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.

[Regional differences and trends in healthy life expectancy in Germany]. / Regionale Unterschiede und Trends in gesunder Lebenserwartung in Deutschland.

BACKGROUND: Against the background of increasing life expectancy, the question arises in which state of health the additional years of life are spent. The aim of this study is to assess for the first time regional differences in healthy life expectancy for Germany. METHODS: The concept of healthy life expectancy allows for the combination of regional differences in health status and mortality in a single measure. This article uses the concept of partial healthy life expectancy. We use official data on deaths and population numbers to calculate abridged life tables. Data from the Socio-Economic Panel (SOEP) are used to determine the age- and sex-specific prevalences of health status. Regional differences are analyzed from 2002 to 2019 by dividing Germany into four regions (North, South, East, West). RESULTS: The regional differences in healthy life expectancy in Germany are greater than differences in life expectancy, and trends in healthy life expectancy partly differ from the corresponding trends in mortality. These differences over time also vary according to age: while healthy life expectancy has tended to stagnate and, in some cases, decline among the population aged between 20 and 64, the number and proportion of years in good health has increased among older adults up to the age of 79. CONCLUSION: There are striking regional differences and trends in the distribution of expected years in good health in Germany. The timely identification of regionally divergent developments could facilitate the implementation of targeted health-promoting measures.

[Mortality trends in Germany in an international context]. / Sterblichkeitsentwicklung in Deutschland im internationalen Kontext.

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.

Method for redistributing ill-defined causes of death.

Analysis of causes of death is crucial for monitoring an epidemiological situation and for developing adequate policy responses. However, the comparability of cause-specific mortality data depends on the proportion of ill-defined deaths. To eliminate the bias resulting from the varying proportions of such causes over time and between populations, deaths from ill-defined causes need to be reassigned to other categories. We provide thorough documentation of and tools for the practical implementation of a regression-based method for redistributing ill-defined causes of death, as first proposed by Sully Ledermann in the 1950s. The method relies on subnational cause-specific mortality data to estimate unbiased death rates at both national and subnational levels. We refine Ledermann's method by elaborating on its mathematical properties, making additional adjustments, and evaluating the performance of the approach through simulations. To illustrate the practical application of the method, we rely on French subnational cause-of-death data and provide the R code for performing all calculations.

Spatial Variation in Excess Mortality Across Europe: A Cross-Sectional Study of 561 Regions in 21 Countries.

OBJECTIVE: To measure the burden of the COVID-19 pandemic in 2020 at the subnational level by estimating excess mortality, defined as the increase in all-cause mortality relative to an expected baseline mortality level. METHODS: Statistical and demographic analyses of regional all-cause mortality data provided by the vital statistics systems of 21 European countries for 561 regions in Central and Western Europe. Life expectancy losses at ages 0 and 60 for males and females were estimated. RESULTS: We found evidence of a loss in life expectancy in 391 regions, whilst only three regions exhibit notable gains in life expectancy in 2020. For 12 regions, losses of life expectancy amounted to more than 2 years and three regions showed losses greater than 3 years. We highlight geographical clusters of high mortality in Northern Italy, Spain and Poland, whilst clusters of low mortality were found in Western France, Germany/Denmark and Norway/Sweden. CONCLUSIONS: Regional differences of loss of life expectancy are impressive, ranging from a loss of more than 4 years to a gain of 8 months. These findings provide a strong rationale for regional analysis, as national estimates hide significant regional disparities.

Effects of the COVID-19 pandemic on life expectancy and premature mortality in the German federal states in 2020 and 2021.

