Which factors influence the participation in statutory skin cancer screenings in Germany?

BACKGROUND AND OBJECTIVES: Due to increasing skin cancer incidence, Germany implemented a statutory nationwide routine skin cancer screening (rSCS) in 2008. The present study aims (1) to analyze which patient factors are associated with the participation in rSCS in Germany and (2) to investigate reasons for nonparticipation. PATIENTS AND METHODS: Participants and nonparticipants of rSCS (≥ 35 years) were recruited in routine care in nine dermatological outpatient clinics. Reasons for (non-)participation, knowledge about skin cancer as well as clinical and socioeconomic data were obtained. Stratified by groups, descriptive analyses and binary logistic regression analyses for associations with participation were performed. RESULTS: Of the 294 rSCS participants and 162 non-participants, 46.5% were male with a mean age of 54.5 ± 12.7 years. In total, 87.1% had sunburns in childhood and 47.1% used sunbeds before. Higher age, female gender, previous sunbed use, and concern for and knowledge of skin cancer were significantly associated with previous rSCS participation. Of the non-participants, 46% were unaware of the option for free rSCS and 40% justified their nonparticipation on the basis of feeling healthy. CONCLUSIONS: The reasons for nonparticipation in rSCS, such as sociodemographic characteristics and risk behavior, should be known in order to optimize rSCS programs.

Welche Faktoren beeinflussen die Teilnahme am gesetzlichen Hautkrebsscreenings in Deutschland?: Which factors influence the participation in statutory skin cancer screenings in Germany?

BACKGROUND AND OBJECTIVES: Due to increasing skin cancer incidence, Germany implemented a statutory nationwide routine skin cancer screening (rSCS) in 2008. The present study aims (1) to analyze which patient factors are associated with the participation in rSCS in Germany and (2) to investigate reasons for nonparticipation. PATIENTS AND METHODS: Participants and nonparticipants of rSCS (≥ 35 years) were recruited in routine care in nine dermatological outpatient clinics. Reasons for (non)participation, knowledge about skin cancer as well as clinical and socioeconomic data were obtained. Stratified by groups, descriptive analyses and binary logistic regression analyses for associations with participation were performed. RESULTS: Of the 294 rSCS participants and 162 nonparticipants, 46.5% were male with a mean age of 54.5 ± 12.7 years. In total, 87.1% had sunburns in childhood and 47.1% used sunbeds before. Higher age, female gender, previous sunbed use, and concern for and knowledge of skin cancer were significantly associated with previous rSCS participation. Of the nonparticipants, 46% were unaware of the option for free rSCS and 40% justified their nonparticipation on the basis of feeling healthy. CONCLUSIONS: The reasons for nonparticipation in rSCS, such as sociodemographic characteristics and risk behavior, should be known in order to optimize rSCS programs.

Spatial characteristics of non-communicable diseases and their associations to social conditions in a large urban cohort in Germany-Results from the Hamburg City Health Study.

BACKGROUND: Non-communicable diseases (NCDs) are responsible for many deaths. They are associated with several modifiable and metabolic risk factors and are therefore prone to significant regional variations on different scales. However, only few intra-urban studies examined spatial variation in NCDs and its association with social circumstances, especially in Germany. Thus, the present study aimed to identify associations of personal risk factors and local social conditions with NCDs in a large German city. METHODS: This study is based on a population-based cohort of the Hamburg City Health Study including 10,000 probands. Six NCDs were analyzed (chronic obstructive pulmonary disease [COPD], coronary heart disease [CHD], diabetes mellitus, heart failure, depression, and hypertension) in 68 city district clusters. As risk factors, we considered socio-demographic variables (age, sex, education) and risk behaviour variables (smoking, alcohol consumption). Logistic regression analyses identified associations between the district clusters and the prevalence rates for each NCD. Regional variation was detected by Gini coefficients and spatial cluster analyses. Local social condition indexes were correlated with prevalence rates of NCDs on city district level and hot-spot analyses were performed for significant high or low values. RESULTS: The analyses included 7,308 participants with a mean age of 63.1 years (51.5% female). The prevalence of hypertension (67.6%) was the highest. Risk factor associations were identified between smoking, alcohol consumption and education and the prevalence of NCDs (hypertension, diabetes, and COPD). Significant regional variations were detected and persisted after adjusting for personal risk factors. Correlations for prevalence rates with the local social conditions were significant for hypertension (r = 0.294, p < 0.02), diabetes (r = 0.259, p = 0.03), and COPD (r = 0.360, p < 0.01). CONCLUSIONS: The study shows that regional differences in NCD prevalence persist even after adjusting for personal risk factors. This highlights the central role of both personal socio-economic status and behaviors such as alcohol and tobacco consumption. It also highlights the importance of other potential regional factors (e.g. the environment) in shaping NCD prevalence. This knowledge helps policy- and decision-makers to develop intervention strategies.

