Intended and Actual Participation in the Colorectal Cancer Screening Program­a Prospective Cohort Study With AOK Insurees.

BACKGROUND: The public generally has a positive view of colorectal cancer screening, but there is still room for improvement in participation rates. The aim of this study was to identify factors that are associated with intended and actual participation. METHODS: We conducted a prospective cohort study of a random sample of insurees of the AOK (a statutory health insurance carrier) in the German federal state of Lower Saxony. 50-year-old men and 55-year-old women who were eligible for their first screening colonoscopy received a written questionnaire in June 2020, three weeks after being invited to undergo colorectal cancer screening. For those who intended to do so, we used multivariable logistic regression analysis to determine any statistical associations between sociodemographic and medical characteristics and participation rates within 30 months. RESULTS: 82.7% of the respondents (239/298) intended to participate, and 43.3% (129/298) actually did so within 30 months. The participation rates among persons who had already decided to have a stool test or a colonoscopy were 50.7% (36/71) and 55.2% (58/105), respectively; the participation rate among undecided persons was 33.3% (19/57). The strongest association in the regression model was with an already made appointment (OR = 11.1, 95% confidence interval: [3.9; 31.8]). After exclusion of the existing-appointment variable from the regression model, living in a smaller town (OR = 2.41 [1.08; 5.35]) and a stated preference for colonoscopy (OR = 2.52; [1.20; 5.27]) were positively associated with participation. Insurees with a parent affected by colorectal cancer participated less frequently, even after adjustment for prior colonoscopies (OR = 0.31 [0.12; 0.80]). CONCLUSION: The wide gap between intended and actual participation implies that there is potential for improvement in the prevention of colorectal cancer, and that certain groups of people could benefit from targeted support in making their intention to undergo screening a reality. Because of the methodological limitations of this initial investigation, its findings need to be confirmed by further studies.

Subgroup analyses and patterns of multiple sclerosis health service utilisation: A cluster analysis.

Background: Previous investigations of multiple sclerosis (MS)-related healthcare have focused on utilisation of specific individual health services (e.g. hospital care, office-based neurologists) by people with MS (PwMS). Meanwhile, little is known about possible patterns of utilisation across health services and their potential differences across patient characteristics. Objective: To comprehensively analyse and identify patterns of MS-related health service utilisation and detect patient characteristics explaining such patterns. Methods: In 2021, we invited all PwMS insured by the largest insurance company in Lower Saxony, Germany, to take part in an online survey. We merged respondents' survey and health insurance claims data. We analysed MS-related health service utilisation and defined individual characteristics for subgroup analyses based on Andersen's Behavioural Model. We executed non-parametric missing value imputation and conducted hierarchical clustering to find patterns in health service utilisation. Results: Of 6928 PwMS, 1935 responded to our survey and 1803 were included in the cluster analysis. We identified four distinct health service utilisation clusters: (1) regular users (n = 1130), (2) assistive care users (n = 443), (3) low users (n = 195) and (4) special services users (n = 35). Clusters differ by patient characteristics (e.g. age, impairment). Conclusion: Our findings highlight the complexity of MS-related health service utilisation and provide relevant stakeholders with information allowing them to tailor healthcare planning according to utilisation patterns.

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).

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).

The development of working life expectancy without musculoskeletal diseases against the backdrop of extended working lives.

Musculoskeletal diseases (MSDs) are a major predictor of early retirement. Against the backdrop of the extension of working life, we investigated time trends and educational inequalities in years spent in the labour market free of MSD. Based on German statutory health insurance data (N = 3,405,673), total life years free of MSD (Healthy Life Expectancy, HLE) and years spent in the labour force free of MSD (Healthy Working Life Expectancy, HWLE) were estimated for three periods (2006-2008, 2011-2013, 2016-2018) using multistate analyses. Educational inequalities (8 to 11 vs. 12 or more years of schooling) are reported for 2011-2013. HLE decreased slightly over time in all genders. HWLE in women increased, while it remained rather constant in men. Over time, the share of years in the labour force spent free of MSD declined continuously. People with lower education had lower HLE and HWLE than individuals with higher education. With respect to musculoskeletal diseases, the increase in disease-free working life years cannot keep pace with the extension of working life, resulting in an increasing proportion of years spent in impaired musculoskeletal health in the labour market. Effective prevention strategies are needed, focusing especially on individuals with lower educational attainment.

