German mammography screening program: program sensitivity between 2010 and 2016 estimated based on German health claims data.

BACKGROUND: Program sensitivity is a key quality indicator for mammography screening programs (MSP). Estimating program sensitivity usually requires a linkage of screening and cancer registry data. For the German MSP, such data linkage-based estimates have only been reported for two out of 16 federal states. We aimed to explore the potential of estimating program sensitivity for the German MSP based on information available in health claims data. METHODS: We used data from the second-largest statutory health insurance fund in Germany, BARMER (~ 9 million members all over Germany). We included women aged 50 to 69 years with a non-initial screening mammography between 2010 and 2016 and followed them up for two years. We estimated the rate of screen-detected and interval cancers as well as program sensitivity. RESULTS: Per year, we included 212,400 to 303,667 women (mean age: 60-61 years). Overall, 1,992,287 non-initial MSP screening examinations conducted in these women between 2010 and 2016 were considered for the analyses. Age-standardized program sensitivity ranged between 69.9% [95% CI: 67.3-72.0%] and 71.7% [95% CI: 69.5-73.9%] during the study period. Per 1,000 non-initial screening examinations, the rate of screen-detected breast cancer ranged between 4.6 and 5.3, and the rate of interval breast cancer rates ranged between 0.6 and 0.8 for the first and between 1.3 and 1.4 for the second year after screening. CONCLUSIONS: Our results were plausible and consistent with quality indicators estimated for the German MSP based on data linkage and thus support the value of German health claims data in this regard. The quality indicators estimated in our study are in line with levels expected according to European Guidelines.

German mammography screening program: adherence, characteristics of (non-)participants and utilization of non-screening mammography-a longitudinal analysis.

BACKGROUND: In Germany, all women aged 50-69 have been invited to biennial mammography screening since 2009. We aimed to assess longitudinal adherence over ten years in women aged 50 in 2009 and characterize the different adherence groups. METHODS: Using the German Pharmacoepidemiological Research Database (GePaRD, ~ 20% of the German population), we included women aged 50 in 2009 (baseline) with continuous health insurance coverage and without breast cancer or in-situ-carcinoma. We followed them until age 59 and categorized them according to mammography screening participation into the following groups: never, 1-2, 3-4, 5-6 times. We characterized these groups, inter alia, regarding the use of other preventive measures, non-screening mammography (i.e., mammography outside the organized screening program) and menopausal hormone therapy. RESULTS: Overall, 82,666 women were included. Of these, 27.6% never participated in the screening program, 15.1% participated 1-2 times, 31.7% participated 3-4 times and 25.6% participated regularly (5-6 times). Among regular participants, 91% utilized other preventive measures (e.g., cervical cancer screening, general health checkup) before baseline as compared to 66% among non-participants. Menopausal hormone therapy was least common among non-participants (11% vs. 18% among regular participants). Among non-participants, the proportions using ≥ 1, ≥ 2, and ≥ 3 non-screening mammographies between age 50-59 were 25%, 18%, and 15%, respectively. CONCLUSIONS: Using a large cohort based on claims data, this study provides novel insights into longitudinal adherence to the mammography screening program and the use of mammography outside of the program in Germany. Between age 50-59, 57% of eligible women participated at least three times in the German mammography screening program and 28% (~ 3 in 10 women) never participated. Among non-participants, 15% had at least three non-screening mammographies during this period, indicating potential gray screening. Participants more often utilized other preventive measures as compared to non-participants.

Stability of individual dementia diagnoses in routine care: Implications for epidemiological studies.

