Caring for the elderly: A person-centered segmentation approach for exploring the association between health care needs, mental health care use, and costs in Germany

Autoři: Beate Wild aff001;  Dirk Heider aff002;  Dieter Schellberg aff001;  Friederike Böhlen aff001;  Ben Schöttker aff003;  Dana Clarissa Muhlack aff003;  Hans-Helmut König aff002;  Joris Slaets aff004
Působiště autorů: Department of General Internal Medicine and Psychosomatics, Medical University Hospital, Heidelberg, Germany aff001;  Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Germany aff002;  Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany aff003;  Departments of Internal Medicine and Geriatrics, University Hospital, Groningen, Netherlands aff004
Vyšlo v časopise: PLoS ONE 14(12)
Kategorie: Research Article



Person-centered care demands the evaluation of needs and preferences of the patients. In this study, we conducted a segmentation analysis of a large sample of older people based on their bio-psycho-social-needs and functioning. The aim of this study was to clarify differences in health care use and costs of the elderly in Germany.


Data was derived from the 8-year follow-up of the ESTHER study—a German epidemiological study of the elderly population. Trained medical doctors visited n = 3124 participants aged 57 to 84 years in their home. Bio-psycho-social health care needs were assessed using the INTERMED for the Elderly (IM-E) interview. Further information was measured using questionnaires or assessment scales (Barthel index, Patients Health Questionnaire (PHQ) etc.). The segmentation analysis applied a factor mixture model (FMM) that combined both a confirmatory factor analysis and a latent class analysis.


In total, n = 3017 persons were included in the study. Results of the latent class analysis indicated that a five-cluster-model best fit the data. The largest cluster (48%) can be described as healthy, one cluster (13.9%) shows minor physical complaints and higher social support, while the third cluster (24.3%) includes persons with only a few physical and psychological difficulties (“minor physical and psychological complaints”). One of the profiles (10.5%) showed high and complex bio-psycho-social health care needs (“complex needs”) while another profile (2.5%) can be labelled as “frail”. Mean values of all psychosomatic variables—including the variable health care costs—gradually increased over the five clusters. Use of mental health care was comparatively low in the more burdened clusters. In the profiles “minor physical and psychological complaints” and “complex needs”, only half of the persons suffering from a mental disorder were treated by a mental health professional; in the frail cluster, only a third of those with a depression or anxiety disorder received mental health care.


The segmentation of the older people of this study sample led to five different clusters that vary profoundly regarding their bio-psycho-social needs. Results indicate that elderly persons with complex bio-psycho-social needs do not receive appropriate mental health care.

Klíčová slova:

Allied health care professionals – Anxiety disorders – Depression – Elderly – Frailty – Geriatric depression – Geriatrics – Mental health and psychiatry


1. Singer SJ, Burgers J, Friedberg M, Rosenthal MB, Leape L, Schneider E. Defining and measuring integrated patient care: promoting the next frontier in health care delivery. Med Care Res Rev. 2011;68(1):112–27. Epub 2010/06/18. doi: 10.1177/1077558710371485 20555018.

2. Lafortune L, Beland F, Bergman H, Ankri J. Health state profiles and service utilization in community-living elderly. Med Care. 2009;47(3):286–94. Epub 2009/01/24. doi: 10.1097/MLR.0b013e3181894293 19165121.

3. Forma L, Rissanen P, Aaltonen M, Raitanen J, Jylha M. Age and closeness of death as determinants of health and social care utilization: a case-control study. Eur J Public Health. 2009;19(3):313–8. Epub 2009/03/17. doi: 10.1093/eurpub/ckp028 19286838.

4. Lehnert T, Heider D, Leicht H, Heinrich S, Corrieri S, Luppa M, et al. Review: health care utilization and costs of elderly persons with multiple chronic conditions. Med Care Res Rev. 2011;68(4):387–420. doi: 10.1177/1077558711399580 21813576

5. Mori T, Hamada S, Yoshie S, Jeon B, Jin X, Takahashi H, et al. The associations of multimorbidity with the sum of annual medical and long-term care expenditures in Japan. BMC Geriatr. 2019;19(1):69. doi: 10.1186/s12877-019-1057-7 30841859

6. Lenox-Smith A, Reed C, Lebrec J, Belger M, Jones RW. Resource utilisation, costs and clinical outcomes in non-institutionalised patients with Alzheimer's disease: 18-month UK results from the GERAS observational study. BMC Geriatr. 2016;16(1):195. Epub 2016/11/27. doi: 10.1186/s12877-016-0371-6 27887645.

7. Westphal EC, Alkema G, Seidel R, Chernof B. How to Get Better Care with Lower Costs? See the Person, Not the Patient. J Am Geriatr Soc. 2016;64(1):19–21. Epub 2015/12/08. doi: 10.1111/jgs.13867 26639104.

