9 th Washington group, Dar Es Salaam October 2009

9th Washington group, Dar Es Salaam October 2009

Population estimates of disability

The impact of including or not

the population living in institutions

Emmanuelle Cambois (INED, France)

For the EHLEIS program

% Disability, activity limitations, functional problems…

Householdpopulation

OutsideHouseholds

?

Context: Are disability statistics data representative of the whole population?

The health of the population is measured by health surveys that are most of the time onlybased on household population: difficulty to organise a survey in institution, various situation worldwide.

Shall we develop surveys in institutions to be able to compare?

How do we deal with this so far?

1> Proposing an aggregate health indicator, the disability free life expectancy, Sullivan was suggesting considering that living in institution was an expression of disability and recommended considering the prevalence of disability as 100% in institutions (Sullivan, 1971).

2> Eurostat calculation of Healthy Life years is only based on HH prevalence, tacitly assuming that the same prevalence can be observed in and outside HH

?

Collective HH

Medical, nursing, disability


Householdpopulation

OutsideHouseholds

How relevant are these assumptions 2. A part of the population outside HH lives in collective HH and a part lives in nursing or health care institution.Differences btw countries?

?

?


Collective HH

Medical, nursing, disability

Householdpopulation

OutsideHouseholds

Context3. To what extent the prevalence differs from the HHpopulation prevalence?

Assumptions> Proposing an aggregate health indicator, the disability free life expectancy, Sullivan was suggesting

considering that living in institution was an expression of disability and recommended considering the prevalence of disability as 100% in institutions (Sullivan, 1971).

While this can be reasonable assumption for nursing homes and long term hospital services, this can be consider as a quite strong assumption for other types of collective, while distinction can not be all the time be made with regular statistics

> Eurostat calculation of Healthy Life years is only based on HH prevalence, tacitly assuming that the same prevalence can be observed in and outside HH.

This assumption might be optimistic considering that part of the population is actually in poorest health than in HH, but it depends on the % of such institutions within the population living outside HH.

QuestionsWhat is the impact of these assumptions on estimates?

Is it worth for international comparison to address the issue of survey in institutions?

1.Looking at the European populations living outside HHWhat is the distribution between HH and population outside HH across Europe?What is the distribution of the care institutions in the population outside HH (3 countries)?

2.The impact on the level of prevalence of disability and on healthy life years?– - considering Sullivan vs. Eurostat on outside HH population– - considering Sullivan + + when li;ited to the care related institutions

3.What is the real prevalence of disability in institutions; in between the two assumptions

0%

1%

2%

3%

4%

5%

6%

7%

8%

Greece Hungary France Finland Ireland Denmark Estonia Austria Germany Lithuania CzechRepublic

Italy Cyprus

% Living outside HH

[65+] [65+]

[65+]

[65+]

[65+]

[65+]

[65+]

[65+]

[65+]

[65+]

[65+]

[65+]

[65+]

[15-29][15-29]

[15-29]

[15-29]

[15-29]

[15-29][15-29]

[15-29][15-29]

[15-29][15-29] [15-29]

[15-29]0%

1%

2%

3%

4%

5%

6%

7%

8%

Greece Hungary France Finland Ireland Denmark Estonia Austria Germany Lithuania CzechRepublic

Italy Cyprus

[65+] % for the 65+

[15-29] % for the [15-29]

% Living outside HH

0%

5%

10%

15%

20%

25%

30%

35%

[0-14] [15-19] [20-24] [25-29] [30-34] [35-39] [40-44] [45-49] [50-54] [55-59] [60-64] [65-69] [70-74] [75-79] [80-84] 85+

Netherlands

Ireland

France

Finland

Germany

Cyprus

Denmark

Czech Republic

Hungary

Estonia

Italy

Greece

Lithuania

Population living outside HH. Data from Eurostat circa 2000

1. The European populations living outside HH

What is the distribution between HH population and population outside HH across Europe? (example with 13 countries)

•From 3.5% in Greece to less than 1% in Italy or Cyprus•Large variation in the type of population regarding % in age groups

