Dental care utilization among home care recipients, nursing home residents, and older adults not in need of long-term care: An observational study based on German insurance claims data.

OBJECTIVES: To describe and compare dental care utilization (DCU) among home care recipients, nursing home residents, and older adults not in need of long-term care (LTC). METHODS: Using nationwide claims data of 8 German statutory health and LTC insurance funds, proportions of home care recipients (n = 68,137), nursing home residents (n = 21,167), and non-LTC dependents (n = 632,205) aged 65+ years with DCU in 2017 were determined and compared. Associations between DCU and individual characteristics and setting were investigated via multivariable logistic regression. The proportions of individuals with DCU one year before and after transition to (a) home care (n = 23,590) and (b) nursing home care (n = 6,583) were compared. RESULTS: Proportions of home care recipients and nursing home residents with DCU were lower compared to non-LTC dependents (51.9, 53.1, and 73.2%, respectively). Adjusted odds ratios for DCU for home care recipients vs. non-LTC dependents ranged from 0.55 (LTC grades 1/2; 95% confidence interval 0.54-0.56) to 0.38 (LTC grades 4/5; 0.36-0.40). For nursing home residents vs. non-LTC dependents they ranged from 0.69 (3; 0.65-0.72) to 0.67 (4/5; 0.63-0.71). Women, older individuals, those with 0-1 diseases of the Elixhauser comorbidity index, dementia, and those from West Germany were also less likely to utilize dental care than their counterparts. Utilization decreased after transition to home care (60.0 vs. 55.6%) and increased after transition to nursing homes (46.1 vs. 53.5%). CONCLUSIONS: Nursing home residents and especially home care recipients utilized dental care less frequently than older non-LTC dependents. Organizational barriers for dental care utilization and ways to remove them should be investigated. CLINICAL SIGNIFICANCE: Dental care utilization among LTC dependents is low and should be improved in both the home care and nursing home setting.

[Research Data Center on Health - Vision for Further Development from the Research Perspective]. / Forschungsdatenzentrum Gesundheit ­ Vision für eine Weiterentwicklung aus Sicht der Forschung.

The German research data center for health will provide claims data of statutory health insurances. The data center was set up at the medical regulatory body BfArM pursuant to the German data transparency regulation (DaTraV). The data provided by the center will cover about 90% of the German population, supporting research on healthcare issues, including questions of care supply, demand and the (mis-)match of both. These data support the development of recommendations for evidence-based healthcare. The legal framework for the center (including §§ 303a-f of Book V of the Social Security Code and two subsequent ordinances) leaves a considerable degree of freedom when it comes to organisational and procedural aspects of the center's operation. The present paper addresses these degrees of freedom. From the point of view of researchers, ten statements show the potential of the data center and provide ideas for its further and sustainable development.

Disease burden of and expectations from surgery in patients prior to total knee arthroplasty: Results of the prospective FInGK study.

BACKGROUND: Disease burden in patients prior to total knee arthroplasty (TKA) varies widely between studies and countries. We aimed to characterize individuals undergoing TKA and examine their expectations from the surgery, focusing on variations in disease burden. METHODS: Consecutive patients undergoing primary TKA in a German university hospital were recruited. A questionnaire including information on disease burden, preoperative expectations from surgery, health care utilization, demography, and socioeconomics was collected one day prior to surgery and linked to data from medical records. Patients were categorized into disease burden quartiles using the Western Ontario and McMaster Universities Osteoarthritis Index' (WOMAC) total score. Subsequently, study population's characteristics and expectations from surgery were analyzed stratified by disease burden. RESULTS: A total of 196 patients were included (41 % male; mean age: 68.2 years). The median WOMAC was 52.0 (IQR: 41.0-58.0). Patients in Q1 were more often males (Q1: 63 % vs Q4: 29 %) and had a shorter duration of complaints with the impaired knee. They were also less restricted in social participation, reported less often signs of depression, and were less often treated with physiotherapy (Q1: 27 % vs Q4: 54 %). Furthermore, expectations from surgery were highest in patients with a low disease burden. CONCLUSION: We found large variations in disease burden with a considerable number of patients undergoing TKA whose functional capacity is still maintained and for which guideline-recommended conservative treatment options are not fully exhausted. Further research on this subgroup as well as establishing an international consensus on specific thresholds for TKA indication are needed.

