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Projecting health care system outcomes due to lifestyle changes O’Brien, Richard Michael 1980

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PROJECTING. HEALTH CARE SYSTEM OUTCOMES DUE TO LIFESTYLE CHANGES V \ » ^ | f Richard Michael O'Brien B.A., U n i v e r s i t y of Prince Edward Is l a n d , 1973 A Thesis Submitted i n P a r t i a l F u l f i l l m e n t of the Requirements f o r the Degree of THE FACULTY OF GRADUATE STUDIES DEPARTMENT OF HEALTH CARE AND EPIDEMIOLOGY We accept t h i s t h e s i s as conforming to the r e q u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA December 1980 by MASTER OF SCIENCE in ©Richard Michael O'Brien, 1980 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the Head of my Department or by his representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of Health Care and Epidemiology The University of British Columbia 2075 Wesbrook Place Vancouver, Canada V6T 1W5 Date December 31, 1980 i i ABSTRACT Health promotion has been i d e n t i f i e d as a p r a c t i c a l inexpensive s t r a t e g y to reduce h o s p i t a l costs i n Canada. U n f o r t u n a t e l y there i s a dearth of i n f o r m a t i o n about t h i s , and a l s o the a c t u a l impact of improved l i f e s t y l e s on h e a l t h s t a t u s , i l l n e s s and death. In f a c t , there i s even an appre-hension that by a v o i d i n g premature m o r t a l i t y the numbers and needs of the e l d e r l y w i l l i n c r e a s e d r a m a t i c a l l y , r e s u l t i n g i n cost i n c r e a s e s . T h i s t h e s i s attempts to r e s o l v e t h i s i s s u e by p r o j e c t i n g h o s p i t a l use by Canadians and r e s u l t a n t cost savings or i n c r e a s e s based on assumptions concerning improvements i n l i f e s t y l e s . Four steps were r e q u i r e d : f i r s t , m o r t a l i t y r a t e s were reduced based on assumed improvements i n l i f e s t y l e s ; second, a p o p u l a t i o n model was chosen to p r o j e c t p o p u l a t i o n f o r the s h o r t -term (25 years) and long-term (500 years to s t a b l e s t a t e ) ; t h i r d , h o s p i t a l u t i l i z a t i o n r a t e s were reduced c o n s i s t e n t with r e d u c t i o n s i n m o r t a l i t y ; and f o u r t h , f u t u r e h o s p i t a l use and costs were c a l c u l a t e d and t h e i r burden on s o c i e t y determined. The o v e r a l l e f f e c t of improving l i f e s t y l e s was a decrease i n a g e - s p e c i f i c m o r t a l i t y r a t e s e s p e c i a l l y f o r males and the e l d e r l y . Reducing premature m o r t a l i t y r e s u l t e d i n both i i i s l i g h t i n c r e a s e s i n both t h e . s t a b l e population's t o t a l s i z e and p r o p o r t i o n of e l d e r l y i n the p o p u l a t i o n . The dependency r a t i o remained r e l a t i v e l y constant. A g e - s p e c i f i c h o s p i t a l use decreased,but i n c r e a s e s i n the'number of e l d e r l y o f f s e t t h i s decrease so that there was a s l i g h t o v e r a l l i n c r e a s e i n use and a s s o c i a t e d c o s t s . This r e s u l t e d i n only s l i g h t per c a p i t a costs i n c r e a s e s f o r the p r o d u c t i v e (20-64) age groups. Therefore, the t h e s i s has determined that h e a l t h promotion by i t s e l f w i l l not have a s i g n i f i c a n t e f f e c t i n e i t h e r i n c r e a s i n g or d e c r e a s i n g costs of h o s p i t a l care i n the long term. However, h e a l t h promotion was i d e n t i f i e d as a v i a b l e s t r a t e g y which at very l i t t l e expense w i l l postpone a s i g n i f i c a n t p r o p o r t i o n of premature m o r t a l i t y , allow more persons to