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UnhealthyLongevityintheUnitedStates
AUGUST|2023
UnhealthyLongevityintheUnitedStates
AStudyofMortalitybyHealthStatus
AUTHORSNataliaS.Gavrilova,Ph.D.
SeniorResearchAssociate
NORCattheUniversityofChicago
nsgavril@
SPONSORSMortalityandLongevityStrategic
ResearchProgramSteeringCommittee
LeonidA.Gavrilov,Ph.D.SeniorResearchScientist
NORCattheUniversityofChicago
lagavril@
CaveatandDisclaimer
TheopinionsexpressedandconclusionsreachedbytheauthorsaretheirownanddonotrepresentanyofficialpositionoropinionoftheSocietyof
ActuariesResearchInstitute,SocietyofActuaries,oritsmembers.TheSocietyofActuariesResearchInstitutemakesnorepresentationorwarrantytotheaccuracyoftheinformation.
Copyright©2023bytheSocietyofActuariesResearchInstitute.Allrightsreserved.
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Copyright©2023SocietyofActuariesResearchInstitute
CONTENTS
Introduction 5
ExecutiveSummary 5
KeyTakeaways 5
AnalysisofKeyTakeaways 6
OtherAnalysisHighlights 7
Section1:DefinitionofHealthyandUnhealthyStatus 8
Section2:TheSourceofInformationonPopulationHealth 9
Section3:ConstructionofPeriodLifeTables 10
3.1LifeTableConstructionforHealthyandUnhealthyIndividuals 11
3.2ComparisonofAge-SpecificDeathRatesbyHealthStatus 12
Section4:MortalityandLifeExpectancyofHealthyandUnhealthySubgroupsoftheU.S.Population 14
4.1GeneralDefinitionsofHealth:Self-RatedHealthandFrailtyIndex 14
4.2SpecificDefinitionsofHealth:MentalConditions,DisabilityandChronicDiseases 16
4.3LifeExpectancyin2010-2014and2015-2018byHealthStatus 23
Section5:MultimorbidityandMortality 26
Section6:PrevalenceofUnhealthyStatusbyRaceandRegion 28
6.1PrevalenceofUnhealthyStatusbyRace 28
6.2PrevalenceofUnhealthyStatusbyRegion 32
Section7:HealthStatusandCausesofDeath 37
7.1MortalitybyCausesofDeath 37
7.2ContributionofCVDandCancertoDifferencesinLifeExpectancy 40
Section8:PrevalencebyHealthStatusduringtheCOVID-19PandemicYears 42
8.1PrevalenceofUnhealthyStatusin2020and2021YearsComparedtoPre-Pandemic2019Year 42
8.2PrevalenceofPoorHealthAmongCOVID-19Survivors 47
Section9:Acknowledgments 52
AppendixA:DataSourceandDataPreparation 54
A.1NHISOverview 54
A.2OverviewofVariablesCollectedintheNHIS 55
A.3DataPreparation 57
AppendixB:MeasuresofHealth.LiteratureReviewandDefinitions 59
B.1MeasuresofGeneralHealth:Self-RatedHealth 59
B.2MeasuresofGeneralHealth:RockwoodFrailtyIndex 59
B.3ListofDeficitstoCalculateFrailtyIndexforNHISSurveysConductedBefore2019 62
B.4SpecificMeasuresofHealthImpairment 64
B.5ListofDeficitstoCalculateFrailtyIndexfortheNHISConductedin2019-2021 66
AppendixC:PeriodLifeTables 67
C.1MethodologyofLifeTableConstruction 67
C.2NotesonLifeTableConstructionforSmallPopulations 70
C.3ValidationofLifeTableConstructionMethod 71
C.4DecompositionMethodofLifeExpectancy 72
AppendixD:LifeTablesExcelFile 74
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AppendixE:Limitations 75
AboutTheSocietyofActuariesResearchInstitute 79
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Copyright©2023SocietyofActuariesResearchInstitute
UnhealthyLongevityintheUnitedStates
AStudyofMortalitybyHealthStatus
Introduction
Thepurposeofthisreportistoquantifydifferencesinmortalityanddiseaseprevalencebyhealthstatus.This
projectwasconductedinresponsetoarequestfromtheSocietyofActuaries(SOA)MortalityandLongevitySteeringCommitteeandisintendedtoassistbothpracticingactuariesandthepublictobetterunderstanddifferencesin
mortalityforpeopleingoodandpoorhealth.
