[Regionalization of health indicators. Results from the GEDA-Study 2009]

Migraine and tension-type headache in Germany. Prevalence and disease severity from the BURDEN 2020 Burden of Disease Study

Headache disorders are widespread among women and men in Germany and are primarily associated with restrictions on quality of life. The two most common types of headache disorders are migraine and tension-type headache. In order to gain valid estimates of the prevalence of these conditions, a cross-sectional telephone-based survey was conducted among adults in Germany (N=5,009) between October 2019 and March 2020. The frequency, duration, the characteristics and comorbidities associated with headache were measured using the diagnostic criteria defined in the International Classification of Headache Disorders. 57.5% of women and 44.4% of men in Germany stated that they had had a headache in the last twelve months. 14.8% of women and 6.0% of men meet all of the diagnostic criteria for migraine. Tension-type headache affects 10.3% of women and 6.5% of men. Migraine and tension-type headache are predominantly found among people of working age and steadily decrease with age. Migraine is often accompanied by comorbidities such as depressive symptoms and anxiety disorders. People affected by headache disorders tend to receive very little professional medical care, with only a minority seeking treatment within a year. These results provide a comprehensive picture of the population-related impact of headache disorders and are used in the BURDEN 2020 study to quantify key indicators for burden of disease assessment.

[Geographic methods for health monitoring]

The interest in using geographic methods for health monitoring has grown strongly over the last two decades. Through these methods, analysis and visualization of health data can be more focused and target-group specific. The application in health monitoring is possible mostly due to broader technical possibilities and more available datasets. In this article, we show which geographic aspects are adapted in health monitoring at different levels (federal, state, municipality).For example, at the federal level, surveillance methods are used; at the state level health atlases are created; and on the municipality level geographic analyses are performed for possible public health interventions.Methods range from simple maps on different levels of aggregation to more complex methods like space-temporal visualization or spatial-smoothing methods. While the technical possibilities are in place, a broader implementation of geographic methods is mostly hindered by missing data access to small-area information and data protection policies. Better access to data could especially improve the possibility for geographic methods in health monitoring and could inform the population and decision makers to inform and improve population health or healthcare.

Trends and regional distribution of outpatient claims for asthma, 2009-2016, Germany

OBJECTIVE

To investigate asthma morbidity in Germany by calculating current prevalence, examining its temporal and spatial trends and estimating the total number of asthmatics in Germany and calculating age-, sex- and residence-specific risk.

METHODS

We used claims data reported by physicians during 2009-2016, including outpatient diagnoses of all statutory health insured individuals, comprising 85.3% (70 416 019/82 521 653) of the total population in Germany in 2016. We performed a spatial analysis of asthma prevalence according to administrative district by calculating Global and Local Moran's I. We assessed the risk of asthma by sex, age, type of residence (rural versus urban) and federal state (East versus West) using a multilevel parametric survival regression.

FINDINGS

We estimated that 4.7 million individuals were affected by asthma in 2016, including 0.8 million children and 3.9 million adults. We observed a slightly higher prevalence (with an increasing trend) among adults (5.85%; 3 408 622/58 246 299) compared to children (5.13%; 624 899/12 169 720), and calculated an age-standardized prevalence of 5.76% (95% confidence interval, CI: 5.76-5.77). We found evidence of a strong spatial autocorrelation (Global Moran's I: 0.50, P < 0.0001), and identified local spatial clusters with higher levels of prevalence. Living in the western (versus eastern) federal states and living in densely populated large urban municipalities (versus rural area) were independently associated with an increased risk of asthma, with hazard ratios of 1.33 (95% CI: 1.32-1.34) and 1.32 (95% CI: 1.31-1.32), respectively.

CONCLUSION

Our insights into the spatial distribution of asthma morbidity may inform public health interventions, including region-specific prevention programmes and control.

[Primary and secondary data on dementia care as an example of regional health planning]

BACKGROUND

Health service planning that takes into account as far as possible the regional needs and regional discrepancies is a controversial health issue in Germany.

OBJECTIVES

In a pilot scheme, we tested a planning process for regional healthcare services, based on the example of dementia care. The aim of this article is to present the strengths and limitations of this planning process.

