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

Forgone and delayed care in Germany- inequalities and perceived health risk of unmet need

BACKGROUND

Subjective unmet need is an established indicator of unequal access to medical care and is often measured by delaying and forgoing medically necessary treatment. Research on delayed and forgone care among the general population in Germany including different reasons, social deprivation measures, and the perceived health risk of unmet need is sparse. This study aims to examine reasons, inequalities, and health-related consequences of unmet need in terms of delayed and forgone care.

METHODS

A cross-sectional online survey was carried out based on a randomly drawn sample of the German adult population in December 2022 (N = 2,201). Respondents were asked whether medical treatments were delayed or forgone in the past 12 months due to different reasons (waiting time, travel distance, financial costs). If unmet need was indicated, the respondents were subsequently asked about their perception of related health risks. Associations with individual social (sex, age, migration history, education, income) and regional factors (social deprivation) as well as insurance status were examined using multilevel logistic regressions analyses.

RESULTS

Among N = 1,955 respondents who indicated need for medical care, 30% reported at least one reason for forgone care (waiting time 23%, financial costs 11%, travel distance 9%). In terms of delayed care, highest rate was found for waiting time (34%). Multilevel analyses revealed significant associations of unmet need with female sex, younger age, lower education, lower income, and statutory health insurance. Associations varied depending on the reason for unmet need. Differences in regional social deprivation were particularly found for forgone care due to distance. Between half and nearly two-thirds of the participants reported worsening of symptoms in case of unmet need. Associations with social characteristics were inconsistent.

DISCUSSION

Unmet need is a prevailing issue in Germany and associated with perceived worsening of health, various indicators of social inequality, and health insurance. Reducing waiting times (e.g. through the further development of appointment service centres) and private co-payments as well as ensuring health care provision in deprived areas can contribute to a decrease of barrier-related unmet need and health risks. However, more in-depth studies are required to account for the complex nature of health care access.

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

OBJECTIVES

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

STUDY DESIGN

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

METHODS

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

RESULTS

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

CONCLUSION

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

Social disparities in access and quality of consultation in outpatient care in Germany

BACKGROUND

Overall, research on social determinants of access and quality of outpatient care in Germany is scarce. Therefore, social disparities (according to sex, age, income, migration background, and health insurance) in perceived access and quality of consultation in outpatient care (primary care physicians and specialists) in Germany were explored in this study.

METHODS

Analyses made use of a cross-sectional online survey. An adult population sample was randomly drawn from a panel which was recruited offline (N = 2,201). Perceived access was assessed by waiting time for an appointment (in days) and travel time to the practice (in minutes), while quality of consultation was measured by consultation time (in minutes) and quality of communication (scale of four items, Cronbach's Alpha 0.89).

RESULTS

In terms of primary care, perceived access and quality of consultation was worse among women compared to men. Estimated consultation time was shorter among people with statutory health insurance compared to privately insured respondents. Regarding specialist care, people aged 60 years and older reported shorter waiting times and better quality of communication. Lower income groups reported lower quality of communication, while perceived access and quality of consultation was worse among respondents with a statutory health insurance. Variances explained by the social characteristics ranged between 1% and 4% for perceived access and between 3% and 7% for quality of consultation.

CONCLUSION

We found social disparities in perceived access and quality of consultation in outpatient care in Germany. Such disparities in access may indicate structural discrimination, while disparities in quality of consultation may point to interpersonal discrimination in health care.

Cancer incidence and digital information seeking in Germany: a retrospective observational study

Awareness is vital for cancer prevention. US studies show a strong link between web searches and cancer incidence. In Europe, the relationship remains unclear. This study characterizes regional and temporal relationships between cancer incidence and web searches and investigates the content of searches related to breast, cervical, colorectal, lung, prostate, and testicular cancer, brain tumors, and melanoma in Germany (July 2018-December 2019). Aggregate data from Google Ads Keyword Planner and national cancer registry data were analyzed. Spearman's correlation coefficient (rS) examined associations between cancer incidence and web search, repeated measures correlation (rrm) assessed time trends and searches were qualitatively categorized. The frequency of malignancy-related web searches correlated with cancer incidence (rS = 0.88, P = 0.007), e.g., breast cancer had more queries than the lower-incidence cervical cancer. Seasonally, incidence and searches followed similar patterns, peaking in spring and fall, except for melanoma. Correlations between entity incidence and searches (0.037 ≤ rrm ≤ 0.208) varied regionally. Keywords mainly focused on diagnosis, symptoms, and general information, with variations between entities. In Germany, web searches correlated with regional and seasonal incidence, revealing differences between North/East and South/West. These insights may help improve prevention strategies by identifying regional needs and assessing impact of awareness campaigns.