[Routine Practice Data for Health Care Analyses: Part 3 of the Manual]. / Versorgungsnahe Daten für Versorgungsanalysen ­ Teil 3 des Manuals.

Analyses of health and health care (hereafter referred to as "health care analyses") usually aim to make transparent the structures, processes, results and interrelationships of health care and to record the degree to which health care systems and their actors have achieved their goals. Health care-related data are an indispensable source of data for many health care analyses. A prerequisite for the examination of a degree of goal achievement is first of all an agreement on those goals that are to be achieved by the system and its substructures, as well as the identification of the determinants of the achievement of the objectives. Primarily it must be examined how safely, effectively and patient-centred systems, facilities and service providers are operating. It also addresses issues of need, accessibility, utilisation, timeliness, appropriateness, patient safety, coordination, continuity, and health economic efficiency and equity of health care. The results of health care include system services (outputs), on the one hand, and results (outcomes), on the other, whereby the results (patient-reported outcomes) and experiences (patient-reported experiences) reported are of particular importance. Health care analyses answer basic questions of health care research: who does what, when, how, why and with which resources and effects in routine health care. Health care analyses thus provide the necessary findings and key figures to further develop health care in order to improve the quality of health care. The applications range from capacity analyses to following innovations up to the concept of regional and supra-regional monitoring of the quality of care given to the population. Given the progress of digitalisation in Health Care, direct data from the care processes will be increasingly available for health care research. This can support care givers significantly if the findings of the studies are applied precisely and correctly within an adequate methodological frame. This can lead to measurable improved health care quality for patients. Data from the process of health care provision have a high potential. Their use needs the same scientific scrutiny as in all other scientific studies.

Characteristics and place of death in home care recipients in Germany - an analysis of nationwide health insurance claims data.

BACKGROUND: Most care-dependent people live at home, where they also would prefer to die. Unfortunately, this wish is often not fulfilled. This study aims to investigate place of death of home care recipients, taking characteristics and changes in care settings into account. METHODS: We retrospectively analysed a cohort of all home-care receiving people of a German statutory health insurance who were at least 65 years and who deceased between January 2016 and June 2019. Next to the care need, duration of care, age, sex, and disease, care setting at death and place of death were considered. We examined the characteristics by place of care, the proportion of dying in hospital by care setting and characterised the deceased cohort stratified by their actual place of death. RESULTS: Of 46,207 care-dependent people initially receiving home care, 57.5% died within 3.5 years (n = 26,590; mean age: 86.8; 66.6% female). More than half of those moved to another care setting before death with long-term nursing home care (32.3%) and short-term nursing home care (11.7%) being the most frequent transitions, while 48.1% were still cared for at home. Overall, 36.9% died in hospital and in-hospital deaths were found most often in those still receiving home care (44.7%) as well as care in semi-residential arrangements (43.9%) at the time of death. People who died in hospital were younger (mean age: 85.5 years) and with lower care dependency (low care need: 28.2%) as in all other analysed care settings. CONCLUSION: In Germany, changes in care settings before death occur often. The proportion of in-hospital death is particularly high in the home setting and in semi-residential arrangements. These settings should be considered in interventions aiming to decrease the number of unwished care transitions and hospitalisations at the end of life.

Patterns and trends of antibacterial treatment in patients with urinary tract infections, 2015-2019: an analysis of health insurance data.

