Outpatient Health Service Utilization Among Adults with Diabetes, Hypertension and Cardiovascular Disease During the COVID-19 Pandemic - Results of Population-Based Surveys in Germany from 2019 to 2021

Purpose

Fear of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and lockdown measures may have an impact on health care utilization particularly for people with chronic diseases. We investigated changes in outpatient utilization behavior in pandemic phases among people with selected chronic diseases in Germany.

Methods

The nationwide population-based telephone surveys German Health Update (GEDA) 2019/2020 (April 2019 to September 2020) and GEDA 2021 (July to December 2021) covered 4 out of 7 pandemic phases from the pre-pandemic to the 4th pandemic wave. Data on hypertension, diabetes and major cardiovascular diseases (CVD) in the past 12 months and visiting a general practitioner (GP) or a specialist (excluding dentist) in the past 4 weeks was collected using a standardized questionnaire. Proportions and odds ratios were derived from logistic regression models adjusted for age, sex, education and federal states.

Results

Among 27,967 participants aged ≥16 years, 8,449, 2,497 and 1,136 individuals had hypertension, diabetes and major CVD. Participants with these chronic diseases visited a GP or specialist significantly more often than the overall study population, irrespective of pandemic phases. Compared to the pre-pandemic phase, a significant reduction in specialist-visiting was found in the first pandemic wave among people with hypertension (34.3% vs 24.1%), diabetes (39.5% vs 25.5%) and major CVD (41.9% vs 25.6%). GP-visiting was lower only among people with hypertension (53.0% vs 46.0%). No difference in GP or specialist visiting was found in the 4th pandemic wave compared to the pre-pandemic phase.

Conclusion

The observed decrease particularly in specialist utilization among people with the selected chronic diseases at the beginning of the pandemic was not observed for the second half of 2021 despite the ongoing pandemic. Further studies are required to examine whether the temporary changes in the utilization of ambulatory health care have affected the disease management of people with chronic diseases.

The Burden of Disease due to COVID-19 (BoCO-19): A study protocol for a secondary analysis of surveillance data in Southern and Eastern Europe, and Central Asia

INTRODUCTION

The COVID-19 pandemic has had an extensive impact on public health worldwide. However, in many countries burden of disease indicators for COVID-19 have not yet been calculated or used for monitoring. The present study protocol describes an approach developed in the project "The Burden of Disease due to COVID-19. Towards a harmonization of population health metrics for the surveillance of dynamic outbreaks" (BoCO-19). The process of data collection and aggregation across 14 different countries and sub-national regions in Southern and Eastern Europe and Central Asia is described, as well as the methodological approaches used.

MATERIALS AND METHODS

The study implemented in BoCO-19 is a secondary data analysis, using information from national surveillance systems as part of mandatory reporting on notifiable diseases. A customized data collection template is used to gather aggregated data on population size as well as COVID-19 cases and deaths. Years of life lost (YLL), as one component of the number of Disability Adjusted Life Years (DALY), are calculated as described in a recently proposed COVID-19 disease model (the 'Burden-EU' model) for the calculation of DALY. All-cause mortality data are collected for excess mortality sensitivity analyses. For the calculation of Years lived with disability (YLD), the Burden-EU model is adapted based on recent evidence. Because Covid-19 cases vary in terms of disease severity, the possibility and suitability of applying a uniform severity distribution of cases across all countries and sub-national regions will be explored. An approach recently developed for the Global Burden of Disease Study, that considers post-acute consequences of COVID-19, is likely to be adopted. Findings will be compared to explore the quality and usability of the existing data, to identify trends across age-groups and sexes and to formulate recommendations concerning potential improvements in data availability and quality.

DISCUSSION

BoCO-19 serves as a collaborative platform in order to build international capacity for the calculation of burden of disease indicators, and to support national experts in the analysis and interpretation of country-specific data, including their strengths and weaknesses. Challenges include inherent differences in data collection and reporting systems between countries, as well as assumptions that have to be made during the calculation process.

Exploring HPV vaccine knowledge, attitudes, barriers and information sources among parents, health professionals and teachers in Kazakhstan: a mixed-methods study protocol

INTRODUCTION

Human papillomavirus (HPV) is a prevalent sexually transmitted infection linked to certain types of malignant neoplasms, notably cervical cancer (CC). In Kazakhstan, a high prevalence of high oncogenic HPV types (HR-HPV) has been observed, and CC ranks as the second most common malignancy among women with a crude incidence rate of 18.3 cases per 100 000 women. The HPV vaccine, developed as the primary prevention measure against HPV infection, including the most prevalent HR-HPV, received approval from the WHO in 2009. In 2014, Kazakhstan initiated HPV vaccination as a pilot project in four sub-national regions; however, it was later in 2017 discontinued due to widespread parental refusal influenced by negative media reports. This study aims to examine knowledge, attitudes, information sources, barriers to HPV vaccination and factors associated with HPV vaccination hesitancy among different target groups in Kazakhstan prior to the HPV vaccine re-launch announced by the Ministry of Health.

METHODS AND ANALYSIS

This mixed-method-designed research comprises quantitative and qualitative components. Data on HPV awareness, attitudes towards HPV vaccination and sources of information will be collected through an online survey administered by parents and legal guardians, health professionals, and schoolteachers in the Republic of Kazakhstan between January 2023 and January 2024. Additionally, qualitative data on Kazakhstani parental beliefs and attitudes toward HPV vaccination will be collected through online focus group discussions.

ETHICS AND DISSEMINATION OF RESULTS

The study has been approved by the local ethics committee at the Kazakhstan Medical University "Higher School of Public Health" (KMU "KSPH") (No. 138 of 31.05.2021). The results will be reported in publications, at conferences among researchers and healthcare and school education professionals in Kazakhstan, and internationally.

Cross-national data on informal caregivers of older people with long-term care needs in the European population: time for a more coordinated and comparable approach

To promote long-term care policies for older adults, accurate mapping of the often invisible and insufficiently recognized role of their informal caregivers is needed. This paper measures the prevalence of informal caregivers in the European population, illustrates current difficulties in gathering unequivocal information on this topic and deals with the scientific and policy implications of the problem. Using the European Health Interview Survey (EHIS), the European Quality of Life Survey (EQLS) and the Study on Health and Ageing in Europe (SHARE), the current difficulties in gathering unequivocal information on this topic are illustrated. In most countries, the share of informal caregivers varies, sometimes markedly, among the three surveys. As for the sex of caregivers, while confirming the well-known higher prevalence of caregivers among women than among men, large variations emerge across the three surveys in most countries in respect of the two sexes. The takeaway message of the paper is that it is urgent to promote international concerted action in gathering comprehensive informal caregiving information and/or exploring in greater depth the different intercultural understandings of informal care itself.

Health of people with selected citizenships: results of the study GEDA Fokus

Background

The health situation of people with a history of migration is influenced by a variety of factors. This article provides an overview of the health of people with selected citizenships using various indicators.

Methods

The analyses are based on the survey 'German Health Update: Fokus (GEDA Fokus)', which was conducted from November 2021 to May 2022 among people with Croatian, Italian, Polish, Syrian and Turkish citizenship. The prevalence for each health outcome is presented and differentiated by sociodemographic and migration-related characteristics. Poisson regressions were performed to identify relevant factors influencing health situation.

Results

Self-assessed general health, the presence of depressive symptoms, prevalence of current smoking and the utilisation of general and specialist healthcare differed according to various factors considered here. In addition to sociodemographic determinants, the sense of belonging to society in Germany and self-reported experiences of discrimination were particularly associated with health outcomes.

