Major Health Insurance Research Articles

Care transitions programs for older adults-a worldwide need.

In many countries around the world, including the United States, care for vulnerable older people is fragmented, especially at the time of hospital discharge and in the postacute hospital period. Thus, a major challenge for health care systems is to deliver the right type of post-acute care, in the right setting, by the right health care professionals, and for the right length of time. Care transition programs should avoid unnecessary harm related to poor transfer of care between settings, and address common problems as care transitions occur. In the US, Medicare, the major health insurance for older people, is incentivizing value-based over volume-based care, and financially penalizing hospitals for high 30-day readmission rates. In value-based care programs such as Medicare managed care, accountable care organizations, and bundled payments, effective care transitions programs are financially feasible because they have the potential for substantial cost savings from preventing unnecessary emergency department visits, hospital readmissions, other misuse of resources, and costly complications for patients and their families. In this special article, we provide a brief overview of the challenges of care transitions, and elements of care transitions programs developed and tested in the US that could be adapted to the dynamic, heterogeneous health care system in Europe as well as other countries around the world.

Pediatric Chronic Inflammatory Bowel Disease in a German Statutory Health INSURANCE-Incidence Rates From 2009 to 2012.

The incidence of pediatric inflammatory bowel disease (PIBD) varies over time and geographic region. We attempted to generate incidence rates form German health insurance data. We used health care data for 2009-2015 provided by BARMER, a major statutory health insurance company in Germany, insuring approximately 8% of the pediatric population. We applied a Canadian case definition for PIBD based on International Classification of Diseases coding, documentation of (ileo)colonoscopy and the number of PIBD related visits, without external validation for Germany. An internal validation of the specificity of the diagnosis by checking whether the identified incident cases had also prescriptions of PIPD specific drugs was performed. In 2012, 187 pediatric patients were newly diagnosed, accounting for an overall PIBD incidence of 17.41 (95% CI 15.08-20.10) per 100,000 insured children and adolescents from 0 to 17.9 years per year compared with 13.65/100,000 (95% CI 11.63-16.01) in 2009. The age-specific incidence showed a steep increase as of the age of 7 years. The PIBD prevalence in 2012 was 66.29/100,000. In conclusion, the incidence of PIBD in 0 to 17.9-year-olds in Germany with health BARMER health insurance in 2012 is among the highest reported in the literature.

Tooth loss after periodontal treatment—Mining an insurance database

ObjectivesThe aim of this study was to evaluate tooth loss after periodontal treatment. MethodsThe data was collected from the digital database of a major German national health insurance company. Periodontal treatment was the intervention in the treatment group. Kaplan-Meier survival analyses on the patient level with the primary outcome extraction were carried out over four years. A control group without treatment was matched and analysed. Differences were tested with the Log-Rank-test. Extraction incidences were calculated over a matched observation period six years before and four years after treatment for both treatment and control group. ResultsA total of 415,718 periodontal treatments could be traced. Focussing on the outcome “extraction”, the cumulative four-year survival rate was 63.8% after periodontal treatment. The matched control group without periodontal treatment showed a survival rate of 72.5%. These differences were significant (p < 0.0001). The extraction incidence over time was higher in a four-year period after periodontal treatment compared to a six-year period before periodontal treatment. ConclusionsThe outcome of periodontal treatment was acceptable. In about two thirds of the patients, extractions could be completely avoided within a four year period after treatment. Clinical significance statementThis study within the German national health insurance system shows that extractions were not observed after periodontal treatment in the majority of cases. Although periodontitis is a chronic disease, patients suffering from periodontitis have a considerable chance to prevent further tooth loss.

ROLE OF CANCER HISTORY AND GENDER IN MAJOR HEALTH INSURANCE TRANSITIONS: A LONGITUDINAL NATIONALLY REPRESENTATIVE STUDY.

