Morbidity and mortality after surgery for lower urinary tract symptoms: a study of 95 577 cases from a nationwide German health insurance database.

BACKGROUND: Little real-world data is available on the comparison of different methods in surgery for lower urinary tract symptoms due to benign prostatic obstruction in terms of complications. The objective was to evaluate the proportions of TURP, open prostatectomy (OP) and laser-based surgical approaches over time and to analyse the effect of approach on complication rates. METHODS: Using data of the German local healthcare funds (Allgemeine Ortskrankenkassen (AOK)), we identified 95 577 cases with a primary diagnosis of hyperplasia of prostate who received TURP, laser vaporisation (LVP), laser enucleation (LEP) of the prostate or OP between 2008 and 2013. Univariable logistic regression was used to analyse proportions of surgical approach over time, and the effect of surgical method on outcomes was analysed by means of multivariable logistic regression. RESULTS: The proportion of TURP decreased from 83.4% in 2008 to 78.7% in 2013 (P<0.001). Relative to TURP and adjusting for age, co-morbidities, AOK hospital volume, year of surgery and antithrombotic medication, OP had increased mortality (odds ratio (OR) 1.47, P<0.05), transfusions (OR 5.20, P<0.001) and adverse events (OR 2.17, P<0.001), and lower re-interventions for bleeding (OR 0.75, P<0.001) and long-term re-interventions (OR 0.55, P<0.001). LVP carried a lower risk of transfusions (OR 0.57, P<0.001) and re-interventions for bleeding (OR 0.76, P<0.001), but a higher risk of long-term re-interventions (OR 1.43, P<0.001). LEP had increased re-interventions for bleeding (OR 1.35, P<0.01). Complications were also dependent on age and co-morbidity. Limitations include the lack of clinical information and functional results. CONCLUSIONS: OP has the greatest risks of complication despite a low re-intervention rate. LVP demonstrated favourable results for transfusion and bleeding, but increased long-term re-interventions compared with TURP, while LEP showed increased re-interventions for bleeding. Findings support a careful indication and choice of method for surgery for LUTS, taking age and co-morbidities into account.

Volume-outcome relationship in pancreatic surgery.

BACKGROUND: Volume-outcome relationships related to major surgery may be of limited value if observation ends at the point of discharge without taking transfers and later events into consideration. METHODS: The volume-outcome relationship in patients who underwent pancreatic surgery between 2008 and 2010 was assessed using claims data for all inpatient episodes from Germany's largest provider of statutory health insurance covering about 30 per cent of the population. Multiple logistic regression models with random effects were used to analyse the effect of hospital volume (using volume quintiles) on 1-year mortality, adjusting for age, sex, primary disease, type of surgery and co-morbidities. Additional outcomes were in-hospital (including transfer to other hospitals until final discharge) and 90-day mortality. RESULTS: Of 9566 patients identified, risk-adjusted 1-year mortality was significantly higher in the three lowest-volume quintiles compared with the highest-volume quintile (odds ratio 1·73, 1·53 and 1·37 respectively). A similar, but less pronounced, effect was demonstrated for in-hospital and 90-day mortality. The effect of hospital volume on 1-year mortality was comparable to the effect of co-morbid conditions such as renal failure. CONCLUSION: Although mortality related to pancreatic surgery is influenced by many factors, this study demonstrated lower mortality at 1 year in high-volume centres in Germany.

Age of major depression onset, depressive symptoms, and risk for subsequent dementia: results of the German study on Ageing, Cognition, and Dementia in Primary Care Patients (AgeCoDe).

BACKGROUND: Whether late-onset depression is a risk factor for or a prodrome of dementia remains unclear. We investigated the impact of depressive symptoms and early- v. late-onset depression on subsequent dementia in a cohort of elderly general-practitioner patients (n = 2663, mean age = 81.2 years). METHOD: Risk for subsequent dementia was estimated over three follow-ups (each 18 months apart) depending on history of depression, particularly age of depression onset, and current depressive symptoms using proportional hazard models. We also examined the additive prediction of incident dementia by depression beyond cognitive impairment. RESULTS: An increase of dementia risk for higher age cut-offs of late-onset depression was found. In analyses controlling for age, sex, education, and apolipoprotein E4 genotype, we found that very late-onset depression (aged ≥ 70 years) and current depressive symptoms separately predicted all-cause dementia. Combined very late-onset depression with current depressive symptoms was specifically predictive for later Alzheimer's disease (AD; adjusted hazard ratio 5.48, 95% confidence interval 2.41-12.46, p < 0.001). This association was still significant after controlling for cognitive measures, but further analyses suggested that it was mediated by subjective memory impairment with worries. CONCLUSIONS: Depression might be a prodrome of AD but not of dementia of other aetiology as very late-onset depression in combination with current depressive symptoms, possibly emerging as a consequence of subjectively perceived worrisome cognitive deterioration, was most predictive. As depression parameters and subjective memory impairment predicted AD independently of objective cognition, clinicians should take this into account.

