Associations of Migration, Socioeconomic Position and Social Relations With Depressive Symptoms - Analyses of the German National Cohort Baseline Data.

Objectives: We analyze whether the prevalence of depressive symptoms differs among various migrant and non-migrant populations in Germany and to what extent these differences can be attributed to socioeconomic position (SEP) and social relations. Methods: The German National Cohort health study (NAKO) is a prospective multicenter cohort study (N = 204,878). Migration background (assessed based on citizenship and country of birth of both participant and parents) was used as independent variable, age, sex, Social Network Index, the availability of emotional support, SEP (relative income position and educational status) and employment status were introduced as covariates and depressive symptoms (PHQ-9) as dependent variable in logistic regression models. Results: Increased odds ratios of depressive symptoms were found in all migrant subgroups compared to non-migrants and varied regarding regions of origins. Elevated odds ratios decreased when SEP and social relations were included. Attenuations varied across migrant subgroups. Conclusion: The gap in depressive symptoms can partly be attributed to SEP and social relations, with variations between migrant subgroups. The integration paradox is likely to contribute to the explanation of the results. Future studies need to consider heterogeneity among migrant subgroups whenever possible.

The impossibility of mortality evaluation of skin cancer screening in Germany based on health insurance data: a case-control study.

BACKGROUND: The aim of this paper was to perform a mortality evaluation of skin cancer screening (SCS) in Germany using General Local Health Insurance Fund (AOK) data. METHODS: AOK-insured men and women aged 35-99 years who died of cutaneous malignant melanoma in 2015-2016 were identified. Controls were AOK-insured people who survived to the end of each case's year of death. For each case, 10 controls were matched. The SCS history of each individual was reconstructed using the billing codes 01745 and 01746. RESULTS: In total, 1037 melanoma deaths and 10,370 controls were included. Cumulative SCS prevalence increased among controls over calendar years, as expected (males and females, 2009: 13.5% and 12.5%; 2015: 52.1% and 55.1%). In contrast, among cases, cumulative SCS prevalence was already high in 2009 and did not show a monotonic increase over the years of diagnosis. Of the 1037 melanoma deaths, 224 (21.6%) had at least one SCS settled in the 12 months after diagnosis. DISCUSSION: A mortality evaluation with health insurance data alone is not possible because SCS billing codes are not only used for real SCS but also for occasion-related diagnostic work-up of abnormal skin findings. A mortality evaluation with health insurance data requires an individual linking with data of the screening physician and the cancer registries.

One-year follow-up healthcare costs of patients diagnosed with skin cancer in Germany: a claims data analysis.

BACKGROUND: Routine skin cancer screening (SCS) is covered by the German statutory health insurance (SHI) since 2008. The objective of this study was to compare direct healthcare costs between patients in whom skin cancer was detected by routine SCS and patients in whom skin cancer was not detected by routine SCS. METHODS: A retrospective observational study of administrative claims data from a large German SHI was performed. Patients with a diagnosis of malignant melanoma (MM) or non-melanoma skin cancer (NMSC) diagnosed in 2014 or 2015 were included. Costs were obtained for one year before and one year after diagnosis and analyzed in a difference-in-differences approach using regression models. Frequency matching was applied and risk adjustment was performed. Additional analyses were conducted, separately for specific age groups, excluding persons who died during the observation period and without taking costs for screening into consideration. RESULTS: A total of 131,801 patients were included, of whom 13,633 (10.3%) had a diagnosis of MM and 118,168 (89.7%) had a diagnosis of NMSC. The description of total costs (without risk adjustment) shows lower mean total costs among patients whose skin cancer was detected via routine SCS compared to patients in whom skin cancer was not detected by routine SCS (MM: €5,326 (95% confidence interval (CI) €5,073; €5,579) vs. €9,038 (95% CI €8,629; €9,448); NMSC: €4,660 (95% CI €4,573; €4,745) vs. €5,890 (95% CI €5,813; €5,967)). Results of the regression analysis show cost savings of 18.8% (95% CI -23.1; -8.4) through routine SCS for patients with a diagnosis of MM. These cost savings in MM patients were more pronounced in patients younger than 65 years of age. For patients with a diagnosis of NMSC, the analysis yields a non-substantial increase in costs (2.5% (95% CI -0.1; 5.2)). CONCLUSION: Cost savings were detected for persons with an MM diagnosed by routine SCS. However, the study could not detect lower costs due to routine SCS in the large fraction of persons with a diagnosis of NMSC. These results offer important insights into the cost structure of the routine SCS and provide opportunities for refinements.

