Sociodemographic and Environmental Determinants of Regional Prevalence of Psoriasis in Germany: A Spatiotemporal Study of Ambulatory Claims Data.

There are regional differences in the prevalence of psoriasis between countries, as well as within countries. However, regional determinants of differences in prevalence are not yet understood. The aim of this study was to identify sociodemographic and environmental determinants of regional prevalence rates for psoriasis. Analyses were based on German outpatient billing data from statutory health insurance, together with data from databases on sociodemographic and environment factors at the county level (N = 402) for 2015-2017. Descriptive statistics were calculated for all variables. To identify determinants for prevalence at the county level, spatiotemporal regression analysis was performed, with prevalence as the dependent variable, and the number of physicians, mean age, mean precipitation, sunshine hours, mean temperature, level of urbanity, and the German Index of Socioeconomic Deprivation (GISD) as independent variables. Mean prevalence of psoriasis increased from 168.63 per 10,000 in 2015 to 173.54 per 10,000 in 2017 for Germany as a whole, with high regional variation. Five determinants were detected (p < 0.05). The prevalence increased by 4.18 per 10,000 persons with SHI with each GISD unit, and by 3.76 per 10,000 with each year increase in age. Each additional hour of sunshine resulted in a decrease of 0.04 and each °C increase in mean temperature resulted in an increase of 4.22. Each additional dermatologist per 10,000 inhabitants resulted in a decrease of 0.07. In conclusion, sociodemographic and environmental factors result in significant differences in prevalence of psoriasis, even within-country.

Subjective evaluation of home environment and levels of self-reported depression in middle to old age: Results from the HCHS study.

OBJECTIVES: The immediate living environment might, like other lifestyle factors, be significantly related to mental well-being. The current study addresses the question whether five relevant subjective home environment variables (i.e., protection from disturbing nightlight, daylight entering the home, safety at home, quality of window views, and noise disturbance) are associated with levels of self-reported depression over and above well-known sociodemographic and common lifestyle variables. METHODS: Data from the Hamburg City Health Study (HCHS) were analyzed. In N = 8757 with available PHQ-9 depression data, multiple linear regression models were computed, with demographic data, lifestyle variables, and variables describing the subjective evaluation of the home environment. RESULTS: The model explained 15% of variance in depression levels, with ratings for the subjective evaluation of home environment accounting for 6%. Better protection from disturbing light at night, more daylight entering the home, feeling safer, and perceived quality of the window views, were all significantly associated with lower, while more annoyance by noise was associated with higher levels of self-reported depression. Results did not differ if examining a sample of the youngest (middle-aged participants: 46-50 years) versus oldest (70-78 years) participants within HCHS. CONCLUSION: Beyond studying the role of lifestyle factors related to self-reported depression, people's homes may be important for subclinical levels of depression in middle and older age, albeit the direction of effects or causality cannot be inferred from the present study. The development of a consensus and tools for a standardized home environment assessment is needed.

[The impact of the Ahr Valley flood on the health of the local population - an analysis based on SHI routine data]. / Auswirkungen des Ahrtal-Hochwassers auf die Gesundheit der lokalen Bevölkerung ­ eine Analyse auf Grundlage von GKV-Routinedaten.

BACKGROUND: In recent decades, Germany has experienced flood events that posed a threat to the health of the local population. However, there is a paucity of studies on the health consequences of these events. Therefore, the aim of the study was to investigate the health consequences of the Ahr Valley flood in 2021. METHODS: The data basis of this longitudinal study are nationwide billing data (inpatient/outpatient) of the BKK-Landesverband Nordwest. The study region was Ahrweiler and the study periods were the third quarters of 2020 and 2021. Among other things, prevalence rate ratio tests were used to determine which diagnoses (inpatient/outpatient) were spatially and temporally associated with the flood event on the basis of ICD-10 coding. RESULTS: The results show a significant increase in billed services for some diagnosis groups in the inpatient sector. In particular, there was an increase in F diagnoses (mental and behavioural disorders), S diagnoses (injuries) and various diagnosis codes within Z codes (factors influencing health status and leading to healthcare utilisation). In the outpatient sector, a decrease was observed in many diagnosis groups (F and Z diagnoses). CONCLUSION: The results of the study showed that the mental health of the local population was particularly affected by the floods. Healthcare was also affected. As floods are expected to become more frequent and severe in the future, measures to protect the population and health infrastructure need to be adapted accordingly.

Association of early-stage incidence and mortality in malignant melanoma - a population-based ecological study.