Thisprojectusesfivedefinitionsofunhealthystatus,thefirsttwoofwhicharebroad:(1)poororfairself-rated
healthand(2)FrailtyIndex(FI)valuesequaltoorhigherthan0.2(FI≥0.2).Thethreespecificdefinitionsincluded
(1)mentalconditions,(2)disabilityoractivitylimitationsand(3)presenceofchronicdiseases(basedonalistofninediseases).A“healthy”groupwasalsostudiedforcomparisonpurposes.
TheNationalHealthInterviewSurvey(NHIS),oneofthelargestU.S.healthsurveys,wasusedasasourceofdatafortheU.S.populationhealth.Estimatesofmortalityratesforunhealthyandhealthygroupsofadults(ages45and
over)werestratifiedbysexandperiod.Mortalityestimatesbyhealthstatuswereobtainedfortworecentperiods:2010–2014and2015–2018.Age-specificprevalencebyhealthstatuswasestimatedfor2010–2021toincludeyearsimpactedbyCOVID-19.
Theprojectresultswereexpressedintheformoflifeexpectanciesandlifetablesusingaspectrumofindividualhealthmeasures.
ExecutiveSummary
KEYTAKEAWAYS
1.Incomparingtheunhealthyandhealthygroups,regardlessofdefinitionemployed,mortalitywasmuchworsefortheunhealthygroup.
2.Thementalconditionssubgrouphadworselifeexpectancyatage45versusthedisabilityandthechronicdiseasesubgroups.
3.Personswiththreeormorechronicdiseaseshadasignificantincreaseinmortalityversusindividualswithoneortwochronicdiseases.
4.Theself-ratedhealthdefinitionprovedtobejustasgoodofameasureforbeingunhealthyasthemoresophisticatedFrailtyIndexdefinition,whichisbasedon64healthconditions.
5.AhigherprevalenceofpoorhealthwasfoundamongrespondentswhohavehadCOVID-19versusrespondentsindicatingtheyneverhadCOVID-19.
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ANALYSISOFKEYTAKEAWAYS
Unhealthygroupshavemuchhighermortalityandshorterlifeexpectancythanhealthygroups.Thedifferenceinlifeexpectancyatage45betweenhealthyandunhealthysubgroupsusingboththeFrailtyIndexandself-ratedhealth
measuresexceeds15yearsforbothsetsofdataperiodsandforbothmalesandfemales.
Additionallyinexaminingthethreetypesofspecifichealthimpairments,mentalhealth(memoryimpairments)
resultedinthelargestdecreaseinlifeexpectancyatage45.In2015–2018,thelifeexpectancyestimatesatage45were21yearsformalesand25yearsforfemalescomparedto35yearsformalesand44yearsforfemaleswithoutmemoryimpairments.Althoughdisabilityaccountedforthesecondlargestportionoflifeexpectancydecline,thepresenceofchronicdiseaseshadasmallereffectonthelifeexpectancydecreaseamongunhealthysubgroups.Lifeexpectancyestimatesatage45forpersonshavingandnothavingchronicdiseaseswere31versus40yearsfor
malesand39versus45yearsforfemales(Table7).
Analysisofmortalityforpersonshavingthreediseasesormoreshowedanassociationwithasignificantincreaseinmortality.In2015–2018,lifeexpectancyatage45droppedfrom35yearsformaleswithonediseaseto22yearsformaleswiththreeormorediseases.Forfemales,lifeexpectancyatage45droppedfrom36yearsto28years.