Increase in Mental Disorders During the COVID-19 Pandemic-The Role of Occupational and Financial Strains.

BACKGROUND: Numerous studies have reported an increase in mental disorders during the COVID-19 pandemic, but the exact reasons for this development are not well understood. In this study we investigate whether pandemic-related occupational and financial changes (e.g., reduced working hours, working from home, financial losses) were associated with increased symptoms of depression and anxiety compared with the situation before the pandemic. METHODS: We analyzed data from the German National Cohort (NAKO) Study. Between May and November 2020, 161 849 study participants answered questions on their mental state and social circumstances. Their responses were compared with data from the baseline survey before the pandemic (2014-2019). Linear fixed-effects models were used to determine whether individual changes in the severity of symptoms of depression (PHQ-9) or anxiety (GAD-7) were associated with occupational/ financial changes (controlling for various covariates). RESULTS: The prevalence of moderate or severe symptoms of depression and anxiety increased by 2.4% and 1.5%, respectively, during the COVID-19 pandemic compared with the preceding years. The mean severity of the symptoms rose slightly. A pronounced increase in symptoms was observed among those who became unemployed during the pandemic (+ 1.16 points on the depression scale, 95% confidence interval [0.91; 1.41], range 0-27). Increases were also seen for reduced working hours with no short-time allowance, increased working hours, working from home, insecurity regarding employment, and financial strain. The deterioration in mental health was largely statistically explained by the occupational and financial changes investigated in the model. CONCLUSION: Depressive symptoms and anxiety disorders increased slightly in the study population during the first year of the COVID-19 pandemic. Occupational and financial difficulties were an essential contributory factor. These strains should be taken into account both in the care of individual patients and in the planning of targeted prevention measures.

[The baseline assessment of the German National Cohort (NAKO Gesundheitsstudie): participation in the examination modules, quality assurance, and the use of secondary data]. / Die Basiserhebung der NAKO Gesundheitsstudie: Teilnahme an den Untersuchungsmodulen, Qualitätssicherung und Nutzung von Sekundärdaten.

BACKGROUND: The German National Cohort (NAKO) is an interdisciplinary health study aimed at elucidating causes for common chronic diseases and detecting their preclinical stages. This article provides an overview of design, methods, participation in the examinations, and their quality assurance based on the midterm baseline dataset (MBD) of the recruitment. METHODS: More than 200,000 women and men aged 20-69 years derived from random samples of the German general population were recruited in 18 study centers (2014-2019). The data collection comprised physical examinations, standardized interviews and questionnaires, and the collection of biomedical samples for all participants (level 1). At least 20% of all participants received additional in-depth examinations (level 2), and 30,000 received whole-body magnet resonance imaging (MRI). Additional information will be collected through secondary data sources such as medical registries, health insurances, and pension funds. This overview is based on the MBD, which included 101,839 participants, of whom 11,371 received an MRI. RESULTS: The mean response proportion was 18%. The participation in the examinations was high with most of the modules performed by over 95%. Among MRI participants, 96% completed all 12 MRI sequences. More than 90% of the participants agreed to the use of complementary secondary and registry data. DISCUSSION: Individuals selected for the NAKO were willing to participate in all examinations despite the time-consuming program. The NAKO provides a central resource for population-based epidemiologic research and will contribute to developing innovative strategies for prevention, screening and prediction of chronic diseases.