Conclusions

This article highlights the heterogeneity of the health situation of people with a history of migration and points to the need for further analyses to identify the reasons for health inequalities.

Informal caregivers in Germany - who are they and which risks and resources do they have?

Background

The aim of this study is to describe the social characteristics, the health and living situation and the prevalence of behavioral risk factors of adult informal caregivers compared to non-caregivers in Germany.

Methods

We used data from the German Health Update (GEDA 2019/2020-EHIS survey) which is a cross-sectional population-based health interview survey conducted between 04/2019 and 09/2020. The sample comprised 22,646 adults living in private households. Three mutually exclusive groups of providing informal care or assistance were differentiated: intense caregivers (informal care ≥10 h/week), less-intense caregivers (informal care<10 h/week) and non-caregivers. For the three groups weighted prevalences of social characteristics, health status (self-perceived health, health-related activity limitations, chronic diseases, low back disorder or other chronic back defect, depressive symptoms), behavioral risk factors (at-risk drinking, current smoking, insufficient physical activity, non-daily fruit and vegetable consumption, obesity) and social risk factors (single household, low social support) were calculated and stratified by gender. Separate regression analyses adjusted for age-group were conducted to identify significant differences between intense and less-intense caregivers vs. non-caregivers, respectively.

Results

Overall, 6.5% were intense caregivers, 15.2% less-intense caregivers and 78.3% non-caregivers. Women provided care more often (23.9%) than men (19.3%). Informal care was most frequently provided in the age group of 45 to 64 years. Intense caregivers reported worse health status, were more often current smokers, physical inactive, obese and lived less often alone than non-caregivers. However, in age-group adjusted regression analyses only few significant differences were seen: Female and male intense caregivers had more often a low back disorder and lived less often alone compared to non-caregivers. In addition, male intense care-givers reported more often worse self-perceived health, health-related activity limitation, and the presence of chronic diseases. In contrast, less-intense caregivers and non-caregivers differed in favor of the less-intense caregivers.

Discussion

A substantial proportion of the adult German population provides informal care regularly, especially women. Intense caregivers are a vulnerable group for negative health outcomes, especially men. In particular measures to prevent low back disorder should be provided. As the necessity of providing informal care will probably increase in the future, this will be important for the society and public health.

The Burden of Disease in Germany at the National and Regional Level

BACKGROUND

.Summary measures such as disability-adjusted life years (DALY) are becoming increasingly important for the standardized assessment of the burden of disease due to death and disability. The BURDEN 2020 pilot project was designed as an independent burden-of-disease study for Germany, which was based on nationwide data, but which also yielded regional estimates.

METHODS

DALY is defined as the sum of years of life lost due to death (YLL) and years lived with disability (YLD). YLL is the difference between the age at death due to disease and the remaining life expectancy at this age, while YLD quantifies the number of years individuals have spent with health impairments. Data are derived mainly from causes of death statistics, population health surveys, and claims data from health insurers.

RESULTS

In 2017, there were approximately 12 million DALY in Germany, or 14 584 DALY per 100 000 inhabitants. Conditions which caused the greatest number of DALY were coronary heart disease (2321 DALY), low back pain (1735 DALY), and lung cancer (1197 DALY). Headache and dementia accounted for a greater disease burden in women than in men, while lung cancer and alcohol use disorders accounted for a greater disease burden in men than in women. Pain disorders and alcohol use disorders were the leading causes of DALY among young adults of both sexes. The disease burden rose with age for some diseases, including cardiovascular diseases, dementia, and diabetes mellitus. For some diseases and conditions, the disease burden varied by geographical region.

CONCLUSION

The results indicate a need for age- and sex-specific prevention and for differing interventions according to geographic region. Burden of disease studies yield comprehensive population health surveillance data and are a useful aid to decision-making in health policy.

Burden of disease assessment for Germany and its regions – results from the BURDEN 2020 study

Background

Epidemiological measures such as incidence, prevalence, or deaths are essential for monitoring population health. However, evaluating them in isolation cannot adequately compare and assess the relative importance of different diseases. Assessments of the burden of disease (BoD) are therefore of growing importance in supporting health policy decisions. Using disability-adjusted life years (DALY) as a summary measure of population health, BoD integrates morbidity and mortality in a transparent approach.

Methods

Within BoD methodology, deviations in the health of the population from an ‘ideal’ health status is quantified in the unit of life years. DALY are the sum of years of life lost due to death (YLL) and years lived with disability (YLD). While YLL describe the gap between age at death and statistical life expectancy, the indicator YLD quantifies years lived with a disability or disease. Calculations were based on different primary and secondary data sources for Germany, especially cause-of-death statistics, epidemiological survey data, and statutory health insurance data.

Results

In Germany, there were about 12 million DALY in 2017, the equivalent of 14,584 DALY per 100,000 population. Coronary heart disease contributes the most to the overall burden of disease, followed by lower back pain and lung cancer. In women, headache disorders and dementias account for more DALY as compared to men. Men have a higher burden of disease from lung cancer or alcohol use disorders. Pain disorders and alcohol use disorders lead the DALY rankings for both sexes in younger adulthood. The burden due to cardiovascular disease, COPD, and diabetes mellitus increases with age and also varies by region.

Conclusions

The results suggest age- and gender-specific prevention as well as regional health care needs. BoD studies therefore provide comprehensive data for population health surveillance and can support health policy decisions.

Key messages

• The importance of specific diseases as measured by DALY differs greatly by age and gender, highlighting the need for targeted prevention measures.

• Regional patterns emerge for cardiovascular disease, COPD, and depressive disorders, among others, which may indicate health care needs.

Health situation in Germany during the COVID-19 pandemic. Developments over time for selected indicators of GEDA 2019/2020 - An update

The spread of the coronavirus SARS-CoV-2 in 2020 and the containment measures associated therewith have changed many aspects of daily life. An impact on health even beyond infections itself is assumed as well. The health situation of the population in the first phase of the pandemic was thus analysed using data from the German Health Update (GEDA 2019/2020-EHIS). By continuing the survey, the analyses for 2020 are completed (n=26,507 participants), whereby the focus is now on the third phase of the pandemic (second wave of infection, gradual reintroduction of containment measures). The health indicators are presented on a monthly basis. As in the first phase of the pandemic, no pandemic-related changes were observed for tobacco smoking/ second-hand smoke exposure and for received/lack of/provided support. In contrast to the first phase of the pandemic, declines in utilisation of medical services and depressive symptoms are not observed in the third phase. The increase in body weight/body mass index after the first phase of the pandemic did not continue. The survey period allows for a comparison of the periods before and as of the pandemic situation. A decrease in the medical services utilisation and depressive symptoms as well as an increase in the body weight/body mass index is observed in the period from March 2020 to January 2021 compared to the pre-pandemic period from April 2019 to March 2020.

Survey of sex/gender diversity in the GEDA 2019/2020-EHIS study - objectives, procedure and experiences

Sex/gender diversity is increasingly recognised by society and should be taken into account more in population-representative studies, as they are important data sources for targeting health promotion, prevention and care. In 2019, the Robert Koch Institute started a population-representative health survey with the study Health in Germany Update (GEDA 2019/2020-EHIS) with a modified, two-stage measures of sex/gender. The survey covered sex registered at birth and gender identity with an open response option. This article describes the aims, the procedure and the experiences with the operationalisation of sex/gender and the results. Out of 23,001 respondents, 22,826 persons are classified as cisgender, 113 persons as transgender and 29 persons as gender-diverse. 33 respondents were counted as having missing values. A survey of interviewers showed that the two-stage measures of sex/gender had a high level of acceptance overall and that there were only a few interview drop-outs. On the basis of previous experience, the modified query can be used for further surveys, but should also be adapted in perspective. For this purpose, participatory studies are desirable that focus on how the acceptance of measures of sex/gender can be further improved and how hurtful experiences in the context of the questions asked can be avoided.

