Hendrik van den Bussche

University Medical Center Hamburg - Eppendorf, Hamburg, Hamburg, Germany

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Publications (173)522.9 Total impact

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    ABSTRACT: In this article three research questions are addressed: (1) Is there an association between socioeconomic status (SES) and patient-reported outcomes in a cohort of multimorbid patients? (2) Does the association vary according to SES indicator used (income, education, occupational position)? (3) Can the association between SES and patient-reported outcomes (self-rated health, health-related quality of life and functional status) be (partly) explained by burden of disease? Analyses are based on the MultiCare Cohort Study, a German multicentre, prospective, observational cohort study of multimorbid patients from general practice. We analysed baseline data and data from the first follow-up after 15 months (N = 2,729). To assess burden of disease we used the patients’ morbidity data from standardized general practitioner (GP) interviews based on a list of 46 groups of chronic conditions including the GP’s severity rating of each chronic condition ranging from marginal to very severe. In the cross-sectional analyses SES was significantly associated with the patient-reported outcomes at baseline. Associations with income were more consistent and stronger than with education and occupational position. Associations were partly explained (17% to 44%) by burden of disease. In the longitudinal analyses only income (but not education and occupational position) was significantly related to the patient-reported outcomes at follow-up. Associations between income and the outcomes were reduced by 18% to 27% after adjustment for burden of disease. Results indicate social inequalities in self-rated health, functional status and health related quality of life among older multimorbid patients. As associations with education and occupational position were inconsistent, these inequalities were mainly due to income. Inequalities were partly explained by burden of disease. However, even among patients with a similar disease burden, those with a low income were worse off in terms of the three patient-reported outcomes under study.
    International Journal for Equity in Health 12/2015; 14(1). DOI:10.1186/s12939-015-0142-6 · 1.71 Impact Factor
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    ABSTRACT: Constraint-induced movement therapy (CIMT) is recommended for patients with upper limb dysfunction after stroke, yet evidence to support the implementation of CIMT in ambulatory care is insufficient. We assessed the efficacy of home CIMT, a modified form of CIMT that trains arm use in daily activities within the home environment. In this parallel, cluster-randomised controlled trial, we selected 71 therapy practices in northern Germany that treat adult patients with upper limb dysfunction after stroke. Practices were stratified by region and randomly allocated by an external biometrician (1:1, block size of four) using a computer-generated sequence. 37 practices were randomly assigned to provide 4 weeks of home CIMT and 34 practices to provide 4 weeks of standard therapy. Eligible patients had mild to moderate impairment of arm function at least 6 months after stroke and a friend or family member willing to participate as a non-professional coach. Patients of both groups received 5 h of professional therapist contact in 4 weeks. In the home CIMT group, therapists used the contact time to instruct and supervise patients and coaches in home CIMT. Patients in the standard therapy group received conventional physical or occupational therapy, but additional home training was not obligatory. All assessments were done by masked outcome assessors at baseline, after 4 weeks of intervention, and at 6 month follow-up. The primary outcomes were quality of movement, assessed by the Motor Activity Log (MAL-QOM, assessor-assisted self-reported), and performance time, assessed by the Wolf Motor Function Test (WMFT-PT, assessor-reported). Primary outcomes were tested hierarchically after 4 weeks of intervention and analysed by intention to treat, using mixed linear models. This trial is registered with ClinicalTrials.gov, NCT01343602. Between July 11, 2011, and June 4, 2013, 85 of 156 enrolled patients were assigned home CIMT and 71 patients were assigned standard therapy. 82 (96%) patients in the home CIMT group and 71 (100%) patients in the standard therapy group completed treatment and were assessed at 4 weeks. Patients in both groups improved in quality of movement (MAL-QOM; change from baseline 0·56, 95% CI 0·41-0·71, p<0·0001 for home CIMT vs 0·31, 0·15-0·46, p=0·0003 for standard therapy). Patients in the home CIMT group improved more than patients in the standard therapy group (between-group difference 0·26, 95% CI 0·05-0·46; p=0·0156). Both groups also improved in motor function performance time (WMFT-PT; change from baseline -25·60%, 95% CI -36·75 to -12·49, p=0·0006 for home CIMT vs -27·52%, -38·94 to -13·94, p=0·0004 for standard therapy), but the extent of improvement did not differ between groups (2·65%, -17·94 to 28·40; p=0·8152). Nine adverse events (of which six were serious) were reported in the home CIMT group and ten (of which seven were serious) in the standard therapy group; however, none was deemed related to the study intervention. Home-based CIMT can enhance the perceived use of the stroke-affected arm in daily activities more effectively than conventional therapy, but was not superior with respect to motor function. Further research is needed to confirm whether home CIMT leads to clinically significant improvements and if so to identify patients that are most likely to benefit. German Federal Ministry of Education and Research. Copyright © 2015 Elsevier Ltd. All rights reserved.
