EAPC Country of the Month - Germany

The authors

Professor Stephan Gielen
National CVD Prevention Coordinator (NCPC) for Germany

Report coordinated by Prof. Stephan Gielen, with contributions by:

Prof. Helmuth Gohlke, Prof. Martin Halle, Prof. Ulrich Laufs, Prof. Bernhard Rauch, Prof. Bernhard Schwaab, Prof. Harm Wienbergen, Prof. Heinz Völler (in alphabetical order).

(update of the 2013 report by Prof. Helmut Gohlke and Prof. Ulrich Keil, NCPC's - 2017)

Document to download

Full report.

Structure of health care in Germany

The German healthcare system is built on two foundations:

1. Health insurance system
Initiated in 1883 by Bismarck the German state health insurance is probably one of the oldest national health systems in the world. It is compulsory in Germany to have health insurance with full coverage of diagnosis and treatment of diseases, rehabilitation, maternity, and medical/surgical treatment of accidents. In case the person is unable to pay (i.e. lack of income, immigration etc.) the state covers the health insurance premiums.

2. Sectoral structure of the healthcare system
The German healthcare system is split into three sectors:

1. The hospital sector, which provides the highest density of hospital beds per capita in Europe (6.0 hospital beds per 1,000, data from 2018),
2. The ambulatory sector as provided by general practitioners and specialists in private practice and hospital outpatient units, and
3. The rehabilitation sector, which still largely relies on in-hospital rehabilitation programmes.

Read the full report.

Risk factor statistics

The major significant improvement in the risk factor profile in Germany during the last decade is the reduction of smoking prevalence, particularly among adolescents and young adults. However, the reduction in smoking prevalence is more than counterbalanced by the steady increase in overweight and obesity in the population. Today, less than 1/3 of all adults have normal weight. This development is reflected by the rise in diabetes prevalence.

Read the full report.

Main actors in the healthcare sector

1. Healthcare sector employees and cardiologists

In 2016 (last available data) 420 physicians per 100,000 inhabitants (EU average: 360) worked in the German healthcare system, about half of these in private practice (2, 3). In total, 3,293 cardiologists (2019) are currently working in Germany, equivalent to 3.97 cardiologists per 100,000 inhabitants.

2. Hospitals with departments of cardiology

38 university hospitals with a department of cardiology and cardiovascular surgery and about 220 hospitals outside a university with a major department of cardiology and with additional 32 CV-surgery sites provide in-hospital cardiovascular care.

3. Rehabilitation centers

More than 160 rehabilitation hospitals offer residential CR; the German Society for Cardiovascular Prevention and Rehabilitation (DGPR) organises an annual symposium and continuing education on prevention and rehabilitation.

Read the full report.

Prevention activities

1. Prevention of smoking

Different societies and groups are committed to reducing the rate of active and second-hand smoking in Germany and opposing the interests of the tobacco industry. In the "Task Force Non-Smoking” 15 German societies together try to improve non-smoker rights by lobbying for a better legislation.

2. Promotion of physical activity

An effective way to increase the public level of physical activity is to provide large-scale outreach programs. They may have a high potential to motivate even sedentary people to be physically active. The “Walk 10!” programme is one example to demonstrate how these programs could be successfully performed.

3. Promotion of guideline-oriented dyslipidaemia management

Established coronary artery disease: With the publication of the new ESC/EAS Clinical Practice Guidelines on the Management of Dyslipidaemias the LDL-C target for very high-risk patients was lowered to <55 mg/dl. In Germany, like in many other European countries, this more aggressive target range continues to be a matter of controversy. 

Familial hypercholesterolaemia: Since 2014 newly diagnosed patients with familial hypercholesterolaemia are registered in the Cascade Screening and Registry for High Cholesterol (CAREHIGH registry). The aim of the prospective registry is to improve the identification of patients with familial hypercholesterolemia and to collect data about treatment status and disease course. Additionally, the registry encourages the cascade screening of families in case of newly diagnosed cases to identify asymptomatic FH patients at young age.

4. Nutrition

After years of lobbying efforts – both at national and EU level – Germany has recently introduced a 5-class colour-coded classification system for the labelling of preproduced food called Nutri-Score. The new legislation was finally approved on 9 October 2020 and introduced in November 2020.

5. Academy courses of special cardiovascular prevention

Courses on cardiac prevention and rehabilitation are becoming more common in Germany. A few years after the German Society of Cardiac Prevention and Rehabilitation (DGPR) started, the German Society of Cardiology (DGK) also started offering special courses.

Read the full report.

Cardiac rehabilitation

Phase II cardiac rehabilitation (CR) in Germany has been established for more than 50 years. Traditionally, a 3-week course of comprehensive CR takes place, predominantly as inpatient CR, with emphasis on exercise training, dietary counselling, patient education on lifestyle risk factors, and psychosocial support as core components. In the last 20 years, however, outpatient CR is a well-established alternative being performed in up to 10% of patients younger than 65 years and less than 5% in older ones (1). The current indications from a survey from the German Society of Prevention and Rehabilitation of Cardiovascular Diseases (DGPR) in 2018 are listed in the full report.

Aims for the future 

On a general note, primary prevention has not yet become a priority of German health policy. We are still lacking a lifelong concept for primary prevention, starting during school, continuing during work, and going on after retirement. First studies on workplace prevention interventions (i.e. PreFord study) document the health benefits derived from such efforts, but a larger vision is clearly needed.

Read the full report.

Recommended reading 

• Predicting 10-Year Risk of Fatal Cardiovascular Disease in Germany: An Update Based on the SCORE-Deutschland Risk Charts (downloadable pdf file)
  Viktoria Rücker et al.
• Changes in life expectancy 1950–2010: contributions from age- and disease specific mortality in selected countries
  Jochen Klenk et al.
  (full text can be downloaded)

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology