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. ß = -2.31, p = 0.021; 2019: std. ß = -4.14, p < 0.001) and higher unemployment rate (2015: std. ß = -2.84, p = 0.005; 2019: std. ß = -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. ß = -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.

The role of leukocytes in cognitive impairment due to long-term exposure to fine particulate matter: A large population-based mediation analysis.

INTRODUCTION: Our understanding of how fine particulate matter (PM2.5) impacts cognitive functioning is limited. Systemic inflammation processes may play a role in mediating this effect. METHODS: This prospective cohort study used data from 66,254 participants aged 18+ between 2006 and 2015 from the Dutch Lifelines Cohort Study and Biobank. Causal mediation analysis was conducted to examine the impact of ambient PM2.5 exposure on cognitive processing time (CPT), using the change in white blood cell (WBC) count and its subtypes as potential mediators. RESULTS: Heightened PM2.5 exposure was associated with slower CPT (total effect = 81.76 × 10-3, 95% confidence interval [CI] 59.51 × 10-3-105.31 × 10-3). The effect was partially mediated via increased WBC count (indirect effect [IE] = 0.42 × 10-3, 95% CI 0.07 × 10-3-0.90 × 10-3), particularly driven by an increase in monocytes (IE = 0.73 × 10-3, 95% CI 0.24 × 10-3-1.31 × 10-3). DISCUSSION: Systemic inflammation processes may partially explain the harmful effects of PM2.5 on cognitive functioning, why lower levels of systemic inflammation may help contain its neurotoxic effects. HIGHLIGHTS: The pathways leading to the neurotoxic effects of fine particulate matter (PM2.5) are poorly understood. We analyzed data from over 66,000 participants using causal pathway analysis. Increased white blood cell (WBC) count mediates the effect of PM2.5 on cognitive functioning. Monocyte count played a crucial role in this low-pollution setting. Systemic inflammation may contribute to the neurotoxic effects of PM2.5.

Long-term exposure to fine particulate matter, lung function and cognitive performance: A prospective Dutch cohort study on the underlying routes.

BACKGROUND: Exposure to fine particulate matter and black carbon is related to cognitive impairment and poor lung function, but less is known about the routes taken by different types of air pollutants to affect cognition. OBJECTIVES: We tested two possible routes of fine particulate matter (PM2.5) and black carbon (BC) in impairing cognition, and evaluated their importance: a direct route over the olfactory nerve or the blood stream, and an indirect route over the lung. METHODS: We used longitudinal observational data for 49,705 people aged 18+ from 2006 to 2015 from the Dutch Lifelines cohort study. By linking current home addresses to air pollution exposure data from ELAPSE in 2010, long-term average exposure to PM2.5 and BC was assessed. Lung function was measured by spirometry and Global Initiative (GLI) z-scores of forced expiratory volume in 1s (FEV1) and forced vital capacity (FVC) were calculated. Cognitive performance was measured by cognitive processing time (CPT) assessed by the Cogstate Brief Battery. Linear structural equation modeling was performed to test direct/indirect associations. RESULTS: Higher exposure to PM2.5 but not BC was related to higher CPT and slower cognitive processing speed [Total Effect PM2.5: FEV1 model = 8.31 × 10-3 (95% CI: 5.71 × 10-3, 10.91 × 10-3), FVC model = 8.30 × 10-3 (95% CI: 5.69 × 10-3, 10.90 × 10-3)]. The direct association of PM2.5 constituted more than 97% of the total effect. Mediation by lung function was low for PM2.5 with a mediated proportion of 1.32% (FEV1) and 2.05% (FVC), but higher for BC (7.01% and 13.82% respectively). DISCUSSION: Our results emphasise the importance of the lung acting as a mediator in the relationship between both exposure to PM2.5 and BC, and cognitive performance. However, higher exposure to PM2.5 was mainly directly associated with worse cognitive performance, which emphasises the health-relevance of fine particles due to their ability to reach vital organs directly.

[Risk of Reduced Earning Capacity Pension due to Cardiovascular Diseases after Medical Rehabilitation: An Event History Analysis based on German Statutory Pension Insurance Data]. / Das Risiko für Erwerbsminderungsrente bei Herz-Kreislauf-Erkrankungen nach medizinischen Rehabilitationen: Eine ereignisdatenanalytische Studie auf Basis von Daten der Deutschen Rentenversicherung.