The burden of injury in Central, Eastern, and Western European sub-region: a systematic analysis from the Global Burden of Disease 2019 Study

BACKGROUND

Injury remains a major concern to public health in the European region. Previous iterations of the Global Burden of Disease (GBD) study showed wide variation in injury death and disability adjusted life year (DALY) rates across Europe, indicating injury inequality gaps between sub-regions and countries. The objectives of this study were to: 1) compare GBD 2019 estimates on injury mortality and DALYs across European sub-regions and countries by cause-of-injury category and sex; 2) examine changes in injury DALY rates over a 20 year-period by cause-of-injury category, sub-region and country; and 3) assess inequalities in injury mortality and DALY rates across the countries.

METHODS

We performed a secondary database descriptive study using the GBD 2019 results on injuries in 44 European countries from 2000 to 2019. Inequality in DALY rates between these countries was assessed by calculating the DALY rate ratio between the highest-ranking country and lowest-ranking country in each year.

RESULTS

In 2019, in Eastern Europe 80 [95% uncertainty interval (UI): 71 to 89] people per 100,000 died from injuries; twice as high compared to Central Europe (38 injury deaths per 100,000; 95% UI 34 to 42) and three times as high compared to Western Europe (27 injury deaths per 100,000; 95%UI 25 to 28). The injury DALY rates showed less pronounced differences between Eastern (5129 DALYs per 100,000; 95% UI: 4547 to 5864), Central (2940 DALYs per 100,000; 95% UI: 2452 to 3546) and Western Europe (1782 DALYs per 100,000; 95% UI: 1523 to 2115). Injury DALY rate was lowest in Italy (1489 DALYs per 100,000) and highest in Ukraine (5553 DALYs per 100,000). The difference in injury DALY rates by country was larger for males compared to females. The DALY rate ratio was highest in 2005, with DALY rate in the lowest-ranking country (Russian Federation) 6.0 times higher compared to the highest-ranking country (Malta). After 2005, the DALY rate ratio between the lowest- and the highest-ranking country gradually decreased to 3.7 in 2019.

CONCLUSIONS

Injury mortality and DALY rates were highest in Eastern Europe and lowest in Western Europe, although differences in injury DALY rates declined rapidly, particularly in the past decade. The injury DALY rate ratio of highest- and lowest-ranking country declined from 2005 onwards, indicating declining inequalities in injuries between European countries.

Results and Strategies for a Diversity-Oriented Public Health Monitoring in Germany

Germany is a country of immigration; 27% of the population are people with a migration background (PMB). As other countries, Germany faces difficulties in adequately including hard-to-survey populations like PMB into national public health monitoring. The IMIRA project was initiated to develop strategies to adequately include PMB into public health monitoring and to represent diversity in public health reporting. Here, we aim to synthesize the lessons learned for diversity-oriented public health monitoring and reporting in Germany. We also aim to derive recommendations for further research on migration and health. We conducted two feasibility studies (interview and examination surveys) to improve the inclusion of PMB. Study materials were developed in focus groups with PMB. A systematic review investigated the usability of the concept of acculturation. A scoping review was conducted on discrimination as a health determinant. Furthermore, core indicators were defined for public health reporting on PMB. The translated questionnaires were well accepted among the different migrant groups. Home visits increased the participation of hard-to-survey populations. In examination surveys, multilingual explanation videos and video-interpretation services were effective. Instead of using the concept of acculturation, we derived several dimensions to capture the effects of migration status on health, which were more differentiated. We also developed an instrument to measure subjectively perceived discrimination. For future public health reporting, a set of 25 core indicators was defined to report on the health of PMB. A diversity-oriented public health monitoring should include the following: (1) multilingual, diversity-sensitive materials, and tools; (2) different modes of administration; (3) diversity-sensitive concepts; (4) increase the participation of PMB; and (5) continuous public health reporting, including constant reflection and development of concepts and methods.

Burden 2020: The German Burden of Disease Study Informative, comprehensive, appealing and digital: Providing health data to users. Accessibility of scientific results in the burden context

The aim of the BURDEN 2020 project is to calculate the Burden of Disease for Germany at the national and regional level. Based on the methods of the Global Burden of Disease study, the results will assess the impact of diseases on population health thus providing a freely accessible information basis for policy making and health care planning. How can the transfer from science to society take place on a low-threshold basis? We will talk about our strategy reaching out to decision-makers within health care planning in Germany and Europe. In addition, it will be examined how we wanted our results to be accessible, which possibilities of publication we choose beyond scientific articles and what options we had when talking about research marketing. We will also have a closer look on our demands for data visualization and transparency. In an ongoing process, two things were at stake: how do we define our target groups and how we address them. It has been proven to be a good strategy to continuously build up (international) networks, to share our knowledge and implement feedback. When publishing scientific results, it has turned out to be helpful for the project to approach a well-known bi-lingual journal with a wide range of coverage. We aimed to present the pilot project online with an appealing data visualization and graphic formats. This type of presentation made it easier to approach members of the press. Also, the inclusion of current topics such as COVID-19 helped to increase the media response. There are plans to include the use of the data in media formats such as webinars. Burden of Disease assessments can be challenging in implementation and communication. Before the start, the use of the metrics for Germany had to be thoroughly explained to national stakeholders. Within the project, we had to discuss how our data should be communicated to the public, to explain strength and weaknesses, and to produce publication formats that suit different target groups.

Utilisation of outpatient medical services in Germany - Results from GEDA 2019/2020-EHIS

Outpatient health care provision plays an important role in the identification and treatment of health problems. Data are needed on the utilisation of health care services and their determinants to enable health policy decision-making and needs-based care provision. The analyses set out in this article are based on current data on the utilisation of outpatient health care services. The data stem from the German Health Update (GEDA 2019/2020-EHIS), a nationwide cross-sectional survey of the resident population in Germany that is undertaken as part of the health monitoring conducted at the Robert Koch Institute. Around 80% of the population aged 18 or over were treated at least once within twelve months by a general practitioner, 60% by a specialist, and 10% received psychiatric or psychotherapeutic treatment. Less than half of those eligible had had a stool test during the past two years, and just over half had had a colonoscopy in the past ten years. Around 80% of women and 70% of men had had their blood pressure checked within the last year, and 60% had had their blood cholesterol or blood sugar levels monitored. Over 50% reported that they had taken medically prescribed drugs in the past two weeks. In general, most of the indicators under study suggest that utilisation increases with age and that utilisation is higher among women than men, with the exception of psychiatric and psychotherapeutic services, among others.

Recommendations to plan a national burden of disease study

Background

The InfAct (Information for Action) project is a European Commission Joint Action on Health Information which has promoted the potential role of burden of disease (BoD) approaches to improve the current European Union-Health Information System (EU-HIS). It has done so by raising awareness of the concept, the methods used to calculate estimates and their potential implications and uses in policymaking. The BoD approach is a systematic and scientific effort to quantify and compare the magnitude of health loss due to different diseases, injuries, and risk factors with estimates produced by demographic characteristics and geographies for specific points in time. Not all countries have the resources to undertake such work, and may therefore start with a more restricted objective, e.g., a limited number of diseases, or the use of simple measures of population health such as disease prevalence or life expectancy. The main objective to develop these recommendations was to facilitate those countries planning to start a national burden of disease study.

