency care providers prior to EMS use. Respondents negating an emergency as a reason were less likely to confirm wanting immediate medical care on site or quick transports compared to those affirming an emergency. Patients using EMS at night more often denied having an emergency compared to patients with access to care during the day. CONCLUSION: The study identified a bundle of reasons leading to EMS use apart from medical complaints. Attempts for needs-oriented EMS use should essentially include optimization of the health care and social support system and measures to reduce patients' insecurity.

[Health Insurance in Old Age and Differences in Cognition, Depressive Symptoms and Health-Related Quality of Life]. / Unterschiede in Kognition, Depressivität und gesundheitsbezogener Lebensqualität zwischen Versicherten der GKV und PKV im hohen Alter.

OBJECTIVE: We aimed at identifying differences regarding cognition, depressive symptoms and health-related quality of life between members of private and statutory health insurance (SHI) in very old age in Germany. METHODS: Cross-sectional data were gathered from the multicenter prospective "Study on Needs, health service use, costs and health-related quality of life in a large sample of oldest-old primary care patients (85+)" (AgeQualiDe), covering primary care patients aged ≥ 85 years (n = 854; with 773 members of SHI). The Global Deterioration Scale measured cognition, the Geriatric Depression Scale assessed depressive symptoms, and health-related quality of life was measured by using a Visual Analogue Scale (EQ-VAS). RESULTS: While members of private health insurance showed slightly better cognitive function, less depressive symptoms and better health-related quality of life descriptively, regression models showed that none of these differences was statistically significant. CONCLUSIONS: There are no differences between members of private health insurance and SHI regarding cognitive function, depressive symptoms and health-related quality of life in very old age.

Frailty and healthcare costs-longitudinal results of a prospective cohort study.

Objective: to investigate how frailty and frailty symptoms affect healthcare costs in older age longitudinally. Methods: data were gathered from a prospective cohort study in Saarland, Germany (two waves with 3-year interval, n = 1,636 aged 57-84 years at baseline). Frailty was assessed by the five Fried frailty criteria. Frailty was defined as having at least three criteria, the presence of 1-2 criteria as 'pre-frail'. Healthcare costs were quantified based on self-reported healthcare use in the sectors of inpatient treatment, outpatient treatment, professional nursing care and informal care as well as the provision of pharmaceuticals, medical supplies and dental prostheses. Results: while the onset of pre-frailty did not increase (log) total healthcare costs after adjusting for potential confounders including comorbidity, progression from non-frailty to frailty was associated with an increase in total healthcare costs (for example, costs increased by ~54 and 101% if 3 and 4 or 5 symptoms were present, respectively). This association of frailty onset with increased healthcare costs was in particular observed in the inpatient sector and for informal nursing care. Among the frailty symptoms, the onset of exhaustion was associated with an increase in total healthcare costs, whereas changes in slowness, weakness, weight loss and low-physical activity were not significantly associated with an increase in total healthcare costs. Conclusions: our data stress the economic relevance of frailty in late life. Postponing or reducing frailty might be fruitful in order to reduce healthcare costs.

Unmet needs in the depressed primary care elderly and their relation to severity of depression: results from the AgeMooDe study.

OBJECTIVES: This study aims at examining the distribution of unmet environmental, physical, social and psychological care needs in a sample of the oldest old primary care patients with different levels of depression severity. Furthermore, the objective of this study was to analyze the association between specific unmet care needs and severity of depression. METHOD: The sample of patients aged 75 years (n = 202) and more was derived from the multicenter prospective cohort study AgeMooDe ('Late-life depression in primary care: Needs, health care utilization and costs'). Patients were assessed via structured clinical interviews containing the German version of the Camberwell Assessment of Need for the Elderly (CANE) and the German Hospital Anxiety and Depression Scale (HADS-D). Descriptive statistics, Spearman correlation coefficients and binary logistic regression analyses were computed. RESULTS: Unmet needs appeared to be substantially higher in the patient group with higher levels of depression severity according to the HADS-D score. Overall, there was weak positive linear correlation between depression and CANE total unmet needs. Except of the physical unmet needs category, all other CANE care categories showed little to moderate positive linear correlations with depression according to the HADS-D score. Depression and psychological unmet needs showed the strongest of all correlations, followed by social unmet needs. The binary logistic regression analysis revealed that patients having psychological unmet needs were 4.8 times more likely diagnosed with a probable depression. CONCLUSION: Systematic needs assessment, especially psychological needs, may play a crucial role in the course of prevention and effective treatment of late-life depression in the primary care context.

