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Background There are a few epidemiological studies that (1) link increased ambient air pollution (AP) with an increase in lung cancer incidence rates and (2) investigate whether residing in green spaces could be protective against cancer. However, it is completely unclear whether other forms of cancer are also affected by AP and if residential green spaces could lower cancer incidence rates in general. Therefore, the objective was to estimate whether AP and green space are associated with several cancer types. Methods The analysis was based on routine health care data from around 1.9 million people from Saxony who were free of cancer in 2008 and 2009. Incident cancer cases (2010–2014) of mouth and throat, skin (non-melanoma skin cancer - NMSC), prostate, breast, and colorectum were defined as: (1) one inpatient diagnosis, or (2) two outpatient diagnoses in two different quarters within one year and a specific treatment or death within two quarters after the diagnosis. Exposures, derived from freely available 3rd party data, included particulate matter with aerodynamic diameter of less than 10 μm (PM 10 ) and nitrogen dioxide (N0 2 ) as well as green space (Normalized Difference Vegetation Index - NDVI). Associations between air pollutants, green space, and cancer incidence were assessed by multilevel Poisson models. Age, sex, physician contacts, short- and long-term unemployment, population density, and having an alcohol-related disorder were considered as potential confounders. Results Three thousand one hundred seven people developed mouth and throat cancer, 33,178 NMSC, 9611 prostate cancer, 9577 breast cancer, and 11,975 colorectal cancer during the follow-up period (2010–2014). An increase in PM 10 of 10 μg/m 3 was associated with a 53% increase in relative risk (RR) of mouth and throat cancer and a 52% increase in RR of NMSC. Prostate and breast cancer were modestly associated with PM 10 with an increase in RR of 23 and 19%, respectively. The associations with N0 2 were in the same direction as PM 10 but the effect estimates were much lower (7–24%). A 10% increase in NDVI was most protective of mouth and throat cancer (− 11% RR) and of NMSC (− 16% RR). Colorectal cancer was not affected by any of the exposures. Conclusions In addition to the studies carried out so far, this study was able to provide evidence that higher ambient AP levels increase the risk of mouth and throat cancer as well as of NMSC and that a higher residential green space level might have a protective effect for NMSC in areas with low to moderate UV intensity. Nevertheless, we cannot rule out residual confounding by socioeconomic or smoking status.

Long-term health sequelae of the Coronavirus Disease 2019 (COVID-19) are a major public health concern. However, evidence on post-acute COVID-19 syndrome (post-COVID-19) is still limited, particularly for children and adolescents. Utilizing comprehensive healthcare data on approximately 46% of the German population, we investigated post-COVID-19-associated morbidity in children/adolescents and adults. We used routine data from German statutory health insurance organizations covering the period between January 1, 2019 and December 31, 2020. The base population included all individuals insured for at least 1 day in 2020. Based on documented diagnoses, we identified individuals with polymerase chain reaction (PCR)-confirmed COVID-19 through June 30, 2020. A control cohort was assigned using 1:5 exact matching on age and sex, and propensity score matching on preexisting medical conditions. The date of COVID-19 diagnosis was used as index date for both cohorts, which were followed for incident morbidity outcomes documented in the second quarter after index date or later.Overall, 96 prespecified outcomes were aggregated into 13 diagnosis/symptom complexes and 3 domains (physical health, mental health, and physical/mental overlap domain). We used Poisson regression to estimate incidence rate ratios (IRRs) with 95% confidence intervals (95% CIs). The study population included 11,950 children/adolescents (48.1% female, 67.2% aged between 0 and 11 years) and 145,184 adults (60.2% female, 51.1% aged between 18 and 49 years). The mean follow-up time was 236 days (standard deviation (SD) = 44 days, range = 121 to 339 days) in children/adolescents and 254 days (SD = 36 days, range = 93 to 340 days) in adults. COVID-19 and control cohort were well balanced regarding covariates. The specific outcomes with the highest IRR and an incidence rate (IR) of at least 1/100 person-years in the COVID-19 cohort in children and adolescents were malaise/fatigue/exhaustion (IRR: 2.28, 95% CI: 1.71 to 3.06, p < 0.01, IR COVID-19: 12.58, IR Control: 5.51), cough (IRR: 1.74, 95% CI: 1.48 to 2.04, p < 0.01, IR COVID-19: 36.56, IR Control: 21.06), and throat/chest pain (IRR: 1.72, 95% CI: 1.39 to 2.12, p < 0.01, IR COVID-19: 20.01, IR Control: 11.66). In adults, these included disturbances of smell and taste (IRR: 6.69, 95% CI: 5.88 to 7.60, p < 0.01, IR COVID-19: 12.42, IR Control: 1.86), fever (IRR: 3.33, 95% CI: 3.01 to 3.68, p < 0.01, IR COVID-19: 11.53, IR Control: 3.46), and dyspnea (IRR: 2.88, 95% CI: 2.74 to 3.02, p < 0.01, IR COVID-19: 43.91, IR Control: 15.27). For all health outcomes combined, IRs per 1,000 person-years in the COVID-19 cohort were significantly higher than those in the control cohort in both children/adolescents (IRR: 1.30, 95% CI: 1.25 to 1.35, p < 0.01, IR COVID-19: 436.91, IR Control: 335.98) and adults (IRR: 1.33, 95% CI: 1.31 to 1.34, p < 0.01, IR COVID-19: 615.82, IR Control: 464.15). The relative magnitude of increased documented morbidity was similar for the physical, mental, and physical/mental overlap domain. In the COVID-19 cohort, IRs were significantly higher in all 13 diagnosis/symptom complexes in adults and in 10 diagnosis/symptom complexes in children/adolescents. IRR estimates were similar for age groups 0 to 11 and 12 to 17. IRs in children/adolescents were consistently lower than those in adults. Limitations of our study include potentially unmeasured confounding and detection bias. In this retrospective matched cohort study, we observed significant new onset morbidity in children, adolescents, and adults across 13 prespecified diagnosis/symptom complexes, following COVID-19 infection. These findings expand the existing available evidence on post-COVID-19 conditions in younger age groups and confirm previous findings in adults. ClinicalTrials.gov https://clinicaltrials.gov/ct2/show/NCT05074953.

