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Background: Frailty, resilience and intrinsic capacity (IC) are concepts to evaluate older person`s health status, but no comparison of their associations with adverse health outcomes exists. We therefore aimed to assess which concept is most useful for determining long-term health of older adults. Methods: Analyses were based on the KORA (Cooperative Health Research in the Region of Augsburg)-Age study (n = 940, 65–93 years). Frailty was evaluated using the physical frailty-phenotype by Fried et al. For comparability to resilience and IC, we chose the protective concept of robustness instead of frailty in the present analysis. Resilience was measured by the 11-item resilience-scale. The IC-score was based on 4 domains (locomotion, cognition, vitality and psychiatric capacities). Associations with falls, disability, and hospitalization at 3-year and 7-year follow-up and with mortality were evaluated by multivariable adjusted logistic and Cox regression. Concept overlaps were illustrated by a Venn-diagram. Results: In the fully adjusted models, robustness showed significant inverse associations with most outcomes (3-year follow-up: OR (95%CI): disability 0.448 (0.300−0.668), 7-year follow-up: falls 0.477 (0.298−0.764), hospitalization 0.547 (0.349−0.856), and all-cause mortality 0.649 (0.460−0.915)) while resilience and IC showed significant inverse associations with disability only (e.g., 7-year-follow-up: resilience: 0.467 (0.304−0.716), IC: 0.510 (0.329−0.793)). 23% of the participants met the criteria for both robustness and IC while 22% met those for robustness and resilience. Conclusion: Robustness was the most useful concept, showing the strongest protective associations for most adverse health outcomes. IC and resilience showed their main strengths in capturing protective associations for disabilities. Robustness overlapped with resilience and IC, supporting the concept of mind-body-interaction.

Abstract Although healthcare systems across Europe face rather similar challenges, their organization varies widely. Even neighbouring countries substantially differ with respect to healthcare structures, processes, and resulting outcomes. Focusing on Germany and the Netherlands as examples of such neighbouring countries, this paper will first identify and discuss similarities and major differences between both systems on the macro-level of healthcare. It further argues that it is often unknown how these differences trickle down to individual healthcare organizations, providers, patients or citizens, i.e., to the meso- and micro-level of healthcare. Hence, in a second step, potential implications of macro-level differences are described by considering the examples of total hip arthroplasty, antibiotic prescription practices and resistance, and nursing home care in Germany and the Netherlands. The paper concludes with an outlook on how these differences can be studied using the example of the project “Comparison of healthcare structures, processes and outcomes in the Northern German and Dutch cross-border region” (CHARE-GD). It further discusses potential prospects and challenges of corresponding cross-national research.

Abstract Mental health problems (MHP) have a considerable negative impact on health-related quality of life (HRQoL) in children and their families. A low threshold Health Coaching (HC) program has been introduced to bring MH services to primary care and strengthen the role of pediatricians. It comprised training concepts as a hands-on approach for pediatricians, standardization of diagnosis and treatment, and extended consultations. The aim of this study was to evaluate the potential effects of the HC on HRQoL in children with MHP and their parents. We used data from the PrimA-QuO cohort study conducted in Bavaria, Germany from November 2018 until November 2019, with two assessments one year apart. We included children aged 17 years or younger with developmental disorder of speech and language, non-organic enuresis, head and abdominal pain, and conduct disorder. All included children were already part of the Starke Kids (SK) program, a more general preventive care program, which includes additional developmental check-ups for children enrolled in the program. In addition, treatment according to the HC guidelines can be offered to children and adolescents with mental health problems, who are already enrolled in the SK program. These children form the intervention group; while all others (members of BKK and SK but not HC) served as controls. HRQoL in children was assessed using the KINDL questionnaire. Parental HRQoL was measured by the visual analogue scale. To analyze the effects of the intervention on children´s HRQoL over the 1-year follow-up period, we used linear mixed effects models. We compared 342 children receiving HC with 767 control patients. We could not detect any effects of the HC on HRQoL in children and their parents. This may be attributed to the relatively high levels of children´s HRQoL at baseline, or because of highly motivated pediatricians for the controls because of the selection of only participant within the Starke Kids program. Generally, HRQoL was lower in older children (-0.42 points; 95% CI [-0.73; -0.11]) and in boys (-1.73 points; 95% CI [-3.11; -0.36]) when reported by proxy. Parental HRQoL improved significantly over time (2.59 points; 95% CI [1.29; 3.88]). Although this study was not able to quantitatively verify the positive impact of this HC that had been reported by a qualitative study with parents and other stakeholders, and a cost-effectiveness study, the approach of the HC may still be valid and improve health care of children with MHP and should be evaluated in a more general population.

