Skip navigation
Link to Back issues listing | Back Issue Listing with content Index | Subject Index

Quality of life, health status, and cost

Chronic conditions and quality of life [1]
Results
Health status in older Americans [2]
Results
Age, chronic conditions, and costs [3]
Results
Comment

Bandolier has long been interested in quality as much as quantity of life, how quality is related to chronic conditions, how chronic conditions are related to age, and how all three are related to costs. A framework like this might be important in framing decisions about healthcare interventions, and about the value we put on them.

Value here is taken to mean an informal composite of societal and personal value, rather than value as it relates to some computed cost of an intervention, like cost of a quality adjusted life year (QALY). Cost per QALY is a useful metric, although more often a rather broad-brush assessment of value. The medical literature is quiet as a mouse when it comes to definitions of value outside of the dictionary. In the dictionary value can be defined as an amount expressed in money thought to be a fair exchange for something - hence cost per QALY. Other definitions of value include the worth, importance, or usefulness of something to somebody.

Cheap can be valuable, expensive valueless. As a start, then, a look at three useful papers looking at quality of life and chronic conditions, factors associated with health status, and age, chronic conditions, and cost.

Chronic conditions and quality of life [1]

Cross sectional mail and interview surveys conducted in eight countries (Denmark, France, Germany, Italy, Japan, Netherlands, Norway and USA) were used, with individual sample sizes of 2,000 to 4,000 adults. Self-reported prevalence of various chronic conditions, demographic data, and SF-36 questionnaires were obtained. Analysis was adjusted for age, sex, marital status and SF-36 administration.

Results

Information was obtained for 25,000 people with a mean age of 44 years, half of whom were men. Overall, 44% had no chronic condition, with 56% of people reporting 1, 2, or more chronic conditions (Figure 1). The proportion with no chronic conditions was highest in Japan and Denmark (58%) and lowest in the USA (34%). Overall a high proportion of those with one chronic condition had another chronic condition, the lowest being 66% for allergies and the highest 91% for congestive heart failure.



Figure 1: Percent with chronic conditions





Seven main conditions were analysed (Table 1), together with back problems, dermatitis, and vision and hearing problems. For the seven main conditions (Table 1) there was considerable variability between countries, but for the pooled sample hypertension, arthritis, and allergies were most common. Adjusted reductions in the physical and mental summaries of SF-36 for each of the main conditions are shown in Table 1.



Table 1: SF-36 summaries across eight countries



SF-36 summaries
Condition
Prevalence (%)
Physical
Mental
Allergies
15.5
1.0
1.1
Arthritis
15.7
4.5
1.5
Chronic lung disease
5.9
4.4
2.0
Congestive heart failure
4.0
4.4
2.1
Diabetes
3.7
3.5
1.0
Hypertension
17.1
1.5
1.7
Ischaemic heart disease
4.2
3.3
2.1
SF-36 summaries show adjusted reduction in score compared to those with no reported chronic condition


Arthritis, chronic lung disease and congestive heart failure had the largest negative impact on quality of life. For these, the reduction of quality of life is predictive of a 27% increase in inability to work due to health problems in one year, or a 16% increase in mortality in five years.

Health status in older Americans [2]

To investigate associations between physical and mental health status in older Americans and demographic factors, symptoms, or diseases, a survey was conducted of over 100,000 Medicare beneficiaries aged 65 or older. From each of over 250 plans, 1000 people were randomly selected. A short form of SF-36 was used to collect information about health status, with demographic data and additional questions about a range of different symptoms scaled from whether they affected individuals from all of the time to none of the time. Factors associated with physical and mental health summaries scores of SF-36 were then sought through regression analysis. Excluded were people who did not complete forms themselves, or who did not provide all the information.

Results

Information was available from 108,000 older Americans who did not live in institutions and who answered the questions themselves, with an average age of 74 years (range 65-108), and 58% were women. Symptoms or diagnoses in 10% or more respondents are shown in Table 2.



Table 2: Common symptoms or diagnoses in older Americans



Symptom or diagnosis
Percent
High blood pressure
52
Arthritis of hip or knee
36
Arthritis of hand or wrist
33
Acid indigestion/ heartburn
31
Difficulty walking
30
Difficulty controlling urine
25
Difficulty getting in or out of chair
22
Sciatica
22
Other heart condition
20
Felt sad 2 weeks in last year
18
Health somewhat/much worse in last year
16
Angina or coronary artery disease
15
Diabetes
15
Shortness of breath on walking
15
Any cancer
13
Emphysema, asthma, COPD
12
Depressed, sad most days for 2 years
12
Shortness of breath climbing stairs
11
Cannot hear most things people say
11
Sad much of time
11
Back pain all or most time last month
10


For the physical component summary, the average score was 43, below that for the general population. Regression analysis showed that the number of chronic conditions, and disease diagnoses and symptoms contributed most to lowered physical health status. Age was not an important factor. Of the symptoms and diagnoses, the most important were shortness of breath climbing stairs, back pain, difficulty in getting into or out of chairs, arthritis of hip or knee, and worsened health in the last year.

For the mental component summary, the average score was 54, above that for the general population. Factors associated with worsened mental health were shortness of breath when sitting, back pain, chest pain on exercise, and worsened health in the last year.

Age, chronic conditions, and costs [3]

All US veterans aged 65 or older (1.6 million) who received full benefits during 2000 formed the basis of a study relating age, chronic condition, and cost of medical care. Twenty-nine chronic conditions were identified, and persons with more than one condition were allocated to one on the basis of which was the more expensive. Total costs for the fiscal year 2000 were then reported under that heading. Two age groups were used, those aged 65 to 79 years (1.3 million), and those aged 80 years or older (300,000).

