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Tetzlaff F, Sauerberg M, Grigoriev P, Tetzlaff J, Mühlichen M, Baumert J, Michalski N, Wengler A, Nowossadeck E, Hoebel J. Age-specific and cause-specific mortality contributions to the socioeconomic gap in life expectancy in Germany, 2003-21: an ecological study. Lancet Public Health 2024; 9:e295-e305. [PMID: 38702094 DOI: 10.1016/s2468-2667(24)00049-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 03/01/2024] [Accepted: 03/05/2024] [Indexed: 05/06/2024]
Abstract
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.
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Affiliation(s)
- Fabian Tetzlaff
- Division of Social Determinants of Health, Department of Epidemiology and Health Monitoring, Robert Koch Institute, Berlin, Germany.
| | - Markus Sauerberg
- Research Area of Ageing, Mortality and Population Dynamics, Federal Institute for Population Research (BiB), Wiesbaden, Germany
| | - Pavel Grigoriev
- Research Area of Ageing, Mortality and Population Dynamics, Federal Institute for Population Research (BiB), Wiesbaden, Germany
| | - Juliane Tetzlaff
- Medical Sociology Unit, Hannover Medical School, Hannover, Germany
| | | | - Jens Baumert
- Division of Physical Health, Department of Epidemiology and Health Monitoring, Robert Koch Institute, Berlin, Germany
| | - Niels Michalski
- Division of Social Determinants of Health, Department of Epidemiology and Health Monitoring, Robert Koch Institute, Berlin, Germany
| | - Annelene Wengler
- Division of Health Reporting, Department of Epidemiology and Health Monitoring, Robert Koch Institute, Berlin, Germany
| | - Enno Nowossadeck
- Division of Social Determinants of Health, Department of Epidemiology and Health Monitoring, Robert Koch Institute, Berlin, Germany
| | - Jens Hoebel
- Division of Social Determinants of Health, Department of Epidemiology and Health Monitoring, Robert Koch Institute, Berlin, Germany
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Hoebel J, Nowossadeck E, Michalski N, Baumert J, Wachtler B, Tetzlaff F. [Socioeconomic deprivation and premature mortality in Germany, 1998-2021 : An ecological study with what-if scenarios of inequality reduction]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2024; 67:528-537. [PMID: 38587641 PMCID: PMC11093858 DOI: 10.1007/s00103-024-03862-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 03/04/2024] [Indexed: 04/09/2024]
Abstract
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.
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Affiliation(s)
- Jens Hoebel
- Fachgebiet Soziale Determinanten der Gesundheit, Abteilung für Epidemiologie und Gesundheitsmonitoring, Robert Koch-Institut, Berlin, Deutschland.
| | - Enno Nowossadeck
- Fachgebiet Soziale Determinanten der Gesundheit, Abteilung für Epidemiologie und Gesundheitsmonitoring, Robert Koch-Institut, Berlin, Deutschland
| | - Niels Michalski
- Fachgebiet Soziale Determinanten der Gesundheit, Abteilung für Epidemiologie und Gesundheitsmonitoring, Robert Koch-Institut, Berlin, Deutschland
| | - Jens Baumert
- Fachgebiet Körperliche Gesundheit, Abteilung für Epidemiologie und Gesundheitsmonitoring, Robert Koch-Institut, Berlin, Deutschland
| | - Benjamin Wachtler
- Fachgebiet Soziale Determinanten der Gesundheit, Abteilung für Epidemiologie und Gesundheitsmonitoring, Robert Koch-Institut, Berlin, Deutschland
| | - Fabian Tetzlaff
- Fachgebiet Soziale Determinanten der Gesundheit, Abteilung für Epidemiologie und Gesundheitsmonitoring, Robert Koch-Institut, Berlin, Deutschland
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Tesch F, Schmitt J, Dröge P, Günster C, Seidler A, Flechtenmacher J, Lembeck B, Kladny B, Wirtz DC, Niethard FU, Lange T. Socioeconomic differences in the utilization of diagnostic imaging and non-pharmaceutical conservative therapies for spinal diseases. BMC Musculoskelet Disord 2023; 24:774. [PMID: 37784063 PMCID: PMC10544477 DOI: 10.1186/s12891-023-06909-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 09/23/2023] [Indexed: 10/04/2023] Open
Abstract
BACKGROUND A different utilization of health care services due to socioeconomic status on the same health plan contradicts the principle of equal treatment. We investigated the presence and magnitude of socioeconomic differences in utilization of diagnostic imaging and non-pharmaceutical conservative therapies for patients with spinal diseases. METHODS The cohort study based on routine healthcare data from Germany with 11.7 million patient-years between 2012 and 2016 for patients with physician-confirmed spinal diseases (ICD-10: M40-M54), occupation and age 20 to 64 years. A Poisson model estimated the effects of the socioeconomic status (school education, professional education and occupational position) for the risk ratio of receiving diagnostic imaging (radiography, computed tomography, magnetic resonance imaging) and non-pharmaceutical conservative therapies (physical therapy including exercise therapy, manual therapy and massage, spinal manipulative therapy, acupuncture). RESULTS Patients received diagnostic imaging in 26%, physical therapy in 32%, spinal manipulative therapy in 25%, and acupuncture in 4% of all patient-years. Similar to previous survey-based studies higher rates of utilization were associated with higher socioeconomic status. These differences were most pronounced for manual therapy, exercise therapy, and magnetic resonance imaging. CONCLUSIONS The observed differences in health care utilization were highly related to socioeconomic status. Socioeconomic differences were higher for more expensive health services. Further research is necessary to identify barriers to equitable access to health services and to take appropriate action to decrease existing social disparities.
