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Background: To reduce the burden of disease attributable to alcohol, screening for at-risk alcohol use in the general population is recommended. Screening is usually carried out at only one point in time although individual alcohol use may change over time and self-reported consumption may be biased by underreporting. However, there are gaps in research on temporal variability of alcohol use. Therefore, this cumulative dissertation investigated (1) changes in drinking patterns within 4 weeks; (2) changes in screening results within 12 months and factors predicting a transition from low-risk to at-risk alcohol use; (3) whether underreporting can be reduced by prompting respondents to recall their alcohol use in the past week prior to screening.
Methods: Participants were adults from the general population recruited in a municipal registry office. For the first paper, 288 alcohol users were assessed four times using Timeline Follow-Back, each one week apart. Changes in drinking patterns were analyzed using latent transition modeling. For the second paper, 831 control group participants of a randomized controlled trial were screened for at-risk alcohol use at baseline, 3, 6, and 12 months later using the Alcohol Use Disorders Identification Test - Consumption (AUDIT-C). The transition from low-risk to at-risk alcohol use was predicted using logistic regression. For the third paper, 2,379 alcohol users were screened for at-risk alcohol use using the AUDIT-C, either before or after receiving the prompt to recall their past week alcohol use. Data were analyzed using logistic regression.
Results: Within 4 weeks, 35 percent of alcohol users changed their drinking pattern. Changes were more likely for individuals with moderate or heavy compared to light drinking. Within 12 months, 30 percent of alcohol users changed their screening result. Changes were more likely for at-risk compared to low-risk alcohol users. Transitioning from low-risk to at-risk alcohol use was more likely for women (vs. men; Odds Ratio, OR = 1.66), 18- to 29-year-old adults (vs. 30- to 45-year-old adults; OR = 2.30), and individuals reporting two or more drinking days in the past week (vs. less than two; OR = 3.11). When respondents were prompted to recall their alcohol use in the past week prior to screening, they were less likely to report at-risk alcohol use compared to when the screening was conducted without prior prompt (OR = 0.83).
Conclusions: One in three alcohol users changed their consumption, some of them even within a period as short as 4 weeks. These changes might compromise the validity of screening that is commonly based on a single assessment of typical alcohol use. Furthermore, underreporting cannot be reduced by prompting individuals to recall their alcohol use in the past week prior to the screening for at-risk alcohol use. Rather, consecutive questionnaires addressing different aspects of alcohol use within a single survey might be a potential source of bias.
Copattern of depression and alcohol use in medical care patients: cross- sectional study in Germany
(2020)
Objective
To predict depressive symptom severity and presence of major depression along the full alcohol use continuum.
Design
Cross-sectional study.
Setting
Ambulatory practices and general hospitals from three sites in Germany.
Participants
Consecutive patients aged 18–64 years were proactively approached for an anonymous health screening (participation rate=87%, N=12 828). Four continuous alcohol use measures were derived from an expanded Alcohol Use Disorder Identification Test (AUDIT): alcohol consumption in grams per day and occasion, excessive consumption in days per months and the AUDIT sum score. Depressive symptoms were assessed for the worst 2-week period in the last 12 months using the Patient Health Questionnaire (PHQ-8). Negative binomial and logistic regression analyses were used to predict depressive symptom severity (PHQ-8 sum score) and presence of major depression (PHQ-8 sum score≥10) by the alcohol use measures.
Results
Analyses revealed that depressive symptom severity and presence of major depression were significantly predicted by all alcohol use measures after controlling for sociodemographics and health behaviours (p<0.05). The relationships were curvilinear: lowest depressive symptom severity and odds of major depression were found for alcohol consumptions of 1.1 g/day, 10.5 g/occasion, 1 excessive consumption day/month, and those with an AUDIT score of 2. Higher depressive symptom severity and odds of major depression were found for both abstinence from and higher levels of alcohol consumption. Interaction analyses revealed steeper risk increases in women and younger individuals for most alcohol use measures.
Conclusion
Findings indicate that alcohol use and depression in medical care patients are associated in a curvilinear manner and that moderation by gender and age is present.
Analysis based on claims data showed no clinical benefit from AGR intervention regarding theinvestigated outcomes. The slightly worse outcomes may reflect limitations in matching based on claims data,which may have insufficiently reflected morbidity and psychosocial factors. It is possible that the interventiongroup had poorer health status at baseline compared to the control group.
Background
In combination with systematic routine screening, brief alcohol interventions have the potential to promote population health. Little is known on the optimal screening interval. Therefore, this study pursued 2 research questions: (i) How stable are screening results for at‐risk drinking over 12 months? (ii) Can the transition from low‐risk to at‐risk drinking be predicted by gender, age, school education, employment, or past week alcohol use?
Methods
A sample of 831 adults (55% female; mean age = 30.8 years) from the general population was assessed 4 times over 12 months. The Alcohol Use Disorders Identification Test—Consumption was used to screen for at‐risk drinking each time. Participants were categorized either as low‐risk or at‐risk drinkers at baseline, 3, 6, and 12 months later. Stable and instable risk status trajectories were analyzed descriptively and graphically. Transitioning from low‐risk drinking at baseline to at‐risk drinking at any follow‐up was predicted using a logistic regression model.
