Effects of organized screening programs on breast cancer screening, incidence, and mortality in Europe.

We link data on regional Organized Screening Programs (OSPs) throughout Europe with survey data and population-based cancer registries to estimate effects of OSPs on breast cancer screening (mammography), incidence, and mortality. Identification is from regional variation in the existence and timing of OSPs, and in their age-eligibility criteria. We estimate that OSPs, on average, increase mammography by 25 percentage points, increase breast cancer incidence by 16% five years after the OSPs implementation, and reduce breast cancer mortality by about 10% ten years after.

Trust and COVID-19 vaccine hesitancy.

This article uses novel data collected on a weekly basis covering more than 35,000 individuals in the EU to analyze the relationship between trust in various dimensions and COVID-19 vaccine hesitancy. We found that trust in science is negatively correlated, while trust in social media and the use of social media as the main source of information are positively associated with vaccine hesitancy. High trust in social media is found among adults aged 65+, financially distressed and unemployed individuals, and hesitancy is largely explained by conspiracy beliefs among them. Finally, we found that the temporary suspension of the AstraZeneca vaccine in March 2021 significantly increased vaccine hesitancy and especially among people with low trust in science, living in rural areas, females, and financially distressed. Our findings suggest that trust is a key determinant of vaccine hesitancy and that pro-vaccine campaigns could be successfully targeted toward groups at high risk of hesitancy.

Emergency department and hospital admissions among people with dementia living at home or in nursing homes: results of the European RightTimePlaceCare project on their frequency, associated factors and costs.

BACKGROUND: Evidence is lacking on the differences between hospitalisation of people with dementia living in nursing homes and those living in the community. The objectives of this study were: 1) to describe the frequency of hospital admission among people with dementia in eight European countries living in nursing homes or in the community, 2) to examine the factors associated with hospitalisation in each setting, and 3) to evaluate the costs associated with it. METHODS: The present study is a secondary data analysis of the RightTimePlaceCare European project. A cross-sectional survey was conducted with data collected from people with dementia living at home or who had been admitted to a nursing home in the last 3 months, as well as from their caregivers. Data on hospital admissions at 3 months, cognitive and functional status, neuropsychiatric symptoms, comorbidity, polypharmacy, caregiver burden, nutritional status, and falls were assessed using validated instruments. Multivariate regression models were used to investigate the factors associated with hospital admission for each setting. Costs were estimated by multiplying quantities of resources used with the unit cost of each resource and inflated to the year 2019. RESULTS: The study sample comprised 1700 people with dementia living in the community and nursing homes. Within 3 months, 13.8 and 18.5% of people living in nursing homes and home care, respectively, experienced ≥1 hospital admission. In the nursing home setting, only polypharmacy was associated with a higher chance of hospital admission, while in the home care setting, unintentional weight loss, polypharmacy, falls, and more severe caregiver burden were associated with hospital admission. Overall, the estimated average costs per person with dementia/year among participants living in a nursing home were lower than those receiving home care. CONCLUSION: Admission to hospital is frequent among people with dementia, especially among those living in the community, and seems to impose a remarkable economic burden. The identification and establishment of an individualised care plan for those people with dementia with polypharmacy in nursing homes, and those with involuntary weight loss, accidental falls, polypharmacy and higher caregiver burden in the home care setting, might help preventing unnecessary hospital admissions.

Sources of regional variation in healthcare utilization in Germany.

We examine sources of regional variation in ambulatory care utilization in Germany. We exploit patient migration to examine which share of regional variation in ambulatory care utilization can be attributed to demand factors and to supply factors, respectively. Based on administrative claim-level data we find that regional variation can be overwhelmingly explained by patient characteristics. Our results contrast with previous results for other countries, and they suggest that institutional rules in Germany successfully constrain supply-side variation in ambulatory care use between German regions for most patients. Furthermore, we find that both demographics and other patient characteristics substantially contribute to regional variation and that causes of regional variation vary when comparing different regions within Germany.

Do hospitals respond to decreasing prices by supplying more services?

Regulated prices are common in markets for medical care. We estimate the effect of changes in regulated reimbursement prices on volume of hospital care based on a reform of hospital financing in Germany. Uniquely, this reform changed the overall level of reimbursement-with increasing prices for some hospitals and decreasing prices for others-without directly affecting the relative prices for different groups of patients or types of treatment. Based on administrative data, we find that hospitals react to increasing prices by decreasing the service supply and to decreasing prices by increasing the service supply. Moreover, we find some evidence that volume changes for hospitals with different price changes are nonlinear. We interpret our findings as evidence for a negative income effect of prices on volume of care.

