The impact of regional deprivation and individual socio-economic status on the prevalence of Type 2 diabetes in Germany. A pooled analysis of five population-based studies

Respiratory rate and its associations with disease and lifestyle factors in the general population - results from the KORA-FF4 study

OBJECTIVE

The aim of the study was to derive median age- and sex-specific respiratory rates in a population-based sample of adults and to identify disease and lifestyle factors associated with elevated respiratory rates.

METHODS

In the population-based KORA FF4 study conducted in Augsburg, Germany, 5-minute 12-lead resting electrocardiograms (ECGpro-system, AMEDTEC) were recorded in 2,224 participants from 39 to 88 years. Respiratory rate was derived from these electrocardiograms. Sex- and age-specific medians, IQRs, and percentiles were calculated. Associations of sociodemographic, disease, and lifestyle variables with elevated resting respiratory rate were assessed by univariable and multivariable logistic regression analyses.

RESULTS

Respiratory rate decreased slightly from youngest to middle-aged women and men and increased in old age. Overall, median (IQR) was 15.80 (3.16) breaths per minute (brpm). Five percent of the participants had values lower than 12.06 brpm, and five percent had values above 20.06 brpm (95th percentile). Elevated respiratory rates of ≥  18.6 brpm were found in 13.8% (n =  308). In an adjusted logistic regression model, age, abdominal obesity, diabetes, COPD, smoking, and low education were significantly associated with elevated respiratory rate. Stratified analyses showed that education appeared to be more relevant in women, while the effect of diabetes was more pronounced in men.

CONCLUSIONS

High respiratory rate may be an indicator of impaired health in the general population, especially regarding pulmonary and metabolic characteristics, and unfavorable lifestyle and living conditions. Individuals with an increased respiratory rate should therefore be examined and followed up more closely to recognize diseases and adverse progressions at an early stage and to possibly prevent them.

Contextualization of Diabetes: A Review of Reviews from Organisation for Economic Co-operation and Development (OECD) Countries

PURPOSE OF REVIEW

The prevalence of diabetes is rising around the world and represents an important public health concern. Unlike individual-level risk and protective factors related to the etiology of diabetes, contextual risk factors have been much less studied. Identification of contextual factors related to the risk of type 1 and type 2 diabetes in Organisation for Economic Co-operation and Development (OECD) countries may help health professionals, researchers, and policymakers to improve surveillance, develop policies and programs, and allocate funding.

RECENT FINDINGS

Among 4,470 potential articles, 48 were included in this review. All reviews were published in English between 2005 and 2023 and were conducted in over 20 different countries. This review identified ten upstream contextual risk factors related to type 1 and type 2 diabetes risk, including income, employment, education, immigration, race/ethnicity, geography, rural/urban status, built environment, environmental pollution, and food security/environment. The ten upstream contextual risk factors identified this review may be integrated into diabetes research, surveillance and prevention activities to help promote better outcomes for people at risk or living with diabetes in OECD countries. Additional research is needed to better quantify the measures of associations between emerging key contextual factors and diabetes outcomes.

Latent classes of learners in people with type 2 diabetes, stratified by educational status: A cross-sectional study

OBJECTIVE

Research suggests that people with type 2 diabetes (PWT2D) exhibit different approaches to learning about disease-management. This study's aims to identify distinct learner groups among PWT2D and stratify them by educational status (ES).

METHODS

Cross-sectional data from 227 PWT2D, collected through 46 Likert-scale questions on learning behaviors, preferences, and attitudes, were analyzed using latent class analysis, to identify learner groups. Participants were recruited via healthcare practices in central Germany and a countrywide online survey. Group membership was displayed according to low, medium, and high ES, defined by years of schooling.

RESULTS

Four learner groups were identified: casual, versatile, insecure, and theorist learners. Insecure learners accounted for almost half of all respondents in the low ES group (46 %), casual learners were most prevalent among PWT2D with a medium (27 %), versatile (34 %) and theorist (29 %) learners among those with a high ES.

CONCLUSION

This study sheds light on learner groups among PWT2D, which differ by ES, suggesting social disparities in diabetes care. Further research is needed to validate these findings.

PRACTICE IMPLICATIONS

Understanding individual learning preferences and motivations is crucial for developing effective diabetes self-management trainings, which may involve providing additional background material for theorists and practical applications for insecure learners.

Regional Deprivation and Suicide

BACKGROUND

Regional deprivation due to regional economic and social differences can increase the risk of suicide. This study investigated whether regional structural deprivation in Germany is associated with a higher rate of suicide.

METHODS

Data from cause-of-death statistics for the years 2015-2021 were analyzed. A regression analysis for data with a negative binomial distribution was used to study the association between suicide mortality and the German Index of Multiple Deprivation (GIMD), which is based on data from 2015 and includes 401 districts and independent cities in Germany.

RESULTS

Among the districts and independent cities covered by the GIMD, the quintile with the highest deprivation had higher suicide rates than the quintile with the lowest deprivation (relative risk [RR]: 1.85; 95% confidence interval [1.72; 2.00]). A sensitivity analysis revealed similar associations when the analysis was restricted to men (RR = 1.99 [1.80; 2.18]) or women (RR = 1.69 [1.49; 1.92]). A stronger association, however, was found in a comparison of rural (RR = 2.29 [2.04; 2.57]) with urban areas (RR = 1.51 [1.36; 1.68]).

CONCLUSION

These findings document an association between regional deprivation and suicide. They highlight the need for a more targeted approach to suicide prevention in deprived regions. At the same time, more research is needed into the mechanisms and effects of regional deprivation on mortality due to suicide.

Deprivation as a fundamental cause of morbidity and reduced life expectancy: an observational study using German statutory health insurance data

Across all developed countries, there is a steep life expectancy gradient with respect to deprivation. This paper provides a theoretical underpinning for this gradient in line with the Grossman model, indicating that deprivation affects morbidity and, consequently, life expectancy in three ways: directly from deprivation to morbidity, and indirectly through lower income and a trade-off between investments in health and social status. Using rich German claims data covering 6.3 million insured people over four years, this paper illustrates that deprivation increases morbidity and reduces life expectancy. It was estimated that highly deprived individuals had approximately two more chronic diseases and a life expectancy reduced by 15 years compared to the least deprived individuals. This mechanism of deprivation is identified as fundamental, as deprived people remain trapped in their social status, and this status results in health investment decisions that affect long-term morbidity. However, in the German setting, the income and investment paths of the effects of deprivation were of minor relevance due to the broad national coverage of its SHI system. The most important aspects of deprivation were direct effects on morbidity, which accumulate over the lifespan. In this respect, personal aspects, such as social status, were found to be three times more important than spatial aspects, such as area deprivation.

Diagnosis rates, therapeutic characteristics, lifestyle, and cancer screening habits of patients with diabetes mellitus in a highly deprived region in Hungary: a cross-sectional analysis

Introduction

Low socioeconomic status affects not only diagnosis rates and therapy of patients with diabetes mellitus but also their health behavior. Our primary goal was to examine diagnosis rates and therapy of individuals with diabetes living in Ormánság, one of the most deprived areas in Hungary and Europe. Our secondary goal was to examine the differences in lifestyle factors and cancer screening participation of patients with diagnosed and undiagnosed diabetes compared to healthy participants.

Methods

Our study is a cross-sectional analysis using data from the "Ormánság Health Program". The "Ormánság Health Program" was launched to improve the health of individuals in a deprived region of Hungary. Participants in the program were coded as diagnosed diabetes based on diagnosis by a physician as a part of the program, self-reported diabetes status, and self-reported prescription of antidiabetic medication. Undiagnosed diabetes was defined as elevated blood glucose levels without self-reported diabetes and antidiabetic prescription. Diagnosis and therapeutic characteristics were presented descriptively. To examine lifestyle factors and screening participation, patients with diagnosed and undiagnosed diabetes were compared to healthy participants using linear regression or multinomial logistic regression models adjusted for sex and age.

Results

Our study population consisted of 246 individuals, and 17.9% had either diagnosed (n=33) or undiagnosed (n=11) diabetes. Metformin was prescribed in 75.8% (n=25) of diagnosed cases and sodium-glucose cotransporter-2 inhibitors (SGLT-2) in 12.1% (n=4) of diagnosed patients. After adjustment, participants with diagnosed diabetes had more comorbidities (adjusted [aOR]: 3.50, 95% confidence interval [95% CI]: 1.34-9.18, p<0.05), consumed vegetables more often (aOR: 2.49, 95% CI: 1.07-5.78, p<0.05), but desserts less often (aOR: 0.33, 95% CI: 0.15-0.75, p<0.01) than healthy individuals. Patients with undiagnosed diabetes were not different in this regard from healthy participants. No significant differences were observed for cancer screening participation between groups.

Conclusions

To increase recognition of diabetes, targeted screening tests should be implemented in deprived regions, even among individuals without any comorbidities. Our study also indicates that diagnosis of diabetes is not only important for the timely initiation of therapy, but it can also motivate individuals in deprived areas to lead a healthier lifestyle.

