Quality of life in patients with severe mental illness: a cross-sectional survey in an integrated outpatient health care model.

PURPOSE: This study (a) assessed quality of life (QoL) in a patient sample with severe mental illness in an integrated psychiatric care (IC) programme in selected regions in Germany, (b) compared QoL among diagnostic groups and (c) identified socio-demographic, psychiatric anamnestic and clinical characteristics associated with QoL. METHODS: This cross-sectional study included severely mentally ill outpatients with substantial impairments in social functioning. Separate dimensions of QoL were assessed with the World Health Organisation's generic 26-item quality of life (WHOQOL-BREF) instrument. Descriptive analyses and analyses of variance (ANOVAs) were conducted for the overall sample as well as for diagnostic group. RESULTS: A total of 953 patients fully completed the WHOQOL-BREF questionnaire. QoL in this sample was lower than in the general population (mean 34.1; 95% confidence interval (CI) 32.8 to 35.5), with the lowest QoL in unipolar depression patients (mean 30.5; 95% CI 28.9 to 32.2) and the highest in dementia patients (mean 53.0; 95% CI 47.5 to 58.5). Main psychiatric diagnosis, living situation (alone, partner/relatives, assisted), number of disease episodes, source of income, age and clinical global impression (CGI) scores were identified as potential predictors of QoL, but explained only a small part of the variation. CONCLUSION: Aspects of health care that increase QoL despite the presence of a mental disorder are essential for severely mentally ill patients, as complete freedom from the disorder cannot be expected. QoL as a patient-centred outcome should be used as only one component among the recovery measures evaluating treatment outcomes in mental health care.

Estimation of background incidence rates of Guillain-Barré syndrome in Germany - a retrospective cohort study with electronic healthcare data.

BACKGROUND: The Guillain-Barré syndrome (GBS) occurs after infections and as an adverse reaction to vaccines. No detailed information on incidence rates (IRs) in Germany is available. METHODS: This retrospective cohort study estimated age- and sex-specific IRs of GBS in Germany in the years 2007-2009 based on electronic healthcare data from the German Pharmacoepidemiological Research Database (GePaRD). Two case definitions were applied. GBS cases had a main discharge diagnosis of GBS. GBS_PROCEDURE cases in addition had codes for relevant diagnostic procedures. Crude and standardized IRs (SIRs) with 95% confidence intervals were stratified by year, age group, sex, region and season. IR ratios (IRRs) for each stratification factor were calculated by multivariable Poisson regression. RESULTS: Among 13,297,678 persons, 889 (693) incident GBS (GBS_PROCEDURE) cases were identified. Overall SIRs per 100,000 person years were 2.4 (2.2-2.5) for GBS and 1.8 (1.7-2.0) for GBS_PROCEDURE. (S)IRs increased with age, peaking in the age group 70-79 years (IR GBS: 5.5 (4.7-6.5)) and were higher in males than in females (e.g., IR GBS: IRR = 1.5 (1.3-1.7)) and in February-April, as compared to the rest of the year. No regional pattern was observed. CONCLUSION: (S)IRs of GBS in Germany differed by age, sex and season and were comparable to those found in other studies. RESULTS might be used as a comparator in vaccine safety monitoring.

Assessment of selection bias in a health survey of children and families - the IDEFICS Sweden-study.

BACKGROUND: A health survey was performed in 2007-2008 in the IDEFICS/Sweden study (Identification and prevention of dietary- and lifestyle-induced health effects in children and infants) in children aged 2-9 years. We hypothesized that families with disadvantageous socioeconomic and -demographic backgrounds and children with overweight and obesity were underrepresented. METHODS: In a cross-sectional study, we compared Swedish IDEFICS participants (N=1,825) with referent children (N=1,825) using data from Statistics Sweden population registers. IDEFICS participants were matched for age and gender with a referent child living in the same municipality. Longitudinal weight and height data from birth to 8 years was collected for both populations (n=3,650) from the children's local health services. Outcome measures included the family's socioeconomic and demographic characteristics, maternal body mass index (BMI) and smoking habits before pregnancy, the children's BMI standard deviation score (SDS) at the age of inclusion in the IDEFICS study (BMISDS-index), and the children's BMI-categories during the age-span. Comparisons between groups were done and a multiple logistic regression analysis for the study of determinants of participation in the IDEFICS study was performed. RESULTS: Compared with IDEFICS participants, referent families were more likely to have lower education and income, foreign backgrounds, be single parents, and have mothers who smoked before pregnancy. Maternal BMI before pregnancy and child's BMISDS-index did not differ between groups. Comparing the longitudinal data-set, the prevalence of obesity was significantly different at age 8 years n= 45 (4.5%) versus n= 31 (2.9%) in the referent and IDEFICS populations, respectively. In the multivariable adjusted model, the strongest significant association with IDEFICS study participation was parental Swedish background (odds ratio (OR) = 1.91, 95% confidence interval (CI) (1.48-2.47) followed by parents having high education OR 1.80, 95% CI (1.02-3.16) and being married or co-habiting OR 1.75 95% CI (1.38-2.23). CONCLUSION: Families with single parenthood, foreign background, low education and income were underrepresented in the IDEFICS Sweden study. BMI at inclusion had no selection effect, but developing obesity was significantly greater among referents.

