Claims data analysis of medical specialist utilization among nursing home residents and community-dwelling older people

Older adults preferences for long-term caregivers in China: a discrete choice experiment

OBJECTIVE

Understanding the preferences of old-age adults for their long-term caregivers can improve person-centred health care and the quality of long-term care (LTC). This study examines Chinese older adults' preferences for long-term caregivers.

STUDY DESIGN

This is a cross-sectional study.

METHODS

A national representative discrete choice experiment (DCE) surveyed 2031 adults aged 50-70 across 12 provinces in China. Each DCE scenario described five attributes: type of caregivers, place of LTC, contents of LTC, out-of-pocket payments, and quality of life (QoL). Preferences and the marginal willingness to pay (WTP) were derived using mixed-logit and latent class models.

RESULTS

Older adults displayed higher preferences for long-term caregivers who improve their QoL, incur lower out-of-pocket payments, and provide medical LTC services at home, with the maximum WTP of $22.832 per month. QoL was rated as the most important LTC factor, followed by the place of LTC and the type of caregivers. When the level of QoL improved from poor to good, respondents would be willing to pay $18.375 per month more (95% confidence interval: 16.858 to 20.137), and the uptake rate increased by 76.47%. There was preference heterogeneity among older people with different sex, education, family size, and knowledge of LTC insurance.

CONCLUSION

QoL was the most important factor in older Chinese adults' preference for caregivers. Home care and medical care from formal caregivers was preferred by older adults. We recommend training family caregivers, raising older people's awareness of LTC insurance, and guiding policymakers in developing people-oriented LTC and a multi-level LTC system.

Cost-benefit analysis of the CoCare intervention to improve medical care in long-term care nursing homes: an analysis based on claims data

BACKGROUND

Providing adequate medical care to nursing home residents is challenging. Transfers to emergency departments are frequent, although often avoidable. We conducted the complex CoCare intervention with the aim to optimize nursing staff-physician collaboration to reduce avoidable hospital admissions and ambulance transportations, thereby reducing costs.

METHODS

This prospective, non-randomized study, based on German insurance data, includes residents in nursing homes. Health care cost from a payer perspective and cost-savings of such a complex intervention were investigated. The utilisation of services after implementation of the intervention was compared with services in previous quarters as well as services in the control group. To compensate for remaining differences in resident characteristics between intervention and control group, a propensity score was determined and adjusted for in the regression analyses.

RESULTS

The study population included 1240 residents in the intervention and 7552 in the control group. Total costs of medical services utilisation were reduced by €468.56 (p < 0.001) per resident and quarter in the intervention group. Hospital stays were reduced by 0.08 (p = 0.001) and patient transports by 0.19 (p = 0.049). This led to 1.66 (p < 0.001) avoided hospital days or €621.37 (p < 0.001) in costs-savings of inpatient services. More services were billed by general practitioners in the intervention group, which led to additional costs of €97.89 (p < 0.001).

CONCLUSION

The benefits of our intervention clearly exceed its costs. In the intervention group, avoided hospital admissions led to additional outpatient billing. This indicates that such a multifactorial intervention program can be cost-saving and improve medical care in long-term care homes.

Patient-focused outcomes after initiation of dialysis for ESRD: mortality, hospitalization and functional impairment

BACKGROUND

Outcome data regarding clinically relevant endpoints after starting dialysis for end-stage renal disease (ESRD) are sparse, and early events after starting dialysis are particularly underestimated. The aim of this study was to describe patient-focused outcomes in ESRD patients starting from first dialysis.

METHODS

The data basis for this retrospective observational study were anonymized healthcare data from Germany's largest statutory health insurer. We identified ESRD patients who initiated dialysis in 2017. Deaths, hospitalizations and occurrence of functional impairment within 4 years after starting dialysis were recorded starting from first treatment. Hazard ratios in dialysis patients compared with an age- and sex-matched reference population without dialysis were generated, stratified by age.