MATERIALS AND METHODS

We developed an indicator set for dementia care based on routine regional data obtained from two German statutory health insurance companies. Additionally, primary data based on a questionnaire sent to all GPs in the area were evaluated. These data were expanded through the addition of official socio-demographic population data. Procedures and evaluation strategies, discussion of the results and the derivation of planning measures followed, in close agreement with a group of local experts.

RESULTS

Few epidemiological data on regional variations in health care planning are publicly available. Secondary data from statutory health insurance companies can be assessed to support the estimation of regional health care needs, but interpretation is difficult. The use of surveys to collect primary data, and the assessment of results by the local health board may facilitate interpretation and may contribute towards more valid statements regarding regional health planning.

CONCLUSIONS

Despite the limited availability of data and the considerable efforts involved in data analysis, the project demonstrates how needs-based health service planning can be carried out in a small region, taking into account the increasing demands of the local health care providers and the special local features.

Who is where at risk for Chronic Obstructive Pulmonary Disease? A spatial epidemiological analysis of health insurance claims for COPD in Northeastern Germany

Background

Chronic obstructive pulmonary disease (COPD) has a high prevalence rate in Germany and a further increase is expected within the next years. Although risk factors on an individual level are widely understood, only little is known about the spatial heterogeneity and population-based risk factors of COPD. Background knowledge about broader, population-based processes could help to plan the future provision of healthcare and prevention strategies more aligned to the expected demand. The aim of this study is to analyze how the prevalence of COPD varies across northeastern Germany on the smallest spatial-scale possible and to identify the location-specific population-based risk factors using health insurance claims of the AOK Nordost.

Methods

To visualize the spatial distribution of COPD prevalence at the level of municipalities and urban districts, we used the conditional autoregressive Besag–York–Mollié (BYM) model. Geographically weighted regression modelling (GWR) was applied to analyze the location-specific ecological risk factors for COPD.

Results

The sex- and age-adjusted prevalence of COPD was 6.5% in 2012 and varied widely across northeastern Germany. Population-based risk factors consist of the proportions of insurants aged 65 and older, insurants with migration background, household size and area deprivation. The results of the GWR model revealed that the population at risk for COPD varies considerably across northeastern Germany.

Conclusion

Area deprivation has a direct and an indirect influence on the prevalence of COPD. Persons ageing in socially disadvantaged areas have a higher chance of developing COPD, even when they are not necessarily directly affected by deprivation on an individual level. This underlines the importance of considering the impact of area deprivation on health for planning of healthcare. Additionally, our results reveal that in some parts of the study area, insurants with migration background and persons living in multi-persons households are at elevated risk of COPD.

[Mental disorders of working age : Evaluation of the administrative incidence and prevalence as well as regional differences in Lower Saxony on the basis of secondary data from a statutory health insurance provider]

BACKGROUND

Mental disorder is the subject of ever-increasing attention in the field of public health. However, the actual number of such cases is difficult to determine owing to the lack of comprehensive longitudinal studies.

OBJECTIVES

The administrative incidence and prevalence of mental disorders were estimated on the basis of data from 2010 to 2013 provided by the health insurance company AOK, Lower Saxony, and were assessed according to age and gender. Additionally, possible correlations between local conditions and the occurrence of diagnosed mental disorders were examined for both urban and rural districts.

MATERIALS AND METHODS

Analyses were conducted using the secondary datasets of 1.5 million persons born between 1940 and 1994 who had been continuously insured throughout the period specified. Only documented diagnoses from outpatient care were taken into account.

RESULTS

One third of the insured persons showed at least one documented diagnosis of a mental disorder within a 12-month period. In approximately 11 out of 100 cases, there was a newly documented diagnosis in 2012. With the exception of cases relating to psychotropic substance use, women were significantly more frequently affected than men. Age-specific differences were also determined. At a regional level, in relation to administrative prevalence, mental disorders showed positive correlations in the density of doctors and psychotherapists. Moreover, regions with a high rate of unemployment generally show a higher prevalence of mental disorders.

CONCLUSION

Despite certain limitations, the use of administrative incidence and prevalence data is a viable approach to assessing gender- and age-specific, and regional differences. Our regional analyses suggest a correlation between the local job situation and the level of regional administrative prevalence.

