Dusan Simic

Efficacy of a long-term secondary prevention programme following inpatient cardiovascular rehabilitation on risk and health-related quality of life in a low-education cohort: a randomized controlled study

Objective The aim of this study was to evaluate the efficacy of a long-term secondary prevention programme following inpatient cardiovascular rehabilitation on cardiovascular risk and health-related quality of life in a cohort of middle-aged (≤58 years) coronary artery disease (CAD) patients of low educational level compared to usual care. Design and methods The study included 600 patients with CAD, with 271 in the intervention group (IG) and 329 in the control group (CG). The average age was nearly 50 years in both groups, nearly 90% were male, and 77% had less than 10 years of school education. No significant differences existed between the groups at baseline. Both groups had a 3-week comprehensive cardiovascular inpatient rehabilitation programme at the beginning, the intervention consisted of one further rehabilitation session in hospital after 6 months and regular telephone reminders over a period of 36 months. Analyses were conducted on an intention-to-treat basis. To evaluate the individual risk level, we used the PROCAM score and intima-media thickness (IMT) was measured at the common carotid artery on both sides following international standards. Health-related quality of life was assessed with the EUROQOL and HADS. Results Patients in the IG showed better 3-year risk profile outcomes. The PROCAM score increased by 3.0 (IG) and by 3.7 (CG) from the beginning to after 3 years (p > 0.05 intention-to-treat). The average IMT increased by 0.04 mm in the CG and was reduced by 0.03 mm in the IG (p = 0.014 for the difference). The IG had a significant improvement in health-related quality of life. Mortality, myocardial infarction, and stroke were not different although ‘other cardiac events’ (cardiac surgery or intervention) were significantly lower in the IG than the CG patients (p < 0.05). Conclusion This long-term secondary prevention programme with inpatient rehabilitation at the beginning and telephone reminder for a 3-year period was successful. There were significant differences in health-related quality of life between the IG and CG, despite the relatively positive outcomes in the CG. In this low-education (predominantly male), middle-aged cohort, the positive impact on cardiovascular risk was pronounced in the high-risk subgroup (PROCAM 10-year risk 10–40%).

Risk factors for the prescription of potentially inappropriate medication (PIM) in the elderly

SummaryElderly people are especially prone to suffer adverse drug reactions (ADR). Main reasons for the higher vulnerability of the elderly to ADR are changes in metabolism as i.e. slower renal clearance and polypharmacie which often results from multimorbidity. To prevent ADR careful prescription with special consideration of these aspects is warranted. To help physicians avoid drugs which are especially likely to cause ADR lists have been developed following the consensus method process. For Germany this list is called the PRISCUS list. It was developed based on a literature review, review of international lists such as the American Beers list, and a consensus process based on a Delphi survey. It contains 83 drugs from 18 classes which are classified as potentially inapropriate medication (PIM). It also lists alternatives for each PIM. If a drug is registered with the PRISCUS list this does not mean automatically that it is contraindicated in the elderly but that special caution should be excercised in prescribing the drug, alternatives should be considered and the patient carefully monitored.Prescription rates for PIMs in Germany in the elderly is pretty much stable at around 23% with only a small decline in the past years. Also, more than 5% of all prescriptions in the elderly are PIM prescriptions. Physicians specially trained in geriatrics tend to prescribe less PIMs compared to other physicians.ZusammenfassungUnerwünschte Arzneimittelwirkungen (UAW) sind für rund 5% aller Krankenhauseinweisungen in Deutschland verantwortlich. Insbesondere ältere Menschen sind durch Veränderungen im Metabolismus sowie durch Medikamenteninteraktionen aufgrund von Polypharmazie gefährdet. Um UAWs zu vermeiden, wurde in den USA in den 1990er Jahren im Delphi-Konsensusverfahren eine Liste mit potentiell inadäquaten Medikamenten (PIMs) für ältere Menschen entwickelt, die sog. Beers-Liste. In Deutschland existiert seit Kurzem eine an die deutsche Versorgungsrealität angepasste Liste mit potentiell inadäquaten Medikamenten für ältere Personen, die sogenannte PRISCUS Liste. Sie basiert auf einem systematischen Literaturreview, einem Review international vorhandener Listen, wie z. B. der Beers Liste und einem Delphi-Konsensusprozess. Sie enthält 83 Arzneistoffe aus 18 Arzneistoffklassen welche als potenziell inadäquat für ältere Patienten eingestuft wurden. Die in der PRISCUS Liste aufgeführten Medikamente sind bei älteren Patienten nicht automatisch kontraindiziert. Vielmehr sollte bei ihrer Verschreibung besondere Sorgfalt verwendet, Alternativen geprüft bzw. ein intensives Monitoring durchgeführt werden.In Deutschland erhalten 23% aller älteren Menschen mindestens ein PIM, mit einem unwesentlichen Rückgang in den vergangenen Jahren. Somit sind mehr als 5% aller Verschreibungen bei älteren Menschen PIMs. Ärzte mit einer Fortbildung in Geriatrie tendieren zu einer niedrigeren Verschreibungsrate im Vergleich zu anderen Ärzten.

