Significance and Costs of Complex Biopsychosocial Health Care Needs in Elderly People: Results of a Population-Based Study BEATE WILD, PHD, DIRK HEIDER, PHD, IMAD MAATOUK, MD, JORIS SLAETS, MD, HANS-HELMUT KO¨NIG, MD, DOROTHEA NIEHOFF, MD, KAI-UWE SAUM, MD, HERMANN BRENNER, MD, WOLFGANG SO¨LLNER, MD, AND WOLFGANG HERZOG, MD Objective: To improve health care for the elderly, a consideration of biopsychosocial health care needs may be of particular importanceVespecially because of the prevalence of multiple conditions, mental disorders, and social challenges facing elderly people. The aim of the study was to investigate significance and costs of biopsychosocial health care needs in elderly people. Methods: Data were derived from the 8-year follow-up of the ESTHER studyVa German epidemiological study in the elderly population. A total of 3124 participants aged 57 to 84 years were visited at home by trained medical doctors. Biopsychosocial health care needs were assessed using the INTERMED for the Elderly (IM-E) interview. Health-related quality of life (HRQOL) was measured by the 12-Item ShortForm Health Survey, and psychosomatic burden was measured by the Patient Health Questionnaire. Results: The IM-E correlated with decreased mental (mental component score: r = j0.38, p G .0001) and physical HRQOL (physical component score: r = j0.45, p G .0001), increased depression severity (r = 0.53, p G .0001), and costs (R = 0.41, p G .0001). The proportion of the participants who had an IM-E score of at least 21 was 8.2%; according to previous studies, they were classified as complex patients (having complex biopsychosocial health care needs). Complex patients showed a highly reduced HRQOL compared with participants without complex health care needs (mental component score: 37.0 [10.8] versus 48.7 [8.8]; physical component score: 33.0 [9.1] versus 41.6 [9.5]). Mean health care costs per 3 months of complex patients were strongly increased (1651.1 € [3192.2] versus 764.5 € [1868.4]). Conclusions: Complex biopsychosocial health care needs are strongly associated with adverse health outcomes in elderly people. It should be evaluated if interdisciplinary treatment plans would improve the health outcomes for complex patients. Key words: biopsychosocial, elderly, health care needs, complex patients, costs, integrated care. ESTHER study = population-based cohort study in Germany; GAD = generalized anxiety disorder; HRQOL = health-related quality of life; IM-E = INTERMED Interview for the Elderly; MCS = mental component scale of the SF-12; PCS = physical component scale of the SF-12; PHQ = Patient Health Questionnaire; SF-12 = Short-Form Health Survey.

INTRODUCTION o date, many researchers and clinicians are convinced that integrated care approaches should be considered to improve health outcomes in elderly people with chronic diseases (1). Patients with high or complex biopsychosocial health care needs are in need of integrated care (2). This study aims to give evidence about the significance of biopsychosocial health care needs in elderly people based on observational data from a large population-based study. Elderly people face challenges on various dimensions of life. MultimorbidityVthat is, having more than one chronic conditionVis highly prevalent among the elderly. Results of a population-based study indicate that 67.3% of the German population aged 50 to 75 years experience multimorbidity (3);

T

From the Department of General Internal Medicine and Psychosomatics (B.W., I.M., D.N., W.H.), Medical University Hospital, Heidelberg, Germany; Division of Clinical Epidemiology and Aging Research (K.-U.S., H.B.), German Cancer Research Center, Heidelberg, Germany; Departments of Internal Medicine and Geriatrics (J.S.), University Hospital, Groningen, the Netherlands; Department of Psychosomatics and Psychotherapy (W.S.), General Hospital, Nu¨rnberg, Germany; and Department of Health Economics and Health Services Research (D.H., H.-H.K.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany. Address correspondence and reprint requests to Beate Wild, PhD, Department of General Internal Medicine and Psychosomatics, Medical University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany. E-mail: [email protected] Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.psychosomaticmedicine.org). Received for publication October 5, 2013; revision received May 1, 2014. DOI: 10.1097/PSY.0000000000000080

