The Costs of Dementia From the Societal Perspective: Is Care Provided in the Community Really Cheaper than Nursing Home Care?

JAMDA 15 (2014) 117e126

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Original Study

The Costs of Dementia From the Societal Perspective: Is Care Provided in the Community Really Cheaper than Nursing Home Care? Hans-Helmut König MD, MPH a, *, Hanna Leicht PhD a, Christian Brettschneider MSc a, Cadja Bachmann MD b, Horst Bickel PhD c, Angela Fuchs MSc d, Frank Jessen MD e, f, Mirjam Köhler MSc b, Melanie Luppa PhD g, Edelgard Mösch PhD c, Michael Pentzek PhD d, Jochen Werle PhD h, Siegfried Weyerer PhD h, Birgitt Wiese MSc i, Martin Scherer MD b, Wolfgang Maier MD e, f, Steffi G. Riedel-Heller MD, MPH g, for the AgeCoDe Study Group** a Department of Health Economics and Health Services Research, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany b Institute of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany c Department of Psychiatry, Technical University of Munich, Munich, Germany d Department of General Practice, Medical Faculty, University of Düsseldorf, Düsseldorf, Germany e Department of Psychiatry, University of Bonn, Bonn, Germany f German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany g Institute of Social Medicine, Occupational Health and Public Health, University of Leipzig, Leipzig, Germany h Central Institute of Mental Health, Medical Faculty Mannheim/Heidelberg University, Mannheim, Germany i Institute of Biometrics, Hannover Medical School, Hannover, Germany

a b s t r a c t Keywords: Cost-of-illness dementia nursing home informal care

Objective: To compare the costs of care for community-dwelling dementia patients with the costs of care for dementia patients living in nursing homes from the societal perspective. Design: Cross-sectional bottom-up cost of illness study nested within the multicenter German AgeCoDecohort. Setting: Community and nursing homes. Participants: One hundred twenty-eight community-dwelling dementia patients and 48 dementia patients living in nursing homes. Intervention: None. Measurements: Utilization and costs of medical care and long term care, including formal and informal social and nursing care based on proxy interviews. Informal care was valued using the replacement cost method. Results: Unadjusted mean annual total costs including informal care were V29,930 ($43,997) for community-dwelling patients and V33,482 ($49,218) for patients living in nursing homes. However, multiple regression analysis controlling for age, sex, deficits in basic and instrumental activities of daily living and comorbidity showed that living in the community significantly increased total costs by V11,344 ($16,676; P < .01) compared with living in a nursing home, mainly due to higher costs of informal care (þV20,585; þ$30,260; P < .001). Conclusion: From the societal perspective care for dementia patients living in the community tends to cost more than care in nursing homes when functional impairment is controlled for. Ó 2014 - American Medical Directors Association, Inc. All rights reserved.

The authors declare no conflicts of interest. Principal Investigators: Wolfgang Maier, Martin Scherer. Heinz-Harald Abholz, Christian Brettschneider, Cadja Bachmann, Horst Bickel, Wolfgang Blank, Hendrik van den Bussche, Sandra Eifflaender-Gorfer, Marion Eisele, Annette Ernst, Angela Fuchs, Kathrin Heser, Frank Jessen, Hanna Kaduszkiewicz, Teresa Kaufeler, Mirjam Köhler, Hans-Helmut König, Alexander Koppara, Carolin Lange, Tobias Luck, Melanie Luppa, Manfred Mayer, Edelgard Mösch, Julia Olbrich, Michael Pentzek, Jana Prokein, Anna Schumacher, Steffi Riedel-Heller, Janine Stein, Susanne Steinmann, Franziska Tebarth, Michael Wagner, Klaus

Weckbecker, Dagmar Weeg, Jochen Werle, Siegfried Weyerer, Birgitt Wiese, Steffen Wolfsgruber, Thomas Zimmermann. Hendrik van den Bussche (served from 2002e2011). * Address correspondence to Hans-Helmut König, MD, MPH, Department of Health Economics and Health Services Research, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf, Martinistr. 52, D-20246 Hamburg, Germany. E-mail address: [email protected] (H.-H. König). ** Members of the AgeCoDe Study Group.

1525-8610/$ - see front matter Ó 2014 - American Medical Directors Association, Inc. All rights reserved. http://dx.doi.org/10.1016/j.jamda.2013.10.003

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Similar to other European countries the number of dementia patients in Germany is expected to increase by approximately 50% by 2030 because of demographic change.1 At early stages, patients are usually cared for in the community where they receive informal care mostly provided by family members, or formal care provided by professional community services. When the need for care grows as the disease progresses, many patients are eventually admitted to a nursing home. Because of the great need for long term care, the economic impact of dementia in terms of costs is tremendous.2,3 Like in many other countries, health policy in Germany aims at avoiding or postponing patients’ admission to nursing homes by giving priority to care provided in the community over nursing home care (x 3 Social Security Code XI).4 One of several reasons for this policy is that the care provided in the community, predominantly by informal caregivers, tends to be less costly for the social security system.5 In Germany, mean annual costs of nursing home care amounted to approximately V33,000 ($48,510) in 2009 of which on average about V15,000 ($22,050) were covered by the social long term care insurance.6 By contrast, social long term care insurance in Germany paid on average only about V5000 ($7350) of cash benefits per year to patients for care provided in the community by informal caregivers.6 Although the perspective of the social security system care provided at home is less costly than nursing home care, this may not be true from the societal perspective that takes into account all costs regardless of who bears them.7 It has been argued that economic evaluations should preferably take the societal perspective to prevent undesirable shifts in costs between the health care sector and other sectors including the informal economy.7,8 When the societal perspective is adopted, informal care needs to be incorporated in cost calculation as it is a valuable substitute and complement of formal care.8 However, there is no gold standard for the monetary valuation of informal care, and, therefore, sensitivity analysis on the monetary value of informal care has been recommended.7 Various studies have estimated the costs of dementia from the societal perspective, emphasizing the relevance of informal care.2 According to a recent estimate, costs of informal care may make up almost one-half of total societal costs of dementia in the USA. 3 Yet, only few studies have compared the societal costs of community-dwelling patients and institutionalized patients.9e13 Of these studies, only very few9e11 controlled for severity of dementia or other confounding variables, and none performed sensitivity analysis on the value of informal care. Thus, the purpose of our study was to compare the societal costs of care for community-dwelling dementia patients with the costs of care for dementia patients living in nursing homes controlling for confounding variables and conducting extensive sensitivity analysis on the value of informal care.