The mortality impact of COVID-19 has mainly been studied at the national level. However, looking at the aggregate impact of the pandemic at the country level masks heterogeneity at the subnational level. Subnational assessments are essential for the formulation of public health policies. This is especially important for federal countries with decentralised healthcare systems, such as Germany. Therefore, we assess geographical variation in the mortality impact of COVID-19 for the 16 German federal states in 2020 and 2021 and the sex differences therein. For this purpose, we adopted an ecological study design, using population-level mortality data by federal state, age, and sex, for 2005-2021 obtained from the German Federal Statistical Office. We quantified the impact of the pandemic using the excess mortality approach. We estimated period life expectancy losses (LE losses), excess premature mortality, and excess deaths by comparing their observed with their expected values. The expected mortality was based on projected age-specific mortality rates using the Lee-Carter methodology. Saxony was the most affected region in 2020 (LE loss 0.77 years, 95% CI 0.74;0.79) while Saarland was the least affected (-0.04, -0.09;0.003). In 2021, the regions with the highest losses were Thuringia (1.58, 1.54;1.62) and Saxony (1.57, 1.53;1.6) and the lowest in Schleswig-Holstein (0.13, 0.07;0.18). Furthermore, in 2021, eastern regions experienced higher LE losses (mean: 1.13, range: 0.85 years) than western territories (mean: 0.5, range: 0.72 years). The regional variation increased between 2020 and 2021, and was higher among males than among females, particularly in 2021. We observed an unequal distribution of the mortality impact of COVID-19 at the subnational level in Germany, particularly in 2021 among the male population. The observed differences between federal states might be partially explained by the heterogeneous spread of the virus in 2020 and by differences in the population's propensity to follow preventive guidelines.

Evaluating Spatial, Cause-Specific and Seasonal Effects of Excess Mortality Associated with the COVID-19 Pandemic: The Case of Germany, 2020.

BACKGROUND: Evaluating mortality effects of the COVID-19 pandemic using all-cause mortality data for national populations is inevitably associated with the risk of masking important subnational differentials and hampering targeted health policies. This study aims at assessing simultaneously cause-specific, spatial and seasonal mortality effects attributable to the pandemic in Germany in 2020. METHODS: Our analyses rely on official cause-of-death statistics consisting of 5.65 million individual death records reported for the German population during 2015-2020. We conduct differential mortality analyses by age, sex, cause, month and district (N = 400), using decomposition and standardisation methods, comparing each strata of the mortality level observed in 2020 with its expected value, as well as spatial regression to explore the association of excess mortality with pre-pandemic indicators. RESULTS: The spatial analyses of excess mortality reveal a very heterogenous pattern, even within federal states. The coastal areas in the north were least affected, while the south of eastern Germany experienced the highest levels. Excess mortality in the most affected districts, with standardised mortality ratios reaching up to 20%, is driven widely by older ages and deaths reported in December, particularly from COVID-19 but also from cardiovascular and mental/nervous diseases. CONCLUSIONS: Our results suggest that increased psychosocial stress influenced the outcome of excess mortality in the most affected areas during the second lockdown, thus hinting at possible adverse effects of strict policy measures. It is essential to accelerate the collection of detailed mortality data to provide policymakers earlier with relevant information in times of crisis.

Sex differences in cause-specific mortality: regional trends in seven European countries, 1996-2019.

BACKGROUND: Male excess mortality is mostly related to non-biological factors, and is thus of high social- and health-policy concern. Previous research has mainly focused on national patterns, while subnational disparities have been less in the focus. This study takes a spatial perspective on subnational patterns, covering seven European countries at the crossroad between Eastern and Western Europe. METHODS: We analyze a newly gathered spatially detailed data resource comprising 228 regions with well-established demographic methods to assess the contribution of specific causes of death to the evolution of sex mortality differentials (SMDs) since the mid-1990s. RESULTS: Our results show that declines in SMDs were mostly driven by a reduction of male excess mortality from cardiovascular diseases and neoplasms (about 50-60% and 20-30%, respectively). In Western Europe, trends in deaths from neoplasms contributed more to the reduction of SMDs, while among regions located in Eastern-Central Europe narrowing SMDs were mostly driven by changes in cardiovascular disease-related deaths. Moreover, men show up to three times higher mortality levels from external causes as compared to women in several analyzed regions. But in absolute terms, external deaths play only a minor role in explaining SMDs due to their small contribution to overall mortality. CONCLUSIONS: We conclude that examining the regional development of SMDs is useful for introducing targeted social and health policies in order to reduce and prevent mortality inequalities between women and men.