[Physical activity in the German National Cohort (NAKO): use of multiple assessment tools and initial results]. / Körperliche Aktivität in der NAKO Gesundheitsstudie: erste Ergebnisse des multimodalen Erhebungskonzepts.

BACKGROUND: Physical activity is a complex behavior that is difficult to measure validly and reliably in large, population-based studies. Data on physical activity are available for the initial 100,000 participants of the German National Cohort. OBJECTIVES: To describe the baseline physical activity assessment in the cohort and to present initial descriptive results. MATERIAL AND METHODS: Physical activity was assessed using a combination of tools, including two self-administered questionnaires, the Questionnaire on Annual Physical Activity Pattern (QUAP) and the Global Physical Activity Questionnaire (GPAQ); a computer-based 24­h physical activity recall (cpar24); and 7­day accelerometry (Actigraph GT3X/+; ActiGraph, Pensacola, FL, USA). RESULTS: The availability of data varied between assessment instruments (QUAP: n = 16,372; GPAQ: n = 90,900; cpar24: n = 23,989; accelerometry: n = 35,218). Analyses across measurement tools showed that on average, women spent 75 to 216 min/d, and men spent 73 to 224 min/d in moderate or higher intensity total physical activity. Persons aged 20-39 years spent 66 to 200 min/d, and persons aged 40-69 years spent 78 to 244 min/d in moderate or higher intensity total physical activity. CONCLUSIONS: Initial baseline analyses of physical activity in this cohort show the value of using a combination of questionnaires, 24­h recalls, and a movement sensor. The comprehensive data collection represents a valuable resource for future analyses and will improve our understanding of the association between physical activity and disease prevention.

The association between geographic location and incidence of Merkel cell carcinoma in comparison to melanoma: An international assessment.

AIM: The aim of this article was to provide worldwide, population-based incidence rates for Merkel cell carcinoma (MCC). METHODS: We included 11,576 cases from 20 countries for time trend analyses (1990-2007) and 11,028 cases (2.5 billion person-years) from 21 countries for the period 2003-2007 extracted from Cancer Incidence in Five Continents. We computed age-standardised incidence rates (World Standard population) per million person years and sex ratios of these rates. We estimated annual percentage changes (EAPCs) of the incidence and studied the association between geographic latitude and MCC incidence. We examined the body site distribution of MCC. FINDINGS: In the majority of populations, the incidence has increased over time (EAPC, men 2.0-21.0%; women 1.6-27.2%). Rate differences between 1995 and 2007 were typically small (men: 0.8-2.2; women: 0.2-1.7). The incidence was relatively stable in some populations (men: U.S. blacks, Japan, Norway, Denmark; women: Denmark, Norway, Sweden). Incidences from 2003 to 2007 were highest in Australia, New Zealand, the United States and Israel among men and in New Zealand, Australia, Ireland and the Netherlands among women. The incidence of MCC and melanoma among white non-Hispanic males in North America was positively associated with living closer to the equator. The proportion of MCC on the head was higher with advanced age. The head was a less likely primary site among blacks as compared with any other ethnicity. INTERPRETATION: Several countries showed increases in MCC incidence among white non-Hispanics over time. Latitude closer to the equator was associated with the MCC incidence in North American men, but barely in women, possibly due to occupational sunlight exposure patterns.

Do patients with intake of drugs labelled as sleep disturbing really sleep worse? A population based assessment from the Heinz Nixdorf Recall Study.