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.

[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.

PsoBarrier EU study: a Multicentre, Cross-sectional Survey Investigating the Quality of Psoriasis Care in Four European Countries.

Enhanced treatment options for psoriasis and growing use of guidelines increased the potential to better quality of psoriasis care in Europe. The aim of the PsoBarrier EU study is to compare the quality and processes of psoriasis care in four European countries with different healthcare systems, based on validated quality indicators. This cross-sectional survey was conducted in dermatology centres in Denmark, Germany, Poland and Spain on 1,304 patients, using standardized patient and physician questionnaires. Measured by quality of psoriasis care indicators, patients in Poland had the most critical outcomes, such as the highest disease severity (Psoriasis Area and Severity Index; PASI) and lowest health-related quality of life (Dermatology Life Quality Index; DLQI). This indicates differences in psoriasis care, with Polish participants experiencing more severe psoriasis and its consequences. Differences in the healthcare systems, which create barriers to accessing treatments, could explain variations in quality of care.

Spatial Aspects of Health-Developing a Conceptual Framework.

Numerous studies and models address the determinants of health. However, in existing models, the spatial aspects of the determinants are not or only marginally taken into account and a theoretical discussion of the association between space and the determinants of health is missing. The aim of this paper is to generate a framework that can be used to place the determinants of health in a spatial context. A screening of the current first serves to identify the relevant determinants and describes the current state of knowledge. In addition, spatial scales that are important for the spatial consideration of health were developed and discussed. Based on these two steps, the conceptual framework on the spatial determinants of health was derived and subsequently discussed. The results show a variety of determinants that are associated with health from a spatial point of view. The overarching categories are global driving forces, policy and governance, living and physical environment, socio-demographic and economic conditions, healthcare services and cultural and working conditions. Three spatial scales (macro, meso and micro) are further subdivided into six levels, such as global (e.g., continents), regional (e.g., council areas) or neighbourhood (e.g., communities). The combination of the determinants and spatial scales are presented within a conceptual framework as a result of this work. Operating mechanisms and pathways between the spatial levels were added schematically. This is the first conceptual framework that links the determinants of health with the spatial perspective. It can form the working basis for future analyses in which spatial aspects of health are taken into account.

Psoriasis comorbidities in Germany: A population-based study on spatiotemporal variations.

Psoriasis is a chronic disease with high impact on patients' health and their quality of life. Psoriasis often occurs along with other comorbidities, but it is not yet clear what role the comorbidities play in regional psoriasis prevalence. This study investigates the temporal and regional variation of the psoriasis comorbidities diabetes mellitus type II, obesity, hypertension, affective disorders in Germany and their association with psoriasis prevalence. This analysis based on the population set of ambulatory claims data (2010-2017) of the statutory health insurance (SHI) in Germany (approx. 70.3 million people in 2017). Psoriasis comorbidities rates were determined on county level. We performed descriptive spatiotemporal analyses of psoriasis comorbidity prevalence rates. In addition, we identified and compared spatial clusters and examined regional variations using spatial statistical methods. The results show strong regional variations (northeast to south gradient) and an increasing psoriasis prevalence (max. 28.8%) within the observation period. Considering the comorbidities, results indicate comparable spatial prevalence patterns for diabetes mellitus type II, obesity and hypertension. This means that the highest prevalence of comorbidities tends to be found where the psoriasis prevalence is highest. The spatiotemporal cluster analyses could once again confirm the results. An exception to this is to be found in the case of affective disorders with different spatial patterns. The results of the studies show the first spatiotemporal association between psoriasis prevalence and comorbidities in Germany. The causalities must be investigated in more detail in order to be able to derive measures for improved care.

Associations between a Subjective Living Environment and Quality of Life among People with Arterial Hypertension-Results from the Hamburg City Health Study.

