title: Social disparities in Disease Management Programmes for coronary heart disease in Germany: a cross-classified multilevel analysis.
abstract: BACKGROUND
  Disease Management Programmes (DMPs) aim to improve effectiveness and equity of care but may suffer from selective enrolment. We analysed social disparities in DMP enrolment among elderly patients with coronary heart disease (CHD) in Germany, taking into account contextual effects at municipality and primary care practice levels.
  
  
  METHODS
  Cross-sectional analysis of effects of educational attainment and regional deprivation on physician-reported DMP enrolment in a subsample of a large population-based cohort study in Germany, adjusting for individual-level, practice-level and area-level variables. We calculated OR and their 95% CIs (95% CI) in cross-classified, multilevel logistic regression models.
  
  
  RESULTS
  Among N=1280 individuals with CHD (37.3% women), DMP enrolment rates were 22.2% (women) and 35% (men). The odds of DMP enrolment were significantly higher for male patients (OR=1.98 (1.50 to 2.62)), even after adjustment for potential confounding by individual-level, practice-level and area-level variables (range: OR=1.60 (1.08 to 2.36) to 2.16 (1.57 to 2.98)). Educational attainment was not significantly associated with DMP enrolment. Compared to patients living in least-deprived municipalities, the adjusted propensity of DMP enrolment was statistically significantly lower for patients living in medium-deprived municipalities (OR=0.41 (0.24 to 0.71)), and it also tended to be lower for patients living in the most-deprived municipalities (OR=0.70 (0.40 to 1.21)). Models controlling for the social situation (instead of health-related behaviour) yielded comparable effect estimates (medium-deprived/most-deprived vs least-deprived areas: OR=0.45 (0.26 to 0.78)/OR=0.68 (0.33 to 1.19)). Controlling for differences in comorbidity attenuated the deprivation effect estimates.
  
  
  CONCLUSIONS
  We found evidence for marked gender, but not educational disparities in DMP enrolment among patients with CHD. Small-area deprivation was associated with DMP enrolment, but the effects were partly explained by differences in comorbidity. Future studies on DMPs should consider contextual effects when analysing programme effectiveness or impacts on equity and efficiency.
authors.affiliation: Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany.
authors.forename: Kayvan
authors.initials: K
authors.lastname: Bozorgmehr
authors.affiliation: Institute of Health Economics and Health Care Management, Helmholtz Zentrum München-German Research Center for Environmental Health (GmbH), Neuherberg, Germany.
authors.forename: Werner
authors.initials: W
authors.lastname: Maier
authors.affiliation: Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany.
authors.forename: Hermann
authors.initials: H
authors.lastname: Brenner
authors.affiliation: Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany.
authors.forename: Kai-Uwe
authors.initials: KU
authors.lastname: Saum
authors.affiliation: Institute of Medical Biometry and Informatics, University Heidelberg, Heidelberg, Germany.
authors.forename: Christian
authors.initials: C
authors.lastname: Stock
authors.affiliation: Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany.
authors.forename: Antje
authors.initials: A
authors.lastname: Miksch
authors.affiliation: Saarland Cancer Registry, Saarbrücken, Germany.
authors.forename: Bernd
authors.initials: B
authors.lastname: Holleczek
authors.affiliation: Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany.
authors.forename: Joachim
authors.initials: J
authors.lastname: Szecsenyi
authors.affiliation: Department of Epidemiology and International Public Health, School of Public Health, Bielefeld University, Bielefeld, Germany.
authors.forename: Oliver
authors.initials: O
authors.lastname: Razum
mesh_terms: D000368:Aged; D015897:Comorbidity; D003324:Coronary Artery Disease / Q000191:economics / Q000453:epidemiology / Q000628:therapy*; D003430:Cross-Sectional Studies; D019468:Disease Management; D004522:Educational Status; D005260:Female; D005858:Germany / Q000453:epidemiology; D054625:Healthcare Disparities; D006801:Humans; D008297:Male; D008875:Middle Aged; D055361:Multilevel Analysis; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D015995:Prevalence; D011446:Prospective Studies; D017678:Sex Distribution; D012923:Social Class
keywords: ACCESS TO HLTH CARE; HEALTH SERVICES; HEART DISEASE; MULTILEVEL MODELLING; SOCIAL INEQUALITIES