From sleep duration to childhood obesity--what are the pathways?

UNLABELLED: Sleep duration has been identified as risk factor for obesity already in children. Besides investigating the role of fat mass (FM), this study addressed the question whether endocrine mechanisms act as intermediates in the association between sleep duration and overweight/obesity. Within the framework of the IDEFICS study, the present research was conducted in 609 German resident children aged 2-9 years with information on fasting insulin, C-reactive protein and cortisol levels next to anthropometric measurements and parental questionnaires. Emphasising methodological aspects, an age-specific measure of sleep duration was derived to account for alteration in sleep duration during childhood/period of growth. Multivariate linear regression and quantile regression models confirmed an inverse relationship between sleep duration and measures of overweight/obesity. The estimate for the association of sleep duration and body mass index (BMI) was approximately halved after adjustment for FM, but remained significant. The strength of this association was also markedly attenuated when adjusting for insulin mainly for the upper BMI quantiles (Q80, ß = -0.36 vs. ß = -0.26; Q95, ß = -0.87 vs. ß = -0.47). Adjustment for cortisol and CrP did not yield this attenuation. CONCLUSION: The inverse relationship between sleep duration and BMI is mainly explained by the association between sleep duration and FM. Insulin may explain part of this association, in particular at the upper tail of the BMI distribution.

Descriptive Cost-Effectiveness Analysis of a Counseling and Coordination Model in Psychosocial Care. Integration of Health Care and Social Rehabilitation.

INTRODUCTION: A psychosocial outreach clinic was established to offer counseling and coordination of healthcare and complementary services for persons with psychosocial and mental problems. The cost-effectiveness of these services was measured based on a pre-post comparison. METHODS: A prospective observational study was conducted with clients of the outreach clinic. Data on resource consumption and quality of life were collected at baseline and follow-up after 3, 6, and 12 months using the Client Sociodemographic and Service Receipt Inventory to assess service utilization, and the 12-Item Short Form Health Survey to assess quality of life. The objective of the present analysis was to estimate the relation between monetary expenditure and QALYs (quality-adjusted life-years), before and after the outreach clinic was established, descriptively. The analysis was constructed from payer's perspective and was supplemented by a sensitivity analysis. RESULTS: A total of 85 participants were included. Total annual expenditures before the intervention were 5,832 € per client for all service segments. During the 12-months study duration expenditures decreased to 4,350 € including the costs associated with outreach clinic services. QALYs for the 12-month study period were 0.6618 and increased about 0.0568 compared to the period before. DISCUSSION: Despite methodological limitations due to small sample size, a pre-post comparison and the retrospective cost data collection, this study suggests acceptability of the outreach clinic as cost-effective. CONCLUSION: The activities of the outreach clinic as an integrated care model seem to be cost-effective regarding the relation between monetary expenditures and clients' quality of life.

European Core Health Indicators - status and perspectives.

BACKGROUND: The European Core Health Indicators (ECHI) are a key source of comparable health information for the European Union (EU) and its Member States (MS). The ECHI shortlist contains 88 indicators which were developed by experts from MS and international organisations. Most indicators are derived from data sources at the EU's statistical office (Eurostat), the World Health Organisation (WHO) and the Organisation for Economic Co-operation and Development (OECD) and are available for most MS. The remaining indicators on the shortlist are at different stages of conceptual and/or methodological development. The indicators have been reviewed in the past against scientific developments, changes in data collections and emerging policy needs, yet not as part of a systematic and sustainable procedure. There is also no regular inventory of problems met by the MS in collecting the necessary data. Work package 4 of the BRIDGE Health project aimed at updating and improving the existing ECHI-indicator knowledge and expertise and at strengthening the scientific base that supports the effective development and use of health indicators for health policy evaluation and prioritization by the EU and its MS. The aim of this paper is to present a first overview of its outcomes and to explore issues concerning the ECHI data availability, content and policy relevance, update process and accessibility to stakeholders, in light of working towards a sustainable future. METHODS: Two surveys were conducted within the framework of the BRIDGE Health project to reassess the status of the ECHI shortlist. The first survey focused on data availability in EU MS, candidate countries and European Free Trade Association (EFTA) countries. The second survey evaluated current needs and criteria with respect to content and policy relevance of the ECHI shortlist. Exploring potential new indicator topics was part of both surveys. All evaluations were supported by an advisory network of national and international experts. RESULTS: Of the 36 countries (EU MS, candidate and EFTA countries) contacted for the data availability mapping, 23 countries (63%) participated in the survey. Data availability from preferred data sources varied between chapters. Availability was highest for the chapter on demography and socio-economic situation, followed by the chapter on health status, where data were available for most indicators from more than 90% of the participating countries. Problems experienced by MS relating to the incorporation of ECHI into their health systems were also identified through the survey. Findings from the survey on policy relevance point at the need for strengthening the links with policy (priorities) and for exploring a possible format change of the list to accommodate actionability. It also showed support for embedding ECHI in a sustainable health information structure; this may practically be aided by a web-based single point of access to an information repository. CONCLUSION: Policy relevance is an essential but not systematically developed criterion for the inclusion of indicators into the ECHI shortlist. Data availability is crucial for the actual implementation of indicators and has considerably increased for ECHI in the last decade. The data availability mapping provides a structured overview of the current status of data availability for implemented indicators. The ECHI shortlist can contribute to the collection of comparable policy-relevant health data in Europe, foster evidence-based public health and contribute to Member States learning from each other. Flexible and systematic incorporation of policy relevance in the ECHI shortlist review and revision process may substantiate ECHI as a core component of a future sustainable European health information infrastructure.

