Friedrich Wilhelm Schwartz

Maternal occupational exposure to chemical substances and the risk of infants small-for-gestational-age

BACKGROUND The association between maternal occupational exposure to specific chemical substances (organic solvents, carbon tetrachloride, herbicides, chlorophenols, polychlorinated biphenyls, aromatic amines, lead and lead compounds, mercury and mercury compounds) and birth of small-for-gestational-age (SGA) infants was evaluated using data from a prospective cohort study of 3,946 pregnant women in West Germany from 1987 to 1988. METHODS Occupational, medical, and psychosocial information was gathered through a questionnaire from pregnant women who were recruited between 15 and 28 gestational weeks. Exposure to chemical substances at the current workplace was assessed by a job-exposure matrix constructed by Pannett in 1985 and weighted for the number of working hours per week. Women not working at the time of the interview, women with multiple births, and women with stillbirths were excluded from analysis. Data were analyzed using dichotomous and polytomous logistic regression to control for age, smoking status, alcohol consumption, body mass index, and number of former births. RESULTS The results of the dichotomous logistic regression analysis suggest that leather work might be associated with the birth of infants small-for-gestational-age through exposure to chlorophenols (P = 0.02) and aromatic amines (P = 0.05). In the polytomous logistic regression analysis, only the association between exposure to mercury and growth retardation reached statistical significance (P = 0.02); however, the power of the study is limited. Further adjustment for income, shift work, and heavy physical work had no substantial effect on the results. CONCLUSIONS These findings suggest that maternal exposure to specific chemicals at work may be a risk factor for the birth of SGA infants.

Health in the context of growing old: social representations of health.

Senior citizens have become a major part of the clientele of general practitioners and home care nurses due to a major demographic transition in most western countries. How do the health concepts in professional practice reflect these trends? Research has largely investigated the health concepts of lay people. This study is focused on the representations of health in old age held by two groups of professionals— general practitioners and nurses—both working in home care with elderly people in two German cities. The results show how health professionals use an extended concept of health, which focuses on the life situation of the old person, on autonomy, self-determination or independence and on how the elderly manage disease and physical restrictions.

Prevalence of depression diagnosis and prescription of antidepressants in East and West Germany: an analysis of health insurance data

AimThis study aimed to analyse depression-related factors. The prevalence of depression has been shown in prior surveys to vary between East and West Germany. Do these differences also appear in health insurance data?MethodThe outpatient data of a large German statutory health insurance company were analysed for regional differences in (a) the prevalence of depression diagnosis, (b) prescription rates of antidepressants and (c) risk factors of being diagnosed with depression or prescribed antidepressants. Diagnosis rates of depression in outpatient care (ICD-10 diagnosis F32/33) were analysed for the first quarter of 2004, and prescription rates of antidepressants were analysed for the first half of 2004. Odds ratios were calculated for the likelihood of being diagnosed with depression and of being prescribed antidepressants whilst considering socio-demographic and regional variables.ResultsThe prevalence of depression diagnosis is up to 41% lower in East Germany than the expected mean rate and 30% above the expected mean rate in Berlin. Regional distribution rates of antidepressant prescriptions largely follow the same pattern as rates for depression diagnosis, with the exception of Berlin where prescription rates are 10% below the expected mean rate. Unemployed persons in West Germany have a higher chance of being diagnosed with depression and of being prescribed antidepressants than those unemployed in East Germany.DiscussionResults correspond greatly to findings of epidemiologic surveys. However, the lower rate of depression diagnosis and prescription rates in East Germany might also be due to fewer mental health professionals practising there and possible differences in reporting style of emotional symptoms. This might contribute to the differences in diagnosis and prescription prevalence but cannot be solely responsible for this phenomenon. Probable causes of the different depression prevalence rates in East and West Germany will be discussed in this analysis. More research into factors impacting on regional differences in the prevalence of depression is needed.

Organochlorine residues in human breast milk: analysis through a sentinel practice network.

