German claims data analysis to assess impact of different intraocular lenses on posterior capsule opacification and related healthcare costs

Aim: Cataract extraction is one of the most frequent surgeries in Germany. In most cases, the clouded natural lens is replaced by a hydrophobic or hydrophilic acrylic intraocular lens (IOL) implant. The most common long-term complication after cataract surgery is the development of a posterior capsule opacification (PCO). Although no precise real world data are available, published evidence suggests a lower risk for PCO development for hydrophobic acrylic IOLs compared to hydrophilic acrylic IOLs. Therefore, in the present study we assessed real world data on the impact of different IOL material types on the incidence of post-operative PCO treatment. Subject and methods: In this retrospective study, we included 3,025 patients who underwent cataract extraction and implantation of either an acrylic hydrophobic or hydrophilic IOL in 2010. We assessed clinical outcomes and direct costs in a 4-year follow-up period after cataract surgery from a statutory health insurance (SHI) perspective in Germany. Results: PCO that required capsulotomies occurred significantly (p < 0.0001) less frequent in patients who had received a hydrophobic IOL (31.57% of 2,078 patients) compared to the group with hydrophilic IOL implants (56.6% of 947 patients) and costs per patient for postoperative treatment in a 4-year follow-up were 50.03 € vs. 87.81 € (i.e. 75% higher in the latter group, p < 0.0001). Conclusion: Considering the high prevalence of cataract, the economic burden associated with adverse effects of cataract extraction is of great relevance for the German SHI. Hydrophobic lenses seem to be superior regarding both medical and economic results

Health-related quality of life among patients with treated alcohol use disorders, schizophreniform disorders or affective disorders and the influence of flexible and integrative psychiatric care models in Germany (PsychCare)

IntroductionFlexible and integrated treatment options (FIT) have been established in German psychiatric hospitals to enhance continuous and patient-centered treatment for patients with mental disorders. We hypothesized that patients with experience in FIT treatment showed higher health-related quality of life (HRQoL) and comparable symptom severity compared with patients treated as usual (TAU). Further, we expected that some sub-dimensions of HRQoL determined HRQoL results clearer than others, while certain factors influenced HRQoL and symptom severity stronger in the FIT compared to the TAU group. In addition, we hypothesized that HRQoL is correlated with symptom severity.MethodsWe undertook a controlled, prospective, multicenter cohort study (PsychCare) conducted in 18 psychiatric hospitals in Germany, using the questionnaires Quality of Well Being Self-Administered (QWB-SA) (HRQoL) and Symptom-Checklist-K-9 (SCL-K-9) (symptom severity) at recruitment (measurement I) and 15 months later (measurement II). We assessed overall HRQoL (measured in health utility weights (HUW) and symptom severity score for patients from FIT and TAU treatment. We investigated the QWB-SA dimensions and separated the results by diagnosis. We used beta regressions to estimate the effect of multiple co-variates on both outcomes. To investigate the correlation between HRQoL and symptom severity, we used Pearson correlation.ResultsDuring measurement I, 1,150 patients were recruited; while 359 patients participated during measurement II. FIT patients reported higher HUWs at measurement I compared to TAU patients (0.530 vs. 0.481, p = 0.003) and comparable HUWs at measurement II (0.581 vs. 0.586, p = 0.584). Symptom severity was comparable between both groups (I: 21.4 vs. 21.1, p = 0.936; II: 18.8 vs. 19.8, p = 0.122). We found lowest HRQoL and highest symptom severity in participants with affective disorders. HRQoL increased and symptom severity decreased over time in both groups. The QWB-SA dimension acute and chronic symptoms was associated with highest detriments in HRQoL. We identified risk/protective factors that were associated with lower quality of life and higher symptom severity in both groups. We confirmed that HRQoL was negatively associated with symptom severity.DiscussionHealth-related quality of life (during hospital treatment) was higher among patients treated in FIT hospitals compared to patients in routine care, while symptom severity was comparable between both groups

Common variants in Alzheimer's disease and risk stratification by polygenic risk scores.