Participatory epidemiology: the contribution of participatory research to epidemiology

Background

Epidemiology has contributed in many ways to identifying various risk factors for disease and to promoting population health. However, there is a continuing debate about the ability of epidemiology not only to describe, but also to provide results which can be better translated into public health practice. It has been proposed that participatory research approaches be applied to epidemiology as a way to bridge this gap between description and action. A systematic account of what constitutes participatory epidemiology practice has, however, been lacking.

Methods

A scoping review was carried out focused on the question of what constitutes participatory approaches to epidemiology for the purpose of demonstrating their potential for advancing epidemiologic research. Relevant databases were searched, including both the published and non-published (grey) literature. The 102 identified sources were analyzed in terms of comparing common epidemiologic approaches to participatory counterparts regarding central aspects of the research process. Exemplary studies applying participatory approaches were examined more closely.

Results

A highly diverse, interdisciplinary body of literature was synthesized, resulting in a framework comprised of seven aspects of the research process: research goal, research question, population, context, data synthesis, research management, and dissemination of findings. The framework specifies how participatory approaches not only differ from, but also how they can enhance common approaches in epidemiology. Finally, recommendations for the further development of participatory approaches are given. These include: enhancing data collection, data analysis, and data validation; advancing capacity building for research at the local level; and developing data synthesis.

Conclusion

The proposed framework provides a basis for systematically developing the emergent science of participatory epidemiology.

Kroll L, K. Neuhauser H, N. Willich S, Reinhold T, A. Busch M. Regional Differences in the Prevalence of Cardiovascular Disease

BACKGROUND

Cardiovascular disease continues to be the single most common cause of death and to account for the largest single portion of treatment costs in Germany. Reliable data on regional differences in the frequency of cardio - vascular disease are important for the planning of targeted care structures and preventive measures.

METHODS

Pooled data from the German Health Update (GEDA), a nationwide telephone health survey conducted in 2009, 2010 and 2012 (n = 62 214) were used to estimate the lifetime prevalence of major cardiovascular disease (self-reported medical diagnosis of myocardial infarction, other coronary heart disease, stroke, or congestive heart failure) in each of the German federal states. The influence of sociodemographic factors on regional prevalence differences was examined in adjusted logistic regression analyses. Prevalences were compared with mortality rates from cardiovascular disease that were obtained from cause-of-death statistics.

RESULTS

The lifetime prevalence of cardiovascular disease in Germany ranged from 10.0% in Baden-W¨rttemberg to 15.8% in Saxony-Anhalt. After adjustment for age, sex, socioeconomic status, and size of the communities of residence, nine of the other 15 states had significantly higher prevalences than Baden-W¨rttemberg, with odds ratios ranging from 1.26 (Hesse) to 1.55 (Saxony-Anhalt). Four of the five states that previously constituted the German Democratic Republic (East Germany) had above-average figures for prevalence and mortality.

CONCLUSION

There are relevant differences among the German federal states in the lifetime prevalence of major cardiovascular disease, which are only partly accounted for by differences in age and sex distribution, socioeconomic status, and community size.

The spatial structure of chronic morbidity: evidence from UK census returns

Background

Disease prevalence models have been widely used to estimate health, lifestyle and disability characteristics for small geographical units when other data are not available. Yet, knowledge is often lacking about how to make informed decisions around the specification of such models, especially regarding spatial assumptions placed on their covariance structure. This paper is concerned with understanding processes of spatial dependency in unexplained variation in chronic morbidity.

Methods

2011 UK census data on limiting long-term illness (LLTI) is used to look at the spatial structure in chronic morbidity across England and Wales. The variance and spatial clustering of the odds of LLTI across local authority districts (LADs) and middle layer super output areas are measured across 40 demographic cross-classifications. A series of adjacency matrices based on distance, contiguity and migration flows are tested to examine the spatial structure in LLTI. Odds are then modelled using a logistic mixed model to examine the association with district-level covariates and their predictive power.

Results

The odds of chronic illness are more dispersed than local age characteristics, mortality, hospitalisation rates and chance alone would suggest. Of all adjacency matrices, the three-nearest neighbour method is identified as the best fitting. Migration flows can also be used to construct spatial weights matrices which uncover non-negligible autocorrelation. Once the most important characteristics observable at the LAD-level are taken into account, substantial spatial autocorrelation remains which can be modelled explicitly to improve disease prevalence predictions.

