Area-based socioeconomic status and mortality: the Ludwigshafen Risk and Cardiovascular Health study

Regional socioeconomic characteristics and density of general practitioners in Germany: A nationwide cross-sectional and longitudinal spatial analysis

OBJECTIVES

Limited healthcare availability impacts population health. Regional disparities in GP density across Germany raise questions about their association with regional socioeconomic characteristics.

STUDY DESIGN

This longitudinal nationwide ecological German study used regional data at the county level (n = 401) from 2015 to 2019 provided by the Federal Institute for Research on Building, Urban Affairs and Spatial Development (BBSR). The outcome was general practitioners (GPs) density, defined as the number of GPs per 10,000 inhabitants.

METHODS

Univariate Moran's I, cluster analysis (LISA), and spatial lag of X (SLX) models were employed to analyse the spatial distribution of GP density and its correlation with various regional socioeconomic characteristics from a cross-sectional and longitudinal perspective.

RESULTS

In contrast to the univariate analysis, rural counties showed the highest GP density the multivariate model. Several counties were identified as embedded in low- or high-GP-density clusters. In 2015 and 2019, larger household size (2015: std. β = -2.31, p = 0.021; 2019: std. β = -4.14, p < 0.001) and higher unemployment rate (2015: std. β = -2.84, p = 0.005; 2019: std. β = -5.47, p < 0.001) were associated with lower GP density. In the longitudinal model, a greater increase in the unemployment rate was related to a greater decrease in GP density (std. β = -2.17, p = 0.030).

CONCLUSION

A higher regional unemployment rate is linked to lower GP availability in Germany, and a greater increase in the unemployment rate was related to a greater decrease in GP availability over time. This necessitates policy intervention to avoid socioeconomic disparities in GP care.

Mapping the Heartbeat of America with ChatGPT-4: Unpacking the Interplay of Social Vulnerability, Digital Literacy, and Cardiovascular Mortality in County Residency Choices

Cardiovascular disease remains a leading cause of morbidity and mortality in the United States (US). Although high-quality data are accessible in the US for cardiovascular research, digital literacy (DL) has not been explored as a potential factor influencing cardiovascular mortality, although the Social Vulnerability Index (SVI) has been used previously as a variable in predictive modeling. Utilizing a large language model, ChatGPT4, we investigated the variability in CVD-specific mortality that could be explained by DL and SVI using regression modeling. We fitted two models to calculate the crude and adjusted CVD mortality rates. Mortality data using ICD-10 codes were retrieved from CDC WONDER, and the geographic level data was retrieved from the US Department of Agriculture. Both datasets were merged using the Federal Information Processing Standards code. The initial exploration involved data from 1999 through 2020 (n = 65,791; 99.98% complete for all US Counties) for crude cardiovascular mortality (CCM). Age-adjusted cardiovascular mortality (ACM) had data for 2020 (n = 3118 rows; 99% complete for all US Counties), with the inclusion of SVI and DL in the model (a composite of literacy and internet access). By leveraging on the advanced capabilities of ChatGPT4 and linear regression, we successfully highlighted the importance of incorporating the SVI and DL in predicting adjusted cardiovascular mortality. Our findings imply that just incorporating internet availability in the regression model may not be sufficient without incorporating significant variables, such as DL and SVI, to predict ACM. Further, our approach could enable future researchers to consider DL and SVI as key variables to study other health outcomes of public-health importance, which could inform future clinical practices and policies.

Spatial scale analysis for the relationships between the built environment and cardiovascular disease based on multi-source data

To examine what built environment characteristics improve the health outcomes of human beings is always a hot issue. While a growing literature has analyzed the link between the built environment and health, few studies have investigated this relationship across different spatial scales. In this study, eighteen variables were selected from multi-source data and reduced to eight built environment attributes using principal component analysis. These attributes included socioeconomic deprivation, urban density, street walkability, land-use diversity, blue-green space, transportation convenience, ageing, and street insecurity. Multiscale geographically weighted regression was then employed to clarify how these attributes relate to cardiovascular disease at different scales. The results indicated that: (1) multiscale geographically weighted regression showed a better fit of the association between the built environment and cardiovascular diseases than other models (e.g., ordinary least squares and geographically weighted regression), and is thus an effective approach for multiscale analysis of the built environment and health associations; (2) built environment variables related to cardiovascular diseases can be divided into global variables with large scales (e.g., socioeconomic deprivation, street walkability, land-use diversity, blue-green space, transportation convenience, and ageing) and local variables with small scales (e.g., urban density and street insecurity); and (3) at specific spatial scales, global variables had trivial spatial variation across the area, while local variables showed significant gradients. These findings provide greater insight into the association between the built environment and lifestyle-related diseases in densely populated cities, emphasizing the significance of hierarchical and place-specific policy formation in health interventions.

