Visual evoked potential-based acuity assessment: overestimation in amblyopia.

BACKGROUND/AIMS: When visual acuity (VA) is assessed with spatially repetitive stimuli (e.g., gratings) in amblyopes, VA can be markedly overestimated. We evaluated to what extent this also applies to VEP-based objective acuity assessment, which typically uses gratings or checkerboards. METHODS: Seventeen subjects with amblyopia (anisometropic and strabismic) participated in the study; decimal VA range of their amblyopic eye covered 0.03-1.0 (1.5-0.0 logMAR). Using the Freiburg Acuity VEP (FrAVEP) method, checkerboard stimuli with six check sizes covering 0.02°-0.4° were presented in brief-onset mode (40 ms on, 93 ms off) at 7.5 Hz. All VEPs were recorded with a Laplacian montage. Fourier analysis yielded the amplitude and significance at the stimulus frequency. Psychophysical VA was assessed with the Landolt-C-based automated Freiburg Visual Acuity Test (FrACT). RESULTS: Test-retest limits of agreement for both FrACT and FrAVEP were ±0.20 logMAR. In all but two dominant eyes and high-acuity amblyopic eyes (VA<0.3 logMAR), FrACT and FrAVEP agreed within the expected limits of ±0.3 logMAR. However, the VEP-based acuity procedure overestimated single Landolt-C acuity by more than 0.3 logMAR in 9 of 17 (53%) of the amblyopic eyes, up to 1 logMAR. While all subjects had a psychophysical acuity difference>0.2 logMAR between the dominant and amblyopic eye, only three of them showed such difference with the FrAVEP. CONCLUSION: Both measurements of visual acuity with the VEP and FrACT were highly reproducible. However, as expected, in amblyopia, acuity can be markedly overestimated using the VEP. We attribute this to the use of repetitive stimulus patterns (checkerboards), which also lead to overestimation in psychophysical measures. The VEP-based objective assessment never underestimated visual acuity, but needs to be interpreted with appropriate caution in amblyopia.

[Determinants of direct cost in schizophrenia patients with persistent positive symptoms]. / Determinanten direkter Kosten bei persistierender Positivsymptomatik psychotischer Erkrankungen.

OBJECTIVE: To analyze direct costs and cost determinants in psychotic patients with persistent positive symptoms (PPS). METHODS: A total of 330 patients with PPS were recruited via 6 university clinics and interviewed about service utilization in the previous 3 months. After monetary valuation, costs were analyzed via generalized linear mixed models with gamma distribution and log-link function to identify determinants of direct costs. RESULTS: The mean costs were 7,065 € and resulted predominantly from psychiatric hospital care (63 %), assisted living (17 %) and complementary services (8 %). We found statistically significant associations between direct costs and an increasing score of the negative subscale of the Positive and Negative Syndrome Scale (+ 2,484 € per point, p < 0.001) and experiencing less than one social contact per week (- 2,272 €, p = 0.003). CONCLUSION: PPS incurred substantial direct costs which primarily resulted from hospital treatment, and were strongly associated with symptom severity.

Association of costs with somatic symptom severity in patients with medically unexplained symptoms.

OBJECTIVE: To analyse the association of direct and indirect costs in patients with medically unexplained symptoms (MUS) with somatic symptom severity (SSS). METHODS: A cross-sectional cost analysis for retrospective 6 months was conducted in 294 primary care patients with MUS. Health care utilisation and loss of productivity were measured by questionnaires. SSS was measured using the "Patient Health Questionnaire 15" (PHQ-15). Direct and indirect costs and the association of costs with SSS were analysed via multiple linear regression analysis. RESULTS: Patients with MUS had average 6-month direct costs of 1098 EUR and indirect costs of 7645 EUR. For direct costs, outpatient physician visits were the most expensive single cost category (36%), followed by pharmaceuticals (25%) and hospital stays (19%). Indirect costs were predominantly caused by productivity reduction at work (56%) followed by early retirement (29%) and acute sickness absence (14%). As compared to mild SSS, moderate SSS was not significantly associated with direct, but with indirect costs (+2948 EUR; p<.001); severe SSS was associated with increased direct cost (+658 EUR; p=.001) and increased indirect costs (+4630 EUR; p<.001). Age was positively associated with direct cost (+15 EUR for each additional year; p=.015) as well as indirect cost (+104 EUR for each additional year; p<.001). CONCLUSIONS: MUS are associated with relevant direct and even much higher indirect costs that strongly depend on SSS.

