[Intended utilization of health care services in cases of mental illnesses with varying urgency]. / Intendierte Inanspruchnahme von Versorgungsangeboten bei psychischen Erkrankungen mit unterschiedlicher Dringlichkeit.

OBJECTIVE: To investigate variations in intended utilization in cases of an acute psychotic episode, an alcohol related or depressive disorder depending on different case characteristics. METHODS: A telephone survey with case vignettes was conducted (N=1,200). Vignettes varied in terms of urgency of symptoms, daytime, sex of the afflicted person and age/mental disorder. The respondents were asked to indicate whom they would contact first in the described case. RESULTS: Outpatient physicians were named most frequently as the first point of contact (61.1%) while only 6.5% of the respondents named emergency medicine including the medical on call service (8.1% in high urgency cases, i. e. emergencies that did not tolerate any delay). Intended utilization varied by urgency and age/mental illness. CONCLUSION: More Information about the need to seek medical help immediately in cases of mental illnesses with high urgency should be provided.

Profiles of met and unmet care needs in the oldest-old primary care patients with depression - results of the AgeMooDe study.

BACKGROUND: Unmet care needs have been associated with an increased risk of depression in old age. Currently, the identification of profiles of met and unmet care needs associated with depressive symptoms is pending. Therefore, this exploratory study aimed to identify profiles of care needs and analyze associated factors in oldest-old patients with and without depression. METHODS: The sample of 1092 GP patients aged 75+ years is based on the multicenter study "Late-life depression in primary care: needs, health care utilization and costs (AgeMooDe)". Depression (i.e. clinically meaningful depressive symptoms) was determined using the Geriatric Depression Scale (GDS) (cutoff score ≥ 4). Needs of patients were assessed using the Camberwell Assessment of Need for the Elderly (CANE). Associated sociodemographic and clinical factors were examined, and latent class analysis identified the need profiles. RESULTS: The main result of the study indicates three need profiles: 'no needs', 'met physical needs', and 'unmet social needs'. Members of the 'met physical needs' (OR = 3.5, 95 %-CI: 2.5-4.9) and 'unmet social needs' (OR = 17.4, 95 %-CI: 7.7-39.7) profiles were significantly more likely to have depression compared to members of the 'no needs' profile. LIMITATIONS: Based on the cross-sectional design, no conclusions can be drawn about the causality or direction of the relationships between the variables. CONCLUSIONS: The study results provide important insights for the establishment of needs-based interventions for GPs. Particular attention should be paid to the presence of unmet social needs in the oldest-old GP patients with underlying depressive symptoms.

Cost-effectiveness of a specialist palliative care nurse-patient consultation followed by an interprofessional case conference for patients with non-oncological palliative care needs: results of the KOPAL trial.

BACKGROUND: Worldwide, progressive chronic, non-malignant diseases are highly prevalent. Especially with increasing age, they are characterised by high hospitalisation rates and high healthcare costs. Improved interprofessional collaboration between general practitioners (GPs) and specialist palliative home care (SPHC) teams might reduce hospitalisation while improving symptoms and quality of life, or preventing them from deterioration. The aim of this study was to examine the cost-effectiveness of a newly developed intervention in patients with advanced chronic, non-malignant diseases consisting of a structured palliative care nurse-patient consultation followed by an interprofessional telephone case conference. METHODS: The analysis was based on data from 172 participants of the KOPAL multi-centre, cluster randomised controlled trial. Patients with advanced congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), or dementia were randomised into intervention group (IG) and control group (CG, usual care). Cost-effectiveness was examined over 48 weeks from a societal and healthcare payer's perspective. Effects were quantified as quality-adjusted life years (QALYs, EQ-5D-5L). Incremental cost-effectiveness ratios were calculated and cost-effectiveness acceptability curves were constructed. RESULTS: Baseline imbalances in costs and effects could be observed between IG and CG. After adjusting for these imbalances and compared to the CG, mean costs in the IG were non-significantly higher from a societal and lower from a payer's perspective. On the effect side, the IG had marginally lower mean QALYs. The results were characterized by high statistical uncertainty, indicated by large confidence intervals for the cost and effect differences between groups and probabilities of cost-effectiveness between 18% and 65%, depending on the perspective and willingness-to-pay. CONCLUSIONS: Based on the results of this study, the cost-effectiveness of the KOPAL intervention was uncertain. The results highlighted (methodological) challenges of economic evaluations in patients with chronic, non-malignant diseases related to sample size, heterogeneity of participants, and the way the intervention effectiveness is typically captured in economic evaluations.

