[Reducing Health Inequalities: Development of a Stepwise Procedure from Data to Political Interventions]. / Verringerung der gesundheitlichen Ungleichheit: Entwicklung eines Stufenplans zur gesundheitspolitischen Entscheidungsfindung.

Low socioeconomic status (assessed by indicators such as educational level or income) is often associated with increased morbidity and mortality. This has been shown in many empirical studies, also in Germany. There are numerous calls for political interventions aimed at reducing these health inequalities, in scientific discussions as well as in the public. Asked for scientifically based recommendations on how to proceed 'from data to action̓, we have to admit that we are still faced with many questions and few answers. Developing these recommendations poses many challenges such as, for example, how to integrate the expertise from different public health disciplines. The present study focuses on the cooperation between social epidemiology, public health ethics and health economics, as we believe that these three disciplines are of particular importance here. We briefly outline what each of them could contribute to the development of practical interventions aimed at reducing health inequalities. We particularly emphasize the importance of public health ethics, as it focuses on questions that to date have largely been neglected in the German discussion: How can we evaluate the empirical data and the proposed political interventions from an ethical point of view? Which health inequalities are 'unjust̓, and how can this normative judgement be justified? Based on the expertise from the three disciplines mentioned above, the aim is to pave the way 'from data to action̓ by developing a well-structured stepwise procedure for interventions aimed at reducing health inequalities. The joint scheme could be very beneficial not only for developing practical interventions, but also for further developing each discipline in itself. The simple scheme proposed here could be a starting point that helps specify many open questions on this path 'from data to action̓.

German cooperation-network 'equity in health'-health promotion in settings.

In 2003, the German Federal Centre for Health Education (BZgA) initiated the national Cooperation-Network (CN) 'Equity in Health'. The CN is constantly increasing in size and scope, supporting setting approaches aimed at reducing health inequalities. A detailed description of the CN has not yet been available in English. The CN comprises a total of 66 institutional cooperation partners. Information concerning the structure and activities can be found on a special website. Coordination Centres (CC) have been established in the 16 federal states, for the coordination of all state-specific activities. Funding for the CN and CC is provided by the BZgA, the German statutory sickness funds and by the state-specific ministries of health. These partners also support the continuous quality improvement, which is based on the good-practice criteria developed by the Advisory Committee of the CN. In 2011, the 'Municipal Partner Process (MPP)' has been launched, specifically supporting local partners and integrated life-course approaches focussing on children. In 2015, the focus has been widened to include all age-groups. In July 2015, a new national health law concerning health promotion and prevention has been ratified by the federal Parliament, with a focus on reducing health inequalities. Currently, the details of its implementation are discussed on a nationwide basis. The CN has long advocated for such a law, and today the CN is a well-accepted partner providing concepts, methods and a strong and long-standing network. The article closes with future challenges faced by the CN.

Impact of regional socioeconomic variation on coordination and cost of ambulatory care: investigation of claims data from Bavaria, Germany.

OBJECTIVES: A considerable proportion of regional variation in healthcare use and health expenditures is to date still unexplained. The aim was to investigate regional differences in the gatekeeping role of general practitioners and to identify relevant explanatory variables at patient and district level in Bavaria, Germany. DESIGN: Retrospective routine data analysis using claims data held by the Bavarian Association of Statutory Health Insurance Physicians. PARTICIPANTS: All patients who consulted a specialist in ambulatory practice within the first quarter of 2011 (n=3 616 510). OUTCOMES MEASURES: Of primary interest is the effect of district-level measures of rurality, physician density and multiple deprivation on (1) the proportion of patients with general practitioner (GP) coordination of specialist care and (2) the mean amount in Euros claimed by specialist physicians. RESULTS: The proportion of patients whose use of specialist services was coordinated by a GP was significantly higher in rural areas and in highly deprived regions, as compared with urban and less deprived regions. The hierarchical models revealed that increasing age and the presence of chronic diseases are the strongest predictive factors for coordination by a GP. In contrast, the presence of mental illness, an increasing number of medical condition categories and living in a city are predictors for specialist use without GP coordination. The amount claimed per patient was €10 to €20 higher in urban districts and in regions with lower deprivation. Hierarchical models indicate that this amount is on average higher for patients living in towns and lower for patients in regions with high deprivation. CONCLUSION: The present study shows that regional deprivation is closely associated with the way in which patients access primary and specialist care. This has clear consequences, both with respect to the role of the general practitioner and the financial costs of care.