Abstract Objectives Although a growing share of the population in many countries has been vaccinated against the SARS-CoV-2 virus to different degrees, social distancing and hygienic non-pharmaceutical interventions still play a substantial role in containing the pandemic. The goal of this study was to investigate which factors are correlated with a higher compliance with these regulations in the context of a cohort study in the city of Munich, southern Germany, during the summer of 2020, i.e. after the first lockdown phase. Methods Using self-reported compliance with six regulations and personal hygiene rules (washing hands, avoiding touching face, wearing a mask, keeping distance, avoiding social gatherings, avoiding public spaces) we extracted two compliance factor scores, namely compliance with personal hygiene measures and compliance with social distancing regulations. Using linear and logistic regressions, we estimated the correlation of several socio-demographic and risk perception variables with both compliance scores. Results Risk aversion proved to be a consistent and significant driver of compliance across all compliance behaviors. Furthermore, being female, being retired and having a migration background were positively associated with compliance with personal hygiene regulations, whereas older age was related with a higher compliance with social distancing regulations. Generally, socioeconomic characteristics were not related with compliance, except for education, which was negatively related with compliance with personal hygiene measures. Conclusions Our results suggest that for a targeted approach to improve compliance with measures to prevent SARS-CoV-2 infection, special attention should be given to younger, male and risk-prone individuals.

IntroductionThe functional burden of vertigo, dizziness, and balance problems (VDB) might depend on the personality traits of the patients affected. The aim of this study thus was to investigate the impact of self-efficacy, risk attitudes, and time preferences on functioning in older patients with VDB before and after treatment in a specialized tertiary care center.MethodsData for this study was obtained from the MobilE-TRA2 cohort study, conducted at a specialized tertiary care center in Germany. Patients aged 60 and older were assessed during their initial stay at the care center and 3 months later, using self-administered questionnaires. Self-efficacy was measured on a scale from 1 (very low) to 5 (very high). Health-related risk attitudes were inquired using an 11-point scale. Time preferences were measured by evaluating patients' willingness to postpone a reward in favor of a greater benefit on an 11-point Likert scale. Functioning was evaluated using the Dizziness Handicap Inventory, representing functional, emotional, and physical aspects of functional disability caused by VDB. Mixed-effects regression models were used to analyze the association between the selected personality traits and functioning over time. Interaction terms with time were incorporated for each personality trait, enabling the assessment of their influence on functioning 3 months following the initial observation period.ResultsAn overall of 337 patients (53% women, median age at baseline = 70 years) were included. Patients with higher self-efficacy (Beta = −3.82, 95%-CI [−6.56; −1.08]) and higher willingness to take risks (Beta = −1.31, 95%-CI [−2.31; −0.31]) reported better functioning during their initial visit at the care center. Self-efficacy significantly predicted functioning after 3 months for overall functioning (Beta = −4.21, 95%-CI [−6.57; −1.84]) and all three domains.ConclusionOur findings suggest that patients with high self-efficacy and high willingness to take risks may exhibit better coping mechanisms when faced with the challenges of VDB. Promoting self-efficacy may help patients to better manage the duties accompanying their treatment, leading to improved functioning. These insights may inform the development of personalized treatment aimed at reducing the functional burden of VDB in older patients.

Abstract Pulmonary hypertension (PH) is the most severe complication in preterm infants with bronchopulmonary dysplasia (BPD) and associated with significant mortality. Diagnostic and treatment strategies, however, still lack standardization. By the use of a survey study (PH in BPD), we assessed clinical practice (diagnosis, treatment, follow‐up) in preterm infants with early postnatal persistent pulmonary hypertension of the newborn (PPHN) as well as at risk for or with established BPD‐associated PH between 06/2018 and 10/2020 in two‐thirds of all German perinatal centers with >70 very low birthweight infants/year including their cardiology departments and outpatient units. Data were analyzed descriptively by measures of locations and distributional shares. In routine postnatal care, clinical presentation and echocardiography were reported as the main diagnostic modalities to screen for PPHN in preterm infants, whereas biomarkers brain natriuretic peptide/N‐terminal pro b‐type natriuretic peptide were infrequently used. For PPHN treatment, inhaled nitric oxide was used in varying frequency. The majority of participants agreed to prescribe diuretics and steroids (systemic/inhaled) for infants at risk for or with established BPD‐associated PH and strongly agreed on recommending respiratory syncytial virus immunization and the use of home monitoring upon discharge. Reported oxygen saturation targets, however, varied in these patients in in‐ and outpatient care. The survey reveals shared practices in diagnostic and therapeutic strategies for preterms with PPHN and BPD‐associated PH in Germany. Future studies are needed to agree on detailed echo parameters and biomarkers to diagnose and monitor disease next to a much‐needed agreement on the use of pulmonary vasodilators, steroids, and diuretics as well as target oxygen saturation levels.

Abstract Background Regional deprivation has been shown to be an influential factor in stroke incidence risk. However, there is a paucity of knowledge on regional differences in stroke incidence and mortality in Germany. Methods We assessed data from the Diagnosis Related Groups statistics (2016–2019) and the German Federal Registry of Physicians (2019). Negative binomial regression analysis was used to examine the association between the German Index of Multiple Deprivation 2015 covering 401 districts and district-free cities in Germany and stroke incidence, treatment, and mortality. Results The adjusted rate ratios of stroke incidence and mortality with the highest deprivation level compared with the least deprived area were 1.161 (95% CI [1.143, 1.179]) and 1.193 (95% CI [1.148, 1.239]), respectively. Moreover, this study revealed that physician density was higher in district-free cities compared to districts. Conclusions Our results indicate that regional deprivation is associated with incident and mortality cases of stroke, necessitating a more targeted approach to stroke prevention in deprived regions.