Funder: Funder: Fundación bancaria ‘La Caixa’ Number: LCF/PR/PR16/51110003 Funder: Grifols SA Number: LCF/PR/PR16/51110003 Funder: European Union/EFPIA Innovative Medicines Initiative Joint Number: 115975 Funder: JPco-fuND FP-829-029 Number: 733051061Genetic discoveries of Alzheimer's disease are the drivers of our understanding, and together with polygenetic risk stratification can contribute towards planning of feasible and efficient preventive and curative clinical trials. We first perform a large genetic association study by merging all available case-control datasets and by-proxy study results (discovery n = 409,435 and validation size n = 58,190). Here, we add six variants associated with Alzheimer's disease risk (near APP, CHRNE, PRKD3/NDUFAF7, PLCG2 and two exonic variants in the SHARPIN gene). Assessment of the polygenic risk score and stratifying by APOE reveal a 4 to 5.5 years difference in median age at onset of Alzheimer's disease patients in APOE ɛ4 carriers. Because of this study, the underlying mechanisms of APP can be studied to refine the amyloid cascade and the polygenic risk score provides a tool to select individuals at high risk of Alzheimer's disease

Equitable access to primary health care in Germany: addressing access dimensions to reduce geographic variation

Because of evidence of regional variation in health and healthcare use, this thesis used health equity and access to care theory to examine regional differences in access to primary care, using survey- as well as secondary data in four empirical studies. First, a systematic literature review was used to categorize forms and reasons for regional healthcare shortages and access barriers, with a particular focus on rural areas. After information extraction from the selected studies and a thematic content analysis, the forms and causes identified in the literature were grouped and discussed. Following the literature-based review of these thematic foundations, a study was then designed to evaluate patient-reported access to primary care in exemplary German regions and assess empirical differences in rural vs. urban populations. This allowed the importance to patients of different access dimensions to be evaluated. For a subgroup of study participants with multidisciplinary care needs, care coordination failures and the supportive role of the general practitioner as a primary point of access was investigated. Finally, regional factors that are associated with variations in need, health, and utilisation beyond individual health determinants were identified, and placed on different regional framework conditions. These health-related factors were summarised in a regional deprivation measure and small-scale regions in Germany were differentiated by their regional deprivation by the main dimensions (material, social, ecological). Finally, their association to regional health outcomes were cross-sectionally estimated. To reduce unwarranted access variation, while also taking the patient perspective (by region) into account, the thesis concludes with a chapter on implications. Here, concepts for regional and multidimensional access monitoring, as well as further regulatory measures in capacity and distribution planning of primary care, are discussed.:Content Tables ........................................................................................................................... V Figures ....................................................................................................................... VI Abbreviations ........................................................................................................... VII 1. Background and research objectives .................................................................. 9 1.1. Health equity and access to health care ........................................................ 10 1.2. Regional variation as a contradiction to the equity principle ....................... 16 1.3. Reducing unwarranted regional variation in health care .............................. 20 1.4. Research objectives and thesis structure ...................................................... 24 References ............................................................................................................... 28 Legal sources .......................................................................................................... 33 2. Rural health care shortages and access barriers ............................................. 34 3. Regional access and satisfaction with primary care........................................ 35 Appendix 3 .............................................................................................................. 36 4. Access to primary care and outpatient care coordination .............................. 48 4.1. Introduction .................................................................................................. 49 4.2. Background ................................................................................................... 51 4.2.1. The patient perspective of care coordination ......................................... 51 4.2.2. Coordinating mechanisms ..................................................................... 52 4.3. Methods ........................................................................................................ 55 4.3.1. Data collection and sample .................................................................... 55 4.3.2. Measures ................................................................................................ 55 4.3.3. Data analysis .......................................................................................... 58 4.4. Results .......................................................................................................... 59 4.5. Discussion and limitations ............................................................................ 62 4.6. Implications .................................................................................................. 65 References ............................................................................................................... 69 Appendix 4 .............................................................................................................. 73 5. Area deprivation and its impact on health ....................................................... 76 6. Summary of implications ................................................................................... 77 6.1. Establishing a framework to assess primary care access and performance .. 77 6.2. Strengthening patient involvement in health care structure planning .......... 81 6.3. Strengthening access to GPs as outpatient care coordinators ....................... 84 6.4. Including regional deprivation factors in health care structure planning ..... 86 References ............................................................................................................... 9

Rural-urban differences in determinants of patient satisfaction with primary care

