Abstract Background The COVID-19 pandemic has exposed the vulnerability of older people living in long-term care facilities (LTCF), highlighting the urgent need for research on the quality of care for this group of the population. There is no universal definition for quality of care in LTCF, and yet, multiple tools and indicators have been developed to measure it. In this rapid scoping review, we aim to provide a comprehensive overview of the current knowledge on quality of care concepts and indicators for older people in LTCF in OECD countries. Methods This review follows the World Health Organization (WHO) guide for rapid reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA-ScR) extension for scoping reviews, including protocol registration (https://doi.org/10.17605/OSF.IO/34B2S). The electronic bibliographic databases MEDLINE (PubMed), EMBASE, and CINAHL were searched in September 2023 for studies published between 2013 and 2023 for quality indicators in LTCF. Experts in quality of care in LTCF were contacted and consulted to retrieve sources of grey literature. Information on the definition or framework of quality of care, quality of care dimensions, measurement instruments, context and purpose of the measurement will be extracted. Results Of the 8,516 identified records, 6,449 were screened by title and abstract after removing duplicates. A total of 469 publications will be screened in full-text. Experts recommended 40 websites to be screened for quality indicators. The PRISMA flowchart diagram will be provided to describe the selection process. Conclusions This review aims to improve the quality of care for older people living in LTCF. Our results will identify which concepts and dimensions of care are currently being measured in OECD countries, whether they are backed by any definition and scientific framework of quality of care for older residents of LTCF, and whether there is consideration of closing gaps in quality measurement. Key messages • Quality of care is an understudied field in the context of long-term care facilities for older people. • In order to further improve quality in long-term care for older people, it is necessary to systematically review the current state of knowledge on quality concepts and indicators.

Abstract Background Increasing evidence points to a relation between cardiometabolic and mental health, but population-based data are scarce. We investigated the association of type 2 diabetes (T2D) risk to general and mental health with a focus on potential differences between women and men. Methods The study population comprised 5,192 adults (18+ years) without known diabetes based on data of the German Health Update (GEDA) 2022. T2D risk was assessed by the German Diabetes Risk Score (GDRS), that estimates the 5-year probability of developing T2D and was categorized into low, still low, elevated, and high risk. Sex-specific Poisson regression analyses were conducted including self-rated health (SRH), self-rated mental health (SRMH), depressive symptoms (PHQ-2) and anxiety symptoms (GAD-2) as dichotomous dependent variables and age, educational level, living alone, region of residence, and social support as covariables. Results Women had a higher prevalence of low T2D risk (66.1%) and a lower prevalence of high T2D risk (9.4 %) than men (55.3% vs. 16.3%). Compared to those with low T2D risk, women and men with a high T2D risk were less likely to report very good/good SRH (women: prevalence ratio: 0.63; 95% confidence interval: 0.51-0.79; men: 0.69; 0.57-0.84) or excellent/very good SRMH (women: 0.53, 0.39-0.73; men: 0.85, 0.63-1.15). Further, those with a high T2D risk had a higher risk of depressive symptoms (women: 1.71, 1.05-2.81; men: 2.23, 1.22-4.05) and anxiety symptoms (women: 1.84, 1.03-3.29; men: 2.73, 1.09-6.81). No statistically significant interactions between sex and T2D risk were observed regarding the included health outcomes. Conclusions A high T2D risk is associated with a lower probability of a favourable SRH and SRMH and a higher risk of depressive and anxiety symptoms in men and women. The underlying mechanisms need further identification, in order to design synergistically beneficial health promotion for cardiometabolic and mental health. Key messages • No sex-specific differences in general and mental health were found in people at high T2D risk. • Further research is needed to identify the underlying mechanism to improve general and mental health.

