Dementia diseases between medicine and nursing - difficulties for health care research

Using the example of dementia-related illnesses, the Barmer-GEK Care Report 2010 implicitly shows an essential dilemma in health services research: On the one hand, the diverse interdependencies between care and dementia are very well illuminated, and on the other hand, the broader connections between medicine, care and dementia can be presented, but on the other hand The presentation is only of limited use because billing data from outpatient and statutory health care is becoming less and less useful for making statements about the quality of care. This is becoming an increasing challenge for health insurance companies and the health system: How can the performance data from outpatient and statutory health care be meaningfully used for health services research?

>> The extrapolated facts leave no doubt: in 2060 there will be 2.5 million people with dementia living in Germany (today there are 1.2 million people), but in just under 50 years, according to the 12th coordinated population forecast, there will only be a maximum of 70 million people live in Germany (Federal Statistical Office, Wiesbaden 2009). Society must prepare for this foreseeable challenge today. In this respect, reforms to long-term care insurance are also necessary to ensure sustainable financing.
This article aims to examine what the situation is with the interface between medicine and care in dementia, because this topic is becoming more topical because the care pillar will have an immense burden and the question is: Will all other resources be mobilized? in the sense of diagnosis, therapy and rehabilitation in order to reduce the bottleneck in care?

Four aspects should be examined:
1. What is the frequency of medical treatment?
2. What is the supply of medicines like?
3. How important is occupational and movement therapy?
4. Dementia-specific care costs - what are the cost drivers?
Since the database in the area of medical care services comes from 2009 (in the area of medicinal product regulations from 2008), the conclusions can be drawn from current surveys.
Medical treatment frequency
Some previous publications (e.g. SÄVIP study on medical care in nursing homes, Hanover 2005) have already examined how intensive medical care is in inpatient care facilities; There was a high frequency of contact in general medical care, but a significantly reduced presence of other specialist medical disciplines in the nursing home, for example neurologists, psychiatrists, urologists, gynecologists and ophthalmologists.
In this respect, the 2010 Nursing Report offers the opportunity to examine: has there been a change in medical care? Especially since the 2010 care report carried out more comprehensive research by also looking at patients who are not in need of care but who are demented or those suffering from dementia who are in need of care - differentiated between informal and inpatient care. Table 1 shows an example of the number of treatment cases from the field of general medicine, broken down according to the patient groups shown.
Table 1 shows a relatively unspectacular result, a treatment case of around 1 per quarter in old and very old people is no surprise, and this uniform picture is confirmed by a differentiated analysis according to age and gender groups - see the following Figure 1.
This apparently very homogeneous treatment situation only arises in the representation, but not in the reality of treatment, because in order to assess the quality of medical care for people in need of care and for people with dementia, it is the frequency of contact with the doctor that is important and not the Treatment cases.
To clarify this, the care report states: “The number of medical treatment cases is determined from the billed cases from the outpatient and medical care data for 2009. All services provided to a patient by a specific doctor within a quarter usually constitute a treatment case (Grobe et al. 2007: 34). Multiple contacts can occur within one treatment case.”
[Note: Emphasis by the author] (Rothgang et al. 2010).

