The frequency and determinants of blood pressure measurement by a health professional in Germany: A cross-sectional study.

Strong evidence exists for the benefits of screening for hypertension to reduce the risk of cardiovascular disease and death. The aim of this study was to analyze the frequency and determinants of blood pressure (BP) measurement by a health professional in the general population and in individuals without hypertension in Germany.Data from 17,431 participants 15+ years from the cross-sectional GEDA2014/2015-EHIS survey were used to calculate the percentage of the population who had no BP measurement within the last year and the last 3 years. In multivariate models, the determinants of no BP measurement were analyzed. The frequency of BP measurement was compared between 30 European countries.In Germany, 27.5% of men and 16.6% of women had no BP measurement by a health professional within the last year and 10.9%, respectively 5.4% not within the last 3 years. In individuals without known hypertension, 34.1% of men and 23.6% of women aged 15 to 19 years had no BP measurement in the last 3 years compared to 5.2% of men and 4.8% of women 70+ years. Independent predictors of not receiving a BP measurement in the last 3 years besides age were male sex, good self-rated health, low health awareness, and no medical consultations but not educational level. Germany has low proportions of no BP measurement compared to other European countries.Hypertension screening needs improvement in all age groups, especially in the young who have the lowest screening proportions but also in the elderly who have the highest hypertension risk.

Health literacy in men and women with cardiovascular diseases and its association with the use of health care services - Results from the population-based GEDA2014/2015-EHIS survey in Germany.

BACKGROUND: Health literacy (HL), defined as the ability to access, understand, appraise and apply health information, offers a promising approach to reduce the development of cardiovascular diseases (CVD) and to improve the management of CVD in populations. DESIGN: We used data from nationwide cross-sectional German Health Update (GEDA2014/2015-EHIS) survey. 13,577 adults ≥ 40 years completed a comprehensive standardized paper or online questionnaire including the short form of the European Health Literacy Survey Questionnaire (HLS-EU-Q16). METHODS: We compared participants with and without CVD with regard to their HL. We also analyzed the association between HL level and health care outcomes among individuals with CVD, i.e. frequency of general practitioner or specialist consultations, hospitalization and treatment delay. RESULTS: The percentage of "problematic" or "inadequate" HL, defined as "not sufficient" HL, was significantly higher in individuals with CVD compared to without CVD (men 41.8% vs. 33.6%, women 46.7% vs. 33.4%). Having CVD was independently associated with "not sufficient" HL after adjusting for age, education, income, health consciousness and social support (adjusted OR: men 1.36, women 1.64). Among participants with CVD, individuals with "inadequate" HL were more likely to have more than 6 general practitioner consultations (49.3% vs. 28.7%), hospitalization (46.6% vs. 36.0%) in the last 12 months and to experience delay in getting health care because of long waiting lists for an appointment (30.7% vs. 18.5%) compared to participants with "sufficient" HL. CONCLUSION: "Problematic" or "inadequate" HL is independently associated with CVD and health care use. This is a challenge and an opportunity for both CVD prevention and treatment.

Predicted 10-year risk of cardiovascular mortality in the 40 to 69 year old general population without cardiovascular diseases in Germany.

AIMS: To estimate the 10-year risk of fatal cardiovascular disease (CVD) in the 40 to 69 year old general population in Germany stratified by sex and to analyze differences between socio-economic status (SES), region and community size in individuals without CVD. The analysis is based on the newly recalibrated SCORE Deutschland risk charts and considered other comorbidities for the classification of the high CVD risk group according to the guidelines of the European Society of Cardiology. METHODS AND RESULTS: In 3,498 participants (40-69 years) from the German Health Examination Survey for Adults 2008-2011 (DEGS1) without a history of CVD (myocardial infarction, coronary heart disease, heart failure, stroke) we estimated the proportion with a low (SCORE <1%), moderate (SCORE 1-<5%) and high 10-year CVD mortality risk (SCORE ≥5% or diabetes, renal insufficiency, SBP/DPB ≥180/110 mmHg or cholesterol >8 mmol/l). The prevalence of low, moderate and high risk was 42.8%, 38.5% and 18.8% in men and 73.7%, 18.1% and 8.2% in women. The prevalence of high risk was significantly lower in women with a high compared to a low SES (3.3% vs. 11.2%) and in communities with ≥100.000 inhabitants compared to <20.000 inhabitants (5.4% vs.10.9%). There were no significant associations between predicted CVD mortality risk and SES or community size in men and regions in men and women. Among the high risk group, 58.2% of men and 9.8% of women had SCORE ≥5%, leaving the majority of women (60.1%) classified as high risks due to diabetes and SCORE <5%. CONCLUSION: Our results suggest the persistence of socioeconomic disparities in predicted cardiovascular mortality in women and support the need of large-scale prevention efforts beyond individual lifestyle modification or treatment. Furthermore, the importance of additional comorbidities for the high risk group classification is highlighted.