The role of mesolevel characteristics of the health care system and socioeconomic factors on health care use - results of a scoping review

BACKGROUND

Besides macrolevel characteristics of a health care system, mesolevel access characteristics can exert influence on socioeconomic inequalities in healthcare use. These reflect access to healthcare, which is shaped on a smaller scale than the national level, by the institutions and establishments of a health system that individuals interact with on a regular basis. This scoping review maps the existing evidence about the influence of mesolevel access characteristics and socioeconomic position on healthcare use. Furthermore, it summarizes the evidence on the interaction between mesolevel access characteristics and socioeconomic inequalities in healthcare use.

METHODS

We used the databases MEDLINE (PubMed), Web of Science, Scopus, and PsycINFO and followed the 'Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols extension for scoping reviews (PRISMA-ScR)' recommendations. The included quantitative studies used a measure of socioeconomic position, a mesolevel access characteristic, and a measure of individual healthcare utilisation. Studies published between 2000 and 2020 in high income countries were considered.

RESULTS

Of the 9501 potentially eligible manuscripts, 158 studies were included after a two-stage screening process. The included studies contained a wide spectrum of outcomes and were thus summarised to the overarching categories: use of preventive services, use of curative services, and potentially avoidable service use. Exemplary outcomes were screening uptake, physician visits and avoidable hospitalisations. Access variables included healthcare system characteristics such as physician density or distance to physician. The effects of socioeconomic position on healthcare use as well as of mesolevel access characteristics were investigated by most studies. The results show that socioeconomic and access factors play a crucial role in healthcare use. However, the interaction between socioeconomic position and mesolevel access characteristics is addressed in only few studies.

CONCLUSIONS

Socioeconomic position and mesolevel access characteristics are important when examining variation in healthcare use. Additionally, studies provide initial evidence that moderation effects exist between the two factors, although research on this topic is sparse. Further research is needed to investigate whether adapting access characteristics at the mesolevel can reduce socioeconomic inequity in health care use.

[Access to cardiological care infrastructure in the federal state of Brandenburg considering the local care needs]

AIM OF THE STUDY

In a nationwide comparison, the state of Brandenburg has one of the highest morbidity and mortality rates of ischemic heart disease. Access to medical care infrastructure is considered to be one possible explanation for regional health inequalities. Accordingly, the study aims to calculate the distances to different types of cardiology care at the community level and to consider these in the context of local care needs.

METHODOLOGY

Preventive sports facilities, general practitioners, outpatient specialist care, hospitals with cardiac catheterization laboratory and outpatient rehabilitation were chosen and mapped as essential facilities for cardiological care. Thereafter, the distances across the road network from the center of each Brandenburg community to the nearest location of each care facility was calculated and divided into quintiles. Medians and interquartile ranges of the German Index of Socioeconomic Deprivation and the proportion of the population over 65 were used as measures of the need for care. They were then related to the distance quintiles per type of care facility.

RESULTS

For 60% of Brandenburg's municipalities, general practitioners were found to be within 2.5 km, preventive sports facilities within 19.6 km, cardiology practices within 18.3 km, hospitals with cardiac catheterization laboratories within 22.7 km, and outpatient rehabilitation facilities within 14.7 km. The median of the German Index of Socioeconomic Deprivation rose with increasing distance for all types of care facilities. The median of the proportion of over 65-year-olds showed no significant variation between distance quintiles.

CONCLUSIONS

The results show that a high proportion of the population lives far away from cardiology care services, while a high proportion seems to be able to reach a general practitioner. In Brandenburg, a regional and locally oriented cross-sectoral care seems to be necessary.

