[How has life expectancy without functional limitations developed in Germany? An analysis with data from the German Ageing Survey (DEAS)]. / Wie hat sich die Lebenserwartung ohne funktionelle Einschränkungen in Deutschland entwickelt? Eine Analyse mit Daten des Deutschen Alterssurveys (DEAS).

INTRODUCTION: The long-term increase in life expectancy raises the question of whether the increased life expectancy is accompanied by an extension of years without health limitations. The study analyzes how life expectancy without functional and mobility limitations from the ages of 46 and 65 and their proportions of remaining life expectancy have changed since 2008. METHODS: We analyze data from the German Ageing Survey of the 2008, 2014, and 2020/21 waves. Life expectancy without functional limitations (disability-free life expectancy-DFLE) was calculated using the Sullivan method. Severe functional limitations (using the Global Activity Limitation Indicator-GALI) and mobility limitations (climbing stairs, walking more than 1 km) were examined. RESULTS: Compression of morbidity in the GALI has been observed in 46- and 65-year-old men since 2014, but not in women of the same age. In terms of mobility, 46- and 65-year-old men show trends towards compression when climbing stairs and 46-year-old men when walking more than 1 km since 2014. The values for women have stagnated for the first two indicators mentioned, but not for 46-year-old women since 2014 when walking more than 1 km. DISCUSSION: Our analyses show different trends in DFLE depending on the indicator, age, and gender and do not allow a clear answer to the question of morbidity compression or expansion. We tend to see morbidity compression in men, whereas trends of stagnation or expansion tend to be seen in women. These results signal challenges in maintaining functional health, especially in women, and point to the need for targeted interventions to improve quality of life and healthy life expectancy.

[Socioeconomic deprivation and premature mortality in Germany, 1998-2021 : An ecological study with what-if scenarios of inequality reduction]. / Sozioökonomische Deprivation und vorzeitige Sterblichkeit in Deutschland 1998­2021 : Eine ökologische Studie mit What-if-Szenarien der Ungleichheitsreduktion.

BACKGROUND: Earlier mortality in socioeconomically disadvantaged population groups represents an extreme manifestation of health inequity. This study examines the extent, time trends, and mitigation potentials of area-level socioeconomic inequalities in premature mortality in Germany. METHODS: Nationwide data from official cause-of-death statistics were linked at the district level with official population data and the German Index of Socioeconomic Deprivation (GISD). Age-standardized mortality rates before the age of 75 were calculated stratified by sex and deprivation quintile. A what-if analysis with counterfactual scenarios was applied to calculate how much lower premature mortality would be overall if socioeconomic mortality inequalities were reduced. RESULTS: Men and women in the highest deprivation quintile had a 43% and 33% higher risk of premature death, respectively, than those in the lowest deprivation quintile of the same age. Higher mortality rates with increasing deprivation were found for cardiovascular and cancer mortality, but also for other causes of death. Socioeconomic mortality inequalities had started to increase before the COVID-19 pandemic and further exacerbated in the first years of the pandemic. If all regions had the same mortality rate as those in the lowest deprivation quintile, premature mortality would be 13% lower overall. DISCUSSION: The widening gap in premature mortality between deprived and affluent regions emphasizes that creating equivalent living conditions across Germany is also an important field of action for reducing health inequity.

Trends in cancer incidence by socioeconomic deprivation in Germany in 2007 to 2018: An ecological registry-based study.

