The relationship between physical and psychosocial workplace exposures and life expectancy free of musculoskeletal and cardiovascular disease in working life - an analysis based on German health insurance data.

BACKGROUND: Against the backdrop of the debate on extending working life, it is important to identify vulnerable occupational groups by analysing inequalities in healthy life years. The aim of the study is to analyse partial life expectancy (age 30-65) [1] free of musculoskeletal diseases (MSD) and [2] free of cardiovascular diseases (CVD) in occupational groups with different levels of physical and psychosocial exposures. METHODS: The study is based on German health insurance claims data from 2015 to 2018. The study population comprises all employed insured persons aged 18 to 65 years (N = 1,528,523). Occupational exposures were assessed using a Job Exposure Matrix. Life years free of MSD / CVD and life years with MSD /CVD during working age were estimated using multistate life tables. RESULTS: We found inequalities in MSD-free and CVD-free life years, with less disease-free years among men and women having jobs with high levels of physical and psychosocial exposures. Men with low physical exposures had 2.4 more MSD-free and 0.7 more CVD-free years than men with high physical exposures. Women with low psychosocial exposures had 1.7 MSD-free and 1.0 CVD-free years more than women with high psychosocial exposures. CONCLUSIONS: Employees in occupations with high physical and psychosocial demands constitute vulnerable groups for reduced life expectancy free of MSD and CVD. Given the inequalities and high numbers of disease-affected life years during working age, the prevention potential of occupational health care and workplace health promotion should be used more extensively.

End-of-life care in Germany between 2016 and 2020 - A repeated cross-sectional analysis of statutory health insurance data.

BACKGROUND: The Hospice and Palliative Care Act of 2015 aimed at developing and regulating the provision of palliative care (PC) services in Germany. As a result of the legal changes, people with incurable diseases should be enabled to experience their final stage of life including death according to their own wishes. However, it remains unknown whether the act has impacted end-of-life care (EoLC) in Germany. OBJECTIVE: The present study examined trends in EoLC indicators for patients who died between 2016 and 2020, in the context of Lower Saxony, Germany. METHODS: Repeated cross-sectional analysis was conducted on data from the statutory health insurance fund AOK Lower Saxony (AOK-LS), referring to the years 2016-2020. EoLC indicators were: (1) the number of patients receiving any form of outpatient PC, (2) the number of patients receiving generalist outpatient PC and (3) specialist outpatient PC in the last year of life, (4) the onset of generalist outpatient PC and (5) the onset of specialist outpatient PC before death, (6) the number of hospitalisations in the 6 months prior to death and (7) the number of days spent in hospital in the 6 months prior to death. Data for each year were analysed descriptively and a comparison between 2016 and 2020 was carried out using t-tests and chi-square tests. RESULTS: Data from 160,927 deceased AOK-LS members were analysed. The number of patients receiving outpatient PC remained almost consistent over time (2016 vs. 2020 p = .077). The number of patients receiving generalist outpatient PC decreased from 28.4% (2016) to 24.5% (2020; p < .001), whereas the number of patients receiving specialist outpatient PC increased from 8.5% (2016) to 11.2% (2020; p < .001). The onset of generalist outpatient PC moved from 106 (2016) to 93 days (2020; p < .001) before death, on average. The onset of specialist outpatient PC showed the reverse pattern (2016: 55 days before death; 2020: 59 days before death; p = .041). CONCLUSION: Despite growing needs for PC at the end of life, the number of patients receiving outpatient PC did not increase between 2016 and 2020. Furthermore, specialist outpatient PC is being increasingly prescribed over generalist outpatient PC. Although the early initiation of outpatient PC has been proven valuable for the majority of people at the end of life, generalist outpatient PC was not initiated earlier in the disease trajectory over the study period, as was found to be true for specialist outpatient PC. Future studies should seek to determine how existing PC needs can be optimally met within the outpatient sector and identify factors that can support the earlier initiation of especially generalist outpatient PC. TRIAL REGISTRATION: The study "Optimal Care at the End of Life" was registered in the German Clinical Trials Register (DRKS00015108; 22 January 2019).

Consensus-based recommendations for the development and expansion of palliative day care clinics in Germany: results of a Delphi study.

