Hanna Kaduszkiewicz

University Medical Center Schleswig-Holstein, Kiel, Schleswig-Holstein, Germany

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Publications (83)261.43 Total impact

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    ABSTRACT: The aim of the study was to investigate the psychometric properties of a Short Form of the Mini-Mental State Examination (SMMSE) for the screening of dementia in older primary care patients. Data were obtained from a large longitudinal cohort study of initially nondemented individuals recruited via primary care chart registries and followed at 18-month intervals. Item and scale parameters for MMSE and SMMSE scores were analyzed and cross-validated for 2 follow-up assessments (n1 = 2,657 and n2 = 2,274). Binary logistic regression and receiver-operating-characteristic (ROC) curve analyses were conducted in order to assess diagnostic accuracy parameters for MMSE and SMMSE scores. Cross-sectional differentiation between dementia-free and dementia patients yielded moderate to good results for MMSE and SMMSE scores. With regard to most diagnostic accuracy parameters, SMMSE scores did not outperform the MMSE scores. The current study provides first evidence regarding the psychometric properties of the SMMSE score in a sample of older primary care patients. However, our findings do not confirm previous findings that the SMMSE is a more accurate screening instrument for dementia than the original MMSE. Further studies are needed in order to assess and to develop short, reliable and valid instruments for routine cognitive screening in clinical practice and primary care settings. (PsycINFO Database Record (c) 2015 APA, all rights reserved).
    Psychological Assessment 03/2015; DOI:10.1037/pas0000076 · 2.99 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: Type 2 diabetes mellitus (T2DM) is a risk factor of dementia. The effect of T2DM treatment quality on dementia risk, however, is unclear. 1,342 elderly individuals recruited via general practitioner registries (AgeCoDe cohort) were analyzed. This study analyzed the association between HbA1c level and the incidence of all-cause dementia (ACD) and of Alzheimer's disease dementia (referred to here as AD). HbA1c levels ≥6.5% were associated with 2.8-fold increased risk of incident ACD (p = 0.027) and for AD (p = 0.047). HbA1c levels ≥7% were associated with a five-fold increased risk of incident ACD (p = 0.001) and 4.7-fold increased risk of incident AD (p = 0.004). The T2DM diagnosis per se did not increase the risk of either ACD or AD. Higher levels of HbA1c are associated with increased risk of ACD and AD in an elderly population. T2DM diagnosis was not associated with increased risk if HbA1c levels were below 7%.
    Journal of Alzheimer's disease: JAD 12/2014; DOI:10.3233/JAD-141521 · 3.61 Impact Factor
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    ABSTRACT: For general practioners (GP) the treatment of patients suffering from multimorbidity is an everyday challenge. For these patients guidelines which each focus on a specific chronic disease cannot be applied comprehensively and equally; therefore, it is necessary to prioritize.
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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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    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 · 3.53 Impact Factor
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    ABSTRACT: We compared the prevalence of dementia in nursing home residents and community-dwelling older adults . Using health insurance claims data for the year 2009, we estimated the prevalence of at least three of four quarters with a diagnosis of dementia in persons aged ≥65 years. Of 213,694 persons aged 65+ years, 4,584 (2.2 %) lived in nursing homes. The prevalence of dementia was 51.8 % (95 % CI 50.4-53.3) in nursing home residents and 2.7 % (95 % CI 2.6-2.8) in community-dwelling elderly. Increasing prevalences with age were found in both sexes in community-dwelling elderly. These trends were not seen in nursing home residents where prevalences were already high for the age group 65-69 years (35.7 % in males and 40.9 % in females, respectively). More than half of nursing home residents suffer from dementia, which is about 19-fold higher than the prevalence in insured living in the community.