This means that the doctor/patient contacts can vary considerably within the patient groups under consideration without this being noticeable in the display.
The chapter heading “Treatment Frequency” chosen in the nursing report is irritating because the casual reader assumes the number of patient contacts behind it based on the usual language usage.
The same lack of clarity arises when considering the frequency of treatment by specialists. It is not surprising that the frequency of treatment is significantly lower among the group of neurologists and psychiatrists - as well as among other specialists. However, since the treatment contacts cannot be identified, the knowledge value for presenting the interface problem between medicine and nursing is relatively low (Table 2).
The data from Table 2 tend to show that people with dementia require and receive neurological/psychiatric treatment more often, but even among demented patients, the average number of treatment cases with this group of specialists is less than 1 per six months. It is doubtful that this corresponds to adequate medical care (see Hallauer et al. 2005).
The presentation of the treatment cases under the heading of “other specialists” is of dubious informative value; The serious question arises as to what conclusions can be made when treatment data from completely different specialists such as internists, radiologists, ophthalmologists, urologists, ear, nose and throat specialists and orthopedists are combined in one group (Rothgang et al. 2010 , p. 207).
Even if this group formation is not very meaningful because of the different area names, the age-stratified analysis shows that for men and women the number of treatment cases decreases almost without exception with each further higher level of care (see Fig. 2).
The question arises: Does the medical care pattern still follow a traditional image of aging? Or will medical care be reduced as care becomes more professional?
It was necessary that the sixth report on the situation of the older generation in the Federal Republic of Germany deals with the images of aging in society; Regarding the role of images of aging in health care, it says: “The professionals’ ideas about age determine their actions in dealing with older people and determine the design of care and thus the use of existing potential.”*
It is not surprising if some diagnostic and treatment guidelines are only followed to a limited extent.
Overall, the 2010 nursing report states the following about the frequency of treatment for those in need of care and patients with dementia: The presentation of the frequency of medical treatment based on billed quarterly cases is certainly not suitable for making a statement about the quality and intensity of the collaboration between nursing and medicine. This may not have been the aim of the authors of the report, but both would be desirable so that usable and meaningful information can be generated.
With the publication of the Berlin Aging Study and other studies, it is known that people over 70 need a family doctor six to seven times in the course of a quarter. Whether this required contact density is reflected in the data from the treatment cases cannot be approximately determined (see Table 3).
In particular, due to the extensive flat rate pricing for medical services, the number of contacts between an outpatient doctor and the patient cannot be adequately represented using billing data. But the focus is not on the presentation; in fact, the generalization of medical services affects geriatric medical care in particular.
The flat rate fees from the AOK family doctor contract in Baden-Württemberg show, as an example, that this remuneration contradicts the wish and need of the very old patient to consult the treating contracted doctor more often per quarter (AOK family doctor contract in Baden-Württemberg, Stuttgart 2008) (see Table 4 ).
In this respect, an initiative by the AOK Baden-Württemberg and the Baden-Württemberg General Practitioners Association to supplement the contract concluded in 2008 as part of a model project by providing additional fees for visits to nursing homes is to be welcomed. This correction is overdue, because deficits in outpatient care accelerate spending on inpatient care (contract for networking medical and nursing care in nursing homes in the model regions Esslingen and Stuttgart dated January 12, 2011).
Drug care for dementia
The information on drug supply is based on the statutory health insurance prescription (the actual consumption cannot be derived) and is summarized in the number of defined daily doses (DDD). This is a calculation quantity that should not be confused with the prescribed dose. The following data represents prescription quantities of the respective drug groups per quarter for the respective defined patient groups.
In general, the 2010 nursing report also shows that the undersupply of anti-dementia drugs continues.
In addition, some inconsistencies and breaks are becoming apparent in the supply of medicines, which have little in common with guideline-oriented quality of care.
Using the example of acetylcholinesterase inhibitors, the data from Table 5 shows that the more institutionalized the care, the lower the level of care in Alzheimer's therapy. The indicative focuses of this group of preparations can only partially explain these discrepancies, as can be seen from the following example of Memantine.
A comparable picture emerges with the active ingredient Memantine. Although the active ingredient is approved throughout Europe for the indication range of moderate to severe Alzheimer's disease, the inverse relationship becomes clear: the more intensive the care, the lower the extent of drug therapy (see Table 6).
The gender and age-specific discrepancy in the supply of memantine is striking: Patients in care level II receive less and less DDD according to increasing age groups: 60 to 69-year-old women 11.3 DDD, 90-year-olds and older only 2.2 DDD . This delta of 9.1 is hardly found in the same level of care for men with only 1.2 DDD.
Since the dementia problem is primarily a problem for women from a prevalence perspective, this discrepancy is of particular interest in terms of care policy. It cannot be ruled out that men are better cared for in old age because they are less likely to experience widowhood than women; the caretaker is missing. Of the women over 80, 78.4 % are widowed, but only 34.8 % of men in this age group are widowers (Fourth Report on the Situation of the Older Generation in the Federal Republic of Germany, Berlin 2002).
Occupational and movement therapy
The disruptions in care described above are also identified in the nursing report in the area of occupational and exercise therapy. Across all groups, people in need of care receive 0.7 occupational therapy units compared to people in need of care who also suffer from dementia (0.2 units). There is also a gender discrepancy in occupational therapy. With 1.0 prescribed units, men receive around 0.4 units more than women.
A comparable picture can be seen with physiotherapy (physical therapy): people who are not in need of care and have dementia at the same time receive 0.9 units, but only people in need of care without dementia receive 5.2 units and people in need of care with dementia receive 3.7 units. Since exercise therapy in particular helps to stabilize residual potential in people with dementia, the withholding of these useful additional measures is incomprehensible, especially since several studies clearly indicate that medical rehabilitation is also beneficial for people with dementia (see, for example, 1. Welz -Barth A, Stella S, Füsgen I, Frequency of cognitive disorders in geriatric rehabilitation, phys rehab Kur Med 2007; 17: 94-97.2.Volicer l, Hurley A, Alzheimer Disease and Disorders Vol. 11, 1997, Lippincott Raven Publishers, Philadelphia).
Costs of dementia
The dementia-specific expenses of the statutory health and nursing care insurance cannot easily be allocated according to causation, because any mono-causal allocation is subject to errors due to the increasing multimorbidity in older age groups.
“According to the Berlin Aging Study, the prevalence of at least five co-existing diseases among people over 70 years of age and older is 88 %” (Sachversicherenrat 2009).
In the BARMER/GEK care report 2010, the expenses of the health insurance company and the nursing care insurance company are not only differentiated according to age groups and gender, but the expenses per insured person are also examined according to whether dementia is present or not. This means that the main expenditure blocks within the health insurance company and the nursing care insurance fund as a whole can be analyzed to determine which dementia-specific additional costs arise. This pragmatic approach is helpful, and from this perspective the report is a very good and up-to-date basis for health economics.