Expanded nursing competencies to improve person-centred care for nursing home residents with complex health needs (Expand-Care): study protocol for an exploratory cluster-randomised trial.

INTRODUCTION: Older age is associated with multimorbidity, chronic diseases and acute deteriorations and leads to complex care needs. Nursing home residents are more often unnecessarily transferred to emergency departments or hospitals than community dwellers-largely due to a lack of qualified staff and diffusion of responsibility in the institutions. In Germany, only few academically trained nurses work in nursing homes, and their potential roles are unclear. Therefore, we aim to explore feasibility and potential effects of a newly defined role profile for nurses with bachelors' degree or equivalent qualification in nursing homes. METHODS AND ANALYSIS: A pilot study (Expand-Care) with a cluster-randomised controlled design will be conducted in 11 nursing homes (cluster) in Germany, with an allocation ratio of 5:6 to the intervention or control group, aiming to include 15 residents per cluster (165 participants in total). Nurses in the intervention group will receive training to perform role-related tasks such as case reviews and complex geriatric assessments. We will collect data at three time points (t0 baseline, t1 3 months and t2 6 months after randomisation). We will measure on residents' level: hospital admissions, further health services use and quality of life; clinical outcomes (eg, symptom burden), physical functioning and delivery of care; mortality, adverse clinical incidents and changes in care level. On nurses' level, we will measure perception of the new role profile, competencies and implementation of role-related tasks as part of the process evaluation (mixed methods). An economic evaluation will explore resource use on residents' (healthcare utilisation) and on nurses' level (costs and time expenditure). ETHICS AND DISSEMINATION: The ethics committees of the University of Lübeck (Nr. 22-162) and the University Clinic Hamburg-Eppendorf (Nr. 2022-200452-BO-bet) approved the Expand-Care study. Informed consent is a prerequisite for participation. Study results will be published in open-access, peer-reviewed journals and reported at conferences and in local healthcare providers' networks. TRIAL REGISTRATION NUMBER: DRKS00028708.

Compliance and patient satisfaction with treatment settings recommended by the medical on-call service 116117 in Germany using computer-assisted structured initial assessment: a cross-sectional observational study accompanying the demand intervention.

OBJECTIVES: In order to reduce the use of emergency departments, computer-assisted initial assessment was implemented at the medical on-call service 116117. Our study assessed compliance and patient satisfaction. DESIGN: Cross-sectional observational postal survey. SETTING: Medical on-call service 116117 by eight Associations of Statutory Health Insurance Physicians in Germany. PARTICIPANTS: The intervention was observed between January 2020 and March 2021. Minors and patients with invalid contact data were excluded. A random sample of eligible patients received standardised questionnaires by mail. OUTCOME MEASURES: We analysed associations of sociodemographic data, health status, previous service use, health literacy, and recommended settings with compliance and patient satisfaction by multivariable, multilevel logistic regression. INTERVENTIONS: Based on symptoms and context factors, the computer software suggested service levels. Staff and patient discussed if higher levels were indicated, services were available and self-transport was possible. They then agreed on recommendations for treatment settings. RESULTS: Of 9473 contacted eligible patients, 1756 patients (18.5%) participated. Median age was 66 years (IQR=50-79), and 986 (59.0%) were women. At least one recommended setting was used by 1397 patients (85.4%). General practitioner (GP) practices were used by 143 patients (68.4%). Generally, better compliance was associated with lower depression levels (OR 1.59, 95% CI 1.17 to 2.17, p=0.003), fewer previous hospital stays (OR 2.02, 95% CI 1.27 to 3.23, p=0.003) and recommendations for any setting other than GP practices (OR 0.13, 95% CI 0.06 to 0.29, p<0001, to OR 0.37, 95% CI 0.19 to 0.72, p=0.003). A total of 606 patients (50.7%) were completely satisfied. Patient satisfaction was associated with higher age (OR 1.30, 95% CI 1.13 to 1.49, p<0.001), better self-rated health (OR 1.30, 95% CI 1.10 to 1.53, p=0.002), not having musculoskeletal disorders (OR 0.68, 95% CI 0.49 to 0.94, p=0.021), better health literacy (OR 0.69, 95% CI 0.54 to 0.89, p=0.005, and OR 0.49, 95% CI 0.36 to 0.67, p<0.001) and receiving no recommendation for GP practices (OR 0.61, 95% CI 0.43 to 0.87, p=0.006). CONCLUSIONS: Most patients were compliant and satisfied. Lowest compliance and satisfaction were found in GP practices, but nonetheless, two of three patients with respective recommendations were willing to use this setting. TRIAL REGISTRATION NUMBER: German Clinical Trials Register DRKS00017014.