To examine associations by gender between cancer history and major health insurance transitions (gains and losses), and relationships between insurance transitions and access to care. Longitudinal 2008-2013 Medical Expenditure Panel Survey data pooled yielding 2,223 cancer survivors and 50,692 individuals with no cancer history ages 18-63 years upon survey entry, with gender-specific sub-analyses. Access-to-care implications of insurance loss or gain were compared by cancer history and gender. Initially uninsured cancer survivors were significantly more likely to gain insurance coverage than individuals with no cancer history (RR: 1.25; 95% CI: 1.08-1.44). Females in particular were significantly more likely to gain insurance (unmarried RR: 1.16; 95% CI: 1.06-1.28; married RR: 1.09; 95% CI: 1.02-1.16). Significantly higher rates of difficulty accessing needed medical care and prescription medications were reported by those remaining uninsured, those who lost insurance, and women in general. Remaining uninsured, losing insurance, and male gender were associated with lack of a usual source of care. Additional outreach to disadvantaged populations is needed to improve access to affordable insurance and medical care. Future longitudinal studies should assess whether major Affordable Care Act (ACA) provisions enacted after the 2008-2013 study period (or those of ACA's replacement) are addressing these important issues. Loss of health insurance coverage can reduce health care access resulting in poor health outcomes. Cancer survivors may be particularly at risk of insurance coverage gaps due to the long-term chronic disease trajectory. This study is novel in exploring associations between cancer history by gender and health insurance transitions, both gains and losses, in a national non-elderly adult sample.

The TALENT II study: a randomized controlled trial assessing the impact of an individual health management (IHM) on stress reduction

BackgroundUnfavorable lifestyle factors influence the risk of stress disorders. For risk reduction, lifestyle modifications, such as regular physical activity, balanced nutrition and competence in stress management, are a means of choice. The clinical study examines the efficacy of an intensive lifestyle intervention, named Individual Health Management (IHM), − with regard to a reduction of perceived stress. The study is supported by the major regional health insurance, which conducts, in cooperation with the Traditional Chinese Medicine (TCM) hospital, Bad Kötzting, a local model project offering insurants the IHM program as prevention measure against stress and related aftermath.MethodsThe study is a controlled, randomized, monocentric trial with a 12-months intervention phase. Feasible persons are checked according to inclusion and exclusion criteria and assigned to the intervention or control group. Randomization ratio is 1:1. (A) Participants of the intervention group receive the lifestyle program IHM, have access to a web-based health portal (www.viterio.de), and join 3 full-day and 10 two-hour training sessions during the first 3 months. During the remaining 9 months, 4 training sessions and a weekly monitoring are performed with remote assistance. Besides measurement of perceived stress, examinations include burnout symptoms, heart rate variability, laboratory and physical findings. Further patient reported outcomes are documented (e.g. well-being, life satisfaction, severity of mood state, sense of coherence, psycho-vegetative test, cardio-metabolic risk factors, hypertension and diabetes risk. (B) Participants in the control group have access to the intensive lifestyle intervention IHM after a waiting period of at least 6 months. Examinations are conducted at baseline, after 3 and 6 months and in the intervention group additionally after 9 and 12 months. The confirmatory analysis examines the differences between the two groups with regard to changes in perceived stress after 6 months compared to the initial value.DiscussionIn order to enhance adherence, avoid attrition and to insure data quality, different measures will be implemented in the study. Based on a blended learning concept including a web-based e-health tool named VITERIO®, the program promises to achieve sustainable effects in perceived stress.Trial registrationGerman Clinical Trial Register Freiburg (DRKS): DRKS00013040 (date registered 2017–10-1).

Risk Prediction Using Routine Data: Development and Validation of Multivariable Models Predicting 30- and 90-day Mortality after Surgical Treatment of Colorectal Cancer

