Longitudinal association between panic disorder and health care costs in older adults.

BACKGROUND: To analyze whether probable panic disorder (PD) is associated with health care costs in older age over time. METHODS: Data regarding individuals aged 65 and over were derived from two waves of the ESTHER cohort study (nt1 = 2,348, nt2 = 2,090). Probable PD was assessed using the panic screening module from the Patient Health Questionnaire. Health care costs were obtained through monetary valuation of self-reported health care use data. Fixed effects regressions analyzed the association between transitions in probable PD status and change in health care costs, while adjusting for potential confounders. RESULTS: On a descriptive level, study participants with a positive PD screening displayed higher three-month health care costs compared to those without (incremental costs: € 259 for t1 , € 1,544 for t2 ). Transitions in probable PD were associated with an approximate increase of 65% in outpatient health care costs (ß = 0.50, p < .05). There was no significant association between probable PD transition and change in any other cost category. CONCLUSIONS: Using longitudinal data, our results highlight the economic consequences of probable PD in older adults. Future research should address whether reducing PD in older adults may reduce the associated economic burden and analyze underlying mechanisms.

A short intervention targeting psychosomatic care in older adults with complex health care needs-results of a randomized controlled trial.

OBJECTIVE: The aim of this randomized controlled trial (RCT) was to assess the efficacy of a short intervention targeting psychosomatic care in older adults with complex health care needs. METHODS: Participants were recruited in the frame of the 11-year follow-up of a large population-based study by means of the INTERMED interview. The INTERMED interview is an integrative assessment method to identify bio-psycho-social health care needs. Persons with high health care needs (interview score ≥ 17) were invited to take part. Participants were randomized with a 1:1 ratio to a control and an intervention group. The intervention group received a home visit conducted by a doctor trained in psychosomatic medicine. The primary hypothesis stated that the intervention group would have a better outcome with respect to health related quality of life (HRQOL) measured by the 12-item short-form health survey (mental component score, MCS) 6 months after randomization (T1). Secondary outcomes were physical HRQOL, health care needs, depression, anxiety, and somatic symptom severity. RESULTS: In total, 175 participants were included. At the three-year follow-up (T2), 97 participants (55.4%) were included. At T1, we did not find a difference regarding MCS between the intervention and control groups. At T2, the intervention group showed significantly lower health care needs compared with the control group. Regarding HRQOL, depression, and somatic symptom severity the two groups did not differ at T2. CONCLUSIONS: The primary hypothesis was not confirmed. However, results indicate that a short intervention with complex patients could lead to reduced bio-psycho-social health care needs.

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.

Burden of hip fracture using disability-adjusted life-years: a pooled analysis of prospective cohorts in the CHANCES consortium.

BACKGROUND: No studies have estimated disability-adjusted life-years (DALYs) lost due to hip fractures using real-life follow-up cohort data. We aimed to quantify the burden of disease due to incident hip fracture using DALYs in prospective cohorts in the CHANCES consortium, and to calculate population attributable fractions based on DALYs for specific risk factors. METHODS: We used data from six cohorts of participants aged 50 years or older at recruitment to calculate DALYs. We applied disability weights proposed by the National Osteoporosis Foundation and did a series of sensitivity analyses to examine the robustness of DALY estimates. We calculated population attributable fractions for smoking, body-mass index (BMI), physical activity, alcohol intake, type 2 diabetes and parity, use of hormone replacement therapy, and oral contraceptives in women. We calculated summary risk estimates across cohorts with pooled analysis and random-effects meta-analysis methods. FINDINGS: 223 880 men and women were followed up for a mean of 13 years (SD 6). 7724 (3·5%) participants developed an incident hip fracture, of whom 413 (5·3%) died as a result. 5964 DALYs (27 per 1000 individuals) were lost due to hip fractures, 1230 (20·6%) of which were in the group aged 75-79 years. 4150 (69·6%) DALYs were attributed to disability. Current smoking was the risk factor responsible for the greatest hip fracture burden (7·5%, 95% CI 5·2-9·7) followed by physical inactivity (5·5%, 2·1-8·5), history of diabetes (2·8%, 2·1-4·0), and low to average BMI (2·0%, 1·4-2·7), whereas low alcohol consumption (0·01-2·5 g per day) and high BMI had a protective effect. INTERPRETATION: Hip fracture can lead to a substantial loss of healthy life-years in elderly people. National public health policies should be strengthened to reduce hip fracture incidence and mortality. Primary prevention measures should be strengthened to prevent falls, and reduce smoking and a sedentary lifestyle. FUNDING: European Community's Seventh Framework Programme.

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.

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.

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.

Social disparities in Disease Management Programmes for coronary heart disease in Germany: a cross-classified multilevel analysis.

