Wilma J. Nusselder

Inequalities in healthy life years in the 25 countries of the European Union in 2005: a cross-national meta-regression analysis

BACKGROUND Although life expectancy in the European Union (EU) is increasing, whether most of these extra years are spent in good health is unclear. This information would be crucial to both contain health-care costs and increase labour-force participation for older people. We investigated inequalities in life expectancies and healthy life years (HLYs) at 50 years of age for the 25 countries in the EU in 2005 and the potential for increasing the proportion of older people in the labour force. METHODS We calculated life expectancies and HLYs at 50 years of age by sex and country by the Sullivan method, which was applied to Eurostat life tables and age-specific prevalence of activity limitation from the 2005 statistics of living and income conditions survey. We investigated differences between countries through meta-regression techniques, with structural and sustainable indicators for every country. FINDINGS In 2005, an average 50-year-old man in the 25 EU countries could expect to live until 67.3 years free of activity limitation, and a woman to 68.1 years. HLYs at 50 years for both men and women varied more between countries than did life expectancy (HLY range for men: from 9.1 years in Estonia to 23.6 years in Denmark; for women: from 10.4 years in Estonia to 24.1 years in Denmark). Gross domestic product and expenditure on elderly care were both positively associated with HLYs at 50 years in men and women (p<0.039 for both indicators and sexes); however, in men alone, long-term unemployment was negatively associated (p=0.023) and life-long learning positively associated (p=0.021) with HLYs at 50 years of age. INTERPRETATION Substantial inequalities in HLYs at 50 years exist within EU countries. Our findings suggest that, without major improvements in population health, the target of increasing participation of older people into the labour force will be difficult to meet in all 25 EU countries. FUNDING EU Public Health Programme.

Socioeconomic status and the 25 × 25 risk factors as determinants of premature mortality: A multicohort study and meta-analysis of 1·7 million men and women

Summary Background In 2011, WHO member states signed up to the 25 × 25 initiative, a plan to cut mortality due to non-communicable diseases by 25% by 2025. However, socioeconomic factors influencing non-communicable diseases have not been included in the plan. In this study, we aimed to compare the contribution of socioeconomic status to mortality and years-of-life-lost with that of the 25 × 25 conventional risk factors. Methods We did a multicohort study and meta-analysis with individual-level data from 48 independent prospective cohort studies with information about socioeconomic status, indexed by occupational position, 25 × 25 risk factors (high alcohol intake, physical inactivity, current smoking, hypertension, diabetes, and obesity), and mortality, for a total population of 1 751 479 (54% women) from seven high-income WHO member countries. We estimated the association of socioeconomic status and the 25 × 25 risk factors with all-cause mortality and cause-specific mortality by calculating minimally adjusted and mutually adjusted hazard ratios [HR] and 95% CIs. We also estimated the population attributable fraction and the years of life lost due to suboptimal risk factors. Findings During 26·6 million person-years at risk (mean follow-up 13·3 years [SD 6·4 years]), 310 277 participants died. HR for the 25 × 25 risk factors and mortality varied between 1·04 (95% CI 0·98–1·11) for obesity in men and 2 ·17 (2·06–2·29) for current smoking in men. Participants with low socioeconomic status had greater mortality compared with those with high socioeconomic status (HR 1·42, 95% CI 1·38–1·45 for men; 1·34, 1·28–1·39 for women); this association remained significant in mutually adjusted models that included the 25 × 25 factors (HR 1·26, 1·21–1·32, men and women combined). The population attributable fraction was highest for smoking, followed by physical inactivity then socioeconomic status. Low socioeconomic status was associated with a 2·1-year reduction in life expectancy between ages 40 and 85 years, the corresponding years-of-life-lost were 0·5 years for high alcohol intake, 0·7 years for obesity, 3·9 years for diabetes, 1·6 years for hypertension, 2·4 years for physical inactivity, and 4·8 years for current smoking. Interpretation Socioeconomic circumstances, in addition to the 25 × 25 factors, should be targeted by local and global health strategies and health risk surveillance to reduce mortality. Funding European Commission, Swiss State Secretariat for Education, Swiss National Science Foundation, the Medical Research Council, NordForsk, Portuguese Foundation for Science and Technology.

