Trends in health expectancies in Europe:
Link to the retirement age
La Pénibilité au Travail: une Notion Centrale en Prévention 12/5/2017
Prof Dr H. Van Oyen
Increase in life expectancy
Source: Christensen, Doblhammer, Rau, and Vaupel,
Lancet, Vol. 374, 2009
Trends in life expectancy at birth 1840-2007 Demographic transition
Epidemiologic transition Second important shifts in the patterning of ageing and dying
Epidemiologic transition : Shift in mortality pattern: infectious => man-made diseases
Source: Christensen, Doblhammer, Rau, and Vaupel, Lancet, Vol. 374, 2009
Trends in life expectancy at birth: Age S50 by birthcohort
Source: Stat Belgium
Trends in life expectancy at birth, Belgium
Trends in life expectancy at ages 50 and 65, Belgium
10
15
20
25
30
35
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
M_50
M_65
F_50
F_65
+3.74
+2.28
+2.13
+3.21
Source: Christensen, Doblhammer, Rau, and Vaupel, Lancet, Vol. 374, 2009
Trends in life expectancy at birth: mortality rate at older ages
Source: Christensen, Doblhammer, Rau, and Vaupel, Lancet, Vol. 374, 2009
Trends in life expectancy at birth: age specific contribution
Trends in life expectancy at age 65
Men Women
Ageing of populations: demographic and epidemiologic transitions
• Long live • Low fertility • Low immigration • Shift in morbidity and mortality pattern KEY QUESTIONS:
1. Are the increases in LE accompanied by concurrent postponement of ill-health morbidity disability : functional limitations participation restrictions 2. Link retirement age with increasing longevity
Retirement age and increasing duration of live
SUMMARY MEASURE OF POPULATION HEALTH HEALTH EXPECTANCY
14
SUMMARY MEASURE OF POPULATION HEALTH
Combines information on • mortality and • non-fatal health outcomes to represent the health of a population into a single index Types: • Quality adjusted Life Years (QALY): medical intervention • Disability adjusted Life Years (DALY): health gap • Health expectancy (HE)
In 1989…
• REVES: The International network on health expectancies and the disablement process
• One of its main objectives was (and is still) to monitor change over time in population health, and especially to monitor the compression of morbidity/disability hypothesis
1980’s Health theories
• The compression of morbidity: According to Fries, life expectancy was close to its maximum in the 1980s. Medical and especially health behaviors progress will reduce the number of bad years to a small part of the life expectancy (Fries, 1980).
• The expansion of morbidity: On the opposite side, according
to Gruenberg and Kramer, the same medical progress will increase the survival of frail elderly people such as those with dementia (Gruenberg, 1977; Kramer, 1980).
• The dynamic equilibrium: Between these two extreme
futures, Manton proposed a dynamic equilibrium in which increased survival is offset by better control of chronic diseases, keeping the proportion of life lived in good health more or less constant (Manton, 1982).
18
Model of health transitions
Compression of morbidity: the number of years lived increases slower than the number of healthy years lives (Fries)
Expansion of morbidity: the number of years lived increases more than the number of healthy years lives (Gruenberg: Failure of success)
Dynamic equilibrium: there is more ill-health, but the severity levels are going down
Sullivan, 1971 Sullivan D.F. A single index of mortality and morbidity. Health Services Reports 1971;86:347-354. • Prevalence based Multistate life tables • Incidence based: transitions probabilities
between health states.
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Health expectancy indicators
Divide life expectancy into life spent in different states of health, from say good to bad health (different levels of severity). It is at age x, the average number of years persons live in a health state Add a dimension of quality to the quantity of life lived. It is related to the initial WHO-Europe target (1980-1990ties) « add health to life » WHO-Health21 targets:
healthy ageing as reflected in increases in life expectancy, disability-free life expectancy, and the proportion of older people who are healthy and at home
Are health expectancies increasing faster than total life expectancy?
