Healthy life expectancy for selected race and gender subgroups: the case of Tennessee.

Objective: To analyze healthy life expectancy (HLE) for major racial and gender subgroups, based on the diverse population of Tennessee and compared with the United States.

Materials and Methods: We use life table methodology and the HLE calculation model of the National Center for Health Statistics (NCHS), using two databases for 2001: NCHS National Vital Statistics Reports life tables and CDC Behavioral Risk Factor Surveillance System (BRFSS) survey.

Results: For Tennessee, although average total life expectancy (TLE) is 73.6 years at birth, only 61.1 years of "good" health are expected. Substantial racial and gender differences are found in both TLEs and HLEs with black males having the lowest and white females the highest. Although females have longer TLE, they spend more years in an unhealthy state than males.

Conclusions: The findings raise new challenges for researchers and health policy makers for accomplishing the dual goals of longer life expectancy and elimination of health disparities among population subgroups.

Key Words: total life expectancy, healthy life expectancy, quality-adjusted life expectancy, diversity, race and gender

**********

As total life expectancy (TLE) has risen in recent years, greater attention has shifted to determining the number of healthy years that individuals can expect to live. (1) Increased concern with healthy life expectancy (HLE) is due largely to advances in medical technology and greater awareness of health promotion and disease prevention. As people live longer, the debate has shifted toward the dual issues of length of life, and length of healthy life. (2,3) Adjusting traditional life tables to reflect these new measures of healthy life expectancy will result in a more accurate reflection of the health status of a population. (4,5)

The Healthy People 2010 project established the national health agenda for the first decade of the 21st century with two overarching goals--increasing quality and years of healthy life for all Americans and eliminating health disparities among diverse population subgroups. (6) Our study provides input for evaluating the same Healthy People 2010 goals based on the diverse population of the State of Tennessee. It presents an analysis of TLEs and HLEs for the state population and for diverse racial and gender subgroups. We combine health status information with life expectancy data to measure years of healthy life that subgroups can expect to live at various ages. Data regarding healthy life expectancies will provide important input for policy decision making and evaluation of current policies, and may serve as a model for other states.

Healthy life expectancy

The construction of healthy life expectancies begins with the development of life expectancy tables. (7) Life tables are frequently referred to as mortality tables, as they provide statistics regarding mortality rates on the average lifespan. (8) Although useful in many ways, TLE measures do not take into account the health aspects of human life. Therefore, the second step in the construction of HLEs involves the development and application of a health-related quality adjustment to convert traditional life table estimates into health quality-adjusted life expectancies.

"Healthy life expectancy" is a summary measure of population health that integrates mortality information and health status prevalence data into a single measure of the health of a population. (9) Summary measures of population health can be classified into two major groups; those that measure health gaps and those that measure health expectancies. Measures of health gaps reflect the differences between the actual health outcome of a population and some stated health goal or norm for this population. There are a variety of methods for estimating "years of life lost" (10,11) and the well-known health gap measure developed and supported by the World Bank and World Health Organization (WHO), called Disability-Adjusted Life Years (DALYs). (12,13,5)

Healthy life expectancies can be formulated in a variety of ways. When health-related quality is defined in terms of social or functional limitation, the resulting summary measure of years of healthy life is usually referred to as disability-free life expectancy (DFLE). (14,15) When health-related quality is defined in terms of activity limitation, the resulting measure is usually called "active life expectancy." (16) Still another set of summary measures of population health has been developed by the WHO. In 2000, the WHO introduced a summary measure in The World Health Report 2000 called Disability-Adjusted Life Expectancy (DALE). It is based on disability weights that reflect social preferences for seven severity levels of disability. (17,18) In 2001, a newer measure, called health-adjusted life expectancy (HALE), was introduced in The World Health Report 2001 to emphasize the inclusion of all states or attributes of health in the calculation of healthy life expectancy. (19)

When health-related life quality and health states are measured on the basis of broadly defined chronic or acute morbid conditions, the summary measure is commonly referred to as years of healthy life (YHL). (20) The definition of health-related quality of life used by this measure is frequently based on a combination of activity limitation and perceived health data from, for example, the National Health Interview Survey.

