Journal of Health Monitoring - Health and health care of women aged 50 years and older - Results of the research project 'Frauen 5.0'

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JUNE 2020   FEDERAL HEALTH REPORTING
 ISSUE
      2     JOINT SERVICE BY RKI AND DESTATIS

            Journal of Health Monitoring

            Health and health care of women aged
            50 years and older – Results of the research
            project ‘Frauen 5.0’

                                                           1
Journal of Health Monitoring    Index

                                                  Health and health care of women aged 50 years
                                                  and older – Results of the research project
                                                 ‘Frauen 5.0’
                                            3 Focus Reasons for women aged 50 years and older
                                              to seek gynaecological advice and treatment
                                           15 Focus Gynaecology and general practitioner services
                                              utilisation by women in the age group 50 years
                                              and older
                                          26 Fact sheet Barriers for women aged 50 years and
                                             older to accessing health care in Germany
                                           35 Fact sheet Demographics of the female
                                              population aged 50 years and older in Germany’s
                                              north east region – Selected aspects

Journal of Health Monitoring 2020 5(2)                                                              2
Journal of Health Monitoring   Reasons for women aged 50 years and older to seek gynaecological advice and treatment                                         FOCUS

Journal of Health Monitoring · 2020 5(2)
DOI 10.25646/6065
                                                       Reasons for women aged 50 years and older to seek gynaecological
Robert Koch Institute, Berlin
                                                       advice and treatment
Laura Krause 1, Lorena Dini 2, Franziska Prütz 1       Abstract
                                                       Gynaecological care is generally perceived as focused on reproductive health. However, when women enter the non-
1
 	Robert Koch Institute, Berlin                       reproductive life phase, other reasons to seek gynaecological care gain in importance. This paper presents findings on
   Department of Epidemiology and                      the reasons for women in the 50 years and older age group to seek gynaecological consultation and treatment. Our
   Health Monitoring
                                                       findings are based on data from the German Health Interview and Examination Survey for Adults (DEGS1, 2008–2011),
2
  	Charité – Universitätsmedizin Berlin
   Institute of General Practice
                                                       conducted by the Robert Koch Institute (RKI), as well as the 2016 claims data from the Associations of Statutory Health
                                                       Insurance Physicians (KVen), provided by the Central Research Institute of Ambulatory Health Care in Germany (Zi). At
Submitted: 03.04.2020                                  this age, cancer screening and menopausal complaints can become, as DEGS1 data shows, important reasons to seek
Accepted: 03.06.2020                                   gynaecological services. Around 65.0% of 50- to 79-year-old women took advantage of breast palpation examinations
Published: 30.06.2020
                                                       during the last twelve months, and 58.0% underwent cervical cell smear tests (pap smear). 47.2% of women had their
                                                       last menstrual period at age 50 or later. KV data shows that with 45.3% and 33.1% of cases respectively, menopausal
                                                       symptoms (International Statistical Classification of Diseases and Related Health Problems, 10th revision, ICD-10: N95)
                                                       and screening for malignant neoplasms (ICD 10: Z12) were the most frequently billed services. The data clearly shows
                                                       reasons for consultation and treatment of women aged 50 years and older and these should therefore be considered in
                                                       treatment planning and design.

                                                          GYNAECOLOGY · REASONS TO SEEK TREATMENT · OUTPATIENT CARE · OLDER WOMEN · GERMANY

                                                       1. Introduction                                                        following menopause, conditions such as urinary inconti-
                                                                                                                              nence, osteoporosis and uterine prolapse become more
                                                       The public and research community primarily relate gynae-              frequent [5, 6]. Some conditions may necessitate surgery
                                                       cological care to reproductive health and questions such               that requires outpatient medical aftercare [7–9]. From the
                                                       as family planning, pregnancy and birth [1]. As women near             perspective of prevention, cancer early detection gains great
                                                       the end of their reproductive years, new reasons to seek               importance in gynaecological practice [10]. For women of
                                                       consultation and treatment with outpatient gynaecological              specified age groups, statutory health insurance offers can-
                                                       service providers arise, in part due to hormonal changes               cer screening tests as a standard benefit. In January 2020,
                                                       that occur during menopause [2–4]. Breast and endome-                  early detection of cervical cancer was changed from an
                                                       trial cancer incidence rates increase with age and,                    opportunistic screening offer to an organized screening

          Journal of Health Monitoring 2020 5(2)                                                                                                                                 3
Journal of Health Monitoring       Reasons for women aged 50 years and older to seek gynaecological advice and treatment                                        FOCUS

                                                         programme, including an annual cervical cell smear (20-                to gain an overview of the levels of care that are provided
DEGS1                                                    to 34-year-old women) or a cervical cell smear and human               and, building on this, develop concepts to secure outpatient
Data holder: Robert Koch Institute                       papilloma virus test every three years (age 35 and older).             gynaecological care for this group within the population.
Objectives: To provide reliable information about the    For the early detection of breast cancer, women aged 30                   This paper describes gynaecological conditions that
population’s health status, health-related behaviour     years and older are offered annual breast palpation exam-              affect women aged 50 years and older over time, and pos-
and health care in Germany including analysis of
temporal developments and trends.
                                                         inations, and 50- to 69-year-old women can undergo a                   sible reasons for gynaecological appointments. The results
                                                         mammography of both breasts within the scope of a bien-                are based on data from the German Health Interview and
Survey method: Questionnaires, physical examina-
tions and tests, a physician interview, a medication     nial mammography screening [11]. Some patients will                    Examination Survey for Adults (DEGS1, 2008–2011), con-
interview and laboratory investigations (blood and       request further consultation on mammography screening                  ducted by the Robert Koch Institute (RKI). This data allows
urine sample).
                                                         by their gynaecologist [12].                                           us to determine the possible reasons why women in this
Population: German resident population, aged 18
and above
                                                             With regard to the provision of gynaecological services,           group sought gynaecological consultation and treatment.
                                                         the health of women aged 50 years and older is not the only            Furthermore, data from the Associations of Statutory
Sampling: Registry office sample; randomly selected
individuals from 180 communities in Germany were         factor to be considered, as the overall uptake of gynaeco-             Health Insurance Physicians (KVen), provided by the Cen-
invited to participate (120 original sample points of    logical services also considerably decreases with age (see             tral Research Institute of Ambulatory Health Care in Ger-
the German National Health Interview and Examina-
tion Survey 1998 and 60 new sample points).              Focus Article Gynaecology and general practitioner services            many (Zi), reveals the most frequent diagnoses in gynae-
Participants: N=8,151 (4,283 women; 3,868 men). The      utilisation by women in the age group 50 years and older in            cological practices in 2016.
sample included persons who were newly recruited         this issue of the Journal of Health Monitoring). Demo-
and those who had already participated in the Ger-
man National Health Interview and Examination Sur-       graphic ageing, moreover, is leading to an increasing num-             2. Methodology
vey 1998 (mixed design).                                 ber of older women (see Fact Sheet Demographics of the                 2.1 Sample design and study implementation
Response rate: 62% among revisiting participants         female population aged 50 years and older in Germany’s
and 42% first time participants                          north east region – Selected aspects, also in this issue of            As no representative data exists for Germany that indicates
Survey period: 2008 to 2011                              the Journal of Health Monitoring). Against this backdrop,              which gynaecological symptoms or need for consultation
Data protection: DEGS1 is subject to strict compliance   and due to the increasing difficulties related to ensuring             and treatment lead to an uptake of the services provided
with the data protection regulations of the Federal      outpatient care in rural regions, the project ‘Frauen 5.0’             by gynaecological practices, this paper builds on multiple
Data Protection Act and has been approved by the
Federal Commissioner for Data Protection and Free-       (Regionale Versorgung von Frauen über 49 Jahre durch                   data sources that allow us to approximately describe the
dom of Information in Germany. Charité – Univer­         Fachärztinnen und Fachärzte für Gynäkologie und für All-               situation.
sitätsmedizin Berlin’s ethics committee assessed the
ethics of the DEGS1 study and provided its approval      gemeinmedizin) was developed, which is funded by the                      Between 2008 and 2011, as part of DEGS1, the RKI col-
(No.EA2/047/08). Participation in DEGS1 was volun-       Innovation Fund of the Federal Joint Committee [13]. The               lected representative data on the health of the German pop-
tary. The participants were informed about the aims
and contents of the studies and about data protection.   project analyses the provision of gynaecological and gen-              ulation aged 18 to 79 years. This study, which covered 8,151
Informed consent was obtained in writing.                eral practitioner (GP) services to women aged 50 years and             participants, included questionnaires, interviews, physical
More information in German is available at               older in Germany’s north east region (Berlin, Brandenburg              examinations and tests. The DEGS1 concept and survey
www.degs-studie.de
                                                         and Mecklenburg-Western Pomerania). The project aims                   design have previously been described in detail [14, 15].

