Epidemiology, treatment and costs of osteoporosis in Germany--the BoneEVA Study.

INTRODUCTION: In Germany, accurate data on the prevalence and treatment of osteoporosis, as well as the cost of this illness, are not available. The aim of this study is to give a valid estimation of these items for the year 2003. METHODS: Routine data from a German sickness fund covering 1.5 million beneficiaries and billing data for outpatient visits were used to obtain estimates of prevalence for osteoporosis. Claims data for patients with osteoporosis (M80, M81) or an osteoporosis-related fracture diagnosis (S22, S32, S42, S52, S72, S82) or treatment with anti-osteoporosis drugs were examined. Costs were calculated from the perspective of the German health insurance system and the German nursing care insurance system, respectively. Only direct costs of osteoporosis were considered. RESULTS: In 2003, 7.8 million Germans (6.5 million women) were affected by osteoporosis. Of them, 4.3% experienced at least one clinical fracture. Only 21.7% were treated with an anti-osteoporosis drug. The total direct costs attributable to osteoporosis amounted to euros 5.4 billion. CONCLUSION: This study confirms that osteoporosis is underdiagnosed, undertreated and imposes a considerable economic burden on the health system in Germany. Effective strategies for the prevention and management of this disease are needed.

[On the prognosis of hip fractures. Assessment of mortality after hip fractures by analyzing overlapping segments of longitudinal data]. / Zur Prognose der Schenkelhalsfraktur. Beurteilung der Mortalität nach Schenkelhalsfraktur durch sektorübergreifende Datenzusammenführung.

BACKGROUND: Data on the treatment of hip fractures in acute care settings have been collected in a report card system for quality assurance in Germany since the beginning of the 1990s. However, there are no data on the long-term outcome and long-term quality of care. MATERIAL AND METHOD: In a retrospective study, data on 1393 patients from 1999 were collected from different sources: from the department of quality assurance at the medical association of Westfalia-Lippe, the Statutory Health Insurance Funds (AOK), and the Medical Review Board of the Statutory Health Insurance Funds (Medizinischer Dienst der Krankenkasse, MDK). Statistical analyses were performed by the Center for Clinical Studies of the University of Düsseldorf. RESULTS: Uni- and multivariate analyses reveal the following prognostic parameters for survival after hip fracture: sex, age, nursing care dependency, living in a nursing home, risk stratification according to ASA, and postoperative complications. Timing of the operation had no affect on survival. CONCLUSIONS: Prognostic factors for the outcome after hip fracture can only be obtained by analyzing data from the hospital stay and the post-hospital setting as well. Chances of survival can be significantly improved by rehabilitative care.

[Geriatric assessment. Is it significantly helpful in selection of elderly tumour patients for a difficult therapy?]. / Geriatrisches Assessment. Sinnvolle Hilfe bei der Auswahl älterer Tumorpatienten für eine belastende Therapie?

With increasing life expectancy, a therapeutic decision raises the question of the primary goals to be aimed for. Is an absolute gain in age a goal equal to the preservation of an active life? While in younger patients the strategy followed by the patient and the doctor will usually be that of long-term survival, the decision making process for older patients with functional deficits is more challenging. Though functional deficits show a positive correlation with age, a causal relationship does not exist, which implies considerable inter-individual heterogeneity in the group of older patients. In particular, patients who have reached older ages "successfully" without any major limitations in their health should be considered for more intensive treatment strategies. At the same time, younger patients with relevant functional limitations and without any chance of improvement may not benefit from these interventions. The comprehensive geriatric assessment (CGA) offers the opportunity to describe and classify these deficits systematically. It therefore has a key role in the individual decision making process.

[Hip fractures (osteoporosis) and geriatric rehabilitation]. / Proximale Femurfrakturen (Osteoporose) und geriatrische Rehabilitation.

Osteoporosis is one of the ten leading diseases with an enormous epidemiological and economic burden for societies. Research in recent years has shown that osteoporosis is not part of the "normal" aging process, but a disease with an evidence-based body of knowledge concerning diagnostics and therapy. Because the correlation of the frequency with age is high and because of the demographic dynamics in the coming years in Germany, the importance of this disease will dramatically increase. From a societal point of view, several endpoints have to be to considered, especially mortality and loss of independence after fracture. The importance of the social and economical consequences of hip fractures (excess mortality, loss of independence, institutionalization) will increase in the near future. Therefore, it is necessary to have an adequate database for different sectors of the health system (ambulatory, hospital, rehabilitation). A health system will then be able to decide on effective and efficient ways of allocating resources. The experiences of two research projects with registry data show that it is possible to demonstrate the deficits and problems of current medical care and to develop strategies for an optimization in the future.