[How does the Regional Psychiatry Budget (RPB) work in an area with initially low capacity of psychiatric hospital beds?]. / Wie wirkt das Regionale Psychiatriebudget (RPB) in einer Region mit initial niedriger Bettenmessziffer?

OBJECTIVE: To analyze the impact of a capitated multi-sector-financing model for psychiatric care (RPB) in the model region Rendsburg-Eckernförde on costs and effectiveness of care. METHODS: In a prospective controlled cohort study 244 patients with a diagnosis according to ICD-10: F10, F2 or F3 were interviewed in the model region (MR) and compared to 244 patients from a control region (CR) financed according to the fee-for-service principle. At baseline, 1.5 years and 3.5 years follow-up patients were interviewed using measures of psychopathology (CGI-S, HONOS, SCL-90 R/GSI, PANSS, BRMAS/BRMES), functioning (GAF, SOFAS), quality of life (EQ-5 D) and service use/costs (CSSRI). RESULTS: Subjective symptom severity (GSI) and functioning (GAF) developed more favourably in the MR than in the CR, the HONOS score developed slightly worse in the MR. The latter effect occurred mainly in ICD-10: F10 patients, while patients with F2/3 rather did benefit under RPB conditions. The development of total costs of care was not different between MR and CR. The potential to reduce costs of in-patient care was low due to the initially low capacity of inpatient beds. CONCLUSIONS: The RPB did not reduce the total costs of mental health care, but certain diagnosis groups may benefit from improved trans-sectoral treatment flexibility.

Psychiatric comorbidity as predictor of costs in back pain patients undergoing disc surgery: a longitudinal observational study.

BACKGROUND: Psychiatric comorbidity is common in back pain patients undergoing disc surgery and increases economic costs in many areas of health. The objective of this study was to analyse psychiatric comorbidity as predictor of direct and indirect costs in back pain patients undergoing disc surgery in a longitudinal study design. METHODS: A sample of 531 back pain patients was interviewed after an initial disc surgery (T0), 3 months (T1) and 15 months (T2) using the Composite International Diagnostic Interview to assess psychiatric comorbidity and a modified version of the Client Sociodemographic and Service Receipt Inventory to assess resource utilization and lost productivity for a 3-month period prior interview. Health care utilization was monetarily valued by unit costs and productivity by labour costs. Costs were analysed using random coefficient models and bootstrap techniques. RESULTS: Psychiatric comorbidity was associated with significantly (p < 0.05) increased direct (+664 Euro) and indirect costs (+808 Euro) at T0. The direct cost difference predominantly resulted from medical health care utilization and was nearly unchanged at T2. Further important cost predictors were clinical variables like the presence of chronic medical disease, the number of previous disc surgeries, and time and gender. CONCLUSION: Psychiatric comorbidity presents an important predictor of direct and indirect costs in back pain patients undergoing disc surgery, even if patients do not utilize mental health care. This effect seems to be stable over time. More attention should be given to psychiatric comorbidity and cost-effective treatments should be applied to treat psychiatric comorbidity in back pain patients undergoing disc surgery to reduce health care utilization and costs associated with psychiatric comorbidity.

Economics of medically unexplained symptoms: a systematic review of the literature.

