Do alternative weighting approaches for an Index of Multiple Deprivation change the association with mortality? A sensitivity analysis from Germany

Assessing the risk of endogeneity bias in health and mortality inequalities research using composite measures of multiple deprivation which include health-related indicators: A case study using the Scottish Index of Multiple Deprivation and population health and mortality data

The inclusion of health-related indicators in composite measures of multiple deprivation introduces a risk of endogeneity bias when using the latter in health inequalities research. This bias may ultimately result in the inappropriate allocation of healthcare resources and maintenance of preventable health inequalities. Mitigation strategies to avoid this bias include removing the health-related indicators or using single constituent domains (such as income or employment class) in isolation. These strategies have not been widely validated. This study used population-level health and mortality data with a contemporary composite measure of multiple deprivation (Scottish Index of Multiple Deprivation; SIMD) to assess these mitigation strategies. The differences between deprivation methods (original, health excluded, and income domain) were negligible. The results of quantitative research on health inequalities are unlikely to be affected by endogeneity bias.

The impact of regional deprivation on stroke incidence, treatment, and mortality in Germany

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.

Classification of Deprivation Indices That Applied to Detect Health Inequality: A Scoping Review

INTRODUCTION

Many studies around the world are undertaken to establish the association between deprivation and public health indicators. Both separate indicators (e.g., income, education, occupation, public security and social support) and complex models (indices) include several indicators. Deprivation indices are actively used in public health since the mid 1980s. There is currently no clear classification of indices.

METHODS

In the current review, data related to deprivation indices are combined and analyzed in order to create a taxonomy of indices based on the results obtained. The search was carried out using two bibliographic databases. After conducting a full-text review of the articles and searching and adding relevant articles from the bibliography, and articles that were already known to the authors, sixty studies describing the use of sixty deprivation indices in seventeen countries were included in the narrative synthesis, resulting in development of a taxonomy of indices. When creating the taxonomy, an integrative approach was used that allows integrating new classes and sub-classes in the event that new information appears.

RESULTS

In the review, 68% (41/60) of indices were classified as socio-economic, 7% (4/60) of indices as material deprivation, 5% (3/60) of indices as environmental deprivation and 20% (12/60) as multidimensional indices.

CONCLUSIONS

The data stimulates the use of a competent approach, and will help researchers and public health specialist in resolving conflicts or inconsistencies that arise during the construction and use of indices.

Construction of the Ohio Children's Opportunity Index

Objective

To describe the development of an area-level measure of children's opportunity, the Ohio Children's Opportunity Index (OCOI).

Data Sources/Study Setting

Secondary data were collected from US census based-American Community Survey (ACS), US Environmental Protection Agency, US Housing and Urban Development, Ohio Vital Statistics, US Department of Agriculture-Economic Research Service, Ohio State University Center for Urban and Regional Analysis, Ohio Incident Based Reporting System, IPUMS National Historical Geographic Information System, and Ohio Department of Medicaid. Data were aggregated to census tracts across two time periods.

Study Design

OCOI domains were selected based on existing literature, which included family stability, infant health, children's health, access, education, housing, environment, and criminal justice domains. The composite index was developed using an equal weighting approach. Validation analyses were conducted between OCOI and health and race-related outcomes, and a national index.

Principal Findings

Composite OCOI scores ranged from 0–100 with an average value of 74.82 (SD, 17.00). Census tracts in the major metropolitan cities across Ohio represented 76% of the total census tracts in the least advantaged OCOI septile. OCOI served as a significant predictor of health and race-related outcomes. Specifically, the average life expectancy at birth of children born in the most advantaged septile was approximately 9 years more than those born in least advantaged septile. Increases in OCOI were associated with decreases in proportion of Black (48 points lower in the most advantaged vs. least advantaged septile), p < 0.001) and Minority populations (54 points lower in most advantaged vs. least advantaged septile, p < 0.001). We found R-squared values > 0.50 between the OCOI and the national Child Opportunity Index scores. Temporally, OCOI decreased by 1% between the two study periods, explained mainly by decreases in the children health, accessibility and environmental domains.

Conclusion

As the first opportunity index developed for children in Ohio, the OCOI is a valuable resource for policy reform, especially related to health disparities and health equity. Health care providers will be able to use it to obtain holistic views on their patients and implement interventions that can tackle barriers to childhood development using a more tailored approach.