Methods Sample This cross-sectional analysis used data on health and long term care resource use of N ¼ 176 dementia patients collected for the first time in the third follow-up wave of the German Study on Ageing, Cognition, and Dementia in Primary Care Patients (AgeCoDe). For the AgeCoDe-Study 3327 subjects were recruited through general practitioner (GP) offices at 6 centers (Bonn, Düsseldorf, Hamburg, Leipzig, Mannheim, Munich). Inclusion criteria were age 75 years, absence of dementia, and at least 1 contact with the GP during the previous 12 months. Exclusion criteria were insufficient German language skills, GP consultation by home visits only, residence in a nursing home, severe illness that the GP would deem fatal within 3 months, deafness or blindness, and lack of ability to provide

informed consent. Details regarding the cohort have been published elsewhere.14 Between the baseline survey and the third follow-up conducted after 4.5 years (between November 2007 and August 2009), 403 subjects had received a diagnosis of dementia. Yet, 227 of these subjects had died or dropped out of the study before the third follow-up or had been unavailable for a proxy interview at the third follow-up (collectively referred to as “drop-outs”), leaving N ¼ 176 dementia patients to be included in the present analysis. There were no differences in baseline characteristics of dementia patients investigated in this study and drop-outs with regard to age, severity of dementia, comorbidity, sex, marital status, or living situation. The study protocol was approved by the ethics committees of the 6 study centers. All subjects gave informed written consent prior to participation. Clinical and Sociodemographic Variables Trained physicians or psychologists conducted structured interviews with the patients and their caregivers (proxy) at the patients’ homes. Diagnosis of dementia was based on a consensus between the interviewer and an experienced geriatrician or geriatric psychiatrist according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria as implemented in the Structured Interview for the Diagnosis of Dementia of the Alzheimer Type, Multiinfarct Dementia and Dementia of other Etiology according to the International Classification of Diseases, Tenth Edition and Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised interview.15 Diagnostic criteria were objective deficits in memory and another cognitive domain as well as impairment in activities of daily living. Classification of dementia severity was based on the Clinical Dementia Rating (CDR16). In addition the widely-used Mini-Mental Status Examination (MMSE17) was used to assess cognitive impairment. Abilities in activities of daily living (ADL, eg, feeding, washing) were assessed with the Barthel Index.18 Abilities in instrumental activities of daily living (IADL, eg, using the telephone or handling routine finances) were assessed with the IADL scale by Lawton and Brody.19 In addition, patients’ GPs assessed 28 chronic conditions other than dementia and rated these from 1 to 4 according to severity if present.14 Data were combined into simple and weighted count scores (weighted count: added severity ratings for conditions scored as present). Resource Use and Unit Costs Resource use of medical care and long term care (including social and nursing care) was assessed from the societal perspective by means of a questionnaire, which was completed by a caregiver (proxy) as part of the interview and is available from the authors upon request. The recorded resources, units of measurement, and unit cost sources are shown in Table 1. Resource use was recorded retrospectively for a period of 3 months, except for inpatient treatment and nursing home care, for which the time span was 6 months. Annual costs were calculated in Euros at 2008 price levels by multiplication of the costs of healthcare resource use per section by 4 (sections covering 3 months) or 2 (sections covering 6 months), based on the assumption of stable utilization patterns in the sample over a 12-month period. For comparability, costs in Euros (V) were converted to US dollars ($) using the average exchange rate for 2008 (V1 ¼ $1.47).20 Nursing home care was valued by the national average costs per day by type (residential care vs day care) and level of care (level 1 to 3), which reflects the average market price for these services (Federal Statistical Office21). According to regulations by the German social long term care insurance, nursing home residents are categorized into 3 levels of care according to their need of assistance for basic activities of daily living (level 1, 2, and 3 requiring care for basic activities such as

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Table 1 Recorded Resources, Units of Measurement, and Unit Costs used for Calculation of Costs in the Baseline Analysis Sector

Services/Goods

Units

Unit Costs (Source)

Inpatient treatment

Stays in general hospitals, specialised psychiatric and neurological hospitals or rehabilitation clinics (including day-patient treatment) Treatment by GPs, specialists and outpatient clinics eg, physiotherapy, massage, occupational therapy, speech therapy eg, walkers, incontinence pads, hearing aids, surgical stockings; bridge, crown

Days in hospital

Average costs per day by type (Federal Statistical Office, German Hospital Federation, Statutory Pension Insurance Fund)34e36 Calculated costs per contact, by specialization37 Reimbursement schedules (Statutory health insurance funds, calculated costs per contact),37 by type Reimbursement schedules (Statutory health insurance funds, Federal Association of Panel Dentists, calculated costs per item),37 by type Pharmacy retail prices (Rote Liste 2008)38

Outpatient physician treatment Other outpatient treatment Medical supplies and dental prostheses Pharmaceuticals Nursing home care Professional home care

Informal care

Specific products (including trade name, drug code, package size, pharmaceutical form, dosage) Nursing home stays (residential and day care)

Sensitivity Analysis There are different methods to value informal care in monetary terms.8 Therefore, unit costs for informal care were extensively varied in sensitivity analysis, applying (1) no value for informal care, (2) minimum replacement costs, (3) opportunity costs (ie, the value of the best alternative allocation of time) of leisure time, (4) opportunity costs of lost production, and (5) a threshold analysis; furthermore, (6) the impact of including hours of supervision (which were excluded from the baseline analysis) on costs was analyzed. Statistical Analyses Missing values for quantity or frequency of resource use were imputed using the mean of the observed data for the item in question, except for missing values on dosage of continuous medication for which missing values were calculated using a conservative rule, applying the pharmacy retail price of one package of the drug per 3 months. Missing values occurred in items for professional home care, informal care, and dosage of continuous medication. They made up between 0.6% and 3.4% of the data; 2.2% of entries for medication could not be processed on account of insufficiently specific data and were excluded from the analysis.

