Federal State Of Lower Saxony Research Articles

Quality of life in people with multiple sclerosis vs general population: differences increase by age

Abstract Background To enhance health care for chronically ill people, it is crucial to understand the impact of their disease on health-related quality of life (HRQoL). More than 240,000 people in Germany live with multiple sclerosis (PwMS), the most common immune-mediated neurodegenerative disease of the central nervous system. Little is known about HRQoL in PwMS in comparison to the general population and by subgroups. Methods In 2021, 6,928 statutorily-insured PwMS aged ≥18 years and living in the federal state of Lower Saxony, Germany, were invited to take part in an online survey. The German EQ-5D-5L value set was used to analyse HRQoL by index values. Descriptive subgroup analyses were conducted (age, sex) and compared to a general German reference population (Grochtdreis et al. 2019, DOI: 10.1007/s10198-019-01054-1). Mann-Whitney-U- or Kruskal-Wallis-tests were performed as appropriate. Results Of 1,935 respondents (response rate 27.9%), 1,916 PwMS were included in the current preliminary complete case analysis. HRQoL is reduced in PwMS compared to the general population: Mean (M) 0.67 vs. M 0.88, respectively. While no significant differences by sex were found in PwMS (male: M 0.66 vs. female: M 0.68, p = 0.1), HRQoL decreased with increasing age (p < 0.001). The reduction in HRQoL is more pronounced in PwMS than in the general population (difference between means 0.53 in 18-24 years old to ≥ 75 years old PwMS vs. 0.14 in the reference population, respectively). Conclusions PwMS report an overall lower level of HRQoL compared to the general population. Increasing age correlates with a substantial decrease of HRQoL in PwMS. Targeted research is needed to improve HRQoL of this vulnerable population. Key messages • The decline in HRQoL with increasing age is more pronounced in PwMS than in the general population in Germany. • Further research should focus particularly on the extent to which MS-related factors are solely attributable for the considerable decline of HRQoL in PwMS.

Intended and Actual Participation in the Colorectal Cancer Screening Program.

The public generally has a positive view of colorectal cancer screening, but there is still room for improvement in participation rates. The aim of this study was to identify factors that are associated with intended and actual participation. We conducted a prospective cohort study of a random sample of insurees of the AOK (a statutory health insurance carrier) in the German federal state of Lower Saxony. 50-year-old men and 55-year-old women who were eligible for their first screening colonoscopy received a written questionnaire in June 2020, three weeks after being invited to undergo colorectal cancer screening. For those who intended to do so, we used multivariable logistic regression analysis to determine any statistical associations between sociodemographic and medical characteristics and participation rates within 30 months. 82.7% of the respondents (239/298) intended to participate, and 43.3% (129/298) actually did so within 30 months. The participation rates among persons who had already decided to have a stool test or a colonoscopy were 50.7% (36/71) and 55.2% (58/105), respectively; the participation rate among undecided persons was 33.3% (19/57). The strongest association in the regression model was with an already made appointment (OR = 11.1, 95% confidence interval: [3.9; 31.8]). After exclusion of the existingappointment variable from the regression model, living in a smaller town (OR = 2.41 [1.08; 5.35]) and a stated preference for colonoscopy (OR = 2.52; [1.20; 5.27]) were positively associated with participation. Insurees with a parent affected by colorectal cancer participated less frequently, even after adjustment for prior colonoscopies (OR = 0.31 [0.12; 0.80]). The wide gap between intended and actual participation implies that there is potential for improvement in the prevention of colorectal cancer, and that certain groups of people could benefit from targeted support in making their intention to undergo screening a reality. Because of the methodological limitations of this initial investigation, its findings need to be confirmed by further studies.

