Communication patterns in families affected by parental cancer from the healthy parents' perspective-process evaluation of the complex intervention Family-SCOUT.

PURPOSE: Within families affected by parental cancer, open communication impacts the well-being of parents and their children; however, limited research exists on communication patterns in these families. This sub-study addresses this through the Family-SCOUT study, a multicenter, prospective, interventional, and non-randomized investigation with intervention (IG) and control group (CG). The purpose of this sub-study was to identify and compare the differences in communication patterns between the IG and CG as part of the process evaluation. The research question was addressed in both groups: What communication patterns do healthy parents perceive within their families? METHODS: Using a qualitative approach, the study involved interviewing healthy parents as surrogates for their families. The interviews were audio-recorded, transcribed, and coded using a template analysis. The resulting data were analyzed at the group level. RESULTS: Twenty-three interviews were conducted in the IG and 27 interviews in the CG. The analysis of themes centered on communication patterns as seen in the family structure. Both groups exhibited instances of open communication about fears and wishes as well as the use of child-friendly language when discussing cancer. Notable differences were observed: challenges in open communication with children were sorely reported in CG interviews, and "the illness is discussed when necessary" was sorely described in IG interviews. CONCLUSION: This study underscores the need to address and encourage open communication within families with parental cancer.

Health care utilization and excess costs after pelvic fractures among older people in Germany.

Our study demonstrates a strong increase in utilization of inpatient health care and clear excess costs in older people in the first year after pelvic fracture, the latter even after adjustment for several confounders. Excess costs were particularly high in the first few months and mainly attributable to inpatient treatment. INTRODUCTION: We aimed to estimate health care utilization and excess costs in patients aged minimum 60 years up to 1 year after pelvic fracture compared to a population without pelvic fracture. METHODS: In this retrospective population-based observational study, we used routine data from a large statutory health insurance (SHI) in Germany. Patients with a first pelvic fracture between 2008 and 2010 (n=5685, 82% female, mean age 80±9 years) were frequency matched with controls (n=193,159) by sex, age at index date, and index month. We estimated health care utilization and mean total direct costs (SHI perspective) with 95% confidence intervals (CIs) using BCA bootstrap procedures for 52 weeks before and after the index date. We calculated cost ratios (CRs) in 4-week intervals after the index date by fitting mixed two-part models including adjustment for possible confounders and repeated measurement. All analyses were further stratified for men/women, in-/outpatient-treated, and major/minor pelvic fractures. RESULTS: Health care utilization and mean costs in the year after the index date were higher for cases than for controls, with inpatient treatment being particularly pronounced. CRs (95% CIs) decreased from 10.7 (10.2-11.1) within the first 4 weeks to 1.3 (1.2-1.4) within week 49-52. Excess costs were higher for inpatient than for outpatient-treated persons (CRs of 13.4 (12.9-13.9) and 2.3 (2.0-2.6) in week 1-4). In the first few months, high excess costs were detected for both persons with major and minor pelvic fracture. CONCLUSION: Pelvic fractures come along with high excess costs and should be considered when planning and allocating health care resources.

Time spent on self-management by people with diabetes: results from the population-based KORA survey in Germany.

AIMS: Time needed for health-related activities in people with diabetes is assumed to be substantial, yet available data are limited. Time spent on self-management and associated factors was analysed using cross-sectional data from people with diagnosed diabetes enrolled in a population-based study. METHODS: Mean total time spent on self-management activities was estimated using a questionnaire for all participants with diagnosed diabetes in the KORA FF4 study (n = 227, 57% men, mean age 69.7, sd 9.9 years). Multiple two-part regression models were fitted to evaluate associated factors. Multiple imputation was performed to adjust for bias due to missing values. RESULTS: Some 86% of participants reported spending time on self-management activities during the past week. Over the entire sample, a mean of 149 (sd 241) min/week were spent on self-management-activities. People with insulin or oral anti-hyperglycaemic drug treatment, better diabetes education, HbA1c 48 to < 58 mmol/mol (6.5% to < 7.5%) or lower quality of life, spent more time on self-management activities. For example, people without anti-hyperglycaemic medication invested 66 min/week in self-management, whereas those taking insulin and oral anti-hyperglycaemic drugs invested 269 min/week (adjusted ratio 4.34, 95% confidence interval 1.85-10.18). CONCLUSIONS: Time spent on self-management activities by people with diabetes was substantial and varied with an individual's characteristics. Because of the small sample size and missing values, the results should be interpreted in an explorative manner. Nevertheless, time needed for self-management activities should be routinely considered because it may affect diabetes self-care and quality of life.