STUDY OBJECTIVE--The study aimed to assess through a sentinel practice network the validity of data on levels of organochlorine residues in human milk along with personal, lifestyle, and exposure variables of breastfeeding women; to compare the results of this new approach with those of the Lower Saxony breast milk surveillance programme; and to test hypotheses on potential determinants of contamination levels. DESIGN--Eligible women were enrolled into this cross sectional study by a network of 51 paediatric practices when bringing their babies for a U3 infant screening examination (4th to 6th week after delivery). Lifestyle and exposure factors were obtained by questionnaire. All milk samples were analysed for hexachlorocyclohexane, hexachlorbenzole, DDT, dieldrin, polychlorinated biphenyls (PCB) and heptachlor; half the samples were also analysed for dioxin. Analytic statistics were computed using polychotomous logistic regression (PLR). SETTING--The study was conducted in Lower Saxony, Germany, from summer 1992 to summer 1993. PARTICIPANTS--Altogether 156 primiparous, breast feeding German women, aged 25-35 years, who had been born and had grown up in West Germany, were studied. MAIN RESULTS--Compared with the regular programme, participants in this study had their milk analysed sooner after delivery and were more likely to have grown up in rural areas, less likely to have been exposed to hazardous substances, less likely to have a diet of health food, and slightly less likely to be a smoker at the time of the study. Breast milk contamination levels were comparable in both studies, and in all but two cases well below the tolerable concentrations established by the Deutsche Forschungsgemeinschaft (German Research Fellowship). After adjustment for potential confounders using polychotomous logistic regression, there were statistically significant positive associations between breast milk contamination and age (PCB, test for trend: p = 0.006), average dietary fat intake per week (dioxin, p = 0.01), and proximity of residence to hazardous sites (dioxin, p < 0.05), and negative associations between residue levels and relative body weight at the time of the study (PCB; p < 0.0001) and difference in body weight (weight minus weight before the pregnancy; PCB, p = 0.0002), respectively. CONCLUSIONS--Sentinel practice networks are a feasible and low-biased approach to population based breast milk studies. The contamination levels and associations found are biologically plausible and comparable with the results of other studies. To reduce organochlorine residue levels in human milk in the short term, breast-feeding women should be advised not to try to reduce their weight until after lactation. Public promotion of a lower dietary fat intake may reduce the lifetime accumulation of organochlorine compounds in the human body fat tissue in the long term, resulting in lower concentrations in breast milk as well.

Who is treated, and how, for depression? An analysis of statutory health insurance data in Germany

BackgroundStudies on the treatment of depression using epidemiological survey methods suggest a high level of under-treatment. Little is known about the characteristics of those people receiving treatment and indeed what kind of treatment they are likely to receive.MethodAnalysis of the data of a statutory health insurance company in Germany.ResultsIn middle-aged groups, about 50% of those diagnosed as being depressed in outpatient care are prescribed antidepressants and/or psychotherapy in the course of a year. There is more pharmacologic treatment provided in rural areas and more psychotherapy in cities, suggesting that treatment is dependent upon service availability rather than evidence-based treatment decisions. Treatment rates are considerably lower in the very young and the very old and show gender bias. Young females receive less pharmacologic treatment than young males, and elderly men are, in general, treated less than women, suggesting under-treatment at least for these groups.ConclusionsThe low treatment rates following the diagnosis of depression in the young and the old require attention, in particular with respect to gender aspect.

FINANCING REFORMS IN THE GERMAN HOSPITAL SECTOR: FROM FULL COST COVER PRINCIPLE TO PROSPECTIVE CASE FEES

OBJECTIVES The authors provide an overview of the hospital sector in Germany with a focus on the impact of recent reform legislation on this sector. METHODS Data from the Federal Statistics Office, the Ministry of Health, and the Federal Association of Physicians are synthesized with information obtained from a general review of the literature. RESULTS Before the implementation of recent health-care reforms, the German health-care system has been sharply divided into inpatient and ambulatory care sectors, resulting in a fragmented system of care delivery. All hospital operating costs were fully covered through per diem charges. The 1992 Health Care Structure Act and subsequent pieces of legislation have introduced new mechanisms to improve cost efficiency in the hospital sector and increase coordination between the inpatient and outpatient care. These measures notably include implementing an inpatient prospective payment system and permitting ambulatory surgery and care services to be offered in inpatient settings. CONCLUSIONS Whereas prospective payments have greatly reduced the length of stay, hospitals were reluctant to offer ambulatory surgery due to budgetary constraints and the high level of ambulatory surgery by office-based physicians. The reforms passed have not yielded substantial cost savings. These reforms offer a natural experiment that could benefit from national and international studies on the impact of hospital sector redesign on management, financing, and patient outcomes.

