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Tamulevicius M, Bucher F, Dastagir N, Maerz V, Vogt PM, Dastagir K. Demographic shifts reshaping the landscape of hand trauma: a comprehensive single-center analysis of changing trends in hand injuries from 2007 to 2022. Inj Epidemiol 2024; 11:25. [PMID: 38872185 PMCID: PMC11170831 DOI: 10.1186/s40621-024-00510-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 05/28/2024] [Indexed: 06/15/2024] Open
Abstract
INTRODUCTION Hand injuries constitute up to 30% of the total cases treated in emergency departments. Over time, demographic changes, especially an aging population, and shifts in workplace safety regulations and healthcare policies have significantly impacted the landscape of hand trauma. This study aims to identify and analyze these evolving trends over nearly two decades. METHODS In this retrospective, cross-sectional study, we investigated patients who were admitted to the high-volume regional hand trauma center of a university hospital between January 2007 and December 2022. We analyzed trends in patients' demographics and annual alterations of injuries. For the comparative analysis, patients were divided into two groups based on the time of presentation: the early cohort (2007-2014) and the current cohort (2015-2022). RESULTS A total of 14,414 patients were admitted to our emergency department within the study period. A significant annual increase in patient age was identified (R2 = 0.254, p = 0.047). The number of presentations increased annually by an average of 2% (p < 0.001). The incidence of the following hand injuries significantly increased: sprains/strains (+ 70.51%, p = 0.004), superficial lacerations (+ 53.99%, p < 0.001), joint dislocations (+ 51.28%, p < 0.001), fractures (carpal: + 49.25%, p = 0.003; noncarpal: + 39.18%, p < 0.001), deep lacerations (+ 37.16%, p < 0.001) and burns and corrosions (+ 29.45%, p < 0.001). However, rates of amputations decreased significantly (- 22.09%, p = 0.04). CONCLUSIONS A consistent and significant annual increase in both the total number of injuries and the average age of patients was identified. An aging population may increase injury rates and comorbidities, stressing healthcare resources. Our study underscores the need to adapt healthcare structures and reimbursement policies, especially for outpatient hand injury care.
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Affiliation(s)
- Martynas Tamulevicius
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - Florian Bucher
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Nadjib Dastagir
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Vincent Maerz
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Peter M Vogt
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Khaled Dastagir
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
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Dragano N, Jasilionis D. Long echo of sociopolitical upheaval: life events and health in East Germany. J Epidemiol Community Health 2024; 78:343-344. [PMID: 38589222 DOI: 10.1136/jech-2024-221974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Affiliation(s)
- Nico Dragano
- Institute for Medical Sociology, University Hospital and Medical Faculty, University of Düsseldorf, Düsseldorf, Germany
| | - Domantas Jasilionis
- Laboratory of Demographic Data, Max Planck Institute for Demographic Research, Rostock, Germany
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Grigoriev P, Sauerberg M, Jasilionis D, van Raalte A, Klüsener S. [Mortality trends in Germany in an international context]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2024; 67:493-503. [PMID: 38637470 PMCID: PMC11093834 DOI: 10.1007/s00103-024-03867-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 03/12/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND AND AIM Due to its strong economy and a well-developed healthcare system, Germany is well positioned to achieve above-average reductions in mortality. Nevertheless, in terms of life expectancy, Germany is increasingly falling behind Western Europe. We compare mortality trends in Germany with other Western European countries, covering the period from 1960 to 2019. The focus is on long-term trends in Germany's ranking in international mortality trends. In addition, we conduct a detailed mortality analysis by age. METHODS Our analysis is mostly based on mortality data from the Human Mortality Database (HMD). Cause-specific mortality data originate from the database of the World Health Organization (WHO). For the international comparison of mortality trends, we use conventional mortality indicators (age-standardized mortality rate, period life expectancy). RESULTS Compared to other Western European countries, Germany has higher mortality in the middle and older age groups. Germany's life expectancy gap compared to Western Europe has grown during the past 20 years. In 2000, Germany was 0.73 years behind for men and 0.74 years behind for women. By 2019, these figures had risen to 1.43 and 1.34 years, respectively. This is mainly due to mortality from non-communicable diseases. CONCLUSION For Germany to catch up with other Western European countries, a stronger focus on further reducing mortality at ages 50+ is crucial. This also requires further research to understand the factors behind Germany's disadvantageous position.
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Affiliation(s)
- Pavel Grigoriev
- Bundesinstitut für Bevölkerungsforschung (BiB), Friedrich-Ebert-Allee 4, 65185, Wiesbaden, Deutschland.
| | - Markus Sauerberg
- Bundesinstitut für Bevölkerungsforschung (BiB), Friedrich-Ebert-Allee 4, 65185, Wiesbaden, Deutschland
| | - Domantas Jasilionis
- Max-Planck-Institut für demografische Forschung, Rostock, Deutschland
- Demografisches Forschungszentrum, Vytautas-Magnus-Universität, Kaunas, Litauen
- The Max Planck - University of Helsinki Center for Social Inequalities in Population Health (MaxHel Center), Helsinki, Finnland
| | - Alyson van Raalte
- Max-Planck-Institut für demografische Forschung, Rostock, Deutschland
- The Max Planck - University of Helsinki Center for Social Inequalities in Population Health (MaxHel Center), Helsinki, Finnland
| | - Sebastian Klüsener
- Bundesinstitut für Bevölkerungsforschung (BiB), Friedrich-Ebert-Allee 4, 65185, Wiesbaden, Deutschland
- Demografisches Forschungszentrum, Vytautas-Magnus-Universität, Kaunas, Litauen
- Universität zu Köln, Köln, Deutschland
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Tetzlaff J, Epping J. [Healthier at work for longer? Trends in life years free of cardiovascular and musculoskeletal diseases in the employed and general population based on health insurance claims data]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2024; 67:555-563. [PMID: 38607434 PMCID: PMC11093846 DOI: 10.1007/s00103-024-03868-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 03/13/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND Our study focuses on the development of disease-free life years of two disease groups with high public health relevance: musculoskeletal diseases (MSD) and cardiovascular diseases (CVD). Against the backdrop of prolonged working lives, the development of disease-free life years in the working-age population is compared with the trend in the employed population. Differences between occupational groups are also examined. METHODS The study is based on data from the statutory health insurance provider AOK Lower Saxony (N = 2,001,225). Incident cases were identified based on the diagnosis data. The expected years free of MSD and CVD were calculated using multistate life table analysis for three periods between 2006 and 2018. The occupational group is identified via the occupational key. Three groups are distinguished: unskilled and semi-skilled workers, skilled workers and specialists, and highly skilled workers. RESULTS Life years free of MSD clearly decreased in the general population and among the employed population. The decrease was strongest in the higher-skilled occupational groups. Life years free of CVD increased in the general population. The increase was weaker among the employed population. The only occupational group showing increases were men in unskilled and semi-skilled occupations. DISCUSSION The study shows that disease-free life years among employed persons developed in some cases worse than in the general population. For the analysed disease groups MSD and CVD, there are clear inequalities between occupational groups, which decreased somewhat over time. The inequalities and the decrease in years free of MSD highlight the high public health relevance and the need for effective prevention strategies to prevent CVD and MSD in working age.
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Affiliation(s)
- Juliane Tetzlaff
- Medizinische Soziologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Niedersachsen, Deutschland.
| | - Jelena Epping
- Medizinische Soziologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Niedersachsen, Deutschland
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Tetzlaff F, Sauerberg M, Grigoriev P, Tetzlaff J, Mühlichen M, Baumert J, Michalski N, Wengler A, Nowossadeck E, Hoebel J. Age-specific and cause-specific mortality contributions to the socioeconomic gap in life expectancy in Germany, 2003-21: an ecological study. Lancet Public Health 2024; 9:e295-e305. [PMID: 38702094 DOI: 10.1016/s2468-2667(24)00049-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 03/01/2024] [Accepted: 03/05/2024] [Indexed: 05/06/2024]
Abstract
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.