BACKGROUND: Needs-based, patient-oriented palliative care includes palliative day care clinics as a specialized semi-inpatient care offer. However, the establishment and development of these facilities has been unsystematic. Research is needed to strengthen their transparency and ensure their accessibility, quality, and structural adequacy. A national Delphi study was conducted to generate appropriate recommendations for the establishment and development of palliative day care clinics in Germany. METHODS: Recommendations were formulated from focus group data on the development and expansion of palliative day care clinics in Germany. Experts on in- and outpatient palliative care rated 28 recommendations for relevance and feasibility, respectively, using a 4-point Likert-type scale. Suggestions for improvement were captured via free text comments. Items were considered consented when more than 80% of the experts scored them 4 (strongly agree) or 3 (somewhat agree), regarding both relevance and feasibility. RESULTS: A total of 23 experts (32% response rate) completed three Delphi rounds. Following the first round, 10 of 28 recommendations were revised according to participants' comments; 1 recommendation was rejected. After the second round, 3 of these 10 recommendations were revised, while 3 were rejected. Consensus was achieved after the third round for 22 of the initial recommendations. CONCLUSIONS: The Delphi-consented recommendations provide a basis for the targeted evidence- and needs-based development of palliative day care clinics. The findings show a need for standards setting and the meaningful integration of these clinics into existing structures. TRIAL REGISTRATION: The present study was prospectively registered on April 20, 2020, with the German Clinical Trials Register (DRKS00021446).

Heterogeneous Preferences for Colorectal Cancer Screening in Germany: Results of a Discrete Choice Experiment.

OBJECTIVES: Colorectal cancer (CRC) screening tests differ in benefits, harms, and processes, making individual informed decisions preference based. The objective was to analyze the preferences of insurees in Germany for characteristics of CRC screening modalities. METHODS: A generic discrete choice experiment with 2-alternative choice sets and 6 attributes (CRC mortality, CRC incidence, complications, preparation, need for transportation, and follow-up; 3 levels each) depicting characteristics of fecal testing, sigmoidoscopy, and colonoscopy was generated. Participants completed 8 choice tasks. Internal validity was tested using a within-set dominated pair. Between June and October 2020, written questionnaires were sent to a stratified random sample (n = 5000) of 50-, 55-, and 60-year-old insurees of the AOK (Allgemeine Ortskrankenkasse) Lower Saxony, who had previously received an invitation to participate in the organized screening program including evidence-based information. Preferences were analyzed using conditional logit, mixed logit, and latent-class model. RESULTS: From 1282 questionnaires received (26% [1282 of 4945]), 1142 were included in the analysis. Approximately 42% of the respondents chose the dominated alternative in the internal validity test. Three heterogeneous preference classes were identified. Most important attributes were preparation (class 1; n = 505, 44%), CRC mortality (class 2; n = 347, 30%), and CRC incidence (class 3; n = 290, 25%). Contrary to a priori expectations, a higher effort was preferred for bowel cleansing (class 1) and accompaniment home (classes 1 and 2). CONCLUSION: Internal validity issues of choice data need further research and warrant attention in future discrete choice experiment surveys. The observed preference heterogeneity suggests different informational needs, although the underlying reasons remained unclear.

Implementation, barriers, and recommendations for further development of advance care planning for the last phase of life in nursing homes in Germany (Gut-Leben): protocol for a mixed-methods study.

BACKGROUND: Nursing home entry often marks the transition into the end-of-life. In 2018, Germany legally introduced reimbursement for advance care planning (ACP according to § 132 g SGB V) in nursing homes that applied for ACP approval to improve end-of-life care. The Gut-Leben project aims to evaluate the implementation and barriers of ACP in nursing homes in Germany, with a special focus on the federal state of Lower Saxony, and provide practical recommendations for further development of end-of-life care. METHODS: This mixed-methods study spreads across five work packages (WP) over a three-year period. WP 1 will explore the approval process, implementation, and barriers to ACP in nursing homes. Data will be collected through a national postal survey in a random sample of n = 600. WP 2 will explore whether documented ACP reports are applicable as a data source for research (expecting up to 500 available ACP reports). In WP 3a and 3b, data on the ACP process will be collected in n = 15 approved nursing homes in Lower Saxony over a 12-months period. For WP 3a and WP 3b, data on ACP conversations (n = 600) and on end-of-life care paths (n = 300) will be collected by facilitators and nurses of the respective nursing homes. In WP 4, residents' characteristics upon entry and changes in these characteristics over the length of stay are analyzed, utilizing claims data from the AOK Lower Saxony (expected sample of about 100,000 people entering nursing homes over a 10-years period). WP 5 connects, interprets, and reflects on the findings from WP 1-4 through focus groups and individual interviews with facilitators, nursing staff, residents, relatives, and care providers. Within a participatory approach, a practice advisory board will be set up existing of personal of nursing homes and will be closely involved in the whole research process. DISCUSSION: In summary, the Gut-Leben project provides insight into the implementation and barriers of ACP in nursing homes according to German legislation for the first time, including practitioners' and residents' perspectives. Insights will help the further development of ACP in Germany through practical recommendations based on quantitative and qualitative data.