Association of general psychological factors with frequent attendance in primary care: a population-based cross-sectional observational study.

BACKGROUND: Whereas several studies have examined the association between frequent attendance in primary care and illness-specific psychological factors, little is known about the relation between frequent attendance and general psychological factors. Thus, the aim of this study was to investigate the association between being a frequent attender in primary care and general psychological factors. METHODS: Data were used from a large, population-based sample of community-dwelling individuals aged 40 and above in Germany in 2014 (n = 7,446). Positive and negative affect, life satisfaction, optimism, self-esteem, self-efficacy, and self-regulation were included as general psychological factors. The number of self-reported GP visits in the past twelve months was used to quantify frequency of attendance; individuals with more than 9 visits (highest decile) were defined as frequent attenders. RESULTS: Multiple logistic regressions showed that being a frequent attender was positively associated with less life satisfaction [OR: 0.79 (0.70-0.89)], higher negative affect [OR: 1.38 (1.17-1.62)], less self-efficacy [OR: 0.74 (0.63-0.86)], less self-esteem [OR: 0.65 (0.54-0.79)], less self-regulation [OR: 0.74 (0.60-0.91)], and higher perceived stress [OR: 1.46 (1.28-1.66)], after adjusting for sociodemographic factors, morbidity and lifestyle factors. However, frequent attendance was not significantly associated with positive affect and self-regulation. CONCLUSIONS: The present study highlights the association between general psychological factors and frequent attendance. As frequent GP visits produce high health care costs and are potentially associated with increased referrals and use of secondary health care services, this knowledge might help to address these individuals with high needs.

Which factors affect health care use among older Germans? Results of the German ageing survey.

BACKGROUND: It remains an open question how changes in predisposing, enabling, and need factors affect health care use. Consequently, we aimed to investigate how changes in these variables affect health care use in community-dwelling older persons longitudinally. METHODS: Data from two waves of the German Ageing Survey (DEAS), a representative sample of the community-dwelling German population aged ≥40 years, was used. Predictors of visits to general practitioners and specialists as well as hospital stays during a 12-month period were analyzed by fixed effects regressions. RESULTS: Regressions revealed that the need factors 'self-rated health' and the number of chronic diseases affected all measures of health care use (except for the number of chronic diseases on hospital care). An increased duration of physical activities increased GP visits. A decrease of excess weight decreased the number of specialist visits. CONCLUSIONS: Our findings underline the importance of need factors for health care use. Virtually none of the predisposing factors nor enabling resources affected health care use. These findings might indicate that individuals in the second half of life use health care services adequately, i.e. when medically indicated.

A Longitudinal Investigation of Willingness to Pay for Health Insurance in Germany.

OBJECTIVE: To investigate factors affecting willingness to pay (WTP) for health insurance of older adults in a longitudinal setting in Germany. DATA SOURCES: Survey data from a cohort study in Saarland, Germany, from 2008-2010 and 2011-2014 (n1  = 3,124; n2  = 2,761) were used. STUDY DESIGN: Panel data were taken at two points from an observational, prospective cohort study. DATA COLLECTION: WTP estimates were derived using a contingent valuation method with a payment card. Participants provided data on sociodemographics, lifestyle factors, morbidity, and health care utilization. PRINCIPAL FINDINGS: Fixed effects regression models showed higher individual health care costs to increase WTP, which in particular could be found for members of private health insurance. Changes in income and morbidity did not affect WTP among members of social health insurance, whereas these predictors affected WTP among members of private health insurance. CONCLUSIONS: The fact that individual health care costs affected WTP positively might indicate that demanding (expensive) health care services raises the awareness of the benefits of health insurance. Thus, measures to increase WTP in old age should target at improving transparency of the value of health insurances at the moment when individual health care utilization and corresponding costs are still relatively low.

The Impact of Depressive Symptoms on Healthcare Costs in Late Life: Longitudinal Findings From the AgeMooDe Study.