Young children's screen habits are associated with consumption of sweetened beverages independently of parental norms.

OBJECTIVES: This study investigated the associations between children's screen habits and their consumption of sweetened beverages. Because parents might be disposed to regulate their child's screen and dietary habits in a similar direction, our specific aim was to examine whether these associations were independent of parental norms. METHODS: In the Swedish sample of the European Identification and prevention of dietary and lifestyle-induced health effects in children and infants (IDEFICS) study, parents filled in questionnaires about their 2 to 9-year-old children's (n = 1,733) lifestyle and diets. RESULTS: Associations between screen habits and sweetened beverage consumption were found independent of parental norms regarding sweetened beverages. A longitudinal analysis revealed that sweetened beverage consumption at 2-year follow-up was predicted by exposure to commercial TV at baseline (OR 1.4, 95 % CI 1.1-1.9). Cross-sectional analysis showed that the likelihood of consuming sweetened beverages at least 1-3 times per week increased for each hour/day watching television (OR 1.5, 95 % CI 1.2-1.9), and for being exposed to commercials (OR 1.6, 95 % CI 1.3-2.1). TV viewing time and commercial exposure contributed to the associations independently of each other. CONCLUSIONS: The results strengthen the assumption that it is possible to influence children's dietary habits through their TV habits.

HPV vaccine uptake after introduction of the vaccine in Germany: an analysis of administrative data.

In Germany, vaccination against human papilloma virus (HPV) has been recommended by the German Standing Vaccination Committee (STIKO) for girls aged 12-17 years since March 2007. The vaccine is free of charge for this age group. Additionally, some statutory health insurance providers (SHI) offer reimbursement for women aged 18-26 years. Currently available information on the uptake or coverage of HPV vaccination is limited to specific regions, age groups, or study populations. This report describes the HPV vaccine uptake in 2008 for females aged 12-26 years in Germany on a broad regional level based on data from one large SHI. HPV vaccinations were identified by outpatient codes used for reimbursement of vaccine administration. Vaccine uptake was calculated by dividing the number of females, who received at least one HPV vaccine dose by the number of female insurees in the respective age group. The overall study population consisted of 317 234 females, of whom 77 350 received at least one HPV vaccine dose in 2008. Vaccine uptake was 32.2% in the recommended age group, with a peak age at 14-16 years. In the age group of females aged 18-26 years, where HPV vaccination was not officially recommended by the STIKO, uptake was 12.3%. Vaccine uptake in 2008 reflects an early stage after the recommendation of HPV vaccination in 2007. Future changes in vaccine uptake should be further and more promptly monitored.

Agreement of different methods for assessing sleep characteristics: a comparison of two actigraphs, wrist and hip placement, and self-report with polysomnography.

OBJECTIVE: To assess the agreement of sleep parameters measured by two actigraphs (SOMNOwatch plus, ActiGraph GT3X+) at two different placements (wrist, hip) and of self-reported sleep with polysomnography (PSG). METHODS: We estimated agreement with PSG for total sleep time (TST), sleep onset latency (SOL), wake after sleep onset (WASO), number of awakenings after sleep onset (NASO), and sleep efficiency (SE%) for 100 participants of the general population, aged 18-75 years by judging mean differences to PSG and intervals of agreement using Bland-Altman plots. RESULTS: Mean difference to PSG for TST was 8.3 min (95% confidence intervals [CI] -7.4; 24.1) for SOMNOwatch plus (wrist), 39.8 min (95% CI 24.3; 55.3) for self-report, -79.0 min (95% CI -89.0; -68.9) for SOMNOwatch plus (hip), and -81.1 min (95% CI -91.9; -70.4) for GT3X+ (hip), respectively. The width of intervals of agreement differed with the placement of the devices. Mean differences to PSG were higher for hip-based measurements compared with wrist placement for most parameters. CONCLUSIONS: Agreement of sleep parameters assessed by actigraphy with PSG differs with the placement of the device and is limited for hip-based measurements. Agreement of self-report with PSG is comparable to that of actigraphy for some parameters.