Hausärztinnen und Hausärzte (HÄ) bilden die primäre Anlaufstelle für Patientinnen und Patienten mit unklaren Symptomen. Dies zeigt sich zurzeit am Beispiel der postakuten Infektionssyndrome von Long‑/Post-COVID (L/PC) mit einer Vielfalt systemischer, unspezifischer, langanhaltender Symptomkomplexe nach durchgemachter SARS-CoV-2-Infektion. Dieser Beitrag beleuchtet die L/PC-Versorgung aus der hausärztlichen Perspektive und beschreibt Erfahrungen, Herausforderungen und Informationsbedarfe. Im September 2022 wurde eine anonyme Befragung aller in Deutschland niedergelassenen HÄ durchgeführt. Die Datenerhebung erfolgte anhand eines selbstentwickelten Onlinefragebogens. Die Daten wurden mithilfe deskriptiver Analysen ausgewertet. Ergebnisse sind nach Geschlecht, Alter und Region gewichtet. Die Befragung erreichte einen Rücklauf von 2,1

Abstract Background Fatigue is a non-specific symptom complex associated with exhaustion, lack of motivation and concentration. It has high public health relevance due to impairments in quality of life and work ability and increased risk of accidents. Fatigue has increasingly gained attention as one of the most common post-acute consequences of SARS-CoV-2 infection. Fatigue is also common among non-infected people and there is a lack of population-based background data. Therefore, we investigated the prevalence and factors associated with fatigue in a population-based epidemiological study in Germany. Methods The analyses are part of the national population-based cross-sectional telephone survey ‘German Health Update’ (GEDA 2023) in adults (3/2023-2/2024). Fatigue was surveyed using the Fatigue Assessment Scale (FAS) and dichotomized into yes (at least mild/moderate) versus no fatigue. The FAS is an instrument for mild-to-moderate fatigue, which must be distinguished from chronic fatigue syndrome (CFS). Weighted analyses of the data from 9,766 adults were carried out descriptively and in multivariable Poisson models, considering sociodemographic and health-related determinants. Results The prevalence of fatigue in Germany was estimated to be 29.7% (95% CI 28.1-31.2) and was highest in 18- to 29-year-olds at 39.6% (35.0-44.4). The prevalence decreased up to 65- to 79- year-olds (20.6% (18.2-23.3)) and was again higher in people aged 80 and over (33.2% (28.9-37.7)). Women had a higher risk of fatigue than men (aRR 1.19 (1.08-1.32)). Lower education (aRR 1.29 (1.13-1.49)) and medium education (aRR 1.13 (1.01-1.27)) were associated with increased risk of fatigue. There were significant associations between fatigue and chronic illness, depressive symptoms and long COVID. Conclusions Fatigue is a common symptom among adults in Germany. Female gender, young and very old adulthood as well as lower education are associated with higher risk of fatigue. Key messages • The correlations between fatigue and socio-demographic variables as well as parameters of physical and mental health provide important indications of groups particularly affected by fatigue. • The fatigue survey in GEDA 2023 is one of the few current European studies that describe the frequency of fatigue in the general population and analyzes health and sociodemographic determinants.

Abstract Introduction It is still unknown what proportion of persons suffer from long-term consequences of COVID-19. In October 2021, the World Health Organization (WHO) proposed a definition of post COVID-19 condition (PCC) as symptoms that last at least 3 month after onset of SARS-CoV-2 infection and frequently include fatigue, respiratory symptoms and cognitive dysfunction. Methods The WHO definition of PCC was translated into ICD-10-GM Codes and investigated in a cohort of patients with laboratory-confirmed COVID-19 during 2020 and matched to controls in German routine healthcare data. Incidence rates were calculated and incidence rate ratios (IRRs) were estimated for developing any of the predefined diagnoses conditional on a preceding diagnosis of COVID-19. Within the COVID-19 cohort the persistence of PCC was followed up to one year after infection. Results A cohort of COVID-19 patients in the year 2020 was followed up to 2021-09-30 in routine healthcare data. The incidence in the COVID-19 group compared to matched controls for any investigated symptoms and conditions after three months was accessed. Main contributions were dyspnea (R06.0) and malaise/fatigue (R53). The highest IRR was observed for chronic fatigue syndrome (CFS; G93.3) the lowest for cognitive impairment (F06.7, U51). After one year a minority of the patients still had at least one specific diagnosis. The longest persistence of the symptoms was observed for CFS, cognitive impairment (F06.7, U51) and memory loss/disorientation (R41). Conclusions The more specific and serious diagnoses had a higher likelihood to occur in the COVID group compared to the matched control group and also these diagnoses persisted longer in the COVID group compared to less serious diagnoses. Due to the high number of infected people during the first two waves of the pandemic this result translates into considerable burden for the medical system. Key messages • In routine healthcare data of adults more serious ICD-10 diagnoses had a higher likelihood to occur in the COVID-19 cohort compared to the matched control cohort. • Within the COVID-19 cohort more serious ICD-10 diagnoses persisted longer than less serious diagnoses.