Lifeexpectancyat45forunhealthygroups(accordingtoself-ratedhealthandFrailtyIndex[FI]measures)showedadeclineovertimewiththeexceptionoffemaleshavingFI≥0.2.Malesandfemaleswithmemoryimpairmentsandfemaleswithchronicdiseasesdemonstratedanincreaseoflifeexpectancyat45.Malesandfemaleswithdisabilityandmaleswithchronicdiseaseshowedadeclineinlifeexpectancyat45overtime.Allchangesoflifeexpectancyovertimeweresmallandnotstatisticallysignificantforallstudiedhealthgroups.
Thecomparisonofage-specificmortalitytrajectoriesfoundaremarkablesimilarityintrajectoriesbetween
unhealthygroupsbasedonself-ratedhealthandFrailtyIndexdefinitionsofhealth.Itturnsoutthattheverysimple
definitionbasedonself-ratedhealthproducedvirtuallythesamemortalitytrajectoryasusingafarmoresophisticateddefinitionbasedontheFrailtyIndexwith64health-relatedquestions(seeFigureE1).
FigureE1
AGE-SPECIFICMORTALITYINLOGSCALEFORMALESANDFEMALESIN2015–2018ACCORDINGTODIFFERENT
U.S.Females
——SRH,healthy——SRH,unhealthy
FI<0.2——FI≥0.2
Total
0.100
0.010
0.001
45-4955-5965-6975-7985+
DEFINITIONSOFHEALTH:(1)SELF-RATEDHEALTH(SRH)AND(2)FRAILTYINDEX(FI)WITHCUTOFFEQUALTO0.2
U.S.Males
——SRH,healthy——SRH,unhealthy
FI<0.2——FI≥0.2
Total
0.100
0.010
0.001
45-4955-5965-6975-7985+
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ThisprojectanalyzednewlyreleaseddataonhealthdistributionintheCOVID-19pandemic(2020–2021)andpre-pandemic(2019)years.TheNHISquestionnairesin2019–2021aremarkedlydifferentfromthequestionnairesin2018andearliersurveys.Forthisreason,onlythetrendsinhealthindicatorsusing2019–2021datawerestudied.Thiscomparisonshowedanoticeableincreaseintheprevalenceofmentalconditionsin2021comparedto2019and2020.Nonoticeabledifferenceswereobservedfordisability,chronicdiseases,self-ratedhealthandFrailty
Index.
ThedirecteffectsofCOVID-19onhealthwereanalyzedbycomparingCOVID-19survivorswithrespondentswhohadnothadthisdisease.AsignificantincreasewasseeninpoorhealthamongrespondentseverhavingCOVID-19forthosewithmentalconditions,chronicdiseases,self-ratedhealthandfrailty.ForCOVID-19survivorswitha
disability,COVID-19hadnonoticeableeffectonhealth.
OTHERANALYSISHIGHLIGHTS
Changesinlifeexpectancyofunhealthygroupsbetween2010–2014and2015–2018wereverysmall.Similarly,nodifferencewasfoundintheorderofthelifeexpectanciesforthethreegroupsofunhealthyliveswhenmovingfromage45toage65.
Utilizing2015–2018data,thetotaldifferenceinlifeexpectancybetweenhealthyandunhealthysubgroups
accordingtoself-ratedhealthatage45is18years.Thedecompositionoflifeexpectancyatage45yearsshowedthatofthese18years,deathsduetocancercontributefiveyearsanddeathsduetocardiovasculardisease(CVD)contributefouryearstothedifference.Thus,inthecaseofself-ratedhealth,cancerandCVDdeathscombinedrepresenthalfoftheexcessmortalityatage45.
Thetotaldifferenceinlifeexpectancybetweendisabledandnotdisabledsubgroupsatage45is23years.Ofthese23years,deathsduetoCVDcontributesixyearsanddeathsduetocancercontributefiveyears.Thus,inthecaseofdisability,CVDcontributesslightlymorethancancertodifferencesinlifeexpectancybetweendisabledandnot
disabled(unliketheself-ratedhealth).
