health expectancy in denmark 3 rd meeting of the task force on health expectancies luxembourg, 12...

Health expectancy in Denmark

3rd Meeting of the Task Force on Health Expectancies

Luxembourg, 12 December 2006

Henrik Brønnum-Hansen

Secular trends

Social gradient

Social differences in the burden of diseases

Impact of selected risk factors


12 December 2006. Henrik Brønnum-Hansen 2

Secular trends



Purpose

What could be told about the development in

Denmark as to the hypothesises

• Compression of morbidity

• Expansion of morbidity

• Dynamic equilibrium

?



Health interview surveys carried out by the National

Institute of Public Health.

Surveys in 1987, 1991, 1994, 2000 and 2005

Standard life tables from Statistics Denmark for

1986–1987, 1990–1991, 1993–1994, 1999–2000 and

2004–2005

Data sources

New data!



Methods

Health expectancy by Sullivan’s method

Expected lifetime in various health states

• Self-rated health

• Functional limitations

• Long-standing, limiting illness



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

Answer categories: Very good Good Fair Poor Very poor

Self-rated health

}

}Dichotomised



40.9 42.5 43.1 43.0 45.5

12.0 10.8 10.3 12.1 10.8

0

10

20

30

40

50

60

Lif

eti

me (

years

)

1994 2000

20-year-old men

20051987 1991

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

42.4 44.0 42.3 44.1 46.4

16.1 14.6 16.2 15.4 14.4

0

10

20

30

40

50

60

1994 2000

20-year-old women

20051987 1991

Expected lifetime

in self-ratedgood health

in self-ratedfair or poor health



Functional limitations

• walk 400 m without resting,• walk up or down a staircase from one floor to another without resting,• carry 5 kg,• read ordinary newspaper print,• hear what is being said in a normal conversation between three or more

persons,

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

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:



12.2 13.2 14.7 15.5

5.2 4.44.1

4.3

0

5

10

15

20

Lif

eti

me (

years

)

1994 2000

60-year-old men

20051987

Trends in life expectancy and expected lifetimewithout and with functional limitations

13.3 13.114.7 15.6

8.4 8.47.3

7.4

0

5

10

15

20

1994 2000

60-year-old women

20051987

Expected lifetime

without functionallimitations

with functionallimitations



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” a question were asked to clarify whether the

disease implied restrictions to daily life or at work

Long-standing, limiting illness



38.6 40.8 43.5

14.8 14.3 12.8

0

10

20

30

40

50

60

Lif

eti

me (

years

)

1994 2000

20-year-old men

2005

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

38.4 41.1 42.8

20.1 18.4 18.0

0

10

20

30

40

50

60

1994 2000

20-year-old women

2005

Expected lifetime withoutlong-standing,limiting illness

withlong-standing,limiting illness



Compression of morbidity is observed in Denmark

when health expectancy is measured by

Conclusions

• Self-rated health

• Functional limitations

• Long-standing, limiting illness



Social gradient



Purpose

To estimate social inequalities as to expected lifetime

without and with long-standing, limiting illness

Social classification

Educational level



The Danish Health Interview Survey 2000

(National Institute of Public Health)Sex-, age- and educational level-specific prevalence of

long-standing, limiting illness

Mortality, register linkage (Statistics Denmark)Sex- and age-specific numbers of persons at risk and the

numbers of deaths during the period 1995-1999 for each of

three educational groups

Data sources



Information about schooling, vocational training and further

education

Register information (Statistics Denmark)

Questions in the health interview survey (National Institute of Public

Health)

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)

Educational level

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



0

10

20

30

40

50

Exp

ecte

d li

fe-y

ears

High Medium AllLow

Life expectancy30-year-old men. Denmark 2000

Educational level

0

10

20

30

40

50

Exp

ecte

d li

fe-y

ears

High Medium AllLow

Life expectancy30-year-old women. Denmark 2000

Educational level

with long-standing, limiting illness

Expected lifetime

without long-standing, limiting illness

37.0 32.6 28.8 32.4

13.014.7

12.810.7

0

10

20

30

40

50

Exp

ecte

d l

ife-

year

s

High Medium AllLow

Life expectancy with and without long-standing, limiting illness. 30-year-old men. Denmark 2000

