[Postpartum Care by Midwives: Socioeconomic Status has a Strong Influence on the Amount of Care Received An Analysis with Routine Data from BARMER Health Insurance]

BACKGROUND

Socio-economic situation is associated with inequalities in access to health care and health-related resources. This also applies to pregnancy, birth and the postpartum period. Compared to other European countries, Germany has very good care options for the postpartum period. It has an unique system of postpartum care, which comprises home visits by midwives for 12 weeks after birth and beyond in problem cases and thus has structurally good care options. So far, however, there are hardly any studies based on routine data that show which mothers receive homevisits in postpartum care and to what extent.

METHOD

The study population comprised 199,978 women insured with BARMER who gave birth to at least one child in the years 2017-2020. Some women were pregnant several times in this period of time. The services billed by freelance midwives for outreach midwifery care in the puerperium were considered for 227,088 births, taking into account the socioeconomic situation of the mothers.

RESULTS

According to the definition of the German Institute for Economic Research, 26% of the mothers belonged to a low income group, 46% to a medium income group and 29% to a high income group. Similar to what was shown for midwifery care during pregnancy, large differences were also found with regard to postpartum care: While 90.5% of the women with a high income received home visits, only 83.5% of women with a medium income did so, and only 67.9% of women with a low income. The groups did not differ with regard to other characteristics such as rate of caesarean section, preterm births, twins, age or concomitant diseases to an extent that could explain the differences in care. Women who had received midwifery services in pregnancy were much more likely to receive home visits by a midwife in the postpartum period. Furthermore, there was a correlation with the density of midwives in the respective region.

CONCLUSIONS

The results suggest that access to home-based postpartum care by freelance midwives is significantly limited for low-income women. In contrast to antenatal care, women in the postpartum period cannot switch to other service providers, as outreach postpartum care is a reserved activity of midwives. Women with low incomes thus receive less midwifery care, although they have a higher need for support (Eickhorst et al. 2016).

Hospital admissions following emergency medical services in Germany: analysis of 2 million hospital cases in 2022

BACKGROUND

The use of emergency medical services (EMS) in Germany has increased substantially over the last few decades. While current reform efforts aim to increase effectiveness and efficiency of the German hospital and EMS systems, there is lack of data on characteristics of hospital cases using EMS.

OBJECTIVES

To analyze and compare the characteristics of cases hospitalized with and without the use of EMS.

MATERIALS AND METHODS

The BARMER health insurance data on more than 2 million hospital cases admitted in 2022 were analyzed. The distributions of age, clinical complexity (measured by patient clinical complexity levels, PCCL), main diagnoses, costs for EMS and hospital treatment, and multiple severity indicators were described. The overall severity of hospital cases was classified as "low or moderate" or "high" based on a combined severity indicator. All analyses were stratified by use of EMS and EMS type.

RESULTS

A total of 28% of all included hospital cases used EMS. Relative to hospital cases without use of EMS, hospital cases with use of EMS were older (physician-staffed ambulance: 75 years, interquartile range [IQR] 59-84, double-crewed ambulance: 78 years, IQR 64-85) and had a higher clinical complexity. The severity of more than 30% of the cases using EMS (except for patient transport service ambulance) was classified as "low or moderate". The distributions of main diagnoses differed by severity and use of EMS.

CONCLUSIONS

The high proportion of cases with low or moderate severity using EMS may indicate a substantial potential to avoid the use of EMS in the context of hospital admissions in Germany. Further investigation is required to explore whether the proportion of cases using EMS could be reduced by optimizing preclinical service.

