Work stress on rise? Comparative analysis of trends in work stressors using the European working conditions survey.

OBJECTIVE: The rapid transformation of labor markets has been accompanied by the belief of rising stress at work. However, empirical evidence on such trends based on reliable survey data is scarce. This study analyzes long-term trends in well-established measures of work stressors across Europe, as well as potential occupational differences. METHODS: We use repeated cross-sectional data of 15 European countries from waves 1995, 2000, 2005, 2010, and 2015 of the European Working Conditions Surveys. We apply three-way multilevel regressions (with employees nested in country-years, which are in turn nested in countries) to analyze trends in work stressors measured according to the demand-control and effort-reward imbalance models. Trends by occupational groups are also assessed. RESULTS: Our findings suggest that work stress generally increased from 1995 to 2015, and that the increase was mostly driven by psychological demands. People working in lower-skilled occupations had generally higher levels of job strain and effort-reward imbalance, as well as they tend to have a steeper increase in job strain than people working in higher-skilled occupations. Most of the change occurred from 1995 to 2005. CONCLUSION: Our results indicate that work stress has been on rise since 1995, specifically for people working in disadvantageous occupations. This directs the attention to the vulnerable position of the least skilled and also to the use of preventive measures to counteract some of the disadvantages experienced by this occupational group.

Correction to: Associations between change in labour market policies and work stressors: a comparative longitudinal survey data analysis from 27 European countries.

An amendment to this paper has been published and can be accessed via the original article.

Associations between change in labour market policies and work stressors: a comparative longitudinal survey data analysis from 27 European countries.

BACKGROUND: Many studies have shown that work stressors have a negative impact on health. It is therefore important to gain an understanding of how work stressors can be reduced. Recent studies have shown that employees in countries with high investments into labour market policies less often report exposure to work stressors. Although these studies are indicative of an influence of the political level on work stressors, they are based on cross-sectional cross-country analyses where causal assumptions are problematic. The aim of this study is to extend the existing evidence by longitudinally testing whether changes in labour market policies are related to changes in work stressors. METHODS: We used comparative longitudinal survey data from the European Working Conditions Survey (27 countries; for the years 2005, 2010, 2015). The measurement of work stressors is based on two established work stress models: effort-reward imbalance (ERI) and job demand-control (job strain). To measure labour market policies, we used information on active (ALMP) and passive labour market policies (PLMP). After excluding persons with missing data, 64,659 participants were eligible for the ERI and 67,114 for job strain analyses. Estimation results are provided by three-way multilevel models (individuals, country-years, country), which allow us to estimate longitudinal and cross-country macro-effects. RESULTS: An increase in ALMP leads to a decrease of ERI. The analyses for the subcomponents 'effort' and 'reward' showed that mainly the 'reward' component is positively associated with ALMP. The association between ALMP and 'reward' shows that an increase in ALMP investments is related to an increase in rewards. Yet, no significant longitudinal associations between ALMP and job strain, and between PLMP and the work stressors, were observed. CONCLUSIONS: The study extends the current knowledge with longitudinal information by showing that an increase in ALMP is associated with an increase in rewards and a decrease of ERI. These longitudinal analyses may support a causal interpretation. The findings of this study have important policy implications. Our main result suggests that investments into ALMP can lead to better working conditions.

Work and family conflicts in employees with spinal cord injury and their caregiving partners.

STUDY DESIGN: Cross-sectional, observational. OBJECTIVES: To investigate the association of conflicts between work and family life with indicators of health and to examine the antecedents of those conflicts in employees with spinal cord injury (SCI) and their caregiving partners. SETTING: Community, Switzerland. METHODS: Data from employed persons with SCI (n=79) and caregiving partners (n=93) who participated in the pro-WELL study were used. Logistic and tobit regressions were performed to assess the association of work-family and family-work conflicts with health indicators, namely mental health (36-item Short Form Health Survey (SF-36)), vitality (SF-36), well-being (WHOQoL BREF) and positive and negative affect (Positive and Negative Affect Scale short form (PANAS-S)). Own and partners' engagement in productive activities and socioeconomic circumstances were evaluated as potential antecedents of work-family and family-work conflicts using logistic regression. RESULTS: Work-family conflicts were related to reduced mental health (caregiving partners only), vitality and well-being. Family-work conflicts were linked to reduced mental health, vitality, well-being and positive affect in SCI and to reduced vitality in caregiving partners. Persons with lower income (SCI only) and lower subjective social position reported more conflicts than persons with higher income and higher subjective position. Higher workload increased work-family conflicts in caregiving partners and decreased family-work conflicts in SCI. Education, amount of caregiving, care-receiving and partners' employment status were not associated with the occurrence of conflicts. CONCLUSION: The optimal balance between work and family life is important to promote mental health, vitality and well-being in employees with SCI and their caregiving partners. This is especially true in employees perceiving their social position as low and in caregivers with a high workload.

