National health objectives for the year 2000: the demographic impact of health promotion and disease prevention

Health Expectancy

This article presents a methodologic framework for a disability-adjusted life expectancy (DALE), an extended and enhanced variety of the common health expectancy indicator. The DALE is based on a causal link running from risk factors through diseases and disability to mortality. This causal link allows the DALE to be used for evaluation of potential interventions and analysis of observed trends. The DALE methodology consists of a combination multistate life table with explicitly modeled disease processes and disease-specific disability weights. In this article, two illustrations are presented: the impact on the DALE of trends in cardiovascular disease epidemiology and the benefits of nonsmoking. Two problems of the DALE are discussed: estimating "all other causes" disability and the presence of comorbidity.

The effect of different public health interventions on longevity, morbidity, and years of healthy life

BACKGROUND

Choosing cost-effective strategies for improving the health of the public is difficult because the relative effects of different types of interventions are not well understood. The benefits of one-shot interventions may be different from the benefits of interventions that permanently change the probability of getting sick, recovering, or dying. Here, we compare the benefits of such types of public health interventions.

METHODS

We used multi-state life table methods to estimate the impact of five types of interventions on mortality, morbidity (years of life in fair or poor health), and years of healthy life (years in excellent, very good, or good health).

RESULTS

A one-shot intervention that makes all the sick persons healthy at baseline would increase life expectancy by 3 months and increase years of healthy life by 6 months, in a cohort beginning at age 65. An equivalent amount of improvement can be obtained from an intervention that either decreases the probability of getting sick each year by 12%, increases the probability of a sick person recovering by 16%, decreases the probability that a sick person dies by 15%, or decreases the probability that a healthy person dies by 14%. Interventions aimed at keeping persons healthy increased longevity and years of healthy life, while decreasing morbidity and medical expenditures. Interventions focused on preventing mortality had a greater effect on longevity, but had higher future morbidity and medical expenditures. Results differed for older and younger cohorts and depended on the value to society of an additional year of sick life.

CONCLUSION

Interventions that promote health and prevent disease performed well, but other types of intervention were sometimes better. The value to society of interventions that increase longevity but also increase morbidity needs further research. More comprehensive screening and treatment of new Medicare enrollees might improve their health and longevity without increasing future medical expenditures.

Achieving national health objectives: the impact on life expectancy and on healthy life expectancy

Our study quantifies the impact of achieving specific Healthy People 2010 targets and of eliminating racial/ethnic health disparities on summary measures of health. We used life table methods to calculate gains in life expectancy and healthy life expectancy that would result from achievement of Healthy People 2010 objectives or of current mortality rates in the Asian/Pacific Islander (API) population. Attainment of Healthy People 2010 mortality targets would increase life expectancy by 2.8 years, and reduction of population wide mortality rates to current API rates would add 4.1 years. Healthy life expectancy would increase by 5.8 years if Healthy People 2010 mortality and assumed morbidity targets were attained and by 8.1 years if API mortality and activity limitation rates were attained. Achievement of specific Healthy People 2010 targets would produce significant increases in longevity and health, and elimination of racial/ethnic health disparities could result in even larger gains.

Mortality, health services use, and health behavior in a cohort of well older adults

OBJECTIVES

To construct an evidence-based Good Health Behavior Score and examine the relationship between aggregate health behaviors, mortality, and health services utilization in the last year of life in a cohort of well older adults.

DESIGN

A prospective cohort.

SETTING

A large health maintenance organization.

PARTICIPANTS

1867 older enrollees who responded to a health promotion survey.

MEASUREMENTS

A baseline self-administered questionnaire was used to ascertain health behaviors in 1987-1988, and vital status was determined 48 months later. A Good Health Behavior Score was calculated, and a Cox proportional hazards model was used to compare high, middle, and low score groups regarding risk of death. For those who died, differences in amount and type of health services utilization in relation to the summary score were compared for the year before death.

RESULTS

During the 4 years of follow-up, the mortality rate for the mid-level score group was 50% less, and in the highest score group was 70% less, than in the lowest score group. Among decedents, no significant differences were found between high and low Good Health Behavior score groups for inpatient and outpatient utilization, pharmacy use, or total cost during the last year of life.

CONCLUSION

An easily developed and simple health behavior score can predict short term mortality quite strongly. Medical care costs in the last year of life were similar in individuals with higher and lower health behavior scores.