Deprivation as a fundamental cause of morbidity and reduced life expectancy: an observational study using German statutory health insurance data

Across all developed countries, there is a steep life expectancy gradient with respect to deprivation. This paper provides a theoretical underpinning for this gradient in line with the Grossman model, indicating that deprivation affects morbidity and, consequently, life expectancy in three ways: directly from deprivation to morbidity, and indirectly through lower income and a trade-off between investments in health and social status. Using rich German claims data covering 6.3 million insured people over four years, this paper illustrates that deprivation increases morbidity and reduces life expectancy. It was estimated that highly deprived individuals had approximately two more chronic diseases and a life expectancy reduced by 15 years compared to the least deprived individuals. This mechanism of deprivation is identified as fundamental, as deprived people remain trapped in their social status, and this status results in health investment decisions that affect long-term morbidity. However, in the German setting, the income and investment paths of the effects of deprivation were of minor relevance due to the broad national coverage of its SHI system. The most important aspects of deprivation were direct effects on morbidity, which accumulate over the lifespan. In this respect, personal aspects, such as social status, were found to be three times more important than spatial aspects, such as area deprivation.

Multilevel Quality Indicators: Methodology and Monte Carlo Evidence

BACKGROUND

Quality indicators are frequently used to assess the performance of health care providers, in particular hospitals. Established approaches to the design of such indicators are subject to distortions due to indirect standardization and high variance of estimators. Indicators for geographical regions are rarely considered.

OBJECTIVES

To develop and evaluate a methodology of multilevel quality indicators (MQIs) for both health care providers and geographical regions.

RESEARCH DESIGN

We formally derived MQIs from a statistical multilevel model, which may include characteristics of patients, providers, and regions. We used Monte Carlo simulation to assess the performance of MQIs relative to established approaches based on the standardized mortality/morbidity ratio (SMR) and the risk-standardized mortality rate (RSMR).

MEASURES

Rank correlation between true provider/region effects and quality indicator estimates; shares of the 10% best and 10% worst providers identified by the quality indicators.

RESULTS

The proposed MQIs are (1) standardized hospital outcome rate (SHOR), (2) regional SHOR, and (3) regional standardized patient outcome rate. Monte Carlo simulations indicated that the SHOR provides substantially better estimates of provider performance than the SMR and risk-standardized mortality rate in almost all scenarios. The regional standardized patient outcome rate was slightly more stable than the regional SMR. We also found that modeling of regional characteristics generally improves the adequacy of provider-level estimates.

CONCLUSIONS

MQIs methodology facilitates adequate and efficient estimation of quality indicators for both health care providers and geographical regions.

Incident autoimmune diseases in association with SARS-CoV-2 infection: a matched cohort study

OBJECTIVES

To investigate whether the risk of developing an incident autoimmune disease is increased in patients with prior COVID-19 disease compared to those without COVID-19, a large cohort study was conducted.

METHOD

A cohort was selected from German routine health care data. Based on documented diagnoses, we identified individuals with polymerase chain reaction (PCR)-confirmed COVID-19 through December 31, 2020. Patients were matched 1:3 to control patients without COVID-19. Both groups were followed up until June 30, 2021. We used the four quarters preceding the index date until the end of follow-up to analyze the onset of autoimmune diseases during the post-acute period. Incidence rates (IR) per 1000 person-years were calculated for each outcome and patient group. Poisson models were deployed to estimate the incidence rate ratios (IRRs) of developing an autoimmune disease conditional on a preceding diagnosis of COVID-19.

RESULTS

In total, 641,704 patients with COVID-19 were included. Comparing the incidence rates in the COVID-19 (IR=15.05, 95% CI: 14.69-15.42) and matched control groups (IR=10.55, 95% CI: 10.25-10.86), we found a 42.63% higher likelihood of acquiring autoimmunity for patients who had suffered from COVID-19. This estimate was similar for common autoimmune diseases, such as Hashimoto thyroiditis, rheumatoid arthritis, or Sjögren syndrome. The highest IRR was observed for autoimmune diseases of the vasculitis group. Patients with a more severe course of COVID-19 were at a greater risk for incident autoimmune disease.

CONCLUSIONS

SARS-CoV-2 infection is associated with an increased risk of developing new-onset autoimmune diseases after the acute phase of infection. Key Points • In the 3 to 15 months after acute infection, patients who had suffered from COVID-19 had a 43% (95% CI: 37-48%) higher likelihood of developing a first-onset autoimmune disease, meaning an absolute increase in incidence of 4.50 per 1000 person-years over the control group. • COVID-19 showed the strongest association with vascular autoimmune diseases.