PURPOSE: Epidemiological and health care research frequently rely on diagnoses from routine care, but the intra-individual stability of diagnoses of Alzheimer's disease (AD), vascular dementia (VD) or other forms of dementia (oD) in patients over time is understudied. More data on the diagnostic stability is needed to appraise epidemiological findings from such studies. METHODS: Using health claims data of the years 2004-2016 from the German Pharmacoepidemiological Research Database, 160 273 patients aged ≥50 with incident dementia were identified and followed for 4 years. According to the incident ICD-10 codes patients were assigned to the categories AD, VD or oD. Changes between categories during follow-up were calculated. RESULTS: Overall, 18.8% had incident AD (VD: 21.5%, oD: 59.7%). Fifteen thousand eight hundred forty-two patients had only one dementia diagnosis during 4 years (AD: 7.4%, VD: 12.4%, oD: 9.8%). Among those with more than one diagnosis, the incident diagnosis matched the last diagnosis in 65.1% (AD), 53.9% (VD) and 73.8% (oD) of patients. Changes in the diagnostic category were higher in patients with AD (mean: 5.1) than in patients with VD (3.6) or oD (3.3). Patients with stable AD diagnoses during the observation period were younger (median: 76 vs. 79 years) and had less inpatient treatment days (median: 14 days) than patients with changes from an AD diagnosis to another category or from another category to AD (27 days). CONCLUSIONS: While health claims data are feasible for estimating the incidence of dementia in general, the substantial number of changes in dementia diagnoses during the course of the disease warrant caution on the interpretation of epidemiological data on specific dementia types.

Linkage of Routine Data to Other Data Sources in Germany: A Practical Example Illustrating Challenges and Solutions.

Routine data have a high potential for epidemiological and health care research but lack information, for instance, on the cause of death. Often detailed information, such as on lifestyle factors is also missing. In Germany, obtaining the missing information by linkage to data sources is challenging, mainly due to strict data protection regulations. One key challenge arises from the fact that routine data users usually have no access to person identifiers which would be necessary for record linkage. A second key challenge is that sensitive information (i. e., the cause of death) should not be transferred to an institution that holds person identifiers. In this paper, we illustrate these key challenges and present corresponding solutions based on a practical example where claims data from statutory health insurance providers are linked to an epidemiological cancer registry to obtain cause of death information. We describe the approval procedures necessary for the record linkage, the dataflow between the involved institutions and explain the rationale of the dataflow in view of the key challenges. Finally, we generalize the questions that need to be addressed when a record linkage is planned and point to additional potential challenges. Overall, we illustrate that a linkage between routine data and other data sources in Germany is feasible, but specific restrictions and hurdles need to be taken into consideration.

Potential Explanations for Increasing Methylphenidate Use in Children and Adolescents With Attention-Deficit/Hyperactivity Disorder in Germany From 2004 to 2013.

BACKGROUND: Despite a decreasing population of children and adolescents, the cumulative total amount of dispensed methylphenidate (MPH), the first-choice treatment of attention-deficit/hyperactivity disorder (ADHD) in this age group, has increased dramatically in Germany. We investigated potential reasons for this increase such as changes in the ADHD prevalence over time and other potential explanations including the cumulative amount of dispensed MPH per person. METHODS: Based on German claims data, we calculated standardized annual ADHD prevalence rates, proportions of ADHD cases treated with MPH and/or psychotherapy, and mean cumulative defined daily doses of ADHD drugs for 3- to 17-year-old children and adolescents from 2004 to 2013. RESULTS: The ADHD prevalence increased continuously from 2004 to 2011 and remained stable thereafter. In ADHD cases, there was little variation in the proportion of individuals treated with drugs and in the frequency of psychotherapeutic treatment during the whole study period. The annual cumulative mean amount of MPH defined daily doses increased by approximately 30% from 2004 to 2008. CONCLUSIONS: Our analyses suggest that the increase in MPH use in Germany was mainly influenced by an increasing ADHD prevalence and increasing amounts of dispensed MPH per person.

[Enrichment of Claims Data with Official Causes of Death Using a Record Linkage with the Epidemiological Cancer Registry of North Rhine-Westphalia: Feasibility Study and Comparison of Procedures]. / Anreicherung eines GKV-Datensatzes mit amtlichen Todesursachen über einen Abgleich mit dem Epidemiologischen Krebsregister Nordrhein-Westfalen: Machbarkeitsstudie und Methodenvergleich.

