Morbidity compression, morbidity expansion, or dynamic equilibrium? The time trend of AOK-insured patients with type 2 diabetes in Lower Saxony, Germany

A vertical-horizontal approach to examine social inequalities in early onset type 2 diabetes in the German workforce through occupational sector, education and income

Early onset type 2 diabetes (T2D) is increasingly recognized as a significant public health concern, leading to more severe complications and a greater decline in quality of life compared to T2D diagnosed later in life. This can have a profound impact on the workforce. Social status-whether assessed vertically through levels of income, education or job position or horizontally through occupational groups-can play a critical role in the risk of developing early onset T2D. While research focusing on vertical socioeconomic inequalities related to T2D is abundant, there is currently no study that combines both vertical and horizontal perspectives to explore vulnerable groups. We aim to combine the vertical and horizontal approaches to examine vulnerable groups within the employed population regarding early onset T2D. Using data from the largest statutory health insurance provider in the state of lower Saxony, Germany for the year 2019 "Allgemeine Ortskrankenkasse Niedersachsen" (AOKN), we examined education and income inequalities in early onset T2D among nine occupational sectors using logistic regression analyses (N = 365059). Age and gender adjusted prevalence rates as illustrated by predicted probabilities were displayed to compare rates of early onset T2D among different education and income levels and occupational groups. Regression tree analysis was used to examine intersectionality between the vertical (levels of income and education) and the horizontal (occupational sector) dimensions in order to determine the most vulnerable groups. Both vertical and horizontal inequalities in early onset T2D exist within the employed population. On the one hand, disparities in education and income were present across various occupational sectors. On the other hand, significant differences in T2D prevalence could be observed within the same education and income levels across different sectors. Notably, affiliation to occupational sector was the primary factor influencing vulnerability to early onset T2D, followed by educational attainment. Individuals with low education working in the "Transport, logistics, protection and security" and "Health, social work, teaching, and education" sectors were among the most vulnerable. It is important to simultaneously examine both vertical and horizontal dimensions of inequalities to identify vulnerable groups within the workforce. Future research should adopt this approach while also exploring other populations and health outcomes.

More Drugs and Fewer Strokes? Time Trends in CVD Medication and Incidence of Stroke With German Health Insurance Data

BACKGROUND

Successful prevention of cardiovascular diseases (CVD) may reduce the burden of diseases. Preventive medication is an important measure to decrease the risks of cardiovascular events, in particular myocardial infarction and stroke. The aim of this study is to analyze the prevalence of CVD preventive medication in Germany over time with respect to sex and age and to compare it with the temporal development of strokes.

METHODS

The study is based on statutory health insurance claims data from the AOK Niedersachsen (AOKN) covering the years 2005-2018. The study population comprises all AOKN insured persons aged 18 years and older (N = 2 088 495). Age-standardized time trends of the prevalence of CVD preventive medication and incidence of stroke were calculated for men and women in different age groups. After that, the relationship of both measures was examined in an ecological correlation.

RESULTS

We found a clear increase in medication prevalence over time. In 2018, about 35% of the total population and about 85% of those over 85 years of age received CVD preventive medication. At the same time, age-standardized incidence rates of ischemic stroke were decreasing slightly. The ecological correlation showed a negative association between medication prevalence and stroke incidence especially in the higher age groups.

CONCLUSION

High correlation coefficients indicate that higher medication prevalence could be linked to better population health. Further research is needed to draw conclusions about the effects of increasing medicalization, including adverse risks and side effects at the population level.