BACKGROUND: Disease Management Programmes (DMPs) aim to improve effectiveness and equity of care but may suffer from selective enrolment. We analysed social disparities in DMP enrolment among elderly patients with coronary heart disease (CHD) in Germany, taking into account contextual effects at municipality and primary care practice levels. METHODS: Cross-sectional analysis of effects of educational attainment and regional deprivation on physician-reported DMP enrolment in a subsample of a large population-based cohort study in Germany, adjusting for individual-level, practice-level and area-level variables. We calculated OR and their 95% CIs (95% CI) in cross-classified, multilevel logistic regression models. RESULTS: Among N=1280 individuals with CHD (37.3% women), DMP enrolment rates were 22.2% (women) and 35% (men). The odds of DMP enrolment were significantly higher for male patients (OR=1.98 (1.50 to 2.62)), even after adjustment for potential confounding by individual-level, practice-level and area-level variables (range: OR=1.60 (1.08 to 2.36) to 2.16 (1.57 to 2.98)). Educational attainment was not significantly associated with DMP enrolment. Compared to patients living in least-deprived municipalities, the adjusted propensity of DMP enrolment was statistically significantly lower for patients living in medium-deprived municipalities (OR=0.41 (0.24 to 0.71)), and it also tended to be lower for patients living in the most-deprived municipalities (OR=0.70 (0.40 to 1.21)). Models controlling for the social situation (instead of health-related behaviour) yielded comparable effect estimates (medium-deprived/most-deprived vs least-deprived areas: OR=0.45 (0.26 to 0.78)/OR=0.68 (0.33 to 1.19)). Controlling for differences in comorbidity attenuated the deprivation effect estimates. CONCLUSIONS: We found evidence for marked gender, but not educational disparities in DMP enrolment among patients with CHD. Small-area deprivation was associated with DMP enrolment, but the effects were partly explained by differences in comorbidity. Future studies on DMPs should consider contextual effects when analysing programme effectiveness or impacts on equity and efficiency.

Analysing horizontal equity in enrolment in Disease Management Programmes for coronary heart disease in Germany 2008-2010.

BACKGROUND: Disease Management Programmes (DMPs) have been introduced in Germany ten years ago with the aim to improve effectiveness and equity of care, but little is known about the degree to which enrolment in the programme meets the principles of equity in health care. We aimed to analyse horizontal equity in DMP enrolment among patients with coronary heart disease (CHD). METHODS: Cross-sectional analysis of horizontal inequities in physician-reported enrolment in the DMP for CHD in a large population-based cohort-study in Germany (2008-2010). We calculated horizontal inequity indices (HII) and their 95% confidence intervals [95%CI] for predicted need-standardised DMP enrolment across two measures of socio-economic status (SES) (educational attainment, regional deprivation) stratified by sex. Need-standardised DMP enrolment was predicted in multi-level logistic regression models. RESULTS: Among N = 1,280 individuals aged 55-84 years and diagnosed with CHD, DMP enrolment rates were 22.2% (women) and 35.0% (men). Education-related inequities in need-standardised DMP enrolment favoured groups with lower education, but HII estimates were not significant. Deprivation-related inequities among women significantly favoured groups with higher SES (HII = 0.086 [0.007 ; 0.165]. No such deprivation-related inequities were seen among men (HII = 0.014 [-0.048 ; 0.077]). Deprivation-related inequities across the whole population favoured groups with higher SES (HII estimates not significant). CONCLUSION: Need-standardised DMP enrolment was fairly equitable across educational levels. Deprivation-related inequities in DMP enrolment favoured women living in less deprived areas relative to those living in areas with higher deprivation. Further research is needed to gain a better understanding of the mechanisms that contribute to deprivation-related horizontal inequities in DMP enrolment among women.

Significance and costs of complex biopsychosocial health care needs in elderly people: results of a population-based study.

OBJECTIVE: To improve health care for the elderly, a consideration of biopsychosocial health care needs may be of particular importance-especially because of the prevalence of multiple conditions, mental disorders, and social challenges facing elderly people. The aim of the study was to investigate significance and costs of biopsychosocial health care needs in elderly people. METHODS: Data were derived from the 8-year follow-up of the ESTHER study-a German epidemiological study in the elderly population. A total of 3124 participants aged 57 to 84 years were visited at home by trained medical doctors. Biopsychosocial health care needs were assessed using the INTERMED for the Elderly (IM-E) interview. Health-related quality of life (HRQOL) was measured by the 12-Item Short-Form Health Survey, and psychosomatic burden was measured by the Patient Health Questionnaire. RESULTS: The IM-E correlated with decreased mental (mental component score: r = -0.38, p < .0001) and physical HRQOL (physical component score: r = -0.45, p < .0001), increased depression severity (r = 0.53, p < .0001), and costs (R = 0.41, p < .0001). The proportion of the participants who had an IM-E score of at least 21 was 8.2%; according to previous studies, they were classified as complex patients (having complex biopsychosocial health care needs). Complex patients showed a highly reduced HRQOL compared with participants without complex health care needs (mental component score: 37.0 [10.8] versus 48.7 [8.8]; physical component score: 33.0 [9.1] versus 41.6 [9.5]). Mean health care costs per 3 months of complex patients were strongly increased (1651.1 &OV0556; [3192.2] versus 764.5 &OV0556; [1868.4]). CONCLUSIONS: Complex biopsychosocial health care needs are strongly associated with adverse health outcomes in elderly people. It should be evaluated if interdisciplinary treatment plans would improve the health outcomes for complex patients.

