Spatial characteristics of non-communicable diseases and their associations to social conditions in a large urban cohort in Germany-Results from the Hamburg City Health Study

BACKGROUND

Non-communicable diseases (NCDs) are responsible for many deaths. They are associated with several modifiable and metabolic risk factors and are therefore prone to significant regional variations on different scales. However, only few intra-urban studies examined spatial variation in NCDs and its association with social circumstances, especially in Germany. Thus, the present study aimed to identify associations of personal risk factors and local social conditions with NCDs in a large German city.

METHODS

This study is based on a population-based cohort of the Hamburg City Health Study including 10,000 probands. Six NCDs were analyzed (chronic obstructive pulmonary disease [COPD], coronary heart disease [CHD], diabetes mellitus, heart failure, depression, and hypertension) in 68 city district clusters. As risk factors, we considered socio-demographic variables (age, sex, education) and risk behaviour variables (smoking, alcohol consumption). Logistic regression analyses identified associations between the district clusters and the prevalence rates for each NCD. Regional variation was detected by Gini coefficients and spatial cluster analyses. Local social condition indexes were correlated with prevalence rates of NCDs on city district level and hot-spot analyses were performed for significant high or low values.

RESULTS

The analyses included 7,308 participants with a mean age of 63.1 years (51.5% female). The prevalence of hypertension (67.6%) was the highest. Risk factor associations were identified between smoking, alcohol consumption and education and the prevalence of NCDs (hypertension, diabetes, and COPD). Significant regional variations were detected and persisted after adjusting for personal risk factors. Correlations for prevalence rates with the local social conditions were significant for hypertension (r = 0.294, p < 0.02), diabetes (r = 0.259, p = 0.03), and COPD (r = 0.360, p < 0.01).

CONCLUSIONS

The study shows that regional differences in NCD prevalence persist even after adjusting for personal risk factors. This highlights the central role of both personal socio-economic status and behaviors such as alcohol and tobacco consumption. It also highlights the importance of other potential regional factors (e.g. the environment) in shaping NCD prevalence. This knowledge helps policy- and decision-makers to develop intervention strategies.

Is loneliness associated with cancellation of medical appointments during the COVID-19 pandemic? Evidence from the Hamburg City Health Study (HCHS)

BACKGROUND

The COVID-19 pandemic engendered numerous societal and economic challenges in addition to health-related concerns. Maintenance of healthcare utilization assumed immense significance during this period. However, few studies have examined the association between loneliness and cancelled medical appointments during the COVID-19 pandemic. This study aimed to examine whether medical appointments are less likely to be cancelled with increased loneliness during a pandemic. We analyzed the association between loneliness and both patient- and provider-initiated appointment cancellations.

METHODS

Cross-sectional data from the Hamburg City Health Study (HCHS) were collected during April 2020-November 2021. The analytical sample included 1,840 participants with an average age of 55.1 years (standard deviation: 6.5, range 45-76 years). Medical appointments cancelled by individuals-medical appointments in general, and GP, specialist, and dentist appointments-and appointments cancelled by healthcare providers served as outcome measures. Loneliness was quantified using a single item ranging from 0 to 10. Accordingly, we created empirical loneliness tertiles. Covariates were selected based on the Andersen model. Several penalized maximum likelihood logistic regressions were utilized to examine the association between loneliness and cancellation of medical appointments during the COVID-19 pandemic.

RESULTS

The penalized maximum likelihood logistic regressions showed that, compared to individuals in the lowest loneliness tertiles, individuals in the other two tertiles reported a higher chance of medical appointments cancellation by individuals, particularly driven by cancelled GP appointments. Except for age and sex, none of the covariates were comparably associated with the outcomes. When appointments cancelled by healthcare providers served as outcomes, only a higher number of chronic conditions was significantly positively associated with it.

CONCLUSIONS

Individuals scoring higher in loneliness had a greater chance of cancelling medical (particularly GP) appointments. This may contribute to a potential cascade of loneliness and skipped medical appointments in the future, resulting in adverse health outcomes over the medium-to-long term. Future research should examine whether lonely people are more likely to lack the social motivation to visit the doctor.

Cross-Sectional Association of Dietary Patterns and Supplement Intake with Presence and Gray-Scale Median of Carotid Plaques-A Comparison between Women and Men in the Population-Based Hamburg City Health Study

This population-based cross-sectional cohort study investigated the association of the Mediterranean and DASH (Dietary Approach to Stop Hypertension) diet as well as supplement intake with gray-scale median (GSM) and the presence of carotid plaques comparing women and men. Low GSM is associated with plaque vulnerability. Ten thousand participants of the Hamburg City Health Study aged 45-74 underwent carotid ultrasound examination. We analyzed plaque presence in all participants plus GSM in those having plaques (n = 2163). Dietary patterns and supplement intake were assessed via a food frequency questionnaire. Multiple linear and logistic regression models were used to assess associations between dietary patterns, supplement intake and GSM plus plaque presence. Linear regressions showed an association between higher GSM and folate intake only in men (+9.12, 95% CI (1.37, 16.86), p = 0.021). High compared to intermediate adherence to the DASH diet was associated with higher odds for carotid plaques (OR = 1.18, 95% CI (1.02, 1.36), p = 0.027, adjusted). Odds for plaque presence were higher for men, older age, low education, hypertension, hyperlipidemia and smoking. In this study, the intake of most supplements, as well as DASH or Mediterranean diet, was not significantly associated with GSM for women or men. Future research is needed to clarify the influence, especially of the folate intake and DASH diet, on the presence and vulnerability of plaques.