in family practice, patients older than 65 years, Fortin et al. (4) found prevalence rates of multimorbidity of 93% to 100%. Aggravating the course of multimorbidity in old age is the frequent co-occurrence of mental disorders, particularly depression (5). In general, approximately 16% of people aged 53 years and older show symptoms of clinically significant depression (6). The 12-month prevalence rate for any anxiety disorder in people aged 55 years and older was estimated to be 11.6% (7). In addition to an increased psychosomatic burden, elderly people also experience changing social situations such as the loss of family members and friends and the restriction of social contacts that can also affect outcomes. When taking into account the potential need for social and psychological support for elderly patients with chronic diseases, a specific patient group in need of interdisciplinary (biopsychosocial) care emerges. However, if these patients with complex health care needs are not identified and adequately treated, they could form a high-risk group for complications, diminished response to medical treatment, and communication failures (8). It is known that multimorbidity and mental disorders in older adults are associated with significantly higher health care costs (9). Based on previous studies and clinical experience, we hypothesize that high biopsychosocial health care needs are a main indicator of increased costs in elderly patients. However, to date, no population-based study has investigated the association between biopsychosocial health care needs and costs in elderly people. The INTERMED interview is a method that reflects a biopsychosocial approach to the integrative assessment of health care needs and case complexity of patients with a physical illness. The INTERMED assessment method is based on a semistructured interview that classifies the information into the four domains of the patient’s biological, psychological, social, and health careYrelated characteristics (10,11). Patients with an INTERMED score of at least 21 are considered to have complex health care needs (=complex patients). The ‘‘INTERMED for the Elderly’’

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B. WILD et al. (IM-E) was developed specifically for use in populations of elderly persons and for application in epidemiological studies. It has proven to be a reliable assessment instrument (12). The aim of this study was two-fold: a) to show that biopsychosocial health care needs in elderly people are associated with quality of life, psychosomatic burden, and costs and b) to show that patients with complex biopsychosocial health care needs according to the IM-E show a highly deteriorated quality of life and increased psychosomatic burden and health care costs. METHODS Study Sample The data were derived from the 8-year follow-up of the ESTHER studyVa population-based cohort study of older adults in Germany (13,14). The study was approved by the ethics committees of the University of Heidelberg and of the medical board of the state of Saarland, Germany. Written informed consent was obtained from all participants. At the baseline of the ESTHER study, between July 2000 and December 2002, in the federal state of Saarland, 9953 participants were recruited by their general practitioners in the course of a health checkup that is offered biennially to older adults in Germany. The ESTHER study sample was shown to be representative with respect to both demographic variables and chronic diseases of the general German population (15). At the beginning of the 8-year follow-up of the ESTHER study, 8770 participants were still alive. Of these, 505 participants were not able to complete a standardized questionnaire Vleaving 8265 possible participants. All in all, between 2008 and 2010, 6086 elderly people participated in the third 8-year follow-up. All participants of the 8-year follow-up were asked if they would take part in a longer home visit to be conducted for personal interviews and a geriatric assessment. Of the 6086 ESTHER participants, 3124 agreed to be visited at

home. The home visits served as a comprehensive assessment tool regarding functional status as well as medical, pharmacological, socioeconomic, and psychosocial aspects of their life. At the end of the home visit, the IM-E was conducted to assess the biopsychosocial health care needs of the participants. The demographic characteristics of the participants of the home visits are shown in Table 1. Compared with the persons of the ESTHER study who did not participate in the home visits, persons who participated in the home visits were more frequently male and more frequently had a higher education.

Measurements The IM-E is based on the original INTERMED interview. It was altered and adjusted specifically for application in elderly populations (12). The IM-E classifies the information into the four domains of the patient’s biological, psychological, social, and health careYrelated characteristics. The questions in each domain are related to a time axis that is divided into past, present, and future. The answers of the individual questions are scored by means of a four-level rating scale. The scores range from 0 to 3 and encompass the spectrum of zero evidence for a symptom or disturbance or health service need (0) to evidence of complex symptoms or health service needs (3). Scores of 0 reflect protective health factors, whereas scores of 3 reflect a serious disruption and a high need. The variables are rated according to given anchor points. The Appendix shows the structure and scoring procedure of the IM-E interview (Supplemental Digital Content 1, http://links.lww.com/PSYMED/A142). The interview results in an assessment of the four domains (over three periods); the respective scores of the four domains are added to give a total score ranging from 0 to 60. The total score reflects the amount of health care needs of the participant. In previous INTERMED studies, it was found that a cutoff point of 20/21 of the total score detected outpatients with complex biopsychosocial health care needs. Stiefel et al. (16) emphasized the hypothesis that to explain differences between patients in regard to medical outcome and quality of life, the resulting case complexity is the most important factorVnot the chronic conditions, psychiatric diagnosis, or psychopathology per se. They further describe that ‘‘case complexity

