Association Between Hearing and Vision Impairment and Risk of Dementia: Results of a Case-Control Study Based on Secondary Data

Introduction: Hearing and vision loss are highly prevalent in elderly adults, and thus frequently occur in conjunction with cognitive impairments. Studies have shown that hearing impairment is associated with a higher risk of dementia. However, evidence concerning the association between vision loss and dementia, as well as the co-occurrence of vision and hearing loss and dementia, has been inconclusive. Objectives: To assess the association between: (i) either hearing or vision loss and the risk of dementia, as well as between; and (ii) the combination of both sensory impairments and the risk of dementia. Methods: This case-control study was based on a 5-year data set that included patients aged 65 years and older who had initially been diagnosed with dementia diseases by one of 1,203 general practitioners in Germany between January 2013 and December 2017. In total, 61,354 identified dementia cases were matched to non-dementia controls, resulting in a sample size of 122,708 individuals. Hearing loss and vision loss were identified using the ICD-10 diagnoses documented in the general practitioners’ files prior to the initial dementia diagnosis. Multivariate logistic regression models were fitted to evaluate the associations between visual and/or hearing impairment and the risk of dementia and controlled for sociodemographic and clinical variables. Results: Hearing impairment was documented in 11.2% of patients with a dementia diagnosis and 9.5% of patients without such a diagnosis. Some form of vision impairment was documented in 28.4% of patients diagnosed with dementia and 28.8% of controls. Visual impairment was not significantly associated with dementia (OR = 0.97, CI = 95% 0.97–1.02, p = 0.219). However, patients with hearing impairment were at a significantly higher risk of developing dementia (OR = 1.26, CI = 95% 1.15–1.38, p < 0.001), a finding that very likely led to the observed significant association of the combination of both visual and hearing impairments and the risk of dementia (OR = 1.14, CI = 95% 1.04–1.24, p = 0.005). Discussion: This analysis adds important evidence that contributes to the limited body of knowledge about the association between hearing and/or vision loss and dementia. It further demonstrates that, of the two, only hearing impairment affects patients’ cognition and thus contributes to dementia risk

Cost of care of community-dwelling primary care patients screened positive for dementia in Germany - Results of the DelpHi-MV trial

