[Differences in chronic back pain and joint disorders among health insurance funds : Results of a cross-sectional study based on the data of the Socioeconomic Panel from 2013]

Indication for spinal surgery: associated factors and regional differences in Germany

BACKGROUND

Rising surgery rates have raised questions about the indications for spinal surgery. The study investigated patient-level and regional factors associated with spinal surgery for patients with spinal diseases.

METHODS

We undertook a cohort study based on routine healthcare data from Germany of 18.4 million patients within 60.9 million episodes of two patient-years before a possible spinal surgery in the time period 2008 to 2016. Using a Poisson model, the effects of a broad range of patient-related (sociodemographic, morbidity, social status), disease- and healthcare-related (physicians' specialty, conservative treatments) and regional variables were analyzed.

RESULTS

There was substantial regional heterogeneity in the occurrence of spinal surgery which decreased by only one quarter when controlling for the various determinants assessed. Previous musculoskeletal and mental health disorders as well as physical therapy were associated with a lower probability of surgery in the fully-adjusted model. Prescriptions for pain medication and consultations of specialists were associated with a higher probability of surgery. However, the specific severity of the vertebral diseases could not be taken into account in the analysis. Furthermore, a substantial proportion of patients with surgery did not receive a consultation with an outpatient specialist (29.5%), preoperative diagnostics (37.0%) or physical therapy (48.3%) before hospital admission.

CONCLUSION

This large study on spinal diseases in Germany highlights important patterns in medical care of spinal diseases and their association with the probability of spinal surgery. However, only a relatively small proportion of the regional heterogeneity in spinal surgery could be explained by the extensive consideration of confounders, which suggests the relevance of other unmeasured factors like physicians' preferences.

Use of Physical Therapy in Patients With Osteoarthritis in Germany: An Analysis of a Linkage of Claims and Survey Data

OBJECTIVE

To examine the utilization of physical therapy (PT) and predictors for its use in individuals with osteoarthritis (OA) while focusing on sociodemographic and disease-related factors.

METHODS

For this cross-sectional study, 657,807 patients (age 30-79 years) diagnosed with hip, knee, or polyarticular OA were identified in claims data. In 2016, a questionnaire including information on disease status, demography, and socioeconomics was sent to a random sample of 8,995 patients stratified by sex, age, and type of diagnosis. Claims data from 2016 included the utilization and type of PT, as well as the prescribing medical specialist, and were linked to questionnaire data. Multivariable logistic regression was conducted to determine variables associated with the use of PT.

RESULTS

In total, 3,564 (40%) patients completed the questionnaire and agreed to linking questionnaire and claims data (69% female, mean age 66.5 years). In 2016, 50% of the study population received PT at least once, and women received it more frequently than men (53% versus 43%). Most PT was prescribed by orthopedists (45%) and general practitioners (32%). Multivariable logistic regression showed that women, higher household income, having both hip and knee OA, lower functional status, higher disease activity, and individuals living in the eastern, southern, and western states of Germany were associated with an increased utilization of PT.

CONCLUSION

Considering current guideline recommendations and that more than one-third of OA patients with high functional impairment and/or pain did not receive PT in the last 12 months, there is considerable potential for improvement. This is especially true for men and individuals with a low income.

Regional Differences in Prescribing Patterns of Metamizole in Germany Based on Data from 70 Million Persons

The non-opioid analgesic metamizole (dipyrone) is commonly used in Germany despite its narrow indications and market withdrawal from several countries. In this study we analyzed prescribing patterns of metamizole focusing on regional differences. The source of data was the “Information system for health care data” which includes data from the statutory health insurance funds for about 70 million Germans. We received aggregated data of individuals with at least one metamizole prescription in 2010 as well as the number of prescribed packages by age, sex, state and district along with the number of insured persons in each stratum. We calculated prescription prevalence stratified by age, sex, state and district. Among 68.4 million insured persons (mean age: 43.6 years; 53.0% female) 5.5 million received at least one metamizole prescription (8.1%, overall 12.2 million packages). Prevalence increased with age, and women received metamizole more often than men. In adults (total prevalence: 9.4%), levels varied between 7.0% (Saxony) and 11.1% (Schleswig-Holstein), whereas on a district level use ranged from 4.3% to 14.3%. In 2010, one of 12 individuals received metamizole at least once. Noticeable were the large regional variations which certainly cannot be explained by patient-related factors.