Quantity

Quantity Days

Care and assistance provided by professional nursing services and other paid help, differentiated by type (eg, basic care, assistance with cleaning, shopping, financial matters etc.) and limited to care or assistance required due to illness or age Care and assistance provided by family or friends, differentiated by type (eg, basic care, assistance with cleaning, shopping, financial matters etc.) and limited to care or assistance required due to illness or age

washing, feeding, or dressing for at least 0.75, 2, and 4 hours per day, respectively). Categorization is based on an assessment by a physician of the medical service of the social long term care insurance. Consequently, nursing homes differentiate prices according to these 3 levels of care. Accordingly, for residential nursing home care at level 1, 2, and 3, national average costs per day were V56.40 ($82.91), V70.76 ($104.02), and V85.13 ($125.14), respectively. Costs of accommodation and meals are not included in these rates as they are not attributable to the disease and would have occurred in healthy individuals too. Informal care was valued using the replacement cost method (also called proxy good or market cost method) (ie, it was assumed that informal care could have been substituted by paying a professional caregiver, and hours of informal care were therefore valued using the same hourly wage rate as used for professional home care).8 According to the German Federal Statistical Office, the hourly gross wage rate plus nonwage labor costs for employees in the domain of care and assistance for the elderly or handicapped was V18.69/hour ($27.47/hour) in 2008.22

Number of contacts Number of contacts

Hours

Hours

Average costs per day for care and assistance (Federal Statistical Office21), by type and level of care Hourly gross wage rate plus nonwage labor costs for employees in the domain of care and assistance for the elderly or handicapped (Federal Statistical Office22) Replacement cost method: Hourly gross wage rate plus nonwage labor costs for employees in the domain of care and assistance for the elderly or handicapped (Federal Statistical Office22)

Differences in proportions were tested using the c2 test or Fisher exact test, as appropriate. Differences in means were analysed by 2-tailed t-tests. To test for difference in the various cost categories by living situation, simple and multiple ordinary least squares (OLS) regression models with bootstrapped standard errors (4000 replications) were used. In these models, a dummy variable for living situation (nursing home vs community-dwelling), anddin multiple regression modelsdadditionally age, sex, Barthel Index Score, IADL score, and comorbidity were used as predictor variables. Bootstrapped standard errors were used in regression models because resource use and cost data tend to be highly skewed. The level of significance was set at a ¼0.05. Statistical analysis was performed using STATA Release 11 (Stata Corporation, College Station, TX) on PC. Results Sociodemographic Data and Clinical Data Of the 176 dementia patients, 128 lived in the community and 48 lived in a nursing home at the time of the interview. There were no significant differences in proportions of male and female subjects in the 2 groups. However, nursing home residents were on average 1.2 years older (P ¼ .035), significantly more frequently widowed (64.6% vs 46.9%), and less frequently married (20.8% vs 45.4%) than community-dwelling patients (Table 2). As expected, dementia severity based on CDR scores was significantly higher among patients living in a nursing home of whom 27.1% suffered from severe dementia compared with only 7.8% of community-dwelling patients. Consequently, nursing home residents had significantly worse scores of MMSE (17.1. vs 20.1), Barthel Index (49.4 vs 77.0), and IADL (0.9 vs 2.8) than community-dwelling patients. The degree of comorbidity did not differ significantly between nursing home residents and community-dwelling patients. Of nursing home residents, 23 (47.9%) were categorized into nursing home care level 1, 21 (43.8%) into care level 2, and 4 (8.3%) into care level 3. Health Care Resource Use Table 3 compares health care resource use patterns of dementia patients living in the community and patients living in a nursing home. With respect to medical care, there were no differences

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Table 2 Sociodemographic and Disease-Related Sample Characteristics, by Living Situation

Age Mean (SD) Range Sex: n (%) Female Male Marital status: n (%) Single Married Divorced Widowed Dementia severity: n (%) Mild, CDR  1 Moderate, CDR ¼ 2 Severe, CDR ¼ 3 MMSEx Mean (SD) Range Barthel Index score Mean (SD) Range IADL score Mean (SD) Range Comorbidity: mean (SD) Simple count Weighted score

Community-Dwelling n ¼ 128

Nursing Home n ¼ 48

85.0 (3.2) 79e96

86.2 (3.6) 80e93

P Value

.035*

85 (66.4%) 43 (33.6%)

36 (75.0%) 12 (25.0%)

.273y

7 58 3 60

6 10 1 31

(12.5%) (20.8%) (2.1%) (64.6%)

.011z

23 (47.9%) 12 (25.0%) 13 (27.1%)

< .001y

(5.5%) (45.3%) (2.3%) (46.9%)

98 (76.6%) 20 (15.6%) 10 (7.8%) 20.1 (5.0) 0e27

17.1 (5.9) 0e25

.003*

77.0 (27.0) 0e100

49.4 (29.2) 0e100

< .001*

2.8 (2.3) 0e8

0.9 (1.2) 0e4

< .001*

5.9 (4.1) 10.3 (8.5)

5.3 (5.1) 10.0 (11.8)

.379* .886*

CDR, Clinical Dementia Rating; IADL, instrumental activities of daily living; MMSE, Mini-Mental Status Examination; SD, standard deviation. *t-test (two-tailed). y 2 c test. z Fisher exact test. x Missing MMSE scores in the patient sample.

between the groups in the proportion of patients who received outpatient treatment or pharmaceuticals, nor in the number of GP contacts or pharmaceuticals. In both groups, more than 94% of patients used outpatient physician treatment in the past 3 months. Yet, among nursing home residents the proportion of patients who had been admitted to hospital was significantly higher than among community-dwelling patients (43.8% vs 23.4% in past 6 months), with

the number of hospital days also tending to be higher (5.6 vs 2.9 in past 6 months; P ¼ .096). By contrast, resource use patterns for nursing care differed markedly between the 2 groups with all differences being highly significant. Not surprisingly, nursing home residents on average spent more days in nursing homes than community-dwelling patients (165.1 vs 1.6 days in past 6 months). Community-dwelling patients, on the other hand, used more professional home care (users: 57.8% in past 3 months; mean: 7.4 hours per week) and, in particular, more informal care (users: 72.7% in past 3 months; mean: 16.3 hours per week) than nursing home residents, who used some informal care (47.9%; 1.9 hour per week).

Health Care Costs Unadjusted mean annual total costs including informal care were V29,930 ($43,997) for patients living at home and V33,482 ($49,219) for patients living in nursing homes, not being significantly different (Table 4). Yet, there were highly significant differences in costs of formal and informal nursing care between the 2 groups. Formal nursing care accounted for 64.6% of total costs in nursing home residents (V21,625; $31,789) but only 26.6% in community-dwelling patients (V7947; $11,682), with costs of formal care among community-dwelling patients being almost completely due to professional home care. Informal care amounted to 52.8% of total costs in community-dwelling patients (V15,803; $23,230) and only 5.5% in nursing home residents (V1843; $2709). Costs of medical care were significantly higher in nursing home residents (V9580; $14,083; 28.6% of total costs), compared with community-dwelling patients (V6001; $8821; 20.1%). This difference was mainly due to hospital inpatient treatment whereas other categories of medical care costs differed only little between the groups. Total costs without informal care amounted to V14,127 ($20,767) for patients living at home and V31,638 ($46,508) for patients living in nursing homes. Multiple regression analysis controlling for sociodemographic variables, Barthel Index score, IADL score, and comorbidity showed that living in the community was significantly associated with increased total costs by V11,344 ($16,676; P < .01) compared with living in a nursing home (Table 5). The reason for this difference is revealed by analogous regression analyses for the different cost