BACKGROUND: Germany-wide skin cancer screening was introduced in 2008 to reduce skin cancer mortality and morbidity. However, the effectiveness of the program is still unclear. We explore the relationship between early-stage melanoma incidence and melanoma mortality in subsequent years, using early-stage melanoma incidence as surrogate for screening participation and early detection. PATIENTS AND METHODS: Data on melanoma incidence for 2005-2016 and melanoma mortality for 2005-2018 were obtained for 244 German counties. We investigated the correlation between several measures of incidence and mortality with correlation analyses and linear regressions. RESULTS: Melanoma incidence of early stages (in situ and T1) rose by 69% between pre-screening (2005-2007) and screening period (2008-2010). In contrast, there was no temporal trend in mortality over time. Correlation coefficients between incidence and mortality variables ranged between -0.14 and 0.10 (not significant). Linear regression indicated that mortality 6 years after screening introduction decreases with increasing change in early-stage incidence (b = -0.0029, 95% confidence interval [-0.0066, 0.0007]). CONCLUSIONS: The estimated population-based effects of skin cancer screening on melanoma mortality were minimal and not significant. A potential effectiveness cannot be demonstrated.

Evaluation of skin cancer screening in Germany - Spatiotemporal associations between skin cancer screening and skin cancer mortality based on ambulatory claims data.

BACKGROUND: There are regional differences in skin cancer screening uptake in Germany. So far, it is unclear whether a high uptake of screening services leads to a reduction in mortality. This article presents study results on the investigation of spatiotemporal associations between skin cancer screening and mortality. The methods used are discussed regarding their suitability. MATERIAL AND METHODS: The basis is ambulatory claims data on the utilization of early skin cancer detection as well as data on skin cancer mortality from the cause-of-death statistics of the years 2011-2015 at county level in Germany. In addition to a descriptive evaluation, spatiotemporal cluster analyses and regression models were used to investigate the relationship between the uptake of early detection and mortality. In addition to age, adjustments were also made for other selected socio-economic and socio-graphical variables. RESULTS: The descriptive results show striking spatial patterns of skin cancer screening and mortality. Cluster analyses identified regions with significantly higher and lower cases of early detection and skin cancer mortality. The spatiotemporal regression analyses show no clear association. Only early detection by a dermatologist, adjusted for age, shows an association with mortality. CONCLUSIONS: No clear association between early skin cancer detection and mortality can be derived from the results. However, the study design used with a spatiotemporal cluster and regression analysis has shown that these methods allow in-depth statements about the relationship between early skin cancer detection and mortality.

Evaluation of early skin cancer detection in Germany with cancer registry data - challenges, solutions and current trends.

BACKGROUND AND AIMS: The evidence for the benefit of the skin cancer screening introduced in Germany in 2008 is weak. We investigate to what extent data from the German epidemiological cancer registries are suitable to contribute to the evaluation of skin cancer screening and report these evaluation results. MATERIAL AND METHODS: Skin cancer-related cancer registry data from 1999-2019 were described in terms of completeness and comprehensiveness. Regional pools with data of different validity were defined, missing data were multiply imputed where appropriate, and temporal trends were analyzed. In addition, data from the cause of death statistics were used. RESULTS: Reliable estimates of completeness are only available for malignant melanoma (ICD-10: C43). Based on a regional data pool covering approximately 21% of the German population, melanoma-related incidence can be validly described since 2005. Sufficient information for multiple imputation is available for T-stage and localization. The trend analyses show incidence changes that can be expected in the short term in the temporal context of the introduction of early detection, which changes into a long-lasting high incidence. The rate of advanced stages does not decrease significantly. From 2014 onwards, the melanoma mortality rate, which had been rising until then, decreases. CONCLUSIONS: Adequately selected and processed cancer registry data are suitable for population-based evaluation of skin cancer screening. An explanation of the persistently high incidence level is not possible based on the cancer registry data. Overdiagnosis or an increase in the background incidence can be considered. The benefit of skin cancer screening remains open.

Evaluation of skin cancer screening in Germany - participation, tumor detection and interval tumors based on SHI data.