Background: Demographic changes are leading to a rapid increase in the number and proportion of the elderly. This goes along with an increase of prevalence of age-associated illnesses, such as dementia. The prevalence of dementia is estimated to amount to 1.5 million in Germany. Up to three-quarter of the persons with dementia (PWD) were living in their own homes. In European countries, dementia is associated with substantial and increasing healthcare costs, which makes dementia one of the most expensive diseases in old age and a serious health care priority. Whereas analyses of total healthcare costs in dementia have been the focus of various cost-of-illness (COI) studies, so far little is known about several cost categories in detail. Firstly, detailed economic analyses of medication cost are currently still missing. Secondly, it is well known that dementia is under-diagnosed, but there is a lack of knowledge about the differences in resource utilization and its costs between dementia patients with and those without a formal dementia diagnosis. Finally, analyses that take the utilization and costs of professional formal and unpaid informal care as well as caregiver’s productivity losses into a consideration are currently missing. Objectives: (1) To determine medication cost, cost per drug and number of drugs taken and analyze their associated factors; to estimate the current price reduction of anti-dementia drugs due to implementation of low-priced generics. (2) To determine health care resource utilisation and costs of patients with a formal diagnosis and those without a formal diagnosis of dementia, and to analyse the association between having received a formal dementia diagnosis and health care costs (3) To determine the utilization and costs of formal and informal care for PwD, indirect costs because of productivity losses of caregivers and the associations between cost, socio-demographic and clinical variables. Methods: The present study is a cross-sectional analysis of health care resource utilization and health care cost of community-dwelling PWD in primary care. Analyses are based on primary data from the ongoing DelpHi-MV trial (Dementia: Life- and person-centered help in Mecklenburg-Western Pomerania, Germany), a population-based, cluster-randomized, controlled intervention trial in the primary care setting (Clinical Trials gov. Identifier: NCT01401582). Eligible patients (older than 70 years, living at home) were screened in participating general practitioner practices for dementia using the DemTect. The utilization of healthcare resources was assessed within the baseline assessment at practitioner’s homes. Costs were calculated from the perspective of the statutory health insurance or the social perspective. Factors associated with healthcare cost were evaluated using multiple regression models. Results: (1) Medication cost and cost per drug were higher and the number of taken drugs lower in advanced stages of cognitive impairment. Prescription of anti-dementia generics could decrease overall medication cost by 28%. Medication cost was associated with number of diagnoses, deficits in activities of daily living and age. Dementia severity was related to cost per drug and number of drugs taken. (2) Patients formally diagnosed with dementia were treated significantly more often by a neurologist, but less often by all other outpatient specialists, and received anti-dementia drugs and day care more often. Diagnosed patients underwent shorter and less frequent planned in-hospital treatments. Dementia diagnosis was significantly associated with higher costs of anti-dementia drug treatment, but significantly associated with less total medical care costs, which valuated to be € 5,123 compared, to € 5,565 for undiagnosed patients. (3) Formal care were utilized less (26.3%) than informal care (85.1%), resulting in a cost ratio of one to ten (1,646 €; 16,473 €, respectively). In total, 29% of caregivers were employed, and every seventh (14.3%) experienced productivity losses, which corresponded to 1,258 € annually. Whereas increasing deficits in daily living activities were associated with higher formal and higher informal costs, living alone was significantly associated with higher formal care costs and the employment of a caregiver was associated with lower informal care costs. Conclusion: (1) Medication cost increases with the number of diagnoses and growing deficits in activities of daily living and decreases with age. Severely cognitively impaired persons are treated with a small number of high-priced drugs, which could suggest inadequate medication of multimorbid persons. (2) There are no significant differences in total health care cost between diagnosed and undiagnosed patients. Dementia diagnosis is beneficial for receiving cost-intensive anti-dementia drug treatments, but is currently insufficient to ensure adequate non-medication treatment for community-dwelling patients. (3) Informal care contributes the most to total care costs. Living alone is a major cost driver for formal costs because of the lower availability of potential informal care. The availability of informal care is limited and productivity losses are increased when a caregiver is employed.Hintergrund: Der demografische Wandel führt zu einem Anstieg altersassoziierter Krankheiten, denen auch die demenziellen Erkrankungen angehören. Im Jahre 2015 lebten ca. 1,5 Millionen Menschen mit Demenz (MmD) in Deutschland. 