Different health systems - Different mortality outcomes? Regional disparities in avoidable mortality across German-speaking Europe, 1992-2019.

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.

The underwhelming German life expectancy.

This article contributes to the discussion on the determinants of diverging life expectancy in high-income countries, with a focus on Germany. To date, much of this discourse has centered around the social determinants of health, issues of healthcare equity, poverty and income inequality, and new epidemics of opioids and violence. Yet despite doing well on all of these metrics and having numerous advantages such as comparatively strong economic performance, generous social security, and an equitable and well-resourced health care system, Germany has been a long-time life expectancy laggard among the high-income countries. Using aggregated population-level mortality data for Germany and selected six high-income countries (Switzerland, France, Japan, Spain, the United Kingdom, and the United States) from the Human Mortality Database and WHO Mortality Database, we find that the German longevity shortfall is mainly explained by a longstanding disadvantage in survival among older adults and adults nearing statutory retirement age, which mainly stems from sustained excess cardiovascular disease mortality, even when compared to other laggard countries such as the US and the UK. Patchy contextual data suggests that the unfavorable pattern of cardiovascular mortality may be driven by underperforming primary care and disease prevention. More systematic and representative data on risk factors are needed to strengthen the evidence base on the determinants of the controversial and long-standing health gap between more successful countries and Germany. The German example calls for broader narratives of population health that embed the variety of epidemiological challenges populations face around the globe.

Inhomogeneous Superconductivity Onset in FeSe Studied by Transport Properties.

Heterogeneous superconductivity onset is a common phenomenon in high-Tc superconductors of both the cuprate and iron-based families. It is manifested by a fairly wide transition from the metallic to zero-resistance states. Usually, in these strongly anisotropic materials, superconductivity (SC) first appears as isolated domains. This leads to anisotropic excess conductivity above Tc, and the transport measurements provide valuable information about the SC domain structure deep within the sample. In bulk samples, this anisotropic SC onset gives an approximate average shape of SC grains, while in thin samples, it also indicates the average size of SC grains. In this work, both interlayer and intralayer resistivity were measured as a function of temperature in FeSe samples of various thicknesses. To measure the interlayer resistivity, FeSe mesa structures oriented across the layers were fabricated using FIB. As the sample thickness decreases, a significant increase in superconducting transition temperature Tc is observed: Tc raises from 8 K in bulk material to 12 K in microbridges of thickness ∼40 nm. We applied analytical and numerical calculations to analyze these and earlier data and find the aspect ratio and size of the SC domains in FeSe consistent with our resistivity and diamagnetic response measurements. We propose a simple and fairly accurate method for estimating the aspect ratio of SC domains from Tc anisotropy in samples of various small thicknesses. The relationship between nematic and superconducting domains in FeSe is discussed. We also generalize the analytical formulas for conductivity in heterogeneous anisotropic superconductors to the case of elongated SC domains of two perpendicular orientations with equal volume fractions, corresponding to the nematic domain structure in various Fe-based superconductors.

Quantifying the contribution of smoking to regional mortality disparities in Germany: a cross-sectional study.

OBJECTIVES: Substantial regional variation in smoking behaviour in Germany has been well documented. However, little is known about how these regional differences in smoking affect regional mortality disparities. We aim to assess the contribution of smoking to regional mortality differentials in Germany over the last four decades. DESIGN: A cross-sectional study using official cause-specific mortality data by German Federal State aggregated into five macro-regions: East, North, South, West-I and West-II. PARTICIPANTS: The entire population of Germany stratified by sex, age and region during 1980-2019. MAIN OUTCOME MEASURES: Smoking-attributable fraction estimated using the Preston-Glei-Wilmoth method; life expectancy at birth before and after the elimination of smoking-attributable deaths. RESULTS: In all macro-regions, the burden of past smoking has been declining among men but growing rapidly among women. The hypothetical removal of smoking-attributable deaths would eliminate roughly half of the contemporary advantage in life expectancy of the vanguard region South over the other macro-regions, apart from the East. In the latter, smoking only explains around a quarter (0.5 years) of the 2-year difference in male life expectancy compared with the South observed in 2019. Among women, eliminating smoking-attributable deaths would put the East in a more disadvantageous position compared with the South as well as the other macro-regions. CONCLUSION: While regional differences in smoking histories explain large parts of the regional disparities in male mortality, they are playing an increasingly important role for female mortality trends and differentials. Health policies aiming at reducing regional inequalities should account for regional differences in past smoking behaviour.