OBJECTIVE: To examine whether depressive symptoms affect healthcare costs in old age longitudinally. DESIGN: Multicenter prospective observational cohort study (two waves with nt1 = 1,195 and nt2 = 951) in Germany. SETTING: Community. PARTICIPANTS: Participants aged 75 years and older recruited via general practitioners. MEASUREMENTS: Depressive symptoms were assessed by the Geriatric Depression Scale (GDS). The health-related resource use was measured retrospectively from a societal perspective based on a questionnaire, covering outpatient services, inpatient treatment, pharmaceuticals, as well as formal and informal nursing care. Hybrid regression models were used to determine the between- and within-effect of depressive symptoms on healthcare costs, adjusting for important covariates. RESULTS: Six-month total cost increased from €3,090 (t1) to €3,748 (t2). The hybrid random effects models showed that individuals with more depressive symptoms had higher healthcare costs compared with individuals with less depressive symptoms (between-effect). Moreover, an intra-individual increase in depressive symptoms increased healthcare costs by €539.60 (within-effect) per symptom on GDS. CONCLUSIONS: Our findings emphasize the economic importance of depressive symptoms in old age. Appropriate interventions to treat depressive symptoms in old age might also be a promising strategy to reduce healthcare costs.

Unmet care needs of the oldest old with late-life depression: A comparison of patient, caring relative and general practitioner perceptions - Results of the AgeMooDe study.

BACKGROUND: Research showed that the perception of unmet needs may differ between patients, caregivers and professionals. Lacking agreement with regard to unmet needs between raters involved may have a negative impact on treatment of late-life depression. METHODS: As part of the multicenter German study "Late-life depression in primary care: needs, health care utilization and costs" (AgeMooDe), n=1188 primary care patients aged 75-98 with and without depression, relatives (n=366) and general practitioners (GPs, n=1152) were assessed using the German version of the Camberwell Assessment of Need for the Elderly (CANE) in order to identify patients' unmet needs from different perspectives. Kappa coefficients were computed to determine level of agreement between perspectives. Penalized likelihood logistic regression models were run in order to assess the association between depression severity and disagreement between perspectives with regard to unmet needs. RESULTS: The prevalence of unmet needs was higher in depressive patients. Kappa coefficients were on average higher for depressive patients ranging from poor to substantial. Severity of depression was significantly associated with disagreement regarding unmet needs between perspectives. LIMITATIONS: The cross-sectional design of the study limits the results. Only a part of caring relatives was able to participate. CONCLUSIONS: Perceptions of unmet needs in the oldest old primary care patients suffering from depression strongly differ between raters. Severity of depression seems to exacerbate the discrepancy between involved perspectives. The negative impact that depression severity may have on the perception and assessment of unmet needs requires greater attention by GPs.

Associations of frailty with health care costs--results of the ESTHER cohort study.

BACKGROUND: The concept of frailty is rapidly gaining attention as an independent syndrome with high prevalence in older adults. Thereby, frailty is often related to certain adverse outcomes like mortality or disability. Another adverse outcome discussed is increased health care utilization. However, only few studies examined the impact of frailty on health care utilization and corresponding costs. The aim of this study was therefore to investigate comprehensively the relationship between frailty, health care utilization and costs. METHODS: Cross sectional data from 2598 older participants (57-84 years) recruited in the Saarland, Germany, between 2008 and 2010 was used. Participants passed geriatric assessments that included Fried's five frailty criteria: weakness, slowness, exhaustion, unintentional weight loss, and physical inactivity. Health care utilization was recorded in the sectors of inpatient treatment, outpatient treatment, pharmaceuticals, and nursing care. RESULTS: Prevalence of frailty (≥3 symptoms) was 8.0%. Mean total 3-month costs of frail participants were €3659 (4 or 5 symptoms) and €1616 (3 symptoms) as compared to €642 of nonfrail participants (no symptom). Controlling for comorbidity and general socio-demographic characteristics in multiple regression models, the difference in total costs between frail and non-frail participants still amounted to €1917; p < .05 (4 or 5 symptoms) and €680; p < .05 (3 symptoms). Among the 5 symptoms of frailty, weight loss and exhaustion were significantly associated with total costs after controlling for comorbidity. CONCLUSIONS: The study provides evidence that frailty is associated with increased health care costs. The analyses furthermore indicate that frailty is an important factor for health care costs independent from pure age and comorbidity. Costs were rather attributable to frailty (and comorbidity) than to age. This stresses that the overlapping concepts of multimorbidity and frailty are both necessary to explain health care use and corresponding costs among older adults.