Finally, when health-related quality of life is based on the number of days of perceived health, the summary measure is referred to as healthy life expectancy or HLE. (11,21) HLE estimates were initially compiled in the 1960s by the US Department of Health, Education and Welfare. (9) In the United States, the National Center for Health Statistics (NCHS) has made further significant contributions to this approach and has integrated its use into the Healthy People 2010 project. (22) This summary measure has another advantage: consistent health status data based on individual health perception is available for individual states. Since 1993, the CDC has tracked the population health status of the US using a health-related quality of life assessment system that is now part of the Behavioral Risk Surveillance System (BRFSS). (23,24)

A limited number of states such as New Jersey, (25) North Carolina, (26) and Utah (27) have completed HLE reports of their populations, using BRFSS data on self-reported health status. New Jersey (25) examined HLE for black and white racial and gender subpopulations, and found that TLE and HLE was highest in white females and lowest in black males. North Carolina (26) explored HLE by gender for white and minority subgroups, with results comparable to New Jersey but slightly lower. The Utah Department of Health (2002) analyzed years of healthy life by gender alone, and found averages for men and women higher than the national averages.

Materials and Methods

First, we developed life tables for the Tennessee population and its major racial and gender subgroups from the 2001 mortality data. In the United States, the NCHS publishes life tables for the general population and for major racial and gender subgroups, which are updated annually in the National Vital Statistics Reports series. (28) Using the NCHS method, we constructed life tables for Tennessee with age-specific mortality data from the CDC WONDER web site (29) (including the Compressed Mortality File for 1999 to 2001, Series 20, 2G 2004) and the 2001 Census population data for Tennessee. Both data sets included age, race, and gender subgroups for white males and females and black males and females at 5-year intervals from 0 to 4 to 65 and older. Thus, the total life expectancy data is based on life tables that indicate actual recorded deaths and are not based on survey data. However, the Healthy Life Expectancy data is based on the Behavioral Risk Factor Surveillance System sample of 2,040 to 3,059 Tennesseans during the study years, who responded to the survey question: "How is your general health?" The percentages reported are weighted to population characteristics, so that nonreporters and/or nonresponders are accounted for in this database. The number of nonresponders to this question ranged only from 4 to 24 (0.14% to 0.8%).

Following the methods of previous state studies, (25-27) we used the HLE approach to derive health quality-adjusted life expectancy. We merged the compiled life table results with the 2001 BRFSS health perception data to estimate perceived healthy years of life at defined 5-year intervals for white and black males and females in Tennessee.

To partition the raw BRFSS life expectancies into "good" health years and years when health is "not good," we used the self-perceived health assessment from the survey question: "Would you say that in general your health is (a) excellent, (b) very good, (c) good, (d) fair, or (e) poor?" For each age group (20 years old and above), we combined the "excellent," "very good," and "good" responses into one group and divided that number by the total number of respondents for that age group to derive the proportion of adults who perceived their health to be "good." Since the BRFSS survey does not provide information on health perception for those aged 18 or under, to complete the HLE tables, we interpolated and applied the proportions of "good" health versus "not good" health calculated for the 20 to 24 age group to each of the age groups below age 20. To derive an estimate for the total number of healthy years by age group, the good health factor was multiplied by the total number of years lived for each specific age interval. Dividing the total number of healthy years by the number of individuals, we obtained an estimate for HLE. Survey respondents who did not answer the health perception question were excluded from this determination; however, as noted above, nonresponders were well under 1% of the study data in each year.