Results

These recommendations could be considered as minimum requirements for those countries planning to start a BoD study and includes following elements: (1) Define the objectives of a burden of disease study within the context of your country, (2) Identify, communicate and secure the benefits of performing national burden of disease studies, (3) Secure access to the minimum required data sources, (4) Ensure the minimum required capacity and capability is available to carry out burden of disease study, (5) Establish a clear governance structure for the burden of disease study and stakeholder engagement/involvement, (6) Choose the appropriate methodological approaches and (7) Knowledge translation. These were guided by the results from our survey performed to identify the needs of European countries for BoD studies, a narrative overview from four European countries (Belgium, Germany, The Netherlands and Scotland) and the summary of a comparative study of country health profiles with national health statistics.

Conclusions

These recommendations as minimum requirements would facilitate efforts by those European countries who intend to perform national BoD studies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13690-021-00652-x.

The Excess Costs of Depression and the Influence of Sociodemographic and Socioeconomic Factors: Results from the German Health Interview and Examination Survey for Adults (DEGS)

INTRODUCTION

The aim of this study was to estimate excess costs of depression in Germany and to examine the influence of sociodemographic and socioeconomic determinants.

METHODS

Annual excess costs of depression per patient were estimated for the year 2019 by comparing survey data of individuals with and without self-reported medically diagnosed depression, representative for the German population aged 18-79 years. Differences between individuals with depression (n = 223) and without depression (n = 4540) were adjusted using entropy balancing. Excess costs were estimated using generalized linear model regression with a gamma distribution and log-link function. We estimated direct (inpatient, outpatient, medication) and indirect (sick leave, early retirement) excess costs. Subgroup analyses by social determinants were conducted for sex, age, socioeconomic status, first-generation or second-generation migrants, partnership, and social support.

RESULTS

Total annual excess costs of depression amounted to €5047 (95% confidence interval [CI] 3214-6880) per patient. Indirect excess costs amounted to €2835 (1566-4103) and were higher than direct excess costs (€2212 [1083-3341]). Outpatient (€498), inpatient (€1345), early retirement (€1686), and sick leave (€1149) excess costs were statistically significant, while medication (€370) excess costs were not. Regarding social determinants, total excess costs were highest in the younger age groups (€7955 for 18-29-year-olds, €9560 for 30-44-year-olds), whereas total excess costs were lowest for the oldest age group (€2168 for 65+) and first-generation or second-generation migrants (€1820).

CONCLUSIONS

Depression was associated with high excess costs that varied by social determinants. Considerable differences between the socioeconomic and sociodemographic subgroups need further clarification as they point to specific treatment barriers as well as varying treatment needs.

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.

Utilization of preventive care among migrants and non-migrants in Germany: results from the representative cross-sectional study 'German health interview and examination survey for adults (DEGS1)'

BACKGROUND

In Germany, different health checks for adults are offered for primary and secondary prevention. Previous findings indicate that preventive care utilization varies according to social determinants, especially migration background. This study examined the extent to which migration background is associated with preventive care utilization, independent of factors like age and socioeconomic status and whether length of stay in Germany has a positive effect on the use of preventive care.

METHODS

The first wave of the 'German Health Interview and Examination Survey for Adults' (DEGS1) is a comprehensive data collection facilitating the description of the utilization of general health checks, dental check-ups, skin cancer screening, and cervical cancer screening among people aged 18-79 years with and without migration background. Migration background was differentiated in first-generation migrants having immigrated to Germany themselves or second-generation migrants born in Germany. First-generation migrants were further differentiated by length of stay in Germany, and second-generation migrants as having one or two parents who were born abroad. Multivariate binary logistic regression models with average marginal effects were calculated to analyse the associations between preventive care utilization and migration background.

RESULTS

The sample comprised 7987 participants, 1091 of whom had a migration background. Compared with non-migrants, women and men with migration background- particularly first-generation migrants with length of stay <=20 years in Germany - make less use of preventive care. This association was observed statistically independent from sociodemographic factors. For dental check-ups a significantly lower use was also found for first-generation migrants who have lived in Germany for more than 20 years and second-generation of migrants with two parents born abroad. Post-model predictions showed that the utilization rates of first-generation migrants are gradually converging to the average values for non-migrants.

CONCLUSIONS

Our findings suggest inequalities in realized access to preventive care for first-generation migrants particularly for those who have lived in Germany for 20 years or less. Barriers to the utilization of preventive care may be addressed by informing migrant communities about preventive health care services at an early stage after immigration using migrant-sensitive information strategies.

Corrigendum: Developments in the health situation in Germany during the initial stage of the COVID-19 pandemic for selected indicators of GEDA 2019/2020-EHIS

[This corrects the article on p. 3-20 in vol. 5.].

Excess costs of type 2 diabetes and their sociodemographic and clinical determinants: a cross-sectional study using data from the German Health Interview and Examination Survey for Adults (DEGS1)

OBJECTIVES

The objectives of this study were to estimate the direct and indirect excess costs of type 2 diabetes mellitus (T2D) using data representative for the German adult population and to investigate the association of sociodemographic and clinical determinants with these excess costs.

SETTING

We calculated mean annual costs for individuals with T2D and a control group without diabetes, using data on healthcare utilisation and productivity losses from the cross-sectional German Health Interview and Examination Survey for Adults. We adjusted for group differences using entropy balancing and estimated excess costs for total, direct, indirect costs and additional cost categories using generalised linear models. We performed subgroup analyses to investigate the association of sociodemographic (age, sex and education) and clinical determinants (diabetes duration, glycaemic index and complications) with excess costs.

PARTICIPANTS

The final study sample included n=325 individuals with T2D and n=4490 individuals without diabetes in the age between 18 and 79 years.

RESULTS

Total excess costs amounted to €927, of which €719 were attributable to direct and €209 to indirect excess costs. Total costs were significantly increased by 28% for T2D compared with controls. Group differences in direct, outpatient and medication costs were statistically significant. Medication costs were 88% higher for T2D and had the highest share in direct excess costs. With respect to specific determinants, direct excess costs ranged from €203 for 4-10 years diabetes duration to €1405 for diabetes complications. Indirect excess costs ranged from €-544 for >10 years diabetes duration to €995 for high education.

CONCLUSIONS

T2D was associated with high costs, mainly due to direct costs. As pointed out by our results, diabetes complications and comorbidities have a large impact on the costs, leaving medication costs as main contributor of T2D excess costs.

Population with an increased risk of severe COVID-19 in Germany. Analyses from GEDA 2019/2020-EHIS

Only a minority of people who test positive for COVID-19 develop a severe or critical form of the disease. Many of these have risk factors such as old age or pre-existing conditions and, therefore, are at the focus of protective measures. This article determines the number of people at risk in Germany and differentiates them according to age, sex, education, household type and federal state. The analyses presented here are based on data from the German Health Update (GEDA) 2019/2020-EHIS, which was carried out as a nationwide cross-sectional telephone-based survey between April 2019 and October 2020. The definition of being at increased risk of severe COVID-19 is primarily based on a respondent’s age and the presence of pre-existing conditions. Around 36.5 million people in Germany are at an increased risk of developing severe COVID-19. Of these, 21.6 million belong to the high-risk group. An above-average number of people at risk live alone. The prevalence of an increased risk is higher among middle-aged men than among women of the same age, and significantly higher among people with a low level of education than among people with a high level of education. The highest proportion of people with an increased risk live in Saarland and in the eastern German federal states. When fighting the pandemic, it is important to account for the fact that more than half of the population aged 15 or over is at increased risk of severe illness. Moreover, the regional differences in risk burden should be taken into account when planning interventions.

