Background: New technology-based dietary assessment tools, including Web-based programs, mobile applications, and wearable devices, may improve accuracy and reduce costs of dietary data collection and processing. The International Life Sciences Institute (ILSI) Europe Dietary Intake and Exposure Task Force launched this project to evaluate new tools in order to recommend general quality standards for future applications. Methods: A comprehensive literature search identified technology-based dietary assessment tools, including those published in English from 01/2011 to 09/2017, and providing details on tool features, functions and uses. Each of the 43 tools identified (33 for research and 10 designed for consumer use) was rated on 25 attributes. Results: Most of the tools identified (79%) relied on self-reported dietary intakes. Most (91%) used text entry and 33% used digital images to help identify foods. Only 65% had integrated databases for estimating energy or nutrients. Fewer than 50% contained any features of customization and about half generated automatic reports. Most tools reported on usability or reported validity compared with another assessment method (77%). A set of Best Practice Guidelines was developed for reporting dietary assessment tools using new technology. Conclusions: Dietary assessment methods that utilize technology offer many advantages for research and are often preferable to consumers over more traditional methods. In order to meet general quality standards, new technology tools require detailed publications describing tool development, food identification and quantification, customization, outputs, food composition tables used, and usability/validity testing.

Evaluation of New Technology-Based Tools for Dietary Intake Assessment—An ILSI Europe Dietary Intake and Exposure Task Force Evaluation

Accuracy in quantifying energy intake (EI) using common dietary assessment methods is crucial for interpreting the relationship between diet and chronic disease. The aim of this systematic review was to evaluate the validity of dietary assessment methods used to estimate the EI of adults in comparison to total energy expenditure (TEE) measured by doubly labeled water (DLW). Articles in English across nine electronic databases, published between 1973 and February 2019 were retrieved. Studies were included if participants were adults (≥18 years) and used the DLW technique to measure TEE compared to self-reported EI. A total of 59 studies were included, with a total of 6,298 free living adults and a mean of 107 participants per study. The majority of studies including 16 studies that included a technology based method reported significant (P < 0.05) under-reporting of EI when compared to TEE, with few over-reporting EI. Misreporting was more frequent among females compared to males within recall based dietary assessment methods. The degree of under-reporting was highly variable within studies using the same method, with 24 h recalls having less variation and degree of under-reporting compared to other methods.

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Validity of Dietary Assessment Methods When Compared to the Method of Doubly Labeled Water: A Systematic Review in Adults.

Background: New methods for assessing diet in research are being developed to address the limitations of traditional dietary assessment methods. Mobile device–assisted ecological momentary diet assessment (mEMDA) is a new dietary assessment method that has not yet been optimized and has the potential to minimize recall biases and participant burden while maximizing ecological validity. There have been limited efforts to characterize the use of mEMDA in behavioral research settings. Objective: The aims of this study were to summarize mEMDA protocols used in research to date, to characterize key aspects of these assessment approaches, and to discuss the advantages and disadvantages of mEMDA compared with the traditional dietary assessment methods as well as implications for future mEMDA research. Methods: Studies that used mobile devices and described mEMDA protocols to assess dietary intake were included. Data were extracted according to Preferred Reporting of Systematic Reviews and Meta-Analyses and Cochrane guidelines and then synthesized narratively. Results: The review included 20 studies with unique mEMDA protocols. Of these, 50% (10/20) used participant-initiated reports of intake at eating events (event-contingent mEMDA), and 50% (10/20) used researcher-initiated prompts requesting that participants report recent dietary intake (signal-contingent mEMDA). A majority of the study protocols (60%, 12/20) enabled participants to use mobile phones to report dietary data. Event-contingent mEMDA protocols most commonly assessed diet in real time, used dietary records for data collection (60%, 6/10), and provided estimates of energy and nutrient intake (60%, 6/10). All signal-contingent mEMDA protocols used a near real-time recall approach with unannounced (ie, random) abbreviated diet surveys. Most signal-contingent protocols (70%, 7/10) assessed the frequency with which (targeted) foods or food groups were consumed. Relatively few (30%, 6/20) studies compared mEMDA with the traditional dietary assessment methods. Conclusions: This review demonstrates that mEMDA has the potential to reduce participant burden and recall bias, thus advancing the field beyond current dietary assessment methods while maximizing ecological validity.

