Kayvan Bozorgmehr

Effect of Restricting Access to Health Care on Health Expenditures among Asylum-Seekers and Refugees: A Quasi-Experimental Study in Germany, 1994–2013

Background Access to health care for asylum-seekers and refugees (AS&R) in Germany is initially restricted before regular access is granted, allegedly leading to delayed care and increasing costs of care. We analyse the effects of (a) restricted access; and (b) two major policy reforms (1997, 2007) on incident health expenditures for AS&R in 1994-2013. Methods and Findings We used annual, nation-wide, aggregate data of the German Federal Statistics Office (1994-2013) to compare incident health expenditures among AS&R with restricted access (exposed) to AS&R with regular access (unexposed). We calculated incidence rate differences (∆IRt) and rate ratios (IRRt), as well as attributable fractions among the exposed (AFe) and the total population (AFp). The effects of between-group differences in need, and of policy reforms, on differences in per capita expenditures were assessed in (segmented) linear regression models. The exposed and unexposed groups comprised 4.16 and 1.53 million person-years. Per capita expenditures (1994–2013) were higher in the group with restricted access in absolute (∆IRt = 375.80 Euros [375.77; 375.89]) and relative terms (IRR = 1.39). The AFe was 28.07% and the AFp 22.21%. Between-group differences in mean age and in the type of accommodation were the main independent predictors of between-group expenditure differences. Need variables explained 50-75% of the variation in between-group differences over time. The 1997 policy reform significantly increased ∆IRt adjusted for secular trends and between-group differences in age (by 600.0 Euros [212.6; 986.2]) and sex (by 867.0 Euros [390.9; 1342.5]). The 2007 policy reform had no such effect. Conclusion The cost of excluding AS&R from health care appears ultimately higher than granting regular access to care. Excess expenditures attributable to the restriction were substantial and could not be completely explained by differences in need. An evidence-informed discourse on access to health care for AS&R in Germany is needed; it urgently requires high-quality, individual-level data.

A comparison of tooth retention and replacement across 15 countries in the over-50s

OBJECTIVES Oral diseases are still among the most common chronic diseases globally with substantial detrimental impact especially on elderly peoples health and well-being. However, limited evidence exists on international variation in the oral health status of the older population. We aimed to examine international variation in tooth loss and tooth replacement in the general population aged between 50 and 90 years. METHODS A cross-sectional analysis of data from the fifth wave of the Survey of Health, Ageing and Retirement in Europe (SHARE) was conducted. The data cover 14 European countries (Austria, Belgium, Czech Republic, Denmark, Estonia, France, Germany, Italy, Luxembourg, the Netherlands, Slovenia, Spain, Sweden, and Switzerland) and Israel, and they were collected during the year 2013. Age-specific percentages of the population having all natural teeth, the age-specific numbers of natural (and artificial) teeth, and the age-specific percentages of full, partial, or no replacement of missing teeth were assessed with stratification by country. It was further evaluated to which extent proposed oral health goals concerning tooth loss at higher ages had been achieved. RESULTS In total, 62,763 individuals were included in the study. Age-standardized mean numbers of natural teeth exhibited substantial variation, ranging from 14.3 (Estonia) to 24.5 (Sweden). The oral health goal of retaining at least 20 teeth at age 80 years was achieved by 25% of the population or less in most countries. A target concerning edentulism (≤15% in population aged 65-74 years) was reached in Sweden, Switzerland, Denmark, France, and Germany. Tooth replacement practices varied especially for a number of up to five missing teeth which were more likely to be replaced in Austria, Germany, Luxembourg, and Switzerland than in Israel, Denmark, Estonia, Spain, and Sweden. CONCLUSIONS This study suggests that the age-specific number of natural teeth and the practice of tooth replacement in the over 50s differ substantially among the included countries. The present results may be helpful in the formulation and evaluation of oral health goals in the older population.

Restricted entitlements and access to health care for refugees and immigrants: The example of Germany:

Health and access to health care are seen as inalienable human rights (UN, 1948). On a global scale, supranational organizations such as the World Health Organization (WHO) promote Universal Health Coverage (UHC) as a strategy for achieving equity in health (WHO, 2013). Still, major differentials in access exist not only between countries with different levels of economic development but also within countries, even rich countries (Marmot, 2015). The example of Germany can be used to illustrate these inequalities, especially as they pertain to immigrants and refugees.