Basis for a One Health Approach—Inventory of Routine Data Collections on Zoonotic Diseases in Lower Saxony, Germany

Two-thirds of human infectious diseases are zoonotic diseases and routine data collections exist for each sector (human, veterinary, environmental). However, these operate separately and the collected data are not integrated across sectors. Publicly available information on these routine data collections in terms of metadata and the information collected is sparse. The aim was to create an inventory of routine data collections in the Federal State of Lower Saxony, Germany. A systematic screening of existing routine data collections from the human and veterinary sectors on zoonotic infectious diseases was carried out on the basis of expert interviews. A standardised template was used to collect relevant metadata on data collections and pathogens they contain. The template was transferred to Research Electronic Data Capture tools. We recorded metadata for 19 veterinary, 16 human and 2 other data collections, and for 69 different zoonotic pathogens. The frequencies of a selection of metadata were analysed descriptively. The data collections, which served different purposes, differed, e.g., in underlying population and sampling strategy, export format and access to the original data. We identified challenges for integrated analyses of data from different collections, which need to be addressed to develop a One Health monitoring and surveillance system.

Seroprevalence of tick-borne encephalitis virus in wild and domestic animals in northern Germany

Tick-borne encephalitis virus (TBEV) is a tick-transmitted flavivirus, which can infect humans and animals, sometimes even with a fatal outcome. Since many decades, TBEV is endemic in southern Germany, while only sporadic occurrence has been noted in northern parts of the country so far. Nevertheless, autochthonous human clinical cases are increasing in the federal state of Lower Saxony in north-western Germany, and several natural foci of TBEV transmission have recently been detected in this federal state. In order to shed more light on the current distribution of TBEV in Lower Saxony, the present study examined blood samples from wild and domestic animals for antibodies against TBEV. Overall, samples from 4,085 animals were tested by ELISA, including wild boar (N = 1,208), roe deer (N = 149), red deer (N = 61), fallow deer (N = 18), red foxes (N = 9), nutria (N = 9), raccoon dogs (N = 3), raccoons (N = 3), badgers (N = 1), European pine martens (N = 1), horses (N = 574), sheep (N = 266), goats (N = 67), dogs (N = 1,317) and cats (N = 399). Samples with an ELISA result of ≥60 Vienna units (VIEU)/ml were subjected to confirmatory serum neutralization tests (SNT). In total, 343 of 4,085 (8.4%) animals tested positive for anti-TBEV-IgG by ELISA, of which 60 samples were confirmed by SNT. Samples of 89 animals showed a cytotoxic effect in the SNT and were excluded from seroprevalence calculation, resulting in an overall seroprevalence of 1.5% (60/3,996). Seroprevalence was higher among wild animals (wild boar: 2.9% [34/1,190], roe deer: 2.7% [4/149], red deer: 1.7% [1/60], fallow deer: 5.6% [1/18]) than among domestic animals (dogs: 1.1% [15/1,317], horses: 0.8% [4/505], sheep: 0.4% [1/266]). No anti-TBEV-antibodies were detected in the other wild animal species as well as goats and cats. A notable clustering of positive samples was observed in districts where TBEV transmission foci have been described. Further clusters in other districts suggest the existence of so far undetected transmission foci, underlining the fact that both wild and domestic animals are useful sentinels for monitoring the spread of TBEV.

Pandemic management: Analysis of availability and relevance of surveillance indicators by COVID-Task-Forces in the German federal state of Lower Saxony

Locally, the introduction of measures during times of a pandemic emergency is embodied in a pandemic containment plan created by the Robert Koch Institute in 2017. In addition to central indicators such as incidence rates and number of deaths, various indicators are used at the local level to assess the pandemic situation. So far, there hasn't been analyses of the availability and perceived relevance of the surveillance indicators used to manage the SARS-CoV-2 pandemic by the local German pandemic task forces. This study examined whether local decision-makers had access to surveillance-related indicators in a way that they could be used to make informed decisions in response to the pandemic situation. A cross sectional study was conducted, using an online questionnaire developed by experts of The Public Health Agency of Lower Saxony and The University Medical Center Göttingen (UMG). All local COVID-19 task forces of the German state of Lower-Saxony were enrolled in the study. The surveillance indicators assessed by survey respondents as most available and relevant are included under the German Infection Protection Act (IfSG). In contrast, the indicators that are not bound by the IfSG have a significantly lower availability and an inconsistent assessment of relevance. Against the background of efficiency, it seems central to be able to reliably provide the highly weighted surveillance indicators. Nevertheless, the relevance assessment gap between the indicators embedded in the IfSG and the ones that are not may be explained by cognitive processes such as anchoring bias. The collection and use of indicators to assess the pandemic situation and to evaluate measures should be the subject of continuous multidisciplinary discussions.