Occupational position, work stress and depressive symptoms: a pathway analysis of longitudinal SHARE data.

BACKGROUND: Several studies tested whether stressful work mediates the association between socioeconomic position (SEP) and health. Although providing moderate support, evidence is still inconclusive, partly due to a lack of theory-based measures of SEP and work stress, and because of methodological limitations. This contribution aims at overcoming these limitations. METHODS: We conduct pathway analysis and investigate indirect effects of SEP on mental health via stressful work. Data are derived from the first two waves of the 'Survey of Health, Ageing and Retirement in Europe' (SHARE) with information from employed men and women aged 50-64 across 11 European countries (N=2798). SEP is measured according to two alternative measures of occupational position: occupational class (focus on employment relations) and occupational status (focus on prestige). We assess work stress according to the effort-reward imbalance and the demand-control model (wave 1), and we use newly occurring depressive symptoms as health outcome (wave 2). RESULTS: Effort-reward imbalance and, less consistently, low control mediate the effect of occupational class and occupational status on depressive symptoms. CONCLUSIONS: Our findings point to two important aspects of work stress (effort-reward imbalance and low control) in explaining socioeconomic differences in health. Further, we illustrate the significance of two alternative dimensions of occupational position, occupational class and occupational status.

[Effort-reward imbalance at work and depression: current research evidence]. / Berufliche Gratifikationskrisen und depressive Störungen : Aktuelle Forschungsevidenz.

In view of highly prevalent stressful conditions in modern working life, in particular increasing work pressure and job insecurity, it is of interest to know whether specific constellations of an adverse psychosocial work environment increase the risk of depressive disorder among employed people. This contribution gives a short overview of current research evidence based on an internationally established work stress model of effort-reward imbalance. Taken together, results from seven prospective epidemiological investigations demonstrate a two-fold elevated relative risk of incident depressive disorder over a mean observation period of 2.7 years among exposed versus non-exposed employees. Additional findings from experimental and quasi-experimental studies point to robust associations of effort-reward imbalance at work with proinflammatory cytokines and markers of reduced immune competence. These latter markers may indicate potential psychobiological pathways. In conclusion, incorporating this new knowledge into medical treatment and preventive efforts seems well justified.

[The changing role of physicians]. / Die ärztliche Rolle im Wandel.

Despite a very successful process of professionalisation during the past 150 years, today's physicians face several challenges urging them to adapt their traditional professional role and the patient-physician relationship inherent in this role. Among these challenges, a growing economic influence on physicians' practices, new demands from particular groups of patients (consumerism, role of the Internet etc.), and increasing inter-professional competition deserve special attention. New evidence of an association between a stressful work environment and physician's increased health risks provides additional support in favour of this notion. This contribution suggests potential directions of change of the physician's role by pointing to (a) a growing 'feminisation' of medicine, (b) an even stronger emphasis on patient needs and (c) extended teamwork and inter-professional cooperation.

Job strain in relation to body mass index: pooled analysis of 160 000 adults from 13 cohort studies.

