Evaluation of a collaborative ambulatory orthopedic care program for patients with hip and knee osteoarthritis: a comparative observational cohort study.

BACKGROUND: In 2014, the novel orthopedic care program was established by the AOK health insurance fund in southern Germany to improve ambulatory care for patients with musculoskeletal disorders. The program offers extended consultation times, structured collaboration between general practitioners and specialists, as well as a renewed focus on guideline-recommended therapies and patient empowerment. The aim of this study was to assess the impact of the program on health service utilization in patients with hip and knee osteoarthritis (OA). METHODS: This retrospective cohort study, which is based on claims data, evaluated health service utilization in patients with hip and knee OA from 2014 to 2017. The intervention group comprised OA patients enrolled in collaborative ambulatory orthopedic care, and the control group received usual care. The outcomes were participation in exercise interventions, prescription of physical therapy, OA-related hospitalization, and endoprosthetic surgery rates. Generalized linear regression models were used to analyze the effect of the intervention. RESULTS: Claims data for 24,170 patients were analyzed. Data for the 23,042 patients in the intervention group were compared with data for the 1,128 patients in the control group. Participation in exercise interventions (Odds Ratio (OR): 1.781; 95% Confidence Interval (CI): 1.230-2.577; p = 0.0022), and overall prescriptions of physical therapy (Rate Ratio (RR): 1.126; 95% CI: 1.025-1.236; p = 0.0128) were significantly higher in the intervention group. The intervention group had a significantly lower risk of OA -related hospitalization (OR: 0.375; 95% CI: 0.290-0.485; p < 0.0001). Endoprosthetic surgery of the knee was performed in 53.8% of hospitalized patients in the intervention group vs. 57.5% in the control group; 27.7% of hospitalized patients underwent endoprosthetic surgery of the hip in the intervention group versus 37.0% in the control group. CONCLUSIONS: In patients with hip and knee OA, collaborative ambulatory orthopedic care is associated with a lower risk of OA-related hospitalization, higher participation in exercise interventions, and more frequently prescribed physical therapy.

Health related quality of life of immigrant children: towards a new pattern in Germany?

BACKGROUND: To study Health related quality of life (HRQoL) of a sample of kindergarten children with migration background. METHODS: Five kindergartens in Frankfurt/Main and Darmstadt (Germany) participated. HRQoL was measured with the Kiddy-KINDL (KK) in 3 to 5 year old children. We examined the associations of HRQoL with socio-demographic variables, positive development and resilience, socio-emotional and motor development. Linear regression models were applied to examine differences in HRQoL between migrant and native-born German children. RESULTS: The response rate was 90.5% (N = 283). The children had predominantly migrant background (81.35%). Perceived health was slightly higher in migrants (69.85, SD 17.00) compared to native-born German children (68.33, SD 17.31, p > 0.05), even though migrant children were characterized by a lower socio-economic status (p < 0.01). CONCLUSIONS: Results suggest that HRQoL at early ages in our study exhibits a different pattern than reported previously in studies among older individuals. We attribute the discrepancy partly to a possible changing pattern of migration in Europe with more migrants capable to migrate with healthy profiles, and to the age of our population. Our findings underscore the need to study the life course trajectory of HRQoL among young immigrants and replication in representative samples.

Collaborative Ambulatory Orthopaedic Care in Patients with Hip and Knee Osteoarthritis: A Retrospective Comparative Cohort Study on Health Utilisation and Economic Outcomes.

Objective: To evaluate a novel healthcare programme for the treatment of patients with hip and knee osteoarthritis in southern Germany in terms of clinical and health economic outcomes. The study is based on claims data from 2014 to 2017. Methods: We conducted a retrospective comparative cohort study of 9768 patients with hip and knee osteoarthritis, of whom 9231 were enrolled in a collaborative ambulatory orthopaedic care programme (intervention group), and 537 patients received usual orthopaedic care (control group). Key features of the programme are coordinated care, morbidity-adapted reimbursement and extended consultation times. Multivariable analysis was performed to determine effects on health utilisation outcomes. The economic analysis considered annual costs per patient from a healthcare payer perspective, stratified by healthcare service sector. Besides multivariable regression analyses, bootstrapping was used to estimate confidence intervals for predicted mean costs by group. Results: Musculoskeletal-disease-related hospitalisation was much less likely among intervention group patients than control group patients [odds ratio (OR): 0.079; 95% CI: 0.062-0.099]. The number of physiotherapy prescriptions per patient was significantly lower in the intervention group (RR: 0.814; 95% CI: 0.721-0.919), while the likelihood of participation in exercise programmes over one year was significantly higher (OR: 3.126; 95% CI: 1.604-6.094). Enrolment in the programme was associated with significantly higher ambulatory costs (€1048 vs. €925), but costs for inpatient care, including hospital stays, were significantly lower (€1003 vs. €1497 and €928 vs. €1300 respectively). Overall annual cost-savings were €195 per patient. Conclusions: Collaborative ambulatory orthopaedic care was associated with reduced hospitalisation in patients with hip and knee osteoarthritis. Health costs for programme participants were lower overall, despite higher costs for ambulatory care.