Implementation, barriers, and recommendations for further development of advance care planning for the last phase of life in nursing homes in Germany (Gut-Leben): protocol for a mixed-methods study

BackgroundNursing home entry often marks the transition into the end-of-life. In 2018, Germany legally introduced reimbursement for advance care planning (ACP according to § 132 g SGB V) in nursing homes that applied for ACP approval to improve end-of-life care. The Gut-Leben project aims to evaluate the implementation and barriers of ACP in nursing homes in Germany, with a special focus on the federal state of Lower Saxony, and provide practical recommendations for further development of end-of-life care.MethodsThis mixed-methods study spreads across five work packages (WP) over a three-year period. WP 1 will explore the approval process, implementation, and barriers to ACP in nursing homes. Data will be collected through a national postal survey in a random sample of n = 600. WP 2 will explore whether documented ACP reports are applicable as a data source for research (expecting up to 500 available ACP reports). In WP 3a and 3b, data on the ACP process will be collected in n = 15 approved nursing homes in Lower Saxony over a 12-months period. For WP 3a and WP 3b, data on ACP conversations (n = 600) and on end-of-life care paths (n = 300) will be collected by facilitators and nurses of the respective nursing homes. In WP 4, residents’ characteristics upon entry and changes in these characteristics over the length of stay are analyzed, utilizing claims data from the AOK Lower Saxony (expected sample of about 100,000 people entering nursing homes over a 10-years period). WP 5 connects, interprets, and reflects on the findings from WP 1–4 through focus groups and individual interviews with facilitators, nursing staff, residents, relatives, and care providers. Within a participatory approach, a practice advisory board will be set up existing of personal of nursing homes and will be closely involved in the whole research process.DiscussionIn summary, the Gut-Leben project provides insight into the implementation and barriers of ACP in nursing homes according to German legislation for the first time, including practitioners’ and residents’ perspectives. Insights will help the further development of ACP in Germany through practical recommendations based on quantitative and qualitative data.

Overcoming Language Barriers in Paramedic Care With an App Designed to Improve Communication With Foreign-Language Patients: Nonrandomized Controlled Pilot Study

Communication across language barriers is a particular challenge for health care providers. In emergency medical services, interpreters are mostly not available on rescue scenes, which jeopardizes safe and high-quality medical care. In a cocreative process together with paramedics and software designers, we developed a fixed-phrase translation app with 600 phrases and 18 supported languages that supports paramedics when providing care to foreign-language patients. This paper reports on the results of a pilot study to evaluate the app's effect on paramedic-patient communication. This study aims to gain insights into the efficacy and feasibility of a multilingual app that helps paramedics to communicate with patients who are not proficient in the local language. A 3-armed nonrandomized interventional pilot study was conducted in 4 rescue stations in the German Federal State of Lower Saxony: 3 rural areas and 1 in urban environment. The intervention group comprised rescue missions with patients with limited German language proficiency (LGP) with whom the app was used; control group 1 comprised LGP patients without app usage; and control group 2 consisted of rescue missions with German-speaking patients. For each rescue operation with LGP patients, paramedics filled out questionnaires about the communications with patients. From standardized Rescue Service Case Protocols, we extracted information on patient demographics (age and sex), clinical aspects (preliminary diagnosis and Glasgow Coma Scale), and rescue operation characteristics (time spent on emergency scene and additional dispatch of emergency physicians). The primary outcome was the paramedics' perceived quality of communication with LGP patients. The secondary outcome was the ability to obtain necessary information from patients and the ability to provide important information to patients. A linear regression model was applied to assess the impact of the app on perceived communication, controlling demographic factors, and severity of illness. A total of 22 LGP patients were recruited into the intervention group and 122 into control group 1. The control group 2 included 27,212 German-speaking patients. LGP patients were more than 2 decades younger than German-speaking patients. App usage among LGP patients was associated with higher perceived overall quality of communication (0.7 points on a 5-point Likert scale, P=.03). Applying a linear regression model controlling for age, sex, and Glasgow Coma Scale, the quality of communication was associated with an increase of 0.9 points (95% CI 0.2-1.6, P=.01). Compared to either German-speaking patients or LGP patients, paramedics spent 6-7 minutes longer on an emergency scene when the app was used (P=.24). The use of the app suggests a relevant improvement in communication with patients with limited proficiency in the locally spoken language in paramedic care. The small sample size and the lack of randomization reduce the generalizability of the findings. German Clinical Trials Register DRKS00016719; https://drks.de/search/de/trial/DRKS00016719.

