Construction and evaluation of a practical model for measuring health-adjusted life expectancy (HALE) in China.

BACKGROUND: HALE is now a regular strategic planning indicator for all levels of the Chinese government. However, HALE measurements necessitate comprehensive data collection and intricate technology. Therefore, effectively converting numerous diseases into the years lived with disability (YLD) rate is a significant challenge for HALE measurements. Our study aimed to construct a simple YLD rate measurement model with high applicability based on the current situation of actual data resources within China to address challenges in measuring HALE target values during planning. METHODS: First, based on the Chinese YLD rate in the Global Burden of Disease (GBD) 2019, Pearson correlation analysis, the global optimum method, etc., was utilized to screen the best predictor variables from the current Chinese data resources. Missing data for predictor variables were filled in via spline interpolation. Then, multiple linear regression models were fitted to construct the YLD rate measurement model. The Sullivan method was used to measure HALE. The Monte Carlo method was employed to generate 95% uncertainty intervals. Finally, model performances were assessed using the mean absolute error (MAE) and mean absolute percentage error (MAPE). RESULTS: A three-input-parameter model was constructed to measure the age-specific YLD rates by sex in China, directly using the incidence of infectious diseases, the incidence of chronic diseases among persons aged 15 and older, and the addition of an under-five mortality rate covariate. The total MAE and MAPE for the combined YLD rate were 0.0007 and 0.5949%, respectively. The MAE and MAPE of the combined HALE in the 0-year-old group were 0.0341 and 0.0526%, respectively. There were slightly fewer males (0.0197, 0.0311%) than females (0.0501, 0.0755%). CONCLUSION: We constructed a high-accuracy model to measure the YLD rate in China by using three monitoring indicators from the Chinese national routine as predictor variables. The model provides a realistic and feasible solution for measuring HALE at the national and especially regional levels, considering limited data.

Living longer but in poor health: healthcare system responses to ageing populations in industrialised countries based on the Findings from the Global Burden of Disease Study 2019.

OBJECTIVES: This study aimed to examine changes in life expectancy (LE), health-adjusted life expectancy (HALE), unhealthy years of life, and disease burden of older people in industrialised countries and associations with health systems. METHODS: We used estimates of LE and HALE, unhealthy years of life, years of life loss (YLL), years lived with disability (YLD) for individuals aged 70 years and over in 33 industrialised countries from 1990 to 2019 from the Global Burden of Disease Study 2019. A linear regression analysis was conducted to examine the association of health outcomes with the Healthcare Access and Quality (HAQ) index. RESULTS: LE and HALE increased with improved HAQ index from 1990 to 2019. However, the number of unhealthy years of life increased. An increased HAQ index was associated with decreases in YLL. However, changes in YLD were relatively small and were not correlated with HAQ index. CONCLUSIONS: The healthcare system needs to more address the increased morbidity burden among older people. It should be designed to handle to healthcare needs of the ageing population.

Trends in Healthy Life Expectancy (HALE) and Disparities by Income and Region in Korea (2008-2020): Analysis of a Nationwide Claims Database.

BACKGROUND: Healthy life expectancy is a well-recognized indicator for establishing health policy goals used in Korea's Health Plan. This study aimed to explore Koreans' healthy life expectancy and its gender, income, and regional disparities from 2008 to 2020. METHODS: This study was conducted on the entire population covered by health insurance and medical aid program in Korea. The incidence-based "years lived with disability" for 260 disease groups by gender, income level, and region was calculated employing the methodology developed in the Korean National Burden of Disease Study, and it was used as the number of healthy years lost to calculate health-adjusted life expectancy (HALE). RESULTS: Koreans' HALE increased from 68.89 years in 2008 to 71.82 years in 2020. Although the gender disparity in HALE had been decreasing, it increased to 4.55 years in 2020. As of 2020, 5.90 years out of 8.67 years of the income disparity (Q5-Q1) in HALE were due to the disparity between Q1 and Q2, the low-income groups. Income and regional disparities in HALE exhibited an increasing trend, and these disparities were higher in men than in women. CONCLUSION: A subgroup with a low health level was identified through the HALE results, and it was confirmed that improving the health level of this population can reduce health inequalities and improve health at the national level. Further exploration of the HALE calculation methodology may help in the development of effective policies such as prioritizing interventions for health risk factors.

Trends of Gaps Between Health-Adjusted Life Expectancy and Life Expectancy at the Regional Level in Korea Using a Group-Based Multi-Trajectory Modeling Approach (2008-2019).