          Journal of Health Monitoring 2020 5(2)                                                                                                                                  4
Journal of Health Monitoring    Reasons for women aged 50 years and older to seek gynaecological advice and treatment                                         FOCUS

                                         DEGS1 included questions on gynaecological conditions                  2.2 Statistical methods
                                         and symptoms which could lead women to seek gynaeco-
                                         logical services [5–10]. We can group these reasons into              On the basis of data from DEGS1 (2008–2011), we ini-
                                         the following four categories: ‘gynaecological cancer screen-         tially determine gynaecological conditions and operations
                                         ing’, ‘menopause and contraception’, ‘diseases and com-               in 18- to 79-year-old women (n=4,198). We also report
                                         plaints’ and ‘gynaecological operations’. These are thereby           potential reasons to seek gynaecological consultation
                                         only reasons for which women potentially sought gynae-                and treatment by women aged 50 years and older
                                         cology services; the survey did not ask whether women                 (n=2,287) and provide these as prevalences (in percent).
                                         then actually visited a gynaecologist.                                DEGS1 calculations were carried out using a weighting
                                            Claims data from the KVen, provided by the Zi (2016)               factor that corrects deviations within the sample from
                                         provide further indicators of actual service provision and            the population structure (as of 31 December 2010) with
                                         uptake. Every three months, the KVen provide the Zi with              regard to age, sex, region, citizenship, type of municipal-
                                         pseudonymised claims data from the quarterly accounts                 ity and education [14].
                                         of office-based physicians. The information on the treat-                 Based on the 2016 KV claims data that we received from
                                         ment cases, which this data contains, makes it possible               the Zi, the most frequent ICD-10 diagnoses (three-digit
                                         to precisely record the coded diagnoses [16]. Therefore               codes) in gynaecology and GP practices are presented as
                                         this data permits an assessment of actually provided                  the number of cases and proportion (in percent) of all
                                         gynaecology services in outpatient practices either across            cases.
                                         Germany or for certain regions. Based on a special eval-
                                         uation on request of the RKI, this paper presents the ten              3. Results
                                         most frequently recorded codes from the 10th revision of
                                         the International Statistical Classification of Diseases and          The prevalence of conditions and symptoms that women
                                         Related Health Problems (ICD-10, three-digit codes) in                receive treatment for in gynaecology practices increases
                                         gynaecology practices for women aged 18 years and older               with age (Table 1). They include urinary incontinence, osteo­
                                         in Germany. Furthermore, we report the 20 most fre-                   porosis, uterine prolapse, as well as breast cancer and gynae-
                                         quently recorded ICD-10 codes (three digits) for women                cological cancers such as cervical, endometrium and ovar­
                                         aged 50 years and older in gynaecology practices in the               ian cancers. The proportion of women who undergo
                                         north east region (Berlin, Brandenburg and Mecklen-                   gynaecological surgeries, such as hysterectomy and ovariec-
                                         burg-Western Pomerania). We also present data from GP                 tomy, also, as expected, increases with age.
                                         practices that refer to gynaecological diagnoses.                        Figure 1 presents the prevalences for these conditions
                                                                                                               as recorded in DEGS1 data for the group of 50- to 79-year-
                                                                                                               old women, as well as further possible reasons to seek an

Journal of Health Monitoring 2020 5(2)                                                                                                                             5
Journal of Health Monitoring   Reasons for women aged 50 years and older to seek gynaecological advice and treatment                                                                 FOCUS

                                       Table 1                                                                                                                              Age group
          Prevalence of specific diseases and                                                                  18–29 years 30–39 years 40–49 years 50–59 years 60–69 years 70–79 years
operations in 18- to 79-year-old women by age    Diseases
                                     (n=4,198)    Urinary incontinence (currently, n=3,276)                            4.2%             11.4%          17.1%          23.2%         30.1%              42.3%
                   Source: DEGS1 (2008–2011)      Osteoporosis (lifetime, n=313)                                         n.s.              n.s.           n.s.         4.1%         12.7%              25.2%
                                                  Uterus prolapse (lifetime, n=136)                                    0.2%              0.0%           2.5%           4.7%          4.6%               7.6%
                                                  Breast cancer (lifetime, n=112)                                      0.0%              0.1%           1.3%           2.9%          5.4%               6.2%
                                                  Gynaecological cancers (lifetime, n=87)                              0.2%              0.9%           1.1%           3.3%          3.6%               1.7%
                                                 Operations
                                                  Hysterectomy (lifetime, n=784)                                       0.0%              0.5%          10.2%          26.8%          35.2%             38.0%
                                                  Ovariectomy (lifetime, n=349)                                        0.0%              1.1%           4.5%           9.2%          15.8%             19.5%
                                                 n.s. = not surveyed

                                                 appointment at a gynaecology practice. Cancer screening,                         screening programme and during normal practice). 65.0%
                                                 in particular, plays an important role: 73.1% of women had                       had undergone breast palpation during the last twelve
 Cancer screening is one                         undergone a mammography during the last two years                                months and 58.0% cervical cancer screening (cervical cell
 of the main reasons for                         (examinations carried out as part of the mammography                             smear test, pap smear).
 women aged 50 years and
 older to seek outpatient                                                          Gynaecological cancer screening
 gynaecological services.                                                 Mammography (during the last two years)
                                                            Palpation of the breast (during the last twelve months)
                                                     Cervical cancer cell smear test (during the last twelve months)
                                                                                        Menopause and contraception
                                                                                                  Last menstrual period
                                                                                   Use of hormone therapy (currently)
                                                                Use of contraception (currently, age range 50–65 years)
                                                                                              Diseases and complaints
                                                                                        Urinary incontinence (currently)
                                                                                                 Osteoporosis (lifetime)
                                                                                             Uterine prolapse (lifetime)
                                                                                                 Breast cancer (lifetime)
                                                                                        Gynaecological cancer* (lifetime)
                                                                                                            Operations
                                      Figure 1                                                   Hysterectomy (lifetime)
        Reasons for 50- to 79-year-old women                                                      Ovariectomy (lifetime)
        to seek consultation and treatment at
                                                                                                                              0         10        20    30       40    50     60        70        80
              gynaecology practices (n=2,287)
                                                                                                                                                                                   Proportion (in %)
                  Source: DEGS1 (2008–2011)           *
                                                          Cervical, endometrium and/or ovarian cancer (lifetime: lifetime prevalence)

        Journal of Health Monitoring 2020 5(2)                                                                                                                                                   6
Journal of Health Monitoring    Reasons for women aged 50 years and older to seek gynaecological advice and treatment                                                      FOCUS

