Age-specific and cause-specific mortality contributions to the socioeconomic gap in life expectancy in Germany, 2003-21: an ecological study.

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.

[Socioeconomic deprivation and premature mortality in Germany, 1998-2021 : An ecological study with what-if scenarios of inequality reduction]. / Sozioökonomische Deprivation und vorzeitige Sterblichkeit in Deutschland 1998­2021 : Eine ökologische Studie mit What-if-Szenarien der Ungleichheitsreduktion.

BACKGROUND: Earlier mortality in socioeconomically disadvantaged population groups represents an extreme manifestation of health inequity. This study examines the extent, time trends, and mitigation potentials of area-level socioeconomic inequalities in premature mortality in Germany. METHODS: Nationwide data from official cause-of-death statistics were linked at the district level with official population data and the German Index of Socioeconomic Deprivation (GISD). Age-standardized mortality rates before the age of 75 were calculated stratified by sex and deprivation quintile. A what-if analysis with counterfactual scenarios was applied to calculate how much lower premature mortality would be overall if socioeconomic mortality inequalities were reduced. RESULTS: Men and women in the highest deprivation quintile had a 43% and 33% higher risk of premature death, respectively, than those in the lowest deprivation quintile of the same age. Higher mortality rates with increasing deprivation were found for cardiovascular and cancer mortality, but also for other causes of death. Socioeconomic mortality inequalities had started to increase before the COVID-19 pandemic and further exacerbated in the first years of the pandemic. If all regions had the same mortality rate as those in the lowest deprivation quintile, premature mortality would be 13% lower overall. DISCUSSION: The widening gap in premature mortality between deprived and affluent regions emphasizes that creating equivalent living conditions across Germany is also an important field of action for reducing health inequity.

Widening area-based socioeconomic inequalities in cancer mortality in Germany between 2003 and 2019.

Cancer mortality has declined in recent decades, but-due to a lack of national individual-level data-it remains unclear whether this applies equally to all socioeconomic groups in Germany. Using an area-based approach, this study investigated socioeconomic inequalities in cancer mortality and their secular trends on a German nationwide scale for the first time. Official cause-of-death data from 2003 to 2019 were linked to the district-level German Index of Socioeconomic Deprivation. Age-standardised mortality rates for all cancers combined and the most common site-specific cancers were calculated according to the level of regional socioeconomic deprivation. To quantify the extent of area-based socioeconomic inequalities in cancer mortality, absolute (SII) and relative (RII) indices of inequality were estimated using multilevel Poisson models. On average, cancer mortality was 50% (women) and 80% (men) higher in Germany's most deprived than least deprived districts (absolute difference: 84 deaths per 100,000 in women and 185 deaths per 100,000 in men). As declines in cancer mortality were larger in less deprived districts, the socioeconomic gap in cancer mortality widened over time. This trend was observed for various common cancers. Exceptions were cancers of the lung in women and of the pancreas in both sexes, for which mortality rates increased over time, especially in highly deprived districts. Our study provides first evidence on increasing socioeconomic inequalities in cancer mortality on a nationwide scale for Germany. Area-based linkage allows to examine socioeconomic inequalities in cancer mortality across Germany and identify regions with high needs for cancer prevention and control.

Trends in cancer-free working life expectancy based on health insurance data from Germany-Is the increase as strong as in working life expectancy?

BACKGROUND: Against the backdrop of population ageing, governments are facing the need to raise the statutory retirement age. In this context, the question arises whether these extra years added to working life would be spent in good health. As cancer represents a main contributor to premature retirement this study focuses on time trends and educational inequalities in cancer-free working life expectancy (WLE). METHODS: The analyses are based on the data of a large German health insurer covering annually about 2 million individuals. Cancer-free WLE is calculated based on multistate life tables and reported for three periods: 2006-2008, 2011-2013, and 2016-2018. Educational inequalities in 2011-2013 were assessed by two educational levels (8 to 11 years and 12 to 13 years of schooling). RESULTS: While labour force participation increased, cancer incidence rates decreased over time. Cancer-free WLE at age 18 increased by 2.5 years in men and 6.3 years in women (age 50: 1.3 years in men, 2.4 years in women) between the first and third period while increases in WLE after a cancer diagnosis remained limited. Furthermore, educational inequalities are substantial, with lower groups having lower cancer-free WLE. The proportion of cancer-free WLE in total WLE remained constant in women and younger men, while it decreased in men at higher working age. CONCLUSION: The increase in WLE is accompanied by an increase in cancer-free WLE. However, the subgroups considered have not benefitted equally from this positive development. Among men at higher working age, WLE increased at a faster pace than cancer-free WLE. Particular attention should be paid to individuals with lower education and older men, as the general level and time trends in cancer-free WLE are less favourable.

German Index of Socioeconomic Deprivation (GISD): Revision, update and applications.

