Post-COVID-19-associated morbidity in children, adolescents, and adults: A matched cohort study including more than 157,000 individuals with COVID-19 in Germany

BACKGROUND

Long-term health sequelae of the Coronavirus Disease 2019 (COVID-19) are a major public health concern. However, evidence on post-acute COVID-19 syndrome (post-COVID-19) is still limited, particularly for children and adolescents. Utilizing comprehensive healthcare data on approximately 46% of the German population, we investigated post-COVID-19-associated morbidity in children/adolescents and adults.

METHODS AND FINDINGS

We used routine data from German statutory health insurance organizations covering the period between January 1, 2019 and December 31, 2020. The base population included all individuals insured for at least 1 day in 2020. Based on documented diagnoses, we identified individuals with polymerase chain reaction (PCR)-confirmed COVID-19 through June 30, 2020. A control cohort was assigned using 1:5 exact matching on age and sex, and propensity score matching on preexisting medical conditions. The date of COVID-19 diagnosis was used as index date for both cohorts, which were followed for incident morbidity outcomes documented in the second quarter after index date or later.Overall, 96 prespecified outcomes were aggregated into 13 diagnosis/symptom complexes and 3 domains (physical health, mental health, and physical/mental overlap domain). We used Poisson regression to estimate incidence rate ratios (IRRs) with 95% confidence intervals (95% CIs). The study population included 11,950 children/adolescents (48.1% female, 67.2% aged between 0 and 11 years) and 145,184 adults (60.2% female, 51.1% aged between 18 and 49 years). The mean follow-up time was 236 days (standard deviation (SD) = 44 days, range = 121 to 339 days) in children/adolescents and 254 days (SD = 36 days, range = 93 to 340 days) in adults. COVID-19 and control cohort were well balanced regarding covariates. The specific outcomes with the highest IRR and an incidence rate (IR) of at least 1/100 person-years in the COVID-19 cohort in children and adolescents were malaise/fatigue/exhaustion (IRR: 2.28, 95% CI: 1.71 to 3.06, p < 0.01, IR COVID-19: 12.58, IR Control: 5.51), cough (IRR: 1.74, 95% CI: 1.48 to 2.04, p < 0.01, IR COVID-19: 36.56, IR Control: 21.06), and throat/chest pain (IRR: 1.72, 95% CI: 1.39 to 2.12, p < 0.01, IR COVID-19: 20.01, IR Control: 11.66). In adults, these included disturbances of smell and taste (IRR: 6.69, 95% CI: 5.88 to 7.60, p < 0.01, IR COVID-19: 12.42, IR Control: 1.86), fever (IRR: 3.33, 95% CI: 3.01 to 3.68, p < 0.01, IR COVID-19: 11.53, IR Control: 3.46), and dyspnea (IRR: 2.88, 95% CI: 2.74 to 3.02, p < 0.01, IR COVID-19: 43.91, IR Control: 15.27). For all health outcomes combined, IRs per 1,000 person-years in the COVID-19 cohort were significantly higher than those in the control cohort in both children/adolescents (IRR: 1.30, 95% CI: 1.25 to 1.35, p < 0.01, IR COVID-19: 436.91, IR Control: 335.98) and adults (IRR: 1.33, 95% CI: 1.31 to 1.34, p < 0.01, IR COVID-19: 615.82, IR Control: 464.15). The relative magnitude of increased documented morbidity was similar for the physical, mental, and physical/mental overlap domain. In the COVID-19 cohort, IRs were significantly higher in all 13 diagnosis/symptom complexes in adults and in 10 diagnosis/symptom complexes in children/adolescents. IRR estimates were similar for age groups 0 to 11 and 12 to 17. IRs in children/adolescents were consistently lower than those in adults. Limitations of our study include potentially unmeasured confounding and detection bias.

CONCLUSIONS

In this retrospective matched cohort study, we observed significant new onset morbidity in children, adolescents, and adults across 13 prespecified diagnosis/symptom complexes, following COVID-19 infection. These findings expand the existing available evidence on post-COVID-19 conditions in younger age groups and confirm previous findings in adults.

TRIAL REGISTRATION

ClinicalTrials.gov https://clinicaltrials.gov/ct2/show/NCT05074953.

Post-COVID-19-associated morbidity in children, adolescents, and adults: A matched cohort study including more than 157,000 individuals with COVID-19 in Germany

BACKGROUND

Long-term health sequelae of the Coronavirus Disease 2019 (COVID-19) are a major public health concern. However, evidence on post-acute COVID-19 syndrome (post-COVID-19) is still limited, particularly for children and adolescents. Utilizing comprehensive healthcare data on approximately 46% of the German population, we investigated post-COVID-19-associated morbidity in children/adolescents and adults.