                                                       Menopause is a further reason to seek consultation and                          a contraceptive coil and 27.9% said they used the pill (data
                                                   treatment. Nearly half of all women (47.2%) had their last                          not shown). However, due to the low number of cases
                                                   menstruation at the age of 50 or later (average age for the                         (n=80), these results should be interpreted with caution.
                                                   last menstrual period in Germany: 49.7 years [17]). Over one                        Nonetheless, they do show that a need for consultation
                                                   third of women (35.5%) stated that they used menopausal                             and, in some cases, medical check-up examinations may
                                                   hormone therapy.                                                                    also exist here [18–20].
                                                       Gynaecological conditions and post-operative care can                               An analysis of the most frequent diagnoses billed by
                                                   also lead women to seek an appointment at gynaecology                               gynaecology practices for women aged 18 years and older
                                                   practices: at the point of survey, 30.8% of women stated                            showed that menopausal and climacteric states (ICD-10:
                                                   they had acute urinary incontinence, and around one third                           N95) ranked fourth (Table 2). The diagnoses ranked sec-
                                                   (32.7%) had undergone hysterectomy. Osteoporosis (with                              ond and third (N89: other specified noninflammatory dis-
                                                   a lifetime prevalence among 50- to 79-year-old women of                             orders of vagina, Z12 encounter for screening for malignant
   Menopausal symptoms also                        13.1%), uterine prolapse (5.5%), breast cancer (4.7%), as                           neoplasms) are, as the following analyses show, also fre-
   frequently lead women to                        well as gynaecological cancers (cervical, endometrium,                              quently billed for women aged 50 years and older.
   seek gynaecological services;                   ovarian cancer 2.9%) could be further reasons to seek                                   Figure 2 presents the 20 most frequently billed diagnoses
   nearly half of all women aged                   gynaecological treatment.                                                           in gynaecology practices for women aged 50 years and older
                                                       6.5% of 50- to 65-year-old women said they used con-                            in the north east region in 2016. The largest recorded pro-
   50 continue to menstruate.
                                                   traceptives. Of these, 22.9% used condoms, 46.6% used                               portion, 45.3% or 655,459 cases, concerned menopausal

                                                   Rank     ICD-10 Code        Diagnosis                                                                          Number of cases       Proportion
                                                   1        Z30**              Contraceptive management                                                               18,734,546           39.15%
                                                   2        N89                Other noninflammatory disorders of vagina                                              12,931,229            27.0%
                                                   3        Z12**              Special screening examination for neoplasms                                            11,447,844            23.9%
                                                   4        N95                Menopausal and other perimenopausal disorders                                           7,036,573            14.7%
                                                   5        Z01**              Other special examinations and investigations of persons without                        6,418,212            13.4%
                                                                               complaint or reported diagnosis
                                                   6        N76                Other inflammation of vagina and vulva                                                    4,835,146            10.1%
                                                   7        N94                Pain and other conditions associated with female genital organs and                       4,410,731             9.2%
                                       Table 2                                 menstrual cycle
   The ten most frequent ICD-10 codes (three       8        N92                Excessive, frequent and irregular menstruation                                            3,883,673             8.1%
   digits) used by gynaecological practices for    9        R10                Abdominal and pelvic pain                                                                 3,122,270             6.5%
  women aged 18 years and older in Germany         10       C50                Malignant neoplasm of breast                                                              2,063,227             4.3%
                                                   ICD-10 = International Statistical Classification of Diseases and Related Health Problems, 10th revision
          Source: Central Research Institute of    *
                                                     Quarterly collection of case numbers, multiple registration of responses possible
Ambulatory Health Care in Germany (2016)* [21]     **
                                                      Z diagnoses describe factors influencing health status and contact with health services.

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Journal of Health Monitoring    Reasons for women aged 50 years and older to seek gynaecological advice and treatment                                                        FOCUS

                                      Figure 2            N95 Menopausal and other perimenopausal disorders
The 20 most frequent ICD-10 codes (three digit)               Z12 Special screening examination for neoplasms
       recorded by gynaecological practices for            Z01 Other special examinations and investigations of
                                                               persons without complaint or reported diagnosis
  women aged 50 years and older in the region
                                                                N89 Other noninflammatory disorders of vagina
  north east (Berlin, Brandenburg and Mecklen-
                                                                           I10 Essential (primary) hypertension
      burg-Western Pommerania) (n=1,448,162)
                                                                             C50 Malignant neoplasm of breast
          Source: Central Research Institute of                                    N81 Female genital prolapse
Ambulatory Health Care in Germany (2016) [21]                                   Z30 Contraceptive management
                                                                   N76 Other inflammation of vagina and vulva
                                                        Z90 Acquired absence of organs, not elsewhere classified
                                                                                      D25 Leiomyoma of uterus
                                                                                  N64 Other disorders of breast
                                                                                     F45 Somatoform disorders
                                                                                                    E66 Obesity
                                                                         N39 Other disorders of urinary system
                                                                                 R10 Abdominal and pelvic pain
                                                                                        F32 Depressive episode
                                                                      Z80 Family history of malignant neoplasm
                                                                               N60 Benign mammary dysplasia
                                                   N85 Other noninflammatory disorders of uterus, except cervix

                                                                                                                    0       5        10      15       20     25   30   35        40        45        50
                                                                                                                                                                            Proportion of all cases (%)
                                                    ICD-10 = International Statistical Classification of Diseases and Related Health Problems, 10 revision
                                                                                                                                                th

                                                   states (ICD-10: N95). Second came encounters for screening                     absence of organs (Z90: 140,106, 9.7%). One possible rea-
                                                   for malignant neoplasms (Z12: 478,683 cases, 33.1%). Other                     son for the frequency of breast cancer as a billing diagnosis
                                                   special examinations (Z01: 316,622 cases, 21.9%), which also                   could be, considering the relatively early age at the onset of
                                                   include general gynaecological examinations, ranked third.                     disease and the often good prognosis, regular aftercare.
                                                   Further frequently billed diagnoses were noninflammatory                          Gynaecology practices not only bill gynaecological diag-
                                                   disorders of vagina (N89: 291,281 cases, 20.1%) and other                      noses but also internal medicine diagnoses such as hyper-
                                                   inflammations of the external genitals such as vaginitis and                   tension (I10) and obesity (E66). Further diagnoses
                                                   vulvitis (N76: 141,013 cases, 9.7%), but also hypertension                     included conditions with a psychological/psychiatric back-
                                                   (I10: 194,762, 13.4%), breast cancer (mammary carcinoma,                       ground, such as somatoform disorders (F45) and depres-
                                                   C50: 178,947, 12.4%), uterine prolapse (N81: 164.941, 11.4%),                  sive episodes (F32), as well as unspecified diagnoses (Z01,
                                                   contraception (Z30: 155,573, 10.7%) as well as acquired                        Z12, Z90).

          Journal of Health Monitoring 2020 5(2)                                                                                                                                            8
Journal of Health Monitoring    Reasons for women aged 50 years and older to seek gynaecological advice and treatment                                          FOCUS