AIM: Not much is known on risks for reduced earning capacity pensions (RECP) for patients with specific diseases. Our study focusses on individuals who have completed a course of rehabilitation due to cardiovascular disease. METHODS: This study is based on a scientific use file from the German statutory pension insurance that covers completed rehabilitations between 2006-2013. Using survival analysis, we modeled the transition into RECP in general and for specific diagnostic groups. We used Kaplan-Meier-estimates and age-standardized and sex-specific transition rates. Multivariate Cox Proportional Hazard models are used to identify the most important socio-demographic risk factors for RECP. RESULTS: Patients who completed rehabilitation after cerebral infarction, cardiomyopathy or cerebrovascular diseases were most likely to transition into RECP due to these diseases. The most important socio-demographic risk factors for RECP were low educational attainments, part-time or no employment and living in Eastern Germany. CONCLUSION: Especially patients with cerebral infarction, cardiomyopathy or cerebrovascular diseases require successful medical rehabilitation. In case of multimorbid patients, these diagnoses require special attention. Also, the reintegration into the labor market of people from lower social strata after medical rehabilitation to avoid RECP appears to be especially difficult.

Effects of changes in living environment on physical health: a prospective German cohort study of non-movers.

BACKGROUND: Longitudinal studies on associations between changes in living environment and health are few and focus on movers. Next to causal effects, differences in health can, however, result due to residential mobility. The present study explored changes in living environment related to (changes in) physical health among non-movers. Causality was reinforced by a novel study design. METHODS: We obtained longitudinal data on both living environment and physical health covering 4601 non-movers aged 18+ with 16 076 health observations from the German Socio-Economic Panel between 1999 and 2014. Changing and stable perceived living environment from three domains (infrastructure, environmental pollution, housing conditions) were included at household level. We performed linear regressions with robust standard errors and generalized estimating equations to predict the physical component summary (PCS) at baseline and changes in PCS over time. RESULTS: Stable moderate and worst as well as worsened environmental pollution and infrastructure were associated with worse PCS at baseline, as were stable poor and worsened housing conditions. Stable worst infrastructure was associated with negative changes in PCS for both sexes. Men's changes in PCS were more affected by worsened environmental pollution than women's. CONCLUSION: A suboptimal living environment has short- and long-term negative effects on physical health. Because even short-term changes in the living environment have an immediate influence on an individual's health status and health trajectories, public attention to living environment is essential to fight existing health inequalities.

Associations between COVID-19 Pandemic-Related Overtime, Perceived Chronic Stress and Burnout Symptoms in German General Practitioners and Practice Personnel-A Prospective Study.

BACKGROUND: The mental burdens of general practitioners (GPs) and practice assistants (PrAs) during the COVID-19 pandemic are well investigated. Work-related conditions like overtime are known to contribute to perceived chronic stress and burnout symptoms. However, there is limited evidence regarding the specific mechanisms, which link pandemic-related overtime, chronic stress and burnout symptoms. This study used data from the IMPROVEjob trial to improve psychological well-being in general practice personnel. METHODS: This prospective study with 226 German GPs and PrAs used the baseline (pre-pandemic: October 2019 to March 2020) and follow-up data (pandemic: October 2020 to April 2021) of the IMPROVEjob trial. Overtime was self-reported as hours above the regular work time. Perceived chronic stress was assessed using the Trier Inventory for the Assessment of Chronic Stress Screening Scale (TICS-SSCS), while burnout symptoms were evaluated using a short version of the Maslach Burnout Inventory (MBI). A mediation analysis investigated the differences of the three main variables between pre-pandemic and pandemic periods. RESULTS: Burnout symptoms increased significantly from baseline to follow-up (p = 0.003). Overtime correlated positively with burnout symptoms (Total Effect: 0.13; 95% CI: 0.03, 0.23). Decomposition of the total effect revealed a significant indirect effect over perceived chronic stress (0.11; 95% CI: 0.06, 0.18) and no significant direct effect (0.02; 95% CI: -0.08, 0.12), indicating a full mediation. CONCLUSION: In this large longitudinal study, pandemic-related overtime led to significantly higher levels of burnout symptoms, linked by a pathway through perceived chronic stress. Future prevention strategies need to aim at reducing the likelihood of overtime to ensure the mental well-being of practice personnel.

Use of the FallAkte Plus System as an IT Infrastructure for the North Rhine-Westphalian General Practice Research Network: Mixed Methods Usability Study.