IntroductionDiabetes technology improves glycemic control and quality of life for many people with type 1 diabetes (T1D). However, inequalities in access to diabetes technology exist in many countries. In Germany, disparities in technology use have been described in pediatric T1D, but no data for adults are available so far. We therefore aimed to analyze whether demographic factors and area deprivation are associated with technology use in a representative population of adults with T1D.Materials and methodsIn adults with T1D from the German prospective diabetes follow-up registry (DPV), we analyzed the use of continuous subcutaneous insulin infusion (CSII), continuous glucose monitoring (CGM), and sensor augmented pump therapy (SAP, with and without automated insulin delivery) in 2019-2021 by age group, gender, migration background, and area deprivation using multiple adjusted regression models. Area deprivation, defined as a relative lack of area-based resources, was measured by quintiles of the German index of Multiple Deprivation (GIMD 2015, from Q1, least deprived, to Q5, most deprived districts).ResultsAmong 13,351 adults with T1D, the use of technology decreased significantly with older age: CSII use fell from 56.1% in the 18−

Abstract Background Physical activity (PA) is a proven strategy to prevent chronic diseases and reduce falls. Furthermore, it improves or at least maintains performance of activities of daily living, and thus fosters an independent lifestyle in older adults. However, evidence on the association of PA with relevant subgroups, such as older adults with utilization of long-term care (LTC), is sparse. This knowledge would be essential for establishing effective, need-based strategies to minimize the burden on healthcare systems due to the increasing need for LTC in old age. Methods Data originate from the 2011/12 (t1) baseline assessment and 2016 (t2) follow-up of the population-based Cooperative Health Research in the Region of Augsburg (KORA-)Age study in southern Germany. In 4812 observations of individuals ≥65 years, the association between various types of PA (walking, exercise (i. e., subcategory of PA with the objective to improve or maintain one or more components of physical fitness), walking+exercise) and utilization of LTC (yes/no) was analyzed using generalized estimating equation logistic models. Corresponding models stratified by sex (females: 2499 observations; males: 2313 observations) examined sex-specific associations. Descriptive analyses assessed the proportion of individuals meeting the suggested minimum values in the German National Physical Activity Recommendations for older adults (GNPAR). Results All types of PA showed a statistically significant association with non-utilization of LTC in the entire cohort. “Walking+exercise” had the strongest association with non-utilization of LTC in the entire cohort (odds ratio (OR): 0.52, 95% confidence interval (CI): 0.39–0.70) and in males (OR: 0.41, CI: 0.26–0.65), whereas in females it was “exercise” (OR: 0.58; CI: 0.35–0.94). The proportion of individuals meeting the GNPAR was higher among those without utilization of LTC (32.7%) than among those with LTC (11.7%) and group differences were statistically significant (p ≤ 0.05). Conclusions The GNPAR are rarely met by older adults. However, doing any type of PA is associated with non-utilization of LTC in community-dwelling older adults. Therefore, older adults should be encouraged to walk or exercise regularly. Furthermore, future PA programs should consider target-groups’ particularities to reach individuals with the highest needs for support.

Abstract 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.

Abstract Background In Germany, 19.1% of boys and 14.5% of girls are affected by mental health problems (MHP). Paediatricians are usually the first in line to be contacted but they often do not feel adequately trained to diagnose and treat MHP in primary care. A major statutory health insurance fund introduced a health coaching (HC) programme to strengthen primary care consultation for MHP. The HC includes a training concept for paediatricians, standardised guidelines for actions and additional payments. The aim of this study was to investigate the potential effects of the HC programme on the change of MHP in children and adolescents. Methods A prospective cohort study was conducted in Bavaria, Germany, in 2018 and 2019. Data were collected at 2 points 1 year apart using an online questionnaire. Parents of patients with developmental disorder of speech and language, head/abdominal pain, conduct disorder or non-organic enuresis were approached by their health insurance. Families treated according to the HC programme form the intervention group while all others serve as controls. MHP was assessed using the Strengths and Difficulties Questionnaire (SDQ) as a child self-assessment (SDQ-S)/or external assessment by parents (SDQ-P). Determinants of SDQ total score were analysed using linear mixed effects models. Results Cross-sectional (n = 1090) and longitudinal analyses (n = 599) were performed. At baseline, a total of 23.5% had an SDQ total score “at risk” (SDQ-S > 15/SDQ-P > 13). There were no significant differences between intervention and controls. After full adjustment for all potential confounders, higher SDQ scores indicating more problems were significantly associated with male sex (2.000, p

Abstract Background Two antifibrotic drugs, pirfenidone and nintedanib, are licensed for the treatment of patients with idiopathic pulmonary fibrosis (IPF). However, there is neither evidence from prospective data nor a guideline recommendation, which drug should be preferred over the other. This study aimed to compare pirfenidone and nintedanib-treated patients regarding all-cause mortality, all-cause and respiratory-related hospitalizations, and overall as well as respiratory-related health care costs borne by the Statutory Health Insurance (SHI). Methods A retrospective cohort study with SHI data was performed, including IPF patients treated either with pirfenidone or nintedanib. Stabilized inverse probability of treatment weighting (IPTW) based on propensity scores was applied to adjust for observed covariates. Weighted Cox models were estimated to analyze mortality and hospitalization. Weighted cost differences with bootstrapped 95% confidence intervals (CI) were applied for cost analysis. Results We compared 840 patients treated with pirfenidone and 713 patients treated with nintedanib. Both groups were similar regarding two-year all-cause mortality (HR: 0.90 95% CI: 0.76; 1.07), one-year all cause (HR: 1.09, 95% CI: 0.95; 1.25) and respiratory-related hospitalization (HR: 0.89, 95% CI: 0.72; 1.08). No significant differences were observed regarding total (€− 807, 95% CI: €− 2977; €1220) and respiratory-related (€− 1282, 95% CI: €− 3423; €534) costs. Conclusion Our analyses suggest that the patient-related outcomes mortality, hospitalization, and costs do not differ between the two currently available antifibrotic drugs pirfenidone and nintedanib. Hence, the decision on treatment with pirfenidone versus treatment with nintedanib ought to be made case-by-case taking clinical characteristics, comorbidities, comedications, individual risk of side effects, and patients’ preferences into account.

