The two Cologne professors Dr. Stephan Baldus (Director of Clinic III for Internal Medicine at the University Hospital of Cologne) and Dr. Karl Lauterbach (appointed professor of health economics and clinical epidemiology at the University of Cologne in 1997, but since 2005 on leave as a member of parliament according to Section 5 of the Parliamentary Act and currently Federal Minister of Health (20th legislative period 2021-2025)) have written a joint, albeit short, paper . It is called “Prevention-oriented healthcare in Germany – a nation that needs a turnaround” and was published in English on July 31st of this year in the open access journal “European Journal of Epidemiology” (Springer).

>> In this article (1), the author duo warns that the decline in mortality in industrialized countries has recently slowed despite significant increases in health spending and that there is also strong evidence from European countries that the overall gain in lifespan appears to be by an increase in the number of years with disabilities. The two of them quote the team of authors around Jasilionis (10), who have drawn “a bleak picture of the development of life expectancy in Germany” using comparative analyzes of life expectancy based on life tables from the human mortality database and subsequent age- and cause-specific decomposition Substantial evidence has been provided that “Germany is currently performing below average compared to other developed countries when it comes to increasing life expectancy”.
The two authors describe the method described by Jasilionis et al. The data presented for Germany is “alarming”, but there is “also reason for encouragement”. Germany has a highly developed and easily accessible healthcare system, and the country is known for its macroeconomic performance. Baldus and Lauterbach therefore hope that “a strong, nationwide initiative for primary prevention should be possible”. According to the author duo, such a program would have “the potential to be highly efficient in terms of both reducing mortality and health care costs.” It is known from other sources cited in her article that “the number of examinations required to prevent death when screening for dyslipidemia or hypertension is approximately ten times lower than for programs to combat cancer or hepatitis - and is therefore extremely cost-effective.” In her opinion, “improving primary prevention of cardiovascular disease could ultimately reduce health care spending.”
In their conclusion, they write that a reduction in cardiovascular mortality in Germany is urgently needed and that joint efforts from primary and tertiary care providers, researchers and politicians are required. Baldus/Lauterbach: “Initiatives need to be taken to help change dietary behavior at public and individual levels, implement powerful screening programs, improve adherence to guidelines in primary care, and develop new treatment strategies based on digitalization and an appropriate allocation of research funds." A more aggressive approach to tobacco consumption must also be considered, which would ultimately help to increase not only the overall numerical life expectancy, but also the number of years without disability - that is the " most important goal of prevention and early detection of chronic diseases. If this succeeds, Germany could go from Saul to Paul of cardiovascular prevention and become “a model for a modern, nationwide prevention-centered health concept with a focus on cardiovascular diseases.”
The article by Baldus and Lauterbach is a continuation of the one published on 25.
April 2023, also published in the Springer journal “European Journal of Epidemiology” by Dr. “The inadequate life expectancy in Germany” (2). Domantas Jasilionis. In their study, the research associate at the Max Planck Institute for Demographic Research in Rostock and his three co-authors Alyson A. van Raalte (also Max Planck, Rostock) as well as Sebastian Klüsener and Pavel Grigoriev (Federal Institute for Population Research, Wiesbaden) investigate Long-term German life expectancy compared to six equally high-income countries using demographic methods and a cause of death analysis. Than there are:
• Switzerland (constantly leading in life expectancy for men),
• France (known for a particularly low mortality rate in old age)
• Japan (has had the highest life expectancy for women for several decades)
• Spain (which will overtake Japan as the next leader in life expectancy)
• UK and USA (recently experiencing a well-documented slowdown in mortality)
With the aim of the study to find out whether Germany has “taken its own, unconvincing path to life expectancy” despite maintaining higher health care spending, the quartet of authors come up with interesting findings when they break down life expectancy by age. They detect an increased mortality among men aged 65 and older in this country, which would have “consistently made the largest contribution” to the life expectancy gap between Germany and Japan, Switzerland, France and the United Kingdom. The second largest contributor to this difference was excess mortality between the ages of 50 and 64 (except in comparison to France).
For women, however, the pattern looks different: Here, the higher mortality between the ages of 65 and 79 “contributes significantly to the life expectancy gap”. But unlike men, the contribution of higher mortality at the age of 80+ for women is crucial for the difference in longevity between Germany and the four leading countries, especially in the recent period.
The decomposition also shows differences in the age structure of mortality between Germany and the United Kingdom and the USA. For example, Germany has lower mortality in most age groups, but higher mortality at the age of 80 and older. In addition, the spread of age at death in Germany is lower than in the other laggards in life expectancy, such as the United Kingdom
and the USA. According to the authors, their results would confirm that
(a) the slower progress in life expectancy in Germany is not caused by increasing heterogeneity in the health status of the population, which is due to deaths in working age; and
(b) the main trigger is the mortality disadvantage among people of older age, especially among those who are close to the modal (most typical) age of death.

The team of authors also examined whether Germany's poor performance in life expectancy could, as often assumed, be mainly attributed to
1) cardiovascular diseases and 2) inadequate treatment of chronic and age-related diseases.

In fact, according to Jasilionis et al., a cause-specific decomposition of life expectancy compared to the best-performing countries - including Japan, Switzerland and Spain - shows that cardiovascular diseases (CVD) are indeed the main culprits for this disadvantage . This large group of causes of death was the most represented in all study periods, although overall progress had been made in reducing CVD mortality in Germany. However, over the study period, the proportion of the shortfall in life expectancy that can be attributed to the excessive CVD mortality in Germany remained high or even increased further.
According to the quartet of authors, Germany's growing life expectancy disadvantage compared to the best-performing countries is also clear when one looks at the latest annual trends in standardized death rates due to cardiovascular diseases at the age of 50 to 64 and 65+. Germany began the 21st century with a higher rate of cardiovascular disease than the leading countries, but then experienced slower progress or even signs of stagnation.
nation of decline in CVD mortality recorded after 2010. However, a particularly “worrying trend” during the study period was the systematically higher premature CVD mortality among the ages of 50 to 64 in Germany, with mortality among German men and women twice as high as in the leading group of leading countries with the exception of the USA and the United Kingdom.
In their conclusion, the authors write that Germany's performance in terms of life expectancy at the age of 65 is even worse because in this indicator for men, Germany actually lags behind the USA, a "known underperformer" in the group of countries under consideration. When it comes to longevity, Germany and the USA are well below average, although their health care spending is similar or much higher than in many countries that are among the longevity leaders. According to the authors, the observed discrepancies between investments in the healthcare system and the health outcomes of the population should be understood as “a warning signal for the sustainability of the entire healthcare system in Germany,” as the demand for healthcare services will continue to increase in the near future due to population aging .
Limiting their expenditure, Jasilionis' team of authors admits that their findings on the potential determinants of the German disadvantage in life expectancy were largely based on aggregated survey-based and routinely collected statistical data on socioeconomic, health-related behavior. Although these data would show some statistical relationships, they cannot make causal statements. <<
by: MVF editor-in-chief Peter Stegmaier