[30 years of German unification: achievements and remaining differences in mortality trends by age and cause of death]. / 30 Jahre Deutsche Einheit: Errungenschaften und verbliebene Unterschiede in der Mortalitätsentwicklung nach Alter und Todesursachen.

BACKGROUND: During the German division, two culturally very similar populations were exposed to very disparate socioeconomic conditions, which converged again after 1989. The impact of healthcare and life circumstances on mortality differences can better be estimated when cultural explanations are widely neglectable. OBJECTIVES: For the first time, we analyse harmonised cause-of-death data explicitly by age. Hereby, we can show which ages or birth cohorts were particularly affected by German division and reunification in their mortality and to which causes of death this is attributable. MATERIALS AND METHODS: We harmonised the German cause-of-death statistics by applying an internationally standardised harmonisation process to account for differences and breaks in cause-of-death coding practices. We analysed the data using decomposition methods. RESULTS: During the 1980s, east-west disparities were increasing as progress in the reduction of cardiovascular mortality was much stronger in West Germany, notably at older ages. After 1989, East Germany was able to catch up to the west in many areas. This is especially true for elderly persons and women, while east-west disparities are still visible today, particularly among male adult cohorts (1950-1970) strongly affected by the East German transition crisis. CONCLUSIONS: The lower life expectancy of the East German population in the late 1980s was primarily caused by a slower pace of the cardiovascular revolution. The remaining present-day disparities are rather an aftermath of the East German transition crisis than direct aftereffects of the division.

Spatial patterns of male alcohol-related mortality in Belarus, Lithuania, Poland and Russia.

INTRODUCTION AND AIMS: Eastern Europe is known to suffer from a large burden of alcohol-related mortality. However, persisting unfavourable conditions at the national level mask variation at the sub-national level. We aim to explore spatial patterns of cause-specific mortality across four post-communist countries: Belarus, Lithuania, Poland and Russia (European part). DESIGN AND METHODS: We use official mortality data routinely collected over 1179 districts and cities. The analysis refers to males aged 20-64 years and covers the period 2006-2014. Mortality variation is mainly assessed by means of the standardised mortality ratio. Getis-Ord Gi* statistic is employed to detect hot and cold spots of alcohol-related mortality. RESULTS: Alcohol-related mortality exhibits a gradient from very high levels in northwestern Russia to low levels in southern Poland. Spatial transitions from higher to lower mortality are not explicitly demarcated by national boundaries. Within these countries, hot spots of alcohol-related mortality dominate the territories of northwestern and western Russia, eastern and northwestern Belarus, southeastern Lithuania, and eastern and central Poland. DISCUSSION AND CONCLUSIONS: The observed mortality gradient is likely associated with the spread of alcohol epidemics from the European part of Russia to the other countries, which appears to have started more than a century ago. Contemporary socioeconomic and demographic factors should be taken into account when developing anti-alcohol policies. The same is true for the peculiarities of culture, norms, traditions and behavioural patterns observed in specific geographical areas of the four countries. Reducing alcohol-related harm in the areas identified as hot spots should be prioritised.

Alcohol control policies and mortality trends in Belarus.