The association of self-reported diabetes with impaired social functioning in low-, middle- and high-income countries: findings from the World Health Survey.

AIM: Epidemiological studies from high-income countries show that diabetes is associated with impaired social functioning. As healthcare systems in middle- and low-income countries offer fewer resources to curtail the potential social impact of diabetes, we performed a comparative study on the diabetes-social impairment link in low-, middle- and high-income countries. METHODS: We use data from the cross-sectional World Health Survey (n = 235 428 from 10 low-income, 29 middle-income and 9 high-income countries). Diabetes was defined by self-reports of a diagnosis. Impaired social functioning was considered present if participants reported severe or extreme difficulties with personal relationships or participation in the community. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) in the overall sample and by income regions. ORs were corrected for demographics and health-related lifestyles, and then additionally adjusted for impairments that may explain any observed association (i.e. impaired vision, mood, cognition and mobility). RESULTS: In the overall sample, we confirmed an association between self-reported diabetes and impaired social functioning (OR = 1.47, 95% CI = 1.18-1.83). The strength of that relationship increased with decreasing country income (e.g. OR in low-income countries = 2.23, 95% CI = 1.14-4.37). Associations were substantially attenuated by further correction for impairments, in particular mood problems, in the overall sample (OR = 0.92, 95% CI = 0.72-1.16) and all income regions. CONCLUSIONS: Self-reported diabetes is associated with impaired social functioning in high- and middle-income countries, and this relationship is even stronger in low-income countries. Associations are largely explained by physical and mental impairments, which may be due to diabetes.

Healthcare costs of Type 2 diabetes in Germany.

AIM: To describe for the first time the direct costs of Type 2 diabetes treatment by analysing nationwide routine data from statutory health insurance in Germany. METHODS: This cost-of-illness-study was based on a 6.8% random sample of all German people with statutory health insurance (4.3 out of 70 million people). The healthcare expenses show direct per capita costs from the payer perspective. Healthcare expenses for physicians, dentists, pharmacies, hospitals, sick benefits and other healthcare costs were considered. Per capita costs, cost ratios for people with Type 2 diabetes and without diabetes as well as diabetes-attributable costs were calculated. RESULTS: Per capita costs for people with Type 2 diabetes amounted to €4,957 in 2009 and €5,146 in 2010. People with Type 2 diabetes had 1.7-fold higher health expenses than people without diabetes. The largest differences in health expenses were found for prescribed medication from pharmacies (cost ratio diabetes/no diabetes: 2.2) and inpatient treatment (1.8). Ten percent of the total statutory health insurance expense, in total €16.1 billion, was attributable to the medical care of people with Type 2 diabetes. CONCLUSIONS: This nationwide study indicates that one in 10 Euros of healthcare expenses is spent on people with Type 2 diabetes in Germany. In the future, national statutory health insurance data can be used to quantify time trends of costs in the healthcare system.

[Prevention of Type 2 Diabetes: Evidence-Based Patient Information--A Randomised Controlled Trial]. / Effekt einer evidenzbasierten Patienteninformation zur Prävention von Typ 2-Diabetes.

The aim of this study was to compare the effect of our newly developed online evidence-based patient information (EBPI) vs. standard patient information about subthreshold elevated blood glucose levels and primary prevention of diabetes on informed patient decision-making. EBPI significantly improved knowledge about elevated glucose levels, but also increased decisional conflict and critical attitudes to screening and treatment options. The intention to undergo metabolic screening decreased as a result.

Effectiveness of a comprehensive support program for families with parental cancer (Family-SCOUT): results of a multicenter non-randomized controlled trial.