Age-standardized cancer incidence has decreased over the last years for many cancer sites in developed countries. Whether these trends led to narrowing or widening socioeconomic inequalities in cancer incidence is unknown. Using cancer registry data covering 48 million inhabitants in Germany, the ecological association between age-standardized total and site specific (colorectal, lung, prostate and breast) cancer incidence in 2007 to 2018 and a deprivation index on district level (aggregated to quintiles) was investigated. Incidence in the most and least deprived districts were compared using Poisson models. Average annual percentage changes (AAPCs) and differences in AAPCs between deprivation quintiles were assessed using Joinpoint regression analyses. Age-standardized incidence decreased strongly between 2007 and 2018 for total cancer and all cancer sites (except female lung cancer), irrespective of the level of deprivation. However, differences in the magnitude of trends across deprivation quintiles resulted in increasing inequalities over time for total cancer, colorectal and lung cancer. For total cancer, the incidence rate ratio between the most and least deprived quintile increased from 1.07 (95% confidence interval: 1.01-1.12) to 1.23 (1.12-1.32) in men and from 1.07 (1.01-1.13) to 1.20 (1.14-1.26) in women. Largest inequalities were observed for lung cancer with 82% (men) and 88% (women) higher incidence in the most vs the least deprived regions in 2018. The observed increase in inequalities in cancer incidence is in alignment with trends in inequalities in risk factor prevalence and partly utilization of screening. Intervention programs targeted at socioeconomically deprived and urban regions are highly needed.

[M2Q or Something else? The Impact of Varying Case Selection Criteria on the Prevalence Estimation of Chronic Diseases Based on Outpatient Diagnoses in German Claims Data]. / M2Q oder doch etwas Anderes? Der Einfluss verschiedener Aufgreifkriterien auf die Prävalenzschätzung chronischer Erkrankungen mit ambulanten GKV-Diagnosedaten.

BACKGROUND: To determine the prevalence of chronic disease conditions based on outpatient health insurance data, we often rely on repeated occurrence of a diagnosis over the course of a year, usually in two or more quarters (M2Q). It remains unclear whether prevalence estimates change after adapting repeated occurrence of a diagnosis in different quarters of a year compared to a single occurrence or to some other case selection criteria. This study applies different case selection criteria and analyses their impact on the prevalence estimation based on outpatient diagnoses. METHODS: Administrative prevalence for 2019 was estimated for eight chronic conditions based on outpatient physician diagnoses. We applied five case selection criteria: (1) single occurrence, (2) repeated occurrence (including in the same quarter or treatment case), (3) repeated occurrence in at least two different treatment cases (including in the same quarter), (4) occurrence in two quarters and (5) occurrence in two consecutive quarters. Only information on persons with continuous insurance history within the statutory health insurance provider AOK Niedersachsen in 2019 was used (n=2,168,173). RESULTS: Prevalence estimates differed quite strongly depending on the diagnosis and on age group if a criterion with repeated occurrence of a diagnosis was applied compared to a single occurrence. These differences turned out to be higher among men and younger patients. The application of a repeated occurrence (criterion 2) did not show different results compared to the repeated occurrence in at least two treatment cases (criterion 3) or in two quarters (criterion 4). The application of the strict criterion of two consecutive quarters (criterion 5) resulted in further reduction of the prevalence estimates. CONCLUSIONS: Repeated occurrence is increasingly becoming the standard for diagnosis validation in health insurance claims data. Applying such criteria results partly in a distinct reduction of prevalence estimates. The definition of the study population (e. g., repeated visits to a physician in two consecutive quarters as a mandatory condition) can also strongly influence the prevalence estimates.

Widening or narrowing income inequalities in myocardial infarction? Time trends in life years free of myocardial infarction and after incidence.

BACKGROUND: Despite substantial improvements in prevention and therapy, myocardial infarction (MI) remains a frequent health event, causing high mortality and serious health impairments. Previous research lacks evidence on how social inequalities in incidence and mortality risks developed over time, and on how these developments affect the lifespan free of MI and after MI in different social subgroups. This study investigates income inequalities in MI-free life years and life years after MI and whether these inequalities widened or narrowed over time. METHODS: The analyses are based on claims data of a large German health insurance provider insuring approximately 2.8 million individuals in the federal state Lower Saxony. Trends in income inequalities in incidence and mortality were assessed for all subjects aged 60 years and older by comparing the time periods 2006-2008 and 2015-2017 using multistate survival models. Trends in the number of life years free of MI and after MI were calculated separately for income groups by applying multistate life table analyses. RESULTS: MI incidence and mortality risks decreased over time, but declines were strongest among men and women in the higher-income group. While life years free of MI increased in men and women with higher incomes, no MI-free life years were gained in the low-income group. Among men, life years after MI increased irrespective of income group. CONCLUSIONS: Income inequalities in the lifespan spent free of MI and after MI widened over time. In particular, men with low incomes are disadvantaged, as life years spent after MI increased, but no life years free of MI were gained.

