Large German Statutory Health Insurance Research Articles

Date of Service Provision and Date of Payment in Claims Data: Dealing with Time Differences

The paper quantifies discrepancies between date of payment and date of service provision when doing analyses in relation to date of death and also in relation to the end of a calendar year. In analyses of this type, time differences between service provision and payment can lead to both under- and overestimation of service use. We aim to capture these phenomena in claims data from different sectors (primary care, medication prescription, prescription of remedies and medical aids, hospital care). We have used pre-structured claims data from a scientific data warehouse of a large German statutory health insurance covering people that died in 2016. We investigated the discrepancies in time between date of service provision and date of payment for different outpatient and inpatient services based on data from 2015 to 2017. An exact date (dd/mm/yyyy) was only available for data covering prescriptions of remedies and medical aids. Data covering medication prescriptions were only exact to the month of payment (mm/yyyy), whereas data covering outpatient physician care were only exact to the quarter of payment (q/yyyy). For both outpatient physician care and hospital care, less than 1% had a payment date after the date of death. The share is considerably higher (28-31%) for prescriptions of remedies and medical aids. The majority of payments occurred within 3 months after death (93% for prescriptions of remedies and medical aids, 67% for primary care services). Less than 1% of outpatient physician care and about 18% of remedies had been paid after the end of the calender year 2015. Here too, the majority of payments were made within the first 3 months of 2016 (100% of prescriptions of remedies and medical aids, 65% of primary care services). Discrepancies in time between date of service provision and date of payment pose a challenge and are a potential source of under-/overestimation of health service utilization when doing analyses in relation to date of death or the end of a calendar year. This needs to be taken into account when requesting the data, but also in preparing and analysing them. The primary recommendation is to ensure that services with a payment date after death are included explicitly.

Pain And The Use Of Gabapentinoids In German Nursing Home Residents - Results From An Analysis Based On Statutory Health Insurance Data.

BackgroundGabapentinoids (gabapentin and pregabalin) are psychoactive medications that are increasingly used for different conditions. Since there is evidence that psychotropic drugs, in general, are often inappropriately prescribed in elderly patients, we aimed to determine frequency and indications of gabapentinoid prescribing for nursing home residents.MethodsWe analyzed data from a large German statutory health insurance database. Included were records from people ≥65 years-of-age, who were admitted to a nursing home between January 2010 and December 2014. We determined the number and proportion of common indications for on- and off-label prescriptions, the most frequent co-medications, and the characteristics of patients and prescribers.ResultsOf 127,277 residents, 9539 (7.5%) received gabapentinoids and 4852 initiated treatment (4.0%; with 66.3% pregabalin). Median age of gabapentinoid initiators was 84 years (78.5% females). In these users, on-label prescribing was found in 57.4%, predominantly for neuropathic pain. Other painful conditions were also chief causes (84.7%) for off-label prescribing. Gabapentinoids were mainly started by general practitioners (64.5%) while pain specialists contributed <2%. Forty-six percent of users received additional opioids and in 27.5% gabapentinoids were prescribed only once.ConclusionGabapentinoids were frequently used in nursing home residents. Regular co-prescribing with opioids and psychotropic drugs might indicate employment to improve pain or assist treatment of conditions that are frequently associated with disruptive behavior such as dementia. However, more research is needed to better understand decision-making regarding gabapentinoid prescribing, especially in view of aggressive marketing, uncertain analgesic effects, problematic side effects, and uncritical use in the elderly.

Patients with somatoform disorders: More frequent attendance and higher utilization in primary Out-of-Hours care?