Relationships between the Structural Characteristics of General Medical Practices and the Socioeconomic Status of Patients with Diabetes-Related Performance Indicators in Primary Care

The implementation of monitoring for general medical practice (GMP) can contribute to improving the quality of diabetes mellitus (DM) care. Our study aimed to describe the associations of DM care performance indicators with the structural characteristics of GMPs and the socioeconomic status (SES) of patients. Using data from 2018 covering the whole country, GMP-specific indicators standardized by patient age, sex, and eligibility for exemption certificates were computed for adults. Linear regression models were applied to evaluate the relationships between GMP-specific parameters (list size, residence type, geographical location, general practitioner (GP) vacancy and their age) and patient SES (education, employment, proportion of Roma adults, housing density) and DM care indicators. Patients received 58.64% of the required medical interventions. A lower level of education (hemoglobin A1c test: β = -0.108; ophthalmic examination: β = -0.100; serum creatinine test: β = -0.103; and serum lipid status test: β = -0.108) and large GMP size (hemoglobin A1c test: β = -0.068; ophthalmological examination β = -0.031; serum creatinine measurement β = -0.053; influenza immunization β = -0.040; and serum lipid status test β = -0.068) were associated with poor indicators. A GP age older than 65 years was associated with lower indicators (hemoglobin A1c test: β = -0.082; serum creatinine measurement: β = -0.086; serum lipid status test: β = -0.082; and influenza immunization: β = -0.032). Overall, the GMP-level DM care indicators were significantly influenced by GMP characteristics and patient SES. Therefore, proper diabetes care monitoring for the personal achievements of GPs should involve the application of adjusted performance indicators.

Diabetes mellitus affects the treatment outcomes of drug-resistant tuberculosis: a systematic review and meta-analysis

BACKGROUND

Both tuberculosis (TB) and diabetes mellitus (DM) are major public health problems threatening global health. TB patients with DM have a higher bacterial burden and affect the absorption and metabolism for anti-TB drugs. Drug-resistant TB (DR-TB) with DM make control TB more difficult.

METHODS

This study was completed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guideline. We searched PubMed, Excerpta Medica Database (EMBASE), Web of Science, ScienceDirect and Cochrance Library for literature published in English until July 2022. Papers were limited to those reporting the association between DM and treatment outcomes among DR-TB and multidrug-resistant TB (MDR-TB) patients. The strength of association was presented as odds ratios (ORs) and their 95% confidence intervals (CIs) using the fixed-effects or random-effects models. This study was registered with PROSPERO, number CRD: 42,022,350,214.

RESULTS

A total of twenty-five studies involving 16,905 DR-TB participants were included in the meta-analysis, of which 10,124 (59.89%) participants were MDR-TB patients, and 1,952 (11.54%) had DM history. In DR-TB patients, the pooled OR was 1.56 (95% CI: 1.24-1.96) for unsuccessful outcomes, 0.64 (95% CI: 0.44-0.94) for cured treatment outcomes, 0.63 (95% CI: 0.46-0.86) for completed treatment outcomes, and 1.28 (95% CI: 1.03-1.58) for treatment failure. Among MDR-TB patients, the pooled OR was 1.57 (95% CI: 1.20-2.04) for unsuccessful treatment outcomes, 0.55 (95% CI: 0.35-0.87) for cured treatment outcomes, 0.66 (95% CI: 0.46-0.93) for treatment completed treatment outcomes and 1.37 (95% CI: 1.08-1.75) for treatment failure.

CONCLUSION

DM is a risk factor for adverse outcomes of DR-TB or MDR-TB patients. Controlling hyperglycemia may contribute to the favorite prognosis of TB. Our findings support the importance for diagnosing DM in DR-TB /MDR-TB, and it is needed to control glucose and therapeutic monitoring during the treatment of DR-TB /MDR-TB patients.

Population health differences in cross-border regions within the European Union and Schengen area: a protocol for a scoping review

INTRODUCTION

Along with European integration and the harmonisation of living conditions, improvements in health have been observed over the past decades. However, sociospatial inequalities within and across member states still exist today. While drivers of these health inequalities have been widely researched on a national and regional scale, cross-border regions remain understudied. The removal of border controls within the European Union (EU) member states has facilitated economic convergence and created new opportunities, including cross-border cooperation in the healthcare systems. However, whether and how these developments have influenced the population health in the respective cross-border regions is unclear. Hence, this scoping review aims to examine the empirical literature on the changes in health outcomes over time at the population level in EU cross-border areas. Additionally, we aim to identify the type of evidence and available data sources in those studies. Finally, we will determine the research gaps in the literature.

METHODS AND ANALYSIS

We will follow the Joanna Briggs Institute methodology for this scoping review. The 'Population-Concept-Context' framework will be used to identify the eligibility criteria. A three-step search strategy will be conducted to find relevant studies in the databases of PubMed, Web of Science, Scopus and EBSCOhost (SocIndex). Additionally, we will search on websites of international governmental institutions for further reports and articles. The finalisation of the search is planned for August 2023. The extracted data from the scoping review will be presented in a tabular form. A narrative summary of the selected studies will accompany the tabulated results and describe how they answer the research questions.

ETHICS AND DISSEMINATION

We will exclusively use secondary data from available studies for our analysis. Therefore, this review does not require ethical approval. We aim to publish our findings at (inter-)national conferences and as an open-access, peer-reviewed journal article.

Spatio-Temporal Trends in the Incidence of Type 2 Diabetes in Germany

BACKGROUND

There are no data on recent trends in the incidence rate of type 2 diabetes (T2D) in Germany. The aim of this study was to determine the sex-, age-, and region-specific trends in the T2D incidence rate between 2014 and 2019.

METHODS

Based on nationwide data from statutorily insured persons in Germany, negative binomial regression models were used to analyze age- and sex-specific trends in the T2D incidence rate. Age- and sex-adjusted trends were calculated for 401 administrative districts using a Bayesian spatio-temporal regression model.

RESULTS

During the period concerned, approximately 450 000 new cases of T2D were observed each year among some 63 million persons. Taking all age groups together, the incidence rate decreased in both women and men, from 6.9 (95% confidence interval [6.7; 7.0]) and 8.4 [8.2; 8.6] respectively per 1000 persons in 2014 to 6.1 [5.9; 6.3] and 7.7 [7.5; 8.0] per 1000 persons in 2019. This corresponds to an annual reduction of 2.4% [1.5; 3.2] for women and 1.7% [0.8; 2.5] for men. The incidence rate increased in the age group 20-39 years. The age- and sex-adjusted incidence rate decreased in almost all districts, although regional differences persisted.

CONCLUSION

The T2D incidence rate should be closely monitored to see whether the decreasing trend continues. One must not forget that the prevalence can rise despite decreasing incidence. For this reason, the findings do not necessarily mean a decrease in the disease burden of T2D and the associated demand on healthcare resources.

Assessing the risk of endogeneity bias in health and mortality inequalities research using composite measures of multiple deprivation which include health-related indicators: A case study using the Scottish Index of Multiple Deprivation and population health and mortality data

The inclusion of health-related indicators in composite measures of multiple deprivation introduces a risk of endogeneity bias when using the latter in health inequalities research. This bias may ultimately result in the inappropriate allocation of healthcare resources and maintenance of preventable health inequalities. Mitigation strategies to avoid this bias include removing the health-related indicators or using single constituent domains (such as income or employment class) in isolation. These strategies have not been widely validated. This study used population-level health and mortality data with a contemporary composite measure of multiple deprivation (Scottish Index of Multiple Deprivation; SIMD) to assess these mitigation strategies. The differences between deprivation methods (original, health excluded, and income domain) were negligible. The results of quantitative research on health inequalities are unlikely to be affected by endogeneity bias.

The impact of regional deprivation on stroke incidence, treatment, and mortality in Germany

BACKGROUND

Regional deprivation has been shown to be an influential factor in stroke incidence risk. However, there is a paucity of knowledge on regional differences in stroke incidence and mortality in Germany.

METHODS

We assessed data from the Diagnosis Related Groups statistics (2016-2019) and the German Federal Registry of Physicians (2019). Negative binomial regression analysis was used to examine the association between the German Index of Multiple Deprivation 2015 covering 401 districts and district-free cities in Germany and stroke incidence, treatment, and mortality.

RESULTS

The adjusted rate ratios of stroke incidence and mortality with the highest deprivation level compared with the least deprived area were 1.161 (95% CI [1.143, 1.179]) and 1.193 (95% CI [1.148, 1.239]), respectively. Moreover, this study revealed that physician density was higher in district-free cities compared to districts.

CONCLUSIONS

Our results indicate that regional deprivation is associated with incident and mortality cases of stroke, necessitating a more targeted approach to stroke prevention in deprived regions.

Psoriasis comorbidities in Germany: A population-based study on spatiotemporal variations

Psoriasis is a chronic disease with high impact on patients' health and their quality of life. Psoriasis often occurs along with other comorbidities, but it is not yet clear what role the comorbidities play in regional psoriasis prevalence. This study investigates the temporal and regional variation of the psoriasis comorbidities diabetes mellitus type II, obesity, hypertension, affective disorders in Germany and their association with psoriasis prevalence. This analysis based on the population set of ambulatory claims data (2010-2017) of the statutory health insurance (SHI) in Germany (approx. 70.3 million people in 2017). Psoriasis comorbidities rates were determined on county level. We performed descriptive spatiotemporal analyses of psoriasis comorbidity prevalence rates. In addition, we identified and compared spatial clusters and examined regional variations using spatial statistical methods. The results show strong regional variations (northeast to south gradient) and an increasing psoriasis prevalence (max. 28.8%) within the observation period. Considering the comorbidities, results indicate comparable spatial prevalence patterns for diabetes mellitus type II, obesity and hypertension. This means that the highest prevalence of comorbidities tends to be found where the psoriasis prevalence is highest. The spatiotemporal cluster analyses could once again confirm the results. An exception to this is to be found in the case of affective disorders with different spatial patterns. The results of the studies show the first spatiotemporal association between psoriasis prevalence and comorbidities in Germany. The causalities must be investigated in more detail in order to be able to derive measures for improved care.