                                                The results for the 20 most frequent diagnoses coded               TK were prescribed hormone therapy during menopause.
                                             by gynaecological practices for women aged 50 years and               The figures for 2010 and 2000 were 9.6% and 37.0%,
                                             older are widely congruent between the north east region              respectively [24]. DEGS1 data shows considerably higher
                                             and Germany as a whole, whereby the order of these con-               figures for the proportion of women who use hormone
                                             ditions sometimes differs slightly (data not shown). The              therapy during menopause (35.5% between 2008 and 2011),
                                             20 most frequent diagnoses coded for women aged 50                    but this data refers to a different age range and includes
                                             years and older by GPs in the region north east and for               policy holders of all insurers. International studies estimate
                                             Germany as a whole include no gynaecology-related diag-               a uterine prolapse prevalence of around 30% [25–27]. How-
                                             noses (data not shown).                                                ever, these results are based on gynaecological examina-
                                                                                                                   tion data; how many of these women actually had symp-
                                             4. Discussion                                                         toms was not considered in the studies. Current prevalences
                                                                                                                   of cancer are shown in the report 'Cancer in Germany' of
                                             The results highlight that certain gynaecological conditions          the Center for Cancer Registry Data and the Association of
                                             and operations occur more frequently with age, and give               Population-based Cancer Registries in Germany e.V. [28].
Women aged 50 years and                      an overview of reasons why women aged 50 years and older              Comparisons between DEGS1 data and cancer registry data
older are an important group                 might seek gynaecological consultation and treatment.                 show differences in the disease spectrum and in the aver-
of gynaecological patients.                  DEGS1 data (2008–2011) and KV data (2016) both indicated              age age of cancer diagnosis. This indicates that the survey
                                             that cancer screening and menopause were the most fre-                participants are not representative of women with a cancer
                                             quent reasons for appointments at gynaecology practices.               diagnosis in Germany in general. Women with severe
                                             Inflammatory and noninflammatory disorders of the exter-              courses of disease are likely to be underrepresented. Also,
                                             nal genitals, uterine prolapse, as well as breast cancer and          the number of cases (Table 1) is too small to achieve the
                                             gynaecological cancers were among the further identified              – actually desirable – differentiation to validly map different
                                             key reasons to seek consultation and treatment. Gynaecol-             types of cancer according to age.
                                             ogy practices also billed some typical GP diagnoses, such                 Representative studies by the Federal Centre for Health
                                             as hypertension and obesity. GPs, however, very rarely diag-          Education (BZgA) on use of contraception showed that in
                                             nose gynaecology-related conditions.                                  Germany in 2018, 39% of 40- to 49-year-old women took
                                                 Prevalence estimates that could be compared to DEGS1              the pill, 34% used condoms and 20% a contraceptive coil
                                             data are rare. According to international studies, the aver-          (2011: 34%, 26% and 13%, respectively) [20]. One in two
                                             age age for the onset of menopause is around 51 years [22,            women that used some kind of contraception stated that
                                             23]. Data from the Techniker Krankenkasse (TK) health                  questions on contraception had led to an appointment in
                                             insurance on menopausal hormone therapy shows that in                 gynaecology practices [20]. The study did not examine con-
                                             2017, 6.6% of the 45- to 65-year-old women covered by the             traceptive behaviour of women aged 50 years and older.

    Journal of Health Monitoring 2020 5(2)                                                                                                                              9
Journal of Health Monitoring    Reasons for women aged 50 years and older to seek gynaecological advice and treatment                                               FOCUS

                                         BZgA studies show gynaecologists to be important contact               women should seek treatment (in the sense of a medical-
                                         persons for women’s health-related questions, yet the                  isation of life phases [32]), but should, rather, contribute
                                         (potential) reasons to seek consultation and treatment in              to ensuring that middle-aged and older women also receive
                                         gynaecology practices can obviously only represent a pro-              adequate care, for example regarding cancer screening
                                         portion of all female health concerns. Due to be published             examinations. Against this backdrop, we should mention
                                         this year, the women’s health report of Federal Health                 two further findings: the decreasing number of women who
                                         Reporting will contain a comprehensive overview of the                 seek appointments with gynaecologists with age – around
                                         diverse aspects of women’s health [29].                                80% of 18- to 29-year-olds, but only 60% of 50- to 79-year-
                                             Both survey and claims data have their limitations. While          old women have at least one appointment per year in a
                                         DEGS1 is generally representative for the German popula-               gynaecology practice – as well as the increasing number of
                                         tion, the survey tends to underrepresent people living in              older women due to demographic ageing and the frequently
                                         institutions, as well as older and less healthy people, an             higher average age found in rural regions [33, 34]. When
                                         aspect which an analysis concerned with middle-aged and                planning care, it is important to consider that the screen-
                                         older women should take into account. Health conditions                ing programmes for the ealy detection of breast cancer
                                         are self-reported in the survey, which could lead to a certain         and – since January 2020 – cervical cancer have an influ-
                                         level of recall bias. Events such as a hysterectomy, however,          ence on the use of gynaecological services, as have the
                                         are remembered with a high degree of reliability [30]. In addi-        decreasing number of women who use hormone therapy
                                         tion, DEGS1 did not ask women whether health problems                  during menopause [24] and the declining number of hys-
                                         actually led them to seek outpatient gynaecology services. A           terectomies [35]. Reasons for seeking gynaecological ser-
                                         strength of claims data is the large sample size and that it           vices from the perspective of women themselves were
                                         comprises all women covered by statutory health insurance.             analysed by the project ‘Frauen 5.0’, as were concepts to
                                         However, the data is collected for billing purposes, and it is         ensure that women in the 50 years and older age group
                                         therefore impossible to directly deduce the prevalences for            receive adequate gynaecological services, in particular in
                                         particular conditions in the population. Moreover, since the           sparsely populated rural regions, and regional models that
                                         introduction of lump sum payment in 2008, data is only                 include the relevant actors were developed [1].
                                         available for cases per quarter and practice [31].
                                             Women are in the reproductive phase for less than half                                                          Corresponding author
                                         of their entire lifespan. A perception of women’s health as                                                               Dr Laura Krause
                                         being primarily reproductive health does not do justice to                                                           Robert Koch Institute
                                                                                                                                 Department of Epidemiology and Health Monitoring
                                         this fact and veils the consultation and treatment needs of
                                                                                                                                                          General-Pape-Str. 62–66
                                         women aged 50 years and older. Taking these needs into                                                              12101 Berlin, Germany
                                         account does not imply postulating new reasons why                                                                E-mail: KrauseL@rki.de

Journal of Health Monitoring 2020 5(2)                                                                                                                                  10
Journal of Health Monitoring    Reasons for women aged 50 years and older to seek gynaecological advice and treatment                                                   FOCUS

                                                                                Please cite this publication as   References
                                                                             Krause L, Dini L, Prütz F (2020)     1.   Charité – Universitätsmedizin Berlin (Ed) (2020) Frauen 5.0 –
                                                                 Reasons for women aged 50 years and older             Executive Summary: Regionale Versorgung von Frauen 50+ durch
                                                                 to seek gynaecological advice and treatment.          Fachärztinnen und Fachärzte für Allgemeinmedizin und Gynäko-
                                                                      Journal of Health Monitoring 5(2): 3–14.         logie.
                                                                                                                       https://allgemeinmedizin.charite.de/fileadmin/user_upload/
                                                                                          DOI 10.25646/6065            microsites/m_cc01/allgmed/DOCS/Executive_Summary_
                                                                                                                       Frauen50_Printed.pdf (As at 26.03.2020)
                                         The German version of the article is available at:                       2.   Maschewsky-Schneider U, Hellbernd H, Schaal W et al. (2001)
                                                                                                                       Über-, Unter-, Fehlversorgung und Frauengesundheit. Ein For-
                                         www.rki.de/journalhealthmonitoring                                            schungsgegenstand für Public Health. Bundesgesundheitsbl
                                                                                                                       44(8):771–779
                                         Data protection and ethics                                               3.   Kreienberg R, Digel S (2005) Krebsvorsorgeuntersuchungen bei
                                                                                                                       älteren Patientinnen. Der Gynäkologe 38(12):1074–1079
                                         DEGS1 is subject to strict compliance with the data protec-
                                         tion regulations of the Federal Data Protection Act and has              4.   Bundesministerium für Familie, Senioren, Frauen und Jugend
                                                                                                                       (1999) Bericht zur gesundheitlichen Situation von Frauen in
                                         been approved by the Federal Commissioner for Data Pro-                       Deutschland. Eine Bestandsaufnahme unter Berücksichtigung
                                         tection and Freedom of Information in Germany. Charité                        der unterschiedlichen Entwicklung in West- und Ostdeutschland.
                                                                                                                       https://www.bmfsfj.de/blob/94878/0d550875836e1adc15c12e20e-
                                         – Universitätsmedizin Berlin’s ethics committee assessed                      9a92e54/prm-24001-umschlag-sr-band-209-data.pdf
                                         the ethics of the DEGS1 study and provided its approval                       (As at 20.04.2020)