Costs of coordinated versus uncoordinated care in Germany: results of a routine data analysis in Bavaria.

OBJECTIVES: The efficiency of a gatekeeping system for a health system, as in Germany, remains unclear particularly as access to specialist ambulatory care is not restricted. The aim was to compare the costs of coordinated versus uncoordinated patients (UP) in ambulatory care; with additional subgroup analysis of patients with mental disorders. DESIGN: Retrospective routine data analysis of patients with statutory health insurance, using claims data held by the Bavarian Association of Statutory Health Insurance Physicians. A patient was defined as uncoordinated if he or she visited at least 1 specialist without a referral from a general practitioner within a quarter. Outcomes were compared with propensity score matching analysis. PARTICIPANTS: The study encompassed all statutorily insured patients in Bavaria contacting at least 1 ambulatory specialist in the first quarter of 2011 (n=3 616 510). PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcome was total costs of ambulatory care; secondary outcomes were financial claims of general physicians, specialists and for medication. RESULTS: The average age was 55.3 years for coordinated patients (CP, n=1 629 302), 48.3 years for UP (n=1 825 840). CP more frequently had chronic diseases (85.4%) as compared with UP (67.5%). The total unadjusted financial claim per patient was higher for UP (€234.52) than for CP (€224.41); the total adjusted difference was -€9.65 (95% CI -11.64 to -7.67), indicating lower costs for CP. The cost differences increased with increasing age. Total adjusted difference per patient with mental diseases as documented with an International Classification of Diseases (ICD)-10 F-diagnosis, was -€20.31 (95% CI -26.43 to -14.46). CONCLUSIONS: Coordination of care is associated with lower ambulatory healthcare expenditures and is of particular importance for patients who are more vulnerable to medical interventions, especially for elderly and patients with mental disorders. The role of general practitioners as coordinators should be strengthened to improve care for these patients as this could also help to frame a more efficient health system.

[Consolidated efforts to strengthen health promotion in living environments: The cooperation network "Equity in Health"]. / Gesundheitsförderung in den Lebenswelten gemeinsam stärken : Der Kooperationsverbund "Gesundheitliche Chancengleichheit".

BACKGROUND: In 2003, the German Federal Center for Health Education (BZgA) initiated a national Cooperation Network named "Equity in Health" to address scientific results, focusing on the association between social inequalities and health. The main goal is to support setting approaches aimed at reducing these health inequalities. RESULTS AND KEY ACTIVITIES: In the autumn of 2015 the Cooperation Network comprised a total of 65 (institutional) cooperation partners, e.g., from prevention and health promotion, from the medical profession, from the welfare associations, and from the municipal umbrella organziations. The website www.gesundheitliche-chancengleichheit.de was created to present the information available on all activities and structures. Further, Coordination Centers for Health Equity were established in all federal states of Germany to advise, coordinate and provide support for all those who are actively engaged in the key issues for each state. These Coordination Centers are sponsored by the statutory sickness funds and the Health Ministry of the respective states. They also support continuous quality improvement, based on the good practice criteria developed by the Cooperation Network. Since 2011, the local partner process "Health for All" (until November 2015 "Growing Up Healthily for All") has assisted the municipalities in developing their own integrated health strategies oriented toward the different stages in the life course ("prevention chains"). PERSPECTIVES: The results and structures that have emerged from the Cooperation Network form a good basis for the implementation of the new national Prevention Law passed by German Parliament in July 2015, to expand and develop further, on a country-wide basis and in the various states, living-space-oriented prevention and health promotion consolidating activities. The paper also discusses the present and future challenges of the Cooperation Network.

Relevance of community structures and neighbourhood characteristics for participation of older adults: a qualitative study.