Conclusions

Systematic investigation of spatial structures and dependency is important to develop model-based estimation tools in chronic disease mapping. Spatial structures reflecting migration interactions are easy to develop and capture autocorrelation in LLTI. Patterns of spatial dependency in the geographical distribution of LLTI are not comparable across ethnic groups. Ethnic stratification of local health information is needed and there is potential to further address complexity in prevalence models by improving access to disaggregated data.

Electronic supplementary material

The online version of this article (doi:10.1186/s12942-016-0057-5) contains supplementary material, which is available to authorized users.

Expansion or compression of long-term care in Germany between 2001 and 2009? A small-area decomposition study based on administrative health data

Background

Studies state profound cross-country differences in healthy life years and its time trends, suggesting either the health scenario of expansion or compression of morbidity. A much-discussed question in public health research is whether the health scenarios are heterogeneous or homogeneous on the subnational level as well. Furthermore, the question arises whether the morbidity trends or the mortality trends are the decisive drivers of the care need-free life years (CFLY), the life years with care need (CLY), and, ultimately, the health scenarios.

Methods

This study uses administrative census data of all beneficiaries in Germany from the Statutory Long-Term Care Insurance 2001–2009. We compute the CFLY and CLY at age 65+ for 412 counties. The CFLY and CLY gains are decomposed into the effects of survival and of the prevalence of care need, and we investigate their linkages with the health scenarios by applying multinomial regression models.

Results

We show an overall increase in CFLY, which is higher for men than for women and higher for severe than for any care need. However, spatial variation in CFLY and in CLY has increased. In terms of the health scenarios, a majority of counties show an expansion of any care need but a compression of severe care need. There is high spatial heterogeneity, with expansion-counties surrounding compression-counties and vice versa, which is mainly caused by divergent trends in the prevalence of care need. We show that mortality is responsible for the absolute changes in CFLY and CLY, while morbidity is the decisive driver that determines the health scenario of a county.

Conclusion

Combining regionalized administrative data and advanced statistical methods permits a deeper insight into the complex relationship between health and mortality. Our findings demonstrate a compression of life years with severe care need, which however, depends on the region of residence. To attenuate regional inequalities, more efforts are needed that improve health by medical and infrastructural interventions and by the exchange of insights in the efficiency of small- and large-area policy measures between the vanguard and the rearguard counties. In future research, the underlying latent mechanisms should be investigated in more detail.

Electronic supplementary material

The online version of this article (doi:10.1186/s12963-016-0093-1) contains supplementary material, which is available to authorized users.

Prevalence trends in lifestyle-related risk factors

BACKGROUND

The regional prevalence of risk factors can vary over time. The Study of Health in Pomerania (SHIP) addresses prevalence trends for common risk factors in a region in northeast Germany.

METHODS

A longitudinal study was carried out from 1997 to 2001 (SHIP-0, with 4308 subjects), and a second, independent random sample of the population in the same region was studied from 2008 to 2012 (SHIP-Trend, with 4420 subjects). All data were standardized with post-stratification weighting derived from the adult population of the state of Mecklenburg-West Pomerania.

RESULTS

SHIP reveals a marked decline of mean alcohol consumption in the adult population, from 5.57 g/day (95% confidence interval, 5.51-5.63) to 3.12 g/day (95% CI 3.09-3.15). The percentage of active smokers among men declined from 38.6% (95% CI 36.0-41.2) to 34.3% (95% CI 32.1-36.6). Simultaneously, however, there was a rightward shift of the BMI distribution, with a marked increase in the prevalence of obesity, from 24.7% to 32.0%. There was a corresponding increase in the prevalence of diabetes, from 9.1% to 13.8%. Compared to eleven years ago, the amount of exercise taken during free time has risen among the elderly, but fallen among young women.

CONCLUSION

Tobacco and alcohol consumption have declined over the past decade, although this study may have overestimated these trends through a combination of selection bias and reporting bias. Meanwhile, the northeast German population now has a worse metabolic risk profile, as indicated by the increased prevalence of obesity and diabetes. Society as a whole must take measures to combat this trend.

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