Thecomparisonoftheprevalenceofpoorhealthstatusbyraceshowedthatage-specificprevalenceofthe
unhealthygroupwasalmostalwayssignificantlyhigheramongtheBlackorAfricanAmericanpopulation(hereafterBlackwillbeusedforbrevity)comparedtothewhitepopulation.Overall,age-specificprevalenceofunhealthy
groupsishigheramongtheBlackpopulationcomparedtothewhitepopulationforallstudieddefinitionsofhealth.
DifferencesinprevalenceofpoorhealthstatusbetweentheBlackandwhitepopulationswerehigherwhenusingtheself-ratedhealthmeasureforunhealthystatusthanwhenusingmoreobjectivemeasuresofunhealthystatussuchaschronicdiseasesanddisability.Prevalenceofunhealthystatusforthe“Other”racialgrouptendstobe
closertothewhitepopulationatyoungeragesandtotheBlackpopulationatolderages.
ThestudyofprevalenceaccordingtohealthstatusbyregionshowedsomewhathigherprevalenceofunhealthygroupsintheSouthregioncomparedtootherregions.Thisobservationagreeswithexistingreportsofhighermortalityandlowerlifeexpectancyinthisregion.
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Section1:DefinitionofHealthyandUnhealthyStatus
Thepurposeofthisprojectwas“toanalyzedifferencesinmortalitypatternsandtrendsbetweenhealthyand
unhealthylivesintheU.S.”asformulatedinthecallbytheSocietyofActuary(SOA)forproposals.Toanalyzethe
mortalityofhealthyandunhealthyindividualsitisimportanttodefinehealth.Manyapproachescouldbefoundforsuchdefinitions.Definitionsofhealthcanconsidermultipledimensions,ortheycanbebasedonasingle
dimension(Crimmins2015).TheFrailtyIndex(FI)isanexampleofamultidimensionalmeasureofhealth
encompassingindicatorsofdisability,diseaseandriskfactors.Similarly,self-ratedhealthisabroadmeasureof
health,butitisbasedonanindividual’sperception,andweassumepeopleincludeallofthesefactorsintheir
assessment.Anotherapproachistoconsideronedimensionofhealthatatime,suchasdisability,mentalconditionsorthepresenceofchronicdiseases.Forthisreport,weconsideredmortalityofunhealthyandhealthygroupsoftheU.S.populationusingbothbroaderandspecificdefinitionsofhealth.AliteraturereviewoftheexistingmeasuresofhealthstatusisavailableinAppendixB.1.
Inthisstudywewerelimitedbytheavailabledatainchoosinghowtodefinehealthyandunhealthystatus.We
assessedtheavailableinformationintheNationalHealthInterviewSurvey(NHIS)andmadechoicesthatwethinkreflecthealthyandunhealthydefinedinmultipleways.Weusedthefollowingdefinitionsofpoorgeneralhealth:
•Self-ratedhealthasfairorpoor.Thisdefinitionofpoorhealthisoftenusedinthescientificliterature.Itwasusedhereforcomparisonwithmoresophisticateddefinitions.Self-ratedhealthisoneoftheoldestmeasuresofhealthstatus.Respondentsaretypicallyaskedtoratetheirperceivedhealthusingafive-pointLikertscale(excellent,verygood,good,fair,poor).Thesefivegroupsareoftencombinedintothreegroups(very
good/excellent,good,fair/poor).Thisisthesimplestwaytomeasureindividualhealthstatus,anditwasshown
tobeagoodpredictorofsubsequentmortality(IdlerandKasl1991,DeSalvo,Bloser,Reynolds,HeandMuntner2005).
•FrailtyIndexequalto0.2orhigher.Empiricalstudiesestimatedthatthecutoffvalueof0.2isrecognizedby
multiplefrailtymeasuresasapproachingafrailstate(Rockwood,etal.2005,RockwoodandMitnitski2006,
Kulminski,Ukraintseva,Akushevich,ArbeevandYashin2007),sothatindividualscanbeclassifiedashavingnofrailty(FI<0.2)andfrail(FI=0.2–1.0).CalculationsoftheFrailtyIndexwerebasedonquestionsavailableintheNHISSampleAdultfile,whichprovidesindexestimatescomparabletothepublishedestimates.Sixty-four
questionsreflectingthreedomainsofhealthwereused:(1)medicalconditions(arthritis,cancer,diabetes
mellitusandothers),(2)healthconditionscausingdifficultywithactivity(hearingdifficulties,poorcognitionetc.)and(3)health-relatedbehaviorssuchassmoking.Overall,theFrailtyIndexcalculationwasbasedon64possiblehealthconditions(deficits)listedinAppendixB.3.DetailsofthecalculationincludingtreatmentofmissingvaluesaredescribedinAppendixB.2.