AIM: The sleep disturbing effect of many drugs is derived from clinical trials with highly selected patient collectives. However, the generalizability of such findings to the general population is questionable. Our aim was to assess the association between intake of drugs labelled as sleep disturbing and self-reported nocturnal sleep disturbances in a population-based study. METHODS: We used data of 4221 participants (50.0% male) aged 45 to 75 years from the baseline examination of the Heinz Nixdorf Recall Study in Germany. The interview provided information on difficulties falling asleep, difficulties maintaining sleep and early morning arousal. We used the summary of product characteristics (SPC) for each drug taken and assigned the probability of sleep disturbances. Thereafter, we calculated cumulative probabilities of sleep disturbances per subject to account for polypharmacy. We estimated prevalence ratios (PR) using log Poisson regression models with robust variance. RESULTS: The adjusted PRs of any regular nocturnal sleep disorder per additional sleep disturbing drug were 1.01 (95% confidence interval (CI) 0.97, 1.06) and 1.03 (95% CI 1.00, 1.07) for men and women, respectively. Estimates for each regular nocturnal sleep disturbance were similarly close to 1. PRs for regular nocturnal sleep disturbances did not increase with rising cumulative probability for drug-related sleep disturbances. CONCLUSIONS: SPC-based probabilities of drug-related sleep disturbances showed barely any association with self-reported regular nocturnal sleep disturbances. We conclude that SPC-based probability information may lack generalizability to the general population or may be of limited data quality.

The regional myocardial infarction registry of Saxony-Anhalt (RHESA) in Germany - rational and study protocol.

BACKGROUND: In 2012 the age-standardized acute myocardial infarction (AMI) mortality rate was in the federal state Saxony-Anhalt 67 deaths per 100.000 whereas in Germany the AMI-rate was 47 deaths per 100.000. The rate in Saxony-Anhalt was therefore 43 % above the national average. Many factors may explain this above-average AMI mortality rate: First, the prevalence of cardiovascular risk factors (e.g. arterial hypertension, diabetes mellitus, smoking) in Saxony-Anhalt is the highest among all the Federal States of Germany. Second, structural health care for patients with AMI is potentially deficient (e.g. insufficient number of percutaneous coronary intervention-centers or deficits in the pre-hospital logistics of care). Third, the pre- and in-hospital process quality of health care for patients with AMI is possibly insufficient (e.g. time to reperfusion therapy). In July 2013 we established the regional myocardial infarction registry of Saxony-Anhalt (Regionales Herzinfarktregister in Sachsen-Anhalt, RHESA). RHESA is a population-based registry in the eastern part of Germany. Aims of RHESA are to calculate the AMI morbidity and mortality rates. Furthermore we study the factors that may potentially influence these rates in Saxony-Anhalt. METHODS: RHESA is a population-based registry of patients with fatal or non-fatal AMI that was established in July 2013. The registry population comprises inhabitants aged 25 years or more of the city of Halle (Saale) (n = 179.000) and inhabitants of the rural district Altmark (n = 165.000) in the federal state Saxony-Anhalt, Germany. DISCUSSION: The main objectives of RHESA are to provide detailed estimates of the burden of AMI in Saxony-Anhalt which is the federal state with the highest AMI mortality rate in Germany and to investigate factors that influence morbidity and mortality rates due to AMI. Data collected in RHESA enable us to assess different levels of quality of health care of patients with AMI (structural, process and outcome). RHESA provides for the first time estimates of the burden of AMI in Saxony-Anhalt, and therefore contributes considerably to an improvement of the German Health Monitoring that strives for a more valid extrapolation of the nationwide morbidity and mortality rates of AMI.

Assessment of the effect of iris colour and having children on 5-year risk of death after diagnosis of uveal melanoma: a follow-up study.