[Care planning for people with dementia on the margins of care between home care and nursing home: the balance of care approach in the RightTimePlaceCare project in Germany]. / Versorgungsplanung für Menschen mit Demenz am Übergang von der Häuslichkeit ins Pflegeheim: der "Balance-of-Care"-Ansatz im RightTimePlaceCare-Projekt in Deutschland.

BACKGROUND: The balance of care approach is a strategic planning framework that can be used to research the adequacy of care arrangements and the cost implications. It seeks to identify people who are on the margins of care, i. e. whose care and nursing needs could be met in more than one setting, and explores the relative costs of the possible alternatives. This article describes a balance of care application for people with dementia in a transitional phase between home and institutional care in Germany. METHODS: A sequential mixed-methods design was applied that combined empirical data, the decision of healthcare professionals (panels) and cost estimates in a structured way. Data were collected as part of the RightTimePlaceCare project from 235 people with dementia and their caregivers in 2 settings, in nursing homes and domestic care. RESULTS: Based on five key variables, case types of people with dementia with comparable needs were developed. In panels with healthcare professionals there was consensus that people represented by four of these case types could by cared for at home while the reference group of actual study participants was currently being cared for in nursing homes. For these four case types, exemplary home care arrangements were formulated, costs were estimated and compared to institutional care costs. CONCLUSION: There is a potential for home care for a significant group of people with dementia currently admitted to institutional care. Some of the alternative home care arrangements were cost-saving. Despite some limitations, the study demonstrated the utility of the balance of care approach to support the development of empirically based expert recommendations on care provision.

Volume-outcome relationship and minimum volume regulations in the German hospital sector - evidence from nationwide administrative hospital data for the years 2005-2007.

BACKGROUND: This paper analyses the volume-outcome relationship and the effects of minimum volume regulations in the German hospital sector. METHODS: We use a full sample of administrative data from the unselected, complete German hospital population for the years 2005 to 2007. We apply regression methods to analyze the association between volume and hospital quality. We measure hospital quality with a binary variable, which indicates whether the patient has died in hospital. Using simulation techniques we examine the impact of the minimum volume regulations on the accessibility of hospital services. RESULTS: We find a highly significant negative relationship between case volume and mortality for complex interventions at the pancreas and oesophagus as well as for knee replacement. For liver, kidney and stem cell transplantation as well as for CABG we could not find a strong association between volume and quality. Access to hospital care is only moderately affected by minimum volume regulations. CONCLUSION: The effectiveness of minimum volume regulations depends on the type of intervention. Depending on the type of intervention, quality gains can be expected at the cost of slightly decreased access to care.

Costs of Care of Agitation Associated With Dementia in 8 European Countries: Results From the RightTimePlaceCare Study.

OBJECTIVE: To estimate the additional societal costs for people living with dementia (PwD) with agitation in home care (HC) and institutional long-term care (ILTC) settings in 8 European countries. DESIGN: Cross-sectional data from the RightTimePlaceCare cohort. SETTING: HC and ILTC settings from 8 European countries (Estonia, Finland, France, Germany, Netherlands, Spain, Sweden, and England). PARTICIPANTS: A total of 1997 PwD (1217 in HC group and 780 lived in an ILTC) and their caregivers. MAIN OUTCOME MEASURES: Medical care, community care, and informal care were recorded using the Resource Utilization in Dementia (RUD) questionnaire. Agitation was assessed based on the agitation symptoms cluster defined by the presence of agitation and/or irritability and/or disinhibition and/or aberrant motor behavior items of the Neuropsychiatric Inventory Questionnaire (NPI-Q). RESULTS: Total monthly mean cost differences due to agitation were 445€ in the HC setting and 561€ in the ILTC setting (P = .01 and .02, respectively). Informal care costs were the main driver in the HC group (73% of total costs) and institutional care costs were the main driver in the ILTC group (53% of total costs). After adjustments, the log link generalized linear mixed model showed an association between agitation symptoms and an increase of informal care costs by 17% per month in HC setting (P < .05). CONCLUSION: This study found that agitation symptoms have a substantial impact on informal care costs in the community care setting. Future research is needed to evaluate which strategies may be efficient by improving the cost-effectiveness ratio and reducing the burden associated with informal care in the management of agitation in PwD.

Introducing risk adjustment and free health plan choice in employer-based health insurance: Evidence from Germany.

