Morbidity compression in myocardial infarction 2006 to 2015 in terms of changing rates and age at occurrence: A longitudinal study using claims data from Germany

[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]

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.

[Are Prevalence Rates Comparable in Survey and Routine Data? Prevalence of Myocardial Infarction in Claims Data of the AOK Lower Saxony and in Data of German Health Interview and Examination (DEGS1)]

AIMS OF THE STUDY

This study compared prevalences of myocardial infarction between data drawn from health interviews and claims data from statutory health insurance. Previous comparative studies have drawn comparisons without having considered possible differences in the sociodemographic structure of the underlying study populations. The approach applied here aimed to match the sociodemographic structure via available information in both datasets and to compare prevalences in parallelized samples.

METHODOLOGY

Data from the German Health Interview and Examination Study for Adults (DEGS1) and claims data from the AOK Lower Saxony (AOKN) were used. To match the sociodemographic structure of the two data sets, a parallelized sample was drawn from the AOKN data according to sex, age, and vocational training qualification. As part of a sensitivity analysis, additional samples were drawn and a mean overall prevalence was calculated from them.

RESULTS

Data from 5779 DEGS1 respondents and 22 534 AOKN insured persons were used for the analysis. After parallelization of the AOKN-sample by sex, age, and vocational training qualification, no significant differences in prevalence of myocardial infarction could be found between claims data from the AOKN and data from the DEGS1 Health Survey. In men, there were tendencies toward lower prevalence of myocardial infarction in the AOKN data. Possible explanations include the selection of less morbid insured persons by using the vocational education degree for parallelization or memory discrepancies in survey data.

CONCLUSION

Differences in sociodemographic structure may play a role the interpretation of disease prevalence from difference data sources. This can be compensated for by parallelizing the samples. Future comparative analyses should take into account characteristics of the socioeconomic status. Similar analyses of other diseases such as stroke, diabetes, and metabolic disorders would be desirable.

Regulation of autophagy of the heart in ischemia and reperfusion

Ischemia/reperfusion (I/R) of the heart leads to increased autophagic flux. Preconditioning stimulates autophagic flux by AMPK and PI3-kinase activation and mTOR inhibition. The cardioprotective effect of postconditioning is associated with activation of autophagy and increased activity of NO-synthase and AMPK. Oxidative stress stimulates autophagy in the heart during I/R. Superoxide radicals generated by NADPH-oxidase acts as a trigger for autophagy, possibly due to AMPK activation. There is reason to believe that AMPK, GSK-3β, PINK1, JNK, hexokinase II, MEK, PKCα, and ERK kinases stimulate autophagy, while mTOR, PKCδ, Akt, and PI3-kinase can inhibit autophagy in the heart during I/R. However, there is evidence that PI3-kinase could stimulate autophagy in ischemic preconditioning of the heart. It was found that transcription factors FoxO1, FoxO3, NF-κB, HIF-1α, TFEB, and Nrf-2 enhance autophagy in the heart in I/R. Transcriptional factors STAT1, STAT3, and p53 inhibit autophagy in I/R. MicroRNAs could stimulate and inhibit autophagy in the heart in I/R. Long noncoding RNAs regulate the viability and autophagy of cardiomyocytes in hypoxia/reoxygenation (H/R). Nitric oxide (NO) donors and endogenous NO could activate autophagy of cardiomyocytes. Activation of heme oxygenase-1 promotes cardiomyocyte tolerance to H/R and enhances autophagy. Hydrogen sulfide increases cardiac tolerance to I/R and inhibits apoptosis and autophagy via mTOR and PI3-kinase activation.

