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      Overutilization of ambulatory medical care in the elderly German population? – An empirical study based on national insurance claims data and a review of foreign studies

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          Abstract

          Background

          By definition, high utilizers receive a large proportion of medical services and produce relatively high costs. The authors report the results of a study on the utilization of ambulatory medical care by the elderly population in Germany in comparison to other OECD countries. Evidence points to an excessive utilization in Germany. It is important to document these utilization figures and compare them to those in other countries since the healtcare system in Germany stopped recording ambulatory healthcare utilization figures in 2008.

          Methods

          The study is based on the claims data of all insurants aged ≥ 65 of a statutory health insurance company in Germany ( n = 123,224). Utilization was analyzed by the number of contacts with physicians in ambulatory medical care and by the number of different practices contacted over one year. Criteria for frequent attendance were ≥ 50 contacts with practices or contacts with ≥ 10 different practices or ≥ 3 practices of the same discipline per year. Descriptive statistical analysis and logistic regression were applied. Morbidity was analyzed by prevalence and relative risk for frequent attendance for 46 chronic diseases.

          Results

          Nineteen percent of the elderly were identified as high utilizers, corresponding to approximately 3.5 million elderly people in Germany. Two main types were identified. One type has many contacts with practices, belongs to the oldest age group, suffers from severe somatic diseases and multimorbidity, and/or is dependent on long-term care. The other type contacts large numbers of practices, consists of younger elderly who often suffer from psychiatric and/or psychosomatic complaints, and is less frequently multimorbid and/or nursing care dependent.

          Conclusion

          We found a very high rate of frequent attendance among the German elderly, which is unique among the OECD countries. Further research should clarify its reasons and if this degree of utilization is beneficial for elderly people.

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          Most cited references53

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          Untangling the concepts of disability, frailty, and comorbidity: implications for improved targeting and care.

          Three terms are commonly used interchangeably to identify vulnerable older adults: comorbidity, or multiple chronic conditions, frailty, and disability. However, in geriatric medicine, there is a growing consensus that these are distinct clinical entities that are causally related. Each, individually, occurs frequently and has high import clinically. This article provides a narrative review of current understanding of the definitions and distinguishing characteristics of each of these conditions, including their clinical relevance and distinct prevention and therapeutic issues, and how they are related. Review of the current state of published knowledge is supplemented by targeted analyses in selected areas where no current published data exists. Overall, the goal of this article is to provide a basis for distinguishing between these three important clinical conditions in older adults and showing how use of separate, distinct definitions of each can improve our understanding of the problems affecting older patients and lead to development of improved strategies for diagnosis, care, research, and medical education in this area.
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            Multimorbidity, health care utilization and costs in an elderly community-dwelling population: a claims data based observational study

            Background Chronic conditions and multimorbidity have become one of the main challenges in health care worldwide. However, data on the burden of multimorbidity are still scarce. The purpose of this study is to examine the association between multimorbidity and the health care utilization and costs in the Swiss community-dwelling population, taking into account several sociodemographic factors. Methods The study population consists of 229'493 individuals aged 65 or older who were insured in 2013 by the Helsana Group, the leading health insurer in Switzerland, covering all 26 Swiss cantons. Multimorbidity was defined as the presence of two or more chronic conditions of a list of 22 conditions that were identified using an updated measure of the Pharmacy-based Cost Group model. The number of consultations (total and divided by primary care physicians and specialists), the number of different physicians contacted, the type of physician contact (face-to-face, phone, and home visits), the number of hospitalisations and the length of stay were assessed separately for the multimorbid and non-multimorbid sample. The costs (total and divided by inpatient and outpatient costs) covered by the compulsory health insurance were calculated for both samples. Multiple linear regression modelling was conducted to adjust for influencing factors: age, sex, linguistic region, purchasing power, insurance plan, and nursing dependency. Results Prevalence of multimorbidity was 76.6%. The mean number of consultations per year was 15.7 in the multimorbid compared to 4.4 in the non-multimorbid sample. Total costs were 5.5 times higher in multimorbid patients. Each additional chronic condition was associated with an increase of 3.2 consultations and increased costs of 33%. Strong positive associations with utilization and costs were also found for nursing dependency. Multimorbid patients were 5.6 times more likely to be hospitalised. Furthermore, results revealed a significant age-gender interaction and a socioeconomic gradient. Conclusions Multimorbidity is associated with substantial higher health care utilization and costs in Switzerland. Quantified data on the current burden of multimorbidity are fundamental for the management of patients in health service delivery systems and for health care policy debates about resource allocation. Strategies for a better coordination of multimorbid patients are urgently needed. Electronic supplementary material The online version of this article (doi:10.1186/s12913-015-0698-2) contains supplementary material, which is available to authorized users.
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              Is there time for management of patients with chronic diseases in primary care?

              Despite the availability of national practice guidelines, many patients fail to receive recommended chronic disease care. Physician time constraints in primary care are likely one cause. We applied guideline recommendations for 10 common chronic diseases to a panel of 2,500 primary care patients with an age-sex distribution and chronic disease prevalences similar to those of the general population, and estimated the minimum physician time required to deliver high-quality care for these conditions. The result was compared with time available for patient care for the average primary care physician. Eight hundred twenty-eight hours per year, or 3.5 hours a day, were required to provide care for the top 10 chronic diseases, provided the disease is stable and in good control. We recalculated this estimate based on increased time requirements for uncontrolled disease. Estimated time required increased by a factor of 3. Applying this factor to all 10 diseases, time demands increased to 2,484 hours, or 10.6 hours a day. Current practice guidelines for only 10 chronic illnesses require more time than primary care physicians have available for patient care overall. Streamlined guidelines and alternative methods of service delivery are needed to meet recommended standards for quality health care.
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                Author and article information

                Contributors
                +49 40 22715823 , bussche@uke.de
                kaduszkiewicz@allgemeinmedizin.uni-kiel.de
                i.schaefer@uke.de
                koller@bwl.lmu.de
                h.hansen@uke.de
                m.scherer@uke.de
                g.schoen@uke.de
                Journal
                BMC Health Serv Res
                BMC Health Serv Res
                BMC Health Services Research
                BioMed Central (London )
                1472-6963
                14 April 2016
                14 April 2016
                2016
                : 16
                : 129
                Affiliations
                [ ]Institute of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
                [ ]Institute of General Practice, Christian-Albrechts-University Kiel, Kiel, Germany
                [ ]Department of Health Services Management, Ludwig-Maximilians-University Munich, Munich, Germany
                [ ]Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
                Article
                1357
                10.1186/s12913-016-1357-y
                4831189
                27074709
                c8bc2862-c3bd-4482-839c-7e374e3fa857
                © van den Bussche et al. 2016

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 9 August 2015
                : 21 March 2016
                Funding
                Funded by: German Federal Ministry for Education and Research
                Award ID: 01ET0731
                Award Recipient :
                Funded by: FundRef http://dx.doi.org/10.13039/501100002347, Bundesministerium für Bildung und Forschung (DE);
                Award ID: 01ET0725
                Award Recipient :
                Categories
                Research Article
                Custom metadata
                © The Author(s) 2016

                Health & Social care
                primary care,health services utilization,frequent attenders,high utilizers,multimorbidity,elderly population

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