reach o l d age, and r e s u l t i n a more vigorous p o p u l a t i o n . The i n c r e a s e d numbers of e l d e r l y and t h e i r impact on the s t r u c t u r e and components of the h e a l t h and i l l n e s s care system were i d e n t i f i e d . Future r e s e a r c h i n t o the question of cost e f f e c t i v e -ness of h e a l t h promotion would r e q u i r e a much improved data base, e s p e c i a l l y i n the area of m o r b i d i t y and h o s p i t a l care. However, i t was suggested that more p r o d u c t i v e r e s e a r c h e f f o r t s might seek to i d e n t i f y optimal methods of modifying and improving l i f e s t y l e s , such as long-term demonstration p r o j e c t s with e v a l -u a t i o n components. There was s u f f i c i e n t evidence found to conclude that h e a l t h promotion should be advanced as a v i a b l e and necessary component of the Canadian h e a l t h care system. i v TABLE OF CONTENTS Page ABSTRACT i i TABLE OF CONTENTS i v LIST OF TABLES v i LIST OF FIGURES i x ACKNOWLEDGEMENTS x INTRODUCTION 1 1 . 1 Background 1 1.2 Purpo s e 7 1.3 S t r u c t u r e § Content 8 LITERATURE REVIEW 9 2.1 Background 9 2.2 Issues 16 2.3 Measurement 30 2.4 Conclusions 38 METHODOLOGY ";:V 4 0 3.1 B a s e l i n e Demographic Data 40 3.2 Causes of Preventable Deaths 42 3.3 Changing M o r t a l i t y Rates 43 3.4 Q u a n t i f i c a t i o n of Decreased M o r t a l i t y 49 3.5 Po p u l a t i o n P r o j e c t i o n 57 3.6 F o r e c a s t i n g H o s p i t a l U t i l i z a t i o n 61 3.7 F o r e c a s t i n g H o s p i t a l Costs 73 V Page RESULTS AND DISCUSSION 77 4.1 I n t r o d u c t i o n 77 4.2 The P o p u l a t i o n - 77 4.3 Crude Death Rates 79 4.4 L i f e Expectancy 83 4.5 F e r t i l i t y 89 4.6 P o p u l a t i o n Age S t r u c t u r e 90 4.7 H o s p i t a l U t i l i z a t i o n 105 CONCLUSION 119 5.1 Background 119 5.2 Fi n d i n g s - I n t e r p r e t a t i o n s 121 5.2.1 M o r t a l i t y 121 5.2.2 Po p u l a t i o n S t r u c t u r e 122 5.2.3 H o s p i t a l U t i l i z a t i o n 123 5.2.4 Costs 125 5.3 I m p l i c a t i o n s 126 5.4 Future Research 128 BIBLIOGRAPHY 130 APPENDICES 1 L i f e 136 2 P r o j e c t 143 v i , LIST OF TABLES Table Page 2.1 Ten Leading Causes of Death United States - 12 1900, 1930, 1970 2.2 P r o b a b i l i t y Table of Deaths i n the Next Ten 15 Years Males and Females Ages 15-80 Canada 1971 2.3 PYLL and Deaths Between Ages 1 and 70 by Major 19 Causes Canada 1974 2.4 H i s t o r i c a l P a tterns of Average L i f e Expectancy 20 2.5 Percentage D i s t r i b u t i o n of the Po p u l a t i o n of 24 the United States by Year and Age Group 3.1 P o p u l a t i o n and Deaths by S e l e c t e d Age Groups and 41 Sex, and B i r t h by Age of Mothers - Canada 1971 3.2 L i f e s t y l e Factors and Cause of Death Matrix 44 3.3 Cause of Death and Ranking f o r Deaths, P o t e n t i a l 45 Years of L i f e Lost, and T o t a l Days of H o s p i t a l i -z a t i o n . 3.4 M o r t a l i t y by S e l e c t e d Causes Canada 1971 46 3.5 Risk F a c t o r T r i a l s 48 3.6 Example C a l c u l a t i o n M o d i f i e d M o r t a l i t y Rates f o r 54 Motor V e h i c l e A c c i d e n t s ; f o r 25% Reduction i n A l c o h o l § S e a t b e l t s Risk F a c t o r s ; Males 3.7 T o t a l Deaths f o r S e l e c t e d T r i a l s 1971 - 56 H y p o t h e t i c a l P o p u l a t i o n 3.8 Input Data K e y f i t z " L i f Program" Standard 1971 60 3.9 Deaths and Days of H o s p i t a l i z a t i o n Due to Motor 63 V e h i c l e A c c i d e n t s B r i t i s h Columbia 1972 3.10 T o t a l Days of H o s p i t a l i z a t i o n by S e l e c t e d Diseases 65 by Sex and by Selected-Age-Groups - 1971 3.11 T o t a l Days of H o s p i t a l i z a t i o n by Sex