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Background and Objective: Empirical data, representative of the total population, are necessary for medico-actuarial risk calculations. Our study compares mortalities of long-term care (LTC) patients who are covered by statutory health insurance with regard to age and distribution of care levels when in home or institutional care with a special focus on whether rehabilitative care was performed., Methods: The data of 88,575 LTC patients were analyzed longitudinally for 10 years, using routine data analyses on the files of the German Federal Health Insurance fund (average observation period 2.5 years, a total of 221,625 observation years). The numbers of LTC patients and their care levels while in home or institutional care were calculated, as were any changes to another care level or discontinuation of LTC benefits (as a result of the need for care falling below the eligibility criteria for care leveI or to death) during 1-10 years after the onset of LTC, always with respect to whether rehabilitative care had taken place or not. For the evaluation of care factors an indicator was developed., Results: Total mortality was found to decline and reactivation to increase considerably for LTC patients after rehabilitation, basically irrespective of their age or care level and in home or institutional care settings as well. Ten years after the onset of care, 30.7 % of the patients with rehabilitation were still in nursing care, 9.8 % were reactivated and 59.5 % deceased. In contrast, only 9.2 % were still in nursing care, 3.7 % reactivated and 87.1 % deceased without rehabilitation. These results are irrespective of age distribution, care level, and residence in home or institutional care settings. The care status of patients, measured by the percentage in reactivation, care level I-III, and death, substantially depends on age at onset and care level and in addition on rehabilitative procedures. Hypotheses for further research are outlined., Conclusion: Rehabilitation has a clear-cut potential for life extension as well as reducing or detaining long-term care if applied to (LTC) patients. The group of rehabilitated LTC patients has a comparatively higher degree of reducing or resolving LTC up to a complete reactivation or prolonging of life in spite of care needed. A successful rehabilitative effect occurs over all age groups and all care levels during home care considerably as well as during institutional care to a lower extent. Differentiation between the age at onset of LTC, care level, and first year and follow-up mortalities is recommended as well as between rehabilitated and nonrehabilitated care patients when undertaking medico-actuarial calculations.

Background: Anxiety and depression are the most common psychiatric disorders and are the cause of a large and increasing amount of sick-leave in most developed countries. They are also implicated as an increasing mortality risk in community surveys. In this study we addressed, whether sick leave due to anxiety, depression or comorbid anxiety and depression was associated with increased risk of retirement due to permanent disability and increased mortality in a cohort of German workers., Methods: 128,001 German workers with statutory health insurance were followed for a mean of 6.4 years. We examined the associations between 1) depression/anxiety-related sick leave managed on an outpatient basis and 2) anxiety/depression-related psychiatric inpatient treatment, and later permanent disability/mortality using Cox proportional hazard regression models (stratified by sex and disorder) adjusted for age, education and job code classification., Results: Outpatient-managed depression/anxiety-related sick leave was significantly associated with higher permanent disability (hazard ratio (95% confidence interval)) 1.48 (1.30, 1.69) for depression, 1.25 (1.07, 1.45) for anxiety, 1.91 (1.56, 2.35) for both). Among outpatients, comorbidly ill men (2.59 (1.97,3.41)) were more likely to retire early than women (1.42 (1.04,1.93)). Retirement rates were higher for depressive and comorbidly ill patients who needed inpatient treatment (depression 3.13 (2,51, 3,92), both 3.54 (2.80, 4.48)). Inpatient-treated depression was also associated with elevated mortality (2.50 (1.80, 3.48)). Anxiety (0.53 (0.38, 0.73)) and female outpatients with depression (0.61 (0.38, 0.97)) had reduced mortality compared to controls., Conclusions: Depression/anxiety diagnoses increase the risk of early retirement; comorbidity and severity further increase that risk, depression more strikingly than anxiety. Sickness-absence diagnoses of anxiety/depression identified a population at high risk of retiring early due to ill health, suggesting a target group for the development of interventions.