BACKGROUND: Evidence of an association between job strain and obesity is inconsistent, mostly limited to small-scale studies, and does not distinguish between categories of underweight or obesity subclasses. OBJECTIVES: To examine the association between job strain and body mass index (BMI) in a large adult population. METHODS: We performed a pooled cross-sectional analysis based on individual-level data from 13 European studies resulting in a total of 161 746 participants (49% men, mean age, 43.7 years). Longitudinal analysis with a median follow-up of 4 years was possible for four cohort studies (n = 42 222). RESULTS: A total of 86 429 participants were of normal weight (BMI 18.5-24.9 kg m(-2) ), 2149 were underweight (BMI < 18.5 kg m(-2) ), 56 572 overweight (BMI 25.0-29.9 kg m(-2) ) and 13 523 class I (BMI 30-34.9 kg m(-2) ) and 3073 classes II/III (BMI ≥ 35 kg m(-2) ) obese. In addition, 27 010 (17%) participants reported job strain. In cross-sectional analyses, we found increased odds of job strain amongst underweight [odds ratio 1.12, 95% confidence interval (CI) 1.00-1.25], obese class I (odds ratio 1.07, 95% CI 1.02-1.12) and obese classes II/III participants (odds ratio 1.14, 95% CI 1.01-1.28) as compared with participants of normal weight. In longitudinal analysis, both weight gain and weight loss were related to the onset of job strain during follow-up. CONCLUSIONS: In an analysis of European data, we found both weight gain and weight loss to be associated with the onset of job strain, consistent with a 'U'-shaped cross-sectional association between job strain and BMI. These associations were relatively modest; therefore, it is unlikely that intervention to reduce job strain would be effective in combating obesity at a population level.

Associations between neighbourhood characteristics, body mass index and health-related behaviours of adolescents in the Kiel Obesity Prevention Study: a multilevel analysis.

BACKGROUND/OBJECTIVES: To understand determinants of overweight, several studies addressed the association between neighbourhood characteristics and adult obesity. However, little is known about the association of such characteristics with adolescents' overweight. This study aims at the influence of neighbourhood characteristics on adolescent body mass index (BMI) and lifestyle and to what extent BMI and lifestyle variation between neighbourhoods can be explained by neighbourhood characteristics. SUBJECTS/METHODS: We used cross-sectional data from the Kiel Obesity Prevention Study collected between 2004 and 2008 in 28 different residential districts of the city of Kiel (North Germany). Anthropometric data were available for 1675 boys and 1765 girls (n=3440) aged 13-15 years, and individual lifestyle factors and sociodemographic data were included in the analysis. At the macro level, six different neighbourhood characteristics were used: unemployment rate, population density, traffic density, prevalence of energy-dense food supply, number of sports fields and parks, and crime rate. To test our main hypothesis, linear and logistic multilevel regression analyses were performed to predict BMI and lifestyle factors in individuals nested in neighbourhoods. RESULTS: Findings of multilevel analysis show little between-neighbourhood variations in BMI and health-related behaviours. In all, 2% of BMI variation, 4% of media time variation and 3% of variation in snacking behaviour could be attributed to differences in neighbourhoods. CONCLUSIONS: Environmental factors are significantly associated with adolescent BMI and health-related behaviour; however, their total effect is small. Owing to these results, recommendations for structural policy measures as part of prevention of overweight in adolescents must be made cautiously.

[Medical decision making in symptoms of type 2 diabetes mellitus in general practice]. / Hausärztliche entscheidungen bei symptomen für diabetes mellitus typ 2.

BACKGROUND: Patient and physician attributes influence medical decisions as non-medical factors. The current study examines the influence of patient age and gender and physicians' gender and years of clinical experience on medical decision making in patients with undiagnosed diabetes type 2. METHOD: A factorial experiment was conducted to estimate the influence of patient and physician attributes. An identical physician patient encounter with a patient presenting with diabetes symptoms was videotaped with varying patient attributes. Professional actors played the "patients". A sample of 64 randomly chosen and stratified (gender and years of experience) primary care physicians was interviewed about the presented videos. RESULTS: Results show few significant differences in diagnostic decisions: Younger patients were asked more frequently about psychosocial problems while with older patients a cancer diagnosis was more often taken into consideration. Female physicians made an earlier second appointment date compared to male physicians. Physicians with more years of professional experience considered more often diabetes as the diagnosis than physicians with less experience. CONCLUSION: Medical decision making in patients with diabetes type 2 is only marginally influenced by patients' and physicians' characteristics under study.

[Lifestyle modification programs protecting cardiovascular health in Germany and Sweden. A qualitative interview study]. / Lebensstiländerungen zur Förderung der kardiovaskulären Gesundheit in Deutschland und Schweden. Eine qualitative Interviewstudie.