Is vitamin D deficiency a cause of increased morbidity and mortality at older age or simply an indicator of poor health?

To assess whether vitamin D deficiency is a cause of increased morbidity and mortality or simply an indicator of poor health, we assessed (1) the cross-sectional and longitudinal association of vitamin D deficiency with self-rated health (SRH) and frailty and (2) the association of vitamin D deficiency with mortality, with and without control for SRH and frailty. Analyses were performed in 9,579 participants of the German, population-based ESTHER cohort (age-range at baseline: 50-74 years), with follow-ups after 2, 5 and 8 years (mortality: 12 years). During follow-up, 129 subjects newly reported poor SRH, 510 developed frailty and 1,450 died. In cross-sectional analyses, subjects with vitamin D deficiency had higher odds of a poor SRH and frailty but no association with SRH or frailty was observed in longitudinal analyses. The association of vitamin D deficiency with all-cause and several cause-specific mortalities was strong and unaltered by time-dependent adjustment for classic mortality risk factors, SRH and frailty. In conclusion, vitamin D deficiency may not cause frailty or poor general health but may nevertheless be a prognostic marker for mortality, independent of the individual's morbidity.

Frailty prevalence and 10-year survival in community-dwelling older adults: results from the ESTHER cohort study.

The frailty index (FI), defined by a deficit accumulation approach, has emerged as a promising concept in gerontological research, but applications have been mostly restricted to populations from Canada and the United States aged 65 years or older. Baseline data from the German ESTHER cohort study (N 9,886; age 50-75; mean follow-up 8.7 years) were used to create a FI through a deficit accumulation approach. For estimation of frailty prevalence, we used cut-points for the FI to define three categories (non-frail 0 to ≤0.20; pre-frail >0.20 to <0.45; frail ≥0.45). We assessed variation of the FI by age and sex: 10-year survival according to baseline FI was assessed by Kaplan-Meier curves and bivariate and multivariate Cox proportional hazard models. Cubic splines were used to assess sex-specific dose-response associations. Prevalence of frailty was 9.2 and 10.5% in women and men, respectively. Age-specific prevalence of frailty ranged from 4.6% in 50-54 year old participants to 17.0% in 70-75 year old participants. Below 60 years of age, men had a higher FI than women. However, the FI showed a stronger increase with age among women (3.1% per year) than among men (1.7% per year) and was higher among women than men in older age groups. Adjusted hazard ratios (95% confidence intervals) for all-cause mortality were 1.08 (0.84-1.39), 1.32 (1.05-1.66), 1.77 (1.41-2.22), and 2.60 (2.11-3.20) for the 2nd, 3rd, 4th, and 5th quintile of the FI compared to 1st quintile, respectively. There was a strong dose-response relationship between the FI and total mortality among both men and women and both younger (<65 years) and older subjects. We found sex differences in the FI and its increase with age, along with a consistent strong association of the FI with mortality in both sexes, even for age group 50-64.

Health care costs in the elderly in Germany: an analysis applying Andersen's behavioral model of health care utilization.

BACKGROUND: To analyze the association of health care costs with predisposing, enabling, and need factors, as defined by Andersen's behavioral model of health care utilization, in the German elderly population. METHODS: Using a cross-sectional design, cost data of 3,124 participants aged 57-84 years in the 8-year-follow-up of the ESTHER cohort study were analyzed. Health care utilization in a 3-month period was assessed retrospectively through an interview conducted by trained study physicians at respondents' homes. Unit costs were applied to calculate health care costs from the societal perspective. Socio-demographic and health-related variables were categorized as predisposing, enabling, or need factors as defined by the Andersen model. Multimorbidity was measured by the Cumulative Illness Rating Scale for Geriatrics (CIRS-G). Mental health status was measured by the SF-12 mental component summary (MCS) score. Sector-specific costs were analyzed by means of multiple Tobit regression models. RESULTS: Mean total costs per respondent were 889 € for the 3-month period. The CIRS-G score and the SF-12 MCS score representing the need factor in the Andersen model were consistently associated with total, inpatient, outpatient and nursing costs. Among the predisposing factors, age was positively associated with outpatient costs, nursing costs, and total costs, and the BMI was associated with outpatient costs. CONCLUSIONS: Multimorbidity and mental health status, both reflecting the need factor in the Andersen model, were the dominant predictors of health care costs. Predisposing and enabling factors had comparatively little impact on health care costs, possibly due to the characteristics of the German social health insurance system. Overall, the variables used in the Andersen model explained only little of the total variance in health care costs.

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.