BACKGROUND: Claims data of the statutory health insurance (SHI) are an important data source for the evaluation of cancer prevention programs. However, this source does not contain relevant information on cause of death. This study examined whether individual claims data can be enriched with data on the required cause of death using record linkage procedures with suitable external data sources. METHODS: In the German pharmacoepidemiologic research database (GePaRD) we identified a sample of 25,528 deceased female residents of North Rhine Westphalia (NRW) who, according to GePaRD information, died between 2006 and 2013. Date and cause of all deaths among inhabitants of NRW since 2005 were available in the epidemiological cancer registry of NRW. In cooperation with 2 SHI companies, we tried to match each individual of the sample with a case of death in NRW and the corresponding cause of death using a probabilistic and, alternatively, a deterministic linkage procedure. RESULTS: Of the study sample, 94.72% were successfully matched by the probabilistic and 93.36% by the deterministic method. CONCLUSIONS: The probabilistic and the deterministic record linkage approach produced comparably high matching rates. Cases without matches are probably due to errors occurring at the stage of personal data entry. Given the lower technical efforts, the deterministic approach appears to be the method of choice for the enrichment of claims data with cause of death information from suitable external data sources in Germany.

[Evaluation of organized cancer screening programs: general aspects and current status in Germany]. / Evaluation von organisierten Programmen zur Krebsfrüherkennung: Allgemeine Aspekte und aktueller Stand in Deutschland.

In the past decades, it has been increasingly recognized that cancer screening is not always or not exclusively beneficial and, in the case of some measures, the negative effects may even outweigh the benefits. This has fundamentally changed the significance and emphasis placed on the evaluation of cancer screening programs. Generally, there is a distinction between an endpoint evaluation, which assesses the effectiveness or risk/benefit ratio, and a process evaluation, which aims to ensure optimum implementation of the program.Prior to the nationwide introduction of a screening measure, proof of effectiveness should ideally be provided by a randomized controlled trial (RCT), in which persons without a screening offer form the control group. From a scientific point of view, this study design is by far the best method to evaluate the endpoint, as it avoids biases that may distort the results in observational studies. RCT evidence on cancer screening measures currently offered by statutory health insurance providers in Germany - if available at all - originates exclusively from other countries.When mammography screening was introduced as the first organized screening program in Germany, comprehensive measures for process evaluation were taken. In April 2013, the legal basis for the transfer of colorectal and cervical cancer screening into organized programs was created. According to the legal provisions, both a process and an endpoint evaluation are planned for the new programs. It remains to be seen how the necessary data flows will be conceptualized and later implemented in practice.

Validating mortality in the German Pharmacoepidemiological Research Database (GePaRD) against a mortality registry.

PURPOSE: The study aimed at validating the status and date of death of a large electronic health insurance database against data of a mortality registry, using a probabilistic record linkage. METHODS: Data were obtained from one local health insurance company contributing to the German Pharmacoepidemiological Research Database (GePaRD). Furthermore, data of the Bremen Mortality Index (BreMI) containing all information from death certificates were used as reference information. Both data sources were probabilistically linked. The study sample consisted of insurants dying in 2005 or 2006. RESULTS: Of 3245 deaths in GePaRD, 83.7% were successfully linked to BreMI records. The linkage success did not differ between men and women, age groups or insurance status groups. Date of death was accurate in 97.1% of all linked deaths. CONCLUSIONS: The accuracy of the status of death in GePaRD is likely to be underestimated in this study because of factors related to the record linkage procedure leading to failure of the probabilistic record linkage approach and the limited completeness of BreMI. A previous validation study comparing aggregate mortality information in GePaRD with German national statistics did not indicate an overreporting of deaths in GePaRD. Thus, a higher accuracy of the status of death in GePaRD than estimated here can be assumed. Copyright © 2016 John Wiley & Sons, Ltd.

Mortality in the German Pharmacoepidemiological Research Database (GePaRD) compared to national data in Germany: results from a validation study.