BackgroundOne significant health policy challenge in many European countries at present is developing strategies to deal with the increase in patient attendance at Out-of-Hours care (OOHC), whether this is at OOHC-Centres in primary care settings or hospital emergency departments (ED). FAs (FAs) presenting in OOHC are a known challenge and previous studies have shown that FAs present more often with psychological problems and psychiatric comorbidities rather than severe physical complaints. FAs may be also contributing to the rising workload in OOHC-Centres in primary care. The aim of this study was to determine attendance frequencies and health problem presentation patterns for patients with and without somatoform disorders (ICD-10 F45 diagnoses) in OOHC-Centres in primary care. Some of these somatoform disorders may have a psychiatric character. Moreover, we wanted to compare health care utilization patterns (pharmacotherapy and hospitalizations) between these patients groups.MethodsRoutine OOHC data from a large German statutory health insurance company in the federal state of Baden-Wuerttemberg were evaluated. 3,813,398 health insured persons were included in the data set from 2014. The data were initially made available for our study group in order to evaluate a comprehensive evaluation programme in German primary care, the “Hausarztzentrierte Versorgung” (HZV), loosely translated as “family doctor coordinated care”. We used the ICD-10 codes F45.0-F45.9 in regular care to identify patients with somatoform disorders and compared their health care utilization patterns (attendance rates, diagnoses, prescriptions, hospitalization rates) in OOHC to patients without somatoform disorders. Attendance rates were calculated with multivariable regression models in order to adjust for age, gender, comorbidities and for participation in the HZV intervention.Results350,528 patients (9.2%) of the 3,813,398 insured persons had an F45-diagnosis. In comparison with the whole study-sample, patients with an F45-diagnosis were on average seven years older (51.7 vs. 44.0 years; p<0,0001) and the percentage of women was significantly higher (70.1% vs 53.3%; p<0,0001). In OOHC, as opposed to normal office hours, the adjusted rate of patients with an F45-diagnosis was 60.6% higher (adjusted for age, gender and co-morbidity) than in the general study-sample. Accordingly, in OOHC, prescriptions for antidepressants, hypnotics, anxiolytics but also opioids were significantly higher than in the general study population i.e. those without F45- diagnoses. However, an F45 diagnosis was only made in 3.45% of all F45 patients seen in OOHC in 2014.ConclusionsPatients with somatoform disorders were more FAs in both regular office hours and in OOHC in primary care settings. In OOHC, they are normally not identified as such because the somatoform illness is secondary to other acutely presenting symptoms such as pain. While it is acknowledged that it is difficult to make an exact diagnosis in this complex group of somatoform disorders in an OOHC setting, it is still important to develop continuing education programmes for medical staff working in OOHC, to support effective recognition and response to the specific needs of this complex patient group.

A cohort study of mammography screening finds that comorbidity measures are insufficient for controlling selection bias

ObjectiveTo examine the potential of claims-based comorbidity measures for controlling selection bias in observational studies of mammography screening. Study Design and SettingBased on claims data of a large German Statutory Health Insurance fund, the single comorbidities considered by the Charlson, Elixhauser, Multipurpose Australian Comorbidity Scoring System, and M3 comorbidity measures were identified for mammography screening participants and nonparticipants. Total death rates within 4 years after screening invitation were compared. Cox proportional hazards regressions were performed unadjusted and adjusted for age, federal state of residence, and comorbidity. ResultsAmong 1,247,919 insured women aged 50–68 years (56.2% participants), 10,311 participants (death rate 375.8/100,000 person-years) and 18,113 nonparticipants (death rate 854.8/100,000 person-years) died from any cause during the follow-up. The unadjusted hazard ratio (HR) for death from any cause for participants vs. nonparticipants was 0.44 (99.9% confidence interval 0.42–0.46). Adjustments attenuated the HR to a maximum of 0.52 (0.50–0.54). ConclusionThe lower short-term all-cause mortality among participants cannot be explained by mammography screening effects and should be interpreted as selection bias. Adjusting for comorbidities only slightly attenuated this bias. Future studies should examine whether claims data include further information that is beneficial to adequately control selection bias in observational studies of mammography screening.

Incidence of pneumonia in nursing home residents in Germany: results of a claims data analysis.

Pneumonia is one of the most common infectious diseases with a high mortality, especially in the elderly population. To date, there have been only a few population-based studies dealing with the incidence of pneumonia in nursing homes (NHs). We conducted a cohort study using data from a large German statutory health insurance fund. Between 2010 and 2014, 127 227 NH residents 65 years and older were analysed. For the calculation of incidences per 100 person-years (PY) and 95% confidence intervals (CIs), we assessed the first diagnosis of pneumonia during the time in NH. We compared the rates between sexes, age groups, care levels, and comorbidities and we performed a multivariate Cox regression analysis. The mean age in the cohort was 84.0 years (74.6% female). A total of 19 183 incident cases led to an overall 5-year-incidence of 11.8 per 100 PY (95% CI 11.7-12.0). The incidence in men was substantially higher than in women. Rates were highest in the first month after NH placement. Our study revealed that the incidence of pneumonia is high in German NH residents and especially in males. Due to demographic changes, pneumonia will likely be increasingly relevant in the health care of the elderly and institutionalised population.