RESULTS

The dialysis cohort included 10 328 ESRD patients who started dialysis in 2017. First dialysis was performed in-hospital for 7324 patients (70.9%), and 865 of these died during the same hospitalization. One-year mortality for ESRD patients initiating dialysis was 33.8%. Functional impairment occurred in 27.1% of patients, while 82.8% of patients required hospitalization within 1 year. Hazard ratios of dialysis patients compared with the reference population for mortality, functional impairment and hospitalization at 1-year were 8.6, 4.3 and 6.2. Dialysis patients <50 years were disproportionately affected, with >40-fold increased risk of adverse events compared with their peers.

CONCLUSIONS

The emergence of morbidity and mortality after starting dialysis for ESRD is significant, especially in younger patients. Patients have a right to be informed about the prognosis associated with their condition.

[Impact of CoCare, a Complex Model Intervention, on medical care in long-term care nursing homes in Germany: An overview of the outcome and process evaluation]

INTRODUCTION

More and more people are being cared for in nursing homes these days. Multimorbidity results in frequent but sometimes unnecessary patient transports and hospitalisations. The CoCare intervention was developed as a nursing home-based intervention to improve coordination of medical care and GP and specialist care in long-term care homes. The project aimed to reduce avoidable hospital admissions and ambulance transportation, minimise costs through the resulting better collaboration and improving the quality of life of nursing home residents. This article presents the results of the process and outcome evaluation of the intervention in an integrated way and assesses them against the background of the project objectives.

METHODS

Intervention and data collection started in January 2018 and ended in September 2020. A mixed-methods design was chosen for the evaluation. The (cost) effectiveness of the intervention was tested by a controlled observational study, comparing intervention (IG) and control group (CG). As part of the evaluation of the results, claims data from health insurance funds and a questionnaire-based survey among nursing staff, physicians and nursing home residents were analysed. As part of the process evaluation, subjectively perceived changes in care and implementation difficulties were recorded with the help of focus groups and telephone interviews conducted quarterly.

RESULTS

From the point of view of the health economic evaluation, with a decrease in total costs of € 468.56 (p<.001) per nursing home resident and quarter, an advantageous cost-benefit ratio can be assumed. Thus, the significant increase in outpatient care for nursing home residents goes along with a reduction of ambulance transportation by 0.19 (p=.049) and hospitalization rates by 0.08 (p=.001). In the nursing staff sample, a significant positive difference between IG (T1) and CG was observed with regard to communication and cooperation. In addition, pre-post comparison showed a significant improvement in the nursing staff's assessment of interprofessional cooperation in IG at T1 compared to T0. Both nursing staff and physicians perceived positive changes in care and positively assessed the benefit of the intervention. While practitioners experienced an intensification and improvement of communication and cooperation through the implementation of the CoCare measures, these changes were not perceived by residents.

DISCUSSION

The CoCare intervention lowered the barriers for nursing homes to contact general practitioners, specifically in unclear situations and can thus be seen as an effective tool to reduce potentially avoidable hospital admissions and costs. It is conceivable that results can be transferred to other regions in Germany and to similar care scenarios. It should be examined to what extent approaches of this new form of care can be transferred to standard care and whether adjustments to facilitate the implementation of coordinated care approaches across occupational groups in inpatient care facilities can be proposed within the framework of legislative procedures.

Dental care utilization among home care recipients, nursing home residents, and older adults not in need of long-term care: An observational study based on German insurance claims data

OBJECTIVES

To describe and compare dental care utilization (DCU) among home care recipients, nursing home residents, and older adults not in need of long-term care (LTC).

METHODS

Using nationwide claims data of 8 German statutory health and LTC insurance funds, proportions of home care recipients (n = 68,137), nursing home residents (n = 21,167), and non-LTC dependents (n = 632,205) aged 65+ years with DCU in 2017 were determined and compared. Associations between DCU and individual characteristics and setting were investigated via multivariable logistic regression. The proportions of individuals with DCU one year before and after transition to (a) home care (n = 23,590) and (b) nursing home care (n = 6,583) were compared.