BACKGROUND: Health-adjusted life expectancy (HALE) is an indicator of the average lifespan in good health. Through this study, we aimed to identify regional disparities in the gap between HALE and life expectancy, considering the trends that have changed over time in Korea. METHODS: We employed a group-based multi-trajectory modeling approach to capture trends in the gap between HALE and life expectancy at the regional level from 2008 to 2019. HALE was calculated using incidence-based "years lived with disability." This methodology was also employed in the Korean National Burden of Disease Study. RESULTS: Based on five different information criteria, the most fitted number of trajectory groups was seven, with at least 11 regions in each group. Among the seven groups, one had an exceptionally large gap between HALE and life expectancy compared to that of the others. This group was assigned to 17 regions, of which six were metropolitan cities. CONCLUSION: Based on the results of this study, we identified regions in which health levels have deteriorated over time, particularly within specific areas of metropolitan cities. These findings can be used to design comprehensive policy interventions for community health promotion and urban regeneration projects in the future.

Potential Gains in Health-Adjusted Life Expectancy by Reducing Burden of Noncommunicable Diseases in 188 Countries: A Population-Based Study.

OBJECTIVES: This article quantifies the potential gains in health-adjusted life expectancy for people aged 30 to 70 years (HALE[30-70]) by examining the reductions in disability in addition to premature mortality from noncommunicable diseases (NCDs). METHODS: We extracted data from the Global Burden of Disease Study 2019 for 4 major NCDs (cancers, cardiovascular diseases, chronic respiratory diseases, and diabetes mellitus) in 188 countries from 2010 to 2019. Estimates of the potential gains in HALE[30-70] were based on a counterfactual analysis involving 3 alternative future scenarios: (1) achieve Sustainable Development Goals target 3.4 but do not make any progress on disability reduction, (2) achieve Sustainable Development Goals target 3.4 and eliminate NCD-related disability, and (3) eliminate all NCD-related mortality and disability. RESULTS: In all scenarios, the high-income group has the greatest potential gains in HALE[30-70], above the global average. For all specific causes, potential gains in HALE[30-70] decrease as income levels fall. Across these 3 scenarios, the potential gains in HALE[30-70] globally of reducing premature mortality for 4 major NCDs are 3.13 years, 4.53 years, and 7.32 years, respectively. In scenario A, all income groups have the greatest potential gains in HALE[30-70] from diabetes and chronic respiratory diseases. In scenarios B and C, the high-income group has the greatest potential gains in HALE[30-70] from cancer intervention, and the other income groups have the greatest potential gains in HALE[30-70] from cardiovascular diseases intervention. CONCLUSION: Reducing premature death and disability from 4 major NCDs at once and attaching equal importance to each lead to a sizable improvement in HALE[30-70].

Potential gains in health-adjusted life expectancy from reducing four main non-communicable diseases among Chinese elderly.

BACKGROUND: To estimate the potential gains in health-adjusted life expectancy (HALE) after hypothetical elimination of four non-communicable diseases (NCDs) among Chinese elderly from 1990 to 2016, including cardiovascular diseases (CVD), cancers, chronic respiratory diseases (CRD) and diabetes mellitus (DM). METHODS: Based on data from Global Burden of Disease 2016, we generated life table by gender using Sullivan method to calculate HALE. Disease-deleted method was used to calculate cause-elimination HALE, after hypothetical elimination of specific diseases. RESULTS: From 1990 to 2016, HALE increased for all age groups. After hypothetic eliminating the four main NCDs, potential gain in HALE by CVD, DM and cancers increased while by CRD decreased from 1990 to 2016 for both genders. Among four main NCDs, potential gain in HALE after eliminating CVD was largest and increased most for both genders. Although elimination of DM led to the smallest gain in HALE, the increasing speed of gain in HALE by DM was faster than that by CVD and cancers from 1990 to 2016. CONCLUSIONS: This study highlights the potential gains in HALE of NCDs among Chinese elderly from 1990 to 2016. HALE of Chinese elderly could further increase from the reduction of NCDs. Control measures and targeted prevention should be carried out.

Health-Adjusted Life Expectancy (HALE) in Korea: 2005-2011.