BACKGROUND: To examine the all-cause mortality and uveal melanoma specific mortality among newly diagnosed uveal melanoma patients after five years. Furthermore, we assess of the effect of iris colour and having children on 5-year risk of death after diagnosis of uveal melanoma. Therefore, we assess the performance of an individual prediction model of survival from uveal melanoma. METHODS: A cohort of 459 patients aged 45 to 79 years with newly diagnosed uveal melanoma was recruited between 2002 and 2004 from the Division of Ophthalmology, University of Essen, Germany. Survival probabilities were estimated by Kaplan-Meier survival analysis. The clinical and histopathological characteristics were obtained from medical records. Iris colour and childbearing history were assessed at baseline by a computer-assisted telephone interview. We used crude and multivariable Cox proportional hazards regression to estimate unadjusted and adjusted hazard ratios (HR) and corresponding 95% confidence intervals (95%CIs) with respect to death from uveal melanoma and death from all causes. We used the Cox model to estimate adjusted probabilities of primary events. For computing Harrell's C statistics, we used a Cox model including the prognostics factors gender, age at diagnosis, ciliary body involvement, largest basal tumour diameter, and iris colour. RESULTS: The 5-year uveal melanoma-specific survival probability was 82.9% (95% CI: 79.1-86.3). Main prognostic factors for the death of uveal melanoma were ciliary body involvement (HR: 1.7 (95% CI:1.0-2.8)), largest basal tumour diameter >15 mm HR: 7.0 (95% CI: 3.5-13.9), light iris colour (HR: 2.3 (95% CI: 0.9-5.8), having children (HR: 0.6 (95% CI: 0.2 - 1.7)), and gender (HR: 0.7 (95% CI: 0.4-1.1)). The value of the bootstrap-corrected C statistics was 0.76 (95% CI: 0.74-0.77). CONCLUSION: Beyond the established prognostic factors, light iris colour also appears to be a prognostic factor for death from uveal melanoma.

Nationwide shoulder arthroplasty rates and revision burden in Germany: analysis of the national hospitalization data 2005 to 2006.

BACKGROUND: The aim of this study was to provide nationwide shoulder arthroplasty rates in Germany based on the national hospitalization file and to estimate the revision burden for shoulder arthroplasty and its determinants. METHODS: We analyzed the nationwide, population-based, German diagnosis-related groups data from the years 2005 and 2006. Procedure codes and diagnosis were analyzed for each hospitalization. Overall, 16,488 primary shoulder arthroplasties and 1302 revisions were performed during the study period. Age-standardized rates, age-specific rates, rates by indication, and revision burden were calculated. RESULTS: The age-standardized hemiarthroplasty (HA) rates were 3.6 per 100,000 person-years (standard error [SE], 0.1) for men and 9.3 per 100,000 person-years (SE, 0.1) for women and clearly exceeded the age-standardized total shoulder arthroplasty (TSA) rates of 1.7 per 100,000 person years (SE, 0.1) for men and 3.7 per 100,000 person-years (SE, 0.1) for women. The revision burden was 4.7% for HA and 15.0% for TSA. Multivariable-adjusted analysis showed increasing age was associated with a lower relative burden of revision, and an increased Charlson comorbidity index and male gender were associated with a higher relative burden of revision. The adjusted relative burden of revision was considerably higher for TSA than for HA (adjusted relative burden of revision, 2.89; 95% confidence interval, 2.60-3.22). CONCLUSION: We found more than 2-fold higher primary rates for HA than for TSA and up to 3-fold higher shoulder arthroplasty rates for women than for men. TSA had a 3-fold higher relative burden of revision than HA.

Having children, social characteristics, smoking and the risk of uveal melanoma: a case-control study.

PURPOSE: We analyzed data from the Risk Factors for Uveal Melanoma (RIFA) study to evaluate possible associations between uveal melanoma risk and having children, socioeconomic level and smoking. METHODS: The RIFA study was a German case-control study conducted from September 2002 to March 2005. The study population consisted of 455 incident uveal melanoma patients (20-74 years of age) and 827 matched (age, sex, region of residence) population controls. Odds ratios (OR) and 95% confidence intervals (CI) were estimated using conditional logistic regression. RESULTS: Women with children showed an increased OR (1.59, 95% CI 0.95-2.66) for uveal melanoma development compared to women without children. We estimated decreased ORs for subjects with higher socioeconomic level compared to the lowest status (upper secondary school leaving certificate: OR 0.68, 95% CI 0.49-0.94; higher education: OR 0.60, 95% CI 0.38-0.96). Ever smokers showed an OR of 1.19 (95% CI 0.92-1.55) compared to never smokers. CONCLUSION: The observed association between lower socioeconomic level and increased odds for uveal melanoma possibly represents a higher occupational uveal melanoma risk for occupational categories that are usually associated with lower socioeconomic status. Concerning having children and uveal melanoma development, we hypothesize that the observed association is mediated through alpha-melanocyte-stimulating hormone, a hormone that increases during pregnancy and is linked to pigmentation alterations in pregnant women.