PURPOSE: Community and neighbourhood structures contribute not only to the health and well-being, but also to the participation of older adults. The degree of participation depends on both the living environment and the individual's personal characteristics, preferences and perception. However, there is still limited empirical evidence on how community and neighbourhood structures are linked to participation and health in the aged population. METHODS: A qualitative exploratory approach was chosen with a series of problem-centred, semi-structured focus group discussions. Study participants were selected from within the city of Augsburg, Southern Germany, and from two municipalities in surrounding rural districts. The interviews took place in 2013. Structuring content analysis was used to identify key concepts. RESULTS: We conducted 11 focus group discussions with a total of 78 different study participants. The study participants (33 men and 45 women) had a mean age of 74 years (range 65-92 years). Only two study participants lived in an assisted living facility. Of all study participants, 77% lived in urban and 23% in rural areas. We extracted four metacodes ('Usual activities', 'Requirements for participation', 'Barriers to participation' and 'Facilitators for participation') and 15 subcodes. Health and poorly designed infrastructure were mentioned as important barriers to participation, and friendship and neighbourhood cohesion as important facilitators. CONCLUSIONS: This qualitative study revealed that poor design and accessibility of municipal infrastructure are major barriers to participation in old age in Germany. Community and neighbourhood structures can be part of the problem but also part of the solution when accessibility and social networks are taken into account.

Neighborhood and healthy aging in a German city: distances to green space and senior service centers and their associations with physical constitution, disability, and health-related quality of life.

The composition of the residential environment may have an independent influence on health, especially in older adults. In this cross-sectional study, we examined the associations between proximity to two features of the residential environment (green space and senior service centers) and three aspects of healthy aging (self-rated physical constitution, disability, and health-related quality of life). We included 1711 inhabitants from the city of Augsburg, Germany, aged 65 years or older, who participated in the KORA-Age study conducted in 2008/2009. We calculated the Euclidian distances between each participant's residential address and the nearest green space or senior service center, using a geographic information system. Multilevel logistic regression models were fitted to analyze the associations, controlling for demographic and socioeconomic factors. Contrary to expectations, we did not find clear associations between the distances to the nearest green space or senior service center and any of the examined aspects of healthy aging. The importance of living close to green space may largely depend on the study location. The city of Augsburg is relatively small (about 267,000 inhabitants) and has a high proportion of greenness. Thus, proximity to green space may not be as important as in a densely populated metropolitan area. Moreover, an objectively defined measure of access such as Euclidian distance may not reflect the actual use. Future studies should try to assess the importance of resources of the residential environment not only objectively, but also from the resident's perspective.

Individual Income, Area Deprivation, and Health: Do Income-Related Health Inequalities Vary by Small Area Deprivation?

This paper aims to explore potential associations between health inequalities related to socioeconomic deprivation at the individual and the small area level. We use German cross-sectional survey data for the years 2002 and 2006, and measure small area deprivation via the German Index of Multiple Deprivation. We test the differences between concentration indices of income-related and small area deprivation related inequalities in obesity, hypertension, and diabetes. Our results suggest that small area deprivation and individual income both yield inequalities in health favoring the better-off, where individual income-related inequalities are significantly more pronounced than those related to small area deprivation. We then apply a semiparametric extension of Wagstaff's corrected concentration index to explore how individual-level health inequalities vary with the degree of regional deprivation. We find that the concentration of obesity, hypertension, and diabetes among lower income groups also exists at the small area level. The degree of deprivation-specific income-related inequalities in the three health outcomes exhibits only little variations across different levels of multiple deprivation for both sexes.

The association between resilience and diabetic neuropathy by socioeconomic position: cross-sectional findings from the KORA-Age study.

We investigated whether older adults with diabetes mellitus and lower resilience have an increased risk of diabetic neuropathy as compared to older adults with higher resilience, and whether this association varies by socioeconomic position. In total, 3942 individuals took part in a health survey in Augsburg, Germany, in 2008-2010 (KORA-Age study). We found that among participants with low socioeconomic position, those with higher resilience had a lower probability of suffering from neuropathy as compared to participants with lower resilience (absolute risk reduction = 10%). Adjusted odds ratio with 95% confidence intervals for the outcome diabetic neuropathy also showed that lower resilience scores had an independent effect in increasing the risk of diabetic neuropathy among elderly individuals with a low socioeconomic position (odds ratio: 1.83; confidence interval: 1.09-3.08). Health-promoting strategies focussing on resilience should be further explored.

