Higher prevalence of heart failure in rural regions: a population-based study covering 87% of German inhabitants

  • Jakob HolstiegeEmail author
  • Manas K. Akmatov
  • Stefan Störk
  • Annika Steffen
  • Jörg Bätzing
Original Paper



So far the extent of regional variation of heart failure (HF) prevalence in Germany is unknown.


Using a full sample of nationwide claims data covering ambulatory care of approximately 87% of the German population, this study aimed to (i) examine regional differences of HF prevalence on the level of 402 German administrative districts and (ii) investigate factors associated with HF prevalence. This study included all statutory health-insured patients aged ≥ 40 years in 2017, comprising about 40 million individuals. Age- and sex-standardized HF prevalence was estimated on the district level. Two-level logistic regression analysis was employed to study the influence of the district-related factors degree of urbanisation and regional socio-economic status on HF diagnosis, adjusted for the individual’s age and sex.


HF prevalence in 2017 was 6.0%. Standardized prevalence on the district level varied by a factor of 4.3 (range 2.8–11.9%). Regional socio-economic status and degree of urbanisation were independently associated with HF prevalence. The prevalence increased with decreasing degree of urbanisation. The adjusted risk of suffering from HF was 40% higher in ‘rural areas with a low population density’ as compared to ‘big urban municipalities’ (odds ratio 1.40, 99% CI 1.24–1.59).


Strong regional variations in HF prevalence may inform future public health policies regarding targeted resource planning and prevention strategies. High prevalence in areas with low population density adds to the challenge of ensuring universal access to health services in rural German regions.


Adults Claims data Germany Heart failure Prevalence 



The authors would like to thank the 17 regional Associations of Statutory Health Insurance Physicians in Germany for provision of data and their support in interpreting the results of our analyses.



Compliance with ethical standards

Conflict of interest

JH, MKA, AS and JB declare that they have no conflict of interest. SS receives funding from the German Federal Ministry of Education and Research (01EO1004 and 01EO1504).

Ethical approval

In Germany the use of claims data for scientific research is regulated by the Code of Social Law (SGB X). An ethical approval and informed consent are not required as this study used routinely collected anonymized data.

Data sharing statement

The datasets analysed during the current study are not publicly available due to data protection regulations by the German Social Security Code (Sozialgesetzbuch (SGB) V).


  1. 1.
    Stork S, Handrock R, Jacob J et al (2017) Epidemiology of heart failure in Germany: a retrospective database study. Clin Res Cardiol 106:913–922. CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Ohlmeier C, Mikolajczyk R, Frick J et al (2015) Incidence, prevalence and 1-year all-cause mortality of heart failure in Germany: a study based on electronic healthcare data of more than six million persons. Clin Res Cardiol 104:688–696. CrossRefPubMedGoogle Scholar
  3. 3.
    Ziaeian B, Fonarow GC (2016) Epidemiology and aetiology of heart failure. Nat Rev Cardiol 13:368–378. CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Riedel O, Ohlmeier C, Enders D et al (2018) The contribution of comorbidities to mortality in hospitalized patients with heart failure. Clin Res Cardiol 107:487–497. CrossRefPubMedGoogle Scholar
  5. 5.
    Llorens P, Javaloyes P, Martin-Sanchez FJ et al (2018) Time trends in characteristics, clinical course, and outcomes of 13,791 patients with acute heart failure. Clin Res Cardiol 107:897–913. CrossRefPubMedGoogle Scholar
  6. 6.
    Stork S, Handrock R, Jacob J et al (2017) Treatment of chronic heart failure in Germany: a retrospective database study. Clin Res Cardiol 106:923–932. CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Kaspar M, Fette G, Guder G et al (2018) Underestimated prevalence of heart failure in hospital inpatients: a comparison of ICD codes and discharge letter information. Clin Res Cardiol 107:778–787. CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Deutsche Herzstiftung (2017) Deutscher Herzbericht 2017. Sektorübergreifende Versorgungsanalyse zur Kardiologie, Herzchirurgie und Kinderherzmedizin in Deutschland. Frankfurt am Main. ISBN: 978-3-9817032-7-6Google Scholar
  9. 9.
    Conrad N, Judge A, Tran J et al (2018) Temporal trends and patterns in heart failure incidence: a population-based study of 4 million individuals. Lancet Lond Engl 391:572–580. CrossRefGoogle Scholar
  10. 10.
    Sun LY, Tu JV, Sherrard H et al (2018) Sex-specific trends in incidence and mortality for urban and rural ambulatory heart failure patients in Eastern Ontario from 1994 to 2013. J Cardiol Fail. Google Scholar
  11. 11.
    Hoebel J, Kroll LE, Fiebig J et al (2018) Socioeconomic inequalities in total and site-specific cancer incidence in germany: a population-based registry study. Front Oncol 8:402. CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Larsen K, Merlo J (2005) Appropriate assessment of neighborhood effects on individual health: integrating random and fixed effects in multilevel logistic regression. Am J Epidemiol 161:81–88. CrossRefPubMedGoogle Scholar
  13. 13.
    Havranek EP, Mujahid MS, Barr DA et al (2015) Social determinants of risk and outcomes for cardiovascular disease: a scientific statement from the American Heart Association. Circulation 132:873–898. CrossRefPubMedGoogle Scholar
  14. 14.
    Kauhl B, Schweikart J, Krafft T et al (2016) Do the risk factors for type 2 diabetes mellitus vary by location? A spatial analysis of health insurance claims in Northeastern Germany using kernel density estimation and geographically weighted regression. Int J Health Geogr 15:38. CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Kauhl B, Maier W, Schweikart J et al (2018) Exploring the small-scale spatial distribution of hypertension and its association to area deprivation based on health insurance claims in Northeastern Germany. BMC Public Health 18:121. CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Ahmad FS, Ning H, Rich JD et al (2016) Hypertension, obesity, diabetes, and heart failure-free survival: the cardiovascular disease lifetime risk pooling project. JACC Heart Fail 4:911–919. CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Verheij RA, van de Mheen HD, de Bakker DH et al (1998) Urban-rural variations in health in The Netherlands: does selective migration play a part? J Epidemiol Commun Health 52:487–493CrossRefGoogle Scholar
  18. 18.
    Steinhaeuser J, Otto P, Goetz K et al (2014) Rural area in a European country from a health care point of view: an adoption of the Rural Ranking Scale. BMC Health Serv Res 14:147. CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Regional Health Care Analysis and Health Care AtlasCentral Research Institute of Ambulatory Health Care in Germany (ZI)BerlinGermany
  2. 2.Comprehensive Heart Failure CenterUniversity of WürzburgWürzburgGermany
  3. 3.Division of Cardiology, Department of Medicine IUniversity Hospital WürzburgWürzburgGermany

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