and by 67 Selected-Age-Groups - Canada 1971 v i i Table Page 3.12 T o t a l Days of H o s p i t a l i z a t i o n f o r Preventable 67 Con d i t i o n s by Sex and by Selected-Age-Groups 1971 3.13 Example C a l c u l a t i o n Rate of Reduction of H o s p i t a l 69 U t i l i z a t i o n 1971 'SAXWB* - B r o n c h i t i s and Emphas ema 3.14 Example C a l c u l a t i o n Reduction of H o s p i t a l 69 U t i l i z a t i o n 1971 'SAXWB' 3.15 H o s p i t a l U t i l i z a t i o n Rates by Sex, S e l e c t e d - 71 Age-Groups, and T r i a l s 3.16 Example C a l c u l a t i o n of T o t a l H o s p i t a l U t i l i z a - 72 t i o n f o r T r i a l 'SAXWB' i n 1996 3.17 H o s p i t a l i z a t i o n Burden on S o c i e t y Rates (BSR) 74 Se l e c t e d T r i a l s 3.18 T o t a l Costs of H o s p i t a l U t i l i z a t i o n by Se l e c t e d 75 T r i a l s , 1971 Constant D o l l a r s 4.1 Crude Death Rates and Ranking by T r i a l "1971" 80 (Canada) For Male, Female, and T o t a l 4.2 Absolute and Percentage Reductions i n M o r t a l i t y 82 Rates by S e l e c t e d T r i a l s and Standard 4.3 L i f e Expectancy Male § Female at Se l e c t e d Ages 84 by T r i a l 4.4 O v e r a l l Increase Above Standard L i f e Expectancy 86 with S e l e c t e d T r i a l s , by Age Group 5 Sex, i n Years 4.5 L i f e Expectancy D i f f e r e n c e Between Male and 88 Female, by Age Group & T r i a l ; i n Years 4. 6A D i s t r i b u t i o n by Age § Sex 1996 Mai es 91 4. 6B D i s t r i b u t i o n by Age § Sex 1996 Females 92 4. 6C D i s t r i b u t i o n by Age § Sex 1996 Males § Females 93 4. 6D Percentage D i s t r i b u t i on by Age & Sex 1996 94 v i i i Table Page 4.7A D i s t r i b u t i o n by Age $ Sex 2471 Males 95 4.7B D i s t r i b u t i o n by Age § Sex 2471 Females 96 4.7C D i s t r i b u t i o n by Age & Sex 2471 Males § Females 97 4.7D Percentage D i s t r i b u t i o n by Age § Sex 2471 98 4.8 P o p u l a t i o n Growth »P' to 'SAXWB-I' 2471 103 4.9 H o s p i t a l U t i l i z a t i o n Rates by S e l e c t e d Age 107 Groups and by Sex f o r S e l e c t e d T r i a l s ; i n H o s p i t a l Days/Per C a p i t a Per Year 4.10 Percentage Reduction i n H o s p i t a l U t i l i z a t i o n 107 by Age and by Sex f o r S e l e c t e d T r i a l s 4.11 H o s p i t a l U t i l i z a t i o n by Age § Sex f o r *P' 110 T r i a l , i n Days 4.12 H o s p i t a l U t i l i z a t i o n by Age and Sex f o r 111 T r i a l 1SAXWB », i n Days 4.13 H o s p i t a l U t i l i z a t i o n by Age and Sex f o r 112 T r i a l 'SAXWB-I' i n Days 4.14 Annual per Capita P r o j e c t e d H o s p i t a l 114 U t i l i z a t i o n by Year f o r S e l e c t e d T r i a l s i n Days 4.15 Burden on S o c i e t y H o s p i t a l U t i l i z a t i o n , by 116 Se l e c t e d T r i a l s , i n Days Per Ca p i t a of Productive Age 4.16 Burden on S o c i e t y H o s p i t a l U t i l i z a t i o n by S e l e c t e d 116 T r i a l s D i f f e r e n c e From 'P' i n Days 4.17 T o t a l P r o j e c t e d Costs of H o s p i t a l U t i l i z a t i o n by 117 S e l e c t e d T r i a l s 1971 Constant D o l l a r s 000's i x LIST OF FIGURES Figure Page 1 S u r v i v a l Curves 29 X ACKNOWLEDGEMENTS I wish to take t h i s o p p o r t u n i t y to s i n c e r e l y thank my wife, G l o r i a Sherman-0'Brien f o r her encouragement and t o l e r a n c e ; Dr. John Milsum f o r h i s i n v a l u a b l e advice, a s s i s t a n c e and pa t i e n c e ; Dr. Marvin Clark f o r h i s c o n t i n u i n g support; and Jane Welch f o r the f i n a l t y p i n g of the manuscript. - 1 -INTRODUCTION 1.1 BACKGROUND "Dis c u s s i o n s about the f u t u r e of the h e a l t h care system i n Ontario are r e p l e t e with statements about the need f o r l a y i n g g