Socioeconomic inequalities in lung cancer - a time trend analysis with German health insurance data.

BACKGROUND: Lung Cancer (LC) is one of the most prevalent cancer diseases. Due to the lack of databases which allow the combination of information on individual socioeconomic status (SES) and cancer incidence, research on social inequalities in LC among the German population is rare. The aim of the study is to analyse time trends in social inequalities in LC in Germany. METHODS: The analyses are based on data of a large statutory health insurance provider. The data contain information on diagnoses, occupation and education (working age), and income (full age range) of the insurance population. Trends were analysed for two subpopulations (retirement age and working age) and stratified by sex. The analyses are based on incidence rates and proportional hazard models spanning the periods 2006-2009, 2010-2013 and 2014-2017. RESULTS: Incidence rates declined in men but increased in women. For men, inequalities were strongest in terms of income and the decline in incidence was most pronounced in middle- and higher-income men. Among women at retirement age, a reversed income gradient was found which disappeared in the second period. The educational gradient among the working-age population decreased over time due to the trend towards increasing incidence among individuals with higher education. Declining gradients were also found for occupational position. CONCLUSION: The findings reveal considerable inequalities in LC and that trends vary with respect to SES, sex and age. Widening income inequalities were found in the retired population, while educational and occupational inequalities tend to narrow among the working-age population.

Social inequalities in mild and severe myocardial infarction: how large is the gap in health expectancies?

BACKGROUND: Acute myocardial infarction (MI) remains a frequent health event and a major contributor to long-term impairments globally. So far, research on social inequalities in MI incidence and mortality with respect to MI severity is limited. Furthermore, evidence is lacking on disparities in the length of life affected by MI. This study investigates social inequalities in MI incidence and mortality as well as in life years free of MI and affected by the consequences of mild or severe MI. METHODS: The study is based on data of a large German statutory health insurance provider covering the years 2008 to 2017 (N = 1,253,083). Income inequalities in MI incidence and mortality risks and in life years with mild or severe MI and without MI were analysed using multistate analyses. The assessment of MI severity is based on diagnosed heart failure causing physical limitations. RESULTS: During the study period a total of 39,832 mild MI, 22,844 severe MI, 276,582 deaths without MI, 15,120 deaths after mild MI and 16,495 deaths after severe MI occurred. Clear inequalities were found in MI incidence and mortality, which were strongest among men and in severe MI incidence. Moreover, substantial inequalities were found in life years free of MI in both genders to the disadvantage of those with low incomes and increased life years after mild MI in men with higher incomes. Life years after severe MI were similar across income groups. CONCLUSIONS: Social inequalities in MI incidence and mortality risks led to clear disparities in the length of life free of MI with men with low incomes being most disadvantaged. Our findings stress the importance of primary and secondary prevention focusing especially on socially disadvantaged groups.

Decline of depressive symptoms in Europe: differential trends across the lifespan.

PURPOSE: We examined changes in the burden of depressive symptoms between 2006 and 2014 in 18 European countries across different age groups. METHODS: We used population-based data drawn from the European Social Survey (N = 64.683, 54% female, age 14-90 years) covering 18 countries (Austria, Belgium, Denmark, Estonia, Finland, France, Germany, Great Britain, Hungary, Ireland, The Netherlands, Norway, Poland, Portugal, Slovenia, Spain, Sweden, Switzerland) from 2006 to 2014. Depressive symptoms were measured via the CES-D 8. Generalized additive models, multilevel regression, and linear regression analyses were conducted. RESULTS: We found a general decline in CES-D 8 scale scores in 2014 as compared with 2006, with only few exceptions in some countries. This decline was most strongly pronounced in older adults, less strongly in middle-aged adults, and least in young adults. Including education, health and income partially explained the decline in older but not younger or middle-aged adults. CONCLUSIONS: Burden of depressive symptoms decreased in most European countries between 2006 and 2014. However, the decline in depressive symptoms differed across age groups and was most strongly pronounced in older adults and least in younger adults. Future studies should investigate the mechanisms that contribute to these overall and differential changes over time in depressive symptoms.