                                         (No.EA2/047/08). Participation in DEGS1 was voluntary.                   5.   Kolip P, Hurrelmann K (2016) Handbuch Geschlecht und
                                                                                                                       Gesundheit. Männer und Frauen im Vergleich. 2., vollständig
                                         The participants were informed about the aims and con-                        überarbeitete und erweiterte Auflage. Hogrefe Verlag, Bern
                                         tents of the study and about data protection. Informed                   6.   Berufsverband der Frauenärzte e.V. (Ed) (no date) Körperliche
                                         consent was obtained in writing.                                              Veränderungen.
                                                                                                                       https://www.frauenaerzte-im-netz.de/de_koerperliche-veraende-
                                                                                                                       rungen-die-veraenderungen-im-einzelnen_256.html
                                         Funding                                                                       (As at 08.02.2018)
                                         DEGS1 was funded by the Robert Koch Institute and the                    7.   Farquhar CM, Sadler L, Harvey SA et al. (2005) The association
                                                                                                                       of hysterectomy and menopause: a prospective cohort study.
                                         Federal Ministry of Health.                                                   BJOG 112(7):956–962
                                            The project ‘Regionale Versorgung von Frauen über 49                  8.   Prütz F, Knopf H, von der Lippe E et al. (2013) Prävalenz von
                                         Jahre durch Fachärztinnen und Fachärzte für Gynäkologie                       Hysterektomien bei Frauen im Alter von 18 bis 79 Jahren: Ergeb-
                                                                                                                       nisse der Studie zur Gesundheit Erwachsener in Deutschland
                                         und für Allgemeinmedizin (Frauen 5.0)’ received funding                       (DEGS1). Bundesgesundheitsbl 56(5/6):716–722
                                         from the Innovation Fund of the Federal Joint Committee
                                                                                                                  9.   Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen
                                         (funding code: 01VSF16030).                                                   Fachgesellschaften e.V. (AWMF) (2015) Indikation und Methodik
                                                                                                                       der Hysterektomie bei benignen Erkrankungen. Registernummer
                                                                                                                       015 - 070.
                                         Conflicts of interest                                                         http://www.awmf.org/leitlinien/detail/ll/015-070.html
                                         The authors declared no conflicts of interest.                                (As at 08.02.2018)

Journal of Health Monitoring 2020 5(2)                                                                                                                                      11
Journal of Health Monitoring    Reasons for women aged 50 years and older to seek gynaecological advice and treatment                                                  FOCUS

                                         10. Berufsverband der Frauenärzte e.V. (no date) Krebsfrüherken-       19. Bundeszentrale für gesundheitliche Aufklärung (2019) Verhütung
                                             nung in der Krankenversicherung.                                       in der Lebensmitte.
                                             https://www.frauenaerzte-im-netz.de/frauengesundheit/krebs-            https://www.familienplanung.de/verhuetung/wechseljahre/
                                             frueherkennung-kfu/kfu-in-der-krankenversicherung/                     (As at 30.03.2020)
                                             (As at 01.04.2019)                                                 20. Bundeszentrale für gesundheitliche Aufklärung (Ed) (2020) Ver-
                                         11. Gemeinsamer Bundesausschuss (G-BA) (2020) Richtlinie des               hütungsverhalten Erwachsener – Ergebnisse der Repräsentativ-
                                             Gemeinsamen Bundesausschusses über die Früherkennung von               befragung 2018. BZgA, Köln
                                             Krebserkrankungen, (Krebsfrüherkennungs-Richtlinie/KFE-RL).        21. Zentralinstitut für die kassenärztliche Versorgung in Deutschland
                                             https://www.g-ba.de/downloads/62-492-2002/KFE-RL_2019-                 (2016) Behandlungsfallzahlen von Frauen für die Fachgruppen
                                             12-05_iK-2020-01-01.pdf (As at 25.05.2020)                             Allgemeinmedizin und Gynäkologie 2016, bundesweit. Sonder-
                                         12. Deutsches Krebsforschungszentrum (dkfz) (2017) Brustkrebs.             auswertung. Zi, Berlin
                                             https://www.krebsinformationsdienst.de/tumorarten/brust-           22. Sapre S, Thakur R (2014) Lifestyle and dietary factors determine
                                             krebs/frueherkennung.php (As at 01.04.2019)                            age at natural menopause. J Midlife Health 5(1):3–5
                                         13. Gemeinsamer Bundesausschuss (G-BA) (2016) Geförderte Pro-          23. Schoenaker DA, Jackson CA, Rowlands JV et al. (2014) Socioeco-
                                             jekte des Innovationsausschusses zur Förderbekanntmachung              nomic position, lifestyle factors and age at natural menopause: a
                                             Versorgungsforschung vom 8. April 2016.                                systematic review and meta-analyses of studies across six conti-
                                             https://innovationsfonds.g-ba.de/downloads/media/50/Versor-            nents. Int J Epidemiol 43(5):1542–1562
                                             gungsforschung-Uebersicht-gefoerderte-Projekte-2016.pdf            24. No author (2018) Weniger Hormonpräparate gegen Wechseljah-
                                             (As at 07.06.2019)                                                     resbeschwerden verordnet.
                                         14. Kamtsiuris P, Lange M, Hoffmann R et al. (2013) The first wave         https://www.aerzteblatt.de/nachrichten/96654/Weniger-
                                             of the German Health Interview and Examination Survey for              Hormonpraeparate-gegen-Wechseljahrsbeschwerden-verordnet
                                             Adults (DEGS1). Sampling design, response, weighting, and              (As at 30.03.2020)
                                             representativeness. Bundesgesundheitsbl 56(5/6):620–630            25. Barber MD (2016) Pelvic organ prolapse. BMJ 354:i3853
                                         15. Gößwald A, Lange M, Dölle R et al. (2013) The first wave of the    26. Hendrix SL, Clark A, Nygaard I et al. (2002) Pelvic organ pro-
                                             German Health Interview and Examination Survey for Adults              lapse in the Women’s Health Initiative: gravity and gravidity. Am
                                             (DEGS1). Recruitment of participants, fieldwork, and quality           J Obstet Gyneco 186(6):1160–1166
                                             assurance. Bundesgesundheitsbl 56(5/6):611–619
                                                                                                                27. Samuelsson EC, Victor FT, Tibblin G et al. (1999) Signs of genital
                                         16. Heuer J (2016) Die 50 häufigsten ICD-10-Schlüsselnummern               prolapse in a Swedish population of women 20 to 59 years of age
                                             nach Fachgruppen aus dem ADT-Panel des Zentralinstituts, Jahr          and possible related factors. Am J Obstet Gyneco 180(2 Pt 1):
                                             2015. Zentralinstitut für die Kassenärztliche Versorgung in            299–305
                                             Deutschland (Zi).
                                                                                                                28. Robert Koch-Institut (Ed) und die Gesellschaft der epidemiologi-
                                             https://www.zi.de/projekte/adt-panel/ (As at 24.09.2018)               schen Krebsregister in Deutschland e.V. (Ed) (2019) Krebs in
                                         17. von der Lippe E, Prütz F (2016) Age at natural menopause:              Deutschland für 2015/2016. 12. Ausgabe. RKI, Berlin
                                             Results from the German Health Interview and Examination           29. Bundesministerium für Gesundheit (BMG) (2017) Robert
                                             Survey. Eur J Public Health 26(Suppl 1):301–302                        Koch-Institut erstellt neuen Frauengesundheitsbericht. Presse-
                                         18. Deutsche Gesellschaft für Gynäkologie und Geburtshilfe (DGGG),         mitteilung.
                                             Österreichische Gesellschaft für Gynäkologie und Geburtshilfe          https://www.bundesgesundheitsministerium.de/presse/presse-
                                             (OEGGG), Schweizerische Gesellschaft für Gynäkologie und               mitteilungen/2017/1-quartal/beauftragung-rki-frauengesund-
                                             Geburtshilfe (SGGG) (2019) Hormonelle Empfängnisverhütung              heitsbericht.html (As at 26.05.2020)
                                             (S3-Leitlinie, AWMF-Registernummer 015/015)                        30. Brett KM, Madans JH (1994) Hysterectomy use: the correspon­
                                             https://www.awmf.org/leitlinien/detail/ll/015-015.html                 dence between self-reports and hospital records. Am J Public
                                             (As at 30.03.2020)                                                     Health 84(10):1653–1655