Cost-Effectiveness of Inter-Professional Collaboration to Reduce Hospitalisations in Nursing Home Residents: Results from the German Interprof ACT Trial.

Background: The German multi-centre cluster-randomised controlled trial interprof ACT investigated interventions to increase inter-professional collaboration between nursing home (NH) staff and local general practitioners to reduce hospitalisations and improve nursing homes residents' (NHRs) quality of life. The trial was funded by the German Health Care Innovation Fund. Methods: Cost-effectiveness of interprof ACT interventions was evaluated and compared to current standard of care (SOC) over 12 months, including 622 NHRs in 34 NHs in Germany. Multiplying resource use of healthcare services with German-specific unit costs generated costs. Health outcome was measured in quality-adjusted life-years QALYs), utility by multiplying EQ-5D-5L values with German-specific utility weights. Incremental cost-effectiveness analysis used an intention-to-treat approach and scenario analyses (SAs). Net-benefit-regression and cost-effectiveness acceptability curves addressed uncertainty. A German healthcare insurance perspective was assumed. Results: Base case results showed non-significant cost savings of 851.88€ and non-significant QALY loss of -0,056. Discussion: Dependency levels at baseline were non-significantly higher in IG compared to control group (CG). Lack of baseline costing data eliminated possibility to evaluate changes in costs due to the interprof ACT measures for both groups. Conclusion: Interprof ACT interventions are not cost-effective compared to current SOC.

Patient satisfaction with computer-assisted structured initial assessment facilitating patient streaming to emergency departments and primary care practices: results from a cross-sectional observational study accompanying the DEMAND intervention in Germany.

BACKGROUND: Patient numbers in emergency departments are on the rise. The DEMAND intervention aims to improve the efficacy of emergency services by computer-assisted structured initial assessment assigning patients to emergency departments or primary care practices. The aims of our study were to evaluate patient satisfaction with this intervention and to analyse if reduced patient satisfaction is predicted by sociodemographic data, health status or health literacy. METHODS: We conducted a cross-sectional patient survey in emergency departments and co-located primary care practices. Each intervention site was planned to participate for two observation periods, each with a duration of one full week. Study participants were recruited by the local staff. The patients filled out a written questionnaire during their waiting time. Patient satisfaction was assessed by agreement to four statements on a four point Likert scale. Predictors of patient satisfaction were identified by multilevel, multivariable logistic regression models adjusted for random effects at the intervention site level. RESULTS: The sample included 677 patients from 10 intervention sites. The patients had a mean age of 38.9 years and 59.0% were women. Between 67.5% and 55.0% were fully satisfied with aspects of the intervention. The most criticised aspect was that the staff showed too little interest in the patients' personal situation. Full satisfaction ("clearly yes" to all items) was reported by 44.2%. Reduced patient satisfaction (at least one item rated as "rather yes", "rather no", "clearly no") was predicted by lower age (odds ratio 0.79 for ten years difference, 95% confidence interval 0.67/0.95, p = 0.009), presenting with infections (3.08,1.18/8.05,p = 0.022) or injuries (3.46,1.01/11.82,p = 0.048), a higher natural logarithm of the symptom duration (1.23,1.07/1.30,p = 0.003) and a lower health literacy (0.71 for four points difference, 0.53/0.94,p = 0.019). CONCLUSIONS: The patients were for the most part satisfied with the intervention. Assessment procedures should be evaluated a) regarding if all relevant patient-related aspects are included; and whether patient information can be improved b) for patients with strong opinions about cause, consequences and treatment options for their health problem; and c) for patients who have problems in the handling of information relevant to health and healthcare. TRIAL REGISTRATION: German Clinical Trials Register ( https://www.drks.de/drks_web/setLocale_EN.do ) no. DRKS00017014.