BackgroundHypertension represents one of the major risk factors for cardiovascular morbidity and mortality globally. Early detection and treatment of this condition is vital to prevent complications. However, hypertension often goes undetected, and even if detected, not every patient receives adequate treatment. Identifying simple and effective interventions is therefore crucial to fight this problem and allow more patients to receive the treatment they need. Therefore, we aim at investigating the impact of a population-based blood pressure (BP) screening and the subsequent "low-threshold" information treatment on long-term cardiovascular disease (CVD) morbidity and mortality.Methods and findingsWe examined the impact of a BP screening embedded in a population-based cohort study in Germany and subsequent personalized "light touch" information treatment, including a hypertension diagnosis and a recommendation to seek medical attention. We pooled four waves of the KORA study, carried out between 1984 and 1996 (N = 14,592). Using a sharp multivariate regression discontinuity (RD) design, we estimated the impact of the information treatment on CVD mortality and morbidity over 16.9 years. Additionally, we investigated potential intermediate outcomes, such as hypertension awareness, BP, and behavior after 7 years. No evidence of effect of BP screening was observed on CVD mortality (hazard ratio (HR) = 1.172 [95% confidence interval (CI): 0.725, 1.896]) or on any (fatal or nonfatal) long-term CVD event (HR = 1.022 [0.636, 1.641]) for individuals just above (versus below) the threshold for hypertension. Stratification for previous self-reported diagnosis of hypertension at baseline did not reveal any differential effect. The intermediate outcomes, including awareness of hypertension, were also unaffected by the information treatment. However, these results should be interpreted with caution since the analysis might not be sufficiently powered to detect a potential intervention effect.ConclusionsThe study does not provide evidence of an effect of the assessed BP screening and subsequent information treatment on BP, health behavior, or long-term CVD mortality and morbidity. Future studies should consider larger datasets to detect possible effects and a shorter follow-up for the intermediate outcomes (i.e., BP and behavior) to detect short-, medium-, and long-term effects of the intervention along the causal pathway.

BackgroundArea deprivation has been shown to be associated with various adverse health outcomes including communicable as well as non-communicable diseases. Our objective was to assess potential associations between area deprivation and COVID-19 standardized incidence and mortality ratios in Bavaria over a period of nearly 2 years. Bavaria is the federal state with the highest infection dynamics in Germany and demographically comparable to several other European countries.MethodsIn this retrospective, observational ecological study, we estimated the strength of associations between area deprivation and standardized COVID-19 incidence and mortality ratios (SIR and SMR) in Bavaria, Germany. We used official SARS-CoV-2 reporting data aggregated in monthly periods between March 1, 2020 and December 31, 2021. Area deprivation was assessed using the quintiles of the 2015 version of the Bavarian Index of Multiple Deprivation (BIMD 2015) at district level, analyzing the overall index as well as its single domains.ResultsDeprived districts showed higher SIR and SMR than less deprived districts. Aggregated over the whole period, the SIR increased by 1.04 (95% confidence interval (95% CI): 1.01 to 1.07, p = 0.002), and the SMR by 1.11 (95% CI: 1.07 to 1.16, p < 0.001) per BIMD quintile. This represents a maximum difference of 41% between districts in the most and least deprived quintiles in the SIR and 110% in the SMR. Looking at individual months revealed clear linear association between the BIMD quintiles and the SIR and SMR in the first, second and last quarter of 2021. In the summers of 2020 and 2021, infection activity was low.ConclusionsIn more deprived areas in Bavaria, Germany, higher incidence and mortality ratios were observed during the COVID-19 pandemic with particularly strong associations during infection waves 3 and 4 in 2020/2021. Only high infection levels reveal the effect of risk factors and socioeconomic inequalities. There may be confounding between the highly deprived areas and border regions in the north and east of Bavaria, making the relationship between area deprivation and infection burden more complex. Vaccination appeared to balance incidence and mortality rates between the most and least deprived districts. Vaccination makes an important contribution to health equality.