Journal of Health Monitoring 2020 5(2)                                                                                                                                     12
Journal of Health Monitoring    Reasons for women aged 50 years and older to seek gynaecological advice and treatment        FOCUS

                                         31. Ohlmeier C, Frick J, Prütz F et al. (2014) Nutzungsmöglichkeiten
                                             von Routinedaten der Gesetzlichen Krankenversicherung in der
                                             Gesundheitsberichterstattung des Bundes. Bundesgesundheitsbl
                                             57(4):464–472
                                         32. Kolip P (Ed) (2000) Weiblichkeit ist keine Krankheit. Die Medika-
                                             lisierung körperlicher Umbruchphasen im Leben von Frauen.
                                             Juventa, Weinheim und München
                                         33. Krause L, Prütz F (2020) Gynaecology and general practitioner
                                             services utilisation by women in the age group 50 years and older.
                                             Journal of Health Monitoring 5(2):15–25.
                                             www.rki.de/journalhealthmonitoring-en (As at 30.06.2020)
                                         34. Nowossadeck E, Prütz F, Thißen M (2020) Demographics of the
                                             female population aged 50 years and older in Germany’s north east
                                             region – Selected aspects. Journal of Health Monitoring 5(2):35–41.
                                             www.rki.de/journalhealthmonitoring-en (As at 30.06.2020)
                                         35. Statistisches Bundesamt (2017) Fallpauschalenbezogene Kranken-
                                             hausstatistik (DRG-Statistik). Operationen und Prozeduren der
                                             vollstationären Patientinnen und Patienten in Krankenhäusern.
                                             www.gbe-bund.de (As at 17.09.2019)

Journal of Health Monitoring 2020 5(2)                                                                                           13
Journal of Health Monitoring    Reasons for women aged 50 years and older to seek gynaecological advice and treatment        FOCUS

                                         Imprint

                                         Journal of Health Monitoring

                                         Publisher
                                         Robert Koch Institute
                                         Nordufer 20
                                         13353 Berlin, Germany

                                         Editors
                                         Johanna Gutsche, Dr Birte Hintzpeter, Dr Franziska Prütz,
                                         Dr Martina Rabenberg, Dr Alexander Rommel, Dr Livia Ryl,
                                         Dr Anke-Christine Saß, Stefanie Seeling, Martin Thißen,
                                         Dr Thomas Ziese
                                         Robert Koch Institute
                                         Department of Epidemiology and Health Monitoring
                                         Unit: Health Reporting
                                         General-Pape-Str. 62–66
                                         12101 Berlin, Germany
                                         Phone: +49 (0)30-18 754-3400
                                         E-mail: healthmonitoring@rki.de
                                         www.rki.de/journalhealthmonitoring-en

                                         Typesetting
                                         Gisela Dugnus, Kerstin Möllerke, Alexander Krönke

                                         Translation
                                         Simon Phillips/Tim Jack

                                         ISSN 2511-2708

                                         Note
                                         External contributions do not necessarily reflect the opinions of the
                                         Robert Koch Institute.

        This work is licensed under a
   Creative Commons Attribution 4.0              The Robert Koch Institute is a Federal Institute within
               International License.            the portfolio of the German Federal Ministry of Health

Journal of Health Monitoring 2020 5(2)                                                                                           14
Journal of Health Monitoring   Gynaecology and general practitioner services utilisation by women in the age group 50 years and older                         FOCUS

Journal of Health Monitoring · 2020 5(2)
DOI 10.25646/6808
                                                       Gynaecology and general practitioner services utilisation by
Robert Koch Institute, Berlin
                                                       women in the age group 50 years and older
Laura Krause 1, Lorena Dini 2,
Franziska Prütz 1                                      Abstract
                                                       There are relatively few representative data on the utilisation of physician services in Germany and its influencing. Based
1
  Robert Koch Institute, Berlin                        on data from the German Health Interview and Examination Survey for Adults (DEGS1, 2008–2011), we analyse the
  Department of Epidemiology and
                                                       utilisation of gynaecology and general practitioner (GP) services, with a focus on women aged 50 years and older. We
  Health Monitoring
2
  Charité – Universitätsmedizin Berlin
                                                       compare these findings with data from the German National Health Interview and Examination Survey 1998 (GNHIES98)
  Institute of General Practice                        and, based on this and further data, discuss possible developments. Figures for seeking GP services (over 80%) are
                                                       constantly high across the entire lifespan, whereas figures for gynaecology services drop with age. Around 60% of women
Submitted: 03.04.2020                                  aged 50 years and older go to a gynaecological practice at least once a year. Socioeconomic status and place of residence
Accepted: 22.06.2020
                                                       are important determinants for the utilisation of services. Around half of all women aged 50 years and older sought both
Published: 30.06.2020
                                                       gynaecology and GP services at least once over a one-year period. Under 10% had only been to a gynaecologist, and
                                                       around one third sought GP services only. Compared to GNHIES98, figures for GP and gynaecology services were
                                                       considerably higher in DEGS1, health insurance data, however, shows no increase in the use of gynaecology services
                                                       between 2008 and 2018. The results highlight the need to increase awareness among GPs of the needs of middle-aged
                                                       and older women for gynaecological consultation and treatment.

                                                          UTILISATION · GYNAECOLOGY · GENERAL PRACTITIONER · GP · WOMEN · GERMANY · DEGS1

                                                       1. Introduction                                                          women the relevant issues differ from those of women
                                                                                                                                still at reproductive age [5] and will be focused more on
                                                       Outpatient care in Germany is mainly provided by spe-                    cancer screening, menopause, uterine prolapse and
                                                       cialists in private practice [1].Generally, the use of outpa-            incontinence [6–8]. In particular, the importance of can-
                                                       tient medical services is higher in women than in men                    cer screening increases: while a majority of women under-
                                                       [2, 3]. These differences by sex are most pronounced at                  go mammography and cervical cancer screening, uptake
                                                       a younger age. This is very likely due to, at least in part,             still decreases with age [9]. A Focus article in this issue
                                                       the utilisation of gynaecological and obstetric services                 of the Journal of Health Monitoring analyses the Reasons
                                                       [3, 4]. However, adequate gynaecological care is impor-                  for women aged 50 years and older to seek gynaecolog-
                                                       tant at every stage in life; for middle-aged and older                   ical advice and treatment.

          Journal of Health Monitoring 2020 5(2)                                                                                                                                 15
Journal of Health Monitoring       Gynaecology and general practitioner services utilisation by women in the age group 50 years and older                          FOCUS