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Affiliation(s)
- Fabian Tetzlaff
- Division of Social Determinants of Health, Department of Epidemiology and Health Monitoring, Robert Koch Institute, Berlin, Germany.
| | - Markus Sauerberg
- Research Area of Ageing, Mortality and Population Dynamics, Federal Institute for Population Research (BiB), Wiesbaden, Germany
| | - Pavel Grigoriev
- Research Area of Ageing, Mortality and Population Dynamics, Federal Institute for Population Research (BiB), Wiesbaden, Germany
| | - Juliane Tetzlaff
- Medical Sociology Unit, Hannover Medical School, Hannover, Germany
| | | | - Jens Baumert
- Division of Physical Health, Department of Epidemiology and Health Monitoring, Robert Koch Institute, Berlin, Germany
| | - Niels Michalski
- Division of Social Determinants of Health, Department of Epidemiology and Health Monitoring, Robert Koch Institute, Berlin, Germany
| | - Annelene Wengler
- Division of Health Reporting, Department of Epidemiology and Health Monitoring, Robert Koch Institute, Berlin, Germany
| | - Enno Nowossadeck
- Division of Social Determinants of Health, Department of Epidemiology and Health Monitoring, Robert Koch Institute, Berlin, Germany
| | - Jens Hoebel
- Division of Social Determinants of Health, Department of Epidemiology and Health Monitoring, Robert Koch Institute, Berlin, Germany
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Stolpe S, Kowall B, Stang A. The pitfalls of focusing on cardiovascular disease mortality to explain differences in life expectancy. Eur J Epidemiol 2024; 39:335-337. [PMID: 38195956 PMCID: PMC10994986 DOI: 10.1007/s10654-023-01089-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 11/28/2023] [Indexed: 01/11/2024]
Affiliation(s)
- Susanne Stolpe
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital Essen, Essen, Germany.
| | - Bernd Kowall
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital Essen, Essen, Germany
| | - Andreas Stang
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital Essen, Essen, Germany
- Department of Epidemiology, School of Public Health, Boston University, Boston, USA
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Jasilionis D, van Raalte A, Klüsener S, Grigoriev P. Re: The pitfalls of focusing on cardiovascular disease mortality to explain differences in life expectancy. Eur J Epidemiol 2024; 39:339-341. [PMID: 38345672 PMCID: PMC10995080 DOI: 10.1007/s10654-024-01102-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 01/12/2024] [Indexed: 04/05/2024]
Affiliation(s)
- Domantas Jasilionis
- Laboratory of Demographic Data, Max Planck Institute for Demographic Research, Konrad-Zuse-Str. 1, DE-18057, Rostock, Germany.
- Max Planck - University of Helsinki Center for Social Inequalities in Population Health (MaxHel Center), Rostock, Germany.