BACKGROUND: Urinary tract infections are among the most common reason for encounter and subsequent antibiotic prescriptions. Due to the risk of collateral damage and increasing resistance rates, explicit recommendations against the use of fluoroquinolones like ciprofloxacin in uncomplicated urinary tract infections have been issued. However, to what extent these recommendations were followed and if there are relevant differences between the disciplines involved (general practitioners, urologists, paediatricians and gynaecologists) are unknown. METHODS: We used anonymized data from a local statutory health insurance (SHI) company, which covered about 38% of all SHI-insured persons in the federal state of Bremen, Germany between 2015-2019. Data included demographics, outpatient diagnoses and filled prescriptions on an individual level. RESULTS: One-year prevalence of urinary tract infections was 5.8% in 2015 (females: 9.2%, males: 2.5%). Of all 102,715 UTI cases, 78.6% referred to females and 21.4% to males, 6.0% of cases were younger than 18 years. In females, general practitioners were the most common diagnosing speciality (52.2%), followed by urologists (20.0%) and gynaecologists (16.1%). Overall, fluoroquinolones were most often prescribed (26.3%), followed by fosfomycin (16.1%) and the combination of sulfamethoxazole and trimethoprim (14.2%). Fluoroquinolones were most often prescribed by urologists and general practitioners, while gynaecologists preferred fosfomycin. During the study period, shares of fluoroquinolones decreased from 29.4% to 8.7% in females and from 45.9% to 22.3% in males. CONCLUSIONS: Despite a clear trend toward a more guideline adherent prescription pattern, there is still room for improvement regarding the use of second-line antibiotics especially fluoroquinolones. The choice of antibiotics prescribed differs between specialities with higher uptake of guideline-recommended antibiotics by gynaecologists, mainly because of higher prescription shares of fosfomycin.

Antidepressant drug use and regional prescribing patterns in Germany: results from a large population-based study.

OBJECTIVE: To consider antidepressant prescribing on a population level with a focus on regional prescribing patterns in Germany. BASIC METHODS: Based on data from about 70 million individuals covered by all statutory health insurance funds in Germany in 2010, the prevalence of antidepressant use (overall, for drug classes and individual drugs) was calculated stratified by age and sex. Regional analyses were performed on a state and also on a district level. MAIN RESULTS: The study population comprised 68 427 464 (female: 53.0%) persons, of which 5 052 293 (7.4%) were prescribed at least one antidepressant. The most frequently prescribed drug class was tricyclic antidepressants whereas on a substance level citalopram was most commonly used. Antidepressant prescribing was lowest in children and adolescents (0.2%) and most common in persons aged 70 years and older (13.4%). Women more often received antidepressants than men (9.7% vs. 4.8%). Prevalence of antidepressant use varied between 8.7% (Saarland) and 6.3% (Saxony-Anhalt) and was generally highest in the southwestern and lowest in the eastern states. Accordingly, districts with the highest prevalence were located in the southwestern states. PRINCIPAL CONCLUSIONS: Antidepressant use in Germany varied considerably by age and sex and also on a state and district level.

Health Services Use and Costs in Individuals with Autism Spectrum Disorder in Germany: Results from a Survey in ASD Outpatient Clinics.

Autism spectrum disorders (ASD) are associated with high services use, but European data on costs are scarce. Utilisation and annual costs of 385 individuals with ASD (aged 4-67 years; 18.2% females; 37.4% IQ < 85) from German outpatient clinics were assessed. Average annual costs per person were 3287 EUR, with psychiatric inpatient care (19.8%), pharmacotherapy (11.1%), and occupational therapy (11.1%) being the largest cost components. Females incurred higher costs than males (4864 EUR vs. 2936 EUR). In a regression model, female sex (Cost Ratio: 1.65), lower IQ (1.90), and Asperger syndrome (1.54) were associated with higher costs. In conclusion, ASD-related health costs are comparable to those of schizophrenia, thus underlining its public health relevance. Higher costs in females demand further research.

[Now is the Time to Establish an Efficient Health Research Data Centre]. / Jetzt die Weichen stellen für ein leistungsfähiges Forschungsdatenzentrum Gesundheit.