Control of Blood Vessel Formation by Notch Signaling.

Blood vessels span throughout the body to nourish tissue cells and to provide gateways for immune surveillance. Endothelial cells that line capillaries have the remarkable capacity to be quiescent for years but to switch rapidly into the activated state once new blood vessels need to be formed. In addition, endothelial cells generate niches for progenitor and tumor cells and provide organ-specific paracrine (angiocrine) factors that control organ development and regeneration, maintenance of homeostasis and tumor progression. Recent data indicate a pivotal role for blood vessels in responding to metabolic changes and that endothelial cell metabolism is a novel regulator of angiogenesis. The Notch pathway is the central signaling mode that cooperates with VEGF, WNT, BMP, TGF-ß, angiopoietin signaling and cell metabolism to orchestrate angiogenesis, tip/stalk cell selection and arteriovenous specification. Here, we summarize the current knowledge and implications regarding the complex roles of Notch signaling during physiological and tumor angiogenesis, the dynamic nature of tip/stalk cell selection in the nascent vessel sprout and arteriovenous differentiation. Furthermore, we shed light on recent work on endothelial cell metabolism, perfusion-independent angiocrine functions of endothelial cells in organ-specific vascular beds and how manipulation of Notch signaling may be used to target the tumor vasculature.

Primary palliative Care in General Practice - study protocol of a three-stage mixed-methods organizational health services research study.

BACKGROUND: The focus of this project is on improving the provision of primary palliative care (PC) by general practitioners (GPs). While approximately 10-15% of the incurable, seriously ill or dying people will be in need of specialist PC, the vast majority can be adequately treated within generalist care. The strengthening of the GP's role in PC, as well as ensuring close collaboration between specialist PC services and GPs have been identified as top priorities for the improvement of PC in Germany. Despite healthcare policy actions, diverse obstacles still exist to successful implementation of primary PC on a structural, process, and economic level. Therefore, this project aims at addressing barriers and facilitators to primary PC delivery in general practice in Germany. METHODS: The study follows a three-step approach; first, it aims at systematically analyzing barriers and facilitators to primary PC provision by GPs. Second, based on these outcomes, a tailored intervention package will be developed to enhance the provision of primary PC by GPs. Third, the intervention package will be implemented and evaluated in practice. The expected outcome will be an evidence-based model for successful implementation of primary PC delivery tailored to the German healthcare system, followed by a strategic action plan on how to improve current practice both on a local level and nationally. DISCUSSION: The first step of the project has been partly completed at the time of writing. The chosen methodologies of four sub-projects within this first step have opened up different advantages and disadvantages for the data collection. In sum of all sub-projects, the different methodologies and target groups contributed valuable information to the systematic analysis of barriers and facilitators to primary PC provision by GPs. TRIAL REGISTRATION: The study (BMBF-FK 01 GY 1610) was retrospectively registered at the German Clinical Trials Register (Deutsches Register Klinischer Studien) (Registration N° DRKS00011821 ; date of registration: December 04th 2017) and at the German Register of health care research (Versorgungsforschung Deutschland - Datenbank) (Registration N° VfD_ALLPRAX_16_003817 ; date of registration: March 30th 2017).

NZ28-induced inhibition of HSF1, SP1 and NF-κB triggers the loss of the natural killer cell-activating ligands MICA/B on human tumor cells.

