Income inequalities in stroke incidence and mortality: Trends in stroke-free and stroke-affected life years based on German health insurance data

Autoři: Juliane Tetzlaff aff001;  Siegfried Geyer aff001;  Fabian Tetzlaff aff002;  Jelena Epping aff001
Působiště autorů: Medical Sociology Unit, Hannover Medical School, Hanover, Germany aff001;  Institute for General Practice, Hannover Medical School, Hanover, Germany aff002
Vyšlo v časopise: PLoS ONE 15(1)
Kategorie: Research Article
doi: 10.1371/journal.pone.0227541



Due to substantial improvements in prevention and therapy, stroke incidence and mortality rates have decreased during the last decades, but evidence is still lacking on whether all socioeconomic groups benefited equally and how the length of life affected by stroke developed over time. Our study investigates time trends in stroke-free life years and life years affected by stroke. Special emphasis is given to the question whether trends differ between income groups, leading to decreasing or increasing social inequalities.


The analyses are based on claims data of a German statutory health insurance company of the two time periods 2006–2008 and 2014–2016. Income inequalities and time trends in incidence and mortality risks were estimated using multistate survival models. Trends in stroke-free life years and life years affected by stroke are analysed separately for income groups by applying multistate life table analyses.


Stroke incidence and mortality risks decreased in men and women in all income groups. While stroke-free lifetime could be gained in men having higher incomes, improvements in mortality counterbalanced decreasing incidences, leading to increases in life years affected by stroke among men of the lower and higher income group. Among women, no significant changes in life years could be observed.


Changes in stroke-affected life years occur among men in all income groups, but are more pronounced in the higher income group. However, irrespective of the income group the proportion of stroke-affected life years remains quite stable over time, pointing towards constant inequalities. Further research is needed on whether impairments due to stroke reduced over time and whether all socioeconomic groups are affected equally.

Klíčová slova:

Age groups – Death rates – German people – Health insurance – Hemorrhagic stroke – Life expectancy – Socioeconomic aspects of health – Stroke


1. Li L, Yiin GS, Geraghty OC, Schulz UG, Kuker W, Mehta Z, et al. Incidence, outcome, risk factors, and long-term prognosis of cryptogenic transient ischaemic attack and ischaemic stroke: a population-based study. The Lancet Neurology. 2015;14(9):903–13. doi: 10.1016/S1474-4422(15)00132-5 26227434

2. Laditka JN, Laditka SB. Stroke and active life expectancy in the United States, 1999–2009. Disability and health journal. 2014;7(4):472–7. doi: 10.1016/j.dhjo.2014.06.005 25096630

3. Feigin VL, Krishnamurthi RV, Parmar P, Norrving B, Mensah GA, Bennett DA, et al. Update on the Global Burden of Ischemic and Hemorrhagic Stroke in 1990–2013: The GBD 2013 Study. Neuroepidemiology. 2015;45(3):161–76. doi: 10.1159/000441085 26505981

4. Zhao Y, Condon J, Lawton P, He V, Cadilhac DA. Lifetime direct costs of stroke for indigenous patients adjusted for comorbidities. Neurology. 2016;87(5):458–65. doi: 10.1212/WNL.0000000000002908 27371489

5. Gloede TD, Halbach SM, Thrift AG, Dewey HM, Pfaff H, Cadilhac DA. Long-term costs of stroke using 10-year longitudinal data from the North East Melbourne Stroke Incidence Study. Stroke. 2014;45(11):3389–94. doi: 10.1161/STROKEAHA.114.006200 25342028

6. Kolominsky-Rabas PL, Heuschmann PU, Marschall D, Emmert M, Baltzer N, Neundorfer B, et al. Lifetime cost of ischemic stroke in Germany: results and national projections from a population-based stroke registry: the Erlangen Stroke Project. Stroke. 2006;37(5):1179–83. doi: 10.1161/01.STR.0000217450.21310.90 16574918

7. Bejot Y, Bailly H, Durier J, Giroud M. Epidemiology of stroke in Europe and trends for the 21st century. Presse medicale (Paris, France: 1983). 2016;45(12 Pt 2):e391–e8.

