A spatial obesity risk score for describing the obesogenic environment using kernel density estimation: development and parameter variation.

BACKGROUND: Overweight and obesity are severe public health problems worldwide. Obesity can lead to chronic diseases such as type 2 diabetes mellitus. Environmental factors may affect lifestyle aspects and are therefore expected to influence people's weight status. To assess environmental risks, several methods have been tested using geographic information systems. Freely available data from online geocoding services such as OpenStreetMap (OSM) can be used to determine the spatial distribution of these obesogenic factors. The aim of our study was to develop and test a spatial obesity risk score (SORS) based on data from OSM and using kernel density estimation (KDE). METHODS: Obesity-related factors were downloaded from OSM for two municipalities in Bavaria, Germany. We visualized obesogenic and protective risk factors on maps and tested the spatial heterogeneity via Ripley's K function. Subsequently, we developed the SORS based on positive and negative KDE surfaces. Risk score values were estimated at 50 random spatial data points. We examined the bandwidth, edge correction, weighting, interpolation method, and numbers of grid points. To account for uncertainty, a spatial bootstrap (1000 samples) was integrated, which was used to evaluate the parameter selection via the ANOVA F statistic. RESULTS: We found significantly clustered patterns of the obesogenic and protective environmental factors according to Ripley's K function. Separate density maps enabled ex ante visualization of the positive and negative density layers. Furthermore, visual inspection of the final risk score values made it possible to identify overall high- and low-risk areas within our two study areas. Parameter choice for the bandwidth and the edge correction had the highest impact on the SORS results. DISCUSSION: The SORS made it possible to visualize risk patterns across our study areas. Our score and parameter testing approach has been proven to be geographically scalable and can be applied to other geographic areas and in other contexts. Parameter choice played a major role in the score results and therefore needs careful consideration in future applications.

Comparing outcomes of ILD patients managed in specialised versus non-specialised centres.

BACKGROUND: Early appropriate diagnosis and treatment of interstitial lung diseases (ILD) is crucial to slow disease progression and improve survival. Yet it is unknown whether initial management in an expert centre is associated with improved outcomes. Therefore, we assessed mortality, hospitalisations and health care costs of ILD patients initially diagnosed and managed in specialised ILD centres versus non-specialised centres and explored differences in pharmaceutical treatment patterns. METHODS: An epidemiological claims data analysis was performed, including patients with different ILD subtypes in Germany between 2013 and 2018. Classification of specialised centres was based on the number of ILD patients managed and procedures performed, as defined by the European Network on Rare Lung Diseases. Inverse probability of treatment weighting was used to adjust for covariates. Mortality and hospitalisations were examined via weighted Cox models, cost differences by weighted gamma regression models and differences in treatment patterns with weighted logistic regressions. RESULTS: We compared 2022 patients managed in seven specialised ILD centres with 28,771 patients managed in 1156 non-specialised centres. Specialised ILD centre management was associated with lower mortality (HR: 0.87, 95% CI 0.78; 0.96), lower all-cause hospitalisation (HR: 0.93, 95% CI 0.87; 0.98) and higher respiratory-related costs (€669, 95% CI €219; €1156). Although risk of respiratory-related hospitalisations (HR: 1.00, 95% CI 0.92; 1.10) and overall costs (€- 872, 95% CI €- 75; €1817) did not differ significantly, differences in treatment patterns were observed. CONCLUSION: Initial management in specialised ILD centres is associated with improved mortality and lower all-cause hospitalisations, potentially due to more differentiated diagnostic approaches linked with more appropriate ILD subtype-adjusted therapy.

Small-area analysis on socioeconomic inequalities in cancer survival for 25 cancer sites in Germany.