Based on sections 303a to 303f social code book V, the course is currently being set for an innovative and high-performance national information and data platform. This requires short-term provision of current and relevant data on the health care system, especially process data on statutory health insurance and other social insurance carriers, using established methodological standards as well as taking into account data protection regulations. From the point of view of future users, expectations regarding an "ideal" research health data centre are formulated in ten recommendations. The present article is an offer from health services researchers intended to support decision-makers in the field of politics and self-administration in the German health system in their task of establishing and further development of a research health data centre.

[Prevalence and Treatment of Posttraumatic Stress Disorder in Germany: An Analysis of Nationwide Health Insurance Data, 2008 vs 2017]. / Prävalenz und Versorgung der Posttraumatischen Belastungsstörung in Deutschland: Eine bundesweite Auswertung von Krankenkassendaten aus den Jahren 2008 und 2017.

OBJECTIVE: To provide German data regarding prevalence and treatment (pharmacotherapy, psychotherapy) for individuals with PTSD. METHODS: Based on BARMER health insurance data, the administrative prevalence of PTSD (ICD-10: F43.1), psychiatric comorbidity, psychotherapy and pharmacotherapy were estimated. Additionally, prevalence trends for years 2008 vs. 2017 were computed. RESULTS: In 2017, the overall PTSD prevalence was 0.7 % (females: 0.9 %, males: 0.4 %), whereas in 2008 it was 0.3 %. 74.4 % of all PTSD cases received psychotherapy, 43.6 % were prescribed an antidepressant (first choice: venlafaxine), and 14.4 % were prescribed an antipsychotic (first choice: quetiapine). CONCLUSION: Within the studied period, the administrative prevalence of PTSD has more than doubled. Still, the prevalence rate found in our study is lower than figures from epidemiological studies, thus indicating room for improvement in diagnosing PTSD.

[Hospitalization of nursing home residents in the last phase of life: an analysis of health insurance data]. / Krankenhausaufenthalte von Pflegeheimbewohnern in der letzten Lebensphase: eine Analyse von Krankenkassenroutinedaten.

BACKGROUND: Compared to the international literature a higher proportion of German nursing home residents (NHR) die in hospital. Data on longer periods before death and on regional differences are not available. OBJECTIVE: The frequency of hospitalizations of NHR in different periods during their last year of life were investigated. Differences between age, sex, level of nursing care, dementia and federal states were also assessed. MATERIAL AND METHODS: This study used data of a large German health insurance fund and included NHR aged 65+ years who died between 1 January 2010 and 31 December 2014. We assessed the proportion of NHR with at least one hospitalization during different periods before death. In-depth analyses were conducted for 0 (which corresponds to in-hospital death), 28 and 365 days before death. RESULTS: Of the 67,328 deceased residents (mean age: 85.3 years, 69.8% female), 29.5% died in hospital. A total of 51.5% and 74.3% were hospitalized during the last 28 and 365 days of life, respectively. These values were higher in the eastern parts of Germany. Males were hospitalized more often than women in all time periods. A higher care dependency was associated with fewer hospitalizations, especially shortly before death. There was no noticeable difference in the frequency of hospitalization between NHR with and without dementia. CONCLUSION: Approximately half of all NHR in Germany are hospitalized during the last month of life and one third die in hospital, which is relatively high compared to the international literature. No major differences were found between NHR with and without dementia, which is also contradictory to international studies. Overall, there is a need to optimize palliative care for NHR in Germany.

Factors Associated with Survey Non-Response in a Cross-Sectional Survey of Persons with an Axial Spondyloarthritis or Osteoarthritis Claims Diagnosis.