    The Lancet Neurology 07/2015; DOI:10.1016/S1474-4422(15)00147-7 · 21.82 Impact Factor
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    Heike Hansen · Nadine Pohontsch · Hendrik van den Bussche · Martin Scherer · Ingmar Schäfer
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    ABSTRACT: Chronic conditions are the most common themes in doctor-patient communication, especially for older patients with multimorbidity and their GPs. Former quantitative studies identified a variety of socio-demographic and health-related factors which were associated with the (dis-)agreement between medical records and patient self-reported diseases. The aim of this qualitative study was to identify reasons for disagreement regarding illnesses between patients and their GPs. We conducted three focus groups with GPs (n = 15) and three focus groups with multimorbid patients aged 65 to 85 (n = 21). The participants were recruited from the MultiCare Cohort Study. Focus groups were audiotaped and transcribed verbatim. The transcripts of the focus groups were analysed using the qualitative content analysis according to Mayring. Categories were determined deductively and inductively. The analysis revealed seven themes concerning reasons for disagreement regarding illnesses between patients and their GPs: problems with communication and cooperation between health care professionals, disease management by the GP and the patient, the documentation behaviour of the GP, communication challenges between GP and patient, differences in the understanding of a disease between GP and patient, the prioritization and rating of diseases by GP and patient and obliviousness, repression and avoidance by the patient. For older patients with multimorbidity, our study demonstrated that there is a need to enhance the cooperation between GPs, specialists and outpatient care, a demand to improve doctor-patient communication and a need for interventions to increase patients' knowledge of diseases.
    BMC Family Practice 06/2015; 16(1). DOI:10.1186/s12875-015-0286-x · 1.74 Impact Factor
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    ABSTRACT: Multimorbidity is highly prevalent in the elderly and relates to many adverse outcomes, such as higher mortality, increased disability and functional decline. Many studies tried to reduce the heterogeneity of multimorbidity by identifying multimorbidity clusters or disease combinations, however, the internal structure of multimorbidity clusters and the linking between disease combinations and clusters are still unknown. The aim of this study was to depict which diseases were associated with each other on person-level within the clusters and which ones were responsible for overlapping multimorbidity clusters. The study analyses insurance claims data of the Gmunder ErsatzKasse from 2006 with 43,632 female and 54,987 male patients who were 65 years and older. The analyses are based on multimorbidity clusters from a previous study and combinations of three diseases ("triads") identified by observed/expected ratios >= 2 and prevalence rates >= 1%. In order to visualise a "disease network", an edgelist was extracted from these triads, which was analysed by network analysis and graphically linked to multimorbidity clusters. We found 57 relevant triads consisting of 31 chronic conditions with 200 disease associations ("edges") in females and 51 triads of 29 diseases with 174 edges in males. In the disease network, the cluster of cardiovascular and metabolic disorders comprised 12 of these conditions in females and 14 in males. The cluster of anxiety, depression, somatoform disorders, and pain consisted of 15 conditions in females and 12 in males. We were able to show which diseases were associated with each other in our data set, to which clusters the diseases were assigned, and which diseases were responsible for overlapping clusters. The disease with the highest number of associations, and the most important mediator between diseases, was chronic low back pain. In females, depression was also associated with many other diseases. We found a multitude of associations between disorders of the metabolic syndrome of which hypertension was the most central disease. The most prominent bridges were between the metabolic syndrome and musculoskeletal disorders. Guideline developers might find our approach useful as a basis for discussing which comorbidity should be addressed.