Comprehensive geriatric assessment in the elderly cancer patient.

The proportion of older cancer patients is increasing due to demographic and disease-specific reasons. However, this group of patients is severely underrepresented in research and clinical therapy. Limitation in physical and functional capacity with considerable interindividual heterogeneity remains one of the important problems in the treatment decision process. One approach to this problem is the use of a Comprehensive Geriatric Assessment (CGA) to describe and classify these deficits with high validity and reliability. The different domains of CGA are described with special respect to the instruments applied, as CGA has also a key role in the decision process.

[AR-DRG effects on geriatrics in Germany]. / AR-DRG Auswirkungen auf die Geriatrie in Deutschland.

The parties of the self-governing Health Service are at present preparing the introduction of a general case, flat rate compensation system for the hospital section on behalf of the legislature. The system is based on the performance definitions and case classifications of the Australian DRG System, Version 4.1. The relative evaluation of the individual DRG for the implementation into the system in Germany will be based on German cost and benefit data. For this purpose a calculation of case-specific treatment costs based on a representative selection of hospitals will be made. The geriatrics field will have to adapt itself to these regulations in the same way as all other medical disciplines. Difficulties are arising due to the inconsistent classification of cost and benefit data in connection with the classification. The geriatric field is under-represented in the calculation of relative evaluation and, therefore, the spectrum of benefit cannot be shown in the planned calculation system. Analogous to the calculation of German relative cost evaluation, the geriatric section will define in a project the actual costs for their treatment cases and determine the consecutive relative evaluation.

[Health services research in geriatrics and geriatric rehabilitation from the national and international viewpoint]. / Versorgungsforschung auf dem Gebiet der Geriatrie und geriatrischen Rehabilitation aus nationaler und internationaler Sicht.

In Germany, health services research geriatric problems is not of major scientific and political importance. Focusing on geriatrics, it is essential to produce good data concerning efficacy, effectiveness and costs of the interventions. Otherwise, the discussion about the allocation of resources in the German health care system will take place without good arguments for special geriatric interventions. Prerequisite for this goal is the definition of adequate endpoints targeting functional deficits and the operationalization of multi- and comorbidity. Another problem is research focused on the "black box" of specific geriatric interventions. A special German situation is the distinction between acute and rehabilitative geriatric settings where very similar patients are treated. For this reason, it is essential for the geriatrician in the German context to focus more on health services research to demonstrate with scientific evidence their important contribution for the care of the elderly.

Performance of the score systems Acute Physiology and Chronic Health Evaluation II and III at an interdisciplinary intensive care unit, after customization.

BACKGROUND: Mortality predictions calculated using scoring scales are often not accurate in populations other than those in which the scales were developed because of differences in case-mix. The present study investigates the effect of first-level customization, using a logistic regression technique, on discrimination and calibration of the Acute Physiology and Chronic Health Evaluation (APACHE) II and III scales. METHOD: Probabilities of hospital death for patients were estimated by applying APACHE II and III and comparing these with observed outcomes. Using the split sample technique, a customized model to predict outcome was developed by logistic regression. The overall goodness-of-fit of the original and the customized models was assessed. RESULTS: Of 3383 consecutive intensive care unit (ICU) admissions over 3 years, 2795 patients could be analyzed, and were split randomly into development and validation samples. The discriminative powers of APACHE II and III were unchanged by customization (areas under the receiver operating characteristic [ROC] curve 0.82 and 0.85, respectively). Hosmer-Lemeshow goodness-of-fit tests showed good calibration for APACHE II, but insufficient calibration for APACHE III. Customization improved calibration for both models, with a good fit for APACHE III as well. However, fit was different for various subgroups. CONCLUSIONS: The overall goodness-of-fit of APACHE III mortality prediction was improved significantly by customization, but uniformity of fit in different subgroups was not achieved. Therefore, application of the customized model provides no advantage, because differences in case-mix still limit comparisons of quality of care.

[Osteoporosis: the epidemiologic and health economics perspective]. / Osteoporose: Die epidemiologische und gesundheitsökonomische Perspektive.