OBJECTIVE: To review cost-of-illness studies (COI) and economic evaluations (EE) conducted for medically unexplained symptoms and to analyze their methods and results. METHODS: We searched the databases PubMed, PsycINFO and National Health Service Economic Evaluations Database of the University of York. Cost data were inflated to 2006 using country-specific gross domestic product inflators and converted to 2006 USD purchasing power parities. RESULTS: We identified 5 COI and 8 EE, of which 6 were cost-minimization analyses and 2 were cost-effectiveness analyses. All studies used patient level data collected between 1980 and 2004 and were predominantly conducted in the USA (n = 10). COI found annual excess health care costs of somatizing patients between 432 and 5,353 USD in 2006 values. Indirect costs were estimated by only one EE and added up to about 18,000 USD per year. In EE, educational interventions for physicians as well as cognitive-behavioral therapy approaches for patients were evaluated. For both types of interventions, effectiveness was either shown within EE or by previous studies. Most EE found (often insignificant) cost reductions resulting from the interventions, but only two studies explicitly combined changes in costs with data on effectiveness to cost-effectiveness ratios (ratio of additional costs to additional effects). CONCLUSIONS: Medically unexplained symptoms cause relevant annual excess costs in health care that are comparable to mental health problems like depression or anxiety disorders and which may be reduced by interventions targeting physicians as well as patients. More extensive research on indirect costs and cost-effectiveness is needed.

Review: health care utilization and costs of elderly persons with multiple chronic conditions.

This systematic literature review identified and summarized 35 studies that investigated the relationship between multiple chronic conditions (MCCs) and health care utilization outcomes (i.e. physician use, hospital use, medication use) and health care cost outcomes (medication costs, out-of-pocket costs, total health care costs) for elderly general populations. Although synthesis of studies was complicated because of ambiguous definitions and measurements of MCCs, and because of the multitude of outcomes investigated, almost all studies observed a positive association of MCCs and use/costs, many of which found that use/costs significantly increased with each additional condition. Several studies indicate a curvilinear, near exponential relationship between MCCs and costs. The rising prevalence, substantial costs, and the fear that current care arrangements may be inappropriate for many patients with MCCs, bring about a multitude of implications for research and policy, of which the most important are presented and discussed.

Effects of psychiatric comorbidity on costs in patients undergoing disc surgery: a cross-sectional study.

BACKGROUND CONTEXT: Back pain presents a significant cause of health care costs and lost productivity. In most cases, conservative treatment will be sufficient, but in the most severe cases, disc surgery is indicated. PURPOSE: To analyze the effect of psychiatric comorbidity on health care costs and lost productivity in patients with back pain undergoing disc surgery. STUDY DESIGN: A cross-sectional study design was used. PATIENT SAMPLE: A sample of 305 disc surgery patients (lumbar, 239; cervical, 66). OUTCOME MEASURES: Patients were interviewed using the German version of the Composite International Diagnostic Interview to assess psychiatric comorbidity and a questionnaire to assess resource utilization and lost productivity for a 3-month period prior disc surgery. Health care resources were monetarily valued by unit costs, whereas productivity was valuated by labor costs. METHODS: Cost differences between patients with and without psychiatric comorbidity were analyzed using bootstrap regression techniques. RESULTS: Back pain was associated with mean 3-month direct health care costs ranging from €5,534 (lumbar disc herniation without psychiatric comorbidity) to €8,507 (cervical disc herniation with psychiatric comorbidity), of which between 51% and 79% were caused by disc surgery. Mean indirect costs ranged from €7,589 to €8,492. Psychiatric comorbidity was significantly associated with increased direct costs in lumbar disc herniation (€7,042 vs. €5,534). Regression analysis showed increments of €851 (p=.043) in direct costs and €1,636 (p=.058) in total costs for psychiatric comorbidity, which predominantly resulted from nonpsychiatric health care utilization. CONCLUSIONS: Severe back pain is associated with high direct and indirect costs, which are influenced by the presence of psychiatric comorbidity. We found a lack of treatment for psychiatric comorbidity indicated by low mental health care utilization in affected individuals. More attention should be given to psychiatric comorbidity in the treatment of patients undergoing disc surgery. Clinicians should be aware of the high prevalence rates of psychiatric comorbidity in this patient group. They should consider the assessment of psychiatric distress and support of mental health professionals if applicable.

Service use and costs of incident femoral fractures in nursing home residents in Germany: the Bavarian Fall and Fracture Prevention Project (BF2P2).