BACKGROUND: Electronic healthcare databases are of increasing importance in health research and mortality is one of the most relevant outcomes. However, data in these databases need to be validated, since they are often generated for reimbursement purposes. The aims of this study were to compare mortality figures from the German Pharmacoepidemiological Research Database (GePaRD) on an aggregated level with external data from the Federal Statistical Office of Germany (FSOG) and to assess consistency of records of death from core data and hospital data within GePaRD. METHODS: The study population comprised insurants of four statutory health insurances providing data for GePaRD with either continuous insurance coverage from January 1(st) to December 31(st) 2006 or until death. The sex-specific mortality rate, stratified and standardized by age, and the percentage of hospital deaths among all deaths was compared with data from the FSOG. Furthermore, the agreement between the dates of death according to hospital data and core data was assessed within GePaRD. RESULTS: The study population comprised 12,033,622 insurants. Compared to FSOG data, the age-standardised mortality rate in GePaRD was 21% and 29% lower in women and men, respectively. Regional analyses also indicated lower mortality rates in all federal states except for Bremen, where the age-standardised mortality rate was similar to FSOG data for both sexes. The percentage of hospital deaths among all deaths corresponded well with external data. The proportion of inpatient deaths also recorded in the health insurance core data was 98.5%. Furthermore, 94% of dates of death documented in hospital agreed with the dates of death according to the health insurance core data. CONCLUSIONS: The lower mortality rates in almost all federal states might result from the higher socioeconomic status of the GePaRD study population compared to the overall population in Germany. In the federal state of Bremen, where socioeconomic representativeness is higher due to additional inclusion of two local health insurances, the mortality rates were in good accordance with external data. Agreement of the percentage of hospital deaths among all deaths between GePaRD and national statistics suggested completeness of outpatient mortality information.

Comorbidities in ADHD children treated with methylphenidate: a database study.

BACKGROUND: Methylphenidate (MPH) is the most common drug treatment of attention deficit / hyperactivity disorder (ADHD) in children. Treatment with MPH is contraindicated in the presence of certain psychiatric, cerebro- and cardiovascular conditions. We assessed MPH treatment prevalence and incidence and the frequency of comorbid conditions related to these contraindications in new MPH users compared to a control group without ADHD and ADHD medication. METHODS: We used health care data for the years 2004 to 2006 from the German Pharmacoepidemiological Research Database (GePaRD) which includes about 18% of the German population. MPH treatment prevalence and incidence was assessed based on at least one MPH prescription in the given year. In MPH users, the prevalence of psychiatric and other comorbidities was assessed in the quarter of the first MPH prescription and the three preceding quarters, whereas in controls it was assessed in the earliest four quarters of continuous insurance time starting at 01.01.2004 or the start of insurance if this was later. Differences in the presence of comorbid diagnoses between MPH users and controls were tested by logistic regression. RESULTS: In 2005, 1.5% of all children and adolescents aged 3 to 17 years (2.3% of males and 0.6% of females) received MPH in Germany. The proportion of children with a record of a psychiatric comorbidity in any of the nine ICD categories of diagnoses was substantially higher in new MPH users (83%) compared to controls (20%). Cerebro- and cardiovascular comorbidities were rare in general. Still, among new MPH users, 2% of males and females had a diagnosis of a pre-existing cardiovascular disorder but only 1.2% of controls. CONCLUSIONS: Besides MPH treatment prevalence we first publish age-specific incidence rates for Germany. A high proportion of children who were started on MPH had a record of a psychiatric comorbidity preceding the first prescription. Cerebro- and cardiovascular conditions were rare in the studied age range, but still higher among children who received MPH than in the control group. Results show that in a substantial subgroup of patients, comorbidities require a thorough weighting of possible risks of MPH medication against the risks of untreated ADHD.

Regional variation in caesarean deliveries in Germany and its causes.

