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Changing mortality patterns in East and West Germany and Poland. II: short-term trends during transition and in the 1990s.

OBJECTIVES: To examine trends in life expectancy at birth and age and cause specific patterns of mortality in the former German Democratic Republic (GDR) and Poland during political transition and throughout the 1990s in both parts of Germany and in Poland. METHODS: Decomposition of life expectancy by age and cause of death. Changes in life expectancy during transition by cause of death were examined using data for 1988/89 and 1990/91 for the former GDR and Poland; examination of life expectancy changes after transition were based on 1992-97 data for Germany and 1991-96 data for Poland. RESULTS: In both the former GDR and Poland male life expectancy at birth declined by almost one year during transition, mainly attributable to rising death rates from external causes and circulatory diseases. Female life expectancy in Poland deteriorated by 0.3 years, largely attributable to increasing circulatory mortality among the old, while in East German female rising death rates in children and young adults were nearly outbalanced by declining circulatory mortality among those over 70. Between 1991/92 and 1996/97, male life expectancy at birth increased by 2.4 years in the former GDR, 1.2 years in old Federal Republic, and 2.0 years in Poland (women: 2.3, 0.9, and 1.2 years). In East Germany and Poland, the overall improvement was largely attributable to falling mortality among men aged 40-64, while those over 65 contributed the largest proportion to life expectancy gains in women. The change in deaths among men aged 15-39 accounted for 0.4 of a year to life expectancy at birth in East Germany and Poland, attributable largely to greater decreases from external causes. Among those over 40, absolute contributions to changing life expectancy were greater in the former GDR than in the other two entities in both sexes, largely attributable to circulatory diseases. A persisting East-west life expectancy gap in Germany of 2.1 years in men in 1997 was largely attributable to external causes, diseases of the digestive system and circulatory diseases. Higher death rates from circulatory diseases among the elderly largely explain the female life expectancy gap of approximately one year. CONCLUSIONS: This study provides further insights into the health effects of political transition. Post-transition improvements in life expectancy and mortality have been much steeper in East Germany compared with Poland. Changes in dietary pattern and, in Germany, medical care may have been important factors in shaping post-transition mortality trends.

Adolescent↗

Does geography explain ethnic inequalities in health in New Zealand?

OBJECTIVE: To quantify the potential contribution of inter-district relative to intradistrict variation to the Maori disparity in life expectancy in 2000-02, by counterfactual modelling. SETTING, DATA SOURCES AND METHODS: The setting was New Zealand's 21 health districts (District Health Boards, DHBs). All data (population estimates and life expectancy estimates) were sourced from Statistics New Zealand and relate to the 2000-02 period. Maori life expectancy (nationally) was recalculated under the counterfactual that Maori life expectancy in each DHB did not differ from total population life expectancy in the corresponding DHB (so eliminating intra-district variation). The difference between the observed total population and counterfactual Maori life expectancies therefore represents the contribution of inter-district variation to the Maori life expectancy disparity. RESULTS: Observed total population and Maori life expectancies at birth in 2000-02, pooling sexes, were 78.7 and 71.1 years respectively, giving a total disparity of 7.6 years. Under the counterfactual, Maori life expectancy increased to 78.4 years (and total population life expectancy to 79.0 years). Inter-district variation was therefore estimated to potentially contribute only 0.6 years or 8% to the total Maori disparity. Allowing for imprecision, inter-district variation almost certainly accounts for less than 10.5% of the total disparity. CONCLUSION: Inter-district or geographic variation makes only a small contribution to the total Maori disparity in life expectancy. Adjustment or standardisation for district is not necessary when comparing Maori and non-Maori health outcomes. If the policy goal is to reduce ethnic inequalities in health, then the focus of policy (e.g. funding formulae) needs to be on factors directly linked to ethnicity, rather than on geographic variations in health and health care that have an impact on all ethnic groups more-or-less alike.

Aged↗

Using renal transplantation to evaluate a simple approach for predicting the impact of end-stage renal disease therapies on patient survival: observed/expected life span.