Socioeconomic inequalities in cancer survival have been reported in various countries but it is uncertain to what extent they persist in countries with relatively comprehensive health insurance coverage such as Germany. We investigated the association between area-based socioeconomic deprivation on municipality level and cancer survival for 25 cancer sites in Germany. We used data from seven population-based cancer registries (covering 32 million inhabitants). Patients diagnosed in 1998 to 2014 with one of 25 most common cancer sites were included. Area-based socioeconomic deprivation was assessed using the categorized German Index of Multiple Deprivation (GIMD) on municipality level. We estimated 3-month, 1-year, 5-year and 5-year conditional on 1-year age-standardized relative survival using period approach for 2012 to 2014. Trend analyses were conducted for periods between 2003-2005 and 2012-2014. Model-based period analysis was used to calculate relative excess risks (RER) adjusted for age and stage. In total, 2 333 547 cases were included. For all cancers combined, 5-year survival rates by GIMD quintile were 61.6% in Q1 (least deprived), 61.2% in Q2, 60.4% in Q3, 59.9% in Q4 and 59.0% in Q5 (most deprived). For most cancer sites, the most deprived quintile had lower 5-year survival compared to the least deprived quintile even after adjusting for stage (all cancer sites combined, RER 1.16, 95% confidence interval 1.14-1.19). For some cancer sites, this association was stronger during short-term follow-up. Trend analyses showed improved survival from earlier to recent periods but persisting deprivation differences. The underlying reasons for these persisting survival inequalities and strategies to overcome them should be further investigated.

Walkability and its association with prevalent and incident diabetes among adults in different regions of Germany: results of pooled data from five German cohorts.

BACKGROUND: Highly walkable neighbourhoods may increase transport-related and leisure-time physical activity and thus decrease the risk for obesity and obesity-related diseases, such as type 2 diabetes (T2D). METHODS: We investigated the association between walkability and prevalent/incident T2D in a pooled sample from five German cohorts. Three walkability measures were assigned to participant's addresses: number of transit stations, points of interest, and impedance (restrictions to walking due to absence of intersections and physical barriers) within 640 m. We estimated associations between walkability and prevalent/incident T2D with modified Poisson regressions and adjusted for education, sex, age at baseline, and cohort. RESULTS: Of the baseline 16,008 participants, 1256 participants had prevalent T2D. Participants free from T2D at baseline were followed over a mean of 9.2 years (SD: 3.5, minimum: 1.6, maximum: 14.8 years). Of these, 1032 participants developed T2D. The three walkability measures were not associated with T2D. The estimates pointed toward a zero effect or were within 7% relative risk increase per 1 standard deviation with 95% confidence intervals including 1. CONCLUSION: In the studied German settings, walkability differences might not explain differences in T2D.

Colorectal cancer screening by colonoscopy and trends in disease-specific mortality: a population-based ecological study of 358 German districts.

PURPOSE: Screening for colorectal cancer (CRC) by colonoscopy was implemented in Germany in 2002. Although the procedure has proven to be effective in reducing disease-specific mortality in numerous clinical studies, its effect at the population level is unclear. We performed an ecological study at the level of 358 German districts, testing the hypothesis that a higher participation rate in screening colonoscopy is associated with a stronger decline in CRC mortality from 2001 to 2012. METHODS: Information on the use of colonoscopy in each district was extracted from settlement data, used for the remuneration of physicians of the ambulant sector from 2008 to 2011. Yearly mortality rates for each district from 2001 to 2012 were derived from the official mortality statistics. A spatial model was fitted, considering other factors which might influence early detection of CRC (fecal occult blood test (FOBT), diagnostic colonoscopy, material and social area deprivation, and rural-urban disparities). RESULTS: The population-weighted mean annual participation rate during 2008-2011 in screening colonoscopy was 2.0% (range 0.6 to 3.9%). The weighted mean annual percentage change (APC) of CRC mortality was - 2.9% (range - 7.8 to 1.2%). According to the fully adjusted model, a 1% higher annual participation rate in colonoscopy screening was associated with an additional annual change in CRC mortality rate of - 0.34% (p = 0.015). Given an annual 2.0% participation rate, colonoscopy screening attributed 23% to the observed decline. CONCLUSIONS: Our real-world data from Germany provide first evidence that colonoscopy screening for CRC is effective in reducing disease-specific mortality at the population level.

Using data from online geocoding services for the assessment of environmental obesogenic factors: a feasibility study.