Non-response in surveys can lead to bias, which is often difficult to investigate. The aim of this analysis was to compare factors available from claims data associated with survey non-response and to compare them among two samples. A stratified sample of 4471 persons with a diagnosis of axial spondyloarthritis (axSpA) and a sample of 8995 persons with an osteoarthritis (OA) diagnosis from a German statutory health insurance were randomly selected and sent a postal survey. The association of age, sex, medical prescriptions, specialist physician contact, influenza vaccination, hospitalization, and Elixhauser comorbidity index with the survey response was assessed. Multiple logistic regression models were used with response as the outcome. A total of 47% of the axSpA sample and 40% of the OA sample responded to the survey. In both samples, the response was highest in the 70-79-year-olds. Women in all age groups responded more often, except for the 70-79-year-olds. Rheumatologist/orthopedist contact, physical therapy prescription, and influenza vaccination were more frequent among responders. In the logistic regression models, rheumatologist/orthopedist treatment, influenza vaccination, and physical therapy were associated with a higher odds ratio for response in both samples. The prescription of biologic drugs was associated with higher response in axSpA. A high Elixhauser comorbidity index and opioid use were not relevantly associated with response. Being reimbursed for long-term care was associated with lower response-this was only significant in the OA sample. The number of quarters with a diagnosis in the survey year was associated with higher response. Similar factors were associated with non-response in the two samples. The results can help other investigators to plan sample sizes of their surveys in similar settings.

How Do German General Practitioners Assess Medical Specialist Care Needs of Nursing Home Residents? Results of a Postal Survey in North-Western Germany.

The frequency of contacts of nursing home residents with medical specialists is lower compared to the general population of the same age group in Germany. The aim of this study was to assess general practitioners' (GPs) views on specialist care needs of nursing home residents, on questions of qualification and care coordination. A cross-sectional study was conducted with a postal questionnaire among a representative sample of 1121 GPs in north-western Germany in 2018. The perceptions of GPs about the relative importance of the type of specialist care that is required in nursing homes was assessed on a five-point Likert scale (0 = very low to 4 = very high). A total of 375 GPs (response 33.5%; mean age 54.4 years; 57.6% male) participated in the survey. GPs assessed care needs as highest for neurologists and psychiatrists (68.7%) and lowest for gynecologists (6.5%). Almost all respondents (96.2%) strongly agreed that medical care for nursing home residents should be coordinated by GPs and that GPs should initiate the referral for further specialist care when required (87.5%). A minority (25.7%) agreed that quality of medical care would improve when care for a nursing home was provided by only one GP practice. GPs perceive the needs of nursing home residents for specialist care as high only in relation to care by neurologists and psychiatrists. GPs consider their own coordination function for medical care in nursing homes as very important.

Are there changes in medical specialist contacts after transition to a nursing home? an analysis of German claims data.

BACKGROUND: Provision of ambulatory care by medical specialists for nursing home residents (NHR) is discussed to be inadequate in Germany, however with only incomplete evidence on this topic. We wanted to know whether the transition to a nursing home is associated with a general decrease in medical specialist care and therefore compared contact rates before and after institutionalization. METHODS: Claims data of 18,779 newly admitted NHR in 2013 were followed for the whole year prior to and up to two years after admission. The frequencies of contacts to specialists were assessed and stratified by sex, age, care level, dementia diagnosis and chronic conditions. Multivariate analyses were conducted to identify predictors for contacts to specialists. RESULTS: One year after institutionalization the most pronounced decrease was found in contacts with ophthalmologists (38.4% vs. 30.6%) whereas with most other specialties only small changes were found. The only specialty with a large increase were neurologists and psychiatrists (27.2% vs. 43.0%). Differences depending on sex and age were rather small while NHR with dementia or a higher care level had lower contact rates after institutionalization. Before institutionalization most patients were referred to a specialist by a general practitioner (61.7-73.9%) while thereafter this proportion decreased substantially (27.8-58.6%). The strongest predictor for a specialist contact after admission to a nursing home was a contact to a specialist before (OR 8.8, CI 7.96-9.72 for contacts to neurologists or psychiatrists). A higher nursing care level and a higher age were also predictors for specialist contacts. CONCLUSIONS: Relevant decreases of ambulatory specialist care utilization after institutionalization are restricted to ophthalmologists. NHR of higher age and higher nursing care level had a lower chance for a specialist contact. The assessment of the adequacy of the provided care after institutionalization remains inconclusive due to little investigated but assumable changes in care needs of NHR. The decreased coordination of care by general practitioners after institutionalization conflicts with health policy goals.