A large amount of evidence, including neurohumoral, inflammatory, and metabolic physiological adaptations, emphasize the importance of the individual lifestyle as a public health concern. The related burden of chronic diseases in the European Union, which could be minimized by appropriate lifestyles, requires consistent transfer of evidence-based prevention guidelines. Due to the epidemiologic importance of cardiovascular diseases and innovative health-promoting strategies in Sweden, a comparative analysis between German and Swedish practices preventing cardiovascular events in high-risk populations is presented in this paper. This qualitative analysis demonstrates that lifestyle-related risk and protective factors based on smoking, physical activity, nutrition, and psychosocial determinants are of growing importance in cardiac death prevention. Especially in Sweden, behavioral prevention is joined by condition prevention. In Germany, intersectoral rehabilitation concepts improve patient adherence to behavioral recommendations but interdisciplinary communication between different health experts needs to be improved. The health-promoting hospital composes a health professional's interface, which is based on the understanding that behavioral risk factors are not only highly interrelated, but also require sophisticated healthcare delivery to optimize health management effectiveness.

A randomized, placebo-controlled trial of sustained-release dextroamphetamine for treatment of methamphetamine addiction.

Sixty treatment-seeking individuals with methamphetamine (MA) dependence entered a randomized, placebo-controlled, double-blind clinical trial of oral dextroamphetamine (d-AMP) as a replacement therapy for MA dependence. The subjects took 60 mg sustained-release d-AMP for 8 weeks, during which time they received eight 50-min sessions of individual psychotherapy. Adverse events and urine toxicology for MA were assessed two times a week. There were no serious adverse events. Urine samples containing <1,000 ng/ml of MA were classified as negative for MA. The MA-negative scores in the d-AMP group (3.1 ± SD 4.6) were no higher than those in the placebo group (3.3 ± SD 5.3; P > 0.05). However, withdrawal and craving scores were significantly lower in the d-AMP group (P < 0.05 for both). Although subjects taking d-AMP did not reduce their use of MA, the significant reductions observed in withdrawal and craving scores in this group support the need for further exploration of d-AMP as a pharmacologic intervention for MA dependence, possibly at higher doses.

Is the co-occurrence of smoking and poor consumption of fruits and vegetables confounded by socioeconomic conditions?

OBJECTIVES: As smoking and unhealthy diet are more prevalent in lower socioeconomic groups, this study aims at exploring whether associations between smoking and fruit and vegetable consumption are confounded by socioeconomic conditions or if smoking is independently associated with consumption. METHODS: Cross-sectional analyses of 4,814 middle-aged participants from the Heinz Nixdorf recall study, a population-based cohort study in Germany. Fruit and vegetable consumption was assessed by a food frequency questionnaire. Education and income were used as indicators for socioeconomic groups. Logistic regression models were run to estimate odds ratios for consumption by smoking status. RESULTS: Smoking is associated with poor consumption of fruits and raw vegetables/salad in both genders, and with poor consumption of boiled vegetables and fruit/vegetable juice in men. Importantly, poor consumption is related to smoking independently of people's socioeconomic conditions. CONCLUSION: The findings imply that smokers in all socioeconomic groups are at higher risk for unhealthy intake of fruits and vegetables. Public health interventions targeted to smokers should include dietary instructions.

Work stress and health in Western European and post-communist countries: an East-West comparison study.

BACKGROUND: There is evidence that psychosocial factors at work influence the risk of poor health in Western societies, but little is known about the effect of work stress in the former communist countries. The aim of this paper is to compare the association of work stress with self-rated health in Western European and post-communist countries. METHODS: Data from four epidemiological studies were used: the HAPIEE study (Poland, Russia and the Czech Republic), the Hungarian Epidemiological Panel (Hungary), the Heinz Nixdorf Recall study (Germany) and the Whitehall II study (UK). The overall sample consisted of 18 494 male and female workers aged 35-65 years. RESULTS: High effort-reward imbalance at work was associated with poor self-rated health. The adjusted odds ratios for the highest versus lowest quartile of the effort-reward ratio were 3.8 (95% CI 1.9 to 7.7) in Hungary, 3.6 (95% CI 2.3 to 5.7) in the Czech Republic, 2.5 (95% CI 1.5 to 4.1) in the UK, 2.3 (95% CI 1.6 to 3.5) in Germany, 1.5 (95% CI 1.0 to 2.1) in Poland and 1.4 (95% CI 1.1 to 1.8) in Russia. The differences in odds ratios between countries were statistically significant (p<0.05). A similar pattern was observed for the effect of overcommitment on poor health. CONCLUSION: The association of effort-reward imbalance at work and of a high degree of work-related overcommitment with poor self-rated health was seen in all countries, but the size of the effects differed considerably. It does not appear that the effects in Eastern Europe are systematically stronger than in the West.