75% von diesen leben Schätzungen zu Folge zu Hause und werden primärärztlich versorgt. Demenzielle Erkrankungen sind mit erheblichen Gesundheitsausgaben verbunden. Schon heute gehören die demenziellen Erkrankungen zu den teuersten Alterserkrankungen und damit zu einen der größten Herausforderungen für das Gesundheitssystem. Während viele Studien die Krankheitskosten der Demenz analysiert haben, fehlt es bislang an detaillierten Analysen einzelner Kostenkategorien. Einerseits sind die Medikamentenkosten der MmD nicht ausreichend analysiert, vor allem nicht vor dem Hintergrund des in 2012 ausgelaufenen Patentschutzes der Antidementiva. Zudem ist hinlänglich bekannt das die demenzielle Erkrankung unterdiagnostiziert ist. Ca. 60% der primärärztlich versorgten MmD besitzen keine formale Demenzdiagnose. Jedoch existieren bislang keine Krankheitskostenanalysen bezüglich des Unterschiedes zwischen MmD mit und den MmD ohne eine formale Demenzdiagnose. Ebenfalls fehlen Analysen, welche die Kosten der formellen und informellen Pflege sowie die durch die informelle Pflege entstehenden Produktivitätsverluste pflegender Angehöriger analysieren. Ziele: (1) Analyse der Medikamentenkosten, der Kosten pro Medikament und der Anzahl an eingenommenen Medikamenten sowie der Assoziationen zwischen diesen und weiteren klinischen und sozio-demografischen Variablen. (2) Analyse der Inanspruchnahme und der Kosten medizinischer und pflegerischer Leistungen zwischen MmD mit und ohne formale Demenzdiagnose. Analyse der Assoziation zwischen einer formalen Demenzdiagnose und den Krankheitskosten. (3) Analyse der Inanspruchnahme und der Kosten der formellen Pflege, informellen Pflege sowie Produktivitätsverluste pflegender Angehöriger. Analyse der Assoziationen zwischen den Kosten und weiteren soziodemografischen und klinischen Faktoren. Methode: Die Analysen der Krankheitskosten basieren auf primären Querschnittsdaten der hausarztbasierten, cluster-randomisierten, kontrollierten Interventionsstudie DelpHi-MV (Demenz: lebensweltorientierte und personenzentrierte Hilfen in Mecklenburg-Vorpommern) (Identifikationsnummer: NCT01401582). Die Patienten (älter als 70 Jahre, zu Hause lebend) wurden in der Hausarztpraxis mithilfe des DemTects auf einen Verdacht auf Demenz gescreent und bei Abgabe einer Einverständniserklärung in die Studie (ggf. zusammen mit der Hauptversorgungsperson) eingeschlossen. Die Daten zur Inanspruchnahme von medizinischen und pflegerischen Leistungen wurden innerhalb verschiedener Hausbesuche durch Interviews erhoben. Die Kosten wurden aus der Perspektive der Kostenträger oder der gesamten Gesellschaft nach dem Bottom-up- und Prävalenz-Ansatz kalkuliert. Die assoziierten Faktoren wurden unter Nutzung multivariater Regressionsmodelle analysiert. Ergebnisse: (1) MmD mit höheren kognitiven Defiziten verursachten höhere Medikamentenkosten und Kosten pro Medikament. Die Verschreibung von generischen Antidementiva könnten Kosteneinsparungen von 28% generieren. Kognitive Defizite waren assoziiert mit höheren Kosten pro Medikament aber einer geringeren Anzahl an eingenommen Präparaten. Höhere Medikamentenkosten waren assoziiert mit einer höheren Komorbidität, höheren körperlichen Defiziten und einem geringeren Alter. (2) MmD mit einer formalen Diagnose wurden öfter von einem Neurologen/ Psychiater behandelt, jedoch seltener von weiteren Fachärzten. Ebenfalls nahmen sie häufiger Antidementiva ein. MmD ohne eine formale Demenzdiagnose wurden seltener und kürzer stationär im Krankenhaus behandelt. Die Demenzdiagnose war assoziiert mit geringeren Gesamtkosten der medizinischen Versorgung (5,123€ vs. 5,565€). (3) MmD nehmen wenig formelle Pflege (26.6%) und oft informelle Pflege (85.1%) in Anspruch. Die Kosten der formellen Pflege beliefen sich auf 1,646€ und die der informellen Pflege auf 16,473€. Insgesamt arbeiteten 29% der pflegenden Angehörigen, 14.3% dieser verursachten Produktivitätsverluste. Diese lagen bei 1,258€ jährlich. Während Defizite in den Aktivitäten des täglichen Lebens mit höheren formellen und informellen Pflegekosten assoziiert waren, konnte eine positive Assoziation zwischen dem Alleinleben sowie eine negative Assoziation zwischen der Berufstätigkeit des pflegenden Angehörigen und den informellen Pflegekosten festgestellt werden. Schlussfolgerungen: (1) Schwer kognitive eingeschränkte MmD erhalten wenige aber dafür kosten-intensive Medikamente. Es ist fraglich, ob dies einer medikamentösen Versorgung von multimorbiden MmD gerecht wird. (2) Während keinerlei Unterschiede in den Gesamtkosten zwischen MmD mit und ohne Demenzdiagnose feststellbar war, konnte aufgezeigt werden, dass die Demenzdiagnose mit geringeren Kosten der medizinischen Versorgung assoziiert war. Dies ergab sich aufgrund einer geringeren Inanspruchnahme von Fachärzten und einer stationären Krankenhausversorgung. (3) Informelle Pflege verursacht zehnfach höhere Kosten als die formelle Pflege. Aufgrund der fehlenden Verfügbarkeit von informeller Pflege war das Alleinleben der MmD Kostentreiber der formellen Pflege. Die Verfügbarkeit der informellen Pflege ist limitiert im Falle der Berufstätigkeit des informell Pflegenden, dies verringert die Kosten der informellen Kosten und erhöht die Produktivitätsverluste

