1. The experience of Denmark with Summary Measures of Population Health 7 th 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

2. The experience of Denmark with SMPH 2 December 2008. Henrik Brønnum-Hansen2 University of Southern Denmark Impact of selected risk factors on quality-adjusted life-years (QALY)

3. The experience of Denmark with SMPH 2 December 2008. Henrik Brønnum-Hansen3 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)

4. The experience of Denmark with SMPH 2 December 2008. Henrik Brønnum-Hansen4 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

5. The experience of Denmark with SMPH 2 December 2008. Henrik Brønnum-Hansen5 University of Southern Denmark Results 9.6 11.2 QALYs lost 5.4 6.1 QALYs lost 2.6 2.1 6.7 7.4 3.3 5.1 5.7 5.0 3.0 2.4 2.7 5.9 2.4 3.2 0.8 3.7 2.3 5.2 6.1

6. The experience of Denmark with SMPH 2 December 2008. Henrik Brønnum-Hansen6 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

7. The experience of Denmark with SMPH 2 December 2008. Henrik Brønnum-Hansen7 University of Southern Denmark -Mortality and life expectancy -Expected lifetime in self-rated good and fair or poor health Trends in social inequality

8. The experience of Denmark with SMPH 2 December 2008. Henrik Brønnum-Hansen8 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

9. The experience of Denmark with SMPH 2 December 2008. Henrik Brønnum-Hansen9 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 198019851990199520002005 Year Age-standardized death rate Men Educational level Low Medium High

10. The experience of Denmark with SMPH 2 December 2008. Henrik Brønnum-Hansen10 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

11. The experience of Denmark with SMPH 2 December 2008. Henrik Brønnum-Hansen11 University of Southern Denmark Changes in the social gradient in life expectancy and expected lifetime in self-rated good and fair or poor health in Danish men Increasing social gap

12. The experience of Denmark with SMPH 2 December 2008. Henrik Brønnum-Hansen12 University of Southern Denmark Changes in the social gradient in life expectancy and expected lifetime in self-rated good and fair or poor health in Denmark Increasing social gap

13. The experience of Denmark with SMPH 2 December 2008. Henrik Brønnum-Hansen13 University of Southern Denmark Numbers of interviewees aged 30 or over who participated in the Danish Health Interview Surveys 1994, 2000 and 2005 by sex and educational level

14. The experience of Denmark with SMPH 2 December 2008. Henrik Brønnum-Hansen14 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

15. The experience of Denmark with SMPH 2 December 2008. Henrik Brønnum-Hansen15 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

16. The experience of Denmark with SMPH 2 December 2008. Henrik Brønnum-Hansen16 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

17. The experience of Denmark with SMPH 2 December 2008. Henrik Brønnum-Hansen17 University of Southern Denmark 0 5 10 15 20 Lifetime (years) 19942000 65-year-old men 20051987 0 5 10 15 20 19942000 65-year-old women 20051987 Trends in life expectancyExpected lifetime In good healthIn fair or poor health 8.2 9.1 9.7 11.0 5.9 5.1 5.3 5.0 9.3 9.4 10.3 12.1 8.6 8.2 7.8 6.9 Trends in life expectancy and expected lifetime in self-rated good and fair or poor health

18. The experience of Denmark with SMPH 2 December 2008. Henrik Brønnum-Hansen18 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,

19. The experience of Denmark with SMPH 2 December 2008. Henrik Brønnum-Hansen19 University of Southern Denmark 0 5 10 15 20 Lifetime (years) 19942000 65-year-old men 20051987 0 5 10 15 20 19942000 65-year-old women 20051987 Trends in life expectancyTrends in life expectancy and expected lifetime without and with functional limitations Expected lifetime without functional limitations with functional limitations 8.9 9.9 11.3 11.9 5.2 4.3 3.7 4.1 9.9 9.7 11.0 11.9 8.0 7.9 7.1

20. The experience of Denmark with SMPH 2 December 2008. Henrik Brønnum-Hansen20 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

21. The experience of Denmark with SMPH 2 December 2008. Henrik Brønnum-Hansen21 University of Southern Denmark 0 5 10 15 20 Lifetime (years) 19942000 65-year-old men 2005 0 5 10 15 20 19942000 65-year-old women 2005 Trends in life expectancy Trends in life expectancy and expected lifetime without and with long-standing, limiting illness Expected lifetime without long-standing, limiting illness with long-standing, limiting illness 7.9 8.9 10.5 6.2 6.1 5.5 8.2 9.5 11.1 9.4 8.6 7.9