Effect of socioeconomic status on survival in patients on the Diabetes Shared Care Program: Finding from a Taiwan nationwide cohort

BACKGROUND

The Diabetes Shared Care Program (DSCP) is an integrated care model in Taiwan to improve the care quality of patients with diabetes. Socioeconomic status (SES) is one of the important factors affecting health, and it is confirmed as a predictor of various diseases and deaths.This study aimed to determine the relationship between survival rate and SES among patients who participated in the DSCP.

METHODS

A cohort population-based study was conducted using the National Health Insurance Research Database of Taiwan from 2008 to 2013. The study subjects were type 2 diabetes. We defined individual SES and neighborhood SES by each patient's job category and household income, which were characterized as advantaged or disadvantaged. Then we compared the survival rates of SES groups by Cox proportional hazards model to adjust risk factors.

RESULTS

This study included 16 614 patients with type 2 diabetes who participated in the DSCP program. The DSCP cohort showed a high hospitalization rate in low individual SES. In terms of 10-year overall survival, DSCP participants with high individual SES living in advantaged and disadvantaged neighborhoods had lower risk of mortality than those with low SES living in advantaged and disadvantaged neighborhoods, after adjustment for age and comorbidity. DSCP participants with low individual SES living in disadvantaged neighborhoods had no significant difference of mortality as those with low individual SES living in advantaged neighborhoods.

CONCLUSION

In this study, we found that low individual SES, but not neighborhood SES, was associated with an increased mortality rate among DSCP participants.

Longitudinal relationship of particulate matter and metabolic control and severe hypoglycaemia in children and adolescents with type 1 diabetes

BACKGROUND

Evidence for the metabolic impact of long-term exposure to air pollution on diabetes is lacking. We investigated the association of particulate matter <10 μm (PM₁₀) and <2.5 μm (PM_2.5) with yearly averages of HbA1c, daily insulin dose (IU/kg) and rates of severe hypoglycaemia in type 1 diabetes (T1D).

METHODS

We studied data of 44,383 individuals with T1D < 21 years which were documented in 377 German centres within the diabetes prospective follow-up registry (DPV) between 2009 and 2018. Outcomes were aggregated by year and by patient. PM₁₀-and PM_2.5-yearly averages prior to the respective treatment year were linked to individuals via the five-digit postcode areas of residency. Repeated measures linear and negative binomial regression were used to study the association between PM-quartiles (Q1 lowest, Q4 highest concentration) and yearly averages of HbA1c, daily insulin dose and rates of severe hypoglycaemia (confounders: sex, time-dependent age, age at diabetes onset, time-dependent type of treatment, migratory background, degree of urbanisation and socioeconomic index of deprivation).

RESULTS

Adjusted mean HbA1c increased with PM₁₀ (Q1: 7.96% [95%-CI: 7.95-7.98], Q4: 8.03% [8.02-8.05], p-value<0.001) and with PM_2.5 (Q1: 7.97% [7.95-7.99], Q4: 8.02% [8.01-8.04], p < 0.001). Changes in daily insulin dose were inversely related to PM (PM₁₀ and PM_2.5: Q1 0.85 IU/kg [0.84-0.85], Q4: 0.83 IU/kg [0.82-0.83], p < 0.001). Adjusted rates of severe hypoglycaemia increased with PM-quartile groups (PM₁₀ Q1:11.2 events/100 PY [10.9-11.5], PM₁₀ Q4: 15.3 [14.9-15.7], p < 0.001; PM_2.5 Q1: 9.9 events/100 PY [9.6-10.2], PM_2.5 Q4: 14.2 [13.9-14.6], p < 0.001).

DISCUSSION

Air pollution was associated with higher HbA1c levels and increased risk of severe hypoglycaemia in people with T1D, consequently indicating a higher risk of diabetes complications. Further studies are needed to explore causal pathways of the observed associations.

Regional variations and prevalence of psoriasis in Germany from 2010 to 2017: a cross-sectional, spatio-epidemiological study on ambulatory claims data

OBJECTIVES

Global prevalence rates of psoriasis differ significantly, with lowest rates in the equator region and increasing tendencies towards the north but also differences within-country. Information on regional variations in Germany is missing. This study aims to analyse the change of psoriasis prevalence in Germany over time and to detect regional variations.

DESIGN

Cross sectional, spatio-epidemiological study on regional psoriasis prevalence in Germany.

SETTING

Claims data study based on nationwide outpatient billing data on county level.

METHODS

Analyses based on outpatient billing data for 2010-2017 derived from all people insured in statutory health insurances (about 72.8 million). We performed descriptive spatio-temporal analyses of prevalence rates using probability mapping and statistical smoothing methods, identified spatial clusters and examined a north-south gradient using spatial statistics.

RESULTS

The prevalence increased from 147.4 per 10 000 in 2010 to 173.5 in 2017. In 2017, counties' prevalence rates ranged between 93.8 and 340.9. Decreased rates occurred mainly in southern counties, increased rates in northern and eastern counties. Clusters of low rates occur in southern and south-western Germany, clusters of high rates in the north and north-east. The correlation between counties' latitudes and their prevalence rates was high with Pearson's r=0.65 (p<0.05).

CONCLUSION

Increased prevalence of psoriasis over time and marked regional variations in Germany were observed which need further investigation.

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.

Regional and sex differences in retinal detachment surgery: Japan-retinal detachment registry report

It is known that social factors affect the choice of treatments, and special attention has been paid to sex differences. The purpose of this study was to determine whether regional and sex differences exist in the treatment of rhegmatogenous retinal detachment (RD). We used Japan-RD Registry database of 2523 patients aged ≥ 40 years between February 2016 and March 2017 in 5 Japanese regions. Regional differences of patients' perioperative factors were analyzed. The factors affecting the proportion of patients who underwent surgery within one week of the onset, defined as early-surgery, were examined by logistic regression. We observed regional differences in perioperative factors, especially in the use of phacovitrectomy, general anesthesia, and air-tamponade, which was higher in certain regions. (Fisher's exact test, all P = 0.012) The proportion of early-surgery was significantly higher among men in Kyushu region (Odds ratio (OR) 1.83; 95% confidence interval (CI) 1.08-3.12; P = 0.02), and it was also significantly higher after adjusting for covariates (OR 1.89; 95% CI 1.06-3.42; P = 0.02). Regional and sex differences exist in the treatment of RD in Japan. Although there was no significant differences in the anatomical outcomes, women in certain regions of Japan are less likely to receive early surgical intervention for RD.

Association between sepsis incidence and regional socioeconomic deprivation and health care capacity in Germany - an ecological study

Background

Sepsis is a substantial health care burden. Data on regional variation in sepsis incidence in Germany and any possible associations with regional socioeconomic deprivation and health care capacity is lacking.

Methods

Ecological study based on the nationwide hospital Diagnosis-related Groups (DRG) statistics data of 2016. We identified sepsis by ICD-10-codes and calculated crude and age-standardized incidence proportions in the 401 administrative German districts. Associations between socioeconomic and health care capacity indicators and crude and age-adjusted sepsis incidence were investigated by simple and multiple negative binomial (NB) regressions.

Results

In 2016, sepsis incidence was 178 per 100,000 inhabitants and varied 10-fold between districts. We found that the rate of students leaving school without certificate was significantly associated with crude and age-standardized explicit sepsis incidence in the simple and multiple NB regressions. While we observed no evidence for an association to the capacity of hospital beds and general practitioners, the distance to the nearest pharmacy was associated with crude- and age-standardized sepsis incidence. In the multiple regression analyses, an increase of the mean distance + 1000 m was associated with an expected increase by 21.6 [95% CI, 10.1, 33.0] (p < 0.001), and 11.1 [95% CI, 1.0, 21.2]/100,000 population (p = .026) after adjusting for age differences between districts.

Conclusions

Residence in districts with lower socioeconomic status (e.g., less education) and further distance to pharmacies are both associated with an increased sepsis incidence. This warrants further research with individual-level patient data to better model and understand such dependencies and to ultimately design public health interventions to address the burden of sepsis in Germany.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11629-4.

Regional Deprivation, Stroke Incidence, and Stroke Care

BACKGROUND

Regional deprivation can increase the risk of illness and adversely affect care outcomes. In this study, we investigated for the German state of Rhineland-Palatinate whether spatial-structural disadvantages are associated with an increased frequency of ischemic stroke and with less favorable care outcomes.