Table 3 Resource Utilization of Dementia Patients, by Living Situation Community-Dwelling n ¼ 128 Medical care Proportion with resource use: n (%) Inpatient treatment, 6 months* Outpatient physician treatment, 3 months Pharmaceuticals, 3 months Other outpatient treatment, 3 months Medical supplies and dentures, 3 months Amount of resource use: mean (SD) Days in hospital, 6 months* Number of GP contacts, 3 months Number of pharmaceuticals, 3 months Nursing care Proportion with resource use: n (%) Nursing home care, 6 months Professional home care, 3 months Informal care, 3 months Amount of resource use: mean (SD) Days in nursing home, 6 months Hours of professional home care per week Hours of informal care per week

30 121 120 60 67

(23.4%) (94.5%) (93.8%) (46.9%) (52.3%)

Nursing Home n ¼ 48

21 47 45 23 37

(43.8%) (97.9%) (93.8%) (47.9%) (77.8%)

2.9 (7.81) 1.7 (2.7) 6.8 (4.3)

5.6 (9.9) 1.9 (3.7) 6.2 (3.5)

8 (6.3%) 74 (57.8%) 93 (72.7%)

48 (100.0%) 7 (14.6%) 23 (47.9%)

1.6 (8.8) 7.4 (16.8) 16.3 (24.1)

165.1 (34.7) 0.0 (0.1) 1.9 (3.6)

OLS, ordinary least squares; SD, standard deviation. *General hospitals and specialised psychiatric/neurological hospitals (excluding day patient treatment). y Proportions of resource use: c2 test; amount of resource use: simple OLS regression with bootstrapped standard errors (4000 replications).

P Valuey

.008 .337 1.000 .902 .003 .096 .740 .344

< .001 < .001 .002 < .001 < .001 < .001

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Table 4 Mean Annual Costs in V (Year 2008 Values) for Dementia Patients, by Living Situation Cost Category

Community-Dwelling, n ¼ 128 Mean (SD)

Nursing Home, n ¼ 48 Mean (SD)

Medical care Inpatient treatment Outpatient physician treatment Pharmaceuticals Other outpatient treatment Medical supplies and dental prostheses Formal nursing care Nursing home care Professional home care Other Total Informal care Total incl. informal care

6001 2909 660 1478 433 519 7947 262 7685 179 14,127 15,803 29,930

9580 5669 1044 1410 696 759 21,625 21,513 112 434 31,638 1843 33,482

(8735) (7795) (994) (1358) (921) (1010) (16,650) (1182) (16,571) (1229) (20,108) (23,374) (30,492)

P Value*

(10,369) (9759) (1116) (1354) (1259) (1120) (5568) (5494) (651) (1600) (10,212) (3474) (10,129)

< < < < <

.035 .081 .041 .769 .187 .195 .001 .001 .001 .322 .001 .001 .247

OLS, ordinary least squares; SD, standard deviation. *Simple OLS regression with bootstrapped standard errors (4000 replications).

categories, which showed that nursing home residence on the one hand was associated with higher costs of formal nursing care (þV7983; þ$11,735; P < .01), but on the other hand, with substantially lower costs of informal care (V20,585; $30,260; P < .001). Costs of medical care were not significantly associated with living situation. Deficits in ADL were significantly associated with higher costs of formal nursing care (and higher total costs) whereas deficits in IADL were significantly associated with higher costs of informal care (and higher total costs). Comorbidity, age, and sex showed no significant association with the various cost categories. Sensitivity Analyses Running the multiple regression analysis for total costs without considering informal care resulted in nursing home residence being associated with increased costs by V9241 ($13,584; P < .05) compared with living in the community (Table 6). When applying the minimum wage of V10.96 ($16.11) per hour for informal care, the corresponding regression analysis resulted in higher costs for living in the community (V3244; $4769), yet not being significant; applying opportunity costs for lost leisure time of V18.00 (26.46 $) or lost production in the formal economy of V29.60 ($43.51) resulted in significantly higher costs for living in the community by V10,584 ($15,558) and V23,360 ($34,339), respectively. The threshold value indicating equal costs of care for patients living in the community and patients living in nursing homes in the regression analysis was V8.39 ($12.33) per hour of informal care. Including hours of supervision

almost doubled mean costs of informal care for community-dwelling patients to V29,215 ($42,946) whereas mean costs of informal care for nursing home residents changed only a little (V1873; $2753); corresponding multiple regression analysis for total costs resulted in living in the community being associated with increased costs by V30,653 ($45,060) compared with nursing home residence. Discussion From the societal perspective, costs of care for dementia patients living in the community tend to be higher than for patients living in nursing homes. When informal care provided by families and friends was valued by replacement costs, mean annual costs of care for community-dwelling patients was about V11,000 ($16,170) higher than for patients living in nursing homes after controlling for impairment in (instrumental) activities of daily living. This amount increased substantially if time spent on supervision of patients was included in the analysis. Care provided by family and friends in the community on the one hand saved costs of formal care but on the other hand caused informal care costs, which more than outweighed the savings. One reason for care provided in the community being more expensive is that it is rendered on an individual basis whereas in nursing homes caregivers care for more than one patient simultaneously. Expressed in economic terms, nursing home care clearly exhibits economies of scale. Noteworthy, costs of medical care did not differ significantly between the settings when severity of impairment was controlled for.

Table 5 Multiple Regression Analyses With Mean Annual Costs in V (Year 2008 Values) as Dependent Variable (N ¼ 175) Predictor variables Constant Living situation: nursing home (reference category: community-dwelling) Barthel Index scorey (centered) IADL scorey (centered) Age (centered) Male sex (reference category: female) Comorbidity (weighted score) R2 (adjusted)

Medical Care Costs b (SE)* 8762 (1475){ 1177 (1699) 58 308 L14 L2310 L77 0.06

(31) (332) (161) (1183) (60)

IADL, instrumental activities of daily living; OLS, ordinary least squares; SE, standard error. Significant coefficients are in bold. *Multiple OLS regression with bootstrapped standard errors (4000 replications). y Barthel Index score and IADL score: reverse coded. z P < .05. x P < .01. { P < .001.