Abstract Background Current evidence suggests that the information needs of people with diabetes mellitus differ across patient groups. With a view to being able to provide individualized information, this study aims to identify (i) the diabetes-related information needs of people with diabetes mellitus; (ii) different subgroups of people with specific information needs; and (iii) associated characteristics of the identified subgroups, such as sociodemographic characteristics, diabetes-related comorbidities, and well-being. Methods This cross-sectional study was based on data from 837 respondents with diabetes mellitus who participated in the population-based KORA (Cooperative Health Research in the Augsburg Region) Health Survey 2016 in Southern Germany (KORA GEFU 4 study) (45.6% female, mean age 71.1 years, 92.8% Type 2 diabetes). Diabetes-related information needs were assessed with a questionnaire asking about patients’ information needs concerning 11 diabetes-related topics, e.g. ‘long-term complications’ and ‘treatment/therapy’. Subgroups of people with different information needs and associated characteristics were identified using latent class analysis. Results We identified the following four classes of people with different information needs: ‘high needs on all topics’, ‘low needs on all topics’, ‘moderate needs with a focus on complications and diabetes in everyday life’, and ‘advanced needs with a focus on social and legal aspects and diabetes research’. The classes differed significantly in age, years of education, type of diabetes, diabetes duration, diabetes-related comorbidities, smoking behaviour, diabetes education, current level of information, and time preference. Conclusions Knowledge about different patient subgroups can be useful for tailored information campaigns or physician-patient interactions. Further research is needed to analyse health care needs in these groups, changes in information needs over the course of the disease, and prospective health outcomes.

Abstract Background 11.5 % of girls and 17.8 % of boys are affected by a mental health problem (MHP). The most prevalent problem areas are behavioural problems (girls/boys in %: 11.9/17.9), emotional problems (9.7/8.6) and hyperactivity problems (4.8/10.8). Primary care paediatricians are the first in line to be contacted. Nevertheless, even for less severely affected patients, referral rates to specialised care are constantly high. Therefore, a major statutory health insurance fund introduced a Health Coaching (HC) programme, including a training concept for paediatricians, standardised guidelines for actions and additional payments to strengthen primary care consultation for MHP and to decrease referrals to specialised care. The aim of this study was to examine how the HC is perceived and implemented in daily practice to indicate potential strengths and challenges. Methods During a one-year period starting in November 2017, a series of guideline-based interviews were conducted by phone with HC-developers, HC-qualified paediatricians, parents and patients (≥14 years) treated according to the HC programme. Paediatricians were selected from a Bavarian practice network with a total of 577 HC qualified paediatricians. Parents of patients with the four most common MHP diagnoses were approached by their health insurance: [World Health Organization, 2013] developmental disorder of speech and language [Wille N, et al., 2008] head/abdominal pain (somatoform) [Holling H, et al., 2003-2006 and 2009-2012] conduct disorder [Plass-Christl A, et al., 2018] non-organic enuresis. 23 paediatricians, 314 parents and 10 adolescents consented to be interviewed. Potential participants were selected based on purposeful sampling, according to principles of maximum variance. All interviews were recorded and transcribed verbatim. Two researchers analysed the transcripts independently of each other. Structuring content analysis derived from Mayring was used for analysis. Results 11 paediatricians, 3 co-developers, 22 parents and 4 adolescents were included. Families were generally satisfied with paediatric care received in the programme’s context. The HC supported paediatricians’ essential role as consultants and improved their diagnostic skills. Lack of time, financial restrictions and patients’ challenging family structures were reported as major barriers to success. Conclusion The HC programme is perceived as a facilitator for more patient-centred care. However, structural barriers remain. Starting points for improvement are further options to strengthen families’ resources and expanded interdisciplinary networking.

Abstract Background Acute myocardial infarction (AMI), a major source of morbidity and mortality, is also associated with excess costs. Findings from previous studies were divergent regarding the effect on health care expenditure of adherence to guideline-recommended medication. However, gender-specific medication effectiveness, correlating the effectiveness of concomitant medication and variation in adherence over time, has not yet been considered. Methods We aim to measure the effect of adherence on health care expenditures stratified by gender from a third-party payer’s perspective in a sample of statutory insured Disease Management Program participants over a follow-up period of 3-years. In 3627 AMI patients, the proportion of days covered (PDC) for four guideline-recommended medications was calculated. A generalized additive mixed model was used, taking into account inter-individual effects (mean PDC rate) and intra-individual effects (deviation from the mean PDC rate). Results Regarding inter-individual effects, for both sexes only anti-platelet agents had a significant negative influence indicating that higher mean PDC rates lead to higher costs. With respect to intra-individual effects, for females higher deviations from the mean PDC rate for angiotensin-converting enzyme (ACE) inhibitors, anti-platelet agents, and statins were associated with higher costs. Furthermore, for males, an increasing positive deviation from the PDC mean increases costs for β-blockers and a negative deviation decreases costs. For anti-platelet agents, an increasing deviation from the PDC-mean slightly increases costs. Conclusion Positive and negative deviation from the mean PDC rate, independent of how high the mean was, usually negatively affect health care expenditures. Therefore, continuity in intake of guideline-recommended medication is important to save costs.