Real-world experience for the outcomes and costs of treating hepatitis C patients: Results from the German Hepatitis C-Registry (DHC-R).

BACKGROUND & AIMS: With long-term consequences like the development of liver cirrhosis and hepatocellular carcinoma, chronic hepatitis C virus (HCV) infection is associated with a significant health burden. Information on HCV treatment outcomes and costs in routine care is still rare, especially for subgroups. The aim of this study was to analyse the treatment outcomes and costs of subgroups in routine care and to compare them over time with previous analyses. METHODS: Data were derived from a noninterventional study including a subset of 10298 patients receiving DAAs with genotypes 1 and 3. Sociodemographic, clinical parameters and costs were collected using a web-based data recording system. The total sample was subdivided according to treatment regimen, cirrhosis status as well as present HIV infection and opioid substitution treatment (OST). RESULTS: 95% of all patients achieved SVR. Currently used DAA showed higher SVR-rates and less adverse events (AE) compared to former treatments. Concerning subgroups, cirrhotic patients, HIV-coinfected patients and OST patients showed lower but still high SVR-rates. In comparison, cirrhotic had considerably longer treatment duration and more frequent (serious) AE. Overall, average treatment costs were €48470 and costs per SVR were €51129; for currently used DAAs costs amounted to €30330 and costs per SVR to €31692. After the end of treatment, physical health is similar to the general population in all patients except cirrhotic. Mental health remains far behind in all subgroups, even for currently used DAA. CONCLUSIONS: Over time, some relevant factors developed positively (SVR-rates, costs, treatment duration, adverse events, health-related quality of life (HRQoL)). Further research on HRQoL, especially on mental health, is necessary to evaluate the differences between subgroups and HRQoL over time and to identify influencing factors.

[M2Q or Something else? The Impact of Varying Case Selection Criteria on the Prevalence Estimation of Chronic Diseases Based on Outpatient Diagnoses in German Claims Data]. / M2Q oder doch etwas Anderes? Der Einfluss verschiedener Aufgreifkriterien auf die Prävalenzschätzung chronischer Erkrankungen mit ambulanten GKV-Diagnosedaten.

BACKGROUND: To determine the prevalence of chronic disease conditions based on outpatient health insurance data, we often rely on repeated occurrence of a diagnosis over the course of a year, usually in two or more quarters (M2Q). It remains unclear whether prevalence estimates change after adapting repeated occurrence of a diagnosis in different quarters of a year compared to a single occurrence or to some other case selection criteria. This study applies different case selection criteria and analyses their impact on the prevalence estimation based on outpatient diagnoses. METHODS: Administrative prevalence for 2019 was estimated for eight chronic conditions based on outpatient physician diagnoses. We applied five case selection criteria: (1) single occurrence, (2) repeated occurrence (including in the same quarter or treatment case), (3) repeated occurrence in at least two different treatment cases (including in the same quarter), (4) occurrence in two quarters and (5) occurrence in two consecutive quarters. Only information on persons with continuous insurance history within the statutory health insurance provider AOK Niedersachsen in 2019 was used (n=2,168,173). RESULTS: Prevalence estimates differed quite strongly depending on the diagnosis and on age group if a criterion with repeated occurrence of a diagnosis was applied compared to a single occurrence. These differences turned out to be higher among men and younger patients. The application of a repeated occurrence (criterion 2) did not show different results compared to the repeated occurrence in at least two treatment cases (criterion 3) or in two quarters (criterion 4). The application of the strict criterion of two consecutive quarters (criterion 5) resulted in further reduction of the prevalence estimates. CONCLUSIONS: Repeated occurrence is increasingly becoming the standard for diagnosis validation in health insurance claims data. Applying such criteria results partly in a distinct reduction of prevalence estimates. The definition of the study population (e. g., repeated visits to a physician in two consecutive quarters as a mandatory condition) can also strongly influence the prevalence estimates.