"Harm per litre" as a concept and a measure in studying determinants of relations between alcohol consumption and harm

The term "harm per litre" has been increasingly used in alcohol research in recent years as a concept and a comparative measure of alcohol-attributable harm in comparisons between environments, circumstances, and patterns of drinking. This essay discusses the origins of the term in connection with analyses in terms of patterns as well as levels of drinking and with concerns about differential harms from drinking different beverage types. Also discussed is the term's current primary usage, in the context of epidemiological concerns about differentially severe harms for poorer persons who drink. It is noted that these same concerns have been discussed, particularly in Britain, using the phrase "alcohol harm paradox". "Harm per litre" was initially most often used in comparisons between rates of alcohol-attributable harm by beverage type. After 2010, the expression was applied more broadly, particularly after its use in various World Health Organization-related discussions and documents. In addition, and especially from 2018 onwards when most of the papers using this term were published, it has been used in comparisons by socioeconomic status at the individual level, and by level of socioeconomic development at the country level. Almost all the findings indicate that people with lower socioeconomic status, and countries with lower average income, e.g., low income and lower-middle income countries, incur considerably higher harm per litre (with harm being expressed in disease burden and mortality) than upper middle-income and high-income countries. "Harm per litre" is a practicable and easy-to-understand concept to compare groups of individuals or countries, and to quantify health inequalities. The next important step will need to be elucidating a better causal understanding of the processes underlying these inequalities, with an emphasis on factors which can be most easily changed by interventions.

Is area-level socioeconomic deprivation associated with mortality due to circulatory system diseases in Poland?

BACKGROUND

Socioeconomic deprivation (SED) is known to influence cardiovascular health. However, studies analyzing the relationship between deprivation and circulatory system diseases (CSD) in Central and Eastern Europe are limited. This study aimed to assess the relationship between SED and mortality due to CSD at a population level in 66 sub-regions of Poland.

METHODS

The 2010-2014 data regarding mortality and SED components were obtained from the Central Statistical Office. An area-based SED index was calculated based on the higher education rates, employment structure, wages, unemployment, and poverty. The dynamics of changes in mortality due to CSD was expressed by the number of deaths prevented or postponed (DPP) in terciles of the SED index. The associations between the mortality from CSD and SED index were analyzed using multivariate Poisson regression models and generalized estimating equations.

RESULTS

Among men, the percentage of DPP in 2014 was 13.1% for CSD, 23.4% for ischemic heart disease (IHD), and 21.4% for cerebrovascular diseases (CeVD). In the case of women, the proportion of DPP was 12.8, 25.6, and 21.6%, respectively. More deprived sub-regions experienced a greater decrease in CSD-related mortality than less deprived sub-regions. The disparity in mortality reduction between more deprived and less deprived sub-regions was even more pronounced for women. After adjusting for smoking prevalence, average BMI, population density, and changes in mortality over time, it was found that the SED index over the 2010-2014 time period was significantly associated with CSD- and IHD-related mortality for men (respectively 5.3 and 19.5% expected mortality increase per 1-unit increase of SED index), and with IHD- and CeVD-related mortality for women (respectively 30.3 and 23.0% expected mortality increase per 1-unit increase of SED index).

CONCLUSIONS

Significant differences in mortality changes due to CSD in Poland could be observed in relation to socioeconomic deprivation, resulting in reduced health inequalities. To reduce CSD mortality, more comprehensive preventive measures, including approaches addressing the socioeconomic factors, mainly poverty, education and employment, are needed, particularly in less urbanized areas.

Socioeconomic disparities in endometrial cancer survival in Germany: a survival analysis using population-based cancer registry data

PURPOSE

Area-based socioeconomic deprivation has been established as an important indicator of health and a potential predictor of survival. In this study, we aimed to measure the effect of socioeconomic inequality on endometrial cancer survival.

METHODS

Population-based data on patients diagnosed with endometrial cancer between 2004 and 2014 were obtained from the German Centre for Cancer Registry Data. Socioeconomic inequality was defined by the German Index of Socioeconomic Deprivation. We investigated the association of deprivation and overall survival through Kaplan-Meier curves and Cox proportional regression models.