Introduction Vertigo, dizziness and balance problems (VDB) as well as osteoarthritis (OA) are among the health conditions with the greatest impact on mobility and social participation in older adults. Patients with VDB and OA were shown to benefit from specialised care such as vestibular rehabilitation therapy or joint replacement. However, these effects are not permanent and seem to disappear over time. One important reason might be a decreasing adherence to therapy recommendations. Findings from behavioural economics (BE) can help to shed light on individual effects on adherence behaviour and long-term outcomes of VDB and OA.Objective Based on insights from BE concepts (ie, self-efficacy, intention, and time and risk preferences), MobilE-TRA 2 investigates the determinants of functioning and health-related quality of life (HRQoL) 3 and 12 months after discharge from total hip replacement (THR)/total knee replacement (TKR) in patients with OA and after interdisciplinary evaluation for VDB.Methods and analysis MobilE-TRA 2 is a longitudinal observational study with data collection in two specialised tertiary care centres at the university hospital in Munich, Germany between 2020 and 2023. Patients aged 60 and older presenting for their first THR/TKR or interdisciplinary evaluation of VDB at Ludwig Maximilians University (LMU) hospital will be recruited for study participation. Three and twelve months after baseline assessment, all patients will receive a follow-up questionnaire. Mixed-effect regression models will be used to examine BE concepts as determinants of adherence, HRQoL and functioning.Ethics and dissemination The study was approved by the ethics committee at the medical faculty of the LMU Munich under the number 20-727. Results will be published in scientific, peer-reviewed journals and at national and international conferences. Findings will also be disseminated via newsletters, the project website and a regional conference for representatives of local and national authorities.

Introduction More than 17% of German children and adolescents have clinically relevant mental health problems (MHP). Typically, general paediatricians are often the first contact for children with MHP, and referrals to specialised care tend to be the standard approach. A statutory health insurance fund developed a programme for children with MHP (Health Coaching (HC)) aiming to offer targeted but low-threshold services. However, little is known about whether HC has the potential for optimising patient care. The aim of the PrimA-QuO study is to examine the effectiveness and the acceptance, barriers and facilitators of all stakeholders of this structured primary care programme for children affected by the most frequently encountered MHP in paediatric practice.Methods and analysis In this mixed-methods approach, children (n=800; aged 0–17 years) with MHP meeting all inclusion criteria will be identified in the health insurance database according to International Classification of Diseases, 10th Revision diagnoses between 2018 and 2019. The qualitative component uses a series of semistructured interviews with programme developers, paediatricians trained in HC, adolescents with MHP treated according to the programme guidelines and their parents. In addition, a prospective, pragmatic, parallel-group cohort study will be conducted using an online questionnaire to examine the effects of HC on health-related quality of life of affected children and their families as well as on change in MHP. Children treated according to the HC guidelines form the intervention group, whereas all others serve as controls. Primary data from the cohort study are linked to children’s health insurance claims data to calculate the costs of care as proxies for healthcare utilisation. The hypothesis is that HC is an effective and efficient primary care programme with the potential to improve patients’ and their families’ health outcomes.Ethics and dissemination The study was approved by the Ethical Committee of Ludwig-Maximilians-Universität München. Grant number 01VSF16032 (funded by the German Innovationsfonds)

Abstract Background Diabetes mellitus is a major chronic disease, which is connected to direct and indirect costs and productivity losses. However, its effects on labour market participation are not straightforward to identify, nor are they consistently included in cost-of-illness studies. First, this study aims to synthesise existing evidence regarding the impact of diabetes on labour market outcomes that imply a complete absence of work. Second, the analysis takes a particular look at relevant methodological choices and the resulting quality of the studies included. Methods We conducted a systematic literature research (PubMed, Embase, PsychINFO), by applying a standard screening, selection and results extraction process, which considered all types of studies including cross-sectional and longitudinal approaches. Risk-of-bias and quality within the studies were assessed and results were compared. We dedicated special attention to the modelling of potential reverse causality between diabetes and labour market outcomes and the consideration of comorbidities and complications. Results Overall, 30 studies satisfied our inclusion criteria. We identified four main labour participation outcomes: absence of employment, unemployment, early retirement, and disability pension. The studies reviewed show a negative impact of diabetes on the labour market participation outcomes considered. However, only a few studies controlled for endogeneity, differentiated between type 1 and type 2 diabetes or modelled the impact of comorbidities. We report how modelling choices affect the directions and interpretations of the effects. Conclusions The available evidence mainly suggests a negative impact of diabetes on several outcomes indicating labour market participation. The methodological limitations identified can guide future research with respect to both outcomes and methods. This study provides therefore an empirical contribution to the discussion on how to model the economic impact of diabetes.

Management of radiological incidental findings (IF) is of rising importance; however, psychosocial implications of IF reporting remain unclear. We compared long-term psychosocial effects between individuals who underwent whole-body magnetic resonance imaging (MRI) with and without reported IF, and individuals who did not undergo imaging. We used a longitudinal population-based cohort from Western Europe. Longitudinal analysis included three examinations (exam 1, 6 years prior to MRI; exam 2, MRI; exam 3, 4 years after MRI). Psychosocial outcomes included PHQ-9 (Patient Health Questionnaire), DEEX (Depression and Exhaustion Scale), PSS-10 (Perceived Stress Scale) and a Somatization Scale. Univariate analyses and adjusted linear mixed models were calculated. Among 855 included individuals, 25% (n = 212) underwent MRI and 6% (n = 50) had at least one reported IF. Compared to MRI participants, non-participants had a higher psychosocial burden indicated by PHQ-9 in exam 1 (3.3 ± 3.3 vs. 2.5 ± 2.3) and DEEX (8.6 ± 4.7 vs. 7.7 ± 4.4), Somatization Scale (5.9 ± 4.3 vs. 4.8 ± 3.8) and PSS-10 (14.7 ± 5.7 vs. 13.7 ± 5.3, all p < 0.05) in exam 3. MRI participation without IF reporting was significantly associated with lower values of DEEX, PHQ-9 and Somatization Scale. There were no significant differences at the three timepoints between MRI participants with and without IF. In conclusion, individuals who voluntarily participated in whole-body MRI had less psychosocial burden and imaging and IF reporting were not associated with adverse long-term psychosocial consequences. However, due to the study design we cannot conclude that the MRI exam itself represented a beneficial intervention causing improvement in mental health scores.