Abstract Health data in Germany is collected through official statistics, registries, health insurance and population-based health information surveys. These data are used for monitoring progress of the Sustainable Development Goal on Good Health and Well-being (SDG3). According to the Sustainable Development Report 2022, Germany has achieved an overall high-performance score; however, there are still two health indicators which are stagnating or back-warding: “Gap in self-reported health status by income” and “Gap in life expectancy at birth among regions”. In order to illustrate regional inequalities in health, the Robert Koch Institute has developed the German Index of Socioeconomic Deprivation, which merges the dimensions of education, employment and income. It has been estimated that life expectancy between the least and most deprived district in Germany in 2017 differed by 6.0 years among men and by 3.2 years among women. In addition, data on all-cause premature mortality in Germany between 1992 and 2016 showed that while 13% of women and 27% of men from the lowest income group died before reaching the age of 65, this was the case for 8% of women and 14% of men from the highest income group. Self-rated health (SRH) according to income showed in Germany 2019 the largest gap (31% points) compared to other high-income OECD countries. Data from the German Health Update 2019/2020 also showed differences in SRH according to educational background. These differences were more pronounced among women (54% vs. 82%) than men (64% vs. 81%) and largely persisted across all age groups. Unfavorable SRH is an indicator known to be associated with increased morbidity and health-related limitations in daily life as well as a predictor of premature mortality. In Germany progress towards achieving SDG3 has been made; however, it is important to identify vulnerable groups and health inequalities in order to develop target-oriented interventions.

Abstract Introduction Long-term health effects of COVID-19 have been investigated by several large cohort studies. As most of these studies have been conducted in adults, data on the incidence and persistence of post-COVID-19 condition (PCC) among children and adolescents are still limited. Methods Using routine healthcare data from statutory health insurance in Germany, children and adolescents with laboratory-confirmed COVID-19 in 2020 were matched to controls (neither documented nor clinically suspected COVID-19) and followed for incident health conditions until 2021-09-30. To study PCC in children we considered selected health outcomes including malaise/fatigue (R53), dyspnea (R06.0), and cognitive dysfunction (F06.7, U51, R41), developmental delay (F80-89), adjustment disorder (F43), chronic fatigue syndrome (CFS; G93.3), and altered smell/anosmia (R43). The incidence of PCC was determined based on the lack of related diagnoses in the 12 months preceding the index quarter. For each outcome incidence rate ratios (IRR) were estimated using Poisson regression. Results At 3-month-follow-up, about 40% more individuals with COVID-19 suffered from at least one of the specified health conditions compared to controls. IRR were highest for smell/anosmia and CFS. IRR were generally higher among adolescents (≥12 years) than among younger children. Only a minority of PCC diagnoses persisted for 12 months within the COVID cohort. Diagnoses were more frequently persistent in the younger age group after one year. Conclusions Despite that long-term consequences of COVID-19 are less common and usually less severe in children, a considerable share of those diagnosed with PCC still suffered from specific symptoms 12 months after acute infection. Considering the high number of infected persons our findings suggest a relevant PCC related burden for health care even among children and adolescents. Key messages • In routine healthcare data adolescents showed stronger associations between COVID-19 and post COVID-19 related ICD-10 diagnoses than children < 12 years of age. • Serious ICD-10 diagnoses persisted for a longer time in younger children than adolescents.