General practitioner-centred paediatric primary care reduces risk of hospitalisation for mental disorders in children and adolescents with ADHD: findings from a retrospective cohort study.

BACKGROUND: General practitioners (GPs) play an essential role in the sustainable management of attention-deficit/hyperactivity disorder (ADHD). To our knowledge, the healthcare programme described here is the first integrated care programme for paediatric ambulatory care embedded in GP-centred-healthcare in Germany. OBJECTIVES: To compare the health-service-utilisation of patients with ADHD enrolled in a GP-centred-paediatric-primary-care-programme with usual care in terms of disease-related hospitalisation, pharmacotherapy and psychotherapy. METHODS: In 2018, we conducted a retrospective cohort study of 3- to 18-year-old patients with ADHD in Baden-Wuerttemberg, southern Germany. The intervention group (IG) comprised patients enrolled in a GP-centred-paediatric-primary-healthcare-programme and consulted a participating GP for ADHD at least once. GP-centred-paediatric-primary-care provides high continuity of care, facilitated access to specialist care, extended routine examinations and enhanced transition to adult healthcare. Patients in the control group (CG) received usual care, meaning they consulted a non-participating GP for ADHD at least once. Main outcomes were disease-related hospitalisation, pharmacotherapy and psychotherapy. Multivariable logistic regression was performed to compare groups. RESULTS: A total of 2317 patients were included in IG and 4177 patients in CG. Mean age was 8.9 ± 4.4. The risk of mental-disorder-related hospitalisations was lower in IG than CG (odds ratio (OR): 0.666, 95% confidence interval (CI): 0.509-0.871). The prescription rate for stimulants was lower in IG (OR: 0.817; 95% CI: 0.732-0.912). There was no statistically significant difference in the participation rate of patients in cognitive behavioural therapy between groups (OR: 0.752; 95% CI: 0.523-1.080). CONCLUSION: Children and adolescents with ADHD enrolled in GP-centred-paediatric-primary-care are at lower risk of mental-disorder-related hospitalisation and less likely to receive stimulants.

Differences in opioid prescription rates between patients with musculoskeletal disorders enrolled in coordinated ambulatory healthcare and patients receiving usual care: a retrospective observational cohort study.

OBJECTIVES: To compare opioid prescription rates between patients enrolled in coordinated ambulatory care and patients receiving usual care. DESIGN: In this retrospective cohort study, we analysed claims data for insured patients with non-specific/specific back pain or osteoarthritis of hip or knee from 2014 to 2017. SETTING: The study was based on administrative data provided by the statutory health insurance fund 'Allgemeine Ortskrankenkasse', in the state of Baden-Wurttemberg, Germany. PARTICIPANTS: The intervention group consisted of patients enrolled in a coordinated ambulatory healthcare model; the control group included patients receiving usual care. Outcomes were overall strong and weak opioid prescriptions. Generalised linear regression models were used to analyse the effect of the intervention. RESULTS: Overall, 46 001 (non-specific 18 787/specific 27 214) patients with back pain and 19 366 patients with osteoarthritis belonged to the intervention group, and 7038 (2803/4235) and 963 patients to the control group, respectively. No significant difference in opioid prescriptions existed between the groups. However, the chance of being prescribed strong opioids was significantly lower in the intervention group (non-specific back pain: Odds Ratio (OR) 0.735, 95% Confidential Interval (CI) 0.563 to 0.960; specific back pain: OR 0.702, 95% CI 0.577 to 0.852; osteoarthritis: OR 0.644, 95% CI 0.464 to 0.892). The chance of being prescribed weak opioids was significantly higher in patients with specific back pain (OR 1.243, 95% CI 1.032 to 1.497) and osteoarthritis (OR 1.493, 95% CI 1.037 to 2.149) in the intervention group. CONCLUSION: Coordinated ambulatory healthcare appears to be associated with a lower prescription rate for strong opioids in patients with chronic musculoskeletal disorders. TRIAL REGISTRATION NUMBER: German Clinical Trials Register (DRKS00017548).

Clinical correlates of word recognition memory in obsessive-compulsive disorder: an event-related potential study.