    Aging - Clinical and Experimental Research 03/2014; 26(5). DOI:10.1007/s40520-014-0210-6 · 1.01 Impact Factor
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    ABSTRACT: PURPOSE The concept of mild cognitive impairment (MCI) has recently been introduced into the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) as mild neurocognitive disorder, making it a formal diagnosis. We investigated the prognostic value of such a diagnosis and analyzed the determinants of the future course of MCI in the AgeCoDe study (German Study on Ageing, Cognition, and Dementia in Primary Care Patients). METHODS We recruited 357 patients with MCI aged 75 years or older from primary care practices and conducted follow-up with interviews for 3 years. Depending on the course of impairment over time, the patients were retrospectively split into 4 groups representing remittent, fluctuating, stable, and progressive courses of MCI. We performed ordinal logistic regression analysis and classification and regression tree (CART) analysis. RESULTS Overall, 41.5% of the patients had remission of symptoms with normal cognitive function 1.5 and 3 years later, 21.3% showed a fluctuating course, 14.8% had stable symptoms, and 22.4% had progression to dementia. Patients were at higher risk for advancing from one course to the next along this spectrum if they had symptoms of depression, impairment in more than 1 cognitive domain, or more severe cognitive impairment, or were older. The result on a test of the ability to learn and reproduce new material 10 minutes later was the best indicator at baseline for differentiating between remittent and progressive MCI. Symptoms of depression modified the prognosis. CONCLUSIONS In primary care, about one-quarter of patients with MCI have progression to dementia within the next 3 years. Assessments of memory function and depressive symptoms are helpful in predicting a progressive vs a remittent course. When transferring the concept of MCI into clinical diagnostic algorithms (eg, DSM-5), however, we should not forget that three-quarters of patients with MCI stayed cognitively stable or even improved within 3 years. They should not be alarmed unnecessarily by receiving such a diagnosis.
    The Annals of Family Medicine 03/2014; 12(2):158-165. DOI:10.1370/afm.1596 · 4.57 Impact Factor
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    ABSTRACT: The evidence of undertreatment of pain in patients with dementia is inconsistent. This may largely be due to methodological differences and shortcomings of studies. In a large cohort of patients with incident dementia and age- and sex-matched controls we examined (1) how often they receive diagnoses indicating pain, (2) how often they receive analgesics and (3) in which agents and formulations. Using health insurance claims data we identified 1,848 patients with a first diagnosis of dementia aged >= 65 years and 7,385 age- and sex-matched controls. We analysed differences in diagnoses indicating pain and analgesic drugs prescribed between these two groups within the incidence year. We further fitted logistic regression models and stepwise adjusted for several covariates to study the relation between dementia and analgesics. On average, patients were 78.7 years old (48% female). The proportions receiving at least one diagnosis indicating pain were similar between the dementia and control group (74.4% vs. 72.5%; p = 0.11). The proportion who received analgesics was higher in patients with dementia in the crude analysis (47.5% vs. 44.7%; OR: 1.12; 95% CI: 1.01-1.24), but was significantly lower when adjusted for socio-demographic variables, care dependency, comorbidities and diagnoses indicating pain (OR: 0.78; 95% CI: 0.68-0.88). Analgesics in liquid form such as metamizole and tramadol were more often used in dementia. Our findings show a comparable documentation of diagnoses indicating pain in persons with incident dementia compared to those without. However, there still seems to be an undertreatment of pain in patients with dementia. Irrespective of dementia, analgesics seem to be more often prescribed to sicker patients and to control pain in the context of mobility.
    BMC Geriatrics 02/2014; 14(1):20. DOI:10.1186/1471-2318-14-20 · 2.00 Impact Factor
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    ABSTRACT: Working memory, the capacity of actively maintaining task-relevant information during a cognitive task, is a heritable trait. Working memory deficits are characteristic for many psychiatric disorders. We performed genome-wide gene set enrichment analyses in multiple independent data sets of young and aged cognitively healthy subjects (n = 2,824) and in a large schizophrenia case-control sample (n = 32,143). The voltage-gated cation channel activity gene set, consisting of genes related to neuronal excitability, was robustly linked to performance in working memory-related tasks across ages and to schizophrenia. Functional brain imaging in 707 healthy participants linked this gene set also to working memory-related activity in the parietal cortex and the cerebellum. Gene set analyses may help to dissect the molecular underpinnings of cognitive dimensions, brain activity, and psychopathology.