Area deprivation and the prevalence of type 2 diabetes and obesity: analysis at the municipality level in Germany.

BACKGROUND: The objective of this study was to analyse the association between area deprivation at municipality level and the prevalence of type 2 diabetes (T2D) and obesity across Germany, controlling for individual socioeconomic status (SES). METHODS: The analyses are based on a large survey conducted in 2006. Information was included from 39,908 adults aged 20 years or above. Area deprivation was assessed using the German Index of Multiple Deprivation (GIMD) at municipality level. About 4,700 municipalities could be included and assigned to a deprivation quintile. Individual SES was assessed by income and educational level. Multilevel logistic models were used to control for individual SES and other potential confounders such as age, sex and physical activity. RESULTS: We found a positive association of area deprivation with T2D and obesity. Controlling for all individual-level variables, the odds ratios for municipalities in the most deprived quintile were significantly increased for T2D (OR 1.35; 95% CI 1.12-1.64) as well as for obesity (OR 1.14; 95% CI 1.02-1.26). Further analyses showed that these associations were relatively similar for both men and women. CONCLUSIONS: Based on a nationwide dataset, we were able to show that area deprivation at municipality level is significantly associated with the prevalence of T2D and obesity. It will be important to focus preventive efforts on very deprived municipalities.

Prevalence of use and level of awareness of CAM in older people - results from the KORA-Age study.

BACKGROUND: Despite the growing proportion of older adults in Europe there is only limited knowledge of CAM use among the elderly. This analysis aims to provide estimates for the prevalence of CAM use in persons with an age of ≥65, and to investigate correlations of CAM use with demographic characteristics. METHODS: Based on participants of the MONICA/KORA studies S1-S4 who were born before 1944, a random sample of 1,079 was selected for comprehensive medical examinations. Questions were presented in structured face-to-face interviews conducted from February to November 2009. RESULTS: Data on CAM use were available for 1,026 subjects with a mean age of 76 years, ranging from 65 to 93 years. 14% of the participants were unaware of CAM. The overall prevalence of CAM use was estimated 37% with minor differences between age groups, but clear differences between male (29%) and female (44%) participants. 1-year prevalence of CAM use was 22% (16% males, 28% females). 1-year of CAM use was associated with a higher level of education in both men and women; with higher income in men; and with more actual diseases in women. CONCLUSION: Findings indicate that awareness of CAM is high even among people ≥65 years. Estimates for the prevalence of CAM use confirm the relevance of this treatment sector in the healthcare system for the elderly.

Influence of external, intrinsic and individual behaviour variables on serum 25(OH)D in a German survey.

The objective of the present study was to identify external, intrinsic or behavioural factors that significantly influenced serum 25-hydroxyvitamin D (25(OH)D) concentrations in a German survey. Data from 3061 participants in the Cooperative Health Research in the Region of Augsburg, Germany (KORA) F4 survey were used to relate potential determinants to measured mean serum 25(OH)D concentrations using multivariable regression models. The factors significantly associated with hypovitaminosis D (defined as 25(OH)D<25 nmolL(-1)) were season (winter, spring and autumn), urban environment and high body mass index. In contrast, times spent in sunny regions, hours per day spent outdoors in the summer as well as additional oral intake were associated with higher 25(OH)D concentrations. These results suggest that mainly ambient UV exposure but also individual behaviour are the most important determinants for personal 25(OH)D concentrations. The analyses further showed that in winter 43% of subjects were vitamin D deficient and 42% insufficient. Even in summer over half the population has insufficient vitamin D status with 8% deficient and 47% insufficient. Therefore measures to mitigate widespread vitamin D insufficiency such as regular short-term sun exposure and/or improved dietary intake/supplementation recommendations by public health bodies need to be considered.

Inequalities in health care among patients with type 2 diabetes by individual socio-economic status (SES) and regional deprivation: a systematic literature review.