In this population-based study evaluating the effectiveness of the 13-valent pneumococcal conjugate vaccine (2012–2016) to prevent all-cause pneumonia in adults ≥60 years of age, we found significant, 0.63% absolute risk and 11.9% relative risk reductions on the 3-year (2014–2016) cumulative incidences of all-cause pneumonia after vaccination.

The citizens' perspectives on health care are central to the assessment of the health care situation and to regional development. In Germany, however, strategic goals for health care delivery are planned based on population statistics and partly on regional morbidity. Saxony is a German federal state with high average age and low density of physicians which makes the population perspective on quality of health care especially intersting. No existing panel surveys cover issues related to the perceived quality of health care delivery on a regional level in Germany. We aim to conduct a longitudinal panel study of the perceived health status and perceived quality of health care of the Saxon citizens as a basis for the systematic derivation of health care goals/measures and target group-specific, regionally suitable prevention measures. With an anticipated 15% response rate, 15,000 potential participants have to be contacted to achieve a calculated sample size of about 2,250 participants. The questionnaire will be circulated every other year with the option for adaptations depending on insights of each panel wave. The study protocol was approved by the local ethics committee of the Technische Universität Dresden, Germany (ethical approval code BO-EK-320072022) and has been registered at the German Clinical Trials Register as the German WHO primary registry (study registration number DRKS00031229). The results are intended to identify gaps in health care and to develop patient-centered health care goals for the region together with stakeholders in Saxon health care planning. At the same time, longitudinal data allow mapping of perceived health status and perceived health care trends.

PurposeThe need for drug-related safety warnings is undisputed, but their impact on prescribing behaviour is not always clear. Safety warnings usually do not contain therapeutic alternatives. Based on German outpatient routine healthcare data, our cohort study investigated the impact of three warnings for fluoroquinolones on prescribing behaviour.MethodsStructural breaks were estimated in a time-series analysis (2005–2014) of 184,134 first antibiotic prescriptions for patients (≥ 18 years) diagnosed with community-acquired pneumonia (CAP), acute bacterial sinusitis (ABS), or acute exacerbation of chronic bronchitis (AECB). Subsequently, risk factors for patients’ before/after safety warnings presented as risk ratios (RR) were estimated by Poisson regression.ResultsFollowing the 2008 warning for moxifloxacin, the RR of being prescribed moxifloxacin was reduced by 56% (95% CI 0.41–0.47; p < 0.001) for CAP, by 65% (95% CI 0.32–0.39; p < 0.001) for ABS, by 57% (95% CI 0.41–0.45; p < 0.001) for AECB. After the 2012 warning for levofloxacin, the RR of being prescribed levofloxacin was reduced by 31% (95% CI 0.64–0.74; p < 0.001) for CAP, by 14% (95% CI 0.77–0.96; p = 0.007) for ABS, by 27% (95% CI 0.69–0.77; p < 0.001) for AECB. We noticed a prescription-switch to other antibiotics which was not in line with the national guideline recommendations. The warning for moxifloxacin 2009 had no impact on prescribing behaviour.ConclusionThis study observed an impact on prescribing behaviour in response to regulatory safety warnings for two out of three warnings. Information on therapeutic alternatives should be a part of any safety warning to encourage the intended changes in prescribing behaviour.