r e a t e r emphasis on the p r e v e n t i o n of d i s e a s e , h e a l t h promotion, h e a l t h maintenance and h e a l t h e d u c a t i o n . " "There i s not much doubt t h a t , i n g e n e r a l , t h i s new emphasis i s r e l e v a n t to our cur r e n t needs. But the t r a n s l a t i o n of t h i s g e n e r a l i t y i n t o a s p e c i f i c , w ell d e f i n e d program of a c t i o n i s a very d i f f i c u l t and complex matter. The rec o r d thus f a r has h a r d l y been impressive. P e r s i s t e n t advocacy of p r e v e n t a t i v e medicine, h e a l t h education, environmental management, l i f e s t y l e changes, mass scre e n i n g and the l i k e , cover a multitude of s p e c i f i c suggestions f o r p u b l i c p o l i c y , but i n very broad terms. Claims of a l a r g e p o t e n t i a l f o r improving h e a l t h and c o n t r o l l i n g expenditures abound. However, there are counter claims and much s k e p t i c i s m . The s k e p t i c i s m i s p a r t i c u l a r l y d i r e c t e d at the e x p e c t a t i o n of l a r g e savings. U n f o r t u n a t e l y , f a c t s or a n a l y s i s are hard to come by i n t h i s area." (Ontario Economic C o u n c i l , 1976) This t h e s i s p r o j e c t s h o s p i t a l use by Canadians based on assumptions concerning improvements i n l i f e s t y l e s . An attempt i s made to determine the p o t e n t i a l c o s t - s a v i n g s or i n c r e a s e s r e s u l t i n g from the p r e v e n t i o n of disease and a c c i d e n t s . Therefore, the t h e s i s purports to provide i n i t i a l a n a l y s i s as suggested to be so badly needed i n the opening qu o t a t i o n . It i s b e l i e v e d by proponents of h e a l t h promotion and i l l n e s s p r e v e n t i o n t h a t , through h e a l t h f u l l i f e s t y l e - 2 -•changes, the net e f f e c t on the h e a l t h care system would be a r e d u c t i o n i n the demand f o r s e r v i c e s (Thornton, 1978). This r e d u c t i o n would p o t e n t i a l l y reduce the amount of money expended on c u r a t i v e medicine. Milsum (1980) has s t a t e d that "the apparently inexhaust-i b l e 'need' f o r s i c k care - with costs i n c r e a s i n g f a s t e r than GNP - has s t i m u l a t e d c o n s i d e r a t i o n s of i l l n e s s p r e v e n t i o n and h e a l t h promotion". The authors of "A New P e r s p e c t i v e on the Health of Canadians" (Lalonde, 1974) take a cautious approach when they p r e d i c t that " i f the i n c i d e n c e of sic k n e s s can be reduced by p r e v e n t i o n then the cost of present s e r v i c e s w i l l go down or at l e a s t the r a t e of in c r e a s e w i l l d i m i n i s h " . This r e p o r t notes that s i n c e i l l n e s s care i s v i r t u a l l y 100% funded by a l l l e v e l s of Government, i t i s p l a c i n g an i n c r e a s e d burden on s o c i e t y . "The annual r a t e of cost e s c a l a t i o n has been between 12% and 16% which i s f a r i n excess of economic growth of the country. I f unchecked, h e a l t h care costs w i l l soon be beyond the c a p a c i t y of s o c i e t y to f i n a n c e them." (Lalonde, 1974) Approximately 95% of a province's h e a l t h care expenditures are d i r e c t e d to the i l l n e s s care system. Of t h i s amount, over two-thirds i s u t i l i z e d f o r the p r o v i s i o n of t e c h n o l o g i c a l l y - o r i e n t e d h o s p i t a l care ( C a l l b e c k , 1977) - 3 -Given an aging Canadian p o p u l a t i o n and ongoing t e c h n o l o g i c a l advances, i t would seem i n e v i t a b l e that there w i l l be co n t i n u i n g cost e s c a l a t i o n , unless some mediating f a c t o r i s found. Since h o s p i t a l care