TreeSatAI Benchmark Archive: a multi-sensor, multi-label dataset for tree species classification in remote sensing

Abstract. Airborne and spaceborne platforms are the primary data sources for large-scale forest mapping, but visual interpretation for individual species determination is labor-intensive. Hence, various studies focusing on forests have investigated the benefits of multiple sensors for automated tree species classification. However, transferable deep learning approaches for large-scale applications are still lacking. This gap motivated us to create a novel dataset for tree species classification in central Europe based on multi-sensor data from aerial, Sentinel-1 and Sentinel-2 imagery. In this paper, we introduce the TreeSatAI Benchmark Archive, which contains labels of 20 European tree species (i.e., 15 tree genera) derived from forest administration data of the federal state of Lower Saxony, Germany. We propose models and guidelines for the application of the latest machine learning techniques for the task of tree species classification with multi-label data. Finally, we provide various benchmark experiments showcasing the information which can be derived from the different sensors including artificial neural networks and tree-based machine learning methods. We found that residual neural networks (ResNet) perform sufficiently well with weighted precision scores up to 79 % only by using the RGB bands of aerial imagery. This result indicates that the spatial content present within the 0.2 m resolution data is very informative for tree species classification. With the incorporation of Sentinel-1 and Sentinel-2 imagery, performance improved marginally. However, the sole use of Sentinel-2 still allows for weighted precision scores of up to 74 % using either multi-layer perceptron (MLP) or Light Gradient Boosting Machine (LightGBM) models. Since the dataset is derived from real-world reference data, it contains high class imbalances. We found that this dataset attribute negatively affects the models' performances for many of the underrepresented classes (i.e., scarce tree species). However, the class-wise precision of the best-performing late fusion model still reached values ranging from 54 % (Acer) to 88 % (Pinus). Based on our results, we conclude that deep learning techniques using aerial imagery could considerably support forestry administration in the provision of large-scale tree species maps at a very high resolution to plan for challenges driven by global environmental change. The original dataset used in this paper is shared via Zenodo (https://doi.org/10.5281/zenodo.6598390, Schulz et al., 2022). For citation of the dataset, we refer to this article.

Do anglers and managers think similarly about stocking, habitat management and harvest regulations? Implications for the management of community-governed recreational fisheries

Perceptions about suitable fisheries management directions can differ between anglers and fisheries managers. Opposing beliefs, attitudes and norms about how to manage a local fishery can in turn create conflict. Within a system of community-held local fishing rights, typical for central Europe, the interaction of anglers and local-level fisheries managers is particularly strong and direct because the managers are typically elected members of the local angling communities that are organized in clubs. In this role local fisheries managers are responsible for decisions about management measures, such as stocking or harvest regulations. Our objectives were to assess the perceived objectives, beliefs and attitudes towards a range of management-relevant issues, while contrasting anglers and elected fisheries managers in the context of German fishing clubs. Based on three large mail surveys conducted between 2010 and 2018 and including a total of 3112 anglers and 314 elected fisheries managers from the Federal State of Lower Saxony (north-western Germany) we found that anglers and fisheries managers both supported conservation objectives and held strong pro-stocking beliefs, which was particularly pronounced among anglers. Both groups significantly differed in their pro-ecological beliefs and the perceived functionality of habitat management and harvest regulations relative to fish stocking. Fisheries managers considered habitat enhancement and harvest regulations to deliver greater benefits than stocking compared to anglers. Both groups also differed in their behavioural intention to alter stocking practices, particularly with respect to the stocking of large and adult fish, which was desired by anglers, but on average rejected by fisheries managers in favour of the release of smaller fish. Our work shows that even within the traditional practice of fish stocking, anglers and fisheries managers differ in their perceptions. Engaging in decisions that deviate from the perception of anglers is prone to create conflicts. Harmonization of perspectives maybe possible through joint experiments in fisheries management at the club level, aiming to collectively learn about successes and risks of traditional and novel management approaches.