Regional Differences in Prescribing Patterns of Metamizole in Germany Based on Data from 70 Million Persons.

The non-opioid analgesic metamizole (dipyrone) is commonly used in Germany despite its narrow indications and market withdrawal from several countries. In this study we analyzed prescribing patterns of metamizole focusing on regional differences. The source of data was the "Information system for health care data" which includes data from the statutory health insurance funds for about 70 million Germans. We received aggregated data of individuals with at least one metamizole prescription in 2010 as well as the number of prescribed packages by age, sex, state and district along with the number of insured persons in each stratum. We calculated prescription prevalence stratified by age, sex, state and district. Among 68.4 million insured persons (mean age: 43.6 years; 53.0% female) 5.5 million received at least one metamizole prescription (8.1%, overall 12.2 million packages). Prevalence increased with age, and women received metamizole more often than men. In adults (total prevalence: 9.4%), levels varied between 7.0% (Saxony) and 11.1% (Schleswig-Holstein), whereas on a district level use ranged from 4.3% to 14.3%. In 2010, one of 12 individuals received metamizole at least once. Noticeable were the large regional variations which certainly cannot be explained by patient-related factors.

Needs and availability of medical specialists' and allied health professionals' visits in German nursing homes: a cross-sectional study of nursing home staff.

BACKGROUND: The medical care for nursing home residents is estimated to be partly inadequate in Germany. The aim of this study is to investigate the needs and utilization of general practitioners (GPs), medical specialists and allied health professionals. METHODS: A survey was sent to a nationwide random sample of 1069 nursing homes in Germany in January 2019. Nursing staff managers were asked about medical care. Regular nursing home visits by medical specialists and allied health professionals were defined as at least one contact per year to at least one nursing home resident. RESULTS: A total of 486 persons responded (45.5%). On average, nursing homes have contact to 8.6 (interquartile range: 4-10) different GPs. Almost 70% of respondents agreed that residents' medical care should be coordinated by GPs. However, only 46.0% stated that specialist treatment should require GP referral. A high need was seen for care from physiotherapists (91.0%), neurologists or psychiatrists (89.3%), dentists (73.7%), and urologists (71.3%). Regarding the actual utilization of medical specialists and health professionals, most nursing homes have regular contact to physiotherapists (97.1%), psychiatrists or neurologists (90.4%), speech therapists (85.0%), and dentists (84.8%). Remarkable discrepancies between need and utilization were found for urologists and ophthalmologists. CONCLUSION: There is large variance in the number of GPs per nursing home, and needs for medical specialists, especially urologists and ophthalmologists, seem unmet. Interprofessional collaboration between GPs, medical specialists and allied health professionals should be improved, and GPs should play a more coordinating role.

Study on advance care planning in care dependent community-dwelling older persons in Germany (STADPLAN): protocol of a cluster-randomised controlled trial.

BACKGROUND: In Germany, advance care planning (ACP) was first introduced by law in 2015. However, ACP is still uncommon in Germany and only few people have advance directive forms. This study aims to evaluate an ACP program in care dependent community-dwelling persons, compared to optimised usual care. METHODS: A cluster-randomised controlled trial of 12 months duration will be conducted in 3 German study sites comparing the pretested ACP-counselling offered by trained nurses with a control group receiving optimised usual care. Using external concealed randomisation, 16 home care services each will be included in the intervention and the control group (30 participants per cluster; n = 960). Eligibility criteria for patients are: ≥60 years, somehow care dependent, adequate German language skills, assumed life-expectancy of ≥4 weeks, and cognitive ability for participation. ACP will be delivered by trained nurse facilitators of the respective home care services and communication will include proxy decision-makers. The primary endpoint will be patient activation, assessed by the Patient Activation Measure (PAM-13). Secondary endpoints include ACP-engagement, proportion of prepared advance directives, number and duration of hospitalisations, quality of life as well as depression and anxiety. Further, comprehensive economic and process evaluations will be conducted. DISCUSSION: STADPLAN is the first study in Germany that assesses an adapted ACP intervention with trained nurses in home care services and the first international study focusing on cost effectiveness of ACP in community-dwelling older persons. The results will help to improve the understanding and communicating of patients' preferences regarding medical treatment and care and thereby contribute to patients' autonomy. TRIAL REGISTRATION: German Clinical Trials Register: DRKS00016886 (Date of registration: 04.06.2019).