OBJECTIVES: Hip fractures are one of the most costly consequences of falls in the elderly. Despite their increased risk of falls and fractures, nursing home residents are often neglected in service utilization and costing studies. The purpose of this study was to determine service use, initial and long-term direct costs of incident femoral fractures in nursing home residents 65 years or older in Germany. DESIGN: An incidence-based, bottom-up cost-of-illness study aiming at measuring fracture-related direct costs from a payer perspective was conducted. SETTING: Nursing homes PARTICIPANTS: The retrospective dataset included all insurants of a sickness fund (Allgemeine Ortskrankenkasse Bavaria), who were 65 years or older, resided in a nursing home, and had a level of care of at least one in the statutory long-term care insurance (n = 60,091). MEASUREMENTS: Incident femoral fractures (ICD-10, S72) in 2006 were followed until the end of 2008, incorporating service use and costs of inpatient care (up to 12 months after the initial hospitalization episode), nursing home care (until death or the end of 2008), and ambulatory care (pharmaceuticals, nonphysician providers, and medical supply within 3 months after the initial hospitalization episode). Additional costs for nursing home and ambulatory care were determined with a before/after design. Costs beyond the year 2006 were discounted with a rate of 5%. Sensitivity analyses on key parameters were performed. RESULTS: Overall mean direct costs of 9488 USD (SD ± 4453 USD, 2006) occurred for incident femoral fractures (n = 1525). This included inpatient care (90.2%), additional costs for nursing home care (7.1%), and ambulatory care (2.7%). Eighty-seven percent of the costs occurred for the initial hospitalization episode and 13% for long-term costs. After the index admission, 12.1% were admitted to a rehabilitation facility, 4.1% were rehospitalized within a year, and in 17.7% the level of care increased within 90 days after the end of the initial hospital episode. The share of residents with incident femoral fractures rehospitalized was significantly higher and costs for nonphysician providers were significantly lower for male residents. CONCLUSION: Residents with femoral fractures used a wide range of health services. Our study underestimates the true costs to society in Germany. Efforts should be directed to economic evaluations of fall-prevention programs aiming at reducing fall-related fractures including femoral fractures.

Accuracy of self-reports of mental health care utilization and calculated costs compared to hospital records.

Assessments of service utilization is often based on self-reports. Concerns regarding the accuracy of self-reports are raised especially in mental health care. The purpose of this study was to analyze the accuracy of self-reports and calculated costs of mental health services. In a prospective cohort study in Germany, self-reports regarding psychiatric inpatient and day-care use collected by telephone interviews based on the Client Socio-Demographic and Service Receipt Inventory (CSSRI) as well as calculated costs were compared to computerized hospital records. The sample consisted of patients with mental and behavioral disorders resulting from alcohol (ICD-10 F10, n=84), schizophrenia, schizophrenic and delusional disturbances (F2, n=122) and affective disorders (F3, n=124). Agreement was assessed using the concordance correlation coefficient (CCC), mean difference (95% confidence intervals (CI)) and the 95% limits of agreement. Predictors for disagreement were derived. Overall agreement of mean total costs was excellent (CCC=0.8432). Costs calculated based on self-reports were higher than costs calculated based on hospital records (15 EUR (95% CI -434 to 405)). Overall agreement of total costs for F2 patients was CCC=0.8651, for F3 CCC=0.7850 and for F10 CCC=0.6180. Depending on type of service, measure of service utilization and costs agreement ranged from excellent to poor and varied substantially between individuals. The number of admissions documented in hospital records was significantly associated with disagreement. Telephone interviews can be an accurate data collection method for calculating mean total costs in mental health care. In the future more standardization is needed.

Validity and responsiveness of the EQ-5D in assessing and valuing health status in patients with anxiety disorders.