BACKGROUND: Determinants of regional variation in caesarean sections can contribute explanations for the observed overall increasing trend of caesarean sections. We assessed which mechanism explains the higher rate of caesarean sections in the former West than East Germany: a more liberal use of caesarean sections in the case of relative indications or more common caesarean sections without indications. METHODS: We used a health insurance database from all regions of Germany with approximately 14 million insured individuals (about 17% of the total population in Germany). We selected women who gave birth in the years 2004 to 2006 and identified indications for caesarean section on the basis of hospital diagnoses in 30 days around birth. We classified pregnancies into three groups: those with strong indications for caesarean section (based on classification of absolute indications recommended by the Unmet Obstetrics Need network), those with moderate indications (other indications increasing the probability of caesarean section) and those with no indications. We investigated the percentage of caesarean sections among all births, presence of strong or moderate indications in all pregnancies, the probability of caesarean sections in the presence of indications and the fraction of caesarean sections attributable to strong, moderate and no indications. RESULTS: In total, 294,841 births from 2004-2006 were included in the analysis. In the former West Germany, 30% births occurred by caesarean section, while in the former East Germany the caesarean section rate was 22%. Proportions of pregnancies with strong and moderate indications for caesarean section were similar in both regions. For strong indications the probability of caesarean section was similar in East and West Germany, but the probability of caesarean section among women with moderate indications was substantially higher in the former West Germany. Caesarean sections were also more common among women with no indications in the former West (8%) than in the former East (4-5%). The higher probability of caesarean section in the case of strong or moderate indications in the former West than in the East explained 87% of the difference between section rates in these two regions, while caesarean sections without indications contributed to only 13% of the difference observed. CONCLUSIONS: The observed difference between caesarean section rates in the former East and West Germany was most likely due to different medical practice in handling relative indications.

Antidepressant drug use and off-label prescribing in children and adolescents in Germany: results from a large population-based cohort study.

The off-label use of drugs in children and adolescents is widespread. In Germany, the use of selective serotonin reuptake inhibitors (SSRIs) and other antidepressants (OADs) is not licensed for the treatment of depressive disorders in children and adolescents except for fluoxetine, which was approved in 2006. Against this background, antidepressant drug (ATD) use with a particular focus on off-label prescribing was characterised in a retrospective cohort study including cross-sectional analyses based on claims data of 2,599,685 patients up to 17 years of age. Prevalence of ATD use was 1.84 (95% CI 1.78-1.90) per 1,000 children in 2004, 1.57 (95% CI 1.52-1.62) in 2005 and 1.66 (95% CI 1.61-1.72) in 2006. More than half of all children treated with ATDs (51.29%) received only one single prescription of an ATD during the study period. Of all prescribed ATDs, 11,172 (42.09%) were tricyclic antidepressants 9,179 (34.58%) were SSRIs, 4,371 (16.47%) were St John's wort preparations and 1,821 (6.86%) were OADs. Around half of all children and adolescents who were treated with ATDs were diagnosed with depressive disorders (56.30%). Overall, 13,035 (49.11%) of all ATDs were prescribed off-label. Off-label use by age (40.18%) was found to be more common than off-label use by indication (16.63%) with 7.70% of off-label use occurring in both categories. Specialist treatment by hospital-based physicians increased the risk (odds ratio: 2.26, 95% CI 2.05-2.48) of receiving an off-label prescription compared to treatment by general practitioners. In summary, off-label use of ATDs in children and adolescents was substantial in Germany.

Dementia in health claims data: The influence of different case definitions on incidence and prevalence estimates.

OBJECTIVES: The epidemiology of dementia subtypes including Alzheimer's disease (AD) and vascular dementia (VD) and their reliance on different case definitions ("algorithms") in health claims data are still understudied. METHODS: Based on health claims data, prevalence estimates (per 100 persons), incidence rates (IRs, per 100 person-years), and proportions of AD, VD, and other dementias (oD) were calculated. Five algorithms of increasing strictness considered inpatient/outpatient diagnoses (#1, #2), antidementia drugs (#3) or supportive diagnostics (#4, #5). RESULTS: Algorithm 1 detected 213,409 cases (#2: 197,400; #3: 48,688; #4: 3033; #5: 3105), a prevalence for any dementia of 3.44 and an IR of 1.39 (AD: 0.80/0.21, VD: 0.79/0.31). The prevalence decreased by algorithms for any dementia (#2: 3.19; #3: 0.75; #4: 0.04; #5: 0.05) as did IRs (#2: 1.13; #3: 0.18; #4: 0.05, #5: 0.05). Algorithms 1-2, and 4-5 revealed similar proportions of AD (23.3%-26.6%), VD (19.9%-23.2%), and oD (53.1%-53.8%), algorithm 3 estimated 45% (AD), 12.1% (VD), and 43.0% (oD). CONCLUSIONS: Health claims data show lower estimates of AD than previously reported, due to markedly lower prevalent/incident proportions of patients with corresponding codes. Using medication in defining dementia potentially improves estimating the proportion of AD while supportive diagnostics were of limited use.