Social Representations of Health Held by Health Professionals: the Case of General Practitioners and Home-care Nurses

To date, social representations research in the field of health and illness has focused mainly on lay representations of health. In the context of the “New Public Health”, the more general concept of health (instead of the more reduced concept of curing illness) has become a major target for professional work. From this trend, the following research questions can be drawn: do health professionals hold a concept of health? If so, what is the major focus of such a concept? And does it include topics from the New Public Health discourse? Following a short review of the research into social representations of health, some preliminary results of a qualitative research study are presented. This study focused on representations of health held by two groups of professionals - general practitioners and nurses - both working in home care with elderly people in two German cities. The first results of this study found that, in both groups, different types of health concepts can be identified. In both groups, a strong reference was made to the World Health Organization definition. Among other concepts, a relative concept of health was held. The concepts are expressed with reference to the specific clientele of home-care work. The results are discussed with reference to the differences and overlaps with the other research on health concepts.

Who is diagnosed as suffering from depression in the German statutory health care system? An analysis of health insurance data

BackgroundDepressive disease is becoming increasingly relevant in industrialised countries. For public health policy and planning it is important to know about the epidemiology of this disease as well as the extent to which this epidemiology impacts on health service provision.MethodAnalysis of data from a major German statutory health insurance company: Longitudinal micro-level claims data containing information about diagnoses obtained from inpatient and outpatient sources as well as information collected from prescriptions issued for antidepressants. Data was analysed with regard to the differences in drug utilisation and the risk of being diagnosed with depression according to age, sex, marital status and area of residence.ResultsResults correspond significantly with the findings of population surveys on depression epidemiology. They also confirm the finding of a lower prevalence of depression in East Germany compared to West Germany. However, the claims data revealed an unexpectedly high prevalence of depression diagnosis in older age groups.ConclusionStatutory health insurance data seems to be a reliable source of epidemiological information that is both easily accessible and longitudinally available, and thus provides important information that is needed for health policy and service planning.With regard to service provision it should be considered that depression in old age is a greater problem than is suggested by most epidemiological surveys.

Hoher Entwicklungsbedarf und viele offene Fragen bei der Versorgung von Palliativpatienten

ZusammenfassungDer Versorgung von Patienten mit unheilbaren, fortgeschrittenen Erkrankungen wird in Deutschland zunehmend Aufmerksamkeit gewidmet, u. a. vor dem Hintergrund der Sterbehilfe-Debatte und der Kritik an den gegenwärtigen Versorgungsstrukturen und Prozessabläufen. Die Palliativversorgung richtet sich gleichermaßen an Tumorpatienten und an Patienten mit anderen, nichtmalignen Erkrankungen; in Anbetracht der demographischen Entwicklung wird die Palliativversorgung immer wichtiger für eine steigende Zahl alter und hochbetagter Patienten mit besonders komplexen Bedürfnissen (z. B. infolge von Multimorbidität, Demenz und chronischem Schmerz). Deshalb besteht ein hoher Bedarf, die Palliativversorgung zu verbessern. Die Stellungnahmen zur gegenwärtigen Situation und die Empfehlungen zur Verbesserung basieren allerdings nur in geringem Umfang auf aussagekräftigen wissenschaftlichen Daten. Dieser Übersichtsartikel aus der Perspektive der Versorgungsforschung fokussiert auf die speziellen palliativen Versorgungsstrukturen (z. B. Palliativdienste und Palliativstationen) und die politischen Rahmenbedingungen. Dabei werden zentrale offene Fragen auf unterschiedlichen Ebenen thematisiert und der Bedarf für interdisziplinäre, anwendungsorientierte Forschung herausgestellt.AbstractThe health care for patients with incurable, advanced diseases is increasingly attended to in Germany. Among other things, this is enforced by the debate on euthanasia and by the criticism of the inadequate structure of services and processes of care. The palliative care approach refers to cancer as well as to non-cancer patients; due to demographic changes, it becomes more and more important for an increasing number of old and very old patients with particular complex needs (e. g., caused by multimorbidity, dementia and chronic pain). Therefore, the need for improving palliative care is immense. However, the statements on the current situation and the recommendations for improvement are based only slightly on valid scientific data. This article (written from the perspective of health services research) provides an overview on the topic with particular respect to the structure of specialized palliative care services (such as palliative care teams and palliative care units) and to the political framework. Open questions on diverse levels are picked out as a central theme, and the need for interdisciplinary, application-oriented research is pointed out.

Gesundheit der Älteren und Potenziale der Prävention und Gesundheitsförderung

In den vergangenen Jahrzehnten stieg die Lebenserwartung in Deutschland stark an. In die Gesamtlebenserwartung geht die Sterblichkeitsentwicklung aller Altersgruppen ein. Diese nahm zwischen 1959/60 bis 1993/95 um 6,8 Jahre bei Mannern auf 73,5 Jahre und bei Frauen um 7,9 Jahre auf 79,8 Jahre zu (Deutscher Bundestag 1998).