UNDERSANDING DISABILITY IN
EUROPE AND THE UNITED STATES:
A
H e a l t h
P e r s p e c t i v e
Rolando A. Pabon
Paris-Jourdan Sciences Economiques, France and OECD
Mauricio Avendano
Erasmus Medical Center, The Netherlands
R A N D
C o r p o r a t i o n
Santa Monica „ July 10-11 2006
1
Background and Facts
2
Prevalence of Disability in Europe and the US
3
Contribution of Diseases and Health Behavior
4
Conclusions
BACKGROUND
• About 25% of those aged 50 to 64 in the OECD have chronic
disabilities.
• No single country can be considered as having a particularly
successful policy for disabled people (OECD 2003).
• The cost of medical care for a disabled older person averages
3 times that for a non-disabled senior.
Source: Vicki A. Freedman, Linda G. Martin, Robert F. Schoeni. “Recent Trends in Disability and Functioning
Among Older Adults in the United States A Systematic Review. ” JAMA. 2002;288:3137-3146.
Disability expenditure varies
considerably between countries
VARIATIONS IN PUBLIC EXPENDITURE ON
DISABILITY PROGRAMS
7
Percentage of GDP
6
1990
1999
5
4
3
2
1
0
Se
Dk
De
Nl
Fr
Ch
Au
It
Es
Source: “Transforming disability into ability: Policies for Promoting Work
Work and Income
Security for Disabled People”. OECD, Paris. 2003.
EU
US
In general, a higher prevalence of disease is
observed among Americans
SELF REPORTED HEALTH DIFFERENCES
(AGE 55-64 YEARS)
45
40
Percent Distribution
35
United
States
-20%
England
30
25
20
15
-36%
10
-51%
-42%
-22%
5
-26%
-39%
0
Hypertension
All heart
Disease
Diabetes
Cancer
Lung disease
Source: Banks, J. Marmot, M. Oldfield,
Oldfield, Z. & J. Smith. “Disease and Disadvantage in the
United States and in England”. Journal of the American Medical Association. May 2006.
Myocardial
infarction
Stroke
OBJECTIVES
1. Are there differences between European countries and the
United States in the level of functioning and disability?
• Self-reported
• Objective indicators (i.e., walking speed)
2. What is the contribution of specific chronic diseases, healthrelated behavior to cross-country variations in disability?
3. What is the impact of physical disability on disability benefit
enrolment and how this varies across countries?
DATA AND METHODS
„ 50 years or older
„ Health and retirement survey:
– 7th Wave 2004
– Non-Hispanic whites
– n=14,303
„ Share study:
– 2004 wave for 10 countries
– n=21,596
OUTCOME VARIABLES
„ ADL : activities related to personal care, i.e., bathing or showering,
dressing, getting in or out of bed or a chair, using the toilet, and
eating.
„ IADL : Activities related to independent living, i.e., preparing meals,
managing money, shopping for groceries or personal items,
performing light or heavy housework, and using a telephone
„ Mobility (including arm and fine motor function): Walk 100 mts,
sitting 2 hours, getting up from chair, climbing stairs, stooping,
reaching arms, pulling, lifting, picking up coin
„ Walking Speed:
– Meters per second
– Walking disability: Prob. of walking 0.4 m/s or less
THE MODEL
Basic Model:
⎛ Disabilityi ⎞
⎟⎟ = β 0 + β1 Agei + β 2 Sexi + β 3Countryi + ε i