Health-Adjusted Life Expectancy (HALE) is a summary measurement that estimates the average number of years that a person at a given age can expect to live an equivalent of full health. HALE has not been previously reported at national or regional levels in Korea. This study aimed to measure HALE from 2005 to 2011 in Korea at both the national and regional levels as part of the Korean National Burden Study of 2012. To measure life expectancy (LE) and HALE, we used the life table method and an approach proposed by Sullivan. We used three main data sets to estimate HALE: probability of death, prevalence of disease, and disability weights. Overall, LE and HALE have increased from 2005 to 2011. For example, in 2011, LE and HALE at birth in males were 77.6 and 65.8 years, respectively, and 84.4 and 68.9 in females. It might be assumed that the overall health status of Korean population has been increasing. However, we confirmed that a gap between LE and HALE still exists. Additionally, we found out that there was a significant difference between LE and HALE among various sub-regions. This study is the first to measure HALE using our own database, including disability weight that reflected Korean preferences. Finally, the Korean government and society should make an effort to reduce the gap between LE and HALE and to reduce regional differences.

How much might a society spend on life-saving interventions at different ages while remaining cost-effective? A case study in a country with detailed data.

OBJECTIVE: We aimed to estimate the maximum intervention cost (EMIC) a society could invest in a life-saving intervention at different ages while remaining cost-effective according to a user-specified cost-effectiveness threshold. METHODS: New Zealand (NZ) was used as a case study, and a health system perspective was taken. Data from NZ life tables and morbidity data from a burden of disease study were used to estimate health-adjusted life-years (HALYs) gained by a life-saving intervention. Health system costs were estimated from a national database of all publicly funded health events (hospitalizations, outpatient events, pharmaceuticals, etc.). For illustrative purposes we followed the WHO-CHOICE approach and used a cost-effectiveness threshold of the gross domestic product (GDP) per capita (NZ$45,000 or US$30,000 per HALY). We then calculated EMICs for an "ideal" life-saving intervention that fully returned survivors to the same average morbidity, mortality, and cost trajectories as the rest of their cohort. FINDINGS: The EMIC of the "ideal" life-saving intervention varied markedly by age: NZ$1.3 million (US$880,000) for an intervention to save the life of a child, NZ$0.8 million (US$540,000) for a 50-year-old, and NZ$0.235 million (US$158,000) for an 80-year-old. These results were predictably very sensitive to the choice of discount rate and to the selected cost-effectiveness threshold. Using WHO data, we produced an online calculator to allow the performance of similar calculations for all other countries. CONCLUSIONS: We present an approach to estimating maximal cost-effective investment in life-saving health interventions, under various assumptions. Our online calculator allows this approach to be applied in other countries. Policymakers could use these estimates as a rapid screening tool to determine if more detailed cost-effectiveness analyses of potential life-saving interventions might be worthwhile or which proposed life-saving interventions are very unlikely to benefit from such additional research.

Gender-Specific Health-Adjusted Life Expectancy of Type 2 Diabetes Mellitus Among the Rural Elderly Population.

Objectives: This study aimed to estimate the life expectancy (LE) and health-adjusted life expectancy (HALE) of type 2 diabetes mellitus (T2DM) among the rural elderly population. Methods: A total of 10,318 participants aged 65 to 79 were derived from the Henan Rural Cohort. The LE and HALE were calculated via the Sullivan method and multistate life table. Results: Among 10,318 subjects, 1,325 suffered from T2DM at the baseline, and 394 participants had newly-developed T2DM. The results from the Sullivan method showed that the LE, HALE, and HALE/LE were 17.98, 16.18 years, and 89.95% for men aged 65 to 69, and the corresponding estimates for women were 21.81, 18.73 years, and 85.86%, respectively. The LE, HALE and HALE/LE calculated via multistate life table were 19.86, 17.53 years, and 88.29% for men at aged 65, and the corresponding values for women were 25.01, 20.87 years, and 83.44%, respectively. Conclusion: Rural elderly women have a longer LE and HALE of T2DM, but they have lower quality of life than men. More attention should be paid to T2DM among rural elderly people, especially in women. Clinical Trial Registration: The Henan Rural Cohort Study has been registered at Chinese Clinical Trial Register (Registration number: ChiCTR-OOC-15006699). Date of registration: 06 July 2015. http://www.chictr.org.cn/showproj.aspx?proj=11375.

Cost-effectiveness of caesarean sections in a post-conflict environment: a case study of Bunia, Democratic Republic of the Congo.