[Methotrexate treatment before use of biologics in rheumatoid arthritis : Analysis of guideline compliance]. / Methotrexat-Versorgung vor dem Einsatz von Biologika bei rheumatoider Arthritis : Eine Analyse der Leitliniengerechtigkeit.

BACKGROUND: With the introduction of biologics the treatment landscape for patients with rheumatoid arthritis (RA) has rapidly expanded; however, according to German and European treatment guidelines the use of biologic disease-modifying antirheumatic drugs (bDMARD) is only indicated after insufficient response under methotrexate (MTX) doses of at least 20 mg/week (first-line treatment). The aim of the study was to analyze the guideline compliance of MTX prescription in the outpatient sector prior to treatment with biologics. MATERIAL AND METHODS: Claims data from the AOK Lower Saxony from 2013 to 2016 were provided for all insured patients with a diagnosis of RA and bDMARD prescription during the study period. Within a patient-specific observational period of 180 days prior to the first bDMARD prescription, the maximum prescribed MTX dosage was examined. RESULTS: Data from 90 incident and 315 prevalent RA patients were analyzed. A maximum MTX prescription of < 20 mg/week was observed in 60.0% of incident patients and in 67.0% of prevalent patients. Men had a higher mean MTX maximum dose (17.1 ± 4.8 mg) than women (14.9 ± 5.0 mg; p < 0.0001). Of the study population 29.6% received oral only prescriptions during the observational period. In 12.4% of patients a switch to parenteral administration was made. DISCUSSION: Targeted use of the full spectrum of therapies provided prior to initiation of bDMARD treatment may contribute to cost-effective RA care. This study showed indications for potential deficits in outpatient MTX prescription practice and can raise awareness for efficient treatment.

Willingness and preparedness to provide care: interviews with individuals of different ages and with different caregiving experiences.

BACKGROUND: At present, the provision of informal care to older relatives is an essential pillar of the long-term care system in Germany. However, the impact of demographic and social changes on informal caregiving remains unclear. METHODS: Thirty-three semi-structured interviews were conducted with care consultants, informal caregivers and people without any caregiving experience to explore if people are willing to provide older adult care and how prepared these are with regard to the possibility of becoming care dependent themselves. RESULTS: In total, three main categories (willingness to provide care, willingness to receive care and information as preparation) with several sub-categories were identified during the content analysis. While almost all interviewees were willing to provide care for close family members, most were hesitant to receive informal care. Other factors such as the available housing space, flexible working hours and the proximity of relatives were essential indicators of a person's preparedness to provide informal care. It is, however, unclear if care preferences change over time and generations. Six out of 12 informal caregivers and nine out of 14 care consultants also reported an information gap. Because they do not possess adequate information, informal caregivers do not seek help until it is too late and they experience high physical and mental strain. Despite the increased efforts of care consultants in recent years, trying to inform caregivers earlier was seen as almost impossible. CONCLUSIONS: The very negative perception of caregiving as a burden was a reoccurring theme throughout all interviews and influenced people's willingness to receive care as well as seeking timely information. Despite recent political efforts to strengthen home-based care in Germany, it remains unclear whether political efforts will be effective in changing individuals' perceptions of informal caregiving and their willingness to be better prepared for the highly likely scenario of having to care for a close relative or becoming care dependent at a later stage in life.

Exploring the status of and demand for palliative day-care clinics and day hospices in Germany: a protocol for a mixed-methods study.