The incidence of hypertension and its risk factors in the German adult population: results from the German National Health Interview and Examination Survey 1998 and the German Health Interview and Examination Survey for Adults 2008-2011.

OBJECTIVE: To analyze incident hypertension and its risk factors based on 11.9 years follow-up of a recent National Examination Survey cohort in Germany. METHODS: Out of 7124 participants of the German National Health Interview and Examination Survey 1998 (GNHIES98), 640 had died at follow-up 2008-2011 and 3045 were reexamined as part of the German Health Interview and Examination Survey for Adults 2008-2011 (DEGS1). Baseline and follow-up included standardized blood pressure (BP) measurements. Hypertension was defined as BP of at least 140/90 mmHg or intake of antihypertensive medication in participants with known hypertension. RESULTS: Out of 2231 GNHIES98-DEGS1 participants aged 18-79 years without hypertension in 1998, 26.2% developed hypertension within a mean of 11.9 (range 10.0-14.1) years (men 29.0%, women 23.4%). In univariate analysis, hypertension incidence was positively associated with age, BMI, initial BP levels, pulse pressure, and alcohol consumption. Comorbidities such as diabetes and hyperlipidemia increased the chance to develop hypertension. In the multivariate model, initial SBP and DBP levels had the strongest influence on the development of future hypertension (7% increase in men and 5% in women per mmHg SBP). The percentage of aware, treated, and controlled hypertensive patients were 75.8, 62.1, and 50.3% in men and 83.8, 73.3, and 59.0% in women. CONCLUSION: The high 11.9-year incidence in all age groups points to the lifelong potential for prevention of hypertension.

[Regional differences in the prevalence of cardiovascular risk factors in men and women in Germany]. / Regionale Unterschiede in der Prävalenz von kardiovaskulären Risikofaktoren bei Männern und Frauen in Deutschland.

BACKGROUND: More than half of all cardiovascular diseases are caused by eight, mostly preventable risk factors. OBJECTIVES: In view of the considerable differences in the prevalence and mortality of cardiovascular diseases between the 16 German federal states, the regional distribution of cardiovascular risk factors was analyzed stratified for men and women, using population-based data. METHODS: Pooled data (n = 62,606) from the national, telephone health surveys "German Health Update" from 2009, 2010 and 2012 were used to estimate the prevalence of physical inactivity, risky alcohol consumption, smoking, low fruit and vegetable consumption, obesity and diagnosed hypertension, diabetes and dyslipidemia and the accumulated number of risk factors stratified for men and women in the federal states. Furthermore, we analyzed the influence of age and social status on prevalence differences. RESULTS: At the national level, 36.0% of men and 26.6% of women had three or more risk factors. Large differences between men and women were found for risky alcohol consumption (32.8% versus 21.7%), low fruit and vegetable consumption (20.6% versus 10.4%) and current smoking (32.6% versus 24.9%). The prevalence of all eight risk factors differed considerably between federal states. The highest prevalence of physical inactivity, obesity, hypertension and diabetes in both sexes as well as risky alcohol consumption in men were observed in the Eastern federal states (except for Berlin). Sachsen-Anhalt was the only federal state with the highest prevalence for two risk factors. Current smoking was most prevalent in the three federal city states Berlin, Hamburg and Bremen. Saarland had the highest prevalence of low fruit and vegetable consumption in both sexes. Regional differences remained after adjustment for age and social status. CONCLUSIONS: There is evidence for regional differences in cardiovascular risk factor levels in Germany that resemble variations in the prevalence and mortality of cardiovascular diseases between federal states with a more unfavorable situation in the East (except for Berlin). Overall, this study shows a considerable need for the prevention of mostly modifiable risk factors for cardiovascular diseases in men and women in Germany.

Hypertension in Germany.

BACKGROUND: Hypertension is a key risk factor. However, population data based on blood pressure measurements in Germany are scarce. METHODS: Standardized blood pressure (BP) measurements and medication data from seven population-based studies conducted in Germany between 1994 and 2012 (66 845 participants, 25-74 years) were analyzed: the EPICPotsdam study (1994-1998, EPIC), the KORA-S4 Study (1999-2001) in Augsburg, and the Gutenberg Health Study (2007-2012, GHS) in Mainz/Mainz-Bingen provided data for descriptive comparisons. Time trends were analyzed based on identical study regions for the German National Health Interview and Examination Survey 1998 (BGS98) and the German Health Examination Survey for Adults (2008-11, DEGS1) as well as the Study of Health in Pomerania (SHIP) in Northeast Germany (1997-2001) and the SHIP-TREND study (2008-2012). BP data were adjusted for study-specific measurement devices based on calibration studies. RESULTS: After adjustment for study-specific measurement devices, mean systolic and diastolic BP values were lower and treatment proportions higher in recent (2007-2012) compared to older (1994-2001) studies. Mean BP decrease was most pronounced (systolic ≥ 10 mmHg) in the elderly (55-74 years). The regional SHIP-TREND data for Northeast Germany showed a decrease in mean systolic BP in young men aged 25 to 34 years; on a national level according to the DEGS1 data, however, no such decrease was observed for this group. CONCLUSION: New data add evidence for lower BP in Germany. However, the prevention potential remains high. Future research based on population-based data should place a special focus on blood pressure data in young men.