METHODS AND FINDINGS

We used routine data from German statutory health insurance organizations covering the period between January 1, 2019 and December 31, 2020. The base population included all individuals insured for at least 1 day in 2020. Based on documented diagnoses, we identified individuals with polymerase chain reaction (PCR)-confirmed COVID-19 through June 30, 2020. A control cohort was assigned using 1:5 exact matching on age and sex, and propensity score matching on preexisting medical conditions. The date of COVID-19 diagnosis was used as index date for both cohorts, which were followed for incident morbidity outcomes documented in the second quarter after index date or later.Overall, 96 prespecified outcomes were aggregated into 13 diagnosis/symptom complexes and 3 domains (physical health, mental health, and physical/mental overlap domain). We used Poisson regression to estimate incidence rate ratios (IRRs) with 95% confidence intervals (95% CIs). The study population included 11,950 children/adolescents (48.1% female, 67.2% aged between 0 and 11 years) and 145,184 adults (60.2% female, 51.1% aged between 18 and 49 years). The mean follow-up time was 236 days (standard deviation (SD) = 44 days, range = 121 to 339 days) in children/adolescents and 254 days (SD = 36 days, range = 93 to 340 days) in adults. COVID-19 and control cohort were well balanced regarding covariates. The specific outcomes with the highest IRR and an incidence rate (IR) of at least 1/100 person-years in the COVID-19 cohort in children and adolescents were malaise/fatigue/exhaustion (IRR: 2.28, 95% CI: 1.71 to 3.06, p < 0.01, IR COVID-19: 12.58, IR Control: 5.51), cough (IRR: 1.74, 95% CI: 1.48 to 2.04, p < 0.01, IR COVID-19: 36.56, IR Control: 21.06), and throat/chest pain (IRR: 1.72, 95% CI: 1.39 to 2.12, p < 0.01, IR COVID-19: 20.01, IR Control: 11.66). In adults, these included disturbances of smell and taste (IRR: 6.69, 95% CI: 5.88 to 7.60, p < 0.01, IR COVID-19: 12.42, IR Control: 1.86), fever (IRR: 3.33, 95% CI: 3.01 to 3.68, p < 0.01, IR COVID-19: 11.53, IR Control: 3.46), and dyspnea (IRR: 2.88, 95% CI: 2.74 to 3.02, p < 0.01, IR COVID-19: 43.91, IR Control: 15.27). For all health outcomes combined, IRs per 1,000 person-years in the COVID-19 cohort were significantly higher than those in the control cohort in both children/adolescents (IRR: 1.30, 95% CI: 1.25 to 1.35, p < 0.01, IR COVID-19: 436.91, IR Control: 335.98) and adults (IRR: 1.33, 95% CI: 1.31 to 1.34, p < 0.01, IR COVID-19: 615.82, IR Control: 464.15). The relative magnitude of increased documented morbidity was similar for the physical, mental, and physical/mental overlap domain. In the COVID-19 cohort, IRs were significantly higher in all 13 diagnosis/symptom complexes in adults and in 10 diagnosis/symptom complexes in children/adolescents. IRR estimates were similar for age groups 0 to 11 and 12 to 17. IRs in children/adolescents were consistently lower than those in adults. Limitations of our study include potentially unmeasured confounding and detection bias.

CONCLUSIONS

In this retrospective matched cohort study, we observed significant new onset morbidity in children, adolescents, and adults across 13 prespecified diagnosis/symptom complexes, following COVID-19 infection. These findings expand the existing available evidence on post-COVID-19 conditions in younger age groups and confirm previous findings in adults.

TRIAL REGISTRATION

ClinicalTrials.gov https://clinicaltrials.gov/ct2/show/NCT05074953.

The study on health of older people in Germany (Health 65+): Design and first results

Background

Integrating older persons into continuous national public health monitoring is crucial but challenging. Health 65+ is the first national health interview and examination survey in Germany specifically tailored to the needs of the population 65+ years.

Methods

Health 65+ is based on two-stage stratified random sampling from 128 local population registries. It is based on a previously tested three-step procedure to contact the study population (letter, telephone, home visits). 12,448 individuals 65+ years were invited for survey participation between June 2021 and April 2022. Participation comprised answering a baseline-questionnaire/interview covering a consented set of key health indicators including SARS-COV2 infections, and 3 follow-ups. After one year participants are invited to an examination (e.g. blood pressure, grip strength, cognitive function) during a home visit. All-cause mortality, health insurance data and information on social and built environment will be linked to survey data. The preliminary data set comprises 3,107 baseline participants.