Mobile Ecological Momentary Diet Assessment Methods for Behavioral Research: Systematic Review

Background Statins are guidelines recommended in patients with peripheral artery disease (PAD) for the prevention of cardiovascular (CV) events. Comprehensive meta-data on the impact of statins on major adverse limb events (MALE) in PAD patients are lacking. We examined the association of statin use with MALE in patients with PAD. Methods We performed a systematic review (registered at PROSPERO: number CRD42019137111) and metanalysis of studies retrieved from PubMed (via MEDLINE) and Cochrane (CENTRAL) databases addressing the impact of statin on MALE including amputation and graft occlusion/revascularization. Secondary endpoints were all-cause death, composite CV endpoints, CV death, and stroke. Results We included 51 studies with 138,060 PAD patients, of whom 48,459 (35.1%) were treated with statins. The analysis included 2 randomized controlled trials, 20 prospective, and 29 retrospective studies. Overall, 11,396 MALE events, 21,624 deaths, 4,852 composite CV endpoints, 4,609 CV deaths, and 860 strokes were used for the analysis. Statins reduced MALE incidence by 30% (pooled hazard ratio [HR]: 0.702; 95% confidence interval [CI]: 0.605–0.815) and amputations by 35% (HR: 0.654; 95% CI: 0.522–0.819), all-cause mortality by 39% (pooled HR: 0.608, 95% CI: 0.543–0.680), CV death by 41% (HR: 0.594; 95% CI: 0.455–0.777), composite CV endpoints by 34% (pooled HR: 0.662; 95% CI: 0.591–0.741) and ischemic stroke by 28% (pooled HR: 0.718; 95% CI: 0.620–0.831). Conclusion Statins reduce the incidence of MALE, all-cause, and CV mortality in patients with PAD. In PAD, a high proportion of MALE events and deaths could be prevented by implementing a statin prescription in this patient population.

Statins and Major Adverse Limb Events in Patients with Peripheral Artery Disease: A Systematic Review and Meta-Analysis.

The ecological momentary assessment (EMA) of eating behaviors represents an innovative, detailed and valid approach to capture the complexity of food intake and to overcome limitations of traditional dietary assessment methods. Moreover, EMA studies might generate a large variety of data (e.g., dietary, behavioral, physical, sociopsychological, and contextual information), thereby enabling to examine concurrent exposures and events. Due to the increasing number of studies in this field of research, here we systematically reviewed EMA methods for the assessment of dietary intake in epidemiological studies, and discussed implications and perspectives for future research. Our study summarized several protocols and platforms that may be applied to assess diet in terms of eating frequency, choices, and habits. Nearly 38% of studies used an event-contingent strategy by asking participants to report foods and beverages consumed in real-time at each eating occasion. Instead, approximately 55% of studies used a signal-contingent prompting approach that notified the participants to record their dietary consumption. The remaining studies used a combination of event- and signal-contingent protocols to compare their accuracy or to improve the assessment of dietary data. Although both approaches might improve the accuracy and ecological validity of dietary assessment—also reducing the burden for participants—some limitations should nevertheless be considered. Despite these limitations, our systematic review pointed out that EMA can be applied in various fields of nutritional epidemiology, from the identification of determinants of dietary habits in healthy people to the management of patients with eating or metabolic disorders. However, more efforts should be encouraged to improve the validity and the reliability of EMA and to provide further technological innovations for public health research and interventions.

A Systematic Review of Ecological Momentary Assessment of Diet: Implications and Perspectives for Nutritional Epidemiology

In international comparisons, rates of amputations of the lower limb are relatively high in Germany. This study aims to analyze trends in lower limb amputations over time, as well as outcomes of care concerning in-hospital mortality and reamputation rates during the same hospital stay which might indicate the quality of surgical and perioperative health care processes. This work is an observational population-based study using complete national hospital discharge data (Diagnosis-Related Group Statistics (DRG Statistics)) from 2005 to 2015. All inpatient cases with lower limb amputation were identified and stratified by eight amputation levels. Time trends of case numbers and in-hospital mortality were studied age-sex standardized. For inpatient cases with reamputation during the same hospital stay, first and last amputation levels were cross tabulated. A total of 55,595 amputations of the lower limb in 2015 (52,096 in 2005) were identified. After age-sex standardization to the demographic structure of 2005, a relative decrease of − 11.1% was revealed (men − 2.6%, women − 25.0%). The stratified analysis by amputation levels showed that the decreases were induced by higher amputation levels, whereas the amputation levels of toe/foot ray after standardization still showed a relative increase of + 12.8%. In-hospital mortality of all cases with lower limb amputation fell from 19.8% in 2005 to 17.4% in 2015 (SMR 0.89 [95% CI 0.86; 0.92]). The percentage of reamputations during the same hospital stay declined from 13.2 to 10.2%. The number of lower limb amputations declined in Germany, however distinctly stronger in women than in men. The observed decreases of in-hospital mortality as well as of reamputation rates point to improvements in perioperative health care. Despite these indications of improvements, the distinct increase in case numbers at the level of toe/foot ray calls for additional targeted prevention efforts, especially for patients with diabetes.

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Amputation rates of the lower limb by amputation level - observational study using German national hospital discharge data from 2005 to 2015.