Inadditiontomeasuresofgeneralhealththisprojectstudiedmortalitybyhealthstatususingthreemorespecificdefinitionsofhealth.Specificdefinitionsofhealthconsideredinthisstudyincludethefollowingthreegroupsofhealthimpairment:(1)disability,(2)mentalconditionsand(3)presenceofchronicdiseases.
Inthisprojectmortalitypatternswerestudiedusingthefollowingspecificdefinitionsofhealth:
Disability.DisabilitywasdefinedashavinganylimitationofactivitymentionedbyaNHISrespondentincluding
activitiesofdailyliving(ADLs)andinstrumentalactivitiesofdailyliving(IADLs)anddifficultyremembering.This
definitionincludesbothphysicalandmentaldisability,whichisinlinewiththedefinitionappliedbylong-termcareinsurance(Stallard2019).
Mentalconditions.Mentalconditionsweredefinedasapositiveanswertoatleastoneofthequestions:(1)Personislimitedbydifficultyremembering;(2)Intellectualdisabilitycausesdifficultywithactivity;(3)Senilitycauses
difficultywithactivity[ICD-9codeforsenilityis797,Senilitywithoutmentionofpsychosis];(4)
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Depression/anxiety/emotionalproblemcausesdifficultywithactivity;and(5)Othermental
conditions/ADD[attentiondeficitdisorder]/bipolar/schizophreniacausesdifficultywithactivity.Memory
impairments(questions1and3)werealsostudiedseparately.IntheNHISquestionnaireallmentionedmentalconditionswereassociatedwithdifficultyofactivity.
Presenceofchronicdiseases.Chronicdiseasesweredefinedasapositiveresponsetoatleastoneofninequestionswhetherrespondenteverhasbeentoldthatheorshehashypertension,coronaryheartdisease,anginapectoris,
heartattack,heartcondition/disease,stroke,emphysema,cancerordiabetes.Theseninediseaseswerechosenoutof12diseasesmentionedintheNHISbecauseoftheirstrongassociationwithaging-relatedmortality.
Foreachofthesehealthsubgroupsage-specificmortalityandremaininglifeexpectancywereestimated.Estimatesweredoneformalesandfemalesseparately.
Section2:TheSourceofInformationonPopulationHealth
SeverallargenationallyrepresentativesurveyscollectindividualhealthinformationsuchasNationalHealth
InterviewSurvey(NHIS),HealthandRetirementStudy(HRS),GeneralSocialSurvey(GSS)andNationalHealthandNutritionExaminationSurvey(NHANES).ComparabilityofmortalityestimatesbasedonthesesurveysandtheU.S.vitalstatisticsdemonstratedagoodconsistencyacrosstimeintheNHISandHRSbutnotGSS(Keyes,Rutherford,Popham,MartinsandGray2018,Brown,LariscyandKalousová2019).WhencomparingtheNHISandHRSsurveys,itshouldbeconsideredthattheHRScollectsdataforrespondentsolderthan50yearswhereastheNHIScollectsdataforadultsaged18yearsandolder.Also,theNHISisconductedeveryyearratherthanbiannuallyastheHRSandhasalargersamplesize.