Results

Total life expectancies

TLEs in 2001 for Tennessee and for gender and two dominant racial (white and black) subgroups are summarized by 5-year age intervals in Table 1. The average life-years remaining at birth and at the beginning of each selected age interval are calculated using the CDC life table methodology. (30,31) In 2001, a newborn child in Tennessee could expect to live an average of 73.6 years, assuming that the age-specific death rates in effect at the time of birth continued throughout the entire lifetime. This is 3.6 years shorter than the US national TLE at birth of 77.2 years, (8) as seen in Table 2. A female newborn in Tennessee could expect to live 76.6 years on average, whereas a male newborn could expect only 70.3 years, a difference of 9%. This is 4.1 years less than the US average for males and 3.2 years less for females at birth. Among those Tennesseans who reached age 65 in 2001, the expected years remaining for males and females were 13.1 and 17.1 years, respectively, a 30% gender gap. Comparing Tennessee males and females with the US average expected years remaining at age 65, the gaps are 3.3 years and 2.3 years respectively. However, the absolute years of gender life expectancy gap for older Tennesseans is smaller than the gap for newborns, revealing that males who attain older ages have achieved life expectancy closer to that of females, which is also the case for the US population.

When whites are compared with blacks, similar TLE gaps are found, with whites having longer TLE, but with the gap narrowing substantially as individuals in the population age, as is the case for the entire US. The racial TLE gap in Tennessee declined from 5.6 years at birth to only 2.4 years at age 65. Among racial/gender subgroups in Tennessee, white females have the greatest TLE with an average of 77.4 years at birth and 17.3 years remaining at age 65. Black females have the second highest TLE, followed closely by white males. Black males have the lowest TLE, with a newborn black male facing a TLE of 64.7 years and only 10.5 years at age 65. Complete life tables for the total Tennessee population and each subgroup are available from the authors on request. The TLE data for Tennessee by race is consistently lower for each racial/gender subgroup than for the United States.

Healthy life expectancies

As discussed, HLEs provide estimates of the number of years of "good health" remaining at the beginning of each age interval. The HLE estimations for Tennessee and four racial/gender subgroups, for under 1-year and 5-year age intervals to age 65 and over, are presented in Table 3.

Life expectancy for the Tennessee population declines from 73.6 TLE years to 61.1 HLE years, which indicates that only 83% of the average expected lifetime is likely to be spent in good health. The number of good HLE years found for Tennesseans aged 65 and over (9.7 years) is similar to that found for North Carolina for 1998 to 2000 but lower than the 10.7 years found for New Jersey for 1996 to 1998. (25,26) The male-female HLE difference in Tennessee is 4.2 years at birth, which narrows to 2.5 years at age 65. The black-white comparison shows a similar pattern of convergence, with a difference of 3.9 years of HLE at birth and only 1.5 HLE years for those 65 years of age and older.

Among the four racial/gender subgroups, HLEs reveal the same pattern of differences as TLEs at each of the different age intervals, with white females having the highest HLE levels and black males the lowest. Consequently, white females are the only population subgroup with an average HLE higher than that for the total state population at each age interval. Although the other three racial/gender groups have lower HLEs than the state population as a whole, black males have the largest gaps from birth to old age. Black females and white males have similar HLE patterns, with black females showing slightly better HLE data than white males.

Although white females in Tennessee have the greatest TLE at birth (77.4 years) and also the highest HLE (63.6 years), older females will likely have an assortment of illnesses and chronic conditions that reduce the health quality of their lives, as evidenced by their 13.8 years of less-than-good life years when health quality perception is taken into account. White males and black females have similar HLEs, averaging about 60 years at birth, whereas black males can expect to have only 55 years of healthy life at birth. In terms of HLE at age 65, white females have 11 years, followed by black females (9.5), white males (8.4), and black males (6.7).

Figure 1 presents comparative gaps in years of HLE by race and gender subgroups, in terms of male HLE years minus female HLE years, black HLE years minus white HLE years, black male HLE years minus white male HLE years, and black female HLE years minus white female HLE years. The narrowing of the differences in HLE years remaining among the groups as individuals grow older is clearly demonstrated. However, reverse trends are presented in Figure 2 showing comparative proportions of HLE between race and gender subgroups. It shows increasing relative shares of male HLE years as a percentage share of female HLE years, of black HLE years as a percentage share of white HLE years, of black male HLE years as a percentage share of white male HLE years, and of black female HLE years as a percentage share of white female HLE years. The data reveal that all of these comparative ratios decline with increasing age, but the relative HLE gaps between these subgroups worsen with increased age.