The effectiveness of therapy for a chronic disease can be assessed by evaluating the length of time that a patient survives after receiving treatment. We used a novel means for measuring the effectiveness of renal replacement therapy for patients with end-stage renal disease (ESRD): the ratio of observed life span divided by expected life span. This ratio incorporated observed life span for patients from the time of ESRD and expected life span based on state-specific life-table analyses. A total of 3,782 individuals with ESRD were analyzed (average follow-up, 14.2 +/- 4.9 years); 3, 192 patients in that group received a kidney transplant at some point during their course of ESRD. For each patient, we determined a curve of observed/expected life span. Separate patient groups were analyzed to determine the median population observed/expected life span or the percentage of patients who reached 0.5 observed/expected life span. Younger transplant recipients (<21 years) had a median observed/expected life span of 67%, significantly greater than the median observed/expected life span for those aged 21 to 40 years (49%; P = 0.01) and 41 to 60 years (47%; P = 0.01). Surprisingly, 57% of the patients aged older than 60 years reached their median observed/expected life span (P = 0.02 versus <21 years; P = not significant against all others). A Cox proportional hazards model identified era of immunosuppression (hazards ratio, 0.32) and atherosclerotic vascular disease-related ESRD (hazards ratio, 2.07) as significant variables influencing patient survival and observed/expected life span. This simple ratio is easy to use and may be a helpful tool for assessing the survival benefits of risk-factor modifications and therapeutic advances in transplantation and ESRD care.

Adult↗

Policy goals for health and safety.

Health management and safety regulation are separate disciplines but share the aim to extend expectancy of life in good health. The need to improve cost-effectiveness calls for their co-ordinated management according to a unified rationale. Three guiding principles of accountability, demonstrable net benefit and a uniform measure of performance, have been laid out in Canada by the Joint Committee on Health and Safety. They call for open accounting in terms of (health-related quality-adjusted) life expectancy. The principles are utilitarian in format but, it is argued, inequity is naturally diminished in the process of optimizing cost-effectiveness through maximum marginal returns. Comments are made on practical implementation. The need for public consent in practice calls for two additional principles reflecting fair procedure and sovereignty of the citizens. It is concluded that public health and safety measures should be surveyed, documented for cost-effectiveness and prioritized for improvement.

Canada↗

The effects of pharmaceutical consumption and obesity on the quality of life in the organization of economic cooperation and development (OECD) countries.

OBJECTIVE: The objective of this study is to validate our earlier work on life expectancy with more recent data and, more importantly, to extend it to examine quality of life, not only the length of life. DESIGN AND SETTING: The analysis focuses on the production of health, disaggregating healthcare into pharmaceutical consumption and other healthcare. Going beyond our earlier work, measures of health include life expectancy and disability-adjusted life expectancy (DALE). Also, we consider the impact of obesity. The sample was 18 Organization of Economic Cooperation and Development (OECD) countries. The measure of pharmaceutical consumption is the best that is available for these countries. MAIN OUTCOME MEASURES AND RESULTS: Confirming our earlier work, pharmaceutical consumption has a positive and statistically significant effect on life expectancy at 40 and 60 years (significant at the 0.05 level, based on a two-tailed test). The effects are slightly larger than in the earlier work. Turning to DALE, pharmaceutical consumption has a positive and statistically significant effect at birth and at 60 years (significant at the 0.05 and 0.01 levels, respectively), based on a two-tailed test. The effects on DALE are larger than the effects on life expectancy. CONCLUSIONS: Increased pharmaceutical consumption helps improve quality of life, as well as life expectancy.

Developed Countries↗

Sex-specific trends in mortality for the aging population in Norway: a model with age, period, and cohort effects.

During the last few decades, the citizens of most western countries have experienced an increased expectation of life. The rate of this change differs for males and females. We evaluated reasons for this pattern, using a Poisson model, with age, period, and cohort effects applied to vital statistics data from the Central Bureau of Statistics of Norway. The data comprised the total Norwegian population aged 45 to 104 years who died in the period from 1966 until 1986. Differential changes in life expectancy for the elderly are explained by differences in sex-specific cohort effects. We also observed an extra-Poisson variation, or overdispersion, in the distribution for females.