METHODS

We compared billing data from DRG statistics (2008-2017) and quality assurance data (2017) for acute ischemic stroke with the German Index of Multiple Deprivation 2010 (GIMD 2010) for the 36 districts (Landkreise) and independent cities (i.e., cities not belonging to a district) in Rhineland-Palatinate using correlation analyses, a Poisson regression analysis, and logistic regression analyses.

RESULTS

The age-standardized stroke rates (ASR) ranged from 122 to 209 per 100 000 inhabitants, while the GIMD 2010 ranged from 4.6 to 47.5; the two values were positively correlated (Spearman's ρ = 0.47; 95% confidence interval [0.16; 0.85]). In 2017, mechanical thrombectomies were performed more commonly (5.7%) in the first GIMD 2010 quartile of the regional areas (i.e., in the least deprived areas) than in the remaining quartiles (4.2-4.6%). The intravenous thrombolysis rates showed no differences from one GIMD 2010 quartile to another. Severe neurological deficits (National Institutes of Health Stroke Scale ≥ 5) on admission to the hospital were slightly more common in the fourth quartile (i.e., in the most deprived areas), while antiplatelet drugs and statins were somewhat less commonly ordered on discharge in those areas than in the first quartile.

CONCLUSION

These findings document a relationship between regional deprivation and the occurrence of acute ischemic stroke. Poorer GIMD 2010 scores were associated with worse care outcomes in a number of variables, but the absolute differences were small.

Association between area- and individual-level socio-economic factors with glycated haemoglobin-Evidence from a Portuguese population-based study

AIMS

This study aims to estimate the associations between area-level deprivation and individual-level socio-economic factors, as well as their interaction, with glycated haemoglobin (HbA_1c ) levels.

METHODS

We conducted a gamma multilevel regression analysis using individual-level data from the Portuguese National Health Examination Survey and a deprivation index built through factor analysis, at municipality level, with census variables.

RESULTS

Living in a municipality with high material deprivation and having a low level of education were independently associated with an increase of 2.3% (95% confidence interval [CI] 0.6, 4.0) and of 1.6% (95% CI 0.6, 2.7) in the mean levels of HbA_1c , respectively. The interaction between area material deprivation and individual-level education was not associated with the levels of HbA_1c (0.5%, 95% CI -1.3, 2.3).

CONCLUSIONS

Our findings support the collective resources model that argues that people in less deprived areas have better health because there are more collective resources. The results suggest that to reduce socio-economic inequalities associated with the levels of HbA_1c and, consequently, with diabetes, will require attention to the area material deprivation and individual-level education. Upstream social determinants of health are thus highlighted.

Association of diabetes type and chronic diabetes complications with early exit from the labour force: register-based study of people with diabetes in Finland

AIMS/HYPOTHESIS

Diabetes and diabetes complications are a cause of substantial morbidity, resulting in early exits from the labour force and lost productivity. The aim of this study was to examine differences in early exits between people with type 1 and 2 diabetes and to assess the role of chronic diabetes complications on early exit. We also estimated the economic burden of lost productivity due to early exits.

METHODS

People of working age (age 17-64) with diabetes in 1998-2011 in Finland were detected using national registers (Ntype 1 = 45,756, Ntype 2 = 299,931). For the open cohort, data on pensions and deaths, healthcare usage, medications and basic demographics were collected from the registers. The outcome of the study was early exit from the labour force defined as pension other than old age pension beginning before age 65, or death before age 65. We analysed the early exit outcome and its risk factors using the Kaplan-Meier method and extended Cox regression models. We fitted linear regression models to investigate the risk factors of lost working years and productivity costs among people with early exit.

RESULTS

The difference in median age at early exit from the labour force between type 1 (54.0) and type 2 (58.3) diabetes groups was 4.3 years. The risk of early exit among people with type 1 diabetes increased faster after age 40 compared with people with type 2 diabetes. Each of the diabetes complications was associated with an increase in the hazard of early exit regardless of diabetes type compared with people without the complication, with eye-related complications as an exception. Diabetes complications partly but not completely explained the difference between diabetes types. The mean lost working years was 6.0 years greater in the type 1 diabetes group than in the type 2 diabetes group among people with early exit. Mean productivity costs of people with type 1 diabetes and early exit were found to be 1.4-fold greater compared with people with type 2 diabetes. The total productivity costs of incidences of early exits in the type 2 diabetes group were notably higher compared with the type 1 group during the time period (€14,400 million, €2800 million).

CONCLUSIONS/INTERPRETATION

We found a marked difference in the patterns of risk of early exit between people with type 1 and type 2 diabetes. The difference was largest close to statutory retirement age. On average, exits in the type 1 diabetes group occurred at an earlier age and resulted in higher mean lost working years and mean productivity costs. The potential of prevention, timely diagnosis and management of diabetes is substantial in terms of avoiding reductions in individual well-being and productivity.

Low health literacy is associated with higher risk of type 2 diabetes: a cross-sectional study in Germany

Background

Low health literacy is believed to be associated with behaviours that increase the risk of type 2 diabetes. But there is limited knowledge on the relation between health literacy (HL) and diabetes risk, and whether improving HL could be a potential prevention strategy. Therefore, the main purpose of this study was to examine the link between HL and diabetes risk among non-diabetic adults.

Methods

We used data from the Hamburg Diabetes Prevention Survey, a population-based cross-sectional study in Germany. One thousand, two hundred and fifty-five non-diabetic subjects aged 18–60 years were eligible. The German Diabetes Risk Score (GDRS, ranging 0 to 123 points) was used to determine the individual risk of type 2 diabetes. The short version of the European Health Literacy Questionnaire (HLS-EU-Q16, ranging 0 to 16 points) was applied to assess the individual self-reported HL. Subjects were asked to self-estimate their diabetes risk, which was then compared with the calculated GDRS. Descriptive statistics were calculated to investigate group differences in the GDRS and self-estimated diabetes risk. Linear as well as logistic regression models were performed to analyse potential influencing variables of the GDRS as well as incorrect self-estimated diabetes risk. In three nested statistical models for each outcome, these analyses were adjusted for age, gender, educational level and the presence of chronic conditions.

Results

According to the criteria of the GDRS, 996 (79.4%) subjects showed “low risk”, 176 (14.0%) “still low risk”, 53 (4.2%) “elevated risk”, and 30 (2.4%) “high to very high risk” to develop type 2 diabetes within the next 5 years. In the statistical models including all control variables, subjects with “inadequate HL” scored 2.38 points higher on the GDRS (95% CI 0.378 to 4.336; P = 0.020) and had a 2.04 greater chance to estimate their diabetes risk incorrectly (OR 2.04; 95% CI 1.33 to 3.14; P = 0.001) compared to those with “sufficient HL”.

Conclusion

The risk of type 2 diabetes is increased in people with inadequate self-reported HL. People with high diabetes risk and inadequate HL might be provided with educational programs to improve diabetes knowledge and reduce behavioural risk factors.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10508-2.

Influencing Indicators and Spatial Variation of Diabetes Mellitus Prevalence in Shandong, China: A Framework for Using Data-Driven and Spatial Methods

To control and prevent the risk of diabetes, diabetes studies have identified the need to better understand and evaluate the associations between influencing indicators and the prevalence of diabetes. One constraint has been that influencing indicators have been selected mainly based on subjective judgment and tested using traditional statistical modeling methods. We proposed a framework new to diabetes studies using data-driven and spatial methods to identify the most significant influential determinants of diabetes automatically and estimated their relationships. We used data from diabetes mellitus patients' health insurance records in Shandong province, China, and collected influencing indicators of diabetes prevalence at the county level in the sociodemographic, economic, education, and geographical environment domains. We specified a framework to identify automatically the most influential determinants of diabetes, and then established the relationship between these selected influencing indicators and diabetes prevalence. Our autocorrelation results showed that the diabetes prevalence in 12 Shandong cities was significantly clustered (Moran's I = 0.328, p < 0.01). In total, 17 significant influencing indicators were selected by executing binary linear regressions and lasso regressions. The spatial error regressions in different subgroups were subject to different diabetes indicators. Some positive indicators existed significantly like per capita fruit production and other indicators correlated with diabetes prevalence negatively like the proportion of green space. Diabetes prevalence was mainly subjected to the joint effects of influencing indicators. This framework can help public health officials to inform the implementation of improved treatment and policies to attenuate diabetes diseases.

Association of community types and features in a case-control analysis of new onset type 2 diabetes across a diverse geography in Pennsylvania

OBJECTIVES

To evaluate associations of community types and features with new onset type 2 diabetes in diverse communities. Understanding the location and scale of geographic disparities can lead to community-level interventions.

DESIGN

Nested case-control study within the open dynamic cohort of health system patients.

SETTING

Large, integrated health system in 37 counties in central and northeastern Pennsylvania, USA.

PARTICIPANTS AND ANALYSIS

We used electronic health records to identify persons with new-onset type 2 diabetes from 2008 to 2016 (n=15 888). Persons with diabetes were age, sex and year matched (1:5) to persons without diabetes (n=79 435). We used generalised estimating equations to control for individual-level confounding variables, accounting for clustering of persons within communities. Communities were defined as (1) townships, boroughs and city census tracts; (2) urbanised area (large metro), urban cluster (small cities and towns) and rural; (3) combination of the first two; and (4) county. Community socioeconomic deprivation and greenness were evaluated alone and in models stratified by community types.