[Empirically derived recommendations for the development and expansion of day hospices in Germany - Results of a Delphi expert panel]. / Empirisch abgeleitete Empfehlungen für den Auf- und Ausbau von Tageshospizen in Deutschland ­ Ergebnisse einer Delphi-Befragung mit Expert:innen.

INTRODUCTION: A needs-based and patient-oriented hospice and palliative care also includes day hospices as a specialised semi-inpatient care offer. The establishment and development of these facilities in Germany has been rather unsystematic. In order to ensure quality and adequacy of these structures, research is needed. METHODS: A Delphi consensus study was conducted online from November 2022 to February 2023 aiming at generating recommendations for the development and expansion of day hospices in Germany. For each recommendation, the participants indicated on a four-point verbal rating scale how much they agreed upon a) the relevance and b) the feasibility of the recommendation. Items were considered consented when 80% of the participants (strongly) agreed with the recommendation regarding both criteria. If no consensus was reached, the recommendations were revised according to the participants' free text comments and presented in the next Delphi round. Descriptive analyses were applied. RESULTS: A total of 64 experts participated in the first Delphi round and 44 in the second. In round 1, 34 recommendations and in round 2 six recommendations were consented. The final set contains a total of 40 recommendations: 18 on the tasks of day hospices, 13 on cooperation, 7 on funding, and 2 on public relations. DISCUSSION: Recommendations for the development and expansion of day hospices in Germany were developed. Due to their highly rated feasibility, the recommendations should be directly transferable into care practice. It remains to be seen to what extent they will be taken into account in the renegotiation of the framework agreement for day hospices. CONCLUSION: The Delphi-consented recommendations provide a basis to guide action in the currently very dynamic development of hospice work and palliative care in Germany.

Decreasing COPD-related incidences and hospital admissions in a German health insurance population.

Chronic obstructive pulmonary disease (COPD) is associated with smoking and work-related health hazards. Most studies have reported prevalences, and the number of studies examining incidences and social inequalities is small. We analyzed the development of social inequalities of COPD-incidences in terms of income and exacerbations in terms of hospital admissions. Findings were based on claims data from a German statutory health insurance covering 2008 to 2019. Outpatient diagnoses were used for defining COPD-cases, hospital admissions were used for detecting exacerbations. Analyses were performed using Cox-regression. Individual incomes were depicted at three levels defined according to national averages for each year. Data of 3,040,137 insured men and women were available. From 2008 to 2019 COPD-incidences in men decreased by 42% and 47% in women. After stratification by income the reduction at the lowest income level was 41% and 50% in women. Respectively, at the highest income level reductions were 28% and 41%. Disease exacerbations decreased over time, and also social inequalities between income groups emerged. COPD-rates decreased over time at all income levels, but at a faster pace in the lowest income group, thus leading to a positive development of diminishing social gradients in men as well as in women.

Lifestyle interventions for patients with non-alcoholic steato-hepatitis-Design, rationale and protocol of the study "target group-specific optimisation of lifestyle interventions for behavior change in non-alcoholic steato-hepatitis (OPTI-NASH)".

BACKGROUND: Non-alcoholic steato-hepatitis (NASH) is the inflammatory, progressive form of non-alcoholic fatty liver disease (NAFLD). A delayed diagnose interval is typical for the majority of the patients because of the asymptomatic natural course. However, serious sequelae may develop such as cirrhosis or hepatocellular carcinoma. NASH is also associated with an increased risk of metabolic diseases. Obesity developed due to a lack of exercise or a disadvantageous diet often leads to NAFLD or NASH, thereby interventions including enhanced physical activity and calorie reduction form the actual gold standard of treatment. To date, patients rarely use these. The project aims to model lifestyle interventions based on the preferences of the NASH patients. METHODS: Based on a systematic review and focus group discussions, two discrete choice experiments (DCE) will be designed, one on aspects influencing successful uptake of lifestyle interventions and one to analyses parameters contributing to long-term participation. An online survey will be used to elicit patient's preferences on program design and on motivational aspects in a cross-sectional design. The recruitment will take place in nine certified specialist practices and hospital outpatient clinics aiming to reach a sample size of n = 500 which is also required for the DCE design. DISCUSSION: The results will provide an overview of the NASH patient's preferences regarding the successful uptake and long-term implementation of lifestyle interventions. Recommendations for optimized lifestyle change programs will be derived and an intervention manual will be developed to facilitate target group-specific inclusion in programs in practice.