Are people interested in receiving advice from their general practitioner on how to protect their health during heatwaves? A survey of the German population

OBJECTIVE

Climate change increases the frequency, intensity and length of heatwaves, which puts a particular strain on the health of vulnerable population groups. General practitioners (GPs) could reach these people and provide advice on protective health behaviour against heat. Data is lacking on whether and what topic of GP advice people are interested in, and whether specific person characteristics are associated with such interests.

DESIGN

Cross-sectional, nationwide, face-to-face household survey, conducted during winter 2022/2023.

SETTING

Germany.

PARTICIPANTS

Population-based sample of 4212 respondents (aged 14-96 years), selected by using multistratified random sampling (50%) combined with multiquota sampling (50%).

MAIN OUTCOME MEASURE

Interest in receiving GP advice on health protection during heatwaves (yes/no), and the topic people find most important (advice on drinking behaviour, nutrition, cooling, cooling rooms, physical activity or medication management). Associations between predefined person characteristics and the likelihood of interest were estimated using adjusted logistic regressions.

RESULTS

A total of 4020 respondents had GP contact and provided data on the outcome measure. Of these, 23% (95% CI=22% to 25%) expressed interest in GP advice. The likelihood of expressing interest was positively associated with being female, older age (particularly those aged 75+ years: 38% were interested), having a lower level of educational attainment, having a migration background, living in a more urban area, and living in a single-person household. It was negatively associated with increasing income. Advice on medication management received highest interest (25%).

CONCLUSIONS

During winter season 2022/2023, around one quarter of the German population with GP contact-and around 40% of those aged 75+ years-was estimated to have a stated interest in receiving GP advice on protective health behaviour during heatwaves, especially on medication management. Climate change is creating new demands for healthcare provision in general practice. This study provides initial relevant information for research and practice aiming to address these demands.

Urban-rural differences in health literacy in the metropolitan area of Berlin, Germany, and its surroundings

BACKGROUND

Health literacy is gaining importance as it concerns the ability of individuals to encounter the complex demands of health in modern societies. Little is known about the environmental associations of health literacy in high-income countries. This study aims to (i) analyse urban-rural differences in health literacy and further (ii) investigate the interrelations of associated factors.

METHODS

Based on secondary analyses using a population-based survey of individuals aged 35 years and older from Berlin, Germany, and the surrounding rural area. Health literacy, sociodemographic factors (gender, age, educational level, marital status, income), environmental factors (urban/rural) and health behaviour (physical activity) were assessed with questionnaires. T-tests, Analyses of Variance and multiple regression with interaction terms have been applied.

RESULTS

In total, 1822 participants (51.2% female and 56.8% living in an urban region) took part in this study. Health literacy was significantly higher in rural regions (mean = 35.73, SD = 7.56) than in urban regions (mean = 34.10, SD = 8.07). Multiple multivariate regressions showed that living in urban regions, being older, having vocational or basic education, having mid or low income, being widowed, having moderate or low levels of physical activity were significantly negatively associated with health literacy. Incorporating interaction terms showed significance that being older is positively associated with urban regions.

CONCLUSION

We found higher levels of health literacy in rural regions and also demonstrated that multiple associated factors of health literacy work congruously. Thus, the environment, associated factors and their interplay must be considered in future urban-rural health literacy research.

What is the impact of introducing a non-clinical community health advice and navigation service on the demand for primary care in socially deprived areas? Evidence from an observational panel study with difference-in-differences design

OBJECTIVES

To examine the effect of introducing a non-clinical community health advice and navigation service on the demand for primary care in a socially deprived area.

DESIGN

Observational panel study with difference-in-differences design. We conducted fixed-effects negative binomial regressions to compare changes in the number of visits to general practitioners (GPs) in individuals who visited the health advice and navigation service and a matched control group of individuals who did not visit the service. In addition, we analysed the effects of visiting the service multiple times.

SETTING AND PARTICIPANTS

Our empirical setting is a socially deprived urban area in Germany with a multicultural population of about 110 000 people. Our analyses are based on patient data (N=1044) from a non-clinical community health advice and navigation service and from two statutory health insurers.

OUTCOME MEASURES

Patient demand for primary care measured as the number of visits to GPs before and after the first visit to the health advice and navigation service.