Risk factors for the prescription of potentially inappropriate medication (PIM) in the elderly : an analysis of sickness fund routine claims data from Germany.

SummaryElderly people are especially prone to suffer adverse drug reactions (ADR). Main reasons for the higher vulnerability of the elderly to ADR are changes in metabolism as i.e. slower renal clearance and polypharmacie which often results from multimorbidity. To prevent ADR careful prescription with special consideration of these aspects is warranted. To help physicians avoid drugs which are especially likely to cause ADR lists have been developed following the consensus method process. For Germany this list is called the PRISCUS list. It was developed based on a literature review, review of international lists such as the American Beers list, and a consensus process based on a Delphi survey. It contains 83 drugs from 18 classes which are classified as potentially inapropriate medication (PIM). It also lists alternatives for each PIM. If a drug is registered with the PRISCUS list this does not mean automatically that it is contraindicated in the elderly but that special caution should be excercised in prescribing the drug, alternatives should be considered and the patient carefully monitored.Prescription rates for PIMs in Germany in the elderly is pretty much stable at around 23% with only a small decline in the past years. Also, more than 5% of all prescriptions in the elderly are PIM prescriptions. Physicians specially trained in geriatrics tend to prescribe less PIMs compared to other physicians.ZusammenfassungUnerwünschte Arzneimittelwirkungen (UAW) sind für rund 5% aller Krankenhauseinweisungen in Deutschland verantwortlich. Insbesondere ältere Menschen sind durch Veränderungen im Metabolismus sowie durch Medikamenteninteraktionen aufgrund von Polypharmazie gefährdet. Um UAWs zu vermeiden, wurde in den USA in den 1990er Jahren im Delphi-Konsensusverfahren eine Liste mit potentiell inadäquaten Medikamenten (PIMs) für ältere Menschen entwickelt, die sog. Beers-Liste. In Deutschland existiert seit Kurzem eine an die deutsche Versorgungsrealität angepasste Liste mit potentiell inadäquaten Medikamenten für ältere Personen, die sogenannte PRISCUS Liste. Sie basiert auf einem systematischen Literaturreview, einem Review international vorhandener Listen, wie z. B. der Beers Liste und einem Delphi-Konsensusprozess. Sie enthält 83 Arzneistoffe aus 18 Arzneistoffklassen welche als potenziell inadäquat für ältere Patienten eingestuft wurden. Die in der PRISCUS Liste aufgeführten Medikamente sind bei älteren Patienten nicht automatisch kontraindiziert. Vielmehr sollte bei ihrer Verschreibung besondere Sorgfalt verwendet, Alternativen geprüft bzw. ein intensives Monitoring durchgeführt werden.In Deutschland erhalten 23% aller älteren Menschen mindestens ein PIM, mit einem unwesentlichen Rückgang in den vergangenen Jahren. Somit sind mehr als 5% aller Verschreibungen bei älteren Menschen PIMs. Ärzte mit einer Fortbildung in Geriatrie tendieren zu einer niedrigeren Verschreibungsrate im Vergleich zu anderen Ärzten.