Age Factors↗

Changing mortality patterns in East and West Germany and Poland. I: long term trends (1960-1997)

OBJECTIVES: To examine the long term evolution of mortality in the former German Democratic Republic (GDR) in the period from 1960 and its specific position in health terms compared with the Federal Republic (FRG) in the west and Poland in the east. METHODS: Decomposition of life expectancy by age and cause of death. Differences in life expectancy at birth between the former GDR and the old FRG were decomposed by age using data on all cause mortality for the period 1960 to 1997. Changes in life expectancy over time by cause of death were examined using data for 1974 and 1989 for both parts of Germany and for 1974 and 1988 for Poland. RESULTS: Male life expectancy in the two parts of Germany diverged twice, in the mid-1960s, favouring the GDR, and in the mid-1970s, giving increasing advantage to the FRG, while female life expectancy remained similar until the mid-1970s and began to diverge thereafter. The initial advantage of the GDR was mainly attributable to an improving mortality rate among children compared with that in the west in both sexes. During the 1980s, mortality among men over 15 and women over 40 steadily worsened relative to their western counterparts, although men were doing considerably better than those in Poland who actually experienced deterioration. In the FRG, falling death rates among adults of all ages have contributed substantially to the improvement in life expectancy between 1974 and 1989, largely attributable to falling deaths from cardiovascular disease and from injuries at younger adult ages. In Poland, death rates among male adults have risen at all ages over 35, mostly attributable to worsening death rates from cardiovascular disease and neoplasms while women experienced stagnation. The GDR showed a small worsening among men under 60, counterbalanced by improvements among those over 60, and some improvement in women, attributable to falling deaths from cardiovascular disease among the middle aged and elderly. CONCLUSIONS: This study provides further evidence for the complexity of the east-west mortality differential emerging in the 1960s in Europe, highlighting the intermediate position in health terms the former GDR occupied during much of the communist period. Further research is required to assess the underlying causes for the specific position of the former GDR between east and west.

Adolescent↗

Prophylaxis for disseminated Mycobacterium avium complex (MAC) infection in patients with AIDS: a cost-effectiveness analysis.

OBJECTIVE: To determine the effectiveness and costs of prophylaxis for disseminated Mycobacterium avium complex (MAC) infection in patients with AIDS. DESIGN: A decision analysis model was constructed to compare rifabutin (300 mg/day), azithromycin (1200 mg/week), and clarithromycin (500 mg twice per day) with no prophylaxis. Sensitivity analysis was done on all model parameters, including initial CD4 count for beginning prophylaxis. SETTING: The setting was hypothetical for the cost-effectiveness model. Clinical data were taken from published prospective randomized controlled trials. MAIN OUTCOME MEASURES: Outcomes were measured in terms of projected life expectancy, quality-adjusted life expectancy, direct medical costs, and cost-effectiveness in U.S. dollars per quality-adjusted life-year saved ($/QALY). RESULTS: For patients with AIDS and those having CD4 counts <75 cells/mm3, azithromycin, clarithromycin, and rifabutin prophylaxis increased lifetime per person MAC-related costs by $994, $2,117, and $2,185 U.S., respectively. Quality-adjusted life expectancy increased from 1.6068 QALYs to between 1.6186 and 1.6255 QALYs. The cost-effectiveness ratios were $58,200, $116,000, and $179,100/QALY saved for azithromycin, clarithromycin, and rifabutin prophylaxis, respectively, each compared with no prophylaxis. Results were most dependent on the annual cost of prophylaxis, the initial CD4 count when starting prophylaxis, and any survival benefit with prophylaxis. For each type of prophylaxis, strategies beginning with CD4 counts <25 or 50 cells/mm3 were substantially more cost-effective than those beginning in patients with higher CD4 counts. CONCLUSIONS: MAC prophylaxis is likely to cost society an additional $99 to $219 million U.S. per 100,000 patients treated. In the context of Centers for Disease Control and Prevention (CDC) recommendations to use prophylaxis in patients with CD4 counts <75 cells/mm3, azithromycin represents the best value and is most cost-effective when used in patients with CD4 counts <25 cells/mm3.