8. Heidenreich PA, Trogdon JG, Khavjou OA, Butler J, Dracup K, Ezekowitz MD, et al. Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association. Circulation. 2011;123(8):933–44. doi: 10.1161/CIR.0b013e31820a55f5 21262990

9. Fries JF. Aging, natural death and the compression of morbidity. The New England Journal of Medicine. 1980;303:130–5. doi: 10.1056/NEJM198007173030304 7383070

10. Fries JF. The theory and practice of active aging. Current Gerontology and Geriatrics Research. 2012; ID 420637: doi: 10.1155/2012/420637 23118746

11. Gruenberg EM. The failures of success. The Milbank Memorial Fund quarterly Health and society. 1977;55(1):3–24. 141009

12. Manton KG. Changing concepts of morbidity and mortality in the elderly population. The Milbank Memorial Fund quarterly Health and society. 1982;60(2):183–244. 6919770

13. Thiele I, Linseisen J, Heier M, Holle R, Kirchberger I, Peters A, et al. Time trends in stroke incidence and in prevalence of risk factors in Southern Germany, 1989 to 2008/09. Scientific reports. 2018;8(1):11981. doi: 10.1038/s41598-018-30350-8 30097633

14. Feigin VL, Lawes CM, Bennett DA, Barker-Collo SL, Parag V. Worldwide stroke incidence and early case fatality reported in 56 population-based studies: a systematic review. The Lancet Neurology. 2009;8(4):355–69. doi: 10.1016/S1474-4422(09)70025-0 19233729

15. Carandang R, Seshadri S, Beiser A, Kelly-Hayes M, Kase CS, Kannel WB, et al. Trends in incidence, lifetime risk, severity, and 30-day mortality of stroke over the past 50 years. Jama. 2006;296(24):2939–46. doi: 10.1001/jama.296.24.2939 17190894

16. Icks A, Claessen H, Kvitkina T, Narres M, Weingartner M, Schwab S, et al. Incidence and relative risk of stroke in the diabetic and the non-diabetic population between 1998 and 2014: A community-based stroke register. PloS one. 2017;12(11):e0188306. doi: 10.1371/journal.pone.0188306 29145522

17. Kolominsky-Rabas PL, Wiedmann S, Weingartner M, Liman TG, Endres M, Schwab S, et al. Time trends in incidence of pathological and etiological stroke subtypes during 16 years: the Erlangen Stroke Project. Neuroepidemiology. 2015;44(1):24–9. doi: 10.1159/000371353 25659352

18. Bachus L, Eberhard S, Weissenborn K, Muschik D, Epping J, Geyer S. Morbidity Compression in Stroke: Longitudinal Analyses on Changes in the Incidence of Stroke. Gesundheitswesen. 2019;81(4):351–60. doi: 10.1055/s-0043-109860 28586940

19. Modig K, Andersson T, Drefahl S, Ahlbom A. Age-Specific Trends in Morbidity, Mortality and Case-Fatality from Cardiovascular Disease, Myocardial Infarction and Stroke in Advanced Age: Evaluation in the Swedish Population. PLoS ONE. 2013;8(5):e64928. doi: 10.1371/journal.pone.0064928 23741426

20. Townsend N, Nichols M, Scarborough P, Rayner M. Cardiovascular disease in Europe—epidemiological update 2015. European Heart Journal. 2015.

21. Koton S, Schneider AL, Rosamond WD, Shahar E, Sang Y, Gottesman RF, et al. Stroke incidence and mortality trends in US communities, 1987 to 2011. Jama. 2014;312(3):259–68. doi: 10.1001/jama.2014.7692 25027141

22. Lecoffre C, de Peretti C, Gabet A, Grimaud O, Woimant F, Giroud M, et al. National Trends in Patients Hospitalized for Stroke and Stroke Mortality in France, 2008 to 2014. Stroke. 2017;48(11):2939–45. doi: 10.1161/STROKEAHA.117.017640 28970279

23. Busch MA, Schienkiewitz A, Nowossadeck E, Gößwald A. Prevalence of stroke in adults aged 40 to 79 years in Germany. Bundesgesundheitsblatt—Gesundheitsforschung—Gesundheitsschutz. 2013;56(5):656–60.

24. Addo J, Ayerbe L, Mohan KM, Crichton S, Sheldenkar A, Chen R, et al. Socioeconomic status and stroke: an updated review. Stroke. 2012;43(4):1186–91. doi: 10.1161/STROKEAHA.111.639732 22363052

25. Marshall IJ, Wang Y, Crichton S, McKevitt C, Rudd AG, Wolfe CD. The effects of socioeconomic status on stroke risk and outcomes. The Lancet Neurology. 2015;14(12):1206–18. doi: 10.1016/S1474-4422(15)00200-8 26581971

26. Andersen KK, Olsen TS. Social Inequality by Income in Short- and Long-Term Cause-Specific Mortality after Stroke. Journal of stroke and cerebrovascular diseases: the official journal of National Stroke Association. 2019;28(6):1529–36.