Excess health care costs of late-life depression - Results of the AgeMooDe study.

INTRODUCTION: The study aimed at determining excess costs of late-life depression from a societal perspective. Moreover, the impact of recognition of depression by GPs on costs was investigated. METHODS: Cross-sectional data were obtained from a large multicenter observational cohort study (AgeMooDe). Participants (n=1197) aged 75 years or older and were recruited via their GPs in Leipzig, Bonn, Hamburg, and Mannheim in Germany from May 2012 until December 2013. In the base case analysis, depression was assessed using the Geriatric Depression Scale (GDS; cutoff GDS≥6). Data on health care utilization and costs were based on participants' self-reports for inpatient treatment, outpatient treatment, pharmaceuticals, and formal and informal nursing care. RESULTS: Unadjusted mean costs in a six-month period for depressed individuals (€5031) exceeded those of non-depressed (€2700) by the factor 1.86 and were higher in all health care sectors considered. Statistically significant positive excess costs persisted in all formal health care sectors after adjusting for comorbidity and socio-demographics. Recognition of depression by the GP did not moderate the relationship of depression and health care costs. LIMITATIONS: Analyses were restricted to a cross-sectional design, not permitting any conclusions on causal interference of the variables considered. CONCLUSION: The findings stress the enormous burden of depression in old age for all sectors of the health care system. The fact that GPs' recognition of depression does not moderate the relationship between depression and costs adds further insights into the economics of this frequent psychiatric disorder.

The assessment of met and unmet care needs in the oldest old with and without depression using the Camberwell Assessment of Need for the Elderly (CANE): Results of the AgeMooDe study.

BACKGROUND: Depression belongs to the most common mental disorders in late life and will lead to a significant increase of treatment and health care needs in the future. The Camberwell Assessment of Need for the Elderly (CANE) evaluates met and unmet care needs in older individuals. Reports on needs of the elderly with depression are currently lacking. The aim of the present study was to identify met and unmet needs in older primary care patients with and without depression using the German-language version of the CANE. Furthermore, the association between unmet needs and depression ought to be explored. METHODS: As part of the study "Late-life depression in primary care: needs, health care utilization and costs (AgeMooDe)", a sample of 1179 primary care patients aged 75 years and older was assessed. Descriptive and inferential statistics as well as logistic regression analyses were conducted. RESULTS: This study, for the first time in Germany, provides data on the distribution of met and unmet needs in depressive and non-depressive older primary care patients. As a main result, unmet needs were significantly associated with depression; other risk factors identified were gender, institutionalization, care by relatives and impaired functional status. LIMITATIONS: The conclusions about directions and causality of associations between the variables are limited due to the cross-sectional design. CONCLUSIONS: The study results provide an important contribution to generate a solid base for an effective and good-quality health and social care as well as to an appropriate allocation of health care resources in the elderly population.

Willingness to pay for health insurance among the elderly population in Germany.

INTRODUCTION: All elderly Germans are legally obliged to have health insurance. About 90 % of this population are members of social health insurances (SHI) whose premiums are generally income-related and independent of health status. For most of these members, holding social health insurance is mandatory. As a consequence, genuine information about preferences for health insurance is not available. The aim of this study was therefore to determine and analyze the willingness to pay (WTP) for health insurance among elderly Germans. METHODS: Data from a population-based 8-year follow-up of a large cohort study conducted in the Saarland, Germany was used. Participants aged 57-84 years passed a geriatric assessment and responded to a health economic questionnaire. Individuals' WTP was elicited based on a contingent valuation method with a payment card. RESULTS: Mean monthly WTP per capita for health insurance amounted to €260. This corresponded to about 20% of individual disposable income. Regression analyses showed that WTP increased significantly with higher income, male gender, higher educational level, and privately insured status. In contrast, neither increasing morbidity level nor higher individual health care costs influenced WTP significantly. DISCUSSION: The relatively large extent of average WTP for health insurance indicates that the elderly would probably accept higher contributions to SHI rather than policy efforts to reduce contributions. The identified determinants of WTP might indicate that elderly generally approve the principle of solidarity of the SHI with contributions depending on income rather than morbidity.