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

>25 25-34 35-44 45-54 55-64 65-74 75-84 85+

Care and nursing home

Care institutions

Institutions for disabled

Religious institutions

Other institution (assistance)

Jails

Residences for immigrants

Other

For students

Residences for children

Italy Men

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

>25 25-34 35-44 45-54 55-64 65-74 75-84 85+


Care institutions




Jails


Other

For students


Italy Women

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0-14 15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85+

Old ages/Nursing homes

Long term care

Religious communities

For w orkers

Other

Other collective housing

Shelters

Itinerant

For students

France Men

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+


Long term care


For w orkers

Other


Shelters

Itinerant

For students

France Women

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0-14 15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85+

Home for elderly

Nursing home

Psychiatric Hopsital

Institution for mentallyimpaired

Other institutions

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0-14 15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85+

Home for elderly

Nursing home


Institution for mentallyimpairedOther institutions


What is the distribution of the institutions/collective HH in the population outside HH across Europe? Example with France, Italy, The Netherlands

0%

5%

10%

15%

20%

25%

30%

35%

[0-14] [15-19] [20-24] [25-29] [30-34] [35-39] [40-44] [45-49] [50-54] [55-59] [60-64] [65-69] [70-74] [75-79] [80-84] 85+

FranceFrance 2ItalyItaly 2NetherlandsNetherlands 2

Gap on the Eurostat estimates vs Sullivan with the care related institutions?

% living outside HH and % in nursing/care institutions


0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

16+

65+

80+

16+

65+

80+

16+

65+

80+

16+

65+

80+

16+

65+

80+

France - Italy - latvia - TheNetherlands

- hungary

Household

Sullivan

Sullivan++

Men

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

16+

65+

80+

16+

65+

80+

16+

65+

80+

16+

65+

80+

16+

65+

80+

France - Italy - latvia - TheNetherlands

- hungary

Household

Sullivan

Sullivan++

Women

2. Impact of the assumptions on the prevalence of « Activity limitation »

+492 548

+125 342

+11 585

+59 293 +114 217

+199 021

+52 699

+13 5311 000 000

2 000 000

3 000 000

4 000 000

5 000 000

6 000 000

France Italie Latvia The Netherlands Hungary

Household

Sullivan

Sullivan+++ 4,3% + 1,4%

+ 1,2%

2. Effect on the prevalance of « Activity limitation »

The number of people with activity limitation in adult population

0

2

4

6

8

10

12

14

16

France Germany Italy Estonia Finland Austria Cyprus CzechRepublic

Denmark Greece Ireland Hungary Lithuania TheNetherlands

Yea

rs o

f h

ealt

hy

life

HLY Eurostat

DFLE Sullivan

Men

0

2

4

6

8

10

12

14

16



Yea

rs o

f h

ealt

hy

life

HLY

DFLE Sullivan

Women

2. Effect on HLY calculations

At age 65

0

12

24

36



HL

Y-D

FL

E (

in m

on

ths)

At birth

0

2

4

6

8

10

12



HL

Y-D

FL

E (

in m

on

ths) At 65

0

12

24

36



HL

Y-D

FL

E (

in m

on

ths)

0

2

4

6

8

10

12



HL

Y-D

FL

E (

in m

on

ths)


At birth, gap from30 mth (Gr men) to 2.9 mth (Lth/Cy women)

At 65, gap from8 mth (Ir women) to <1 mth (Lth/Cy women

Differences in healthy life years according to Eurostat/Sullivan method (in months)

0

6

12

18

At birth At age 50 At age 65 At age 80

Mo

nth

s o

f lif

e ex

pec

tan

cy

Men

Women


Number of years differences between HLY and DFLE in The Netherlands

• High institutionalization rate, due to high rate for elderly• Up to 1 year difference according to the assumption• Reduced to less than 10 month if limiting to « care related institutions »

2. Effect on HYL calculations

• Eurostat calculations overestimate the HLY to a different extent from one country to another regarding Sullivan assumption

• The gap reduces if considering only care related institutions

• How reliable could be Sullivan assumption compared to Eurostat? What could be the gap in prevalence of GALI in institution vs. HH or vs. 100%?