BACKGROUND: The EQ-5D is a generic questionnaire which generates a health profile as well as index scores for health-related quality of life that may be used in cost-utility analysis. AIMS OF THE STUDY: To examine validity and responsiveness of the EQ-5D in patients with anxiety disorders. METHODS: 389 patients with anxiety disorders completed the EQ-5D at baseline and 6-month follow-up. Subjective measures of quality of life (WHOQOL-BREF) and psychopathology (BAI, BDI-II, BSQ, ACQ, MI) were used for comparison. Validity was analyzed by assessing associations between EQ-5D scores and related other scores. Responsiveness was analyzed by calculating effect sizes of differences in scores between baseline and follow-up for 3 groups indicating more, constant or less anxiety. Meaningful difference scores for shifting to less or more anxiety were derived by means of regression analysis. RESULTS: 88.4% of respondents reported problems in at least one of the EQ-5D dimension at baseline; the mean EQ VAS score was 63.8. The EQ-5D dimension most consistently associated with the measures used for comparison was 'anxiety/depression'. EQ VAS and EQ-5D index scores were highly correlated (|r|>0.5) with scores of the WHOQOL-BREF dimensions 'physical', 'mental' and 'overall' as well as BAI and BDI-II. The EQ-5D index tended to be the most responsive score. Standardized meaningful difference scores were not significantly different between EQ VAS, EQ-5D index and measures used for comparison. CONCLUSIONS: The EQ-5D seems to be reasonably valid and moderately responsive in patients with anxiety disorders. The EQ-5D index may be suitable for calculating QALYs in economic evaluation of health care interventions for patients with anxiety disorders. TRIAL REGISTRATION: Current Controlled Trials ISRCTN15716049.

[The regional psychiatry budget (RPB): a model for a new payment system of hospital based mental health care services]. / Das Regionale Psychiatriebudget (RPB): Ein Modell für das neue pauschalierende Entgeltsystem psychiatrischer Krankenhausleistungen?

OBJECTIVE: To analyze the impact of a capitated multi-sector-financing model for psychiatric care (RPB) on costs and effectiveness of care. METHODS: Patients with a diagnosis according to ICD-10 F10, F2 or F3 were interviewed in the model region (MR, n = 258) and a control region (CR, n = 244) financed according to the fee-for-service principle. At baseline, 1.5 years and 3.5 years follow-up patients were interviewed using measures of psychopathology (CGI-S, HoNOS, SCL-90R, PANSS, BRMAS / BRMES), functioning (GAF, SOFAS) and quality of life (WHOQOL-BREF, EQ-5D). Use of care was determined semi-annually. RESULTS: There were no significant differences in the development of psychopathology and quality of life between MR and CR. In the MR, functioning of patients with schizophrenia and affective disorders improved significantly more strongly. The development of total mental health care costs was not different between MR and CR. However, the costs of office based mental health care increased slightly more strongly in the MR, indicating a small cost-shift from the RPB to extrabudgetary financed services. CONCLUSIONS: The RPB showed slight advantages regarding the effectiveness of care and did not significantly change the total mental health care costs.

Cost-effectiveness of a primary care model for anxiety disorders.

BACKGROUND: Individuals with anxiety disorders often do not receive an accurate diagnosis or adequate treatment in primary care. AIMS: To analyse the cost-effectiveness of an optimised care model for people with anxiety disorders in primary care. METHOD: In a cluster randomised controlled trial, 46 primary care practices with 389 individuals positively screened with anxiety were randomised to intervention (23 practices, 201 participants) or usual care (23 practices, 188 participants). Physicians in the intervention group received training on diagnosis and treatment of anxiety disorders combined with the offer of a psychiatric consultation-liaison service for 6 months. Anxiety, depression, quality of life, service utilisation and costs were assessed at baseline, 6-month and 9-month follow-up. RESULTS: No significant differences were observed between intervention and control group on the Beck Anxiety Inventory, Beck Depression Inventory and EQ-5D during follow-up. Total costs were higher in the intervention group (euro4911 v. euro3453, P = 0.09). The probability of an incremental cost-effectiveness ratio

Permutation-based significance tests for multiharmonic steady-state evoked potentials.

Sensitivity and specificity of permutation tests for the detection of multiharmonic responses in steady-state evoked potentials were assessed using simulated responses embedded in real and artificial EEG noise. Different statistics may serve as input for the permutation algorithm. Among those tested, the sum of magnitudes of harmonics performed best.

[The regional psychiatry budget: costs and effects of a new multisector financing model for psychiatric care]. / Das Regionale Psychiatriebudget: Kosten und Effekte eines neuen sektorübergreifenden Finanzierungsmodells für die psychiatrische Versorgung.