    Neuron 02/2014; 81(5). DOI:10.1016/j.neuron.2014.01.010 · 15.98 Impact Factor
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    ABSTRACT: We analyzed the differences in morbidity patterns of chronic diseases between long-term care dependent persons in nursing homes compared to those dwelling in the community. We also investigated morbidity differences between long-term care need stages in Germany. The study included claims data of one nationwide operating statutory health insurance in 2006. Inclusion criteria were age ≥ 65 years, minimum 1 out of 46 diagnoses in at least 3 quarters of the year (n = 8,670). A comparison population was formed with n = 114,962. Prevalences, relative risks, and odds ratios for the risk of nursing home care were calculated. In the bivariate analysis, only three chronic diseases - dementia, urinary incontinence, and chronic heart failure - showed a higher risk for nursing home care. Regression analysis revealed that only dementia showed higher odds related to the stage of nursing needs. Among the chronic diseases, only dementia shows a substantially elevated risk for nursing home care. Risk studies on other chronic diseases associated with higher risks of long-term care dependency and specific intervention strategies aiming at delaying or preventing nursing home admission should be developed.
    Zeitschrift für Gerontologie + Geriatrie 02/2014; DOI:10.1007/s00391-013-0556-y · 1.02 Impact Factor
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    ABSTRACT: Since the beginning of the 21st century, serious adverse events and an increased risk of mortality have been documented in patients with dementia treated with antipsychotics. The aim of this study was to assess antipsychotic prescribing in patients with incident dementia compared with a non-demented control group. We analysed the claims data of a German health insurance company for incident dementia patients and age-matched and sex-matched non-demented controls aged 65 years and older in 2004 to 2006. The data were used to analyse the prescribing patterns of antipsychotics in the year of dementia incidence. We estimated odds ratios stratified by age, sex, care setting and care dependence and in a multivariate logistic regression. The 1848 patients with and 7385 persons without dementia were on average 78.8 years old (standard deviation: 7.4), and 47.6% were women. A total of 25.4% of the dementia patients received antipsychotics compared with 4.3% of the controls (ORcrude : 7.61; 95%CI: 6.52-8.87). An increase in care level, age, female gender and living in a nursing home is associated with a considerably higher prevalence of at least one prescription for antipsychotics. After adjusting for all these variables, a significant influence of age could no longer be found. The results show that antipsychotics play an important role in dementia care-despite the risk of adverse events. Further research is needed with regard to safe pharmacological and non-pharmacological approaches for the behavioural and psychological symptoms of dementia in this vulnerable group. Copyright © 2013 John Wiley & Sons, Ltd.
    Pharmacoepidemiology and Drug Safety 12/2013; 22(12). DOI:10.1002/pds.3527 · 3.17 Impact Factor
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    ABSTRACT: Objective: On the basis of data from one German Sickness Fund we analyzed which medical discipline coded the incident diagnosis of dementia in ambulatory medical care in Germany, which type of dementia was coded and how the initial code eventually changed during the year of incidence.Methods: Claims data of 1,848 insured people aged ≥ 65 years in 2004 with incident dementia were analyzed by means of descriptive statistics.Results: The diagnosis within the first quarter of the incidence year was coded by the GP in 71 %, by a psychiatrist or neurologist in 14 %, by both in 6 % and by other disciplines in 9 % of the cases. The percentage of unspecified diagnoses was 62 % among GPs and 46 % among psychiatrists or neurologists, a number differing largely from epidemiological studies. In 27 % of the cases patients received two or more different dementia diagnoses during the incidence year.Conclusion: Studies and care concepts regarding dementia on the basis of diagnosis codes in ambulatory claims data should be interpreted with great caution.