Versorgung geriatrischer Krankheitsbilder unter ausgewählten ambulanten Facharztgruppen: Kombination von Befragungs- und GKV-Routinedaten zur Abbildung des Leistungsgeschehens

BACKGROUND

In light of an aging population, the German health system faces the challenge of adapting regional health care structures to the changing care needs of geriatric patients. Since geriatric care is interprofessional, a structural analysis of the service providers involved is required. Therefore, the aim of this study is to determine the primary and joint care responsibilities for geriatric patients with specific characteristics, to estimate the associated effort for selected outpatient medical service providers and to identify resulting care concentrations.

METHODS

The analysis includes six selected specialist disciplines in the outpatient sector and is based on two databases: 1) A representative survey among outpatient physicians related to geriatric care (n = 400) to examine both the primary geriatric care needs that professionals treat regularly and aggravating geriatric morbidity. 2) A claims data analysis determines services and efforts for approximately 300,000 geriatric patients for every year from 2014 to 2018. For the specialists included in the analysis, care concentration was determined by association analysis comparing the care efforts of outpatient physicians for patients with different geriatric characteristics.

RESULTS

General practitioners, in particular, serve as primary care providers for all geriatric characteristics; there is no concentration of care on specific patient groups. Concentrations associated with care efforts and joint care responsibilities for patients with certain geriatric characteristics are found among the more specialized physician groups. Across all professions, the physicians surveyed believe that geriatric-specific immobility, depression, anxiety disorders and cognitive deficits make the provision of care more difficult.

DISCUSSION

The results contribute to the understanding of primary and interdisciplinary care responsibilities of outpatient physicians related to the treatment of geriatric conditions and can thus represent an important basis for the structural planning of geriatric care. Nevertheless, it should be noted that within the scope of the analysis presented, only general practitioners and five specialist disciplines could be taken into account. Therefore, the considerations primarily allow initial conclusions about the care responsibility of outpatient physicians with regard to geriatric morbidity. To enable comprehensive structural planning, however, the analyses would have to be expanded to include all specialists involved in geriatric care.

CONCLUSION

The joint care responsibility of outpatient physicians for specific geriatric patients underlines the relevance for interdisciplinary care models and the need for expansion of geriatric expertise in the outpatient sector. In view of the ageing population and an increase in morbidity, the planning of care structures should be based on the needs of geriatric patients and the associated expenses incurred by the various health care providers.

The Long-Term Sequelae of Traumatic Brain Injury Over 10 Years of Follow-Up—A Matched Cohort Study Based on Routine Data of a Statutory Health Insurance Carrier

BACKGROUND

The acute effects of traumatic brain injury (TBI) are well documented, but there is no systematic quantification of its long-term sequelae in Germanlanguage literature. The purpose of this article is to compare the frequency of conditions linked to prior TBI with their frequency in the non-brain-injured population.

METHODS

A matched cohort study was carried out on the basis of routine data from the BARMER statutory health insurance carrier. The exposure group consisted of patients treated over the period 2006-2009 for TBI at a variety of treatment intensities, including persons with multiple organ trauma. The control group consisted of BARMER insurees without prior TBI who were matched with the patients in the exposure group for age, sex, and pre-existing diseases. Late sequelae were sought in the routine data for a period of ten years after the injury. The outcome rates of the exposure and control groups were compared with Kaplan-Meier estimators and Poisson regression.

RESULTS

114 296 persons with TBI in the period 2006-2009 were included in the study. The mortality within ten years of TBI was 305 per 1000 individuals. The relative mortality in the exposure group was higher than that in control individuals of the same age and sex, with an incidence rate ratio (IRR) of 1.67 (95% confidence interval, [1.60; 1.74]). Immobility, dementia, epilepsy, endocrine disorders, functional disorders, depression, anxiety, cognitive deficits, headache, and sleep disorders were also more common in the exposure group. Persons with TBI requiring highintensity treatment displayed the highest relative incidence rates of the conditions studied over 10 years of follow-up. Persons who had been admitted to the hospital because of TBI had higher relative incidence rates for epilepsy and dementia than those who had been cared for on an outpatient basis.