Assessing the validity of the Global Activity Limitation Indicator in fourteen European countries

BackgroundThe Global Activity Limitation Indicator (GALI), the measure underlying the European indicator Healthy Life Years (HLY), is widely used to compare population health across countries. However, the comparability of the item has been questioned. This study aims to further validate the GALI in the adult European population.MethodsData from the European Health Interview Survey (EHIS), covering 14 European countries and 152,787 individuals, were used to explore how the GALI was associated with other measures of disability and whether the GALI was consistent or reflected different disability situations in different countries.ResultsWhen considering each country separately or all combined, we found that the GALI was significantly associated with measures of activities of daily living, instrumental activity of daily living, and functional limitations (P < 0.001 in all cases). Associations were largest for activity of daily living and lowest though still high for functional limitations. For each measure, the magnitude of the association was similar across most countries. Overall, however, the GALI differed significantly between countries in terms of how it reflected each of the three disability measures (P < 0.001 in all cases). We suspect cross-country differences in the results may be due to variations in: the implementation of the EHIS, the perception of functioning and limitations, and the understanding of the GALI question.ConclusionThe study both confirms the relevance of this indicator to measure general activity limitations in the European population and the need for caution when comparing the level of the GALI from one country to another.

Smoking and the compression of morbidity

OBJECTIVE To examine whether eliminating smoking will lead to a reduction in the number of years lived with disability (that is, absolute compression of morbidity). DESIGN Multistate life table calculations based on the longitudinal GLOBE study (the Netherlands) combined with the Longitudinal Study of Aging (LSOA, United States of America). SETTING the Netherlands. SUBJECTS Dutch nationals aged 30–74 years living in the city of Eindhoven and surrounding municipalities (GLOBE) and United States citizens age 70 and over (LSOA). MAIN OUTCOME MEASURES Life expectancy with and without disability and total life expectancy at ages 30 and 70. RESULTS A non-smoking population on balance spends fewer years with disability than a mixed smoking-non-smoking population. Although non-smokers have lower mortality risks and thus are exposed to disability over a longer period of time, their lower incidence of disability and higher recovery from disability yield a net reduction of the length of time spent with disability (at age 30: −0.9 years in men and −1.1 years in women) and increases the length of time lived without disability (2.5 and 1.9 years, for men and women, respectively). These outcomes indicate that elimination of smoking will extend life and the period of disability free life, and will compress disability into a shorter period. CONCLUSIONS Eliminating smoking will not only extend life and result in an increase in the number of years lived without disability, but will also compress disability into a shorter period. This implies that the commonly found trade off between longer life and a longer period with disability does not apply. Interventions to discourage smoking should receive high priority.

Decomposition of differences in health expectancy by cause.

Health expectancy is a widely used measure for monitoring trends in the health of a population and assessing differences in health among population groups. However, no decomposition method is available to examine the contribution made by causes of death and disability to differences in health expectancy among population groups or periods. We present a method for decomposing differences in health expectancy, based on the Sullivan method. This method is an extension of the decomposition method for life expectancy developed by Arriaga. We illustrate the method and its added value by decomposing male-female differences in health expectancy for the Netherlands.

Preventing fatal diseases increases healthcare costs: cause elimination life table approach

Abstract Objectives: To examine whether elimination of fatal diseases will increase healthcare costs. Design: Mortality data from vital statistics combined with healthcare spending in a cause elimination life table. Costs were allocated to specific diseases through the various healthcare registers. Setting and subjects: The population of the Netherlands, 1988. Main outcome measures: Healthcare costs of a synthetic life table cohort, expressed as life time expected costs. Results: The life time expected healthcare costs for 1988 in the Netherlands were £56 600 for men and £80 900 for women. Elimination of fatal diseases—such as coronary heart disease, cancer, or chronic obstructive lung disease—increases health- care costs. Major savings will be achieved only by elimination of non-fatal disease—such as musculoskeletal diseases and mental disorders. Conclusion: The aim of prevention is to spare people from avoidable misery and death not to save money on the healthcare system. In countries with low mortality, elimination of fatal diseases by successful prevention increases healthcare spending because of the medical expenses during added life years. Key messages In countries with low mortality prevention of fatal diseases adds life years predominantly to old age, when disabling conditions are prevalent If fatal diseases are eliminated, the medical costs of life extension at old age will generally be higher than the costs prevented. Prevention of disabling conditions, particularly mental disorders and musculoskeletal conditions, might both lower healthcare costs and improve public health The aim of prevention is to save people from preventable morbidity and mortality not to save money For the time being, prevention of disability should have the highest priority for future research

Determinants of levels and changes of physical functioning in chronically ill persons: results from the GLOBE Study

