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The experience of Denmark with Summary Measures of Population Health. 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. - PowerPoint PPT Presentation
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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
University of Southern Denmark
Impact ofselected risk factors on
quality-adjusted life-years (QALY)
The experience of Denmark with SMPH
2 December 2008. Henrik Brønnum-Hansen 3
University of Southern Denmark
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 experience of Denmark with SMPH
2 December 2008. Henrik Brønnum-Hansen 4
University of Southern Denmark
• 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
The experience of Denmark with SMPH
2 December 2008. Henrik Brønnum-Hansen 5
University of Southern Denmark
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
The experience of Denmark with SMPH
2 December 2008. Henrik Brønnum-Hansen 6
University of Southern Denmark
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
The experience of Denmark with SMPH
2 December 2008. Henrik Brønnum-Hansen 7
University of Southern Denmark
- Mortality and life expectancy
- Expected lifetime in self-rated good and fair or poor health
Trends in social inequality
The experience of Denmark with SMPH
2 December 2008. Henrik Brønnum-Hansen 8
University of Southern Denmark
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
The experience of Denmark with SMPH
2 December 2008. Henrik Brønnum-Hansen 9
University of Southern Denmark
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
Increasing social gap
The experience of Denmark with SMPH
2 December 2008. Henrik Brønnum-Hansen 10
University of Southern Denmark
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
Increasing social gap
Increasing social gap
Increasing social gap
Increasing social gap
The experience of Denmark with SMPH
2 December 2008. Henrik Brønnum-Hansen 11
University of Southern Denmark
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
Increasing social gap
The experience of Denmark with SMPH
2 December 2008. Henrik Brønnum-Hansen 12
University of Southern Denmark
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
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
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
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
Increasing social gap
Increasing social gap
The experience of Denmark with SMPH
2 December 2008. Henrik Brønnum-Hansen 13
University of Southern 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
The experience of Denmark with SMPH
2 December 2008. Henrik Brønnum-Hansen 14
University of Southern Denmark
Health expectancy trends at age 65
Purpose
To determine the trends in health expectancy at
age 65 in Denmark during the period 1987-2005
The experience of Denmark with SMPH
2 December 2008. Henrik Brønnum-Hansen 15
University of Southern Denmark
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
The experience of Denmark with SMPH
2 December 2008. Henrik Brønnum-Hansen 16
University of Southern Denmark
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
The experience of Denmark with SMPH
2 December 2008. Henrik Brønnum-Hansen 17
University of Southern Denmark
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
The experience of Denmark with SMPH
2 December 2008. Henrik Brønnum-Hansen 18
University of Southern Denmark
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,
The experience of Denmark with SMPH
2 December 2008. Henrik Brønnum-Hansen 19
University of Southern Denmark
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
The experience of Denmark with SMPH
2 December 2008. Henrik Brønnum-Hansen 20
University of Southern Denmark
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
The experience of Denmark with SMPH
2 December 2008. Henrik Brønnum-Hansen 21
University of Southern Denmark
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
The experience of Denmark with SMPH
2 December 2008. Henrik Brønnum-Hansen 22
University of Southern Denmark
Conclusions
Compression of morbidity is observed in Denmark
when health expectancy is measured by
• Self-rated health
• Functional limitations
• Long-standing, limiting illness
The experience of Denmark with SMPH
2 December 2008. Henrik Brønnum-Hansen 23
University of Southern Denmark
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
The experience of Denmark with SMPH
2 December 2008. Henrik Brønnum-Hansen 24
University of Southern Denmark
The experience of Denmark with SMPH
2 December 2008. Henrik Brønnum-Hansen 25
University of Southern Denmark
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
The experience of Denmark with SMPH
2 December 2008. Henrik Brønnum-Hansen 26
University of Southern Denmark
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
The experience of Denmark with SMPH
2 December 2008. Henrik Brønnum-Hansen 27
University of Southern Denmark
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
The experience of Denmark with SMPH
2 December 2008. Henrik Brønnum-Hansen 28
University of Southern Denmark
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
The experience of Denmark with SMPH
2 December 2008. Henrik Brønnum-Hansen 29
University of Southern Denmark
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
The experience of Denmark with SMPH
2 December 2008. Henrik Brønnum-Hansen 30
University of Southern Denmark
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 experience of Denmark with SMPH
2 December 2008. Henrik Brønnum-Hansen 31
University of Southern Denmark
• 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.
The experience of Denmark with SMPH
2 December 2008. Henrik Brønnum-Hansen 32
University of Southern Denmark
Lifetime accordingto health among the
oldest old
Purpose
To quantify the average lifetime according to health
status among the oldest-old in Denmark
The experience of Denmark with SMPH
2 December 2008. Henrik Brønnum-Hansen 33
University of Southern 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
The experience of Denmark with SMPH
2 December 2008. Henrik Brønnum-Hansen 34
University of Southern Denmark
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
The experience of Denmark with SMPH
2 December 2008. Henrik Brønnum-Hansen 35
University of Southern Denmark
More good news?
And now...
The experience of Denmark with SMPH
2 December 2008. Henrik Brønnum-Hansen 36
University of Southern Denmark
The Lancet, 17 November 2008
The experience of Denmark with SMPH
2 December 2008. Henrik Brønnum-Hansen 37
University of Southern Denmark
Monday 17 November 2008
Danish elderly themost healthy in Europe
To be discuss
ed
by Ola in
a minute
=
The experience of Denmark with SMPH
2 December 2008. Henrik Brønnum-Hansen 39
University of Southern Denmark
Some extratechnical notes
The experience of Denmark with SMPH
2 December 2008. Henrik Brønnum-Hansen 40
University of Southern Denmark
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
The experience of Denmark with SMPH
2 December 2008. Henrik Brønnum-Hansen 41
University of Southern Denmark
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
The experience of Denmark with SMPH
2 December 2008. Henrik Brønnum-Hansen 42
University of Southern Denmark
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
The experience of Denmark with SMPH
2 December 2008. Henrik Brønnum-Hansen 43
University of Southern Denmark
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
The experience of Denmark with SMPH
2 December 2008. Henrik Brønnum-Hansen 44
University of Southern Denmark
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
The experience of Denmark with SMPH
2 December 2008. Henrik Brønnum-Hansen 45
University of Southern Denmark
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
The experience of Denmark with SMPH
2 December 2008. Henrik Brønnum-Hansen 46
University of Southern Denmark
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
The experience of Denmark with SMPH
2 December 2008. Henrik Brønnum-Hansen 47
University of Southern Denmark
Estimated as
Physical independence without
cognitive impairment
Physical and cognitive functioning
Oldest old study
The experience of Denmark with SMPH
2 December 2008. Henrik Brønnum-Hansen 48
University of Southern Denmark
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.