RESULTS

Proportions of home care recipients and nursing home residents with DCU were lower compared to non-LTC dependents (51.9, 53.1, and 73.2%, respectively). Adjusted odds ratios for DCU for home care recipients vs. non-LTC dependents ranged from 0.55 (LTC grades 1/2; 95% confidence interval 0.54-0.56) to 0.38 (LTC grades 4/5; 0.36-0.40). For nursing home residents vs. non-LTC dependents they ranged from 0.69 (3; 0.65-0.72) to 0.67 (4/5; 0.63-0.71). Women, older individuals, those with 0-1 diseases of the Elixhauser comorbidity index, dementia, and those from West Germany were also less likely to utilize dental care than their counterparts. Utilization decreased after transition to home care (60.0 vs. 55.6%) and increased after transition to nursing homes (46.1 vs. 53.5%).

CONCLUSIONS

Nursing home residents and especially home care recipients utilized dental care less frequently than older non-LTC dependents. Organizational barriers for dental care utilization and ways to remove them should be investigated.

CLINICAL SIGNIFICANCE

Dental care utilization among LTC dependents is low and should be improved in both the home care and nursing home setting.

[Epidemiology of long-term care: prevalence and utilisation as well as the healthcare of long-term care recipients in Germany]

According to official statistics from the German long-term care insurance funds, around six out of every one hundred people with statutory health insurance are considered to be in need of long-term care. In this context, "need of long-term care" is defined according to the Eleventh Book of the Social Code (SGB XI) and therefore follows a demand-driven understanding of care, which also aligns with public discourse.In order to meet the increasing number of people in need of long term care - mostly caused by demographic change - with needs-based service structures, knowledge and evaluation of several factors are necessary: the prevalence of care dependency as defined by the SGB XI, the different degrees of severity, and the utilisation of long-term care and healthcare services.In this respect, the article presents findings and calculations based on currently available administrative data from German health and long-term care insurance funds and states its limitations. In terms of an actual epidemiological approach to the topic of long-term care, the aim should be broader reporting based on primary surveys.

Association of potentially inappropriate medications and need for long-term care among older adults: a matched cohort study

BACKGROUND

With an increase in the aging population, the number of older adults who require long-term care (LTC) is growing, enhancing drug-related issues. The reduced capacity of LTC users to precisely utilize medical services poses additional challenges owing to restrictions in daily activities. We compared older adults who required LTC with those who did not require LTC to confirm differences in the use of potentially inappropriate medications (PIMs), frequently used PIMs, and associating factors in Korea.

METHODS

Using the Korean National Health Insurance Service cohort data, adults aged ≥ 65 years as of 2017 who were LTC beneficiaries (at home and LTC facilities) were selected and matched 1:1 with a control group (LTC non-beneficiaries). PIM was defined based on the 2019 American Society of Geriatrics Beers criteria. PIM use and medical resource utilization according to LTC requirements were compared for one year after the index date. After correcting for other confounding variables, differences in the risk of PIM use on person-based according to LTC eligibility were assessed using multivariate logistic regression.