Hypertension is a global public health concern and an important contributor to cardiovascular disease. It remains disputed how important life circumstances are for the etiology of hypertension. Thus, the aim of this study is to assess the spatial variation of hypertension within an urban population and to investigate the association with the quality of life of city dwellers and their subjective evaluation of their residential district, as well as their home environment, using the example of Hamburg, Germany. In this cross-sectional study, the first 10,000 participants from the Hamburg City Health Study (HCHS) were analysed. Only participants who had resided at the current address for a minimum of five years were considered. In the descriptive analysis, participants with and without arterial hypertension were compared considering various parameters. The subjective quality of the living environment was obtained using an appropriate subjective living environment index. Quality of life was mapped using the EuroQol Group quality of life questionnaire (EQ-5D) score and the two (mental and physical health) scores of the Short Form Health Questionnaire SF-8. The Gini-coefficient was used to quantify the regional economic variation within Hamburg. Linear and logistic regression analyses were performed. Regional levels were 68 city district clusters in Hamburg. The analysis included n = 8192 participants living at least five years in Hamburg at the time of participation in the HCHS. There was a spatial variation in the prevalence of arterial hypertension within Hamburg. Prevalence rates between city district clusters ranged from 50.0% to 88.5%. The results showed that city district clusters with a worse subjective perception of the living environment were partly associated with an increased prevalence of arterial hypertension. Furthermore, a negative association was observed between arterial hypertension prevalence and the sociodemographic status of participants in the city district clusters. Thus, participants with a high level of education suffered less frequently from arterial hypertension than participants with a rather low level of education. The subjective living environment index and quality of life were significantly related to the occurrence of arterial hypertension; however, more extensive and detailed studies are necessary to derive possible clinical implications.

Regional variations and prevalence of psoriasis in Germany from 2010 to 2017: a cross-sectional, spatio-epidemiological study on ambulatory claims data.

OBJECTIVES: Global prevalence rates of psoriasis differ significantly, with lowest rates in the equator region and increasing tendencies towards the north but also differences within-country. Information on regional variations in Germany is missing. This study aims to analyse the change of psoriasis prevalence in Germany over time and to detect regional variations. DESIGN: Cross sectional, spatio-epidemiological study on regional psoriasis prevalence in Germany. SETTING: Claims data study based on nationwide outpatient billing data on county level. METHODS: Analyses based on outpatient billing data for 2010-2017 derived from all people insured in statutory health insurances (about 72.8 million). We performed descriptive spatio-temporal analyses of prevalence rates using probability mapping and statistical smoothing methods, identified spatial clusters and examined a north-south gradient using spatial statistics. RESULTS: The prevalence increased from 147.4 per 10 000 in 2010 to 173.5 in 2017. In 2017, counties' prevalence rates ranged between 93.8 and 340.9. Decreased rates occurred mainly in southern counties, increased rates in northern and eastern counties. Clusters of low rates occur in southern and south-western Germany, clusters of high rates in the north and north-east. The correlation between counties' latitudes and their prevalence rates was high with Pearson's r=0.65 (p<0.05). CONCLUSION: Increased prevalence of psoriasis over time and marked regional variations in Germany were observed which need further investigation.

Social participation of people with chronic wounds: A systematic review.

Living with chronic ulcers can be burdensome and restrictive, with regard to not only physical and psychological but also social well-being. This review aims to analyse social participation in patients with chronic wounds and to compare results across different wound types. A search string was applied in several electronic databases. Results were screened according to predefined inclusion and exclusion criteria. Data of eligible articles were extracted and synthesised narratively. The search revealed 42 eligible publications. Only minor differences across different ulcer types could be detected. Overall, family members were the main social contacts for patients; they often provided wound care and emotional support. Patients had few non-family relations, but those existing were often very close. Patients felt guilty as their condition imposed burden on family and friends, as well. A close relationship with nurses was described. Restrictions were caused by direct and indirect consequences of the wound. Overall, social support and social connections were reduced in wound patients. Inconsistent results were found regarding social isolation. In summary, people with chronic wounds experience impairments in all aspects of social participation. Therefore, social participation deserves increased attention in routine care both as a trigger of burden and as an outcome of therapy.

Challenges and lessons learned from using anchoring vignettes to explore quality of life response behavior.

