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



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.

This is a preview of subscription content, log in to check access.

Fig. 1


  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. https://doi.org/10.1007/s00392-017-1137-7

    Article  PubMed  PubMed Central  Google 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. https://doi.org/10.1007/s00392-015-0841-4

    Article  Google Scholar 

  3. 3.

    Ziaeian B, Fonarow GC (2016) Epidemiology and aetiology of heart failure. Nat Rev Cardiol 13:368–378. https://doi.org/10.1038/nrcardio.2016.25

    Article  PubMed  PubMed Central  Google 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. https://doi.org/10.1007/s00392-018-1210-x

    Article  PubMed  Google 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. https://doi.org/10.1007/s00392-018-1261-z

    Article  PubMed  Google 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. https://doi.org/10.1007/s00392-017-1138-6

    Article  PubMed  PubMed Central  Google 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. https://doi.org/10.1007/s00392-018-1245-z

    Article  PubMed  PubMed Central  Google Scholar 

  8. 8.

    Deutsche Herzstiftung (2017) Deutscher Herzbericht 2017. Sektorübergreifende Versorgungsanalyse zur Kardiologie, Herzchirurgie und Kinderherzmedizin in Deutschland. Frankfurt am Main. ISBN: 978-3-9817032-7-6

  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. https://doi.org/10.1016/S0140-6736(17)32520-5

    Article  Google 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. https://doi.org/10.1016/j.cardfail.2018.07.465

    Article  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. https://doi.org/10.3389/fonc.2018.00402

    Article  PubMed  PubMed Central  Google 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. https://doi.org/10.1093/aje/kwi017

    Article  PubMed  Google 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. https://doi.org/10.1161/CIR.0000000000000228

    Article  PubMed  Google 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. https://doi.org/10.1186/s12942-016-0068-2

    Article  PubMed  PubMed Central  Google 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. https://doi.org/10.1186/s12889-017-5017-x

    Article  CAS  PubMed  PubMed Central  Google 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. https://doi.org/10.1016/j.jchf.2016.08.001

    Article  PubMed  PubMed Central  Google 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 52:487–493

    Article  CAS  Google 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. https://doi.org/10.1186/1472-6963-14-147

    Article  PubMed  PubMed Central  Google Scholar 

Download references


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.



Author information



Corresponding author

Correspondence to Jakob Holstiege.

Ethics declarations

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).

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Holstiege, J., Akmatov, M.K., Störk, S. et al. Higher prevalence of heart failure in rural regions: a population-based study covering 87% of German inhabitants. Clin Res Cardiol 108, 1102–1106 (2019). https://doi.org/10.1007/s00392-019-01444-8

Download citation


  • Adults
  • Claims data
  • Germany
  • Heart failure
  • Prevalence