Comparison of rainfall generators with regionalisation for the estimation of rainfall erosivity at ungauged sites

Abstract. Rainfall erosivity values are required for soil erosion prediction. To calculate the mean annual rainfall erosivity (R), long-term high-resolution observed rainfall data are required, which are often not available. To overcome the issue of limited data availability in space and time, four methods were employed and evaluated: direct regionalisation of R, regionalisation of 5 min rainfall, disaggregation of daily rainfall into 5 min time steps, and a regionalised stochastic rainfall model. The impact of station density is considered for each of the methods. The study is carried out using 159 recording and 150 non-recording (daily) rainfall stations in and around the federal state of Lower Saxony, Germany. In addition, the minimum record length necessary to adequately estimate R was investigated. Results show that the direct regionalisation of mean annual erosivity is best in terms of both relative bias and relative root mean square error (RMSE), followed by the regionalisation of the 5 min rainfall data, which yields better results than the rainfall generation models, namely an alternating renewal model (ARM) and a multiplicative cascade model. However, a key advantage of using regionalised rainfall models is the ability to generate time series that can be used for the estimation of the erosive event characteristics. This is not possible if regionalising only R. Using the stochastic ARM, it was assessed that more than 60 years of data are needed in most cases to reach a stable estimate of annual rainfall erosivity. Moreover, the temporal resolution of measuring devices was found to have a significant effect on R, with coarser temporal resolution leading to a higher relative bias.

Catch Crops in Lower Saxony—More Than 30 Years of Action against Water Pollution with Nitrates: All in Vain?

Intensive animal production, vast amounts of biogas plants, and the spreading of manure and digestates, exerts strong pressure on water quality in the German federal state of Lower Saxony. Catch and cover crop (c&c) cultivation is seen as one measure to inhibit nitrate leaching into soils, and to prevent water pollution with nitrates. A document analysis was carried out, covering the time span of 1992 to 2020, and the findings were combined with available quantitative data of the same period, and with GIS analysis. From 1994 to the year 2020, the acreage of subsidized c&cs increased from ca. 10,000 ha to ca. 380,000 ha. In addition, there was an acreage of unsubsidized c&cs of about 100,000 ha declining to 50,000 ha. In comparison, the acreage of arable land remained at approximately 1,880,000 ha. We found that c&cs did not contribute substantially to water protection for the following reasons: the design of the measure, control of farmer’s actions, and the antagonistic trend due to the increase in animal numbers and biogas plants. The development of c&cs over time and space reveals that frame conditions and management requirements of cultivating c&cs need to be well designed to be effective and efficient (with regard to N reduction and reduction of costs). It is vital to coordinate all programs and schemes in one region. From our evaluation, we conclude that a measure such as c&c cultivation, which is simple to introduce and easy to control, should be implemented over winter as a mandatory measure in order to achieve a greater uptake. Additionally, result-based measures could complement this scheme, as there is a strong link between subsidy level and the success of the measure.

New and Confirmed Foci of Tick-Borne Encephalitis Virus (TBEV) in Northern Germany Determined by TBEV Detection in Ticks.

Tick-borne encephalitis (TBE) is a tick-transmitted, virus-induced neurological disease with potentially fatal outcomes in humans and animals. Virus transmission takes places in so-called tick-borne encephalitis virus (TBEV) microfoci, which constitute small areas of sustained virus circulation. In southern Germany, TBEV has been endemic for decades; however, a northward expansion of risk areas, based on disease incidence in the human population, has been observed in recent years. The present study investigated TBEV occurrence in questing ticks at eight locations in the federal state of Lower Saxony, northwestern Germany, chosen due to reported associations with human TBE cases (N = 4) or previous virus detection (N = 4). A total of 20,056 ticks were collected in 2020 and 2021 and tested for TBEV RNA in pools of ten nymphs or five adults by quantitative reverse transcription-PCR (RT-qPCR). Positive results were confirmed by RT amplification of the viral E gene. In total, 18 pools from five different sampling locations were positive for TBEV RNA. One previously unknown transmission focus was detected, while ongoing virus circulation was confirmed at the four further locations. Phylogenetic analysis showed that two different virus strains with different origins circulate in the locations identified as natural foci.