RESULTS

Among the 13,251 older adults requiring LTC in 2017, 9682 were matched with counterparts and included. Among those who received an outpatient prescription including PIM at least once yearly, 83.6 and 87.6% were LTC beneficiaries and LTC non-beneficiaries, respectively (p < 0.001). Using the number of outpatient prescriptions as the baseline, 37.2 and 33.2% were LTC beneficiaries and LTC non-beneficiaries, respectively (p < 0.001). In both groups, elevated PIM use depended on increased medical resource utilization, as shown by increased outpatient visits and medical care institutions visited. Adjusting other influencing factors, the need for LTC did not significantly associated with PIM use (odds ratio [OR] 0.93, 95% confidence interval [CI] 0.84-1.04); the number of drugs consumed (3-4: OR 1.42, 95% CI 1.25-1.61; 5-9: OR 2.24, 95% CI 1.98-2.53; 10 and more: OR 3.72, 95% CI 3.03-4.55; reference group: 2 and less), frequency of visits (7-15: OR 1.95, 95% CI 1.71-2.23; 16-26: OR 3.51, 95% CI 3.02-4.07; 27-42: OR 5.84, 95% CI 4.84-7.05; 43 and more: OR 10.30, 95% CI 8.15-13.01; reference group: 6 and less), and visits to multiple medical care institutions (3-4: OR 1.96, 95% CI 1.76-2.19; 5 and more: OR 3.21, 95% CI 2.76-3.73; reference group: 2 and less) emerged as primary influencing factors. PIMs mainly prescribed included first-generation antihistamines, benzodiazepines, and Z-drugs in both groups; quetiapine ranked second-highest among LTC beneficiaries.

CONCLUSIONS

The LTC demand did not significantly associated with PIM utilization. However, the number of drugs consumed, and the pattern of medical resource use were important factors, regardless of LTC requirements. This highlights the need to implement comprehensive drug management focusing on patients receiving polypharmacy and visiting multiple care institutions, regardless of LTC needs.

COVID-19 related decline in cancer screenings most pronounced for elderly patients and women in Germany: a claims data analysis

Purpose

This study aimed to analyze the utilization of cancer screenings in Germany before and during the COVID-19 pandemic in 2020. The objective of the analysis was to identify the population at particular risk and to derive recommendations for the future use of resources to prevent long-term deteriorations in health outcomes.

Methods

The analysis was conducted based on claims data of all preventive health services for 15,833,662 patients from the largest statutory health insurance fund in Germany. Utilization of general female cancer screening, general male cancer screening, general health checkup, colorectal cancer screening stool test, colorectal cancer screening consultation, colonoscopy, skin cancer screening, and mammography screening was compared before (2017–2019) and during (2020) the pandemic.

Results

Data of a total of 42,046,078 observed screenings showed that the utilization of the individual screenings developed differently, but that the overall utilization decreased significantly by 21.46% during the COVID-19 pandemic (p < 0.001). At the same time, no catch-up effects were detected for total screenings throughout the entire year 2020. The highest decline in screenings was found for the elderly (p < 0.001) and women (p < 0.001).

Conclusion

Because the elderly are at higher risk for cancer, the omission of early detection might lead to higher treatment costs, reduced quality of life, and higher mortality. In addition, women's medical care in particular has been negatively affected, for example, by the interruption of mammography screenings and the lack of catch-up effects. Therefore, resources must be targeted to reduce burdens on health outcomes and public health in the long term.

Contacts with general practitioners, dentists, and medical specialists among nursing home residents: a cross-sectional study in 44 German nursing homes

Background

Nursing home residents have high medical care needs. Their medical care utilization is, however, lower compared to community-dwelling elderly and varies widely among nursing homes. This study quantified the utilization of general practitioners (GPs), dentists, and medical specialists among nursing homes and residents, and investigated whether dentist utilization is associated with individual and nursing home characteristics.

Methods

Forty-four nursing homes invited 2124 residents to participate in a cross-sectional study. For 10 medical specialties, data on contacts in nursing homes, practices, and by telephone in the last 12 months were assessed at individual and nursing home level. The proportion of nursing homes and residents with any form of contact, and the median number and interquartile range (IQR) of contacts among individuals with contact were determined. Using multilevel logistic regression, associations between the probability of individual dental care utilization and sex, age, LTC grade, years of residence, sponsorship, number of nursing home beds, and transport and medical escort services for consultations at a practice were investigated.