BACKGROUND: Cancer patients with minor children but also their families suffer from significant psychological distress and comorbidity. Protective factors predicting successful coping are well known. Corresponding systematic interventions are rare and limited by access barriers. We developed a comprehensive family-centered intervention for cancer patients with at least one dependent minor. PATIENTS AND METHODS: Family-SCOUT represents a multicentric, prospective, interventional, and controlled study for families with parental cancer and their minor children. In the intervention group (IG), all family members were addressed using a care and case management approach for nine months. Families in the control group (CG) received standard of care. Participating parents were asked to complete the Hospital-Anxiety-Depression-Scale (HADS) questionnaire at enrolment (T0) and after 9 months (T2). The primary outcome was a clinically relevant reduction of distress in at least one parent per family, measured as minimal important difference (MID) of ≥1.6 in the HADS total score. The percentage of families achieving MID is compared between the IG and CG by exact Fisher's test, followed by multivariate confounder analyses. RESULTS: T0-questionnaire of at least one parent was available for 424 of 472 participating families, T2-questionnaire after 9 months was available for 331 families (IG n = 175, CG n = 156). At baseline, both parents showed high levels of distress (HADS total: sick parents IG: 18.7 ± 8.1; CG: 16.0 ± 7.2; healthy partners: IG: 19.1 ± 7.9; CG: 15.2 ± 7.7). The intervention was associated with a significant reduction in parental distress in the IG (MID 70.4% in at least one parent) compared with the CG (MID 55.8%; P = 0.008). Adjustment for group differences from specific confounders retained significance (P = 0.047). Bias from other confounders cannot be excluded. CONCLUSIONS: Parental cancer leads to a high psychosocial burden in affected families. Significant distress reduction can be achieved through an optimized and structured care approach directed at the family level such as family-SCOUT.

Projection of the burden of type 2 diabetes mellitus in Germany: a demographic modelling approach to estimate the direct medical excess costs from 2010 to 2040.

AIM: To model the future costs of Type 2 diabetes in Germany, taking into account demographic changes, disease dynamics and undiagnosed cases. METHODS: Using a time-discrete Markov model, the prevalence of diabetes (diagnosed/undiagnosed) between 2010 and 2040 was estimated and linked with cost weights. Demographic, epidemiological and economic scenarios were modelled. Inputs to the model included the official population forecasts, prevalence, incidence and mortality rates, proportions of undiagnosed cases, health expenditure and cost ratios of an individual with (diagnosed/undiagnosed) diabetes to an individual without diabetes. The outcomes were the case numbers and associated annual direct medical excess costs of Type 2 diabetes from a societal perspective in 2010€. RESULTS: In the base case, the case numbers of diabetes will grow from 5 million (2.8 million diagnosed) in 2010 to a maximum of 7.9 million (4.6 million diagnosed) in 2037. From 2010 to 2040, the prevalence rate amonf individuals ≥40 years old will increase from 10.5 to 16.3%. The annual costs of diabetes will increase by 79% from €11.8 billion in 2010 to €21.1 billion in 2040 (€9.5 billion to €17.6 billion for diagnosed cases). CONCLUSIONS: The projected increase in costs will be attributable to demographic changes and disease dynamics, and will be enhanced by higher per capita costs with advancing age. Better epidemiological and economic data regarding diabetes care in Germany would improve the forecasting accuracy. The method used in the present study can anticipate the effects of alternative policy scenarios and can easily be adapted to other chronic diseases.

Diabetes incidence does not differ between subjects with and without high depressive symptoms--5-year follow-up results of the Heinz Nixdorf Recall Study.

AIMS: Cross-sectional studies have consistently reported evidence for an association between diabetes and depressive disorders. However, only limited prospective studies have examined this association, reporting conflicting results. In a population-based cohort study, we compared cumulative incidences of diabetes between participants with and without high depressive symptoms. METHOD: We analysed the 5-year follow-up data from the German Heinz Nixdorf Recall study of 3547 participants without diabetes at baseline [mean age 58.8 (sd 7.6) years, 47.5% male]. Depressive symptoms were defined using the Centre for Epidemiologic Studies Depression scale (cut point ≥ 17). Diabetes (diagnosed or previously undetected) was identified by self-reported physician-diagnosed diabetes, medication and high blood glucose levels. We estimated 5-year cumulative incidences with 95% confidence intervals and fitted multiple logistic regression models to calculate the odds ratios, adjusted for age, sex, physical activity, smoking, living with or without partner, and educational level. RESULTS: The cumulative incidence of diabetes was 9.2% (95% CI 6.3-12.8) in participants with high depressive symptoms at baseline and 9.0% (95% CI 8.0-10.0) in participants without these symptoms. The age- and sex-adjusted odds ratio of diabetes in participants with depressive symptoms compared with those without was 1.13 [95% CI 0.77-1.68; fully adjusted 1.11 (95% CI 0.74-1.65)]. These results did not substantially change in several additional sensitivity analyses. CONCLUSION: Our study did not show a significantly increased risk of developing diabetes in individuals with high depressive symptoms compared with those without high depressive symptoms during a 5-year follow-up period.