Performance of an interferon-γ release assay-based test for cell-mediated immunity to SARS-CoV-2

In search for immunological correlates of protection against acute coronavirus disease 2019 (COVID-19) there is a need for high through-put assays for cell-mediated immunity (CMI) to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We established an interferon-γ release assay -based test for detection of CMI against SARS-CoV-2 spike (S) or nucleocapsid (NC) peptides. Blood samples obtained from 549 healthy or convalescent individuals were measured for interferon-γ (IFN-γ) production after peptide stimulation using a certified chemiluminescence immunoassay. Test performance was calculated applying cutoff values with the highest Youden indices in receiver-operating-characteristics curve analysis and compared to a commercially available serologic test. Potential confounders and clinical correlates were assessed for all test systems. 522 samples obtained from 378 convalescent in median 298 days after PCR-confirmed SARS-CoV-2 infection and 144 healthy control individuals were included in the final analysis. CMI testing had a sensitivity and specificity of up to 89% and 74% for S peptides and 89% and 91% for NC peptides, respectively. High white blood cell counts correlated negatively with IFN-γ responses but there was no CMI decay in samples obtained up to one year after recovery. Severe clinical symptoms at time of acute infection were associated with higher measures of adaptive immunity and reported hair loss at time of examination. This laboratory-developed test for CMI to SARS-CoV-2 NC peptides exhibits excellent test performance, is suitable for high through-put routine diagnostics, and should be evaluated for clinical outcome prediction in prospective pathogen re-exposure.

[Non-utilisation of medical services during the COVID-19 pandemic among persons with chronic diseases]

INTRODUCTION

The COVID-19 pandemic is also impacting the medical care for other diseases. The extent to which people with chronic diseases are affected by the suspension of medical services is investigated-differentiating between patient and provider perspectives.

METHOD

A cross-sectional study was conducted based on data from the longitudinal Hamburg City Health Study (HCHS). The study population was all HCHS participants (a sample of the population of Hamburg, 45-74 years) between April 2020 and November 2021. Utilisation of medical services was collected via the "COVID-19-module" of the HCHS. The chronic conditions included cardiovascular disease, kidney and lung disease, cancer and diabetes mellitus; analyses were descriptive and multivariate.

RESULTS

Of the 2047 participants, 47.9% had at least one previous illness. Of those with pre-existing conditions, 21.4% had at least one healthcare service suspended or an appointment cancelled. In addition, 15.4% stated that they decided by themselves not to attend a doctor's appointment. Specialist care services (43.8% of all cancellations) were cancelled more frequently than general practitioner care (16.6%). After adjustment for age, gender and education, lung disease (OR 1.80; p < 0.008) and cancer (OR 2.33; p < 0.001) were found to be independent risk factors for appointment cancellations by healthcare providers. Of cancellations by patients, 42.2% were due to their fear of an infection with the coronavirus SARS-CoV‑2.

DISCUSSION

Health policy and the media are faced with the challenge of dealing with fears of infection in the population in such a way that they do not lead to an avoidance of necessary care services.

Detection of stage I HPV-driven oropharyngeal cancer in asymptomatic individuals in the Hamburg City Health Study using HPV16 E6 serology - A proof-of-concept study

BACKGROUND

The lack of detectable precancerous lesions poses challenges to the early detection of human papillomavirus-driven oropharyngeal cancer (HPV-OPC). Antibodies against HPV16 early proteins, especially E6, are uniquely sensitive and specific biomarkers detectable years prior to HPV-OPC diagnosis. Thus, HPV16 early protein serology warrants clinical investigation for HPV-OPC screening.

METHODS

Using multiplex serology, we analyzed HPV16 serum antibodies of the first 5000 participants (n=4,424 sera, recruited 2016-2017) of the Hamburg City Health Study, a population-based prospective cohort (45-74 years). Participants seropositive for HPV16 E6 and at least one additional early protein (E1, E2, E7) were considered at high risk for HPV-OPC development and invited to six-monthly non-invasive head and neck follow-up (FU) examinations (visual inspection, endoscopy, ultrasonography, performed 2019-2020). Participants with suspicious lesions were examined by magnetic resonance imaging and panendoscopy with biopsy. Histologically confirmed OPC cases were treated according to standard of care.

FINDINGS

In total, 35 out of 4,424 study participants (0·8%, 95% confidence interval (CI) 0·6-1·1%) were HPV16 E6 seropositive. Among these, eleven (0·3%, 95%CI 0·1-0·5%) were considered at high risk for HPV-OPC of which nine were successfully re-contacted and invited to regular clinical FU examinations. Two males and one female were diagnosed with stage I HPV-OPC within 1·3 years of clinical FU (3-4 years after initial blood draw), representing one diagnosis of prevalent advanced disease, one incident diagnosis of advanced disease, and one incident diagnosis of early disease. The remaining participants showed no detectable signs of cancer, and undergo regular examinations (median clinical FU: 1·0 years, median total FU from blood draw to last clinical FU visit: 4·7 years).