Formal Nursing Care Costs b (SE)*

Informal Care Costs b (SE)*

Total Costs Incl. Informal Care b (SE)*

11,375 (2866){ 7983 (3044)x

14,165 (4007){ L20,585 (3558){

34,639 (4358){ L11,344 (4304)x

75 2648 L458 484 24 0.17

280 3672 103 276 L147 0.23

141 708 586 2435 L104 0.24

(56)z (478) (350) (2520) (104)

(86) (904)x (317) (3503) (143)

(98)x (995){ (482) (4372) (177)

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Table 6 Sensitivity Analysis of Total Costs for Variations in Valuation of Informal Care Method of Monetary Valuation of Informal Care

Monetary Value per Hour

Excess Costs of Nursing Home Residence Compared With Community-Dwelling*

(1) No monetary valuation (2) Minimum replacement costs: minimum wage rate in the domain of care and assistance for the elderly or handicapped including nonwage labor costs, population-weighted average for Eastern and Western Germany. (3) Opportunity costs of lost leisure time14,39: mean hourly net wage plus unemployment and pension insurance contributions.40,41 (4) Opportunity costs of lost production14,39: mean hourly gross market wage rate including nonwage labor costs.41 (5) Threshold analysis: monetary value per hour of informal care for which total costs of care provided for patients living in the community equalled the costs of care for nursing home residents. This was done by determining the monetary value per hour of informal care for which the parameter estimate for the dummy variable indicating living situation in the multiple regression analysis of total costs was equal to 0. (6) Including hours of supervision at replacement costs: hours of supervision recorded as part of informal care were included but the data were adjusted by capping the sum of hours of supervision and of informal care in direct contact with the patient at a maximum of 18 hours per day. This was based on the assumption of 6 sleeping hours per night with no need of supervision. Hours of supervision were valued at the same unit cost as informal care in the baseline analysis.

V0.00V V10.96

þV9241y V3244

V18.00

V10,584y

V29.60 V8.39

V23,360z V0

V18.69

V30,653z

*Parameter estimate for dummy variable ‘nursing home’ (reference category: ‘community-dwelling’) in total cost model. y P < .01. z P < .001.

Total societal costs strongly depend on the costs of informal care. We assessed informal care time in a very detailed manner by conducting personal interviews with the caregivers (proxies) applying a validated questionnaire,23 which is based on the Resource Utilization in Dementia instrument.24 Yet, for the monetary valuation of informal care, there is no universally accepted gold standard. Problems in valuing informal care are due to the fact that by definition there is no market price for informal care. In the health economic literature, it has often been argued that either the replacement or the opportunity cost method should be used to value informal care.7,8 In our baseline analysis, we applied the replacement cost method, which values informal care as if 1 hour of informal care perfectly replaces 1 hour of care provided by a professional caregiver. Therefore, we used the same hourly wage rate for informal and professional home care. However, the replacement cost method has been criticized for assuming that the quality and efficiency of care provided by informal caregivers is the same as of professional care. The quality of informal care may be better or worse in reality. Yet, the efficiency of informal care measured as the time necessary to complete specific tasks (eg, washing, bedding) is likely to be inferior compared with trained and experienced professional caregivers. Therefore, we reduced the monetary value per hour of informal care in sensitivity analysis. When applying the minimum instead of the mean wage of health care and nursing professions in Germany for valuing informal care, care provided in the community still tended to be more expensive than nursing home care. The monetary threshold value below which care provided in the community became less expensive than nursing home care was V8.39 ($12.33) per hour of informal care. A further disadvantage of the replacement cost method is the inherent assumption that informal care giving is not associated with any utility or disutility for the informal caregiver or care recipient. In contrast, the opportunity cost method aims at quantifying the informal caregiver’s loss in utility. Opportunity costs consist of foregone opportunities to derive utility from activities (leisure or work), which were made impossible due to care giving. As we had no information in our data on which activity was given up by the caregiver to provide informal care, we conducted the analysis using opportunity costs for lost leisure time and, alternatively, lost production time in the formal economy for valuing informal care. Using the opportunity costs of lost leisure time hardly changed the baseline results; yet, applying opportunity costs of lost production in the formal economy markedly increased the costs of care for community-dwelling patients. This is noteworthy because with

further increasing labor force participation rates due to demographic and social change, opportunity costs of informal care giving, in particular by the care recipients’ children, would increasingly consist of lost production rather than lost leisure time. Finally, it should be noted that utility or disutility for the informal care recipient was not considered by the opportunity cost method either. More recently, stated preference methods such as contingent valuation and conjoint analysis have been used to monetarily value the caregiver’s disutility associated with informal care giving.25e28 The (hypothetical) amount of money necessary to compensate for 1 (additional) hour of informal care giving was estimated mostly between V8 ($11.76) and V12 ($17.64). This amount is similar to the minimum wage rate used in our sensitivity analysis. Multiple regression analysis showed that costs of formal nursing care were associated with impairment in ADL, whereas costs of informal care were associated with deficits in IADL. Thus, besides living situation, ADL and IADL were the most important predictors of costs. The finding that impairment in ADL was not significantly associated with costs of informal care may be due to the frequently reported ceiling effect of the Barthel Index (eg, in reference 2929) among community-dwelling patients of whom 33% had the best possible score, whereas only 4% of nursing home residents had no impairment in ADL. Comorbidity, age, and sex showed no significant association with the various cost categories. Adding cognitive functioning (MMSE score) as predictor for total costs over and above ADL and IADL resulted in an insignificant regression coefficient and slight reduction of adjusted R2 indicating no improvement of the model. Because of the differences in price levels between countries, calculated costs may not directly apply outside Germany. However, as severity specific care time required for dementia patients might be similar in different countries, the ratio of prices of community-based care and nursing home care mainly determines which setting is more costly. Price ratios are likely to be similar in different countries. For example, according to the Personal Social Services Research Unit cost catalogue for 200830 in the United Kingdom mean costs per nursing home day were 96.86 £ ($179.72), whereas mean costs per hour of social care were 19.30 £ ($35.81) corresponding to a ratio of 5.0. In Germany, the corresponding unit costs applied in our study were V85.13 ($125.14; nursing home care level 3) and V18.69 ($27.47), resulting in an only slightly lower ratio of 4.6. Thus, compared with community-based care, nursing home care might be only slightly less costly in Germany than in the United Kingdom.