Results
Consistent screening results over time were observed in 509 participants (61%). Of all baseline low‐risk drinkers, 113 (21%) received a positive screening result in 1 or more follow‐up assessments. Females (vs. males; OR = 1.66; 95% confidence intervals [95% CI] = 1.04; 2.64), 18‐ to 29‐year‐olds (vs. 30‐ to 45‐year‐olds; OR = 2.30; 95% CI = 1.26; 4.20), and those reporting 2 or more drinking days (vs. less than 2; OR = 3.11; 95% CI = 1.93; 5.01) and heavy episodic drinking (vs. none; OR = 2.35; 95% CI = 1.06; 5.20) in the week prior to the baseline assessment had increased odds for a transition to at‐risk drinking.
Conclusions
Our findings suggest that the widely used time frame of 1 year may be ambiguous regarding the screening for at‐risk alcohol use although generalizability may be limited due to higher‐educated people being overrepresented in our sample.
Abstract
Purpose
This study aims to assess the implementation of published research, contraindications, and warnings on the prescription of dual renin‐angiotensin‐hormone system (RAS) blockade in ambulatory care in Germany.
Methods
Cohort study based on health claims data of 6.7 million subjects from 2008 to 2015. Yearly prevalence and incidence for dual RAS blockade with (a) angiotensin‐converting enzyme inhibitors and angiotensin‐receptor blockers (ACEI + ARB) and (b) aliskiren and ACEI or ARB (aliskiren + ACEI/ARB) were calculated. We assessed prescriber specialty and associations between discontinuing dual RAS blockade with specialist (internal medicine, cardiology, nephrology) visits and hospital discharge in the previous year.
Results
A total of 2 984 517 patients were included (age 51.4 ± SD 18.4 y, 48.5% male). Prescription rates for ACEI + ARB decreased from 0.6% (n = 17 907) to 0.4% (n = 12 237) and for aliskiren + ACEI/ARB from 0.23% (n = 6634) to 0.03% (n = 818). Incident prescriptions decreased from 0.23% (n = 6705) to 0.19% (n = 5055) (ACE + ARB) and from 0.1% (n = 2796) to 0.005% (n = 142) (aliskiren + ACE/ARB); 59% of ACEI + ARB and 48% of aliskiren + ACE/ARB combinations were prescribed only by one physician. Of those, 73% (ACEI + ARB) and 58% (aliskiren + ACE/ARB) were primary care providers (PCPs). Discontinuing dual RAS blockade was associated with specialist care and hospital discharge in the previous year (specialist care: RR 1.4, 95% CI, 1.3‐1.6; hospital visit: RR 1.5, 95% CI, 1.3‐1.6).
Conclusions
Our results suggest a delayed uptake of treatment recommendation for ACEI + ARB and a higher impact of Dear Doctor letters addressing PCPs directly compared with published research, contraindications, and warnings. Targeted continuous medical education, practice software alerts, and stronger involvement of pharmacists might improve the implementation of medication safety recommendations in ambulatory care.
Scope
Previous work identified three metabolically homogeneous subgroups of individuals (“metabotypes”) using k‐means cluster analysis based on fasting serum levels of triacylglycerol, total cholesterol, HDL cholesterol, and glucose. The aim is to reproduce these findings and describe metabotype groups by dietary habits and by incident disease occurrence.
Methods and results
1744 participants from the KORA F4 study and 2221 participants from the KORA FF4 study are assigned to the three metabotype clusters previously identified by minimizing the Euclidean distances. In both KORA studies, the assignment of participants results in three metabolically distinct clusters, with cluster 3 representing the group of participants with the most unfavorable metabolic characteristics. Individuals of cluster 3 are further characterized by the highest incident disease occurrence during follow‐up; they also reveal the most unfavorable diet with significantly lowest intakes of vegetables, dairy products, and fibers, and highest intakes of total, red, and processed meat.
Conclusion
The three metabotypes originally identified in an Irish population are successfully reproduced. In addition to this validation approach, the observed differences in disease incidence across metabotypes represent an important new finding that strongly supports the metabotyping approach as a tool for risk stratification.
Statistisch gesehen erkrankt weltweit alle 3 Sekunden ein Mensch an Demenz, allein in Deutschland beträgt die jährliche Inzidenz 300.000 Fälle. Demenzerkrankungen sind aufgrund des demographischen Wandels schon jetzt eine Herausforderung für das Gesundheitswesen, welches zusätzlich noch durch einen Mangel an Ärztenachwuchs in der Primärversorgung verschärft wird. Ein prominenter Ärztemangel ist statistisch schwer nachzuweisen, jedoch gibt es ernst zu nehmende Hinweise wie er schon heute beispielweise durch das Phänomen der sogenannten „Over-utilizer“ auftritt. Eine weitere Herausforderung ist, dass Demenz in der älteren Bevölkerung unterdiagnostiziert ist. Allgemein ist über die Quantität der Kooperation zwischen niedergelassenen Haus- und Fachärzten in der Demenzdiagnostik und Therapie wie in der S3-Leitlinie empfohlen, wenig bekannt.
