Household deprivation, comorbidities and COVID-19 hospitalization in 690,115 children/adolescents

Background

Studies document that adults in disadvantaged socio-economic positions have elevated risks of a severe course of COVID-19, but it is unclear if this holds true for children. We investigate in this population-based study whether young people from socio-economically disadvantaged households in Germany had a higher risk of COVID-19 hospitalization compared with more affluent counterparts. We also examined if differences were related to comorbidities that predict severe courses in children.

Methods

We included data from all 690,115 children and adolescents (0-18 years) enrolled in a statutory health insurance carrier. Daily hospital diagnoses of COVID-19 were recorded from 1.1.2020 to 13.7.2021. Logistic regressions were used to compare children from households with an indication of poverty (e.g. long- or short-term unemployed) with children from households with insurance holders in regular employment. We also assessed socio-economic characteristics of the area of residence. We controlled for age, sex, days under observation, nationality, and comorbidities (e.g. obesity).

Findings

A COVID-19 hospital diagnosis was a rare event (n = 1637). Children of long-term unemployed parents had a 1·36 times (95% CI 1·21-1·51) higher adjusted odds of hospitalization compared with those of employed parents. Elevated odds were also found for short-term unemployed or low-wage employment. Those living in poor areas had a 3·02 (1·81-5·22) higher odds of hospitalization than those in less deprived areas. Comorbidities were strongly related to hospitalization, but their adjustment did not change main estimates for household deprivation.

Discussion

Results suggest that children from poor households are at higher risk of severe courses of COVID-19 than their affluent counterparts. This underlies the need to implement effective Public Health strategies to protect deprived children from COVID-19 and other infectious disease even in high income countries such as Germany.

Key messages

• Children and adolescents from poor families seem to be at higer risk for sever courses of COVID-19.

• Comorbidities were no key mediating factor in this study.

Association of Household Deprivation, Comorbidities, and COVID-19 Hospitalization in Children in Germany, January 2020 to July 2021

IMPORTANCE

Adults in disadvantaged socioeconomic positions have elevated risks of a severe course of COVID-19, but it is unclear whether this holds true for children.

OBJECTIVE

To investigate whether young people from disadvantaged households have a higher risk of COVID-19 hospitalization and whether differences were associated with comorbidities that predispose children to severe courses.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study included all children and adolescents (aged 0-18 years) who were enrolled in a statutory health insurance carrier in Germany during the observation period of January 1, 2020, to July 13, 2021. Logistic regressions were calculated to compare children from households with and without an indication of poverty. Age, sex, days under observation, nationality, and comorbidities (eg, obesity, diabetes) were controlled for to account for explanatory factors.

EXPOSURES

Disadvantage on the household level was assessed by the employment status of the insurance holder (ie, employed, long- or short-term unemployed, low-wage employment, economically inactive). Socioeconomic characteristics of the area of residence were also assessed.

MAIN OUTCOMES AND MEASURES

Daily hospital diagnoses of COVID-19 (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes U07.1 and U07.2) were recorded. Comorbidities were assessed using inpatient and outpatient diagnoses contained in the insurance records.

RESULTS

A total of 688 075 children and adolescents were included, with a mean (SD) age of 8.3 (5.8) years and 333 489 (48.4%) female participants. COVID-19 hospital diagnosis was a rare event (1637 participants [0.2%]). Children whose parents were long-term unemployed were 1.36 (95% CI, 1.22-1.51) times more likely than those with employed parents to be hospitalized. Elevated odds were also found for children whose parents had low-wage employment (odds ratio, 1.29; 95% CI, 1.05-1.58). Those living in low-income areas had 3.02 (95% CI, 1.73-5.28) times higher odds of hospitalization than those in less deprived areas. Comorbidities were associated with hospitalization, but their adjustment did not change main estimates for deprivation.

