Disparities in mortality by disability: an 11-year follow-up study of 1 million individuals

Additive interaction of disability with chronic conditions on mortality risk in middle-aged and older adults in Spain

BACKGROUND

Disability and chronic diseases are prevalent conditions associated with mortality, but little information is available on their potential synergistic effects.

OBJECTIVE

This study aimed to describe additive interactions between disability and chronic diseases on mortality risk in middle-aged and older adults.

METHODS

A representative cohort of 22,800 community-dwelling Spanish people aged 50 years or older were interviewed for disability with the Global Activity Limitation Indicator and specific chronic diseases in the 2011-12 and 2014 National Health Surveys and subsequently followed up for mortality. Five-year all-cause mortality risks were standardized in each disability-by-comorbidity category through inverse probability weighting. We computed interaction contrasts as the departure of the standardized risk difference for people with both conditions from the sum of the standardized risk differences for those with any single condition.

RESULTS

The baseline prevalence of disability was 35.1 % (95 % confidence interval [CI] 34.4 %, 35.9 %). There was compelling evidence of synergistic effects of disability with chronic liver disease, heart diseases other than myocardial infarction, cancer, and cerebrovascular disease, with large positive interaction contrasts (95 % CIs) of 106.7 (-16.4, 229.9), 45.7 (6.9, 84.5), 45.1 (-15.0, 105.2), and 42.9 (-41.0, 126.9) excess deaths per 1000 persons. Less clear synergistic responses were observed for other comorbidities. We found some evidence of antagonism for osteoporosis, with a negative interaction contrast of -18.0 (95 % CI -82.2, 46.2) deaths per 1000 persons.

CONCLUSION

Given the high mortality risk in people with disability, the study of its synergistic effects with target comorbidities can provide relevant information regarding preventive measures.

The association between disability and mortality: a mixed-methods study

BACKGROUND

Globally, 1·3 billion people have a disability and are more likely to experience poor health than the general population. However, little is known about the mortality or life expectancy gaps experienced by people with disabilities. We aimed to undertake a systematic review and meta-analysis of the association between disability and mortality, compare these findings to the evidence on the association of impairment types and mortality, and model the estimated life expectancy gap experienced by people with disabilities.

METHODS

We did a mixed-methods study, which included a systematic review and meta-analysis, umbrella review, and life expectancy modelling. For the systematic review and meta-analysis, we searched MEDLINE, Global Health, PsycINFO, and Embase for studies published in English between Jan 1, 2007, and June 7, 2023, investigating the association of mortality and disability. We included prospective and retrospective cohort studies and randomised controlled trials with a baseline assessment of disability and a longitudinal assessment of all-cause mortality or cause-specific mortality. Two reviewers independently assessed study eligibility, extracted the data, and assessed risk of bias. We did a random-effects meta-analysis to calculate a pooled estimate of the mortality rate ratio for people with disabilities compared with those without disabilities. We did an umbrella review of meta-analyses examining the association between different impairment types and mortality. We used life table modelling to translate the mortality rate ratio into an estimate of the life expectancy gap between people with disabilities and the general population. The systematic review and meta-analysis is registered with PROSPERO, CRD42023433374.

FINDINGS

Our search identified 3731 articles, of which 42 studies were included in the systematic review. The meta-analysis included 31 studies. Pooled estimates showed that all-cause mortality was 2·24 times (95% CI 1·84-2·72) higher in people with disabilities than among people without disabilities, although heterogeneity between the studies was high (τ2=0·28, I2=100%). Modelling indicated a median gap in life expectancy of 13·8 years (95% CI 13·1-14·5) by disability status. Cause-specific mortality was also higher for people with disabilities, including for cancer, COVID-19, cardiovascular disease, and suicide. The umbrella review identified nine meta-analyses, which showed consistently elevated mortality rates among people with different impairment types.

INTERPRETATION

Mortality inequities experienced by people with disabilities necessitate health system changes and efforts to address inclusion and the social determinants of health.

FUNDING

National Institute for Health and Care Research, Rhodes Scholarship, Indonesia Endowment Funds for Education, Foreign, Commonwealth and Development Office (Programme for Evidence to Inform Disability Action), and the Arts and Humanities Research Council.

Mortality in residential care facilities for people with disability: a descriptive cross-sectional analysis of statutory notifications in Ireland

OBJECTIVES

To determine incidence of death in residential care facilities for people with disability in Ireland, primary cause of death, associations of facility characteristics and deaths, and to compare characteristics of deaths reported as expected and unexpected.

DESIGN

Descriptive cross-sectional study.

SETTING

All residential care facilities for people with disability operational in Ireland in 2019 and 2020 (n=1356).