INTERPRETATION

HPV16 early antibodies allowed identifying three asymptomatic stage I HPV-OPC patients, out of eleven participants considered at high risk. However, two of the three cases already showed signs of advanced disease at diagnosis. Targeting multiple early proteins may considerably improve the positive predictive value of HPV16 serology and may have clinical utility for HPV-OPC screening.

FUNDING

This work was funded by DKFZ and UKE intramural funding.

Epidemiology of skin diseases in Germany: systematic review of the current state of research - part 2: non-infectious skin diseases

The aim of this work was to systematically collect all previously published population-based epidemiological data on skin diseases in Germany. The present part 2 of the publication series deals with non-infectious skin diseases. The results on cutaneous tumor diseases (part 1) and infectious skin diseases (part 3) form the other parts of this publication series. A systematic literature search was performed using PubMed/MEDLINE for the period of the last 15 years. With the aim of including all dermatologic diseases, a diagnostic list was developed based on the ICD-11 catalogue. This list included 1,347 skin diseases and formed the basis for the search. The literature search yielded 4,650 hits, of which 72 were included in the synthesis. Among them were 37 publications on non-infectious skin diseases. Among these, psoriasis and atopic eczema were the most common. The highest lifetime prevalence was found for acne. This work is the first systematic literature review that aimed to report all available epidemiological data on skin diseases in Germany. It was found that representative data on many non-infectious diseases are not yet available. Among the included studies, there was a high heterogeneity regarding the methodology. Nevertheless, the utility of these epidemiological data is wide-ranging and can serve as a reference of various epidemiological questions.

Epidemiology of skin diseases in Germany: systematic review of the current state of research - part 3: infectious skin diseases

The aim of this work was to systematically collect all previously published population-based epidemiological data on skin diseases in Germany. A systematic literature search was performed using PubMed/MEDLINE for the period of the last 15 years. With the aim to include all dermatological diseases, a diagnostic list based on the ICD-11 catalogue was compiled. This list included 1,347 skin diseases and formed the basis for the search. The present part 3 of the publication series deals with infectious skin diseases. The results on cutaneous tumor diseases (part 1) and non-infectious skin diseases (part 2) form the other parts of this publication series. The literature search yielded 4,605 hits, of which 72 papers on 43 different skin diseases were included in the synthesis. Among them were twelve hits on infectious dermatoses, of which six papers were related to measles. The highest lifetime prevalence rates were found for varicella and verrucae vulgaris. This work is the first systematic literature review that aimed to report all available epidemiological data on skin diseases in Germany. It was found that representative data on many infectious diseases are not yet available. Among the included studies, a high heterogeneity was found with regard to the methodology. Nevertheless, these epidemiological data have a wide range of uses and can serve as a reference for various epidemiological questions.

Multi-organ assessment in mainly non-hospitalized individuals after SARS-CoV-2 infection: The Hamburg City Health Study COVID programme

AIMS

Long-term sequelae may occur after SARS-CoV-2 infection. We comprehensively assessed organ-specific functions in individuals after mild to moderate SARS-CoV-2 infection compared with controls from the general population.

METHODS AND RESULTS

Four hundred and forty-three mainly non-hospitalized individuals were examined in median 9.6 months after the first positive SARS-CoV-2 test and matched for age, sex, and education with 1328 controls from a population-based German cohort. We assessed pulmonary, cardiac, vascular, renal, and neurological status, as well as patient-related outcomes. Bodyplethysmography documented mildly lower total lung volume (regression coefficient -3.24, adjusted P = 0.014) and higher specific airway resistance (regression coefficient 8.11, adjusted P = 0.001) after SARS-CoV-2 infection. Cardiac assessment revealed slightly lower measures of left (regression coefficient for left ventricular ejection fraction on transthoracic echocardiography -0.93, adjusted P = 0.015) and right ventricular function and higher concentrations of cardiac biomarkers (factor 1.14 for high-sensitivity troponin, 1.41 for N-terminal pro-B-type natriuretic peptide, adjusted P ≤ 0.01) in post-SARS-CoV-2 patients compared with matched controls, but no significant differences in cardiac magnetic resonance imaging findings. Sonographically non-compressible femoral veins, suggesting deep vein thrombosis, were substantially more frequent after SARS-CoV-2 infection (odds ratio 2.68, adjusted P < 0.001). Glomerular filtration rate (regression coefficient -2.35, adjusted P = 0.019) was lower in post-SARS-CoV-2 cases. Relative brain volume, prevalence of cerebral microbleeds, and infarct residuals were similar, while the mean cortical thickness was higher in post-SARS-CoV-2 cases. Cognitive function was not impaired. Similarly, patient-related outcomes did not differ.

CONCLUSION

Subjects who apparently recovered from mild to moderate SARS-CoV-2 infection show signs of subclinical multi-organ affection related to pulmonary, cardiac, thrombotic, and renal function without signs of structural brain damage, neurocognitive, or quality-of-life impairment. Respective screening may guide further patient management.