How Do Hunters Hunt Wild Boar? Survey on Wild Boar Hunting Methods in the Federal State of Lower Saxony.

Simple SummaryHigh wild boar population densities lead to human–wildlife conflicts. For proper wildlife management, knowledge of wildlife biology as well as human attitudes is needed. We conducted inquiries on hunting methods and on hunters’ attitudes in the German Federal State of Lower Saxony to better understand hunting strategies. Single hunt, especially at bait, is still the most widely used method for hunting wild boar. The proportion of drive hunts within the hunting bag is increasing. The proportions of hunting methods vary regionally due to wild boar densities, geographical conditions and hunters’ practices. Private hunting is important for wild boar management, although it is just insufficient. Besides promoting more efficient hunting methods and motivating hunters, in the future, additionally, administrative wildlife managers could be established as coordinators of wild boar management, and as such, could manage hunting, the incorporation of regional conditions and investigating hunters’ attitudes and abilities.High wild boar population densities lead to demands for a population reduction to avoid crop damages or epidemic diseases. Along with biological studies, a better understanding of the human influence on wildlife and on wildlife management is important. We conducted inquiries on hunting methods and on hunters’ attitudes in the Federal State of Lower Saxony, Germany, to better understand hunting strategies and the influence on increasing wild boar population, as well as to underpin game management concepts. Single hunt, especially at bait, is still the most widely used method for hunting wild boar. The proportion of drive hunts within the hunting bag is increasing. The proportions of hunting methods vary regionally due to wild boar densities, geographical features (vegetation, terrain, etc.) and hunters’ practices. Hunters increased the proportion of conjoint hunts on wild boar. Baiting remains an important hunting method in wild boar management and the proportion of drive hunts should be fostered. Private hunting is important for wild boar management, although it is just insufficient. Additionally, administrative wildlife managers are recommended for the near future as coordinators of wild boar management, and as such, could manage hunting, the incorporation of regional conditions and investigating hunters’ attitudes and abilities.

Psychometric properties of the Somatic Symptom Scale 8 (SSS-8) in a representative sample of German adolescents

ObjectiveThe psychometric properties of the Somatic Symptom Scale 8 (SSS-8) have been investigated in different studies. However, there is no study examining its psychometric properties on representative data of adolescents. The study at hand will present results from a large representative sample of German adolescents (13 to 18 years). MethodsThe following analyses draw on cross-sectional data from German ninth-grade students collected in 2015. Altogether, 10,638 individuals were surveyed with a return rate of 68.5% as part of a periodic representative survey in the German federal state of Lower Saxony. ResultsFor the SSS-8, coefficient omega for the full sample was ω = 0.90, and ω = 0.77 and 0.79 for males and females, respectively. In addition, a convergent validity was determined with the Patient Health Questionnaire 2 (PHQ-2), Generalized Anxiety Disorder 2 (GAD-2), and the brief form of Perceived Social Support Questionnaire (FSozU-K6). Based on a confirmatory factor analysis and measurement invariance analysis (for gender and migration background), the initially determined factor structure by Gierk et al. of the SSS-8 could be confirmed. ConclusionThe results support the reliability and validity of the SSS-8 for use with adolescents. The use of the SSS-8 seems to be meaningful within different frameworks, especially when, due to a lack of time or for reasons of cost, no face-to-face interviews can be conducted.

Who beats their partner, and who beats their schoolmates? A comparison of teen dating and school physical violence perpetration in Lower Saxony, Germany.