CONCLUSIONS AND RELEVANCE

In this cohort study, children who had parents who were unemployed and those who lived in low-income areas were at higher risk of COVID-19 hospitalization. This finding suggests that attention must be paid to children with SARS-CoV-2 from vulnerable families and closer monitoring should be considered. A number of explanatory factors, including comorbidities, were taken into account, but their analysis yielded no clear picture about underlying processes.

Study protocol for a mixed methods exploratory investigation of aftercare services for gestational diabetes in women to develop a new patient-centred model in Germany: the GestDiNa_basic study

INTRODUCTION

Women with gestational diabetes mellitus (GDM) have a higher risk of developing type 2 diabetes mellitus compared with women who never had GDM. Consequently, the question of structured aftercare for GDM has emerged. In all probability, many women do not receive care according to the guidelines. In particular, the process and interaction between obstetrical, diabetic, gynaecological, paediatric and general practitioner care lacks clear definitions. Thus, our first goal is to analyse the current aftercare situation for women with GDM in Germany, for example, the participation rate in aftercare diabetes screening, as well as reasons and attitudes stated by healthcare providers to offer these services and by patients to participate (or not). Second, we want to develop an appropriate, effective and patient-centred care model.

METHODS AND ANALYSIS

This is a population-based mixed methods study using both quantitative and qualitative research approaches. In various working packages, we evaluate data of the GestDiab register, of the Association of Statutory Health Insurance Physicians of North Rhine and the participating insurance companies (AOK Rheinland/Hamburg, BARMER, DAK Gesundheit, IKK classic, pronova BKK). In addition, quantitative (postal surveys) and qualitative (interviews) surveys will be conducted with randomly selected healthcare providers (diabetologists, gynaecologists, paediatricians and midwives) and affected women, to be subsequently analysed. All results will then be jointly examined and evaluated.

ETHICS AND DISSEMINATION

The study was approved by the ethics committee of the Faculty of Medicine, Heinrich-Heine-University Düsseldorf (Ethics Committee No.: 2019-738). Participants of the postal surveys and interviews will be informed in detail about the study and the use of data as well as the underlying data protection regulations before voluntarily participating. The study results will be disseminated through peer-reviewed journals, conferences and public information.

TRIAL REGISTRATION NUMBER

DRKS00020283.

[Higher risk of COVID-19 hospitalization for unemployed: an analysis of health insurance data from 1.28 million insured individuals in Germany]

BACKGROUND AND OBJECTIVE

Unemployment is related to poverty and is a risk factor for poor health. The present study investigates if unemployment increases the risk of COVID-19 hospitalization for men and women of working age in Germany.

METHODS

The study uses the health insurance data from AOK Rhineland/Hamburg (from 1 January 2020 until 18 June 2020) of 1,288,745 persons aged between 18 and 65. Four employment situations are distinguished: (1) regular employment, (2) low-wage employment with social support, (3) unemployment with receipt of unemployment benefit 1, and (4) long-term unemployment with receipt of unemployment benefit 2. COVID-19 hospitalizations are measured on the basis of the ICD codes U07.1 and U07.2 reported by the hospitals. Multiple logistic regression models are calculated (adjusted for age and sex).

RESULTS

During the observation period, 1521 persons had hospitalization with COVID-19 as primary or secondary diagnosis. Overall, this corresponds to a rate of 118 cases per 100,000 insured persons. Rates varied by employment situation. Compared with regularly employed persons, the odds ratio for a hospitalization was 1.94 (CI 95%: 1.74-2.15) for long-term unemployment, 1.29 (0.86-1.94) for unemployed, and 1.33 (0.98-1.82) for low-wage employment.

CONCLUSION

The results are in line with earlier studies from the USA and Great Britain reporting socioeconomic inequalities in COVID-19 hospitalization risk. This provides the first empirical support that socioeconomic inequalities in the severity of COVID-19 also exists in Germany.