BACKGROUND AND AIM: Belarus is among the countries that have very high alcohol consumption levels, and that suffer from a huge burden of excessive drinking. This paper aims to explore the peculiarities of the alcohol control policies implemented in Belarus, and to link these policies to the trends in alcohol consumption and mortality. DATA AND METHODS: Our narrative review of alcohol policies and anti-alcohol measures is based on the laws, directives and other official documents issued by Belarusian authorities since the early 1990s. The data on alcohol consumption and other relevant variables originate from official statistical books. Our analysis of mortality trends is based upon official statistical tables by causes of death. RESULTS: Despite the large number of government policy initiatives that authorities claimed were controlling the problem, alcohol consumption in Belarus grew rapidly up to 2010, when it reached the highest level in the world. This negative trend can be largely attributed to inconsistent alcohol control policies. In particular, the implementation of excise taxes encouraged the manufacturing of inexpensive fortified fruit wines. Additionally, measures designed to raise the price of alcohol were inadequate, resulting in strong alcoholic drinks (e.g. vodka) becoming more affordable. However, the third anti-alcohol campaign, which was launched in 2011, led to declines in both alcohol consumption and alcohol-related mortality. CONCLUSIONS: Belarus has acquired the experience and the legislative foundation needed to implement effective alcohol control polices. To further reduce alcohol-related harm in Belarus, a steady and consistent long-term policy perspective is required.

Declining regional disparities in mortality in the context of persisting large inequalities in economic conditions: the case of Germany.

BACKGROUND: Subnational regional mortality inequalities are large and appear to be mostly increasing within industrialized countries, although comparative studies across high-income countries are scarce. Germany is an important country to examine because it continues to experience considerable economic disparities between its federal states, in part resulting from its former division. METHODS: We analyse state-level mortality in Germany utilizing data from a newly constructed regional database based on the methodology of the Human Mortality Database. We compare time trends (1991-2015) in the German state-level standard deviation in life expectancy to that of other large, wealthy countries and examine the association between mortality and economic inequalities at the regional level. Finally, using contour-decomposition methods, we investigate the degree to which age patterns of mortality are converging across German federal states. RESULTS: Regional inequalities in life expectancy in Germany are comparatively low internationally, particularly among women, despite high state-level inequalities in economic conditions. These low regional mortality inequalities emerged 5-10 years after reunification. Mortality is converging over most ages between the longest- and shortest-living German state populations and across the former East-West political border, with the exception of an emerging East-West divergence in mortality among working-aged men. CONCLUSIONS: The German example shows that large regional economic inequalities are not necessarily paralleled with large regional mortality disparities. Future research should investigate the factors that fostered the emergence of this unusual pattern in Germany.

Socioeconomic differences in mortality among 27 million economically active Germans: a cross-sectional analysis of the German Pension Fund data.

OBJECTIVES: To assess disparities in mortality by socioeconomic status in Germany. DESIGN AND PARTICIPANTS: We analyse a large administrative dataset of the German Pension Fund (DRV), including 27 million person-years of exposure and 42 000 deaths in 2013. The data cover the economically active population, stratified by sex and by East and West. OUTCOME MEASURES: Age-standardised mortality rates and Poisson regression mortality rate ratios (MRRs). RESULTS: The risk of dying increases with decreasing income: the MRRs of the lowest to the highest income quintile are 4.66 (95% CI 4.48 to 4.85) among men and 3.06 (95% CI 2.90 to 3.23) among women. The impact of income attenuates after controlling for education and other explanatory variables, especially for females. In the fully controlled model for females, individual income is a weaker predictor of mortality, but there is a clear educational mortality gradient. In the fully controlled model, the MRRs of the unemployed to the employed are 2.09 (95% CI 2.03 to 2.15) among men and 2.01 (95% CI 1.92 to 2.10) among women. The risk of dying is around half as high among foreigners as among German citizens. The socioeconomic disparities are greater among East than West German men. CONCLUSIONS: Low socioeconomic status is a major determinant of excess adult mortality in Germany. The persisting East-West differences in male adult mortality can be explained by the higher socioeconomic status of men living in the West, rather than by contextual differences between East and West. These differences can be further monitored using DRV data.