Background: Alcohol use disorders (AUDs) are associated with the highest all-cause mortality rates of all mental disorders. The majority of patients with AUDs never receive inpatient treatment for their AUD, and there is lack of data about their mortality risks despite their constituting the majority of those affected. Absenteeism from work (sick leave) due to an AUD likely signals worsening. In this study, we assessed whether AUD-related sick leave was associated with mortality in a cohort of workers in Germany., Methods: 128,001 workers with health insurance were followed for a mean of 6.4 years. We examined the associations between 1) AUD-related sick leave managed on an outpatient basis and 2) AUD-related psychiatric inpatient treatment, and mortality using survival analysis, and Cox proportional hazard regression models (separately by sex) adjusted for age, education, and job code classification. We also stratified analyses by sick leave related to three groups of alcohol-related conditions (all determined by International Classification of Diseases 9th ed. (ICD-9) codes): alcohol abuse and dependence; alcohol-induced mental disorder; and alcohol-induced medical conditions., Results: Outpatient-managed AUD-related sick leave was significantly associated with higher mortality (hazard ratio (HR) 2.90 (95% Confidence interval (CI) 2.24-3.75) for men, HR 5.83 (CI 2.90-11.75) for women). The magnitude of the association was similar for receipt of AUD-related psychiatric inpatient treatment (HR 3.2 (CI 2.76-3.78) for men, HR 6.5 (CI 4.41-9.47) for women). Compared to those without the conditions, higher mortality was observed consistently for outpatients and inpatients across the three groups of alcohol-related conditions. Those with alcohol-related medical conditions who had AUD-related psychiatric inpatient treatment appeared to have the highest mortality., Conclusions: Alcohol use disorder-related sick leave as documented in health insurance records is associated with higher mortality. Such sick leave does not necessarily lead to any specific AUD treatment. Therefore, AUD-related sick leave might be used as a trigger for insurers to intervene by offering AUD treatment to patients to try to reduce their risk of death.

Background and Objective: Empirical data, representative of the total population are necessary for medico-actuarial risk calculations. Our study compares mortalities of long-term care (LTC) patients with regard to age, gender and distribution of care levels when in home or institutional care., Methods: The data of 88.575 long-term care patients were analysed longitudinally for ten years, using routine data on the files of the German Federal Health Insurance fund (average observation period 2.5 years, a total of 221.625 observation years). The numbers of LTC patients and their care levels while remaining in home or institutional care were calculated, as were any changes to another care level or discontinuation of long-term care benefits (as a result of the need for care falling below the eligibility criteria for care level I or to death) during 1 - 10 years after the onset of long-term care., Results: Total mortality was found to increase with age and care level in homecare as well as in institutional settings for both sexes. It is greatly influenced by the first year mortality, which for both genders was lower for care level 1 in home care settings but higher for care level 2 and much higher for care level 3 than in institutional care settings. Follow-up mortality (second to tenth year after the start of LTC) was lower for care level 1 and 2 in home care settings than for institutional care. But for care level 3 the follow-up mortality was conversely higher in home care settings than in institutional care (for both genders). The number of patients returning to an active life after rehabilitation is much higher for home care patients than those who had been in institutional care. The transfer rate from homecare to institutional care increased during the first three years after onset of care, descending thereafter, and was much higher than conversely., Conclusion: The slogan "outpatient care before inpatient care" must be differentiated and considered carefully with regard to the character and constellation of diseases, age attained, length of time after onset of care, care level, potential for resuming an active life, as well as level of compensation and number and nature of activities of daily life together with being given the necessary help when choosing between homecare or institutional care. Differentiation between first year and follow-up mortalities is recommended when undertaking medico-actuarial calculations., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Several large studies have identified factors associated with long-term outcome after orthopaedic injuries. However, long-term social and economic implications have not been published so far. The aim of this investigation is to study the long-term socio-economic consequences of patients sustaining severe trauma., Methods: Patients treated at a level one trauma center were invited for a follow-up (at least 10 years) examination. There were 637 patients who responded and were examined. Inclusion criteria included injury severity score (ISS) ≥ 16 points, presence of lower and upper extremity fractures, and age between 3 and 60 years. Exclusion criteria included the presence of amputations and paraplegia. The socio-economic outcome was evaluated in three age groups: group I (< 18 years), group II (19 - 50 years), and group III (> 50 years). The following parameters were analyzed using a standardized questionnaire: financial losses, net income losses, pension precaution losses, need for a bank loan, and the decrease in number of friends., Results: 510 patients matched all study criteria, and breakdown of groups were as follows: 140 patients in group I, 341 patients in group II, and 29 patients in group III. Financial losses were reported in all age groups (20%-44%). Younger patients (group I) were associated with less income losses when compared with other groups (p < 0.05). Financial deterioration was more frequently reported in age group II (p < 0.05). Social consequences (number of friends decreased) were predominantly stated in patients younger than 18 years old (p < 0.05)., Conclusions: Economic consequences are reported by polytraumatized patients even ten or more years after injury. Financial losses appear to be common in patients between 19 and 50 years. In contrast, social deprivation appears to be most pronounced in the younger age groups. Early socio-economic support and measures of injury prevention should focus on these specific age groups.