Associations of myeloid hematological diseases of the elderly with osteoporosis: A longitudinal analysis of routine health care data

BackgroundMyelodysplastic Syndromes (MDS) and Acute Myeloid Leukemia (AML) are hematological stem cell diseases mainly of the elderly. Studies indicate a close relationship between bone metabolism and hematopoietic stem cells within the osteo-hematopoietic niche. However, it remains unclear how the disturbed interaction within the osteo-hematopoietic niche affects bone homeostasis in MDS and AML patients. MethodsWe utilized data of a large German statutory health insurance of approximately 2 million persons living in the German federal state of Saxony. Applying case definitions based on diagnosis, procedures and prescriptions we identified prevalent and incident cases with MDS, AML and osteoporosis (OSP) in persons aged ≥60 years. We applied time-to-event analyses to determine the relationship of MDS and AML with OSP with a specific focus on temporality. ResultsAmong all individuals aged ≥60 years (n = 891,095), 2.62% (n = 23,326), 0.14% (n = 1219) and 0.10% (n = 893) were identified with incident OSP, MDS and AML, respectively. The risk of incident OSP was significantly increased in patients with prevalent MDS (sex and age-adjusted model: HR = 1.87, 95%CI: 1.51–2.23). Conversely, patients with prevalent OSP had an increased risk to be diagnosed with incident MDS in the adjusted model (HR = 1.42, 1.19–1.65). For AML no significant associations were observed (adjusted models: inc. OSP with pre. AML; HR = 1.06, 0.65–1.47; inc. AML with pre. OSP; HR = 0.82, 0.41–1.23). DiscussionOur results could indicate a clinically relevant relationship between MDS and OSP in elderly patients, most likely resulting from a disturbed microenvironment within the osteo-hematopoietic niche. An alternative, non-causal explanation that MDS is caused by the medication prescribed for OSP can be partially ruled out, as the association between the two diseases remains if incident OSP cases are considered in patients with pre-existing MDS. These results need to be confirmed within other prospective studies and may allow then for comprehensive strategies for the prevention, early detection and clinical care of patients with MDS and OSP.

Guidelines versus reality: is coronary stent application in three-vessel disease standard or the exception?

The national guidelines for treatment of chronic coronary heart disease (CHD) recommend surgical coronary aortic bypass grafting (CABG) rather than percutaneous coronary intervention (PCI) for patients with a coronary three-vessel disease. The epidemiology of three-vessel CHD and data about the application of different revascularisation strategies raise suspicion of deviation from the guidelines in the treatment of those patients. Claims data containing records of almost 10 million patients of the largest German statutory health insurance fund (Techniker Krankenkasse) were utilised to measure adherence to the guidelines for treatment of groups of patients with one-, two-, and three-vessel CHD, respectively. The impact of age, sex, and comorbidity on each patient's revascularisation procedure was investigated as well. There was no significant difference in the rate of PCI between the groups. In conclusion, the hypothesis that patients with a coronary three-vessel disease are not always treated according to the recommendations of the national guidelines could not be disproved by this study. Finally, the results of this study suggest that the best revascularisation strategy for each patient with two- and three-vessel disease should be decided upon by an interdisciplinary discussion between both cardiologists and cardiac surgeons.

Comparison of therapy persistence for fixed versus free combination antihypertensives: a retrospective cohort study

ObjectivesThe aim of the study was to compare therapy persistence among patients who started with one of three drug regimens: a monotherapy, or combination therapy either as a fixed combination...

Cohort Study on Predictors of Need forNursing Care in Alzheimer's Disease: An Analysis of Healthcare Data.

The individual and societal burden of Alzheimer's disease (AD) is substantial. Identifying relevant factors deteriorating AD and inducing need for nursing care would be of high relevance for healthcare planning. The main objective of this study was the identification of predictors of first assignment of a level of long-term care in AD, used as an approximation for disease progression. In a retrospective cohort study using data from a large German statutory health and long-term care insurance (SHI) company, co-morbidities and drug exposure were evaluated with respect to their predictive value for disease progression (first day the amount of daily nursing care exceeded 1.5 hours). Time to disease progression was modeled using COX-proportional hazard regression with stepwise selection of predictor variables. The risk of nursing care need increased substantially with increasing age. Number of hospitalizations and number of different drugs used were significant indicators for progression, whereas outpatient visits were associated with a reduced need for care. Gender did not indicate significant influence on progression. Malignant neoplasms of ill-defined, secondary, and unspecified sites, malnutrition, renal failure, and injuries increased the risk of need for nursing care most significantly. Among prescribed drugs, significant increased risks were associated with drugs used in diabetes, preparations for treatment of wounds and ulcers, antiseptics and disinfectants, and analgesics. Physical comorbidities are relevant contributors to an increase in need for nursing care. Some medical predicting conditions may be linked to cognition, while others may be directly linked to demand for care. AD patients with these comorbidities should be monitored with special attention, as they may be under an increased risk of care dependency.