Redistributing ill-defined causes of death - a case study from the BURDEN 2020-project in Germany

BACKGROUND

The cause of death statistics in Germany include a relatively high share (26% in 2017) of ill-defined deaths (IDD). To make use of the cause of death statistics for Burden of Disease calculations we redistribute those IDD to valid causes of death.

METHODS

The process of proportional redistribution is described in detail. It makes use of the distribution of the valid ICD-codes in the cause of death data. We use examples of stroke, diabetes, and heart failure to illustrate how IDD are reallocated.

RESULTS

The largest increases in the number of deaths for both women and men were found for lower respiratory infections, diabetes mellitus, and stroke. The numbers of deaths for these causes more than doubled after redistribution.

CONCLUSION

This is the first comprehensive redistribution of IDD using the German cause of death statistics. Performing a redistribution is necessary for burden of disease analyses, otherwise there would be an underreporting of certain causes of death or large numbers of deaths coded to residual or unspecific codes.

Years of Life Lost to Death—A Comprehensive Analysis of Mortality in Germany Conducted as Part of the BURDEN 2020 Project

BACKGROUND

Knowing which diseases and causes of death account for most of the years of life lost (YLL) can help to better target appropriate prevention and intervention measures. The YLL in Germany for specific causes of death were estimated as part of the BURDEN 2020 project at the Robert Koch Institute.

METHODS

Data from cause-of-death statistics were used for the analysis. ICD codes were grouped into causes of death categories at different levels of disaggregation. The YLL were estimated by combining each cause of death with the remaining life expectancy at the age of death. Deaths and YLL were compared by sex, age category, and regional distribution.

RESULTS

Approximately 11.6 million years were estimated to be lost in Germany in 2017, of which 42.8% were lost by women and 57.2% by men. The largest number of YLL were due to (malignant) neoplasms (35.2%), followed by cardiovascular diseases (27.6%), gastrointestinal diseases (5.8%), and neurological diseases (5.7%). Deaths at younger ages had a greater impact on population health if expressed in YLL: the death share of persons under age 65 was 14.7%, but the years of life lost in this age group amounted to 38.3% of all YLL. The most common causes of death in this group include accidents, self-injury and violence, malignant neoplasms, and alcohol-related diseases.

CONCLUSION

A large proportion of YLL is borne by young and middle-aged persons. These findings emphasize the need to introduce preventive strategies early in life to reduce the YLL at younger ages, as well as to prevent risk factors for diseases in older ages.

The COVID-19 Disease Burden in Germany in 2020—Years of Life Lost to Death and Disease Over the Course of the Pandemic

BACKGROUND

The SARS-CoV-2 pandemic presented major challenges to the health sector in 2020. The burden of disease arising from COVID-19 can be expressed as the number of years of life lost to disease or death. For example, death at age 40 involves a loss of far more years of life than death at age 80.

METHODS

The disability-adjusted life years (DALY) lost to COVID-19 were calculated as the sum of the years of life lost through death (YLL) and the number of years lived with disability (YLD), on the basis of laboratory-confirmed notifiable cases of SARS-CoV-2 infection in Germany in 2020 (documented as of 18 January 2021). The methodology was based on that used in the Global Burden of Disease Study. Pre-existing diseases do not enter into the determination of YLL; rather, the residual life expectancy that is applied in this calculation corresponds to a mean age-specific level of morbidity.

RESULTS

305 641 years of life were lost to COVID-19 in Germany in 2020. The percentage of DALY lost by persons under 70 was 34.8% in men and 21.0% in women. 99.3% of the COVID-19 disease burden was accounted for by death (YLL). The daily average years of life lost due to death was lower for COVID-19 than for the major non-communicable diseases. Persons who died of COVID-19 lost a mean of 9.6 years of life; those who were under 70 when they died lost a mean of 25.2 years of life. Men lost more years of life than women (11.0 vs. 8.1 years).

CONCLUSION

The effects of COVID-19 on public health can be expressed through the burden of disease indicators. This method yields additional information that should be put to use early in the course of future outbreaks.

Prevalence of back and neck pain in Germany. Results from the BURDEN 2020 Burden of Disease Study

Back and neck pain are widespread and can significantly reduce quality of life. A cross-sectional telephone survey (N=5,009) was carried out between October 2019 and March 2020 to gain a valid estimate of the prevalence of back and neck pain among adults in Germany. In addition to the frequency and intensity of back and neck pain, the study collected information about quality of life and comorbidity. The findings showed that 61.3% of respondents reported back pain in the last twelve months. Lower back pain was reported about twice as often as upper back pain, with 15.5% of respondents stating that they experienced chronic back pain. 45.7% reported neck pain, and 15.6% of respondents have experienced lower and upper back pain in addition to neck pain in the past year. Women are affected by all types of pain more often than men. About half of the respondents categorise their back or neck pain as moderate; older respondents report significantly more pain episodes per month than younger respondents. The results described here provide a comprehensive picture of the population-related limitations associated with back and neck pain and are used within the framework of the BURDEN 2020 study to quantify key indicators of burden of disease calculation.

Developments in the health situation in Germany during the initial stage of the COVID-19 pandemic for selected indicators of GEDA 2019/2020-EHIS

SARS-CoV-2, the novel coronavirus, has posed major challenges in Germany in 2020. It is unclear whether the pandemic and containment measures will have an impact on the health of the population beyond the point of infection. The German Health Update (GEDA 2019/2020-EHIS) is a nationwide survey of the population aged 15 years and older (n=23,001) that was conducted between April 2019 and September 2020. The focus of the analysis was on indicators for which pandemic-related changes could be expected. Based on regression models, adjusted proportions and mean values were estimated as trends over time. Any differences in the values found for the time period of containment measures in spring 2020 and the reference period 2019 were statistically tested. Since the implementation of containment measures, both body weight and body mass index (BMI) have increased. The utilisation of general and specialist medical services decreased temporarily. The number of tobacco smokers during the observation period also decreased, yet without revealing a clear link to the pandemic situation. No differences were found in the general population for depressive symptoms and household assistance received and provided. During the period of containment measures, changes to the health situation beyond the occurrence of infections can be observed. However, a more differentiated explanation of these findings will require further analyses.

Why should gender-sensitive health reports be intersectional?

Background

A key focus of both epidemiology and PHMR is the identification of health inequity between population groups and its determinants. However, scholars in the social sciences have criticised prevalent approaches of describing health differences according to single social categories like sex/gender or race/ethnicity, glossing over significant heterogeneity within and relations between presumed population groups. Applying these critiques to the field of PHMR, we would argue that intersectionality scholarship offers vital impulses for the study of health inequity by focusing on several, interrelated social categories and emphasising the structural determinants affecting unique population subgroups differently.

Methods

We mapped existing approaches to describing population differences in health. We also conducted a literature review on intersectionality scholarship in public health and then synthesised results to develop a conceptual framework for deploying intersectionality to epidemiology and PHMR.

Findings

We identified four key principles through which the reporting on subgroup differences could be strengthened: addressing the internal heterogeneity of population groups; contextualising inequities and focusing on societal power relations rather than individual characteristics; deploying novel multivariable modelling approaches in data analysis; and aiming towards the empowerment of population groups rather than deploying deficit-oriented and paternalistic models.

Discussion

To be discussed are the unique contributions of intersectionality to PHMR compared to other approaches, for example from social epidemiology or medical anthropology.

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.

Suggestions for a gender-sensitive and intersectional practice of health monitoring and reporting

Background

Health reports summarize the evidence basis on disease burden and its causes and are intended to inform decisions of policy makers. By focusing on health needs of social groupings according to sex/gender or race/ethnicity, PHMR crucially contributes to achieving health equity. In order to realise its aims, PHMR relies on the availability of high-quality data, appropriate analysis methods and intuitive presentation of results.

