Background Fractures are a major health problem in aging societies. Preventive approaches combining bone health and fall prevention are rare. The osteoporotic fracture prevention program in rural areas (OFRA) is a health care fund-driven program for older people in randomly selected districts in Germany. The components of the program were falls prevention exercise classes, examination of bone health by a dual-energy X-ray absorptiometry (DXA) scan, and a consultation about “safety in the living environment.” The aim of this study was to evaluate this complex preventive intervention in a routine health care setting. Methods This cluster-randomized trial was performed from October 2015 to October 2018 and took place in 186 administrative districts in five federal states, 47 districts served as intervention districts, and 139, as controls. Within these districts, we included (a) all community-living women and men aged 70–85 years with prior fragility fractures and (b) all community-living women aged 75–80 years. The analysis used routine data collected by a health insurance company. The primary endpoint was all fragility fractures combined. Fracture types, mortality, and nursing home admission were explorative endpoints. Cox frailty models were used for comparative analyses with a median follow-up time of 365 days (interquartile range: 0 days). Results Nine thousand four hundred eight individuals were approached to participate in one of the program components, 27,318 individuals served as controls. The mean age was 78.7 years. Of those approached to participate, nearly 30% joined the exercise classes. DXA measurement was reimbursed for 13.6%, and 51.8% received advice about measures to increase “safety in the living environment.” The incidence of fragility fractures did not differ between the intervention and the control group (HR 0.94; 95% CI 0.80–1.11). However, femoral fractures, the most frequent fracture type, were reduced in the intervention group (HR 0.76; 95% CI 0.59–0.99). Mortality and nursing home admission did not differ between the intervention and the control group. Conclusions A comprehensive fracture prevention program for older people living in rural areas was implemented. The program did not affect the primary endpoint of all fragility fractures combined. It has to be considered that we used a modified intention to treat approach based on geographic randomization and information about endpoints relied exclusively on routine data of the health care insurance. Trial registration German Clinical Trials Register DRKS-ID: 00009000

Background In Germany, geriatricians deliver acute geriatric care during an acute hospital stay and subacute rehabilitation after transfer to a rehabilitation clinic. However, the proportion of patients who receive acute geriatric care (AGC) or are transferred to subacute rehabilitation (TSR) differs considerably between hospitals. The aim of this study was to analyse the association between the two geriatric treatment systems and care home admission or mortality in patients following hip fracture. Methods Health insurance claims data were used to identify the rate of AGC per hospital and the rate of TSR per hospital following hip fracture surgery in patients aged ≥ 80 years. Outcomes were cumulative admission to a care home and cumulative mortality within 6 months after hospital admission. Results Data from 23,046 hip fracture patients from 561 hospitals were analysed. The rate of AGC was not associated with care home admission. However, compared to high rates of AGC medium rates or no AGC were associated with increased death rates by 12% or 20%, respectively. Treatment in hospitals with low rates of TSR was associated with a 8% higher risk of care home admission and a 10% increased risk of death compared to treatment in hospitals with high rates of TSR. Conclusions Our study suggests potential effects of geriatric treatment: reduction of mortality in hospitals with high rates of AGC or reduction of care home admission and mortality in hospitals with high rates of TSR.

ZusammenfassungIm vorliegenden Beitrag wird die veränderte Inanspruchnahme des psychiatrischen Versorgungsangebots während der Covid-19-Pandemie im Jahr 2020 im Vergleich zum Vorjahr analysiert. Betrachtet werden die Entwicklung der Krankenhausfälle im Rahmen von voll- und teilstationären Versorgungsleistungen sowie die Auslastung in Hochschulambulanzen und psychiatrischen Institutsambulanzen während der Lockdown-Maßnahmen über verschiedene Diagnosegruppen hinweg. Ein zweiter Fokus des Beitrags liegt auf der Entwicklung der Verschreibungen von Psychopharmaka während der Pandemie. Die Analysen beruhen auf einer Stichprobe von Versicherten der AOK bzw. auf Daten des Wissenschaftlichen Instituts der AOK (WIdO) aus den Jahren 2019 und 2020. Wichtige Ergebnisse zeigen einen starken Rückgang der Fallzahlen in allen psychiatrischen Versorgungsbereichen, der insbesondere während des ersten Lockdowns im Frühjahr 2020 stärker ausgeprägt war. Im Hinblick auf die Verschreibung von Psychopharmaka fand sich keine absolute Zunahme, aber eine Häufung von Verordnungen im Frühjahr sowie Herbst 2020. Die vorgelegten Auswertungen zeigen die deutlichen Auswirkungen der Covid-19-Pandemie auf psychiatrische Versorgungsleistungen.