OBJECTIVE: To evaluate a new multi-sector financing model for psychiatric care based on the capitation principle (Regional Psychiatry Budget, RPB). METHODS: Patients with a diagnosis according to ICD-10 F10, F2, and F3 were interviewed in the model region (MR, N=258) and a control region (CR, N=244) financed according to the fee-for-service principle. Effectiveness of care was assessed before RPB-introduction and after 1.5 years. Use of care was determined semi-annually. RESULTS: Costs of inpatient psychiatric treatment decreased more strongly in the MR, while hospital based outpatient care and day clinic treatment were intensified in comparison to the CR. Quality of life, severity of illness and illness-specific symptoms in patients improved similarly in MR and CR. The functional level improved more in the MR than in the CR, which was especially evident in schizophrenia patients. CONCLUSIONS: Inpatient psychiatric care costs can be reduced with the RPB without compromising the quality of care.

Healthcare costs associated with recognized and unrecognized depression in old age.

BACKGROUND: Inadequate recognition of depression in old age in primary care and the consequences for individuals are now well reported, but little research has been undertaken on its impact on healthcare costs. It is not known whether these costs (i) differ between GP-recognized and -unrecognized depressed individuals, and (ii) differ between these groups and non-depressed individuals. METHODS: 451 primary care patients aged 75+ were interviewed face-to-face regarding depressive symptoms (Geriatric Depression Scale), chronic medical illness (Chronic Disease Score), resource utilization and healthcare costs (questionnaire of service utilization and costs). A general practitioner (GP) questionnaire was used to measure GPs' recognition of depression. Resource utilization was valued in monetary terms using 2004/2005 prices. RESULTS: Thirty-eight (60%) of the 63 depressed patients were not identified by the GPs. From a societal perspective, mean annual healthcare costs were euro 5,582 for unrecognized depressed and euro 4,722 for recognized depressed patients with no significant difference. Healthcare costs of recognized and unrecognized depressed exceeded the healthcare costs of non-depressed patients (euro 3,648) by 23% and 35% respectively (p < 0.05). CONCLUSION: Although mean annual healthcare costs for GP-unrecognized depressed patients exceed the costs of GP-recognized depressed patients in absolute numbers, differences were not found to be statistically significant. Both groups differ from non-depressed individuals regarding their healthcare costs. Results encourage further research into the effect of recognition on healthcare costs of depression in large-scale studies.

Growing old at home - a randomized controlled trial to investigate the effectiveness and cost-effectiveness of preventive home visits to reduce nursing home admissions: study protocol [NCT00644826].

BACKGROUND: Regarding demographic changes in Germany it can be assumed that the number of elderly and the resulting need for long term care is increasing in the near future. It is not only an individual's interest but also of public concern to avoid a nursing home admission. Current evidence indicates that preventive home visits can be an effective way to reduce the admission rate in this way making it possible for elderly people to stay longer at home than without home visits. As the effectiveness and cost-effectiveness of preventive home visits strongly depends on existing services in the social and health system existing international results cannot be merely transferred to Germany. Therefore it is necessary to investigate the effectiveness and cost-effectiveness of such an intervention in Germany by a randomized controlled trial. METHODS: The trial is designed as a prospective multi-center randomized controlled trial in the cities of Halle and Leipzig. The trial includes an intervention and a control group. The control group receives usual care. The intervention group receives three additional home visits by non-physician health professionals (1) geriatric assessment, (2) consultation, (3) booster session. The nursing home admission rate after 18 months will be defined as the primary outcome. An absolute risk reduction from a 20% in the control-group to a 7% admission rate in the intervention group including an assumed drop out rate of 30% resulted in a required sample size of N = 320 (n = 160 vs. n = 160). Parallel to the clinical outcome measurement the intervention will be evaluated economically. The economic evaluation will be performed from a society perspective. DISCUSSION: To the authors' knowledge for the first time a trial will investigate the effectiveness and cost-effectiveness of preventive home visits for people aged 80 and over in Germany using the design of a randomized controlled trial. Thus, the trial will contribute to the existing evidence on preventive home visits especially in Germany.