Results

The proportion of nursing homes with any form of contact with physicians ranged from 100% for GPs, dentists, and urologists to 76.7% for gynecologists and orthopedists. Among the nursing homes, 442 residents participated (20.8% response). The proportion of residents with any contact varied from 97.8% for GPs, 38.5% for neurologists/psychiatrists, and 32.3% for dentists to 3.0% for gynecologists. Only for GPs, neurologists/psychiatrists, dentists, otorhinolaryngologists, urologists, and dermatologists, the proportion was higher for nursing home contacts than for practice and telephone contacts. Among residents with any contact, the median number of contacts was highest for GPs (11.0 [IQR 7.0-16.0]), urologists (4.0 [IQR 2.0-7.0]), and neurologists/psychiatrists (3.0 [IQR 2.0-5.0]). Dentist utilization varied widely among nursing homes (median odds ratio 2.5) and was associated with higher age.

Conclusions

Almost all residents had regular contact to GPs, but only one third had contact with dentists. Lower proportions with contact were found for medical specialists, except for neurologists/psychiatrists. Reasons for the large variations in dental care utilization among nursing homes should be identified.

Trial registration

DRKS00012383 [2017/12/06].

[Medical specialist undertreatment in nursing home residents-Prevalence and extrapolation]

Hintergrund

Bisherige Studien deuten darauf hin, dass Pflegebedürftige eine geringere fachärztliche Versorgung aufweisen als Nichtpflegebedürftige. Insbesondere im stationären Setting ist die fachärztliche Versorgungsintensität gering. Aus den bestehenden quantitativen Versorgungsunterschieden lässt sich bislang jedoch nicht ableiten, inwieweit von einer Unterversorgung bei Pflegebedürftigen ausgegangen werden muss. Für die Versorgungsbereiche Sehfähigkeit, Hörfähigkeit, Mundgesundheit und Parkinson-Syndrom wird geprüft, inwieweit Heimbewohner fachärztlich unterversorgt sind.

Material und Methoden

In 44 Pflegeheimen in Bremen und Niedersachsen wurde der Gesundheitszustand von 409 Pflegebedürftigen mittels standardisierter Assessments und Befragungen erhoben; zusätzlich wurden Diagnosen und die medizinische Versorgung aus der Pflegedokumentation ausgewertet. Ärzteteams beurteilten auf dieser Grundlage für jeden Pflegebedürftigen, inwieweit eine bedarfsgerechte fachärztliche Versorgung vorlag oder nicht.

Ergebnisse

Gemäß ärztlichem Urteil zeigt sich bei 45 % (Sehfähigkeit), 19 % (Parkinson-Syndrom), 16 % (Mundgesundheit) und 15 % (Hörfähigkeit) der Bewohner mit entsprechendem Versorgungsbedarf eine fachärztliche Unterversorgung. Bei 27 % aller Bewohner zeigt sich in mindestens einem der 4 Versorgungsbereiche eine fachärztliche Unterversorgung. Hochgerechnet entspricht dies bis zu 205.000 fachärztlich unterversorgten Pflegeheimbewohnern in Deutschland.

Diskussion

Die Studie liefert für ausgewählte Versorgungsbereiche die ersten empirischen Belege über das Ausmaß fachärztlicher Unterversorgung von Pflegeheimbewohnern. Daher erscheint es notwendig, entsprechende Interventionen zur Reduktion der Unterversorgung zu entwickeln und zu erproben.

Zusatzmaterial online

Die Online-Version dieses Beitrags (10.1007/s00391-021-01865-z) enthält eine detaillierte Erklärung zur Methodik der Datenerhebung sowie 6 Tabellen mit weiterführenden Analysen. Beitrag und Zusatzmaterial stehen Ihnen im elektronischen Volltextarchiv auf https://www.springermedizin.de/link/10.1007/10.1007/s0391-021-01865-z zur Verfügung. Sie finden das Video am Beitragsende unter „Supplementary Material“.