Interprofessional collaboration to support patients with social problems in general practice-a qualitative focus group study.

BACKGROUND: Social problems of patients such as family or work-related conflicts as well as financial difficulties affect the individual health situation and the treatment of diseases in general practice. General practitioners (GPs) would like to have direct access to professionals in social care services. In Germany, there are many different social care facilities for people with a wide range of social problems. As the social and health care systems hardly interact collaborations between social professionals (SPs) and GPs are rare exceptions. This study explored perspectives of GPs regarding their patients with social problems in combination with the perspectives of SPs. Aim of this study was to explore how a systematic interprofessional collaboration between GPs and SPs could be realised. METHODS: We carried out a participatory sequential qualitative study design consisting of two focus groups with GPs, two with SPs and two mixed-professional focus groups with GPs and SPs. The focus groups were conducted with semi-structured moderating guidelines and analysed with a qualitative content analysis approach using inductive and deductive categories. RESULTS: GPs view themselves as the first point of contact for their patients' social problems. For persistent social problems, they expressed a desire for support and SPs were willing to provide this. We developed a stepped care implementation model for a systematic cooperation consisting of nine collaboration strategies. These strategies included: index or website of social care services, referrals to the social care system, using flyers and posters of social care services, direct contact/hotline to local social care services, participation in meetings of social care facilities, involving physician assistants, external social care advice service in GP rooms, implementation in education and training and access to volunteers. CONCLUSIONS: Our stepped care implementation model for a systematic cooperation of GPs and SPs could be a feasible need- and resource-oriented approach for the collaborative care of patients with social problems to improve their medical treatment in most western healthcare systems. GPs and SPs are ready to generate the necessary evidence for policy makers in high quality RCTs.

[Family Medicine in the Digital Age: Scenarios and Recommendations]. / Hausärztliche Medizin im digitalen Zeitalter: Szenarien und Empfehlungen.

AIMS: The aim of this study was to examine the situation of family medicine in the digital age in order to discuss future trends and outline recommendations for action. METHODS: We conducted a structured deliberative process employing elements of the scenario method and involving relevant stakeholder perspectives. Based on an empirically informed analysis of current situations and trends, the scenario method allows the formation of practical recommendations. RESULTS: Extrapolating current trends in the medical profession, the patients, the technological development, and the healthcare system, we developed a best case and a worst case scenario of family medicine in the year 2050. From the analysis and discussion of the scenarios, we derived recommendations for practitioners and decision makers. CONCLUSIONS: Based on the developed scenarios, we recommend twelve measures towards a model of future healthcare that is centered on family medicine and enables a comprehensive, digitally supported holistic and patient-oriented service provision.

Regional and patient-related factors influencing the willingness to use general practitioners as coordinators of the treatment in northern Germany - results of a cross-sectional observational study.

BACKGROUND: In most countries, the general practitioner (GP) is the first point of contact in the healthcare system and coordinator of healthcare. However, in Germany it is possible to consult an outpatient specialist even without referral. Coordination by a GP might thus reduce health expenditures and inequalities in the healthcare system. The study describes the patients' willingness/commitment to use the GP as coordinator of healthcare and identifies regional and patient-related factors associated with the aforementioned commitment to the GP. METHODS: Cross-sectional observational study using a standardised telephone patient survey in northern Germany. All counties and independent cities within a radius of 120 km around Hamburg were divided into three regional categories (urban areas, environs, rural areas) and stratified proportionally to the population size. Patients who had consulted the GP within the previous three months, and had been patients of the practice for at least three years were randomly selected from medical records of primary care practices in these districts and recruited for the study. Multivariate linear regression models adjusted for random effects at the level of federal states, administrative districts and practices were used as statistical analysis methods. RESULTS: Eight hundred eleven patients (25.1%) from 186 practices and 34 administrative districts were interviewed. The patient commitment to a GP attained an average of 20 out of 24 possible points. Significant differences were found by sex (male vs. female: + 1.14 points, p < 0.001), morbidity (+ 0.10 per disease, p = 0.043), education (high vs. low: - 1.74, p < 0.001), logarithmised household net adjusted disposable income (- 0.93 per step on the logarithmic scale, p = 0.004), regional category (urban areas: - 0.85, p = 0.022; environs: - 0.80, p = 0.045) and healthcare utilisation (each GP contact: + 0.30, p < 0.001; each contact to a medical specialist: - 0.75, p = 0.018). Professional situation and age were not significantly associated with the GP commitment. CONCLUSION: On average, the patients' commitment to their GP was relatively strong, but there were large differences between patient groups. An increase in the patient commitment to the GP could be achieved through better patient information and targeted interventions, e.g. to women or patients from regions of higher urban density. TRIAL REGISTRATION: The study was registered in ClinicalTrials.gov (NCT02558322).