[Costs of illness in dementia from a societal perspective. An overview]. / Krankheitskosten bei Demenz aus gesellschaftlicher Perspektive. Eine Übersicht.

Dementias are one of the most expensive disease groups among the population aged 65 years and over. This is mainly due to the patients' deficits in activities of daily living which increase with the progression of dementia, leading to an increasing need for care. As a result, the costs of dementia may more than double over the course of the disease. The costs of medical care account for a relatively small share of total costs and are not greatly influenced by disease severity. By contrast, the costs of care make up at least three quarters of total costs in the majority of studies. When patients are cared for in the community, most of the care is often provided informally by relatives. Accordingly, up to 75 or 80% of the costs of illness in this setting, from a societal perspective, may be due to informal care. Additional professional home care accounts for a relatively small share of total costs. The costs of caring for patients who live in the community are directly related to the degree of functional impairment. By contrast, it can be difficult to estimate the costs which are specifically due to dementia in patients that are institutionalised.

Assessing cognitive changes in the elderly: reliable change indices for the Mini-Mental State Examination.

OBJECTIVE: The diagnosis of dementia includes evidence of decline in cognitive functioning over time measured by objective cognitive tasks. Normative data for changes adjusted for the impact of socio-demographic factors on cognitive test performance are lacking to interpret changes in Mini-Mental State Examination (MMSE) test scores. METHOD: As part of the German Study on Ageing, Cognition and Dementia in Primary Care Patients (AgeCoDe Study), a sample of 1090 cognitively healthy individuals, aged 75 years and older, was assessed at 1.5-year intervals over a period of 4.5 years using the MMSE. Age- and education-specific Reliable Change Indices (RCIs) were computed. RESULTS: Age and education were significantly associated with MMSE test performance, and gender indicated no impact. Across different age and education subgroups, changes from at least 2 up to 3 points indicated significant (i.e., reliable) changes in MMSE test scores at the 90% confidence level. Furthermore, the calculation of RCIs for individual patients is demonstrated. CONCLUSION: This study provides age- and education-specific MMSE norms based upon RCI methods to interpret cognitive changes in older age groups. The computation of RCI scores improves the interpretation of changes in MMSE test scores by controlling for measurement error, practice effects, or regression to the mean.

Net costs of dementia by disease stage.

OBJECTIVE: To estimate net costs of dementia by degree of severity from a societal perspective, including a detailed assessment of costs of formal and informal nursing care. METHOD: In a cross-sectional study, costs of illness were analysed in 176 dementia patients and 173 matched non-demented control subjects. Healthcare resource use and costs were assessed retrospectively by means of a questionnaire. Dementia patients were classified into three disease stages, and linear regression models were applied to estimate net costs of dementia by degree of severity. RESULTS: Annual net costs of dementia by stage were approximately €15 000 (mild), €32 000 (moderate) and €42 000 (severe), corresponding to US-$21 450, 45 760 and 60 060 respectively. Across disease stages, nursing care accounted for approximately three-quarters of total costs, of which half resulted from informal care. In sensitivity analyses using different valuation methods for nursing care, total costs decreased or increased by more than 20%. CONCLUSION: Net costs more than double across stages of dementia. Informal care accounts for a considerable share of nursing care costs, and the approach to valuation of informal care has a large impact on cost-of-illness estimates.

Critical evaluation of self-rated quality of life in mild cognitive impairment and Alzheimer's disease--further evidence for the impact of anosognosia and global cognitive impairment.

OBJECTIVES: The present study investigates the effect of anosognosia (impaired insight for an illness) and cognitive deficits on the reliability and validity of self-rated Quality of Life (QoL) in Mild Cognitive Impairment (MCI) and Alzheimer's Disease (AD). DESIGN: Cross-sectional study. SETTING: Cross-sectional study with a consecutive clinical sample from a memory clinic in Leipzig (Germany). SUBJECTS: 27 patients (aged 65 years or above) with a diagnosis of either MCI (N=12) or AD (N=15), each together with a caregiver. MEASUREMENTS: The patients' QoL was measured using the Dementia Quality of Life self and proxy ratings (DEMQoL and DEMQoLproxy). The degree of anosognosia was rated by means of the Clinical Insight Rating Scale (CIR). In addition the Mini-Mental-State Examination (MMSE), and for diagnostic purposes the Bayer Activities of Daily Living Scale (B-ADL) and the Consortium to Establish a Registry of Alzheimer;s Disease (CERAD) word list were applied. RESULTS: In accordance with the results of Ready et al. (1), patients with impaired insight were found to produce less reliable QoL ratings than those with unimpaired insight. The validity (concordance between self- and proxy QoL ratings) is influenced by cognitive deficits, anosognosia and the interaction between these factors. CONCLUSIONS: Data which are based on dementia patients' QoL self-ratings need to be interpreted with caution when anosognosia is present.