PURPOSE: Asking patients to rate health-related quality of life (HRQoL) of hypothetical individuals described in anchoring vignettes has been proposed to enhance knowledge on how patients understand and respond to HRQoL questionnaires. In this article, we describe the development of anchoring vignettes and explore their utility for measuring response shift in patients' self-reports of HRQoL. METHODS: We conducted an explorative mixed-methods study. One hundred patients with multiple sclerosis or psoriasis participated in two interviews at intervals of 3-6 months. During both interviews, patients assessed HRQoL of 16 hypothetical individuals on the SF-12 questionnaire (two vignettes for each of the eight domains of the SF-12). In addition to these quantitative ratings, we used the think-aloud method to explore changes in patients' verbalization of their decision processes during vignette ratings. RESULTS: Agreement of vignette ratings at baseline and follow-up was low (ICCs < 0.55). In addition, paired sample t-tests revealed no significant directional mean changes in vignette ratings. Thus, ratings changed non-directionally, neither confirming retest reliability nor a systematic change of assessment. Furthermore, patients' verbalization of their decision processes did not indicate whether or not the assessment strategy of individual patients had changed. CONCLUSIONS: Patients' ratings of anchoring vignettes fluctuate non-directionally over time. The think-aloud method appears not to be informative in exploring whether these fluctuations are due to changes in the individual decision process. Overall, vignettes might not be an appropriate approach to explore response shift, at least with regard to the specific target population and the use of the SF-12.

Economic evaluation of a tertiary prevention program for occupational skin diseases in Germany.

BACKGROUND: Occupational skin diseases (OSDs) are the most common work-related diseases in Germany and responsible for a large individual and financial burden. Therefore, a tertiary individual prevention program (TIP) is offered to patients with severe OSD who are at increased risk of abandoning their profession. OBJECTIVES: To define cost of illness (COI) of OSD in Germany and to economically evaluate the TIP from a societal perspective. METHODS: In this study, data on patients taking part in the TIP (September 2005 to December 2009) were collected. Sociodemographic and medical data, costs, disease severity (Osnabrueck Hand Eczema Severity Index), and quality of life (QoL; Dermatology Life Quality Index) were assessed. COI and cost-effectiveness analyses were performed with a simulated control group. RESULTS: In the analysis, 1041 patients were included. Intervention costs per person were €15 009 with decreasing COI over time. The incremental cost-effectiveness ratio revealed expenses per patient of €8942 for a reduction in severity level and €9093 for an improvement in QoL in the base case. Considering costs for retraining, the break-even point is reached if the TIP prevents retraining in approximately 64% of participants. CONCLUSIONS: The decreased COI in this long-term evaluation indicates that the TIP is cost-effective in patients with severe OSD.

[Access to statutory skin cancer screening : Organizational and regional factors in Germany]. / Zugang zum gesetzlichen Hautkrebsscreening : Organisatorische und regionale Faktoren in Deutschland.

BACKGROUND: In 2008, statutory skin cancer screening (gesetzliches Hautkrebsscreening, gHKS), conducted by dermatologists or general practitioners, was introduced in Germany. The aim was earlier detection of cancer and therefore improved health care delivery. To assess the success of the gHKS and to increase utilization, the opinion of the population on access to the gHKS is of great relevance. OBJECTIVES: The study examines administrative and regional factors of access to the gHKS in Germany. MATERIALS AND METHODS: In this cross-sectional study, a nationwide survey was conducted among statutory health insured persons aged 18 and over. They were interviewed by telephone about the gHKS with focus on the access to the gHKS. Descriptive statistics and subgroup analysis based on sociodemographic variables and physician specialties were performed. RESULTS: Overall, 1015 people were interviewed, of whom 359 (35.4%) had already utilized the gHKS. Most of them (38.3%) were informed about this service by their general practitioner. Most respondents (70%) preferred having the dermatologists conduct the screening and more participants consulted the dermatologist than the general practitioner for it (76% vs. 24%). At the dermatologist, the travel time to the gHKS was more often longer than 30 min (12% vs. 1%, p < 0.05) and the waiting times for appointments were more often longer than 2 weeks (67% vs. 18%, p < 0.05). Regional differences were identified for travel times and the choice of travel modalities. CONCLUSIONS: The participants of the study preferred having a dermatologist conduct the gHKS. The dermatologist was also consulted more frequently by the gHKS participants. However, access in terms of travel and waiting times for the gHKS was longer at the dermatologist than at the general practitioner.

Recall of health-related quality of life: how does memory affect the SF-6D in patients with psoriasis or multiple sclerosis? A prospective observational study in Germany.