This paper demonstrates the feasibility of health services research in an unstable environment during the transition from crisis to development and its importance for future planning. Effectiveness and the cost of caesarean sections (CSs) were investigated in Bunia, a town affected by conflict and insecurity, in the Democratic Republic of the Congo (DRC) in 2008. The CS rate was 9.7 per cent of expected deliveries. All CSs in the study sample were emergency procedures. A humanitarian non-governmental organisation (NGO) hospital, offering free services, performed 75 per cent of all CSs. The estimated provider cost for CS in 2008 at this hospital was USD 103,514 (that is, USD 144 per CS). With a cost of between USD 3.8 and 9.2 per year of health adjusted life expectancy (HALE) gained, CSs at the NGO hospital were very cost-effective. The estimates give an indication of funding requirements to maintain adequate access to CS after the departure of the humanitarian organisation.

Prevalence and Health-Adjusted Life Expectancy Among Older Adults With Hypertension in Chinese Rural Areas.

Background: The objectives of the present study were to explore the epidemiological characteristics of hypertension among rural older adults in resource-limited regions, and then evaluate the loss of health-adjusted life expectancy due to hypertension. Methods: Participants aged between 60 and 79 years were enrolled from Henan rural cohort study. The prevalence, awareness, treatment, and control of hypertension were detailed across subgroups. Variances within subgroups were identified via Student's t tests or one-way ANOVA for continuous variables and chi-squared tests for categorical ones, and logistic regression model was employed to detect the potential influencing factors. The health-adjusted life expectancy was calculated by the Sullivan method with EuroqOL-5D data. Results: Among 16,785 participants, 7,472 (44.52%) were attacked by hypertension, 4,858 (65.02%) had been already aware of their condition, 4,009 (53.65%) were taking antihypertensive medication for treatment, while only 1,478 (19.78%) had their hypertension controlled. The prevalence of hypertension was significantly higher among women than men and it increased with age for both genders. For the older ones aged 60 years, the life expectancy was 22.0872 years and the health-adjusted life expectancy was 15.5578 and 15.9418 for those with or without hypertension, respectively. Namely, in this particular age group, subjects without hypertension could gain 0.3840 years of health-adjusted life expectancy. Conclusion: The prevalence of hypertension was relatively high while the awareness, treatment, and control were fairly low. The health-adjusted life expectancy of older adults in resource-limited areas could increase from the reduction of hypertension. There is an urgent need for strategies pertaining to the prevention and treatment of hypertension. Clinical Trial Registration: The Henan Rural Cohort Study has been registered at the Chinese Clinical Trial Register (Registration number: ChiCTR-OOC-15006699). Date of registration: 06 July, 2015. http://www.chictr.org.cn/showproj.aspx?proj=11375.

Changes and Trend Disparities in Life Expectancy and Health-Adjusted Life Expectancy Attributed to Disability and Mortality From 1990 to 2019 in China.

Objective: This study aims to investigate sex, age, and cause-specific contributions to changes and trend disparities in life expectancy (LE) and health-adjusted life expectancy (HALE) attributed to disability and mortality from 1990 to 2019 in China, which provides insight into policy-making, health systems planning, and resource allocation. Methods: Contributions of disability and mortality to changes and trend disparities in LE and HALE were estimated with standard abridged life table, Sullivan's method, and decomposition method, using retrospective demographic analysis based on mortality and years lived with disability (YLD) rates extracted from Global Burden of Disease Study 2019 (GBD 2019). Results: From 1990 to 2019, LE and HALE increased by 10.49 and 8.71 years for both sexes, mainly due to noncommunicable diseases (NCDs) (5.83 years, 55.58% for LE and 6.28 years, 72.10% for HALE). However, HIV/AIDS and sexually transmitted infections had negative effects on changes in LE (-0.03 years, -0.29%) and HALE (-0.05 years, -0.57%). Lung cancer and ischemic heart disease caused the biggest reduction in LE (-0.14 years, -1.33%) and HALE (-0.42 years, -4.82%). Also, cardiovascular diseases (-0.08 years, -0.92%), neurological disorders (-0.08 years, -0.92%), diabetes and kidney diseases (-0.06 years, -0.69%), and transport injuries (-0.06 years, -0.69%) had main negative disability effects in HALE. Moreover, life expectancy lived with disability (LED) increased by 1.78 years, mainly attributed to respiratory infections and tuberculosis (1.04 years, 58.43%) and maternal and neonatal disorders (0.78 years, 43.82%). Conclusion: The LE and HALE in China have grown rapidly over the past few decades, mainly attributed to NCDs. It is necessary to further reduce the negative mortality effect of HIV/AIDS, lung cancer, colon and rectum cancer, pancreatic cancer, and ischemic heart disease and the negative disability effect of stroke, diabetes mellitus, and road injuries. In addition, the signs of disparities in mortality and disability of different sexes and ages call for targeted and precise interventions for key groups such as males and the elderly. According to the decomposition results, we may better determine the key objects of health policies that take into account substantial cause-specific variations to facilitate the realization of "healthy China 2030" plan.

