Claudia Terschüren

Is telemonitoring an option against shortage of physicians in rural regions? attitude towards telemedical devices in the North Rhine-Westphalian health survey, Germany

BackgroundGeneral practitioners (GP) in rural areas of Germany are struggling to find successors for their private practices. Telemonitoring at home offers an option to support remaining GPs and specialists in ambulatory care.MethodsWe assessed the knowledge and attitude towards telemedicine in the population of North Rhine-Westphalia (NRW), Germany, in a population-based telephone survey.ResultsOut of 2,006 participants, 734 (36.6%) reported an awareness of telemedical devices. Only 37 participants (1.8%) have experience in using them. The majority of participants were in favour of using them in case of illness (72.2%). However, this approval declined with age. These findings were similar in rural and urban areas. Participants who were in favour of telemedicine (n = 1,480) strongly agreed that they would have to see their doctor less often, and that the doctor would recognize earlier relevant changes in their vital status. Participants who disliked to be monitored by telemedical devices preferred to receive immediate feedback from their physician. Especially, the elderly fear the loss of personal contact with their physician. They need the direct patient-physician communication.ConclusionsThe fear of being left alone with the technique needs to be compensated for todays elderly patients to enhance acceptance of home telemonitoring as support for remaining doctors either in the rural areas or cities.

The feasibility of estimating the total environmental burden of disease due to cadmium: experiences of the VegAS project

Abstract Background Cadmium is associated with several human health effects. Exposure via ambient background air is far less significant than through the food chain. The question is whether current concentrations of cadmium in the air still pose a health threat in terms of attributable cases of lung cancer in Germany. The German VegAS project (long title: Distribution-based analysis of the health effect of environmental stressors) quantified the environmental burden of disease (EBD) of cadmium in ambient air. Methods A comprehensive review of the literature until early 2012 was done to identify cadmium-induced health outcomes and exposure–response functions. Evidence was checked using predefined criteria. National data sources for health and exposure information were consulted to estimate disability-adjusted life-years (DALYs) lost due to cadmium. The range of uncertainty by variation of uncertain parameters was described in detail. Findings DALYs of lung cancer due to inhalation of cadmium in ambient background air in Germany (0·2131 ng/m 3 ) were quantifiable and estimated at 7 DALYs lost (0·0087 DALYs per 100 000 population). Uncertainty analysis using various unit risk estimates yielded a maximum of 348 DALYs. Interpretation By quantifying the EBD of airborne cadmium and lung cancer, only a very small part of the total EBD due to cadmium is quantified. Still, looking only at this small fraction of possible EBD due to cadmium, up to 348 DALYs (range maximum) could be prevented if this toxic substance was reduced to zero. Evidence supports an association between exposure to cadmium and kidney damage; bone disease; and lung, kidney, and prostate cancer. However, incompatibility of data affecting all dimensions of exposure and the EBD model undercut most quantification for supporting a scientifically validated environmental health policy. Funding The VegAS project was funded by the Federal Ministry of Environment, Nature Conservation, and Nuclear Safety in context of the Environment Research Plan 2009. The corresponding author had full access to all the data in the study and final responsibility for the decision to submit for publication.

Disability Weight – ein umstrittenes Maß zur Bewertung von Gesundheitsbeeinträchtigungen

Das Disability Adjusted Life Year (DALY) ist ein etabliertes Mas zur Darstellung der Krankheitslast von Bevolkerungen. Zur Quantifizierung des DALYs werden Gewichtungsfaktoren (Disability Weights) fur Gesundheitszustande benotigt, um mit einer Erkrankung verlebte Lebensjahre mit durch vorzeitigen Tod verloren Lebensjahren aufsummieren zu konnen. Zur Bestimmung der Disability Weights wird ein Gesundheitszustand auf einer Skala zwischen 0 und 1 eingeordnet, wobei 0 vollkommene Gesundheit abbildet und 1 einen Zustand vergleichbar mit dem Tod beschreibt.

Quantification of the health impact of environmental stressors in Germany for use in policy making: results of the VegAS project

Abstract Background The German VegAS project (long title: Distribution-based analysis of the health effect of environmental stressors) deals with the health impact of environmental stressors in Germany, aiming for a comparative risk assessment (CRA) using the environmental burden-of-disease (EBD) approach developed by WHO. Methods Extensive literature and data searches were conducted to determine the evidence-based environment–health relations of seven stressors (benzene, cadmium, noise [various types], ozone, particulate matter, perfluorinated compounds [PFC], and second-hand smoke) and their distribution of exposure in Germany. The EBD was expressed as lost disability-adjusted life-years (DALYs) attributable to these stressors. Uncertainties and limitations at different stages of the analysis were identified and discussed in detail. Moreover, an expert meeting was held to review the methods and data. The VegAS results were discussed regarding compatibility requirements of CRA. Findings DALYs attributable to the seven environmental stressors were determined for 11 health outcomes, some of them attributed to more than one stressor. Five stressors could be associated with years of life lost. The quality of EBD quantification was restricted by missing sources of exposure data, lack of exposure–response functions, or incomplete knowledge on the outcome weighting. DALY estimates were reported for all stressors except PFC. Interpretation A full DALY calculation failed for several outcomes because of insufficient or missing data. CRAs building on this approach should therefore be interpreted with caution. The VegAS results provide evidence-based, stressor-specific EBD estimates that can support informed decision making in environmental health. These estimates, however, should be used against the background of a detailed uncertainty analysis that should also help close data gaps, as applied in VegAS. Funding The VegAS project was funded by the Federal Ministry of Environment, Nature Conservation, and Nuclear Safety in context of the Environment Research Plan 2009. The corresponding author had full access to all the data in the study and final responsibility for the decision to submit for publication.

A nonparametric random coefficient approach for life expectancy growth using a hierarchical mixture likelihood model with application to regional data from North Rhine-Westphalia (Germany)

BackgroundLife expectancy is of increasing prime interest for a variety of reasons. In many countries, life expectancy is growing linearly, without any indication of reaching a limit. The state of North Rhine–Westphalia (NRW) in Germany with its 54 districts is considered here where the above mentioned growth in life expectancy is occurring as well. However, there is also empirical evidence that life expectancy is not growing linearly at the same level for different regions.MethodsTo explore this situation further a likelihood-based cluster analysis is suggested and performed. The modelling uses a nonparametric mixture approach for the latent random effect. Maximum likelihood estimates are determined by means of the EM algorithm and the number of components in the mixture model are found on the basis of the Bayesian Information Criterion. Regions are classified into the mixture components (clusters) using the maximum posterior allocation rule.ResultsFor the data analyzed here, 7 components are found with a spatial concentration of lower life expectancy levels in a centre of NRW, formerly an enormous conglomerate of heavy industry, still the most densely populated area with Gelsenkirchen having the lowest level of life expectancy growth for both genders. The paper offers some explanations for this fact including demographic and socio-economic sources.ConclusionsThis case study shows that life expectancy growth is widely linear, but it might occur on different levels.

Urban Health in North Rhine-Westphalia

North Rhine-Westphalia (Nordrhein-Westfalen, NRW) is a large federal state (Bundesland) of Germany (Fig. 7.1). Reaching from 50° 19′ to 52° 32′ North (distance 242 km) and from 5° 52′ to 9° 28′ East (distance 252 km), NRW is situated in the western part of the country, sharing borders with Belgium and the Netherlands.