BACKGROUND: To date, the establishment and development of palliative day-care clinics and day hospices in Germany have been completely unsystematic. Research is needed to gain insight into these services and to ensure their accessibility and quality. Accordingly, the ABPATITE research project aims at: (1) identifying the characteristics of palliative day-care clinics and day hospices in Germany, (2) determining demand and preferences for these services, and (3) proposing recommendations (with expert agreement) for the needs-based establishment and development of these services. METHODS: The research is a multi-perspective, prospective, observational study following a mixed-methods approach across three study phases. In phase 1a, qualitative expert interviews will be conducted to capture the facility-related characteristics of palliative day-care clinics and day hospices in Germany; the results will feed into a questionnaire sent to all such institutions identified nationwide. In phase 1b, a questionnaire will be sent to local statutory health insurance providers, to gain insight into their contracts and accounting and remuneration models. In phase 2a, a service preference survey will be conducted with patients and family caregivers. In phase 2b, semi-structured interviews with management staff will explore the factors that promote and hinder the provision of service. In phase 2c, the external perspective will be surveyed via focus groups with local actors involved in hospice and palliative care. In phase 3a, focus groups with representatives from relevant areas will be conducted to develop recommendations. Finally, in phase 3b, recommendations will be agreed upon through a Delphi survey. DISCUSSION: The empirically developed recommendations should enable the establishment and development of day hospices and palliative day-care clinics in Germany to be better managed, more oriented to actual demand, and more effectively integrated into wider health care services. Importantly, the findings are expected to optimize the overall development of hospice and palliative care services. TRIAL REGISTRATION: The study was prospectively registered in the German Clinical Trials Register (Deutsches Register Klinischer Studien) (Registration N° DRKS00021446; date of registration: April 20, 2020). The study is searchable under the International Clinical Trials Registry Platform Search Portal of the World Health Organization, under the German Clinical Trials Register number.

Determinants of colorectal cancer screening in Germany: a claims data analysis.

With an incidence of 58,000 cases per year, colorectal cancer (CRC) is the third most common type of cancer in Germany. Although guaiac-based fecal occult blood tests (gFOBT) and colonoscopy are accepted strategies for CRC screening offered for individuals aged 50 or 55 onwards, utilization rates remain low.This study examines various determinants for participation in CRC screening using claims data provided by the AOK Niedersachsen and covering the years 2014 to 2016. Using multivariate logistic regression models, we analyzed sociodemographic factors (sex, age, nationality, type of employment) associated with screening behavior, including individuals who underwent colonoscopy or gFOBT. The effect of school education and professional qualification was estimated using subgroups of employees with social insurance.The analysis consisted of 620,977 insured individuals in the study population for screening colonoscopy, while the gFOBT study population contained 845,191 individuals. With increasing age, individuals were less likely to participate in CRC screening. Participation rates for screening were higher for women than men in younger age groups. However, men in higher age groups showed increased participation rates in gFOBT screening. When compared with German citizens, Turkish citizens use the colonoscopy less often and the gFOBT more often. In contrast to employees with social insurance, unemployed individuals accept the prevention services less frequently, whereas pensioners and voluntarily insured individuals exhibit increased participation rates. In terms of education and professional qualification, we estimated a significantly lower participation rate exclusively for the least educated individuals. The results help to better understand patterns of utilization and can contribute to the development of information programs for specific groups.

[Frequency of diagnosed non-alcololic fatty liver disease (NAFLD) in the German population - An analysis based on health insurance data]. / Die Häufigkeit von diagnostizierten Fettlebererkrankungen (NAFLD) in der deutschen Bevölkerung ­ Eine Analyse auf der Basis von GKV-Routinedaten.

BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) is one of the most common chronic liver diseases in Germany. In the long term, there is an increased risk of developing liver cirrhosis and subsequent diseases. Epidemiologic studies on NAFLD prevalence in Germany are scarce. The aim of the study was to assess administrative incidence and prevalence or, more specifically, the number of patients diagnosed with NAFLD in the period from 2008 to 2018. METHODS: Analyses are based on administrative data of a large statutory health insurance fund. All individuals who were insured in the year of analysis and in the three-year pre-observation period were included (between 1.7-2 million insured per analysis year). NAFLD-patients were identified using relevant ICD-10 codes (K76.0 und K75.8). RESULTS: In 2018, 4.66 % of insured persons had a NAFLD diagnosis, 0.87 % were diagnosed first-time. Diagnoses of nonalcoholic steatohepatitis (NASH) were comparatively rare (0.09 %). Data show an uptake of NAFLD diagnoses over time. The number of incident cases per year has hardly changed. Patients with diseases of the metabolic syndrome had an increased chance of being diagnosed with NAFLD. CONCLUSION: It becomes evident that NAFLD is frequently diagnosed in everyday medical practice, although data from population-based studies suggest an even higher prevalence.

[Healthcare expenditure and the impact of age: a detailed analysis for survivors and decedents]. / Gesundheitsausgaben und die Rolle des Alters: Eine detaillierte Analyse der Kosten von Überlebenden und Verstorbenen.

