[Physical activity in the German National Cohort (NAKO): use of multiple assessment tools and initial results]. / Körperliche Aktivität in der NAKO Gesundheitsstudie: erste Ergebnisse des multimodalen Erhebungskonzepts.

BACKGROUND: Physical activity is a complex behavior that is difficult to measure validly and reliably in large, population-based studies. Data on physical activity are available for the initial 100,000 participants of the German National Cohort. OBJECTIVES: To describe the baseline physical activity assessment in the cohort and to present initial descriptive results. MATERIAL AND METHODS: Physical activity was assessed using a combination of tools, including two self-administered questionnaires, the Questionnaire on Annual Physical Activity Pattern (QUAP) and the Global Physical Activity Questionnaire (GPAQ); a computer-based 24­h physical activity recall (cpar24); and 7­day accelerometry (Actigraph GT3X/+; ActiGraph, Pensacola, FL, USA). RESULTS: The availability of data varied between assessment instruments (QUAP: n = 16,372; GPAQ: n = 90,900; cpar24: n = 23,989; accelerometry: n = 35,218). Analyses across measurement tools showed that on average, women spent 75 to 216 min/d, and men spent 73 to 224 min/d in moderate or higher intensity total physical activity. Persons aged 20-39 years spent 66 to 200 min/d, and persons aged 40-69 years spent 78 to 244 min/d in moderate or higher intensity total physical activity. CONCLUSIONS: Initial baseline analyses of physical activity in this cohort show the value of using a combination of questionnaires, 24­h recalls, and a movement sensor. The comprehensive data collection represents a valuable resource for future analyses and will improve our understanding of the association between physical activity and disease prevention.

The association of intensive care with utilization and costs of outpatient healthcare services and quality of life.

BACKGROUND: Little is known about outpatient health services use following critical illness and intensive care. We examined the association of intensive care with outpatient consultations and quality of life in a population-based sample. METHODS: Cross-sectional analysis of data from 6,686 participants of the Study of Health in Pomerania (SHIP), which consists of two independent population-based cohorts. Statistical modeling was done using Poisson regression, negative binomial and generalized linear models for consultations, and a fractional response model for quality of life (EQ-5D-3L index value), with results expressed as prevalence ratios (PR) or percent change (PC). Entropy balancing was used to adjust for observed confounding. RESULTS: ICU treatment in the previous year was reported by 139 of 6,686 (2,1%) participants, and was associated with a higher probability (PR 1.05 [CI:1.03;1.07]), number (PC +58.0% [CI:22.8;103.2]) and costs (PC +64.1% [CI:32.0;103.9]) of annual outpatient consultations, as well as with a higher number of medications (PC +37.8% [CI:17.7;61.5]). Participants with ICU treatment were more likely to visit a specialist (PR 1.13 [CI:1.09; 1.16]), specifically internal medicine (PR 1.67 [CI:1.45;1.92]), surgery (PR 2.42 [CI:1.92;3.05]), psychiatry (PR 2.25 [CI:1.30;3.90]), and orthopedics (PR 1.54 [CI:1.11;2.14]). There was no significant effect regarding general practitioner consultations. ICU treatment was also associated with lower health-related quality of life (EQ-5D index value: PC -13.7% [CI:-27.0;-0.3]). Furthermore, quality of life was inversely associated with outpatient consultations in the previous month, more so for participants with ICU treatment. CONCLUSIONS: Our findings suggest that ICU treatment is associated with an increased utilization of outpatient specialist services, higher medication intake, and impaired quality of life.

Relative impact of COPD and comorbidities on generic health-related quality of life: a pooled analysis of the COSYCONET patient cohort and control subjects from the KORA and SHIP studies.