Results

The proportion of people with no chronic conditions, or one, two, or three or more were similar for both age groups (Figure 2). The average costs were higher for those who had at least one chronic condition than those with none, but not for those who were older (Figure 3).



Figure 2: Percent with chronic conditions







Figure 3: Costs by age and chronic conditions





Annual costs for each condition and age group in Table 3, only include medical costs, and not costs of long term care. Long term care costs formed a higher proportion of total cost for older than for younger people (Figure 4), because about twice as many older people needed long term care. Other than long term care, the mix of service costs was similar.



Table 3: Mean cost for chronic condition, and prevalence, by age in US veterans



Mean cost (US$)
Prevalence (%)
Condition
65-79
years
≥80
years
65-79
years
≥80
years
Spinal cord injury
25200
2230
0.42
0.32
Renal failure
18900
16200
2.73
3.73
Lung cancer
15200
12400
1.28
1.08
Dementia
11400
10000
1.33
3.65
Alzheimer's disease
6740
6700
0.56
1.77
AIDS/HIV
12400
9600
0.08
0.02
Cancer, not otherwise listed
9920
9400
2.65
2.60
CVA/stroke
9250
8750
2.50
2.86
Colorectal cancer
9480
8650
1.04
1.22
Congestive heart failure
9150
8200
5.71
8.07
Alcoholism
7600
7150
1.67
0.59
Multiple sclerosis
5350
6700
0.14
0.07
Parkinson's disease
4700
4400
1.16
1.78
Peripheral vascular disase
6160
5500
4.20
4.33
Psychoses
6700
5650
2.94
2.48
Hepatitis C
5200
5000
0.19
0.08
Prostate cancer
4250
4250
4.27
5.21
Depression
4200
4350
1.89
1.36
COPD
3550
3700
7.07
5.94
Acid-related disorders
3280
3400
2.50
2.16
Asthma
3050
3100
1.44
1.05
Headache
3300
3150
0.72
0.53
Ischaemic heart disease
2600
2500
12.11
10.91
Diabetes
2300
2350
8.32
5.36
Lower back pain
2200
2400
2.08
1.67
Arthritis
1800
1950
4.70
4.80
Substance abuse
1600
1750
0.66
0.21
Benign prostatic hyperplasia
1450
1700
3.22
3.02
Hypertension
1300
1450
7.93
6.58




Figure 4: Long term care as percent of total





The overall cost burden is a product of the cost per case and the number of cases. For those aged 65-79 years, congestive heart failure and renal failure both incurred 11% of the total burden, including long term care costs. For those 80 years or older, dementia and Alzheimer's disease (15%) was also a major contributor to overall burden. Ischaemic heart disease, diabetes, and hypertension were the most prevalent conditions. The prevalence of each condition is also in Table 3. The number of people in the top 10 most expensive chronic conditions was 18% for the younger patients and 25% in the oldest patients, and the top 10 conditions were responsible for 50% or more of total cost.

Comment

The finding from the multinational quality of life survey [1] that chronic arthritis, lung disease or heart failure had the largest negative impact on health related quality of life accords with previous studies ranking chronic diseases (Bandolier 83). To some extent this is not new, though it is interesting to see differences between countries. What it does is to reinforce that the paradigms we become used to (importance of ischaemic heart disease, for instance), while not wrong, may not always be completely right either, and we need a broad not narrow approach to how we see chronic diseases.

A similar type of result came from the survey of older Americans [2]. The large number of respondents had to be living in the community, and able to fill the forms themselves, but represent a very large proportion of older people. Age was not an important factor in reduced physical or mental health. Having chronic conditions, especially musculoskeletal conditions like arthritis and back pain was the major component of reduced physical and mental health, combined with shortness of breath.

Conditions with large negative impact on health status, like musculoskeletal conditions need not have a concomitant impact on overall costs, as the survey of US veterans found [3]. Nor did age consistently mean higher medical costs, though long term care costs were higher in the oldest old. Resource use was concentrated in a few chronic conditions, with the top 10 most expensive conditions (based on total cost) accounting for half or more of the medical costs.

There are several implications. First, that healthy older people are not expensive, and it is the chronic disorders that are expensive. Policies designed to reduce them (smoking and lung cancer, obesity and heart disease, for example) should reduce the overall burden, possibly very substantially. Looking at the costs in this way also provides targets for technology or management improvements that could improve care while reducing costs, perhaps through care pathways. It certainly helps in prioritising.

Then we recognise that conditions with large negative impacts on quality of life, like arthritis or back pain, are not among the most expensive. There is a tension between looking at health status and health costs.

For us as individuals, all of the above emphasises that it is better to be healthy than not. It brings to mind a quote from Izaac Walton from some hundreds of years ago who said “Look to your health; and if you have it, praise God and value it next to conscience; for health is the second blessing that we mortals are capable of, a blessing money can't buy.”

References:

  1. J Alonso et al. Health-related quality of life associated with chronic conditions in eight countries: results from the international quality of life assessment (IQOLA) project. Quality of Life Research 2004 13: 283-298.
  2. JK Cooper, T Kohlmann. Factors associated with health status of older Americans. Age and Ageing 2001 30: 495-501.
  3. W Yu et al. The relationships among age, chronic conditions, and healthcare costs. American Journal of Managed Care 2004 10: 909-916.

previous story