TABLE 1. Demographic Characteristics of Persons Who Participated in the Home Visits Compared With Those Who Did Not Participate Participants of the Home Visits (n = 3124) Demographic Variable

n

Persons Who Did Not Participate in the Home Visits (n = 2962) %

n

%

W2 Value (df)

9.7 (5)

.08

16.2 (1)

G.001

52.4 (3)

G.001

5.1 (2)

.08

p

Age, y 57Y59

155

5.0

195

6.7

60Y64

621

19.9

568

19.4

65Y69 70Y74

684 931

21.9 29.8

664 834

22.6 28.4

75Y79

537

17.2

481

16.4

80Y84

196

6.3

192

6.5

Sex Female

1643

52.6

1710

57.3

Male

1481

47.4

1252

42.3

G9 9Y10

47 2541

1.5 82.5

82 2521

2.8 86.9

11Y12

269

8.7

170

5.9

912

222

7.2

127

4.4

Education, y

Marital status Never married Married Divorced, widowed

105

3.4

122

4.2

2217

71.8

2036

69.4

765

24.8

775

26.4

Percentages of the two groups were compared using W2 tests. 498

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COMPLEX HEALTH CARE NEEDS IN THE ELDERLY refers to the characteristics which describe how patients with similar types and stages of disease vary in their health care needs and utilization.’’ (16). Using the cutoff point of 20/21, complex patients at risk for extended hospital stay and diminished response to medical treatment could be detected within the first few days of admission (17). Thus, in our study, elderly persons with an IM-E total score of at least 21 were considered to be complex patients (i.e., patients with complex health care needs). In a previous study, we found an interrater reliability (intraclass correlation [2,1]) of 0.95 for the sum score of the IM-E. Regarding the cutoff point of 20/21 for patients with complex health care needs, a J of 0.75 was achieved (12). The IM-E interviews were performed by the study doctors who conducted the home visits. The study doctors were trained in a 1-day-session in the use and scoring procedure of the INTERMED (see ‘‘Appendix’’). Subsequently, telephone conferences were conducted to discuss new videos of patient interviews. During the period where the home visits were conducted, the use of the IM-E was supervised by regular meetings and telephone conferences. Multimorbidity is commonly defined as having more than one chronic disease. In our study, multimorbidity of the participants was evaluated by the study doctors using the IM-E assessment. The first lead question of the IM-E asks about the existence of somatic diseases: ‘‘Which of your physical illnesses have been ascertained over the last 5 years?’’ The variable ‘‘chronicity’’ of the IM-E is coded with ‘‘3’’ for the occurrence of more than one chronic disease (see ‘‘Appendix,’’ item 1a). Thus, patients with an IM-E score of ‘‘3’’ in the variable ‘‘chronicity’’ were classified as multimorbid. Data to describe the main chronic diseases of the multimorbid patients were derived from the patient questionnaires of all measurement time points of the ESTHER study as well as from the questionnaires completed by the patients’ general practitioner. Health-related quality of life (HRQOL) was measured using the 12-Item Short-Form Health Survey (SF-12). The SF-12 is a widely used generic questionnaire that does not focus on specific disease groups. Several domains of HRQOLVsuch as physical, social, and role functioningVare assessed. Items are weighted and totalled to provide both physical (PCS) and mental component scores (MCS) ranging from 0 to 100. A higher score in the respective summary scales indicates a higher quality of life. Retest reliability for the PCS ranged between 0.86 and 0.89, and retest reliability scores for the MCS were estimated to be 0.76 to 0.77 (18). Depression was assessed using the eight-item Patient Health Questionnaire (PHQ-8) depression scale (19). The PHQ-8 consists of eight of the nine DSM-IV diagnostic criteria for major depressive disorder. The ninth criterion assessing suicidal thoughts was omitted, which is common in population-based studies (20). Scores of the PHQ-8 range from 0 to 24, with higher scores indicating a higher depression severity. Test-retest reliability of the PHQ depression module ranged between 0.81 and 0.96 (21). Somatic symptom severity was assessed using 13 items from the PHQ-15 questionnaire (22). The PHQ-15 comprises 15 somatic symptoms (stomach pain, back pain, chest pain, etc); each symptom was scored from 0 to 2. In this study, we applied only 13 items, omitting items regarding problems of menstruation and sexual intercourse. Test-retest reliability of the PHQ somatic symptom scale was estimated to be 0.60 (23). The Generalized Anxiety Disorder Scale (GAD-7) was applied to assess symptom severity of generalized anxiety disorder (GAD). The German version of the GAD-7 proved to be a reliable and valid instrument for screening for GAD (24). Results from a validation study in elderly people are published elsewhere (25). Test-retest reliability of the GAD-7 was estimated to be 0.83 (26). Health service use of the participants was assessed using a short version of a questionnaire that has been applied in several previous studies (27). The questionnaire is available from the authors upon request. Data on health service use were collected for 3 months retrospectively. Frequency, type, and duration/quantity of health service use were recorded, including inpatient care, treatment at day clinics and rehabilitation, outpatient treatment by physicians and other therapists, pharmaceuticals, medical supplies, and dental prostheses as well as formal nursing care and informal care. Costs were calculated from the societal perspective by multiplying resource use with unit costs for the year 2009. Unit costs reflect average prices within the German health care system (28). All costs were expressed in euros. The costs reported in the tables and figures are 3-month averages of service costs (and not annual service usage).