STUDY OBJECTIVE Declines in physical functioning are a common result of chronic illness, but relatively little is known about factors not directly related to severity of disease that influence the occurrence of disability among chronically ill persons. The aim of this study was to assess the effect of a large number of potential determinants (sociodemographic factors, health related behaviour, structural living conditions, and psychosocial factors). DESIGN Longitudinal study of levels and changes of physical functioning among persons suffering from four chronic diseases (asthma/chronic obstructive pulmonary disease (COPD), heart disease, diabetes, chronic low back pain). In 1991, persons suffering from one or more of these diseases were identified in a general population survey. Self reported disabilities, using a subset of the OECD disability indicator, were measured six times between 1991 and 1997. These data were analysed using generalised estimating equations, relating determinants measured in 1991 to disability between 1991 and 1997, and controlling for a number of potential confounders (age, gender, year of measurement, and type and severity of chronic disease). SETTING Region of Eindhoven (south eastern Netherlands). PARTICIPANTS 1784 persons with asthma/COPD, heart disease, diabetes mellitus and/or low back pain. MAIN RESULTS In a “repeated prevalence” model, statistically significant (p<0.05) and strong associations were found between most of the determinants and the prevalence of disabilities. In a “longitudinal change” model, statistically significant (p<0.05) predictors of unfavourable changes in physical functioning were low income and excessive alcohol consumption, while we also found indications for effects of marital status, degree of urbanisation, smoking, and external locus of control. CONCLUSIONS Other factors than characteristics of the underlying disease have an important influence on levels and changes of physical functioning among chronically ill persons. Reduction of the prevalence of disabilities in the population not only depends on medical interventions, but may also require social interventions, health education, and psychological interventions among chronically ill persons.

Contribution of Chronic Disease to the Burden of Disability

Background Population ageing is expected to lead to strong increases in the number of persons with one or more disabilities, which may result in substantial declines in the quality of life. To reduce the burden of disability and to prevent concomitant declines in the quality of life, one of the first steps is to establish which diseases contribute most to the burden. Therefore, this paper aims to determine the contribution of specific diseases to the prevalence of disability and to years lived with disability, and to assess whether large contributions are due to a high disease prevalence or a high disabling impact. Methodology/Principal Findings Data from the Dutch POLS-survey (Permanent Onderzoek Leefsituatie, 2001–2007) were analyzed. Using additive regression and accounting for co-morbidity, the disabling impact of selected chronic diseases was calculated, and the prevalence and years lived with ADL and mobility disabilities were partitioned into contributions of specific disease. Musculoskeletal and cardiovascular disease contributed most to the burden of disability, but chronic non-specific lung disease (males) and diabetes (females) also contributed much. Within the musculoskeletal and cardiovascular disease groups, back pain, peripheral vascular disease and stroke contributed particularly by their high disabling impact. Arthritis and heart disease were less disabling but contributed substantially because of their high prevalence. The disabling impact of diseases was particularly high among persons older than 80. Conclusions/Significance To reduce the burden of disability, the extent diseases such as back pain, peripheral vascular disease and stroke lead to disability should be reduced, particularly among the oldest old. But also moderately disabling diseases with a high prevalence, such as arthritis and heart disease, should be targeted.

Gender differences in healthy life years within the EU: an exploration of the “health–survival” paradox

ObjectivesTo evaluated the female–male health–survival paradox by estimating the contribution of women’s mortality advantage versus women’s disability disadvantage.MethodsDisability prevalence was measured from the 2006 Survey on Income and Living Conditions in 25 European countries. Disability prevalence was applied to life tables to estimate healthy life years (HLY) at age 15. Gender differences in HLY were split into two parts: that due to gender inequality in mortality and that due to gender inequality in disability. The relationship between women’s mortality advantage or disability disadvantage and the level of population health between countries was analysed using random-effects meta-regression.ResultsWomen’s mortality advantage contributes to more HLY in women; women’s higher prevalence of disability reduces the difference in HLY. In populations with high life expectancy women’s advantage in HLY was small or even a men’s advantage was found. In populations with lower life expectancy, the hardship among men is already evident at young ages.ConclusionsThe results suggest that the health–survival paradox is a function of the level of population health, dependent on modifiable factors.

Adult obesity and number of years lived with and without cardiovascular disease

Objective: To determine the differences in number of years lived free of cardiovascular disease (CVD) and number of years lived with CVD between men and women who were obese, pre‐obese, or normal weight at 45 years of age.