BACKGROUND: Germany faces various socio-political challenges due to its ongoing ageing population. Significant increases in social security contributions are widely expected. The impact of ageing on healthcare expenditure is a controversial issue. Experts agree that costs for end-of-life care account for a significant part of total healthcare expenditures. For a meaningful forecast, detailed information on healthcare costs differentiated by survivors and decedents is necessary. Extensive data are hardly available for Germany. The aim of the analysis was therefore to describe healthcare costs in the statutory health insurance. METHODS: The basis for the calculation is billing data from the statutory health insurance "AOK Niedersachsen" (Lower Saxony). Persons who survived or died in 2017 were included in the analysis. Average costs were standardised. RESULTS: The data of 2.46 million survivors and 34,307 decedents were analysed. The average annual healthcare costs were 2756 € for survivors and 21,830 € for decedents in the last year of life. The average healthcare costs for survivors increase with age whereas costs for decedents are highest in younger age groups and decline with increasing age. A detailed analysis of end-of-life costs shows an exponential increase of costs in the last three years of life with the highest costs in the quarter before death (10,577 €). DISCUSSION: The analysis gives a detailed overview on the structure of healthcare expenditure in the statutory health insurance and can serve as a basis for future forecasts regarding healthcare expenditure.

Quality indicators for the evaluation of end-of-life care in Germany - a retrospective cross-sectional analysis of statutory health insurance data.

BACKGROUND: The provision and quality of end-of-life care (EoLC) in Germany is inconsistent. Therefore, an evaluation of current EoLC based on quality indicators is needed. This study aims to evaluate EoLC in Germany on the basis of quality indicators pertaining to curative overtreatment, palliative undertreatment and delayed palliative care (PC). Results were compared with previous findings. METHODS: Data from a statutory health insurance provider (AOK Lower Saxony) pertaining to deceased members in the years 2016 and 2017 were used to evaluate EoLC. The main indicators were: chemotherapy for cancer patients in the last month of life, first-time percutaneous endoscopic gastrostomy (PEG) for patients with dementia in the last 3 months of life, number of hospitalisations and days spent in inpatient treatment in the last 6 months of life, and provision of generalist and specialist outpatient PC in the last year of life. Data were analysed descriptively. RESULTS: Data for 64,275 deceased members (54.3% female; 35.1% cancer patients) were analysed. With respect to curative overtreatment, 10.4% of the deceased with cancer underwent chemotherapy in the last month and 0.9% with dementia had a new PEG insertion in the last 3 months of life. The mean number of hospitalisations and inpatient treatment days per deceased member was 1.6 and 16.5, respectively, in the last 6 months of life. Concerning palliative undertreatment, generalist outpatient PC was provided for 28.0% and specialist outpatient PC was provided for 9.0% of the deceased. Regarding indicators for delayed PC, the median onset of generalist and specialist outpatient PC was 47.0 and 24.0 days before death, respectively. CONCLUSION: Compared to data from 2010 to 2014, the data analysed in the present study suggest an ongoing curative overtreatment in terms of chemotherapy and hospitalisation, a reduction in new PEG insertions and an increase in specialist PC. The number of patients receiving generalist PC remained low, with delayed onset. Greater awareness of generalist PC and the early integration of PC are recommended. TRIAL REGISTRATION: The study was registered in the German Clinical Trials Register ( DRKS00015108 ; 22 January 2019).

[Influence of a spontaneous bacterial peritonitis, nosocomial infections and acute-on-chronic liver failure on treatment revenues in patients with decompensated cirrhosis in Germany]. / Einfluss einer spontan bakteriellen Peritonitis, nosokomialer Infektionen und eines akut auf chronischen Leberversagens auf die Behandlungserlöse bei Patienten mit dekompensierter Leberzirrhose in Deutschland.