What Regional Living Conditions Affect Individual Smoking of Adults in Russia

Objectives: Our study evaluated the impact of a wide range of characteristics of large administrative regions on the individual level of cigarette smoking in the Russian adult population. Methods: The pool of participants included 20,303 individuals aged 25-64 years. We applied 64 characteristics of the 12 Russian regions under study for 2010-2014. Using principal component analysis, we deduced five evidence-based composite indices of the regions. We applied the generalized estimating equation to determine associations between the regional indices and the individual level of smoking. Results: The increased Industrial index in the region is associated with the probability of smoking (odds ratio = 1.15; 95% confidence interval = 1.06-1.24). The other indices show associations with smoking only in separate gender and educational groups. Surprisingly, it was found that the Economic index has no associations with the probability of smoking. Conclusion: We evaluated the key associations of the territorial indices with the individual probability of smoking, as well as the mutual influence between the territorial indices and individual factors.

Regional Deprivation, Stroke Incidence, and Stroke Care

BACKGROUND

Regional deprivation can increase the risk of illness and adversely affect care outcomes. In this study, we investigated for the German state of Rhineland-Palatinate whether spatial-structural disadvantages are associated with an increased frequency of ischemic stroke and with less favorable care outcomes.

METHODS

We compared billing data from DRG statistics (2008-2017) and quality assurance data (2017) for acute ischemic stroke with the German Index of Multiple Deprivation 2010 (GIMD 2010) for the 36 districts (Landkreise) and independent cities (i.e., cities not belonging to a district) in Rhineland-Palatinate using correlation analyses, a Poisson regression analysis, and logistic regression analyses.

RESULTS

The age-standardized stroke rates (ASR) ranged from 122 to 209 per 100 000 inhabitants, while the GIMD 2010 ranged from 4.6 to 47.5; the two values were positively correlated (Spearman's ρ = 0.47; 95% confidence interval [0.16; 0.85]). In 2017, mechanical thrombectomies were performed more commonly (5.7%) in the first GIMD 2010 quartile of the regional areas (i.e., in the least deprived areas) than in the remaining quartiles (4.2-4.6%). The intravenous thrombolysis rates showed no differences from one GIMD 2010 quartile to another. Severe neurological deficits (National Institutes of Health Stroke Scale ≥ 5) on admission to the hospital were slightly more common in the fourth quartile (i.e., in the most deprived areas), while antiplatelet drugs and statins were somewhat less commonly ordered on discharge in those areas than in the first quartile.

CONCLUSION

These findings document a relationship between regional deprivation and the occurrence of acute ischemic stroke. Poorer GIMD 2010 scores were associated with worse care outcomes in a number of variables, but the absolute differences were small.

Estimation of the Potentially Avoidable Excess Deaths Associated with Socioeconomic Inequalities in Cancer Survival in Germany

Many countries have reported survival inequalities due to regional socioeconomic deprivation. To quantify the potential gain from eliminating cancer survival disadvantages associated with area-based deprivation in Germany, we calculated the number of avoidable excess deaths. We used population-based cancer registry data from 11 of 16 German federal states. Patients aged ≥15 years diagnosed with an invasive malignant tumor between 2008 and 2017 were included. Area-based socioeconomic deprivation was assessed using the quintiles of the German Index of Multiple Deprivation (GIMD) 2010 on a municipality level nationwide. Five-year age-standardized relative survival for 25 most common cancer sites and for total cancer were calculated using period analysis. Incidence and number of avoidable excess deaths in Germany in 2013-2016 were estimated. Summed over the 25 cancer sites, 4100 annual excess deaths (3.0% of all excess deaths) could have been avoided each year in Germany during the period 2013-2016 if relative survival were in all regions comparable with the least deprived regions. Colorectal, oral and pharynx, prostate, and bladder cancer contributed the largest numbers of avoidable excess deaths. Our results provide a good basis to estimate the potential of intervention programs for reducing socioeconomic inequalities in cancer burden in Germany.

A Decade of Disparities in Diabetes Technology Use and HbA1c in Pediatric Type 1 Diabetes: A Transatlantic Comparison

OBJECTIVE

As diabetes technology use in youth increases worldwide, inequalities in access may exacerbate disparities in hemoglobin A1c (HbA1c). We hypothesized that an increasing gap in diabetes technology use by socioeconomic status (SES) would be associated with increased HbA1c disparities.

