Unobserved heterogeneity and the comparison of coefficients across nested logistic regression models: how to avoid comparing apples and oranges

Separating the wheat from the chaff: How to measure hospital quality in routine data?

OBJECTIVE

To measure hospital quality based on routine data available in many health care systems including the United States, Germany, the United Kingdom, Scandinavia, and Switzerland.

DATA SOURCES AND STUDY SETTING

We use the Swiss Medical Statistics of Hospitals, an administrative hospital dataset of all inpatient stays in acute care hospitals in Switzerland for the years 2017-2019.

STUDY DESIGN

We study hospital quality based on quality indicators used by leading agencies in five countries (the United States, the United Kingdom, Germany, Austria, and Switzerland) for two high-volume elective procedures: inguinal hernia repair and hip replacement surgery. We assess how least absolute shrinkage and selection operator (LASSO), a supervised machine learning technique for variable selection, and Mundlak corrections that account for unobserved heterogeneity between hospitals can be used to improve risk adjustment and correct for imbalances in patient risks across hospitals.

DATA COLLECTION/EXTRACTION METHODS

The Swiss Federal Statistical Office collects annual data on all acute care inpatient stays including basic socio-demographic patient attributes and case-level diagnosis and procedure codes.

PRINCIPAL FINDINGS

We find that LASSO-selected and Mundlak-corrected hospital random effects logit models outperform common practice logistic regression models used for risk adjustment. Besides the more favorable statistical properties, they have superior in- and out-of-sample explanatory power. Moreover, we find that Mundlak-corrected logits and the more complex LASSO-selected models identify the same hospitals as high or low-quality offering public health authorities a valuable alternative to standard logistic regression models. Our analysis shows that hospitals vary considerably in the quality they provide to patients.

CONCLUSION

We find that routine hospital data can be used to measure clinically relevant quality indicators that help patients make informed hospital choices.

Soccer above all? Analysis of academic and vocational education among female soccer players in the German women's Bundesliga and 2nd women's Bundesliga

Introduction

Career-related (financial) reasons as well as advantages in terms of expanding social support systems, promoting a balanced lifestyle and personal development suggest that female soccer players should pursue academic or vocational education in parallel to elite sport. However, dual careers are fraught with challenges, mainly due to simultaneity in time and the associated conflicting goals. The aim of this article is to analyze the vocational or academic educational careers of professional female soccer players.

Methods

To generate the data, an online survey was conducted among soccer players in the German Women's Bundesliga and 2nd Women's Bundesliga. A total of n = 200 questionnaires (German: n = 191; English: n = 9) were included in the analysis, which corresponds to approx. 29.6% of the population addressed.

Results

90.6% of the players are pursuing or have already completed academic or vocational education. The majority (71.2%) of female soccer players choose to study. 81.8% of players report no impact or even a positive impact of soccer on their performance in academic or vocational education. Willingness to pursue and complete academic or vocational education is influenced by membership of the A-National Team, time spent playing soccer, form of school-leaving qualification, nationality and age.

Discussion

This study increases the visibility of professional women's soccer as an object of analysis in sports science research, follows up on demands for a more athlete-centered approach and generates further insights for research and practice with regard to the success of dual careers in elite sport.

Medical rehabilitation of older employees with migrant background in Germany: Does the utilization meet the needs?

Due to demographic change with an ageing workforce, the proportion of employees with poor health and a need for medical rehabilitation is increasing. The aim was to investigate if older employees with migrant background have a different need for and utilization of medical rehabilitation than employees without migrant background. To investigate this, self-reported data from older German employees born in 1959 or 1965 of the first and second study wave of the lidA cohort study were exploratory analyzed (n = 3897). Subgroups of employees with migrant background were separated as first-generation, which had either German or foreign nationality, and second-generation vs. the rest as non-migrants. All subgroups were examined for their need for and utilization of medical rehabilitation with descriptive and bivariate statistics (chi-square, F- and post-hoc tests). Furthermore, multiple logistic regressions and average marginal effects were calculated for each migrant group separately to assess the effect of need for utilization of rehabilitation. According to our operationalizations, the foreign and German first-generation migrants had the highest need for medical rehabilitation while the German first- and second-generation migrants had the highest utilization in the bivariate analysis. However, the multiple logistic model showed significant positive associations between their needs and utilization of rehabilitation for all subgroups. Further in-depth analysis of the need showed that something like under- and oversupply co-exist in migrant groups, while the foreign first-generation migrants with lower need were the only ones without rehabilitation usage. However, undersupply exists in all groups independent of migrant status. Concluding, all subgroups showed suitable use of rehabilitation according to their needs at first sight. Nevertheless, the utilization does not appear to have met all needs, and therefore, the need-oriented utilization of rehabilitation should be increased among all employees, e.g. by providing more information, removing barriers or identifying official need with uniform standards.