RESULTS

A total of 21,602 women, with a mean age of 67.8 years, were included in our analysis. The observed 5-year overall survival time for endometrial cancer patients living in the most affluent districts (first quintile) was 78.6%. The overall survival rate decreased as the level of deprivation increased (77.2%, 73.9%, 76.1%, 74.7%, for patients in the second, third, fourth, and fifth quintile (most deprived patients), respectively). Cox regression models showed stage I patients living in the most deprived districts to have a higher hazard of overall mortality when compared to the cases living in the most affluent districts [Hazard ratio: 1.20; 95% Confidence interval (0.99-1.47)] after adjusting for age, tumor characteristics, and treatment.

CONCLUSION

Our results indicate differences in endometrial cancer survival according to socioeconomic deprivation among stage I patients. Considering data limitations, future studies with access to individual-level patient information should be conducted to examine the underlying causes for the observed disparity in cancer survival.

Circulating Sclerostin Levels Are Positively Related to Coronary Artery Disease Severity and Related Risk Factors

Romosozumab is a newly available treatment for osteoporosis acting by sclerostin inhibition. Its cardiovascular safety has been questioned after finding excess cardiovascular disease (CVD)-related events in a pivotal phase 3 trial. Previous studies of relationships between circulating sclerostin levels and CVD and associated risk factors have yielded conflicting findings, likely reflecting small numbers and selected patient groups. We aimed to characterize relationships between sclerostin and CVD and related risk factors in more detail by examining these in two large cohorts, Ludwigshafen Risk and Cardiovascular Health study (LURIC; 34% female, mean age 63.0 years) and Avon Longitudinal Study of Parents and Children study (ALSPAC) mothers (mean age 48.1 years). Together these provided 5069 participants with complete data. Relationships between sclerostin and CVD risk factors were meta-analyzed, adjusted for age, sex (LURIC), body mass index, smoking, social deprivation, and ethnicity (ALSPAC). Higher sclerostin levels were associated with higher risk of diabetes mellitus (DM) (odds ratio [OR] = 1.25; 95% confidence interval [CI] 1.12, 1.37), risk of elevated fasting glucose (OR 1.15; CI 1.04, 1.26), and triglyceride levels (β 0.03; CI 0.00, 0.06). Conversely, higher sclerostin was associated with lower estimated glomerular filtration rate (eGFR) (β -0.20; CI -0.38, -0.02), HDL cholesterol (β -0.05; CI -0.10, -0.01), and apolipoprotein A-I (β -0.05; CI -0.08, -0.02) (difference in mean SD per SD increase in sclerostin, with 95% CI). In LURIC, higher sclerostin was associated with an increased risk of death from cardiac disease during follow-up (hazard ratio [HR] = 1.13; 1.03, 1.23) and with severity of coronary artery disease on angiogram as reflected by Friesinger score (0.05; 0.01, 0.09). Associations with cardiac mortality and coronary artery severity were partially attenuated after adjustment for risk factors potentially related to sclerostin, namely LDL and HDL cholesterol, log triglycerides, DM, hypertension, eGFR, and apolipoprotein A-I. Contrary to trial evidence suggesting sclerostin inhibition leads to an increased risk of CVD, sclerostin levels appear to be positively associated with coronary artery disease severity and mortality, partly explained by a relationship between higher sclerostin levels and major CVD risk factors. © 2021 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Educational Level, but Not Income or Area Deprivation, is Related to Macrovascular Disease: Results From Two Population-Based Cohorts in Germany

Objectives: An inverse relationship between education and cardiovascular risk has been described, however, the combined association of education, income, and neighborhood socioeconomic status with macrovascular disease is less clear. The aim of this study was to evaluate the association of educational level, equivalent household income and area deprivation with macrovascular disease in Germany.

Methods: Cross-sectional data from two representative German population-based studies, SHIP-TREND (n = 3,731) and KORA-F4 (n = 2,870), were analyzed. Multivariable logistic regression models were applied to estimate odds ratios and 95% confidence intervals for the association between socioeconomic determinants and macrovascular disease (defined as self-reported myocardial infarction or stroke).

Results: The study showed a higher odds of prevalent macrovascular disease in men with low and middle educational level compared to men with high education. Area deprivation and equivalent income were not related to myocardial infarction or stroke in any of the models.

Conclusion: Educational level, but not income or area deprivation, is significantly related to the macrovascular disease in men. Effective prevention of macrovascular disease should therefore start with investing in individual education.