BACKGROUND: Health-related quality of life (HRQL) is an important patient-reported outcome measure used to describe the burden of chronic obstructive pulmonary disease (COPD) which is often accompanied by comorbid conditions. METHODS: Data from 2275 participants in the COPD cohort COSYCONET and from 4505 lung-healthy control subjects from the population-based KORA and SHIP studies were pooled. Main outcomes were the five dimensions of the generic EQ-5D-3 L questionnaire and two EQ-5D index scores using a tariff based on valuations from the general population and an experience-based tariff. The association of COPD in GOLD grades 1-4 and of several comorbid conditions with the EQ-5D index scores was quantified by multiple linear regression models while adjusting for age, sex, education, body mass index (BMI), and smoking status. RESULTS: For all dimensions of the EQ-5D, the proportion of participants reporting problems was higher in the COPD group than in control subjects. COPD was associated with significant reductions in the EQ-5D index scores (-0.05 points for COPD grades 1/2, -0.09 for COPD grade 3, -0.18 for COPD grade 4 according to the preference-based utility tariff, all p < 0.0001). Adjusted mean index scores were 0.89 in control subjects and 0.85, 0.84, 0.81, and 0.72 in COPD grades 1-4 according to the preference-based utility tariff and 0.76, 0.71, 0.68, 0.64, and 0.58 for control subjects and COPD grades 1-4 for the experience-based tariff respectively. Comorbidities had additive negative effects on the index scores; the effect sizes for comorbidities were comparable to or smaller than the effects of COPD grade 3. No statistically significant interactions between COPD and comorbidities were observed. Score differences between COPD patients and control subjects were most pronounced in younger age groups. CONCLUSIONS: Compared with control subjects, the considerable reduction of HRQL in patients with COPD was mainly due to respiratory limitations, but observed comorbidities added linearly to this effect. Younger COPD patients showed a greater loss of HRQL and may therefore be in specific need of comprehensive disease management. TRIAL REGISTRATION: NCT01245933.

Associations of androgens with health care utilization and costs in women-Perspectives of a population-based cohort study.

OBJECTIVE: Despite associations between total testosterone (TT) concentrations and increased cardiometabolic risk, the impact of serum androgens on health care utilization and costs among women is unknown. METHODS: We used data from 1521 women in the population-based cohort Study of Health in Pomerania (SHIP) to investigate the associations of serum TT (measured by liquid chromatography-tandem mass spectrometry), sex hormone-binding globulin (SHBG), and free testosterone (free T) with health care utilization and costs at baseline and five-year follow-up (N=1210), implementing multivariable-adjusted econometric models. RESULTS: Cross-sectional analyses showed no association of TT, SHBG, or free T with hospitalization or total health costs (outpatient as well as inpatient costs). Prospective analyses revealed an inverse association of baseline SHBG with follow-up total health care costs (% change per standard deviation (SD): -26.2%, 95% confidence interval (CI): -42.2%; -8.9%) and inpatient costs (% change per SD: -26.5%%, 95% CI: -45.5%; -2.5%). Baseline free T was positively associated with total health care costs at the five-year follow-up (% change per SD: +37.7%, 95% CI: +4.6%; +81.4%). CONCLUSIONS: In this first cost analysis among women from the general population, we observed no association of androgen serum concentration with health care utilization and costs. However, baseline SHBG appeared to be inversely correlated and free T positively correlated with long-term health care costs.

Health Care Access Among Asian American Subgroups: The Role of Residential Segregation.

Few studies have examined differences in health care access across Asian American ethnicities and none have considered the effects of residential segregation. The segregation of Asians by neighborhood has been steadily increasing over the past few decades due in part to the settlement patterns of immigrants. Data from the 2009 National Longitudinal Study of Adolescent Health (n = 746) were used. We examined differences in yearly medical checkups between Asian subgroups as well as among foreign-born and US-born Asians. Results showed that immigrant Filipinos and Vietnamese were less likely to get a checkup compared with foreign-born Chinese. The effect of Asian subgroup was modified by the percentage of Asians in a census tract (p < 0.01). Koreans and other Asians had a higher probability of getting a checkup when living in a predominately Asian neighborhood. For Chinese and Vietnamese residential concentration of Asians had a stronger inverse association with having a yearly checkup.

Change in depressive symptoms and mental health-related quality of life in northeast Germany between 1997-2001 and 2008-2012.

OBJECTIVES: Little is known about changes in depression and quality of life in East Germany. We examined changes in the prevalence of lifetime and current depressive symptoms and mental health-related quality of life among adults in northeast Germany between 1997-2001 and 2008-2012. METHODS: Population-based data were drawn from two repeated cross-sectional surveys conducted 11 years apart within the Study of Health of Pomerania project (Ns of 4,228 and 4,251). Assessments included screening items for lifetime depressive symptoms from the Munich Composite International Diagnostic Interview (M-CIDI), the Depression and Exhaustion Scale (DEEX), and the Short Form Health Survey (SF-12). RESULTS: Lifetime depressive symptoms rose from 13.2 to 27.8%. The increase was stronger in men than in women and in individuals aged 35-64 years. No substantial changes occurred in the overall prevalence of current depressive symptoms (DEEX) and mental health-related quality of life (SF-12). A small decrease in current depressive symptoms was observed in middle-aged men and older women and small improvements in mental health-related quality of life in young adults. CONCLUSIONS: Higher reporting of lifetime depressive symptoms might reflect methodological influences as well as lower stigmatization and higher awareness, while the current burden seems similar.

Development, external validation, and comparative assessment of a new diagnostic score for hepatic steatosis.

OBJECTIVES: We used data from population-based studies to determine the accuracy of the Fatty Liver Index (FLI) and the Hepatic Steatosis Index (HSI) in determining individual risk of hepatic steatosis. We also developed a new risk scoring system and validated all three indices using external data. METHODS: We used data from the Study of Health in Pomerania (SHIP; n=4,222), conducted in North-eastern Germany, to validate the existing scoring systems and to develop our own index. Data from the South German Echinococcus Multilocularis and Internal Diseases in Leutkirch (EMIL) study (n=2,177) were used as an external validation data set. Diagnostic performance was evaluated in terms of discrimination (area under the receiver operating characteristic curve (AUC)) and calibration plots. We applied boosting for generalized linear models to select relevant diagnostic separators. RESULTS: The FLI accurately discriminated patients with fatty liver disease from those without (AUC=0.817) but had poor calibration, in that predicted risks differed considerably from observed risks, based on SHIP data. The FLI performed well in discrimination and calibration in the analysis of EMIL data (AUC=0.890). The HSI performed worse than the FLI in analysis of both data sets (SHIP: AUC=0.782 and EMIL: AUC=0.841), showing an extremely skewed calibration. Our newly developed risk score had a good performance in the development data set (SHIP: AUC=0.860) and also good discrimination ability in the validation data (EMIL: AUC=0.876), but it had low calibration based on the validation data set. CONCLUSIONS: We compared the ability of the FLI, HSI, and our own scoring system to determine the risk of hepatic steatosis using two population-based data sets (one for the development of our own system and one for validation). In the development and independent replication data set, all three indices discriminated well between patients with and without hepatic steatosis, but the predicted risks did not match well with the observed risks, when applied to external data. Scoring systems for fatty liver disease could depend on methodological standardization of ultrasound diagnosis and laboratory measurements.

Do social relations explain health inequalities? Evidence from a longitudinal survey in a changing eastern German region.

OBJECTIVES: This study explores the contribution of social relations to explain inequalities in self-rated health in a changing north-eastern German region. So far, there are only few studies that analysed the mediating effects of social relations in a longitudinal design. METHODS: We used data from the Study of Health in Pomerania (SHIP) consisting of 3,300 randomly selected men and women at baseline (2001), and at the 5-year follow-up (2006). Indicators of social inequality were education, equivalent household income and occupational status. Social relations were estimated by the Social Integration Index (SII) and the perceived instrumental and emotional support. Self-rated general health was assessed at both waves of data collection. RESULTS: Depending on the indicators used, social relations explain up to 35% of the inequalities in self-rated health. Changes in odds ratios are slightly more pronounced when education and income are used as inequality indicator and when adjusting for the SII. CONCLUSIONS: Overall findings suggest that social relations are an important explanatory factor for health inequalities in a deprived German region.

Association of IGF-I and IGFBP-3 with health care costs and hospitalization: results from a prospective observational study.

OBJECTIVE: Previous cohort studies found robust associations of serum insulin-like growth factor I (IGF-I) and its main binding protein IGFBP-3 with increased morbidity or mortality. This study investigates the relationships between IGF-I and IGFBP-3 with health care costs and hospitalization in a general population and whether adding IGF-I or IGFBP-3 to a model of established health care predictors improves prediction. METHODS: Data from a population-based cohort study of 3139 men and women in Germany, aged 20 to 80 years at baseline were used (median follow-up time: 5.0 years). Self-reported physician visits, length of hospital stay were used to estimate annual costs. IGF-I and IGFBP-3 were categorized at the 10th and 90th percentile, to indicate 'low', 'intermediate', and 'high' concentrations, respectively. RESULTS: Total annual health care costs, with the major component of inpatient costs, and risk of hospitalization at baseline and follow-up were higher in subjects with low compared to intermediate IGF-I or IGFBP-3, after multivariable-adjustment. Subjects with low in contrast to intermediate IGF-I exhibited 30.6% higher annual total costs 5 years after baseline examination, corresponding to a difference in adjusted costs of EUR436.61. CONCLUSIONS: Low IGF-I and IGFBP-3 independently predict future health care costs and hospitalization. IGF-I or IGFBP-3 might be useful to identify subjects with excess health care use. The predictive performance of cross-sectional and longitudinal models of total and inpatient costs were slightly improved by adding IGF-I or IGFBP-3 but the cost-effectiveness of inclusion into prediction models needs to be examined.