Preliminary results

Only few individuals were excluded for survey participation as they had deceased before invitation, moved to an unknown residence or had insufficient German language skills. Of the adjusted gross sample, 32% took part in the survey (47.9% women, mean age 78.8 years). Only 3.3% of the participants did not receive any vaccination against COVID-19, with no differences between gender or age-groups. 3.5% had already experienced a laboratory-confirmed SARS-CoV-2 infection.

Conclusions

Health 65+ collects information that cannot be obtained from any other data sources. In combination with information from routine health data and official health statistics, the results will aid health policy planning and implementation research to improve health and wellbeing of older people in Germany. For example, preliminary results show, that vaccination acceptance was high in persons 65+ years in Germany.

Key messages

• Health 65+ will provide health data of people 65+ years in Germany.

• The results will aid health policy planning.

Long-Term Health Symptoms and Sequelae Following SARS-CoV-2 Infection: An Evidence Map

Post-COVID-19 conditions, also known as 'Long-COVID-19', describe a longer and more complex course of illness than acute COVID-19 with no widely accepted uniform case definition. We aimed to map the available evidence on persistent symptoms and sequelae following SARS-CoV-2 in children and adults. We searched the Cochrane COVID-19 Study Register and the WHO COVID-19 Global literature on coronavirus disease database on 5 November 2021. We included longitudinal and cross-sectional studies and we extracted their characteristics, including the type of core outcomes for post-COVID-19 conditions. We included 565 studies (657 records). Most studies were uncontrolled cohort studies. The median follow-up time was 13 weeks (IQR 9 to 24). Only 72% of studies were conducted in high-income countries, 93% included unvaccinated adults with mild-to-critical disease, only 10% included children and adolescents, and less than 5% included children under the age of five. While most studies focused on health symptoms, including respiratory symptoms (71%), neurological symptoms (57%), fatigue (54%), pain (50%), mental functioning (43%), cardiovascular functioning (40%), and post-exertion symptoms (28%), cognitive function (26%), fewer studies assessed other symptoms such as overall recovery (24%), the need for rehabilitation (18%), health-related quality of life (16%), changes in work/occupation and study (10%), or survival related to long-COVID-19 (4%). There is a need for controlled cohort studies with long-term follow-up and a focus on overall recovery, health-related quality of life, and the ability to perform daily tasks. Studies need to be extended to later phases of the pandemic and countries with low resources.

Non-utilisation of health care services during the COVID-19 pandemic: Results of the CoMoLo study

Based on data from the CORONA-MONITORING lokal (CoMoLo) study conducted in four municipalities particularly affected by the COVID-19 pandemic, this article investigates the non-utilisation of health care services in the population aged 18 years and older (n=9,002) in relation to the period after the introduction of the containment measures in March 2020. The results show that about one third of the respondents (35.5%) gave up at least one of the surveyed health care services. The most frequent cancellations were dental (15.2%) and specialist check-ups (11.8%), followed by postponement of physiotherapy, ergotherapy or speech therapy (6.1%), cancellation of general practitioner (GP) check-ups (5.8%), postponement of psychotherapy (2.0%), postponement of planned hospital treatment (1.8%) and not going to an emergency room (0.7%). Almost 10% of the respondents reported not visiting a physician despite health complaints. Compared to respondents without such a waiver, these respondents were more often female and younger than 35 years, less often rated their health as very good or good, more often had a diagnosis of depression and more often used telemedical contacts as an alternative to visiting the practice during the pandemic. Further analyses of trends in utilisation behaviour and changes in health status over the course of the COVID-19 pandemic are important.

Sex-specific impact of major depressive disorder on 12-year change in glycaemic status: Results from a nationwide cohort study of adults without diabetes in Germany

AIMS

There is evidence for an increased type 2 diabetes (T2D) risk associated with depression, but its role for diabetes prevention remains unclear. This study aimed to add insight by investigating the impact of major depressive disorder (MDD) on prospective glycaemic changes.

METHODS

The study was based on a cohort of n = 1,766 adults without diabetes (776 men, 990 women; 18-65 years of age) who participated in the mental health supplement of the German National Health Interview and Examination Survey (GNHIES98-MHS, 1997-1999) and in a follow-up survey (DEGS1, 2008-2011). Glycaemic status was defined as normoglycaemia [HbA1c < 39 mmol/mol (<5.7%)], prediabetes [39 ≤ HbA1c < 48 mmol/mol (5.7-6.4%)] and diabetes [HbA1c ≥ 48 mmol/mol (≥ 6.5%), diagnosed diabetes, or antidiabetic medication], and glycaemic changes categorized as 'remission', 'stability' and 'progression'. Baseline MDD was assessed via a modified German version of the WHO Composite International Diagnostic Interview. Multivariable logistic regressions were applied to analyse the association of MDD with glycaemic changes and incident T2D, adjusting for socio-demographics, lifestyle conditions, chronic diseases, antidepressant use and mental health care.