RESULTS

Borough and city census tract residence (vs townships) were associated (OR (95% CI)) with higher odds of type 2 diabetes (1.10 (1.04 to 1.16) and 1.34 (1.25 to 1.44), respectively). Urbanised areas (vs rural) also had increased odds of type 2 diabetes (1.14 (1.08 to 1.21)). In the combined definition, the strongest associations (vs townships in rural areas) were city census tracts in urban clusters (1.41 (1.22 to 1.62)) and city census tracts in urbanised areas (1.33 (1.22 to 1.45)). Higher community socioeconomic deprivation and lower greenness were each associated with increased odds.

CONCLUSIONS

Urban residence was associated with higher odds of type 2 diabetes than for other areas. Higher community socioeconomic deprivation in city census tracts and lower greenness in all community types were also associated with type 2 diabetes.

Toward targeted prevention: risk factors for prediabetes defined by impaired fasting glucose, impaired glucose tolerance and increased HbA1c in the population-based KORA study from Germany

AIMS

To identify socioeconomic, behavioral and clinical factors that are associated with prediabetes according to different prediabetes definition criteria.

METHODS

Analyses use pooled data of the population-based Cooperative Health Research in the Region of Augsburg (KORA) studies (n = 5312 observations aged ≥ 38 years without diabetes). Prediabetes was defined through either impaired fasting glucose (IFG), impaired glucose tolerance (IGT) or elevated HbA1c according to thresholds of the American Diabetes Association. Explanatory variables were regressed on prediabetes using generalized estimating equations.

RESULTS

Mean age was 58.4 years; 50% had prediabetes (33% had IFG, 16% IGT, and 26% elevated HbA1c, 10% fulfilled all three criteria). Age, obesity, hypertension, low education, unemployment, statutory health insurance, urban residence and physical inactivity were associated with prediabetes. Male sex was a stronger risk factor for IFG (OR = 2.5; 95%-CI: 2.2-2.9) than for IGT or elevated HbA1c, and being unemployed was a stronger risk factor for IGT (OR = 3.2 95%-CI: 2.6-4.0) than for IFG or elevated HbA1c.

CONCLUSIONS

The overlap of people with IFG, IGT and elevated HbA1c is small, and some factors are associated with only one criterion. Knowledge on sociodemographic and socioeconomic risk factors can be used to effectively target interventions to people at high risk for type 2 diabetes.

Patients with coronary artery disease after acute myocardial infarction: effects of continuous enrollment in a structured Disease Management Program on adherence to guideline-recommended medication, health care expenditures, and survival

OBJECTIVE

Acute myocardial infarction (AMI) carries increased risk of mortality and excess costs. Disease Management Programs (DMPs) providing guideline-recommended care for chronic diseases seem an intuitively appealing way to enhance health outcomes for patients with chronic conditions such as AMI. The aim of the study is to compare adherence to guideline-recommended medication, health care expenditures and survival of patients enrolled and not enrolled in the German DMP for coronary artery disease (CAD) after an AMI from the perspective of a third-party payer over a follow-up period of 3 years.

METHODS

The study is based on routinely collected data from a regional statutory health insurance fund (n = 15,360). A propensity score matching with caliper method was conducted. Afterwards guideline-recommended medication, health care expenditures, and survival between patients enrolled and not enrolled in the DMP were compared with generalized linear and Cox proportional hazard models.

RESULTS

The propensity score matching resulted in 3870 pairs of AMI patients previously and continuously enrolled and not enrolled in the DMP. In the 3-year follow-up period the proportion of days covered rates for ACE-inhibitors (60.95% vs. 58.92%), anti-platelet agents (74.20% vs. 70.66%), statins (54.18% vs. 52.13%), and β-blockers (61.95% vs. 52.64%) were higher in the DMP group. Besides that, DMP participants induced lower health care expenditures per day (€58.24 vs. €72.72) and had a significantly lower risk of death (HR: 0.757).

CONCLUSION

Previous and continuous enrollment in the DMP CAD for patients after AMI is a promising strategy as it enhances guideline-recommended medication, reduces health care expenditures and the risk of death.

Sociodemographic and lifestyle-related risk factors for identifying vulnerable groups for type 2 diabetes: a narrative review with emphasis on data from Europe

BACKGROUND

Type 2 diabetes mellitus (T2DM) comprises the vast majority of all diabetes cases in adults, with alarmingly increasing prevalence over the past few decades worldwide. A particularly heavy healthcare burden of diabetes is noted in Europe, where 8.8% of the population aged 20-79 years is estimated to have diabetes according to the International Diabetes Federation. Multiple risk factors are implicated in the pathogenesis of T2DM with complex underlying interplay and intricate gene-environment interactions. Thus, intense research has been focused on studying the role of T2DM risk factors and on identifying vulnerable groups for T2DM in the general population which can then be targeted for prevention interventions.

METHODS

For this narrative review, we conducted a comprehensive search of the existing literature on T2DM risk factors, focusing on studies in adult cohorts from European countries which were published in English after January 2000.

RESULTS

Multiple lifestyle-related and sociodemographic factors were identified as related to high T2DM risk, including age, ethnicity, family history, low socioeconomic status, obesity, metabolic syndrome and each of its components, as well as certain unhealthy lifestyle behaviors. As Europe has an increasingly aging population, multiple migrant and ethnic minority groups and significant socioeconomic diversity both within and across different countries, this review focuses not only on modifiable T2DM risk factors, but also on the impact of pertinent demographic and socioeconomic factors.

CONCLUSION

In addition to other T2DM risk factors, low socioeconomic status can significantly increase the risk for prediabetes and T2DM, but is often overlooked. In multinational and multicultural regions such as Europe, a holistic approach, which will take into account both traditional and socioeconomic/socioecological factors, is becoming increasingly crucial in order to implement multidimensional public health programs and integrated community-based interventions for effective T2DM prevention.

A greedy stacking algorithm for model ensembling and domain weighting

OBJECTIVE

Because it is impossible to know which statistical learning algorithm performs best on a prediction task, it is common to use stacking methods to ensemble individual learners into a more powerful single learner. Stacking algorithms are usually based on linear models, which may run into problems, especially when predictions are highly correlated. In this study, we develop a greedy algorithm for model stacking that overcomes this issue while still being very fast and easy to interpret. We evaluate our greedy algorithm on 7 different data sets from various biomedical disciplines and compare it to linear stacking, genetic algorithm stacking and a brute force approach in different prediction settings. We further apply this algorithm on a task to optimize the weighting of the single domains (e.g., income, education) that build the German Index of Multiple Deprivation (GIMD) to be highly correlated with mortality.

RESULTS

The greedy stacking algorithm provides good ensemble weights and outperforms the linear stacker in many tasks. Still, the brute force approach is slightly superior, but is computationally expensive. The greedy weighting algorithm has a variety of possible applications and is fast and efficient. A python implementation is provided.

Prevalence of modifiable cardiovascular risk factors in Yazd inner-city municipalities

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death in the world. With effective intervention and control of cardiovascular risk factors, mortality rates may be reduced. The aim of this study was to investigate the prevalence of modifiable risk factors across five municipalities in Yazd city.

METHODS

Ten thousand residents of the Yazd greater area aged 20-69 years were selected using cluster random sampling method. Overall, 200 clusters were randomly selected based on the postcodes of residents who lived in the five municipalities of Yazd. Those who lived in Yazd annexed cities and rural areas were excluded. A valid questionnaire was completed and physical examination performed as done (94.9% response rate). Instances of self-reported diabetes mellitus, high blood cholesterol, tobacco smoking, and unhealthy diet were recorded. Blood pressure, height, and weight were measured and physical activity was classified by International Physical Activity Questionnaire (IPAQ). A chi-square test was used to analyze the differences in variables across municipalities. Statistical analyses were performed using SPSS V. 16.

RESULTS

We analyzed 8749 participants' data from Yazd city. The prevalence of diabetes mellitus, hypercholesterolemia, and hypertension were 14.1, 16.7 and 18.6%, respectively. One in every four people consumed the recommended five servings of vegetables per day. Fish consumption was less than 5% at least once a week among participants. An unhealthy diet (85.7%); low physical activity (52.2%), hypertension (36.7%) and obesity (26.3%) were the most common cardiovascular risk factors. Only 2.1% of adults had no risk factors for CVD, and almost 75% of people had more than one risk factor. The prevalence of risk factors (excluding hypertension) was significantly different across the municipalities. Residents of region three had the highest prevalence of all risk factors aside from inactivity and unhealthy diet.

CONCLUSION

unhealthy dietary habits and inactivity are the most common modifiable risk factors of CVD in Yazd. Spatial variations of cardiovascular risk factors observed. This geographic health inequality requires more attention from policymakers to control CVD risk factors across different municipalities accordingly. Promoting healthy lifestyle is the top priority of health intervention programs. It is recommended to increase access to sport arenas and restrict access to tobacconist in high-risk areas.

Association between regional deprivation and type 2 diabetes incidence in Germany

Objective

The aim of this analysis was to estimate the association between regional deprivation and type 2 diabetes incidence and to investigate differences by age and sex for Germany.