ComparisonofseveralpopulationsurveysbroughtustotheconclusionthattheNHISisoneofthebestsourcesofdataonU.S.populationhealth.ItisconductedbytheCentersforDiseaseControlandPrevention’sNationalCenterforHealthStatistics(CentersforDiseaseControlandPrevention2016).Thisisanannualcross-sectionalhouseholdinterviewsurvey,whichprovidesdemographic,socioeconomicandhealthcharacteristicsofthecivilian,
noninstitutionalizedpopulationintheUnitedStates.SamplingandinterviewingfortheNHISarecontinuousthroughouteachyear.TheNHISisconductedinaface-to-faceinterviewformat.Toincreasetheprecisionof
estimatesoftheBlackorAfricanAmerican(hereafterBlackwillbeusedforbrevity),Hispanic/LatinoandAsian
Americanpopulations,thecurrentNHISsampledesign(startingin2006)oversamplesBlackpersons,Hispanic/LatinopersonsandAsianAmericanpersons.
TheNHIShasrichinformationonthehealthstatusofrespondents.Itasksrespondentsaboutself-ratedhealthandhasasetofquestionsonhealthconditionsandADLsthatallowsresearcherstoestimatetheFrailtyIndex.TheNHIShasmorethan64questionsonhealthstatusandlimitationofactivityandhealthbehaviors.Summarizing,theNHISprovidesallnecessaryinformationforcalculatingtheRockwoodFrailtyIndexscore,whichiscomparabletoscoresobtainedinotherstudies(Biritwum,etal.2016,Rockwood,etal.2017,Mousa,etal.2018).Italsoincludesseveralquestionsonmentalconditions.
TheNHISmadesignificantchangesofitsquestionnairein2019sothatdefinitionsofmentalconditionsanddisabilityin2019becameincompatiblewithearlierNHISquestionnaires.HealthmeasuresforFrailtyIndex,disabilityand
mentalconditionswereupdatedtoreflectanewNHISquestionnaireintroducedin2019(seeAppendixB.4andB.5).In2020and2021NHISquestionnairesaskedrespondentsiftheyhavehadCOVID-19.ThisinformationwasusedtocomparehealthstatusamongthosewhohadCOVID-19withthosewhohadnothadthisdisease.Thishasbeen
doneforthewholespectrumofhealthstatusmeasuresmentionedabove.
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In2022theNHISreleasedinformationonrespondents’deathsintheformof2019Public-UseLinkedMortalityfilesandallowedustoestimatemortalityofrespondentsbyhealthstatus.Mortalitybyhealthstatuswasestimatedfortworecentperiodscorrespondingtoyearswhenthesurveywasconducted:2010–2014and2015–2018.In2010–2014,5,811deathswererecordedoutof90,404respondentssurveyedin2010–2014andaged45yearsandover.In2015–2019therewere4,404deathsoutof70,678respondentsaged45yearsandoverandsurveyedin2015–2018.
Section3:ConstructionofPeriodLifeTables
Unhealthylongevityinthisprojectwasanalyzedbyconstructionofcross-sectionalorperiodlifetables.Constructionofperiodlifetablesisastandardwayofpresentingmortalitydataindemography(Prestonetal.2001).Withthis
approach,periodlifetablesandlifeexpectanciesinthisreportwerecalculatedinamannerdifferentfromthatwithwhichsomeactuariesareaccustomed.Periodlifetablesshowsurvivalofhypotheticalratherthanrealbirthcohorts.
Lifeexpectancyofahypotheticalbirthcohortshowstheaveragenumberofyearsababyborninaparticular
populationcanbeexpectedtoliveifitexperiencesthecurrentage-specificmortalityratesofthatparticular
populationthroughoutitslife.Itdoesnotreflecttheexpectationsoflifeforarealcohortofindividualsatagivenage.1
Thesetablesaretypicallybasedonofficialgovernmentalsourcesofpopulationcountsanddeathcounts.Cross-sectionalmortalityratescanbeestimateddirectlyusingastandarddemographicapproachwhentheannual
numberofdeathsinaparticularagegroupisdividedbytheexposureinthisagegroup.Thisapproachisappliedlessoftentosurveysdatacomparedtoacohortapproach,althoughexamplesofitssuccessfulapplicationdoexist
(Manton,StallardandCorder1997,Arias,Escobedo,Kennedy,FuandCisewski2018,Steensma,Choi,LoukineandSchanzer2018).Across-sectionallifetableapproachtodataonhealthwasalsoappliedinthestudyof
multimorbidityandmortalityusingMedicaredata(DuGoff,Canudas-Romo,Buttorff,LeffandAnderson2014).This
approachhasnotbeenwidelyappliedtosurveydataalthoughitmaybepromisingforobtainingnationallyrepresentativemortalityestimates.