BACKGROUND AND GOALS: The rising incidence of skin cancer in Germany has increased the need for secondary prevention measures. For this purpose, a statutory skin cancer screening for insured persons aged 35 and older was introduced on 1 June 2008. The aim of this work package in the Innovation Fund project "Perspectives of a multimodal evaluation of early skin cancer detection" (Pertimo) was to test an evaluation of skin cancer screening using secondary data. PATIENTS AND METHODS: The data basis was statutory insured persons of the DAK Health from the age of 35 who were insured as of 31 December 2010 and were followed up until the end of 2015. The rates of participation, skin tumors detected in skin cancer screening (tumor detections), and interval tumors that occurred within two years after a finding-free skin cancer screening were calculated. RESULTS: The biennial skin cancer screening take-up rate in 2014 and 2015 was 33.6% for women and 32.6% for men. Of those screened, 4.2% had a skin cancer finding (tumor detection) in the course of skin cancer screening. Of all incident skin cancer diagnoses (2012-2015), 50.1% were detected in skin cancer screening. In 1.5% of the insured persons with skin cancer screening without findings, an incidental skin tumor was diagnosed in the following two years (interval tumor). CONCLUSIONS: The data from the statutory health insurance mapped the skin cancer screening occurrence in Germany and highlighted the importance of dermatologists in the screening process. The analysis provided important new insights.

[Predictors of Utilization of Cardiovascular and Respiratory Emergency Department Visits - what Impact does the Environment have?] / Prädiktoren der Inanspruchnahme von kardiovaskulären und respiratorischen Notfallaufnahmen ­ welchen Einfluss hat die Umwelt?

AIM: There has been an increasing number of emergency department (ED) visits recently. It is unclear whether, in addition to a shift in services from the outpatient to the inpatient sector, other causes, (e. g. environmental factors), play a role. The aim was to investigate associations between the number of cardiovascular and respiratory ED visits and environmental variables. METHODS: Highly correlated environmental data were subjected to a principal component analysis. By using cross-correlation functions, environmental variables with time lags that showed the highest correlation with the number of ED visits were taken into consideration in the UNIANOVA analysis model, together with, among others, the day of the week and interaction terms. RESULTS: The final regression model explained 47% of the variation in respiratory ED visits demonstrating main effects for Mondays (B=10.69; p<0.001). Season showed significant effects with highest ED visits in autumn. No direct associations between environmental variables and number of respiratory ED visits were found. The results for the cardiovascular outcome were less expressive (R2=0.20). Again, the day of the week had the main effect on cardiovascular ED visits (p<0.001). CONCLUSIONS: The results suggest that weekdays had the main effect on ED visits. In future, we will collect and analyze environmental data at the micro level to achieve a higher model quality and better interpretability.

Comparison of patient pathways in the early detection of skin cancer - a claims data analysis.

BACKGROUND: Regarding skin cancer screening, patients in Germany have the choice between a direct screening by dermatologists or an initial screening by general practitioners followed by dermatological screening if further examination is required. The aim of this study is to evaluate whether screening by general practitioners is associated with risk selection in subsequent dermatological screenings. PATIENTS AND METHODS: We conducted a retrospective observational study based on claims data from a German health insurance company (Barmer GEK). Patient pathways in skin cancer screenings between 2008 and 2016 were analyzed, and differences between the two groups were tested at 95 % confidence intervals. RESULTS: A total of 495,000 initial and 111,000 secondary examinations by dermatologists were analyzed. The proportion of subsequent excisions was lower in initial screenings by dermatologists. To diagnose one person with non-melanoma skin cancer or melanoma, five or 23 to 42 excisions were necessary, depending on the type of excision considered. The number of examinations to identify one patient ranged from 25 to 53 for non-melanoma skin cancer and 42 to 165 for melanoma. For melanoma, the number of excisions and screenings to diagnose skin cancer was lower in secondary examinations. CONCLUSIONS: The results indicate a risk selection through initial examinations by general practitioners. However, there are other aspects that should be taken into account when comparing the two pathways.

Inpatient care for skin diseases in Germany: multi-source analysis on the current and future health care needs.

BACKGROUND: In Germany, skin diseases are mainly treated in the 115 dermatological hospitals. METHODS: Health care and health economic analysis of dermatological inpatient care and prediction of future care needs based on primary and secondary data. RESULTS: Outpatient and inpatient care for dermatologic treatment indications is predominantly provided by dermatology specialists. Inpatient treatment was provided for 833,491 cases in 2018, corresponding to 4.21 % of all inpatient cases (19,808,687). Most common treatment cases were: epithelial skin cancer (total 87,386, of which dermatology clinics 52,608), followed by melanoma (23,917/17,774), psoriasis (19,291/13,352), erysipelas (73,337/11,260), other dermatitis (12,671/10,842), atopic dermatitis (AD) (11,421/9,734), and herpes zoster (26,249/9,652). With an average length of stay of 5.69 days, dermatology hospitals were in the bottom third. The proportion of inpatient indications cared for in dermatology hospitals was highest for prurigo (95.2 %), pemphigus (94.9 %), parapsoriasis (94.6 %), pemphigoid (90.3 %), eczema other than AD (85.6 %), and AD (85.2 %). While the total number of inpatient treatment cases in Germany has increased by an average of 17.5 % between 2000 and 2018, this is the case for 26.6 % of skin diseases and over 150 % for individual ones. The projection of current to future inpatient care suggests a continued high demand for inpatient care by dermatology hospitals. CONCLUSION: Inpatient dermatological care will continue to be an indispensable component of qualified, socially necessary care in Germany.