The Minimal European Health Module (MEHM)
3 concepts:
• Self perceived health
• Long standing or chronic health problems
• Functional health / disability
3 global questions >>> The world smallest health survey
In EU-SILC since 2004/2005
23
Minimal European Health module To measure health expectancies accross Europe:
General Perceived Health : Self assessed health (SAH): How is your health in general? Is it… very good/ good / fair/ bad/ very bad
0
5
10
15
20
25
30
verybad
bad fair good verygood
verybad
bad fair good verygood
verybad
bad fair good verygood
verybad
bad fair good verygood
verybad
bad fair good verygood
no formal education primary lower secundary higher secundary tertiary
Relative Risk for mortality by highest educational level and SAH in men 60-79, 2001 Census Belgium with mortality follow-up
No formal educ Tertiary educ Primary educ Lower sec educ Higher sec educ
Deboosere P, Neels K, Van Oyen H
0
10
20
30
40
50
60
very good
Relative Risk for mortality by highest educational level and SAH men 25-39
0
20
40
60
80
100
120
very good
Relative Risk for mortality by highest educational level and SAH women 25-39
0
5
10
15
20
25
30
35
very good
Relative Risk for mortality by highest educational level and SAH men 40-59
0
10
20
30
40
50
60
70
very good
Relative Risk for mortality by highest educational level and SAH women 40-59
0
5
10
15
20
25
30
very good
Relative Risk for mortality by highest educational level and SAH men 60-79
0
5
10
15
20
25
30
very good
Relative Risk for mortality by highest educational level and SAH women 60-79
0
1
2
3
4
5
6
7
8
9
10
very good
Relative Risk for mortality by highest educational level and SAH men 80-99
0
1
2
3
4
5
6
7
8
9
10
very good
Relative Risk for mortality by highest educational level and SAH women 80-99
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Minimal European Health module To measure health expectancies accross Europe:
General Perceived Health : Self assessed health (SAH): How is your health in general? Is it… very good/ good / fair/ bad/ very bad
Chronic Health Problems
Do you have any longstanding illness or longstanding health problem? [longstanding = which have lasted, or are expected to last, for 6 months or more]. Yes / No
Functional health / disability
Macular degeneration
Alteration of central vision
Difficulty to see details
Cannot not drive
Need help for daily shopping Do not go and visit
friend
Iimpairment Disease Disability Disadvantage
Environmental factors and individual resources(physical, intellectual, social, behavioral…)Environmental factors and individual resources(physical, intellectual, social, behavioral…)
The disablement process (Wood, 1975, WHO, 1980, Verbrugge et al., 1994)
Disability in ICF: function (disability) & participation (disadvantage)
Functional Limitations
Sensory, physical, cognitive
Activity restrictions
Disability
Potentially disabling diseases
Impairments
Operationalization of the model in surveys?
Nagi, OECD questions
and the 4 Q of the UN
Washington group short set
ADLs, IADLs, setting (work,
…) Single Global
measure: GALI
List of main diseases or general question on chronic morbidity
29
Minimal European Health module To measure health expectancies accross Europe:
General Perceived Health : Self assessed health (SAH): How is your health in general? Is it… very good/ good / fair/ bad/ very bad
Chronic Health Problems
Do you have any longstanding illness or longstanding health problem? [longstanding = which have lasted, or are expected to last, for 6 months or more]. Yes / No
Functional heath / disability : Global Activity Limitation (GALI)
For at least the past 6 months, to what extent have you been limited because of a health problem in activities people usually do? Would you say you have been … severely limited/ limited but not severely/ not limited at all
Prevalence of participation restriction (GALI), 2012-2014
SILC mean 2012-2014
GALI & Health care expenditure (FUP :12 mths)
HIS 2008, BELGIUM Van der Heyden, BMC Public Health, 2015, 15:267
GALI and mortality (FUP :10 years), HIS 2001
Berger, Archives if Public Health, 2015, 73:25
Health expectancies in Europe
•Life expectancy in good perceived health
How is your health in general? Is it… Very good + Good •Life expectancy without chronic disease
Do you have any chronic illness or condition? No
•Life expectancy without activity limitation: healthy life years (HLY) For at least the past 6 months, to what extent have you been limited
because of a health problem in activities people usually do? Not limited at all
Health Expectancies at age 65 in BELGIUM 2014
http://www.eurohex.eu/index.php?option=countryreports
HLY at age 50 in EU Member States
Jagger C. Lancet 2008; 372: 2124–31
Policy needs on Healthy Life Years (HLY) and Global Activity Limitation Indicator (GALI) in the EU
Policy needs HLY/ GALI in Europe
• Overall strategic policies
• Lisbon strategy (2000-2010): development plan for the economy of the European Union.
Under the strategy, a stronger economy would create employment in the EU, alongside inclusive social and environmental policies, which would themselves drive economic growth even further
• HLY: structural indicator at age 50 years to be measured every year
Policy needs HLY/ GALI in Europe
• Overall strategic policies
• Europe 2020 – Innovation Union • Active and Healthy Ageing through innovation
Target: increase the HLY at birth on EU average by 2 years by 2020
See: Lagiewka K. European Innovation Partnership on Active and Healthy Ageing: what have been the policy drivers and determinants to set a headline target of 2 additional Healthy Life Years at birth at EU average by 2020? Arch Public Health 2012;70:23. Jagger C, et al. Mind the gap-reaching the European target of a 2-year increase in healthy life years in the next decade. Eur J Publ Health 2013 Mar 13;23(5):829-33.