Evidence-based quality indicators for primary healthcare in association with the risk of hospitalisation: a population-based cohort study in Switzerland.

OBJECTIVES: The quality of ambulatory care in Switzerland is widely unknown. Therefore, this study aimed to evaluate the recently proposed quality indicators (QIs) based on a nationwide healthcare claims database and determine their association with the risk of subsequent hospitalisation at patient-level. DESIGN: Retrospective cohort study. SETTING: Inpatient and outpatient claims data of a large health insurance in Switzerland covering all regions and population strata. PARTICIPANTS: 520 693 patients continuously insured during 2015 and 2016. MEASURES: A total of 24 QIs were obtained by adapting the existing instruments to the Swiss national context and measuring at patient-level. The association between each QI and hospitalisation in the subsequent year was assessed using multiple logistic regression models. RESULTS: The proportion of patients with good adherence to QIs was high for the secondary prevention of diabetes and myocardial infarction (glycated haemoglobin (HbA1c) control, 89%; aspirin use, 94%) but relatively low for polypharmacy (53%) or using potentially inappropriate medications (PIMs) in the elderly (PIM, 33%). Diabetes-related indicators such as the HbA1c control were significantly associated with a lower risk of hospitalisation (OR, 0.87; 95% CI, 0.80 to 0.95), whereas the occurrence of polypharmacy and PIM increased the risk of hospitalisation in the following year (OR, 1.57/1.08; 95% CI, 1.51 to 1.64/1.05 to 1.12). CONCLUSIONS: This is the first study to evaluate the recently presented QIs in Switzerland using nationwide real-life data. Our study suggests that the quality of healthcare, as measured by these QIs, varied. The majority of QIs, in particular QIs reflecting chronic care and medication use, are considered beneficial markers of healthcare quality as they were associated with reduced risk of hospitalisation in the subsequent year. Results from this large practical test on real-life data show the feasibility of these QIs and are beneficial in selecting the appropriate QIs for healthcare implementation in general practice.

Needs and health care costs in old age: a longitudinal perspective: results from the AgeMooDe study.

Background: The current study aimed to identify whether needs are associated with health care costs in late life longitudinally.Methods: Data were gathered from two waves (at baseline, n = 1199; at follow-up, n = 958) of a multicenter prospective cohort study ('Late-life depression in primary care: needs, health care utilization and costs', AgeMooDe) in Germany. Individuals aged 75 years and above were recruited via general practitioners. The 'Camberwell Assessment of Need for the Elderly' (CANE) was used to assess needs. Based on a questionnaire, the health-related resource use was assessed retrospectively from a societal perspective. The assessment covered outpatient services, inpatient treatment, pharmaceuticals, as well as formal and informal nursing care. Random effects regressions were used.Results: Regressions showed that the number of 'no needs' is inversely associated with total health care costs from a societal perspective (ß = -584.0, p < .001). When a health care perspective was adopted, this association was also significant (ß = -298.8, p < .001). The association between needs and health care costs persisted in all health care sectors considered in this study.Limitations: It might be difficult to generalize our findings to individuals residing in institutional settings.Conclusion: Adjusting for several potential confounders (e.g. sociodemographic and health-related factors), our study showed that needs - quantified using the CANE - are important for health care costs. Interventions should be developed to reduce needs in late life. These interventions may be beneficial for the health care system.

Quality of life assessment in patients with heart failure: validity of the German version of the generic EQ-5D-5L™.