CONCLUSION

Adverse sequelae of TBI can still be seen ten years after the exposure. These patients die earlier than persons without TBI and suffer earlier and more frequently from associated conditions.

Development of a risk score to identify patients at high risk for a severe course of COVID-19

Aim

We aimed to develop a risk score to calculate a person's individual risk for a severe COVID-19 course (POINTED score) to support prioritization of especially vulnerable patients for a (booster) vaccination.

Subject and methods

This cohort study was based on German claims data and included 623,363 individuals with a COVID-19 diagnosis in 2020. The outcome was COVID-19 related treatment in an intensive care unit, mechanical ventilation, or death after a COVID-19 infection. Data were split into a training and a test sample. Poisson regression models with robust standard errors including 35 predefined risk factors were calculated. Coefficients were rescaled with a min-max normalization to derive numeric score values between 0 and 20 for each risk factor. The scores' discriminatory ability was evaluated by calculating the area under the curve (AUC).

Results

Besides age, down syndrome and hematologic cancer with therapy, immunosuppressive therapy, and other neurological conditions were the risk factors with the highest risk for a severe COVID-19 course. The AUC of the POINTED score was 0.889, indicating very good predictive validity.

Conclusion

The POINTED score is a valid tool to calculate a person's risk for a severe COVID-19 course.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10389-023-01884-7.

Post-COVID-19-associated morbidity in children, adolescents, and adults: A matched cohort study including more than 157,000 individuals with COVID-19 in Germany

BACKGROUND

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.

METHODS AND FINDINGS

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.

CONCLUSIONS

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.

TRIAL REGISTRATION

ClinicalTrials.gov https://clinicaltrials.gov/ct2/show/NCT05074953.

Optimising the impact of COVID-19 vaccination on mortality and hospitalisations using an individual additive risk measuring approach based on a risk adjustment scheme

In this population-based cohort study, billing data from German statutory health insurance (BARMER, 10% of population) are used to develop a prioritisation model for COVID-19 vaccinations based on cumulative underlying conditions. Using a morbidity-based classification system, prevalence and risks for COVID-19-related hospitalisations, ventilations and deaths are estimated. Trisomies, behavioural and developmental disorders (relative risk: 2.09), dementia and organic psychoorganic syndromes (POS) (2.23) and (metastasised) malignant neoplasms (1.99) were identified as the most important conditions for escalations of COVID-19 infection. Moreover, optimal vaccination priority schedules for participants are established on the basis of individual cumulative escalation risk and are compared to the prioritisation scheme chosen by the German Government. We estimate how many people would have already received a vaccination prior to escalation. Vaccination schedules based on individual cumulative risk are shown to be 85% faster than random schedules in preventing deaths, and as much as 57% faster than the German approach, which was based primarily on age and specific diseases. In terms of hospitalisation avoidance, the individual cumulative risk approach was 51% and 28% faster. On this basis, it is concluded that using individual cumulative risk-based vaccination schedules, healthcare systems can be relieved and escalations more optimally avoided.

[Healthcare in Pregnancy and Access to Midwives according to Socio-Economic Situation: An Analysis with Routine Data from BARMER Health Insurance]

BACKGROUND

Socio-economic status is an important cause of inequality in health status and access to healthcare. This also applies to pregnancy, birth and the postpartum period. Healthcare during pregnancy plays a crucial role in the success of the life phase around birth. On the basis of routine data from BARMER health insurance, the study investigated which services pregnant women received during pregnancy depending on their socio-economic situation.

METHODS

The study population comprised 237,251 women insured with BARMER with 278,237 births in 2015-2019. The services billed by gynaecologists and midwives during pregnancy were considered in relation to the socio-economic situation of the women involved.