BACKGROUND: The increasing prevalence of obesity is a major public health problem in many countries. Built environment factors are known to be associated with obesity, which is an important risk factor for type 2 diabetes. Online geocoding services could be used to identify regions with a high concentration of obesogenic factors. The aim of our study was to examine the feasibility of integrating information from online geocoding services for the assessment of obesogenic environments. METHODS: We identified environmental factors associated with obesity from the literature and translated these factors into variables from the online geocoding services Google Maps and OpenStreetMap (OSM). We tested whether spatial data points can be downloaded from these services and processed and visualized on maps. True- and false-positive values, false-negative values, sensitivities and positive predictive values of the processed data were determined using search engines and in-field inspections within four pilot areas in Bavaria, Germany. RESULTS: Several environmental factors could be identified from the literature that were either positively or negatively correlated with weight outcomes in previous studies. The diversity of query variables was higher in OSM compared with Google Maps. In each pilot area, query results from Google showed a higher absolute number of true-positive hits and of false-positive hits, but a lower number of false-negative hits during the validation process. The positive predictive value of database hits was higher in OSM and ranged between 81 and 100% compared with a range of 63-89% for Google Maps. In contrast, sensitivities were higher in Google Maps (between 59 and 98%) than in OSM (between 20 and 64%). CONCLUSIONS: It was possible to operationalize obesogenic factors identified from the literature with data and variables available from geocoding services. The validity of Google Maps and OSM was reasonable. The assessment of environmental obesogenic factors via geocoding services could potentially be applied in diabetes surveillance.

[Socioeconomic status and health insurance expenditures for children and adolescents with conduct disorder : An analysis of statutory health insurance data]. / Einfluss des sozioökonomischen Status auf Gesundheitskosten für Kinder und Jugendliche mit Störungen des Sozialverhaltens : Eine Analyse von Routinedaten einer gesetzlichen Krankenversicherung.

BACKGROUND: For various psychiatric and somatic disorders, there is evidence of an association between patients' socioeconomic status (SES), healthcare utilisation, and the resulting costs. In the field of child and adolescent psychiatric disorders, studies on this topic are lacking. OBJECTIVES: To exploratively analyse the association of healthcare expenditures for children and adolescents with conduct disorder (including oppositional-defiant disorder) - one of the most prevalent child and adolescent psychiatric disorders - and SES. MATERIALS AND METHODS: The analysis is based on routine data from the German statutory health insurance company AOK Nordost for the calendar year 2011, covering 6461 children and adolescents (age 5-18 years) with an ICD-10 diagnosis of conduct disorder. The insureds' SES was estimated indirectly, based on the social structure of the postcode area, using the German Index of Multiple Deprivation (Mecklenburg-Vorpommern, Brandenburg), and the Berliner Sozialindex I (Berlin), respectively. From the two indices, quintiles were derived. Based on these quintiles, average costs per case for the following cost types were analysed: inpatient healthcare, outpatient healthcare (general practitioners, paediatricians, child and adolescent psychiatrists, child and adolescent psychotherapists), and prescribed medication. RESULTS: There was no significant functional association between SES and healthcare costs for any of the analysed cost types. CONCLUSIONS: In contrast to findings in adults, this study on children and adolescents with conduct disorders did not reveal an association between SES and healthcare costs. Within this group of patients, social inequality does not seem to have a significant influence on healthcare utilisation in Germany.

Association of individual and area-level socioeconomic conditions with quality of life and glycaemic control in 11- to 21-year-old adolescents with early-onset type 1 diabetes: a cross-sectional study.

PURPOSE: To analyse the association of area-level deprivation (German Index of Multiple Deprivation, GIMD 2010) with health- and disease-related quality of life (QoL) and glycaemic control (HbA1c) jointly with individual-level socioeconomic status (SES) in young patients with preschool-onset type 1 diabetes. METHODS: A total of 425 male and 414 female patients aged 11-21 years from a Germany-wide population-based survey completed the generic KINDL-R, the DISABKIDS chronic-generic module (DCGM-12), and the DISABKIDS diabetes-specific module with impact and treatment scales (QoL indicators; range 0-100 with higher scores representing better QoL). To analyse the association of area-level deprivation and SES with QoL and HbA1c, multiple linear regression models were applied adjusting for sociodemographic and health-related variables. RESULTS: Mean QoL scores (SD) were 73.2 (12.2) for the KINDL-R, 76.1 (16.1) for the DCGM-12, 66.2 (19.9) for diabetes impact, and 56.4 (27.3) for diabetes treatment (DISABKIDS). Mean HbA1c was 8.3 (1.4)%. While both QoL outcomes and HbA1c level improved with increasing individual SES, no association was observed between area-level deprivation (GIMD 2010) and either outcome. CONCLUSIONS: Compared with individual SES, area-level deprivation seems to be of minor importance for QoL and glycaemic control in young people with early-onset type 1 diabetes.

