Elsevier

The Lancet

Volume 349, Issue 9062, 10 May 1997, Pages 1347-1352
The Lancet

Articles
Regional patterns of disability-free life expectancy and disability-adjusted life expectancy: Global Burden of Disease Study

https://doi.org/10.1016/S0140-6736(96)07494-6Get rights and content

Summary

Background

Information on non-fatal health outcomes of disease and injury has been largely neglected in health planning because of the conceptual and definitional complexity of measuring morbidity and disability in populations. One of our major objectives was to quantify disability for inclusion in health policy debates. We analysed these health outcomes in terms of disability-free life expectancy (DFLE) and disability-adjusted life expectancy (DALE).

Methods

Published and unpublished data were systematically reviewed to estimate the incidence, prevalence, and duration of 483 disabling sequelae of 107 diseases and injuries. To ensure internal consistency of these estimates, a software programme (DisMod) was applied many times until consistent parameters were identified. The severity of disability, on a scale of O (perfect health) to 1 (death), was measured in a deliberate manner by the person-trade-off method. Spearman's and Pearson's correlation coefficients were used to measure disability weights among groups. Prevalence of seven classes of disability was back-calculated from the distribution of each disabling sequela across disabilities. Prevalence for each class of disability for different age-sex groups was used to calculate seven forms of DELE and DALE based on Sullivan's method.

Findings

Prevalence of most disability classes is highest in sub-Saharan Africa and lowest in established market economies. Low-severity disabilities (class I and class II) are the most common. The expectation at birth of class I disability ranges from 6-5 years in established market economies to 14-7 years in sub-Saharan Africa, and for class II disabilities, from 8-5-18-4 years. DELE varies significantly among regions: DFLE for class I disabilities at birth ranges from 9-9 years in sub-Saharan Africa to 47-7 years in established market economies for females and DFLE for class V disabilities ranges from 43-4 years for men in sub-Saharan Africa to 74-8 years for women in established market economies. The proportion of expected life span at birth lived with disability adjusted for severity, varies from about 8% in established market economies to 15% in sub-Saharan Africa, with little difference between men and women. In high-income regions, nearly 90% of expected disability is due to non-communicable diseases and most of the remainder to injuries. In poorer regions, almost half of expected disabiity is due to communicable diseases and injuries.

Interpretation

The higher proportion of lifespan spent disabled in high-mortality populations is consistent with the compression of morbidity hypothesis. The threshold definition of disability used substantially affects the results of DFLE. DALE, which incorporates severity weights for disabilities, is a useful summary measure of the burden of disability and mortality.

Introduction

In this second instalment of a four-part series on the findings of the Global Burden of Disease Study (GBD)1 we report the regional rates and patterns of disability by age, sex, and region, with various health expectancy measures for 107 diseases (see Lancet 1997; 349: 1269–76 for part 1; parts 3 and 4 follow in the next two issues). Disability-free life expectancy (DFLE) and disability-adjusted life expectancy (DALE)-a health-adjusted expectancy based on the GBD's disability severity weights-are used to describe regional differences in health expectancy. We also discuss the relevance of the cross-sectional pattern of DALE by region to the debate on the compression of morbidity hypothesis.

Health expectancies refer to life expectancy in various health states,2 and can be divided into indicators such as DFLE, in which the expected length of life lived without a given impairment or disability is calculated, or into health-adjusted life expectancy, which can be estimated by calculation of life expectancy for different health states with adjustment for severity weights. Both types of health expectancies may be useful ways to summarise the health status of the population. International comparisons of DFLE and other health expectancies have, however, been severely hampered by differences in calculation and definition.3 Some investigators have examined trends in health expectancies in only one country to try to reduce such discrepancies.4, 5, 6 Even interpretation of trends in DFLE has been confounded by changes in definition and method. When measurements are based on self-reported disability, trends in health expectancies may be affected by changes in the perception of illness, the willingness to take on the sick role, and the cost to the individual of missing work or school.7, 8, 9

Trends in life lived with disability that have accompanied the rise in life expectancy during this century have been subject to extensive debate.10, 11, 12 There are three types of theories about the changes in disability that go with longer life expectancy. Fries and colleagues13, 14 argue that with improvements in survival, the prevalence of disability will decrease and, therefore, the proportion of life lived with disability will also decrease. This theory is often called compression of morbidity. Conversely, other theories predict that the proportion of life lived with disability will increase as mortality declines. Gruenberg15 and Kramer16 suggest that as the length of survival of individuals with chronic disorders such as Down's syndrome increases, the prevalence of these disorders will also rise. Others17, 18, 19, 20 suggest that improved survival among frail individuals who have higher expected incidence rates of disability will lead to an increased prevalence of disability. A third, “mixed” theory predicts that the progression of chronic diseases to severe disability will be slowed by medical intervention, which will lead to a decline in the prevalence of severe disability, but a rise in the prevalence of mild disability;21 increasing life expectancy would also contribute to the latter. Available cross-sectional estimates of health expectancies and longitudinal analyses were not very useful in the investigation of these theories. For example, recent evidence from France suggests that a compression of morbidity is occurring, but similar studies in Australia have more ambiguous results.4 Several data sources suggest that the prevalence of disability in the USA is rising.10

Section snippets

Methods

We emphasised in the GBD examination of internal consistency of epidemiological estimates, and, therefore, that incidence, prevalence, case-fatality, and death rates for each disease or sequela were all compatible with each other. As discussed in more detail elsewhere,22 the efforts to ensure internal consistency included reviews of all available published and unpublished surveys or studies for each sequela and repeated estimation of rates specific for age and sex that were based on available

Results

Table 2 shows summarised prevalences of each of the seven classes of disability by age, sex, and region. For nearly every class of disability and every region, prevalence rises with age. The exception is female class III disability, for which prevalence reaches a peak in the 15-44 years age-group in the six developing regions. This pattern is largely due to a concentration of infertility caused by sexually transmitted diseases and maternal disorders. The rise in prevalence with age is much less

Discussion

The estimates of DFLE and DALE may be affected by two potential sources of bias. First, the approximation method used to estimate the prevalence of disability from the residual categories of diseases may be inaccurate. If the set of diseases and injuries that have been estimated are representative of the relation between disability and mortality for all conditions, then the estimates may not be biased. One factor that may have compromised representativeness is that idiopathic disabilities (for

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