Purpose Comparisons of ureteroscopy (URS), extracorporeal shockwave lithotripsy (SWL) and percutaneous nephrolithotomy (PCNL) for urolithiasis considering long-term follow-up are rare. We aimed to analyze re-intervention rates, costs and sick leave days of URS, SWL and PCNL patients within 7 years. Methods This retrospective cohort study was based on German health insurance claims data. We included 54,609 urolithiasis patients incidentally treated in 2008–2010. We investigated time to re-intervention, number of sick leave days and healthcare costs. We applied negative binomial, extended Cox regression and gamma models. Results 54% were incidentally treated with URS, 40% with SWL and 6% with PCNL. 15% of URS, 26% of SWL and 23% of PCNL patients were re-treated within 7 years. Time to re-intervention was significantly lower for PCNL (955 days) and SWL (937 days) than URS (1078 days) patients. Costs for incident treatment were significantly higher for PCNL (2760€) and lower for SWL (1342€) than URS (1334€) patients. Yet, total costs including re-interventions were significantly higher for PCNL (5783€) and SWL (3240€) than URS (2979€) patients. Total number of sick leave days was increased for PCNL (13.0 days) and SWL (10.1 days) compared to URS (6.8 days) patients. Conclusion This study describes outcomes after use of different intervention options for urolithiasis. URS patients showed longest time free of re-interventions and lowest number of sick leave days. Although SWL patients initially had lower costs, URS patients had lower costs in the long run. PCNL patients showed high costs and sick leave days.

Background Fragility fractures are one of the leading causes of disability in older adults. Yet, evidence for effectiveness and cost-effectiveness of preventive approaches combining bone health and fall prevention is rare. Objective To conduct a health-economic evaluation of the German osteoporotic fracture prevention program in rural areas (OFRA). Design Secondary cluster–randomized intervention study based on routine data. Participants All districts in five federal states in Germany were cluster-randomized as intervention or control districts. OFRA was offered to community-living (a) women aged 75–79 years or (b) women and men aged 70–84 years with a prior fragility fracture in the intervention districts. Individuals who meet these criteria in the control districts were assigned to the control group. Intervention OFRA comprised mobility and falls prevention classes, examination of bone health by bone density measurement, and consultation on safety in the home living environment. Main Measures We measured health-care costs and effectiveness in terms of time to fragility fracture or death within 1 year after initial contact, based on health insurance claims data. Implementation costs were recorded by the intervention performers. We calculated an incremental cost-effectiveness ratio (ICER) and employed the net-benefit approach to construct a cost-effectiveness acceptability curve (CEAC). Key Results There were 9408 individuals in the intervention group and 27,318 in the control group. Mean time to fragility fracture or death (difference: 0.82 days) and health-care costs (difference: 111.73€, p < .01) were reduced, but mean intervention costs (difference: 260.10€) increased total costs (difference: 148.37€, p < .001) in the intervention group. The ICER per fracture-free year of survival was 66,094.63€. The CEAC showed no acceptable probability of cost-effectiveness at a reasonable willingness to pay. Conclusion OFRA showed reduced rates of fragility fractures, but had high implementation costs, resulting in an unfavorable ICER. The cost-effectiveness of OFRA may improve with a longer follow-up.

IntroductionOlder people in need of home care are at risk of declining oral health as their visits to dentists are becoming less frequent due to restricted mobility. There is increasing evidence that poor oral health and systemic diseases are closely associated, for example, in cardiological, metabolic or neurodegenerative conditions. Thus, Interaction of Systemic Morbidity and Oral Health in Ambulatory Patients in Need of Home Care (InSEMaP) is investigating the need, provision and utilisation of oral healthcare, systemic morbidity and clinical status of the oral cavity in older people.Methods and analysisInSEMaP consists of four subprojects (SP), all involving the target population of older people in need of home care. In SP1 part a, a sample is surveyed using a self-report questionnaire. In SP1 part b, stakeholders (general practitioners, dentists, medical assistants, family and professional caregivers) are interviewed regarding barriers and facilitators using focus groups and personal interviews. In SP2, a retrospective cohort study, health insurance claims data are examined to investigate the utilisation of oral healthcare, its association with systemic morbidity and healthcare costs. In SP3, a clinical observational study will assess the oral health of participants by a dentist’s visit at home. SP4 synthesises the results of SP1, SP2 and SP3 to develop integrated clinical pathways, identifying strategies to uphold oral healthcare in older people. In assessing and evaluating the process of oral healthcare, and its associated systemic morbidity, InSEMaP aims to improve general healthcare across the sector boundary of dental and general practitioner care.Ethics and disseminationEthics approval was obtained from the Institutional Review Board of the Hamburg Medical Chamber (approval number: 2021-100715-BO-ff). The results of this study will be disseminated through conference presentations and publications in peer-reviewed journals. An expert advisory board to support the InSEMaP study group will be established.Trial registration numberGerman Clinical Trials Register: DRKS00027020.