To equalize differences in health plan premiums due to differences in risk pools, the German legislature introduced a simple Risk Adjustment Scheme (RAS) based on age, gender and disability status in 1994. In addition, effective 1996, consumers gained the freedom to choose among hundreds of existing health plans, across employers and state-borders. This paper (a) estimates RAS pass-through rates on premiums, financial reserves, and expenditures and assesses the overall RAS impact on market price dispersion. Moreover, it (b) characterizes health plan switchers and investigates their annual and cumulative switching rates over time. Our main findings are based on representative enrollee panel data linked to administrative RAS and health plan data. We show that sickness funds with bad risk pools and high pre-RAS premiums lowered their total premiums by 42 cents per additional euro allocated by the RAS. Consequently, post-RAS, health plan prices converged but not fully. Because switchers are more likely to be white collar, young and healthy, the new consumer choice resulted in more risk segregation and the amount of money redistributed by the RAS increased over time.

Informal dementia care: Consequences for caregivers' health and health care use in 8 European countries.

BACKGROUND: Informal (dementia) care has economic consequences throughout the health care system. Whilst the health and wellbeing of the care recipient might improve, the health of the caregiver might also change, typically for the worse. Therefore, this analysis aims to examine the association between caregiving intensity and caregivers' health and health care utilization. DATA AND METHODS: The empirical analysis is based on cross-sectional survey data generated by the European Project "RightTimePlaceCare" (RTPC). RTPC was a prospective cohort study conducted in eight European countries (Estonia, Finland, France, Germany, Netherlands, Sweden, Spain and the United Kingdom). The health status of 1029 informal caregivers was assessed by measures of psychological wellbeing (GHQ-12) and self-rated overall health (EQ-VAS). Health care utilization was measured by (i) the self-stated proportion of health care use influenced by caregiving and (ii) the probability of at least one visit to a general practitioner within in the last 30 days. The association between caregiving intensity and caregivers' health and health care utilization was assessed by descriptive analysis and multivariate OLS- and probit-models. RESULTS: A higher amount of informal care was significantly related to negative health outcomes for informal caregivers. On average, one additional hour of informal caregiving per day was associated with a decrease of psychological wellbeing and self-rated overall health by 0.16 and 0.42 index points respectively. Furthermore, one more hour of informal caregiving corresponded with increased self-stated proportion of health care use by 0.56 percentage points. However, the claim of increased health care demand due to caregiving as measured by GP visits was only partly confirmed. CONCLUSION: When evaluating the full economic effect of informal care, the impact of providing care on caregivers' health and health care utilization has to be taken into account.

Costs of care for people with dementia just before and after nursing home placement: primary data from eight European countries.

BACKGROUND: Dementia is the most common cause of functional decline among elderly people and is associated with high costs of national healthcare in European countries. With increasing functional and cognitive decline, it is likely that many people suffering from dementia will receive institutional care in their lifetime. To delay entry to institutional care, many European countries invest in home and community based care services. OBJECTIVES: This study aimed to compare costs for people with dementia (PwD) at risk for institutionalization receiving professional home care (HC) with cost for PwD recently admitted to institutional long-term nursing care (ILTC) in eight European countries. Special emphasis was placed on differences in cost patterns across settings and countries, on the main predictors of costs and on a comprehensive assessment of costs from a societal perspective. METHODS: Interviews using structured questionnaires were conducted with 2,014 people with dementia and their primary informal caregivers living at home or in an ILTC facility. Costs of care were assessed with the resource utilization in dementia instrument. Dementia severity was measured with the standardized mini mental state examination. ADL dependence was assessed using the Katz index, neuropsychiatric symptoms using the neuropsychiatric inventory (NPI) and comorbidities using the Charlson. Descriptive analysis and multivariate regression models were used to estimate mean costs in both settings. A log link generalized linear model assuming gamma distributed costs was applied to identify the most important cost drivers of dementia care. RESULTS: In all countries costs for PwD in the HC setting were significantly lower in comparison to ILTC costs. On average ILTC costs amounted to 4,491 Euro per month and were 1.8 fold higher than HC costs (2,491 Euro). The relation of costs between settings ranged from 2.4 (Sweden) to 1.4 (UK). Costs in the ILTC setting were dominated by nursing home costs (on average 94%). In the HC setting, informal care giving was the most important cost contributor (on average 52%). In all countries costs in the HC setting increased strongly with disease severity. The most important predictor of cost was ADL independence in all countries, except Spain and France where NPI severity was the most important cost driver. A standard deviation increase in ADL independence translated on average into a cost decrease of about 22%. CONCLUSION: Transition into ILTC seems to increase total costs of dementia care from a societal perspective. The prevention of long-term care placement might be cost reducing for European health systems. However, this conclusion depends on the country, on the valuation method for informal caregiving and on the degree of impairment.