The Geriatric Nutritional Risk Index predicts increased healthcare costs and hospitalization in a cohort of community-dwelling older adults: results from the MONICA/KORA Augsburg cohort study, 1994-2005.

OBJECTIVE: To determine if the Geriatric Nutritional Risk Index (GNRI), an index for the risk of nutrition-related complications, is associated with healthcare costs and risk of hospitalization at baseline and after 10 y. METHODS: Data from a German population-based cohort of 1999 subjects 55 to 74 y of age at baseline were used. Self-reported physician visits, length of hospital stay, and drug intake were used to estimate costs. The GNRI is based on serum albumin values and the discrepancy between real and ideal body weights. Low GNRI values were defined as mean minus 2 times standard deviation. Mean GNRI values were regarded as normal. RESULTS: Low baseline GNRI was consistently associated with increased total costs, probability of hospitalization, inpatient costs, and pharmaceutical costs at baseline and follow-up, after adjustment for socioeconomic characteristics, lifestyle factors, and coexisting conditions. Subjects with low GNRI at baseline had approximately 47% higher total costs, 50% higher risk of hospitalization, 62% higher inpatient costs and 27% higher pharmaceutical costs at follow-up than subjects with normal GNRI values. CONCLUSION: The GNRI risk predicted increased future healthcare costs and higher risk of hospitalization in independent-living older adults. The GNRI is a rapid and low-cost tool that might be routinely used in population-based settings.

Changes in alcohol consumption and beverage preference among adolescents after the introduction of the alcopops tax in Germany.

AIMS: The aim of this study is to assess the contribution of the alcopops tax to changes in alcohol consumption and beverage preference among adolescents in Germany. We hypothesize that the decrease of alcohol intake by alcopops is substituted by an increase of alcohol intake by other alcoholic beverages. DESIGN: Data came from the German 2003 (n = 10 551) and 2007 (n = 10 598) cross-sectional study of the European School Survey Project on Alcohol and other Drugs (ESPAD). PARTICIPANTS: A propensity score-matched subsample of 9(th) and 10(th) graders (n = 4694) was used for the analyses. MEASUREMENT: Alcohol consumption within the last 7 days was assessed by a beverage-specific quantity-frequency index. An individual's beverage preference was assigned for the beverage that had the highest share in total alcohol consumption. Multiple regression analyses were used to assess changes in alcohol consumption; changes in beverage preference were tested using multinomial logistic regression. FINDINGS: While alcopop consumption declined after the alcopops tax was implemented, consumption of spirits increased. Changes in beverage preference revealed a decrease in alcopop preference and an increase in the preference for beer and spirits. CONCLUSIONS: Results indicate a partial substitution of alcopops by spirits and a switch in preference to beverages associated with riskier drinking patterns. Effective alcohol policies to prevent alcohol-related problems should focus upon the reduction of total alcohol consumption instead of regulating singular beverages.

Effect of chronic kidney disease and comorbid conditions on health care costs: A 10-year observational study in a general population.

BACKGROUND: Chronic kidney disease (CKD) is common, but the longitudinal effects of CKD and associated comorbidities on health care costs in the general population are unknown. METHODS: Population-based cohort study of 2,988 subjects in Germany, aged 25-74 years at baseline, who participated both in the baseline and 10-year follow-up examination (1994/95-2004/05). Presence of CKD was based on serum creatinine and defined as an estimated glomerular filtration rate of <60 ml/min/1.73 m(2). Self-reported health services utilization was used to estimate costs. RESULTS: Health care costs at baseline and follow-up were higher for subjects with CKD. Controlling for socio-economics, lifestyle factors and comorbid conditions, subjects with baseline CKD, in comparison to those without, exhibited 65% higher total costs 10 years after baseline examination, corresponding to a difference in adjusted costs of EUR 743. Incident CKD was related to 38% higher total costs. Costs for inpatient treatment and drug costs were the major costs components, while CKD revealed no effect on outpatient costs. The effect of CKD was strongly modified by angina, myocardial infarction, diabetes, and anemia. CONCLUSIONS: The direct effect of CKD on costs is modified by comorbid conditions. Therefore, early treatment of CKD and its precipitous factors may save future health care costs.