The activity of natural killer (NK) cells is regulated by activating and inhibiting receptors, whereby the C-type lectin natural killer group 2D (NKG2D) receptor serves as the major activating receptor on NK cells which recognizes major histocompatibility class I chain-related proteins A and B (MICA/B). The MICA/B expression has been described to be regulated by the transcription factor heat shock factor 1 (HSF1). Inhibition of heat shock protein 90 (Hsp90) is known to induce the heat shock response via activation of HSF1 which is associated with tumor development, metastasis and therapy resistance and also with an increased susceptibility to NK cell-mediated lysis. Therefore, we compared the effects of Hsp90 inhibitor NVP-AUY922, HSF1 inhibitor NZ28 and HSF1 knockdown on the sensitivity of lung (H1339) and breast (MDA-MB-231, T47D) cancer cells to NK cell-mediated cytotoxicity and the expression of the NKG2D ligands MICA/B. Although NVP-AUY922 activates HSF1, neither the MICA/B surface density on tumor cells nor their susceptibility to NK cell-mediated lysis was affected. A single knockdown of HSF1 by shRNA decreased the surface expression of MICB but not that of MICA, and thereby, the NK cell-mediated lysis was only partially blocked. In contrast, NZ28 completely blocked the MICA/B membrane expression on tumor cells and thereby strongly inhibited the NK cell-mediated cytotoxicity. This effect might be explained by a simultaneous inhibition of the transcription factors HSF1, Sp1 and NF-κB by NZ28. These findings suggest that new anticancer therapeutics should be investigated with respect to their effects on the innate immune system.

The development of working life expectancy without musculoskeletal diseases against the backdrop of extended working lives.

Musculoskeletal diseases (MSDs) are a major predictor of early retirement. Against the backdrop of the extension of working life, we investigated time trends and educational inequalities in years spent in the labour market free of MSD. Based on German statutory health insurance data (N = 3,405,673), total life years free of MSD (Healthy Life Expectancy, HLE) and years spent in the labour force free of MSD (Healthy Working Life Expectancy, HWLE) were estimated for three periods (2006-2008, 2011-2013, 2016-2018) using multistate analyses. Educational inequalities (8 to 11 vs. 12 or more years of schooling) are reported for 2011-2013. HLE decreased slightly over time in all genders. HWLE in women increased, while it remained rather constant in men. Over time, the share of years in the labour force spent free of MSD declined continuously. People with lower education had lower HLE and HWLE than individuals with higher education. With respect to musculoskeletal diseases, the increase in disease-free working life years cannot keep pace with the extension of working life, resulting in an increasing proportion of years spent in impaired musculoskeletal health in the labour market. Effective prevention strategies are needed, focusing especially on individuals with lower educational attainment.

Age-specific and cause-specific mortality contributions to the socioeconomic gap in life expectancy in Germany, 2003-21: an ecological study.

BACKGROUND: Earlier death among people in socioeconomically deprived circumstances has been found internationally and for various causes of death, resulting in a considerable life-expectancy gap between socioeconomic groups. We examined how age-specific and cause-specific mortality contributions to the socioeconomic gap in life expectancy have changed at the area level in Germany over time. METHODS: In this ecological study, official German population and cause-of-death statistics provided by the Federal Statistical Office of Germany for the period Jan 1, 2003, to Dec 31, 2021, were linked to district-level data of the German Index of Socioeconomic Deprivation. Life-table and decomposition methods were applied to calculate life expectancy by area-level deprivation quintile and decompose the life-expectancy gap between the most and least deprived quintiles into age-specific and cause-specific mortality contributions. FINDINGS: Over the study period, population numbers varied between 80 million and 83 million people per year, with the number of deaths ranging from 818 000 to 1 024 000, covering the entire German population. Between Jan 1, 2003, and Dec 31, 2019, the gap in life expectancy between the most and least deprived quintiles of districts increased by 0·7 years among females (from 1·1 to 1·8 years) and by 0·1 years among males (from 3·0 to 3·1 years). Thereafter, during the COVID-19 pandemic, the gap increased more rapidly to 2·2 years in females and 3·5 years in males in 2021. Between 2003 and 2021, the causes of death that contributed the most to the life-expectancy gap were cardiovascular diseases and cancer, with declining contributions of cardiovascular disease deaths among those aged 70 years and older and increasing contributions of cancer deaths among those aged 40-74 years over this period. COVID-19 mortality among individuals aged 45 years and older was the strongest contributor to the increase in life-expectancy gap after 2019. INTERPRETATION: To reduce the socioeconomic gap in life expectancy, effective efforts are needed to prevent early deaths from cardiovascular disease and cancer in socioeconomically deprived populations, with cancer prevention and control becoming an increasingly important field of action in this respect. FUNDING: German Cancer Aid and European Research Council.

