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.

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.

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.

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.

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.

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.

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.

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.

Years of Life Lost to Death­A 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 2020­Years 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.

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.

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.

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.