AIDS-Related Opportunistic Infections↗

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

BACKGROUND: The national objectives in Healthy People 2000, drafted by health professionals aware of currently available public health interventions, represent a wealth of information about near-term future mortality and morbidity. METHODS: Life table methods were used to calculate the impact of projected changes in mortality and activity limitation rates on life expectancy and expected disability years. RESULTS: Meeting the mortality objectives would increase life expectancy at birth by 1.5 to 2.1 years, raising life expectancy to 76.6 to 77.2 years. In addition, meeting the target for disability from chronic conditions would increase the number of years of life without activity limitations from 66.8 years to 69.3-69.7 years. If the targets for coronary heart disease and unintentional injury were changed to reflect recent trends, a greater improvement in life expectancy at birth would be achieved: from 1.8 to 2.7 years to 76.9 to 77.8 years. CONCLUSION: Meeting the targets would have an important demographic impact. Including changes in the coronary heart disease and injuries targets, life expectancy in the year 2000 would be above the middle of the ranges used in current Census Bureau projections.

Aged↗

Evolution of all-cause and cause-specific mortality in the age-class 75-84 years during the period 1970-1996. A worldwide overview.

The mean age of nearly all industrialised populations is increasing, due to a lower birth rate and increased expectation of life. The calendar age, however, does not equal biological age. At all ages below 85 years subjects now have higher life expectancies than e.g. 40 years ago. In the age class 75-84 years, during the period 1970-latest available year (around 1996), important decreases in all-cause and cardiovascular mortalities occur both from ischemic heart disease and cerebrovascular disease, with the exception of Eastern Europe. Gompertz equations demonstrate that all-cause mortality in the age class 75-84 years cannot be isolated from groups age classes above age of 35 years since the R2 of the equations > 0.99 in all countries. In the age class 75-84 years cancer mortality increased in a majority of countries: as a result the decline in mortality is nearly exclusively due to a decrease in non-cancer mortality especially cardiovascular mortality. A passive attitude towards the possibility of influencing all-cause mortality in the age class 75-84 years is not warranted.

Aged↗

The significance of quality of life in health care.

This paper compares a traditional biomedical model with an outcomes model for evaluating health care. The traditional model emphasizes diagnosis and disease-specific outcomes. In contrast, the outcomes model emphasizes life expectancy and health-related quality of life. Although the models are similar, they lead to different conclusions with regard to some interventions. For some conditions, diagnosis and treatment may reduce the impact of a particular disease without extending life expectancy or improving quality of life. Older individuals with multiple co-morbidities may not benefit from treatments for a particular disease if competing health problems threaten life or reduce quality of life. In preventive medicine, diagnosis of disease is made more difficult because of ambiguity, uncertainty, lead-time bias, and length bias. In some circumstances, successful diagnosis and treatment may actually reduce life expectancy or overall life quality. Example applications of the outcomes model from clinical policy analysis, individual decision making and shared decision-making are offered. The outcomes model has received little attention in dental health care but may have parallels to applications in other areas of medicine.

Decision Making↗

Reducing health disparity in Taiwan: quantifying the role of smoking.

OBJECTIVE: To assess the impact of smoking disparities on health disparities, in terms of gap in life expectancy, in Taiwan cities and counties. METHODS: Using the decomposition method of life expectancy, the contribution of each disease category to the life expectancy gap was quantitatively expressed as the number of years of life. The smoking attributable fraction (SAF) was calculated for each city and county based on their respective smoking prevalence and relative risk for each smoking related disease. The smoking attributable gap (SAG) in life expectancy between two sites is the sum of the difference in SAF between two sites for each smoking related disease multiplied by the number of years this disease contributed to the life expectancy gap. RESULTS: Significant health and smoking disparities were present among the 23 cities and counties in Taiwan. These health disparities and smoking disparities were highly correlated (R2 = 0.3676). Generally, the health gap increased with increasing smoking disparity. The disparity in smoking prevalence and intensity among cities and counties in Taiwan was responsible for up to 19% of the health disparity. The health disparity is also highly correlated (R2 = 0.3745) with SAG in life expectancy. CONCLUSIONS: Reducing smoking is important to health, and reducing the smoking disparity is also important for reducing the health disparity observed in Taiwan. The larger the health disparity is, the more important the smoking attributable disparity could be. The reduction of smoking disparities could be a realistic and cost effective way toward reducing health disparities.