Epidemiology of skin diseases in Germany: systematic review of the current state of research - part 1: cutaneous tumor diseases

Epidemiological data are of great importance for the identification of health care needs, the detection of gaps in care, the development of targeted prevention measures, and for the optimization of resource allocation. The aim of this work was to systematically collect all previously published population-based epidemiological data on skin diseases in Germany. The present part 1 of the publication series deals with tumor diseases of the skin. The results on non-infectious (part 2) and infectious skin diseases (part 3) form the other parts of this publication series. A systematic search of the literature spanning the last 15 years was conducted using the PubMed/MEDLINE database. With the aim of including all dermatologic diseases, a diagnostic list was developed based on the ICD-11 catalogue. This list included 1,347 skin diseases and formed the basis for the search. The literature search yielded 4,650 publications. After two-stage screening, 72 studies on 43 different skin diseases were included in the synthesis. Among them were 30 publications on cutaneous tumor diseases, the majority was related to malignant melanoma. This work is the first systematic literature review that aimed to report all available epidemiological data on skin diseases in Germany. In terms of study characteristics, a high heterogeneity was found for the different skin diseases. Even though the methodology of the included epidemiological studies varied considerably, the usefulness of these epidemiological data is extremely wide-ranging. Thus, this work can serve as a reference for various epidemiological questions.

Estimating prevalence and incidence of skin cancer in Germany

BACKGROUND AND OBJECTIVES

The aim of the present study was to determine the prevalence and incidence of skin cancer.

PATIENTS AND METHODS

We calculated prevalence and incidence for cutaneous melanoma (CM) and non-melanoma skin cancer (NMSC) in 2012 in Germany, using claims data of 2.1 million insured persons. In order to allow statements concerning differences between subgroups, we calculated 95 % confidence intervals. Finally, we standardized prevalence and incidence with regard to the German population.

RESULTS

The prevalence and incidence of CM amounted to 0.12 % and 0.04 % and increased with age. For NMSC these measures were 0.65 % and 0.15 %. Of the prevalent and incident patients, 88.9 % and 87.4 % (CM) and 99.4 % and 98.8 % (NMSC) respectively were at early stages. A projection on the whole population resulted in 75,419 persons affected by CM and 376,004 persons affected by NMSC, including 24,075 (CM) and 84,618 (NMSC) incident patients.

CONCLUSIONS

In this study, we defined epidemiological measures according to the number of patients affected by skin cancer and having a medical consultation indicating a need for treatment. These results can serve in future research as a data basis for analysis of health service demand in skin cancer patients and the associated costs.

Childhood maltreatment and treatment outcome in psychotic disorders: a systematic review and meta-analysis

OBJECTIVE

Childhood maltreatment (CM) plays an important role in the aetiology and course of psychotic disorders and is associated with characteristics that could be relevant for treatment. We aimed to conduct a systematic review and meta-analysis on the association between CM and treatment outcome in psychotic disorders.

METHODS

Treatment outcome was defined as change in psychotic symptoms or in social or occupational functioning between first and last reported measurement in the course of a pharmacological and/or psychological treatment.

RESULTS

Twelve treatment results from seven studies (636 patients, average treatment duration: 59.2 weeks) were included. CM was related to poorer treatment outcomes in psychotic disorders (OR = 1.51, 95% CI = [1.08, 2.10]). There is evidence that this association might increase with illness duration and increasing age and might be stronger in schizophrenia samples.

CONCLUSIONS

Childhood maltreatment is highly understudied with regard to treatment outcome in psychotic disorders. The need for more studies is emphasized by the fact that this meta-analysis reveals evidence for a poorer treatment response in patients with CM. If this association is confirmed, the identification of patients with CM and the consideration of associated clinical and biological conditions could contribute to improve treatment outcome in psychotic disorders.

Strategies to reduce stigma related to visible chronic skin diseases: a systematic review

Many patients with a visible chronic skin disease experience discrimination and stigmatization. This results in psychosocial impairments in addition to the burden of disease and emphasizes the urgency to implement effective stigma-reduction strategies. To synthesize what is known globally about effective interventions to reduce stigma associated with visible chronic skin diseases, a systematic review was conducted. Four electronic databases were searched until May 2018. Studies evaluating interventions to reduce stigmatization in patients with visible chronic skin diseases and applying at least one stigma-related outcome measure were included. Data were extracted on study design, country, study population, outcome measures and main findings. Results were subsequently synthesized in a narrative review. Critical Appraisal Skills Programme tools were used to assess study quality. Nineteen studies were included in the review. Study design was very heterogeneous and study quality rather poor. Thirteen studies addresses patients with leprosy in low- and middle-income countries, and one study each targeted patients with onychomycosis, leg ulcer, facial disfigurement, atopic dermatitis, vitiligo and alopecia. Evaluated interventions were mainly multi-faceted incorporating more than one type of intervention. While 10 studies focused on the reduction in self-stigma and 4 on the reduction in public stigma, another 5 studies aimed at reducing both. The present review revealed a lack of high-quality studies on effective approaches to reduce stigmatization of patients with visible chronic skin diseases. Development and evaluation of intervention formats to adequately address stigma is essential to promote patients' health and well-being.