Patient time costs attributable to healthcare use in diabetes: results from the population-based KORA survey in Germany.

AIMS: Patient time costs have been described to be substantial; however, data are highly limited. We estimated patient time costs attributable to outpatient and inpatient care in study participants with diagnosed diabetes, previously undetected diabetes, impaired glucose regulation and normal glucose tolerance. METHODS: Using data of the population-based KORA S4 study (55-74 years, random sample of n = 350), we identified participants' stage of glucose tolerance by oral glucose tolerance test. To estimate mean patient time costs per year (crude and standardized with respect to age and sex), we used data regarding time spent with ambulatory visits including travel and waiting time and with hospital stays (time valued at a 2011 net wage rate of €20.63/h). The observation period was 24 weeks and data were extrapolated to 1 year. RESULTS: Eighty-nine to 97% of participants in the four groups (diagnosed diabetes, undetected diabetes, impaired glucose regulation and normal glucose tolerance.) had at least one physician contact and 4-14% at least one hospital admission during the observation period. Patient time [h/year (95% CI)] was 102.0 (33.7-254.8), 53.8 (15.0-236.7), 59.3 (25.1-146.8) and 28.6 (21.1-43.7), respectively. Age-sex standardized patient time costs per year (95% CI) were €2447.1 (804.5-6143.6), €880.4 (259.1-3606.7), €1151.6 (454.6-2957.6) and €589.2 (435.8-904.8). CONCLUSIONS: Patient time costs were substantial--even higher than medication costs in the same study population. They are higher in participants with diagnosed diabetes, but also in those with undetected diabetes and impaired glucose regulation compared with those with normal glucose tolerance. Research is needed in larger populations to receive more precise and certain estimates that can be used in health economic evaluation.

Association of lay beliefs about causes of depression with social distance.

OBJECTIVE: The aim of this study was to examine the association of lay attributions about causes of depression with attitudes and prejudiced behaviour towards people with depression. METHOD: Subjects (1631 German-speakers aged 18 and over, randomly selected) were interviewed in two German cities by telephone using a standardized questionnaire. The survey assessed knowledge about depression, stereotypical attitudes and social distance towards persons with depression. RESULTS: The results indicate that a majority of the respondents holds predominantly non-pejorative attitudes towards persons with depression. The majority estimated psychosocial causes as being most important for the genesis of depression. Stronger social distance was linked to an estimation of personal causes as relevant. Subgroup differences were apparent with respect to age, sex and reported contact to people with depression. CONCLUSION: Improvements in the education of the public about depression should be based on a multifactorial model. Future interventions should promote contact with people with depression and place special emphasis on conveying information in a suitable manner depending on the needs of different target groups.

Blood glucose testing and primary prevention of Type 2 diabetes-evaluation of the effect of evidence-based patient information: a randomized controlled trial.