8. Mead N, Bower P. Patient-centredness: a conceptual framework and review of the empirical literature. Soc Sci Med. 2000;51(7):1087–110. Epub 2000/09/27. doi: 10.1016/s0277-9536(00)00098-8 11005395.

9. Laine C, Davidoff F. Patient-centered medicine. A professional evolution. JAMA. 1996;275(2):152–6. Epub 1996/01/10. 8531314.

10. Spoorenberg SLW, Wynia K, Uittenbroek RJ, Kremer HPH, Reijneveld SA. Effects of a population-based, person-centred and integrated care service on health, wellbeing and self-management of community-living older adults: A randomised controlled trial on Embrace. PLoS One. 2018;13(1):e0190751. Epub 2018/01/20. doi: 10.1371/journal.pone.0190751 29351295.

11. Leiber S, Gress S, Manouguian MS. Health care system change and the cross-border transfer of ideas: influence of the Dutch model on the 2007 German health reform. J Health Polit Policy Law. 2010;35(4):539–68. Epub 2010/11/09. doi: 10.1215/03616878-2010-016 21057097.

12. Wieland D, Lamb V, Wang H, Sutton S, Eleazer GP, Egbert J. Participants in the Program of All-Inclusive Care for the Elderly (PACE) demonstration: developing disease-impairment-disability profiles. Gerontologist. 2000;40(2):218–27. Epub 2000/05/23. doi: 10.1093/geront/40.2.218 10820925.

13. Zhou YY, Wong W, Li H. Improving care for older adults: a model to segment the senior population. Perm J. 2014;18(3):18–21. Epub 2014/06/18. doi: 10.7812/TPP/14-005 24937151.

14. Eissens van der Laan MR, van Offenbeek MA, Broekhuis H, Slaets JP. A person-centred segmentation study in elderly care: towards efficient demand-driven care. Soc Sci Med. 2014;113:68–76. Epub 2014/05/24. doi: 10.1016/j.socscimed.2014.05.012 24852657.

15. Löw M, Stegmaier C, Ziegler H, Rothenbacher D, Brenner H. [Epidemiological investigations of the chances of preventing, recognizing early and optimally treating chronic diseases in an elderly population (ESTHER study)]. Dtsch Med Wochenschr. 2004;129(49):2643–7. doi: 10.1055/s-2004-836089 15578318

16. Wild B, Heider D, Maatouk I, Slaets J, Konig HH, Niehoff D, et al. Significance and costs of complex biopsychosocial health care needs in elderly people: results of a population-based study. Psychosom Med. 2014;76(7):497–502. Epub 2014/08/15. doi: 10.1097/PSY.0000000000000080 25121639.

17. Wild B, Lechner S, Herzog W, Maatouk I, Wesche D, Raum E, et al. Reliable integrative assessment of health care needs in elderly persons: the INTERMED for the Elderly (IM-E). J Psychosom Res. 2011;70(2):169–78. doi: 10.1016/j.jpsychores.2010.09.003 21262420

18. Lubben J, Blozik E, Gillmann G, Iliffe S, von Renteln Kruse W, Beck JC, et al. Performance of an abbreviated version of the Lubben Social Network Scale among three European community-dwelling older adult populations. Gerontologist. 2006;46(4):503–13. Epub 2006/08/22. doi: 10.1093/geront/46.4.503 16921004.

19. Fricke J, Unsworth CA. Inter-rater reliability of the original and modified Barthel Index, and a comparison with the Functional Independence Measure. Aust Occup Ther J. 1997;44(1):22–9. doi: 10.1111/j.1440-1630.1997.tb00750.x

20. Lubke N, Meinck M, Von Renteln-Kruse W. [The Barthel Index in geriatrics. A context analysis for the Hamburg Classification Manual]. Z Gerontol Geriatr. 2004;37(4):316–26. Epub 2004/09/01. doi: 10.1007/s00391-004-0233-2 15338161.

21. Wild B, Eckl A, Herzog W, Niehoff D, Lechner S, Maatouk I, et al. Assessing generalized anxiety disorder in elderly people using the GAD-7 and GAD-2 scales: results of a validation study. Am J Geriatr Psychiatry. 2014;22(10):1029–38. Epub 2013/06/19. doi: 10.1016/j.jagp.2013.01.076 23768681.

22. Lowe B, Kroenke K, Herzog W, Grafe K. Measuring depression outcome with a brief self-report instrument: sensitivity to change of the Patient Health Questionnaire (PHQ-9). J Affect Disord. 2004;81(1):61–6. Epub 2004/06/09. doi: 10.1016/S0165-0327(03)00198-8 15183601.