PARTICIPANTS

n=9483 beds.

MAIN OUTCOME MEASURES

All expected and unexpected deaths notified to the social services regulator. Cause of death as reported by the facility.

RESULTS

395 death notifications were received in 2019 (n=189) and 2020 (n=206). 45% (n=178) were for unexpected deaths. Incidence of death per 1000 beds per year was 20.83 for all, 11.44 for expected and 9.39 for unexpected deaths. Respiratory disease was the most common cause of death, accounting for 38% (n=151) of all deaths. In adjusted negative binomial regression analysis, congregated settings versus non-congregated (incidence rate ratio (95% CI): 2.59 (1.80 to 3.73)) and higher bed numbers (highest vs lowest quartile) (4.02 (2.19 to 7.40)) were positively associated with mortality. There was also a positive n-shaped association with category of nursing staff-to-resident ratio when compared with zero nurses. Emergency services were contacted for 6% of expected deaths. Of the deaths reported as unexpected, 29% were receiving palliative care and 10.8% had a terminal illness.

CONCLUSION

Although incidence of death was low, residents of congregated and larger settings had higher incidence of death than residents of other settings. This should be a consideration for practice and policy. Given the high contribution of respiratory diseases to deaths and the potential avoidability of these, there is a need for improved respiratory health management in this population. Nearly half of all deaths were reported as unexpected; however, overlap in the characteristics of expected and unexpected deaths highlights the need for clearer definitions.

Disability type–specific mortality patterns and life expectancy among disabled people in South Korea using 10-year combined data between 2008 and 2017

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People with any disabilities accounted for a quarter of total deaths.

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People with disabilities had higher average ages and poor economic conditions.

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All disability types presented higher mortality rates and lower life expectancy.

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The major causes of death differed according to the type of disability.

People with disabilities have a higher mortality risk than non-disabled people. However, mortality patterns and life expectancy according to disability types are under-researched. This study investigated the sociodemographic characteristics and compared mortality and life expectancy among people with disabilities according to disability type in Korea using 10-year combined data between 2008 and 2017. The National Health Information Database from the National Health Insurance Service covering the total Korean population between 2008 and 2017 was obtained. This study described the age and income distributions of people with disabilities and calculated the mortality rate, proportional mortality ratio, and life expectancy according to disability type. Most disability subgroups had higher average ages than were found for non-disabled people. The proportion of the bottom 20% household income group was also higher in all types of disabilities than in non-disabled people. The crude mortality rate, age-standardized mortality rate, and life expectancy were all worse in people with all types of disabilities than in their non-disabled counterparts, but variations according to disability type were found. The composition of causes of death also varied across disability types. Although all types of disabilities were associated with higher mortality rates and lower life expectancy, the sociodemographic characteristics and mortality and life expectancy patterns differed across types of disability. People with disabilities experienced various health-related problems and financial burdens. Public assistance needs to be strengthened to guarantee adequate income and health care services for people with disabilities, considering their sociodemographic characteristics and mortality patterns.

Transforming Private Pensions: An Actuarial Model to Face Long-Term Costs

A common response in public pension systems to population ageing is to link pensions to observed longevity. This creates an automatic stabiliser that arises from the valuation of a private actuarially funded system. However, no private pension plan mechanism has been articulated to adapt to this ageing in relation to the increased costs it entails. Private pension plans focus on saving for retirement; capital is accumulated to pay for it. However, perceptions of health status change over time and, as retirement age approaches, concerns about long-term care (LTC) increase. Moreover, there is not enough time to plan for it sufficiently in advance. This paper proposes to incorporate a mechanism to add an allowance to the financial pension (retirement, disability, rotation) to cover LTC within a private defined benefit pension plan, in the case of a pensioner becoming dependent. Depending on a pensioner’s health status, both the expected number of payments and their intensity are transformed. For this purpose, a mechanism is defined (through Markov chains) to adapt the amount of LTC support to a beneficiary’s health-related life expectancy. The study’s main contribution is that it establishes a private pension plan model that offers to incorporate dependency aid through this mechanism into the economic pensions without increasing the total cost of the plan. It adapts to life expectancy according to a person’s state (healthy, disabled, dependent).