[Utilization of individual out-of-pocket health services (IGeL) in persons with osteoarthritis in Germany : Results of a survey from the PROCLAIR study]. / Inanspruchnahme von individuellen Gesundheitsleistungen (IGeL) bei Arthrose in Deutschland : Ergebnisse einer Befragung im Rahmen der PROCLAIR-Studie.

BACKGROUND: Little is known about the utilization of individual health services performed by a physician (IGeL) and the services and supplements provided outside a doctor's office (MuPaP) for osteoarthritis patients. OBJECTIVES: The aims of this study are to analyze the use of osteoarthritis-specific IGeL and MuPaP as well as predictors for their utilization. MATERIALS AND METHODS: For this cross-sectional study, claims data was used to identify all persons with hip, knee, or polyarticular osteoarthritis in 2014 (n = 657,807). A random sample (n = 8995) was sent a questionnaire about their usage of IGeL and MuPaP. Furthermore, the type of physicians conducting or recommending services was evaluated. Applying multivariable logistic regression, predictors associated with the utilization of IGeL, MuPaP, and overall individual health services were analyzed. RESULTS: After validating the data and osteoarthritis diagnosis, 2363 persons were enrolled (mean age: 65.5 years, 72% female). In the last 12 months, 39% of patients had used at least one IGeL (MuPaP: 76%), with 86% being primarily performed by orthopedists (MuPaP: 88% patient self-motivated). Knee osteoarthritis was associated with increased utilization of IGeL. Having female gender, higher income, residence in Western Germany, higher disease burden, and lower satisfaction with the healthcare system were influences on the use of overall individual health services. CONCLUSIONS: Since patients with high disease burden in particular tend to use these therapies with varying treatment success, detailed information, especially about the risks and existing evidence, should be a prerequisite for trustworthy doctor-patient relationships.

Healthcare provision, functional ability and quality of life after proximal femoral fracture - 'ProFem': Study protocol of a population-based, prospective study based on individually linked survey and statutory health insurance data.

INTRODUCTION: Proximal femoral fractures (PFF) are among the most frequent fractures in older people. However, the situation of people with a PFF after hospital discharge is poorly understood. Our aim is to (1) analyse healthcare provision, (2) examine clinical and patient-reported outcomes (PROs), (3) describe clinical and sociodemographic predictors of these and (4) develop an algorithm to identify subgroups with poor outcomes and a potential need for more intensive healthcare. METHODS AND ANALYSIS: This is a population-based prospective study based on individually linked survey and statutory health insurance (SHI) data. All people aged minimum 60 years who have been continuously insured with the AOK Rheinland/Hamburg and experience a PFF within 1 year will be consecutively included (SHI data analysis). Additionally, 700 people selected randomly from the study population will be consecutively invited to participate in the survey. Questionnaire data will be collected in the participants' private surroundings at 3, 6 and 12 months after hospital discharge. If the insured person considers themselves to be only partially or not at all able to take part in the survey, a proxy person will be interviewed where possible. SHI variables include healthcare provision, healthcare costs and clinical outcomes. Questionnaire variables include information on PROs, lifestyle characteristics and socioeconomic status. We will use multiple regression models to estimate healthcare processes and outcomes including mortality and cost, investigate predictors, perform non-responder analysis and develop an algorithm to identify vulnerable subgroups. ETHICS AND DISSEMINATION: The study was approved by the ethics committee of the Faculty of Medicine, Heinrich-Heine-University Düsseldorf (approval reference 6128R). All participants including proxies providing written and informed consent can withdraw from the study at any time. The study findings will be disseminated through scientific journals and public information. TRIAL REGISTRATION NUMBER: DRKS00012554.