Discussion

Our investigation of total life expectancy and healthy life expectancy for the population of Tennessee supports findings in previous studies. The Centers for Disease Control and Prevention (CDC) recently reported that the difference in total life expectancy between white and black Americans was 5.5 years in 2002. (8) The same study also reported that white females in the United States continued to have the highest TLE at birth (80.2 years), followed by black females (75.5 years), white males (75.0 years), and black males (68.6 years). Similar racial and gender differences in HLE have also been found in previous studies, and the racial and gender gaps appear to have increased over time. (2,16,32)

Researchers have long attributed the observed racial and gender gaps in both total and healthy life expectancies to differences in socioeconomic status. (30,32-36) Race has also been frequently cited as a major contributing factor in influencing life expectancy. (16,33) In recent years, with more detailed data by socioeconomic status in the United States becoming available, researchers have paid increased attention to the roles of specific measures of socioeconomic status in explaining the TLE gaps among the different racial and gender subgroups. For example, researchers have recently found that education (years of schooling) appears to be a more important predictor of both TLE and HLE than race. (2,37,38) Given that blacks in general and black males in particular have lower educational attainments in the United States as well as in Tennessee, it is not surprising that their life expectancies are shorter than other population subgroups. In Tennessee, 28.1% of blacks have some post high school education and 16.2% have college or higher education, whereas 29.3% and 19.6% of blacks in the United States are in these categories respectively. (39) The challenge now in Tennessee is to continue to improve educational opportunity and socioeconomic status for black males, as well as other groups, to improve their health status and life expectancy.

We find additional cause for concern regarding life expectancy in Tennessee in terms of the leading causes of death in the United States. Table 4 compares death rates per 100,000 population between Tennessee and the United States for the 15 leading causes of death. The data reveal that the death rate is higher in Tennessee than in the United States for all the leading causes of death, except nephritis and HIV, which are 12th and 15th on the list. (40) This appears to indicate that access to healthcare services may be lower in Tennessee than in the country as a whole. Therefore, improving access to healthcare may improve life expectancies and healthy life expectancies for all groups in Tennessee.

It is also notable that the causes of death shown in Table 4 that involve accidents and other nondisease categories are much higher in Tennessee than in the United States as a whole. Accidental death rates are higher by 36%, motor vehicle accidents by 55.5%, firearm injury by 46%, intentional self-harm by 23.4%, and assault (homicide) by 24%. (40) This data appears to indicate that behavioral modification may be critical for extending TLE and HLE in Tennessee, a factor that is doubtless also related to educational and socioeconomic factors.

Conclusion

This analysis presents estimates of TLEs and HLEs at birth and at the beginning of other age intervals for racial and gender subgroups in Tennessee. We calculated HLEs using self-assessed health perception information provided by the BRFSS survey and combined with life expectancy data. For the total Tennessee population in 2001, the average TLE was 73.6 years at birth, with 61.1 years of healthy life.

There are substantial racial and gender differences in both average and healthy life expectancy. Black males have the lowest TLEs and HLEs, whereas white females have the highest. For the two median groups, black females and white males, TLEs are similar at birth but diverge at higher age intervals. And for Tennessee, the patterns of racial and gender differences of HLEs are similar to those found for TLEs. Of particular note, we also find that females, while having longer average and healthy life expectancies, spend more years in an unhealthy state than males. This is consistent with the findings of other studies. (41,42) Thus, our findings of substantial racial disparities in both TLEs and HLEs in Tennessee confirm the findings for other states and for the country as a whole. They also raise new challenges for researchers and public decision makers, if we hope to accomplish the dual goals of longer life expectancy for all Americans and the ultimate elimination of health disparities among the major population groups. In addition, we provide a methodology and model that can be applied for analysis of other state populations or groups.

Acknowledgments

The study was sponsored by the Methodist LeBonheur Center for Healthcare Economics at The University of Memphis and supported in part by a Faculty Research Grant from the Fogelman College of Business and Economics, The University of Memphis. The views expressed, however, are those of the authors.

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Never trouble another for what you can do for yourself.
--Thomas Jefferson

Cyril F. Chang, PHD, Diego Nocetti, MBA, and Rose M. Rubin, PHD

From Fogelman College of Business and Economics at the University of Memphis and Methodist LeBonheur Center for Healthcare Economics, Memphis, TN.