    BMC Public Health 12/2014; 14(1):1285. DOI:10.1186/1471-2458-14-1285 · 2.32 Impact Factor
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    ABSTRACT: Multimorbidity is a health issue mostly dealt with in primary care practice. As a result of their generalist and patient-centered approach, long-lasting relationships with patients, and responsibility for continuity and coordination of care, family physicians are particularly well placed to manage patients with multimorbidity. However, conflicts arising from the application of multiple disease oriented guidelines and the burden of diseases and treatments often make consultations challenging. To provide orientation in decision making in multimorbidity during primary care consultations, we developed guiding principles and named them after the Greek mythological figure Ariadne. For this purpose, we convened a two-day expert workshop accompanied by an international symposium in October 2012 in Frankfurt, Germany. Against the background of the current state of knowledge presented and discussed at the symposium, 19 experts from North America, Europe, and Australia identified the key issues of concern in the management of multimorbidity in primary care in panel and small group sessions and agreed upon making use of formal and informal consensus methods. The proposed preliminary principles were refined during a multistage feedback process and discussed using a case example. The sharing of realistic treatment goals by physicians and patients is at the core of the Ariadne principles. These result from i) a thorough interaction assessment of the patient’s conditions, treatments, constitution, and context; ii) the prioritization of health problems that take into account the patient’s preferences – his or her most and least desired outcomes; and iii) individualized management realizes the best options of care in diagnostics, treatment, and prevention to achieve the goals. Goal attainment is followed-up in accordance with a re-assessment in planned visits. The occurrence of new or changed conditions, such as an increase in severity, or a changed context may trigger the (re-)start of the process. Further work is needed on the implementation of the formulated principles, but they were recognized and appreciated as important by family physicians and primary care researchers. Please see related article: http://www.biomedcentral.com/1741-7015/12/222. Electronic supplementary material The online version of this article (doi:10.1186/s12916-014-0223-1) contains supplementary material, which is available to authorized users.
    BMC Medicine 12/2014; 12(1):223. DOI:10.1186/s12916-014-0223-1 · 7.28 Impact Factor
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    ABSTRACT: Hintergrund Für Hausärzte ist die Betreuung von Patienten mit Multimorbidität eine alltägliche Herausforderung. Leitlinien, die jeweils nur einzelne Erkrankungen im Fokus haben, können hier nicht umfassend und „gleichberechtigt“ Anwendung finden. Stattdessen müssen Prioritäten gesetzt werden. Fragestellung Vor diesem Hintergrund wird herausgearbeitet, wie Hausärzte und ihre Patienten diesen Herausforderungen begegnen und welche Prioritäten sie jeweils setzen. Material und Methoden Neun Hausärzte und 19 ihrer Patienten mit Multimorbidität wurden narrativ interviewt. Die Analyse erfolgte inhaltsanalytisch. Ergebnisse Die Mehrzahl der interviewten Patienten fühlte sich durch ihren Hausarzt gut oder sehr gut betreut. Dennoch stellten sich die Prioritäten der Hausärzte und die ihrer Patienten häufig unterschiedlich dar. Während die Ärzte die meiste Energie auf das Management von Erkrankungen verwendeten, die zu potenziell lebensbedrohlichen Situationen führen können, stand bei den Patienten der unmittelbare Erhalt von Autonomie und sozialem Miteinander im Vordergrund. Diskussion Die Ergebnisse der Studie legen den Schluss nahe, dass die Kommunikation zwischen Hausärzten und ihren Patienten gerade in Bezug auf einen gemeinsamen Prozess der Prioritätensetzung bei Multimorbidität weiterentwickelt werden kann.