Objective: It was the aim of this study to estimate effects of depression on permanent disability and death in a statutory health insurance population., Methods: Data from 128,001 clients were used with a mean follow up of 6.4 years. Excess risks were calculated with Cox regression models adjusted for age, gender, education and job classification., Results: Outpatient treatment for depression was associated with an elevated relative risk for permanent disability, but inpatient treatment even more so. Life table analysis suggests higher risks of early retirement for males who get ill early in life. Depression treated solely in an outpatient setting may be associated with lower mortality early in life, but this was only significant for women., Conclusions: Outpatient treatment should include an emphasis on occupational functioning, but also a gender-specific approach is needed., (© Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: Head injuries are of great relevance for the prognosis of polytrauma patients during acute care. However, knowledge about the impact on the long-term outcome is sparse. Therefore, this study analysed the role of head injuries on the outcome of polytrauma patients more than 10 years after injury in a matched-pair analysis., Patients and Methods: Out of 620 polytrauma patients with and without head injury, a matched-pair analysis with comparable age, injury severity and gender distribution and a minimum of 10 years follow-up was performed. The outcome and quality-of-life were measured using the Hannover Score for Polytrauma Outcome (HASPOC), Short Form 12 (SF-12), Glasgow Outcome Scale (GOS) and other parameters., Results: The matched-pair analysis consisted of 125 pairs (age 27.9 ± 1.2 years, ISS 20.0 ± 0.8 [head injury] vs ISS 19.8 ± 0.8 [no head injury]). A significant difference was shown for the GOS Score only (GOS head injury 4.3 ± 0.3 vs no head injury 4.9 ± 0.2, p = 0.01). The psychological outcome was similar in both groups. Both groups reported comparable subjective rehabilitation satisfaction., Conclusions: Matching pairs of equally injured polytrauma patients of same gender with and without head injury 10 years following trauma indicated significantly worse results in the GOS due to head injury.

Background: The long-term clinical status of surviving patients with multiple injuries has not been well described. The aim of this study was to evaluate whether certain injury patterns predispose a patient to a poor clinical outcome 10 or more years after multiple injuries., Methods: Patients who were treated at a level I trauma center at least 10 years before participation in this study were reinvited for a follow-up physical examination. Clinical outcome included the assessment of pain, gait, and various outcome scores (Short-Form [SF]-12, Lysholm, Merle D'Aubigne) were also used to measure outcome., Statistics: Binary logistic regression was used to test predictors of physical and psychosocial outcomes 10 years or longer after trauma. Differences between the types of injury and outcomes were assessed using Mann-Whitney and Kruskal Wallis tests., Results: Of 1,034, 637 patients (62%) participated in this study. Predictors of poor physical and psychosocial functioning using a clinical outcome score at 10 or more years follow-up included lower extremity amputation (odds ratio = 15.08; 95% confidence interval = 1.87-121.61) and a higher Abbreviated Injury Scale (AIS) spine score (SF-12 Mental subscale [odds ratio = 0.78; 95% confidence interval = 0.64-0.96]). Other factors associated with worse outcome scores were presence of two or more articular injuries, lower extremity injuries, and a combination of shaft and articular injuries., Conclusion: If patients survived, traumatic lower extremity amputation and a high initial maximum AIS (MAIS) spine score was the only predictive parameter for an increased odds of adverse clinical outcomes late after trauma. Injuries associated with these outcomes should be the focus of attention regarding injury prevention and priority in care.