In light of the rising regional inequalities in primary care provider supply, to ensure equitable access is a pressing issue in health policy. Most policy approaches fall short in considering the patient perspective when defining shortage areas. As a consequence, implementations of new service delivery models might fail to be responsive to patients' expectations. To explore regional differences in the relative importance of structure and process attributes as drivers of patient satisfaction with local primary care, we collected data from residents of three objectively well-supplied urban and six objectively worse-supplied rural areas in Germany and tested a multi-group structural equation model. The results suggest that the relative importance of care attributes is different among the regional conditions rural and urban. Regardless of regional constraints, the strongest determinants of satisfaction are not related to structural aspects but are concerned with the quality of the doctor-patient relationship. A lack of available choices and a higher tolerance in terms of distances provide possible explanations for the results. The high importance rural residents attribute to the interpersonal relation should not be neglected in the re-organization of traditional service delivery in rural areas

Oxidative Trifluoromethylation and other Functionalization Reactions of Alkenes and Alkynes

This thesis concerns the use of various potent oxidants in organic synthesis. The main focus is directed at selectively introducing trifluoromethyl groups into compounds containing double or triple bonds. All reactions proceed under mild conditions and can in most cases be performed on the bench-top. We have developed three different procedures for transformations of activated alkenes and alkynes as well as quinones. In paper I the selective introduction of a trifluoromethyl group together with an oxygen functionality to double and triple bonds is demonstrated. Paper II is focused on the related chemoselective cyanotrifluoromethylation in which a cyano group is added instead of the oxygen functionality. Paper III describes a new procedure for C–H trifluoromethylation of quinones. Our studies on the mechanistic aspects of the above reactions are described in Paper IV. In these studies we investigated the ligand and substituent effects in Cu-catalyzed reactions. Paper V is focused on a conceptually new palladium-catalyzed allylic C–H acyloxylation of olefins under oxidative conditions. The procedure uses an inexpensive, safe and environmentally benign oxidant, sodium perborate, which is activated with acetic anhydride.At the time of the doctoral defense, the following paper was unpublished and had a status as follows: Paper 4: Submitted.</p

Table_1_Health-related quality of life among patients with treated alcohol use disorders, schizophreniform disorders or affective disorders and the influence of flexible and integrative psychiatric care models in Germany (PsychCare).DOCX

IntroductionFlexible and integrated treatment options (FIT) have been established in German psychiatric hospitals to enhance continuous and patient-centered treatment for patients with mental disorders. We hypothesized that patients with experience in FIT treatment showed higher health-related quality of life (HRQoL) and comparable symptom severity compared with patients treated as usual (TAU). Further, we expected that some sub-dimensions of HRQoL determined HRQoL results clearer than others, while certain factors influenced HRQoL and symptom severity stronger in the FIT compared to the TAU group. In addition, we hypothesized that HRQoL is correlated with symptom severity.MethodsWe undertook a controlled, prospective, multicenter cohort study (PsychCare) conducted in 18 psychiatric hospitals in Germany, using the questionnaires Quality of Well Being Self-Administered (QWB-SA) (HRQoL) and Symptom-Checklist-K-9 (SCL-K-9) (symptom severity) at recruitment (measurement I) and 15 months later (measurement II). We assessed overall HRQoL (measured in health utility weights (HUW) and symptom severity score for patients from FIT and TAU treatment. We investigated the QWB-SA dimensions and separated the results by diagnosis. We used beta regressions to estimate the effect of multiple co-variates on both outcomes. To investigate the correlation between HRQoL and symptom severity, we used Pearson correlation.ResultsDuring measurement I, 1,150 patients were recruited; while 359 patients participated during measurement II. FIT patients reported higher HUWs at measurement I compared to TAU patients (0.530 vs. 0.481, p = 0.003) and comparable HUWs at measurement II (0.581 vs. 0.586, p = 0.584). Symptom severity was comparable between both groups (I: 21.4 vs. 21.1, p = 0.936; II: 18.8 vs. 19.8, p = 0.122). We found lowest HRQoL and highest symptom severity in participants with affective disorders. HRQoL increased and symptom severity decreased over time in both groups. The QWB-SA dimension acute and chronic symptoms was associated with highest detriments in HRQoL. We identified risk/protective factors that were associated with lower quality of life and higher symptom severity in both groups. We confirmed that HRQoL was negatively associated with symptom severity.DiscussionHealth-related quality of life (during hospital treatment) was higher among patients treated in FIT hospitals compared to patients in routine care, while symptom severity was comparable between both groups.</p

Dispersion and transport of tropospheric aerosol and pollutants in the Western Mediterranean: the role of the Po Valley under different transport regimes