23. Kroenke K, Strine TW, Spitzer RL, Williams JB, Berry JT, Mokdad AH. The PHQ-8 as a measure of current depression in the general population. J Affect Disord. 2009;114(1–3):163–73. doi: 10.1016/j.jad.2008.06.026 18752852

24. Kroenke K, Spitzer RL, Williams JB. The PHQ-15: validity of a new measure for evaluating the severity of somatic symptoms. Psychosom Med. 2002;64(2):258–66. doi: 10.1097/00006842-200203000-00008 11914441

25. Zijlema WL, Stolk RP, Lowe B, Rief W, White PD, Rosmalen JG. How to assess common somatic symptoms in large-scale studies: a systematic review of questionnaires. J Psychosom Res. 2013;74(6):459–68. Epub 2013/06/05. doi: 10.1016/j.jpsychores.2013.03.093 23731742.

26. Hinz A, Ernst J, Glaesmer H, Brahler E, Rauscher FG, Petrowski K, et al. Frequency of somatic symptoms in the general population: Normative values for the Patient Health Questionnaire-15 (PHQ-15). J Psychosom Res. 2017;96:27–31. Epub 2017/05/27. doi: 10.1016/j.jpsychores.2016.12.017 28545789.

27. Heinrich S, Luppa M, Matschinger H, Angermeyer MC, Riedel-Heller SG, Konig HH. Service utilization and health-care costs in the advanced elderly. Value Health. 2008;11(4):611–20. doi: 10.1111/j.1524-4733.2007.00285.x 18179660

28. Hohls JK, Wild B, Heider D, Brenner H, Bohlen F, Saum KU, et al. Association of generalized anxiety symptoms and panic with health care costs in older age-Results from the ESTHER cohort study. J Affect Disord. 2019;245:978–86. Epub 2018/12/19. doi: 10.1016/j.jad.2018.11.087 30562680.

29. Krauth C, Hessel F, Hansmeier T, Wasem J, Seitz R, Schweikert B. [Empirical standard costs for health economic evaluation in Germany—a proposal by the working group methods in health economic evaluation]. Gesundheitswesen. 2005;67(10):736–46. doi: 10.1055/s-2005-858698 16235143

30. Dyer WJ, Day RD. Investigating Family Shared Realities With Factor Mixture Modeling. Journal of Marriage and Family. 2015;77(1):191–208. doi: 10.1111/jomf.12158

31. Lubke GH, Muthen B. Investigating population heterogeneity with factor mixture models. Psychol Methods. 2005;10(1):21–39. Epub 2005/04/07. doi: 10.1037/1082-989X.10.1.21 15810867.

32. Lenze EJ, Wetherell JL. Anxiety disorders: new developments in old age. Am J GeriatrPsychiatry. 2011;19(4):301–4.

33. Kok RM, Reynolds CF 3rd. Management of Depression in Older Adults: A Review. JAMA. 2017;317(20):2114–22. Epub 2017/05/24. doi: 10.1001/jama.2017.5706 28535241.

34. Quinodoz D. Growing old. A journey of self-discovery. East Sussex: Routledge; 2010.

35. Uittenbroek RJ, Kremer HPH, Spoorenberg SLW, Reijneveld SA, Wynia K. Integrated Care for Older Adults Improves Perceived Quality of Care: Results of a Randomized Controlled Trial of Embrace. J Gen Intern Med. 2017;32(5):516–23. Epub 2016/06/09. doi: 10.1007/s11606-016-3742-y 27271728.

36. Spoorenberg SL, Wynia K, Fokkens AS, Slotman K, Kremer HP, Reijneveld SA. Experiences of Community-Living Older Adults Receiving Integrated Care Based on the Chronic Care Model: A Qualitative Study. PLoS One. 2015;10(10):e0137803. Epub 2015/10/22. doi: 10.1371/journal.pone.0137803 26489096.

37. Marcus-Varwijk AE, Peters LL, Visscher TLS, Smits CHM, Ranchor AV, Slaets JPJ. Impact of a Nurse-Led Health Promotion Intervention in an Aging Population: Results From a Quasi-Experimental Study on the "Community Health Consultation Offices for Seniors". J Aging Health. 2018:898264318804946. Epub 2018/10/18. doi: 10.1177/0898264318804946 30326768.

38. Wild B, Herzog W, Schellberg D, Bohlen F, Brenner H, Saum KU, et al. A short intervention targeting psychosomatic care in older adults with complex health care needs-results of a randomized controlled trial. Int J Geriatr Psychiatry. 2019;34(2):272–9. Epub 2018/10/30. doi: 10.1002/gps.5017 30370681.

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