Abstract Background Integrating older persons into continuous national public health monitoring is crucial but challenging. Health 65+ is the first national health interview and examination survey in Germany specifically tailored to the needs of the population 65+ years. Methods Health 65+ is based on two-stage stratified random sampling from 128 local population registries. It is based on a previously tested three-step procedure to contact the study population (letter, telephone, home visits). 12,448 individuals 65+ years were invited for survey participation between June 2021 and April 2022. Participation comprised answering a baseline-questionnaire/interview covering a consented set of key health indicators including SARS-COV2 infections, and 3 follow-ups. After one year participants are invited to an examination (e.g. blood pressure, grip strength, cognitive function) during a home visit. All-cause mortality, health insurance data and information on social and built environment will be linked to survey data. The preliminary data set comprises 3,107 baseline participants. Preliminary results Only few individuals were excluded for survey participation as they had deceased before invitation, moved to an unknown residence or had insufficient German language skills. Of the adjusted gross sample, 32% took part in the survey (47.9% women, mean age 78.8 years). Only 3.3% of the participants did not receive any vaccination against COVID-19, with no differences between gender or age-groups. 3.5% had already experienced a laboratory-confirmed SARS-CoV-2 infection. Conclusions Health 65+ collects information that cannot be obtained from any other data sources. In combination with information from routine health data and official health statistics, the results will aid health policy planning and implementation research to improve health and wellbeing of older people in Germany. For example, preliminary results show, that vaccination acceptance was high in persons 65+ years in Germany. Key messages • Health 65+ will provide health data of people 65+ years in Germany. • The results will aid health policy planning.

Einleitung Eine geringe soziale Unterstützung (SU) gilt als wichtiger Risikofaktor für Diabetes und für vorzeitige Sterblichkeit. Das relative Sterberisiko bei Diabetes in Abhängigkeit von SU ist bislang wenig untersucht.

Einleitung Eine chronische Exposition mit psychosozialen Stressoren ist mit einem erhöhten Risiko für Typ-2-Diabetes (T2D) assoziiert. Anhand von Daten des Gesundheitsmonitorings des Robert Koch-Instituts wurde der Zusammenhang von chronischem Stress mit dem T2D-Risiko bei Erwachsenen untersucht.

▶ Rückblickend auf den Zeitraum seit Pandemiebeginn betrachtend, gaben von den im Juli Befragten insgesamt 46,7 % für eine anstehende Krebsvor sorgeuntersuchung, 41,4 % für einen anstehenden Gesundheits-Check-up und 43,3 % für eine geplante Untersuchung beim Zahnarzt an, den Termin wegen der CoronaSituation aufgeschoben zu haben. Einleitung Um die Verbreitung von SARS-CoV-2 einzudämmen und die individuellen und gesundheitssystembezogenen COVID-19-Folgen zu begrenzen, wurden deutschlandweit nicht-pharmazeutische Maßnahmen zur Bewältigung der SARS-CoV-2-Pandemie von Bund und Ländern beschlossen. So wurden ab Mitte März Schulen und Kindertagesstätten1 sowie Restaurants bundesweit geschlossen und allgemeine Kontaktbeschränkungen verabschiedet.2 Gleichzeitig wurden Krankenhäuser angewiesen, planbare Operationen und Behandlungen aufzuschieben, um Kapazitäten zur Behandlung von schweren COVID-19-Erkrankungen bereitzustellen.3,4 Ab Ende April wurden die Maßnahmen stückweise gelockert, sodass im Mai in vielen Bundesländern Restaurants und Schulen wieder geöffnet werden konnten. Inwieweit diese Maßnahmen aus Sicht der Bevölkerung Auswirkung auf die medizinische Versorgung in diesem Zeitraum hatten, ist bisher wenig untersucht.