Healthcare provision, functional ability and quality of life after proximal femoral fracture - 'ProFem': Study protocol of a population-based, prospective study based on individually linked survey and statutory health insurance data

INTRODUCTION

Proximal femoral fractures (PFF) are among the most frequent fractures in older people. However, the situation of people with a PFF after hospital discharge is poorly understood. Our aim is to (1) analyse healthcare provision, (2) examine clinical and patient-reported outcomes (PROs), (3) describe clinical and sociodemographic predictors of these and (4) develop an algorithm to identify subgroups with poor outcomes and a potential need for more intensive healthcare.

METHODS AND ANALYSIS

This is a population-based prospective study based on individually linked survey and statutory health insurance (SHI) data. All people aged minimum 60 years who have been continuously insured with the AOK Rheinland/Hamburg and experience a PFF within 1 year will be consecutively included (SHI data analysis). Additionally, 700 people selected randomly from the study population will be consecutively invited to participate in the survey. Questionnaire data will be collected in the participants' private surroundings at 3, 6 and 12 months after hospital discharge. If the insured person considers themselves to be only partially or not at all able to take part in the survey, a proxy person will be interviewed where possible. SHI variables include healthcare provision, healthcare costs and clinical outcomes. Questionnaire variables include information on PROs, lifestyle characteristics and socioeconomic status. We will use multiple regression models to estimate healthcare processes and outcomes including mortality and cost, investigate predictors, perform non-responder analysis and develop an algorithm to identify vulnerable subgroups.

ETHICS AND DISSEMINATION

The study was approved by the ethics committee of the Faculty of Medicine, Heinrich-Heine-University Düsseldorf (approval reference 6128R). All participants including proxies providing written and informed consent can withdraw from the study at any time. The study findings will be disseminated through scientific journals and public information.

TRIAL REGISTRATION NUMBER

DRKS00012554.

Ethical Hurdles in the Prioritization of Oncology Care

With finite resources, healthcare payers must make difficult choices regarding spending and the ethical distribution of funds. Here, we describe some of the ethical issues surrounding inequity in healthcare in nine major European countries, using cancer care as an example. To identify relevant studies, we conducted a systematic literature search. The results of the literature review suggest that although prevention, access to early diagnosis, and radiotherapy are key factors associated with good outcomes in oncology, public and political attention often focusses on the availability of pharmacological treatments. In some countries this focus may divert funding towards cancer drugs, for example through specific cancer drugs funds, leading to reduced expenditure on other areas of cancer care, including prevention, and potentially on other diseases. In addition, as highly effective, expensive agents are developed, the use of value-based approaches may lead to unacceptable impacts on health budgets, leading to a potential need to re-evaluate current cost-effectiveness thresholds. We anticipate that the question of how to fund new therapies equitably will become even more challenging in the future, with the advent of expensive, innovative, breakthrough treatments in other therapeutic areas.

[Centralisation of breast cancer management by giving minimum work-load. Empirical effects in the region of North-Rhine, Germany]

INTRODUCTION

The concentration of treatment on a few hospitals is discussed to improve the outcome of care. For the treatment of the breast cancer the distributional effects are evaluated.

METHOD

A systematic literature search in Medline identified six studies dealing with the evidence on the relation between outcome and workload. Using administrative data of a sickness fund in the region of Rhineland, Germany, the number of hospitals and patients affected by minimum work-loads was determined.

RESULTS

Study results show that in general a minimum workload of 100 to 150 new diagnosed cases per year and hospital is recommended. These recommendations would lead to 46% of the presently treating hospitals being excluded (minimum work-load of 150 cases; year 2001). If the workload is set to 100 cases, 31% of the hospitals will be excluded from breast cancer management. No significant differences could be detected in the data of the years 2000 and 2001.

DISCUSSION

The association between minimum workload and outcome of care seems to be evident. Further studies involving larger regions are needed to evaluate the distributional effects and gains of outcome.