BACKGROUND: Chronic heart failure patients typically suffer from tremendous strain and are managed mainly in primary care. New care concepts adapted to the severity of heart failure are a challenge and need to consider health-related quality of life aspects. This is the first psychometric validation of the German EQ-5D-5L™ as a generic instrument for assessing health-related quality of life (HRQOL) in a primary care heart failure patient sample. METHODS: Confirmatory factor analysis (CFA) was performed on the baseline EQ-5D-5L™ data from the RECODE-HF study (responses to all items from n = 3225 of 3778 patients). Basic CFA models for HRQOL were calculated based on the EQ-5D-5L™ items using the maximum likelihood (ML) and the asymptotic distribution-free method. In an extended CFA, physical activity and depression were added. The basic CFA ML model was verified for the reduced number of cases of the extended CFA model (n = 3064). In analyses of variance the association of the EQ-5D-5L™ visual analogue scale (VAS) and both the German and the British EQ-5D-5L™ crosswalk index with the SF-36 measure of general health were examined. The discriminant validity was analysed using Pearson's chi-squared tests applying the New York Heart Association classification, for the VAS and indices analyses of variance were calculated. RESULTS: In the basic CFA models the root mean square error of approximation was 0.095 with the ML method, and 0.081 with the asymptotic distribution-free method (Comparative Fit Index > 0.90 for both). Physical activity and depression were confirmed as influential factors in the extended model. The VAS and indices were strongly associated with the SF-36 measure of general health (partial eta-squared 0.525/0.454/0.481; all p <  0.001; n = 3155/3210/3210, respectively), also for physical activity and depression when included together (partial eta-squared 0.050, 0.200/0.047, 0.213/0.051 and 0.270; all p <  0.001; n = 3015/n = 3064/n = 3064, respectively). The discriminant validity analyses showed p-values < 0.001 and small to moderate effect sizes for all EQ-5D-5L™ items. Analyses of variance demonstrated moderate effect sizes for the VAS and indices (0.067/0.087/0.084; all p <  0.001; n = 3110/3171/3171). CONCLUSION: The German EQ-5D-5L™ is a suitable method for assessing HRQOL in heart failure patients.

Women Outperform Men in Verbal Episodic Memory Even in Oldest-Old Age: 13-Year Longitudinal Results of the AgeCoDe/AgeQualiDe Study.

BACKGROUND: Sex differences in verbal episodic memory function have been widely reported. However, sex-specific effects on rates of episodic memory decline remain controversial, and evidence is particularly scarce in the oldest-old population. OBJECTIVE: We aimed to investigate sex differences in trajectories of episodic memory performance in oldest-old individuals. METHODS: Based on 13-year longitudinal data with 9 follow-up assessments of a large sample of cognitively unimpaired old (75+) primary care patients (n = 3,254) participating in the German AgeCoDe/AgeQualiDe study, we used linear mixed effects analyses to model sex-specific trajectories of change in verbal episodic memory while accounting for covarying factors. RESULTS: We found that even in the highest age group women outperformed men in immediate (b = -1.71, p < 0.001) and delayed (b = -0.85, p < 0.001) free recall conditions. Associated late-life trajectories, however, did not differ significantly between the sexes. We further demonstrated that younger age, higher education, and an absence of depressive symptoms predicted better performance in both sexes. In contrast, past occurrences of stroke and APOE ɛ4 carrier status showed a negative relation to test scores. CONCLUSION: Our findings confirm previous research suggesting that women perform better in verbal episodic memory tests. We add that this advantage is still present in the oldest-old age groups. Our results indicate that sociodemographic and health related factors are as important as genetically based APOE ɛ4 carrier status in the prediction of normal cognitive development in advanced old age.

Association of anxiety symptoms with health care use and costs in people aged 85 and over.

OBJECTIVE: To analyze the association of anxiety symptoms with health care use and costs in people aged 85 and older. METHODS: Baseline data from AgeQualiDe (N = 856), a multicenter prospective cohort study of primary care patients aged 85 and older, were analyzed. Anxiety symptoms (Geriatric Anxiety Inventory-Short Form) and health care use were assessed via questionnaires. Health care use was monetarily valued using German unit costs to obtain sectoral (inpatient, outpatient, nursing care, medical supplies, and medication) and total costs. Health care use and costs were analyzed in regression models as a function of anxiety symptoms, as well as relevant covariates (predisposing, enabling, and other need characteristics based on the Behavioral Model of Health Care Use). RESULTS: On a descriptive level, people with increased anxiety symptoms (12% of the sample) incurred on average € 10 909 (SD: 16 023) in the last 6 months, 31% more than those without increased anxiety (€ 8303, SD: 11 175; P = 0.12). Adjusting for predisposing, enabling, and other need characteristics, anxiety symptoms were not significantly associated with health care use or costs. Specifically, need characteristics (morbidity, cognitive decline, and functional impairment) were associated with total or sectoral costs, depending on the cost category analyzed. CONCLUSION: In a sample of people of the oldest-old age group, the severity of anxiety symptoms was not associated with health care use or costs, when adjusting for relevant covariates. A longitudinal analysis could assess whether a change in anxiety symptom severity is associated with health care use or costs in old age.