[Geographic methods for health monitoring]. / Geografische Ansätze in der Gesundheitsberichterstattung.

The interest in using geographic methods for health monitoring has grown strongly over the last two decades. Through these methods, analysis and visualization of health data can be more focused and target-group specific. The application in health monitoring is possible mostly due to broader technical possibilities and more available datasets. In this article, we show which geographic aspects are adapted in health monitoring at different levels (federal, state, municipality).For example, at the federal level, surveillance methods are used; at the state level health atlases are created; and on the municipality level geographic analyses are performed for possible public health interventions.Methods range from simple maps on different levels of aggregation to more complex methods like space-temporal visualization or spatial-smoothing methods. While the technical possibilities are in place, a broader implementation of geographic methods is mostly hindered by missing data access to small-area information and data protection policies. Better access to data could especially improve the possibility for geographic methods in health monitoring and could inform the population and decision makers to inform and improve population health or healthcare.

[Determinants of the Distance-Related Choice of Physician Using the Example of Patients with Psoriasis and Chronic Wounds]. / Einflussfaktoren auf die distanzbezogene Arztwahl am Beispiel von Patienten mit Psoriasis und chronischen Wunden.

STUDY AIM: There is only little knowledge about the influence of individual and sociodemographic characteristics determining patients' choice of their physicians. Furthermore, the role of patients' mobility is not clear. The primary aim of this study was the analysis of patients' decision patterns when choosing a physician. Patients' mobility as well as sociodemographic aspects were included in the analysis. METHODS: A multicenter cross-sectional study was conducted. Data were assessed at office-based dermatologists and at the University Medical Center Hamburg-Eppendorf. Patients with psoriasis and chronic wounds were interviewed about their behaviour when choosing a physician. Data analysis was performed using descriptive and multivariate methods. RESULTS: Data on 309 patients (50.5% male, mean age 58.3 years) were analysed. 211 patients were recruited at the outpatient unit of the university clinic, 98 at office-based physicians. The decision to visit a physician is primarily influenced by the physicians' competence, his range of service and the physician-patient relationship. The perspective of a better therapy as well as worsening of quality of life are responsible for a higher motivation to travel a longer distance to the physician. CONCLUSION: The results show a complex behaviour pattern of patients when choosing a physician. The physician's competence and his range of services are crucial for the patients' decision. The results also show that patients are willing to travel longer distances than necessary.

Estimating prevalence and incidence of skin cancer in Germany.

BACKGROUND AND OBJECTIVES: The aim of the present study was to determine the prevalence and incidence of skin cancer. PATIENTS AND METHODS: We calculated prevalence and incidence for cutaneous melanoma (CM) and non-melanoma skin cancer (NMSC) in 2012 in Germany, using claims data of 2.1 million insured persons. In order to allow statements concerning differences between subgroups, we calculated 95 % confidence intervals. Finally, we standardized prevalence and incidence with regard to the German population. RESULTS: The prevalence and incidence of CM amounted to 0.12 % and 0.04 % and increased with age. For NMSC these measures were 0.65 % and 0.15 %. Of the prevalent and incident patients, 88.9 % and 87.4 % (CM) and 99.4 % and 98.8 % (NMSC) respectively were at early stages. A projection on the whole population resulted in 75,419 persons affected by CM and 376,004 persons affected by NMSC, including 24,075 (CM) and 84,618 (NMSC) incident patients. CONCLUSIONS: In this study, we defined epidemiological measures according to the number of patients affected by skin cancer and having a medical consultation indicating a need for treatment. These results can serve in future research as a data basis for analysis of health service demand in skin cancer patients and the associated costs.

[Health Atlases in Germany - An Overview]. / Gesundheitsatlanten in Deutschland ­ eine Übersicht.