    Zeitschrift für Gerontologie + Geriatrie 10/2014; DOI:10.1007/s00391-014-0820-9 · 1.02 Impact Factor
  • S Birck · B Gedrose · B-P Robra · A Schmidt · J-H Schultz · C Stosch · R Wagner · N Janßen · M Scherer · H van den Bussche
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    ABSTRACT: Introduction: We investigated persistences and changes of career preferences of medical residents in Germany after two years of postgraduate training with regard to future working place and position. The results are compared with those forwarded at graduation from medical school in a gender comparative perspective. Methods: The study is based on a standardized postal survey among the participants in the "KarMed" study, originally based on 1012 graduates of the medical faculties of Erlangen, Giessen, Hamburg, Heidelberg, Cologne, Leipzig and Magdeburg in 2009. 2107 persons were contacted. The return rate at baseline was 48 %, and the two surveys after the baseline reached return rates of 87 % and 89 % respectively. In all samples 2/3 were women as in actual medical undergraduate education. Descriptive statistics and regression analysis were performed. Results: After 2 years of residency, residents after 2 years of postgraduate training still preferred the hospital over private practice as their final workplace after postgraduate training. The attractiveness of leading positions in the hospital declined among men, whereas it was already low for women at graduation. A large proportion of those physicians preferring the ambulatory sector, especially women, wishes to work as employee instead of private practice. At the personal level, almost 60 % forwarded the same preferences as those at graduation. Gender, parenthood and region of study (East vs. West Germany) did not influence stability or change of preferences. Conclusion: The results demonstrate the persistence of professional preferences regarding future sector and position of medical work during postgraduate training. These preferences do neither match with principles of gender equality nor with future workforce needs (e. g. in primary care).
    DMW - Deutsche Medizinische Wochenschrift 10/2014; 139(43):2173-2177. DOI:10.1055/s-0034-1387274 · 0.55 Impact Factor
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    ABSTRACT: AimThis study explores the current state of collaboration and communication between nurses and general practitioners in nursing homes, as well as needs and expectations of nursing home residents and their families. Finally, we aim to develop a new model of collaboration and communication.Background Rising numbers of residents in nursing homes present a challenge for general practice and nursing in most Western countries. In Germany, general practitioners visit their patients in nursing homes, where nurses work in shifts. This leads to a big variety of contacts with regard to persons involved and ways of communication.DesignQualitative multicentre study.Methods Study part 1 explores needs and problems in interprofessional collaboration in interviews with nursing home residents and their relatives, general practitioners and nurses. Simultaneously, general practitioners' visits in nursing homes are observed directly. In study part 2, general practitioners and nurses will discuss findings from study part 1 in focus groups, aiming to develop strategies for the improvement of shortcomings in a participatory way. Based on the results, experts will contribute to the emerging model of collaboration and communication in a multi-professional workshop. Finally, this model will be tested in a small feasibility study. The German Federal Ministry of Education and Research approved funding in March 2011.DiscussionThe study is expected to uncover deficits and opportunities in interprofessional collaboration in nursing homes. It provides deeper understanding of the concepts of all involved person groups and adds important clues for the interaction between professionals and older people in this setting.
    Journal of Advanced Nursing 10/2014; 71(2). DOI:10.1111/jan.12545 · 1.69 Impact Factor
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    ABSTRACT: Background The objective of the study was to compare General Practitioners׳ (GPs) diagnosis of depression and depression diagnosis according to Geriatric Depression Scale (GDS) and to identify potential factors associated with both depression diagnosis methods. Methods The data were derived from the baseline wave of the German MultiCare1 study, which is a multicentre, prospective, observational cohort study of 3177 multimorbid patients aged 65+ randomly selected from 158 GP practices. Data were collected in GP interviews and comprehensive patient interviews. Depressive symptoms were assessed with a short version of the Geriatric Depression Scale (15 items, cut-off 6). Cohen׳s kappa was used to assess agreement of GP and GDS diagnoses. To identify factors that might have influenced GP and GDS diagnoses of depression, binary logistic regression analyses were performed. Results Depressive symptoms according to GDS were diagnosed in 12.6% of the multimorbid subjects, while 17.8% of the patients received a depression diagnosis by their GP. The agreement between general practitioners and GDS diagnosis was poor. To summarize we find that GPs and the GDS have different perspectives on depression. To GPs somatic and psychological comorbid conditions carry weight when diagnosing depression, while cognitive impairment in form of low verbal fluency, pain and comorbid somatic conditions are relevant for a depression diagnosis by GDS. Conclusions Each depression diagnosing method is influenced by different variables and therefore, has advantages and limitations. Possibly, the application of both, GP and GDS diagnoses of depression, could provide valuable support in combining the different perspectives of depression and contribute to a comprehensive view on multimorbid elderly in primary care setting.