Quality control, benchmarking, and pay for performance (P4P) require valid indicators and statistical models allowing adjustment for differences in risk profiles of the patient populations of the respective institutions. Using hospital remuneration data for measuring quality and modelling patient risks has been criticized by clinicians. Here we explore the potential of prediction models for 30- and 90-day mortality after colorectal cancer surgery based on routine data. Full census of a major statutory health insurer. Surgical departments throughout the Federal Republic of Germany. 4283 and 4124 insurants with major surgery for treatment of colorectal cancer during 2013 and 2014, respectively. Age, sex, primary and secondary diagnoses as well as tumor locations as recorded in the hospital remuneration data according to §301 SGB V. 30- and 90-day mortality. Elixhauser comorbidities, Charlson conditions, and Charlson scores were generated from the ICD-10 diagnoses. Multivariable prediction models were developed using a penalized logistic regression approach (logistic ridge regression) in a derivation set (patients treated in 2013). Calibration and discrimination of the models were assessed in an internal validation sample (patients treated in 2014) using calibration curves, Brier scores, receiver operating characteristic curves (ROC curves) and the areas under the ROC curves (AUC). 30- and 90-day mortality rates in the learning-sample were 5.7 and 8.4%, respectively. The corresponding values in the validation sample were 5.9% and once more 8.4%. Models based on Elixhauser comorbidities exhibited the highest discriminatory power with AUC values of 0.804 (95% CI: 0.776 -0.832) and 0.805 (95% CI: 0.782-0.828) for 30- and 90-day mortality. The Brier scores for these models were 0.050 (95% CI: 0.044-0.056) and 0.067 (95% CI: 0.060-0.074) and similar to the models based on Charlson conditions. Regardless of the model, low predicted probabilities were well calibrated, while higher predicted values tended to be overestimates. The reasonable results regarding discrimination and calibration notwithstanding, models based on hospital remuneration data may not be helpful for P4P. Routine data do not offer information regarding a wide range of quality indicators more useful than mortality. As an alternative, models based on clinical registries may allow a wider, more valid perspective.

Identifying and describing segments of office workers by activity patterns

PurposeThe purpose of this paper is to identify and characterize patterns of physical activity among office workers employed in largely sedentary occupations at a major health insurer located in the Southeastern USA.Design/methodology/approachThe authors used latent class analysis to identify segments of office workers (n=239) based on their self-reported activities of daily living and exercise behaviors. The authors examined the association of demographic characteristics with segment membership, and differences in accelerometer-measured weekly minutes of light and moderate-vigorous physical activity across segments.FindingsThe authors identified two segments and labeled them “exerciser” and “non-exerciser.” Being female was associated with lower odds of membership in the “exerciser” segment (OR=0.18; 95% CI=0.06, 0.52), while those with at least a bachelor’s degree were more likely to be in the “exerciser” segment (OR=2.12; 95% CI=1.02, 4.40). Mean minutes of moderate-vigorous physical activity per week were greater for the “exerciser” segment than the “non-exerciser” segment.Practical implicationsBased on this sample, the authors found that office workers in sedentary occupations were roughly equally divided and distinguished by their engagement in exercise-type behaviors. The findings underscore the need for innovative workplace programming that enhances activity opportunities particularly for those that are not likely to exercise.Originality/valueA scarcity of research on activity patterns among office workers inhibits development of targeted worksite activity programming. The present research reveals two segments of workers with regard to their activity patterns and suggests ways for worksites to meet their unique needs.

Efficiency and Productivity of Australian Private Health Insurers

Private health insurance plays a central role in the Australia’s healthcare system and improving the efficiency of the industry as a means of lowering premiums to policyholders is an important goal of the existing legislation and regulatory framework. In this paper, we examine the technical and scale efficiency of 30 major health insurance funds during the period 2010-2016 using a two-stage approach. In the first stage, we use data envelopment analysis using both constant and variable returns-to-scale assumptions to measure technical efficiency. In the second stage, we employ the truncated bootstrapped regression framework proposed by Simar and Wilson (2007) to model the estimated efficiency scores on fund-level information and the environmental variables. The results show that government policy and fund factors exert significant effects on fund efficiency. We also analyze the productivity of funds using Malmquist productivity indexes. We find that the while the industry averaged an increase of 1.5% in technical efficiency during the period, this was accompanied by a 4.3% regress in technological change and a 2.8% decrease in productivity growth.

Four-year outcomes of restored posterior tooth surfaces-a massive data analysis.