Aperiodlifetableisthemosteffectivewayofsummarizingmortalityexperienceofapopulationandcanalsobeusedtomakestatisticalinferencesandcomparisonsbetweenmortalityexperienceofdifferentpopulations.The
methodologyusedinthisprojectapplieslifetableconstructionforsmallareaswithasmallpopulationsize(EayresandWilliams2004,Eayres2017)andusedmethodsdescribedbyChiang(Chiang1978,1984).ThemethodologyofperiodlifetableconstructionisdescribedinAppendixC.1.
Constructionofperiodlifetableshascertainadvantagescomparedtoastandardcohortapproach:
•Itispossibletostudychangesinmortalityandlifeexpectancyovertimeinastandardmanner.
•Itispossibletostudymortalityoverlongeragespans(e.g.,fromyears45to85andolder).
1Readersneedtocorrectlyinterpretthelifeexpectanciesinthisreport.Twointerpretationsareconsidered:
1.Forindividualsmatchedonage,sexandothercharacteristics,lifeexpectancyrepresentstheaverageremainingnumberofyearstobelivedbysuchindividuals.Generally,halflivelongerandhalflessthantheindicatedvalue.
2.Forapopulationofindividualsatdifferentattainedageswhoarematched,atthoseages,onsexandothercharacteristics,mortalityoverthenextyearcanyieldasetofage-specificdeathratesandanassociatedlifeexpectancythatservesasasummarizationofthoseage-specific
deathrates.Inthesecondcase,thelifeexpectancyvalueistiedtothegivensetofmortalityrateswithoutassumingthattheentiresetofratesappliestoanygivenindividualorgroup.
Thefirstinterpretationappliestocohortlifetables.Thesecondinterpretationappliestoperiodlifetables.Thelatteristheintendedinterpretationforthelifeexpectanciesinthisreport.
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•Itispossibletocomparemortalityindifferentsubgroupsinastandardmannerusingsuchconventionalindicatorsasremaininglifeexpectancy.
Itisimportanttonotethatperiodlifetableshavecertainlimitationsinthecurrentapplicationbecausetheydonottakeintoaccountpossibletransitionsbetweenthestudiedhealthyandunhealthystatuses.Thecalculationsassumethatallinitiallyhealthypersonsareexposedtothemortalityschedulesonlyforhealthypersons,andallinitially
unhealthypersonsareexposedtothemortalityschedulesonlyforunhealthypersonsforallagesanddurations.Inactuality,substantialchangesingroupmembershipoccurovertimewiththepredominantdirectionofchangebeing
fromhealthytounhealthy.TheNHISdatadonotpermitustostudysuchtransitions.Thus,itisimportantin
interpretingtheresultstorememberthatsuchtransitionsarenotincludedinthecalculations.(seeAppendixEformoredetails).
TheNHIShasinformationaboutdeathcountsforeachsurveycohortfolloweduntil2019.Thisinformationcanbe
usedforcohortanalysisofmortality.Atthesametime,thesedatacanalsobeusedforperiodlifetableconstructionusingexistingmethods.Inthisprojectweusedastandardmethodoflifetableconstructionwithsomemodificationstakingintoaccounttherelativelysmallsizeofthepopulationandthewaythissurveyhasbeenconducted.The
numberofdeathswascalculatedasdeathsoccurringduringthefirstfourquartersafterthesurveyinterviewinthe
age/healthstatus/sexsubgroup;thisreflectsthefactthatNHISinterviewswereconductedatdifferenttimesduringthesurveyyear.Thepopulationunderrisk(exposure)includedallrespondentsinaparticularageandhealth
subgroupminusone-halfofdeathsinthissubgroupdu
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