22. The experience of Denmark with SMPH 2 December 2008. Henrik Brønnum-Hansen22 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

23. The experience of Denmark with SMPH 2 December 2008. Henrik Brønnum-Hansen23 University of Southern Denmark The burden of selected diseases at age 65 Purpose To quantify the health impact of diseases with high prevalence or mortality on the burden of long-standing illness among Danes aged 65 or older

24. The experience of Denmark with SMPH 2 December 2008. Henrik Brønnum-Hansen24 University of Southern Denmark

25. The experience of Denmark with SMPH 2 December 2008. Henrik Brønnum-Hansen25 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

26. The experience of Denmark with SMPH 2 December 2008. Henrik Brønnum-Hansen26 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

27. The experience of Denmark with SMPH 2 December 2008. Henrik Brønnum-Hansen27 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 estimates Expected lifetime with and without long-standing, limiting illness Observed Hypothetical after disease elimination

28. The experience of Denmark with SMPH 2 December 2008. Henrik Brønnum-Hansen28 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 0102030405060708090100110 Age Survival probability Years with long- standing illness Years without long-standing illness Life expectancy and expected lifetime with and without long-standing, limiting illness before elimination of a specific disease

29. The experience of Denmark with SMPH 2 December 2008. Henrik Brønnum-Hansen29 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 0102030405060708090100110 Age Survival probability Years with long- standing illness Years without long-standing illness Life expectancy and expected lifetime with and without long-standing, limiting illness after elimination of a specific disease

30. The experience of Denmark with SMPH 2 December 2008. Henrik Brønnum-Hansen30 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

31. The experience of Denmark with SMPH 2 December 2008. Henrik Brønnum-Hansen31 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.

32. The experience of Denmark with SMPH 2 December 2008. Henrik Brønnum-Hansen32 University of Southern Denmark Lifetime according to health among the oldest old Purpose To quantify the average lifetime according to health status among the oldest-old in Denmark

33. The experience of Denmark with SMPH 2 December 2008. Henrik Brønnum-Hansen33 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 1998 and (if still alive) re-assessed in 2000, 2003 and 2005

34. The experience of Denmark with SMPH 2 December 2008. Henrik Brønnum-Hansen34 University of Southern Denmark Results The average lifetime between ages 92 and 100 was 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

35. The experience of Denmark with SMPH 2 December 2008. Henrik Brønnum-Hansen35 University of Southern Denmark More good news? And now...

36. The experience of Denmark with SMPH 2 December 2008. Henrik Brønnum-Hansen36 University of Southern Denmark The Lancet, 17 November 2008

37. The experience of Denmark with SMPH 2 December 2008. Henrik Brønnum-Hansen37 University of Southern Denmark Monday 17 November 2008 Danish elderly the most healthy in Europe To be discussed by Ola in a minute =

38. Thank you! University of Southern Denmark

39. The experience of Denmark with SMPH 2 December 2008. Henrik Brønnum-Hansen39 University of Southern Denmark Some extra technical notes

40. The experience of Denmark with SMPH 2 December 2008. Henrik Brønnum-Hansen40 University of Southern Denmark Construction of life tables by sex and risk factor level P 0 sex and age specific prevalence of unexposed P i prevalence for risk factor exposure level i RR i relative risk (RR 0 = 1) Then sex and age specific death rate, is given by D = ∑ P i ∙RR i ∙D 0 and D 0 death rate of unexposed can be calculated Sex and age specific death rates for unexposed, D 0, are multiplied with the relative risk, RR i 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

41. The experience of Denmark with SMPH 2 December 2008. Henrik Brønnum-Hansen41 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

42. The experience of Denmark with SMPH 2 December 2008. Henrik Brønnum-Hansen42 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 (=3 5 ) states

43. The experience of Denmark with SMPH 2 December 2008. Henrik Brønnum-Hansen43 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

44. The experience of Denmark with SMPH 2 December 2008. Henrik Brønnum-Hansen44 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

45. The experience of Denmark with SMPH 2 December 2008. Henrik Brønnum-Hansen45 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

46. The experience of Denmark with SMPH 2 December 2008. Henrik Brønnum-Hansen46 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

47. The experience of Denmark with SMPH 2 December 2008. Henrik Brønnum-Hansen47 University of Southern Denmark Estimated as Physical independence without cognitive impairment Physical and cognitive functioning Oldest old study

48. The experience of Denmark with SMPH 2 December 2008. Henrik Brønnum-Hansen48 University of Southern Denmark References Brønnum-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.