BACKGROUND: The economic effects of spontaneous bacterial peritonitis (SBP), nosocomial infections (nosInf) and acute-on-chronic liver failure (ACLF) have so far been poorly studied. We analyzed the impact of these complications on treatment revenues in hospitalized patients with decompensated cirrhosis. METHODS: 371 consecutive patients with decompensated liver cirrhosis, who received a paracentesis between 2012 and 2016, were included retrospectively. DRG (diagnosis-related group), "ZE/NUB" (additional charges/new examination/treatment methods), medication costs, length of hospital stay as well as different kinds of specific treatments (e. g., dialysis) were considered. Exclusion criteria included any kind of malignancy, a history of organ transplantation and/or missing accounting data. RESULTS: Total treatment costs (DRG + ZE/NUB) were higher in those with nosInf (€â€Š10,653 vs. €â€Š5,611, p < 0.0001) driven by a longer hospital stay (23 d vs. 12 d, p < 0.0001). Of note, revenues per day were not different (€â€Š473 vs. €â€Š488, p = 0.98) despite a far more complicated treatment with a more frequent need for dialysis (p < 0.0001) and high-complex care (p = 0.0002). Similarly, SBP was associated with higher total revenues (€â€Š10,307 vs. €â€Š6,659, p < 0.0001). However, the far higher effort for the care of SBP patients resulted in lower daily revenues compared to patients without SBP (€â€Š443 vs. €â€Š499, p = 0.18). ACLF increased treatment revenues to €â€Š10,593 vs. €6,369 without ACLF (p < 0.0001). While treatment of ACLF was more complicated, revenue per day was not different to no-ACLF patients (€â€Š483 vs. €â€Š480, p = 0.29). CONCLUSION: SBP, nosInf and/or ACLF lead to a significant increase in the effort, revenue and duration in the treatment of patients with cirrhosis. The lower daily revenue, despite a much more complex therapy, might indicate that these complications are not yet sufficiently considered in the German DRG system.

Elimination of hepatitis C virus in Germany: modelling the cost-effectiveness of HCV screening strategies.

BACKGROUND: Chronic hepatitis C is a major public health burden. With new interferon-free direct-acting agents (showing sustained viral response rates of more than 98%), elimination of HCV seems feasible for the first time. However, as HCV infection often remains undiagnosed, screening is crucial for improving health outcomes of HCV-patients. Our aim was to assess the long-term cost-effectiveness of a nationwide screening strategy in Germany. METHODS: We used a Markov cohort model to simulate disease progression and examine long-term population outcomes, HCV associated costs and cost-effectiveness of HCV screening. The model divides the total population into three subpopulations: general population (GEP), people who inject drugs (PWID) and HIV-infected men who have sex with men (MSM), with total infection numbers being highest in GEP, but new infections occurring only in PWIDs and MSM. The model compares four alternative screening strategies (no/basic/advanced/total screening) differing in participation and treatment rates. RESULTS: Total number of HCV-infected patients declined from 275,000 in 2015 to between 125,000 (no screening) and 14,000 (total screening) in 2040. Similarly, lost quality adjusted life years (QALYs) were 320,000 QALYs lower, while costs were 2.4 billion EUR higher in total screening compared to no screening. While incremental cost-effectiveness ratio (ICER) increased sharply in GEP and MSM with more comprehensive strategies (30,000 EUR per QALY for total vs. advanced screening), ICER decreased in PWIDs (30 EUR per QALY for total vs. advanced screening). CONCLUSIONS: Screening is key to have an efficient decline of the HCV-infected population in Germany. Recommendation for an overall population screening is to screen the total PWID subpopulation, and to apply less comprehensive advanced screening for MSM and GEP.

[The Frequency of Depression Diagnoses in Different Groups of Insured Persons - A Routine Data Analysis of the Years 2006 to 2015]. / Die Häufigkeit von Depressionsdiagnosen nach Versichertengruppen im Zeitverlauf ­ eine Routinedatenanalyse der Jahre 2006­2015.

Depressive disorders are one of the most common type of mental disorders and are associated with a significant loss of social functioning and decrease in quality of life. While survey data from the Robert Koch-Institute show no increase in the prevalence of depression during recent years, data from social insurance agencies demonstrate an increasing social significance. Many people argue that changes in working conditions are a major reason for increasing depression diagnoses. Aim of the current study was to analyze the prevalence of depression diagnoses in health insurance data (administrative prevalence) for different types of insured persons and to examine the development over time with particular regard to working and non-working insured people. We conducted a cross-sectional analysis of administrative depression prevalence for the years 2006 to 2015 using F32 and F33 diagnoses. Analyses were stratified by sex and insured persons were grouped in (1.) employees, (2.) self-employed, (3.) spouses with insurance coverage as family member, (4.) pensioners, (5.) unemployed people receiving unemployment benefit I, (6.) people receiving unemployment benefit II and (7.) students and trainees. During the 10-year period, we found an increase in administrative prevalence from 12.0% in 2006 (women: 16.3%; men: 6.8%) to 16.3% in 2015 (women: 21.3%; men: 10.9%). In 2015, highest administrative prevalence rates were observed in people receiving unemployment benefit I or II and in pensioners. The lowest rates were found in students and trainees as well as self-employed. Employees had significantly lower administrative prevalence rates than people receiving unemployment benefit. We observed large increases in administrative prevalence over time in all groups of insured persons. The results highlight the increasing social significance of depressive disorders. A comparatively greater increase in the working population was not observed. A long-term health objective should be to further improve psychiatric care.

