[30 years of German unification: achievements and remaining differences in mortality trends by age and cause of death]

[Mortality trends in Germany in an international context]

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.

[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.

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.

[Private Prescriptions In East And West Germany - A Secondary Data Analysis]

BACKGROUND AND OBJECTIVE

Benzodiazepines and Z-drugs are prescribed to a considerable extent as private prescription also for persons insured by a statutory health insurance (SHI), with formerly large differences between East and West Germany. The aim of the present study was to investigate whether these differences still exist today.

METHOD

This secondary data analysis used anonymized prescription data from general practitioners (GPs), community neurologists, and psychiatrists. SHI-insured patients with at least one prescription for a benzodiazepine or Z-substance between 2014 and 2020 were included. Differences between East and West Germany in the proportion of private prescriptions were the central outcome. Multiple regression analyses were performed to test whether the factors region (eastern vs. western Germany) and specialist group (GPs vs. neurologists/psychiatrists) were statistically significant predictors of the proportion of private prescriptions - taking into account the age and gender composition of patients in a practice.

RESULTS

From 867 practices, 2,200,446 prescriptions for Z-substances, benzodiazepine anxiolytics, and benzodiazepine hypnotics/sedatives were evaluated. More than 38% of these prescriptions were issued as private prescriptions: 53.6% in eastern Germany and 34.8% in western Germany. For Z-substances, the proportion of private prescriptions was particularly high (70.7% in eastern and 43.0% in western Germany). GPs issued private prescriptions far more frequently than neurologists and psychiatrists. The proportion of private prescriptions increased during the study period, comparatively strongly in the western states (from 33% to 39%) and slightly in the eastern states (from 53% to 54%). In the multivariate model, practice area (east/west) and specialist group were similarly strong predictors of the extent of private prescriptions, especially for Z-substances.

CONCLUSION

Contrary to a general alignment in life expectancy, morbidity risks, and health behaviour in East and West Germany, there is, despite convergence, still a significant difference in the proportion of private prescriptions for benzodiazepines and especially for Z-substances between the two regions. The groups of physicians who mainly prescribe these substances, namely neurologists and psychiatrists, on the one hand, and GPs, on the other, also differ considerably in the proportion of their private prescriptions for these substances.

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.

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.

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.

What Determines That Older Adults Feel Younger Than They Are? Results From a Nationally Representative Study in Germany

Background

There is increasing evidence that subjective age is an important predictor of beneficial health outcomes besides chronological age. However, little is known about the factors associated with younger subjective age. This study aimed to identify which factors are predictive of feeling younger in old age. In this context, feeling younger was defined as an individual's perception of being younger than their current chronological age.

Methods

Data from 4,665 community-dwelling older people were drawn from wave 7 (2020) of the German Aging Survey (DEAS), a nationally representative study in Germany. Network, mediation, and binomial logistic regression analyses were performed to reveal the associations between feeling younger and biopsychosocial factors.

Results

A total of 4,039 participants reported feeling younger, while 626 did not. Older chronological age, engaging in sports more frequently, a better standard of living, a better state of health, higher satisfaction with life, more positive attitudes toward one's aging, and fewer depressive symptoms are associated with feeling younger in older people.

Conclusion

The present study provides novel and consistent evidence regarding the association between feeling younger and biopsychosocial factors. Further research is needed to confirm these factors and identify how they can be adapted in potential intervention studies to generate the life and health circumstances that allow older people the benefit of feeling younger.