RESULTS

MDD prevalence was 21.4% for women and 8.9% for men. Among women, MDD was associated with a lower chance for remission (RRR 0.43; 95% CI 0.23, 0.82). Among men, MDD was not significantly related to glycaemic changes. MDD had no significant effect on incident T2D (men: OR 1.58; 0.55, 4.52; women: OR 0.76; 0.37, 1.58).

CONCLUSIONS

Findings of the current study highlight the role of depression in T2D prevention, particularly among women.

Making Use of Comparable Health Data to Improve Quality of Care and Outcomes in Diabetes: The EUBIROD Review of Diabetes Registries and Data Sources in Europe

Background

Registries and data sources contain information that can be used on an ongoing basis to improve quality of care and outcomes of people with diabetes. As a specific task of the EU Bridge Health project, we carried out a survey of diabetes-related data sources in Europe.

Objectives

We aimed to report on the organization of different sources of diabetes information, including their governance, information infrastructure and dissemination strategies for quality control, service planning, public health, policy and research.

Methods

Survey using a structured questionnaire to collect targeted data from a network of collaborating institutions managing registries and data sources in 17 countries in the year 2017.

Results

The 18 data sources participating in the study were most frequently academic centres (44.4%), national (72.2%), targeting all types of diabetes (61.1%) covering no more than 10% of the target population (44.4%). Although population-based in over a quarter of cases (27.8%), sources relied predominantly on provider-based datasets (38.5%), fewer using administrative data (16.6%). Data collection was continuous in the majority of cases (61.1%), but 50% could not perform data linkage. Public reports were more frequent (72.2%) as well as quality reports (77.8%), but one third did not provide feedback to policy and only half published ten or more peer reviewed papers during the last 5 years.

Conclusions

The heterogeneous implementation of diabetes registries and data sources hampers the comparability of quality and outcomes across Europe. Best practices exist but need to be shared more effectively to accelerate progress and deliver equitable results for people with diabetes.

Health situation of adults in Germany - Results for selected indicators from GEDA 2019/2020-EHIS

In this article, we examine selected health indicators for the adult population aged 18 years and older in Germany (n=22,708) from the German Health Update (GEDA 2019/2020-EHIS) conducted between April 2019 and September 2020. These indicators include those of self-assessed health and depressive symptoms as well as chronic physical diseases and conditions. In young adulthood (18 to 44 years), over 80% of participants report good or very good subjective health. During this phase of life, most chronic diseases and conditions are rare, although allergies are frequent, and bronchial asthma and depressive symptoms are not uncommon. From mid adulthood (45 years and older), there is a gradual increase in the prevalence of chronic diseases such as cardiovascular disease, diabetes, chronic obstructive pulmonary disease and osteoarthritis. Over 60% of older adults (65 years and older) report a chronic disease or long-term health problem, while only half continue to report good or very good subjective health. During this stage of life, allergies and depressive symptoms become less prevalent. For some diseases, there are also differences according to gender and level of education. This article demonstrates the high public health relevance of age-associated chronic physical diseases and health related limitations in everyday life in an ageing society as well as the need to provide care for certain health conditions already in young adulthood.

Health situation of adults in Germany - Results for selected indicators from GEDA 2019/2020-EHIS

In this article, we examine selected health indicators for the adult population aged 18 years and older in Germany (n=22,708) from the German Health Update (GEDA 2019/2020-EHIS) conducted between April 2019 and September 2020. These indicators include those of self-assessed health and depressive symptoms as well as chronic physical diseases and conditions. In young adulthood (18 to 44 years), over 80% of participants report good or very good subjective health. During this phase of life, most chronic diseases and conditions are rare, although allergies are frequent, and bronchial asthma and depressive symptoms are not uncommon. From mid adulthood (45 years and older), there is a gradual increase in the prevalence of chronic diseases such as cardiovascular disease, diabetes, chronic obstructive pulmonary disease and osteoarthritis. Over 60% of older adults (65 years and older) report a chronic disease or long-term health problem, while only half continue to report good or very good subjective health. During this stage of life, allergies and depressive symptoms become less prevalent. For some diseases, there are also differences according to gender and level of education. This article demonstrates the high public health relevance of age-associated chronic physical diseases and health related limitations in everyday life in an ageing society as well as the need to provide care for certain health conditions already in young adulthood.