Regional differences of macrovascular disease in Northeast and South Germany: the population-based SHIP-TREND and KORA-F4 studies.

BACKGROUND: Previous studies found regional differences in the prevalence and incidence of type 2 diabetes between Northeast and South of Germany. The aim of this study was to investigate if regional variations are also present for macrovascular disease in people with type 2 diabetes and in the general population. A further aim was to investigate if traditional risk factors of macrovascular complications can explain these regional variations. METHODS: Data of persons aged 30-79 from two regional population-based studies, SHIP-TREND (Northeast Germany, 2008-2012, n = 2539) and KORA-F4 (South Germany, 2006-2008, n = 2932), were analysed. Macrovascular disease was defined by self-reported previous myocardial infarction, stroke or coronary angiography. Multivariable logistic regression was performed to estimate odds ratios (OR) and 95% confidence intervals (CI) for prevalence of macrovascular disease in persons with type 2 diabetes and in the general population. RESULTS: The prevalence of macrovascular disease in persons with type 2 diabetes and in the general population was considerably higher in the Northeast (SHIP-TREND: 32.8 and 12.0%) than in the South of Germany (KORA-F4: 24.9 and 8.8%), respectively. The odds of macrovascular disease in persons with type 2 diabetes was 1.66 (95% CI: 1.11-2.49) in the Northeast in comparison to the South after adjustment for sex, age, body mass index, hypertension, hyperlipidemia and smoking. In the general population, SHIP-TREND participants also had a significantly increased odds of macrovascular disease compared to KORA-F4 participants (OR = 1.63, 95% CI: 1.33-2.00). After excluding coronary angiography (myocardial infarction or stroke only), the ORs for region decreased in all models, but the difference between SHIP-TREND and KORA-F4 participants was still significant in the age- and sex-adjusted model for the general population (OR = 1.34, 95% CI: 1.01-1.78). CONCLUSIONS: This study provides an indication for regional differences in macrovascular disease, which is not explained by traditional risk factors. Further examinations of other risk factors, such as regional deprivation or geographical variations in medical care services are needed.

Accessibility of general and specialized obstetric care providers in Germany and England: an analysis of location and neonatal outcome.

BACKGROUND: Health care accessibility is known to differ geographically. With this study we focused on analysing accessibility of general and specialized obstetric units in England and Germany with regard to urbanity, area deprivation and neonatal outcome using routine data. METHODS: We used a floating catchment area method to measure obstetric care accessibility, the degree of urbanization (DEGURBA) to measure urbanity and the index of multiple deprivation to measure area deprivation. RESULTS: Accessibility of general obstetric units was significantly higher in Germany compared to England (accessibility index of 16.2 vs. 11.6; p < 0.001), whereas accessibility of specialized obstetric units was higher in England (accessibility index for highest level of care of 0.235 vs. 0.002; p < 0.001). We further demonstrated higher obstetric accessibility for people living in less deprived areas in Germany (r = - 0.31; p < 0.001) whereas no correlation was present in England. There were also urban-rural disparities present, with higher accessibility in urban areas in both countries (r = 0.37-0.39; p < 0.001). The analysis did not show that accessibility affected neonatal outcomes. Finally, our computer generated model for obstetric care provider demand in terms of birth counts showed a very strong correlation with actual birth counts at obstetric units (r = 0.91-0.95; p < 0.001). CONCLUSION: In Germany the focus of obstetric care seemed to be put on general obstetric units leading to higher accessibility compared to England. Regarding specialized obstetric care the focus in Germany was put on high level units whereas in England obstetric care seems to be more balanced between the different levels of care with larger units on average leading to higher accessibility.

Predictors of non-drug psychiatric/psychotherapeutic treatment in children and adolescents with mental or behavioural disorders.