i s a h i g h l y l a b o u r - i n t e n s i v e i n d u s t r y and, t h e r e f o r e , subject to very small growth i n p r o d u c t i v i t y (Baumal Oates, 1972), the most obvious p o t e n t i a l f o r c o s t - s a v i n g l i e s i n decreasing u s e / u t i l i z a t i o n , as a r e s u l t of decreases i n need/morbidity. However, the economic cost alone i s not the only motivator f o r i n c r e a s i n g emphasis on p r e v e n t i v e h e a l t h programs. It has been reco g n i z e d that a s i g n i f i c a n t p r o p o r t i o n of p o t e n t i a l years of l i f e l o s t are due to preventable c o n d i t i o n s (Romeder § McWhinnie, 1977). S i m i l a r l y , a s i g n i f i c a n t p r o p o r t i o n of i l l n e s s / h o s p i t a l i -z a t i o n i s a l s o due to preventable c o n d i t i o n s ( S t a t i s t i c s Canada, H o s p i t a l S t a t i s t i c s , 1974). Although i t i s recogn i z e d that not a l l preventable c o n d i t i o n s are n e c e s s a r i l y r e l a t e d to personal r i s k - t a k i n g , i t i s important to note that had pop u l a t i o n s avoided many of t h e i r r i s k s there would almost c e r t a i n l y have been a r e d u c t i o n i n recent p a t t e r n s of m o r t a l i t y and m o r b i d i t y . There are those who b e l i e v e that the l i m i t s to medicine have b e e n : p r a c t i c a l l y achieved ( I l l i c h , 1975; Dubos, 1975; C a r l s o n , 1975), and that the b i o l o g i c a l l i f e s p a n of man i s already being reached by many i n d i v i d u a l s - 4 -(Comfort, 1964). However, the m a j o r i t y of people s t i l l s u f f e r from c o n d i t i o n s which prevent them from a c h i e v i n g b i o l o g i c a l maximum age and hence have died prematurely. It has been suggested that other s o l u t i o n s should be i d e n t i f i e d i n order to assure that as many i n d i -v i d u a l s as p o s s i b l e a t t a i n b i o l o g i c a l maximum age and have g r e a t e r freedom from disease and enjoy a high standard of h e a l t h . "The evidence uncovered by the a n a l y s i s of under-l y i n g causes of si c k n e s s and death now i n d i c a t e s that improvement i n the environment and an abatement i n the l e v e l s of r i s k s imposed upon themselves by i n d i v i d u a l s , taken together c o n s t i t u t e the most promising ways by which f u r t h e r advances can be made." (Lalonde, 1974) It i s not s u r p r i s i n g then that p o l i c y makers, faced with i n c r e a s i n g c o s t s , which l i m i t expenditures i n other areas, and with an i l l n e s s care system which i s approaching i t s margin of e f f e c t i v e n e s s , should look towards i l l n e s s p r e v e n t i o n and h e a l t h promotion f o r both improved h e a l t h and decreased c o s t s . In f a c t , recent a n a l y s i s of h e a l t h p o l i c y has suggested that there be a r e b a l a n c i n g of h e a l t h / i l l n e s s - c a r e expenditures so that an i n c r e a s i n g p r o p o r t i o n of t o t a l resources can be d i r e c t e d to h e a l t h promotion e f f o r t s (Bennett 8, Krasny, 1977). The c l i c h e "an ounce of pr e v e n t i o n i s worth a pound of cure" i s r e g a i n i n g p o p u l a r i t y i n the h e a l t h f i e l d . - 5 -U n f o r t u n a t e l y , there i s a p a u c i t y of i n f o r m a t i o n concerning what may be the u l t i m a t e impact of h e a l t h promotion programs. For example, decreased m o r t a l i t y and the r e s u l t i n g i n c r e a s e i n l i f e expectancy would l i k e l y , by themselves, produce an aging Canadian p o p u l a t i o n . When t h i s trend i s combined with the other w e l l - e s t a b l i s h e d trend of d e c