However, this approach ignores two aspects:
• The considerable care expenses incurred by family members do not cause primary expenses within the social security systems, but the exhaustion of the caring family members causes illnesses and sickness-related absences from work, which subsequently place a burden on health insurance companies.
• There is an inexactly quantifiable proportion of people with dementia who have never been diagnosed by a doctor and given specific treatment, but for whom the symptoms of dementia are unmistakable. This group of insured persons and patients inevitably leads to incorrect expenditure allocations (see in particular the analysis by the German Society for Geriatric Psychiatry and Psychotherapy (DIAS) 2008).
In a detailed analysis of the data presented by Rothgang et al. Data on service expenditure in relevant sectors summarized in 2010 is striking: the additional costs attributable to dementia are particularly significant in the area of inpatient hospital costs and care costs.
The dementia-specific additional costs in the area of outpatient medical care - and this applies to both medical care and drug expenditure - are comparatively low.
Please note:
• The delta in dementia-specific additional costs in outpatient medical care on the one hand and the considerable dementia-related additional costs in the hospital sector suggest that the fee incentives for additional visiting activities in nursing homes and senior living complexes should be increased. Examining this interface closely in the future, also with regard to actual doctor/patient contacts, is extremely important in terms of health care policy, and these aspects would have to be analyzed in the follow-up reports.
• Whether the contracted doctors care for a demented or non-demented patient only means a very small difference in the average monthly fee volume for the contracted doctor's work - in this respect, the data in Table 8 cannot be analyzed intensively enough. This is a key finding from the 2010 nursing report. This small difference in fees does not motivate people to seek medical care. The delta in average hospital costs between very old people with and without dementia is all the greater.
• The BARMER/GEK care report 2010 only looks at the expenditure blocks “health insurance” and “nursing care insurance”, but if one generally analyzes the expenditure on medical care and the expenditure on nursing care, it must also be taken into account that, for example: B. In 2007, social welfare providers provided a net total of 2.7 billion euros for care assistance. This means that the society's expenditure block for nursing care will be even larger in relation to medical care (see press release from the Federal Statistical Office destatis No. 460 from December 2, 2008).
Summary
The 2010 Care Report is an important data collection that sheds light on the relationship between dementia and care; The presentation of medical care should be improved because it is important to show the actual number of contacts between the treating doctor and the patients being treated. The deficits that were already described in the SÄVIP study probably persist: suboptimal specialist medical care in inpatient care facilities. In addition, a gender problem is emerging in the provision of suitable anti-dementia medication, which affects patients' care.
With the nursing report, a development becomes obvious: the more severe the stage of the disease, the higher the level of nursing care, the older the patient, the lower the overall level of statutory health care. Analyzing this will not be enough in the future. In fact, in many cases the security mandate is not carried out in outpatient medical care. 11,000 nursing homes with over 700,000 residents is no small feat!
In the future, it must be more attractive for outpatient doctors to provide medical care to old people who receive informal or inpatient care. Flat-rate medical fees or falling point values in medical fees tend to have a counterproductive effect, because the care report clearly shows that two cost blocks are still overwhelming: inpatient hospital stays and care costs. Hospital costs in particular can be reduced by increasing outpatient medical activity. The Berlin model has proven this for years (Kotek, H. 2006). As long as the medical “arm” is not strengthened in parallel with care, care will not be relieved. In this respect, it is important in the future not only to view care in isolation as a challenge, but also to examine how the burden of care can be meaningfully reduced through outpatient medical care. <<