Emmanuelle Cambois for the EHLEIS programme

Healthy Life Years and Institutionalization: The impact of including or not

the population living in institutions

Emmanuelle Camboisfor the EHLEIS programme

Task Firce on Health Expectancies, October 2009

Context: Are disability statistics representative of the whole population?

Householdpopulation

OutsideHouseholds

% Disability, activity limitations, functional problems… ?

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

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

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

How do we deal with this so far?

% Disability, activity limitations, functional problems…

Collective HH

Medical, nursing, disability

?

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?

Householdpopulation

OutsideHouseholds

How relevant are these assumptions

Context

?

?

3. To what extent the prevalence differs from the HH population prevalence?

% Disability, activity limitations, functional problems…

Collective HH

Medical, nursing, disability

Householdpopulation

OutsideHouseholds

> 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).

> 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.

Assumptions

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

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.

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

Questions

What is the impact of these assumptions on estimates?

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

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

1. The European populations living outside HH

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

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

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

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

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


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%

[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


0

10

20

30

40

50

60

70

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

10

20

30

40

50

60

70



Yea

rs o

f h

ealt

hy

life

HLY

DFLE Sullivan

Women

At birth

2. Effect on HYL calculations

0

2

4

6

8

10

12

14

16



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

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)


0

6

12

18

At birth At age 50 At age 65 At age 80

Men

Women

Number of years differences between HLY and DFLE in France

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

0

6

12

18


Mo

nth

s o

f lif

e ex

pec

tan

cy

Men

Women

3. The calculations of HYL: Sullivan to the care related institutions

• High institutionalization rate, due to both high rate for young and elderly• Difference can reach 16 months• But reduced to 7 month at birth if limiting to « care related institutions »

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

0

6

12

18


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 »


• 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%?


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

3. Estimates based on comparable HH/Institutions survey

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

-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.

Conclusion

1. 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 Sulllivan 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

Gap on the Eurostat estimates vs Sullivan with the population outside HH?

2. The calculations of HYL: Sullivan assumption vs. Eurostat assumption

+5,7 months

+6,7 months

+3,5 months

+6,1 months

+2,7 months+5,1 months

0

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

Men Women Men Women Men Women

HLY

Sullivan (out of HH)

At age 50 At age 65 At age 80

France+13,2 months+16,1

months

0

5

10

15

20

25

30

35

40

45

50

55

60

65

Men Women

At birth

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 prevalence of « Activity limitation »

The number of people with activity limitation in adult population

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

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

The Netherlands


Emmanuelle Cambois for the EHLEIS programme

Documents

Transcript of Emmanuelle Cambois for the EHLEIS programme