Health status of and health-care provision to asylum seekers in Germany: protocol for a systematic review and evidence mapping of empirical studies

BackgroundThere are more than 100,000 asylum seekers registered in Germany, who are granted limited access to health services. This study aims to provide a systematic overview of the empirical literature on the health status of and health-care provision to asylum seekers in Germany in order to consolidate knowledge, avoid scientific redundance, and identify research gaps.Methods/designA systematic review and evidence mapping of empirical literature on the health status of and health-care provision to asylum seekers in Germany will be performed. We will apply a three-tiered search strategy: 1. search in databases (PubMed/MEDLINE, Web of Science, IBSS, Sociological Abstracts, Worldwide Political Science Abstracts, CINAHL, Sowiport, Social Sciences Citation Index, ASSIA, MedPilot, DNB), dissertation and theses databases, and the internet (Google); 2. screening references of included studies; 3. contacting authors and civil society organizations for grey literature. Included will be studies which report quantitative and/or qualitative data or review articles on asylum seekers in Germany, published in German or English language. Outcome measures will include physical, mental, or social well-being, and all aspects of health-care provision (access, availability, affordability, and quality). Search results will be screened for eligibility by screening titles, abstracts and full texts. Data extraction comprises information on study characteristics, research aims, and domains of health or health-care services analyzed. The quality of studies will be appraised and documented by appropriate assessment tools. A descriptive evidence map will be drawn by categorizing all included articles by research design and the health conditions and/or domains of health-care provision analyzed. The body of evidence will be evaluated, and a narrative evidence synthesis will be performed by means of a multi-level approach, whereby quantitative and qualitative evidence are analyzed as separate streams and the product of each stream is configured in a final summary.DiscussionThis systematic review will provide an evidence map and synthesis of available research findings on the health status of and health-care provision to asylum seekers in Germany. In anticipation of identifying areas which are amenable to health-care interventions, deserve immediate action, or further exploration, this review will be of major importance for policy-makers, health-care providers, as well as researchers.Systematic review registrationPROSPERO 2014: CRD42014013043

Social disparities in Disease Management Programmes for coronary heart disease in Germany: a cross-classified multilevel analysis

Background Disease Management Programmes (DMPs) aim to improve effectiveness and equity of care but may suffer from selective enrolment. We analysed social disparities in DMP enrolment among elderly patients with coronary heart disease (CHD) in Germany, taking into account contextual effects at municipality and primary care practice levels. Methods Cross-sectional analysis of effects of educational attainment and regional deprivation on physician-reported DMP enrolment in a subsample of a large population-based cohort study in Germany, adjusting for individual-level, practice-level and area-level variables. We calculated OR and their 95% CIs (95% CI) in cross-classified, multilevel logistic regression models. Results Among N=1280 individuals with CHD (37.3% women), DMP enrolment rates were 22.2% (women) and 35% (men). The odds of DMP enrolment were significantly higher for male patients (OR=1.98 (1.50 to 2.62)), even after adjustment for potential confounding by individual-level, practice-level and area-level variables (range: OR=1.60 (1.08 to 2.36) to 2.16 (1.57 to 2.98)). Educational attainment was not significantly associated with DMP enrolment. Compared to patients living in least-deprived municipalities, the adjusted propensity of DMP enrolment was statistically significantly lower for patients living in medium-deprived municipalities (OR=0.41 (0.24 to 0.71)), and it also tended to be lower for patients living in the most-deprived municipalities (OR=0.70 (0.40 to 1.21)). Models controlling for the social situation (instead of health-related behaviour) yielded comparable effect estimates (medium-deprived/most-deprived vs least-deprived areas: OR=0.45 (0.26 to 0.78)/OR=0.68 (0.33 to 1.19)). Controlling for differences in comorbidity attenuated the deprivation effect estimates. Conclusions We found evidence for marked gender, but not educational disparities in DMP enrolment among patients with CHD. Small-area deprivation was associated with DMP enrolment, but the effects were partly explained by differences in comorbidity. Future studies on DMPs should consider contextual effects when analysing programme effectiveness or impacts on equity and efficiency.

Disparities in health and access to healthcare between asylum seekers and residents in Germany: a population-based cross-sectional feasibility study

Objectives To assess disparities in health and healthcare between asylum seekers (AS) and residents in Germany as a proof of concept using European Core Health Indicators (ECHI). Design Population-based cross-sectional feasibility study. Participants All AS (aged 18 years or above) registered in three counties in Germany during a 3-month study period (N=1017). Cross-sectional data on the resident population were taken from the German Health Interview (2008–2011, N=8152), and the European Union Statistics on Income and Living Conditions (2012, N=23 065). Outcome measures Self-reported health status and healthcare access (utilisation and unmet medical need) in line with ECHI. Method Inequalities in health and access to healthcare were quantified both by crude and age-stratified/sex-stratified ORs with 95% CI using cross-tabulations. Results A total of N=156 AS (15.34%) participated in the study. Compared with residents, AS were significantly more likely to report a bad health status (OR=1.72 (1.23 to 2.41)), activity limitations (OR=1.97 (1.39 to 2.79)) or (only younger age groups) any chronic morbidity (18–24 years: OR=6.23 (2.62 to 14.57); 25–49 years: OR=2.05 (1.23 to 3.37)). AS had significantly lower odds for consulting any physician (OR=0.1 (0.07 to 0.16)) or general practitioners (OR=0.44 (0.31 to 0.62)), but higher odds for hospital admissions (OR=2.29 (1.54 to 3.34)), visits to psychotherapists (OR=4.07 (2.48 to 6.43)) and unmet needs (OR=3.74 (2.62 to 5.21)). The direction of healthcare-related associations was consistent across all strata despite variation in magnitude and statistical significance. Conclusions Quantifying disparities between AS and the resident population by means of selected ECHI proved to be feasible. The approach yielded first quantitative evidence for disparities in health and access to healthcare in the German context. Further research is needed to generate representative estimates, for example, by including AS in national health monitoring programmes.