Cosmic radiation and mortality from cancer among male German airline pilots: extended cohort follow-up.

Commercial airline pilots are exposed to cosmic radiation and other specific occupational factors, potentially leading to increased cancer mortality. This was analysed in a cohort of 6,000 German cockpit crew members. A mortality follow-up for the years 1960-2004 was performed and occupational and dosimetry data were collected for this period. 405 deaths, including 127 cancer deaths, occurred in the cohort. The mortality from all causes and all cancers was significantly lower than in the German population. Total mortality decreased with increasing radiation doses (rate ratio (RR) per 10 mSv: 0.85, 95 % CI: 0.79, 0.93), contrasting with a non-significant increase of cancer mortality (RR per 10 mSv: 1.05, 95 % CI: 0.91, 1.20), which was restricted to the group of cancers not categorized as radiogenic in categorical analyses. While the total and cancer mortality of cockpit crew is low, a positive trend of all cancer with radiation dose is observed. Incomplete adjustment for age, other exposures correlated with duration of employment and a healthy worker survivor effect may contribute to this finding. More information is expected from a pooled analysis of updated international aircrew studies.

Exposure to metal-working fluids in the automobile industry and the risk of male germ cell tumours.

INTRODUCTION: In a previous analysis of a case-control study of testicular cancer nested in a cohort of automobile workers, we observed an increased risk for testicular cancer among workers who had ever been involved in occupational metal-cutting tasks. We investigated whether this risk increase was due to exposure to metal-working fluids (MWF). METHODS: Occupational exposure to MWF was assessed in detail using a job-specific questionnaire for metal-cutting work. We calculated ORs and associated 95% CIs individually matched for age (±2 years) and adjusted for a history of cryptorchidism by conditional logistic regression. RESULTS: The prevalence of exposure to MWF was 39.8% among cases and 40.1% among controls. For total germ cell tumours and seminomas we did not observe risk increases for metal-cutting tasks or occupational exposure to MWF (OR 0.95; 95% CI 0.69 to 1.32 and OR 0.88; 95% CI 0.58 to 1.35, respectively). However, dermal exposure to oil-based MWF was associated with an increased risk for non-seminomatous testicular cancer. Dermal exposure to oil-based MWF for more than 5000 h showed particularly high risk estimates (OR 4.72; 95% CI 1.48 to 15.09). DISCUSSION: Long-term dermal exposure to oil-based MWF was a risk factor for the development of non-seminomatous testicular germ cell cancer. Possible measures to reduce exposure include the introduction of engineering control measures such as venting or enclosing of machines, and enforcing the use of personal protective equipment during metal cutting.

Effectiveness of Mammography Screening on Breast Cancer Mortality - A Study Protocol for Emulation of Target Trials Using German Health Claims Data.

Background: The efficacy of mammography screening in reducing breast cancer mortality has been demonstrated in randomized trials. However, treatment options - and hence prognosis - for advanced tumor stages as well as mammography techniques have considerably improved since completion of these trials. Consequently, the effectiveness of mammography screening under current conditions is unclear and controversial. The German mammography screening program (MSP), an organized population-based screening program, was gradually introduced between 2005 and 2008 and achieved nation-wide coverage in 2009. Objective: We describe in detail a study protocol for investigating the effectiveness of the German MSP in reducing breast cancer mortality in women aged 50 to 69 years based on health claims data. Specifically, the proposed study aims at estimating per-protocol effects of several screening strategies on cumulative breast cancer mortality. The first analysis will be conducted once 10-year follow-up data are available. Methods and Analysis: We will use claims data from five statutory health insurance providers in Germany, covering approximately 37.6 million individuals. To estimate the effectiveness of the MSP, hypothetical target trials will be emulated across time, an approach that has been demonstrated to minimize design-related biases. Specifically, the primary contrast will be in terms of the cumulative breast cancer mortality comparing the screening strategies of "never screen" versus "regular screening as intended by the MSP". Ethics and Dissemination: In Germany, the utilization of data from health insurances for scientific research is regulated by the Code of Social Law. All involved health insurance providers as well as the responsible authorities approved the use of the health claims data for this study. The Ethics Committee of the University of Bremen determined that studies based on claims data are exempt from institutional review. The findings of the proposed study will be published in peer-reviewed journals.

