The socioeconomic gap in life expectancy in Germany: a decomposition of age- and cause-specific mortality contributions, 2003—2021

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. This study examines how age- and cause-specific mortality contributions to the socioeconomic gap in life expectancy have changed in Germany over time. Methods Official German population and cause-of-death statistics from 2003 to 2021 were linked to the district-level German Index of Socioeconomic Deprivation. Life-table and decomposition methods were applied to calculate life expectancy by deprivation quintile and decompose the life expectancy gap (∆LE) between the most and least deprived quintiles into age- and cause-specific mortality contributions. Findings From 2003 to 2019, the ∆LE between the most and least deprived quintiles of districts increased from 1.1 to 1.8 years among women and from 3.0 to 3.1 years among men. Thereafter, in the COVID-19 pandemic, it increased more rapidly to 2.2 and 3.5 years respectively in 2021. The causes of death contributing most to the ∆LE were cardiovascular diseases (CVD) and cancer, with declining contributions of CVD deaths at age 70 and above and increasing contributions of cancer deaths at ages 40-74 over time. COVID-19 mortality at ages 45+ was the strongest contributor to the increase in ∆LE after 2019. Interpretation To reduce the socioeconomic gap in life expectancy, effective efforts are needed to prevent early deaths from CVD and cancer in deprived populations, with cancer prevention and control becoming an increasingly important field of action in this respect. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement The study was funded by German Cancer Aid [Deutsche Krebshilfe] and the European Research Council (ERC) under the European Union's Horizon 2020 research and innovation programme [grant agreement No. 851485]. The funder was not involved in the study design, collection, analysis, interpretation of data, the writing of this article or the decision to submit it for publication. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The official German cause-of-death data analysed in this study were provided by the Research Data Centre of the Statistical Offices. At the lowest available level of area aggregation, the data are subject to strict data protection by law and are not publicly available. However, the cause-of-death data are available upon request and application to the Research Data Centre of the Statistical Offices. The German Index of Socioeconomic deprivation is published under CC by 4.0 licence and is freely accessible via the GitHub website of the Robert Koch-Institute. [https://github.com/robert-koch-institut/German\_Index\_of\_Socioeconomic\_Deprivation_GISD][1] [1]: https://github.com/robert-koch-institut/German_Index_of_Socioeconomic_Deprivation_GISD