A population-based case-control study on social factors and risk of testicular germ cell tumours.

OBJECTIVES: Incidence rates for testicular cancer have risen over the last few decades. Findings of an association between the risk of testicular cancer and social factors are controversial. The association of testicular cancer and different indicators of social factors were examined in this study. DESIGN: Case-control study. SETTING: Population-based multicentre study in four German regions (city states Bremen and Hamburg, the Saarland region and the city of Essen). PARTICIPANTS: The study included 797 control participants and 266 participants newly diagnosed with testicular cancer of which 167 cases were classified as seminoma and 99 as non-seminoma. The age of study participants ranged from 15 to 69 years. METHODS: Social position was classified by educational attainment level, posteducational training, occupational sectors according to Erikson-Goldthorpe-Portocarrero (EGP) and the socioeconomic status (SES) on the basis of the International SocioEconomic Index of occupational status (ISEI). ORs and corresponding 95% CIs (95% CIs) were calculated for the whole study sample and for seminoma and non-seminoma separately. RESULTS: Testicular cancer risk was modestly increased among participants with an apprenticeship (OR=1.7 (95% CI 1.0 to 2.8)) or a university degree (OR=1.6 (95% CI 0.9 to 2.8)) relative to those whose education was limited to school. Analysis of occupational sectors revealed an excess risk for farmers and farm-related occupations. No clear trend was observed for the analyses according to the ISEI-scale. CONCLUSIONS: Social factors based on occupational measures were not a risk factor for testicular cancer in this study. The elevated risk in farmers and farm-related occupations warrants further research including analysis of occupational exposures.

Prevalence-corrected hysterectomy rates by age and indication in Germany 2005-2006.

PURPOSE: Few studies have examined the age-specific use of hysterectomy by indication. The aim of this study was to provide detailed nationwide age-specific prevalence-corrected hysterectomy rates for several indications in Germany, representing a population of 42 million women. METHODS: Nationwide population-based diagnosis related group data of the years 2005 and 2006 were used to calculate the prevalence-corrected hysterectomy rates by age and indication group. RESULTS: Prevalence-corrected age-standardized hysterectomy rates (any indication) was 362.9 (295.0 for benign diseases of the genital tract and 44.0 for primary malignant tumors of the genital tract) per 100,000 person-year. Corrected hysterectomy rates become increasingly greater than the uncorrected hysterectomy rates, such that they are about 68 % greater for women in the age groups 75-79, 80-84, and 85-89 years. Age-specific hysterectomy rates showed quite different patterns depending on the indication of hysterectomy. For example, hysterectomy rates closely follow the cancer incidence rates up to age 44 for cervical cancer and age 69 for uterine cancer, diverging noticeably in ages thereafter. CONCLUSIONS: The prevalence-corrected hysterectomy rates presented in this study provide a more accurate indication of the use of hysterectomy, which has implications in terms of costs and resource allocation. Understanding the role of hysterectomy in treating selected diseases across the age span is also important for patients and doctors as they consult together about an appropriate course of treatment.

Thyroid cancer surgery in Germany: an analysis of the nationwide DRG statistics 2005-2006.