Background: The aim of this study was to examine the long-term physical and psychological consequences of multiple blunt forced trauma at ≥ 10-year follow-up for patients with and without traumatic brain injury (TBI)., Methods: A total of 620 patients with multiple injuries were assessed with the Medical Outcomes Study-Short Form-12 and a physical reexamination at ≥ 10-year follow-up. Injury-related characteristics were collected from patients' medical record. Chi-square analysis, Analysis of Variance, and linear and logistic regression were performed to test differences between groups and examine predictors of physical and psychological functioning at ≥ 10-year follow-up., Results: Patients with multiple injuries who sustained a TBI (n = 398) were more likely to be female (p = 0.001), younger in age at the time of injury (p = 0.02), have higher Injury Severity Scores (p = 0.001), shorter ward stays (p = 0.001), and a greater number of upper extremity injuries (p = 0.02) when compared with those without TBI (n = 222). Patients with TBI reported poorer psychological functioning (p = 0.02) and more frequently reported chronic pain (p = 0.01). Patients with TBI used medical aids (p = 0.002) less frequently at follow-up when compared with patients without TBI. Significant predictors of health-related quality of life at ≥ 10-year follow-up included age at the time of injury (physical; p = 0.001), gender (p = 0.05), number of ventilation days (p = 0.02), satisfaction with rehabilitation (p = 0.001), disability caused by the injury (p = 0.001), and use of medical aids (physical p = 0.02)., Conclusions: Prospective studies are needed with a broader range of measures that may be sensitive to the consequences of TBI. Evidence-based interventions to facilitate physical and psychological rehabilitation, designed to target at risk patients, are warranted.

Objective: To bring the data from the Federal German Health report about work disability and pensioning into context with current knowledge about the course and etiology of depression., Methods: The report data about first-time recipients of a disability pension were analysed by year, illness and gender. Resulting data were interpreted and were compared with international publications., Results: The percentage of applications for disability pensions due to psychiatric illnesses have been rising steadily for two decades. Among these, depression (31%) and neurotic disorders (23%) are most frequently responsible, while most other causes of disability have been declining. Current treatment of depressive disorders does not seem to have had any effect in terms of reducing the number of disabled persons per year., Conclusions: Although the risk factors associated with developing a depressive disorder have been extensively studied, data explaining the progression into disability is scarce but essential. More research in the psychodynamics of depression and work participation might be helpful.

Unlabelled: From the period of September 2000 to March 2006 Hannover Reinsurance and the Department of Traumatology of the Hanover Medical School conducted a retrospective observational study of the long-term outcome of patients after polytrauma. The follow-up period was on average 17 +/- 5 years. The goal of the study was to determine the social, financial, medical and psychological long-term outcome after a severe accident. Of the 1560 enrolled patients 519 patients died in the observed period, 397 patients were followed up but could not be examined, 637 patients (female n = 158, male n = 479) were examined and answered detailed questionnaires concerning their social, financial medical and psychological situation. 6 patients did not fullfil the input criteria and one patient had two polytraumata. The average age at the time of accident was 26.5 years (+/- 12.3)., Results: Financial losses were observed in 41.1% of all males and 44.4% of females. 21.7% of all male (female 18.4%) had no financial protection at all. Due to the accident 30.1% of all men were unemployed and 19.8% permanently disabled (women 27.4% and 27.6% respectively). Psychological treatment almost doubled after discharge from rehabilitation centres. Even 20 years after the accident extra-mortality was substantially increased by 79%., Conclusion: Ten to twenty years after polytrauma significant financial, social and medical impairments are still present.

