In the coalition agreement, the new federal government holds out the prospect of a “decade of investment for the future”. It thus recognises that considerable additional investment-related government spending is necessary to overcome the investment backlog in Germany and promote the socio-ecological transformation. Based on current studies, a total of 600 to 800 billion euros over ten year seems plausible, with a significant share accruing at the municipal level. The new government addresses important problems of municipal finances including significant regional disparities, but further measures are needed to enable all local communities to invest sufficiently.

In Chapter 3, K. Rietzler and A. Watt emphasise that against the backdrop of an increasingly broad consensus that Germany has substantially underinvested in public goods for an extended period, the new Traffic Light Coalition Agreement sets out ambitious spending plans that go beyond the modernisation of Germany’s infrastructure and speeding up decarbonisation. At the same time, it has also committed to the debt brake and to avoiding tax hikes. Moreover, since the establishment of this new government, other fiscal challenges have arisen because of the war in Ukraine and a sharp rise in energy and food prices. By exploiting the scope of short-run flexibility (the debt brake is currently still suspended) and new off-budget measures, the government is seeking to square this circle by allowing greater investments in the face of competing demands. The national plan under the Recovery and Resilience Facility (RRF) complements national initiatives; but in Germany’s case, it is of limited macroeconomic relevance. The latest developments in RRF projects are sketched out in the chapter.

BackgroundAssessment of comorbidities in rheumatoid arthritis (RA) has proven to be difficult for the rheumatologist due to lack of time leading to considerable deficits. Nurse-led programs on RA comorbidity management might solve this problem and have been reported to be beneficial.1 MethodsThe cluster randomised multicentre study ERIKO longitudinally assessed the general health status of patients with RA in Germany applying a nurse-led scoring algorithm for individual risk profiles (ERIKO-Score). The ERIKO-Score is a composite score evaluating the following risk factors: cardiovascular (CV) risk (ESC-guideline), infection risk (RABBIT risk calculator), vaccination status (guideline), fracture risk (FRAX), tooth status (PSI), depression (PHQ-9) and health-related quality of life (hrQoL, RAID). The outcome was translated into a three-level ordinal score defined by the categories low, intermediate or high risk with 0, 1 and 2 points, respectively. Afterwards the treating rheumatologist discussed the outcomes with the patient. The primary endpoint, the change in ERIKO-Score between baseline and after one year of follow-up as a consequence of the structured assessment (active arm) was assessed using a mixed model in order to account for a random centre effect. Furthermore, comorbidity management in the active arm versus expert guided assessment following standard of care (SOC, control arm) was evaluated using Fisher’s exact test and the Cochran-Armitage trend test.ResultsThe analysis included 341 patients from 42 rheumatology centres with 210 patients in the active arm (mean disease duration 12.0 years (sd 8.8), mean DAS28 2.6 (sd 1.1)) and 131 patients in the control arm (mean disease duration 9.7 years (sd 7.4), mean DAS28 2.6 (sd 1.2)). After one year of follow-up the structured assessment led to a significant mean decrease in total ERIKO-Score by −0.45 (95% CI ranging from −0.67 to −0.23, p<0.001). This decrease was driven by an improvement in vaccination status, tooth status and depression risk. No difference in comorbidity management was detected between the structured assessment and SOC. At the end of follow-up, the mean ERIKO-Scores for both arms were 4.85 with 95% CIs ranging from 4.59 to 5.11 and 4.47 to 5.24 for the active arm and the control arm, respectively. A significant improvement in risk categorisation after one year of follow-up was observed for vaccination status and depression risk with better outcomes in the active arm as compared to the control arm.ConclusionsA nurse-led comorbidity risk assessment in rheumatology practices resulted in a significant improvement after one year of follow-up. However, improvement was small and there was no benefit compared to expert-opinion based SOC. In clinical routine, applying the ERIKO-Score based on validated tools seems to be feasible. Nurse-led comorbidity assessment seems to be able to reduce existing deficits.Reference[1] Dougados M, et al. Ann Rheum Dis2015;74:1725–33.AcknowledgementsThis study was sponsored by AbbVie Deutschland GmbH and Co KG. AbbVie ...

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