Policy needs HLY/ GALI in Europe
• Overall strategic policies European Pillar of Social Rights (April 26/2017) • => towards better working and living conditions in Europe
• Equal opportunities and access to labour market • Fair working conditions • Social protection and inclusion
• HLY at age 65 is one of the indicators
See: http://europa.eu/rapid/press-release_IP-17-1007_en.htm https://ec.europa.eu/commission/priorities/deeper-and-fairer-economic-and-monetary-union/european-pillar-social-rights_en https://composite-indicators.jrc.ec.europa.eu/social-scoreboard/ http://ec.europa.eu/eurostat/web/european-pillar-of-social-rights/indicators/main-tables
Policy needs HLY/ GALI in Europe HLY/GALI in other policies / policy documents • Social protection:
• HLY by social position • HLY for evaluation of investment in health systems • GALI into Labour Force survey: NUTS2 LEVEL
• Justice:
• Right of people with disability
• Finance: • Evaluation of future health care cost
Monitoring HLY changes over time
Compression of disability?
SILC, Eurostat; www.eurohex.eu
HLY at age 65
Expansion of disability?
SILC, Eurostat; www.eurohex.eu
HLY at age 65
Dynamic equilibrium?
SILC, Eurostat; www.eurohex.eu
HLY at age 65
LE and HLY at age 50,Belgium, 2001-2013
LE : STAT-Belgium, GALI: HIS WIV-ISP
MEN FEMALES
Proportion of remaining life with or without participation restrictions at age 50, Belgium, 2001-2013
LE : STAT-Belgium, GALI: HIS WIV-ISP
MEN FEMALES
LE and HLY at age 65,Belgium, 2001-2013
LE : STAT-Belgium, GALI: HIS WIV-ISP
MEN FEMALES
Proportion of remaining life with or without participation restrictions at age 65, Belgium, 2001-2013
LE : STAT-Belgium, GALI: HIS WIV-ISP
MEN FEMALES
HIS, 1997-2013
Trend in HLY at age 50, HIS2001-2013
AGE GENDER region LE HLY ULE ULY_M ULY 50 MALE FL 2.1 2.5 -0.4 -0.3 -0.1
BR 2.0 1.2 0.8 0.8 0.0
WAL 1.8 2.2 -0.4 -0.3 -0.1
BELGIUM 2.1 2.3 -0.2 -0.2 0.0
FEMALE FL 1.2 2.3 -1.1 -1.1 0.0
BR 1.1 0.7 0.3 1.5 -1.2
WAL 1.2 2.6 -1.4 -0.7 -0.7
BELGIUM 1.2 2.3 -1.1 -0.8 -0.3
Trend in HLY at age 65 among males in selected EU countries, SILC 2004-2014
Trend in %HLY at age 65 among males in selected EU countries, SILC 2005-2014
Trend in HLY at age 65 among females in selected EU countries, SILC 2004-2014
Trend in %HLY at age 65 among females in selected EU countries, SILC 2005-2014
Health expectancy and inequity in Belgium
Life expectancy, Healthy Life Years by educational attainment at age 50
SILC 2004, 5 years follow-up
MEN FEMALES
HLY at age 50 by occupation in men, France, 2003
Without activity limitation (HLY) With activity limitation
Men at age 50
Cambois E; Demographic Research, 25: 407-436, 2011
Occ
upat
ion
25.8
23.7
23.7
23.7
21.7
19.7
5.6
6.4
6.9
7.2
6.5
6.9
7.7
14.6
0 5 10 15 20 25 30 35
Expected years
Inactive
Clerks
Self-empl.
Farmers
Manual Wk.
Interm occup.
High. Qualif.
HLY at age 50 by occupation in women, France, 2003
Without activity limitation (HLY) With activity limitation
Women at age 50
Cambois E; Demographic Research, 25: 407-436, 2011
Occ
upat
ion
27.4
24.8
23.6
24.3
24.5
22.5
21.6
8.7
10.3
11.6
11.0
10.3
11.5
10.8
0 5 10 15 20 25 30 35 40
Expected years
Inactive
Clerks
Self-empl.
Farmers
Manual Wk.
Interm occup.
High. Qualif.
Conclusion
Ageing of populations • Increasing life expectancy asks for composite
measures such health expectancy: • Need to combine health/ill-health and mortality
• In Belgium there is some evidence for compression
• There is a substantial (and not decreasing) inequity
• Discussion on retirement age cannot be done only
using mortality/ life expectancy information