Introduction: There is limited information available about the long-term follow-up of polytrauma patients. In this study, the social and medical sequelae of trauma were reinvestigated at 10 years after the injury., Methods: Patients were selected out of a population of polytraumatised patients treated at Hannover Medical School between 1973 and 1990., Inclusion Criteria: multiple injuries treated at one institution, age between 3 and 60 years of age at the time of injury. Patients were recruited by gathering their residences from the charts. If patients had moved, up to three different registration offices were contacted by mail. The patient was contacted by mail (maximum three times) and by telephone. A patient was documented as lost to follow-up if none of these attempts was successful, or if he did not fulfil three subsequent appointments. All patients were examined by a physician, using a patient questionnaire and a standardized physical exam., Results: Six hundred thirty-seven patients (67.8% of the potential enrollees) were evaluated on an outpatient basis by a trauma surgeon using a self-administered patient questionnaire and a standardized physical exam. In these, the average follow-up was 17.5 (range 10-28) years; the average Injury Severity Score (ISS) was 20.7 (range 4-54). Head injuries were the third most frequent injuries, but represented the most frequent cause of permanent disability (40%). The overall rehabilitation status graded by the patients was very good in 14.1%, good in 33.0%, satisfactory in 29.3%, sufficient in 16.0% and poor or insufficient in 7.5%., Conclusions: This study suggests that a high percentage of patients can be recruited for follow-up even after 10 years post trauma with the use of a meticulous reinvitation strategy. Head injuries accounted for the most frequent cause of disability, suggesting that more research should be provided to minimise the degree of injury and improve the outcome for head injured patients. Subjective grading of the outcome was better than expected in patients who had regained complete social rehabilitation.

Background: Previous studies have shown that work-related injuries are often associated with inferior outcomes. The aim of the current study was to compare the long-term functional outcome after polytrauma between work-related and non-work-related injuries at a minimum follow-up of 10 years., Methods: Six hundred thirty-seven polytrauma patients were evaluated using a patient questionnaire and a physical examination. The average follow-up was 17.5 years (range 10-28 years); the average Injury Severity Score (ISS) was 20.7 (range 4 to 54)., Results: A multivariate analysis, with adjustments for age, sex, injury severity, and injury pattern, demonstrated that work-related injuries resulted in significantly inferior outcomes measured by the Hannove Score for Polytrauma Outcome (HASPOC), 12-Item Short-Form Health Survey (SF-12), requirement for medical aids and devices, length of rehabilitation, and retirement status (P < .05)., Conclusions: Polytrauma patients receiving workers' compensation achieve significantly inferior long-term outcomes than other patients. The obtained results demonstrate that psychosocial variables such as insurance status have a significant impact on the functional recovery following polytrauma.

Previous studies have suggested that the lower-extremities are among the most frequently injured body regions in polytrauma patients and have a major impact on the functional recovery following polytrauma. In particular, injuries to the distal part of the lower-extremity appear to be associated with a poor functional outcome. Therefore, the goal of this study was to evaluate the impact of injuries below the knee joint on the long-term functional outcome following polytrauma. Three hundred eighty-nine polytrauma patients with associated lower-extremity fractures and a minimum follow-up of 10 years were included in this study. All patients were examined by a doctor, using a patient questionnaire and a standardised physical examination. Significantly, inferior outcomes were seen in patients with fractures below the knee joint as measured by the modified Karlström-Olerud score, Lysholm score, range of motion, weight bearing status, Hannover score for polytrauma outcome (HASPOC), SF-12, Tegner activity score, and inability to work (P < 0.05). Fractures below the knee joint have a significant impact on the functional recovery following polytrauma. We suggest that delayed treatment, thin soft tissue envelope below the knee joint, high-energy trauma, unfavorable blood supply, and complex fracture patterns contribute to these unfavorable outcomes.

The key objective of insurance medicine is the scientific based assessment of long term prognosis of a single person with respect to mortality, morbidity and disability. This is always determined in comparison to the standard population or an ideal standardised population. The evaluation of morbidity, mortality and disability is always linked to certain insurance products such as life insurance, disability cover, health insurance or derivates of these products. Additionally, insurance medicine creates the claims evaluation guidelines which are in accordance with established classifications and guidelines of other medical associations. Due to different and various reasons, insurance medicine in Germany has shown substantial deficits in the past years and decades, mostly in the areas of methodology, scientific basis, guidelines and quality control. In order to meet future challenges specific to this industry such as demographic change, longevity and new insurance covers, the discipline of German insurance medicine requires some reorganisation.