Methods

The joint project AdvanceGender used mixed methods to translate principles of intersectionality into new methods for recruitment, data analysis and health reporting. A review of descriptions of representativeness in epidemiological studies was conducted to investigate how an intersectional perspective can inform recruitment. To evaluate intersectional and gender-sensitive data analysis, we reviewed and applied recently developed methods such as classification and regression tree analysis (CART) and multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA).

Findings

An intersectional perspective on representativeness unravelled that study participation of women and men might be differential according to further social categories such as civil status or educational level. CART analysis might help to identify intersectional groupings differing in health behaviours or outcomes by exploring a multitude of social dimensions without facing the risk of stereotyping with predefined categories. MAIHDA depicts an alternative method that is suited for descriptive analyses of health-related outcomes among intersectional strata. In contrast to analysing supposedly static features such as sex, a focus on solution-linked variables like social support might be a fertile ground to identify areas for public health action.

Discussion

Principles of intersectionality open up new perspectives for recruitment and data analysis that might be fruitful for population health research and ultimately for PHMR.

 

Greta Bauer

Schulich School of Medicine & Dentistry, Western University, London, Canada

Contact: gbauer@uwo.ca

Olena Hankivsky

University of Melbourne, Centre for Health Equity, Melbourne, Australia Institute for Intersectionality Research, School of Public Policy, Simon Fraser University, Burnaby, Canada

Contact: o.hankivsky@unimelb.edu.au

Nicole Rosenkötter

NRW Centre for Health, Division of Health Reporting, Bielefeld, Germany

Contact: Nicole.Rosenkoetter@lzg.nrw.de

[Federal health reporting at the Robert Koch Institute-status quo and current developments]

Health reporting as an integral part of public health plays an important role in the development of strategies and concepts that aim to improve the health of all population groups. This article provides an overview of the definition and tasks of federal health reporting and describes important health reporting components in their current form. The publication format of the Journal of Health Monitoring, which was developed for different user groups of health monitoring, is presented. Examples of the uses and effects of health reporting are also presented. Health reporting is designed as a flexible system: changes in databases as well as forms of communication are taken into account in the further development of health reporting.The further development of health reporting requires close interdisciplinary cooperation between different actors in order to integrate current research results from various scientific disciplines into the processes of health reporting, as well as to further expand the scope and impact of health reporting. In addition, to further develop health reporting on a scientific level, the expansion of participatory elements and a stronger internationalization will be important future tasks.

Non-response in a national health survey in Germany: An intersectionality-informed multilevel analysis of individual heterogeneity and discriminatory accuracy

BACKGROUND

Dimensions of social location such as socioeconomic position or sex/gender are often associated with low response rates in epidemiological studies. We applied an intersectionality-informed approach to analyze non-response among population strata defined by combinations of multiple dimensions of social location and subjective health in a health survey in Germany.

METHODS

We used data from the cross-sectional sample of the German Health Interview and Examination Survey for Adults (DEGS1) conducted between 2008 and 2011. Information about non-responders was available from a mailed non-responder questionnaire. Intersectional strata were constructed by combining all categories of age, sex/gender, marital status, and level of education in scenario 1. Subjective health was additionally used to construct intersectional strata in scenario 2. We applied multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) to calculate measures of discriminatory accuracy, proportions of non-responders among intersectional strata, as well as stratum-specific total interaction effects (intersectional effects). Markov chain Monte Carlo methods were used to estimate multilevel logistic regression models.

RESULTS

Data was available for 6,534 individuals of whom 36% were non-responders. In scenario 2, we found weak discriminatory accuracy (variance partition coefficient = 3.6%) of intersectional strata, while predicted proportions of non-response ranged from 20.6% (95% credible interval (CI) 17.0%-24.9%) to 57.5% (95% CI 48.8%-66.5%) among intersectional strata. No evidence for intersectional effects was found. These results did not differ substantially between scenarios 1 and 2.

CONCLUSIONS

MAIHDA revealed that proportions of non-response varied widely between intersectional strata. However, poor discriminatory accuracy of intersectional strata and no evidence for intersectional effects indicate that there is no justification to exclusively target specific intersectional strata in order to increase response, but that a combination of targeted and population-based measures might be appropriate to achieve more equal representation.

The health of lesbian, gay, bisexual, transgender and intersex people

Sex, gender and sexual orientation are diverse, as are the ways of living associated with them. The extent to which people can live a free and self-determined life according to their own body, gender, sexuality and way of life influences their social resources, opportunities for participation and discrimination and has an influence on their life situation and health. A narrative review of lesbian, gay, bisexual, transgender and intersex (LGBTI) health was conducted including international and German reviews, meta-analyses and population-based studies. The focus of this article is the legal, social and medical recognition as well as health status of LGBTI people in Germany. While the legal framework in Germany for homosexual and bisexual people has gradually improved, many civil society stakeholders have pointed to major deficits in the medical and legal recognition of transgender and intersex people. In addition, scientific findings frequently have not yet found its way into medical practice to an adequate extent. Available data on LGBTI health indicate a need for action in the areas of mental health and health care provision. However, due to a lack of comprehensive data, conclusions cannot be drawn on the general health situation and health resources of LGBTI people. For the concrete planning and implementation of measures as well as the differentiated portrayal of the situation in Germany, the databases must be expanded, not least via population-representative surveys.

Civil society stakeholders' participation in national health reporting on sex/gender issues: a study protocol for an intersectionality-informed and sex/gender-sensitive approach to focus group research

INTRODUCTION

Health reporting is one of the foundations on which public health interventions and policies as well as prevention measures are developed. However, it faces the challenge of adequately reflecting social and sex/gender-related heterogeneity. The German Federal Ministry of Education and Research-funded joint project, AdvanceGender, aims to develop guidelines for sex/gender-sensitive and intersectional approach to population-based studies and health reporting. In its subproject, AdvanceHealthReport, four focus groups will be conducted to provide essential information on possible ways of participation of civil society stakeholders and on communication of health information for the further development of the guidelines (research period: from January 2019 to March 2020).

METHODS AND ANALYSIS

The civil society stakeholders provide valuable information which health topics are relevant in regard to specific populations and how health information should be communicated in a non-stigmatising way. The groups will also discuss how civil society stakeholders should participate in health reporting. The starting point for intersections will be sex/gender. The intersection of sex/gender and migration and sex/gender and sexual orientation is particularly taken into account. The focus groups will be recorded, transcribed, anonymised and then analysed according to the qualitative content analysis.

RESULTS

The results will show the pathways as well as benefits and possible limitations of civil society stakeholder involvement in national health reporting and will contribute in developing guidelines for sex/gender-sensitive and intersectional health reporting.

ETHICS AND DISSEMINATION

The results of the focus groups will be published in scientific journals and presented at various national and international conferences. Furthermore, the findings will be incorporated into guidelines for research and health reporting. The study was approved by the Ethics Commission of Brandenburg Medical School Theodor Fontane (AZ: E-01-20180529).

Frequent attenders in the German healthcare system: determinants of high utilization of primary care services. Results from the cross-sectional German health interview and examination survey for adults (DEGS)

BACKGROUND

In Germany, patients are consulting general practitioners increasingly frequently, resulting in a high burden on the healthcare system. This study aimed to identify factors associated with frequent primary care attendance in the German healthcare system.