PURPOSE: In 2004, a Diagnosis Related Groups (DRG)-based hospital reimbursement system became mandatory in Germany. The aim of this study was to provide nationwide data on the surgery of thyroid cancer by analyzing DRG statistics of the years 2005 and 2006. METHODS: The unit of analysis was hospital admission with a diagnosis of thyroid cancer. We assessed the influence of age, sex and region on the relative frequency of thyroid cancer-related hospitalisations with surgery of the thyroid and we measured the association between hospitalisation rates and incidence rates of thyroid cancer among the Federal States of Germany. RESULTS: Over the period 2005 to 2006, 11,107 thyroid cancer-associated hospitalisations included surgical treatment of the thyroid. The age-standardised DRG-based hospitalisation rates and the corresponding cancer registry-based incidences of thyroid cancer were positively associated. Overall, 68% of the hospitalisations with thyroid surgery included a total thyroidectomy. The percentage of surgery of the thyroid with a total thyroidectomy was nearly identical among men and women, decreased among men aged over 60 and varied considerably by region (minimum, 48% in Saarland; maximum, 78% in Saxony-Anhalt). CONCLUSIONS: Our analyses of DRG statistics provide for the first time representative population-based data of the surgical management of thyroid cancer patients in Germany. Despite an identical health care system all over Germany and existing guidelines for surgical treatment of thyroid cancer, we observed a considerable regional variation in the proportion of total thyroidectomies performed in Germany.

Hysterectomy in Germany: a DRG-based nationwide analysis, 2005-2006.

BACKGROUND: Hysterectomy is among the more common surgical procedures in gynecology. The aim of this study was to calculate population-wide rates of hysterectomy across Germany and to obtain information on the different modalities of hysterectomy currently performed in German hospitals. This was done on the basis of nationwide DRG statistics (DRG = diagnosis-related groups) covering the years 2005-2006. METHODS: We analyzed the nationwide DRG statistics for 2005 and 2006, in which we found 305 015 hysterectomies. Based on these data we calculated hysterectomy rates for the female population. We determined the indications for each hysterectomy with an algorithm based on the ICD-10 codes, and we categorized the operations on the basis of their OPS codes (OPS = Operationen- und Prozedurenschlüssel [Classification of Operations and Procedures]). RESULTS: The overall rate of hysterectomy in Germany was 362 per 100 000 person-years. 55% of hysterectomies for benign diseases of the female genital tract were performed transvaginally. Bilateral ovariectomy was performed concomitantly in 23% of all hysterectomies, while 4% of all hysterectomies were subtotal. Hysterectomy rates varied considerably across federal states: the rate for benign disease was lowest in Hamburg (213.8 per 100 000 women per year) and highest in Mecklenburg-West Pomerania (361.9 per 100 000 women per year). CONCLUSION: Hysterectomy rates vary markedly from one region to another. Moreover, even though recent studies have shown that bilateral ovariectomy is harmful to women under 50 who undergo hysterectomy for benign disease, it is still performed in 4% of all hysterectomies for benign indications in Germany.

Nationwide rates of conversion from laparoscopic or vaginal hysterectomy to open abdominal hysterectomy in Germany.

The aim of this study was to provide population-based German-wide hysterectomy rates based on the national hospitalization file and to estimate the rate of conversion from laparoscopical or vaginal hysterectomy to open abdominal hysterectomy. Nationwide population-based DRG (diagnosis related groups) data of the years 2005 and 2006 were used to calculate hysterectomy rates by indication group and type of surgical approach. Overall 305,015 hysterectomies were performed during the study period (4.5 out of 1,000 women aged 20 years or more). The hysterectomy rate for benign diseases of the genital tract among women aged 20 years or more (3.6 out of 1,000 women) is higher than in Sweden but lower than in the US or Australia. Only 6 and 5% of all hysterectomies were performed by laparoscopically assisted vaginal hysterectomy and laparoscopic hysterectomy, respectively. Twenty-six percent of hysterectomies for benign diseases among women aged 50 years or more included bilateral oophorectomy. 10% of laparoscopical hysterectomies and 1% of vaginal hysterectomies necessitated a conversion to an abdominal hysterectomy. For both types of hysterectomies, the conversion rates were highest for primary malignant genital tract cancer and other cancers compared to the other indication groups. Whereas the conversion rate for laparoscopical hysterectomies increased by age, this rate did not change by age for vaginal hysterectomies. Conversion from laparoscopically or vaginal hysterectomy to open abdominal hysterectomy is associated with the indication and type of hysterectomy started with and is considerably higher for laparoscopic than vaginal hysterectomies.