[What motivates patients with atopic diseases to search the internet-a focus group study on expectations and demands]

BACKGROUND

People affected by allergies with mild-to-moderate symptoms are often not treated adequately, despite the availability of prevention and self-therapy measures. Given their good and quick accessibility when seeking information, evidence- and web-based services that are user-friendly may strengthen a more independent way of handling an allergy and may also increase health literacy. In order for such services to be found and read, developers and providers need to know about information needs, demands and users' behavior.

OBJECTIVES

On which occasions does the target group search for allergy-specific information? Which preferences and demands do affected persons have regarding a web-based service?

MATERIALS AND METHODS

Three individual interviews and four focus groups with 37 participants (19-81 years; hay fever, n = 30; asthma, n = 17; eczema, n = 15) were conducted in four German cities. These were recorded and transcribed verbatim. A multiprofessional team developed a system for coding the texts (two independent encoders, MAXQDA analysis software).

RESULTS

Those who are affected usually seek information only in case of a concrete need for action. Impulses are, among others, symptoms, suggestions from the social environment, the beginning of the allergy season or an allergy-related contact with the health system. A web-based service should primarily include information about treatment options, provide individualized support for everyday life action strategies, and promote adequate self-management skills.

DISCUSSION

In order to promote self-management skills, a web-based service should focus on allergy symptoms, treatment options and day-to-day help.

Cost-of-illness of melanoma in Europe - a modelling approach

BACKGROUND

Malignant melanoma is accounting for the vast majority of skin cancer death. The treatment and productivity loss due to morbidity or premature mortality are associated with costs for society. There are few cost-of-illness (COI) studies on malignant melanoma in European countries from societal perspective and currently there is no publication analysing the COI in all European countries.

OBJECTIVES

The objective of the present study was to comparatively estimate COI of malignant melanoma in the European countries based on an identical approach.

METHODS

Cost information was obtained from results of a systematic literature research. For countries with no available cost information, a model for imputation of cost data was developed. Country-specific costs were modelled on the national gross domestic product, health expenditures, gross national income and epidemiological data. The adjustment for purchasing power parity allowed a comparison across countries.

RESULTS

Crude national costs of malignant melanoma ranged between € 1.1 million in Iceland and € 543.8 million in Germany and resulted in € 2.7 billion for all EU/EFTA states. Estimated crude costs per patient were lowest in Bulgaria (€ 6422) and highest in Luxembourg (€ 50 734). The share of direct costs varied from 3% to 26% across countries. After adjustment for the purchasing power parity costs per patient ranged between € 14 420 in Bulgaria and € 50 961 in Cyprus. Treatment expenses and morbidity costs were markedly lower for countries that entered the EU since 2004. By contrast, mortality costs were lower in countries with a high gross domestic product per capita.

CONCLUSION

In this first estimation, malignant melanoma induces relevant COI in Europe. There was large variation in the costs per patient due to different health care systems and expenses. Beyond decreasing patient burden, early intervention and prevention of melanoma could have a relevant potential to save costs across Europe.

Cost-of-illness of melanoma in Europe - a systematic review of the published literature

Malignant melanoma accounts for the vast majority of skin cancer deaths. Primary prevention is used to increase knowledge about skin cancer and set incentives for a change in behaviour, which leads to a decrease in cases. Primary prevention may be cost-effective or even cost saving. Cost-of-illness (COI) studies provide information on such potential savings. The purpose of this study is to give an overview on COI studies in European countries and to compare the COI in total and by cost categories. The results can be used to model potential cost savings from prevention. We conducted a systematic literature research in PubMed using the PRISMA checklist. All costs were converted into Euro and adjusted for the reference year 2012. For the ranking of countries according to their COI, all costs were adjusted for the purchasing power parity. All studies focusing on stage III-IV melanoma include information on hospital, hospice, and outpatient treatment. Costs for the treatment of advanced melanoma range between € 2972 in Italy and € 17 408 in Sweden after adjusting for purchasing power parity. Most studies on stage I-IV melanoma include costs of hospitalization, outpatient treatment and general practitioner consultation. Direct costs range from € 923 in Sweden to € 9829 in Denmark. Three articles also include information on indirect costs. Mortality costs vary between € 3511 in Sweden and € 20 408 in England, morbidity costs between € 103 in Sweden and € 4550 in England. We showed that costs for the treatment of skin cancer are moderately high in the included countries. Since after publication of the articles new costly drugs were approved in Europe, treatment costs of melanoma in Europe may be expected to have risen in the last few years, which means that there is a high expectable potential for prevention programmes to become cost-effective or even cost saving.

Modelling first-year cost-of-illness of melanoma attributable to sunbed use in Europe

BACKGROUND

Melanoma is a life-threatening disease of the skin with an increasing incidence of approximately 87 000 new cases treated per year in the European Union and the European Free Trade Association states resulting in considerable costs for the society. Since the use of sunbeds is known to be a risk factor, which can be easily avoided, costs of malignant melanoma attributable to sunbed use are modelled in the present study.