Differences in price elasticities of demand for health insurance: a systematic review

Many health insurance systems apply managed competition principles to control costs and quality of health care. Besides other factors, managed competition relies on a sufficient price-elastic demand. This paper presents a systematic review of empirical studies on price elasticity of demand for health insurance. The objective was to identify the differing international ranges of price elasticity and to find socio-economic as well as setting-oriented factors that influence price elasticity. Relevant literature for the topic was identified through a two-step identification process including a systematic search in appropriate databases and further searches within the references of the results. A total of 45 studies from countries such as the USA, Germany, the Netherlands, and Switzerland were found. Clear differences in price elasticity by countries were identified. While empirical studies showed a range between −0.2 and −1.0 for optional primary health insurance in the US, higher price elasticities between −0.6 and −4.2 for Germany and around −2 for Switzerland were calculated for mandatory primary health insurance. Dutch studies found price elasticities below −0.5. In consideration of all relevant studies, age and poorer health status were identified to decrease price elasticity. Other socio-economic factors had an unclear impact or too limited evidence. Premium level, range of premiums, homogeneity of benefits/coverage and degree of forced decision were found to have a major influence on price elasticity in their settings. Further influence was found from supplementary insurance and premium-dependent employer contribution.

Price elasticities in the German Statutory Health Insurance market before and after the health care reform of 2009

This paper investigates the change in price elasticity of health insurance choice in Germany after a reform of health insurance contributions. Using a comprehensive data set of all sickness funds between 2004 and 2013, price elasticities are calculated both before and after the reform for the entire market. The general price elasticity is found to be increased more than 4-fold from -0.81 prior to the reform to -3.53 after the reform. By introducing a new kind of health insurance contribution the reform seemingly increased the price elasticity of insured individuals to a more appropriate level under the given market parameters. However, further unintended consequences of the new contribution scheme were massive losses of market share for the more expensive sickness funds and therefore an undivided focus on pricing as the primary competitive element to the detriment of quality.

Erwerbsminderung bei Schizophrenie – eine empirische Analyse der Folgelasten

Objective Quantification of the economic burden for society and the German Statutory Pension Insurance due to early retirement in schizophrenia. Methods Based on empirical data of the German Statutory Pension Insurance, productivity losses were calculated using the human capital approach. Results The total expenditures of the German Statutory Pension Insurance due to pension payments for schizophrenic insurants amounted to € 450 million. Total indirect costs due to morbidity and mortality were estimated at € 2,3 million. Average indirect costs per patient ranged between € 17 000 - 28 000, depending on rates for discounting and inflation. Conclusion Regarding substantial economic consequences, preventive measures and therapeutic procedures should aim to prevent reduction in earning capacity and to promote occupational reintegration of schizophrenic patients.

Kosteneffektive Langzeitnachsorge in der kardiovaskulären Rehabilitation: Fünf-Jahres-Follow-up der SeKoNa-Studie (ISRCTN 15954342)

OBJECTIVE In Germany, the rehabilitative approaches towards patients with coronary artery events are not adequately sustainable despite the high costs. Both sustainability and cost effectiveness are the subjects of this 5-year analysis. METHODS The study was initiated in 2004. One year recruiting phase was followed by 3 years aftercare with telephone as an intervention. This unicentric randomised controlled trial included 600 patients of rehabilitative aftercare (intervention group [IG] 271; control group [CG] 329). Data on (i) mortality, (ii) duration of retirement, (iii) type of retirement and (iv) status of retirement were obtained from the German Retirement Insurance.The analyses for cost-effectiveness are conducted for the intention-to-treat (ITT) approach. The general assessment basis of retirements (partial and full disability pensions) are average values for the year 2013 (year of the measurement). RESULTS On the reporting date (31.12.2013), the values of the IG in part (early) retirement and full (early) retirement are higher than the CG (1.5 and 2.7%, n. s. and 7.4 and 13.4%, respectively n. s.). The same applies for mortality (8.1 and 9.4%, respectively n. s.).The savings through lower pension payments amount to € 1.55 million for the adjusted ITT approach. From this, € 130 080, which represents the cost of the aftercare (intervention), must be deducted. CONCLUSIONS The results of the 5-year follow-up show that a part of pension payment could be reduced. The evidence of cost effectiveness, independently of the methodological approach, is strong. The saving potential is reached by half in both approaches.