INTRODUCTION: Quality of care could be influenced by individual socio-economic status (SES) and by residential area deprivation. The objective is to synthesize the current evidence regarding inequalities in health care for patients with Type 2 diabetes mellitus (Type 2 DM). METHODS: The systematic review focuses on inequalities concerning process (e.g. measurement of HbA1c, i.e. glycolised haemoglobin) and intermediate outcome indicators (e.g. HbA1c level) of Type 2 diabetes care. In total, of n = 886 publications screened, n = 21 met the inclusion criteria. RESULTS: A wide variety of definitions for 'good quality diabetes care', regional deprivation and individual SES was observed. Despite differences in research approaches, there is a trend towards worse health care for patients with low SES, concerning both process of care and intermediate outcome indicators. Patients living in deprived areas less often achieve glycaemic control targets, tend to have higher blood pressure (BP) and worse lipid profile control. CONCLUSION: The available evidence clearly points to the fact that socio-economic inequalities in diabetes care do exist. Low individual SES and residential area deprivation are often associated with worse process indicators and worse intermediate outcomes, resulting in higher risks of microvascular and macrovascular complications. These inequalities exist across different health care systems. Recommendations for further research are provided.

Treatment pattern of type 2 diabetes differs in two German regions and with patients' socioeconomic position.

BACKGROUND: Diabetes treatment may differ by region and patients' socioeconomic position. This may be particularly true for newer drugs. However, data are highly limited. METHODS: We examined pooled individual data of two population-based German studies, KORA F4 (Cooperative Health Research in the Region of Augsburg, south), and the HNR (Heinz Nixdorf Recall study, west) both carried out 2006 to 2008. To ascertain the association between region and educational level with anti-hyperglycemic medication we fitted poisson regression models with robust error variance for any and newer anti-hyperglycemic medication, adjusting for age, sex, diabetes duration, BMI, cardiovascular disease, lifestyle, and insurance status. RESULTS: The examined sample comprised 662 participants with self-reported type 2 diabetes (KORA F4: 83 women, 111 men; HNR: 183 women, 285 men). The probability to receive any anti-hyperglycemic drug as well as to be treated with newer anti-hyperglycemic drugs such as insulin analogues, thiazolidinediones, or glinides was significantly increased in southern compared to western Germany (prevalence ratio (PR); 95% CI: 1.12; 1.02-1.22, 1.52;1.10-2.11 respectively). Individuals with lower educational level tended to receive anti-hyperglycemic drugs more likely than their better educated counterparts (PR; 95% CI univariable: 1.10; 0.99-1.22; fully adjusted: 1.10; 0.98-1.23). In contrast, lower education was associated with a lower estimated probability to receive newer drugs among those with any anti-hyperglycemic drugs (PR low vs. high education: 0.66; 0.48-0.91; fully adjusted: 0.68; 0.47-0.996). CONCLUSIONS: We found regional and individual social disparities in overall and newer anti-hyperglycemic medication which were not explained by other confounders. Further research is needed.

Explanatory models concerning the effects of small-area characteristics on individual health.

OBJECTIVES: Material and social living conditions at the small-area level are assumed to have an effect on individual health. We review existing explanatory models concerning the effects of small-area characteristics on health and describe the gaps future research should try to fill. METHODS: Systematic literature search for, and analysis of, studies that propose an explanatory model of the relationship between small-area characteristics and health. RESULTS: Fourteen studies met our inclusion criteria. Using various theoretical approaches, almost all of the models are based on a three-tier structure linking social inequalities (posited at the macro-level), small-area characteristics (posited at the meso-level) and individual health (micro-level). No study explicitly defines the geographical borders of the small-area context. The health impact of the small-area characteristics is explained by specific pathways involving mediating factors (psychological, behavioural, biological). These pathways tend to be seen as uni-directional; often, causality is implied. They may be modified by individual factors. CONCLUSIONS: A number of issues need more attention in research on explanatory models concerning small-area effects on health. Among them are the (geographical) definition of the small-area context; the systematic description of pathways comprising small-area contextual as well as compositional factors; questions of direction of association and causality; and the integration of a time dimension.

Health-related quality of life and socioeconomic status: inequalities among adults with a chronic disease.