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Furthermore, differences in long term care systems including the availability of long term care insurance may limit generalizability of our results. While long term care insurance is mandatory for all citizens in Germany, it is not available to all citizens in other countries. (eg, in the USA only a small proportion of people have long term care insurance and others are covered by Medicaid after spending down their savings and assets). Due to these financial reasons, families in the USA may be more reluctant to place relatives with dementia in a nursing home, with predominantly the most severe cases being likely to be admitted. As a consequence, dementia patients living in nursing home in the USA may tend to be more costly than in Germany. To our knowledge, in the international literature there are only 3 previous studies that compared the societal costs of communitydwelling and institutionalized dementia patients while controlling for disease severity. All 3 studies used the replacement cost method to value informal care. Applying a value of around $7 per hour of informal care, Leon et al9 found monthly costs of institutionalized patients in the USA to be more than $1000 higher than of community-dwelling patients in 1996. Likewise, Scuvee-Moreau et al10 reported monthly societal costs of institutionalized patients in Belgium to be approximately V1000 ($1470) to V2000 ($2940) higher across all severity stages; yet the authors did not state the applied monetary value per hour of informal care. The only study reporting higher societal costs for community-dwelling dementia patients than institutionalized patients comes from Taiwan: Valuing informal care by 2000 Taiwan Dollar (approximately $62 in 1999) per day, Chiu et al11 reported higher societal costs for community-dwelling patients across all stages of severity; yet, costs of nursing home care were not based on patient level data and costs of medical care were not considered at all. Only the study by Leon et al applied multiple regression analysis to control for confounders and none of the cited studies performed sensitivity analysis on the costs of informal care. Further studies that did not control for severity of dementia reported higher12 or similar13 societal costs for institutionalized dementia patients compared with community-dwelling patients. Limitations As individuals already diagnosed with dementia, nursing home residents and severely ill patients were excluded at recruitment of the cohort the sample is likely to be biased toward less severe and, hence, less costly patients compared with the general population diagnosed with dementia in the same age range. Interviews were completed by caregivers. Given the evident degree of the patients’ cognitive impairment, these caregivers should be sufficiently involved in the patients’ daily affairs to be able to assess health care resource use accurately. However, as subjective caregiver burden is inversely correlated with caregiver ratings of patients’ abilities,31 it is possible that individual caregivers who experience a high degree of subjective burden might overestimate informal care time and thus costs of community-dwelling patients might be positively biased. Calculation of costs of nursing home care was based on average market prices differentiated by type and level of care. Since nursing homes in Germany distinguish only 3 levels of care, assessment of resource consumption of patients living in nursing homes (eg, staff caregiver time etc.) was less detailed than of community-dwelling patients. Yet, detailed costing of nursing home services for individual patients is complicated due to the fact that staff in nursing homes provides care for more than 1 patient simultaneously, and required data is not easily available. We, therefore, decided to use less differentiated market prices instead, which may cause some loss of precision in estimated costs.

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Furthermore, we did not control for behavioral problems, which may influence care burden and costs beyond impairments in activities of daily living.32 Finally, it has to be pointed out that we used a cross-sectional study design that brings about common problems of inference. Future studies should analyze the impact of living situation on the development of costs using a longitudinal study design. Conclusions Care for dementia patients living in the community tends to consume a greater amount of societal resources than care provided in nursing homes. This holds true, in particular, if family caregivers give up employment to provide informal care. Thus, from the societal perspective, which takes into account all resources used, community care tends to cost more than nursing home care, reflecting a shift of costs from the formal care sector to private households. The decision to place a patient with dementia in a nursing home or to provide care in the community is very complex and involves numerous factors other than costs. Among these are patient and caregiver characteristics, their preferences as well as contextual factors.33 Moreover, nursing home care and community care are not perfect substitutes in economic terms. Care provided by informal caregivers may generate more societal benefits than nursing home care if this better corresponds to the preference of patients. In fact, most patients are likely to prefer familial and consistent care givers rather than professionals. Yet, in severely impaired patients community care may become impossible and nursing home care inevitable. However, as societal resources are limited, costs may still be one important factor from a policy making viewpoint. Given that demographic and social changes are likely to cause a shortage in the supply of familial caregivers in the future, high societal costs challenge the focus of health policy on community care provided by families, and call for new ways to provide affordable care for dementia patients. Acknowledgments This study is part of the German Research Network on Dementia (KND) and the German Research Network on Degenerative Dementia (KNDD) and was funded by the German Federal Ministry of Education and Research (grants KND: 01GI0102, 01GI0420, 01GI0422, 01GI0423, 01GI0429, 01GI0431, 01GI0433, 01GI0434; grants KNDD: O1GI0710, 01GI0711, 01GI0712, 01GI0713, 01GI0714, 01GI0715, 01GI0716, 01ET1006B). The authors thank all participating patients and their general practitioners for their good collaboration. References 1. Peters E, Pritzkuleit R, Beske F, Katalinic A. Demographic change and disease rates: A projection until 2050. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2010;53:417e426. 2. Quentin W, Riedel-Heller SG, Luppa M, et al. Cost-of-illness studies of dementia: A systematic review focusing on stage dependency of costs. Acta Psychiatr Scand 2010;121:243e259. 3. Hurd MD, Martorell P, Delavande A, et al. Monetary costs of dementia in the United States. N Engl J Med 2013;368:1326e1334. 4. Federal Ministry of Justice. Social Code Book XI. Berlin: Federal Ministry of Justice; 1994. 5. Schwarzkopf L, Menn P, Leidl R, et al. Are community-living and institutionalized dementia patients cared for differently? Evidence on service utilization and costs of care from German insurance claims data. BMC Health Serv Res 2013;13:2. 6. German Federal Ministry of Health. Factsheet Long-Term Care Insurance. Available at: http://www.bundesgesundheitsministerium.de/fileadmin/dateien/Englische_ Dateien/110923_Factsheet_Long-Term_Care_Insurance.pdf. Accessed on August 13, 2012. 7. Luce BR, Manning WG, Siegel JE, Lipscomb J. Estimating costs in cost-effectiveness analysis. In: Gold MR, Siegel JE, Russell LB, Weinstein MC, editors.