Cause of Death↗

Health expectancy in the Russian Federation: a new perspective on the health divide in Europe.

OBJECTIVES: To compare life expectancy and healthy life expectancy in the Russian Federation and in countries of Eastern and Western Europe. METHODS: WHO mortality data and data on self-reported health from the World Values Survey and the Russian Longitudinal Monitoring Survey were used to compare the above three regions. Life expectancy was calculated using Sullivan's method, with years of life lived divided into healthy and unhealthy. The gap in healthy life expectancy between the Russian Federation and Western Europe was examined by decomposing the difference by gender and age. FINDINGS: The probability of remaining alive and healthy declines faster in the Russian Federation than in Western Europe, with the gap between Eastern Europe and the Russian Federation widening at older ages. In the Russian Federation, this rapid decline is due mainly to the high probability of death or of poor health for men and women, respectively. CONCLUSIONS: There is a large toll of premature male mortality in the Russian Federation but there also appears to be a substantial burden of ill-health among women. As in other countries, the responses of men and women to adversity differ, leading to premature death in men but survival in a poor state of health in women. Epidemiological studies including objective measures of health would help policy-makers to estimate more precisely the scale and nature of this problem. Policy-makers must recognize that health expectancy in the Russian Federation is reduced in both men and women.

Europe↗

State AIDS Drug Assistance Programs: equity and efficiency in an era of rapidly changing treatment standards.

BACKGROUND: The 54 state AIDS Drug Assistance Programs (ADAP) provide medications to HIV-infected persons with limited resources. Eligibility and coverage vary, raising concerns about health inequities. OBJECTIVE: To compare the relative clinical and economic performance of ADAP programs. RESEARCH DESIGN: A state-transition simulation model of HIV disease was used to explore the clinical consequences and lifetime costs associated with selected state policies. Clinical data came from the Multicenter AIDS Cohort Study, AIDS Clinical Trials Group Protocol 320, and other published randomized trials. Cost data came from the national AIDS Cost and Services Utilization Survey, and the 1999 Red Book. ADAP data came from National Association of State and Territorial AIDS Directors reports and interviews. MEASURES: Projected life expectancy, quality-adjusted life expectancy, total lifetime direct medical costs, cost-effectiveness in dollars per quality-adjusted life year (QALY) gained. RESULTS: ADAPs vary considerably in terms of formulary policies, health outcomes, expected costs, and cost-efficiency. Conservative projections, based on a cohort with starting mean CD4 count of 250 cells/microL, yield life expectancies ranging from 5.36 to 6.81 life years (4.69-6.01 quality-adjusted life years [QALYs]). Total per person lifetime direct medical costs range from $81,200 to $112,700; higher costs reflect increased spending on medications. Expected costs per QALY gained range from $7000 to $28,000. Under pessimistic assumptions regarding initial CD4 counts, drug efficacy, and discounting, the most comprehensive policy remains below $33,000/QALY. CONCLUSIONS: Even the most comprehensive ADAPs constitute a cost-effective use of HIV care resources. A uniform, national ADAP formulary warrants consideration.

Acquired Immunodeficiency Syndrome↗

The expectation of life without disability in England and Wales.

This paper calculates the Expectation of Life Without Disability (ELWD) for England and Wales, following the method of Robine et al. (Population 6, 1025-1042, 1986), using a question about limiting long-standing illness from the General Household Survey. Trends over the last decade are estimated. At present ELWD from birth is about 59 years for men, 62 for women. The trend is upward, but by no more and possibly less than the rate of increase in expectation of life. Men live a greater proportion of their lives without disability than do women. The improvement in ELWD is most marked in the highest age-groups, but the evidence is that the health of the elderly in relation to that of the population as a whole has been poorer in England and Wales than in two other countries for which similar evidence is available.

Activities of Daily Living↗

Acarbose in addition to existing treatments in patients with type 2 diabetes: health economic analysis in a German setting.