The global health concept of the German government: strengths, weaknesses, and opportunities

Recognising global health as a rapidly emerging policy field, the German federal government recently released a national concept note for global health politics (July 10, 2013). As the German government could have a significant impact on health globally by making a coherent, evidence-informed, and long-term commitment in this field, we offer an initial appraisal of the strengths, weaknesses, and opportunities for development recognised in this document. We conclude that the national concept is an important first step towards the implementation of a coherent global health policy. However, important gaps were identified in the areas of intellectual property rights and access to medicines. In addition, global health determinants such as trade, economic crises, and liberalisation as well as European Union issues such as the health of migrants, refugees, and asylum seekers are not adequately addressed. Furthermore, little information is provided about the establishment of instruments to ensure an effective inter-ministerial cooperation. Finally, because implementation aspects for the national concept are critical for the success of this initiative, we call upon the newly elected 2013 German government to formulate a global health strategy, which includes a concrete plan of action, a time scale, and measurable goals.Recognising global health as a rapidly emerging policy field, the German federal government recently released a national concept note for global health politics (July 10, 2013). As the German government could have a significant impact on health globally by making a coherent, evidence-informed, and long-term commitment in this field, we offer an initial appraisal of the strengths, weaknesses, and opportunities for development recognised in this document. We conclude that the national concept is an important first step towards the implementation of a coherent global health policy. However, important gaps were identified in the areas of intellectual property rights and access to medicines. In addition, global health determinants such as trade, economic crises, and liberalisation as well as European Union issues such as the health of migrants, refugees, and asylum seekers are not adequately addressed. Furthermore, little information is provided about the establishment of instruments to ensure an effective inter-ministerial cooperation. Finally, because implementation aspects for the national concept are critical for the success of this initiative, we call upon the newly elected 2013 German government to formulate a global health strategy, which includes a concrete plan of action, a time scale, and measurable goals.

Yield of active screening for tuberculosis among asylum seekers in Germany: a systematic review and meta-analysis

All asylum seekers in Germany undergo upon-entry screening for tuberculosis TB, but comprehensive evidence on the yield is lacking. We compared the national estimates with the international literature in a systematic review and meta-analysis of studies reporting the yield of TB, defined as the fraction of active TB cases detected among asylum seekers screened in Germany upon entry. We searched 11 national and international databases for empirical studies and the internet for grey literature published in English or German without restrictions on publication time. Among 1,253 screened articles, we identified six articles reporting the yield of active TB based on German data, ranging from 0.72 (95% confidence interval (CI): 0.45–1.10) to 6.41 (95% CI: 4.19–9.37) per 1,000 asylum seekers. The pooled estimate across all studies was 3.47 (95% CI: 1.78–5.73; I2 = 94.9%; p < 0.0001) per 1,000 asylum seekers. This estimate was in line with international evidence (I2 = 0%; p for heterogeneity 0.55). The meta-analysis of available international estimates resulted in a pooled yield of 3.04 (95% CI: 2.24–3.96) per 1,000. This study provides an estimate across several German federal states for the yield of TB screening in asylum seekers. Further research is needed to develop more targeted screening programmes.

Disgrace at EU's external borders.

The planks measure about 5 feet (1.5 m) in length. They were once painted in dark and light blue and in red colours. Now the paint has chipped off, the wood is splintered; the nails are loose and rusty. The planks belonged to what must have been a small fishing vessel. They were washed ashore in Sicily. It will probably never be known how many people perished when the boat sank, but it is likely that it was overcrowded with men, women and children of all ages, attempting to reach Europe from North Africa.... More than 1600 refugees drowned in the Mediterranean between January and April 2015, according to UNHCR estimates (UNHCR 2015). It is far easier to decry this disgrace than to offer realistic solutions. Integrating refugees into EU societies poses great challenges. Some of those arriving fled from war and terror, others from economic distress and hopelessness. Some have decent education and marketable skills; others never had the chance to acquire these. Some are active and healthy, others deeply traumatised. But we must meet this challenge.... Language: en

Europe's response to the refugee crisis: why relocation quotas will fail to achieve 'fairness' from a health perspective.

EU refugee law is deficient—this has become obvious as thousands of refugees cross the Mediterranean and EU borders to reach a safe destination. Germany’s Chancellor Angela Merkel calls for a scheme of compulsory relocation of refugees to EU member states to achieve a ‘fair’ distribution1 based on ‘objective, quantifiable and verifiable criteria’ such as GDP, population size and unemployment rates.2 While we strongly believe that providing international protection to refugees is a collective duty of EU member states, we argue that the concept of their ‘fair’ (but factually enforced) relocation across the EU is flawed and may ultimately be detrimental from a public health perspective. First, if fairness is defined as the product of a quota based on a contract between EU member states, the interests of non-contractors (here refugees) remain neglected—a dilemma inherent in contractarian concepts of fairness.3 Enforced relocation across the EU based on quota will never be …