OBJECTIVE: This study aimed to quantify recall bias in the measurement of health-related quality of life (HRQoL), that is, the extent to which recollection is impaired and leads to distorted judgements. DESIGN: Prospective observational study. SETTING AND PARTICIPANTS: One hundred patients with two paradigmatic chronic diseases (50 with multiple sclerosis and 50 with psoriasis) were recruited at two outpatient clinics. METHODS AND OUTCOME MEASURES: Patients completed the online version of the 12-Item Short Form Survey (SF-12) repeatedly for 28 consecutive days: (1) daily, considering the past 24 hours; (2) weekly, considering the past 7 days; and (3) on the last day of data collection, considering the past 4 weeks. SF-12 scores for all three measurement approaches were subsequently converted into preference-based utility indices (Short-Form Six-Dimension). Agreement of the three indices was analysed on group and individual patient levels. RESULTS: The mean age of participants was 40.3 years (±12.0), and 63% were female. The utility index based on daily recall (0.74±0.13) was more positive than indices based on a weekly (0.70±0.13, p<0.001) or a monthly (0.70±0.14, p<0.001) recall. While agreement of measurement approaches was high on group level (intraclass correlation coefficient>0.85), it was lower for the subgroup of patients experiencing high variability of HRQoL over time. Bland-Altman plots revealed considerable differences on individual patient level. CONCLUSIONS: On the group level, retrospective overestimation and underestimation of HRQoL almost cancelled out one another and recall bias was relatively small. Therefore, a 4-week recall period could be appropriate when group-level data are used for research or economic evaluations. In contrast, recall bias can be considerable on the individual patient level and may thus impact decision-making in clinical practice. TRIAL REGISTRATION NUMBER: VfD_RECALL_16_003837.

Towards patients' understanding of health-related quality of life-a mixed-method study in psoriasis and multiple sclerosis.

PURPOSE: Patients' individual understanding of health-related quality of life (HRQoL) varies widely, making the measurement of this complex and subjective construct challenging. Anchoring vignettes, i.e., descriptions of fictive patients may provide insights into patients' individual questionnaire reference frames, assessment processes, and understanding of HRQoL. This study analyzes how patients assess HRQoL of vignettes. METHODS: This exploratory mixed-method study included 100 patients with a chronic disease (50 multiple sclerosis (MS); 50 psoriasis). Sixteen vignettes, two for each domain of the SF-12v2, were developed based on literature recommendations and pretested in a convenience sample of seven healthy individuals. Patients assessed their own HRQoL and HRQoL of the vignettes on the SF-12v2. In semi-structured interviews, they justified their assessments. We quantitatively analyzed associations of vignette assessments with individual characteristics using linear regression models and qualitatively analyzed assessment justifications. RESULTS: Patients' age and disease were significant (p < 0.05) predictors for ten and seven vignette assessments, respectively. Older patients assessed vignettes being less extreme; patients diagnosed with MS rated them more positively. Overall, adjusted R2 values ranged from 0.033 to 0.172. Qualitatively, most of the ratings were based on the evaluation of symptoms or impairments in daily life. Fewer participants ranked different dimensions of HRQoL in a personal hierarchy or assumed impairments beyond the vignette description. CONCLUSIONS: The understanding of HRQoL may vary substantially and is associated with individual characteristics, individual assessment strategies, and probably other intrinsic factors as explained variance was quite low. Therefore, usage of generic instruments only allows for limited comparison across groups.

[Volunteers in Refugee Help: is Health Promotion (by Public Health Services) Necessary?] / Ehrenamtliche in der Flüchtlingshilfe ­ sind gesundheitsfördernde Maßnahmen (durch den ÖGD) notwendig?

OBJECTIVES: To investigate health-related strains and resources of volunteers in refugee help. METHODS: Qualitative interviews with 10 volunteers in refugee help as well as 11 interviews with experts involved in coordinative tasks were conducted, transcribed and analysed using qualitative content analysis. RESULTS: Volunteers' work in refugee help is experienced as a strong resource. Volunteers receive a lot of thankfulness and appreciation and experience their work as enriching and enhancing self-worth. On the other hand, they also experience several stresses and problems. Difficulties in setting up appropriate boundaries regarding time and emotional involvement are mentioned as important reasons for the experienced stresses. CONCLUSIONS: Support for volunteers in refugee help should be optimised and expanded in order to protect the volunteers from health-related strains. Public Health Services could play an important role in such improvements.