The mobile Food Record (mFR) is an image-based dietary assessment method for mobile devices. The study primary aim was to test the accuracy of the mFR by comparing reported energy intake (rEI) to total energy expenditure (TEE) using the doubly labeled water (DLW) method. Usability of the mFR was assessed by questionnaires before and after the study. Participants were 45 community dwelling men and women, 21–65 years. They were provided pack-out meals and snacks and encouraged to supplement with usual foods and beverages not provided. After being dosed with DLW, participants were instructed to record all eating occasions over a 7.5 days period using the mFR. Three trained analysts estimated rEI from the images sent to a secure server. rEI and TEE correlated significantly (Spearman correlation coefficient of 0.58, p < 0.0001). The mean percentage of underreporting below the lower 95% confidence interval of the ratio of rEI to TEE was 12% for men (standard deviation (SD) ± 11%) and 10% for women (SD ± 10%). The results demonstrate the accuracy of the mFR is comparable to traditional dietary records and other image-based methods. No systematic biases could be found. The mFR was received well by the participants and usability was rated as easy.

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Reported Energy Intake Accuracy Compared to Doubly Labeled Water and Usability of the Mobile Food Record among Community Dwelling Adults

Ziel der Arbeit Amputationen vermindern irreversibel die Lebensqualitat. Das Ziel vorangehender Versorgung ist stets eine Amputation zu verhindern. Diese Versorgung sollte bundesweit mit derselben Ergebnisqualitat gewahrleistet sein. Ziel dieser Arbeit ist es, regionale Versorgungsunterschiede sichtbar zu machen, indem Amputationsfallzahlen nach Amputationshohen auf Kreisebene analysiert werden. Methodik In den deutschlandweiten Krankenhausabrechnungsdaten (DRG-Statistik) wurden alle Behandlungsfalle mit Amputation an der unteren Extremitat zwischen 2011 und 2015 identifiziert. Auf Kreisebene wurden rohe Raten sowie alters- und geschlechtsstandardisierte Raten pro 100 000 Einwohner dargestellt. Daneben wurde die systematische Variationskomponente (SCV) zwischen den Kreisen betrachtet und das standardisierte Morbiditatsverhaltnis (SMR) in Funnel Plots dargestellt. Ergebnisse Im Beobachtungszeitraum belief sich die mediane jahrliche Amputationsrate auf 67 Falle pro 100 000 Einwohner. Auf Kreisebene variierte die rohe Rate um das 6-fache. Unabhangig von demografischen Unterschieden zeigten sich Variationen zwischen den Kreisen. Erhohte Amputationsraten wurden uberwiegend im Osten und Sudosten beobachtet. Die Variationen waren bei den Amputationshohen Zeh/Zehenstrahl (SCV 11,8) und Fus komplett & Mittel-/Vorfus (SCV 11,7) am starksten ausgepragt. Schlussfolgerung Es bestehen deutliche regionale Unterschiede in den Amputationsraten. Bei peripheren Amputationshohen ist die systematische Variation am starksten. Insbesondere im Osten und Sudosten sind regionale Cluster erkennbar, die Anhaltspunkte fur einen moglichen regionalen Verbesserungsbedarf in der Versorgung liefern.

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[Lower Extremity Amputation in Germany: Regional Analysis using Nationwide Hospital Discharge Data 2011-2015].

In Deutschland ist mit der Fallpauschalenbezogenen Krankenhausstatistik (DRG-Statistik) eine Vollerhebung der Abrechnungsdaten nahezu aller akutstationaren Krankenhausbehandlungsfalle verfugbar. Die Mikrodaten, d. h. die Datensatze der einzelnen Behandlungsfalle, werden von den Forschungsdatenzentren der Statistischen Amter des Bundes und der Lander fur die wissenschaftliche Nutzung bereitgestellt. Krankenhausabrechnungsdaten werden zu Abrechnungszwecken erhoben und haben – wie andere Datenquellen auch – spezifische Besonderheiten und Eigenschaften, die bei der Planung von Analysen und im Studiendesign angemessen berucksichtigt werden mussen. Eine besondere Herausforderung ist dabei die sachgerechte Operationalisierung von Analyseeinheiten, Zielgrosen und weiteren Variablen, die u. a. eine mogliche unterschiedliche Kodierpraxis in verschiedenen Krankenhausern antizipiert und deren Auswirkungen uber eine durchdachte Variablendefinition minimiert. In diesem Beitrag wird anhand von praktischen Beispielen aufgezeigt, was bei der Definition von Variablen in fallbezogenen Krankenhausabrechnungsdaten beachtet werden sollte, um das Risiko von kodierungs- oder anderweitig bedingten Verzerrungen moglichst gering zu halten. Ausgehend von den Erfahrungen der Autoren werden die wichtigsten Schritte und Herausforderungen in Bezug auf ein typisches retrospektives Beobachtungsstudiendesign in der Versorgungsforschung beschrieben. Basierend auf bereits durchgefuhrten Projekten auf der Grundlage der Mikrodaten der Fallpauschalenbezogenen Krankenhausstatistik (DRG-Statistik) werden Beispiele anhand eigener Berechnungen illustriert. Die Verlasslichkeit und Interpretierbarkeit von Analysen auf der Grundlage der Mikrodaten der DRG-Statistik hangt entscheidend von der sachgerechten Operationalisierung der Variablen ab. Um das Risiko von Verzerrungen und Fehlinterpretationen moglichst gering zu halten, sind umfangreiche Voruberlegungen notwendig, die neben medizinisch-klinischen Aspekten auch den Kontext der Datenerhebung und die klassifikatorischen Moglichkeiten zur Abbildung bestimmter Sachverhalte berucksichtigen. Es ist zu hoffen, dass die Akzeptanz von Studien auf der Grundlage von Krankenhausabrechnungsdaten weiter zunimmt und der wertvolle Datenbestand der DRG-Statistik in Zukunft noch intensiver fur Forschungszwecke genutzt wird.