l i n i n g b i r t h r a t e s , the p r o p o r t i o n of Canadian p o p u l a t i o n i n the o l d e r age groups w i l l l i k e l y i n c r e a s e d r a m a t i c a l l y . In t h i s regard, Lalonde notes, "As h e a l t h programs succeed i n extending the l i f e of more Canadians, the number of aged w i l l i n c r e a s e and t h e i r needs w i l l augment a c c o r d i n g l y ... the c h r o n i c a l l y i l l w i l l c o n s t i t u t e a l a r g e and growing p a r t of our p o p u l a t i o n " . (Lalonde, 1974) E l d e r l y persons i n Canada have h i s t o r i c a l l y caused much higher i l l n e s s - c a r e expenditures than the per-c a p i t a n a t i o n a l average. For example, i n 1971 persons over 75 used h o s p i t a l s e r v i c e s at 16times the ra t e of persons i n the age group 0 to 19. ( S t a t i s t i c s Canada, H o s p i t a l S t a t i s t i c s , 1974), Therefore, should the number of e l d e r l y i n c r e a s e due to prevented m o r t a l i t y , i t i s p o s s i b l e that they w i l l r e q u i r e i n c r e a s e d i l l n e s s - c a r e s e r v i c e s , and cause f u r t h e r cost e s c a l a t i o n . However, and f o r t u n a t e l y , the net economic e f f e c t of l i f e s t y l e changes i s not n e c e s s a r i l y i n c r e a s e d expenditures. In p a r t i c u l a r , i f improved l i f e s t y l e s not only extend l i f e but a l s o improve the l e v e l of h e a l t h throughout a person's remaining l i f e -span, then the net r e s u l t may be a r e d u c t i o n i n the - 6 -i l l n e s s care system c o s t s . For example, decreased u t i l i z a t i o n of h e a l t h care s e r v i c e s by the younger age groups, brought about by improved h e a l t h s t a t u s , may more than o f f s e t demand pl a c e d on the system by an increasing:number of e l d e r l y with the same improved h e a l t h s t a t u s , who w i l l use h e a l t h s e r v i c e s to a l e s s e r degree. It has a l s o been suggested t h a t , s i n c e the human b i o l o g i c a l l i f e s p a n i s r e l a t i v e l y f i x e d , a person m a i n t a i n i n g a high l e v e l of h e a l t h throughout h i s l i f e -span could expect a r e l a t i v e l y short p e r i o d of i l l n e s s and d i s a b i l i t y p r i o r to death ( F r i e s , 1980). This b e l i e f i s e x e m p l i f i e d i n 0. W. Holmes' "marvelous one-hoss-shay" which f u n c t i o n e d p e r f e c t l y f o r 100 years, but on that a n n i v e r s a r y d i s i n t e g r a t e d (0. W. Holmes, 1901) To summarize with the words of Lalonde, " ... i f the i n c i d e n c e of s i c k n e s s can be reduced by p r e v e n t i o n then the cost of present s e r v i c e s w i l l go down or at l e a s t the r a t e of i n c r e a s e w i l l d i m i n i s h " (Lalonde, 1974). However, t h i s b e l i e f seems open to question due to p o s s i b l e i n c r e a s i n g needs of the e l d e r l y . This t h e s i s addresses t h i s t o p i c and makes an attempt to r e s o l v e i t . - 7 -1 . 2 PURPOSE The purpose of t h i s t h e s i s i s to perfor m i n i t i a l a n a l y s i s of the s h o r t and long term impact of improvements i n the l i f e s t y l e of Canadians on h o s p i t a l use and i t s c o s t s . We do not address the po1 i t i c a l - m o r a l i s s u e s of h e a l t h p r o m o t i o n s t r a t e g i e s nor d i s c u s s the r e l a t i v e e f f i c a c y of p r e v e n t i o n / p r o m o t i o n programs. The impact w i l l be assumed w i t h o u t c o n s i d e r a t i o n of the means n e c e s s a r y to a c h i e v e them. S p e c i f i c a l l y , the f o l l o w i n g problems are addressed: 1. to develop a methodology f o r e s t i m a t i n g the