The experience of Denmark with Summary Measures of Population Health

The experience of Denmark with Summary Measures of Population Health

7th Meeting of the Task Force on Health Expectancies

Luxembourg, 2 December 2008

Henrik Brønnum-Hansen

• Impact of selected risk factors on QALY• Trends in social inequality as to LE and HE• HE trends at age 65• The burden of selected diseases at age 65• Lifetime according to health among the oldest old

University of Southern Denmark

The experience of Denmark with SMPH

2 December 2008. Henrik Brønnum-Hansen 2


Impact ofselected risk factors on

quality-adjusted life-years (QALY)




Risk factors

Smoking (Never smoker, Ex-smoker, Moderate smoker, Heavy smoker)

Alcohol consumption (Moderate consumption versus High consumption)

Physical inactivity during leisure time (Active versus Inactive)

Overweight (Normal weight, Overweight, Obese)

Psychosocial job strain (Active versus High strain)According to Karaseks job strain model (job demands and influence/control)

Weak social relations- Meet family regularly versus Rare- Can rely on help from others

Educational level (High, Intermediate, Low)




• The Cause of Death Register

Data sources

• As to smoking: Lung cancer death rates and relative risks from the second prospective Cancer Prevention Study (CPS-II) of the American Cancer Society

• Relative risks for death estimated from the Danish National Cohort Study (DANCOS): the Danish Health Interview Surveys in 1987, 1991, 1994 and 2000 linked to the Danish Civil Registration System and other national registers

• EQ-5D questionnaire as a supplement to and linked to the Danish Health Interview Survey 2000




Results 9.611.2QALYs lost5.4

6.1QALYs lost2.6

2.1

6.77.4

3.35.1

5.75.0

3.02.4

2.75.9

2.43.2

0.83.7

2.35.2

6.1




Purpose

To examine whether the social gradient in life expectancy

and health expectancy has changed in Denmark

Trends in social inequality as to life expectancy and

health expectancy




- Mortality and life expectancy

- Expected lifetime in self-rated good and fair or poor health

Trends in social inequality




Health interview surveys (National Institute of Public Health)

Surveys in 1994, 2000 and 2005

Life tables on the basis of data from Statistics Denmark

Data sources




Age-standardized death rates for men aged 30-60.Number of deaths per 100 000 between 1981 and 2005 by educational level

0

100

200

300

400

500

600

700

1980 1985 1990 1995 2000 2005

Year

Ag

e-s

tan

dar

diz

ed d

eath

ra

te

MenEducationallevel

Low

Medium

High

Increasing social gap





Age-standardized death rates for the age group 30-60.Number of deaths per 100 000 between 1981 and 2005 by educational level

0

100

200

300

400

500

600

700

1980 1985 1990 1995 2000 2005

Year

Ag

e-s

tan

da

rdiz

ed

de

ath

ra

te

MenEducationallevel

Low

Medium

High

0

100

200

300

400

500

600

700

1980 1985 1990 1995 2000 2005

Year

Ag

e-s

tan

da

rdiz

ed

de

ath

ra

te

WomenEducationallevel

Low

Medium

High








30-year-old men

0

10

20

30

40

50

High

Med

ium Low

High

Med

ium Low

High

Med

ium Low

Yea

rs

Life expectancy

Expected lifetime inself-rated good health

Educational level

Expected lifetime inself-rated fair or poor health

1994 2000 2005

Difference between high and low educational level1994 2005

4.1 4.9

9.4 11.4

-5.3 -6.5

Changes in the social gradient in life expectancy and expected lifetimein self-rated good and fair or poor health in Danish men





30-year-old men

0

10

20

30

40

50

High

Med

ium Low

High

Med

ium Low

High

Med

ium Low

Yea

rs

Life expectancy


Educational level


1994 2000 2005


4.1 4.9

9.4 11.4

-5.3 -6.5

30-year-old women

0

10

20

30

40

50

High

Med

ium Low

High

Med

ium Low

High

Med

ium Low

Yea

rs

Life expectancy


Educational level


1994 2000 2005


2.5 3.2

11.5 12.8

-9.0 -9.6

Changes in the social gradient in life expectancy and expected lifetimein self-rated good and fair or poor health in Denmark






Number of participants

Year Level of education Men Women

N Percent N Percent

1994 High 375 22.8 406 22.0

Medium 815 49.4 702 38.0

Low 458 27.8 739 40.0

All 1648 100.0 1847 100.0

2000 High 1700 26.8 1810 27.1

Medium 3171 50.0 2769 41.5

Low 1468 23.2 2089 31.3

All 6339 100.0 6668 99.9

2005 High 1763 30.4 2044 32.5

Medium 3017 52.0 2639 42.0

Low 1020 17.6 1600 25.5

All 5800 100.0 6283 100.0

Numbers of interviewees aged 30 or over who participated in the Danish Health Interview Surveys 1994, 2000 and 2005 by sex and educational level




Health expectancy trends at age 65

Purpose

To determine the trends in health expectancy at

age 65 in Denmark during the period 1987-2005




Health interview surveys (National Institute of Public Health)

Surveys in 1987, 1994, 2000 and 2005

Standard life tables (Statistics Denmark)

1986–1987, 1993–1994, 1999–2000 and 2004–2005

Data sources




Interview question:

“How do you rate your present state of health in general?”