47.8 years 45.5 years43.5 years 45.2 years

Educational level

36.3 33.829.0 32.9

15.0 16.519.6

16.7

0

10

20

30

40

50

Exp

ecte

d l

ife-

year

s

High Medium AllLow

Life expectancy with and without long-standing, limiting illness. 30-year-old women. Denmark 2000

51.3 years 50.4 years 48.6 years 49.6 years

Educational level



Social differences in the burden of diseases



Purpose

To quantify the health impact of diseases with high

prevalence or mortality, and to evaluate social

differences in the burden of long-standing illness



Selected diseases of high prevalence or mortality

Disease group ICD-10 code a)

Neoplasms C00 – D48 b)

Breast cancer C50

Endocrine, nutritional and metabolic diseases E00 – E90

Diabetes melitus E10 – E14

Mental and behavioural disorders F00 – F99

Diseases of the nervous system G00 – G99

Diseases of the circulatory system I00 – I99

Ischaemic heart diseases I20 – I25

Cerebrovascular diseases I60 – I69

Chronic obstructive lung disease J40 – J44

Diseases of the musculoskeletal system and connective tissue M00 – M99 a) International Classification of Diseases, tenth revision b) Mortality data included only deaths with ICD codes C00 – D09



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 for each of

three educational groups

Data sources

Long-standing illness, the Danish Health Interview Survey

2000 (National Institute of Public Health)

Sex-, age- and educational level-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 illness



Construction of life tablesby sex and educational level

Methods

Disease elimination• Construction of cause-deleted life tables (specific demographic technique)

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

limiting illness

Health expectancy, Sullivan’s methodExpected lifetime with and without long-standing, limiting illness

• Observed

• Hypothetical after disease elimination



Life expectancy and expected lifetime with and without long-standig illness

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

Partial life expectancy



Life expectancy and expected lifetime with and without long-standig illness

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

Partial life expectancy



Difference in expected lifetime (between age 30 and 75) with and without long-standing, limiting illnessbetween people with high and low educational level

Women

0 2 4 6 8

Years

Men

0 2 4 6 8

Eliminated disease

Years

None

Neoplasms

Endocrine,nutritional, metabolic

Mental andbehavioral disorders

Nervous system

Circulatory system

Chronic obstructivelung disease

Musculoskeletal systemand connective tissue

More years with long-standing, limiting illness among people with low educational level compared to people with high educational level

More years without long-standing, limiting illness among people with high educational level compared to people with low educational level

Difference in partial life expectancy:

3.1 years

Difference in partial life expectancy:

1.6 years



Gain in partial life expectancy and changes in expected lifetime with and without long-standing, limiting

illness due to elimination of cancer at age 30

Men

0.0 0.5 1.0 1.5

High

Medium

Low

All

Years

Gain in lifeexpectancyat age 30

Educationallevel

1.35

Added lifetime without long-standing illnessAdded lifetime with long-standing illness

1.13

1.40

1.33

Eliminated disease: Neoplasms

Women

0.0 0.5 1.0 1.5 Years


1.43

1.33

1.58

1.48

More years w ith long-standing illness




illness due to elimination of diseases of the circulatory system at age 30

Men

-1,0 -0,5 0,0 0,5 1,0 1,5 2,0

High

Medium

Low

All

Years


Educationallevel

1.12


0.80

1.33

1.15

Eliminated disease: Diseases of the circulatory system

Women

-1,0 -0,5 0,0 0,5 1,0 1,5 2,0 Years


0.42

0.30

0.65

0.53

Few er years w ith long-standing illness




illness due to elimination of diseases of the musculoskeletal system at age 30

social gradient

Men

-5 -3 -1 1 3 5

High

Medium

Low

All

Years


Educationallevel

0.02


0.03

0.00

0.01

Eliminated disease: Diseases of the musculoskeletal system

Women

-5 -3 -1 1 3 5 Years


0.03

0.02

0.02

0.02



Gain in partial life expectancy and changes in expected lifetime with and without long-standing, limiting illness

due to elimination of mental and behavioural disorders at age 30

Men

-7 -5 -3 -1 1 3 5 7

High

Medium

Low

All

Months


Educationallevel

1.32


0.96

1.80

1.44

Eliminated disease: Mental and behavioural disorders

Women

-7 -5 -3 -1 1 3 5 7 Months


0.48

0.48

0.72

0.60

social gradient




illness due to elimination of diseases of the nervous system at age 30

social gradient – opposite direction!