Widening area-based socioeconomic inequalities in cancer mortality in Germany between 2003 and 2019.

Cancer mortality has declined in recent decades, but-due to a lack of national individual-level data-it remains unclear whether this applies equally to all socioeconomic groups in Germany. Using an area-based approach, this study investigated socioeconomic inequalities in cancer mortality and their secular trends on a German nationwide scale for the first time. Official cause-of-death data from 2003 to 2019 were linked to the district-level German Index of Socioeconomic Deprivation. Age-standardised mortality rates for all cancers combined and the most common site-specific cancers were calculated according to the level of regional socioeconomic deprivation. To quantify the extent of area-based socioeconomic inequalities in cancer mortality, absolute (SII) and relative (RII) indices of inequality were estimated using multilevel Poisson models. On average, cancer mortality was 50% (women) and 80% (men) higher in Germany's most deprived than least deprived districts (absolute difference: 84 deaths per 100,000 in women and 185 deaths per 100,000 in men). As declines in cancer mortality were larger in less deprived districts, the socioeconomic gap in cancer mortality widened over time. This trend was observed for various common cancers. Exceptions were cancers of the lung in women and of the pancreas in both sexes, for which mortality rates increased over time, especially in highly deprived districts. Our study provides first evidence on increasing socioeconomic inequalities in cancer mortality on a nationwide scale for Germany. Area-based linkage allows to examine socioeconomic inequalities in cancer mortality across Germany and identify regions with high needs for cancer prevention and control.

Distribution of gastrointestinal neuroendocrine tumors in Europe: results from a retrospective cross-sectional study.

BACKGROUND: Gastrointestinal (non-pancreatic) neuroendocrine tumors (GI-NETs) represent a rare but increasingly common tumor entity. Prognosis and biological behavior of these tumors is extremely heterogenous and largely dependent on the specific tumor site, stage and differentiation. However, systematic data on the epidemiology of GI-NET, especially in terms of geographic distributions are missing. METHODS: We used the Oncology Dynamics database (IQVIA) to identify a total of 1354 patients with GI-NET from four European countries (Germany, France, Spain, UK) and compared them with regard to major patient and tumor related characteristics including patients' age, sex, tumor stage, tumor grading and differentiation. RESULTS: Out of the analyzed 1354 NET patients, 535 were found in the UK (39.5%), 289 in Germany (21.3%), 283 in Spain (20.9%) and 247 in France (18.2%). More patients were male than female (53.8% vs. 46.2%) with no significant differences between the analyzed countries. In contrast, the age distribution varied between the different countries, with the highest number of patients identified in the age groups of 61-70 years (31.0%) and 71-80 years (30.7%). The vast majority of patients showed a tumor origin in the small intestine, in German patients NET of the large intestine were slightly overrepresented and NET of the stomach underrepresented compared to all other countries. More than 80% of patients had stage IV disease at the time of diagnosis. Regarding tumor histology, most tumors showed a G2 tumor; interestingly, a G3 grading was found in 40.9% of patients in Germany (Ki-67 > 20%). CONCLUSION: The distribution of important patient- and tumor-specific characteristics of neuroendocrine tumors shows regional differences in four major European countries. These data may help to better understand the specific epidemiology of GI-NET in Europe.