    Journal of Affective Disorders 10/2014; 168(08/09):276–283. DOI:10.1016/j.jad.2014.06.020 · 3.71 Impact Factor
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    G Ketels · G Schön · H van den Bussche · A Barzel
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    ABSTRACT: Background: The introduction of occupational and physical therapy as academic disciplines is evidence of radical changes in the therapeutic health care professions. Therapists' professional associations are planning and negotiating both with health insurance companies and with other branches of the health care professions concerning future spheres of activity. In order to find out what the therapists in these professions think about their future, we conducted a survey of physical and occupational therapists through-out Germany. Our findings regarding profes-sional life, job satisfaction, competition and cooperation have already been published. This article presents therapists' assessments of the future of their professions. Method: From May until December 2008 we performed a cross-sectional survey, interviewing physical and occupational therapists throughout Germany. Statements were answered on a 6-step Likert scale; open questions were answered in free-text fields. The evaluation was performed quantitatively; the free texts were also evaluated qualitatively. Results: A total of 3 506 questionnaires were evaluated; 1 273 were completed by occupational therapists and 2 233 by physical therapists. Nearly half of the therapists (n=1 687; 48.4%) used the opportunity to emphasise the need for change. We identified 4 026 statements about 8 general topics: remuneration, employee co-determination, professional recognition, continuing education, cooperation, initial access to the professions, and their academic status. Therapists illustrated certain items in the questionnaire with examples from their professional experience, suggested add-itional topics, and proposed concrete changes. We document a broad range of opinions and concerns, especially in regard to such subjects concerning the future of the professions as their new academic status and initial access. Conclusion: Physical and occupational therapists are concerned about the future development of their professions. They see a need for change in the following areas: remuneration, employee co-determination, initial access and cooperation as well as in the development of their profession as an academic discipline. Policy makers need to heed therapists' assessments of the state of their professions and their calls for its increased professionalisation.
  • Das Gesundheitswesen 09/2014; 76(08/09). DOI:10.1055/s-0034-1387028 · 0.62 Impact Factor
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    ABSTRACT: The impact of self-efficacy on pain-related disability in multimorbid elderly patients in primary care is not known. The aim of our study was to analyze the influence of self-efficacy on the relation between pain intensity and pain-related disability, controlled for age and disease count, in aged multimorbid primary care patients with osteoarthritis and chronic pain. Patients were recruited in the German MultiCare study (trial registration: ISRCTN89818205). Pain was assessed using the Graded Chronic Pain Scale, and self-efficacy using the General Self-Efficacy Scale. We employed SPSS for statistical analysis. One thousand eighteen primary care patients were included in the study. Correlation analyses showed significant correlations between pain intensity and pain-related disability (r = 0.591, p < 0.001), pain intensity and general self-efficacy (r = 0.078, p < 0.05), and between general self-efficacy and pain-related disability (r = 0.153, p < 0.001). Multiple mediator analysis gives indications that self-efficacy partially mediates the relation between pain intensity and pain-related disability. In our results, we found little evidence that self-efficacy partially mediates the relation between pain intensity and pain-related disability in aged multimorbid primary care patients with osteoarthritis and chronic pain. Further research is necessary to prove the effect.