There is only sparse knowledge concerning the outcomes of treatments with posterior permanent restorations in general practice settings. This study aimed at evaluating outcomes based on a large dataset by using a novel approach on a tooth surface basis. The study based on routine data from a major German national health insurance company. Respective treatment fee codes allowed for tracking the clinical courses on a tooth surface level. The study intervention was defined as the placement of a restoration on an interproximal or occlusal posterior tooth surface regardless of its actual extension and material on which no information was available. All surfaces restored between January 1st, 2010 and December 31st, 2013 were included. Kaplan-Meier survival analyses were conducted to estimate four-year survival. The primary outcome was a restorative re-intervention on the same tooth surface. Separate analyses were performed for the secondary outcomes "crowning" and "extraction". Over ten million interproximal surfaces and eight million occlusal surfaces in nine million posterior teeth had been restored. At 4years, the cumulative survival rates concerning the primary outcome "re-intervention" for mesial surfaces (81.4%; CI 81.3-81.5%) and distal surfaces (81.2%; CI 81.1-81.2%) differed significantly from those for occlusal surfaces (77.0%; CI 76.9-77.0%). Restored surfaces in premolars showed significantly higher survival rates compared to molars. Four-year survival rates for the secondary outcome "crowning" were 91.9% (CI 91.8-91.9%) for mesial surfaces, 92.1% (CI 92.1-92.2%) for distal surfaces and 93.3% (CI 93.2-93.3%) for occlusal surfaces. The respective rates for the secondary outcome "extraction" were 94.5% (CI 94.5-94.5%) for mesial surfaces, 94.8% (CI 94.7-94.8%) for distal surfaces and 95.4% (CI 95.4-95.5%) for occlusal surfaces. Re-interventions after restorative treatment play a significant role in general practice settings. Surface-related survival rates of restorations reveal a need for improvement. This study allows the estimation of the probability of re-interventions after restoring posterior tooth surfaces. It is based on several million cases from general practises under the terms and conditions of a national health insurance system.

Switching gains and health plan price elasticities: 20\xa0years of managed competition reforms in The Netherlands

In this paper we estimate health plan price elasticities and financial switching gains for consumers over a 20-year period in which managed competition was introduced in the Dutch health insurance market. The period is characterized by a major health insurance reform in 2006 to provide health insurers with more incentives and tools to compete, and to provide consumers with a more differentiated choice of products. Prior to the reform, in the period 1995–2005, we find a low number of switchers, between 2 and 4% a year, modest average total switching gains of 2 million euros per year and short-term health plan price elasticities ranging from −0.1 to −0.4. The major reform in 2006 resulted in an all-time high switching rate of 18%, total switching gains of 130 million euros, and a high short-term price elasticity of −5.7. During 2007–2015 switching rates returned to lower levels, between 4 and 8% per year, with total switching gains in the order of 40 million euros per year on average. Total switching gains could have been 10 times higher if all consumers had switched to one of the cheapest plans. We find short-term price elasticities ranging between −0.9 and −2.2. Our estimations suggest substantial consumer inertia throughout the entire period, as we find degrees of choice persistence ranging from about 0.8 to 0.9.

Substance Use Treatment Provider Behavior and Healthcare Reform: Evidence from Massachusetts

We examine the impact of the 2006 Massachusetts healthcare reform on substance use disorder (SUD) treatment facilities' provision of care. We test the impact of the reform on treatment quantity and access. We couple data on the near universe of specialty SUD treatment providers in the USA with a synthetic control method approach. We find little evidence that the reform lead to changes in treatment quantity or access. Reform effects were similar among for-profit and non-profit facilities. In an extension, we show that the reform altered the setting in which treatment is received, the number of offered services, and the number of programs for special populations. These findings may be useful in predicting the implications of major health insurance expansions on the provision of SUD treatment. Copyright © 2017 John Wiley & Sons, Ltd.