AIMS: To compare the effect of our newly developed online evidence-based patient information vs. standard patient information about sub-threshold elevated blood glucose levels and primary prevention of diabetes on informed patient decision making. METHODS: We invited visitors to the cooperating health insurance company, Techniker Krankenkasse, and the German Diabetes Center websites to take part in a web-based randomized controlled trial. The population after randomization comprised 1120 individuals aged between 40 and 70 years without known diabetes, of whom 558 individuals were randomly assigned to the intervention group receiving evidence-based patient information, and 562 individuals were randomly assigned to the control group receiving standard information from the Internet. The primary endpoint was acquired knowledge of elevated blood glucose level issues and the secondary outcomes were attitude to metabolic testing, intention to undergo metabolic testing, decisional conflict and satisfaction with the information. RESULTS: Overall, knowledge of elevated glucose level issues and the intention to undergo metabolic testing were high in both groups. Participants who had received evidence-based patient information, however, had significantly higher knowledge scores. The secondary outcomes in the evidence-based patient information subgroup that completed the 2-week follow-up period yielded significantly lower intention to undergo metabolic testing, significantly more critical attitude towards metabolic testing and significantly higher decisional conflict than the control subgroup (n=466). Satisfaction with the information was not significantly different between both groups. CONCLUSIONS: Evidence-based patient information significantly increased knowledge about elevated glucose levels, but also increased decisional conflict and critical attitude to screening and treatment options. The intention to undergo metabolic screening decreased. Future studies are warranted to assess uptake of metabolic testing and satisfaction with this decision in a broader population of patients with unknown diabetes.

Costs of paediatric diabetes care in Germany: current situation and comparison with the year 2000.

AIMS: To estimate direct costs of paediatric Type 1 diabetes care and associated factors in Germany for the year 2007 and to compare results with the costs for the year 2000. METHODS: Our study includes clinical data and charges for any diabetes-related health care service of 14,185 continually treated subjects with paediatric diabetes aged < 20 years [52.5% male, mean age (SD) 12.1 (4.2) years], derived from a nationwide prospective patient documentation system (DPV). Health-care utilization was valued in monetary terms by using inpatient and outpatient medical fees and retail prices (perspective of the statutory health insurance). Associations between average total diabetes-related costs or various single cost categories per patient and age, sex, migration background, diabetes duration, and metabolic control were analysed by multiple regression procedures and by a two-part model for hospitalization costs. Total direct costs in the whole paediatric diabetes population in Germany were estimated. Mean costs per patient as well as total costs in the German paediatric diabetes population in 2007 were compared to 2000 costs (inflated to the year 2007). RESULTS: Mean direct diabetes-associated costs per subject were €3524 (inter-quartile range: 1831-4743). Main cost categories were hospitalization (32%), glucose self-monitoring (29%), insulin pump therapy (18%), and insulin (15%). Based on the present estimation, the total costs of paediatric diabetes care in Germany exceeded €110 million in 2007. Compared with estimates of the year 2000, average costs per patient had increased by 20% and total costs for German paediatric diabetes care by 47%. CONCLUSIONS: Direct costs for paediatric Type 1 diabetes care increased between 2000 and 2007, probably partly because of new therapeutic strategies and an increase in diabetes prevalence.

Regional differences in the prevalence of known Type 2 diabetes mellitus in 45-74 years old individuals: results from six population-based studies in Germany (DIAB-CORE Consortium).

AIM: In Germany, regional data on the prevalence of Type 2 diabetes mellitus are lacking for health-care planning and detection of risk factors associated with this disease. We analysed regional variations in the prevalence of Type 2 diabetes and treatment with antidiabetic agents. METHODS: Data of subjects aged 45-74 years from five regional population-based studies and one nationwide study conducted between 1997 and 2006 were analysed. Information on self-reported diabetes, treatment, and diagnosis of diabetes were compared. Type 2 diabetes prevalence estimates (95% confidence interval) from regional studies were directly standardized to the German population (31 December 2007). RESULTS: Of the 11,688 participants of the regional studies, 1008 had known Type 2 diabetes, corresponding to a prevalence of 8.6% (8.1-9.1%). For the nationwide study, a prevalence of 8.2% (7.3-9.2%) was estimated. Prevalence was higher in men (9.7%; 8.9-10.4%) than in women (7.6%; 6.9-8.3%). The regional standardized prevalence was highest in the east with 12.0% (10.3-13.7%) and lowest in the south with 5.8% (4.9-6.7%). Among persons with Type 2 diabetes, treatment with oral antidiabetic agents was more frequently reported in the south (56.9%) and less in the northeast (46.0%), whereas treatment with insulin alone was more frequently reported in the northeast (21.6%) than in the south (16.4%). CONCLUSION: The prevalence of known Type 2 diabetes showed a southwest-to-northeast gradient within Germany, which is in accord with regional differences in the distribution of risk factors for Type 2 diabetes. Furthermore, the treatment with antidiabetic agents showed regional differences.