BACKGROUND: A number of studies have shown an association between health-related quality of life (HRQL) and socioeconomic status (SES). Indicators of SES usually serve as potential confounders; associations between SES and HRQL are rarely discussed in their own right. Also, few studies assess the association between HRQL and SES among those with a chronic disease. The study focuses on the question of whether people with the same state of health judge their HRQL differently according to their SES, and whether a bias could be introduced by ignoring these differences. METHODS: The analyses were based on a representative sample of the adult population in Germany (n = 11,177). HRQL was assessed by the EQ-5D-3 L, i.e. the five domains (e.g. 'moderate or severe problems' concerning mobility) and the Visual Analog Scale (VAS). SES was primarily assessed by educational level; age, sex and family status were included as potential confounders. Six chronic diseases were selected, each having a prevalence of at least 1% (e.g. diabetes mellitus). Multivariate analyses were conducted by logistic and linear regression. RESULTS: Among adults with a chronic disease, most 'moderate or severe problems' are reported more often in the low (compared with the high) educational group. The same social differences are seen for VAS values, also in subgroups characterized by 'moderate or severe problems'. Gender-specific analyses show that for women the associations with VAS values can just be seen in the total sample. For men, however, they are also present in subgroups defined by 'moderate or severe problems' or by the presence of a chronic disease; some of these differences exceed 10 points on the VAS scale. CONCLUSIONS: Low SES groups seem to be faced with a double burden: first, increased levels of health impairments and, second, lower levels of valuated HRQL once health is impaired. These associations should be analysed and discussed in their own right, based on interdisciplinary co-operation. Social epidemiologists could include measures of HRQL in their studies more often, for example, and health economists could consider assessing whether recommendations based on HRQL scales might include a social bias.

Impact of vertigo and dizziness on self-perceived participation and autonomy in older adults: results from the KORA-Age study.

PURPOSE: The impact of vertigo and dizziness on healthy ageing, and especially on participation, is not fully understood. The objective of this study was to investigate the association of vertigo and dizziness with self-perceived participation and autonomy in older non-institutionalised individuals, adjusted for the presence of other health conditions. Specifically, we wanted to investigate the different effects of vertigo and dizziness on specific components of participation, i.e. restrictions in indoor and outdoor autonomy, family role, social life and relationships, and work and education. METHODS: Data originate from the second wave of the German KORA-Age cohort study collected in 2012. Participation and autonomy was investigated with the Impact on Participation and Autonomy Questionnaire. We used robust regression to analyse the association of vertigo and dizziness with self-perceived participation and autonomy adjusted for covariates. RESULTS: A total of 822 participants (49.6% female) had a mean age of 78.1 years (SD 6.39). Participation and autonomy were significantly lower in participants with vertigo and dizziness across all domains. Adjusted for age, sex, and chronic conditions, vertigo and dizziness were significantly associated with participation restrictions in all domains except social life and relationships. CONCLUSION: The results of our study indicate that vertigo and dizziness contribute to restrictions in participation and autonomy in individuals of older age. Recognising vertigo and dizziness as independent contributors to loss of autonomy and decreased chances for independent living may create new options for patient care and population health, such as the designing of complex interventions to maintain participation and autonomy.

Area level deprivation is an independent determinant of prevalent type 2 diabetes and obesity at the national level in Germany. Results from the National Telephone Health Interview Surveys 'German Health Update' GEDA 2009 and 2010.

OBJECTIVE: There is increasing evidence that prevention programmes for type 2 diabetes mellitus (T2DM) and obesity need to consider individual and regional risk factors. Our objective is to assess the independent association of area level deprivation with T2DM and obesity controlling for individual risk factors in a large study covering the whole of Germany. METHODS: We combined data from two consecutive waves of the national health interview survey 'GEDA' conducted by the Robert Koch Institute in 2009 and 2010. Data collection was based on computer-assisted telephone interviews. After exclusion of participants <30 years of age and those with missing responses, we included n=33,690 participants in our analyses. The outcome variables were the 12-month prevalence of known T2DM and the prevalence of obesity (BMI ≥ 30 kg/m(2)). We also controlled for age, sex, BMI, smoking, sport, living with a partner and education. Area level deprivation of the districts was defined by the German Index of Multiple Deprivation. Logistic multilevel regression models were performed using the software SAS 9.2. RESULTS: Of all men and women living in the most deprived areas, 8.6% had T2DM and 16.9% were obese (least deprived areas: 5.8% for T2DM and 13.7% for obesity). For women, higher area level deprivation and lower educational level were both independently associated with higher T2DM and obesity prevalence [highest area level deprivation: OR 1.28 (95% CI: 1.05-1.55) for T2DM and OR 1.28 (95% CI: 1.10-1.49) for obesity]. For men, a similar association was only found for obesity [OR 1.20 (95% CI: 1.02-1.41)], but not for T2DM. CONCLUSION: Area level deprivation is an independent, important determinant of T2DM and obesity prevalence in Germany. Identifying and targeting specific area-based risk factors should be considered an essential public health issue relevant to increasing the effectiveness of diabetes and obesity prevention.