Associations between diet and DNA methylation may vary among subjects with different metabolic states, which can be captured by clustering populations in metabolically homogenous subgroups, called metabotypes. Our aim was to examine the relationship between habitual consumption of various food groups and DNA methylation as well as to test for effect modification by metabotype. A cross-sectional analysis of participants (median age 58 years) of the population-based prospective KORA FF4 study, habitual dietary intake was modeled based on repeated 24-h diet recalls and a food frequency questionnaire. DNA methylation was measured using the Infinium MethylationEPIC BeadChip providing data on >850,000 sites in this epigenome-wide association study (EWAS). Three metabotype clusters were identified using four standard clinical parameters and BMI. Regression models were used to associate diet and DNA methylation, and to test for effect modification. Few significant signals were identified in the basic analysis while many significant signals were observed in models including food group-metabotype interaction terms. Most findings refer to interactions of food intake with metabotype 3, which is the metabotype with the most unfavorable metabolic profile. This research highlights the importance of the metabolic characteristics of subjects when identifying associations between diet and white blood cell DNA methylation in EWAS.

Objectives: An inverse relationship between education and cardiovascular risk has been described, however, the combined association of education, income, and neighborhood socioeconomic status with macrovascular disease is less clear. The aim of this study was to evaluate the association of educational level, equivalent household income and area deprivation with macrovascular disease in Germany.Methods: Cross-sectional data from two representative German population-based studies, SHIP-TREND (n = 3,731) and KORA-F4 (n = 2,870), were analyzed. Multivariable logistic regression models were applied to estimate odds ratios and 95% confidence intervals for the association between socioeconomic determinants and macrovascular disease (defined as self-reported myocardial infarction or stroke).Results: The study showed a higher odds of prevalent macrovascular disease in men with low and middle educational level compared to men with high education. Area deprivation and equivalent income were not related to myocardial infarction or stroke in any of the models.Conclusion: Educational level, but not income or area deprivation, is significantly related to the macrovascular disease in men. Effective prevention of macrovascular disease should therefore start with investing in individual education.

Background: A growing number of epidemiological studies show associations between environmental factors and impaired cardiometabolic health. However, evidence is scarce concerning these risk factors and their impact on metabolic syndrome (MetS). This analysis aims to investigate associations between long-term exposure to air pollution, road traffic noise, residential greenness, and MetS. Methods: We used data of the first (F4, 2006–2008) and second (FF4, 2013–2014) follow-up of the population-based KORA S4 survey in the region of Augsburg, Germany, to investigate associations between exposures and MetS prevalence at F4 (N = 2883) and MetS incidence at FF4 (N = 1192; average follow-up: 6.5 years). Residential long-term exposures to air pollution – including particulate matter (PM) with a diameter

Summary: Psychological and social factors are known to influence blood pressure (BP) and risk of hypertension and associated cardiovascular diseases. To identify novel BP loci, we carried out genome-wide association meta-analyses of systolic, diastolic, pulse, and mean arterial BP, taking into account the interaction effects of genetic variants with three psychosocial factors: depressive symptoms, anxiety symptoms, and social support. Analyses were performed using a two-stage design in a sample of up to 128,894 adults from five ancestry groups. In the combined meta-analyses of stages 1 and 2, we identified 59 loci (p value < 5e−8), including nine novel BP loci. The novel associations were observed mostly with pulse pressure, with fewer observed with mean arterial pressure. Five novel loci were identified in African ancestry, and all but one showed patterns of interaction with at least one psychosocial factor. Functional annotation of the novel loci supports a major role for genes implicated in the immune response (PLCL2), synaptic function and neurotransmission (LIN7A and PFIA2), as well as genes previously implicated in neuropsychiatric or stress-related disorders (FSTL5 and CHODL). These findings underscore the importance of considering psychological and social factors in gene discovery for BP, especially in non-European populations.

To strengthen the coordinating function of general practitioners (GPs) in the German healthcare system, a copayment of €10 was introduced in 2004. Due to a perceived lack of efficacy and a high administrative burden, it was abolished in 2012. The present cohort study investigates characteristics and differences of GP-coordinated and uncoordinated patients in Bavaria, Germany, concerning morbidity and ambulatory specialist costs and whether these differences have changed after the abolition of the copayment. We performed a retrospective routine data analysis, using claims data of the Bavarian Association of the Statutory Health Insurance Physicians during the period 2011-2012 (with copayment) and 2013-2016 (without copayment), covering 24 quarters. Coordinated care was defined as specialist contact only with referral. Multinomial regression modelling, including inverse probability of treatment weighting, was used for the cohort analysis of 500 000 randomly selected patients. Longitudinal regression models were calculated for cost estimation. Coordination of care decreased substantially after the abolition of the copayment, accompanied by increasing proportions of patients with chronic and mental diseases in the uncoordinated group, and a corresponding decrease in the coordinated group. In the presence of the copayment, uncoordinated patients had €21.78 higher specialist costs than coordinated patients, increasing to €24.94 after its abolition. The results indicate that patients incur higher healthcare costs for specialist ambulatory care when their care is uncoordinated. This effect slightly increased after abolition of the copayment. Beyond that, the abolition of the copayment led to a substantial reduction in primary care coordination, particularly affecting vulnerable patients. Therefore, coordination of care in the ambulatory setting should be strengthened.