Utilisation of outpatient medical services by people with diagnosed diabetes during the COVID-19 pandemic in Germany

People with diabetes regularly need outpatient medical care due to their disease and possible concomitant and secondary illnesses. Using data from the nationwide GEDA 2019/2020-EHIS survey conducted from April 2019 to September 2020, the present study examines developments in outpatient utilisation behaviour during the measures put in place to contain the SARS-CoV-2 pandemic. During the observation period, people with diabetes had a significantly higher rate of utilisation of medical services provided by general practitioners (GPs) and specialists than the population as a whole. In the spring of 2020, when the restrictions were put in place, utilisation of specialist medical services by people with diabetes decreased temporarily by 46% compared to the 2019 reference period. In contrast, no relevant decline in the utilisation of medical services provided by GPs was observed, but this could be related to adaptations of care provision through telephone consultations for people with regularly requiring GP office visits. The issue examined here requires further observations in view of the renewed containment measures.

Gestational diabetes in Germany: Development of screening participation and prevalence

Gestational diabetes mellitus (GDM) is an important risk factor for pregnancy complications. Since 2012, the Federal Joint Committee's maternity directive recommends a two-step screening for GDM with a pre-test and subsequent diagnostic test if the pre-test is positive. This study analyses the implementation and development over time of GDM screening participation and prevalence in Germany. The data basis is the external inpatient obstetrics quality assurance documentation, which covers all births in hospital. Women with diabetes before pregnancy were excluded. The study defined women as GDM cases if the condition was documented in maternity records or if the ICD-10 diagnosis O24.4 was coded for inpatients at discharge and figures were determined for the years 2013 to 2018. As the documentation of screening tests has only been included in the data set since 2016, screening participation for the years 2016 to 2018 were estimated and evaluated based on the pre-test and/or diagnostic tests documented in maternity records. In 2018, the majority of all women who gave birth in hospitals had had a pre-test conducted (65.0%) or a pre-test and diagnostic test (18.2%) in line with the two-step procedure. A further 6.7% received a diagnostic test alone. GDM screening participation increased over time from 83.4% in 2016 to 89.9% in 2018. The prevalence of a documented GDM increased from 4.6% to 6.8% between 2013 and 2018. In 2018, this equates to 51,318 women with GDM. Reliably assessing the extent and causes of this development will require continuous analyses of screening implementation, documentation and changes in maternal risk factors.

Self-assessed quality of care among adults with diagnosed diabetes in Germany

People who have diabetes require regular medical care. The views of patients about the quality of their care are becoming increasingly relevant when it comes to chronic diseases such as diabetes. As part of the nationwide study Disease Knowledge and Information Needs - Diabetes mellitus (2017), data on self-assessed quality of care by people with diagnosed diabetes was collected using the Patient Assessment of Chronic Illness Care - DAWN short form (PACIC-DSF, scale 1 to 5) and analysed for respondents aged 45 years or above. The average score for quality of care was 2.47 and was lower for women than for men (2.33 vs 2.58). The respondents assessed the quality of their care as being worse with rising age and size of the population in their residential area. No significant differences were observed by education group. Overall, people with diabetes in Germany consider the quality of their care to be moderate, which indicates a need for improvement in care.

Older people at the beginning of the COVID-19 pandemic: A scoping review

This scoping review focuses on evidence gaps regarding the effects on health, social participation and life contexts of older people at the beginning of the COVID-19 pandemic. It is based on a systematic search strategy of the international literature covering a period between December 2019 and June 2020. The review is supplemented by a search of the websites of selected organisations in Germany (cut-off date: 29 June 2020). Search hits were differentiated by types of publication (empirical study, review, discussion paper). The contents were summarised in tabular form according to topic. The publications mainly discussed the high risks of suffering severe courses of COVID-19 faced by older people, specifically those belonging to certain subgroups. In addition, further main topics were the pandemic’s indirect impacts on physical and mental health, physical and cognitive functions and participation in society. Social isolation, loneliness, reduced levels of physical activity and difficulties in maintaining care were discussed as major health risks. Ageism was an issue that was addressed across all of the identified topics. The publications highlighted the need, but also the opportunity, for raising public awareness of the needs of older people in various life contexts. Publications pointed to the urgent need for research into the biological and social causes of older peoples’ high infection risk and how measures could be adapted in a differentiated manner (infection prevention and control measures, social support, medical and nursing care).