Logit ( Disabilityi ) = Log ⎜⎜
⎝ 1 − Disabilityi ⎠
Chronic Model:
Logit ( Disability i ) = α 0 + α 1 Agei + α 2 Sexi + α 3Country i + α 4 Chronic Dummy i + ε i
Ch. Dummy = {CVD, Cancer, Lung, Arthritis}
Behavior Model:
Logit ( Disability i ) = θ 0 + θ1 Agei + θ 2 Sexi + θ 3Country i + θ 4 Behaviour Dummy i + ε i
B. Dummy = {BMI, Smoking, Alcohol, PA, Depression}
1
Background and Facts
2
Prevalence of Disability in Europe and the US
3
Contribution of Diseases and Health Behavior
4
Conclusions
US population appears to have more limitations
than Europeans
ADL MEN (age 50-74)
6%
HRS
Share
5%
ADL WOMEN ( age 50-74)
6%
HRS
Share
5%
4%
4%
3%
3%
2%
2%
1%
1%
0%
0%
Dress
Walk
across
room
Bathing
Eating
Getting
out bed
Using
toilet
MOBILITY MEN (age 50-74)
50%
Dress
HRS
45%
40%
Share
40%
35%
35%
30%
30%
25%
25%
20%
20%
15%
15%
10%
10%
5%
5%
0%
0%
walk
100mts
sitting
get up
chair
climb
stairs
climb one stooping pull/push
stair
Note: Data adjusted for age
lifting
pick up
coin
Bathing
Eating
Getting
out bed
Using
toilet
MOBILITY WOMEN (age 50-74)
50%
45%
Walk
across
room
HRS
Share
walk
100mts
sitting
get up
chair
climb
stairs
climb one
stair
stooping
pull/push
lifting
pick up
coin
…But regional variations decline at
very old ages
WOMEN (age 75 or more)
HRS
Share
0,2
0,18
0,16
0,14
0,12
0,1
0,08
0,06
0,04
0,02
0
Frequency
Frequency
ADL MEN (age 75 or more)
Dress
75%
Walk
across
room
Bathing
Eating
Getting
out bed
75%
HRS
Share
55%
35%
35%
25%
25%
15%
15%
5%
5%
sitting
get up
chair
climb
stairs
climb one stooping pull/push
stair
Note: Data adjusted for age
lifting
pick up
coin
Walk
across
room
Bathing
Eating
Getting
out bed
-5%
Using
toilet
MOBILITY WOMEN (age 75 or more)
HRS
Share
55%
45%
walk
100mts
Share
65%
45%
-5%
HRS
Dress
Using
toilet
MOBILITY MEN (age 75 or more)
65%
0,2
0,18
0,16
0,14
0,12
0,1
0,08
0,06
0,04
0,02
0
walk
100mts
sitting
get up
chair
climb
stairs
climb one
stair
stooping
pull/push
lifting
pick up
coin
There are also intra-regional differences in
disability across Europe
Prevalence of 1 or more ADL limitations
ADL - MEN
ADL - WOMEN
50-64
35%
50-64
35%
65-74
65-74
30%
30%
75 or +
25%
25%
20%
20%
15%
15%
10%
10%
5%
5%
0%
0%
SE
DK
DE
NL
FR
CH
Note: Data adjusted for age
AT
IT
ES
GR
EU
US
75 or +
SE
DK
DE
NL
FR
CH
AT
IT
ES
GR
EU
US
Significant variations in mobility are present
in the first two age-groups
Prevalence of 4 or more mobility limitations
MOBILITY (4 Act.) - MEN
MOBILITY (4 Act.) - WOMEN
35%
50-64
35%
30%
65-74
30%
25%
25%
20%
20%
15%
15%
10%
10%
5%
5%
0%
0%
SE
DK
DE
NL
FR
CH AT
Note: Data adjusted for age
IT
ES
GR EU
US
50-64
65-74
SE
DK
DE
NL
FR
CH
AT
IT
ES
GR EU
US
… intra-European differences in disability
remain, but US-Europe disparities decline
LIMITATIONS WITH MOBILITY
(age 75 years or more)
MOBILITY (4 Act.) - MEN
MOBILITY (4 Act.) - WOMEN
70%
70%
60%
60%
50%
50%
40%
40%
30%
30%
20%
20%
10%
10%
0%
0%
SE
DK DE NL
FR
CH AT
Note: Data adjusted for age
IT
ES
GR EU
US
SE
DK DE NL
FR
CH AT
IT
ES
GR EU
US
Objective indicators confirm intra-European
variation, but US shows lower disability levels!