27. Elfassy T, Grasset L, Glymour MM, Swift S, Zhang L, Howard G, et al. Sociodemographic Disparities in Long-Term Mortality Among Stroke Survivors in the United States. Stroke. 2019;50(4):805–12. doi: 10.1161/STROKEAHA.118.023782 30852967

28. Bray BD, Paley L, Hoffman A, James M, Gompertz P, Wolfe CDA, et al. Socioeconomic disparities in first stroke incidence, quality of care, and survival: a nationwide registry-based cohort study of 44 million adults in England. The Lancet Public health. 2018;3(4):e185–e93. doi: 10.1016/S2468-2667(18)30030-6 29550372

29. Nordahl H, Osler M, Frederiksen BL, Andersen I, Prescott E, Overvad K, et al. Combined effects of socioeconomic position, smoking, and hypertension on risk of ischemic and hemorrhagic stroke. Stroke. 2014;45(9):2582–7. doi: 10.1161/STROKEAHA.114.005252 25123220

30. Bejot Y, Guilloteau A, Joux J, Lannuzel A, Mimeau E, Mislin-Tritsch C, et al. Social deprivation and stroke severity on admission: a French cohort study in Burgundy and the West Indies—Guyana region. European journal of neurology. 2017;24(5):694–702. doi: 10.1111/ene.13271 28236340

31. Jaunzeme J, Eberhard S, Geyer S. How "representative" are SHI (statutory health insurance) data? Demographic and social differences and similarities between an SHI-insured population, the population of Lower Saxony, and that of the Federal Republic of Germany using the example of the AOK in Lower Saxony. Bundesgesundheitsblatt, Gesundheitsforschung, Gesundheitsschutz. 2013;56(3):447–54. doi: 10.1007/s00103-012-1626-9 23334292

32. Statistisches Bundesamt. Sozialleistungen; Angaben zur Krankenversicherung (Ergebnisse des Mikrozensus) [Welfare spendings; Data on health insurance (results from the microcensus)]. Statistisches Bundesamt, editor. Wiesbaden: Statistisches Bundesamt [Federal Statistical Office]; 2016 29. Juli 2016. 140 p.

33. Cook RJ, Lawless JF. Multistate models for the analysis of life history data: Chapman and Hall/CRC; 2018.

34. Van Den Hout A. Multi-state survival models for interval-censored data: Chapman and Hall/CRC; 2016.

35. Palloni A. Increment-decrement life tables. Demography: Measuring and modeling population processes. 2001:256–72.

36. Finger J, Busch M, Du Y, Heidemann C, Knopf H, Kuhnert R, et al. Time trends in cardiometabolic risk factors in adults—results from three nationwide German examination surveys from 1990–2011 Dtsch Arztebl Int. 2016;113:712–9. doi: 10.3238/arztebl.2016.0712 27866566

37. Lampert T, Mensink G, Müters S. Physical and sporting activity among adults in Germany. Results from the "German Health Update 2009" survey. Bundesgesundheitsblatt-Gesundheitsforschung-Gesundheitsschutz. 2012;55(1):102–10. doi: 10.1007/s00103-011-1401-3 22286255

38. Zeiher J, Finger JD, Kuntz B, Hoebel J, Lampert T, Starker A. Trends in smoking among adults in Germany: Evidence from seven population-based health surveys from 1991–2015. Bundesgesundheitsblatt-Gesundheitsforschung-Gesundheitsschutz. 2018;61(11):1365–76. doi: 10.1007/s00103-018-2817-9 30215104

39. Hoebel J, Kuntz B, Kroll LE, Finger JD, Zeiher J, Lange C, et al. Trends in Absolute and Relative Educational Inequalities in Adult Smoking Since the Early 2000s: The Case of Germany. Nicotine & tobacco research: official journal of the Society for Research on Nicotine and Tobacco. 2018;20(3):295–302.

40. Hoebel J, Finger JD, Kuntz B, Kroll LE, Manz K, Lange C, et al. Changing educational inequalities in sporting inactivity among adults in Germany: a trend study from 2003 to 2012. BMC public health. 2017;17(1):547. doi: 10.1186/s12889-017-4478-2 28587641

41. Geyer S, Jaunzeme J. Möglichkeiten und Grenzen von Befragungsdaten und Daten gesetzlicher Krankenversicherungen. In: Swart E, Ihle P, Gothe H, Matusiewicz D, editors. Routinedaten im Gesundheitswesen: Handbuch Sekundärdatenanalyse: Grundlagen, Methoden und Perspektiven. 2 ed. Bern: Verlag Hans Huber; 2014. p. 223–33.

42. Schubert I, Hammer A, Koster I. [Severity assessment strategies based on administrative data using stroke as an example]. Zeitschrift fur Evidenz, Fortbildung und Qualitat im Gesundheitswesen. 2017;126:66–75. doi: 10.1016/j.zefq.2017.06.008 28807634

43. Statistisches Bundesamt. Verdienste auf einen Blick. Wiesbaden; 2017.

44. Geyer S. Income, income, or income? The effects of different income measures on health in a national survey. Journal of Epidemiology & Community Health. 2011;65(6):491–6.

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