Are depressive symptoms associated with quality of care in diabetes? Findings from a nationwide population-based study

INTRODUCTION

We investigated whether the presence of depressive symptoms among adults with diagnosed diabetes is associated with adverse quality of diabetes care.

RESEARCH DESIGN AND METHODS

The study population was drawn from the German national health survey 'German Health Update' 2014/2015-European Health Interview Survey and included 1712 participants aged ≥18 years with self-reported diabetes during the past 12 months. Depressive symptoms in the past 2 weeks were assessed by the eight-item depression module of the Patient Health Questionnaire (PHQ-8), with PHQ-8 sum score values ≥10 indicating current depressive symptoms. We selected 12 care indicators in diabetes based on self-reported information on care processes and outcomes. Associations of depressive symptoms with those indicators were examined in multivariable logistic regression models with stepwise adjustments.

RESULTS

Overall, 15.6% of adults with diagnosed diabetes reported depressive symptoms, which were higher in women than in men (18.7% vs 12.9%). Adjusted for age, sex, education, social support, health-related behaviors, and diabetes duration, adults with depressive symptoms were more likely to report acute hypoglycemia (OR 1.81, 95% CI 1.13 to 2.88) or hyperglycemia (OR 2.10, 95% CI 1.30 to 3.37) in the past 12 months, long-term diabetes complications (OR 2.30, 95% CI 1.55 to 3.39) as well as currently having a diet plan (OR 2.14, 95% CI 1.39 to 3.29) than adults without depressive symptoms. Significant associations between depressive symptoms and other care indicators were not observed.

CONCLUSIONS

The present population-based study of adults with diagnosed diabetes indicates an association between depressive symptoms and adverse diabetes-specific care with respect to outcome but largely not to process indicators. Our findings underline the need for intensified care for persons with diabetes and depressive symptoms. Future research needs to identify underlying mechanisms with a focus on the inter-relationship between diabetes, depression and diabetes-related distress.

Care for the chronically ill in Germany - The challenges during the COVID-19 pandemic

The COVID-19 pandemic is posing major challenges to the health care sector. This scoping review compiles evidence concerning changes to health care service availability and utilisation as well as possible impacts on health for selected groups of chronically ill people in Germany. The focus is on cancer, cardiovascular diseases, diabetes mellitus and mental disorders. Most empirical data available concerned inpatient care and showed a clear decline in the utilisation of inpatient treatments in March and April 2020 in the areas of oncology and cardiology as well as in mental health. For cardiovascular emergencies such as heart attack and stroke, a decline was observed especially regarding less serious cases. Although there were indications of treatment delays, there was no evidence thus far that emergency care had been generally compromised due to adjustments to inpatient care capacities. In the outpatient setting, extensive adjustments to health care services availability were observed for all disease groups considered. Overall, very limited empirical data were available. In particular, hardly any data were available on how changes in care impacted population health. There is an urgent need for continuous surveillance and evaluation based on health care and epidemiological data.

Excess mortality in adults with documented diabetes in Germany: routine data analysis of all insurance claims in Germany 2013-2014

OBJECTIVES

Little is known about the age-specific excess mortality pattern of people with diagnosed diabetes in Germany. Thus, our goal was to determine the excess mortality in diagnosed diabetes overall and stratified by age and sex based on claims data.

DESIGN

Routine data analysis using a claims dataset from all statutory health-insured persons in Germany in 2013, which accounts for about 90% of the population.

PARTICIPANTS

We included persons who lived in Germany, were insured at least 360 days, were not self-paying any health services and were aged 30 years or older leading to a total number of 47.3 million insured persons for analyses.

EXPOSURE

Diabetes was determined by the International Classification of Diseases-10 codes E10-E14, which were documented in 2013 in at least two-quarters on an outpatient setting or at least once on an inpatient setting.

OUTCOME MEASURES

The vital status in the study population was drawn from the claims dataset for the year 2014. We derived the excess mortality estimated as an age-adjusted mortality rate ratio (MRR) by sex and for age groups using a Poisson model.

MAIN RESULTS

We found age-adjusted MRRs (95% CI) for diabetes of 1.52 (1.51 to 1.52) for women and 1.56 (1.56 to 1.56) for men. These figures declined with increasing age and were highest for ages 30-34 years with 6.76 (4.99 to 9.15) for women and 6.87 (5.46 to 8.64) for men, and lowest for age 95 years and older with 1.13 (1.10 to 1.15) for women and 1.11 (1.05 to 1.17) for men.

CONCLUSIONS

We derived deeply age-stratified figures on excess mortality in diabetes for Germany. Establishing a sustainable analysis of excess mortality is aimed at within the framework of diabetes surveillance.