0%

10%

20%

30%

40%

50%

60%

70%

80%

20-24 25-29 30-34 35-36 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+

ADL in institutions

ADL in HH

Women, late 1990's

0%

10%

20%

30%

40%

50%

60%

70%

80%

20-24 25-29 30-34 35-36 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+

ADL in institutions

ADL in HH

Men, late 1990's

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

20-24 25-29 30-34 35-36 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+

Functional limitations in institutions

Functional limitations in HH

Men, late 1990's

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

20-24 25-29 30-34 35-36 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+

Functional limitations in institutions

Functional limitations in HH

Women, late 1990's

3. Estimates based on comparable HH/Institutions survey

In late 1990’s, HID is a HH/Institution based on the French health and disability survey:

-2,8 months

+2,6 months

52,6

52,7

52,8

52,9

53,0

53,1

53,2

53,3

53,4

Sullivan HH/Inst Surv Eurostat

Men. Life expectancy without ADL à 20 ans (prevalence around 3% in HH)

+ 1,1 month

-0,8 month

37,5

37,7

37,9

38,1

38,3

38,5

38,7

38,9

39,1

39,3

39,5


Men. Life expectancy without functional limitations à 20 ans(prevalence = 25% in HH)

-4,9 months

+7 months

58,4

58,6

58,8

59,0

59,2

59,4

59,6

59,8

60,0


Women. Life expectancy without ADL à 20 ans (prevalence aroud 4% in HH)

-0,6 month + 1,8 month

40,5

40,7

40,9

41,1

41,3

41,5

41,7

41,9

42,1

42,3

42,5


Women. Life expectancy without functional limitations à 20 ans(prevalence = 29% in HH)

53,05

53,3

52,8



1. For disability status with low prevalence (ADL), the difference btw HH and Inst are large but the total number of persons concerned is limited: the impact of both assumptions is larger than the confidence interval. Eurostat assumption diverges more than Sullivan, reach a 7 month of HLExp at age 20

2. For disability status with high prevalence (common with age…), the difference btw HH and Inst prevalence reduces with age while % living in institution increases. This inverted trends makes the impact of either assumptions low even if Sullivan is closer to the observation. The differences are within the IC.

Conclusion1. Based only on HH information, population estimates are underestimating the prevalence of

disability. The magnitude of the bias depending on the age patterns of living outside institution and type of disability under consideration.

2. Sullivan assumption seems more accurate but only when statistics allows to focus on health related institutions.

3. But, the variation of the % and type of institutions across Europe prevents from applying Sullivan assumption.

4. In any case, the reality is in between the two assumptions, giving the two limits of a range for the estimates

5. Such approach can be useful to avoid conducting worldwide surveys in institution to better estimate population disability prevalence

0%

5%

10%

15%

20%

25%

>25 25-34 35-44 45-54 55-64 65-74 75-84 85+


Care institutions




Jails


Other

For students


Italy Men

0%

5%

10%

15%

20%

25%

>25 25-34 35-44 45-54 55-64 65-74 75-84 85+


Care institutions




Jails


Other

For students


Italy Women

0%

5%

10%

15%

20%

25%

0-14 15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85+


Long term care


For w orkers

Other


Shelters

Itinerant

For students

France Men

0%

5%

10%

15%

20%

25%

0-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+


Long term care


For w orkers

Other


Shelters

Itinerant

For students

France Women

0%

5%

10%

15%

20%

25%

30%

0-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+

Home for elderly

Nursing home



Other institutions

0%

5%

10%

15%

20%

25%

30%

0-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+

Home for elderly

Nursing home



Other institutions

1. The European populations living outside HH What is the distribution of the institutions/collective HH in the population

outside HH across Europe? Example with France, Italy and the Netherlands

0

10

20

30

40

50

60

70



Yea

rs o

f h

ealt

hy

life

HLY Eurostat

DFLE Sullivan

Men

0

10

20

30

40

50

60

70



Yea

rs o

f h

ealt

hy

life

HLY

DFLE Sullivan

Women

3. The calculations of HLY: Sullivan vs. Eurostat assumption

At birth

Documents

9 th Washington group, Dar Es Salaam October 2009