Widening inequalities in multimorbidity? Time trends among the working population between 2005 and 2015 based on German health insurance data.

BACKGROUND: Previous research has produced evidence for social inequalities in multimorbidity, but little is known on how these disparities change over time. Our study investigates the development of social inequalities in multimorbidity among the middle-aged and older working population. Special attention is paid to whether differing time trends between socio-economic status (SES) groups have taken place, increasing or decreasing inequalities in multimorbidity. METHODS: The analyses are based on claims data of a German statutory health insurance company covering an observation period from 2005 to 2015. Multimorbidity prevalence risks are estimated using logistic generalized estimation equations (GEE) models. Predicted probabilities of multimorbidity prevalence are used to assess time trends in absolute social inequalities in terms of educational level, income, and occupational group. RESULTS: The prevalence risks of multimorbidity rose among all SES groups and social gradients persist throughout the observation period, indicating significantly higher multimorbidity prevalence risks for individuals with lower SES. Widening absolute inequalities are found among men in terms of educational level and among women in terms of occupational groups. CONCLUSIONS: The increases in multimorbidity prevalence among the working population are accompanied by widening social inequalities, pointing towards a growing disadvantage for men and women in lower SES groups. The rising burden and the increasing inequalities among the working population stress the importance of multimorbidity as a major public health concern.

[Healthcare expenditures and the role of demografic change : An analysis of statutory health insurance data]. / Gesundheitsausgabenentwicklung und der Einfluss des demografischen Wandels : Eine Analyse von Daten der Gesetzlichen Krankenversicherung.

The development of healthcare expenditures and the impact of demographic change are the subject of a controversial debate. Yearly healthcare expenditures have more than doubled between 1992 and 2015 and are often justified by the aging demographic. The majority of expenses are paid by the statutory health insurance (SHI). The aim of the current study was to evaluate the contribution of the demographic change to increasing total per capita expenditures in the SHI as well as to analyze the development and the impact in individual areas of spending.We calculated average per capita expenditures from 2004 to 2015 based on data from the German Federal (Social) Insurance Office. Information on the age distribution in SHI was derived from official statistics of the Federal Ministry of Health. To determine the impact of demographic change on per capita expenditures, age distribution was standardized based on 2004 data. Additionally, the impact of inflation and other factors was determined.The results show an increase in per capita expenditures from €1722 in 2004 to €2656 in 2015 (+54.2%). Assuming a constant age distribution at the 2004 level, average per capita expenditures would have increased by 44.9%. The relative share of demographic change is only 17.3%; 32.2% could be explained by inflation and 50.5% are based on other factors. We observed large differences in the increase for the individual areas of spending, which can partly be explained by the impact of demographic change.This analysis illustrates that the demographic change is not the frequently claimed cost driver in healthcare. Other factors have a substantially greater impact on healthcare expenditures.

High resource utilization in liver transplantation-how strongly differ costs between the care sectors and what are the main cost drivers?: a retrospective study.

To control treatment pathways of transplant patients across healthcare sectors, a profound knowledge of the underlying cost structure is necessary. The aim of this study was to analyze the resource utilization of patients undergoing liver transplantation. Data on resource utilization for 182 liver-transplanted patients was investigated retrospectively. The observational period started with the entry on the waiting list and ended up to 3 years after transplantation. Median treatment cost was 144 424€. During waiting time, median costs amounted to 9466€; 72% of costs were attributed to inpatient care, 3% to outpatient care, and 26% to pharmaceuticals. During the first year after transplantation, median costs of 105 566€ were calculated; 83% were allocated for inpatient and 1% outpatient care, 14% for drugs, and 1% for rehabilitative care. During follow-up after the first year of transplantation, median costs amounted to 20 115€; 75% of these were caused by pharmaceuticals, 21% by inpatient, 4% by outpatient, and <1% by rehabilitative services. Subgroup analyses (e.g., for labMELD scores) were done. Costs incurred by inpatient care and pharmaceuticals are the dominating cost factors. These findings encourage a debate on challenges and improvements for cost-efficient clinical management between different healthcare sectors.