Change in the association of body mass index and systolic blood pressure in Germany - national cross-sectional surveys 1998 and 2008-2011.

BACKGROUND: A recent weakening and even decoupling of the association of body mass index (BMI) and systolic blood pressure (SBP) in population data was reported, i. a. for Western Europe. METHODS: The association of BMI and SBP in recent cross-sectional population data from Germany was investigated in participants aged 18-79 years with BMI 17.5-40 kg/m(2) from national health examination surveys 1998 (n = 6,931) and 2008-2011 (n = 6,861) in Germany. The association was analyzed both in the overall samples and in participants without antihypertensive medication. RESULTS: From 1998 to 2008-11, age- and sex-standardized mean SBP decreased from 129.0 (CI 128.2-129.7) to 124.1 (123.5-124.6) mmHg in all participants and from 126.0 (125.4-126.7) to 122.3 (121.7-122.8) mmHg among persons not on antihypertensive medication. The proportion of persons treated with antihypertensives augmented from 19.2 % (17.7-20.8) to 25.3 % (24.0-26.6). Mean BMI remained constant at around 27 kg/m(2) with a slight increase in obesity prevalence. BMI was positively associated with SBP both in 1998 and 2008-11, yet the association tended to level out with increasing BMI suggesting a non-linear association. The strength of the BMI-SBP-association decreased over time in all and untreated men. In women, the association weakened in the overall sample, but remained similarly strong in untreated women. The unadjusted linear regression models were used to estimate the increase in SBP within 5-unit BMI increases. E. g. for men in 1998, SBP was higher by 7.0 mmHg for a BMI increase from 20 to 25 kg/m(2) and by 3.6 mmHg for BMI 30 to 35 kg/m(2). The corresponding values for 2008-11 were 3.8 mmHg and 1.7 mmHg. CONCLUSIONS: The cross-sectional association of BMI and SBP decreased between 1998 and 2008-11 in Germany, however it did not disappear and it is in part explained by improvements in the diagnosis and treatment of high blood pressure.

Regional variations in hypertension prevalence and management in Germany: results from the German Health Interview and Examination Survey (DEGS1).

OBJECTIVE: This study analyzed regional differences in blood pressure (BP) distribution and management in Germany 2008-2011 in a nationwide study. METHODS: The analyses were based on standardized BP measurements and anatomical therapeutic chemical classification-coded medication from the population-based German Health Interview and Examination Survey (DEGS1) 2008-2011 (N = 7074, 18-79 years, 180 study points, five regions: Central-East, South, Central-West, North-West, and North-East). Regional differences were tested between the region with the highest and lowest values. RESULTS: Regional variations were observed in mean SBP, mean DBP, and the prevalence of hypertension in both sexes, as well as awareness, treatment, and control in men. Differences in blood pressure (in mmHg) between Central-East, the region with the highest BP level and the region with the lowest BP level, were SBP 3.2 and DBP 2.5 in men and SBP 4.5 and DBP 2.4 in women. In Central-East 39% of men and 40% of women had hypertension, versus 30% of men in the North-West and 26% of women in the South. The percentage of aware, treated, and controlled men ranged between 92, 78, and 56% in the North-East and 74, 59, and 41% in the South, respectively. After multivariate adjustment for sociodemographic variables and hypertension risk factors, geographical differences persisted for hypertension prevalence in women and hypertension awareness and treatment in men. CONCLUSION: So far, national surveys allowed only BP comparisons along the former East-West border and showed more elevated BP in the East. New analyses suggest regional differences with both the most and the least favorable results in the two neighboring parts of former East Germany.

The influence of neighborhood unemployment on mortality after stroke.