[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.

[Advancement of an intermediate level of outpatient palliative care - A Delphi study]. / Weiterentwicklung der "Besonders qualifizierten und koordinierten palliativmedizinischen Versorgung" (BQKPMV) ­ Ergebnisse einer Delphi-Befragung.

INTRODUCTION: In the course of the further development of palliative care in Germany, an agreement on an intermediate level of outpatient palliative care, the so-called BQKPMV (specially qualified and coordinated palliative homecare) was realised in 2017. Family physicians play a central role in the BQKPMV; among other things, they are responsible for the coordination of care. There are indications that barriers exist in the practical implementation of the BQKPMV and that an adjustment may be necessary. This work is part of the Polite project (analysis of the implementation of an intermediate level of outpatient palliative care in the reality of care and recommendations for further development) and aims at building consensus on recommendations for the further development of the BQKPMV. METHODS: Between June and October 2022, an online Delphi survey was conducted among experts for outpatient palliative care from all over Germany (providers, professional associations, funders, science, self-government). The content of the recommendations, which were voted on as part of the Delphi survey, was based on the results of both the first project phase and an expert workshop. Participants rated the extent to which they agree with a) the clarity of the wording, and b) the relevance for the further development of the BQKPMV on a four-point Likert scale. Consensus was assumed when 75% of the participants (rather) agreed to a recommendation with regard to both criteria. If no consensus was reached, the recommendations were adjusted using the free text comments and presented again in the next round. Descriptive analyses were applied. RESULTS: Forty-five experts participated in the first Delphi round, 31 in the second, and 30 in the third round (43% female, average age 55). Consensus was obtained for seven recommendations in round 1, for six in round 2 and for three in round 3. These final 16 recommendations relate to four topics: awareness and implementation of the BQKPMV (6 recommendations), framework conditions of the BQKPMV (3), discrimination of forms of care (5), and cooperation at the interfaces of care (2). DISCUSSION: The Delphi method was used to identify concrete recommendations for the further development of the BQKPMV that are relevant to health care practice. In the final set of recommendations, a particular focus lies on increasing awareness and communicating information about the scope of the health care service, added value and framework conditions of the BQKPMV. CONCLUSION: The results provide an empirically sound basis for the further development of the BQKPMV. They show a concrete need for change and highlight that an optimisation of the BQKPMV is necessary.

[Informal care and occupation: Factors influencing the willingness to provide care]. / Informelle Pflege und Berufstätigkeit: Einflussfaktoren auf die Bereitschaft.

INTRODUCTION: The proportion of people in need of care will continue to rise in Germany. In 2019, the majority of people in need of care was cared for at home. Reconciling caregiving and work poses a heavy burden for many caregivers. Therefore, a monetary compensation for care is being discussed politically in order to facilitate the reconciliation of work and care. The aim of this study was to investigate whether and under which circumstances a sample of the German population is willing to care for a close relative. A particular focus was placed on the willingness to reduce working hours, the importance of the expected period of caregiving, and monetary compensation. METHODS: A primary data collection was conducted in two modes using a questionnaire. A self-completion postal survey was sent out via the AOK Lower Saxony and complemented with an online survey. Data was analysed descriptively and using logistic regression. RESULTS: 543 participants were included. 90% of the sample surveyed was willing to provide care for a close relative, with the majority stating that their willingness depended on various factors: both the health status and the person of the family member needing care had the greatest influence. 34% of the employed respondents were not willing to reduce their working hours, mostly for financial reasons. DISCUSSION AND CONCLUSION: Many older adults want to stay in their homes for as long as possible. Thus, the willingness to provide and take over the role of informal caregiver is and will remain a central pillar of the German care system. Negotiating between informal caregiving and professional activities often creates a substantial burden. For people from lower income households monetary compensation might enhance their willingness to provide informal care. However, in order to increase the willingness to engage in informal care of people from different backgrounds and life stages, flexible approaches are needed that go beyond monetary compensation.

[Prevalence of metabolic syndrome : Analysis based on routine statutory health insurance data]. / Prävalenz des metabolischen Syndroms : Eine Analyse auf Basis von Routinedaten einer gesetzlichen Krankenversicherung.