METHODS

Costs-of-illness of melanoma were calculated and compared for all member states of the European Union and the European Free Trade Association states using an established modelling approach. Calculations were based on a systematic literature research. For countries with no available information on cost-of-illness the gross domestic product, health expenditures and gross national income served as a basis for extrapolation of costs. International comparison was enabled by adjusting costs by the national purchasing power parity.

RESULTS

After adjusting melanoma treatment costs for the purchasing power parity, direct costs per patient vary between € 1056 in Romania and € 10 215 in Luxembourg. Costs due to morbidity range from € 102 per patient in Sweden and € 5178 in the UK resulting in total costs of € 1751-€ 12 611 per patient. Average weighted total costs per patient amount for € 6861-€ 6967 annually. In total, in 2012 approximately 4450 new cases of melanoma have been induced by sunbed use in the 31 included countries, which corresponds to 5.1% of all incident melanoma cases. National attributable melanoma costs range from € 1570 in Malta to € 11.1 million in Germany and sum up to an amount of € 32.5-€ 33.4 million for all countries.

CONCLUSION

This article provides a first estimation on costs of melanoma in Europe. It illustrates the contribution of exposure to artificial ultraviolet light in the economic burden of malignant melanoma.

Decreasing sunbed use in the German population between 2001 and 2015: survey in 155 679 working persons

BACKGROUND

UV radiation is a proven cause of skin cancer. Use of sunbeds has been shown to provide an attributable risk.

OBJECTIVE

To evaluate the proportion of regular sunbed use in Germany based on large-scale population-based surveys over 15 years.

METHODS

Skin cancer screenings by dermatologists were conducted between 2001 and 2015 in more than 500 German companies, including a clinical examination and interviews on the risk behaviour related to sunburns and sunbeds.

RESULTS

Among 155 679 persons included regular sunbed use significantly declined from 11.0% in 2001 to 1.6% in 2015 (P < 0.001). There were significantly higher rates of sunbed use in women (12.5%/2.0%) vs. men (7.3%/1.3%; P < 0.001), in younger persons and in participants with darker skin (type II and III) vs. fair skin (type I). Individuals with sunburns in childhood were significantly more often sunbed users (5.1% vs. 4.6%; P = 0.002). A remarkable decline of sunbed use was observed after 2009 (7.0% in 2001-2008 and 2.2% in 2009-2015). This reduction occurred in the time of a legal ban of sunbed use for minors but also with the start of the national skin cancer screening programme.

CONCLUSION

Use of sunbeds in the German adult population has dropped by more than 85% in the past decade. Primary prevention, including the large public awareness following the legal ban of sunbed use for young people and the effects of the statutory skin cancer screening programme may have contributed to this.

[Healthcare research in dermatology 2018 - power of the factual : What healthcare research is and who it serves]

In the dermatology practiced in Germany, healthcare research is an established and highly differentiated discipline. In many university dermatological institutions and private practices, studies are carried out on the processes of healthcare research for skin diseases. Commissioned by the German Society of Dermatology and the Professional Association of German Dermatologists, a significant number of the studies and projects are conducted by the German Center for Health Services Research in Dermatology (CVderm) as a nationwide reference center. Important projects include the implementation of patient registers and national care studies, research with secondary data and carrying out methodological studies for the further development of scientific questions. Important results are the national healthcare conferences for psoriasis, skin cancer, wounds and atopic dermatitis, the regional care networks as well as projects and cooperation with health insurance companies, local government and public institutions. In the interests of improved patient care, important factors of care are continuously improved. Future health services research in dermatology will be able to contribute even more efficiently for better care planning and management. Patient registers will facilitate the transfer of innovations into care and help to ensure that new treatment approaches can be implemented. Registers also support the optimization of therapy approaches, which can no longer be carried out on the basis of clinical studies alone, for example in the case of psoriasis, due to the large number of drugs available. In the era of digital medicine, healthcare research has an even more important function.

[Prevalence of dermatomycoses in professional football players : A study based on data of German Bundesliga fitness check-ups (2013-2015) compared to data of the general population]

BACKGROUND

The prevention, early diagnosis and treatment of onychomycosis is of great importance for professional athletes to avoid physical limitations by complications. So far, there is only little data on the prevalence of dermatomycosis in professional athletes.

OBJECTIVES

The aim of the study was to detect the prevalence of dermatomycosis in professional football players compared to the general population.

MATERIALS AND METHODS

The prospective, non-interventional, controlled study on the prevalence of dermatomycosis in professional football players was carried out on football players of a German Bundesliga team compared with a previously studied, equivalently aged German working population. A questionnaire survey, a dermatological check-up and a microbiological detection of pathogens in cases of suspicion were performed.

RESULTS

Data of 84 football players (n = 45 in 2013; n = 39 in 2015) were compared to data of n = 8186 male employees between 17 and 35 years of age. In the group of athletes, there were findings of 60.7% onychomycosis, 36.9% of tinea pedis and 17.8% of pityriasis versicolor. In the group of the age-equivalent general German working population the findings were: onychomycosis 3.3%, tinea pedis 3.2%, pityriasis versicolor 1.4%.

CONCLUSION

Our study shows a clearly higher risk for fungal diseases of the skin especially on the feet of professional football players. The results show a necessity for elucidation within prevention and the establishment of an appropriate therapy of dermatomycosis for professional football players.