Attributable risks for childhood overweight: evidence for limited effectiveness of prevention.

OBJECTIVE: Calculation of attributable risks (ARs) of childhood overweight to estimate effectiveness of prevention strategies. METHODS: We used pooled data of 4 population-based German studies including 34240 children and adolescents aged 3 to 18 years to calculate the impact of familial, social, "early life", and lifestyle factors on overweight. ARs (joint for all determinants as well as partial risks) were calculated. RESULTS: The prevalence of childhood overweight was 13.4%. Successfully tackling all determinants can reduce overweight by 77.7% (ie, from 13.4% to 3.0%; = joint AR) with partial effects of treating parental overweight (42.5%); improving social status (14.3%); reducing media time to <1 hour per day (11.4%); and not smoking during pregnancy, low weight gain during pregnancy, and breastfeeding (together 9.5%), respectively. Improving all preventable risk factors (ie, early life factors and lifestyle) the effect is 9.2%. Media time has the strongest effect. CONCLUSIONS: The determinants identified explained 78% of the prevalence of overweight. Taking into account the partial ARs, the effectiveness of lifestyle interventions to prevent overweight in children is limited. Our data argue in favor of interventions aimed at families and social environments, with a major focus on promoting a lower screen time and computer use in children.

Sleep duration and overweight in European children: is the association modified by geographic region?

STUDY OBJECTIVES: To investigate differences and a possible effect modification by geographical region in the association between sleep duration and overweight. DESIGN: Cross-sectional. SETTING: Primary schools and preschools in 8 European countries. PARTICIPANTS: 7867 children aged 2 to 9 years. INTERVENTIONS: Not applicable. MEASUREMENTS: Nocturnal sleep duration was assessed as part of a parental 24-h recall. Height and weight were measured by standardized procedures across centers. Data on personal, social, environmental and behavioral factors were collected using a standardized parental questionnaire. RESULTS: Sleep duration differed (P < 0.001) between European regions and normal vs. overweight children. A dose-dependent inverse association between sleep duration and overweight could be seen, with crude odds ratios ranging from 1.73 (99% CI 1.33; 2.25) for sleeping between 10 and 11 h to 3.81 (99% CI 2.85; 5.09) for sleeping less than 9 h (reference category > 11 h). This persisted after adjustment, but remained significant only for sleeping less than 9 h per night (north: OR = 1.70; 99% CI 1.13; 2.58 vs. south: OR = 2.84; 99% CI 1.57; 5.12) if stratified by region. No effect modification by region could be found, but adjustment for region accounted for changes in the effect estimate for sleeping less than 9 h (OR = 2.22; 99% CI 1.64; 3.02). The association was stronger in school children than in preschool children. CONCLUSION: Geographic region and related aspects-even if they do not seem to modify the association between sleep and overweight-should in any case be taken in consideration as a confounding factor on this association.

Factors that influence weekday sleep duration in European children.

STUDY OBJECTIVES: To compare nocturnal sleep duration in children from 8 European countries and identify its determinants. DESIGN: Cross-sectional. SETTING: Primary schools and preschools participating in the IDEFICS study. PARTICIPANTS: 8,542 children aged 2 to 9 years from 8 European countries with complete information on nocturnal sleep duration. INTERVENTIONS: Not applicable. MEASUREMENTS: Nocturnal sleep duration was assessed by means of a computer based parental 24-h recall. Data on personal, social, environmental, and behavioral factors were collected by means of standardized parental questionnaire. Physical activity was surveyed with accelerometers. RESULTS: Nocturnal sleep duration in the participating countries ranged from 9.5 h (SD 0.8) in Estonia to 11.2 h (SD 0.7) in Belgium and differed significantly between countries (P < 0.001) in univariate as well as in multivariate analyses, with children from northern countries sleeping the longest. Sleep duration decreased by about 6 min with each year of age over all countries. No effect of season, daylight duration, overweight, parental education level, or lifestyle factors could be seen. CONCLUSION: Sleep duration differs significantly between countries. Our findings allow for the conclusion that regional affiliation, including culture and environmental characteristics, seems to overlay individual determinants of sleep duration.