Memory disturbances found in obsessive-compulsive disorder (OCD) may partially be related to dysfunction of cortico-subcortical circuits. However, it is still unknown how OCD symptomatology is related to memory processing. To explore this question, event-related potentials (ERPs) were recorded in a continuous word-recognition paradigm in OCD patients with either severe or moderate scores on the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) (group S and group M, n=8 each) and in normal healthy controls (n=16). Typically ERPs to repeated items are characterized by more positive waveforms beginning approximately 250 ms post-stimulus. This "old/new effect" has been shown to be relevant for memory processing. The early old/new effect (ca. 300-500 ms) with a frontal distribution is proposed to be a neural correlate of familiarity-based recognition. The late old/new effect (post-500 ms) is assumed to reflect conscious memory retrieval processes. The OCD group S showed a normal early old/new effect and a reduced late old/new effect compared with group M and the control group, but no difference was found between group M and the control group. Source analyses for the late old/new effect showed statistically reduced cerebral activation in the anterior cingulate for OCD group S in contrast to the control group. Additionally, the early old/new effect in OCD group S was negatively correlated with the Y-BOCS total scores, and the late old/new effect was negatively correlated with obsession sub-scores. The severely, not moderately, ill OCD patients showed an impaired conscious recollection of the word-to-be-remembered, which suggested an impairment of working memory capacity in these patients due to a dysfunction in the frontal and cingulate cortex.

Pediatric health-related quality of life: a structural equation modeling approach.

OBJECTIVES: One of the most referenced theoretical frameworks to measure Health Related Quality of Life (HRQoL) is the Wilson and Cleary framework. With some adaptions this framework has been validated in the adult population, but has not been tested in pediatric populations. Our goal was to empirically investigate it in children. METHODS: The contributory factors to Health Related Quality of Life that we included were symptom status (presence of chronic disease or hospitalizations), functional status (developmental status), developmental aspects of the individual (social-emotional) behavior, and characteristics of the social environment (socioeconomic status and area of education). Structural equation modeling was used to assess the measurement structure of the model in 214 German children (3-5 years old) participating in a follow-up study that investigates pediatric health outcomes. RESULTS: Model fit was χ2 = 5.5; df = 6; p = 0.48; SRMR  = 0.01. The variance explained of Health Related Quality of Life was 15%. Health Related Quality of Life was affected by the area education (i.e. where kindergartens were located) and development status. Developmental status was affected by the area of education, socioeconomic status and individual behavior. Symptoms did not affect the model. CONCLUSIONS: The goodness of fit and the overall variance explained were good. However, the results between children' and adults' tests differed and denote a conceptual gap between adult and children measures. Indeed, there is a lot of variety in pediatric Health Related Quality of Life measures, which represents a lack of a common definition of pediatric Health Related Quality of Life. We recommend that researchers invest time in the development of pediatric Health Related Quality of Life theory and theory based evaluations.

Auditory extinction and spatio-temporal order judgment in patients with left- and right-hemisphere lesions.

Auditory extinction and spatio-temporal order judgment (STOJ) were assessed in patients with acquired brain damage by systematically manipulating onset times in bilateral stimulation under free-field conditions. We tested the hypothesis that extinction will be reduced by increasing stimulus onset asynchrony. Two groups of patients with right-hemisphere (RH, n=17) or left-hemisphere (LH, n=17) damage were investigated in comparison to a healthy control group (n=12). The patients were recruited based on previously diagnosed impairments: auditory discrimination deficits with (RH(E)/LH(E)) or without extinction (RH(0)/LH(0)) due to cortical and/or subcortical temporo-parietally centred lesions. Stimuli were presented bilaterally in the acoustic free-field, with an onset asynchrony of ± 30 to ± 150 ms, or unilaterally, from speakers located ± 60°. Low frequency (LF) and high frequency (HF) stimuli were used to address spatial auditory processing in the horizontal plane based on the two main cues of interaural time and interaural intensity differences, respectively. The subjects' task was to indicate whether they perceived one (left or right) or two stimuli (left and right), and in the case of two make an STOJ (left or right first). Temporal asynchrony significantly reduced extinction in those patients that previously exhibited extinction for bilateral-simultaneous stimulation (RH(E)/LH(E)). In addition, their error rates in STOJ were higher than the controls'. A number of patients with no previous signs of extinction in bilateral-simultaneous stimulation (RH(0)/LH(0)) also showed impaired STOJ: in RH(0) patients this was specific to ipsilesional-leading stimuli, whilst in LH(0) patients no side-specific effect was observed. The data support the notion of differential roles for the two hemispheres in spatio-temporal auditory perception and are discussed with respect to prevalent models of extinction and its possible long-term reduction.