Abstract Background While life expectancy (LE) is rising, years lived with severe health impairments especially due to chronic diseases also increase. Diabetes is one of the major chronic diseases with high potential for co-morbidity and premature deaths needing life-long care. Therefore, information about loss in LE and healthy life years (HLY) in people with diabetes compared to people without diabetes is essential for assessing the burden of diabetes. Methods Data on all-cause mortality rates for the general population of Germany in 2014 was drawn from the Federal Statistical Office; mortality rate ratios for people with diabetes compared to people without diabetes were based on claims data from about 70 million people covered by statutory health insurances in 2014. Data of three nationwide health telephone surveys conducted among adults in Germany 2009-2012 (n ∼ 60,000) were used to assess severe health impairments defined as self-reported limitations in daily activities due to diseases for at least six months in people with and without diabetes. Based on these figures, estimates on LE and HLY could be calculated by sex and 5-year age-groups for people with and without diabetes aged ≥ 30 years. Results In both sexes and in all 5-year age-groups, LE and HLY were substantially lower for people with than for people without diabetes. For example, among women in the age group 30-34 years, LE and HLY estimates were 48.0 and 36.4 years for those with diabetes compared to 54.9 and 47.6 years for those without diabetes; in men, these figures were estimated as 42.6 and 32.4 years for those with diabetes compared to 50.3 and 44.1 years for those without diabetes. Differences in LE and HLY between people with and without diabetes attenuated with increasing age. Conclusions The present study revealed substantial reductions in LE and HLY related to diabetes and underlines the importance of integrating both figures in a national diabetes surveillance. Key messages There are substantial differences in life expectancy and healthy life years between people with and without diabetes. Specific intervention and prevention activities should be implemented to tackle disability in persons with diabetes.

Abstract Background Non-communicable diseases (NCD) are a major public health challenge in Germany and throughout the world. The epidemiology of diabetes, in particular type 2 diabetes, exemplifies the need for effective prevention and control. To support policy making with actionable evidence, the Robert Koch Institute (RKI) is developing a diabetes surveillance system for Germany serving as model for NCD surveillance. Methods First, we consented a conceptual framework and key indicators among experts and stakeholders based on an extensive literature review including national and international NCD surveillance systems. After prioritization of indicators applying a two-step Delphi method, we identified data sources for sustainable surveillance including data from nationwide RKI health surveys as well as external data such as claims or registry data. Lastly, in cooperation with stakeholders we developed first dissemination products. Results During concept phase, we identified 40 indicators ranging from risk factors, disease incidence and prevalence to quality of care, mortality and burden of disease. During implementation, suitable data sources and results on temporal trends have been obtained for a large part of the indicators. For dissemination we developed a website with interactive visualization of results supported by an explainer video on YouTube. Additionally, we prepared a printed diabetes report summarizing and interpreting key findings for a broader audience, including health politicians and public health researchers. Conclusions We demonstrated the feasibility of the systematic collection and analysis of health data to describe the disease and care situation of diabetes in Germany. The methodology and data sources of indicators can be transferred to further NCDs and shared risk factors are already depicted. Next steps are to close remaining data gaps and to advance dissemination products in collaboration with our stakeholder network tailored to their information needs. Key messages Considering available health data, we showed the feasibility of implementing a diabetes surveillance system for Germany providing reliable information on disease dynamics for various stakeholders. The knowledge on methodology and data sources gained establishing a diabetes surveillance system can be extended to other noncommunicable diseases.