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Affiliation(s)
- Falko Tesch
- Center for Evidence-Based Healthcare, University Hospital and Faculty of Medicine Carl Gustav Carus, TU Dresden, 01307, Dresden, Germany.
| | - Jochen Schmitt
- Center for Evidence-Based Healthcare, University Hospital and Faculty of Medicine Carl Gustav Carus, TU Dresden, 01307, Dresden, Germany
| | - Patrik Dröge
- Allgemeine Ortskrankenkasse (AOK) Research Institute, Berlin, Germany
| | - Christian Günster
- Allgemeine Ortskrankenkasse (AOK) Research Institute, Berlin, Germany
| | - Andreas Seidler
- Institute and Policlinic of Occupational and Social Medicine (IPAS), Faculty of Medicine Carl Gustav Carus, TU Dresden, Dresden, Germany
| | | | - Burkhard Lembeck
- German Professional Association for Orthopedics and Trauma Surgery, Berlin, Germany
| | - Bernd Kladny
- Department of Orthopedics and Trauma Surgery, m&i Fachklinik Herzogenaurach, Herzogenaurach, Germany
| | | | - Fritz-Uwe Niethard
- German Professional Association for Orthopedics and Trauma Surgery, Berlin, Germany
| | - Toni Lange
- Center for Evidence-Based Healthcare, University Hospital and Faculty of Medicine Carl Gustav Carus, TU Dresden, 01307, Dresden, Germany
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Grigoriev O, Doblhammer G. Does the Mortality of Individuals with Severe Disabilities Contribute to the Persistent East-West Mortality Gap Among German Men? EUROPEAN JOURNAL OF POPULATION = REVUE EUROPEENNE DE DEMOGRAPHIE 2022; 38:247-271. [PMID: 35619745 PMCID: PMC9127014 DOI: 10.1007/s10680-022-09609-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 01/24/2022] [Indexed: 06/15/2023]
Abstract
UNLABELLED After three decades since reunification male life expectancy in East Germany still lags behind that of West Germany. Unlike most of the prior studies focusing on the role of socioeconomic factors, this study aims at assessing the contribution of the population with severe disabilities to the persistent East-West male mortality gap. Our analysis is mainly based on the German Pension Fund data. It is restricted to men aged 30-59 receiving disability pension (DP). We estimate mortality indicators and compare trends among populations with or without DP. We use decomposition method to quantify the effects of changes in mortality and compositional changed in the prevalence of receiving DP on the East-West mortality difference. The analysis covers the period 1995-2013. The German Socioeconomic Panel data and Cox proportional hazard models are used to evaluate the regional differences in the risk of receiving DP. Our results suggest that both the higher prevalence of receiving DP in the East and the higher mortality level among men not receiving DP in the East explain the East-West gap. The mortality difference among those receiving DP is negligible and does not contribute much to it. The observed higher prevalence in receiving DP in the East is very likely to reflect the reality as we found no regional differences in the risk of transitioning to receiving DP. The disadvantageous position of the East can be explained by the post-reunification crisis which particularly hit young men in the 1990s, selective migration from East to West after reunification, and the higher proportion of the healthier foreign population living in the West. SUPPLEMENTARY INFORMATION The online version contains supplementary material available at 10.1007/s10680-022-09609-4.
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Affiliation(s)
- Olga Grigoriev
- Max Planck Institute for Demographic Research, Rostock, Germany
| | - Gabriele Doblhammer
- Institute for Sociology and Demography, University of Rostock, Rostock, Germany
- German Center for Neurodegenerative Disease, Bonn, Germany
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Grigoriev P, Pechholdová M, Mühlichen M, Scholz RD, Klüsener S. [30 years of German unification: achievements and remaining differences in mortality trends by age and cause of death]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2021; 64:481-490. [PMID: 33765247 PMCID: PMC8060242 DOI: 10.1007/s00103-021-03299-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 02/24/2021] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Pavel Grigoriev
- Bundesinstitut für Bevölkerungsforschung, Friedrich-Ebert-Allee 4, 65185, Wiesbaden, Deutschland.,Max-Planck-Institut für demografische Forschung, Rostock, Deutschland
| | | | - Michael Mühlichen
- Bundesinstitut für Bevölkerungsforschung, Friedrich-Ebert-Allee 4, 65185, Wiesbaden, Deutschland.
| | - Rembrandt D Scholz
- Max-Planck-Institut für demografische Forschung, Rostock, Deutschland.,Berliner Institut für Sozialforschung, Berlin, Deutschland
| | - Sebastian Klüsener
- Bundesinstitut für Bevölkerungsforschung, Friedrich-Ebert-Allee 4, 65185, Wiesbaden, Deutschland.,Max-Planck-Institut für demografische Forschung, Rostock, Deutschland.,Demografisches Forschungszentrum, Vytautas-Magnus-Universität, Kaunas, Litauen
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