Key Social Determinants to Narrow the Gap between Health-adjusted Life Expectancy and Life Expectancy in Megacities.

Objective: Improvement in the quality of life is reflected in the narrowing of the gap between health-adjusted life expectancy (HALE) and life expectancy (LE). The effect of megacity expansion on narrowing the gap is rarely reported. This study aimed to disclose this potential relationship. Methods: Annual life tables were constructed from identified death records and population counts from multiple administrative sources in Guangzhou, China, from 2010 to 2020. Joinpoint regression was used to evaluate the temporal trend. Generalized principal component analysis and multilevel models were applied to examine the county-level association between the gap and social determinants. Results: Although LE and HALE in megacities are increasing steadily, their gap is widening. Socio-economic and health services are guaranteed to narrow this gap. Increasing personal wealth, a growing number of newborns and healthy immigrants, high urbanization, and healthy aging have helped in narrowing this gap. Conclusion: In megacities, parallel LE and HALE growth should be highly considered to narrow their gap. Multiple social determinants need to be integrated as a whole to formulate public health plans.

Well-Being Adjusted Health Expectancy: A New Summary Measure of Population Health.

We propose a new summary measure of population health (SMPH), the well-being-adjusted health expectancy (WAHE). WAHE belongs to a subgroup of health-adjusted life expectancy indicators and gives the number of life years equivalent to full health. WAHE combines health and mortality information into a single indicator with weights that quantify the reduction in well-being associated with decreased health. WAHE's advantage over other SMPHs lies in its ability to differentiate between the consequences of health limitations at various levels of severity and its transparent, simple valuation function. Following the guidelines of a Committee on Summary Measures of Population Health, we discuss WAHE's validity, universality, feasibility sensitivity and ensure its reproducibility. We evaluate WAHE's performance compared to life expectancy, the most commonly used indicators of health expectancy (HE) and disability-adjusted life expectancy (DALE) in an empirical application for 29 European countries. Data on health and well-being are taken from the 2018 EU-SILC, and the life tables are from Eurostat. DALE is taken from the database of the Global Burden of Disease Programme. WAHE's sensitivity to univariate and multivariate state specifications is studied using the three Minimum European Health Module health dimensions: chronic morbidity, limitations in activities of daily living, and self-rated health. The empirical tests of the indicators' correspondence reveal that WAHE has the strongest correlation with the other SMPHs. Moreover, WAHE estimates are in agreement with all other SMPHs. Additionally, WAHE and all other SMPHs form a group of reliable indicators for studying population health in European countries. Finally, WAHE estimates are robust, regardless of whether health is defined across one or multiple simultaneous dimensions of health. We conclude that WAHE is a useful and reliable indicator of population health and performs at least as well as other commonly used SMPHs. Supplementary Information: The online version contains supplementary material available at 10.1007/s10680-022-09628-1.

Changing Inequalities in Health-Adjusted Life Expectancy by Income and Race in South Africa.

Trends in socioeconomic-related health inequalities is a particularly pertinent topic in South Africa where years of systematic discrimination under apartheid bequeathed a legacy of inequalities in health outcomes. We use three nationally representative datasets to examine trends in income- and race-related inequalities in life expectancy (LE) and health-adjusted life expectancy (HALE) since the beginning of the millennium. We find that, in aggregate, (HA)LE at age five fell substantially between 2001 and 2007, but then increased to above 2001 levels by 2016, with the largest changes observed among prime age adults. Income- and race-related inequalities in both LE and HALE favor relatively well-off and non-Black South Africans in all survey years. Both income- and race-related inequalities in (HA)LE grew between 2001 and 2007, and then narrowed between 2007 to 2016. However, while race-related inequalities in (HA)LE in 2016 were smaller than in 2001, income-related inequalities in (HA)LE were greater in 2016 than in 2001. Based on the patterns and timing observed, these trends in income- and race-related inequalities in (HA)LE are most likely related to the delayed initial policy response to the HIV epidemic, the subsequent rapid and effective rollout of anti-retroviral therapy, and the changes in the overall income distribution among Black South Africans. In particular, the growth of the Black middle class narrowed the HA(LE) gap with the non-Black population but reinforced income-related inequalities.

[Health-related quality of life and health-adjusted life expectancy among patients with chronic non-communicable diseases, in Guangdong province].