Cost-effectiveness analysis of collaborative treatment of late-life depression in primary care (GermanIMPACT).

BACKGROUND: Late-life depression is a highly prevalent disorder that causes a large economic burden. A stepped collaborative care program was set up in order to improve care for patients with late-life depression in primary care in Germany: GermanIMPACT is the adaption of the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) program that has already been established in primary care in the USA. The aim of this study was to determine the cost-effectiveness of GermanIMPACT compared with treatment as usual from a societal perspective. METHODS: This study is part of a 12-month bi-centric cluster-randomized controlled trial aiming to assess the effectiveness of GermanIMPACT compared with treatment as usual among patients with late-life depression. A cost-effectiveness analysis using depression-free days (DFDs) was performed. Net-monetary benefit (NMB) regressions adjusted for baseline differences for different willingness-to-pay (WTP) thresholds were conducted and cost-effectiveness acceptability curves were constructed. RESULTS: In total, n = 246 patients (intervention group: n = 139; control group: n = 107) with a mean age of 71 from 71 primary care practices were included in the analysis. After 12 months, adjusted mean differences in costs and DFDs between intervention group and control group were +€354 and +21.4, respectively. Only the difference in DFDs was significant (p = 0.022). According to the unadjusted incremental cost-effectiveness ratio, GermanIMPACT was dominant compared with treatment as usual. The probability of GermanIMPACT being cost-effective was 80%, 90% or 95% if societal WTP per DFD was ≥€70, ≥€110 or ≥€180, respectively. CONCLUSION: Evidence for cost-effectiveness of GermanIMPACT relative to treatment as usual is not clear. Only if societal WTP was ≥€180 for an additional DFD, GermanIMPACT could be considered cost-effective with certainty.

A novel superior medication-based chronic disease score predicted all-cause mortality in independent geriatric cohorts.

OBJECTIVES: On the basis of current treatment guidelines, we developed and validated a medication-based chronic disease score (medCDS) and tested its association with all-cause mortality of older outpatients. STUDY DESIGN AND SETTING: Considering the most prevalent chronic diseases in the elderly German population, we compiled a list of evidence-based medicines used to treat these disorders. Based on this list, a score (medCDS) was developed to predict mortality using data of a large longitudinal cohort of older outpatients (training sample; MultiCare Cohort Study). By assessing receiver-operating characteristics (ROC) curves, the performance of medCDS was then confirmed in independent cohorts (ESTHER, KORA-Age) of community-dwelling older patients and compared with already existing medication-based scores and a score using selected anatomical-therapeutic-chemical (ATC) codes. RESULTS: The final medCDS score had an ROC area under the curve (AUC) of 0.73 (95% CI 0.70-0.76). In the validation cohorts, its ROC AUCs were 0.79 (0.76-0.82, KORA-Age) and 0.74 (0.71-0.78, ESTHER), which were superior to already existing medication-based scores (RxRisk, CDS) and scores based on pharmacological ATC code subgroups (ATC3) or age and sex alone (Age&Sex). CONCLUSIONS: A new medCDS, which is based on actual treatment standards, predicts mortality of older outpatients significantly better than already existing scores.

Health behaviour, social support, socio-economic status and the 5-year progression of multimorbidity: Results from the MultiCare Cohort Study.