Socioeconomic inequalities in type 2 diabetes comorbidities in different population subgroups: trend analyses using German health insurance data

While socioeconomic inequalities in the prevalence and management of type 2 diabetes (T2D) are well established, little is known about whether inequalities exist in the prevalence and the temporal development of T2D comorbidities. Previous research points towards expansion of morbidity in T2D as depicted mainly by a rising trend of T2D comorbidities. Against this background, and using German claims data, this study aims to examine whether socioeconomic status (SES) inequalities exist in the rates and the temporal development of T2D comorbidities. Since previous research indicates varying risk levels for T2D prevalence in the population subgroups: working individuals, nonworking spouses and pensioners, the analyses are stratified by these three population subgroups. The study is done on a large population of statutory insured individuals with T2D in three time-periods between 2005 and 2017. Predicted probabilities of three comorbidity groups and the number of comorbidities were estimated using logistic and ordinal regression analyses among different income, education and occupation groups. Interaction analyses were applied to examine whether potential SES inequalities changed over time. The study showed that neither the cross-sectional existence, nor the temporal development of T2D comorbidities differed significantly among SES groups, ruling out SES inequalities in the prevalence and the temporal development of T2D comorbidities in Germany. In men and women of all examined population subgroups, predicted probabilities for less severe cardiovascular (CVD) comorbidities, other vascular diseases and the number of comorbidities per individual rose significantly over time regardless of SES, but little if any change took place for more severe CVD comorbidities. Another important finding is that the population subgroup of nonworking spouses had markedly higher predicted probabilities for most of the examined outcomes compared to working individuals. The study indicates that the expansion of morbidity in T2D in Germany does not appear to be SES-dependent, and applies equally to different population subgroups. Yet, the study highlights that nonworking spouses are a susceptible population subgroup that needs to be focused upon when planning and implementing T2D management interventions.

Trends of Antidiabetic and Cardiovascular Diseases Medication Prescriptions in Type 2 Diabetes between 2005 and 2017-A German Longitudinal Study Based on Claims Data

BACKGROUND

With an attempt to understand possible mechanisms behind the severity-dependent development of type 2 diabetes (T2D) comorbidities, this study examines the trends of antidiabetic and cardiovascular diseases (CVD) medication prescriptions in individuals with T2D.

METHODS

The study is based on claims data from a statutory health insurance provider in Lower Saxony, Germany. The period prevalence of antidiabetic and CVD medication prescriptions was examined for the periods 2005-2007, 2010-2012, and 2015-2017 in 240,241, 295,868, and 308,134 individuals with T2D, respectively. (Ordered) logistic regression analyses were applied to examine the effect of time period on the number and prevalence of prescribed medications. Analyses were stratified by gender and three age groups.

RESULTS

The number of prescribed medications per person has increased significantly for all examined subgroups. For the two younger age groups, insulin prescriptions decreased but those of non-insulin medications increased, while both increased significantly over time for the age group of 65+ years. Except for glycosides and antiarrhythmic medications, the predicted probabilities for CVD medications increased over the examined periods, with lipid-lowering agents demonstrating the highest increase.

CONCLUSIONS

Results point towards an increase in medication prescriptions in T2D, which is in line with the evidence of the increase in most comorbidities indicating morbidity expansion. The increase in CVD medication prescriptions, especially lipid-lowering agents, could explain the specific development of severe and less severe T2D comorbidities observed in this population.

Development of comorbidities in type 2 diabetes between 2005 and 2017 using German claims data

Against the background of increasing life expectancy over time, several hypotheses have been proposed on the way morbidity has been developing. In type 2 diabetes (T2D), previous research suggests that morbidity compression could be ruled out due to increasing prevalence and life expectancy with T2D over time. Understanding how the health state in individuals with T2D is developing would help identify whether morbidity expansion or a dynamic equilibrium pattern applies for this disease. This study aims to answer the following questions: (1) How do the number and the prevalence of T2D concordant comorbidities develop over time? (2) What does this imply in terms of morbidity development in T2D in Germany? The study used claims data from a statutory health insurance provider in Lower Saxony, Germany. Period prevalence of T2D concordant comorbidities was examined for the periods 2005–2007, 2010–2012 and 2015–2017 in 240,241, 295,868 and 308,134 individuals with T2D respectively. The effect of time period on the number and prevalence of comorbidities was examined by means of (ordered) logistic regression. The age-adjusted predicted probabilities of more severe cardiovascular diseases (CVDs) decreased over the three periods while those of less severe CVDs and other vascular diseases increased significantly in men and women and among all examined age-groups. Predicted probability of having at least one more comorbidity over time also increased significantly among all examined groups. While less and more severe CVDs exhibited different developmental patterns, the results of the study point towards morbidity expansion in T2D. Future studies should focus on mechanisms that contribute to these trends.