OBJECTIVE: A recent retrospective meta-analysis of cardiovascular events from long-term studies with acarbose in type 2 diabetes showed that treatment was associated with a significant reduction in the risk of cardiovascular events, supporting the hypothesis that postprandial hyperglycemia is a risk factor for cardiovascular disease. The aim of the present study was to assess the cost-effectiveness of acarbose, given in addition to existing treatments, in type 2 diabetes patients, based on these findings, in the German setting. METHODS: The CORE Diabetes Model, a published, validated computer simulation model, was used to project long-term clinical and cost outcomes in type 2 diabetes patients receiving acarbose or placebo in addition to existing treatments. Direct costs were retrieved from published sources and projected over patient lifetimes from a third party payer perspective. Costs and clinical benefits were discounted at 5% annually. Extensive sensitivity analyses were performed. RESULTS: Acarbose treatment was associated with improvements in discounted life expectancy (0.21 years) and quality-adjusted life expectancy (QALE) (0.19 QALYs) but was on average marginally more expensive than treatment in the placebo arm (euro135 per patient). This led to incremental cost-effectiveness ratios of euro633 per life year and euro692 per quality-adjusted life year gained. Sensitivity analysis showed that these findings were robust under variation in a range of assumptions. CONCLUSIONS: Addition of acarbose to existing treatment was associated with improvements in life expectancy and quality-adjusted life expectancy, and provides excellent value for money over patient lifetimes in the German setting.

Acarbose↗

Epidemiological studies on the expectation of life for cats computed from animal cemetery records.

Based on the Chiang's method, the life table for cats was constructed from the death data of 3936 cats. They died in the Kanto area and were buried in an animal cemetery in Tokyo from June 1981 through May 1982. This life table seems to be the first one for domestic pet cats. The expectation of life for cats was 4.2 years at age 0, 5.0 years at age 1, 5.4 years at age 4, 5.3 years at age 5, 3.5 years at age 10, and 2.2 years at age 15. The maximum age at death was 22 years. From age 0 to age 5, the probability of dying for cats was higher than that for dogs, but over 6 years of age it seemed that Gompertz's equation was applicable to this life table for cats. From these results, if the probability of dying for cats at early ages decreases, the fundamental pattern of dying curve for cats seems to be a similar figure of dogs. The life table was constructed for different breeds and localities. Comparing the expectation of life at age 1 (e1) of the two populations divided by breeds or localities, there was significant difference in the e1 among different localities but not among different breeds. These facts suggest the existence of some factors which may influence the life span of cats among different localities.

Animals↗

Treatment for hepatitis C virus in human immunodeficiency virus-infected patients: clinical benefits and cost-effectiveness.

BACKGROUND: Hepatitis C virus (HCV) is an important cause of liver disease in human immunodeficiency virus (HIV)-infected patients. OBJECTIVE: To assess the cost-effectiveness of alternative management strategies for chronic HCV in co-infected patients with moderate hepatitis. METHODS: A state-transition model was used to simulate a cohort of HIV-infected patients with a mean CD4 cell count of 350 cells/ micro L and moderate chronic hepatitis C stratified by genotype. Strategies included interferon alfa (48 weeks), pegylated interferon alfa (48 weeks), interferon alfa and ribavirin (24 and 48 weeks), pegylated interferon alfa and ribavirin (48 weeks), and no treatment. Outcomes included life expectancy, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios. RESULTS: Treatment for moderate chronic HCV with combination therapy using an interferon-based regimen reduced the incidence of cirrhosis and provided gains in quality-adjusted life expectancy ranging from 6.2 to 13.9 months, depending on genotype. Regardless of genotype, the cost-effectiveness of interferon alfa and ribavirin for patients with moderate hepatitis was lower than $50 000 per QALY vs the next best strategy. With genotype 1, pegylated interferon alfa (vs interferon alfa) and ribavirin therapy provided an additional 1.6 quality-adjusted life-months for $40 000 per QALY. Because treatment is more effective with non-1 genotypes, pegylated interferon (vs interferon alfa) and ribavirin provided only 3 additional quality-adjusted life-months for $105 300 per QALY. For patients who were intolerant of ribavirin, monotherapy with pegylated interferon was always the most cost-effective option. CONCLUSIONS: Combination therapy for moderate hepatitis in coinfected patients will increase quality-adjusted life expectancy and have a cost-effectiveness ratio comparable to that of other well-accepted clinical interventions.

AIDS-Related Opportunistic Infections↗