International audienceThis work reports a characterization of the vertical variability of tropospheric aerosol and gaseous pollutants, over the western Mediterranean, during the 2012 summer season. In particular, we investigate the role of the Po Valley region as a receptor and emissive region of both natural and anthropogenic aerosol. The observational analysis, based on a comprehensive database of meteorological, aerosol and chemical measurements, is integrated with a model analysis using the Lagrangian transport system FLEXPART combined with emission databases, and WRF- Chem, the Weather Research and Forecasting (WRF) model coupled with Chemistry. Observations have been performed in the framework of the Supersito project by Regional Agency of Prevention and Environment of the Emilia Romagna region (ARPA-ER, Ital), the TRAQA campaign (TRAnsport et Qualité de l’Air au dessus du bassin Méditerranéen) performed in the ChArMEx (Chemistry-Aerosol Mediterranean Experiment) project, and the european project PEGASOS (Pan-European Gas-AeroSOl-climate interaction Study). An alternation between different transport regimes characterized the 2012 summer, resulting in a large variability of aerosol and pollution at different time and spatial scales. Particles of different nature have been discriminated basing on optical properties retrieved from lidar data and supported by in-situ observations and transport analysis. Results show that, during the analysed season, aerosol in the Po Valley was mainly confined below 2000 m and dominated (50% of detections) by spherical particles. Two events of dust advection from northern Africa were identified (19th-21th June and 29th June–2nd July), with intrusion and mixing with local pollution in the PBL and a non-negligible occurrence (∼7%) of dust at the ground. Frequent events (22% of occurrence) of non-spherical particles resuspension, likely due to uplift of mineral soil particles, were observed from the ground to 2000 m during afternoon and evening. In the same season, the combination of airborne measurements with transport and chemical model analysis, allowed to individuate two episodes of inversion in the main advection pattern (23th -24th June and 26th -27th June), causing an easterly pollution export from the Po basin toward the Genoa Gulf (North-Western Mediterranean). Using the CO species as a tracer of pollution, we estimated the Po Valley contribution over the local pollution background value. The CO plume affected a layer from the sea level to 1000 m over the Genoa Gulf, with concentrations reaching 50 ppbv

Evaluation of a flexible and integrative psychiatric care model in a department of child and adolescent psychiatry in Tübingen, Germany: study protocol (EVA_TIBAS)

Background!#!Model projects for flexible and integrated treatment (FIT) in Germany aim at advancing the quality of care for people with mental disorders. A new FIT model project was established in 2017 at the Department of child and adolescent psychiatry (KJP) of the University Hospital Tübingen (Universitätsklinikum Tübingen, UKT). The study design of EVA_TIBAS presented here describes the evaluation of the FIT model project at the KJP of the UKT. This evaluation aims at quantifying the anticipated FIT model project changes, which are to improve patients' cross-sectoral care at the same maximum cost as standard care.!##!Methods!#!EVA_TIBAS is a controlled cohort study using a mix of quantitative and qualitative methods. The FIT evaluation consists of three modules. In Module A, anonymized claims data of a statutory health insurance fund will be used to compare outcomes (duration of inpatient and day care psychiatric treatment, inpatient and day care psychiatric length of stay, outpatient psychiatric treatment in hospital, inpatient hospital readmission, emergency admission rate, direct medical costs) of patients treated in the model hospital with patients treated in structurally comparable control hospitals (estimated sample size = ca. 600 patients). In Module B, patient-reported outcomes (health related quality of life, symptom burden, return to psychosocial relationships (e.g. school, friends, hobbies), treatment satisfaction, societal costs) will be assessed quantitatively using validated questionnaires for the model and two control hospitals (estimated sample size = ca. 300 patients). A subsequent health economic evaluation will be based on cost-effectiveness analyses from both the insurance fund's and the societal perspective. In Module C, about 30 semi-structured interviews will examine the quality of offer, effects and benefits of the service offered by the social service of the AOK Baden-Württemberg (for stabilizing the overall situation of care in the family) in the model hospital. A focus group discussion will address the quality of cooperation between employees of the university hospital and the social services.!##!Discussion!#!The results of this evaluation will be used to inform policy makers whether this FIT model project or aspects of it should be implemented into standard care.!##!Trial registration!#!This study was registered at ClinicalTrials.gov PRS (ID: NCT04727359 , date: 27 January 2021)