Regional differences in body fat distributions among people with comparable body mass index: a comparison across six German population-based surveys.

INTRODUCTION: The mortality of circulatory diseases of the German population varies considerably across regions. The comparison of the regional distributions of cardiovascular risk factors can provide clues to the reasons for cardiovascular mortality differences. The aim of this study was to determine whether indirect measures of fat distribution within subgroups of comparable body mass indices (BMIs) differ by region in Germany. METHODS: We included six German population-based epidemiological studies conducted between 1997 and 2006 that included a detailed assessment of anthropometric measures including overall 15 215 people aged 45­74 years. We calculated mean values of BMI, waist circumference (WC), hip circumference (HC), and waist-to-hip ratio (WHR). We estimated mean regional differences of WC, HC, and WHR within narrow ranges of BMI. RESULTS: BMI distributions across the study populations were very similar. However, body fat distributions as measured by WC within subgroups of similar BMIs differed considerably across regions. For example, among people with a BMI of 24.0­25.9, estimated WCs were on average 3.4 and 6.7 cm higher among men and women in Saxony-Anhalt than among men and women in Bavaria, respectively. CONCLUSION: We provide evidence that the BMI distributions across six population-based surveys in Germany are very similar and that body fat distributions among people with comparable BMIs show relevant regional differences. Our observed WC differences might contribute to regional cardiovascular disease risk differences in Germany. Our findings may trigger further similar analyses across European populations to explain large area variations of cardiovascular disease burden.

Compliance assessment of ambulatory Alzheimer patients to aid therapeutic decisions by healthcare professionals.

BACKGROUND: Compliance represents a major determinant for the effectiveness of pharmacotherapy. Compliance reports summarising electronically compiled compliance data qualify healthcare needs and can be utilised as part of a compliance enhancing intervention. Nevertheless, evidence-based information on a sufficient level of compliance is scarce complicating the interpretation of compliance reports. The purpose of our pilot study was to determine the compliance of ambulatory Alzheimer patients to antidementia drugs under routine therapeutic use using electronic monitoring. In addition, the forgiveness of donepezil (i.e. its ability to sustain adequate pharmacological response despite suboptimal compliance) was characterised and evidence-based guidance for the interpretation of compliance reports was intended to be developed. METHODS: We determined the compliance of four different antidementia drugs by electronic monitoring in 31 patients over six months. All patients were recruited from the gerontopsychiatric clinic of a university hospital as part of a pilot study. The so called medication event monitoring system (MEMS) was employed, consisting of a vial with a microprocessor in the lid which records the time (date, hour, minute) of every opening. Daily compliance served as primary outcome measure, defined as percentage of days with correctly administered doses of medication. In addition, pharmacokinetics and pharmacodynamics of donepezil were simulated to systematically assess therapeutic undersupply also incorporating study compliance patterns. Statistical analyses were performed with SPSS and Microsoft Excel. RESULTS: Median daily compliance was 94% (range 48%-99%). Ten patients (32%) were non-compliant at least for one month. One-sixth of patients taking donepezil displayed periods of therapeutic undersupply. For 10 mg and 5 mg donepezil once-daily dosing, the estimated forgiveness of donepezil was 80% and 90% daily compliance or two and one dosage omissions at steady state, respectively. Based on the simulation findings we developed rules for the evidence-based interpretation of donepezil compliance reports. CONCLUSIONS: Compliance in ambulatory Alzheimer patients was for the first time assessed under routine conditions using electronic monitoring: On average compliance was relatively high but variable between patients. The approach of pharmacokinetic/pharmacodynamic in silico simulations was suitable to characterise the forgiveness of donepezil suggesting evidence-based recommendations for the interpretation of compliance reports.