37–HLT Health adjusted life expectancy (HALE)

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37b–HLT Health adjusted life expectancy (HALE) by income

Definition
Rationale and notes for interpretation
Technical specifications
Data availability
Considerations for indicator quality and comparability
Responsibility to produce the data

Definition

Health Adjusted Life Expectancy (HALE) is an indicator of overall population health.  It combines measures of both age- and sex-specific health status, and age– and sex–specific mortality into a single statistic.  HALE represents the number of expected years of life equivalent to years lived in full health, based on the average experience in a population.  In this sense, HALE is not only a measure of quantity of life but also a measure of quality of life.

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Rationale and Notes for Interpretation

Canadians have been experiencing continuing increases in life expectancy for many decades. However, with the increasing prevalence of chronic disease, there has been an international debate as to whether or not these added years of life expectancy are years spent in good or poor health. By examining trends in HALE in conjunctions with trends in life expectancy (LE), it is possible to assess whether Canadians’ increasing life expectancy is associated with a “compression or an expansion of morbidity”. In other words, if HALE increases more over time than LE, we can then conclude that added years of life expectancy are indeed more often years in better health. This example is one illustration of the use and interpretation of HALE.

As with life expectancy, HALE is a standardized statistical indicator. It is not the number of full health equivalent years a particular newborn (or person currently age 65) can actually expect to live. The reason is that mortality rates and levels of health status only for the observation period (e.g. 2001) are used, and these are averages for the entire population. Historically, mortality rates in Canada have been falling, so that the mortality rates individuals are likely to face in future years as they age may be lower. Canada does not yet have consistent data over a sufficiently long period to know what the trends in health status have been, or are likely to be in the future. Moreover, individuals’ circumstances vary so that, for example, if they had become chronically ill at an early age, their particular health-adjusted life expectancy would be less.

This indicator should be presented by sex since HALE of women and men differs so much.

Coefficients of variation, confidence intervals (both of which are provided by Statistics Canada), and tests of significance must be analyzed before differences between provinces can be interpreted as real (statistically significant). HALE will be calculated by income tercile.

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Technical Specifications

Exclusions: The National Population Health Survey Institutional component collects data on long-term residents (expected to stay six months or more) living in health care institutions with four or more beds. Institutions that exclusively provided short-term care, such as drug rehabilitation centres were excluded. Health care institutions on Indian reservations and Canadian Forces Bases or within correctional facilities were excluded.

The CCHS excludes from its target population individuals living on Indian Reserves and on Crown Lands, residents of institutions, full-time members of the Canadian Armed Forces, and residents of certain remote regions. Persons less than 12 years of age are not surveyed.

The life tables exclude non-residents of Canada.

Calculation: Based on previous work by Wilkins et al (2002) 1996 life tables by income terciles were constructed using an ecological approach. Deaths were coded to the EA based on postal codes. Average income for each enumeration area (EA) was calculated and then EAs were assigned to the bottom, middle, or highest income tercile. The life tables were then constructed using deaths assigned to each income tercile. The 1996 percentage of deaths in each income tercile will be applied to the 2000/2001 life tables.

Using the EA link in the CCHS , respondents will be placed in one of the three income terciles. Mean HUI will be calculated for each tercile by age, sex, and province. The 1994 NPHS household longitudinal file was analyzed in order to determine the tercile distribution for institutional residents. The postal codes of respondents who lived in the community in 1994 but were living in an institution during a subsequent survey cycle were assigned to a tercile based on their EA of residence in 1994. This tercile distribution was then applied to determine the percentage of institutional residents in each income tercile.

HALE will be calculated for each province according to the method described below for each income tercile.

Part A: (average Health Utility Index (HUI) for institutional residents * percentage of population in institutions in the province) + (average HUI for household population * percentage of population in households in the province) = overall HUI score by sex and age group in each province

Part B: Overall HUI by sex and age group * years of life lived in each age group = health adjusted years of life lived

Part C: Health adjusted years of life lived are then summed and divided by the total number of persons surviving at given ages. This will provide HALE at birth and age 65 by province.

For details concerning the data sources and the calculations of Coefficient of variation for HALE, see technical notes for Indicator 37 a.

Source: NPHS, Institutional Component for HUI of persons in institutions (1996-1997 cross-sectional sample), 2001 Census for counts of residents living in long-term health care institutions (to match with sampling frame of the NPHS), CCHS Cycle 1.1 (common content) for HUI and counts of persons in households. 2000/2001 abridged life tables adjusted to 1996 income terciles.

References: Berthelot, Jean-Marie. (2003). Health-adjusted Life Expectancy (HALE). In J-M Robine, C. Jagger, C.D. Mathers, E.M. Crimmins and R.M. Suzman (eds.), Determining Health Expectancies p.235-246. West Sussex, England: John Wiley & Sons Ltd.

Wilkins, Russell, Edward Ng, Jean-Marie Berthelot, and Francine Mayer. (2002). “Provincial Differences in Disability-Free Life Expectancy by Neighbourhood Income and Education in Canada, 1996”. Technical Report to the Performance Indicators Reporting Committee (PIRC) of the Federal-Provincial-Territorial Conference of Deputy Ministers of Health.

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Data Availability

• HALE will be calculated at birth and at age 65 by sex only, income tercile, and province.
• The territories will be excluded.

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Considerations for Indicator Quality and Comparability

HALE will be calculated at birth and age 65. However, HALE at birth will be based on data for those aged 15 and over.

Because of the small sample size for the institutional component of the NPHS the average HUI for institutional residents will be calculated for people under 65 and people aged 65 and over. As well, the NPHS provides only regional data so the average HUI for institutional residents will be calculated for the Atlantic Provinces, Quebec, Ontario, the Prairie Provinces, and British Columbia. The average HUI will be the same for all income terciles of institutional residents.

The ecological approach based on enumeration area (EA link) is not appropriate to use for institutional residents since institutional residents move to an institution not because of the neighbourhood but because of their need for health care. Thus neighbourhood income is not necessarily a reflection of the income of institutional residents.

The EA link and coding of deaths to EAs is based on the average incomes in each EA in 1996. The tercile each EA was assigned to in 1996 is then applied to the 2000/2001 CCHS . As well, the same percentage of deaths in each income tercile in 1996 is applied to the 2000/2001 life tables (for example, if 40% of deaths occurred in the lowest income tercile in 1996 then 40% of deaths occurred in the lowest income tercile in 2000/2001).

Note: The HALE is a relatively new indicator, and embodies a number of assumptions, which are important for its interpretation. One such assumption is using an indicator of the self–reported health status of a sample of individuals, each at a moment in time, to represent the double average, first, of that individual's health status over a period of time, such as a year, and then over–all of the individuals in the population (for example, of a province). A second and related assumption is that there is a reciprocity between health and time such that, for example, 5 years lived at a heath state of 0.5 (quite poor health) as measured by the indicator is the same thing as 2.5 years lived in full health.

Responsibility to Produce the Data

Statistics Canada