BACKGROUND: Few studies have investigated the impact of neighborhood characteristics on mortality after stroke. Aim of our study was to analyze the influence of district unemployment as indicator of neighborhood socioeconomic status (SES-NH) on poststroke mortality, and to compare these results with the mortality in the underlying general population. METHODS: Our analyses involve 2 prospective cohort studies from the city of Dortmund, Germany. In the Dortmund Stroke Register (DOST), consecutive stroke patients (N=1883) were recruited from acute care hospitals. In the Dortmund Health Study (DHS), a random general population sample was drawn (n=2291; response rate 66.9%). Vital status was ascertained in the city's registration office and information on district unemployment was obtained from the city's statistical office. We performed multilevel survival analyses to examine the association between district unemployment and mortality. RESULTS: The association between neighborhood unemployment and mortality was weak and not statistically significant in the stroke cohort. Only stroke patients exposed to the highest district unemployment (fourth quartile) had slightly higher mortality risks. In the general population sample, higher district unemployment was significantly associated with higher mortality following a social gradient. After adjustment for education, health-related behavior and morbidity was made the strength of this association decreased. CONCLUSIONS: The impact of SES-NH on mortality was different for stroke patients and the general population. Differences in the association between SES-NH and mortality may be partly explained by disease-related characteristics of the stroke cohort such as homogeneous lifestyles, similar morbidity profiles, medical factors, and old age.

How to weight chronic diseases in multimorbidity indices? Development of a new method on the basis of individual data from five population-based studies.

OBJECTIVE: In multimorbidity indices, chronic conditions are often weighted according to their severity or their impact on different outcomes. These weights are mostly developed on the basis of only one study population by using very specific study participants, such as hospital patients. To overcome the limited validity of the indices, mean weights across five population-based studies were calculated according to the impact of diseases on self-reported health status. STUDY DESIGN AND SETTING: Individual data was provided from the National Health Interview and Examination Survey (n=1,010), Dortmund Health Study (n=281), Memory and Morbidity in Augsburg Elderly Study (n=385), Survey of Health, Aging and Retirement in Europe Study (n=1,278), and Study of Health in Pomerania Study (n=962). By using logistic regression analysis, odds ratios (ORs) were calculated for reporting a fair or poor health status resulting from one of 10 different chronic conditions compared with a reference group without the specific disease, controlling for age and sex. If the results were homogenous across studies (I(2)<40%), significant pooled ORs were considered valid weights for a multimorbidity index. RESULTS: Myocardial infarction has the highest impact on self-reported health status across studies with a pooled OR of 3.9, followed by chronic obstructive pulmonary disease (pooled OR: 3.1). A medium impact was observed for arthrosis, asthma, diabetes mellitus, and osteoporosis. CONCLUSION: This method provided valid weights for seven chronic conditions.

Predictors of dependency on nursing care after stroke: results from the Dortmund and Münster stroke registry.

BACKGROUND: The long-term effects of stroke have been inadequately studied. We identified social and clinical factors that were associated with application for insurance payments for long-term care within 3.6 years after stroke. METHODS: In a quality-assurance project called "Stroke Northwest Germany," information was obtained from 2286 stroke patients on their socio-demographic background, type of stroke, comorbidities, and degree of physical impairment during their hospital stay, as measured on the Rankin Scale, the Barthel Index, and the Neurological Symptom Scale. We used logistic regression models to identify possible associations between these factors and application for insurance payments for long-term care within 3.6 years after stroke. We developed an appropriate prognostic model by means of backward selection. RESULTS: 734 (32.1%) of the patients participated in follow-up and reported whether they had applied for insurance payments for long-term care. 22.5% had submitted an application. The rate of application was positively correlated with age, female sex, the number of comorbidities and complications during hospitalization, and the degree of physical impairment. CONCLUSION: Stroke has major long-term effects. The probability that a stroke patient will apply for insurance payments for long-term care is a function of the patient's age, sex, previous stroke history, and physical impairment as measured on the Rankin Scale and the Barthel Index.

The measurement of multiple chronic diseases--a systematic review on existing multimorbidity indices.

BACKGROUND: Multimorbidity, defined as the coexistence of 2 or more chronic diseases, is a common phenomenon especially in older people. Numerous efforts to establish a standardized instrument to assess the level of multimorbidity have failed until now, and indices are primarily characterized by their high heterogeneity. Thus, the objective is to provide a comprehensive overview on existing instruments on the basis of a systematic literature review. METHODS: The review was performed in MedLine. All articles published between January 1, 1960 and August 31, 2009 in German or English language, with the primary focus either on the development of a weighted index or on the effect of multimorbidity on different outcomes, were identified. RESULTS: A total of 39 articles met the inclusion criteria. In the majority of studies (59.0%), the list of included diseases was presented without any selection criteria. Only the high prevalence of diseases (17.9%), their impact on mortality, function, and health status served as a point of reference. Information on the prevalence of chronic conditions mostly rely on self-reports. On average, the 39 indices included 18.5 diseases, ranging between 4 and 102 different conditions. Most frequently mentioned diseases were diabetes mellitus (in 97.5% of indices), followed by stroke (89.7%), hypertension, and cancer (each 84.6%). Overall, three different weighting methods could be distinguished. CONCLUSIONS: The systematic literature further emphasis the heterogeneity of existing multimorbidity indices. However, one important similarity is that the focus is on diseases with a high prevalence and a severe impact on affected individuals.