                                                             Socioeconomic status (SES) and place of residence are                    Medical needs and the increasing number of older
DEGS1                                                    important determinants for the utilisation of medical care               women make it extremely important to ensure adequate
Data holder: Robert Koch Institute                       [2, 3, 10–15]. People in the low SES group more frequently               gynaecological care also for this population group. The
Objectives: To provide reliable information about the    seek general practitioner (GP) services, while those in the              impact of these demographic developments is twofold –
population’s health status, health-related behaviour     high SES group tend to visit medical specialists more often.             both the population and doctors are ageing [19]. The effect
and health care in Germany including analysis of
temporal developments and trends.
                                                         People in cities see specialist physicians more often than               is particularly notorious in rural regions, where ever fewer
                                                         those in rural regions, and people in rural regions more                 doctors attend to the needs of a growing number of older
Survey method: Questionnaires, physical examina-
tions and tests, a physician interview, a medication     often GPs [2, 12].                                                       people. A Fact Sheet in this issue of the Journal of Health
interview and laboratory investigations (blood and           Regional differences also exist regarding the availability           Monitoring describes the demographic developments for
urine sample).
                                                         of outpatient medical care [1]. The concentration of GPs and             women aged 50 years and older in Berlin, Brandenburg and
Population: German resident population, aged 18
and above
                                                         medical specialists is greater for urban than for rural areas.           Mecklenburg-Western Pomerania.
                                                         In Germany, the Associations of Statutory Health Insurance                   Funded by the Innovation Fund of the Federal Joint Com-
Sampling: Registry office sample; randomly selected
individuals from 180 communities in Germany were         Physicians (KVen) have to ensure that everybody has access               mittee (G-BA), the project ‘Frauen 5.0’ (Regionale Ver-
invited to participate (120 original sample points of    to adequate levels of health care services in close proximity            sorgung von Frauen über 49 Jahre durch Fachärztinnen
the German National Health Interview and Examina-
tion Survey 1998 and 60 new sample points).              to where they live [16]. Need related planning is used as an             und Fachärzte für Gynäkologie und für Allgemeinmedizin
Participants: N=8,151 (4,283 women; 3,868 men). The      instrument to categorise types of doctors into different lev-            [20]) has therefore assessed gynaecology and GP services
sample included persons who were newly recruited         els of care (for example GP care, general medical specialist             for women aged 50 years and older in the north east region
and those who had already participated in the Ger-
man National Health Interview and Examination Sur-       care) with planning regions of different sizes. GP services              (Berlin, Brandenburg and Mecklenburg-Western Pomera-
vey 1998 (mixed design).                                 are planned at the smallest scale. For general medical spe-              nia). The project aimed to gain an overview of actual levels
Response rate: 62% among revisiting participants         cialist care, the level that includes gynaecologists, districts          of care provided, and, based on this, develop concepts for
and 42% first time participants                          and district free towns are the basic unit of planning, taking           adequate outpatient gynaecology services to this popula-
Survey period: 2008 to 2011                              surrounding areas into account too. Need related planning                tion group.
Data protection: DEGS1 is subject to strict compliance   can be adapted according to regional conditions, for exam-                  This overview included a general analysis of the utilisa-
with the data protection regulations of the Federal      ple, with regard to demographic factors. Regions with a                  tion of gynaecology and GP services by women focused
Data Protection Act and has been approved by the
Federal Commissioner for Data Protection and Free-       higher proportion of older women, for example, are assumed               on the age group 50 years and older, which is in the cen-
dom of Information in Germany. Charité – Univer­         to require fewer gynaecologists [16]. In 2019, in Oberspree-             tre of this paper. Gynaecology services for this group are
sitätsmedizin Berlin’s ethics committee assessed the
ethics of the DEGS1 study and provided its approval      wald-Lausitz, a district in the state of Brandenburg with a              rarely the focus of such analyses. As we do not have any
(No.EA2/047/08). Participation in DEGS1 was volun-       high proportion of women aged 50 years and older (58%),                  more up-to-date population representative data on the
tary. The participants were informed about the aims
and contents of the studies and about data protection.   for example, there were nine gynaecologists per 100,000                  utilisation of specialist medical services from Robert Koch
Informed consent was obtained in writing.                people [17, 18]. In the district free town of Potsdam, where             Institute (RKI) health monitoring, we have opted to take
More information in German is available at               the proportion of women aged 50 years and older is smaller               the following approach: based on data from the German
www.degs-studie.de
                                                         (41%), there were 24.5 gynaecologists per 100,000 people.                Health Interview and Examination Survey for Adults

          Journal of Health Monitoring 2020 5(2)                                                                                                                                    16
Journal of Health Monitoring    Gynaecology and general practitioner services utilisation by women in the age group 50 years and older                            FOCUS

                                         (DEGS1, 2008–2011), we illustrate the utilisation of gynae-                 In addition to sex and age, DEGS1 also surveyed the
                                         cology and GP services by women throughout their life-                   sociodemographic variables SES and place of residence.
                                         time. For women aged 50 years and older, we will also                    SES was determined by applying a multidimensional index
                                         analyse the utilisation according to SES and place of res-               comprising data on education and occupational training,
                                         idence, as well as the correlations between the use of                   occupational status and net household income (needs-
                                         gynaecology and GP services. To evaluate trends, we will                 weighted). Based on this, participants were subdivided into
                                         discuss utilisation data from DEGS1 by comparing it to                   low, medium and high SES groups [23]. As regards place
                                         the figures reported in the precursor German National                    of residence, rural and urban environments are divided
                                         Health Interview and Examination Survey 1998 (GNHIES98).                 into four subcategories: rural (100,000
                                         screening uptake data.                                                   inhabitants) [2].

                                         2. Methodology                                                           2.2 Statistical methods
                                         2.1 Sample design and study implementation
                                                                                                                  Based on DEGS1 data, the 12-month prevalence for the uti-
                                         With DEGS1 the RKI has collected representative health                   lisation of gynaecology and GP services by 18- to 79-year-
                                         data for the 18- to 79-year old German adult population.                 old women (n=4,283) was analysed over the course of age.
                                         The study programme included interviews, physical exam-                  Then, the utilisation of gynaecology and GP services by
                                         inations and tests. 8,151 people took part. A description of             women in the age group 50 years and older was mapped,
                                         the concept and design of DEGS1 has previously been pro-                 and differences by SES and place of residence were report-
                                         vided [21, 22].                                                          ed (n=2,287). Regarding indicators on utilisation, preva-
                                            In addition to health status and health behaviour, a focus            lences and the results of multivariate binary logistic regres-
                                         was on the utilisation of health services. In this category,             sion were calculated, as were average values and linear
                                         DEGS1 asked about the use of medical specialists from dif-               regression results for indicators of contact frequency.
                                         ferent disciplines. Participants were asked how often during             Regression analysis were adjusted for age (categorical),
                                         the last twelve months they had seen a resident physician                SES and place of residence. A statistically significant differ-
                                         (12-month prevalence of utilisation). They could also report             ence between groups is assumed for corresponding p-val-
                                         how many times they had contacted physicians (12-month                   ues below 0.05. Cross table analysis between the uptake of
                                         prevalence of contact frequency). Gynaecology and GP ser-                gynaecology and GP services were then conducted in a final
                                         vices were among the 13 specialisations participants could               step and tested for correlations between the two variables
                                         choose from [2].                                                         by applying Pearson chi square tests.

Journal of Health Monitoring 2020 5(2)                                                                                                                                17
Journal of Health Monitoring     Gynaecology and general practitioner services utilisation by women in the age group 50 years and older                                    FOCUS

                                           Figure 1       DEGS1 calculations were carried out using a weighting                 90
                                                                                                                                     Proportion (%)
       12-month prevalence of the utilisation of       factor that corrects deviations within the sample from the
gynaecology and general practitioner services by                                                                                80
                                                       population structure (as at 31 December 2010) with regard
  18- to 79-year-old women over time (n=4,238)                                                                                  70
                                                       to age, sex, region, German citizenship, district type and
Source: Modified according to Rattay et al. 2013 [2]
                                                       education [21]. All analyses were conducted with Stata 15.1              60
                                                       (Stata Corp., College Station, TX, USA, 2017) using the                  50
                                                       DEGS1 data set (Version 18). Stata survey commands were
                                                                                                                                40
                                                       used in all analyses to account for the clustering of partici­
                                                       pants at examination locations, weighting was used in the                30
                                                       calculation of confidence intervals and p-values [24].                   20