Self-rated health

Answer categories: Very good or good

versus Fair, poor or very poor




0

5

10

15

20

Lif

eti

me (

years

)

1994 2000

65-year-old men

200519870

5

10

15

20

1994 2000

65-year-old women

20051987

Trends in life expectancy

Expected lifetime

In good health In fair orpoor health

8.2 9.1 9.7 11.0

5.9 5.15.3

5.0

9.3 9.4 10.312.1

8.6 8.2 7.86.9

Trends in life expectancy and expected lifetimein self-rated good and fair or poor health




Functional limitations

A person was considered to have functional limitations if he/she

could do one or more of the following, only with difficulty or not at all:

mobility

Communication• read ordinary newspaper print,• hear what is being said in a normal conversation between 3+ persons,

or• speak with minor or major difficulty (assessed by the interviewer)

• walk 400 m without resting,• walk up or down a staircase from one floor to another without resting,• carry 5 kg,




0

5

10

15

20

Lif

eti

me (

years

)

1994 2000

65-year-old men

200519870

5

10

15

20

1994 2000

65-year-old women

20051987

Trends in life expectancyTrends in life expectancy and expected lifetimewithout and with functional limitations

Expected lifetime

without functionallimitations

with functionallimitations

8.9 9.911.3 11.9

5.2 4.33.7

4.1

9.9 9.7 11.0 11.9

8.0 7.97.1

7.1




Interview question:“Do you suffer from any long-standing illness, long-standing after-

effect of injury, any disability, or other long-standing condition?”

Long-standing, limiting illness

If “yes” a question were asked to clarify whether the disease

implied restrictions to daily life or at work




0

5

10

15

20

Lif

eti

me (

years

)

1994 2000

65-year-old men

20050

5

10

15

20

1994 2000

65-year-old women

2005

Trends in life expectancyTrends in life expectancy and expected lifetimewithout and with long-standing, limiting illness

Expected lifetime withoutlong-standing,limiting illness

withlong-standing,limiting illness

7.9 8.910.5

6.26.1

5.5

8.2 9.511.1

9.48.6

7.9




Conclusions

Compression of morbidity is observed in Denmark

when health expectancy is measured by

• Self-rated health

• Functional limitations

• Long-standing, limiting illness




The burden ofselected diseases

at age 65

PurposeTo quantify the health impact of diseases with high

prevalence or mortality on the burden of long-standing

illness among Danes aged 65 or older







Mortality, register linkage (Statistics Denmark)

Sex- and age-specific numbers of persons at risk and the

numbers of deaths from selected causes during the period 1995-

1999

Data sources

Health interview survey 2000 (National Institute of Public Health)

Sex- and age-specific prevalence of long-standing, limiting illness




Interview question:“Do you suffer from any long-standing illness, long-standing after-

effect of injury, any disability, or other long-standing condition?”

If “yes” questions were asked to clarify: the nature of the disease(s) (up to four diseases) whether the disease implied restrictions to daily life or at work

Long-standing, limiting illness




Construction of life tables (by sex)

Methods

Disease elimination• Construction of cause-deleted life tables

• Elimination of specific diseases from prevalence of long-standing,

limiting illness

Health expectancy estimatesExpected lifetime with and without long-standing, limiting illness

• Observed

• Hypothetical after disease elimination




0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

0 10 20 30 40 50 60 70 80 90 100 110

Age

Su

rviv

al p

rob

abili

ty

Years with long-standing illness

Years withoutlong-standing illness

Life expectancy and expected lifetime with and without

long-standing, limiting illness before elimination of a specific disease




0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

0 10 20 30 40 50 60 70 80 90 100 110

Age

Su

rviv

al p

rob

abili

ty

Years with long-standing illness

Years withoutlong-standing illness

Life expectancy and expected lifetime with and without

long-standing, limiting illness after elimination of a specific disease




Gain in life expectancy and changes in expected lifetime with and without long-standing,limiting illness at age 65 in Denmark, 2000, because of elimination of specific diseases

Men

-2.5 -1.5 -0.5 0.5 1.5 2.5 3.5

Neoplasms

Breast cancer

Endocrine, nutritional, metabolic

Diabetes

Nervous system

Circulatory system

Ischemic heart disease

Cerebrovascular disease

Chronic obstructive lung disease

Musculoskeletal system

Years

Eliminated disease

Gain in life expectancyAdded lifetime without long-standing illnessAdded lifetime with long-standing illness

Brønnum-Hansen H, Juel K, Davidsen M. The burden of selected diseases among older people in Denmark.

Women

-2.5 -1.5 -0.5 0.5 1.5 2.5 3.5 Years

Journal of Aging and Health 2006;18:491-506.