BACKGROUND: The metabolic syndrome is a decisive risk factor for the manifestation of cardiovascular and metabolic diseases. Metabolic syndrome is the term used to describe the joint presence of specific diseases (obesity, hypertension, type 2 diabetes mellitus, disorders of fat metabolism). A classification is made more difficult by inconsistent definition criteria and a missing International Statistical Classification of Diseases and Related Health Problems (ICD) code. There are no known prevalence studies for Germany based on routine data of the statutory health insurance (GKV). OBJECTIVE: The main aim of the present study was to classify the metabolic syndrome based on routine data of the GKV and to estimate the frequency of diagnosis. In addition, the influence of social factors (school and educational qualifications) was examined for the subgroup of employees with social insurance. MATERIAL AND METHODS: A retrospective routine data analysis was carried out based on routine administrative data from the AOK Lower Saxony (AOKN). In contrast to the established definitions, which use medical parameters, the risk factors are taken into account via four coded diagnoses according to the ICD-10 classification: 1) obesity (E66.0, E66.8, E66.9), 2) type 2 diabetes mellitus (E11), 3) hypertension (I10) and 4) metabolic disorders (E78). A metabolic syndrome is present if at least two of the four diagnoses are present. RESULTS: The prevalence of metabolic syndrome in the population of the AOKN in 2019 was 25.7%. The standardized comparison according to the census population of 2011 showed an increase in the frequency of diagnosis (2009: 21.5% and 2019: 24%). The frequency of diagnosis differed according to school and educational qualifications. CONCLUSION: A classification and analysis of the frequency of the metabolic syndrome based on routine data of the GKV is possible. Between 2009 and 2019 there was a clear increase in the frequency of diagnoses.

Management of Children and Adolescents with Chest Trauma in Pediatric and Non-Pediatric Departments-A Claims Data Analysis.

BACKGROUND: To investigate the management of children and adolescents with isolated and combined chest trauma in pediatric (PD) and non-pediatric departments (non-PD). METHODS: Anonymized claims data were provided by two large German statutory health insurance funds, covering 6.3 million clients over a 10-year period (2010-2019). Data were extracted for patients who had an inpatient ICD diagnosis of section S20-S29 (injuries to the thorax) and were ≤18 years of age. Demographic and clinical data were analyzed. RESULTS: A total of 4064 children and adolescents with chest trauma were included (mean age 12.0 ± 5.0 years; 55% male). In 1928 cases (47.4%), treatment was provided at PD. Patients admitted to PD underwent CT imaging less frequently (8.1%; non-PD: 23.1%; p < 0.0001). Children with a chest drain treated at university/maximum care hospitals (UM) showed more injuries involving multiple body regions compared with non-UM (25.8% vs. 4.5%; p = 0.0061) without a difference in the length of hospital stay. CONCLUSION: Children and adolescents with chest trauma are treated almost equally often in pediatric and adult departments. CT is significantly less frequently used in pediatric departments. Patients with a chest drain treated at a UM showed more concomitant injuries without a longer hospital stay. However, the clinical validity of this finding is questionable.

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.

[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 to provide informal care to older adults in Germany: a discrete choice experiment.

As the German population is continually aging and the majority of older adults still wish to 'age in place', the need for informal care provided by family and friends will correspondingly continue to increase. In addition, while the need for formal (professional) care services is also likely to increase, the supply already does not meet the demand in Germany today. The aim of our study is the elicitation of people's willingness to provide informal care by means of a discrete choice experiment. The self-complete postal survey was disseminated to a random sample of the German general population in Lower Saxony. Data cleansing resulted in a final sample size of 280 participants. A conditional logit and a latent class model were estimated. All attributes were judged as highly relevant by the respondents. The results revealed that an increase in the care hours per day had the greatest negative impact overall on the willingness to provide informal care in our sample. The marginal willingness-to-accept for 1 h of informal care was €14.54 when having to provide informal care for 8 h in reference to 2 h per day. This value is considerably higher than the national minimum wage of €9.82. A three-class latent class model revealed preference heterogeneity. While a monetary compensation is often discussed to increase the willingness and availability of informal care in a country, our results show that this statement could not be generalized within our entire sample.

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.

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.