BACKGROUND: Primary care research networks can generate important information in the setting where most patients are seen and treated. However, this requires a suitable IT infrastructure (ITI), which the North Rhine-Westphalian general practice research network is looking to implement. OBJECTIVE: This mixed methods research study aims to evaluate (study 1) requirements for an ITI and (study 2) the usability of an IT solution already available on the market, the FallAkte Plus (FA+) system for the North Rhine-Westphalian general practice research network, which comprises 8 primary care university institutes in Germany's largest state. METHODS: In study 1, a survey was conducted among researchers from the institutes to identify the requirements for a suitable ITI. The questionnaire consisted of standardized questions with open-ended responses. In study 2, a mixed method approach combining a think-aloud approach and a quantitative survey was used to evaluate the usability and acceptance of the FA+ system among 3 user groups: researchers, general practitioners, and practice assistants. Respondents were asked to assess the usability with the validated system usability scale and to test a short questionnaire on vaccination management through FA+. RESULTS: In study 1, five of 8 institutes participated in the requirements survey. A total of 32 user requirements related primarily to study management were identified, including data entry, data storage, and user access management. In study 2, a total of 36 participants (24 researchers and 12 general practitioners or practice assistants) were surveyed in the mixed methods study of an already existing IT solution. The tutorial video and handouts explaining how to use the FA+ system were well received. Researchers, unlike practice personnel, were concerned about data security and data protection regarding the system's emergency feature, which enables access to all patient data. The median overall system usability scale rating was 60 (IQR 33.0-85.0), whereby practice personnel (median 82, IQR 58.0-94.0) assigned higher ratings than researchers (median 44, IQR 14.0-61.5). Users appreciated the option to integrate data from practices and other health care facilities. However, they voted against the use of the FA+ system due to a lack of support for various study formats. CONCLUSIONS: Usability assessments vary markedly by professional group and role. In its current stage of development, the FA+ system does not fully meet the requirements for a suitable ITI. Improvements in the user interface, performance, interoperability, security, and advanced features are necessary to make it more effective and user-friendly. Collaborating with end users and incorporating their feedback are crucial for the successful development of any practice network research ITI.

The association of unhealthy and healthy food store accessibility with obesity prevalence among adults in the Netherlands: A spatial analysis.

Introduction: Obesity prevalence has almost tripled in Europe since 1980, and the obesogenic (food) environment is hypothesised to be one of the main drivers. Still, empirical evidence is rare for Europe. Objective: This ecological study explores spatial patterns of obesity prevalence of adults (aged 19+) in the Netherlands in 2016. It studies, in particular, its global associations with (un)healthy food store accessibility while assessing local differences and evaluating the importance of the immediate versus the wider food surroundings. Methods: In our ecological study, we used small-area estimated obesity prevalence (adults, aged 19+) from 2836 neighbourhoods (six-digit postal codes, wijken) and combined this with measures from Statistics Netherlands on accessibility to (unhealthy) fast food and (healthy) fresh food. Spatial lag of X (SLX) models were estimated for the entire Netherlands to explore global associations. Separate models for urban, suburban, and rural neighbourhoods and a geographically weighted regression (GWR) were estimated to explore and visualise local variations in the associations. Total associations from the SLX models were then decomposed to yield contributions of the immediate and wider food surroundings. Results: Regional clusters of high obesity were observed in selected areas in the north-east, the south-west, and south-east. Limited accessibility to unhealthy food was globally associated with lower obesity prevalence, whereas better accessibility to fresh food stores and supermarkets was not. The association regarding worse accessibility to unhealthy food was strongest for urban neighbourhoods, especially for the Randstad region. In urban settings, also better accessibility to fresh food stores proved relevant. The wider food surrounding proved more important than the immediate food surrounding, throughout. Discussion: Public policies addressing obesity might be more effective when reducing the presence of unhealthy food rather than expanding healthy food supply. Moreover, they should focus on urban regions and high obesity clusters, thereby considering wider food surroundings.

The short- and long-term effects of the Great Recession on late-life depression in Europe: The role of area deprivation.

INTRODUCTION: The prevalence of depression increases in times of economic crises. Less is known about whether people living in advantaged or disadvantaged areas suffer equally from negative effects of crisis. OBJECTIVE: To explore the role of area deprivation on the short- and long-term effects of the Great Recession in Europe on late-life depression. METHODS: Individual panel data from Austria, Belgium, Denmark, France, Germany, Italy, Spain, Sweden, Switzerland of the SHARE (age 50+, n = 6866) between 2004 and 2017 were used. Late-life depression (LLD) was measured by the EURO-D scale (4+ symptoms). Area deprivation was assessed by a country-specific z-standardized scale measuring perceived access to various services and quality of the social and built environment. Quarterly country-level GDP and yearly unemployment data were explored to define country-specific durations of the Great Recession. Individual fixed effects panel regressions were estimated controlling for time-varying socioeconomic and health-related confounders. RESULTS: Prevalence and incidence of late-life depression was generally higher in deprived than in non-deprived areas, and these differences in prevalence and incidence increased during the Great Recession. Regressions showed that the Great Recession was related to a 23% higher long-term risk of late-life depression (OR: 1.23, CI: 1.05-1.44) for all study participants. In the short-term of the Great Recession, people from deprived areas had a 22% higher risk of late-life depression (OR: 1.22, CI: 1.02-1.46) than people from non-deprived areas. CONCLUSION: The findings suggest that older adults exposed to adverse area determinants suffer more from the negative short-term effects of a severe economic crisis on depression and mental health inequalities may have increased between people living in deprived versus non-deprived areas. This potential increase in mental health inequalities warrants particular attention for those people living in deprived areas.