Traffic exposure and subclinical cardiovascular disease: is the association modified by socioeconomic characteristics of individuals and neighbourhoods? Results from a multilevel study in an urban region.

OBJECTIVES: Traffic-related pollution is associated with cardiovascular disease in general, but previous studies suggested that low socioeconomic status (SES) groups might be more susceptible towards a negative impact. We examined whether the association between long-term exposure to high traffic and early signs of coronary artery disease is modified by SES. METHODS: Individual-level medical and social data from a population-based study were linked with census information on neighbourhood socioeconomic characteristics. Residential exposure to traffic was defined as proximity to major roads using a geographical information system. We studied associations between high traffic and coronary artery calcification (CAC) within strata of SES to examine effect modification. Data stem from an epidemiological study in Germany including 2264 women and 2037 men (45-75 years). RESULTS: High traffic and low SES were both associated with higher amounts of calcification (>or=75th age-specific percentile). More participants with low SES lived close to major roads while stratified analyses did not indicate higher susceptibility in low SES groups. Participants with low SES and simultaneous exposure to high traffic had highest levels of CAC. For example, the prevalence of high calcification was 23.9% in better-educated men with low traffic exposure but 37.7% in lower-educated men with high traffic exposure (women: 22.0% vs 28.1%). CONCLUSIONS: High traffic exposure was associated with coronary calcification in all social groups, but as low SES individuals had higher calcification in general and were also more often exposed to traffic, existing inequalities could be further shaped by traffic exposure.

Association of impaired fasting glucose and coronary artery calcification as a marker of subclinical atherosclerosis in a population-based cohort--results of the Heinz Nixdorf Recall Study.

AIMS/HYPOTHESIS: Atherosclerosis and cardiovascular diseases are often present at the time of diagnosis of type 2 diabetes mellitus. Whether subclinical atherosclerosis can be detected in the pre-diabetic (borderline fasting hyperglycemia) state is not clear. This study investigated the association of impaired fasting glucose (IFG) and coronary artery calcification (CAC), a marker of subclinical atherosclerosis, among participants without a history of coronary heart disease or manifest diabetes mellitus. METHODS: Study participants (aged 45-75 years) of the population-based Heinz Nixdorf Recall Study were categorised into those with normal fasting glucose (glucose <6.1 mmol/l) and those with IFG (glucose >or=6.1 to <7.0 mmol/l), excluding participants with a history of CHD or diabetes mellitus. CAC was assessed by electron-beam computed tomography, and risk factors were assessed by extended interviews, anthropometric measurements and laboratory tests. Various CAC cut-off points were used in multiple logistic and ordinal logistic regression models to estimate ORs and 95% CIs. RESULTS: Of the 2,184 participants, more men had IFG than did women (37% vs 22%). Participants with IFG showed a higher prevalence of CAC > 0 (men OR 1.90, 95% CI 1.33-2.70; women 1.63, 1.23-2.15). Risk factor adjustment weakened this association in both sexes (men 1.63, 1.12-1.36; women 1.26, 0.93-1.70). When the age- and sex-specific 75th percentile was used as the cut-off point for CAC, the association further decreased in men (1.10, 0.81-1.50), but became stronger in women (1.41, 1.02-1.94). CONCLUSIONS/INTERPRETATION: These data support the hypothesis that CAC is already present in the pre-diabetic state and that IFG has a modest and independent impact on the atherosclerotic process. Biological sex appears to modify the association between IFG and CAC.

Social productivity and depressive symptoms in early old age-results from the GAZEL study.

OBJECTIVES: We test associations of frequency of performing three types of socially productive activities (voluntary work, informal help and caring for a person) with depressive symptoms in older people. Are depressive symptoms negatively associated with frequency in all three types or rather in those activities that are characterized by a high degree of autonomy and perceived control? METHODS: Data on social activities and frequency of performance were collected in the frame of the annual follow-up of the French GAZEL cohort study in 2005. Depressive symptoms were measured by the CES-D scale. Perceived control was assessed by two items of a quality of life measure (CASP-19). Total of 14477 respondents aged 52-66 years completed a standardized questionnaire. Linear regression models were calculated adjusting for important confounders including self-rated health assessed during the previous year. RESULTS: In activities characterized by high autonomy (in particular voluntary work) a negative association of frequency with depressive symptoms was observed, whereas the reverse effect was found in the type of activity with low autonomy (care for a person). Perceived control mediated in part the association of frequency of activity with depressive symptoms. CONCLUSION: Being often socially productive in early old age may contribute to well-being to the extent that autonomy and perceived control are given.