Active and successful management predominantly depends on good and trustful cooperation between the claims manager, the field representatives of the administration and the injured or damaged person. Only the early assessment and prompt and purposeful claims handling can minimize the risk of an unexpected claims development. In the early stage, particularly probands with acute psychological maldevelopment can still be helped effectively. The introduction of an adequate therapy is beneficial to the afflicted person and at the same time lowers the final developing costs. As early as in 1918, Horn stated that the early occupational reintegration, apart from granting compensation, positively affects the process of the psychological disturbance. In general, no substantial restriction on the quality of life occurs if the injuries of a physical and mental type have been treated successfully and if occupational reintegration has taken place. However, if a continuous performance loss remains in occupational life due to a chronic psychological disturbance and if the damaged person does not achieve his/her ability to work again, even the contribution of high compensation payments does generally not improve the quality of life.

Disability is a well known and tragic event for children. While adults are an established group for specific disability insurance cover, children were often neglected in the past. Although parents, organizations and paediatricans are aware of the risk, children specific incidence rates for disability are hardly available. The only sufficient source for some statistical data are the accident statistics because they represent a substantial group of specific cause related disability for children. Incidence rates for disease related chronic severe impairment or disability in children are either derived by single disease research or actuarial calculation of the German Social Disability Registration. Based on this statistical background, an extended accident insurance for children was introduced in Germany covering both accidents and disabling diseases. The key limitation for all variations of this insurance are exclusion clauses for congential diseases and mental disorders. This insurance requires a new approach in underwriting of the health risks. Because of the substantial number of impaired children, a simple decline of substandard cases are unacceptable. The early experience or medical underwriting shows predominantly health impairments of the following types: allergies, bronchial asthma, ectopic eczema (neurodermitis), disorders of speech and articulation, vision disorders and mental impairments. The suggested solution for underwriting of substandard risks is the predetermination of the possible future maximum degree of disability. The need for underwriting guidelines is supported by the market impact of the new disability cover with thousands of insurance policies issued in the first month after introduction.

The BMI system meets in an ideal way all requirements in the underwriting of over- or underweight. It is easy to handle, widely applicable and accurate. Its validity has been proved by several studies. Furthermore, it is the leading system for the evaluation of weight in all epidemiological studies. By using the BMI System, the advantages of clinical studies dealing with the prognosis of overweight can be easily introduced to the field of insurance medicine. In wide ranges, the mortality rates given by the BMI system match those of existing guidelines. On the other hand, the more favourable rating for women and older aged people leads to substantial advantages. The extramortality rates introduced by this article can be readily incorporated into automatical rating systems. Thereby, a risk assessment on the preselection level is made possible. By taking cardiovascular risk factors into proportional consideration while assessing the extramortality of overweight, it is possible to increase the accuracy and speed of the underwriting process.

In the German disability insurance, exclusion clauses are the dominating approach to the underwriting of low back pain. This is due to a lack of clear prognostic factors, the nonexistence of severity classifications and the strong impact of individual and psychological circumstances. Considering various clinical, individual and psychological indicators, a new system is introduced to allocate the prognosis of lower back pain to four levels of severity. This approach makes it possible to use extra ratings instead of exclusion clauses of mild and moderate low back pain.

Various long-term prospective studies evaluated subgroups of patients obtaining benefits of prognosis and life quality by undergoing CABG (coronary artery bypass grafting). Early and late graft failure was a recurrent problem. A significant reduction of early graft occlusion was possible by using platelet inhibitory drugs or anticoagulant therapy while IMA grafts showed an excellent long-term patency preventing late graft failure. Additionally IMA grafts improved life expectancy and reduced the risk of myocardial infarction. Although the number of high risk patients and emergency procedures increased the over all mortality rate decreased.