Langzeitergebnisse und Analysen von Zusammenhängen 5 Jahre nach Varizenstripping

Ziel: Überprüfung der Rezidivquote und -einteilung sowie Analyse weiterer Zusammenhänge.

Patienten, Methode: 5 Jahre postoperativ wurden bei 93 Patienten 131 operierte Krossen (inguinal: 117, popliteal: 14) klinisch sowie doppler- und duplexsonographisch nachuntersucht (Quote: 48 %). Die Befunde wurden in 4 Gruppen eingeteilt: 1) Krossenrezidive mit Indikation zur Rekrossektomie, 2) operationsbedürftige Befunde ohne Indikation zur Rekrossektomie, 3) Rezidivvarikosis ohne klinische Relevanz und 4) keine Rezidivvarikosis. Aktuelle Beschwerden, Nebendiagnosen und klinische Einteilungen wurden dokumentiert.

Ergebnisse: 8.5 % der Patienten wiesen inguinale, 28,6 % popliteale Rezidive auf (in Bezug auf die jeweils operierten Krossen. Gesamt: 10,7 %). 11,5 % der Patienten wurden Gruppe 2 zugeordnet, 77,8 % Gruppe 3 und 4. In den Analysen der Zusammenhänge fanden sich signifikante Unterschiede zwischen Beschwerdesymptomatik und Nachuntersuchungsbefund sowie BMI und Nachuntersuchungsbefund.

Schlussfolgerungen: Trotz korrekter Krossektomie finden sich operationsbedürftige Krossenrezidive. Adipöse Patienten entwickeln diese signifikant häufiger. Die Indikation zur operativen Sanierung einer Insuffizienz der Vena saphena parva (VSP) sollte aufgrund höherer Rezidivquoten eher zurückhaltend gestellt werden. Die gewählte Rezidiveinteilung erweist sich als sinnvoll.

Association of atopy and tentative diagnosis of skin cancer - results from occupational skin cancer screenings

BACKGROUND

The relationship between atopic conditions and carcinoma of the skin has been described inconsistently. Population-based data providing information on atopic diseases as well as on skin cancer are sparse.

OBJECTIVE

To determine the correlation between atopy and prevalence of precanceroses, non-melanoma skin cancer and malignant melanoma (MM), while taking into account known risk factors for skin cancer.

METHODS

Data from occupational skin cancer screenings were analysed in a cross-sectional study. Dermatologists performed whole body examinations and collected medical histories. Subjects comprised all employees (16-70 years) examined from 2006 to 2014. 'Atopy' was defined by clinical screening diagnosis and/or by participant-reported, pre-existing atopic dermatitis, allergic asthma or other specified allergies confirmed by a physician. Tentative screening diagnoses of skin cancer related to actinic keratosis, basal cell carcinoma and malignant melanoma.

RESULTS

The study cohort comprised 90 265 employees (mean age 43 ± 11 years, 58.5% male), 30.7% of whom were ever diagnosed with an atopic disease. Persons with atopic conditions recorded in their medical history and at the time of screening had a significantly lower prevalence of actinic keratosis (AK), basal cell carcinoma (BCC) and MM. After controlling for age, sex and relevant risk factors (skin type, childhood sun burns), atopy remained significantly protective against BCC (OR 0.77) and MM (OR 0.53).

CONCLUSION

Design limitations of the study include that all findings of skin cancer were based on clinical examination only and must therefore be considered tentative diagnoses. Furthermore, owing to the cross-sectional study design, causal pathways cannot be proven. However, analyses of data from such a large and general population-based cohort afford valuable insights into the relationship between atopic diseases and skin cancer. They provide the grounds for prospective cohort studies to evaluate and dissect the underlying mechanism.

Regional variations of perceived problems in ambulatory care from the perspective of general practitioners and their patients - an exploratory focus group study in urban and rural regions of northern Germany

BACKGROUND

Patients from rural and urban regions should have equitable access to health care. In Germany, the physician-patient-ratio and the supply of medical services vary greatly between urban and rural areas. The aim of our study was to explore the regional variations of the perceived health care problems in ambulatory care from the perspective of affected professionals and laypersons i.e. general practitioners and their patients.

METHODS

We conducted 27 focus groups with general practitioners (n = 65) and patients (n = 145) from urban areas, environs and rural areas in northern Germany. Discussions were facilitated by two researchers using a semi-structured guideline. The transcripts were content analyzed using deductive and inductive categories.

RESULTS

General practitioners and patients reported problems due to demographic change and patient behaviour, through structural inequalities and the ambulatory reimbursement system as well as with specialist care and inpatient care. A high physician density, associated with high competition between general practitioners, a high fluctuation of patients and a low status of general practitioners were the main problems reported in urban areas. In contrast, participants from rural areas reported an insufficient physician density, a lack of young recruits in primary care and a resulting increased workload as problematic. All regions are concerned with subjectively inadequate general practitioners' budgets, insufficiently compensated consultations and problems in the cooperation with specialists and inpatient care institutions. Most problems were mentioned by GPs and patients alike, but some (e.g. high competition rates in urban regions and problems with inpatient care) were only mentioned by GPs.