METHODS

The German Health Interview and Examination Survey for Adults (DEGS) is part of Germany's national health monitoring, and includes a large representative sample of the German population aged 18-79 years. We defined the 10% of participants with the highest number of general practitioner contacts in the preceding 12 months as frequent attenders of primary care services. Binary logistic regression models with average marginal effects were used to identify potential determinants for frequent use of primary care services.

RESULTS

The sample comprised 7956 participants. Significant effects on frequent use of primary care were observed for low socioeconomic status, stressful life events, factors related to medical need for care such as medically diagnosed chronic conditions and for subjective health. In the full model, the number of non-communicable diseases and subjective health status had the strongest effect on frequent primary care use. We found an interaction effect suggesting that the association between subjective health status and frequent attendance vanishes with a higher number of non-communicable diseases.

CONCLUSIONS

We observed strong associations between frequent primary care attendance and medical need for care as well as subjective health-related factors. These findings suggest that better coordination of care may be a preferred method to manage health services utilization and to avoid redundant examinations and uncoordinated clinical pathways. Further research is needed to clarify moderating and mediating factors contributing to high utilization of primary care services.

[Utilization of outpatient medical services and satisfaction with care in children and adolescents with a migration background-results of the KiGGS study]

BACKGROUND AND AIM

Reasons for lower use of medical services by children and adolescents with migration background have not yet been investigated. The aim is therefore to identify factors that are related to the utilization of outpatient medical care and subjective patient satisfaction as well as explain differences according to migration background.

METHODS

On the basis of the "German Health Interview and Examination Survey for Children and Adolescents" (KiGGS, baseline study: 2003-2006), in which 17,640 children and adolescents participated, prevalences with 95% confidence intervals as well as multivariate binary logistic regression analyzes on the relationship between migration background, country of origin, the use of outpatient medical care services in the last 12 months, and satisfaction with the last medical treatment were calculated.

RESULTS

Children up to age 13 with two-sided migration background had lower utilization of specialist doctors compared to those without migration background (OR = 0.64 [0.56-0.74]). However, among the 14- to 17-year-olds, the utilization did not differ significantly (OR = 0.79 [0.60-1.03]). The lower use of outpatient medical care is associated with a shorter length of stay and limited German language skills. In addition, parents from Poland and the former Soviet Union are less likely to be very satisfied with the last outpatient treatment of their 0‑ to 13-year-old child, even after adjustments for German language skills and length of stay.

CONCLUSION

To make it easier for children with migration background to access specialist services, it is important to reduce language barriers in outpatient medical care and to promote processes of intercultural opening.

[Prevalence and incidence of documented diabetes based on health claims data-reference analysis for diabetes surveillance in Germany]

BACKGROUND

The prevalence and incidence of documented diabetes are two essential indicators intended to be reported on a periodic basis within the framework of diabetes surveillance in Germany.

METHODOLOGY

Data provided based on the Data Transparency Act were analyzed. The data contain information on outpatient and inpatient care for all approximately 70 million persons with statutory health insurance. The case definition for the prevalence of documented diabetes comprises a confirmed outpatient diagnosis in at least two quarters of a year or an inpatient diagnosis in at least one quarter of a year in accordance with ICD-10 codes E10.- to E14.-. The incidence was calculated based on the same definition and with one year of diagnosis-free lead time.

RESULTS

In 2011, a prevalence of 9.7% (women: 9.4%, men: 10.1%) was observed for persons with statutory health insurance. There are considerable differences in prevalence between the federal states and the maximum gap is 7.1 percentage points (age standardized: 4.0 percentage points). Type 2 and type 1 diabetes show a documented prevalence of 7.5% and 0.28%, respectively. Unspecified diabetes is documented relatively frequently with 1.9%. In 0.21% of persons, the diagnosis diabetes is documented via one inpatient secondary diagnosis. In addition, 0.17% of people without documented diabetes have at least one prescription of an antidiabetic drug. In 2012, 565,040 insured persons were newly diagnosed with diabetes; this corresponds to 1.0% of the insured persons (women: 1.0%, men: 1.1%).

DISCUSSION

The developed reference analysis is suitable for reporting the prevalence and incidence of documented diabetes within the framework of diabetes surveillance. The differentiation of diabetes types is difficult due to coding practice.

[ICD coding of causes of death: challenges for calculating the burden of disease in Germany]

In the project BURDEN 2020 - "The burden of disease in Germany and its regions" - the years of life lost (YLL) due to premature mortality are calculated on the basis of official cause-of-death statistics. This requires the identification and redistribution of the so-called ill-defined ICD codes. "Ill-defined" means that an ICD code does not sufficiently reflect the cause of death, such that it is not informative for the calculation of the burden of disease.The first steps on the way to calculating cause-specific YLL are presented. Different frameworks of ill-defined codes are compared. The number of deaths with ill-defined codes that can be found in the German cause-of-death statistics in absolute and relative terms are analyzed, including how they are distributed by age, sex, and region.According to the WHO framework, 15.6% of the 925,200 deaths in Germany in 2015 can be identified as ill-defined. According to the framework of the Institute for Health Metrics and Evaluation (IHME) in the Global Burden of Disease Study (GBD), the proportion of ill-defined codes is 26.6%. The ICD-related distribution patterns hardly differ between WHO and IHME classifications. Considerable differences exist between the federal states, with shares of ill-defined codes between 16 and 35% (IHME framework).The cause-of-death statistics in Germany contain a considerable proportion of ill-defined codes. The differences between the federal states can only partially be explained by different electronic data processing. Due to further dissemination and improvement of electronic data collection, higher quality of cause-of-death statistics can be expected in the future.

Determinants of frequent use of primary care in the German healthcare system

Background

In Germany, patients are consulting general practitioners increasingly frequently, resulting in a high burden on the healthcare system. This study aimed to identify factors associated with frequent primary care attendance in the German healthcare system.

Methods

The German Health Interview and Examination Survey for Adults (DEGS) is part of Germany’s national health monitoring, and includes a large representative sample of the German population aged 18-79 years. We defined the 10% of participants with the highest number of physician contacts in the preceding 12 months as frequent attenders. Binary logistic regression models with average marginal effects were used to identify determinants for the frequent use of primary care services.

Results

The sample comprised 7,956 participants. Significant effects on frequent use of primary care were observed for low socioeconomic status, stressful life events, and factors related to objective need for medical care and subjective health status. In the full model, the number of non-communicable diseases and subjective health status had the strongest effect on frequent primary care use. We found an interaction effect between subjective health status and number of non-communicable diseases, indicating the association of disease with frequent use was highly moderated by subjective perception of health.

Conclusions

We observed strong associations between frequent primary care attendance and objective and subjective health-related factors. These findings suggest that better coordination of care may be a preferred method to manage health services utilization behaviour and avoid redundant examinations and uncoordinated clinical pathways. Further research is needed to clarify moderating and mediating factors contributing to high utilization of primary care services.

Key messages

The number of NCDs diseases and subjective health had the strongest effect on frequent primary care use. The findings suggest that better coordination of care may be the preferred method to manage health services utilization.

Health of adolescents with migration background in Germany: cross-sectional results from KiGGS wave 2

Background

Although 36.5% of minors in Germany had a migration background (MB) in 2017, data on their health situation is scarce. The project ‘Improving Health Monitoring in Migrant Populations’ (IMIRA) initiated in 2016 aims to expand health reporting on the health situation of people with MB, for which a core indicator set was developed. We are describing the health situation of adolescents based on selected core indicators.