Statistical Analysis Correlations between the IM-E total score and further variables were estimated by calculating Pearson’s or Spearman’s correlation coefficient. Percentages and confidence intervals were calculated to estimate the prevalence of patients with complex health care needs (IM-E total score Q 21). Analysis of covarianceVcontrolling for age and sexVwere conducted to compare continuous variables between two or three groups. W2 -tests were used to compare frequencies between groups. To compare groups regarding costs, we used the Wilcoxon signed rank test or the Kruskal-Wallis test. Missing items of the SF-12 were replaced by using the robust modified regression estimation methods published by Maatouk et al. (29) and Spiro et al. (30). The statistical analysis was performed using SAS, version 9.1.

RESULTS Associations Between the IM-E and HRQOL, Psychosocial Variables, and Costs A total of 3121 participants (99% of the home visit participants) completed the IM-E and were included in the present study. For the whole study sample, correlations between IM-E sum scores and HRQOL showed that higher IM-E scores were strongly related to decreased PCS (r = j0.45, p G .0001) and decreased MCS (r = j0.38, p G .0001). The IM-E also correlated highly with depression severity (r = 0.53, p G .0001), GAD severity (r = 0.44, p G .0001), somatic symptom severity (r = 0.57, p G .0001), and health care costs (Spearman’s R = 0.41, p G .0001). Patients With Complex Health Care Needs Using the cutoff score of 20/21 of the IM-E, we found that 8.2% (95% confidence interval = 7.3Y9.2) of the participants showed complex biopsychosocial health care needs; that is, they were classified as complex patients. Women showed a significantly higher prevalence (10.4% of all women) of complex health care needs than did men (5.8%; W2(1) = 21.4, p G .0001). Participants with complex health care needs had a markedly and significantly lower HRQOL and strongly increased health care costs as compared with participants without complex health care needs. The differences between these two groups are illustrated in Table 2. Multimorbid Complex Patients A total of 225 (13.8%) of all multimorbid patients (n = 1628) were assessed as complex. Figure 1 visualizes the proportions of complex and multimorbid patients in the whole study sample. Table 3 summarizes the lifetime prevalences of 12 common chronic diseases of all multimorbid patientsVpatients both with and without complex health care needs. The most prevalent condition among multimorbid patients (with or without complex health care needs) was hypertension. Descriptive percentages of the various diseases indicate that the distribution of chronic diseases is similar in both groups of multimorbid patients (with or without complex health care needs). Further analysis showed that the multimorbid patients with complex health care needs had a markedly and significantly lower MCS and PCS compared with multimorbid patients

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499

B. WILD et al. TABLE 2. Differences Between Complex Persons and Those Without Complex Health Care Needs Regarding HRQOL and Further Variables Complex (IM-E Score Q 21)

Others (IM-E Score G 21)

Test Statistics W value (df) = 21.4 (1) 2

Sex, n (%) Male Female

86 (33.6)