Children and adolescents with mental health problems need effective and safe therapies to support their emotional and social development and to avoid functional impairment and progress of social deficits. Though psychotropic drugs seem to be the preferential treatment, psychotherapy and psychosocial interventions are essential in mental health care. For Germany, current data on the utilization of psychotherapy and psychosocial interventions in children with mental health problems is lacking. To analyse why certain children and adolescents with mental or behavioural disorders do and others do not receive non-drug treatment, we assessed predictors associated with specific non-drug psychiatric/psychotherapeutic treatment including psychosocial interventions, psychotherapy and other non-drug treatments. The study is based on data of two large German health insurance funds, AOK and TK, comprising 30 % of the German child and adolescent population. Predictors of non-drug psychiatric/psychotherapeutic treatment were analysed for 23,795 cases and two controls for every case of the same age and sex in children aged 0-17 years following a new diagnosis of mental or behavioural disorder in 2010. Predictors were divided according to Andersen's behavioural model into predisposing, need and enabling factors. The most prominent and significant predictors positively associated with non-drug psychiatric/psychotherapeutic treatment were the residential region as predisposing factor; specific, both ex- and internalizing, mental and behavioural disorders, psychiatric co-morbidity and psychotropic drug use as need factors; and low area deprivation and high accessibility to outpatient physicians and inpatient institutions with non-drug psychiatric/psychotherapeutic department as enabling factors. In conclusion, the present study suggests that the residential region as proxy for supply of therapist and socioeconomic situation is an influencing factor for the use of psychotherapy. The analysis sheds further light on predisposing, need and enabling factors as predictors of non-drug psychotherapeutic/psychiatric treatment in children and adolescents with mental or behavioural health disorders in Germany. More research is needed to further understand the factors promoting the gap between the need and utilization of mental health care.

[Indices of Multiple Deprivation for the analysis of regional health disparities in Germany : Experiences from epidemiology and healthcare research]. / Indizes Multipler Deprivation zur Analyse regionaler Gesundheitsunterschiede in Deutschland : Erfahrungen aus Epidemiologie und Versorgungsforschung.

BACKGROUND: Deprivation indices allow material and social differences at the regional level to be described in a statistically efficient and concise manner and to use these in health analyses. Following the British example, Indices of Multiple Deprivation (IMDs) are now available for Germany, the German Index of Multiple Deprivation (GIMD) as well as its regional versions. In this study, empirical experiences based on the use of these indices in health studies will be presented. METHOD: The German IMDs consist of seven deprivation domains, which represent single aspects of deprivation (income, employment, and educational deprivation, municipal revenue deprivation, social capital deprivation, environment and security deprivation). Specific indicators were generated from data of official statistics and assigned to the deprivation domains. The weighted single domains were finally combined to an overall index. The German IMDs are available at a municipal level and at a district level. RESULTS: Analyses using the IMDs showed significant associations between regional deprivation and mortality, morbidity and aspects of health services research. Multilevel analyses showed significant associations with regional deprivation, independent of individual factors. CONCLUSIONS: The German IMDs are valid and efficient tools for the use in epidemiology and health services research, but also for health policy. When constructing deprivation indices, several methodological challenges have to be considered.

Residential greenness and blood lipids in children: A longitudinal analysis in GINIplus and LISAplus.

INTRODUCTION: There is some evidence of decreased cardiovascular disease (CVD) mortality and morbidity among adults residing in greener places. Among others, blood lipids are well established risk factors for CVD. In our previous study, we observed the inverse association between greenness and blood pressure in 10-year-old children. In the current study, we investigated whether there is also a link between residential greenness and blood lipids in 10- and 15-year-old children. METHODS: Complete data on blood lipids (total cholesterol, HDL, LDL and triglyceride), residential greenness (NDVI in 100-m, 300- and 500-m buffers around residences) and confounders were available for 1,552 participants at 10 and 15 years of age, residing in two study areas of two German birth cohorts - GINIplus and LISAplus. Longitudinal associations between NDVI and blood lipids were assessed by generalized estimation equations. RESULTS: No associations were observed between residential greenness in any of the chosen buffers and blood lipids in children (e.g., change in blood lipids per interquartile increase in NDVI in 100-m buffer for total cholesterol and LDL: means ratio=1.00 (95% confidence interval: 0.99-1.01), for triglyceride: 0.98 (0.96-1.00)). No area- or sex-varying effects were evident. Change of the residence between 10 and 15 years also did not yield any consistent associations. CONCLUSIONS: There is no evidence of an association between greenness and blood lipids in 10- and 15-years old children.

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.

Does charge-free screening improve detection of gestational diabetes in women from deprived areas: a cross-sectional study.