    Clinical Rheumatology 09/2014; DOI:10.1007/s10067-014-2766-0 · 1.77 Impact Factor
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    ABSTRACT: In primary care, patients with multiple chronic conditions are the rule rather than the exception. The Chronic Care Model (CCM) is an evidence-based framework for improving chronic illness care, but little is known about the extent to which it has been implemented in routine primary care. The aim of this study was to describe how multimorbid older patients assess the routine chronic care they receive in primary care practices in Germany, and to explore the extent to which factors at both the practice and patient level determine their views. This cross-sectional study used baseline data from an observational cohort study involving 158 general practitioners (GP) and 3189 multimorbid patients. Standardized questionnaires were employed to collect data, and the Patient Assessment of Chronic Illness Care (PACIC) questionnaire used to assess the quality of care received. Multilevel hierarchical modeling was used to identify any existing association between the dependent variable, PACIC, and independent variables at the patient level (socio-economic factors, weighted count of chronic conditions, instrumental activities of daily living, health-related quality of life, graded chronic pain, no. of contacts with GP, existence of a disease management program (DMP) disease, self-efficacy, and social support) and the practice level (age and sex of GP, years in current practice, size and type of practice). The overall mean PACIC score was 2.4 (SD 0.8), with the mean subscale scores ranging from 2.0 (SD 1.0, subscale goal setting/tailoring) to 3.5 (SD 0.7, delivery system design). At the patient level, higher PACIC scores were associated with a DMP disease, more frequent GP contacts, higher social support, and higher autonomy of past occupation. At the practice level, solo practices were associated with higher PACIC values than other types of practice. This study shows that from the perspective of multimorbid patients receiving care in German primary care practices, the implementation of structured care and counseling could be improved, particularly by helping patients set specific goals, coordinating care, and arranging follow-up contacts. Studies evaluating chronic care should take into consideration that a patient’s assessment is associated not only with practice-level factors, but also with individual, patient-level factors. Trial registration Current Controlled Trials ISRCTN89818205.
    BMC Health Services Research 08/2014; 14(1):336. DOI:10.1186/1472-6963-14-336 · 1.66 Impact Factor
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    ABSTRACT: Background Obesity and the accompanying increased morbidity and mortality risk is highly prevalent among older adults. As obese elderly might benefit from intentional weight reduction, it is necessary to determine associated and potentially modifiable factors on senior obesity. This cross-sectional study focuses on multi-morbid patients which make up the majority in primary care. It reports on the prevalence of senior obesity and its associations with lifestyle behaviors. Methods A total of 3,189 non-demented, multi-morbid participants aged 65–85 years were recruited in primary care within the German MultiCare-study. Physical activity, smoking, alcohol consumption and quantity and quality of nutritional intake were classified as relevant lifestyle factors. Body Mass Index (BMI, general obesity) and waist circumference (WC, abdominal obesity) were used as outcome measures and regression analyses were conducted. Results About one third of all patients were classified as obese according to BMI. The prevalence of abdominal obesity was 73.5%. Adjusted for socio-demographic variables and objective and subjective disease burden, participants with low physical activity had a 1.6 kg/m2 higher BMI as well as a higher WC (4.9 cm, p<0.001). Current smoking and high alcohol consumption were associated with a lower BMI and WC. In multivariate logistic regression, using elevated WC and BMI as categorical outcomes, the same pattern in lifestyle factors was observed. Only for WC, not current but former smoking was associated with a higher probability for elevated WC. Dietary intake in quantity and quality was not associated with BMI or WC in either model. Conclusions Further research is needed to clarify if the huge prevalence discrepancy between BMI and WC also reflects a difference in obesity-related morbidity and mortality. Yet, age-specific thresholds for the BMI are needed likewise. Encouraging and promoting physical activity in older adults might a starting point for weight reduction efforts.