r e d u c t i o n s i n mortality rates resulting, from a ^ variety of assumptions c o n c e r n i n g improvements i n Canadian l i f e s t y l e s ; 2. to determine an a p p r o p r i a t e p o p u l a t i o n model which a l l o w s p o p u l a t i o n p r o j e c t i o n s to be made through to a s t a b l e s t a t e , based on these changes i n m o r t a l i t y r a t e s ; 3. to develop a methodology f o r r e d u c i n g m o r b i d i t y r a t e s based on a v a r i e t y of assumptions c o n c e r n i n g improve-ments i n Canadian l i f e s t y l e s ; and - 8 -4. to develop a methodology f o r g e n e r a t i n g comparative c o s t s of f u t u r e use of h o s p i t a l s and t h e i r burden on s o c i e t y . 1 . 3 STRUCTURE AND CONTENT Chapter 2 d i s c u s s e s the a v a i l a b l e p e r t i n e n t l i t e r a t u r e . However, i t s h o u l d be noted t h a t t h e r e i s an almost complete l a c k of any s i g n i f i c a n t a n a l y s i s c o n c e r n i n g the o v e r a l l impact of improvements of l i f e -s t y l e and t h e i r h e a l t h system i m p l i c a t i o n s . ( I t i s hoped t h a t the a n a l y s i s c o n t a i n e d i n t h i s t h e s i s w i l l p r o v i d e some guidance i n t h i s r e g a r d . ) Chapter 3 p r e s e n t s the methodology used to s o l v e the problems o u t l i n e d above. The methodology a l s o p r e s e n t s the n e c e s s a r y procedures to be a p p l i e d to e x i s t i n g d a t a i n o r d e r to produce d a t a f o r the a n a l y s i s . Chapter 4 p r e s e n t s and a n a l y s e s the r e s u l t s of the v a r i o u s t r i a l s , i n c l u d i n g u l t i m a t e e s t i m a t e d c o s t s of h o s p i t a l u t i l i z a t i o n of f u t u r e p o p u l a t i o n s . Chapter 5 p r e s e n t s the o v e r a l l c o n c l u s i o n s to be drawn from the work, i n c l u d i n g s u g g e s t i o n s f o r f u r t h e r a n a l y s i s i n t h i s i m p o r t a n t h e a l t h f i e l d . - 9 -L ITERATURE REVIEW " O l d age i s n e i t h e r i n h e r e n t l y m i s e r a b l e n o r i n h e r e n t l y s u b l i m e - l i k e e v e r y s t a g e o f l i f e i t has p r o b l e m s , j o y s , f e a r s , and p o t e n t i a l s . The p r o c e s s o f a g i n g , and e v e n t u a l l y d e a t h , mus t u l t i m a t e l y be a c c e p t e d as a n a t u r a l p r o g r e s s i o n o f t h e l i f e c y c l e , t h e o l d c o m p l e t i n g t h e i r p r e -s c r i b e d l i f e s p a n s and m a k i n g way f o r t h e y o u n g . " ( B u t l e r , 1975 ) 2.1 BACKGROUND Omran ( 1971 ) has i d e n t i f i e d t h r e e d i s t i n c t s t a g e s o f m e d i c a l h i s t o r y : t h e Age o f P e s t i l e n c e and F a m i n e w i t h a l i f e e x p e c t a n c y o f b e t w e e n 20 and 30 y e a r s ; t h e Age o f R e c e d i n g P a n d e m i c s w i t h t h e l i f e e x p e c t a n c y o f b e t w e e n 30 and 50 y e a r s ; and t h e Age o f D e g e n e r a t i v e and Man-Made D i s e a s e s w i t h a l i f e e x p e c -t a n c y o f b e t w e e n 50 and 70 y e a r s . D e v e l o p e d W e s t e r n s o c i e t i e s a r e now i n t h i s t h i r d Age o f D e g e n e r a t i v e and Man-Made D i s e a s e s . Omran a l s o i n d i c a t e s a f o r t h c o m i n g Age o f B a l a n c e . T h i s f o u r t h s t a g e i s c h a r a c t e r i z e d by t h e m a j o r i t y o f p e r s o n s a c h i e v i n g t h e i r b i o l o g i c a l maximum a g e s , s t a b l e p o p u l a t i o n s t r u c t u r e s , and m a t u r e p o p u l a -t i o n s . He has s u g g e s t e d t h a t t h i s s t a g e c a n o n l y be a c h i e v e d i f man-made d i s e a s e s c a n be p r e v e n t e d and h e a l t h y , p r o d u