When does work stress hurt? Testing the interaction with socioeconomic position in the Heinz Nixdorf Recall Study.

STUDY OBJECTIVE: To study systematically the separate and combined effects of work stress and socioeconomic position on three measures of health in an unselected working population. DESIGN: Two exposures (high demand/low control ("job strain"); effort-reward imbalance at work) are related to angina pectoris, depression, and poor self-rated health in a cross-sectional study design in which socioeconomic position was measured by occupational position and educational level. SETTING: Baseline data of a prospective population-based cohort study in Germany, collected between 2000 and 2003. PARTICIPANTS: 1749 employed or self-employed men and women (36.3% of total sample) aged 45-65 years. MAIN RESULTS: Effort-reward imbalance and job strain were associated with elevated odds ratios of all three health measures, using logistic regression analysis. The prevalence of poorer health was always highest in subgroups defined by high work stress and low socioeconomic position, with respective odds ratios ranging from 2.30 to 2.98 (95% CI 1.38 to 4.52) for self-rated health, 1.70 to 2.24 (95% CI 1.04 to 3.88) for angina and 2.61 to 8.20 (95% CI 1.53 to 14.15) for depression. CONCLUSION: Although stress at work was related to poorer health in the total study group, the strongest associations were consistently observed in men and women with low educational level or low occupational position. Worksite health promotion should be directed primarily towards these target groups.

[Psychosocial stress and disease risks in occupational life. Results of international studies on the demand-control and the effort-reward imbalance models]. / Psychosoziale Belastungen und Erkrankungsrisiken im Erwerbsleben : Befunde aus internationalen Studien zum Anforderungs-Kontroll-Modell und zum Modell beruflicher Gratifikationskrisen.

Given the far-reaching changes of modern working life, psychosocial stress at work has received increased attention. Its influence on stress-related disease risks is analysed with the help of standardised measurements based on theoretical models. Two such models have gained special prominence in recent years, the demand-control model and the effort-reward imbalance model. The former model places its emphasis on a distinct combination of job characteristics, whereas the latter model's focus is on the imbalance between efforts spent and rewards received in turn. The predictive power of these models with respect to coronary or cardiovascular disease and depression was tested in a number of prospective epidemiological investigations. In summary, twofold elevated disease risks are observed. Effects on cardiovascular disease are particularly pronounced among men, whereas no gender differences are observed for depression. Additional evidence derived from experimental and ambulatory monitoring studies supplements this body of findings. Current scientific evidence justifies an increased awareness and assessment of these newly discovered occupational risks, in particular by occupational health professionals. Moreover, structural and interpersonal measures of stress prevention and health promotion at work are warranted, with special emphasis on gender differences.

[Influence of patient's age and gender on doctors' decision making about coronary heart disease]. / Einfluss von Patientenalter und Patientengeschlecht auf ärztliche Entscheidungen bei koronarer Herzkrankheit.

BACKGROUND: Studies from the United Kingdom und the United States show that there are variations in doctors' decision making regarding coronary heart disease (CHD) and that patient attributes as well as physician characteristics have an impact on medical decisions regardless of the presented symptoms. This study examines how gender and age of patients influence primary care doctors' diagnostic and management decisions regarding CHD in Germany. METHODS: An experimental design with portrayed videotapes is used. Professional actors play the role of patients with symptoms of CHD. Videotapes were identical apart from varying patients' gender and age (55 vs. 75 years). A randomly selected sample of 128 primary care physicians viewed these videotapes in their practices. Afterwards physicians were asked to describe how to diagnose and treat the patient. RESULTS: Women were less likely to be asked about health related behaviours, less likely to get a CHD diagnosis and less likely to be referred to a cardiologist or other specialist. Younger patients were asked about medical history and smoking more frequently, but they were less likely to be asked about symptoms of pain and discomfort. Moreover, among older patients CHD diagnosis was mentioned more often and with higher certainty and medication appropriate for CHD was prescribed more often. DISCUSSION: Age and gender of patients influence primary care doctors' diagnostic and management strategies relating to CHD in Germany regardless of the presented symptoms.