P.2.d.009 - A patient with delirium and mania secondary to vitamin B12 deficiency: a case report

To investigate the association between smoking in the older population and the risk of inpatient delirium, which is common and has adverse consequences.Participants (N= 3754) were insurants aged ≥ 55 years of the largest German statutory health insurance company, who enrolled in a 6-year prospective population-based study. Baseline smoking, adjusted for age, sex, depressive symptoms, cognitive impairment and alcohol consumption, was analyzed as risk factor of inpatient delirium. Results are presented as hazard ratios (HRs) and 95% confidence intervals (95% CIs).Three-hundred seventy-three (10.0%) participants were smokers at baseline, 865 (23.0%) were quitters and 2516 (67.0%) were lifelong abstainers. Mean pack-years of smokers and quitters were 23.8 (S.D.= 22.4). Sixty-one (1.6%) received a diagnosis of inpatient delirium. Smokers had an increased risk of delirium compared to abstainers in the fully adjusted model (HR=2.87, 95% CI 1.24–6.66). Quitters and abstainers did not differ (HR=0.79, 95% CI 0.37–1.72). Comparing smokers and quitters, current smoking status (HR=3.22, 95% CI 1.20–8.62) but not pack-years [residual χ2(1)=0.25, P= .874] were associated with inpatient delirium.Only current smoking but not being a quitter and the lifetime amount smoked were associated with inpatient delirium, indicating that acute nicotine withdrawal may represent a relevant pathogenic mechanism.

Quality Indicators for Integrated Care in Patients with Schizophrenia - Results from a Feasibility Study

Objective The study aimed to evaluate the applicability of a set of quality indicators to assess models of integrated care for patients with a diagnosis of schizophrenia. We report first values for these indicators in routine care in Germany. Methods The study is based on a cohort of adult patients with schizophrenia insured by one large German statutory health insurance company, which were assessed two times and gave consent to evaluate their routine claims data. The study tried to use 12 basic and 22 quality indicators from claims data. Results It was possible to estimate most structural indicators using available data, but only half of the quality indicators. This means that while assessment of quality indicators is feasible in general, routine claims data needs to be supplemented by additional (primary) data. Four of the calculated quality indicators had clear targets or red-flag values, which were not met in our cohort in all four indicators. None of the patients had an outpatient mental health related contact within one week (target > 90 %). The readmission rate within 30 days (21 %) was twice as high as the proposed red-flag value of 10 %. Similar figures were seen for antipsychotic polypharmacy (25 %, red-flag value > 10 %) and the proportion of patients with compulsory treatment (15 %) exceeded the red-flag value by 5 %. Conclusion The study shows that it is possible to measure quality indicators, but also demonstrates considerable limitations. There is a need to validate indicators in routine care.

Predicting dementia in primary care patients with a cardiovascular health metric: a prospective population-based study.

BackgroundImproving cardiovascular health possibly decreases the risk of dementia. Primary care practices offer a suitable setting for monitoring and controlling cardiovascular risk factors in the older population. The purpose of the study is to examine the association of a cardiovascular health metric including six behaviors and blood parameters with the risk of dementia in primary care patients.MethodsParticipants (N = 3547) were insurants aged ≥55 of the largest German statutory health insurance company, who were enrolled in a six-year prospective population-based study. Smoking, physical activity, body mass index, blood pressure, total cholesterol, and fasting glucose were assessed by general practitioners at routine examinations. Using recommended cut-offs for each factor, the patients’ cardiovascular health was classified as ideal, moderate, or poor. Behaviors and blood parameters sub-scores, as well as a total score, were calculated. Dementia diagnoses were retrieved from health insurance claims data. Results are presented as hazard ratios (HRs) and 95 % confidence intervals (95 % CIs).ResultsOver the course of the study 296 new cases of dementia occurred. Adjusted for age, sex, and education, current smoking (HR = 1.77, 95 % CI 1.09–2.85), moderate (1.38, 1.05–1.81) or poor (1.81, 1.32–2.47) levels of physical activity, and poor fasting glucose levels (1.43, 1.02–2.02) were associated with an increased risk of dementia. Body mass index, blood pressure, and cholesterol were not associated with dementia. Separate summary scores for behaviors and blood values, as well as a total score showed no association with dementia. Sensitivity analyses with differently defined endpoints led to similar results.ConclusionsDue to complex relationships of body-mass index and blood pressure with dementia individual components cancelled each other out and rendered the sum-scores meaningless for the prediction of dementia.

Epidemiology and use of compression treatment in venous leg ulcers: nationwide claims data analysis in Germany.

Chronic venous diseases are the most common causes of leg ulcers. Compression treatment (CT) is a central component of venous leg ulcer (VLU) therapy along with prevention based on guidelines and clinical evidence. However, large-scale data on the use of CT are rare. In particular, there have not yet been published nationwide data for Germany. We analysed data from a large German statutory health insurance (SHI) on incident VLU between 2010 and 2012. VLUs were identified by ICD-10 diagnoses. The status of active disease was defined by wound-specific treatments. Compression stockings and bandages were identified by SHI medical device codes. The overall estimated incident rate of active VLU of all insured persons was 0·34% from 2010 to 2012. Adapted to the overall German population, n = 229 369 persons nationwide had an incident VLU in 2010-2012. Among all VLU patients, only 40·6% received CT within 1 year, including 83·3% stockings, 31·8% bandages and 3·1% multi-component compression systems. Compression rates showed significant differences by gender and age. Large regional variations were observed. Validity of data is suggested by high concordance with a primary cohort study. Although recommended by guidelines, there is still a marked under-provision of care, with CT in incident VLUs in Germany requiring active measures.

Appendectomy in the pediatric population-a German nationwide cohort analysis.

Meta-analyses indicate advantages of laparoscopic compared to open appendectomy. Nationwide analyses on results of laparoscopic appendectomy are scarce and studies from Germany are not available. This observational cohort study based on a nationwide insurance database was performed to analyze results of pediatric laparoscopic versus open appendectomy in general use. Data were extracted from the largest German statutory health insurance TK (∼9 million clients) in a 3-year period (2010-2012). All patients aged 4-17years with International Classification of Procedures in Medicine (ICPM) code "appendectomy" were included. Logistic regression analysis for the risk of a surgical complication within 180 postoperative days was performed. Appendectomy was performed in 8110 patients (52.6% male; 47.4% female) and conducted laparoscopically in 75.0% of the patients (conversion rate = 1.2%). Laparoscopic compared to open surgery was associated with a shorter length of hospital stay in both uncomplicated and complicated appendicitis. Patients with complicated appendicitis had lower readmission rates for surgical complications after laparoscopic appendectomy and logistic regression analysis confirmed a significantly lower risk of readmission for surgical complications after laparoscopic compared to open operation in adolescents. Pediatric surgeons operated 23.9% and general surgeons 76.1% of patients. Laparoscopy was less frequently used and the conversion rate was significantly higher in pediatric surgical departments. This first nationwide German cohort study confirms that laparoscopic appendectomy is associated with a less complicated postoperative course compared to open appendectomy, particularly in patients with complicated appendicitis. Pediatric surgeons used laparoscopy less frequently compared to general surgeons. Laparoscopic appendectomy should therefore be further promoted in pediatric surgical centers in Germany.

Can Additional Homeopathic Treatment Save Costs? A Retrospective Cost-Analysis Based on 44500 Insured Persons.