Utilization of preventive care among migrants and non-migrants in Germany: results from the representative cross-sectional study 'German health interview and examination survey for adults (DEGS1)'

BACKGROUND

In Germany, different health checks for adults are offered for primary and secondary prevention. Previous findings indicate that preventive care utilization varies according to social determinants, especially migration background. This study examined the extent to which migration background is associated with preventive care utilization, independent of factors like age and socioeconomic status and whether length of stay in Germany has a positive effect on the use of preventive care.

METHODS

The first wave of the 'German Health Interview and Examination Survey for Adults' (DEGS1) is a comprehensive data collection facilitating the description of the utilization of general health checks, dental check-ups, skin cancer screening, and cervical cancer screening among people aged 18-79 years with and without migration background. Migration background was differentiated in first-generation migrants having immigrated to Germany themselves or second-generation migrants born in Germany. First-generation migrants were further differentiated by length of stay in Germany, and second-generation migrants as having one or two parents who were born abroad. Multivariate binary logistic regression models with average marginal effects were calculated to analyse the associations between preventive care utilization and migration background.

RESULTS

The sample comprised 7987 participants, 1091 of whom had a migration background. Compared with non-migrants, women and men with migration background- particularly first-generation migrants with length of stay <=20 years in Germany - make less use of preventive care. This association was observed statistically independent from sociodemographic factors. For dental check-ups a significantly lower use was also found for first-generation migrants who have lived in Germany for more than 20 years and second-generation of migrants with two parents born abroad. Post-model predictions showed that the utilization rates of first-generation migrants are gradually converging to the average values for non-migrants.

CONCLUSIONS

Our findings suggest inequalities in realized access to preventive care for first-generation migrants particularly for those who have lived in Germany for 20 years or less. Barriers to the utilization of preventive care may be addressed by informing migrant communities about preventive health care services at an early stage after immigration using migrant-sensitive information strategies.

Subjective employment perspective among older workers with and without migrant background in Germany-Results of the lidA cohort study

OBJECTIVES

The aim of this study was to investigate the subjective employment perspective in higher working age for different employee groups with migrant background (EMB) and without (non-EMB), meaning willing, being able, and planning to work until the individual state pension age (iSPA).

METHODS

A representative sample of socially insured employees born in 1959 or 1965 was surveyed in 2011, 2014, and 2018 with computer-assisted personal interviews. The current cross-sectional analysis is based on data from the third study wave (n = 3286) of the lidA cohort study. EMB were differentiated via generation (first generation, G1, vs second generation, G2) or nationality (German vs foreign). Applying bivariate statistics with the tests of independence and block-wise logistic regressions, group differences were investigated. Sex, age, educational level, net household income, health, and work factors were considered as covariates.

RESULTS

When comparing subgroups of EMB, significant differences appeared in bivariate analyses for willing and planning to work. G1 were to a higher degree planning to work longer than G2 and those with foreign nationality were more willing and planning than those with German nationality. Multivariate analyses revealed significant differences of G1 and non-EMB for planning, being significant in the fully adjusted model, but not for willing.

CONCLUSION

The findings underline the need for differentiation of migrant groups in social research and policy. When it comes to extended working lives, the first-generation migrant group, as well as foreigners may constitute risk groups and require increased attention from a work, health, and economic point of view.

Perception of aging in the relation between sport activity and self-rated health in middle and older age - A longitudinal analysis

Background

This study aims to generate more comprehensive knowledge regarding underlying mechanisms of health production in middle and older age by focusing on perception of aging in the relation between sport activity and self-rated health. More differentiated information can be generated by using more age-specific data and applying advanced empirical methods.

Methods

Panel data from the German Ageing Survey (DEAS) (n = 1027) is used, whereby individuals are included, that participated at least in two waves. First, a blockwise fixed effects logistic regression model is carried out, which allows to investigate mediation as well as moderation effects and controls for time invariant unobserved heterogeneity. Additionally, two recursive bivariate probit models are conducted to identify further indirect pathways.

Findings

A mediating and moderating effect of perception of aging regarding self-rated health is found in the fixed effects model. Indirect pathways of perception of aging and retirement over sport activity (mediator) are confirmed in the recursive bivariate probit models.