Teen dating violence (TDV) and school violence (SV) are two major social problems in adolescence. Until recently, the antecedents of both TDV and SV have been analyzed largely independently of each other. This study analyses and compares the determinants of both TDV and SV, with a focus on physical violence. Based on a comprehensive survey of ninth‐grade adolescents at the average age of 15 years (N = 3,800) conducted in the German federal state of Lower Saxony, the findings showed that there is a significant but low correlation between both physical TDV and SV (r = 0.21). Concerning the determinants, we found that males carry out physical SV significantly more often, but physical TDV significantly less often than female respondents. Acquaintance with violent friends shows a stronger correlation with SV but not with TDV. Low self‐control and violent media consumption are determinants of both TDV and SV. Empathy as a protective factor and parental violence as another risk factor were found to be only weak and sometimes not significantly correlated with both TDV and SV.

Effects of incomplete inter-hospital network data on the assessment of transmission dynamics of hospital-acquired infections.

In the year 2020, there were 105 different statutory insurance companies in Germany with heterogeneous regional coverage. Obtaining data from all insurance companies is challenging, so that it is likely that projects will have to rely on data not covering the whole population. Consequently, the study of epidemic spread in hospital referral networks using data-driven models may be biased. We studied this bias using data from three German regional insurance companies covering four federal states: AOK (historically “general local health insurance company”, but currently only the abbreviation is used) Lower Saxony (in Federal State of Lower Saxony), AOK Bavaria (in Bavaria), and AOK PLUS (in Thuringia and Saxony). To understand how incomplete data influence network characteristics and related epidemic simulations, we created sampled datasets by randomly dropping a proportion of patients from the full datasets and replacing them with random copies of the remaining patients to obtain scale-up datasets to the original size. For the sampled and scale-up datasets, we calculated several commonly used network measures, and compared them to those derived from the original data. We found that the network measures (degree, strength and closeness) were rather sensitive to incompleteness. Infection prevalence as an outcome from the applied susceptible-infectious-susceptible (SIS) model was fairly robust against incompleteness. At incompleteness levels as high as 90% of the original datasets the prevalence estimation bias was below 5% in scale-up datasets. Consequently, a coverage as low as 10% of the local population of the federal state population was sufficient to maintain the relative bias in prevalence below 10% for a wide range of transmission parameters as encountered in clinical settings. Our findings are reassuring that despite incomplete coverage of the population, German health insurance data can be used to study effects of patient traffic between institutions on the spread of pathogens within healthcare networks.

User Satisfaction in Social Media: How do Patients Rate their Hospital Stay Online?

Patients are increasingly using social media and review sites to get information on hospitals, to rate them or to write a review about their own experiences during hospital stay. Hospitals have the opportunity to use these patient reviews for internal quality assurance as well as online reputation marketing. The objective is to analyze the satisfaction ratings of previous hospitals stays by social media users on platforms such as "Google", as well as reviews from the German site "Klinikbewertungen.de", and to compare them. User reviews (n=16,691) for all hospitals (n=180) in the federal state of Lower Saxony (complete survey) for 2013-2018 were extracted from the platforms Google and the German Klinikbewertungen.de. Subsequently, a descriptive and inductive analysis (Chi²-test) of the user reviews and a comparison specific for the platforms were completed. Most users are satisfied with their hospital stay, whereby users of the platform Google ratd their hospital stay worse (n=6,181; 57.6% satisfied) than users of the platform Klinikbewertungen.de (n=10,509; 65.4% satisfied). Features of the hospital (number of beds, specialist departments) and features of the users (author, type of insurance) were significantly associated with the rating for the hospital stay (star review). (Google: number of beds p<0.001; Klinikbewertungen.de: number of beds p<0.001, author p<0.001, specialist departments p<0.001, type of insurance p<0.001). The online review of a hospital stay is associated with the number of beds, the specialist departments of hospitals, whether the author is the patient or a relative, and the type of health insurance they have, namely private or statutory. Online reviews and ratings for hospitals may be used for internal quality assurance or improvements of company online reputation.

Assessment of the relationships between agroecosystem condition and the ecosystem service soil erosion regulation in Northern Germany.