Es besteht der Bedarf an Versorgungsforschung mit Primärdaten über das Thema Diagnostik und Differentialdiagnostik in der Primärversorgung.
Das Ziel der vorliegenden kumulativen Dissertationsschrift ist es, hier einen empirischen Beitrag zu leisten. Unter anderem wurde analysiert wie hoch die Inanspruchnahme niedergelassener Fachärzte durch hausärztlich versorgte Menschen mit mindestens einem V.a. Demenz ist und welche Faktoren damit assoziiert sind. Es wurde auch untersucht ob und wie sich die S3-Empfehlungen zur leitliniengerechten Diagnostik der Demenz bei der Behandlung der Probanden widerspiegeln.
Aus eigenem Interesse lag ein weiterer Fokus auf der Prüfung von Zusammenhängen zwischen experimentellen Scores zur cMRT-Analyse und den in der Versorgung gebräuchlichen kognitiven Kurztests von beteiligten Probanden.
Die Analysen basieren auf Daten von Probanden der DelpHi-Studie. In dieser wurden Probanden mithilfe von Hausärzten unter Anwendung des DemTec rekrutiert. Eingeschlossen wurden Menschen, bei denen aufgrund des Screenings ein Verdacht auf eine Demenz vorlag, diese noch in eigener Häuslichkeit lebten und die ihre informierte Einverständniserklärung abgaben. Bei diesen Probanden wurden die ärztliche Akte, die Facharztkonsultationen und das Bildmaterial angefordert, sowie weitere persönliche Datenerhebungen eingeleitet.
Aufgrund der Analysen der Primärdaten konnte unter anderem die Inanspruchnahme von Fachärzten der Neurologie und Psychiatrie eruiert werden. Abhängig von dem Umstand, ob ein Demenzerkrankter bei einem Facharzt vorstellig gewesen war, wurden die Daten der Studienteilnehmer zur Analyse in 2 Gruppen („GP-only“ und „GP+specialist“) eingeteilt und die beiden Gruppen in ihren Charakteristika miteinander verglichen. Dabei zeigten sich die Variablen „Alter“, „Partnerschaftsstatus“, „Vorhandensein einer formalen Demenzdiagnose bei Studienbeginn“ als statistisch signifikant.
Es zeigt sich, dass Probanden, die einen Facharzt aufgesucht haben, insgesamt eher jünger; eher in einer Partnerschaft leben und dass bei ihnen bereits Demenz diagnostiziert wurde. Werden alle untersuchten Variablen in einem Logistischen Regressionsmodell untersucht, so fallen die Variablen „Alter“ und „B-ADL“ statistisch signifikant auf. Das bedeutet, dass wenn das Alter des Patienten um ein Jahr ansteigt, so sinkt die relative Wahrscheinlichkeit, dass ein MmD zu einem Facharzt überwiesen wird um 5,2 %. Ebenso stellt sich dar, dass wenn die Alltagsmobilität, welche mit dem B-ADL gemessen wurde, um eine Einheit steigt, so erhöht sich die relative Wahrscheinlichkeit, dass ein MmD zum Spezialisten überwiesen wird um 15,2 %,
Des Weiteren konnte ein kritischer Blick auf die Anwendung der aktuellen S3-Leitlinie zur Demenz anhand der Auswertung der DelpHi-Studie geworfen werden. Erstmals wurden in diesem Setting das studienbedingt vorhandene Bildmaterial durch etablierte Scores analysiert und zusammen mit den Ergebnissen aus den kognitiven Kurztests ausgewertet. Dabei wurde in dieser Arbeit ein Fokus auf den MTA-Score von Scheltens et al. gelegt, mit dem die Hippocampusatrophie eines Demenzerkrankten in 4 Schweregrade eingeteilt wird. Anschließend wurden diese Ergebnisse mit den ebenfalls vorhandenen Resultaten der kognitiven Tests des MMST gegenübergestellt, was in fast der Hälfte der Fälle Ambivalenzen auslöste.
Allgemein lässt sich sagen, dass Frauen und Alleinlebende seltener, Jüngere öfter und Patienten mit niedrigerem Funktionsniveau häufiger beim FA gewesen sind und erweiterte bildgebende Diagnostik erhalten haben. Tatsächlich bekamen aber weniger als die Hälfte derer, die überwiesen wurden ein cMRT als erweiterte Diagnostik verordnet. Insgesamt ist es wünschenswert die S3-Leitlinie zur Demenz zu stärken und die Motivation der Fach-, und Hausärzte diese anzuwenden zu steigern, zum Wohle einer umfänglichen Diagnostik von demenzverdächtigen oder erkrankten Patienten. Die Ergebnisse konnten der Fachwelt durch die Publikation in internationalen, peer-reviewed Journals zugänglich gemacht werden.