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GPs Participating at the Time of Follow-Up 5 Bonn Claudia Adrian, Hanna Liese, Inge Bürfent, Johann von Aswege, Wolf-Dietrich Honig, Peter Gülle, Heribert Schützendorf, Elisabeth Benz, Annemarie Straimer, Arndt Uhlenbrock, Klaus-Michael Werner, Maria Göbel-Schlatholt, Hans-Jürgen Kaschell, Klaus Weckbecker, Theodor Alfen, Markus Stahlschmidt, Klaus Fischer, Wolf-Rüdiger Weisbach, Martin Tschoke, Jürgen Dorn, Helmut Menke, Erik Sievert, Ulrich Kröckert, Gabriele Salingré, Christian Mörchen, Peter Raab, Angela Baszenski, Clärli Loth, Christian Knaak, Peter Hötte, Jörg Pieper, Dirk Wassermann, Hans Josef Leyendecker, Gerhard Gohde, Barbara Simons, Achim Brünger, Uwe Petersen, Heike Wahl, Rainer Tewes, Doris Junghans-Kullmann, Angela Grimm-Kraft, Harald Bohnau, Ursula Pinsdorf, Thomas Busch, Gisela Keller, Susanne Fuchs-Römer, Wolfgang Beisel Düsseldorf Birgitt Richter-Polynice, Florinela Cupsa, Roland Matthias Unkelbach, Gerhard Schiller, Barbara Damanakis, Michael Frenkel, Klaus-Wolfgang Ebeling, Pauline Berger, Kurt Gillhausen, Uwe Hellmessen, Helga Hümmerich, Hans-Christian Heede, Boguslaw- Marian Kormann, Wolfgang Josef Peters, Ulrich Schott, Dirk Matzies, Andre Schumacher, Tim Oliver Flettner, Winfried Thraen, Harald Siegmund, Claus Levacher, Tim Blankenstein, Eliane Lamborelle, Ralf Hollstein, Edna Hoffmann, Ingeborg Ghane, Regine Claß, Stefan-Wolfgang Meier, Leo W. Moers, Udo Wundram, Klaus Schmitt, Rastin Missghian, Karin Spallek und Christiane Schlösser Hamburg Kathrin Groß, Winfried Bouché, Ursula Linn, Gundula Bormann, Gerhard Schulze, Klaus Stelter, Heike Gatermann, Doris Fischer-Radizi, Otto-Peter Witt, Stefanie Kavka, Günther Klötzl, Karl-Christian Münter, Michael Baumhöfener, Maren Oberländer, Cornelia Schiewe, Jörg Hufnagel, Anne-Marei Kressel, Michael Kebschull, Christine Wagner, Fridolin Burkhardt, Martina Hase, Matthias Büttner, Karl-Heinz Houcken, Christiane Zebidi, Johann Bröhan, Christiane Russ, Frank Bethge, Gisela Rughase-Block, Margret Lorenzen, Arne Elsen, Lerke Stiller, Angelika Giovanopoulos, Daniela Korte, Ursula Jedicke, Rosemarie Müller-Mette, Andrea Richter, Sanna Rauhala-Parrey, Constantin Zoras, Gabriele Pfeil-Woltmann, Annett Knöppel-Frenz, Martin Kaiser, Johannes Bruns, Joachim Homann, Georg Gorgon, Niklas Middendorf, Kay Menschke, Hans Heiner Stöver, Hans H. Bayer, Rüdiger Quandt, Gisela Rughase-Block, Hans-Michael Köllner, Enno Strohbehn, Thomas Haller, Nadine Jesse, Martin Domsch, Marcus Dahlke Leipzig Thomas Lipp, Ina Lipp, Martina Amm, Horst Bauer, Gabriele Rauchmaul, Hans Jochen Ebert, Angelika Gabriel-Müller, HansChristian Taut, Hella Voß, Ute Mühlmann, Holger Schmidt, Gabi Müller, Eva Hager, Bettina Tunze, Barbara Bräutigam, Thomas Paschke, Heinz-Michael Assmann, Ina Schmalbruch, Gunter Kässner,

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Iris Pförtzsch, Brigitte Ernst-Brennecke, Uwe Rahnefeld, Petra Striegler, Marga Gierth, Anselm Krügel, Margret Boehm, Dagmar Harnisch, Simone Kornisch-Koch, Birgit Höne, Lutz Schönherr, FrankHambsch, Katrin Meitsch, Britta Krägelin-Nobahar, Cornelia Herzig, Astrid Georgi, Erhard Schwarzmann, Gerd Schinagl, Ulrike Pehnke, Mohammed Dayab, Sabine Müller, Jörg-Friedrich Onnasch, Michael Brosig, Dorothea Frydetzki, Uwe Abschke, Volkmar Sperling, Ulrich Gläser, Frank Lebuser, Detlef Hagert

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Dirk Matzies, Andre Schumacher, Tim Oliver Flettner, Winfried Thraen, Clemens Wirtz, Harald Siegmund Hamburg Kathrin Groß, Bernd-Uwe Krug, Petra Hütter, Dietrich Lau, Gundula Bormann, Ursula Schröder-Höch, Wolfgang Herzog, Klaus Weidner, Doris Fischer-Radizi, Otto-Peter Witt, Stefanie Kavka, Günther Klötzl, Ljudmila Titova, Andrea Moritz

Mannheim Leipzig Gerhard Arnold, Viet-Harold Bauer, Hartwig Becker, Hermine Becker, Werner Besier, Hanna Böttcher-Schmidt, Susanne FüllgrafHorst, Enikö Göry, Hartmut Grella, Hans Heinrich Grimm, Petra Heck, Werner Hemler, Eric Henn, Violetta Löb, Grid Maaßen-Kalweit, Manfred Mayer, Hubertus Mühlig, Arndt Müller, Gerhard Orlovius, Helmut Perleberg, Brigitte Radon, Helmut Renz, Carsten Rieder, Michael Rosen, Georg Scheer, Michael Schilp, Angela Schmid, Matthias Schneider, Christian Schneider, Rüdiger Stahl, Christian Uhle, Jürgen Wachter, Necla Weihs, Brigitte Weingärtner, Monika Werner, Hans-Georg Willhauck, Eberhard Wochele, Bernhard Wolfram München Andreas Hofmann, Eugen Allwein, Helmut Ruile, Andreas Koeppel, Peter Dick, Karl-Friedrich Holtz, Gabriel Schmidt, Lutz-Ingo Fischer, Johann Thaller, Guntram Bloß, Franz Kreuzer, Günther Holthausen, Karl Ludwig Maier, Walter Krebs, Christoph Mohr, Heinz Koschine, Richard Ellersdorfer, Michael Speth, Maria Kleinhans, Panagiota Koutsouva-Sack, Gabriele Staudinger, Johann Eiber, Stephan Thiel, Cornelia Gold, Andrea Nalbach, Kai Reichert, Markus Rückgauer, Martin Neef, Viktor Fleischmann, Natalija Mayer, Andreas Spiegl, Fritz Renner, Eva Weishappel-Ketisch, Thomas Kochems, Hartmut Hunger, Marianne Hofbeck, Alfred Neumeier, Elfriede Goldhofer, Thomas Bommer, Reinhold Vollmuth, Klaus Lanzinger, Simone Bustami-Löber, Ramona Pauli, Jutta Lindner, Gerlinde Brandt, Otto Hohentanner, Rosita Urban-Hüttner, Peter Porz, Bernd Zimmerhackl, Barbara Naumann, Margarete Vach, Alexander Hallwachs, Claudia Haseke, Andreas Ploch, Paula Bürkle-Grasse, Monika Swobodnik, Corina Tröger, Detlev Jost, Roman Steinhuber, Renate Narr, Gabriele Nehmann-Hörwick, Christiane Eder, Helmut Pillin, Frank Loth, Beate Rücker, Nicola Fritz, Michael Rafferzeder, Dietmar Zirpel.