Explaining variations in breast cancer screening across European countries.

OBJECTIVE: In this study I aim to explore the statistical causes of country differences in mammography screening among women aged 50-69 years in 13 European countries. I focus on the relative importance of individual (e.g. age, education, etc.) and institutional (e.g. public screening programmes) factors in explaining these differences. DATA AND METHODS: I use individual level data from the first three waves (2004-2006-2009) of the SHARE as well as regional and country level data on institutional factors. The analytical approach is based on multilevel statistical models, which allow me to analyse the contribution of individual and institutional factors in explaining the variation in breast cancer screening across European countries. RESULTS: I find that the standard deviation in screening rates across countries increases slightly from 19.5 to 20.8 per cent after controlling for individual factors. Observed individual factors such as age, education, health status, etc., do not significantly contribute to the explanation of cross-country differences. In contrast, after controlling for observed institutional factors such as the availability of an organised screening programme, the standard deviation drops from 20.86 to 12.92 per cent. These factors can statistically explain about 40 per cent of the between-country differences in screening rates. Moreover, I found that these institutional factors seem to prevent a woman from considering a mammogram "not necessary". CONCLUSION: This analysis provides important insights about patient's attitudes and understanding of benefits of breast cancer prevention and highlights the importance of the availability of an organised screening programme for screening differences across European countries.

Discrimination in waiting times by insurance type and financial soundness of German acute care hospitals.

This paper shows that patients with private health insurance (PHI) are being offered significantly shorter waiting times than patients with statutory health insurance (SHI) in German acute hospital care. This behavior may be driven by the higher expected profitability of PHI relative to SHI holders. Further, we find that hospitals offering private insurees shorter waiting times when compared with SHI holders have a significantly better financial performance than those abstaining from or with less discrimination.

The impact of financial incentives on physician empathy: a study from the perspective of patients with private and statutory health insurance.

OBJECTIVE: We hypothesized that patients' ratings of physician empathy (PE) would be higher among those with private health insurance (PHI, referring to financial incentive) than among patients with statutory health insurance (SHI). METHODS: A postal survey was administered to 710 cancer patients. PE was assessed using the Consultation-and-Relational-Empathy measure. T-tests were conducted to analyse whether PHI and SHI-patients differ in their ratings of PE and variables relating to contact time with the physician. Structural-equation-modelling (SEM) verified mediating effects. RESULTS: PHI-patients rated physician empathy higher. SEM revealed that PHI-status has a strong significant effect on frequency of talking with the physician, which has a strong significant effect (1) on PE and (2) has a moderate effect on patients' perception of medical staff stress, thereby also affecting patients' ratings of PE. CONCLUSIONS: Our findings suggest that PHI-status is one necessary precondition for physicians spending more time with the patient. Spending more time with the PHI-patient has two major effects: it results in a more positive perception of PE and positively impacts PHI-patients' perception of medical staff stress, which in turn, again influences PE. PRACTICAL IMPLICATIONS: Health policy should discuss these findings in terms of equality in receiving high-quality care.

What determines influenza vaccination take-up of elderly Europeans?

We analyse the determinants of influenza vaccination take-up of Europeans above the age of 50 years using the first two waves of the Survey of Health, Ageing, and Retirement (SHARE). Using quality-of-care indicators, special emphasis is put on the measurement and the impact of physician quality. We find that age, health status, lifestyle, labour-force status, and the family structure are important determinants of the decision to get a flu shot. Physician quality, as measured by four indicators, also positively affects the probability of getting a flu shot.

The influence of insurance status on waiting times in German acute care hospitals: an empirical analysis of new data.

BACKGROUND: There is an ongoing debate in Germany about the assumption that patients with private health insurance (PHI) benefit from better access to medical care, including shorter waiting times (Lüngen et al. 2008), compared to patients with statutory health insurance (SHI). PROBLEM: Existing analyses of the determinants for waiting times in Germany are a) based on patient self-reports and b) do not cover the inpatient sector. This paper aims to fill both gaps by (i) generating new primary data and (ii) analyzing waiting times in German hospitals. METHODS: We requested individual appointments from 485 hospitals within an experimental study design, allowing us to analyze the impact of PHI versus SHI on waiting times (Asplin et al. 2005). RESULTS: In German acute care hospitals patients with PHI have significantly shorter waiting times than patients with SHI. CONCLUSION: Discrimination in waiting times by insurance status does occur in the German acute hospital sector. Since there is very little transparency in treatment quality in Germany, we do not know whether discrimination in waiting times leads to discrimination in the quality of treatment. This is an important issue for future research.