CONCLUSIONS

While many problems arise in urban regions as well as in rural regions, our results support the notion that there is an urgent need for action in rural areas. Possible measures include the support of telemedicine, delegation of medical services and reoccupation of vacant practices. The attractiveness of working in rural areas for general practitioners, specialists and clinicians must be increased by consolidating and expanding rural infrastructure (e.g. child care and cultural life). The above mentioned results also indicate that the ambulatory reimbursement system should be examined regarding the reported inequalities. Measures to further enhance the cooperation between general practitioners, specialists and inpatient care should be taken to solve supra-regionally reported problems. Problems showing regional variations indicate the need for measures to balance these variations between the regions. This is the first German study to analyze subjective views of the stakeholders concerned on regionally variating problems in ambulatory care. Further studies are needed to quantify the extent of the identified problems and differences. A corresponding survey is currently under way.

[Risk characteristics and survival rates of malignant melanoma in Germany and the Netherlands]

BACKGROUND

Mortality and lethality of malignant melanoma (MM) show marked variations throughout Europe, thereunder a higher risk within the Netherlands (NL) when compared to Germany (D).

GOAL AND METHODS

Comparison of systems and exploration of possible causal factors that could explain the difference between D and NL. Comparative healthcare research analysis using published international literature, as well as publicly accessible databases, and a subsequent hypothesis-generating analysis.

RESULTS

The higher rate of excised MM less than 1 mm in diameter in D (65 % vs. 45 %) confirms the clinical reports of the cancer registries. The biological factors for the emergence of MM, such as skin type, do not seem to significantly differ from each other. Among the further potential predictors there are no relevant differences within, for example, geographical conditions and the qualifications of the treating physicians. Primary prevention has a longer continual tradition in D. Here, secondary prevention is characterized by population-based extensive screening, which does not occur within the NL. In addition, distinct differences are found regarding access to dermatologists.

CONCLUSION

System access to a medical specialist and the prevention of skin cancer are currently the most distinctive potential determinants of more favorable MM survival rate in Germany.

Prevalence and comorbidities in adults with psoriasis compared to atopic eczema

BACKGROUND

Most data suggesting an association between psoriasis and cardiovascular disease (CVD) have come from specialized populations at either low or high risk of CVD. Atopic dermatitis (AD) has been associated with a number of modifiable risk factors, particularly obesity. There has been a recent controversy on the suggestion that associations with comorbidities in psoriasis may be due to overreporting or biased by disease severity and therefore not necessarily representative of the general psoriasis population.

OBJECTIVES

To evaluate the prevalence of AD and psoriasis and to compare the prevalence rates of comorbidities based on a large sample of health insurance data.

METHODS

Data were collected from a database of non-selected individuals from a German statutory health insurance organization that covers all geographic regions. Individuals identified by International Classification of Diseases (ICD)-10 codes applied to all outpatient and inpatient visits in the year 2009. Comorbidities were evaluated by ICD-10 diagnoses.

RESULTS

The database consisted of 1 642 852 members of a German statutory health insurance. Of 1 349 671 data sets analyzed, 37 456 patients ≥18 years were diagnosed with psoriasis (prevalence 2.78%), and 48 140 patients ≥18 years of age were diagnosed with AD, equivalent to a prevalence of 3.67%. Patients with psoriasis showed increased rates of comorbidities in all age groups. Comorbidities related to the metabolic syndrome including arterial hypertension [prevalence ratio (PR), 1.94; 95% confidence interval (CI), 1.90-1.98], hyperlipidaemia (PR, 1.77; 95% CI, 1.73-1.81), obesity (PR, 1.74; 95% CI, 1.69-1.79) and diabetes mellitus (PR, 1.88; 95% CI, 1.83-1.94) were significantly more common among patients with psoriasis compared to AD.

CONCLUSIONS

Diseases forming part of the metabolic syndrome showed significant lower prevalence rates in patients with AD than in patients with psoriasis. Within the limitations of secondary healthcare data, our study disproves the suggestion that associations with comorbidities in psoriasis may be biased by a higher degree of severity or overreporting.

[Morbidity differences according to nursing stage and nursing setting in long-term care patients: Results of a claims data based study]

BACKGROUND

We analyzed the differences in morbidity patterns of chronic diseases between long-term care dependent persons in nursing homes compared to those dwelling in the community. We also investigated morbidity differences between long-term care need stages in Germany.

MATERIALS AND METHODS

The study included claims data of one nationwide operating statutory health insurance in 2006. Inclusion criteria were age ≥ 65 years, minimum 1 out of 46 diagnoses in at least 3 quarters of the year (n = 8,670). A comparison population was formed with n = 114,962. Prevalences, relative risks, and odds ratios for the risk of nursing home care were calculated.

RESULTS

In the bivariate analysis, only three chronic diseases - dementia, urinary incontinence, and chronic heart failure - showed a higher risk for nursing home care. Regression analysis revealed that only dementia showed higher odds related to the stage of nursing needs.

CONCLUSION

Among the chronic diseases, only dementia shows a substantially elevated risk for nursing home care. Risk studies on other chronic diseases associated with higher risks of long-term care dependency and specific intervention strategies aiming at delaying or preventing nursing home admission should be developed.