Thomas Lipp, Ina Lipp, Martina Amm, Horst Bauer, Gabriele Rauchmaul, Hans Jochen Ebert, Angelika Gabriel-Müller, Hans-Christian Taut, Hella Voß, Ute Mühlmann, Holger Schmidt, Gabi Müller, Eva Hager, Bettina Tunze, Barbara Bräutigam, Sabine Ziehbold, Thomas Paschke, Heinz-Michael Assmann, Ina Schmalbruch, Gunter Kässner Mannheim Gerhard Arnold, Viet-Harold Bauer, Werner Besier, Hanna BöttcherSchmidt, Hartmut Grella, Ingrid Ludwig, Manfred Mayer, Arndt Müller, Adolf Noky, Gerhard Orlovius, Helmut Perleberg, Carsten Rieder, Michael Rosen, Georg Scheer, Michael Schilp, Gerhard Kunzendorf, Matthias Schneider, Jürgen Wachter, Brigitte Weingärtner, Hans- Georg Willhauck München Helga Herbst, Andreas Hofmann, Eugen Allwein, Helmut Ruile, Andreas Koeppel, Peter Friedrich, Hans-Georg Kirchner, Elke Kirchner, Luitpold Knauer, Peter Dick, Karl-Friedrich Holtz, Elmar Schmid, Gabriel Schmidt, Lutz-Ingo Fischer, Johann Thaller, Guntram Bloß, Franz Kreuzer, Ulf Kahmann, Günther Holthausen, Karl Ludwig Maier, Walter Krebs, Christoph Mohr, Heinz Koschine, Richard Ellersdorfer, Michael Speth. GPs Who Used to Participate in the Study Bonn

GPs Who Participated at Baseline

Heinz-Peter Romberg, Eberhard Prechtel, Manfred Marx, Jörg Eimers-Kleene, Paul Reich, Eberhard Stahl, Reinhold Lunow, Klaus Undritz, Bernd Voss, Achim Spreer, Oliver Brenig, Bernhard G. Müller, Ralf Eich, Angelika Vossel, Dieter Leggewie, Angelika Schmidt, Nahid Aghdai-Heuser, Lutz Witten, Michael Igel

Bonn

Düsseldorf

Heinz-Peter Romberg, Hanna Liese, Inge Bürfent, Johann von Aswege, Wolf-Dietrich Honig, Peter Gülle, Heribert Schützendorf, Manfred Marx, Annemarie Straimer, Arndt Uhlenbrock, Klaus-Michael Werner, Maria Göbel-Schlatholt, Eberhard Prechtel, Hans-Jürgen Kaschell, Klaus Weckbecker, Theodor Alfen, Jörg Eimers-Kleene, Klaus Fischer, Wolf-Rüdiger Weisbach, Martin Tschoke

Michael Fliedner, Benjamin Hodgson, Werner Hamkens, Angela Ackermann, Bernhard Hoff, Michael Kirsch, Vladimir Miasnikov, Dieter Lüttringhaus, Clemens Wirtz, Rolf Opitz, Jürgen Bausch, Dirk Mecking, Friederike Ganßauge, Elmar Peters, Alfons Wester

Düsseldorf

Werner Petersen, Martin Daase, Martin Rüsing, Christoph von Sethe, Wilmhard Borngräber, Brigitte Colling-Pook, Ullrich Weidner, Peter Rieger, Lutz Witte, Hans-Wilhelm Busch, Jürgen Unger, Angela Preis, Michael Mann, Ernst Haeberle, Horst Köhler, Ruth Schäfer, Helmut Sliwiok, Volker L. Brühl, Hans-Heiner Stöver, Harald Deest, Margret Ackermann-Körner, Dieter Reinstorff, Christamaria Schlüter, Henrik Heinrichs, Ole Dankwarth, Michael Böse, Ulricke Ryll, Reinhard Bauer, Dieter Möltgen, Sven Schnakenbeck, Karin Beckmann, Annegret Callsen, Ewa Schiewe, Holger Gehm, Volker Lambert, Karin

Birgitt Richter-Polynice, Michael Fliedner, Binjamin Hodgson, Florinela Cupsa, Werner Hamkens, Roland Matthias Unkelbach, Gerhard Schiller, Barbara Damanakis, Angela Ackermann, Michael Frenkel, Klaus-Wolfgang Ebeling, Bernhard Hoff, Michael Kirsch, Vladimir Miasnikov, Pauline Berger, Kurt Gillhausen, Uwe Hellmessen, Helga Hümmerich, Hans-Christian Heede, Boguslaw-Marian Kormann, Dieter Lüttringhaus, Wolfgang Josef Peters, Ulrich Schott,

Hamburg

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Hinkel-Reineke, Carl-Otto Stolzenbach, Peter Berdin, Friedhelm Windler

Meer, Adolf Noky, Christina Panzer, Achim Raabe, Helga SchmidtBack, Ralf Schürmann, Hans-Günter Stieglitz, Marie-Luise von der Heide

Leipzig München Sabine Ziehbold, Sabine Weidnitzer, Erika Rosenkranz, Norbert Letzien, Doris Klossek, Martin Liebsch, Andrea Zwicker, Ulrike Hantel, Monika Pilz, Volker Kirschner, Rainer Arnold, Ulrich Poser Mannheim Wolfgang Barthel, Fritz Blechinger, Marcus Fähnle, Reiner Walter Fritz, Susanne Jünemann, Gabriele Kirsch, Jürgen Kulinna, Gerhard Kunzendorf, Andreas Legner-Görke, Christa Lehr, Wolfgang

Helga Herbst, Peter Friedrich, Hans-Georg Kirchner, Elke Kirchner, Luitpold Knauer, Elmar Schmid, Ulf Kahmann, Jörg Kastner, Ulrike Janssen, Albert Standl, Clemens Göttl, Marianne Franze, Gerhard Moser, Almut Blümm, Petra Weber, Wolfgang Poetsch, Heinrich Puppe, Thomas Bommer, Gerd Specht, Leonard Badmann, May Leveringhaus, Michael Posern, Andreas Ploch, Ralph Potkowski, Christiane Eder, Michael Schwandner, Rudolf Weigert, Christoph Huber