Are We Living Longer and Healthier?

Objective: To examine whether we live healthier as we live longer in Hong Kong, which has one of the highest life expectancies in the world. Methods: Sullivan's method was used to evaluate the chronic disease-free life expectancy (CDFLE), life expectancy in good self-perceived health (GPHLE), and impairment-free life expectancy (IFLE) among population aged 50 years and older in Hong Kong in 2007-2016. Results: In spite of the marked improvement in life expectancy in Hong Kong, the increase in GPHLE was much smaller, while CDFLE and IFLE even declined for both genders. The situation was more severe among older population. Discussion: People in Hong Kong live longer but with worsening health. The expansion of chronic diseases, self-perceived poor health, and impairments among older adults calls for more fiscal investments, government attention, and public health policies.

Diverging Trends in Age at First Myocardial Infarction: Evidence from Two German Population-Based Studies

Little is known about trends in the age of onset of first myocardial infarction. Thus, we examined trends in the age of onset distribution of first myocardial infarction using two population-based datasets from Germany. First, we used German claims data based on an annual case number of approximately 2 million women and men covering the period from 2006 to 2016. Second, we used data from the KORA (Cooperative Health Research in the Region of Augsburg) Myocardial Infarction Registry covering the period from 2000–2016. Analyses were performed by means of quantile regression to estimate trends across the whole distribution of age of onset. Overall, N_{Sample 1} = 69627 and N_{Sample 2} = 9954 first myocardial infarctions were observed. In both samples, we found highly heterogeneous trends in age of onset. In men, we consistently found that age of onset increased before 50 and after 70 but decreased within this age bracket. For women, on the other hand, we consistently found that age of onset decreased for first myocardial infarctions before 70 but increased slightly or remained relatively stable thereafter. Therefore, late myocardial infarctions tended to occur later in life, while regular myocardial infarctions tended to occur earlier. These results suggest that in myocardial infarction, both morbidity compression and morbidity expansion might have occurred at the same time but for different parts of the age at onset distribution.

Morbidity compression in myocardial infarction 2006 to 2015 in terms of changing rates and age at occurrence: A longitudinal study using claims data from Germany

BACKGROUND

According to James Fries morbidity compression is present if morbidity rates are decreasing to a larger extent than mortality rates. Compression also occurs if age at onset is increasing at a faster pace than age at death. These two variants of the compression hypothesis were formulated as a population concept. Compression has seldom been studied with a specific disease as application.

METHODS

Morbidity compression was examined in terms of myocardial infarction (MI) by using German claims data covering the years 2006 to 2015. The findings are based on an annual case number of about 2 m women and men aged 18 years and older. Analyses were performed by means of proportional hazards regression and by using linear regression.

RESULTS

Decreases of morbidity rates were more pronounced than those of mortality. For men, the hazard ratio for contracting MI in 2015 as compared to 2006 was hr = 0.66 and hr = 0.71 for the female population. The respective results for mortality were hr = 0.75 in men and hr = 1.0 in women. They can be interpreted in favor of morbidity compression. For the subgroup of women and men with MI, changes of onset age revealed marked gender differences. For 2015 as compared with 2006, age at MI-occurrence in men increased by 10.5 months as compared to an increase of 10.4 months for age at death. In women changes were smaller and statistically not significant. The findings referring to women have to be interpreted against the backdrop of higher onset age and higher age at death than in men.

CONCLUSIONS

Taken together, morbidity compression has occurred in terms of decreasing MI-rates as well as in terms of increased onset age in men. It can be concluded that both processes have led to an improvement of healthy lifetime. Decreasing morbidity rates in women are also pointing towards morbidity compression, a finding that is not complemented by changes of onset age. Our data are demonstrating that morbidity rates and age at onset may vary independently. From this perspective morbidity compression is a multi-faceted phenomenon.