Research design and methods

Type 2 diabetes incidence rate ratios comparing the most deprived fifth of the population to the remainder of the population (divided into quintiles) were estimated using the illness-death model, which describes the relationship between prevalence, mortality, and incidence. For the analysis, we used the type 2 diabetes prevalence and the general mortality rate according to deprivation quintiles, which we calculated based on valid estimates for Germany. Because mortality rate ratios for people with type 2 diabetes compared with people without type 2 diabetes are lacking for Germany, we used estimates from Scotland. Estimates were standardized to the German population in 2012 and stratified by sex.

Results

Incidence of type 2 diabetes was estimated to be over twice as high among people living in the most deprived regions of Germany compared with people living in the least deprived regions (men: 2.41, 95% CI 1.27 to 4.28; women: 2.40, 95% CI 1.25 to 4.29). The strength of the association increased with increasing age until the age of 75 years. No sex differences were present.

Conclusions

The study adds new evidence regarding the association between type 2 diabetes incidence and regional deprivation for Germany. The results underpin the importance to intensify public health actions to reduce social inequalities in Germany and whole Europe in the future.

[Socioeconomic status and health insurance expenditures for children and adolescents with conduct disorder : An analysis of statutory health insurance data]

BACKGROUND

For various psychiatric and somatic disorders, there is evidence of an association between patients' socioeconomic status (SES), healthcare utilisation, and the resulting costs. In the field of child and adolescent psychiatric disorders, studies on this topic are lacking.

OBJECTIVES

To exploratively analyse the association of healthcare expenditures for children and adolescents with conduct disorder (including oppositional-defiant disorder) - one of the most prevalent child and adolescent psychiatric disorders - and SES.

MATERIALS AND METHODS

The analysis is based on routine data from the German statutory health insurance company AOK Nordost for the calendar year 2011, covering 6461 children and adolescents (age 5-18 years) with an ICD-10 diagnosis of conduct disorder. The insureds' SES was estimated indirectly, based on the social structure of the postcode area, using the German Index of Multiple Deprivation (Mecklenburg-Vorpommern, Brandenburg), and the Berliner Sozialindex I (Berlin), respectively. From the two indices, quintiles were derived. Based on these quintiles, average costs per case for the following cost types were analysed: inpatient healthcare, outpatient healthcare (general practitioners, paediatricians, child and adolescent psychiatrists, child and adolescent psychotherapists), and prescribed medication.

RESULTS

There was no significant functional association between SES and healthcare costs for any of the analysed cost types.

CONCLUSIONS

In contrast to findings in adults, this study on children and adolescents with conduct disorders did not reveal an association between SES and healthcare costs. Within this group of patients, social inequality does not seem to have a significant influence on healthcare utilisation in Germany.

Do alternative weighting approaches for an Index of Multiple Deprivation change the association with mortality? A sensitivity analysis from Germany

OBJECTIVES

This study aimed to assess the impact of using different weighting procedures for the German Index of Multiple Deprivation (GIMD) investigating their link to mortality rates.

DESIGN AND SETTING

In addition to the original (normative) weighting of the GIMD domains, four alternative weighting approaches were applied: equal weighting, linear regression, maximization algorithm and factor analysis. Correlation analyses to quantify the association between the differently weighted GIMD versions and mortality based on district-level official data from Germany in 2010 were applied (n=412 districts).

OUTCOME MEASURES

Total mortality (all age groups) and premature mortality (<65 years).

RESULTS

All correlations of the GIMD versions with both total and premature mortality were highly significant (p<0.001). The comparison of these associations using Williams's t-test for paired correlations showed significant differences, which proved to be small in respect to absolute values of Spearman's rho (total mortality: between 0.535 and 0.615; premature mortality: between 0.699 and 0.832).

CONCLUSIONS

The association between area deprivation and mortality proved to be stable, regardless of different weighting of the GIMD domains. The theory-based weighting of the GIMD should be maintained, due to the stability of the GIMD scores and the relationship to mortality.

Risk Factors for Underdiagnosis of Diabetes Based on the Korean National Health and Nutrition Examination Survey 2013-2015

We included 11 298 subjects aged 30 years or older without diagnosis of diabetes by doctors who had undergone A1C screening. The diagnostic criterion for diabetes was A1C ≥6.5% (48 µmol/mol). This cross-sectional study was performed by reflecting weight of the sample in Korean National Health and Nutrition Examination Survey to represent South Korea. Risk factors were age (odds ratio [OR] = 1.06, 95% confidence interval [CI] = 1.04-1.08), Medicaid beneficiary (OR = 2.77, 95% CI = 1.25-6.14), presence of family history of diabetes (OR = 1.97, 95% CI = 1.36-2.84), serum triglyceride level (OR = 1.01, 95% CI = 1.01-1.03), serum high-density lipoprotein level (OR = 0.96, 95% CI = 0.95-0.98), currently smoking (OR = 1.85, 95% CI = 1.20-2.85), and the presence of regular checkup (OR = 1.41, 95% CI = 1.01-2.00). To prevent diabetes with a healthy life, it is necessary to establish a diabetes prevention program for vulnerable people and implement health-related policies such as smoking cessation and regular checkups.

Vertigo and dizziness cause considerable more health care resource use and costs: results from the KORA FF4 study

OBJECTIVES

Vertigo is a common reason for primary care consultations, and its diagnosis and treatment consume considerable medical resources. However, limited information on the specific cost of vertigo is currently available. The aim of this study is to analyse the health care costs of vertigo and examine which individual characteristics would affect these costs.

STUDY DESIGN

We used cross-sectional data from the German KORA ("Cooperative Health Research in the Augsburg Region") FF4 study in 2013.

METHODS

Impact of personal characteristics and other factors was modelled using a two-part model. Information on health care utilisation was collected by self-report.

RESULTS

We included 2277 participants with a mean age of 60.8 (SD = 12.4), 48.4% male. Moderate or severe vertigo was reported by 570 (25.0%) participants. People with vertigo spent 818 Euro more than people without vertigo in the last 12 months (2720.9 Euro to 1902.9 Euro, SD = 4873.3 and 5944.1, respectively). Consultation costs at primary care physicians accounted for the largest increase in total health care costs with 177.2 Euro (p < 0.01). After adjusting for covariates, the presence of vertigo increased both the probability of having any health care costs (OR = 1.6, 95% CI =[1.2;2.4]) and the amount of costs (exp(β) = 1.3, 95% CI = [1.1;1.5]). The analysis of determinants of vertigo showed that private insurance and a medium level of education decreased the probability of any costs, while higher income increased it.

CONCLUSIONS

The presence of vertigo and dizziness required considerable health care resources and created significantly more related costs in different health care sectors for both primary and pertinent secondary care.

Towards more Accessible Precision Medicine: Building a more Transferable Machine Learning Model to Support Prognostic Decisions for Micro- and Macrovascular Complications of Type 2 Diabetes Mellitus

Although machine learning models are increasingly being developed for clinical decision support for patients with type 2 diabetes, the adoption of these models into clinical practice remains limited. Currently, machine learning (ML) models are being constructed on local healthcare systems and are validated internally with no expectation that they would validate externally and thus, are rarely transferrable to a different healthcare system. In this work, we aim to demonstrate that (1) even a complex ML model built on a national cohort can be transferred to two local healthcare systems, (2) while a model constructed on a local healthcare system's cohort is difficult to transfer; (3) we examine the impact of training cohort size on the transferability; and (4) we discuss criteria for external validity. We built a model using our previously published Multi-Task Learning-based methodology on a national cohort extracted from OptumLabs® Data Warehouse and transferred the model to two local healthcare systems (i.e., University of Minnesota Medical Center and Mayo Clinic) for external evaluation. The model remained valid when applied to the local patient populations and performed as well as locally constructed models (concordance: .73-.92), demonstrating transferability. The performance of the locally constructed models reduced substantially when applied to each other's healthcare system (concordance: .62-.90). We believe that our modeling approach, in which a model is learned from a national cohort and is externally validated, produces a transferable model, allowing patients at smaller healthcare systems to benefit from precision medicine.

Patient and disease characteristics of type-2 diabetes patients with or without chronic kidney disease: an analysis of the German DPV and DIVE databases

BACKGROUND

To evaluate the characteristics of type 2 diabetes (T2DM) patients with or without chronic kidney disease (CKD) in Germany.

METHODS

Using combined DPV/DIVE registry data, the analysis included patients with T2DM at least ≥ 18 years old who had an estimated glomerular filtration rate (eGFR) value available. CKD was defined as an eGFR < 60 mL/min/1.73 m2 or eGFR ≥ 60 mL/min/1.73 m2 and albuminuria (≥ 30 mg/g). Median values of the most recent treatment year per patient are reported.

RESULTS

Among 343,675 patients with T2DM 171,930 had CKD. Patients with CKD had a median eGFR of 48.9 mL/min/1.73 m2 and 51.2% had a urinary albumin level ≥ 30 mg/g. They were older, had a longer diabetes duration and a higher proportion was females compared to patients without CKD (all p < 0.001). More than half of CKD patients (53.5%) were receiving long-acting insulin-based therapy versus around 39.1% of those without (p < 0.001). CKD patients also had a higher rate of hypertension (79.4% vs 72.0%; p < 0.001). The most common antihypertensive drugs among CKD patients were renin-angiotensin-aldosteron system inhibitors (angiotensin converting enzyme inhibitors 33.8%, angiotensin receptor blockers 14.2%) and diuretics (40.2%). CKD patients had a higher rate of dyslipidemia (88.4% vs 86.3%) with higher triglyceride levels (157.9 vs 151.0 mg/dL) and lower HDL-C levels (men: 40.0 vs 42.0 mg/dL; women: 46.4 vs 50.0 mg/dL) (all p < 0.001) and a higher rate of hyperkalemia (> 5.5 mmol/L: 3.7% vs. 1.0%). Comorbidities were more common among CKD patients (p < 0.001).