Mortality rate and cause among people with intellectual disabilities in South Korea: A nationwide representative cross-sectional study from 2015 to 2019

People with intellectual disabilities (ID) age faster and have a higher prevalence of degenerative diseases. The aim of this study was to identify the patterns/ causes of death among people with ID. We conducted a nationwide, retrospective, cross-sectional study of people with ID in South Korea. The database was compiled by merging data of people registered with ID, based on the 2015-2019 Standards from the Ministry of Health and Welfare, with the cause of death data published by the Korea National Statistical Office. The International Classification of Diseases-10 (ICD-10) was used to categorize causes of death. The mortality and standardized mortality rates were calculated and major causes of death were analyzed. As of 2019, the mortality rate of people with ID in South Korea was 784.6. The rate showed an irregular pattern, increasing or decreasing year by year (increasing from 725 in 2015 to 834 in 2018). The mortality rate of people with ID was approximately 1.4 times higher than the general population; the standardized mortality rate was 3.2 times higher. The main causes of death (48%) in people with ID were, in order of prevalence, circulatory diseases (cerebrovascular disease), neoplasms (malignant neoplasms of the digestive system), and diseases of the respiratory system (pneumonia). The leading causes of death (>60%) in the general population were, in order of prevalence, neoplasms, diseases of the circulatory system, and respiratory system diseases. An accurate understanding of the causes of death of people with ID is important to promote the development and application of health promotion programs and management thereof.

Association of disability with mortality in the Spanish adult non-institutionalised population

BACKGROUND

There are scant studies focused on measuring the association between disability and all-cause mortality based on large representative national samples of the community-dwelling adult population; moreover, the number of such studies which also include cause-specific mortality is yet lower.

METHODS

Longitudinal cohort study that used baseline data from 162 381 adults who participated in a countrywide disability survey (2008). A nationally representative sample was selected and interviewed in their homes. We present data on people ≥18 years. Disability was considered as any substantial limitation found on a list of 44 life activities that have lasted or are expected to last more than 1 year and originate from an impairment. Cause-specific mortality data were obtained from the Spanish Statistical Office. Subjects contributed follow-up time from baseline interview until death or the censoring date (31 December 2017). We computed standardised rate ratios (SRRs), with age, sex, living with a partner and education level distribution of the total group as standard population.

RESULTS

Adults with disability (11%) had an adjusted mortality rate more than twice as high as adults without disability (SRR 2.37, 95% CI 2.24 to 2.50). The increased mortality risk remained over the 10-year follow-up period. Mortality due to diseases of the nervous system (SRR 4.86, 95% CI 3.93 to 6.01), diseases of the musculoskeletal system (SRR 3.45, 95% CI 2.18 to 5.47), infectious diseases (SRR 3.38, 95% CI 2.27 to 5.01) and diabetes mellitus (SRR 3.56, 95% CI 2.71 to 4.68) was particularly high in those with disability.

CONCLUSIONS

All-cause mortality rates are markedly higher among adults with disability. Preventive measures and health promotion initiatives are needed to reduce mortality risk in this population. Special attention should be paid to disabled people with certain specific diseases.

Estimation of Life Expectancy for Dependent Population in a Multi-State Context

Population statistics show that there was an increase in life expectancy during the last century. However, this fact hides that this increase was not equal for all groups of the population. One of the most problematic cases for measuring this increase is that of the dependent population because of the absence of specific statistics. This paper describes a methodology for calculating life expectancy using multistate models that take into account the diversity of situations considered by Spanish legislation. For this purpose, statistical information contained in the national survey on disability and dependency (EDAD 2008) is used. The results suggest that life expectancies are lower than those of the general population and that they differ according to gender and intensity of suffering from this contingency. The calculations were made considering the legal framework currently existing in Spain. This fact conditions the definition of dependent person and, therefore, the set of individuals, their characteristics, and therefore, their final results.

The relationship between disability and clinical outcomes in maintenance dialysis patients

BACKGRUOUND

Dialysis patients are prone to having disabilities. We aimed to evaluate the association between disability and various clinical outcomes in Korean dialysis patients.

METHODS

This study consisted of 1,615 dialysis patients from 27 centers. We evaluated disability by using four questions on the activities of daily living (ADLs) concerning whether help was needed for feeding, dressing/undressing, getting in/out of bed, or taking a bath/shower. We divided the patients into three groups: no disability (Non-D, none of the four ADL domains required help; n=1,312), mild disability (Mild-D, one ADL domain required some/full help; n=163), or moderate to severe disability (MS-D, two or more ADL domains required some/full help; n=140). We evaluated falls, frailty, health-related quality of life (HRQoL), mortality, and hospitalization.