Conclusion

The results highlight the complexity of the underlying mechanisms as well as the importance of individual and needs-based designed health promotion. Here, public health policy should not solely focus on sport activity, rather it should include target group specific strategies to shape individual perceptions of aging towards a more positive view on aging, while considering the heterogeneity of middle and older age groups.

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Sport activity and health-specific perception of aging are positively associated with self-rated health.

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A mediating and moderating effect of perception of aging on sport activity regarding self-rated health is found.

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Indirect pathways of perception of aging and retirement over sport activity are confirmed.

Frequent attenders in the German healthcare system: determinants of high utilization of primary care services. Results from the cross-sectional German health interview and examination survey for adults (DEGS)

BACKGROUND

In Germany, patients are consulting general practitioners increasingly frequently, resulting in a high burden on the healthcare system. This study aimed to identify factors associated with frequent primary care attendance in the German healthcare system.

METHODS

The German Health Interview and Examination Survey for Adults (DEGS) is part of Germany's national health monitoring, and includes a large representative sample of the German population aged 18-79 years. We defined the 10% of participants with the highest number of general practitioner contacts in the preceding 12 months as frequent attenders of primary care services. Binary logistic regression models with average marginal effects were used to identify potential determinants for frequent use of primary care services.

RESULTS

The sample comprised 7956 participants. Significant effects on frequent use of primary care were observed for low socioeconomic status, stressful life events, factors related to medical need for care such as medically diagnosed chronic conditions and for subjective health. In the full model, the number of non-communicable diseases and subjective health status had the strongest effect on frequent primary care use. We found an interaction effect suggesting that the association between subjective health status and frequent attendance vanishes with a higher number of non-communicable diseases.

CONCLUSIONS

We observed strong associations between frequent primary care attendance and medical need for care as well as subjective health-related factors. These findings suggest that better coordination of care may be a preferred method to manage health services utilization and to avoid redundant examinations and uncoordinated clinical pathways. Further research is needed to clarify moderating and mediating factors contributing to high utilization of primary care services.

Utilisation of rehabilitation services for non-migrant and migrant groups of higher working age in Germany - results of the lidA cohort study

Background

An ageing and a shrinking labour force implies that the prevention of a premature exit from work due to poor health will become more relevant in the future. Medical rehabilitation is a health service that aims at active participation in working life. The provision of this service will be relevant for an increasing part of the ageing labour force, namely, employees with a migrant background and their different subgroups. Thus, this study examines whether first- and second-generation employees with migrant background differ from non-migrants in their utilisation of rehabilitation services and whether within the subsample of migrant employees, those persons with foreign nationality differ from those with German nationality.

Methods

Socially insured employees born in 1959 or 1965 were surveyed nationwide in 2011 as part of the lidA cohort study (n=6303). Survey data of the first study wave were used to identify the dependent variable of the utilisation of rehabilitation (in- and outpatient), the independent variable of migrant status and the covariates of sociodemographic, work- and non-work-related factors. Applying bivariate statistics with tests of independence and block-wise logistic regressions, differences between the groups were investigated. Additionally, average marginal effects were computed to directly compare the adjusted models.

Results

The study showed that first-generation migrants had a significantly lower likelihood of utilising outpatient rehabilitation than non-migrants (fully adj. OR 0.42, 95% CI 0.22-0.82) and that average marginal effects indicated higher differences in the full model than in the null model. No significant differences were found between the first- or second-generation migrants and non-migrants when comparing the utilisation of inpatient rehabilitation or any rehabilitation or when analysing German and foreign employees with migrant background (n=1148).

Conclusions

Significant differences in the utilisation of outpatient rehabilitation between first-generation migrants and non-migrants were found, which could not be explained by sociodemographic, work- and non-work-related factors. Thus, further factors might play a role. The second-generation migrants resemble the non-migrants rather than their parent generation (first-generation migrants). This detailed investigation shows the heterogeneity in the utilisation of health services such as medical rehabilitation, which is why service sensitive to diversity should be considered.

Discrimination in healthcare as a barrier to care: experiences of socially disadvantaged populations in France from a nationally representative survey

Background

People in socially disadvantaged groups face a myriad of challenges to their health. Discrimination, based on group status such as gender, immigration generation, race/ethnicity, or religion, are a well-documented health challenge. However, less is known about experiences of discrimination specifically within healthcare settings, and how it may act as a barrier to healthcare.