76+ years
PROBABILITY WALKING SPEED<0.4 M/S
MEN vs. WOMEN
Men
0,40
Women
0,35
Probability
0,30
0,25
0,20
0,15
0,10
0,05
0,00
SE
DK
DE
NL
FR
CH
AT
IT
ES
GR
What is going on?
Note: Data adjusted for age
EU
US
1
Background and Facts
2
Prevalence of Disability in Europe and the US
3
Contribution of Diseases and Health Behavior
4
Conclusions
Adjustment for arthritis attenuates crosscountry differences in mobility limitations
ODDS RATIO OF 4 OR MORE MOBILITY LIMITATIONS
Age 50-74
4,5
Se
Fr
4
It
3,5
Es
US
3
2,5
2
1,5
1
Reference
0,5
0
Basic
Basic + CVD
Basic + Cancer
Basic + Lung
Reference Country: Sweden
Note: Basic includes age, sex, education, marital status
Basic + Arthritis
…being almost negligible when looking at
walking speed
ODD RATIOS FOR WALKING DISABILITY
Age 76 or +
Se
Fr
It
7
Es
6
US
5
4
3
2
Reference
1
0
Basic
Basic + CVD
Basic + Cancer
Reference Country: Sweden
Note: Basic includes age, sex, education, marital status
Basic + Lung
Basic + Arthritis
Adjusting for health behavior does not attenuate
cross-country differences in mobility…
ODD-RATIO OF 4 OR MORE DIFFICULTIES WITH MOBILITY
Age 50-74
Se
Fr
4,5
It
Es
4
US
3,5
3
2,5
2
1,5
1
Reference
0,5
0
Basic
Basic+BMI
Basic+Smoking
Basic+Alcohol
Reference Country: Sweden
Note: Basic includes age, sex, education, marital status
Basic+PA
Basic+Depression
Walking disability differences remain
unchanged after risk factor adjustment….
ODD RATIOS FOR WALKING DISABILITY
Age 76 or +
Se
8
Fr
It
Es
US
7
6
5
4
3
2
Reference
1
0
Basic
Basic+BMI
Basic+Smoking
Note: Basic includes age, sex, education, marital status
Basic+Alcohol
Basic+PA
Basic+Depression
DISABILITY BENEFITS
There are huge variations in disability
benefit enrolment across Europe, even after
adjusting for healh and functioning…
DISABILITY INSURANCE UPTAKE
20%
18%
Age & sex adjusted
16%
+disab. & health
14%
12%
10%
8%
6%
4%
2%
0%
Se
Dk
De
Nl
Fr
Ch
Au
It
Es
Gr
EU
US
The proportion of benefit enrolment attributable
to functioning limitations is very large in the US
and vey small in Europe…
Population attributable fraction (%
PROPORTION OF DISABILITY BENEFIT UPTAKE ATTRIBUTABLE
TO ADL, IADL & MOBILITY LIMITATIONS
80,0%
1+ adl
7 0,0%
1+ iadl
60,0%
4+ mobility
50,0%
40,0%
30,0%
20,0%
10,0%
0,0%
Se
Dk
De
Nl
Fr
Ch
Au
It
Es
Gr
EU
US
1
Background and Facts
2
Prevalence of Disability in Europe and the US
3
Contribution of Diseases and Health Behavior
4
Conclusions
Conclusions
„ There are large variations between countries in the
prevalence of disability:
„ Higher disability in France, Italy and Spain, lower in
north Europe
„ Higher disability limitations for the US at 50-74, but
lower disability in the US in oldest old
„ Higher arthritis accounts for a large extent for variations
at ages 50-74, but not among oldest old
„ Health behaviour and depression
contribute to variations in disability
do
not
largely
Conclusions (II)
„ The proportion of benefit enrolment attributable to
functioning limitations is very large in the US and very
small in Europe – other (non-physical) causes for
disability benefit in Europe?
„ Are variations real?
– Self-report bias (vignettes)
– Differences in cohorts, response rates….
ANNEX
Calculation Proportion of Disability
Benefit
Population attributable risk =
Pr evalence × ( RR − 1) × 100
Pr evalence × ( RR − 1) × 1