Age, morbidity, or something else? A residual approach using microdata to measure the impact of technological progress on health care expenditure

This study measures the increment of health care expenditure (HCE) that can be attributed to technological progress and change in medical practice by using a residual approach and microdata. We examine repeated cross-sections of individuals experiencing an initial health shock at different point in time over a 10-year window and capture the impact of unobservable technology and medical practice to which they are exposed after allowing for differences in health and socioeconomic characteristics. We decompose the residual increment in the part that is due to the effect of delaying time to death, that is, individuals surviving longer after a health shock and thus contributing longer to the demand of care, and the part that is due to increasing intensity of resource use, that is, the basket of services becoming more expensive to allow for the cost of innovation. We use data from the Danish National Health System that offers universal coverage and is free of charge at the point of access. We find that technological progress and change in medical practice can explain about 60% of the increment of HCE, in line with macroeconomic studies that traditionally investigate this subject.

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

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

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

BACKGROUND

Despite substantial improvements in prevention and therapy, myocardial infarction (MI) remains a frequent health event, causing high mortality and serious health impairments. Previous research lacks evidence on how social inequalities in incidence and mortality risks developed over time, and on how these developments affect the lifespan free of MI and after MI in different social subgroups. This study investigates income inequalities in MI-free life years and life years after MI and whether these inequalities widened or narrowed over time.

METHODS

The analyses are based on claims data of a large German health insurance provider insuring approximately 2.8 million individuals in the federal state Lower Saxony. Trends in income inequalities in incidence and mortality were assessed for all subjects aged 60 years and older by comparing the time periods 2006-2008 and 2015-2017 using multistate survival models. Trends in the number of life years free of MI and after MI were calculated separately for income groups by applying multistate life table analyses.

RESULTS

MI incidence and mortality risks decreased over time, but declines were strongest among men and women in the higher-income group. While life years free of MI increased in men and women with higher incomes, no MI-free life years were gained in the low-income group. Among men, life years after MI increased irrespective of income group.

CONCLUSIONS

Income inequalities in the lifespan spent free of MI and after MI widened over time. In particular, men with low incomes are disadvantaged, as life years spent after MI increased, but no life years free of MI were gained.

Development of comorbidities in type 2 diabetes between 2005 and 2017 using German claims data

Against the background of increasing life expectancy over time, several hypotheses have been proposed on the way morbidity has been developing. In type 2 diabetes (T2D), previous research suggests that morbidity compression could be ruled out due to increasing prevalence and life expectancy with T2D over time. Understanding how the health state in individuals with T2D is developing would help identify whether morbidity expansion or a dynamic equilibrium pattern applies for this disease. This study aims to answer the following questions: (1) How do the number and the prevalence of T2D concordant comorbidities develop over time? (2) What does this imply in terms of morbidity development in T2D in Germany? The study used claims data from a statutory health insurance provider in Lower Saxony, Germany. Period prevalence of T2D concordant comorbidities was examined for the periods 2005–2007, 2010–2012 and 2015–2017 in 240,241, 295,868 and 308,134 individuals with T2D respectively. The effect of time period on the number and prevalence of comorbidities was examined by means of (ordered) logistic regression. The age-adjusted predicted probabilities of more severe cardiovascular diseases (CVDs) decreased over the three periods while those of less severe CVDs and other vascular diseases increased significantly in men and women and among all examined age-groups. Predicted probability of having at least one more comorbidity over time also increased significantly among all examined groups. While less and more severe CVDs exhibited different developmental patterns, the results of the study point towards morbidity expansion in T2D. Future studies should focus on mechanisms that contribute to these trends.

The effects of different lookback periods on the sociodemographic structure of the study population and on the estimation of incidence rates: analyses with German claims data

BACKGROUND

Defining incident cases has always been a challenging issue for researchers working with routine data. Lookback periods should enable researchers to identify and exclude recurrent cases and increase the accuracy of the incidence estimation. There are different recommendations for lookback periods depending on a disease entity of up to 10 years. Well-known drawbacks of the application of lookback periods are shorter remaining observation period in the dataset or smaller number of cases. The problem of selectivity of the remaining population after introducing lookback periods has not been considered in the literature until now.