• The proportion of expected lifetime without long-standing,

limiting illness would increase from 59.2% to 66.5% for men

and from 52.2% to 55.6% for women if circulatory diseases are

eliminated.

Conclusions

• Elimination of musculoskeletal diseases would not change life

expectancy but would increase the proportion of expected

lifetime without long-standing, limiting illness.

• Cancer and diseases of the circulatory system account for

23% and 42% of deaths among Danes above the age of 65. If

these fatal diseases were eliminated, the life expectancy of 65-

year-olds would increase by 2.3 and 4.0 years, respectively.




Lifetime accordingto health among the

oldest old

Purpose

To quantify the average lifetime according to health

status among the oldest-old in Denmark




Survivors of the 1905 Danish birth cohort

Data

3600 alive in 1998

199 (8.8%) were still alive on 1 January 2006 (age 100)

2259 participants (63% of all survivors) were interviewed in 1998and (if still alive) re-assessed in 2000, 2003 and 2005




ResultsThe average lifetime between ages 92 and 100was about 3 years, of which

• 50% in self-rated good health

• 75% in a state of physical independence

• 33% (at least) in a state of physical independence without cognitive impairment




More good news?

And now...




The Lancet, 17 November 2008




Monday 17 November 2008

Danish elderly themost healthy in Europe

To be discuss

ed

by Ola in

a minute

=

Thank you!





Some extratechnical notes




Construction of life tablesby sex and risk factor level

P0 sex and age specific prevalence of unexposed

Pi prevalence for risk factor exposure level i

RRi relative risk (RR0 = 1)

Then sex and age specific death rate, is given by D = ∑ Pi ∙RRi ∙D0 and

D0 death rate of unexposed can be calculated

Sex and age specific death rates for unexposed, D0, are multiplied with

the relative risk, RRi to estimate sex and age specific death rates for

risk factor level i

Finally, risk factor level specific life tables are constructed

For smoking an indirect method (Peto and colleagues) was used.

QALY study - Methods




Mobility

I have no problems in walking about

I have some problems in walking about

I am confined to bed

EQ-5D (used to calculate QALY)

Self-care

I have no problems with self-care

I have some problems washing and dressing myself

I am unable to wash or dressing myself

Usual activities (e.g. work, study, housework, family or leisure activities)

I have no problems with performing my usual activities

I have some problems with performing my usual activities

I am unable to perform my usual activities

Pain/Discomfort

I have no pain or discomfort

I have moderate pain or discomfort

I have extreme pain or discomfort

Anxiety/Depression

I am not anxious or depressed

I am moderately anxious or depressed

I am extremely anxious or depressed




Official Danish EQ-5D weights established from a study in 2000 at University of Southern Denmark

Danish EQ-5D weights

Weights for all health states defined by the EQ-5D classification system – a total of 243 (=35) states




Information about schooling, vocational training and further

education

Register information (Statistics Denmark)

Questions in the health interview survey (National Institute of Public

Health)

Social inequality study

Educational level

Three levels:

• Low

• Medium

• High




Low - persons with a max. of 10 years of schooling and no more

than semi-skilled training, basic vocational training or business

school (first year)

Medium - persons with either a max. of 10 years of schooling and

further vocational or other training or with post-secondary schooling

but no higher education

High - persons with any type of higher education

Social inequality study

Educational level




Oldest old study

If (s)he did not require assistance to

• get up from a chair or a bed

• walk around in the house

• go to the toilet

If a person was too weak to participate, a proxy was asked to assist

Physically independent




If a person was too weak to participate, a proxy was asked to assist

Measured by

Cognitive function

Scale 0-30

Score > 22: cognitively intact

the Mini-Mental State Examination

Oldest old study




Estimated as

Physical independence without

cognitive impairment

Physical and cognitive functioning

Oldest old study




ReferencesBrønnum-Hansen H, Juel K, Davidsen M. The burden of selected diseases among older people in Denmark. Journal of Aging and Health 2006;18:491-506.

Brønnum-Hansen H, Juel K, Davidsen M, Sørensen J. Impact of selected risk factors on quality-adjusted life expectancy in Denmark. Scandinavian Journal of Public Health 2007;35:510-515.

Brønnum-Hansen H, Baadsgaard M. Increasing social inequality in life expectancy in Denmark. European Journal of Public Health 2007;17:585-586. Brønnum-Hansen H, Baadsgaard M. Increase in social inequality in health expectancy in Denmark. Scandinavian Journal of Public Health 2008;36:44-51.

Jeune B, Brønnum-Hansen H. Trends in health expectancy at age 65 for various health indicators, 1987-2005, Denmark. European Journal of Ageing 2008;5:279-285.

Brønnum-Hansen H, Petersen I, Jeune B, Christensen K. Lifetime according to health status among the oldest old in Denmark. Age and Ageing 2008;doi: 10.1093/ageing/afn239.

Juel K, Sørensen J, Brønnum-Hansen H. Risk factors and public health in Danmark. Scandinavian Journal of Public Health 2008;36(Suppl 1):1-227.

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The experience of Denmark with Summary Measures of Population Health

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