ObjectivesThe aim of this study was to compare the health care costs for patients using additional homeopathic treatment (homeopathy group) with the costs for those receiving usual care (control group).MethodsCost data provided by a large German statutory health insurance company were retrospectively analysed from the societal perspective (primary outcome) and from the statutory health insurance perspective. Patients in both groups were matched using a propensity score matching procedure based on socio-demographic variables as well as costs, number of hospital stays and sick leave days in the previous 12 months. Total cumulative costs over 18 months were compared between the groups with an analysis of covariance (adjusted for baseline costs) across diagnoses and for six specific diagnoses (depression, migraine, allergic rhinitis, asthma, atopic dermatitis, and headache).ResultsData from 44,550 patients (67.3% females) were available for analysis. From the societal perspective, total costs after 18 months were higher in the homeopathy group (adj. mean: EUR 7,207.72 [95% CI 7,001.14–7,414.29]) than in the control group (EUR 5,857.56 [5,650.98–6,064.13]; p<0.0001) with the largest differences between groups for productivity loss (homeopathy EUR 3,698.00 [3,586.48–3,809.53] vs. control EUR 3,092.84 [2,981.31–3,204.37]) and outpatient care costs (homeopathy EUR 1,088.25 [1,073.90–1,102.59] vs. control EUR 867.87 [853.52–882.21]). Group differences decreased over time. For all diagnoses, costs were higher in the homeopathy group than in the control group, although this difference was not always statistically significant.ConclusionCompared with usual care, additional homeopathic treatment was associated with significantly higher costs. These analyses did not confirm previously observed cost savings resulting from the use of homeopathy in the health care system.

Medical management, costs, and consequences of Alzheimer’s disease in Germany: an analysis of health claims data

Objective:The main objective of this analysis was to assess the medical and economic differences between patients with and without diagnosed Alzheimer’s Disease (AD). Analysis included co-morbidities, patterns of drug use, and clinical course, as well as the magnitude of these differences attributable to AD.Methods:This evaluation is based on retrospective analyses of anonymized claims data from 2005–2008 provided by a large German Statutory Health Insurance (SHI). Cross-sectional analyses were performed with the following data: demographics, number of hospitalizations, number of in-patient days, number of ambulatory physician visits, number of drugs used, total number of defined daily doses (DDD) of prescribed drugs, and costs. A propensity score model was used to assess costs attributable to AD.Results:Patients with AD caused substantially higher costs from the perspective of a SHI. The differences in long-term care costs explained 70–75% of the total cost difference, with being responsible for about half of the total costs in AD patients. Comparing matched AD patients with controls resulted in 2.2–2.4-fold higher costs in the cross-sectional analysis, €7413–€9207 for AD patients vs €3378–€3850 for controls. The propensity score model resulted in a difference of €3771 attributable to AD. These costs are mainly caused by differences in hospitalization and long-term care costs.Conclusion:This analysis is one of the largest health economic studies of AD in Germany. The limitations of this study include the fact that reported diagnosis couldn’t be validated and disease severity was not taken into account. Despite these methodological constraints, it can be concluded that AD is a substantial cost driver from the SHI payer perspective in Germany.

Smoking increases the risk of delirium for older inpatients: a prospective population-based study

ObjectivesTo investigate the association between smoking in the older population and the risk of inpatient delirium, which is common and has adverse consequences. MethodParticipants (N=3754) were insurants aged ≥55years of the largest German statutory health insurance company, who enrolled in a 6-year prospective population-based study. Baseline smoking, adjusted for age, sex, depressive symptoms, cognitive impairment and alcohol consumption, was analyzed as risk factor of inpatient delirium. Results are presented as hazard ratios (HRs) and 95% confidence intervals (95% CIs). ResultsThree-hundred seventy-three (10.0%) participants were smokers at baseline, 865 (23.0%) were quitters and 2516 (67.0%) were lifelong abstainers. Mean pack-years of smokers and quitters were 23.8 (S.D.=22.4). Sixty-one (1.6%) received a diagnosis of inpatient delirium. Smokers had an increased risk of delirium compared to abstainers in the fully adjusted model (HR=2.87, 95% CI 1.24–6.66). Quitters and abstainers did not differ (HR=0.79, 95% CI 0.37–1.72). Comparing smokers and quitters, current smoking status (HR=3.22, 95% CI 1.20–8.62) but not pack-years [residual χ2(1)=0.25, P=.874] were associated with inpatient delirium. ConclusionOnly current smoking but not being a quitter and the lifetime amount smoked were associated with inpatient delirium, indicating that acute nicotine withdrawal may represent a relevant pathogenic mechanism.

Case management program for patients with chronic heart failure: effectiveness in terms of mortality, hospital admissions and costs.