CONCLUSION

The results illustrate the prevalence and morbidity burden associated with diabetic kidney disease in patients with T2DM in Germany. The data call for more attention to the presence of chronic kidney disease in patients with diabetes, should trigger intensified risk factor control up and beyond the control of blood glucose and HbA1c in these patients. They may also serve as a trigger for future investigations into this patient population asking for new treatment options to be developed.

[Indices of Multiple Deprivation for the analysis of regional health disparities in Germany : Experiences from epidemiology and healthcare research]

BACKGROUND

Deprivation indices allow material and social differences at the regional level to be described in a statistically efficient and concise manner and to use these in health analyses. Following the British example, Indices of Multiple Deprivation (IMDs) are now available for Germany, the German Index of Multiple Deprivation (GIMD) as well as its regional versions. In this study, empirical experiences based on the use of these indices in health studies will be presented.

METHOD

The German IMDs consist of seven deprivation domains, which represent single aspects of deprivation (income, employment, and educational deprivation, municipal revenue deprivation, social capital deprivation, environment and security deprivation). Specific indicators were generated from data of official statistics and assigned to the deprivation domains. The weighted single domains were finally combined to an overall index. The German IMDs are available at a municipal level and at a district level.

RESULTS

Analyses using the IMDs showed significant associations between regional deprivation and mortality, morbidity and aspects of health services research. Multilevel analyses showed significant associations with regional deprivation, independent of individual factors.

CONCLUSIONS

The German IMDs are valid and efficient tools for the use in epidemiology and health services research, but also for health policy. When constructing deprivation indices, several methodological challenges have to be considered.

Individual and area-level determinants associated with C-reactive protein as a marker of cardiometabolic risk among adults: Results from the German National Health Interview and Examination Survey 2008-2011

BACKGROUND

High-sensitivity C-reactive protein (hsCRP) is a sensitive biomarker of systemic inflammation and is related to the development and progression of cardiometabolic diseases. Beyond individual-level determinants, characteristics of the residential physical and social environment are increasingly recognized as contextual determinants of systemic inflammation and cardiometabolic risks. Based on a large nationwide sample of adults in Germany, we analyzed the cross-sectional association of hsCRP with residential environment characteristics. We specifically asked whether these associations are observed independent of determinants at the individual level.

METHODS

Data on serum hsCRP levels and individual sociodemographic, behavioral, and anthropometric characteristics were available from the German Health Interview and Examination Survey for Adults (2008-2011). Area-level variables included, firstly, the predefined German Index of Socioeconomic Deprivation (GISD) derived from the INKAR (indicators and maps on spatial and urban development in Germany and Europe) database and, secondly, population-weighted annual average concentration of particulate matter (PM10) in ambient air provided by the German Environment Agency. Associations with log-transformed hsCRP levels were analyzed using random-intercept multi-level linear regression models including 6,768 participants aged 18-79 years nested in 162 municipalities.

RESULTS

No statistically significant association of PM10 exposure with hsCRP was observed. However, adults residing in municipalities with high compared to those with low social deprivation showed significantly elevated hsCRP levels (change in geometric mean 13.5%, 95%CI 3.2%-24.7%) after adjusting for age and sex. The observed relationship was independent of individual-level educational status. Further adjustment for smoking, sports activity, and abdominal obesity appeared to markedly reduce the association between area-level social deprivation and hsCRP, whereas all individual-level variables contributed significantly to the model.

CONCLUSIONS

Area-level social deprivation is associated with higher systemic inflammation and the potentially mediating role of modifiable risk factors needs further elucidation. Identifying and assessing the source-specific harmful components of ambient air pollution in population-based studies remains challenging.

Impact of maternal income on the risk of gestational diabetes mellitus in primiparous women

AIMS

Findings concerning the impact of socio-economic status on the risk of gestational diabetes mellitus (GDM) are inconclusive and little is known about the simultaneous impact of income and educational attainment on the risk of GDM. This study aims to assess the impact of maternal prepregnancy income in combination with traditional GDM risk factors on the incidence of GDM in primiparous women.

METHODS

This is an observational cohort study including 5962 Finnish women aged ≥ 20 years from the city of Vantaa, Finland, who delivered for the first time between 2009 and 2015, excluding women with pre-existing diabetes mellitus. The Finnish Medical Birth Register, Finnish Tax Administration, Statistics Finland, Social Insurance Institution of Finland and patient healthcare records provided data for the study. We divided the study population according to five maternal income levels and four educational attainment levels.

RESULTS

Incidence of GDM decreased with increasing income level in primiparous women (P < 0.001 for linearity, adjusted for smoking, age, BMI and cohabiting status). In an adjusted two-way model, the relationship was significant for both income (P = 0.007) and education (P = 0.039), but there was no interaction between income and education (P = 0.52).

CONCLUSIONS

There was an inverse relationship between both maternal prepregnancy taxable income and educational attainment, and the risk of GDM in primiparous Finnish women.

'Learning to shape life' - a qualitative study on the challenges posed by a diagnosis of diabetes mellitus type 2

Background

Diabetes mellitus type 2 is a central challenge for health policy and healthcare in all advanced countries. For the affected persons, living with a diagnosis of type 2 diabetes is difficult because the disease and its treatment have a considerable effect on daily life. The aim of this study was to investigate the challenges associated with a diagnosis of type 2 diabetes for those affected and the range, depth and complexities of the subjective perspectives of the patients under the conditions of the German healthcare system.

Methods

A cross-sectional qualitative study was conducted using a sample of 19 adult patients with type 2 diabetes mellitus. Patients were recruited successively from two specialized diabetological practices, three general practitioner’s offices, and two hospitals. The patients were interviewed once in person using semi-structured interviews. All interviews were recorded, transcribed, and analysed based on grounded theory.

Results

Persons affected by diabetes mellitus type 2 seem to feel responsible for managing their disease. Two strategies of action could be identified: 1) patients strictly followed the recommendations of the physicians, or 2) they showed that they are knowledgably managing their diabetes mellitus type 2. The action strategy to address the disease seemed to be influenced by patients’ confidence in themselves, the effectiveness of the interventions, or the patients’ locus of control. Minor differences in educational status could be discovered, and patients who were less educated tended to follow the recommendations of the physicians very strictly and seemed to place more emphasis on being compliant, which goes hand in hand with a life with prohibitions and restrictions. In contrast, being perceived as competent patients who make their own rules to manage the disease in daily life appeared to be more important for people with higher education levels.

Conclusion

Patient education and self-management programmes for diabetes mellitus type 2 should take different types of learners into account. Giving less-educated patients specific recommendations for successful diabetes self-management is particularly important.

Trial registration

German clinical trial register (DRKS-ID: DRKS00007847).

Electronic supplementary material

The online version of this article (10.1186/s12939-019-0924-3) contains supplementary material, which is available to authorized users.

Prevalence, Determinants, and Consequences of Vestibular Hypofunction. Results From the KORA-FF4 Survey

Objective: Uni- or bilateral vestibular hypofunction (VH) impairs balance and mobility, and may specifically lead to injury from falls and to disability. The extent of this problem in the general population is still unknown and most likely to be underestimated. Objective of this study was to determine the prevalence, determinants, and consequences of VH in the general population. Methods: Data originates from the cross-sectional second follow-up (FF4) in 2013/14 of the KORA (Cooperative Health Research in the Region of Augsburg)-S4 study (1999-2001) from Southern Germany. This was a random sample of the target population consisting of all residents of the region aged 25-74 years in 1999. We included all participants who reported moderate or severe vertigo or dizziness during the last 12 months and a random sub-sample of participants representative for the general population without vertigo or dizziness during the last 12 months were tested. VH was assessed with the Video-Head Impulse Test (vHIT). Trained examiners applied high-acceleration, small-amplitude passive head rotations ("head impulses") to the left and right in the plane of the horizontal semicircular canals while participants fixated a target straight ahead. During head impulses, head movements were measured with inertial sensors, eye movements with video-oculography (EyeSeeCam vHIT). Results: A total of 2,279 participants were included (mean age 60.8 years, 51.6% female), 570 (25.0%) with moderate or severe vertigo or dizziness during the last 12 months. Of these, 450 were assessed with vHIT where 26 (5.8%) had unilateral VH, and 16 (3.6%) had bilateral VH. Likewise, 190 asymptomatic participants were tested. Of these 5 (2.6%) had unilateral VH, and 2 (1.1%) had bilateral VH. Prevalence of uni- or bilateral VH among tested symptomatic participants was 2.4% in those < 48 years, and 32.1% in individuals aged 79 and over. Age-adjusted prevalence was 6.7% (95% CI 4.8%; 8.6%). VH was associated with worse health, falls, hearing loss, hearing impairment, and ear pressure. Conclusion: VH may affect between 53 and 95 million adults in Europe and the US. While not all affected persons will experience the full spectrum of symptoms and consequences, adequate diagnostic and therapeutic measures should become standard of care to decrease the burden of disease.