Trends in cancer-free working life expectancy based on health insurance data from Germany-Is the increase as strong as in working life expectancy?

BACKGROUND: Against the backdrop of population ageing, governments are facing the need to raise the statutory retirement age. In this context, the question arises whether these extra years added to working life would be spent in good health. As cancer represents a main contributor to premature retirement this study focuses on time trends and educational inequalities in cancer-free working life expectancy (WLE). METHODS: The analyses are based on the data of a large German health insurer covering annually about 2 million individuals. Cancer-free WLE is calculated based on multistate life tables and reported for three periods: 2006-2008, 2011-2013, and 2016-2018. Educational inequalities in 2011-2013 were assessed by two educational levels (8 to 11 years and 12 to 13 years of schooling). RESULTS: While labour force participation increased, cancer incidence rates decreased over time. Cancer-free WLE at age 18 increased by 2.5 years in men and 6.3 years in women (age 50: 1.3 years in men, 2.4 years in women) between the first and third period while increases in WLE after a cancer diagnosis remained limited. Furthermore, educational inequalities are substantial, with lower groups having lower cancer-free WLE. The proportion of cancer-free WLE in total WLE remained constant in women and younger men, while it decreased in men at higher working age. CONCLUSION: The increase in WLE is accompanied by an increase in cancer-free WLE. However, the subgroups considered have not benefitted equally from this positive development. Among men at higher working age, WLE increased at a faster pace than cancer-free WLE. Particular attention should be paid to individuals with lower education and older men, as the general level and time trends in cancer-free WLE are less favourable.

Getting Better or Getting Worse? A Population-Based Study on Trends in Self-Rated Health among Single Mothers in Germany between 1994 and 2018.

BACKGROUND: While numerous studies suggest that single motherhood is associated with socioeconomic disadvantages and poor health, few studies have analyzed how these conditions have evolved over time. Addressing this gap, we examined the temporal development of self-rated health (SRH) among single compared to partnered mothers, and the role of socioeconomic factors that may have influenced this trend. METHODS: We used representative longitudinal data from the German Socioeconomic Panel Survey (G-SOEP) between 1994 and 2018, consisting of 83,843 women with children, aged 30-49 years (13,664 single and 70,179 partnered mothers). Time trends in SRH and socioeconomic factors were analyzed by means of logistic regression analyses. We applied the Karlson-Holm-Breen (KHB) method for decomposing the total time effect into direct and indirect parts via socioeconomic mediators. RESULTS: The predicted probabilities of good SRH decreased in single mothers from 57.0% to 48.4%, while they increased in partnered mothers from 54.8% to 61.3%. Similarly, predicted probabilities of poor SRH rose from 15.0% to 22.7% in single mothers while decreasing slightly from 12.0% to 11.4% in partnered mothers. Moreover, socioeconomic factors worsened over time for single mothers, while they mostly improved for partnered mothers. Decomposing the time trend revealed that the deterioration of single mothers' health was partly explained by the worsening of socioeconomic disadvantages, of which the decline in full-time employment, the rise in low incomes, and in unemployment contributed most. CONCLUSIONS: The alarming rise in socioeconomic and health disadvantages among single mothers in Germany shows that action is needed to counter this trend.

Time Trends and Income Inequalities in Cancer Incidence and Cancer-Free Life Expectancy - a Cancer Site-Specific Analysis of German Health Insurance Data.