RESEARCH DESIGN AND METHODS

Participants aged <18 years with diabetes duration ≥1 year in the Type 1 Diabetes Exchange (T1DX, U.S., n = 16,457) and Diabetes Prospective Follow-up (DPV, Germany, n = 39,836) registries were categorized into lowest (Q1) to highest (Q5) SES quintiles. Multiple regression analyses compared the relationship of SES quintiles with diabetes technology use and HbA1c from 2010-2012 to 2016-2018.

RESULTS

HbA1c was higher in participants with lower SES (in 2010-2012 and 2016-2018, respectively: 8.0% and 7.8% in Q1 and 7.6% and 7.5% in Q5 for DPV; 9.0% and 9.3% in Q1 and 7.8% and 8.0% in Q5 for T1DX). For DPV, the association between SES and HbA1c did not change between the two time periods, whereas for T1DX, disparities in HbA1c by SES increased significantly (P < 0.001). After adjusting for technology use, results for DPV did not change, whereas the increase in T1DX was no longer significant.

CONCLUSIONS

Although causal conclusions cannot be drawn, diabetes technology use is lowest and HbA1c is highest in those of the lowest SES quintile in the T1DX, and this difference for HbA1c broadened in the past decade. Associations of SES with technology use and HbA1c were weaker in the DPV registry.

Spatial accessibility of general inpatient care in Germany: an analysis of surgery, internal medicine and neurology

Improving spatial accessibility to hospitals is a major task for health care systems which can be facilitated using recent methodological improvements of spatial accessibility measures. We used the integrated floating catchment area (iFCA) method to analyze spatial accessibility of general inpatient care (internal medicine, surgery and neurology) on national level in Germany determining an accessibility index (AI) by integrating distances, hospital beds and morbidity data. The analysis of 358 million distances between hospitals and population locations revealed clusters of lower accessibility indices in areas in north east Germany. There was a correlation of urbanity and accessibility up to r = 0.31 (p < 0.001). Furthermore, 10% of the population lived in areas with significant clusters of low spatial accessibility for internal medicine and surgery (neurology: 20%). The analysis revealed the highest accessibility for heart failure (AI = 7.33) and the lowest accessibility for stroke (AI = 0.69). The method applied proofed to reveal important aspects of spatial accessibility i.e. geographic variations that need to be addressed. However, for the majority of the German population, accessibility of general inpatient care was either high or at least not significantly low, which suggests rather adequate allocation of hospital resources for most parts of Germany.

Associations of area-level deprivation with adverse obstetric and perinatal outcomes in Bavaria, Germany: Results from a cross-sectional study

Background

We investigated associations of area-level deprivation with obstetric and perinatal outcomes in a large population-based routine dataset.

Methods

We used the data of n = 827,105 deliveries who were born in hospitals between 2009 to 2016 in Bavaria, Germany. The Bavarian Index of Multiple Deprivation (BIMD) on district level was assigned to each mother by the zip code of her residential address. We calculated odds ratios (ORs) with 95% confidence intervals (CIs) for preterm deliveries, Caesarian sections (CS), stillbirths, small for gestational age (SGA) births and low 5-minute Apgar scores by BIMD quintiles with and without adjustment for potential confounders.

Results

We observed a significantly increased risk for preterm deliveries in mothers from the most deprived compared to the least deprived districts (e.g. OR [95% CI] for highest compared to lowest deprivation quintile: 1.06 [1.03, 1.09]) in adjusted analyses. Increased deprivation was also associated with higher SGA and secondary CS rates, but with lower proportions of stillbirths, primary CS and low Apgar scores. When one large clinic with an unusually high stillbirth rate was excluded, the association of BIMD with stillbirths was attenuated and almost disappeared.

Conclusions

We found that area-level deprivation in Bavaria was positively associated with preterm and SGA births, confirming previous studies. In contrast, the finding of an inverse association between deprivation and both stillbirth rates and low Apgar score came somewhat surprising. However, we conclude that the stillbirths finding is spurious and reflects regional bias due to a clinic which seems to specialize in termination of pregnancies.