RESULTS

Physicians dominated the provision of preventive healthcare. For almost 98% of the pregnant women, a medical preventive healthcare flat rate was billed in at least three quarters. A regular participation of the midwife in preventive healthcare from the fourth month of pregnancy with more than four preventive services was the case in only 1.2% of women. Women from low-income backgrounds received fewer antenatal healthcare services from both gynaecologists and midwives, with 31% of women with low income having no antenatal midwife contact at all, compared to only 11% of high-income women. High-income earning women were also more likely to have had early contact with a midwife (47 vs. 37% in the first trimester). The timing of the first contact seemed to be relevant for the subsequent cooperative antenatal healthcare by both professional groups.

CONCLUSION

The potentials of midwifery healthcare are not being leveraged. Midwives should be significantly more involved in prenatal healthcare overall, and access to midwives must be improved, especially for socially disadvantaged women. These women could benefit in particular from midwifery healthcare, as it takes greater account of social aspects in healthcare and also provides outreach services.

Spatial risk adjustment between health insurances: using GWR in risk adjustment models to conserve incentives for service optimisation and reduce MAUP

This paper presents a new approach to deal with spatial inequalities in risk adjustment between health insurances. The shortcomings of non-spatial and spatial fixed effects in risk adjustment models are analysed and opposed against spatial kernel estimators. Theoretical and empirical evidence suggests that a reasonable choice of the spatial kernel could limit the spatial uncertainty of the modifiable area unit problem under heavy-tailed claims data, leading to more precise predictions and economically positive incentives on the healthcare market. A case study of the German risk adjustment shows a spatial risk spread of 86 Euro p.c., leading to incentives for spatial risk selection. The proposed estimator eliminates this issue and conserves incentives for services optimisation.

[Utility Analysis of Oncological Centre Building in the Field of Colorectal Cancer]

BACKGROUND

In the field of colorectal cancer and other cancer entities, there is an ongoing trend to establish multidisciplinary treatment in specialised cancer centres. Little is known by now about the outcomes of this centralised and quality-driven treatment approach. In light of the increasing cost-benefit discussions, assessments of their impact seem to be necessary. This paper discusses positive effects of cancer centres with a particular focus on the multidisciplinary approach and its potential impact on survival outcomes of colorectal cancer patients. The study applies a Markov approach to assess the epidemiological impact of the cancer centre establishment and associated life years gained, both at a regional level and over time.

MATERIALS AND METHODS

We conducted a systematic literature review to evaluate effects of multidisciplinary treatment in specialised cancer centres in the field of colorectal cancer. Applying the PRISMA scheme, 602 articles were assessed by title, abstract and full text. Finally, 10 publications met the inclusion criteria and were included in a meta-analysis. Using the example of the "Krebszentrum Nord" at the University Hospital in the federal state of Schleswig-Holstein, we assessed the impact of changes in survival rates at the regional level by simulating expected incidence, mortality and prevalence rates in a Markov model including detailed population data of Schleswig-Holstein.

RESULTS

The meta-analysis revealed that multidisciplinary treatment in a cancer centre was associated with a 4.5 % reduction of mortality rates in colorectal cancer patients. The greatest benefits were found for patients in advanced disease stages. At the regional level, 106 life years could be gained through the centre for colorectal cancer until 2020, according to the assumptions of the simulation.

CONCLUSION

The establishment of colorectal cancer centres is associated with positive outcomes for patients. However, the scarce evidence base underpins the need for additional studies to further examine the impact of centre building in colorectal cancer care. Cancer registries are a solid foundation for further research. Future requirements for oncological care can be derived from the predicted epidemiological development.

[Incentive for Regional Risk Selection in the German Risk Structure Compensation Scheme]

The introduction of the new law GKV-FQWG strengthens the competition between statutory health insurance. If incentives for risk selection exist, they may force a battle for cheap customers. This study aims to document and discuss incentives for regional risk selection in the German risk structure compensation scheme. Identify regional autocorrelation with Moran's l on financial parameters of the risk structure compensation schema. Incentives for regional risk selection do indeed exist. The risk structure compensation schema reduces 91% of the effect and helps to reduce risk selection. Nevertheless, a connection between regional situation and competition could be shown (correlation: 69.5%). Only the integration of regional control variables into the risk compensation eliminates regional autocorrelation. The actual risk structure compensation is leading to regional inequalities and as a consequence to risk selection and distortion in competition.