METHODS

The analyses were performed with pseudonymized claims data of a German statutory health insurance fund with annual case numbers of about 2,1 million insured persons. Proportions of study population excluded due to the application of lookback periods are shown according to age, occupational qualification and income. Myocardial infarction and stroke were used to demonstrate changes in incidence rates after applying lookback periods of up to 5 years.

RESULTS

Younger individuals show substantial dropouts after the application of lookback periods. Furthermore, there are selectivities regarding occupational qualification and income, which cannot be handled by age standardization. Due to selective dropouts of younger individuals, crude incidence rates of myocardial infarction and stroke increase after applying lookback periods. Depending on the income group, age-standardized incidence rates changed differentially, leading to a decrease and possible underestimation of the social gradient after applying lookback periods.

CONCLUSIONS

Selectivity analyses regarding age and sociodemographic structure should be performed for the study population after applying lookback periods since the selectivity can affect the outcome especially in health care research. The selectivity effects might occur not only in claims data of one health insurance fund, but also in other longitudinal data with left- or right-censoring not covering the whole population. The effects may also apply to health care systems with a mix of public and private health insurance. A trade-off has to be considered between selectivity effects and eliminating recurrent events for more accuracy in the definition of incidence.

Are there social gradients in the occurrence of lung cancer and in the survival of lung cancer patients? Findings from an observational study using German claims data of Lower Saxony

OBJECTIVES

Only a few studies on health inequalities in terms of lung cancer are available. We examined whether social inequalities are present for the occurrence of lung cancer. Confining the analyses to patients, it was also examined whether survival over the observation period and over a standardised period of 18 months differed by occupational position and income.

METHODS

Our findings are based on claims data from a German statutory health insurance covering 2005-2016. The database comprised N=3 163 211 women (50.7%) and men (49.3%) aged 18 years and older. Diagnoses (International Statistical Classification of Diseases and Related Health Problems 10th Revision: C34.0 to C34.9) were hospital-based, and income and occupational position were used as indicators of socioeconomic position. Analyses on social gradients were performed for employed and retired insured, but only for employed insured information on occupation and on income were available, for retired women and men only income was available. Analyses were performed by means of proportional hazard regression.

RESULTS

In employed women, social gradients for the occurrence emerged for occupational position, but not for income. In men, social differences were found for both indicators. For retired insured, income gradients were found in men. Looking at overall survival, neither in women nor in men social gradients emerged.

CONCLUSIONS

The reported social inequalities in the occurrence of lung cancer are pointing towards social differences in smoking behaviour, exposition to hazardous occupation-related substances and differences in preventive strategies. The absence of social inequalities in survival after lung cancer suggests equality in medical treatment of the disease.

Diverging Trends in Age at First Myocardial Infarction: Evidence from Two German Population-Based Studies

Little is known about trends in the age of onset of first myocardial infarction. Thus, we examined trends in the age of onset distribution of first myocardial infarction using two population-based datasets from Germany. First, we used German claims data based on an annual case number of approximately 2 million women and men covering the period from 2006 to 2016. Second, we used data from the KORA (Cooperative Health Research in the Region of Augsburg) Myocardial Infarction Registry covering the period from 2000–2016. Analyses were performed by means of quantile regression to estimate trends across the whole distribution of age of onset. Overall, N_{Sample 1} = 69627 and N_{Sample 2} = 9954 first myocardial infarctions were observed. In both samples, we found highly heterogeneous trends in age of onset. In men, we consistently found that age of onset increased before 50 and after 70 but decreased within this age bracket. For women, on the other hand, we consistently found that age of onset decreased for first myocardial infarctions before 70 but increased slightly or remained relatively stable thereafter. Therefore, late myocardial infarctions tended to occur later in life, while regular myocardial infarctions tended to occur earlier. These results suggest that in myocardial infarction, both morbidity compression and morbidity expansion might have occurred at the same time but for different parts of the age at onset distribution.