The association between patient-reported self-management behavior, intermediate clinical outcomes, and mortality in patients with type 2 diabetes: results from the KORA-A study.

OBJECTIVE: Little is known about the impact of diabetes self-management behavior (SMB) on long-term outcomes. We aimed to examine the association among patient-reported SMB, intermediate clinical outcomes, and mortality in patients with type 2 diabetes. RESEARCH DESIGN AND METHODS: Data were collected from 340 patients with type 2 diabetes of the KORA-A study (1997/1998) who were recruited from two previous population-based surveys (n = 161) and a myocardial infarction registry (n = 179) in southern Germany. Based on previous methodological work, a high level of SMB was defined as being compliant with at least four of six different self-care dimensions, comprising physical exercise, foot care, blood glucose self-monitoring, weight monitoring, having a diet plan, and keeping a diabetes diary. The vital status of the participants was observed until 2009. Multivariable linear, logistic, and Cox regression models were applied to assess the association with intermediate clinical outcomes at baseline and to predict mortality over the follow-up period, adjusted for sociodemographic, behavioral, and disease-related factors. RESULTS: In the cross-sectional perspective, a high level of SMB was weakly associated with a lower glycated hemoglobin A1c level (-0.44% [-4.8 mmol/mol] [95% CI -0.88 to 0.00]), but not with low-density lipoprotein cholesterol, systolic blood pressure, or the presence of microalbuminuria, peripheral arterial disease, or polyneuropathy. During a mean follow-up time of 11.6 years, 189 patients died. SMB was a preventive factor for all-cause (hazard ratio 0.61 [95% CI 0.40-0.91]) and cardiovascular mortality (0.65 [95% CI 0.41-1.03]). CONCLUSIONS: Although measuring SMB is difficult and the used operationalization might be limited, our results give some indication that a high level of SMB is associated with prolonged life expectancy in patients with type 2 diabetes and highlight the potential impact of the patients' active contribution on the long-term trajectory of the disease. We assume that the used proxy for SMB is associated with unmeasured, but important, dimensions of health behavior.

Long-term survival among older patients with myocardial infarction differs by educational level: results from the MONICA/KORA myocardial infarction registry.

BACKGROUND: Socioeconomic disparities in survival after acute myocardial infarction (AMI) have been found in many countries. However, population-based results from Germany are lacking so far. Thus, the objective of this study was to examine the association between educational status and long-term mortality in a population-based sample of people with AMI. METHODS: The sample consisted of 2,575 men and 844 women, aged 28-74 years, hospitalized with a first-time AMI between 1 January 2000 and 31 December 2008, recruited from a population-based AMI registry. Patients were followed up until December 2011. Data on education, risk factors and co-morbidities were collected by individual interviews; data on clinical characteristics and AMI treatment by chart review. Cox proportional hazards models were used to assess the relationship between educational status and long-term mortality. RESULTS: During follow-up, 19.1% of the patients with poor education died compared with 13.1% with higher education. After adjustment for covariates, no effect of education on mortality was found for the total sample and for patients aged below 65 years. In older people, however, low education level was significantly associated with increased mortality (hazard ratio (HR) 1.44, 95% confidence interval (CI) 1.05-1.98, p = 0.023). Stratified analyses showed that women older than 64 years with poor education were significantly more likely to die than women in the same age group with higher education (HR 1.57, 95% CI 1.02-2.41, p = 0.039). CONCLUSIONS: Elderly, poorly educated patients with AMI, and particularly women, have poorer long-term survival than their better educated peers. Further research is required to illuminate the reasons for this finding.