[Structural differences between health insurance funds and their impact on health services research: results from the Bertelsmann Health-Care Monitor]. / Unterschiede in der Versichertenstruktur von Krankenkassen und deren Auswirkungen für die Versorgungsforschung: Ergebnisse des Bertelsmann-Gesundheitsmonitors.

AIM: Claims data of health insurance companies are an important database for health services research. We investigated if there are differences in baseline characteristics and prevalence of chronic diseases between members of several health insurance funds in Germany, and if so, whether adjusting for age and sex could explain these differences. METHODS: 10 representative surveys (conducted between 2004 and 2008) of the 'Bertelsmann Health-Care Monitor' comprising 15 089 participants aged 18 to 79 years were analysed. Our main independent variable was membership in one of 8 health insurance funds. The prevalence of self-reported hypertension, diabetes, atopic diseases, coronary heart disease and heart failure was studied. We first estimated the crude prevalence of chronic diseases stratified by these funds. We further fitted logistic regression models and adjusted for age and sex as well as for further comorbidities and health related factors. RESULTS: Most respondents were insured in the BKK (Betriebskrankenkassen; 20.1%), the AOK (Allgemeinen Ortskrankenkassen; 19.2%) and private health insurances (15.3%). Substantial differences were found according to age, sex, educational level and prevalences of chronic diseases. Stratified by health insurance funds, prevalences ranged between 17.1-29.6% for hypertension, between 3.9-11.4% for diabetes, between 4.3-6.7% for atopic diseases, between 3.4-6.7% for coronary heart disease and between 2.6-5.7% for heart failure. When adjusting for sex and age, estimates for all 5 diseases were significant higher in AOK members compared to privately insured persons (3 diseases within the BAMER and the DAK, accordingly). In total, this was the case for 17 out of 35 comparisons. Even after adjusting for further comorbidities and health related factors 6 out of 35 comparisons showed significant increased estimates compared to privately insured persons. CONCLUSION: We found considerable differences in the prevalence of chronic diseases between German health insurance funds that remained after controlling for age and sex, and even after adjustment for further health-related variables. Further methodological studies are urgently needed to assess strengths and weaknesses of German claim data.

Development of a shared decision-making intervention to improve drug safety and to reduce polypharmacy in frail elderly patients living at home.

Objectives: For patients with geriatric frailty, reducing inappropriate medication is an important goal to improve patient safety in primary care. GP-side barriers include knowledge gaps, legal concerns, and lack of communication between the actors involved. The aim was to develop a multi-faceted intervention to facilitate deprescribing and shared prioritisation among frail elderlies with polypharmacy living at home. Methods: Mixed methods study including: 1) scoping review on family conferences, expert panels; 2) group discussions with GPs, mapping of needs and challenges in Primary Care; 3) workshops and expert interviews with GPs, patient advocates, researchers as a basis for a theoretical intervention model; 4) piloting. Results: A major challenge for GPs is to conduct a productive discussion with patients and family cares on deprescribing and drug safety. A guideline for a structured family conference with a medication check and geriatric assessment was developed and proved to be feasible in the pilot study. Conclusion: The intervention developed to facilitate deprescribing and shared prioritisation of drug therapy based on family conferences seems suitable to be tested in a subsequent cRCT. Innovation: Adapting family conferences to primary care for frail patients with polypharmacy.

Diabetes prevalence based on health insurance claims: large differences between companies.

AIMS: We investigated if there are substantial differences in the prevalence of diabetes between members of different health insurance funds in Germany and, if so, which variables might explain these differences. METHODS: Ten representative surveys (conducted between 2004 and 2008) of the Bertelsmann Healthcare Monitor, comprising 15 089 participants aged 18-79 years, were analysed. Our main independent variable was membership in one of eight health insurance funds. We first estimated the crude prevalence of diabetes stratified by these funds. We further fitted logistic regression models and stepwise adjusted for age and sex, further co-morbidities and anthropometric measures and factors influencing health awareness and lifestyle. RESULTS: The overall prevalence of diabetes was 6.9%. Stratified by health insurance funds, prevalences ranged between 3.9% within the Innungskrankenkassen to 11.4% within the Allgemeine Ortskrankenkassen. Adjusting for age and sex only led to minor changes. After controlling for all mentioned variables, these differences remained. Compared with those who were privately insured, persons within the Allgemeine Ortskrankenkassen (OR 1.73; 95% CI 1.30-2.29), the Betriebskrankenkassen (OR 1.54; 95% CI 1.15-2.07) and the Barmer (OR 1.39; 95% CI 1.01-1.91) had a higher prevalence. CONCLUSIONS: We found considerable differences in diabetes prevalence between German health insurance funds that remained after controlling for several relevant variables.