Erratum zu: Prävalenz von Demenz bei Versicherten mit und ohne deutsche Staatsangehörigkeit

Erratum zu:Bundesgesundheitsbl 2018 https://doi.org/10.1007/s00103-018-2711-5 In der Originalpublikation wurde leider an drei Stellen die Zuordnung „mit DS“ (mit deutscher Staatsangehörigkeit) und „ohne DS“ (ohne deutsche Staatsangehörigkeit) vertauscht.Im Folgenden sind die entsprechenden Absätze …

Measuring customer preferences in the German statutory health insurance

This paper investigates consumer preferences in the German statutory health insurance market. It further aims to test whether preferences differ by age and health status. Evidence is provided by a discrete choice experiment conducted in 2014 using the six most important attributes in sickness fund competition and ten random generated choice sets per participant. Price is found to be the most important attribute followed by additional benefits, managed care programmes, and distance to nearest branch. Other positive attributes of sickness funds are found to balance out a higher price, which would allow a sickness fund to position itself as high quality. However, significant differences in preferences were found between age and health status group. In particular, compromised health is associated with higher preference for illness-related additional benefits and less distance to the lowest branch, but lower preference for a lower price. Based on these differences, a distinct sickness fund offer could be constructed that would allow passive risk selection.

Risk factors for the prescription of potentially inappropriate medication (PIM) in the elderly@@@Risikofaktoren für die Verschreibung potenziell inadäquater Medikation (PIM) bei älteren Patienten in Deutschland: An analysis of sickness fund routine claims data from Germany@@@Eine Analyse von GKV-Routinedaten an Hand der Kriterien der PRISCUS-Liste

SummaryElderly people are especially prone to suffer adverse drug reactions (ADR). Main reasons for the higher vulnerability of the elderly to ADR are changes in metabolism as i.e. slower renal clearance and polypharmacie which often results from multimorbidity. To prevent ADR careful prescription with special consideration of these aspects is warranted. To help physicians avoid drugs which are especially likely to cause ADR lists have been developed following the consensus method process. For Germany this list is called the PRISCUS list. It was developed based on a literature review, review of international lists such as the American Beers list, and a consensus process based on a Delphi survey. It contains 83 drugs from 18 classes which are classified as potentially inapropriate medication (PIM). It also lists alternatives for each PIM. If a drug is registered with the PRISCUS list this does not mean automatically that it is contraindicated in the elderly but that special caution should be excercised in prescribing the drug, alternatives should be considered and the patient carefully monitored.Prescription rates for PIMs in Germany in the elderly is pretty much stable at around 23% with only a small decline in the past years. Also, more than 5% of all prescriptions in the elderly are PIM prescriptions. Physicians specially trained in geriatrics tend to prescribe less PIMs compared to other physicians.ZusammenfassungUnerwünschte Arzneimittelwirkungen (UAW) sind für rund 5% aller Krankenhauseinweisungen in Deutschland verantwortlich. Insbesondere ältere Menschen sind durch Veränderungen im Metabolismus sowie durch Medikamenteninteraktionen aufgrund von Polypharmazie gefährdet. Um UAWs zu vermeiden, wurde in den USA in den 1990er Jahren im Delphi-Konsensusverfahren eine Liste mit potentiell inadäquaten Medikamenten (PIMs) für ältere Menschen entwickelt, die sog. Beers-Liste. In Deutschland existiert seit Kurzem eine an die deutsche Versorgungsrealität angepasste Liste mit potentiell inadäquaten Medikamenten für ältere Personen, die sogenannte PRISCUS Liste. Sie basiert auf einem systematischen Literaturreview, einem Review international vorhandener Listen, wie z. B. der Beers Liste und einem Delphi-Konsensusprozess. Sie enthält 83 Arzneistoffe aus 18 Arzneistoffklassen welche als potenziell inadäquat für ältere Patienten eingestuft wurden. Die in der PRISCUS Liste aufgeführten Medikamente sind bei älteren Patienten nicht automatisch kontraindiziert. Vielmehr sollte bei ihrer Verschreibung besondere Sorgfalt verwendet, Alternativen geprüft bzw. ein intensives Monitoring durchgeführt werden.In Deutschland erhalten 23% aller älteren Menschen mindestens ein PIM, mit einem unwesentlichen Rückgang in den vergangenen Jahren. Somit sind mehr als 5% aller Verschreibungen bei älteren Menschen PIMs. Ärzte mit einer Fortbildung in Geriatrie tendieren zu einer niedrigeren Verschreibungsrate im Vergleich zu anderen Ärzten.