[Cost-Effectiveness of the Treatment of Depression in Old Age]. / Kosteneffektivität der Depressionsbehandlung im Alter.

OBJECTIVE: To conduct a systematic literature review of cost-effectiveness studies evaluating the treatment of depression in old age. METHODS: Systematic literature search in electronic databases in March 2014. RESULTS: Nine studies were included in the review. They were conducted in the Netherlands, the United Kingdom and the United States. The studies investigated psychological interventions (N = 3), pharmacotherapy (N = 1), and integrated care models (N = 5). The results varied greatly. CONCLUSION: The variation of the results in the included studies does not permit generalized conclusions, especially not for the widespread and recommended pharmacotherapy. Cost-effectiveness of psychological interventions and integrated care programs differed depending on the details of the program designs.

Impact of depression on health care utilization and costs among multimorbid patients--from the MultiCare Cohort Study.

OBJECTIVE: The objective of this study was to describe and analyze the effects of depression on health care utilization and costs in a sample of multimorbid elderly patients. METHOD: This cross-sectional analysis used data of a prospective cohort study, consisting of 1,050 randomly selected multimorbid primary care patients aged 65 to 85 years. Depression was defined as a score of six points or more on the Geriatric Depression Scale (GDS-15). Subjects passed a geriatric assessment, including a questionnaire for health care utilization. The impact of depression on health care costs was analyzed using multiple linear regression models. A societal perspective was adopted. RESULTS: Prevalence of depression was 10.7%. Mean total costs per six-month period were €8,144 (95% CI: €6,199-€10,090) in patients with depression as compared to €3,137 (95% CI: €2,735-€3,538; p<0.001) in patients without depression. The positive association between depression and total costs persisted after controlling for socio-economic variables, functional status and level of multimorbidity. In particular, multiple regression analyses showed a significant positive association between depression and pharmaceutical costs. CONCLUSION: Among multimorbid elderly patients, depression was associated with significantly higher health care utilization and costs. The effect of depression on costs was even greater than reported by previous studies conducted in less morbid patients.

Inequalities in out-of-pocket payments for health care services among elderly Germans--results of a population-based cross-sectional study.

INTRODUCTION: In order to limit rising publicly-financed health expenditure, out-of-pocket payments for health care services (OOPP) have been raised in many industrialized countries. However, higher health-related OOPP may burden social subgroups unequally. In Germany, inequalities in OOPP have rarely been analyzed. The aim of this study was to examine OOPP of the German elderly population in the different sectors of the health care system. Socio-economic and morbidity-related determinants of inequalities in OOPP were analyzed. METHODS: This cross-sectional analysis used data of N = 3,124 subjects aged 57 to 84 years from a population-based prospective cohort study (ESTHER study) collected in the Saarland, Germany, from 2008 to 2010. Subjects passed a geriatric assessment, including a questionnaire for health care utilization and OOPP covering a period of three months in the following sectors: inpatient care, outpatient physician and non-physician services, medical supplies, pharmaceuticals, dental prostheses and nursing care. Determinants of OOPP were analyzed by a two-part model. The financial burden of OOPP for certain social subgroups (measured by the OOPP-income-ratio) was investigated by a generalized linear model for the binomial family. RESULTS: Mean OOPP during three months amounted to €119, with 34% for medical supplies, 22% for dental prostheses, 21% for pharmaceuticals, 17% for outpatient physician and non-physician services, 5% for inpatient care and 1% for nursing care. The two-part model showed a significant positive association between income (square root equivalence scale) and total OOPP. Increasing morbidity was associated with significantly higher total OOPP, and in particular with higher OOPP for pharmaceuticals. Total OOPP amounted to about 3% of disposable income. The generalized linear model for the binomial family showed a significantly lower financial burden for the wealthiest quintile as compared to the poorest one. CONCLUSIONS: This is the first study providing evidence of inequalities in OOPP in the German elderly population. Socio-economic and morbidity-related inequalities in OOPP and the resulting financial burden could be identified. The results of this study may contribute to the discussion about the mechanisms causing the observed inequalities and can thus help decision makers to consider them when adapting future regulations on OOPP.