Abstract Background Diabetes mellitus is a non-communicable disease with high public health relevance in Germany. Therefore, the Robert Koch Institute startetd to establish a national diabetes surveillance system in Germany in 2016. Essential part of a surveillance system is the dissemination of health information to the relevant stakeholders to facilitate its translation into action. Methods For the development of the dissemination strategy, different sources of information were used. First, an online-survey combined with structured web-research explored dissemination approaches in the international context. Secondly, a workshop with public health experts from seven countries highlighted best practice examples. Based on this information, a dissemination strategy was developed in close alignment with the scientific advisory board of the diabetes surveillance including experts from politics, prevention research, regional health reporting, physicians/diabetologists and public health scientists. Results Three main questions were identified to be considered in the dissemination of health information: Which audience group is addressed? Which content is relevant to this group? What is the preferred format to communicate the information? Therefore, a diabetes report will be generated focusing on health policy makers summarizing the key information on the disease dynamic. A website containing all information including a visualization tool should facilitate access for stakeholders. Additionally, awareness needs to be raised using social media, classical media and direct interactions with relevant stakeholders. Conclusions In alignment with different stakeholder groups, the diabetes surveillance developed a dissemination strategy considering international best practice examples and innovative ideas for health data visualization. The next steps are to refine the dissemination strategy based on feedback from the different stakeholder groups to ensure the use of the provided information. Key messages A dissemination strategy for the diabetes surveillance has been developed in a participatory approach including experts from various stakeholder groups. Next steps include the refinement of the dissemination strategy and its formats based on stakeholders feedback requirements.

Aims To examine the association between glycaemic status and depressive symptoms in a nationwide sample of the adult population in Germany. MethodsResultsWe conducted a cross-sectional analysis of data from 6385 participants aged 18-79 years in the nationwide German Health Interview and Examination Survey for Adults 2008-2011 (DEGS1). Glycaemic status was classified as follows: diagnosed diabetes (self-reported diagnosis or receiving antidiabetes medication); undiagnosed diabetes (HbA(1c) 48 mmol/mol [6.5%]); prediabetes (HbA(1c) 39-47 mmol/mol [5.7-6.4%]); or normoglycaemia (HbA(1c) <39 mmol/mol [<5.7%]). Current depressive symptoms were measured using the Patient Health Questionnaire depression scale (PHQ-9) and defined as elevated depressive symptoms (PHQ-9 score 10 points; dichotomous variable) and severity of depressive symptoms (PHQ-9 score, range 0-27 points; continuous variable). Associations of glycaemic status and HbA(1c) with both depressive symptoms variables were analysed using multivariable logistic (elevated depressive symptoms) and linear (severity of depressive symptoms) regression models. Compared with normoglycaemia, diagnosed diabetes, but not prediabetes or undiagnosed diabetes, was associated with elevated depressive symptoms (odds ratio 1.55, 95% CI 1.00-2.41) and severity of depressive symptoms ( coefficient 0.71, 95% CI 0.23-1.19) in models adjusting for sociodemographics and health behaviours. Associations were similar among people with diagnosed diabetes taking and not taking antidiabetes medication. Among people without diagnosed diabetes, no associations between HbA(1c) and depressive symptoms were found. ConclusionsWhat's new?Diagnosed diabetes, but not prediabetes, undiagnosed diabetes or HbA(1c), was associated with depressive symptoms among adults in Germany. Studies examining psychosocial and biological mechanisms that may potentially explain relationships between diagnosed diabetes and depressive symptoms are needed. We examined associations between glycaemic status and current depressive symptoms measured using the Patient Health Questionnaire depression scale (PHQ-9) in a nationwide representative study of 6385 adults aged 18-79 years in Germany. Compared with normoglycaemia, diagnosed diabetes, but not prediabetes or undiagnosed diabetes, was associated with elevated depressive symptoms (PHQ-9 score 10: odds ratio 1.55, 95% CI 1.00-2.41) and severity of depressive symptoms (PHQ-9 score: coefficient 0.71, 95% CI 0.23-1.19) in models adjusting for sociodemographics and health-related behaviours. Among people without diagnosed diabetes, HbA(1c) was not associated with depressive symptoms. This study provides evidence that diagnosed diabetes may have stronger associations with depressive symptoms than glucose metabolism alone.