    Psychiatrische Praxis 09/2013; 41(6). DOI:10.1055/s-0033-1349505 · 1.64 Impact Factor
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    ABSTRACT: Hintergrund Ältere Menschen sind oftmals durch mehrere Krankheiten belastet. Mit der daraus resultierenden mehrfachen Medikamenteneinnahme steigt das Risiko für unerwünschte Arzneimittelereignisse. Mit Wirkstofflisten (Beers-Liste, PRISCUS-Liste) soll dieses Risiko für ältere Patienten reduziert werden. Wir stellen hier eine längsschnittliche Analyse (4,5 Jahre) zur Einnahme potenziell inadäquater Medikamente (PIM) in einer Kohorte von hausärztlichen Patienten im Alter von ≥ 75 Jahren vor. Methoden Die Daten wurden für die prospektive, multizentrische Beobachtungsstudie „German Study on Ageing, Cognition and Dementia in Primary Care Patients (AgeCoDe)“ bei initial 3327 Patienten erhoben. Über eine Medikamentenanamnese bei den Patienten zu Hause ermittelten wir die Häufigkeit der PIM-Einnahme und analysierten die Anteile einzelner PIM-Wirkstoffgruppen über die Zeit. Ergebnisse Gemäß der PRISCUS-Liste betrug der Anteil von Patienten mit PIM-Einnahme zu Studienbeginn 28,7 % und sank 4,5 Jahre später auf 25,0 % (χ2: 7,87; p = 0,004). Gemessen an der Beers-Liste lag der Anteil zu Beginn bei 21,0 % und nahm 4,5 Jahre später auf 17,1 % ab (χ2: 10,77; p = 0,000). Das zeitabhängige Mehrebenenmodell bestätigt dies. Hohes Alter, Depression und die Einnahme vieler rezeptpflichtiger Medikamente sind unabhängige Risikofaktoren für eine PIM-Einnahme gemäß PRISCUS-Liste. Diskussion Wir sehen in unseren Ergebnissen einen Trend zur rationaleren Arzneimitteltherapie, weil weniger älteren Patienten PIM verordnet werden. Dies senkt das Risiko für unerwünschte Wirkungen und Nebenwirkungen und die dafür aufzuwendenden Kosten.
    Bundesgesundheitsblatt - Gesundheitsforschung - Gesundheitsschutz 07/2013; 56(7). DOI:10.1007/s00103-013-1767-5 · 1.01 Impact Factor
  • The American journal of managed care 06/2013; 19:499-506. · 2.17 Impact Factor
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    ABSTRACT: Dementia patients suffering from behavioral and psychological symptoms (BPSD) are often treated with antipsychotics. Trial results document an increased risk for serious adverse events and mortality in dementia patients taking these agents. Furthermore, the efficacy of treating BPSD with antipsychotics seems to be only modest. Using data of a German statutory health insurance company, we examined prescription trends of antipsychotics in prevalent dementia patients in the context of official warnings. The study period is 2004-2009. We studied trends in demographics, age and sex, as well as need of care and the intake of typical and atypical antipsychotics. Seeking for linear trends adjusted for age, sex and level of care between 2004 and 2009, we obtained p-values from a multivariate logistic regression. Prescription volumes were calculated by number of packages as well as defined daily doses (DDDs) using multiple linear regressions for trends in prescriptions amount. We included 3460-8042 patients per year (mean age 80 years). The prescription prevalence of antipsychotics decreased from 35.5% in 2004 to 32.5% in 2009 (multivariate analysis for linear trend: p=0.1645). Overall prescriptions for typical antipsychotics decreased (from 27.2% in 2004 to 23.0% in 2009, p<0.0001) and prescriptions for atypical antipsychotics increased from 17.1% to 18.9% (p<0.0001). The mean DDD per treated patient increased from 80.5 to 91.2 (2004-2009; p=0.0047). Our findings imply that warnings of international drug authorities and manufacturers against adverse drug events in dementia patients receiving antipsychotics did not impact overall prescription behavior.
    European neuropsychopharmacology: the journal of the European College of Neuropsychopharmacology 03/2013; DOI:10.1016/j.euroneuro.2013.02.001 · 5.40 Impact Factor
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    ABSTRACT: OBJECTIVE: To compare the risk of developing Alzheimer's disease (AD) dementia in late mild cognitive impairment (LMCI), early MCI (EMCI), and subjective memory impairment (SMI) with normal test performance. METHODS: The baseline sample (n = 2892) of the prospective cohort study in nondemented individuals (German Study on Aging, Cognition and Dementia in Primary Care Patients) was divided into LMCI, EMCI, SMI, and control subjects by delayed recall performance. These groups were subdivided by the presence of self-reported concerns associated with experienced memory impairment. AD dementia risk was assessed over 6 years. RESULTS: Across all groups, risk of AD dementia was greatest in LMCI. In those with self-reported concerns regarding their memory impairment, SMI and EMCI were associated with a similarly increased risk of AD dementia. In those subgroups without concerns, SMI was not associated with increased risk of AD dementia, but EMCI remained an at-risk condition. CONCLUSIONS: SMI and EMCI with self-reported concerns were associated with the same risk of AD dementia, suggesting that pre-LMCI risk conditions should be extended to SMI with concerns.