RESULTS

Visiting the service for the first time significantly decreased the number of GP visits compared with the control group (β=-0.113, p<0.1). Each additional visit to the service, however, significantly decreased the effect of the first visit (β=0.037, p<0.05).

CONCLUSIONS

Our findings suggest that non-clinical community health advice and navigation services can serve as a low-threshold first point of contact. As first point contact, such services might possibly reduce the burden of primary care physicians in socially deprived areas. At the same time, such services might function as a gateway to accessing the health system, reducing unmet care needs and stimulate demand. Ongoing counselling in the service can identify medical needs that require a physician visit. Our findings may be useful for policymakers and healthcare leaders seeking to reduce the demand on the primary care workforce and can stimulate further research in this area.

Does Social Support Affect Older Adults' General Practitioner Attendance Rates? Findings from the North West Coast Household Health Survey

OBJECTIVE

The aim of this study was to explore whether social support and socio-economic status have an effect on primary care attendance in older adults (aged 65+).

METHODS

This study used data from the longitudinal North West Coast (NWC) Household Health Survey (HHS) from across 20 disadvantaged and 8 less disadvantaged neighborhoods. Data included the EQ-5D, social support, frailty-related measures, healthcare utilization, and the Index of Multiple Deprivation (IMD). Principal component analysis was used to derive a factor for social support. Poisson regression analysis was employed to explore the effects of frailty, social support, General Practitioner (GP) distance, education, IMD, living situation, and depression on the number of GP attendances in the past 12 months.

RESULTS

1,685 older adults were included in this analysis. Of those older adults who visited their GP (87.4%), most had visited their GP twice in the past 12 months. Having an educational qualification, higher levels of social support, and being physically fit reduced GP utilization. Being moderately frail, depressed, and living further away from the nearest GP increased attendance. Older adults living in the most disadvantaged neighborhoods were more likely to visit their GP.

CONCLUSIONS

Increasing social support impacts to a small, but important, extent on reducing GP attendance in older adults. Future research needs to explore whether improving social support in old age can reduce GP utilization.

CLINICAL IMPLICATIONS

Findings suggest a need for improving social prescribing in older adults to reduce some GP visits which could be avoided and might not be necessary.

Spatial accessibility of general inpatient care in Germany: an analysis of surgery, internal medicine and neurology

Improving spatial accessibility to hospitals is a major task for health care systems which can be facilitated using recent methodological improvements of spatial accessibility measures. We used the integrated floating catchment area (iFCA) method to analyze spatial accessibility of general inpatient care (internal medicine, surgery and neurology) on national level in Germany determining an accessibility index (AI) by integrating distances, hospital beds and morbidity data. The analysis of 358 million distances between hospitals and population locations revealed clusters of lower accessibility indices in areas in north east Germany. There was a correlation of urbanity and accessibility up to r = 0.31 (p < 0.001). Furthermore, 10% of the population lived in areas with significant clusters of low spatial accessibility for internal medicine and surgery (neurology: 20%). The analysis revealed the highest accessibility for heart failure (AI = 7.33) and the lowest accessibility for stroke (AI = 0.69). The method applied proofed to reveal important aspects of spatial accessibility i.e. geographic variations that need to be addressed. However, for the majority of the German population, accessibility of general inpatient care was either high or at least not significantly low, which suggests rather adequate allocation of hospital resources for most parts of Germany.

Domain-specific effects of physical activity on the demand for physician visits

OBJECTIVES

To assess domain-specific effects of physical activity (PA) in the relationship with health care utilization and to investigate whether a measure that aggregates PA across domains (leisure, transport, work) is appropriate.

METHODS

Data were retrieved from a longitudinal cohort study conducted in Southern Germany (women n = 1330, men n = 766). The number of physician visits was regressed on total PA and on PA differentiated by the domains leisure time, travel time and working time in a negative binomial model.

RESULTS

For women, no association with physician visits is found for total PA, while high leisure time physical activity (LTPA) is associated with 22% more visits. The effect of high LTPA is statistically different from the effect of high total PA. For men, no significant associations are found for both measures.

CONCLUSIONS

The specific, positive effect of high LTPA on physician visits among women shows that using an aggregate measure of PA is inappropriate for analyzing the relation between PA and health care utilization. Further, the positive relationship should be considered in attempts to promote physical activity.