Predictive modeling of health care costs: do cardiovascular risk markers improve prediction?

BACKGROUND: To investigate the ability of multiple cardiovascular disease (CVD) markers to predict future health care costs. CVD markers included traditional risk factors (smoking status, body mass index, waist circumference, alcohol intake, diabetes, total : high-density lipoprotein cholesterol ratio, actual hypertension, physical activity) and newer markers (carotid intima-media thickness, hemoglobin A1c, apolipoprotein B : apolipoprotein A-1 ratio, lipoprotein (a), leukocyte count, high-sensitive C-reactive protein, plasma fibrinogen, estimated glomerular filtration rate, urinary albumin : creatinine ratio). DESIGN AND METHODS: The study sample consisted of 2233 participants without history of myocardial infarction, stroke, heart failure, and angina pectoris at baseline (50.6% women; mean age 60.9 years; age range 45-81 years) from the cohort Study of Health in Pomerania, Germany (median follow-up 5 years). RESULTS: Predictive modeling revealed that a basic model with sex, age, years of school education, insurance status, and income explained 0.9% in baseline total cost variation and 1.5% in total cost variation at 5-year follow-up. The incorporation of a combination of significant CVD markers resulted in an increase in the R2 for total costs of 70% at baseline and 69% after 5 years, with a final R2 of 0.030 at baseline and an R2 of 0.048 at 5-year follow-up. CONCLUSION: Our data suggest that for individuals without history of CVD, the simultaneous addition of several CVD risk markers improves predictive modeling of future health care costs beyond that of a model that is based on established health care predictors.

Association of mental distress with health care utilization and costs: a 5-year observation in a general population.

OBJECTIVE: Previous studies have associated mental distress and disorders with increased health care utilization and costs. However, most studies have selected subjects from treatment facilities or have applied retrospective designs. METHODS: N = 3,300 subjects from the baseline cohort of the Study of Health in Pomerania were followed up 5 years later. Mental distress was assessed with the SF-12 Health Survey and the Composite Diagnostic Screener for mental disorders. Two-part econometric models were applied adjusting for medical confounders and baseline services use. RESULTS: At 5-year follow-up somatization at baseline predicted an increase of inpatient (+39.9%) and outpatient costs (+11.9%). Depression predicted an increase of inpatient (+24.1%) and outpatient costs (+8.9%). Comorbidity of somatization and depression and somatization and anxiety predicted an increase in overall health care costs of > or =50%. CONCLUSION: Simple and time-efficient screening procedures for mental disorders may help to identify subjects at risk for increased future health care utilization. Standardized therapeutic interventions should be evaluated in subjects at risk in primary care.

Impact of fatty liver disease on health care utilization and costs in a general population: a 5-year observation.

BACKGROUND & AIMS: Fatty liver disease is a common condition in the Western world. Fatty liver may progress to steatohepatitis and cirrhosis. It is not yet known whether fatty liver disease results in higher health care utilization and costs. METHODS: We used data from the Study of Health in Pomerania (SHIP), Germany, to assess the relation of fatty liver disease to self-reported health care utilization and costs at baseline and 5 years. The SHIP is a general population cohort study of 4310 adults aged 20 to 79 years at baseline in Pomerania. Fatty liver disease was defined as the presence of a hyperechogenic pattern of the liver and elevated serum alanine aminotransferase (ALT) levels. RESULTS: In multivariable analyses, average annual overall health care costs at baseline and follow-up measurement were significantly higher for individuals with sonographic fatty liver and increased serum ALT levels. For example, controlling for comorbid conditions, subjects with sonographic fatty liver disease and increased serum ALT levels had 26% higher overall health care costs at 5-year follow-up. Analyses also suggest that diabetes and cardiovascular disease might mediate the relation of fatty liver disease and health care utilization and costs. CONCLUSIONS: Policies seeking to minimize costs associated with fatty liver disease might want to consider addressing behavioral risk factors of fatty liver disease.

Effect of school environment on dental students' perceptions of cultural competency curricula and preparedness to care for diverse populations.

Reports of oral health disparities among racial, ethnic, and socioeconomic sectors of the U.S. population have hastened development of strategies to address this issue. Among these strategies is revising dental school curricula in order to develop more culturally competent graduates. The present study uses data from the 2003 American Dental Education Association (ADEA) survey of dental school seniors to assess students' perceptions of the adequacy of their cultural competency training. We hypothesize that these perceptions are influenced by multiple student characteristics and contextual factors, including a school's status with respect to the Pipeline, Professions, and Practice initiative of the Robert Wood Johnson Foundation and The California Endowment. Response data from ADEA survey items reflecting student perceptions of adequacy of curriculum time devoted to cultural competency and their preparedness to treat an ethnically and culturally diverse population were analyzed to assess the influence of selected student and contextual factors. Student gender, marital status, and level of educational debt were found to influence the curriculum time variable, and students at California schools reported higher perceived preparedness levels than students at dental schools nationwide. Dental school environments promoting acceptance and respect of diverse ethnicities/cultures and student race/ethnicity were significantly associated with students' perception of the adequacy of curriculum time for cultural competency and students' perception of their preparedness to provide oral health care for racially and culturally diverse groups. The findings provide insight for development of cultural competency curricula and direction for future study in this area.

What influences dental students to serve special care patients?

This study examines factors associated with graduating dental students' motivation to deliver services to special care patients. We investigated community context and student characteristics, which would influence potential behavior. Higher percentages of older adults and low-income residents in the community were positively correlated with interest in serving special care populations. Factors which correlated with individual student characteristics included having a father with at least a college education, a higher number of weeks spent in extramural clinical rotations, preparedness to provide care to disabled patients, and service orientation and socially conscious attitudes. Frail elderly and disabled persons have limited access to dental care, which is compounded by a shortage of skilled dental professionals who are willing to treat these populations. Our findings suggest that interest in special care dentistry is partly conditioned by the dental school's demographic and dental market context. This study is important to dental educators and policymakers because the challenge of providing care to the "special patient" will increase in the future.

Influence of contextual environment and community-based dental education on practice plans of graduating seniors.

This study investigated senior dental students' plans to provide care to underserved racial/ethnic minority populations. Three sets of determinants were analyzed: contextual environment, community-based dental education (CBDE), and student characteristics. We analyzed data from the ADEA Survey of Dental School Seniors and administrative data sources to construct contextual variables. Multivariable results show three contextual variables predicted practice plans: greater numbers of federally qualified health centers, higher percentages of underrepresented minorities, and attending a California Pipeline dental school. Regarding CBDE predictors, it was alarming to find seniors who viewed the cultural competency curriculum as inadequate and perceived themselves as less prepared to provide oral health care to diverse populations were also those most likely to serve minority patients. Significant student characteristics included racial/ethnic minority, female gender, older age, lower parent's income, and socially conscious orientation. The study provides evidence that contextual environment, CBDE, and student characteristics were significantly associated with plans to care for underserved patients. Findings suggest if the Pipeline initiative is successful in stimulating reform in U.S. dental schools, future students will develop greater awareness regarding critical access problems and the competencies required to effectively care for diverse populations. In the long term, addressing the problem of dental care access will require the creation of policy, financial, and structural interventions to motivate providers to care for the underserved.

Effects of smoking cessation on health care use: is elevated risk of hospitalization among former smokers attributable to smoking-related morbidity?

BACKGROUND: Although the association between smoking status and health services use is well established, this relation is not well-studied for the comparison of current and former smokers. Some studies showed higher utilization of health services among former smokers compared to continuing smokers. This study investigates the relation between smoking status, time since smoking cessation and hospitalization in a general population sample. We hypothesized that elevated risk of hospitalization among former smokers compared with continuing smokers is related to higher smoking-related morbidity among former smokers. METHODS: Data from a cross-sectional sample of 4310 adults aged 20-79 in Pomerania, Germany was used (response proportion 68.8%). Smoking status, time since smoking cessation (in years), and date of diagnosis of smoking-related diseases were determined from self-reports. We used fractional polynomials to determine the dose-response relation of time since cessation and risk of hospitalization. Confounding was investigated allowing for different sets of confounding variables. RESULTS: We found that the probability of hospitalization was highest among those who quit 1-3 years ago and decreased thereafter. Adjustment for health status and socio-economic variables revealed that this association is attenuated by current diagnosis of smoking-related diseases. CONCLUSION: Short-term excess health care utilization among former smokers might result from smoking-related conditions that may have led to smoking cessation. Findings suggest that smoking cessation has long-term health benefits resulting in lower health care needs.