Background: Regional deprivation indices enable researchers to analyse associations between socioeconomic disadvantages and health outcomes even if the health data of interest does not include information on the individuals' socioeconomic position. This article introduces the recent revision of the German Index of Socioeconomic Deprivation (GISD) and presents associations with life expectancy as well as age-standardised cardiovascular mortality rates and cancer incidences as applications. Methods: The GISD measures the level of socioeconomic deprivation using administrative data of education, employment, and income situations at the district and municipality level from the INKAR database. The indicators are weighted via principal component analyses. The regional distribution is depicted cartographically, regional level associations with health outcomes are presented. Results: The principal component analysis indicates medium to high correlations of the indicators with the index subdimensions. Correlation analyses show that in districts with the lowest deprivation, the average life expectancy of men is approximately six years longer (up to three years longer for women) than for those from districts with the highest deprivation. A similar social gradient is observed for cardiovascular mortality and lung cancer incidence. Conclusions: The GISD provides a valuable tool to analyse socioeconomic inequalities in health conditions, diseases, and their determinants at the regional level.

30 years after the fall of the Berlin Wall: Regional health differences in Germany.

Following the fall of the Berlin Wall in November 1989, considerable effort was made to bring the living conditions and levels of social participation in the former East German federal states into line with the former West German federal states. As a result, differences in health between the East and the West diminished significantly, in many cases as early as the 1990s, examples being life expectancy and cardiovascular mortality. In regard to health behaviour, the overall tendency has also clearly been one of convergence. Thus, only very small differences can be observed today, for example in the use of tobacco or in the prevalence of obesity. Yet the results also highlight the insufficiency of regarding the remaining differences as a simple comparison between East and West. Instead, the focus should shift towards smaller-scale approaches that take regional differences in living conditions into account.

[Impact of Population Aging on Utilization of Medical Rehabilitation in Germany Till 2040]. / Einfluss der demografischen Alterung auf die Inanspruchnahme der medizinischen Rehabilitation in Deutschland bis 2040.

BACKGROUND: The paper analyzes the influence of population aging on the future number of medical rehabilitation cases. Implications for the most important providers of rehabilitation services (Deutsche Rentenversicherung (DRV) (German Pension Insurance) and Gesetzliche Krankenversicherung (GKV) (Statutory Health Insurance)) are discussed. METHODS: Data provided by the DRV and the GKV were used. A third database is the Hospital Statistics of the Federal Statistical Office. Each database contains data of rehabilitation cases of certain subpopulations. Based on the 13th coordinated population projection a forecast up to 2040 with each of these databases was undertaken. RESULTS: Population aging will decrease case numbers for the DRV from 961 thousand (2015) to 911 thousand in 2040 (- 5.2%). Cases of GKV will rise from 742 thousand (2015) to 934 thousand in 2040 (+25.9%). Because of population aging, the case numbers of older people (65 years or older) in rehabilitation will increase by about a third until 2040. CONCLUSIONS: The expected increase in the number of elderly rehabilitants concerns especially the GKV. There are a number of problems arising from this, concerning financing of rehabilitation and the aspect of growing importance of multimorbidity and geriatric rehabilitation. Furthermore, there is a growing gap between the demographic development of rehabilitation in working age and the demographic component of the budgets for this rehabilitation in the DRV.

Population aging and hospitalization for chronic disease in Germany.

BACKGROUND: The population of Germany is aging, i.e., the elderly currently make up an increasing percentage of the population from year to year. Furthermore, many common chronic diseases mainly affect the elderly. For these two reasons, the overall cost of health care in Germany is expected to increase. We studied the effect that population aging has had on the number of hospitalizations for major types of chronic disease in Germany since the year 2000. METHODS: This study is based on nationwide hospitalization statistics, classified by diagnosis, that were published by the German Federal Statistical Office. We analyzed data for three classes of diagnoses--malignant neoplasia, cardiovascular diseases, and diseases of the musculoskeletal system and connective tissue--which were further broken down into nine diagnostic subgroups. Changes in inpatient case numbers might be due either to population aging or to changing rates of hospitalization for individual diagnoses. We used index decomposition analysis to determine the relative influence of these two factors on changing case numbers. RESULTS: The author found that the aging of the population increased the number of hospitalizations for all of the diagnoses studied. This was particularly evident with respect to the large birth cohorts born in the 1920s (with the diagnosis of congestive heart failure) and in the period 1934-1944 (with the diagnoses ischemic heart disease, lung cancer, colorectal cancer, and osteoarthritis). On the other hand, changing rates of hospitalization for individual diagnoses increased the number of hospitalizations for some diagnoses (congestive heart failure, diseases of the spine and back) and decreased it for others (ischemic heart disease, cerebrovascular diseases, colorectal cancer, breast cancer). CONCLUSION: The aging of the population and the changing rates of hospitalization for various diagnoses are exerting separate effects on the number of hospitalizations for chronic diseases in Germany. Predictions of hospital case numbers in the future must take both factors into account.