The economic burden of diabetes to French national health insurance: a new cost-of-illness method based on a combined medicalized and incremental approach

A better understanding of the economic burden of diabetes constitutes a major public health challenge in order to design new ways to curb diabetes health care expenditure. The aim of this study was to develop a new cost-of-illness method in order to assess the specific and nonspecific costs of diabetes from a public payer perspective. Using medical and administrative data from the major French national health insurance system covering about 59 million individuals in 2012, we identified people with diabetes and then estimated the economic burden of diabetes. Various methods were used: (a) global cost of patients with diabetes, (b) cost of treatment directly related to diabetes (i.e., ‘medicalized approach’), (c) incremental regression-based approach, (d) incremental matched-control approach, and (e) a novel combination of the ‘medicalized approach’ and the ‘incremental matched-control’ approach. We identified 3 million individuals with diabetes (5% of the population). The total expenditure of this population amounted to €19 billion, representing 15% of total expenditure reimbursed to the entire population. Of the total expenditure, €10 billion (52%) was considered to be attributable to diabetes care: €2.3 billion (23% of €10 billion) was directly attributable, and €7.7 billion was attributable to additional reimbursed expenditure indirectly related to diabetes (77%). Inpatient care represented the major part of the expenditure attributable to diabetes care (22%) together with drugs (20%) and medical auxiliaries (15%). Antidiabetic drugs represented an expenditure of about €1.1 billion, accounting for 49% of all diabetes-specific expenditure. This study shows the economic impact of the assumption concerning definition of costs on evaluation of the economic burden of diabetes. The proposed new cost-of-illness method provides specific insight for policy-makers to enhance diabetes management and assess the opportunity costs of diabetes complications’ management programs.

Chronic conditions and use of health care service among German centenarians.

there is limited data comparing conditions and health service use across care settings in centenarians. To improve health service delivery in centenarians, the aim of this study was to compare the proportion of centenarians who have chronic conditions, take medication and use health care services across different care settings. this cohort study uses routine data from a major health insurance company serving Berlin, Germany and the surrounding region, containing almost complete information on health care transactions. The sample comprised all insured individuals aged 100 years and older (N = 1,121). Community-dwelling and institutionalised individuals were included. Charlson comorbidity index was based on 5 years of recordings. Hospital stays, medical specialist visits and medication prescribed in the previous year were analysed. while 6% of the centenarians did not receive any support; 45% received family homecare or homecare by professional care services; 49% were in long-term care. The most frequent conditions were dementia and rheumatic disease/arthritis, with the highest prevalence found among long-term care residents. A total of 97% of the centenarians saw a general practitioner in the previous year. Women were more often in long-term care and less often without any care. Centenarians with long-term care showed higher proportions of comorbidities, greater medication use, and more visits to medical specialists compared with centenarians in other care settings. the higher prevalence of dementia and rheumatic disease/arthritis in long-term care compared to other care settings emphasises the role of these diseases in relation to the loss of physical and cognitive functioning.

MODEL SELECTION AND AVERAGING OF HEALTH COSTS IN EPISODE TREATMENT GROUPS

Episode Treatment Groups (ETGs) classify related services into medically relevant and distinct units describing an episode of care. Proper model selection for those ETG-based costs is essential to adequately price and manage health insurance risks. The optimal claim cost model (or model probabilities) can vary depending on the disease. We compare four potential models (lognormal, gamma, log-skew-t and Lomax) using four different model selection methods (AIC and BIC weights, Random Forest feature classification and Bayesian model averaging) on 320 ETGs. Using the data from a major health insurer, which consists of more than 33 million observations from 9 million claimants, we compare the various methods on both speed and precision, and also examine the wide range of selected models for the different ETGs. Several case studies are provided for illustration. It is found that Random Forest feature selection is computationally efficient and sufficiently accurate, hence being preferred in this large data set. When feasible (on smaller data sets), Bayesian model averaging is preferred because of the posterior model probabilities.