Health-Related Quality of Life in Patients With Coronary Artery Disease Undergoing Percutaneous Coronary Intervention: A Cross-Sectional Study

BACKGROUND

The percutaneous coronary intervention (PCI) is the most common treatment for coronary artery disease. Health-related quality of life (HRQoL), alongside mortality and recurrence rates, is a key outcome indicator for PCI.

PURPOSE

The aim of this study was to investigate the factors influencing HRQoL in patients with coronary artery disease who had received PCI.

METHODS

A convenience sample from the cardiovascular center of a tertiary hospital in South Korea was recruited for this descriptive, cross-sectional study. This study was conducted using a structured questionnaire and patients' medical records on a sample of 210 patients with coronary artery disease who were ≥ 18 years old and > 1 month post-PCI. The questionnaire collected information on general, clinical, and psychosocial characteristics. Data were analyzed using descriptive statistics, independent t test, one-way analysis of variance, the Scheffé test, and the Pearson correlation test. A multiple linear regression, together with the significant variables in univariate analysis, was used to determine the variables that significantly influenced HRQoL.

RESULTS

HRQoL was found to vary significantly with age, marital status, subjective economic status, primary caregiver, duration since first PCI, New York Heart Association class, anxiety, depression, and social support. The significant general characteristics shown to affect HRQoL in patients who had undergone PCI included age, marital status, and primary caregiver. The significant clinical characteristics shown to affect HRQoL included duration from first PCI and New York Heart Association class. The significant psychosocial characteristics shown to affect HRQoL included anxiety and depression. Primary caregiver and New York Heart Association class were identified as having the greatest impact on HRQoL in the PCI patients in this study.

CONCLUSIONS

To enhance HRQoL in patients who had received PCI, their post-PCI physical and psychological symptoms should be regularly assessed. Furthermore, intervention strategies aimed to improve quality of life in patients with severe functional limitations and those receiving family care are necessary.

Affordability of Different Isocaloric Healthy Diets in Germany-An Assessment of Food Prices for Seven Distinct Food Patterns

Affordability of different isocaloric healthy diets in Germany—an assessment of food prices for seven distinct food patterns Background: For decades, low-fat diets were recommended as the ideal food pattern to prevent obesity, type 2 diabetes and their long-term complications. Nowadays, several alternatives considering sources and quantity of protein, fat and carbohydrates have arisen and clinical evidence supports all of them for at least some metabolic outcomes. Given this variety in diets and the lack of a single ideal diet, one must evaluate if patients at risk, many of which having a lower income, can actually afford these diets. Aim: We modelled four-week food plans for a typical family of two adults and two school children based on seven different dietary patterns: highly processed standard omnivore diet (HPSD), freshly cooked standard omnivore diet (FCSD), both with German average dietary composition, low-protein vegan diet (VeganD), low-fat vegetarian diet (VegetD), low-fat omnivore diet (LFD), Mediterranean diet (MedD) and high-fat moderate-carb diet (MCD). The isocaloric diets were designed with typical menu variation for all meal times. We then assessed the lowest possible prices for all necessary grocery items in 12 different supermarket chains, avoiding organic foods, special offers, advertised exotic super foods and luxury articles. Prices for dietary patterns were compared in total, stratified by meal time and by food groups. Results: Among all seven dietary patterns, price dispersion by supermarket chains was 12–16%. Lowest average costs were calculated for the VegetD and the FCSD, followed by HPSD, LFD, VeganD, MedD and—on top—MCD. VeganD, MedD and MCD were about 16%, 23% and 67% more expensive compared to the FCSD. Major food groups determining prices for all diets are vegetables, salads and animal-derived products. Calculations for social welfare severely underestimate expenses for any kind of diet. Conclusions: Food prices are a relevant factor for healthy food choices. Food purchasing is financially challenging for persons with very low income in Germany. Fresh-cooked plant-based diets are less pricy than the unhealthy HPSD. Diets with reduced carbohydrate content are considerably more expensive, limiting their use for people with low income. Minimum wage and financial support for long-term unemployed people in Germany are insufficient to assure a healthy lifestyle.

Associations of Socioeconomic Status and Rurality With New-Onset Cardiovascular Disease in Cancer Survivors: A Population-Based Analysis

PURPOSE

Patients with cancer are predisposed to develop new-onset cardiovascular disease (CVD). We aimed to assess if rural residence and low socioeconomic status modify such a risk.

METHODS

Patients diagnosed with solid organ cancers without any baseline CVD and on a follow-up of at least 1 year in a large Canadian province from 2004 to 2017 were identified using the population-based registry. We performed logistic regression analyses to examine the associations of rural residence and low socioeconomic status with the development of CVD.