Estimating the impact of tax policy interventions on the projected number and prevalence of adults with type 2 diabetes in Germany between 2020 and 2040

INTRODUCTION

As a population-wide intervention, it has been proposed to raise taxes on unhealthy products to prevent diseases such as type 2 diabetes. In this study, we aimed to estimate the effect of tax policy interventions in 2020 on the projected prevalence and number of people with type 2 diabetes in the German adult population in 2040.

RESEARCH DESIGN AND METHODS

We applied an illness-death model and the German Diabetes Risk Score (GDRS) to project the prevalence and number of adults with type 2 diabetes in Germany under a base case scenario and under a tax policy intervention scenario. For the base case scenario, we assumed constant age-specific incidence rates between 2020 and 2040. For the intervention scenario, we assumed a 50% price increase for sugar-sweetened beverages, tobacco and red meat products in the year 2020. Based on price elasticities, we estimated the impact on these risk factors alone and in combination, and calculated subsequent reductions in the age-specific and sex-specific GDRS. These reductions were used to determine reductions in the incidence rate and prevalence using a partial differential equation.

RESULTS

Compared with the base case scenario, combined tax interventions in 2020 resulted in a 0.95 percentage point decrease in the prevalence of type 2 diabetes (16.2% vs 17.1%), which corresponds to 640 000 fewer prevalent cases of type 2 diabetes and a relative reduction by 6%.

CONCLUSIONS

Taxation of sugar-sweetened beverages, tobacco products and red meat by 50% modestly lowered the projected number and prevalence of adults with type 2 diabetes in Germany in 2040. Raising taxes on unhealthy products as a stand-alone measure may not be enough to attenuate the future rise of type 2 diabetes.

Factors associated with undiagnosed type 2 diabetes in Germany: results from German Health Interview and Examination Survey for Adults 2008-2011

INTRODUCTION

To identify characteristics of people with undiagnosed type 2 diabetes (T2D) among adults in Germany.

RESEARCH DESIGN AND METHODS

The study population comprised participants aged 40-79 years of the German Health Interview and Examination Survey for Adults 2008-2011. Glycemic status was categorized as undiagnosed T2D (glycated hemoglobin A1c (HbA1c) ≥48 mmol/mol (6.5%), n=135), diagnosed T2D (n=518) and normoglycemia (HbA1c<48 mmol/mol (6.5%), n=4451). Multinomial logistic regression models including glycemic status as the outcome variable and sociodemographic characteristics, living alone, diabetes risk factors and healthcare services utilization as independent variables were used to identify factors associated with undiagnosed T2D compared with normoglycemia and diagnosed T2D. Odds ratios (ORs) and 95% confidence intervals (CIs) are reported as measure of association between the outcome and independent variables.

RESULTS

The prevalence of undiagnosed T2D was 2.9% (95% CI 2.2% to 3.9%) at an overall prevalence of 12.3% (11.0% to 13.6%) of persons with undiagnosed or diagnosed T2D. In multivariable analyses, factors associated with undiagnosed as well as diagnosed T2D in comparison to normoglycemia were older age (OR 1.04, 95% CI 1.01 to 1.06, per year, for undiagnosed T2D; OR 1.08, 1.07 to 1.10 for diagnosed T2D), male sex (3.33, 2.18 to 5.07; 1.91, 1.43 to 2.56), obesity (3.47, 2.17 to 5.56; 2.68, 2.04 to 3.52), hypertension (1.66, 1.09 to 2.53; 2.04, 1.42 to 2.95) and parental history of diabetes (2.04, 1.24 to 3.35; 3.16, 2.30 to 4.34). Variables independently associated with undiagnosed T2D but not diagnosed T2D included living alone (2.20; 1.36 to 3.56) and not seeing a doctor within the past year (2.57; 1.34 to 4.93). People with undiagnosed T2D were further younger and more likely to be male sex and reside in the western part of Germany than people with diagnosed T2D.

CONCLUSION

Apart from major known risk factors of diabetes, characteristics specific to undiagnosed diabetes among adults in Germany will serve to inform the national education and communication strategy on diabetes mellitus in Germany.

Patient-assessed quality of care in type 2 diabetes in a German nationwide health survey 2017

Background

Patient-assessed quality of chronic illness care is important to guide medical care for patients with diabetes and other complex chronic diseases, but information from epidemiological studies is scarce. Thus, we examined self-assessed quality of care among adults with type 2 diabetes (T2D) based on a population-based design.