Re-interventions after restoring teeth—Mining an insurance database

ObjectivesThe aim of this study was to examine re-interventions after restorative treatment. MethodsThe data was collected from the digital database of a major German national health insurance company. Only permanent teeth were observed. Placing a permanent restoration other than a crown regardless of involved surfaces and material was the study intervention. The data did not allow for a differentiation between fillings and inlays that were estimated only a very small portion of the restorations. Success was defined as not undergoing any restorative re-intervention with fillings or inlays on the same tooth (primary outcome) and assessed with Kaplan-Meier survival analyses over four years. An additional analysis was conducted rating “crowning” and “extraction” of respective teeth as target events. Differences were tested with the Log-Rank-test. A multivariate Cox regression analyses was carried out. ResultsA total of 17,024,344 restorations placed in 4,825,408 anterior teeth and 9,973,177 posterior teeth could be traced. Focussing on the primary outcome re-intervention, the cumulative four-year success rate was 69.9% for one surface restorations, 74.8% for two surface restorations, 66.6% for three surface restorations and 61.0% for four surface and more extended restorations. These differences were significant (p<0.0001). Focussing on all three target events re-intervention, crowning and extraction, the cumulative four-year success rate was 66.1% for one surface restorations, 67.5% for two surface restorations, 63.0% for three surface restorations and 55.8% for four surface and more extended restorations. The number of restoration surfaces as well as the tooth position remained significant in the multivariate Cox regression. ConclusionsThe sustainability of restorative dental treatment under the terms and conditions of the German national health insurance system shows room for improvement. From a public health perspective, special focus should be laid on primary and secondary prevention to minimize the restorative treatment need. Clinical significance statementThis study shows that re-interventions are observed regularly after restorative treatment. Therefore, preventive and restorative strategies should be revisited and optimised.

Pathway to pharmacist medical provider status in Washington State

ObjectivesTo describe Washington State’s successful legal and legislative efforts to gain pharmacist medical provider status and major medical compensation and to compare those efforts with similar efforts in other states to identify key lessons learned. SummaryWashington State Engrossed Substitute Senate Bill 5557 was enacted in 2015, securing pharmacists as medical providers and requiring compensation under major medical insurance for pharmacists providing health services (Revised Code of Washington 48.43.715). Other states have passed, or attempted to pass, pharmacist provider status bills, but none have achieved both pharmacist medical provider status and mandatory major medical compensation. ConclusionPharmacist medical provider status ideally should include recognition as a medical provider and compensation through major medical health insurance as a clinical decision maker rather than an “incident-to” provider. Both elements should be sought as part of a complete legislative package to ensure sustainable patient access to needed health care services.

Erratum to: Mortality and treatment costs of hospitalized chronic kidney disease patients between the three major health insurance schemes in Thailand.

Thailand has reformed its healthcare to ensure fairness and universality. Previous reports comparing the fairness among the 3 main healthcare schemes, including the Universal Coverage Scheme (UCS), the Civil Servant Medical Benefit Scheme (CSMBS) and the Social Health Insurance (SHI) have been published. They focused mainly on provision of medication for cancers and human immunodeficiency virus infection. Since chronic kidney disease (CKD) patients have a high rate of hospitalization and high risk of death, they also require special care and need more than access to medicine. We, therefore, performed a 1-year, nationwide, evaluation on the clinical outcomes (i.e., mortality rates and complication rates) and treatment costs for hospitalized CKD patients across the 3 main health insurance schemes. All adult in-patient CKD medical expense forms in fiscal 2010 were analyzed. The outcomes focused on were clinical outcomes, access to special care and equipment (especially dialysis), and expenses on CKD patients. Factors influencing mortality rates were evaluated by multiple logistic regression. There were 128,338 CKD patients, accounting for 236,439 admissions. The CSMBS group was older on average, had the most severe co-morbidities, and had the highest hospital charges, while the UCS group had the highest rate of complications. The mortality rates differed among the 3 insurance schemes; the crude odds ratio (OR) for mortality was highest in the CSMBS scheme. After adjustment for biological, economic, and geographic variables, the UCS group had the highest risk of in-hospital death (OR 1.13;95% confidence interval (CI) 1.07–1.20; p < 0.001) while the SHI group had lowest mortality (OR 0.87; 95% CI 0.76–0.99; p = 0.038). The circumscribed healthcare benefits and limited access to specialists and dialysis care in the UCS may account for less favorable comparison with the CSMBS and SHI groups. Significant differences are observed in mortality rates among CKD patients from among the 3 main healthcare schemes. Improvements in equity of care might minimize the differences.