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[Definition of Variables in Hospital Discharge Data: Pitfalls and Proposed Solutions].

Hintergrund Seit der Einfuhrung der Diagnosis related Groups (DRG) zur Vergutung akutstationarer Krankenhausleistungen wurden Anstiege der stationaren Fallzahlen zur Behandlung von Erkrankungen der Wirbelsaule beobachtet. Ziel dieser Arbeit ist, diese Mengenentwicklung bevolkerungsbezogen und nach Behandlungsarten differenziert darzustellen. Material und Methode In den deutschlandweiten Krankenhausabrechnungsdaten (DRG-Statistik) wurden Behandlungsfalle mit operativer sowie nicht operativer Versorgung von Wirbelsaulenerkrankungen identifiziert. Unter Berucksichtigung der demografischen Entwicklung wurde analysiert, in welchem Umfang sich die Fallzahlen im Zeitraum von 2005 bis 2014 verandert haben und in welchen Altersgruppen und bei welchen Eingriffs- bzw. Behandlungsarten Anstiege zu verzeichnen sind. Ergebnisse Im Jahr 2014 (2005) wurden 289 000 (177 000) operativ versorgte und 463 000 (287 000) nicht operativ versorgte Behandlungsfalle identifiziert. Nach Bereinigung um demografische Faktoren wurden sowohl bei operativen als auch bei nicht operativen Behandlungen relative Fallzahlanstiege um jeweils ca. 50% beobachtet, die in hoheren Altersgruppen und bei Frauen besonders ausgepragt waren. Die Mengenentwicklung fiel je nach Art des Eingriffs bzw. der Behandlung sehr unterschiedlich aus. Bei den operativ versorgten Behandlungsfallen hat sich die Anzahl der Bandscheibenoperationen demografiebereinigt nur um + 5% erhoht wahrend sich Wirbelkorperversteifungs- und -ersatzeingriffe, Kypho- und Vertebroplastien und alleinige Dekompressionen der Wirbelsaule mehr als verdoppelt haben. Bei den nicht operativ versorgten Behandlungsfallen wurde bei Behandlungen mit lokaler Schmerztherapie der Wirbelsaule ein demografiebereinigter Anstieg von + 142% beobachtet. Bei rein konservativen Behandlungen lag der demografiebereinigte Anstieg bei + 22%. Schlussfolgerung Welche Ursachen den nicht demografiebedingten Fallzahlanstiegen zugrunde liegen, kann diese Untersuchung nicht direkt klaren. Die stratifizierte Betrachtung der Fallzahlen in den verschiedenen Untergruppen kann aber dazu beitragen, die Entwicklungen differenziert einzuordnen und damit die Diskussion um eine mogliche Uber- oder Fehlversorgung zielgerichteter als bisher zu fuhren.

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Mengenentwicklung stationärer Behandlungen bei Erkrankungen der Wirbelsäule – Analyse der deutschlandweiten Krankenhausabrechnungsdaten von 2005 bis 2014

Melissa Spoden

Papers

Amputation rates of the lower limb by amputation level - observational study using German national hospital discharge data from 2005 to 2015.

Reported Energy Intake Accuracy Compared to Doubly Labeled Water and Usability of the Mobile Food Record among Community Dwelling Adults

[Lower Extremity Amputation in Germany: Regional Analysis using Nationwide Hospital Discharge Data 2011-2015].

[Definition of Variables in Hospital Discharge Data: Pitfalls and Proposed Solutions].

Mengenentwicklung stationärer Behandlungen bei Erkrankungen der Wirbelsäule – Analyse der deutschlandweiten Krankenhausabrechnungsdaten von 2005 bis 2014