Effects of a Brief Web-Based "Social Norms"-Intervention on Alcohol, Tobacco and Cannabis Use Among German University Students: Results of a Cluster-Controlled Trial Conducted at Eight Universities.

Background and Aim: "Social norms" (SN)-interventions are aimed at changing existing misperceptions regarding peer substance use by providing feedback on actual norms, thereby affecting personal substance use. It is unknown whether SN-intervention effects previously demonstrated in US students can be replicated in German students. The aim of the INSIST-study was to examine the effects of a web-based SN-intervention on substance use. Design: Cluster-controlled trial. Setting: Eight Universities in Germany. Participants and Measurements: Students were recruited at four intervention vs. four delayed intervention control Universities. 4,463 students completed baseline, 1,255 students (59% female) completed both baseline and 5-months follow-up web-based surveys on personal and perceived peer substance use. Intervention participants received feedback contrasting personal and perceived peer use with previously assessed use and perceptions of same-sex, same-university peers. Intervention effects were assessed via multivariable mixed logistic regression models. Findings: Relative to controls, reception of SN-feedback was associated with higher odds for decreased alcohol use (OR: 1.91, 95% CI 1.42-2.56). This effect was most pronounced in students overestimating peer use at baseline and under or accurately estimating it at follow-up (OR: 6.28, 95% CI 2.00-19.8). The OR was 1.33 (95% CI 0.67-2.65) for decreased cannabis use in students at intervention Universities and was statistically significant at 1.70 (95% CI 1.13-2.55) when contrasting unchanged and decreased with increased use. Regarding tobacco use and episodes of drunkenness, no intervention effects were found. Conclusions: This study was the first cluster-controlled trial suggesting beneficial effects of web-based SN-intervention on alcohol and cannabis use in a large sample of German University students. Clinical Trial Registration: The trial registration number of the INSIST-study is DRKS00007635 at the "German Clinical Trials Register."

Reduced incidence of blindness in relation to diabetes mellitus in southern Germany?

AIMS: We estimated the incidence of blindness in the diabetic and non-diabetic population in 2008 and compared it with results from 1990-1998 in a neighbouring region. METHODS: All newly registered blindness allowance recipients in 2008 were drawn up in a German region (population 4.5 million). We estimated sex-specific, age-specific and standardized incidence rates of blindness in the diabetic and the non-diabetic population and relative and attributable risks as a result of diabetes. A comparison to the data from 1990-1998 was performed using log-linear Poisson regression. RESULTS: Four-hundred and sixty-eight cases were drawn up (63% female). One-hundred and twenty-two (26.1%) had diabetes. Blindness incidence rates (per 100, 000 person-years) standardized to the 2008 German population were: men 9.1 (95% confidence interval 7.8-10.5), women 9.9 (8.8-11.1); diabetic population: men 21.8 (11.6-31.9), women 19.7 (9.2-30.1); non-diabetic population: men 8.0 (6.6-9.5), women 9.1 (7.9-10.3). Relative risk of blindness, diabetic vs. non-diabetic population: men 2.7 (1.6-4.5), women 2.2 (1.3-3.8). Attributable risk among exposed: 63% in men, 54% in women. Population attributable risk: 12% in men, 8% in women. Incidences of blindness were significantly lower than in all years of the period 1990-1998 in both the diabetic and the non-diabetic population. CONCLUSIONS: We found the incidence of blindness to be approximately 2.5-fold higher in the diabetic compared with the non-diabetic population. Fifty-eight per cent of the risk to become blind in diabetic individuals and 9% of the risk to become blind in the entire population were attributable to diabetes. The decrease of the blindness incidence observed during the 1990s may have continued.