Is the whole larger than the sum of its parts? Impact of missing data imputation in economic evaluation conducted alongside randomized controlled trials

Outcomes in economic evaluations, such as health utilities and costs, are products of multiple variables, often requiring complete item responses to questionnaires. Therefore, missing data are very common in cost-effectiveness analyses. Multiple imputations (MI) are predominately recommended and could be made either for individual items or at the aggregate level. We, therefore, aimed to assess the precision of both MI approaches (the item imputation vs. aggregate imputation) on the cost-effectiveness results. The original data set came from a cluster-randomized, controlled trial and was used to describe the missing data pattern and compare the differences in the cost-effectiveness results between the two imputation approaches. A simulation study with different missing data scenarios generated based on a complete data set was used to assess the precision of both imputation approaches. For health utility and cost, patients more often had a partial (9% vs. 23%, respectively) rather than complete missing (4% vs. 0%). The imputation approaches differed in the cost-effectiveness results (the item imputation: - 61,079€/QALY vs. the aggregate imputation: 15,399€/QALY). Within the simulation study mean relative bias (&amp;lt; 5% vs. &amp;lt; 10%) and range of bias (&amp;lt; 38% vs. &amp;lt; 83%) to the true incremental cost and incremental QALYs were lower for the item imputation compared to the aggregate imputation. Even when 40% of data were missing, relative bias to true cost-effectiveness curves was less than 16% using the item imputation, but up to 39% for the aggregate imputation. Thus, the imputation strategies could have a significant impact on the cost-effectiveness conclusions when more than 20% of data are missing. The item imputation approach has better precision than the imputation at the aggregate level

The long-term impact of the COVID-19 pandemic on primary and specialized care provision and disease recognition in Germany

Background The COVID-19 pandemic and the imposed lockdowns severely affected routine care in general and specialized physician practices. Objective To describe the long-term impact of the COVID-19 pandemic on the physician services provision and disease recognition in German physician practices and perceived causes for the observed changes. Design Observational study based on medical record data and survey data of general practitioners and specialists' practices. Participants 996 general practitioners (GPs) and 798 specialist practices, who documented 6.1 million treatment cases for medical record data analyses and 645 physicians for survey data analyses. Main measures Within the medical record data, consultations, specialist referrals, hospital admissions, and documented diagnoses were extracted for the pandemic (March 2020–September 2021) and compared to corresponding pre-pandemic months in 2019. The additional online survey was used to assess changes in practice management during the COVID-19 pandemic and physicians' perceived main causes of affected primary and specialized care provision. Main results Hospital admissions (GPs: −22% vs. specialists: −16%), specialist referrals (−6 vs. −3%) and recognized diseases (−9 vs. −8%) significantly decreased over the pandemic. GPs consultations initially decreased (2020: −7%) but compensated at the end of 2021 (+3%), while specialists' consultation did not (−2%). Physicians saw changes in patient behavior, like appointment cancellation, as the main cause of the decrease. Contrary to this, they also mentioned substantial modifications of practice management, like reduced (nursing) home visits (41%) and opening hours (40%), suspended checkups (43%), and delayed consultations for high-risk patients (71%). Conclusion The pandemic left its mark on primary and specialized healthcare provision and its utilization. Both patient behavior and organizational changes in practice management may have caused decreased and non-compensation of services. Evaluating the long-term effect on patient outcomes and identifying potential improvements are vital to better prepare for future pandemic waves