1394 (48.7)

170 (66.4)

1471 (51.3) t value (df) = j1.09 (3119)

p G.001

Age, M (SD)

69.2 (6.7)

69.7 (6.3)

PCS, M (SD) MCS, M (SD)

33.0 (9.1) 37.0 (10.8)

41.6 (9.5) 48.7 (8.8)

PHQ_SOM13, M (SD)

10.6 (4.6)

4.8 (3.7)

F value = 517.9 (1,3113)

G.001

7.4 (4.5)

2.3 (2.8)

F value = 689.1 (1,3115)

G.001

PHQ_DEP, M (SD)

5.8 (4.9)

1.7 (2.5)

Health care costs, M (SD), €

GAD-7, M (SD)

1651.1 (3192.2)

764.5 (1868.4)

Multimorbid, n (%)

225 (88.2)

1403 (49.0)

F value (df1,df2) = 191.2 (1,3016) F-value = 352.0 (1,3016)

.28 G.001 G.001

F value = 512.2 (1,3113)

G.001

z value = 10.2

G.001

W2 value (df) = 852.4 (1)

G.0001

HRQOL = health-related quality of life; M = mean; SD = standard deviation; PCS = physical component score of the Short-Form Health Survey; MCS = mental component score of the Short-Form Health Survey (higher PCS or MCS scores indicate a higher quality of life); PHQ_SOM13 = somatic symptom severity according to the PHQ; PHQ_DEP = depression severity (PHQ); GAD-7 = severity of generalized anxiety symptoms (higher scores indicate a higher symptom severity). IM-E = INTERMED Interview for the Elderly; PHQ = Patient Health Questionnaire. Persons with an IM-E score of at least 21 are classified as complex patients. p Values were obtained from W2 tests (sex), t tests (age), or analysis of covariance (PCS, MCS, PHQ) controlling for sex and age. Costs were compared using the nonparametric Wilcoxon test.

without complex health care needs (Fig. 2 and Table S1, Supplemental Digital Content 2, http://links.lww.com/PSYMED/A143). DISCUSSION To our knowledge, this is the first study to investigate the significance of biopsychosocial health care needs in a large population-based sample of elderly people. Results show that the amount of biopsychosocial health care needs assessed is strongly correlated with reduced HRQOL, increased depression, anxiety, and somatic symptom severity as well as increased costs. Complex elderly patientsVthat is, the minor share of mainly multimorbid patients with high biopsychosocial health care needsV show a drastically reduced HRQOL, increased psychosomatic burden, and higher health care costs compared with multimorbid patients without complex health care needs. Thus, by assessing complex health care needs, we can identify the high-risk group of

patients that show strongly decreased health outcomes on various dimensions. In addition, by assessing biopsychosocial health care needs using the IM-E, we get a direct approach to the improvement of health care for complex patients. The IM-E not only quantifies health care needs but also simultaneously provides the medical, psychological, or social starting points where caretaking is required. So-called ‘‘red flags’’ mark the areas that indicate a serious disruption and an urgent need for action. The target of an intervention after the IM-E assessment would be to change these red flags into ‘‘green ones.’’ The IM-E thus offers a framework for a treatment plan, including who should be involved in providing the care (31,32). We argue that such an assessment of biopsychosocial health care needs would TABLE 3. Life Time Prevalences of 12 Main Chronic Diseases of All Multimorbid Patients Patients With IM-E Q 21

Patients With IM-E G 21

Hypertension

64.0

61.1

Stomach ulcer/duodenal ulcer

30.2

16.2

Diabetes mellitus

25.3

22.0

Chronic heart failure

20.0

17.6

Circulatory disorder of the heart Cancer

19.1 16.9

15.3 18.1

Disease

Figure 1. Proportions of complex and multimorbid patients in the whole study sample. 500

Circulatory disorder of the brain

16.4

7.6

Gout

14.2

14.2

Myocardial infarction

8.9

8.7

Asthma

8.2

6.7

Renal failures

3.6

1.8

Parkinson disease

1.8

1.1

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COMPLEX HEALTH CARE NEEDS IN THE ELDERLY