Reprint requests to Dr. Cyril F. Chang, Professor of Economics and Director, Methodist LeBonheur Center for Healthcare Economics, Fogelman College of Business and Economics, The University of Memphis, Memphis, TN 38152. E-mail: [e-mail]

Accepted May 5, 2005.

RELATED ARTICLE: Key Points

* The life table approach and healthy life expectancy model can be applied to state level estimation of total life expectancy and healthy (or disability-free) life expectancy

* Substantial racial and gender differences are found in both total life and healthy life expectancies, with black males having the lowest and white females the highest.

* Although females have longer life expectancy, they spend more years in an unhealthy state than males.

* Researchers and policy makers face health, healthcare, and behavioral challenges in accomplishing the Healthy People 2010 dual goals of longer life expectancy and eliminating health disparities.

Table 1. Total life expectancies for Tennessee by race-gender group,
2001

                                  Race/gender group
              Life-years                              Black
Age group     Tennessee   Male  Female  Black  White  male

Under 1 year  73.6        70.3  76.6    68.7   74.3   64.7
1-4 years     73.2        69.9  76.3    68.8   73.8   64.8
5-9 years     69.3        66.0  72.4    65.0   69.9   61.0
10-14 years   64.3        61.1  67.4    60.0   65.0   56.1
15-19 years   59.4        56.1  62.5    55.1   60.0   51.2
20-24 years   54.6        51.5  57.6    50.4   55.3   46.5
25-34 years   50.0        46.9  52.8    45.8   50.5   42.1
35-44 years   40.6        37.7  43.2    36.7   41.1   33.3
45-54 years   31.5        28.8  34.0    28.0   31.9   24.8
55-64 years   23.0        20.4  25.2    20.0   23.3   17.1
65+ years     15.3        13.1  17.1    13.1   15.5   10.5

               Race/gender group
              Black   White  White
Age group     female  male   female

Under 1 year  72.3    71.1   77.4
1-4 years     72.4    70.6   76.9
5-9 years     68.5    66.7   73.0
10-14 years   63.6    61.8   68.0
15-19 years   58.6    56.8   63.1
20-24 years   53.8    52.1   58.2
25-34 years   49.1    47.5   53.3
35-44 years   39.6    38.2   43.7
45-54 years   30.6    29.2   34.4
55-64 years   22.3    20.8   25.5
65+ years     15.0    13.3   17.3

Table 2. Comparison of Tennessee and US life expectancy at birth and at
65 years of age by gender and race: 2001

                  US                 Tennessee
          At birth  At 65 years  At birth  At 65 years

All       77.2      18.1         73.6      15.3
  Male    74.4      16.4         70.3      13.1
  Female  79.8      19.4         76.6      17.1
White     77.7      18.2         74.3      15.5
  Male    75.0      16.5         71.1      13.3
  Female  80.2      19.5         77.4      17.3
Black     72.2      16.4         68.7      13.1
  Male    68.6      14.4         64.7      10.5
  Female  75.5      17.9         72.3      15.0

Source: US data: US Department of Health and Human Services; Centers for
Disease Control and Prevention; National Center for Health Statistics;
Health, United States, 2004, Table 27; Tennessee data: Calculated by
authors.

Table 3. Healthy life expectancies for Tennessee by race-gender group,
2001

              Healthy                Race/gender group
              life-years                              Black  Black
Age group     Tennessee   Male  Female  Black  White  male   female

Under 1 year  61.1        58.9  63.1    57.8   61.6   55.1   60.2
1-4 years     60.6        58.5  62.7    57.7   61.1   55.1   60.1
5-9 years     56.9        54.7  58.9    54.0   57.3   51.4   56.4
10-14 years   52.1        49.9  54.1    49.3   52.5   46.6   51.6
15-19 years   47.3        45.2  49.4    44.5   47.8   41.9   46.9
20-24 years   42.7        40.6  44.7    39.9   43.1   37.3   42.2
25-34 years   38.2        36.2  40.0    35.4   38.5   33.0   37.6
35-44 years   29.3        27.5  31.0    26.8   29.7   24.6   28.7
45-54 years   21.2        19.5  22.8    19.0   21.5   16.9   20.7
55-64 years   14.7        13.1  16.1    12.8   14.9   10.9   14.3
65+ years      9.7         8.3  10.8     8.3    9.9    6.7    9.5