Methods

Using data from a nationally representative survey of France (N = 21,761) with an oversample of immigrants, we examine rates of reported discrimination in healthcare settings, rates of foregoing healthcare, and whether discrimination could explain disparities in foregoing care across social groups.

Results

Rates of both reporting discrimination within healthcare and reporting foregone care in the past 12 months were generally highest among women, immigrants from Africa or Overseas France, and Muslims. For all of these groups, experiences of discrimination potentially explained significant proportions of their disparity in foregone care (Percent disparity in foregone care explained for: women = 17%, second-generation immigrants = 8%, Overseas France = 13%, North Africa = 22%, Sub-Saharan Africa = 32%, Muslims = 26%). Rates of foregone care were also higher for those of mixed origin and people who reported “Other Religion”, but foregone healthcare was not associated with discrimination for those groups.

Conclusions

Experiences of discrimination within the healthcare setting may present a barrier to healthcare for people that are socially disadvantaged due to gender, immigration, race/ethnicity, or religion. Researchers and policymakers should consider barriers to healthcare that lie within the healthcare experience itself as potential intervention targets.

Are there disparities in different domains of physical activity between school-aged migrant and non-migrant children and adolescents? Insights from Germany

Background

Large proportions of the populations in many European countries, including Germany, are migrants. Migrant children and adolescents tend to be less physically active than their non-migrant peers. However, current research is limited as it does not sufficiently consider different domains of physical activity. Using a representative dataset, the present study examines the patterns of sports participation and other domains of physical activity among migrant and non-migrant children and adolescents residing in Germany.

Methods

Nationwide data from the Motorik-Modul (MoMo) Study is used. Five different domains of physical activity participation (sports clubs, outside of sports clubs, extra-curricular physical activity, physical activity, outdoor play and active commuting to school) were compared between children and adolescents with no, one-sided and two-sided migration background using logistic regression adjusted for demographic factors. Interaction terms were included in order to examine whether difference between the three groups differ by age and gender.

Results

Information on n = 3,323 children and adolescents was available. As compared to non-migrants, children and adolescents with a two-sided migration background had a 40% (adjusted odds ratio [aOR] = 0.60, 95%-CI: 0.44–0.81), those with a one-sided migration background a 26% (aOR = 0.74, 95%-CI: 0.55-<1.00) lower chance of participating in sport club activities. In contrast, children and adolescents with a two-sided migration background were at 65% higher chance of participating in extra-curricular physical activity than non-migrants (OR = 1.65, 95%-CI: 1.15–2.36).

Conclusion

The study shows that differences in levels of physical activity between migrant and non-migrant children and adolescents are less pronounced than previous research has suggested. In particular, it reveals that migrants are only disadvantaged regarding participation in sports clubs whereas they fare better with respect to extra-curricular physical activity. Interventions should therefore address barriers migrant children and adolescents encounter in the access to sport clubs while maintaining their high level of extra-curricular physical activity.

Disparities in health care outcomes between immigrants and the majority population in Germany: A trend analysis, 2006-2014

Background

Immigrants often encounter barriers in the health system that may affect their health care outcomes. In order to better cater to the needs of immigrants, many health care institutions have increased their efforts in recent years to provide services which are more sensitive to the needs of an increasingly diverse population. Little is known about whether these efforts are successful. This study examines difference in outcomes of tertiary prevention between immigrants and the autochthonous population in Germany over the period of 2006–2014.

Methods

The analysis is based on a 10% random sample of routine data on completed tertiary preventive treatments in Germany during 2006–2014. Four different indicators of treatment effectiveness were compared between patients with a nationality from Germany, Portugal/Spain/Italy/Greece, Turkey and Former Yugoslavia using logistic regression adjusted for demographic/socioeconomic factors. Interaction terms for year were modeled to examine group differences over time.

Results

Depending on the outcome, Turkish and Former Yugoslavian nationals had an 23%-69% higher chance of a poor treatment effectiveness than Germans (OR = 1.23 [95%-CI = 1.15,1.32] and OR = 1.69 [95%-CI = 1.55,1.83], respectively). Fewer differences were observed between nationals from Portugal/Spain/Italy/Greece and Germans. Disparities did not significantly differ between the years in which services were utilized.

Conclusion

Measures implemented by health care institutions did not reduce existing health care disparities between immigrants and the majority population in Germany. One potential reason is that existing approaches are unsystematic and often not properly evaluated. More targeted strategies and a thorough evaluation is needed in order to improve health care for immigrants sustainably.