[Hospitalization of nursing home residents in the last phase of life: an analysis of health insurance data]

Hintergrund

Im internationalen Vergleich versterben Pflegeheimbewohner in Deutschland häufig im Krankenhaus. Daten zu längeren Zeiträumen vor dem Tod und zu regionalen Unterschieden fehlen.

Ziel der Arbeit

Es werden Häufigkeiten von Krankenhausaufenthalten bei Pflegeheimbewohnern in verschiedenen Perioden vor dem Tod analysiert. Zudem werden Unterschiede nach Alter, Geschlecht, Pflegestufe, Demenz und Bundesländern untersucht.

Material und Methoden

Wir verwendeten Daten einer großen Krankenkasse und schlossen Pflegeheimbewohner im Mindestalter von 65 Jahren ein, die zwischen dem 01.01.2010 und dem 31. 12.2014 verstarben. Outcome war mindestens ein Krankenhausaufenthalt nach Heimeintritt in verschiedenen Phasen des letzten Lebensjahres. Vertiefende Analysen wurden für die Zeiträume 0 (entspricht Versterben im Krankenhaus), 28 und 365 Tage vor Tod durchgeführt.

Ergebnisse

Von den insgesamt 67.328 verstorbenen Bewohnern (mittleres Alter: 85,3 Jahre; 69,8 % weiblich), verstarben 29,5 % im Krankenhaus. In den letzten 28 bzw. 365 Tagen vor Tod hatten 51,5 % bzw. 74,3 % mindestens einen Krankenhausaufenthalt. Diese Werte waren in ostdeutschen Bundesländern höher. In allen Zeiträumen wurden Männer häufiger hospitalisiert. Bewohner mit höherer Pflegestufe wurden seltener stationär behandelt, besonders unmittelbar vor dem Tod. Demenz hatte keinen nennenswerten Einfluss auf die Hospitalisierungshäufigkeiten.

Diskussion

Etwa die Hälfte der Pflegeheimbewohner wird im letzten Lebensmonat stationär behandelt, und ein Drittel verstirbt im Krankenhaus, was, international betrachtet, hoch ist. Dass wir keine Unterschiede bei Bewohnern mit und ohne Demenz fanden, widerspricht ebenso internationalen Befunden. Somit besteht erheblicher Handlungsbedarf, die palliative Versorgung von Pflegeheimbewohnern zu optimieren.

Ten-year trends in end-of-life hospitalizations of nursing home residents in Germany, 2006-2015

OBJECTIVES

We investigated trends in end-of-life hospitalizations among nursing home residents (NHR) over 10 years and looked at differences between age groups and sexes as well as the length of terminal hospital stays.

STUDY DESIGN

Retrospective cohort study based on health insurance claims data of the AOK Bremen/Bremerhaven. All NHR aged 65 years or more who died between 2006 and 2015 were included.

MAIN OUTCOME MEASURES

We assessed the proportions of decedents who were in hospital on the day of death and during the last 3, 7, 14 and 30 days of life, stratified by two-year periods. Multiple logistic regressions were conducted to study changes over time, adjusting for covariates.

RESULTS

A total of 10,781 decedents were included (mean age 86.1 years, 72.1 % females). Overall, 29.2 % died in hospital, with a slight decrease from 30.3 % in 2006-2007 to 28.3 % in 2014-2015 (OR 0.86; 95 % CI 0.75-0.98). Of the 3150 terminal hospitalizations, 35.5 % lasted up to 3 days and the mean length of stay decreased from 9.0 (2006-2007) to 7.5 days (2014-2015). When looking at the last 7, 14 and 30 days of life, no changes over time were found. Male sex and younger age were associated with a higher chance of end-of-life hospitalization in almost all analyses.

CONCLUSIONS

End-of-life hospitalizations of NHR are common in Germany. There has been a small decrease during recent years in the proportion of in-hospital deaths, but not of hospitalizations during the last 7, 14 and 30 days of life. This might be explained by shorter durations of hospital stays.

Projected number of people with diagnosed Type 2 diabetes in Germany in 2040

AIMS

To project the number of people with Type 2 diabetes in Germany between 2015 and 2040.

METHODS

Based on data from 65 million insurees of the German statutory health insurance, we projected the age-specific prevalence of diabetes using mathematical relations between prevalence, incidence rate and mortality. We compared several scenarios regarding temporal trends in the incidence and mortality rate. The projected age-specific prevalence was applied to the projected age structure of the German population between 2015 and 2040 to calculate the number of people with Type 2 diabetes.