Epidemiology of osteoporosis reveals some specific properties with considerable consequences on economic and social aspects, which are discussed briefly. Large parts of an aging population are under risk of developing osteoporosis with consecutive morbidity and mortality. The epidemiological consequences and economic burden will increase during the next 20 years due to demographic changes. Proximal femoral fractures are most important causing relevant mortality and, if survived, regularly relevant functional loss. Due to the increasing importance of osteoporosis, efficient age-adapted strategies in diagnosis and therapy need to be developed.

[The costs of hip-fracture in Germany: a prospective evaluation]. / Die Kosten hüftgelenksnaher Frakturen in Deutschland: Eine prospektive Untersuchung.

OBJECTIVE: To assess the direct and indirect costs of hip fracture in dependence of postoperative care setting. STUDY DESIGN: Prospective cohort study. METHODS: 227 consecutive patients in three hospitals (city, town, and small town) presenting with hip fracture. For 177 patients there was follow-up regarding post-operative care-setting. During follow-up the cost of the remaining patient at 1, 3, 6 month were recorded and afterwards adjusted to the distribution of the initial cohort. To obtain information on patient characteristics, assessment during hospital stay and follow up have been performed. RESULTS: There was a relevant difference in costs depending on the care setting after hip fracture. The nursing home - nursing home, community - community, and community - nursing home resulted in total costs at 6 month of 17,701 DM, 27,102 DM and 54, 503 DM, respectively (average: 24,508 DM). Nursing home costs contributed significantly to the differences between groups. Valid and predictive measures could not be established in first analysis of performed assessments. CONCLUSION: Due to the high incidence of hip fractures (100,000/y) indirect costs play a major role in the economic impact of this illness. The analysis of the effectiveness of interventions has to take into account these costs to achieve adequate conclusions.

[Geriatric assessment--description of functional deficits and follow-up assessment of elderly stroke patients]. / Geriatrisches Assessment--Beschreibung funktioneller Defizite und Verlaufsbeurteilung beim älteren Schlaganfallpatienten.

The aim of the present study was to describe the course and outcome of rehabilitation using a national recommended assessment program (AGAST). In our study 162 patients with stroke were included. Nearly all patients had improvement of activities of daily living (Barthel Index) and mobility (Tinetti Gait and Balance Score, Frenchay Arm Test). A similar trend was observed in patients with cognitive impairment and depression on admission. Of the different tests, the Barthel Index and mobility scores were shown to be important predictors of length of hospital stay. Further evaluation of the assessment instruments is needed to assess different aspects of quality of life (self-rated well-being, satisfaction). To assess the efficiency of geriatric rehabilitation in patients with stroke, it will be important to measure resource consumption and to evaluate the long-term results.

[The "Geriatric Assessment" Study Group (AGAST): recommendations for the use of assessment procedures]. / Arbeitsgruppe "Geriatrisches Assessment" (AGAST): Empfehlungen für den Einsatz von Assessment-Verfahren.

This work presents preliminary recommendations for a three-step geriatric assessment approach developed by a newly created working group consisting of members from nine geriatric departments in Germany and Switzerland. The recommendations were based on a literature review, expert consultation, and a consensus meeting. As part of this effort, instruments and guidelines for selected geriatric assessment instruments were translated and will be tested in German language. Further research is planned for refining the recommended method. Currently, these recommendations might help to stimulate the spread of geriatric assessment method in German-speaking areas and facilitate joint research projects among geriatric institutions.

[Identification of functional deficits in the acute hospital by geriatric assessment]. / Die Identifikation von funktionalen Defiziten im Akutkrankenhaus durch das geriatrische Assessment.

Functional deficits of elderly patients are often not recognized during routine treatment in acute hospital care. In Germany, there are only limited experiences with the use of standardized assessment-scales in this health care setting. In this study, 112 patients were recruited for a very broad geriatric assessment focused on methodological and practical questions. There were 38.8% with deficits in the ADL and 12.6% with depressive symptoms. Many patients showed low motivational factors such as energy, efficacy and will. Geriatric syndromes such as malnutrition were also very common. In general, many patients in acute care hospitals have functional deficits which are not recognized by the physicians. For many patients, short instruments are sufficient for screening purposes. The effectiveness of a complete geriatric assessment depends mostly on the use of good selection criteria.