Abstract Background and aims Unrealistic comparative optimism (UO), as the erroneous judgement of personal risks to be lower than the risks of others, could help explain differences in diabetes self‐management. The present study tested the hypothesis that individuals with type 2 diabetes who underestimate their comparative heart attack risk, have a lower adherence regarding recommended self‐management. Methods We used data from individuals with type 2 diabetes participating in the German KORA (Cooperative Health Research in the Region of Augsburg) GEFU 4 (self‐administered health questionnaire 2016) study. UO was estimated by comparing participants' subjective comparative risk for having a heart attack within the next 5‐years (ie, “higher than others,” “average,” “lower than others”), with their objective comparative 10‐year cardiovascular disease risk based on the Framingham equations. We estimated binary logistic and linear regression models to analyze which characteristics were associated with UO and to test the association between UO and participants' self‐management behaviors (ie, regular self‐monitoring of body weight, blood sugar, and blood pressure, regular foot care, keeping a diabetes diary, and having a diet plan), and their sum score, respectively. All models were adjusted for socio‐demographic and disease‐related variables. Results The studied sample included n = 633 individuals with type 2 diabetes (mean age 70.7 years, 45% women). Smokers and males were more likely to show UO than nonsmokers and females. Furthermore, a higher blood pressure and a higher body mass index were associated with a higher likelihood of UO regarding heart attack risk. However, UO was not significantly associated with patient self‐management. Conclusions Unfavorable health behavior and risk factors are associated with UO. However, our results suggest that UO with regard to perceived heart attack risk may not be a relevant factor for patient self‐management in those with type 2 diabetes.

Abstract Background The topic of this paper is related to equity in health within a country. In public health care sectors of many countries decisions on priority setting with respect to treatment of different types of diseases or patient groups are implicitly or explicitly made. Priorities are realized by allocation decisions for medical resources where moral judgments play an important role with respect to goals and measures that should be applied. The aim of this study is to explore the moral intuitions held in the German society related to priorities in medical treatment. Methods We use an experimental questionnaire method established in the Empirical Social Choice literature. Participants are asked to make decisions in a sequence of distributive problems where a limited amount of treatment time has to be allocated to hypothetically described patients. The decision problems serve as an intuition pump. Situations are systematically varied with respect to patients’ initial health levels, their ability to benefit from treatment time, and the amount of treatment time available. Subjects are also asked to describe their deliberations. We focus on the acceptance of different allocation principles including equity concepts and utilitarian properties. We investigate rule characteristics like order preservation or monotonicity with respect to resources, severity, or effectiveness. We check the consistency of individual choices with stated reasoning. Results The goals and allocation principles revealed show that the moral intuitions held by our experimental subjects are much more complex than the principles commonly applied in health economic theory. Especially, cost-utility principles are rarely applied, whereas the goal of equality of health gain is observed more often. The principle not to leave any patient untreated is very dominant. We also observe the degrees to which extent certain monotonicity principles, known from welfare economics, are followed. Subjects were able to describe their moral judgments in written statements. We also find evidence that they followed their respective intuitions very consistently in their decisions. Conclusions Findings of the kind presented in this paper may serve as an important input for the public and political discussion when decisions on priorities in the public health care sector are formed.

The outcomes of bargaining over losses, the subject of this paper, have rarely been studied. But experimental studies of related situations, such as those involving bankruptcies or bequests in which the sum of the legal claims that can be made against a bank or firm or estate are greater than their values, have produced strong support for the proportionality principle. To test whether this principle would find support in other situations involving losses we designed an experimental game in which four players start out with differing initial endowments of real money. They are then informed that a certain amount of this resource has to be given back to the experimenter. How should the loss be shared among the agents? This game was run at different locations and under different treatments over a period of almost three years. We found that the proportionality principle was rarely proposed and even less frequently accepted as a solution to this problem. One of the main reasons for this result was that the two players with the smallest endowments opposed most of the proposals which asked them to contribute at least some positive amount of their own initial resource.

Background: Health behaviors are of great importance for public health. Previous research shows that health behaviors are clustered and do not occur by chance. The main objective of this study was to investigate and describe the clustering of alcohol consumption, nutrition, physical activity and smoking while also considering the influence of sex, age and education.Methods: Using data from the population-based KORA S4/F4 cohort study, latent class regression analysis was undertaken to identify different clusters of health behavior patterns. The clusters were described according to demographics. Furthermore, the clusters were described regarding health-related quality of life at baseline and at a 7 year follow-up.Results: Based on a sample of 4,238 participants, three distinct classes were identified. One overall healthy class and two heterogeneous classes. Classes varied especially according to sex, indicating a healthier behavior pattern for females. No clear association between healthier classes and age, education or physical and mental health-related quality of life was found.Discussion: This study strengthens the literature on the clustering of health behaviors and additionally describes the identified clusters in association with health-related quality of life. More research on associations between clustering of health behaviors and important clinical outcomes is needed.