Cancer represents a major burden of morbidity and mortality globally. So far, however, little is known on time trends and inequalities in the lengths of life spent free of any cancer. This study steps into this gap by analyzing time trends and income inequalities in cancer-free life expectancy (CFLE). For this retrospective cohort study, data of a large German health insurer were used (N = 3,405,673individuals, 2006-2018). Income inequalities were assessed using individual income (<60% of German average income (GAI) and ≥60% of GAI). Trends in incidence risks were analysed employing proportional-hazard regression models by splitting the observation time into three periods of 52 months. Trends in CFLE in total and for the most common site-specific cancers were calculated based on multiple decrement life tables. Incidence rates declined in almost all cancers and CFLE increased substantially over time (49.1 (95% CI 48.8-49.4) to 51.9 (95% CI 51.6-52.2) years for men, 53.1 (95% CI 52.7-53.5) to 55.4 (95% CI 55.1-55.8) years for women at age 20 for total cancer) and income groups. Considerable income inequalities in cancer risks were evident in both sexes, but were more pronounced in men (total cancer HR 0.86 (95% CI 0.85-0.87)), with higher-income individuals having lower risks. The highest income inequalities were found in colon (HR 0.90 (95% CI 0.87-0.93)), stomach (HR 0.78 (95% CI 0.73-0.84)), and lung cancer (HR 0.58 (95% CI 0.56-0.60)) in men. A reverse gradient was found for skin (HR 1.39 (95% CI 1.30-1.47) men; HR 1.27 (95% CI 1.20-1.35) women) and prostate cancer (HR 1.13 (95% CI 1.11-1.15)). The proportion of CFLE in total life expectancy declined for lung, skin and cervical cancer in women, indicating a relative shortening of lifetime spent cancer-free. In contrast, increasing proportions were found in breast and prostate cancer. To our knowledge, this is the first study analysing trends and income inequalities in CFLE. The life span free of cancer increased clearly over time. However, not all cancer types contributed equally to this positive development. Income inequalities persisted or tended to widen, which underlines the need for increased public health efforts in socioeconomically vulnerable groups.

Living longer, working longer: analysing time trends in working life expectancy in Germany from a health perspective between 2002 and 2018.

Population ageing poses growing challenges to social security systems, in particular to public pension funds. The study analyses how Working Life Expectancy (WLE) and Healthy Working Life Expectancy (HWLE) in terms of three health indicators developed in Germany. Based on the German Socio-Economic Panel (GSOEP) from 2002 to 2018 (n = 211,141), time trends in labour force rates, mental and physical Health-Related Quality of Life (HRQoL), self-rated health (SRH) and the respective combinations (health indicator*labour force) were analysed for all respondents aged 18-74. WLE and HWLE were calculated using the Sullivan method. WLE and HWLE in men and women at age 18 and 50 clearly increased over time. These increases in HWLE were found in terms of all three health indicators. This development was mainly driven by the clear increase of the labour force rates, since the shares of individuals with good and satisfactory SRH or average and good HRQoL remained largely stable over time. The results show that from a health perspective there have been potentials for increases in WLE during the past two decades and that increasingly more healthy life years are spent economically active. However, life years in the labour force but in poor health have increased, too. The absence of clear improvements in health emphasises the importance of current and future preventive measures to maintain health, especially among the middle-aged and older labour force. Supplementary Information: The online version contains supplementary material available at 10.1007/s10433-022-00707-0.

German Index of Socioeconomic Deprivation (GISD): Revision, update and applications.

Background: Regional deprivation indices enable researchers to analyse associations between socioeconomic disadvantages and health outcomes even if the health data of interest does not include information on the individuals' socioeconomic position. This article introduces the recent revision of the German Index of Socioeconomic Deprivation (GISD) and presents associations with life expectancy as well as age-standardised cardiovascular mortality rates and cancer incidences as applications. Methods: The GISD measures the level of socioeconomic deprivation using administrative data of education, employment, and income situations at the district and municipality level from the INKAR database. The indicators are weighted via principal component analyses. The regional distribution is depicted cartographically, regional level associations with health outcomes are presented. Results: The principal component analysis indicates medium to high correlations of the indicators with the index subdimensions. Correlation analyses show that in districts with the lowest deprivation, the average life expectancy of men is approximately six years longer (up to three years longer for women) than for those from districts with the highest deprivation. A similar social gradient is observed for cardiovascular mortality and lung cancer incidence. Conclusions: The GISD provides a valuable tool to analyse socioeconomic inequalities in health conditions, diseases, and their determinants at the regional level.