At 360 000 cases annually, heart failure is the most common main diagnosis in adults in German hospitals. Treating heart failure is expensive. This study tested whether patients in the case management program (CMP) "CorBene--Better Care for Patients With Heart Failure" have a lower mortality rate and lower hospital admission and readmission rates than patients receiving regular management. Routine data from a large German statutory health insurance company were analyzed. After propensity score matching, a total of 1202 patients (intervention group versus control group) were studied in relation to the endpoint "hospital admission and readmission rate" and the variables "annual physician contact rate," "mortality," and "inpatient treatment costs." The intervention group showed a lower rate of hospital admission/readmission (6.2%/18.9% versus 16.6%/36.0%; p<0.0001 / p = 0.041). Mortality rates did not differ significantly (5.0% versus 6.7%; p = 0.217). Analysis of hospital admission data showed no significant differences between the groups in terms of length of hospital stay or costs for heart failure-related treatment per hospital stay. However, the average annual costs for inpatient treatment in the CMP group, at €222.22 per patient, were 67.5% lower than the equivalent costs in the control group (€683.88) (p<0.0001). Fewer patients in the intervention group were admitted and readmitted to hospital, and lower inpatient treatment costs were identified. The physician contact rate was higher than in the control group.

A claims data-based comparison of comorbidity in individuals with and without dementia

BackgroundMultimorbidity is common in advanced age, and is usually associated with negative – yet to some extent preventable – health outcomes. Detecting comorbid conditions is especially difficult in individuals with dementia, as they might not always be able to sufficiently express discomfort. This study compares relevant comorbidity complexes in elderly people with and without dementia, with a particular look at gender- and living environment-specific differences. Moreover, associations between selected comorbid conditions and dementia are reviewed more closely.MethodsUsing 2006 claims data from a large German Statutory Health Insurance fund, 9,139 individuals with dementia and 28,614 age- and gender-matched control subjects aged 65 years and older were identified. A total of 30 comorbidity complexes were defined based on ICD-10 codes. Corresponding prevalence rates were calculated, and the association between a distinct condition and dementia was evaluated via logistic regression in the overall sample as well as in analyses stratified by gender and living environment.ResultsIndividuals with dementia were more likely to be diagnosed with 15 comorbidity complexes, including Parkinson’s, stroke, diabetes, atherosclerosis (supposed dementia risk factors) or fluids and electrolyte disorders, insomnia, incontinence, pneumonia, fractures and injuries (supposed sequelae). In contrast, they were less likely to be diagnosed with 11 other conditions, which included vision and hearing problems, diseases of the musculoskeletal system, lipoprotein disorders and hypertension. In a gender-stratified analysis, the patterns remained largely the same, but a bigger comorbidity gap between cases and control subjects emerged in the male population. Restricting the analysis to community-living individuals did not lead to any substantial changes.ConclusionBesides strengthening the evidence on accepted dementia risk factors and sequelae, the analyses point to particular conditions that are likely to remain untreated or even undiagnosed. This issue seems to affect male and female individuals with dementia to varying degrees. Raising awareness of these conditions is important to possibly preventing comorbidity-associated complications and disease progression in dementia patients. To more comprehensively understand the mutual interactions between dementia and comorbidity, further research on diagnostic and treatment attitudes regarding comorbidity in dementia patients and on their gender-specific health-seeking behaviour seems to be required.

Prevalence, comorbidities and outpatient treatment of anorexia and bulimia nervosa in German children and adolescents

This study aimed at investigating the prevalence, psychiatric comorbidity and outpatient treatment in a sample of German children and adolescents with eating disorders (EDs). Data of a large German statutory health insurance company were analysed and outpatients aged between 10 and 21years with an ED diagnosis in 2009 were identified. Of 248,558 insured children and adolescents, 1,404 patients (79.9% females, mean age: 16.7; SD: 3.3years) matched the inclusion criteria. The large majority of patients with anorexia nervosa (AN) and bulimia nervosa (BN) were females (94.7 and 92.7%), on which we focus in the following analyses. The prevalence in females was 0.28% (AN) and 0.20% (BN). Psychiatric comorbidity was diagnosed in 59.8% (AN) and 64.1% (BN) of patients, respectively. Most patients were treated with psychotherapy (AN: 75.7%, BN: 78.5%), 16.4% (AN) and 20.2% (BN) of our patients received pharmacotherapy with either antidepressants or antipsychotics. 23.5% (AN) and 21.1% (BN) received no treatment with psychotherapy, antidepressants or antipsychotics. This naturalistic study suggests that in young ED outpatients, EDs seem to be underdiagnosed and treatment does not necessarily comply with current guidelines. Therefore, dissemination of state-of-the-art knowledge on diagnosis and treatment in children and adolescents with EDs constitutes an important educational goal.