    Alzheimer's & dementia: the journal of the Alzheimer's Association 01/2013; 10(1). DOI:10.1016/j.jalz.2012.09.017 · 17.47 Impact Factor
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    ABSTRACT: Background The authors report the results of a study on frequent attenders in ambulatory medical care among elderly people in Germany and on the factors related to frequent attendance such as age, sex, multi-morbidity and long-term care dependency. Methods The study was based on claims data of all policy holders aged 65 and over of a statutory health insurance company operating nationwide in Germany in 2004 (n = 123,224). Utilisation was analysed by the number of contacts with practices of physicians working in the ambulatory medical care sector and by the number of different practices contacted. The criteria for frequent attendance included greater than or equal to 50 contacts and/or greater than or equal to 10 different practices contacted and/or greater than or equal to 3 practices of the same discipline contacted within one year. Descriptive statistical analysis and logistic regression were used. Results 19% of the elderly were identified as frequent attenders, which corresponds to some 3.5 million people in Germany. Two main types of frequent attendance were identified: one is characterised by very many contacts, old age, frequent presence of multi-morbidity, and/or long-term care dependency. The other type is the younger, less frequently multi-morbid attender who is considerably less often dependent on long-term care, and characterised by large numbers of contacted practices and/or practices of the same discipline. Conclusion Frequent attendance is due to several factors. The problem of frequent attendance needs further research that is not exclusively based on claims data. We found a high rate of frequent attendance. Further research should clarify if this is to the benefit of elderly people.
    Zeitschrift für Evidenz Fortbildung und Qualität im Gesundheitswesen 01/2013; 107(7):435–441. DOI:10.1016/j.zefq.2012.12.025
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    ABSTRACT: Frequent attenders utilise a high proportion of medical services and therefore produce relatively high costs. Questions of utility and adequacy and, also, about the reasons for high use arise. The authors report the results of a study on the association between morbidity of the elderly and various forms of frequent attendance in ambulatory medical care in Germany. The study is based on claims data of all policyholders aged 65 and over of a statutory health insurance company operating nationwide in Germany in 2004 (n = 123,224). Utilisation was analysed by the number of contacts with practices of physicians working in the ambulatory medical care sector and by the number of different practices contacted. Criteria for frequent attendance were ≥ 50 contacts with practices or contacts with ≥ 10 individual practices or ≥ 3 practices of the same discipline per year. We analysed prevalences and relative risks for frequent attendance for 46 chronic diseases. Frequent attendance in ambulatory medical care among the elderly is related to both severe somatic and psychic diagnoses. Five chronic diseases showed the highest relative risks for all types of frequent attendance in general: urinary incontinence, anaemia, neuropathies, renal insufficiency, and cancer. Psychic syndromes mainly led to the utilisation of many different physicians. Frequent attendance in ambulatory medical care among the elderly is related to a large number of diseases, both somatic and psychic. Frequent attendance is a complex phenomenon which cannot be addressed by mono-dimensional approaches.
    01/2013; 107(7):442-50. DOI:10.1016/j.zefq.2013.09.001

Publication Stats

1k Citations
261.43 Total Impact Points


  • 2014
    • University Medical Center Schleswig-Holstein
      Kiel, Schleswig-Holstein, Germany
  • 2007–2014
    • University Medical Center Hamburg - Eppendorf
      • • Department of Primary Medical Care
      • • Center for Psychosocial Medicine
      Hamburg, Hamburg, Germany
  • 2010
    • University of Bonn
      Bonn, North Rhine-Westphalia, Germany
  • 2009
    • Universität Bremen
      Bremen, Bremen, Germany
  • 2007–2008
    • University of Hamburg
      • Department of Primary Medical Care
      Hamburg, Hamburg, Germany