Figure 2. HRQOL, psychosomatic variables, and health care costs for three different groups of participants. PCS and MCS: lower values indicate a decreased physical or mental quality of life. PHQ_DEP, PHQ_SOM13, and GAD-7: higher values indicate higher symptom severity. *Significant difference between groups. The error bars depict standard deviations. HRQOL = health-related quality of life; PCS = physical component scale of the Short-Form Health Survey; MCS = mental component scale of the Short-Form Health Survey; PHQ_DEP = depression severity according to the Patient Health Questionnaire; PHQ_SOM13 = somatic symptom severity according to the Patient Health Questionnaire; GAD-7 = Generalized Anxiety Disorder Scale.

be a useful step to overcome the fragmentation of the health care system and to enhance communication between treatment providers. To date, many studies have shown that the comorbidity of mental and somatic disorders in elderly people is associated with reduced health outcomes and increased health care use and costs (33,34). It is known, for example, that elderly patients with depression and poorly controlled diabetes mellitus, coronary heart diseaseVor bothVhave higher medical complication rates and higher health care costs (35). The authors suggested that more effective care management of psychiatric and medical disease control may also reduce medical service use and enhance quality of life. Rathore et al. (8) reported that elderly patients who have both heart failure and mental disorders receive somewhat poorer care during hospitalization and have a greater risk of death and readmission to the hospital. All of these previous studies, however, focused on specific mental and somatic diagnoses. In contrast, the present study illustrates that, independent of specific diagnoses, we can identify the high-risk group of elderly chronically ill patients with a markedly decreased level of functioning on various dimensions. This group has complex health care needs and is marked by the need for additional integrated care. Our study is thus supporting the claim to shift from a disease-based model to one that focuses on care for patients (36). In our study, approximately 8.2% participants of the population-based sample of people aged 57 to 84 years showed complex health care needs. Women more frequently had complex health care needs than did men. This finding corresponds to previous findings that women seem to be more burdened by the co-occurrence of mental and somatic disorders. Complex patients did not differ from persons without complex health care needs regarding age. Interestingly, in many health care approaches, elderly people are targeted according to an age criterion. However, it has been shown that in elderly people, age is not a good predictor of health outcome (37). We are therefore

emphasizing that health care in elderly people could be improved by considering the biopsychosocial health care needs rather than organizing health care according to age. In our study, most of the complex patients were multimorbid, but only 13.8% of the multimorbid patients were assessed as being complex. Results of previous studies showed that, in general, HRQOL scores of multimorbid elderly patients are reduced as compared with patients with none or one chronic condition (38). However, our findings indicate that the biopsychosocial health care needs of elderly people and not multimorbidity per se appear to be the main reason for simultaneously deteriorated health outcomes on various dimensions. Our study has several limitations. Firstly, quality of life, depression severity, and somatic symptom severity were measured by using questionnaires only. However, assessing mental disorders with the use of interviews would have extended the home visit significantly. In addition, the SF-12 and PHQ are questionnaires that proved to be valid and reliable. Secondly, the assessment of multimorbidity was done by the study doctors without indicating which diseases were present. We therefore had to obtain the information about specific diseases from the patients’ questionnaires. Thirdly, health care costs per participants were estimated using a questionnaire; costs could therefore have been underestimated. However, we assume that an underestimation of costs would be equally applicable to all participants, and the large difference between participants with and without complex health care needs regarding costs therefore seems to be valid. In conclusion, our study provides evidence that biopsychosocial health care needs in elderly people are of primary importance. Patients with complex health care needs show strongly adverse health outcomes on various dimensions. In both the diagnostics of and treatment for elderly people, we would recommend the use of the IM-EVor a self-assessment versionV to identify complex elderly patients in need of integrated care.

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B. WILD et al. The authors would like to thank the participants who made this study possible. Source of Funding and Conflicts of Interest: This study is part of the consortium ‘‘Multimorbidity and frailty at old age: epidemiology, biology, psychiatric comorbidity, medical care, and costs’’ funded by the German Ministry of Research and Education (Grant No. 01ET0718). The authors declare no conflict of interest.

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Psychosomatic Medicine 76:497Y502 (2014)

Copyright © 2014 by the American Psychosomatic Society. Unauthorized reproduction of this article is prohibited.

Significance and costs of complex biopsychosocial health care needs in elderly people: results of a population-based study.

To improve health care for the elderly, a consideration of biopsychosocial health care needs may be of particular importance-especially because of the...
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