Regional differences of macrovascular disease in Northeast and South Germany: the population-based SHIP-TREND and KORA-F4 studies

BACKGROUND

Previous studies found regional differences in the prevalence and incidence of type 2 diabetes between Northeast and South of Germany. The aim of this study was to investigate if regional variations are also present for macrovascular disease in people with type 2 diabetes and in the general population. A further aim was to investigate if traditional risk factors of macrovascular complications can explain these regional variations.

METHODS

Data of persons aged 30-79 from two regional population-based studies, SHIP-TREND (Northeast Germany, 2008-2012, n = 2539) and KORA-F4 (South Germany, 2006-2008, n = 2932), were analysed. Macrovascular disease was defined by self-reported previous myocardial infarction, stroke or coronary angiography. Multivariable logistic regression was performed to estimate odds ratios (OR) and 95% confidence intervals (CI) for prevalence of macrovascular disease in persons with type 2 diabetes and in the general population.

RESULTS

The prevalence of macrovascular disease in persons with type 2 diabetes and in the general population was considerably higher in the Northeast (SHIP-TREND: 32.8 and 12.0%) than in the South of Germany (KORA-F4: 24.9 and 8.8%), respectively. The odds of macrovascular disease in persons with type 2 diabetes was 1.66 (95% CI: 1.11-2.49) in the Northeast in comparison to the South after adjustment for sex, age, body mass index, hypertension, hyperlipidemia and smoking. In the general population, SHIP-TREND participants also had a significantly increased odds of macrovascular disease compared to KORA-F4 participants (OR = 1.63, 95% CI: 1.33-2.00). After excluding coronary angiography (myocardial infarction or stroke only), the ORs for region decreased in all models, but the difference between SHIP-TREND and KORA-F4 participants was still significant in the age- and sex-adjusted model for the general population (OR = 1.34, 95% CI: 1.01-1.78).

CONCLUSIONS

This study provides an indication for regional differences in macrovascular disease, which is not explained by traditional risk factors. Further examinations of other risk factors, such as regional deprivation or geographical variations in medical care services are needed.

Area Deprivation and Regional Disparities in Treatment and Outcome Quality of 29,284 Pediatric Patients With Type 1 Diabetes in Germany: A Cross-sectional Multicenter DPV Analysis

OBJECTIVE

This study analyzed whether area deprivation is associated with disparities in health care of pediatric type 1 diabetes in Germany.

RESEARCH DESIGN AND METHODS

We selected patients <20 years of age with type 1 diabetes and German residence documented in the "diabetes patient follow-up" (Diabetes-Patienten-Verlaufsdokumentation [DPV]) registry for 2015/2016. Area deprivation was assessed by quintiles of the German Index of Multiple Deprivation (GIMD 2010) at the district level and was assigned to patients. To investigate associations between GIMD 2010 and indicators of diabetes care, we used multivariable regression models (linear, logistic, and Poisson) adjusting for sex, age, migration background, diabetes duration, and German federal state.

RESULTS

We analyzed data from 29,284 patients. From the least to the most deprived quintile, use of continuous glucose monitoring systems (CGMS) decreased from 6.3 to 3.4% and use of long-acting insulin analogs from 80.8 to 64.3%, whereas use of rapid-acting insulin analogs increased from 74.7 to 79.0%; average HbA_1c increased from 7.84 to 8.07% (62 to 65 mmol/mol), and the prevalence of overweight from 11.8 to 15.5%, but the rate of severe hypoglycemia decreased from 12.1 to 6.9 events/100 patient-years. Associations with other parameters showed a more complex pattern (use of continuous subcutaneous insulin infusion [CSII]) or were not significant.

CONCLUSIONS

Area deprivation was associated not only with key outcomes in pediatric type 1 diabetes but also with treatment modalities. Our results show, in particular, that the access to CGMS and CSII could be improved in the most deprived regions in Germany.

An approach to estimate bidirectional mediation effects with application to body mass index and fasting glucose

Obesity and type 2 diabetes are major public health issues with known interdependence. Genetic variants have been associated with obesity, type 2 diabetes, or both; thus, we hypothesize that some single nucleotide polymorphisms (SNPs) associated with both conditions may be mediated through obesity to affect type 2 diabetes or vice versa. We propose a framework for bidirectional mediation analyses. Simulations show that this approach accurately estimates the parameters, whether the mediation is unidirectional or bidirectional. In many scenarios, when the mediator is regressed on the initial variable and the outcome is regressed on the mediator and the initial variable, the resulting residuals are correlated because of other unmeasured covariates not in the model. We show that the proposed model provides accurate estimates in this scenario, too. We applied the proposed approach to investigate the mediating effects of SNPs associated with type 2 diabetes and obesity using genetic data from the Multi-Ethnic Study of Atherosclerosis cohort. Specifically, we used body mass index (BMI) as a measure for obesity and fasting glucose as a measure for type 2 diabetes. We evaluated the top 6 SNPs associated with both BMI and fasting glucose. Two SNPs (rs3752355 and rs6087982) had indirect effects on BMI mediated through fasting glucose [0.2677; 95% confidence interval (CI) (0.0007, 0.6548) and 0.3301; 95% CI (0.0881, 0.8544), respectively]. The remaining four SNPs (rs7969190, rs4869710, rs10201400, and rs12421620) directly affect BMI and fasting glucose without mediating effects.

Regional differences in type 2 diabetes treatment and outcomes in Germany-An analysis of the German DPV and DIVE registries

AIMS

On the basis of the Diabetes Versorgungs-Evaluation (DIVE) and Diabetes-Patienten-Verlaufsdokumentation (DPV) datasets, we aimed to explore the impact of differences in treatment modalities on outcomes in Germany and put these into a global context.

METHODS

The 2014 to 2016 DIVE and DPV databases were combined, and a total of 127 838 patients 18 years and older was analysed with respect to demographics, cardiovascular risk factors, comorbidities, treatments, and outcomes, separately for each German state. Estimates were expressed as adjusted least squares means together with 95% confidence intervals.

RESULTS

Saarland dataset recorded the lowest mean HbA_1c (6.7%; 6.6%-6.8%; 50 mmol/mol, 49-51 mmol/mol), Saxony-Anhalt showed the highest (8.3%; 8.2%-8.3%; 67 mmol/mol, 66-67 mmol/mol). The highest percentage of hypoglycaemic events was reported in Mecklenburg-West Pomerania (MWP) (4.7%; 3.9%-5.7%), the lowest in Thuringia (0.9%; 0.2%-3.4%). Metformin and sulfonylurea accounted for 36.4% to 53.3% of anti-diabetic treatments across states; other antihyperglycaemic drugs such as DPP-4 inhibitors, SGLT2 inhibitors, and GLP-1 analogues were used most often in MWP (40.0%; 37.8%-42.1%) and least in Rhineland-Palatinate (13.6%; 13.0%-14.2%). Treatment with insulin (alone or in combination) was reported most often in MWP (78.2%; 76.4%-80.0%) and least in Thuringia (26.0%; 20.1%-32.9%).

CONCLUSIONS

Federal states in Germany are heterogeneous concerning diabetes treatment and associated outcomes. These data should stimulate further discussion about how optimal diabetes care can be implemented in all areas of Germany, to achieve good treatment outcomes in all federal states.

Primary care in Germany: access and utilisation-a cross-sectional study with data from the German Socio-Economic Panel (SOEP)

OBJECTIVES

(1) To describe the accessibility of general practitioners (GPs) by the German population; (2) to determine factors on individual and area level, such as settlement structure and area deprivation, which are associated with the walking distance to a GP; and (3) to identify factors that may cause differences in the utilisation of any doctors.

DESIGN

Cross-sectional study using individual survey data from the representative German Socio-Economic Panel (SOEP) linked with area deprivation data from the German Index of Multiple Deprivation for 2010 (GIMD 2010) and official data for settlement structure (urban/rural areas) at district level. Logistic regression models were estimated to determine the relationship of individual and area factors with the distance to a GP. Negative binomial regressions were used to analyse the association with utilisation.

SETTING

Germany.

POPULATION

n=20 601 respondents from the SOEP survey data 2009.

PRIMARY OUTCOME MEASURE

Walking distance to a GP.

SECONDARY OUTCOME MEASURE

Doctor visits.

RESULTS

Nearly 70% of the sample lives within a 20 min walk to a GP. People living in the most deprived areas have a 1.4-fold (95% CI 1.3 to 1.6) increased probability of a greater walking distance compared with the least deprived quintile, even after controlling for settlement structure and individual factors. In rural districts, people have a 3.1-fold (95% CI 2.8 to 3.4) higher probability of a greater walking distance compared with those in cities. Both area deprivation and rurality have a negative relationship with the utilisation of physicians, whereas the distance to a GP is not associated with the utilisation of physicians.

CONCLUSION

Walking distance to a GP depends on individual and area factors. In Germany, area deprivation is negatively correlated with the accessibility of GPs while controlling for settlement structure and individual factors. Both area factors are negatively associated with the utilisation of doctors. This knowledge could be used for future GP requirement plans.