| | - Alyson van Raalte
- Max Planck - University of Helsinki Center for Social Inequalities in Population Health (MaxHel Center), Rostock, Germany
- Independent Research Group of Lifespan Inequalities, Max Planck Institute for Demographic Research, Konrad-Zuse-Str. 1, DE-18057, Rostock, Germany
| | - Sebastian Klüsener
- Research Area of Ageing, Mortality and Population Dynamics, Federal Institute for Population Research (BiB), Friedrich-Ebert-Allee 4, DE-65185, Wiesbaden, Germany
| | - Pavel Grigoriev
- Research Group Mortality, Federal Institute for Population Research (BiB), Friedrich-Ebert-Allee 4, DE-65185, Wiesbaden, Germany
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Wekenborg MK, Künzel RG, Rothe N, Penz M, Walther A, Kirschbaum C, Thayer JF, Hill LK. Exhaustion and cardiovascular risk factors: the role of vagally-mediated heart rate variability. Ann Epidemiol 2023; 87:S1047-2797(23)00182-5. [PMID: 37748549 DOI: 10.1016/j.annepidem.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 09/18/2023] [Accepted: 09/20/2023] [Indexed: 09/27/2023]
Abstract
PURPOSE Exhaustion symptoms are known to be associated with cardiovascular disease (CVD) risk; however, the underlying mechanisms remain unclear. Autonomic imbalance, as indicated by reductions in vagally-mediated heart rate variability (vmHRV), appears to be a valid candidate for such a biological link, as it has been associated with both exhaustion symptoms and CVD risk and mortality. METHODS The present study examined a potential mediation of vmHRV on the association between exhaustion symptoms and self-reported CVD risk factors as well as the age dependency of this mediation in a large, heterogeneous sample of the Dresden Burnout Study (N = 388; 72.9% females; Mage = 42.61, SD = 11.67). RESULTS Results indicate that exhaustion symptoms were indirectly associated with CVD risk factors through vmHRV even after adjusting for well-known confounders (i.e., sex, body mass index, depressive symptoms). Moreover, this pattern was significant only among middle-aged (i.e., 54.27 years) and older individuals. CONCLUSIONS Our findings add to growing evidence that autonomic imbalance may be a key biological link between exhaustion symptoms and CVD risk in middle-aged and older individuals. Implications for public health are discussed.
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Affiliation(s)
- Magdalena K Wekenborg
- Chair of Biological Psychology, Faculty of Psychology, TU Dresden, Dresden, Germany; Else Kröner Fresenius Center for Digital Health, Faculty of Medicine and University Hospital Carl Gustav Carus, Dresden, Germany.
| | - Richard G Künzel
- Chair of Biological Psychology, Faculty of Psychology, TU Dresden, Dresden, Germany.
| | - Nicole Rothe
- Chair of Biological Psychology, Faculty of Psychology, TU Dresden, Dresden, Germany.
| | - Marlene Penz
- Institute of Education and Psychology, Johannes Kepler University, Linz, Austria.
| | - Andreas Walther
- Clinical Psychology and Psychotherapy, University of Zurich, Zürich, Switzerland.
| | - Clemens Kirschbaum
- Chair of Biological Psychology, Faculty of Psychology, TU Dresden, Dresden, Germany.
| | - Julian F Thayer
- Department of Psychological Science, School of Social Ecology, University of California, Irvine.
| | - LaBarron K Hill
- Department of Psychology, North Carolina Agricultural & Technical State University, Greensboro.
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Makhmudova U, Wolf M, Willfeld K, Beier L, Weingärtner O. [Primary and secondary prevention in hypercholesterolemia: differences relevant to patient care in the PROCYON trial]. Dtsch Med Wochenschr 2023; 148:e101-e110. [PMID: 37604168 PMCID: PMC10946085 DOI: 10.1055/a-2117-6504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2023]
Abstract
BACKGROUND Cardiovascular disease accounts for one third of deaths in Germany. Elevated levels of low-density lipoprotein cholesterol (LDL-C) are considered a major risk factor. Lowering LDL-C levels is therefore an integral part of the prevention of cardiovascular events. METHODS The aim of this work is to identify potential differences between primary prevention (PP) and secondary prevention (SP) by means of a post-hoc comparison of cross-sectional data from the PROCYON survey. Medical history, concomitant diseases, adherence, and disease awareness in relation to hypercholesterolemia were queried. RESULTS 5,494 patients had participated in the survey (PP: 3,798; SP: 1,696). Comparison of the results showed a numerically higher proportion of women (PP 70.7% vs. SP 42.5%) as well as more frequent comorbidities such as hypertension (PP 45.6% vs. SP 61.0%), obesity (PP 20.9% vs. SP 27.4%), and type 2 diabetes mellitus (PP 14.1% vs. SP 23.8%). In primary prevention, hypercholesterolemia was most often diagnosed during screening (PP 74.6%), and in secondary prevention, the diagnosis was most often made during cardiovascular-related hospitalization (SP 58.0%). A cardiologist was consulted by 16.3% (PP) and 54.0% (SP) of patients, respectively. At least semiannual LDL-C checks (PP 46.8% vs. SP 77.9%) and drug intervention (PP 43.0% vs. SP 87.0%) were more frequent in the secondary prevention group. In addition, differences in the implementation of lifestyle changes, improvement of LDL-C levels, adjustment of therapy as well as adherence, treatment satisfaction and patient knowledge were observed. CONCLUSION The comparison of primary and secondary prevention from the PROCYON survey shows overall better utilization of treatment options and higher intensity of care in the secondary prevention group. However, there is still great potential for improvement in both groups to ensure efficient prevention of cardiovascular events.