RESULTS

Application of current age-specific prevalence estimates to the projected age structure in 2040, although ignoring temporal trends in incidence and mortality, yielded an increase in the number of Type 2 diabetes cases from 6.9 million in 2015 to 8.3 million (+21%) in 2040. More realistic scenarios that account for decreasing mortality rates and different trends in the incidence rates project between 10.7 million (+54%) and 12.3 million (+77%) Type 2 diabetes cases in 2040.

CONCLUSIONS

For the first time, we projected the number of future Type 2 diabetes cases for the whole adult population in Germany. The results indicate a relative increase in the number of Type 2 diabetes cases of between 54% and 77% from 2015 to 2040. Temporal trends in the incidence rate are the main drivers of this increase. Simply applying current age-specific prevalence to the future age structure probably underestimates the future number of Type 2 diabetes cases.

Dying in hospital among nursing home residents with and without dementia in Germany

OBJECTIVES

Nursing home residents (NHR) often suffer from dementia. As end-of-life care of NHR with dementia and without might differ, our aim was to investigate patterns of in-hospital deaths in NHR with and without dementia.

DESIGN

Retrospective observational study.

SETTING

German nursing homes.

PARTICIPANTS

Deceased NHR.

MEASUREMENTS

Using data of a large German health insurance fund, we included NHR aged 65+ years who died between January 1, 2010, and December 31, 2014. We assessed proportions of in-hospital deaths stratified by dementia status as well as by age, sex, level of care and length of stay. Multiple logistic regression models were applied to explore the association of these variables with in-hospital death.

RESULTS

Data on 67,328 decedents were included (mean age 85.3 years, 69.8% female), of whom 43.1% suffered from dementia. Overall, 29.5% died in hospital, with similar figures found for those with dementia (29.2%) and those without (29.8%). Differences between NHR with and without dementia were noticeable regarding age and length of stay. In those with dementia, the proportion of in-hospital deaths decreased linearly with age from 37.0%-20.2% (65-74 to 95+ years). These results are supported by the multivariate analyses. The terminal hospital stay was up to 3 days in 32.6%. This length did not differ by dementia status.

CONCLUSIONS

Germany has a high proportion of NHR in-hospital deaths. Surprisingly, we found no differences in these figures between NHR with and without dementia, although predictors for in-hospital death seem to differ between these groups.

Prevalence and treatment of hip and knee osteoarthritis in people aged 60 years or older in Germany: an analysis based on health insurance claims data

Objective

Osteoarthritis (OA) is highly prevalent throughout the world, especially in the elderly population, and is strongly associated with patients’ frailty. However, little is known about the prevalence and treatment of OA in elderly patients in routine clinical care in Germany.

Materials and methods

As a part of Linking Patient-Reported Outcomes with CLAIms Data for Health Services Research in Rheumatology (PROCLAIR), a cross-sectional study using claims data from a large Germany statutory health insurance (BARMER) was conducted. We included people aged 60 years or older and assessed the prevalence of OA of the hip or knee, defined as having outpatient diagnoses (ICD: M16 or M17) in at least two quarters of 2014. The use of conservative treatment, including analgesics and physical therapy, and total joint replacement was studied. Analyses were stratified by age, sex, comorbidities, and level of care dependency defined by social law.

Results

A total of 595,754 patients (mean age: 74.9 years; 69.8% female) were diagnosed with OA (21.8%), with the highest prevalence in those between 80 and 89 years (31.0%) and in females compared to males (23.9% vs 18.3%). Prevalence decreased with increasing level of care dependency from 30.5% in patients with a low level (0/1) to 18.7% in the highest level of care dependency. A total of 63.4% of the patients with OA received analgesics, with higher use with increasing age. Physical therapy was prescribed to 43.1% of the patients, but use decreased with age. In all, 5.3% of the patients received total joint replacement in 2014.

Conclusion

The lower frequency of coded OA with increasing level of care dependency may reflect underdiagnosis, and patients with many other medical problems seem to be at risk for inadequate recognition and treatment of their OA.

Waiting times in primary care depending on insurance scheme in Germany

BACKGROUND

Waiting times for an outpatient appointment in Germany differ between insurants of the statutory and private health insurance schemes, especially for specialised care. The aim of this study was to uncover possible differences in waiting times depending on health insurance scheme and to identify predictors for excessive waiting times in primary care.