Objective: To estimate the health-related quality of life (HRQOL) and health-adjusted life expectancy (HALE) which were associated with chronic non-communicable diseases (NCDs) in people from Guangdong province of China. Methods: Data on both NCDs prevalence and EuroQol-5 Dimensions-3 Levels measured HRQOL were gathered from the Fifth National Health Survey in Guangdong province, 2013. Logistic regression model and multiple linear regression model were employed to explore the impact of NCDs on HRQOL. Life expectancy (LE) and HALE were used to evaluate the comprehensive impact of chronic diseases on population health. Results: A total of 68 550 inhabitants were included in the analysis. Graded logistic regression showed that the impact of chronic diseases on all dimensions of quality of life was statistically significant after adjusting for social demographic characteristics. The greatest health impact was on the pain/discomfort health dimension [OR=4.48 (95%CI:4.20-4.77)], followed by anxiety/depression[OR=3.95 (95%CI: 3.62- 4.31)], daily activities [OR=3.69 (95%CI: 3.37-4.04)], mobility [OR=3.63 (95%CI: 3.34-3.94)]and ability on self-care [OR=3.30 (95%CI: 2.98-3.66)]. Losses of LE and HALE caused by NCDs were 12.7 and 14.6 years respectively while the overall expected gain was 3.8 years in HALE, when NCDs were taken away. Conclusions: Our data showed that NCDs had shortened the healthy life span of patients through reducing the HRQOL and also causing heavy disease burden on both patients with NCDs and the communities. Health-care related policies on NCDs need to be developed, for the elderly, in particular.

[Estimation on the health life expectancy of adults in Zhejiang province, 2016].

Objective: To estimate the health-adjusted life expectancy (HALE) of adults in Zhejiang province and evaluate the health status of the adults. Methods: This study was based on the mortality data collected from Zhejiang Chronic Disease Surveillance Information and Management System, and mortality rates from the underreporting survey and self-reported health data in 2016. Hierarchical Ordered Probit (HOPIT) model was used to estimate the severity-weighted prevalence of disability. Sullivan's method was used to calculate the HALE. Results: After adjustment by HOPIT model, the severity-weighted prevalence of disability increased significantly with age (χ(2)=5 795.81,P<0.001), and it was higher in females than in males (χ(2)=5 353.27, P<0.001). The life expectancy and self-evaluated HALE were 59.08 years and 48.68 years, respectively, in those aged ≥20 years, the difference was 10.40 years due to disability. The proportion of HALE loss due to disability in the total life expectancy was 17.61%, and it increased with age. HALE was higher in males than in females (49.21 years vs. 48.14 years), and in urban residents than in rural residents (49.92 years vs. 47.43 years). Conclusion: The proportion of loss of HALE in the total life expectancy in adults was high in Zhejiang, and it higher in males than in females, in urban residents than rural residents. Programs on improving health care in women and rural residents should be promoted.

What really matters: living longer or living healthier Comment on "Shanghai rising: health improvements as measured by avoidable mortality since 2000".

The decline in Avoidable Mortality (AM) and increase in life expectancy in Shanghai is impressive. Gusmano and colleagues suggested that Shanghai's improved health system has contributed significantly to this decline in AM. However, when compared to other global cities, Shanghai's life expectancy at birth is improving as London and New York City, but has yet to surpass that of Hong Kong, Tokyo, and Paris. Over the past decade, the reduction in AM of Shanghai is just in line with the international experience in reducing avoidable premature deaths. We suggest that a more elaborate research design is needed to examine the impact of the improvement in Shanghai's health system on its population health status.

Small-area health comparisons using health-adjusted life expectancies: a Bayesian random-effects approach.

Health-adjusted life expectancy (HALE) is one of the most attractive summary measures of population health. It provides balanced attention to fatal as well as non-fatal health outcomes, is sensitive to the severity of morbidity within the population, and can be readily compared between areas with very different population age structures. HALE, however, cannot be calculated at the small-area level using traditional life table methodology. Hence we propose a Bayesian random-effects modeling approach that recognizes correlations and pools strength between sexes, age-groups, geographical areas, and health outcomes. This approach allows for the calculation of HALE for areas as small as 2000 person years at risk and with relatively modest health state survey sample sizes. The feasibility of the Bayesian approach is illustrated in a real-life example, which also shows how differences in areas' health performances can be adequately quantified. Such information can be invaluable for the appropriate targetting and subsequent evaluation of urban regeneration, neighborhood renewal, and community-based initiatives aimed at improving health and reducing health inequalities.