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Affiliation(s)
| | - Michaela Wolf
- Cholesterin & Co e. V.: Patientenorganisation für Patienten mit Familiärer Hypercholesterinämie oder anderen schweren genetischen Fettstoffwechselstörungen (CholCo e. V.), Frankfurt/M
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Baldus S, Lauterbach K. Prevention-centered health care in Germany - a nation in need to turn the tide. Eur J Epidemiol 2023; 38:835-837. [PMID: 37524897 PMCID: PMC10421807 DOI: 10.1007/s10654-023-01030-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 07/12/2023] [Indexed: 08/02/2023]
Affiliation(s)
- Stephan Baldus
- Department of Cardiology, Heart Center, University Hospital of Cologne, Cologne, Germany.
| | - Karl Lauterbach
- German Ministry of Health, Berlin, Germany.
- Harvard Chan School of Public Health, Harvard University, Boston, MA, USA.
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Mühlichen M, Lerch M, Sauerberg M, Grigoriev P. Different health systems - Different mortality outcomes? Regional disparities in avoidable mortality across German-speaking Europe, 1992-2019. Soc Sci Med 2023; 329:115976. [PMID: 37356189 DOI: 10.1016/j.socscimed.2023.115976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 05/08/2023] [Accepted: 05/18/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND Evaluating the impact of health systems on premature mortality across different countries is a very challenging task, as it is hardly possible to disentangle it from the influence of contextual factors such as cultural differences. In this respect, the German-speaking area in Central Europe (Austria, Germany, South Tyrol and large parts of Switzerland) represents a unique 'natural experiment' setting: While being exposed to different health policies, they share a similar culture and language. METHODS To assess the impact of different health systems on mortality differentials across the German-speaking area, we relied on the concept of avoidable mortality. Based on official mortality statistics, we aggregated causes of death below age 75 that are either 1) amenable to health care or 2) avoidable through primary prevention. We calculated standardised death rates and constructed cause-deleted life tables for 9 Austrian, 96 German, 1 Italian and 5 Swiss regions from 1992 to 2019, harmonised according to the current territorial borders. RESULTS There are strong north-south and east-west gradients in amenable and preventable mortality across the studied regions to the advantage of the southwest. However, the Swiss regions still show significantly lower mortality levels than the neighbouring regions in southern Germany. Eliminating avoidable deaths from the life tables reduces spatial inequality in life expectancy in 2017/2019 by 30% for men and 28% for women. CONCLUSIONS The efficiency of health policies in assuring timely and adequate health care and in preventing risk-relevant behaviour has room for improvement in all German regions, especially in the north, west and east, and in eastern Austria as well.
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Affiliation(s)
- Michael Mühlichen
- Federal Institute for Population Research (BIB), Friedrich-Ebert-Allee 4, 65185, Wiesbaden, Germany.
| | - Mathias Lerch
- Swiss Federal Institute of Technology in Lausanne (EPFL), Route Cantonale, 1015, Lausanne, Switzerland
| | - Markus Sauerberg
- Federal Institute for Population Research (BIB), Friedrich-Ebert-Allee 4, 65185, Wiesbaden, Germany
| | - Pavel Grigoriev
- Federal Institute for Population Research (BIB), Friedrich-Ebert-Allee 4, 65185, Wiesbaden, Germany
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