PET/CT in malignant melanoma: a two-tiered healthcare system? Updated healthcare situation regarding initial staging of malignant melanoma with PET/CT.

BACKGROUND: Patients with stage IIC malignant melanoma are recommended to undergo cross-sectional imaging for initial staging. PET/CT is superior to other methods regarding its diagnostic accuracy of the tumor spread in stage III. So far there is no meaningful data on the nationwide availability, usage and cost recovery of this imaging technique. PATIENTS AND METHODS: Questionnaires on the healthcare situation in 2018 were sent to all German dermatology clinics and PET/CT centers in March and April 2019. RESULTS: 61.2 % of the dermatology clinics (71/115) and 48.2 % of the PET/CT centers (77/160) took part in the survey. A total of 22,645 patients with malignant melanoma were seen in these clinics in 2018. 16.8 % of the patients with stage IIC melanoma received a PET/CT for primary staging. The costs of this examination were covered for all statutory and privately insured patients in 40 % and 68 % of dermatology clinics (20/50 and 34/50), respectively. 68.0 % (34/50) of all dermatology clinics reported relevant changes of treatment according to PET/CT findings. Long examination periods by the health insurance companies and the time required to submit the application were the most common reasons for dermatology clinics to reject a request for PET/CT. Relevant incidental findings were reported in 90.2 % (47/51) of all PET/CT centers. CONCLUSIONS: There are clear differences in the nationwide availability and cost coverage of PET/CT in primary staging for stage IIC melanoma. For these reasons, a two-tiered healthcare system may be assumed.

Assessing and Explaining Geographic Variations in Mammography Screening Participation and Breast Cancer Incidence.

Investigating geographic variations in mammography screening participation and breast cancer incidence help improve prevention strategies to reduce the burden of breast cancer. This study examined the suitability of health insurance claims data for assessing and explaining geographic variations in mammography screening participation and breast cancer incidence at the district level. Based on screening unit data (1,181,212 mammography screening events), cancer registry data (13,241 incident breast cancer cases) and claims data (147,325 mammography screening events; 1,778 incident breast cancer cases), screening unit and claims-based standardized participation ratios (SPR) of mammography screening as well as cancer registry and claims-based standardized incidence ratios (SIR) of breast cancer between 2011 and 2014 were estimated for the 46 districts of the German federal state of Lower Saxony. Bland-Altman analyses were performed to benchmark claims-based SPR and SIR against screening unit and cancer registry data. Determinants of district-level variations were investigated at the individual and contextual level using claims-based multilevel logistic regression analysis. In claims and benchmark data, SPR showed considerable variations and SIR hardly any. Claims-based estimates were between 0.13 below and 0.14 above (SPR), and between 0.36 below and 0.36 above (SIR) the benchmark. Given the limited suitability of health insurance claims data for assessing geographic variations in breast cancer incidence, only mammography screening participation was investigated in the multilevel analysis. At the individual level, 10 of 31 Elixhauser comorbidities were negatively and 11 positively associated with mammography screening participation. Age and comorbidities did not contribute to the explanation of geographic variations. At the contextual level, unemployment rate was negatively and the proportion of employees with an academic degree positively associated with mammography screening participation. Unemployment, income, education, foreign population and type of district explained 58.5% of geographic variations. Future studies should combine health insurance claims data with individual data on socioeconomic characteristics, lifestyle factors, psychological factors, quality of life and health literacy as well as contextual data on socioeconomic characteristics and accessibility of mammography screening. This would allow a comprehensive investigation of geographic variations in mammography screening participation and help to further improve prevention strategies for reducing the burden of breast cancer.

[Hearing test results of 18- to 20-year old men preceding military conscription from 2008-2010]. / Hörtestergebnisse bei 18- bis 20-jährigen Männern aus Kreiswehrersatzämtern von 2008­2010.

OBJECTIVE: High-frequency hearing loss is known to increase with age, whereas the amount and rate of increase of hearing loss in younger people is still unclear. A large proportion of young age groups is expected to preserve normal hearing. Therefore, the requirements for screening methods are particularly high and the motivation to participate is low. The obligatory examinations preceding military conscription include a pure-tone audiogram and thus allow the analysis of the hearing status of young male adults. MATERIAL AND METHODS: The prevalence of hearing impairment was determined using air-conduction thresholds of 18- to 20-year old men, from 54 German registration offices (KWEA), measured in 2008 to 2010. The criterion was based on candidates exceeding a threshold of 20 dB HL for one of the frequencies 3, 4, or 6 kHz in at least one ear. This very strict criterion was compared to other definitions of hearing impairment. RESULTS: The prevalence of hearing impairment was, on average, 15.3 % and thus in the same range as in other studies. However, the results of single KWEA differed by up to a factor of 10. CONCLUSIONS: Due to high fluctuations in measurement quality in the KWEA, regional differences in hearing thresholds of young men are not resolvable and it remains unclear whether the hearing loss has increased in comparison to earlier studies. The high variability of measurements near thresholds requires permanent quality inspections. However, hearing thresholds derived from screening cannot be evaluated applying the same criteria as for hearing tests in audiological centers or studies.