Development and evaluation of a tool for retrospective exposure assessment of selected endocrine disrupting chemicals and EMF in the car manufacturing industry.

OBJECTIVES: A system for retrospective occupational exposure assessment combining the efficiency of a job exposure matrix (JEM) and the precision of a subsequent individual expert exposure assessment (IEEA) was developed. All steps of the exposure assessment were performed by an interdisciplinary expert panel in the context of a case-control study on male germ cell cancer nested in the car manufacturing industries. METHODS: An industry-specific JEM was developed and automatic exposure estimation was performed based on this JEM. A subsample of exposure ratings was done by IEEA to identify determinants of disagreement between the JEM and the individual review. Possible determinants were analyzed by calculating odds ratios (ORs) of disagreement between ratings with regard to different dimensions (e.g. high versus low intensity of exposure). Disagreement in ≥20% of the sampled exposure ratings with a statistically significant OR was chosen as a threshold for inclusion of the exposure ratings into a final IEEA. RESULTS: The most important determinants of disagreement between JEM and individual review were working outside of the production line (disagreement 80%), low probability of exposure (disagreement 25%), and exposure depending on specific activities like usage of specific lacquers (disagreement 32%) for jobs within the production line. These determinants were the selection criteria of exposure ratings for the subsequent final IEEA. CONCLUSIONS: Combining a JEM and a subsequent final IEEA for a selected subset of exposure ratings is a feasible and labor-saving approach for exposure assessment in large occupational epidemiological studies.

Regional and temporal variations in coding of hospital diagnoses referring to upper gastrointestinal and oesophageal bleeding in Germany.

BACKGROUND: Health insurance claims data are increasingly used for health services research in Germany. Hospital diagnoses in these data are coded according to the International Classification of Diseases, German modification (ICD-10-GM). Due to the historical division into West and East Germany, different coding practices might persist in both former parts. Additionally, the introduction of Diagnosis Related Groups (DRGs) in Germany in 2003/2004 might have changed the coding. The aim of this study was to investigate regional and temporal variations in coding of hospitalisation diagnoses in Germany. METHODS: We analysed hospitalisation diagnoses for oesophageal bleeding (OB) and upper gastrointestinal bleeding (UGIB) from the official German Hospital Statistics provided by the Federal Statistical Office. Bleeding diagnoses were classified as "specific" (origin of bleeding provided) or "unspecific" (origin of bleeding not provided) coding. We studied regional (former East versus West Germany) differences in incidence of hospitalisations with specific or unspecific coding for OB and UGIB and temporal variations between 2000 and 2005. For each year, incidence ratios of hospitalisations for former East versus West Germany were estimated with log-linear regression models adjusting for age, gender and population density. RESULTS: Significant differences in specific and unspecific coding between East and West Germany and over time were found for both, OB and UGIB hospitalisation diagnoses, respectively. For example in 2002, incidence ratios of hospitalisations for East versus West Germany were 1.24 (95% CI 1.16-1.32) for specific and 0.67 (95% CI 0.60-0.74) for unspecific OB diagnoses and 1.43 (95% CI 1.36-1.51) for specific and 0.83 (95% CI 0.80-0.87) for unspecific UGIB. Regional differences nearly disappeared and time trends were less marked when using combined specific and unspecific diagnoses of OB or UGIB, respectively. CONCLUSIONS: During the study period, there were substantial regional and temporal variations in the coding of OB and UGIB diagnoses in hospitalised patients. Possible explanations for the observed regional variations are different coding preferences, further influenced by changes in coding and reimbursement rules. Analysing groups of diagnoses including specific and unspecific codes reduces the influence of varying coding practices.