Men

-12 -8 -4 0 4 8 12

High

Medium

Low

All

Months


Educationallevel

0.84


0.96

1.08

0.96

Eliminated disease: Diseases of the nervous system

Women

-12 -8 -4 0 4 8 12 Months


0.72

0.96

0.96

0.84

??



• Persons with a low educational level were more likely to have long-

standing, limiting illness than those with a high educational level.

Conclusions

• The gain in partial life expectancy to be expected by eliminating

certain diseases decreased with educational level.

• The gain in partial life expectancy that could be expected to derive

from elimination of cancer decreases with educational level, but also

added lifetime with long-standing illness decreases with educational

level. A similar phenomenon was seen for cardiovascular diseases: if

they were eliminated, women with a low educational level would gain

lifetime years, but the reduction in lifetime with long-standing illness

would be greatest for women with a high educational level.

• We found a social gradient in the burden of all major diseases with

low fatality, except for diseases of the nervous system for women.



Impact ofselected risk factors



Risk factorsSmoking• Never smoker• Ex-smoker• Moderate smoker 1-14 gram of tobacco per day• Heavy smoker 15 gram of tobacco per day

Alcohol consumption• Moderate consumption 1-14 units of alcohol per week for women

1-21 units of alcohol per week for men• High consumption more than 14 units of alcohol per week for women

more than 21 units of alcohol per week for men

Physical inactivity (during leisure time)• Active At least light physical activity 4 hours per week• Inactive Sedentary (except for disabled individuals)

Overweight• Normal weight 18.5 ≤ BMI < 25.0 • Overweight 25.0 ≤ BMI < 30.0 • Obese 30.0 ≤ BMI

BMI: Body Mass IndexUnderweight (BMI < 18.5) excluded



• Death rates by sex and age from 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

• Prevalence of long-standing, limiting illness by sex, age and risk factor level established from the Danish Health Interview Survey 2000



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.

Methods



Methods

Survey dataPrevalence of long-standing, limiting illness

by sex and risk factor level

Sullivan’s methodto estimate

expected lifetime without longstanding, limiting illness



Results

Risk factors and

expected lifetime without longstanding, limiting illness



Summary – Life expectancyLife expectancy lost Healthy life lost Risk factor

Prevalence

Risk factor YearsMen Women

YearsMen Women

%Men Women

Smoking

Heavy smokers 8.7 10.4 10.4 10.5 23.2 16.5

Moderate smokers 5.0 5.3 6.9 5.3 16.2 18.1

Ex-smokers 2.4 1.5 5.2 2.5 25.2 22.0

Alcohol

High consumption 4.7 4.0 5.0 0.8 14.8 8.7

Physical inactivity

Inactive 5.3 5.1 8.3 10.3 16.0 16.9

Body weight

Overweight 0.0 0.7 -1.4 3.9 39.9 24.8

Obese 2.0 3.2 4.9 10.0 9.8 9.1



Summary – Health expectancyLife expectancy lost Healthy life lost Risk factor

Prevalence


YearsMen Women

%Men Women

Smoking

Heavy smokers 8.7 10.4 10.4 10.5 23.2 16.5


Ex-smokers 2.4 1.5 5.2 2.5 25.2 22.0

Alcohol


Physical inactivity

Inactive 5.3 5.1 8.3 10.3 16.0 16.9

Body weight

Overweight 0.0 0.7 -1.4 3.9 39.9 24.8

Obese 2.0 3.2 4.9 10.0 9.8 9.1



Expected lifetime without longstanding, limitingillness lost due to risk factor exposure

0 3 6 9 12

Obese

Physical inactivity

High alcohol intake

Moderate smoking

Heavy smoking

Years

Women

Men

5.0 5.3

4.7 4.0

5.3 5.1

2.0 3.2

8.710.4

Life-years lost




Prevalence


YearsMen Women

%Men Women

Smoking

Heavy smokers 8.7 10.4 10.4 10.5 23.2 16.5


Ex-smokers 2.4 1.5 5.2 2.5 25.2 22.0

Alcohol


Physical inactivity

Inactive 5.3 5.1 8.3 10.3 16.0 16.9

Body weight

Overweight 0.0 0.7 -1.4 3.9 39.9 24.8

Obese 2.0 3.2 4.9 10.0 9.8 9.1

Thank you!

health expectancy in denmark 3 rd meeting of the task force on health expectancies luxembourg, 12...

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