BACKGROUND: Gestational diabetes mellitus (GDM) occurs in 2-6 % of all pregnancies. We investigated whether area level deprivation is associated with a higher risk for GDM and whether GDM detection rates in deprived regions changed after the introduction of charge-free GDM screening in Germany in 2012. METHODS: We analyzed population-based data from Bavaria, Germany, comprising n = 587,621 deliveries in obstetric units between 2008 and 2014. Area level deprivation was assessed municipality-based using the Bavarian Index of Multiple Deprivation (BIMD), divided into quintiles and assigned to each mother based on her residential address. We estimated annual odds ratios (ORs) for GDM diagnosis by BIMD quintile with adjustment for maternal obesity, maternal age, migration background and single mother status. RESULTS: Women from the most deprived regions were less likely to be diagnosed with GDM before introduction of charge-free GDM screening (OR = 0.76 [95 % confidence interval: 0.66, 0.86] compared to least deprived areas), in 2008. In contrast, high area level deprivation was associated with significantly increased risk of GDM diagnosis in 2013 (OR [95 % confidence interval] = 1.15 [1.02, 1.29]). The OR was also elevated, although not significantly, in 2014 (OR [95 % confidence interval] = 1.05 [0.93, 1.18]). CONCLUSIONS: The prevalence of GDM seems to have been underreported in women from highly deprived areas before introduction of the charge-free GDM screening in Germany. In fact, women living in deprived regions seem to have an increased risk for GDM and may profit from access to charge-free GDM screening.

Analysing horizontal equity in enrolment in Disease Management Programmes for coronary heart disease in Germany 2008-2010.

BACKGROUND: Disease Management Programmes (DMPs) have been introduced in Germany ten years ago with the aim to improve effectiveness and equity of care, but little is known about the degree to which enrolment in the programme meets the principles of equity in health care. We aimed to analyse horizontal equity in DMP enrolment among patients with coronary heart disease (CHD). METHODS: Cross-sectional analysis of horizontal inequities in physician-reported enrolment in the DMP for CHD in a large population-based cohort-study in Germany (2008-2010). We calculated horizontal inequity indices (HII) and their 95% confidence intervals [95%CI] for predicted need-standardised DMP enrolment across two measures of socio-economic status (SES) (educational attainment, regional deprivation) stratified by sex. Need-standardised DMP enrolment was predicted in multi-level logistic regression models. RESULTS: Among N = 1,280 individuals aged 55-84 years and diagnosed with CHD, DMP enrolment rates were 22.2% (women) and 35.0% (men). Education-related inequities in need-standardised DMP enrolment favoured groups with lower education, but HII estimates were not significant. Deprivation-related inequities among women significantly favoured groups with higher SES (HII = 0.086 [0.007 ; 0.165]. No such deprivation-related inequities were seen among men (HII = 0.014 [-0.048 ; 0.077]). Deprivation-related inequities across the whole population favoured groups with higher SES (HII estimates not significant). CONCLUSION: Need-standardised DMP enrolment was fairly equitable across educational levels. Deprivation-related inequities in DMP enrolment favoured women living in less deprived areas relative to those living in areas with higher deprivation. Further research is needed to gain a better understanding of the mechanisms that contribute to deprivation-related horizontal inequities in DMP enrolment among women.

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.

Socioeconomic deprivation and cancer survival in Germany: an ecological analysis in 200 districts in Germany.

Although socioeconomic inequalities in cancer survival have been demonstrated both within and between countries, evidence on the variation of the inequalities over time past diagnosis is sparse. Furthermore, no comprehensive analysis of socioeconomic differences in cancer survival in Germany has been conducted. Therefore, we analyzed variations in cancer survival for patients diagnosed with one of the 25 most common cancer sites in 1997-2006 in ten population-based cancer registries in Germany (covering 32 million inhabitants). Patients were assigned a socioeconomic status according to the district of residence at diagnosis. Period analysis was used to derive 3-month, 5-year and conditional 1-year and 5-year age-standardized relative survival for 2002-2006 for each deprivation quintile in Germany. Relative survival of patients living in the most deprived district was compared to survival of patients living in all other districts by model-based period analysis. For 21 of 25 cancer sites, 5-year relative survival was lower in the most deprived districts than in all other districts combined. The median relative excess risk of death over the 25 cancer sites decreased from 1.24 in the first 3 months to 1.16 in the following 9 months to 1.08 in the following 4 years. Inequalities persisted after adjustment for stage. These major regional socioeconomic inequalities indicate a potential for improving cancer care and survival in Germany. Studies on individual-level patient data with access to treatment information should be conducted to examine the reasons for these socioeconomic inequalities in cancer survival in more detail.

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.

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.