METHODS

We used data of the Bertelsmann Foundation Healthcare Monitor, which is a repeated cross sectional study dealing with experiences in health care and attitudes towards current health policy themes. We analysed the surveys conducted from 2011 to 2013, with respondents assigned to their health insurance fund, namely AOK, BARMER GEK, BKK, DAK, TK, IKK, other statutory funds and private funds. The mean waiting times for an appointment and spent in a physician's waiting room, and the satisfaction with waiting times were evaluated with respect to different health insurance funds. A logistic regression model was used to calculate the chance of excessive waiting times with respect to health insurance fund, age, sex, health and socioeconomic status. The ninetieth percentile of the waiting time distribution (10 days) was chosen as the cut-off point between average and excessive.

RESULTS

A total of 5618 respondents were analysed. Mean waiting times in primary care were low (4.0 days) and homogeneous (SHIs: 3.6-4.9 days), even though privately insured respondents reported shorter waiting times for appointments (3.3 days). They also reported a greater satisfaction with waiting times (77.5%) than SHI insurants (64.5%). However, we identified a group (10.1%), who experienced excessive waiting times in primary care. Compared to privately insured respondents, the chance of excessive waiting times was increased for SHI insurants (highest odds ratio for BKK: 2.17; 95%-CI: 1.38-3.42). Additionally, higher age and residence in East Germany were associated with higher chances of waiting times of 10 days or more.

CONCLUSIONS

Primary care in Germany is readily accessible with generally short waiting times. However, barriers in access to the health care system affect a certain part of patients depending on insurance status, age and region of residence. Ways to improve the access need to be studied.

Transition to adult rheumatology care is necessary to maintain DMARD therapy in young people with juvenile idiopathic arthritis

OBJECTIVE

To evaluate the outpatient health service utilisation of young people (YP) with juvenile idiopathic arthritis (JIA) during transfer from paediatric to adult care in Germany.

METHODS

Based on claims data of a large German statutory health fund (BARMER GEK) we conducted a cohort study of 2008-2014. Insured YP with diagnosis of JIA (ICD: M08 or M09.0) in two quarters at the age of 16 and continuous insurance until the age of 20 were included. Outpatient health care utilisation, prescribed antirheumatic drugs and diagnosis maintenance were analysed over four consecutive years for all YP with JIA and for the subgroup on disease-modifying antirheumatic drugs (DMARDs) at the age of 16.

RESULTS

A total of 256 YP with JIA (67% female) were followed during the transfer period, 115 of them received (DMARDs) at the age of 16. At the age of 20, 30% of all 256 YP utilised adult specialty care, 59% still had a JIA diagnosis and 30% were treated with DMARDs. Of those 115 YP, treated with DMARDs at the age of 16 and in need of follow-up, 49% had visited an adult rheumatologist at the age of 20, 75% had a JIA diagnosis and 56% were on DMARDs. Those 49% YP with successful transfer to adult specialty care had a JIA diagnosis in 93% and were treated with DMARDs in 80%. YP, who were only seen by general practitioners, had a JIA diagnosis in 54% and received DMARDs in 27%.

CONCLUSIONS

One in two YP with JIA and a clear need for ongoing follow-up do not utilise adult rheumatologic care. The maintenance of JIA diagnosis and DMARD therapy depend on the utilisation of specialised care services.

Variations over time in the effects of age and sex on hospitalization rates before and after admission to a nursing home: A German cohort study

OBJECTIVES

We examined hospitalization rates for nursing home residents before and after their entry to the home, stratified by sex and age.

STUDY DESIGN

A cohort study was conducted using data from a large health insurance fund on 127,227 residents aged 65 years and over newly admitted to a nursing home between January 1, 2010, and December 31, 2014.

MAIN OUTCOME MEASUREMENTS

We assessed hospitalization rates and proportions being hospitalized in 6-month intervals one year before nursing home placement and up to 5 years thereafter. Multiple Poisson regression models were fitted to calculate relative risks (RR).

RESULTS

Mean age was 84.0 years and 74.6% of the cohort were females. Hospitalization rates were 194.4 per 100 person-years (PY) in the 12 months before entry to the nursing home and 120.0 per 100 PY thereafter. Rates were highest immediately before entry in both sexes. The influence of age was most pronounced in the 12-7 months before entry (RR: 2.37 for 65-74 vs. 95+ years) and declined thereafter (1.29-1.38 up to month 24 after entry). In contrast, the influence of sex was greater after entry (RR: 1.13 for males vs. females in the 12-7 months before and 1.23-1.31 up to month 24 after entry).

CONCLUSIONS

Hospitalization rates of nursing home residents are much higher in Germany than in other Western countries. We have provided some insight into the influence of age and sex on hospitalization rates, which varied over the period (time before and after entry to the nursing home) analyzed. We urgently recommend that future studies on the hospitalization of residents stratify their analyses by sex, age and period.