Methods

The study population was drawn from a nationwide survey on diabetes-related knowledge and information needs conducted in Germany in 2017 and included participants aged ≥18 years with known type 2 diabetes (T2D) in the last 12 months (n = 1,328). A German short version of the “Patient assessment of chronic illness care (PACIC-DSF)” consisting of 9 items based on 5-point Likert scale was applied to assess self-reported quality of care in diabetes which was operationalized by a standardized PACIC sum score ranging from 1 to 5. Linear regression with different stages of adjustment was applied to assess the association of basic characteristics and diabetes-related factors with the PACIC score.

Results

Quality of care was assessed less favorably by women than by men (PACIC score: 2.38 vs. 2.47) overall and decreased along with age. The PACIC score significantly increased in participants with insulin use (β = 0.16, p = 0.024), ever participating in a diabetes education program (β = 0.33, p &lt; 0.001), following a diet plan at least once a week (β = 0.33, p &lt; =0.001) as well as performing daily self-examination of feet (β = 0.14, p = 0.023), self-control of blood glucose (β = 0.34, p &lt; 0.001), and being physically active for at least 30 min (β = 0.21, p &lt; 0.001) compared to participants without the respective trait.

Conclusions

Self-assessed quality of care by adults with known T2D from this population-based study is moderate and seems lower compared to findings from clinical studies.

Key messages

An active involvement of people with type 2 diabetes into the implementation of care is essential and may contribute to improved self-perceived quality of care. To identify and overcome obstacles in diabetes care based on the patient’s perspective remains a public health challenge.

Life expectancy and healthy life years associated with diabetes in Germany

Background

While life expectancy (LE) is rising, years lived with severe health impairments especially due to chronic diseases also increase. Diabetes is one of the major chronic diseases with high potential for co-morbidity and premature deaths needing life-long care. Therefore, information about loss in LE and healthy life years (HLY) in people with diabetes compared to people without diabetes is essential for assessing the burden of diabetes.

Methods

Data on all-cause mortality rates for the general population of Germany in 2014 was drawn from the Federal Statistical Office; mortality rate ratios for people with diabetes compared to people without diabetes were based on claims data from about 70 million people covered by statutory health insurances in 2014. Data of three nationwide health telephone surveys conducted among adults in Germany 2009-2012 (n ∼ 60,000) were used to assess severe health impairments defined as self-reported limitations in daily activities due to diseases for at least six months in people with and without diabetes. Based on these figures, estimates on LE and HLY could be calculated by sex and 5-year age-groups for people with and without diabetes aged ≥ 30 years.

Results

In both sexes and in all 5-year age-groups, LE and HLY were substantially lower for people with than for people without diabetes. For example, among women in the age group 30-34 years, LE and HLY estimates were 48.0 and 36.4 years for those with diabetes compared to 54.9 and 47.6 years for those without diabetes; in men, these figures were estimated as 42.6 and 32.4 years for those with diabetes compared to 50.3 and 44.1 years for those without diabetes. Differences in LE and HLY between people with and without diabetes attenuated with increasing age.

Conclusions

The present study revealed substantial reductions in LE and HLY related to diabetes and underlines the importance of integrating both figures in a national diabetes surveillance.

Key messages

There are substantial differences in life expectancy and healthy life years between people with and without diabetes. Specific intervention and prevention activities should be implemented to tackle disability in persons with diabetes.

[Health reporting as part of public health surveillance: the example of diabetes]

The continuous collection and analysis of health data on relevant diseases (surveillance) is at the core of public health. The surveillance enables the implementation of measures to protect the populations' health. Therefore, relevant information needs to be provided in a timely and target-group-specific manner to the respective stakeholders.A dissemination strategy supports the effective communication of results and considers three key questions: (1) "What content is relevant to the surveillance?", (2) "Who requires which information?" and (3) "How are the results disseminated to the target audience?" In this context, digitalisation allows for novel possibilities in the design of publication formats.Since 2015, diabetes surveillance has been established at the Robert Koch Institute. Within a structured process of consensus, we defined four fields of action relevant for health policy including 40 indicators. Thereafter, we developed the first publication formats in collaboration with the scientific advisory board of the project that reflected novel possibilities offered by digitalisation. In addition to articles in scientific journals, the essential formats of the first project phase comprise the report "Diabetes in Germany" and a website including interactive visualisations of results. Additional posts on Twitter and YouTube are used to increase coverage.In addition to the further development of the indicator set, the focus of the next project phase is the advancement of the dissemination towards user- and action-oriented reporting. In close exchange with the scientific advisory board, we aim to explore the requirements of the target audience and reflect them in the design of further publication formats.