              Race/gender group
              White  White
Age group     male   female

Under 1 year  59.5   63.6
1-4 years     59.0   63.1
5-9 years     55.2   59.3
10-14 years   50.4   54.5
15-19 years   45.7   49.8
20-24 years   41.1   45.1
25-34 years   36.6   40.4
35-44 years   27.8   31.4
45-54 years   19.8   23.1
55-64 years   13.3   16.3
65+ years      8.4   11.0

Comparative Gaps in Years of HLE between Race/Gender Subgroups,
Tennessee 2001

                   Under   1-4    5-9    10-14  15-19  20-24  25-34
                   1 year  years  years  years  years  years  years

Male/Female        -4.2    -4.2   -4.2   -4.2   -4.2   -4.1   -3.9
(B)lack/(W)hite    -3.9    -3.3   -3.3   -3.3   -3.3   -3.2   -3.1
B Male/W Male      -4.4    -3.9   -3.8   -3.8   -3.8   -3.8   -3.6
B Female/W Female  -3.5    -3.0   -3.0   -2.9   -2.9   -2.9   -2.8

                   35-44  45-54  55-54  65+
                   years  years  years  years

Male/Female        -3.6   -3.3   -3.0   -2.5
(B)lack/(W)hite    -2.8   -2.5   -2.1   -1.5
B Male/W Male      -3.2   -2.8   -2.4   -1.8
B Female/W Female  -2.6   -2.4   -2.0   -1.5

Fig. 1 Comparative gaps in years of HLE between race/gender subgroups,
Tennessee 2001. HLE, healthy life expectancy.

Comparative Proportion of HLE between Race/Gender Subgroups, Tennessee
2001

                   Under   1-4    5-9    10-14  15-19  20-24  25-34
                   1 year  years  years  years  years  years  years

Male/Female        93.3%   93.3%  92.8%  92.2%  91.5%  90.9%  90.4%
(B)lack/(W)hite    93.7%   94.5%  94.3%  93.8%  93.2%  92.5%  92.0%
B Male/W Male      92.5%   93.4%  93.1%  92.5%  91.7%  90.8%  90.1%
B Female/W Female  94.5%   95.3%  95.0%  94.6%  94.2%  93.6%  93.2%

                   35-44  45-54  55-64  65+
                   years  years  years  years

Male/Female        88.5%  85.5%  81.3%  76.6%
(B)lack/(W)hite    90.5%  88.2%  85.9%  84.4%
B Male/W Male      88.5%  85.7%  82.2%  79.1%
B Female/W Female  91.6%  89.6%  87.7%  86.4%

Fig. 2 Comparative proportion of HLE between race/gender: Subgroups,
Tennessee 2001. HLE, healthy life expectancy.

Table 4. Comparison of Tennessee and US death rates for major causes of
death

                                     Death rates per
                                     100,000 population
                                     US     TN

All causes                           877.0  980.5
HIV disease                            5.4    4.7
Malignant neoplasms                  201.6  217.8
Diabetes mellitus                     25.1   26.2
Alzheimer disease                     16.3   18.3
Diseases of heart                    265.9  296.9
Cerebrovascular diseases              61.4   74.8
Influenza and pneumonia               23.4   29.0
Chronic lower respiratory diseases    45.5   50.1
Chronic liver disease and cirrhosis    9.6   10.0
Nephritis and nephrosis               13.0   12.3
Accidents                             35.9   48.8
Motor vehicle accidents               15.5   24.1
Intentional self-harm                 10.7   13.2
Assault (homicide)                     6.2    7.7
Injury by firearms                    10.6   15.5

Source: US Department of Health and Human Services; Centers for Disease
Control and Prevention; National Center for Health Statistics. Special
Reports from the National Vital Statistics Reports, Series 24, Number
15, August 2004, Table 26.