AIM OF THE STUDY: There has been a steady increase in the interest in regional health analysis. This is reflected both in national and international publications of health atlases. The aim of this study was to examine the current national health atlases, as instruments of communication, in a comparative analysis. METHODS: First, a systematic internet search was done using Google, Unbubble and Bing. Prior to that, the term "Atlas", search terms (e. g., atlas, health) and inclusions (e. g., period, language) had been defined. To categorize the result, 12 categories (e. g., data base, topics) and 89 attributes (e. g., epidemiology, drugs) were created. The results found were allocated to these categories and attributes in a matrix. RESULTS: 49 results were found, corresponding to the inclusion criteria. Only 16 of all results were an atlas in terms of the definition. The other findings can be classified as "reports with maps". Epidemiology and health care structure were a topic in 30 and 32, respectively of all the findings. Health care costs and prevention were found in 17 and 16 of all cases, respectively. CONCLUSIONS: The study has identified a variety of health atlases. However, the vast majority of all findings could be categorized as a report with maps of a different quality and not as atlases. Nevertheless, the analysis shows the basic interest in regional topics in the form of atlases for health sciences.

Regionale fachärztliche Versorgung und demographischer Wandel in Deutschland - Szenarien zur dermatologischen Versorgung im Jahr 2035.

HINTERGRUND: Mithilfe der Bedarfsplanungsrichtlinie des Gemeinsamen Bundesausschusses soll die medizinische Versorgung in Deutschland flächendeckend sichergestellt werden. Kalkulatorische Größe zur Abbildung der räumlichen Versorgungssituation ist der "korrigierte Versorgungsgrad". Vor dem Hintergrund des demographischen Wandels und bereits heute existenter Wiederbesetzungsschwierigkeiten steht die Frage, wie sich die dermatologische Versorgung kleinräumig entwickeln wird. METHODIK: Mit bundesweiten Daten zu Hautarztstandorten sowie aktuellen und prognostizierten Bevölkerungszahlen auf Kreisebene wurde auf Basis der aktuellen Bedarfsplanungsrichtlinie der korrigierte Versorgungsgrad in drei Wiederbesetzungsszenarien (Szenario 1: 100%ige Wiederbesetzung, Szenario 2: Wegfall eines Arztsitzes je Planungsbereich, Szenario 3: Wegfall von zwei Arztsitzen in ländlichen Planungsbereichen) für das Prognosejahr 2035 exemplarisch berechnet. ERGEBNISSE: Während sich in Szenario 1 die Versorgungssituation von 2014 auf 2035 in einigen Teilräumen sogar verbessern würde (n = 3 nicht mehr unterversorgt), zeigen die wahrscheinlicheren Szenarien 2 und 3 mit dem Wegfall einzelner Arztstandorte und dem altersselektiven Wanderungsverhalten, dass ganze Regionen in die Unterversorgung gelangen könnten. SCHLUSSFOLGERUNGEN: Es ist davon auszugehen, dass die räumliche Heterogenität der dermatologischen Versorgung unter Berücksichtigung des demographischen Wandels zunehmen wird. Weitere Anstrengungen in der Bedarfsplanung, aber auch hinsichtlich kreativer Versorgungsmodelle und interkommunaler Kooperation sind erforderlich, um die Versorgung dem demographischen Wandel sowie veränderten Lebensentwürfen junger Mediziner anzupassen.

Regional healthcare delivery and demographic change in Germany - scenarios for dermatological care in 2035.

BACKGROUND: The 'demand planning guidelines' issued by the Federal Joint Committee are meant to ensure nationwide delivery of healthcare in Germany. The calculatory variable used to reflect the actual care situation in relation to a given geographical entity is referred to as 'adjusted supply rate'. Against the backdrop of demographic change and already existing problems in replacing retiring physicians, the question arises as to how future dermatological care will evolve at the regional level. METHODS: Using current 'demand planning guidelines' as well as nationwide data on the location of dermatologists and current and projected population figures at the county level, the adjusted supply rate - in terms of dermatological care - was calculated for the year 2035 based on three possible scenarios (scenario 1: 100 % replacement of retiring dermatologists; scenario 2: non-replacement of one dermatologist per planning area; and scenario 3: non-replacement of two dermatologists in rural areas). RESULTS: While scenario 1 shows an actual improvement in regional dermatological care in certain areas between 2014 and 2035 (n = 3 no longer undersupplied), the more likely scenarios 2 and 3 are potentially associated with considerable regional undersupply. CONCLUSIONS: Taking demographic change into account, it is safe to assume that the geographical heterogeneity of dermatological care will increase. This requires greater effort not only in terms of demand planning but also with regard to offering alternative methods of delivering healthcare and intercommunal cooperation. In this context, the objective will be to adapt healthcare delivery to changes both in demography as well as in the plans young physicians have for their own lives.