    PLoS ONE 07/2014; 9(7):e102587. DOI:10.1371/journal.pone.0102587 · 3.23 Impact Factor
  • Jana Schulze · Hendrik van den Bussche · Hanna Kaduszkiewicz · Daniela Koller · Falk Hoffmann
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    ABSTRACT: Dementia is a main reason for nursing home admission. Information on institutionalization is often based on studies of limited methodological quality. We aimed to analyze time until nursing home admission since first coding of dementia diagnosis and factors associated with institutionalization in incident dementia patients compared to non-demented controls. We analyzed claims data of a German Health insurance company including a cohort of 1,440 patients with a first diagnosis of dementia and 6,988 age- and sex-matched controls aged 65 years and older. The follow-up was up to 5 years. We used Kaplan-Meier analysis for examining time until nursing home admission and cox regression for estimating crude and adjusted Hazard ratios. Dementia patients and controls were on average 78 years and about 55 % were males. The mean time to nursing home admission was 4.0 years in patients with dementia and 4.6 years for controls. After the 5-years observation-period 62.7 % (95 % CI 59.0-66.1) of dementia patients still lived in the community in comparison to 86.2 % (95 % CI 85.2-87.2) of controls. Cox regression models show that the risk for institutionalization is 3.45 (95 % CI 3.05-3.90) times higher in dementia patients in comparison to controls when adjusted for sex, age, and comorbidity. Our analysis shows a significant influence of dementia on institutionalization in comparison to age- and sex-matched controls, especially in the youngest age groups. Hence, the results add substantial information on the disease progression of dementia and are, therefore, of great importance for health-care as well as long-term care planning.
    Social Psychiatry and Psychiatric Epidemiology 06/2014; 50(1). DOI:10.1007/s00127-014-0911-3 · 2.58 Impact Factor
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    Daniela Koller · Gerhard Schön · Ingmar Schäfer · Gerd Glaeske · Hendrik van den Bussche · Heike Hansen
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    ABSTRACT: Not only single, but also multiple, chronic conditions are becoming the normal situation rather than the exception in the older generation. While many studies show a correlation between multimorbidity and various health outcomes, the long-term effect on care dependency remains unclear. The objective of this study is to follow up a cohort of older adults for 5 years to estimate the impact of multimorbidity on long-term care dependency. This study is based on claims data from a German health insurance company. We included 115,203 people (mean age: 71.5 years, 41.4% females). To identify chronic diseases and multimorbidity, we used a defined list of 46 chronic conditions based on ICD-10 codes. Multimorbidity was defined as three or more chronic conditions from this list. The main outcome was “time until long-term care dependency”. The follow-up started on January 1st, 2005 and lasted for 5 years until December 31st, 2009. To evaluate differences between those with multimorbidity and those without, we calculated Kaplan–Meier curves and then modeled four distinct Cox proportional hazard regressions including multimorbidity, age and sex, the single chronic conditions, and disease clusters. Mean follow-up was 4.5 years. People with multimorbidity had a higher risk of becoming care dependent (HR: 1.85, CI 1.78–1.92). The conditions with the highest risks for long-term care dependency are Parkinson’s disease (HR: 6.40 vs. 2.68) and dementia (HR: 5.70 vs. 2.27). Patients with the multimorbidity pattern “Neuropsychiatric disorders” have a 79% higher risk of care dependency. The results should form the basis for future health policy decisions on the treatment of patients with multiple chronic diseases and also show the need to introduce new ways of providing long-term care to this population. A health policy focus on chronic care management as well as the development of guidelines for multimorbidity is crucial to secure health services delivery for the older population.
    BMC Geriatrics 05/2014; 14(1):70. DOI:10.1186/1471-2318-14-70 · 2.00 Impact Factor
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    ABSTRACT: Diabetes mellitus is highly prevalent and can lead to serious complications and mortality. Patient education can help to avoid negative outcomes, but up to half of the patients do not participate. The aim of this study was to analyze patients' attitudes towards diabetes education in order to identify barriers to participation and develop strategies for better patient education. We conducted a qualitative study. Seven GP practices were purposively selected based on socio-demographic data of city districts in Hamburg, Germany. Study participants were selected by their GPs in order to increase participation. Semi-structured face-to-face interviews were conducted with 14 patients. Interviews were audiotaped and transcribed verbatim. The sample size was determined by data saturation. Data were analysed by qualitative content analysis. Categories were determined deductively and inductively. The interviews yielded four types of barriers: 1) Statements and behaviour of the attending physician influence the patients' decisions about diabetes education. 2) Both, a good state of health related to diabetes and physical/psychosocial comorbidity can be reasons for non-participation. 3) Manifold motivational factors were discussed. They ranged from giving low priority to diabetes to avoidance of implications of diabetes education as being confronted with illness narratives of others. 4) Barriers also include aspects of the patients' knowledge and activity. First, physicians should encourage patients to participate in diabetes education and argue that they can profit even if actual treatment and examination results are promising. Second, patients with other priorities, psychic comorbidity or functional limitations might profit more from continuous individualized education adapted to their specific situation instead of group education. Third, it might be justified that patients do not participate in diabetes education if they have slightly increased blood sugar values only and no risk for harmful consequences or if they already have sufficient knowledge on diabetes.