BACKGROUND: Multimorbidity in elderly patients is a major challenge for physicians, because of a high prevalence of and associations with many adverse outcomes. However, the mechanisms of progressing multimorbidity are not well-understood. The aim of our study was to determine if the progression of multimorbidity is influenced by health behaviour and social support and to analyse if the patients' socio-economic status had an effect on these prognostic factors. METHODS: The study was designed as prospective cohort study based on interviews of 158 GPs and 3189 patients randomly selected from GP records (response rate: 46.2%). Patients were aged 65-85 years at recruitment and observed in four waves of data collection (dropout rate: 41.5%). Statistical analyses of the 'hot deck' imputed data included multilevel mixed-effects linear regression allowing for random effects at the study centre and GP practice within study centre level. RESULTS: Regarding cardiovascular and metabolic diseases, multimorbidity progressed more rapidly in patients who reported less physical activity (ß = -0.28; 95% confidence interval = -0.35 to -0.20), had more tobacco-related pack years (0.15; 0.07-0.22) and consumed less alcohol (-0.21; -0.31 to -0.12) at baseline. Multimorbidity related to psychiatric and pain-related disorders progressed more rapidly if the patients had less perceived social support (-0.31; -0.55 to -0.07) and reported less physical activity (-0.08; -0.15 to -0.02) at baseline. Education and income only slightly modified the effects of these variables. CONCLUSION: Depending on the multimorbidity cluster, different strategies should be used for slowing down the progression of multimorbidity. Changing lifestyle and increasing social support are beneficial for the entire group of elderly multimorbid patients - regardless of their socio-economic status. REGISTRATION: ISRCTN89818205.

Evidence-based indicators for the measurement of quality of primary care using health insurance claims data in Switzerland: results of a pragmatic consensus process.

BACKGROUND: The level of quality of care of ambulatory services in Switzerland is almost completely unknown. By adapting existing instruments to the Swiss national context, the present project aimed to define quality indicators (QI) for the measurement of quality of primary care for use on health insurance claims data. These data are pre-existing and available nationwide which provides an excellent opportunity for their use in the context of health care quality assurance. METHODS: Pragmatic 6-step process based on informal consensus. Potential QI consisted of recommendations extracted from internationally accepted medical practice guidelines and pre-existing QI for primary care. An independent interdisciplinary group of experts rated potential QI based on explicit criteria related to evidence, relevance for Swiss public health, and controllability in the Swiss primary care context. Feasibility of a preliminary set of QI was tested using claims data of persons with basic mandatory health insurance with insurance at one of the largest Swiss health insurers. This test built the basis for expert consensus on the final set of QI. RESULTS: Of 49 potential indicators, 23 were selected for feasibility testing based on claims data. The expert group consented a final set of 24 QI covering the domains general aspects/ efficiency (7 QI), drug safety (2), geriatric care (4), respiratory disease (2), diabetes (5) and cardiovascular disease (4). CONCLUSIONS: The present project provides the first nationwide applicable explicit evidence-based criteria to measure quality of care of ambulatory primary care in Switzerland. The set intends to increase transparency related to quality and variance of care in Switzerland.

Cost-utility of collaborative nurse-led self-management support for primary care patients with anxiety, depressive or somatic symptoms: A cluster-randomized controlled trial (the SMADS trial).

BACKGROUND: Anxiety, depressive and somatoform disorders are highly prevalent and cause a huge economic burden. A nurse-led collaborative care intervention has been set up in order to improve self-management of patients with these mental disorders in primary care in Hamburg, Germany. The aim of this study was to determine the cost-utility of this nurse-led intervention from the health care payer perspective. METHODS: This analysis was part of a 12-month cluster-randomized controlled trial aiming to increase perceived self-efficacy of primary care patients with anxiety, depressive or somatic symptoms by collaborative nurse-led self-management support compared with routine care. A cost-effectiveness analysis using quality-adjusted life years was performed. Net-monetary benefit regressions adjusted for baseline differences for different willingness-to-pay thresholds were conducted and cost-effectiveness acceptability curves were constructed. RESULTS: In total, n = 325 patients (intervention group: n = 134; control group: n = 191) with a mean age of 40 from 20 primary care practices were included in the analysis. The adjusted differences in quality-adjusted life years and mean total costs between intervention group and control group were +0.02 and +€1145, respectively. Neither of the two differences was statistically significant. The probability for cost-effectiveness of the complex nurse-led intervention was 49% for a willingness-to-pay of €50,000 per additional quality-adjusted life year. The probability for cost-effectiveness did not exceed 65%, independent of the willingness-to-pay. CONCLUSION: The complex nurse-led intervention promoting self-management for primary care patients with anxiety, depressive or somatic symptoms did not prove to be cost-effective relative to routine care from a health care payer perspective.