Ecosystems provide multiple services that are necessary to maintain human life. Agroecosystems are very productive suppliers of biomass-related provisioning ecosystem services, e.g. food, fibre, and energy. At the same time, they are highly dependent on good ecosystem condition and regulating ecosystem services such as soil fertility, water supply or soil erosion regulation. Assessments of this interplay of ecosystem condition and services are needed to understand the relationships in highly managed systems. Therefore, the aim of this study is twofold: First, to test the concept and indicators proposed by the European Union Working Group on Mapping and Assessment of Ecosystems and their Services (MAES) for assessing agroecosystem condition at a regional level. Second, to identify the relationships between ecosystem condition and the delivery of ecosystem services. For this purpose, we applied an operational framework for integrated mapping and assessment of ecosystems and their services. We used the proposed indicators to assess the condition of agroecosystems in Northern Germany and regulating ecosystem service control of erosion rates. We used existing data from official databases to calculate the different indicators and created maps of environmental pressures, ecosystem condition and ecosystem service indicators for the Federal State of Lower Saxony. Furthermore, we identified areas within the state where pressures are high, conditions are unfavourable, and more sustainable management practices are needed. Despite the limitations of the indicators and data availability, our results show positive, negative, and no significant correlations between the different pressures and condition indicators, and the control of erosion rates. The idea behind the MAES framework is to indicate the general condition of an ecosystem. However, we observed that not all proposed indicators can explain to what extent ecosystems can provide specific ecosystem services. Further research on other ecosystem services provided by agroecosystems would help to identify synergies and trade-offs. Moreover, the definition of a reference condition, although complicated for anthropogenically highly modified agroecosystems, would provide a benchmark to compare information on the condition of the ecosystems, leading to better land use policy and management decisions.

First Prospective Cross-Sectional Study on the Impact of Immigration Background and Education in Early Detection of Breast Cancer

Background: Although immigrant health is an important issue in national health policy, there is a serious shortage of data in many countries. Most studies lack information on educational status, which is a major limitation. This prospective cross-sectional study analyzed a real-world breast cancer population on the influence of immigration background and educational status on participation in breast cancer early detection programs in the federal state of Lower Saxony, Germany. Methods: Data collection was conducted from 2012 to 2016 in six certified breast cancer centers using a standardized questionnaire for patients’ interview and tumor-specific data from the patients’ medical records. Results: 2,145/3,047 primary breast cancer cases were analyzed. 17.5% of our patients had a history of immigration, including n = 202 first-generation immigrants and n = 168 second-generation immigrants. Most of them were citizens of EU27 member states. No significant difference was seen in age, tumor stage, histology, grading, Ki-67, Her2/neu-status, and hormone receptor status compared to the native cohort. 100% participation rate in the breast cancer early detection programs were seen in patients with no school graduation. With regards to the national mammography screening program, participation decreased significantly with educational status (p = 0.0003). Conclusions: No tumor biological differences were seen between immigrants and German natives. In first-generation immigrants, early detection programs were well accepted despite sociocultural and language differences. Participation rate decreased significantly with higher education levels irrespective of country of origin. Immigration background does not have a negative effect on the participation in breast cancer screening. This mainly relates to immigrants from EU27 member states.

The impact of anti-establishment parties on the electoral success of independent local lists: Evidence from Germany

Independent local lists (ILL) have become an important non-partisan actor in many local elections. However, little is known about which factors explain their electoral success. Drawing on recent contributions regarding the anti-establishment attitudes of many ILL, we argue that the rise of anti-establishment parties, especially the rise of populist radical-right parties, potentially harms the electoral success of ILL. Our main argument is that both actors attract voters that are dissatisfied with established parties. To test this hypothesis, we draw on the case of municipal elections in the German federal state of Lower Saxony. In the election of 2016, the populist radical-right party AfD competed in only a subset of all municipalities, meaning that some voters could cast their vote for the AfD in only some of the municipalities. We use a difference-in-differences approach to estimate the effect of the AfD on independent local list’s vote share and demonstrate that ILL suffered strongly from the entrance of the AfD to the electoral arena. More specifically, our findings demonstrate that the increase in the success of ILL was halted in municipalities in which the AfD competed, while it continued to increase in regions where the AfD was absent. These findings suggest that the increasing success of ILL is due to voters’ dissatisfaction with the established parties and not necessarily due to an increasing interest in local issues.