RESULTS

We identified 81,418 patients eligible for the analysis. The median age was 62 years, and 54.3% were women. At a median follow-up of 68 months, 29.4% were diagnosed with new CVD. The median time from cancer diagnosis to CVD diagnosis was 29 months. Rural patients (32.3% v 28.5%; P < .001) and those with low income (30.4% v 25.9%; P < .001) or low educational attainment (30.7% v 27.6%; P < .001) experienced higher rates of CVD. After adjusting for baseline factors and treatment, rural residence (odds ratio [OR], 1.07; 95% CI, 1.04 to 1.11; P < .001), low income (OR, 1.17; 95% CI, 1.12 to 1.21; P < .001), and low education (OR, 1.08; 95% CI, 1.04 to 1.11; P < .001) continued to be associated with higher odds of CVD. A multivariate Cox regression model showed that patients with low socioeconomic status were more likely to die, but patients residing rurally were not.

CONCLUSION

Despite universal health care, marginalized populations experience different CVD risk profiles that should be considered when operationalizing lifestyle modification strategies and cardiac surveillance programs for the growing number of cancer survivors.

[Social inequalities in healthcare provision for patients with coronary heart disease: Results from the GEDA (German Health Update) study 2014/2015]

INTRODUCTION

Little is known about social inequalities in outpatient long-term care of coronary heart disease (CHD) in Germany.

METHODS

Regression analyses are based on the responses of women and men who participated in the national cross-sectional study "German Health update" (GEDA) 2014/2015 and had self-reported CHD (N=920). Outpatient healthcare of CHD was analysed on the basis of the self-reported administration of antihypertensive and cholesterol-lowering drugs, and the frequency of general practitioner (GP) contacts.

RESULTS

On average, respondents visited their GP 7.5 times a year (mean). 46 % did not receive guideline-consistent treatment, i. e. both antihypertensive and cholesterol-lowering drugs. Respondents of lower social status consulted their GP more frequently (approx. two visits per year) than those of higher social status (AME: 1.94; 95% CI 0.56 to 3.31). Regarding treatment with antihypertensive and cholesterol-lowering drugs, there were no significant differences for either gender or social status. Nevertheless, the probability that respondents with increased levels of blood lipids or cholesterol took only one or none of the two medications recommended for long-term treatment of CHD was reduced by 54 percentage points (AME: -0,54; 95% CI -0,61 to -0,48).

DISCUSSION

There are no social inequalities in the treatment of CHD patients with antihypertensive and cholesterol-lowering drugs, but inequalities exist in the frequency of visits to the GP who is more often consulted by the more socially disadvantaged patients.

CONCLUSION

With about 7.5 consultations per year, CHD patients visit their general practitioner more often than average, but in about half of these patients the medication supply is less than optimal. This may indicate a deficit in the medical treatment of CHD that cannot be explained by social inequalities. A possible starting point for improving healthcare, especially for patients without other risk factors, is to focus more strongly on a guideline-based approach to prescribing medication for CHD patients.

GeoSES: A socioeconomic index for health and social research in Brazil

The individual’s socioeconomic conditions are the most relevant to predict the quality of someone’s health. However, such information is not usually found in medical records, making studies in the area difficult. Therefore, it is common to use composite indices that characterize a region socioeconomically, such as the Human Development Index (HDI). The main advantage of the HDI is its understanding and adoption on a global scale. However, its applicability is limited for health studies since its longevity dimension presents mathematical redundancy in regression models. Here we introduce the GeoSES, a composite index that summarizes the main dimensions of the Brazilian socioeconomic context for research purposes. We created the index from the 2010 Brazilian Census, whose variables selection was guided by theoretical references for health studies. The proposed index incorporates seven socioeconomic dimensions: education, mobility, poverty, wealth, income, segregation, and deprivation of resources and services. We developed the GeoSES using Principal Component Analysis and evaluated its construct, content, and applicability. GeoSES is defined at three scales: national (GeoSES-BR), Federative Unit (GeoSES-FU), and intra-municipal (GeoSES-IM). GeoSES-BR dimensions showed a good association with HDI-M (correlation above 0.85). The model with the poverty dimension best explained the relative risk of avoidable cause mortality in Brazil. In the intra-municipal scale, the model with GeoSES-IM was the one that best explained the relative risk of mortality from circulatory system diseases. By applying spatial regressions, we demonstrated that GeoSES shows significant explanatory potential in the studied scales, being a compelling complement for future researches in public health.