Mortality and treatment costs of hospitalized chronic kidney disease patients between the three major health insurance schemes in Thailand.

BackgroundThailand has reformed its healthcare to ensure fairness and universality. Previous reports comparing the fairness among the 3 main healthcare schemes, including the Universal Coverage Scheme (UCS), the Civil Servant Medical Benefit Scheme (CSMBS) and the Social Health Insurance (SHI) have been published. They focused mainly on provision of medication for cancers and human immunodeficiency virus infection. Since chronic kidney disease (CKD) patients have a high rate of hospitalization and high risk of death, they also require special care and need more than access to medicine. We, therefore, performed a 1-year, nationwide, evaluation on the clinical outcomes (i.e., mortality rates and complication rates) and treatment costs for hospitalized CKD patients across the 3 main health insurance schemes.MethodsAll adult in-patient CKD medical expense forms in fiscal 2010 were analyzed. The outcomes focused on were clinical outcomes, access to special care and equipment (especially dialysis), and expenses on CKD patients. Factors influencing mortality rates were evaluated by multiple logistic regression.ResultsThere were 128,338 CKD patients, accounting for 236,439 admissions. The CSMBS group was older on average, had the most severe co-morbidities, and had the highest hospital charges, while the UCS group had the highest rate of complications. The mortality rates differed among the 3 insurance schemes; the crude odds ratio (OR) for mortality was highest in the CSMBS scheme. After adjustment for biological, economic, and geographic variables, the UCS group had the highest risk of in-hospital death (OR 1.13;95 % confidence interval (CI) 1.07–1.20; p < 0.001) while the SHI group had lowest mortality (OR 0.87; 95 % CI 0.76–0.99; p = 0.038). The circumscribed healthcare benefits and limited access to specialists and dialysis care in the UCS may account for less favorable comparison with the CSMBS and SHI groups.ConclusionsSignificant differences are observed in mortality rates among CKD patients from among the 3 main healthcare schemes. Improvements in equity of care might minimize the differences.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1792-9) contains supplementary material, which is available to authorized users.

Understanding and reducing the prescription of hypnotics and sedatives at the interface of hospital care and general practice: a protocol for a mixed-methods study

IntroductionHypnotics and sedatives, especially benzodiazepines and Z-drugs, are frequently prescribed for longer periods than recommended—in spite of potential risks for patients. Any intervention to improve this situation has to take...

Age-dependency of prescribing patterns of oral anticoagulant drugs in Austria during 2011-2014.

Direct oral anticoagulants (DOACs) have been introduced within the last years as alternative to vitamin K antagonists (VKAs) as oral anticoagulant drugs (OAC). The mean/median age of the patients included in DOAC-investigating trials was 70-72years. The age-pattern of patients to whom DOAC are prescribed in clinical settings is largely unknown. Thus, aim of the study was to assess the age-pattern of patients who received OAC in the years 2011-2014 in Austria. The data analysis refers to the accounting data of the 13 major health insurance funds, covering >97% of the Austrian population. The number of patients who received OAC in 2011-2014 increased by 43% (182,464-261,347). Patients who received DOACs increased nearly fivefold (20,927-96,247), whereas patients who received VKAs increased by only 2% (161,537-165,100). In 2011, the age of patients receiving VKAs was higher than DOACs (72 vs. 68years), whereas in 2014, the age of the patients receiving VKAs was lower than DOACs (73 vs. 74years). The proportion of patients ≥80years receiving VKAs declined from 26 to 21% of all OAC, receiving DOACs increased from 1 to 12%. Among nonagenarians, the proportion of patients receiving VKAs remained 2% (3316-5858), whereas the proportion of patients receiving DOACs increased 40-fold (91-4296). DOACs are prescribed to patients ≥80years, although there are is a lack of data about efficacy and safety. There is an urgent need for data about this patient group. Since a randomized trial is rather unlikely in this specific age group we suggest subgroup analyses about octo-and nonagenarians, in case they have been included in previously completed or still ongoing trials or registries for OAC.