Purpose Patients with rare diseases often undergo a long diagnostic odyssey. However, there is little empirical evidence on the cost incurred during the diagnostic pathway for patients with suspected rare diseases. This study provides a comprehensive analysis of healthcare costs and utilization during the diagnostic pathway for a heterogeneous sample of patients with suspected rare diseases but unclear diagnosis. Methods Using claims data from five German statutory health insurance organizations for the years 2014–2019, we analyzed costs and healthcare utilization of 1,243 patients (aged 0 to 82 years) with suspected rare diseases referred to a rare disease center. A control cohort was assigned using 1:75 exact matching on age, sex and place of residence. Results In the years prior to referral to an expert center, healthcare utilization of patients with suspected rare diseases was, on average, substantially and significantly higher compared to a matched control cohort during the same observation period – e.g. in terms of the number of hospitalizations (3.1 (95%CI: 2.9–3.4) vs. 0.5 (95%CI: 0.5–0.5)), different diagnoses (50.0 (95%CI: 48.1–51.9) vs. 26.4 (95%CI: 26.2–26.5)), different active substances prescribed (12.7 (95%CI: 12.2–13.3) vs. 8.2 (95%CI: 8.2–8.3)) and the number of genetic tests (14.7 (95%CI: 12.6–16.7) vs. 0.3 (95%CI: 0.3–0.3)). We found evidence of heterogeneity in utilization by age and sex. On average, direct costs (inpatient, outpatient and prescription drug costs) of patients with suspected rare diseases during the diagnostic pathway were 7.6-fold higher than the costs of matched controls (€26,999 (95%CI: €23,751 − 30,247) vs. €3,561 (95% CI: € 3,455-3,667)). Inpatient costs were the main cost component, accounting for 62.5% of total costs. Conclusions The diagnostic odyssey of patients with suspected rare diseases is associated with extensive healthcare utilization and high cost. Against this background, new ways to shorten the diagnostic journey have a high potential to decrease the financial burden related to rare diseases.

A correction to this paper has been published: https://doi.org/10.1007/s15010-021-01616-7

Accurately measuring the quality of stroke care based on claims data alone is challenging. Traditional outcome metrics, e.g. mortality rates, do not capture the effectiveness of critical stroke care processes. We aimed to develop hybrid quality indicators (QIs) by integrating clinical stroke severity data with claims data. Claims data were linked to patient-level clinical data from 15 hospitals (2017–2020) and harmonized in the Observational Medical Outcome Partnership (OMOP) data model. Inclusion criteria, outcomes and risk factors were developed by medical expert panels. We applied machine learning for modeling the outcomes 30-day-mortality , reinfarction within 90 days , and care degree increase within 180 days . We compared extreme gradient boosting (XGBoost) models with and without the National Institutes of Health Stroke Scale (NIHSS) using Receiver-Operating-Characteristic-Area-Under-the-Curve (ROC-AUC) and Brier Score (BS). Hospitals were ranked according to the impact of each QI using Standardized Mortality Ratios (SMRs). The study included 9,348 ischemic (I63) and 1,554 hemorrhagic (I61) strokes, with NIHSS available for 5,012 patients. For all three outcomes, disease severity as measured by NIHSS was the most important determinant. The predictive power of the hybrid models was higher than that of models based on claims data alone. For SMR, the influence of NIHSS was greater than that of age, the most important variable in the claims data model. The results were consistent between the two entities, different outcomes, and sensitivity analyses. Including NIHSS information alongside claims data improves the risk adjustment of quality indicators.

Changes in opening hours for on-premise drinking places may influence the level of alcohol-related violence in two ways. The increased availability of alcohol increases the risks associated with it, while restrictive opening hours may produce more occasions for crime due to overcrowding at closing time. We use a quasi-experimental design with data from 13 Bavarian towns with and without restrictive opening hours and a negative binomial panel model. The outcome measure is violent incidents reported by the police between 2:00 a.m. and 6:00 a.m. over the period of 12 years. Incidents at night disproportionally increase over the study period in the sample. After controlling for daily violence as well as for an interaction between policy regime and violence level, we find that restricted opening hours are only beneficial within settings of a low daily violence level.

Background Post-viral symptoms have long been known in the medical community but have received more public attention during the COVID-19 pandemic. Many post-viral symptoms were reported as particularly frequent after SARS-CoV-2 infection. However, there is still a lack of evidence regarding the specificity, frequency and persistence of these symptoms in comparison to other viral infectious diseases such as influenza. Methods We investigated a large population-based cohort based on German routine healthcare data. We matched 573,791 individuals with a PCR-test confirmed SARS-CoV-2 infection from the year 2020 to contemporary controls without SARS-CoV-2 infection and controls from the last influenza outbreak in 2018 and followed them up to 18 months. Results We found that post-viral symptoms as defined for COVID-19 by the WHO as well as tissue damage were more frequent among the COVID-19 cohort than the influenza or contemporary control cohort. The persistence of post-viral symptoms was similar between COVID-19 and influenza. Conclusion Post-viral symptoms following SARS-CoV-2 infection constitute a substantial disease burden as they are frequent and often persist for many months. As COVID-19 is becoming endemic, the disease must not be trivialized. Research should focus on the development of effective treatments for post-viral symptoms.