Development of a Quantitative Instrument to Elicit Patient Preferences for Person-Centered Dementia Care Stage 1: A Formative Qualitative Study to Identify Patient Relevant Criteria for Experimental Design of an Analytic Hierarchy Process

Background: Person-centered care (PCC) requires knowledge about patient preferences. This formative qualitative study aimed to identify (sub)criteria of PCC for the design of a quantitative, choice-based instrument to elicit patient preferences for person-centered dementia care. Method: Interviews were conducted with n = 2 dementia care managers, n = 10 People living with Dementia (PlwD), and n = 3 caregivers (CGs), which followed a semi-structured interview guide including a card game with PCC criteria identified from the literature. Criteria cards were shown to explore the PlwD’s conception. PlwD were asked to rank the cards to identify patient-relevant criteria of PCC. Audios were verbatim-transcribed and analyzed with qualitative content analysis. Card game results were coded on a 10-point-scale, and sums and means for criteria were calculated. Results: Six criteria with two sub-criteria emerged from the analysis; social relationships (indirect contact, direct contact), cognitive training (passive, active), organization of care (decentralized structures and no shared decision making, centralized structures and shared decision making), assistance with daily activities (professional, family member), characteristics of care professionals (empathy, education and work experience) and physical activities (alone, group). Dementia-sensitive wording and balance between comprehensibility vs. completeness of the (sub)criteria emerged as additional themes. Conclusions: Our formative study provides initial data about patient-relevant criteria of PCC to design a quantitative patient preference instrument. Future research may want to consider the balance between (sub)criteria comprehensibility vs. completeness

Development of a Quantitative Preference Instrument for Person-Centered Dementia Care—Stage 2: Insights from a Formative Qualitative Study to Design and Pretest a Dementia-Friendly Analytic Hierarchy Process Survey

Person-centered care (PCC) requires knowledge about patient preferences. An analytic hierarchy process (AHP) is one approach to quantify, weigh and rank patient preferences suitable for People living with Dementia (PlwD), due to simple pairwise comparisons of individual criteria from a complex decision problem. The objective of the present study was to design and pretest a dementia-friendly AHP survey. Methods: Two expert panels consisting of n = 4 Dementia Care Managers and n = 4 physicians to ensure content-validity, and “thinking-aloud” interviews with n = 11 PlwD and n = 3 family caregivers to ensure the face validity of the AHP survey. Following a semi-structured interview guide, PlwD were asked to assess appropriateness and comprehensibility. Data, field notes and partial interview transcripts were analyzed with a constant comparative approach, and feedback was incorporated continuously until PlwD had no further comments or struggles with survey completion. Consistency ratios (CRs) were calculated with Microsoft® Excel and ExpertChoice Comparion®. Results: Three main categories with sub-categories emerged: (1) Content: clear task introduction, (sub)criteria description, criteria homogeneity, (sub)criteria appropriateness, retest questions and sociodemography for heterogeneity; (2) Format: survey structure, pairwise comparison sequence, survey length, graphical design (incl. AHP scale), survey procedure explanation, survey assistance and response perspective; and (3) Layout: easy wording, short sentences and visual aids. Individual CRs ranged from 0.08 to 0.859, and the consolidated CR was 0.37 (0.038). Conclusions: Our formative qualitative study provides initial data for the design of a dementia-friendly AHP survey. Consideration of our findings may contribute to face and content validity in future quantitative preference research in dementia