RESULTS

The numbers of participants with a fall during the last 1 year were 199 (15.2%), 42 (25.8%), and 44 (31.4%) in the Non-D, Mild-D, and MS-D groups, respectively (p<0.001). The numbers of participants with frailty in the Non-D, Mild-D, and MS-D groups were 381 (29.0%), 84 (51.5%), and 93 (66.4%), respectively (p<0.001). In both univariate and multivariate analyses, the physical component scale and mental component scale scores decreased as the grade of disability increased (p<0.001 for both scores). Hospitalization-free survival rate at 500 days was 64.2%, 56.7%, and 51.1% in the Non-D, Mild-D, and MS-D, respectively (p=0.001 for trend). Patient survival rate at 500 days was 95.3%, 89.5%, and 92.3% in the Non-D, Mild-D, and MS-D, respectively (p=0.005 for trend).

CONCLUSION

Disability was associated with falls, frailty, HRQoL scales, and survival trends in Korean dialysis patients.

Self-reported disability in relation to mortality in rural Malawi: a longitudinal study of over 16 000 adults

OBJECTIVES

We investigated whether self-reported disability was associated with mortality in adults in rural Malawi.

SETTING

Karonga Health and Demographic Surveillance Site (HDSS), Northern Malawi.

PARTICIPANTS

All adults aged 18 and over residing in the HDSS were eligible to participate. During annual censuses in 2014 and 2015, participants were asked if they experienced difficulty in any of six functional domains and were classified as having disabilities if they reported 'a lot of difficulty' or 'can't do at all' in any domain. Mortality data were collected until 31 December 2017. 16 748 participants (10 153 women and 6595 men) were followed up for a median of 29 months.

PRIMARY AND SECONDARY OUTCOME MEASURES

We used Poisson regression to examine the relationship between disability and all-cause mortality adjusting for confounders. We assessed whether this relationship altered in the context of obesity, hypertension, diabetes or HIV. We also evaluated whether mortality from non-communicable diseases (NCD) was higher among people who had reported disability, as determined by verbal autopsy.

RESULTS

At baseline, 7.6% reported a disability and the overall adult mortality rate was 9.1/1000 person-years. Adults reporting disability had an all-cause mortality rate 2.70 times higher than those without, and mortality rate from NCDs 2.33 times higher than those without.

CONCLUSIONS

Self-reported disability predicts mortality at all adult ages in rural Malawi. Interventions to improve access to healthcare and other services are needed.

Psychiatric disorders and suicide risk among adults with disabilities: A nationwide retrospective cohort study

BACKGROUND

Adults with disabilities demonstrate a higher suicide risk than the general population; however, the association between mental illness and death by suicide among disabled adults remains relatively unknown. We aimed to explore the relationship between psychiatric disorders and suicide risk in adults with disabilities.

METHODS

We used nationally representative cohort data and included adults who registered as having a disability from 2004 to 2012, following up with them throughout 2013. We used the clinical diagnoses of all psychiatric disorders as an independent variable and death by suicide as a dependent variable to estimate the adjusted hazard ratio (AHR) of suicide risk using a Cox proportional hazards model.

RESULTS

Among adults with disabilities (n = 30,386), those who had any psychiatric disorder were at an increased risk of death by suicide compared to those without mental illness (AHR 1.42; 95% confidence interval [CI] 1.02-1.99). Adults with mild disabilities who had psychiatric or mood disorders were more likely to commit suicide than the comparison group (AHR 1.67, 3.00; 95% CI 1.13-2.46, 1.95-4.61, respectively).

LIMITATIONS

The actual time of disability onset could differ from the time of disability registration.

CONCLUSIONS

Adults with disabilities who have psychiatric disorders are at increased risk of suicide compared to those without mental illness. During rehabilitation treatment after disability diagnosis, mental health support should be provided to those who have psychiatric illnesses to potentially reduce the risk of death by suicide.

The Life Expectancy Gap between Registered Disabled and Non-Disabled People in Korea from 2004 to 2017

This study aimed to estimate and compare life expectancy at birth among people with and without officially registered disabilities in Korea between 2004 and 2017. We used the National Health Information Database in Korea to obtain aggregate data on the numbers of population and deaths according to calendar year (2004 to 2017), sex, age groups, and officially registered disability status. A total of 697,503,634 subjects and 3,536,778 deaths, including 33,221,916 disabled subjects (829,464 associated deaths), were used to construct life tables. Between 2004 and 2017, life expectancy for people with disabilities increased by 9.1 years in men and 8.3 years in women, while life expectancy for the non-disabled increased by 5.5 years in men and 4.6 years in women. The average life expectancy difference between non-disabled and disabled people was 18.2 years during the study period, decreasing from 20.4 years in 2004 to 16.4 years in 2017. In 2017, the life expectancy of people with the most severe grade of disabilities was 49.7 years, while the life expectancy of people with the least severe grade of disabilities was 77.7 years. The government should implement more effective policies to protect the health of people with officially registered disabilities.