Prevalence of multimodal treatment in children and adolescents with ADHD in Germany: a nationwide study based on health insurance data.

BACKGROUND: Attention-deficit hyperactivity disorder (ADHD) ranks top among neurodevelopmental disorders in children and adolescents. Due to a large number of unfavorable outcomes including psychiatric comorbidities, school problems, and lower socioeconomic status, early and effective treatment of ADHD is essential. Multimodal treatment has become the gold standard in ADHD management, comprising pharmacotherapy and psychosocial interventions, e.g., psychotherapy. Yet, little is known about the prevalence of multimodal treatment in routine care. METHODS: Based on German health claims data for the years 2009-2017, we identified children and adolescents aged 3-17 years diagnosed with ADHD and characterized them cross-sectionally (per calendar year) in terms of treatment status and psychiatric comorbidities. The detection of pharmacotherapy was based on dispensations of drugs to treat ADHD (e.g., methylphenidate); psychotherapeutic treatment was based on corresponding billing codes. Multimodal treatment was assumed if ADHD medication and psychotherapeutic treatment were coded within the same calendar year. Psychiatric comorbidities were based on outpatient and inpatient diagnoses. Prevalences of ADHD and proportions of different treatment options were calculated and standardized by age and sex. RESULTS: In 2017, 91,118 children met the study criteria for ADHD (prevalence: 42.8/1000). Of these, 25.2% had no psychiatric comorbidity, 28.8% had one, 21.6% had two, and 24.5% had three or more. Regarding overall treatment status, 36.2% were treated only pharmacologically, 6.5% received multimodal treatment, and 6.8% were treated with psychotherapy only (neither treatment: 50.2%). With increasing numbers of psychiatric comorbidities, the proportions of patients with multimodal treatment increased from 2.2% (no psychiatric comorbidities) to 11.1% (three or more psychiatric comorbidities) while the proportions of untreated (from 56.8% to 42.7%) or only pharmacologically treated patients (38.4% to 35.0%) decreased. From 2009 to 2017, prevalences were stable and the proportion of patients with only pharmacotherapy decreased from 48% to 36.5%. Concurrently, the proportion of patients with neither pharmacotherapy nor psychotherapy increased from 40.5% to 50.2%. The fraction of patients with multimodal treatment ranged between 6.5% (2017) and 7.4% (2013). CONCLUSIONS: Multimodal treatment, although recommended as the standard of treatment, is rather the exception than the rule. It is, however, increasingly common in ADHD patients with psychiatric comorbidities.

Case-control study of male germ cell tumors nested in a cohort of car-manufacturing workers: Findings from the occupational history.

BACKGROUND: To examine whether the previously observed excess risk of male germ cell cancer in a cohort of car-manufacturing workers can be attributed to occupational activities inside and/or outside the car industry. METHODS: A nested case-control study among workers in six plants included 205 cases of germ cell cancer and 1,105 controls, individually matched by year of birth (±2 years). Job periods of the individual occupational histories were coded based on the International Standard Classification of Occupations (ISCO) and the industrial classification of economic activities (NACE). Odds ratios (ORs) and corresponding 95%-confidence intervals (CI) for ever-never and cumulative employment were calculated by conditional multivariate logistic regression adjusted for cryptorchidism. RESULTS: Significantly increased risks were observed for machinery fitters and assemblers (A) (OR = 1.8, 95% CI 1.25-2.53) and "workers not elsewhere classified" (OR = 2.10, 95% CI 1.27-3.54), but no trend was observed for employment duration in either occupational group. Stratification of job group A by metal-cutting and non-cutting jobs yielded ORs of 1.87 (95% CI 1.31-2.67) and of 1.24 (95% CI 0.68-2.28), respectively. Among "plumbers, welders, sheet & structural metal workers" (adjusted OR 1.4, 95% CI 0.99-1.95) only "structural metal preparers and erectors" showed a substantially increased risk (OR = 2.30; 95% CI 1.27-4.27). CONCLUSIONS: Our results do not fully explain the increased incidence of germ cell cancer in the cohort, but support previous findings showing increased risks among metal workers. These risks were most strongly pronounced in metal-cutting activities.