Methods

Data from the German Health Interview and Examination Survey for Children and Adolescents (KiGGS wave 2) (2014-2017) are used; adolescents from 11 to 17 years are considered. Prevalences and 95% confidence intervals are calculated for the following indicators: General health status, overweight, hazardous alcohol consumption and use of pediatric or general practitioner’s services. These indicators are stratified along socio-demographic (gender, age, socio-economic status (SES)) and migration-related characteristics (MB, parents’ duration of stay, language spoken at home).

Results

There are hardly any migration-related differences in the general health status and the use of general medical services. While adolescents with MB are more often affected by overweight (without MB: 11.2%, one-sided: 18.9%, both-sided: 19.8%), they show less often risky alcohol consumption (without MB: 14.5%, one-sided: 7.8%, both-sided: 4.4%). There are differences in health behavior according to SES, parents’ duration of stay in Germany and language spoken at home.

Conclusions

Overall, the health of adolescents is good, regardless of their MB, and general medical services are used equally. Differences in health behavior cannot be reduced solely to the (non-)existence of a MB, but need a deeper consideration of more specific migration-related characteristics and the SES.

Key messages

The general health status and health care utilization do not differ between adolescents with and without MB. In contrast, the results on indicators of health behavior vary.

The health of children and adolescents with a migration background in Germany - Results of the cross-sectional KiGGS Wave 2 study

Over a third (36.5%) of young people living in Germany have a migration background. Based on the data of the second follow-up to the German Health Interview and Examination Survey for Children and Adolescents (KiGGS Wave 2, 2014-2017), the health situation of 11- to 17-year-olds with and without a migration background is described using selected indicators. In order to account for the diversity among children and adolescents with a migration background, the health indicators used in this study are stratified by migration background but also by additional migration-related characteristics. In addition, the results from the various subgroups are also stratified by sociodemographic characteristics. No differences in self-assessed general health or the outpatient utilisation of paediatric and general medical services were identified between 11- to 17-year-olds with and without a migration background. However, migration-related differences were identified in health behaviour: whereas children and adolescents with a one- or two-sided migration background are more frequently overweight (including obesity), they consume risky amounts of alcohol less often than those of the same age without a migration background. Finally, the outcomes of the indicators also vary according to migration-related and sociodemographic characteristics.

Health reporting on people with a migration background - Selection and definition of (core) indicators

As part of the project Improving Health Monitoring in Migrant Populations (IMIRA), a (core) set of indicators was developed to describe the health of people with a migration background. This work was underpinned by research into and assessment of relevant data sources in the field of migration and health. Initially, four fields of action were identified together with a number of associated topics and potential indicators for each of the area's individual topics. The choice of core indicators was based on (1) a systematic comparison of widely accepted indicator systems, (2) an assessment of public health relevance, (3) comprehensibility and (4) informative value, as well as (5) the availability of (largely) representative data that could properly account for the diversity of the migrant population. The (core) indicator set was finalised using an internal and external indicator development process that involved an interdisciplinary expert panel. This resulted in the selection of 25 core indicators; 41 additional indicators were documented as part of an 'extended' indicator set. The (core) set of indicators is to be continually developed in line with the work being undertaken to improve the integration of people with a migration background in the health monitoring conducted at the Robert Koch Institute. In the future, the indicator set is to be incorporated into an overall concept to regular, migration-related health reporting.

Secondary data in diabetes surveillance - co-operation projects and definition of references on the documented prevalence of diabetes

In addition to the Robert Koch Institute's health surveys, analyses of secondary data are essential to successfully developing a regular and comprehensive description of the progression of diabetes as part of the Robert Koch Institute's diabetes surveillance. Mainly, this is due to the large sample size and the fact that secondary data are routinely collected, which allows for highly stratified analyses in short time intervals. The fragmented availability of data means that various sources of secondary data are required in order to provide data for the indicators in the four fields of action for diabetes surveillance. Thus, a milestone in the project was to check the suitability of different data sources for their usability and to carry out analyses. Against this backdrop, co-operation projects were specifically funded in the context of diabetes surveillance. This article presents the results that were achieved in co-operation projects between 2016 and 2018 that focused on a range of topics: from evaluating the usability of secondary data to statistically modelling the development of epidemiological indices. Moreover, based on the data of the around 70 million people covered by statutory health insurance, an initial estimate was calculated for the documented prevalence of type 2 diabetes for the years 2010 and 2011. To comparably integrate these prevalences over the years in diabetes surveillance, a reference definition was established with external expertise.

Improving the information base regarding the health of people with a migration background.Project description and initial findings from IMIRA

Germany is an immigration country and nearly a quarter of its population has a migration background. Thus, there is increasingly a need for reliable information on the health situation of people with a migration background. The Robert Koch Institute is in charge of expanding its health monitoring to improve the representation of people with a migration background in interview and examination surveys. Studies adequately need to reflect the health status of people with a migration background and currently the Robert Koch Institute’s representative interview and examination surveys for adults do not fully achieve this. At the end of 2016, therefore, the Improving Health Monitoring in Migrant Populations (IMIRA) project was initiated aiming to expand the Robert Koch Institute’s health monitoring to people with migration background and improve their involvement in health surveys in the long-term. This includes carrying out two feasibility studies to test strategies to reach and recruit people with migration background for interview surveys and develop measures to overcome language barriers in examination surveys. In order to expand health reporting on migration and health, a reporting concept and a core indicator set will be developed and the potential of (secondary) data sources will be tested. Furthermore, plans foresee the testing and further development of relevant specific migration sensitive survey instruments and indicators, as well as increasing networking with relevant stakeholders.

Social differences in the utilization of medical services by children and adolescents in Germany. Results of the cross-sectional KiGGS Wave 2 study

Data from the German Health Interview and Examination Survey for Children and Adolescents (KiGGS) enable conclusions about the utilization of outpatient and inpatient medical services by children and adolescents accounting the family's socioeconomic status (SES). Results from the second follow-up to the KiGGS survey (KiGGS Wave 2), which covers the years 2014 to 2017, clearly demonstrate that children and adolescents from families with a low SES visit specialists in general medicine, gynaecologists and psychiatrists, as well as child and adolescent psychiatrists, psychotherapists and psychologists more frequently. In contrast, children and adolescents from families with a high SES visit paediatric, dermatological, dental and orthodontic practices more often. No statistically significant differences between the status groups with regard to the utilization of outpatient medical services in hospitals were identified. However, children and adolescents from the low status group received inpatient hospital treatment more frequently and, on average, spent more nights in hospital. These results reflect status-specific differences both in disease prevalence and care, as well as in patterns related to the utilization of medical services.

Utilization of physical therapy, speech therapy and occupational therapy by children and adolescents in Germany.Results of the cross-sectional KiGGS Wave 2 study and trends

Allied health services such as physical therapy, speech therapy and occupational therapy contribute to the early treatment of health disorders in children and adolescents and promote a healthy development. This article describes the utilization of these allied health services by children and adolescents in Germany and analyses its association with demographic and social factors. The analyses are based on the second wave of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS Wave 2, 2014-2017) including 15,023 participants. Trends are calculated in comparison with the KiGGS baseline study (2003-2006). Within one year, 9.6% of children and adolescents in Germany use physical therapy, 6.1% speech therapy and 4.0% occupational therapy. Speech therapy and occupational therapy are used more frequently by boys than by girls. The utilization of speech therapy is highest among 3- to 6-year-olds with 15.0%. Occupational therapy (8.3%) is most frequently used by 7- to 10-year-olds and physical therapy (16.9%) by 14- to 17-year-olds. Social differences are evident mainly in the higher utilization of occupational therapy and speech therapy and a lower utilization of physical therapy by socially disadvantaged children and adolescents. Over the last ten years, the utilization of speech therapy and physical therapy in children and adolescents has increased significantly.