    PLoS ONE 04/2014; 9(4):e95035. DOI:10.1371/journal.pone.0095035 · 3.23 Impact Factor
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    ABSTRACT: It is not well established how psychosocial factors like social support and depression affect health-related quality of life in multimorbid and elderly patients. We investigated whether depressive mood mediates the influence of social support on health-related quality of life. Cross-sectional data of 3,189 multimorbid patients from the baseline assessment of the German MultiCare cohort study were used. Mediation was tested using the approach described by Baron and Kenny based on multiple linear regression, and controlling for socioeconomic variables and burden of multimorbidity. Mediation analyses confirmed that depressive mood mediates the influence of social support on health-related quality of life (Sobel's p < 0.001). Multiple linear regression showed that the influence of depressive mood (beta = -0.341, p < 0.01) on health-related quality of life is greater than the influence of multimorbidity (beta = -0.234, p < 0.01). Social support influences health-related quality of life, but this association is strongly mediated by depressive mood. Depression should be taken into consideration in research on multimorbidity, and clinicians should be aware of its importance when caring for multimorbid patients.Trial register: ISRCTN89818205.
    BMC Family Practice 04/2014; 15(1):62. DOI:10.1186/1471-2296-15-62 · 1.74 Impact Factor
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    ABSTRACT: We investigated the use of prescription and non-prescription (over-the-counter, OTC) analgesics and the associated risks in elderly patients with multiple morbidities. Pain medication use was evaluated from the baseline data (2008/2009) of the MultiCare cohort enrolling elderly patients with multiple morbidities who were treated by primary care physicians (trial registration: ISRCTN89818205). We considered opioids (N02A), other analgesics, and antipyretics (N02B) as well as nonsteroidal anti-inflammatory drugs (NSAIDs; M01A). OTC use, duplicate prescription, dosages, and interactions were examined for acetylsalicylic acid, diclofenac, (dex)ibuprofen, naproxen, and acetaminophen. Of 3,189 patients with multiple morbidities aged 65-85 years, 1,170 patients reported to have taken at least one prescription or non-prescription analgesic within the last 3 months (36.7 %). Of these, 289 patients (24.7 % of 1,170) took at least one OTC analgesic. Duplicate prescription was observed in 86 cases; 15 of these cases took the analgesics regularly. In two cases, the maximum daily dose of diclofenac was exceeded due to duplicate prescription. In 235 cases, patients concurrently took a drug with a potentially clinically relevant interaction. In 43 cases (18.3 % of 235) an OTC analgesic, usually ibuprofen, was involved. About one third of the elderly patients took analgesics regularly or as needed. Despite the relatively high use of OTC analgesics, the proportions of duplicate prescription, medication overdoses, and adverse interactions due to OTC products was low.
    Der Schmerz 04/2014; 28(2):175-82. DOI:10.1007/s00482-014-1415-5 · 1.50 Impact Factor

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3k Citations
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Institutions

  • 2004–2015
    • University Medical Center Hamburg - Eppendorf
      • Department of Primary Medical Care
      Hamburg, Hamburg, Germany
  • 2005–2014
    • University of Hamburg
      • Department of Primary Medical Care
      Hamburg, Hamburg, Germany
  • 2012
    • Cardiff University
      • School of Medicine
      Cardiff, Wales, United Kingdom
  • 2009–2012
    • Universität Bremen
      Bremen, Bremen, Germany
    • Universitetet i Tromsø
      • Department of Clinical Medicine (IKM)
      Tromsø, Troms, Norway
  • 2006
    • Klinikum Dortmund gGmbH
      Dortmund, North Rhine-Westphalia, Germany