                                                                                                                                10
   Utilisation of gynaecology                          3. Results
   services by women decreases                                                                                                        18 – 29    30 – 39    40– 49       50 – 59   60 – 69     70 – 79
                                                       Around 80% of women across all age groups take up GP                                                                            Age group (years)
   with age, figures for GP                            services within one year (Figure 1). For the use of gynae-                        General medicine            Gynaecology
   services are constantly high                        cology services, in contrast, 12-month prevalence decreas-
   across all age groups.                              es with age, in particular for older age groups: while around            annual utilisation of gynaecology services than women in
                                                       three quarters of 40- to 49-year-old women visited a gynae-              higher status groups. In contrast, women from the high
                                                       cology practice during the 12-month period before the sur-               SES group most seldom see a GP. Socioeconomic differ-
                                                       vey (75.4%), in the 50- to 59-year-old age group this figure             ences are also evident for the 12-month prevalence of con-
                                                       drops to just over two thirds (68.7%). Over the entire                   tact frequency: women in the low and medium SES groups
                                                       lifespan, the 12-month prevalence for the utilisation of                 with 5.5 and 4.8 contacts respectively, saw GPs more often
                                                       gynaecology services almost halves, from 80.4% to 44.2%                  than women with high SES (3.6 contacts).
                                                       for 18- to 29-year-old and 70- to 79-year-old women, respec-                 For the utilisation of GP services by 50- to 79-year-old
                                                       tively.                                                                  women, we can see differences in relation to place of res-
                                                           59.4% of the 50- to 79-year-old women have visited a                 idence (Table 1) – figures are lower for women living in
                                                       gynaecologist at least once within the past year. On aver-               large cities than for those from rural areas. Overall, the
                                                       age, 1.5 contacts were made. 82.6% of women of this age                  statistical probability that a woman will have had at least
                                                       group consulted a GP at least once a year, with an average               one appointment with a GP during the last year is 2.5 times
                                                       4.8 contacts made per year.                                              higher for women living in rural areas. While we found no
                                                           Table 1 shows utilisation for 50- to 79-year-old women               differences in relation to place of residence for the 12-month
                                                       according to SES: women in the low SES group show lower                  prevalence of gynaecology services utilsation, they were

           Journal of Health Monitoring 2020 5(2)                                                                                                                                           18
Journal of Health Monitoring    Gynaecology and general practitioner services utilisation by women in the age group 50 years and older                                       FOCUS

                                         Table 1                                                        Utilisation of gynaecology services              Utilisation of general practitioner services
     12-month prevalence for the utilisation of                                           %        (95% CI)     OR       (95% CI) p-value          %      (95% CI)       OR       (95% CI) p-value
gynaecology and general practitioner services       Socioeconomic status
   by 50- to 79-year-old women and results of        Low                               47.1     (41.1–53.1)        0.56    (0.37–0.84)    0.005   81.8   (75.8–86.6)   1.22    (0.82–1.82)       0.317
multivariate binary logistic regression analysis     Medium                            61.8     (58.5–65.0)        0.88    (0.65–1.20)    0.428   84.7   (82.4–86.8)   1.63    (1.19–2.23)       0.003
   (odds ratios) by socioeconomic status and         High                              68.0     (62.3–73.2)         Ref.           Ref.       –   75.7   (70.4–80.3)    Ref.           Ref.          –
                   place of residence (n=2,287)     Place of residence
                   Source: DEGS1 (2008–2011)         Rural                             55.6     (49.7–61.3)        0.79    (0.57–1.11)    0.175   89.6   (85.9–92.4)   2.46    (1.55–3.91) < 0.001
                                                     Small towns                       56.4     (52.0–60.7)        0.78    (0.59–1.03)    0.076   82.4   (77.7–86.2)   1.29    (0.87–1.92)   0.208
                                                     Medium-sized towns                60.6     (55.8–65.2)        0.87    (0.66–1.15)    0.327   83.1   (80.0–85.8)   1.36    (0.96–1.91)   0.082
                                                     Large cities                      62.8     (58.0–67.3)         Ref.           Ref.       –   78.3   (73.3–82.6)    Ref.           Ref.      –
                                                    CI=Confidence intervals, OR=Odds ratio, Ref.=Reference group

 A considerable decrease in
                                                   found for contact frequency: whereas women in rural areas                       once per year (utilisation across all age groups is 69.6%)
 the utilisation of gynaecology
                                                   on average visited a gynaecologist 1.3 times per year, the                      [2]. Analyses of the Study of Health in Pomerania (SHIP)
 services is observed for                          figure was 1.8 for women in large cities.                                       for the region Western Pomerania provide similar results
 women in the 50- to 59-year                           Cross-table analysis reveals a correlation between the                      [25]: utilisation of gynaecology services decreases from
 age group.                                        12-month prevalence for the utilisation of gynaecology and                      86.3% to 36.6% for 20- to 29-year olds and women aged
                                                   GP services (p
Journal of Health Monitoring    Gynaecology and general practitioner services utilisation by women in the age group 50 years and older                          FOCUS

                                             and that people in this group also less frequently use pre-              which analyses the utilisation of outpatient services. In
                                             vention-oriented services as early detection and screening               2008, 26.6% of the population took up gynaecology ser-
                                             examinations [2, 30].                                                    vices [32], in 2018 25.0 % [33]. In the case of utilisation,
                                                 Differences in the utilisation of GP and specialist med-             therefore, no important developments were found, these
                                             ical services by the German population found between                     figures were, however, not differentiated by age groups.
                                             urban and rural areas [2, 12] are in part reflected in the               Due to the different data basis and methodology (such
                                             group of women aged 50 years and older: compared to                      as including men in the calculations) a comparison with
                                             women in large cities, women in rural areas more frequently              the DEGS1 data is not possible. Data on the utilisation of
                                             seek GP services, with no differences between urban and                  cancer screening examinations provides further indica-
                                             rural areas found for the utilisation of gynaecology services.           tions of more recent developments. The current wave of
                                             The study by Stentzel et al. [31] confirms this finding, show-           the German Health Update (GEDA 2014/2015-EHIS) study
Around one third of women                    ing that even when gynaecologists are hard to reach, this                of the Robert Koch Institute reported that 53.1% of women
                                             does not impact the use of services. According to DEGS1                  aged 20 years and older had a screening examination for
aged 50 years and older
                                             data, women in rural regions report having made less con-                cervical cancer (pap smear) during the last twelve months.
had an appointment with a                    tact with gynaecology practices within the last year than                The proportion was highest for 30- to 34-year-old women
GP only and not with a                       women in large cities. These results call for further anal­              (67.9%). Of 60- to 64-year-olds, fewer than half (49.0%)
gynaecologist.                               ysis of differences in the utilisation of gynaecology services           had this examination, in the age group 70 years and older
                                             also with regard to the actually available services.                     less than a third (29.7%) [9]. Analyses of data from the
                                                 From GNHIES98 to DEGS1, the use of GP services by                    German Mammography Screening Programme show that
                                             women has increased considerably across all age groups                   49% of women who were invited to the Mammography
                                             [2]. When observed as a whole, utilisation of GP services                Screening Programme did take part in 2017. From 2008
                                             has increased by 10% between the two surveys, from                       to 2013, participation rates by invited women increased,
                                             70.9% to 79.4%. An increase in utilisation has also been                 but have been decreasing since 2014. An increase in par-
                                             registered for gynaecology services. This increase is                    ticipation rates was only observed for women who had
                                             mainly owing to older age groups: for the 60- to 69-year-                already previously taken part in screening and had been
                                             old age group, use of gynaecology services has increased                 invited again [34]. Mammography screening does not take
                                             by 18%, from 44% in GNHIES98 to 62% in DEGS1, in the                     place in gynaecology practices. However, this could be an
                                             70- to 79-year-old age group there has even been a 24%                   opportunity to seek consultation in a gynaecology prac-
                                             increase from 21% to 45%, respectively [2]. Health insur-                tice. Further reasons for consultation and treatment that
                                             ance claims data can help estimate whether the utilisa-                  play a role for women aged 50 years and older beyond
                                             tion of services has continued to increase since. Every                  cancer early detection are discussed in a second Focus
                                             year, the BARMER health insurance provides a report                      article in this issue of the Journal of Health Monitoring.

    Journal of Health Monitoring 2020 5(2)                                                                                                                              20
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