Direct costs associated with mild cognitive impairment in primary care.

BACKGROUND/AIMS: Little is known about the direct costs of individuals with Mild Cognitive Impairment (MCI). This study investigates the direct costs associated with MCI according to recent diagnostic criteria from a societal perspective. METHODS: Four hundred and fifty-two primary care patients aged 75+ from Leipzig, Germany, were investigated in face-to-face interviews regarding MCI according to the current diagnostic criteria of the International Working Group on MCI, resource utilisation and costs (questionnaire of service utilisation and costs), as well as chronic medical illness (Chronic Disease Score). Resource utilisation was monetarily valued using 2004/2005 prices. RESULTS: Mean annual direct costs were 4,443 euro for patients with MCI (n=39) and 3,814 euro for patients without MCI (n=413) (p=0.34). Looking at the cost components, patients with and without MCI only significantly differed regarding pharmaceutical costs (1,210 euro vs 1,062 euro; p<0.05) not caused by antidementive drugs. CONCLUSION: Direct costs of individuals having MCI are not significantly increased in comparison to direct costs of individuals without cognitive deficits.

Service utilization and health-care costs in the advanced elderly.

OBJECTIVES: Despite their increasing importance, the advanced elderly are often neglected in service utilization and costing studies. The purpose of this study was to analyze from societal perspective service utilization and direct health-care costs and its predictors in the advanced elderly population. METHODS: A bottom-up costing study was conducted using a cross-sectional primary care sample aged 75+ (n = 452) in Germany. The main instruments were a questionnaire of service utilization and costs administered by an interviewer and the chronic disease score (CDS). Predictors were derived by means of multivariate regression models. RESULTS: Respondents caused mean direct costs of Euro 3730 (95% CI 3203-4257) in prices of 2004/2005. This included inpatient care 34%, pharmaceuticals 29%, outpatient physician services 15%, nursing care 10%, medical supply and dentures 6%, outpatient nonphysician providers 5%, assisted living 1%, and transportation 2%. A shift from lower to middle education and a one-point increase in CDS were associated with an increase of 1678 Euro (95% CI 250-3369) and 482 Euro (95% CI 316-654), respectively. Total mean direct costs did not differ significantly between sexes. Ischemic heart disease and diabetes mellitus were associated with excess costs of 711 Euro and 290 Euro, both being not significant. Altogether 55% of the respondents accounted for 90% of total direct costs. CONCLUSIONS: Advanced elderly used a wide range of health services. Our study still underestimates the true costs to society. Further research should focus on economic evaluation of new health-care programs for this increasingly important age group.

Direct costs associated with depression in old age in Germany.

BACKGROUND: Depression in old age is common. Only few studies, exclusively conducted in the USA, have examined the impact of depression on direct costs in the elderly (60+). This study aims to determine the effect of depression on direct costs of the advanced elderly in Germany from a societal perspective. METHODS: 451 primary care patients aged 75+ were investigated face-to-face regarding depressive symptoms (Geriatric Depression Scale), chronic medical illness (Chronic Disease Score) and resource utilisation and costs (cost diary). Resource utilisation was monetarily valued using 2004/2005 prices. RESULTS: Mean annual direct costs of the depressed (euro5241) exceeded mean costs of non-depressed individuals (euro3648) by one third (p<.01). Significant differences were found for pharmaceutical costs, costs for medical supply and dentures, and for home care. Only few costs were caused by depression treatment. Depression has a significant impact on direct costs after controlling for age, gender, education, chronic medical illness and cognitive functions. A one-point increase in the GDS-Score was associated with a euro336 increase in the annual direct costs. LIMITATIONS: Reported costs can be considered as rather conservative estimates. There were no nursing home residents and no patients with dementia disorders in the sample. Furthermore, recall bias cannot be ruled out completely. CONCLUSION: Depression in old age is associated with a significant increase of direct costs, even after adjustment for chronic medical illness. Future demographic changes in Germany will lead to an increase in the burden of old age depression. Therefore health policy should promote the development and use of cost-effective treatment strategies.