c t i v e e n v i r o n m e n t s made a v a i l a b l e . - 10 -Thomlinson (1976) has suggested t h a t i n g e n e r a l the d e c l i n e of m o r t a l i t y and the i n c r e a s i n g l i f e expectancy which has o c c u r r e d i n the l a s t s e v e r a l c e n t u r i e s i s a t t r i b u t a b l e m a i n l y to r i s i n g s t a n d a r d s of l i v i n g . However, S t o l n i t z (1956) suggests t h a t m e d i c a l advances have p l a y e d the major r o l e i n b r i n g i n g about the r e d u c t i o n of death r a t e s w h i l e economic improve-ments have been more i m p o r t a n t as " p e r m i s s i v e elements r a t h e r than p r e c i p i t a t i n g f a c t o r s " . However, i n r e v i e w i n g the major f a c t o r s i n f l u e n c i n g decreases i n m o r t a l i t y i t i s e v i d e n t t h a t m e d i c a l advances have had o n l y a l i m i t e d impact on h e a l t h improvements. For example, Thomlinson (1976) i d e n t i f i e s the f o l l o w i n g t e n change f a c t o r s a f f e c t i n g m o r t a l i t y d e c l i n e : 1. improved a g r i c u l t u r e t e c h n i q u e s 2. machine f a c t o r y systems, which i n c r e a s e d the amount and v a r i e t y of p r o d u c t s a v a i l a b l e 3. improved t r a n s p o r t a t i o n which f a c i l i t a t e d d i s t r i b u t i o n of a g r i c u l t u r a l and i n d u s t r i a l p r o d u c t s 4. s o c i a l reforms which a l l e v i a t e d many hazards of e a r l y f a c t o r y l i f e 5. c l i m a t e c o n t r o l of homes and work l o c a t i o n s which decreased r e s p i r a t o r y i n f e c t i o n s 6. v a s t l y improved p u b l i c s a n i t a t i o n 7. improved p e r s o n a l hygiene - 11 -8. a s e p t i c and a n t i s e p t i c surgery 9. i n t r o d u c t i o n of immunization 10. changes i n v i r u l e n t diseases (mutual adaption between man and d i s e a s e ) Of these ten causes of m o r t a l i t y d e c l i n e , only the e i g h t h has d i r e c t medical r e l e v a n c e , s i n c e the n i n t h , immunology, could be considered a p u b l i c h e a l t h advance as much as a medical advance. Although, no doubt, l i f e expectancy would be decreased i f medical care was not c u r r e n t l y a v a i l a b l e , i t i s l i k e l y that s o p h i s t i c a t e d medical advances have not had as s i g n i f i c a n t an impact "on h e a l t h as the other f a c t o r s i d e n t i f i e d . McKeown § Brown (1965) suggest that improved medical knowledge, e s p e c i a l l y of anatomy, the i n t r o d u c t i o n of h o s p i t a l s , and improved midwivery had very l i t t l e impact on improvements i n h e a l t h s t a t u s or l i f e expectancy u n t i l the mid 1950's. In f a c t , Wrong (1969) notes that p r i o r to the 20th century f a r more people were k i l l e d by medical p r a c t i t i o n e r s than were cured. The current stage of medical h i s t o r y , the Age of Degenerative and Man-Made Diseases has s t a r t e d only r e c e n t l y . Table 2.1 i n d i c a t e s the s h i f t i n g p a t t e r n of m o r t a l i t y experienced i n the United States i n the l a s t 70 years. The top three k i l l e r s i n the United States during 1900 were i n f e c t i o u s d i s e a s e s , while by 1930, only pneumonia-i n f l u e n z a - b r o n c h i t i s ranked i n the top three k i l l e r s , and TABLE 2. 1 TEN LEADING CAUSES OF DEATH  UNITED STATES - 1900, 1930, 1970 1900 1930 1. P n e u m o n i a - i n f l u e n z a - b r o n c h i t i s 14 . 4 1 . Heart d i s e a s e 18. 9 2 . T u b e r c u l o s i s 11 . 3 2 . P n e u m o n i a - i n f l u e n z a - 9. 4 3. D i a r r h e a and e n t e r i t i s 8 . 1 b r o n c h i t i s 4. Heart d i s e a s e 8 . 0 3. Cancer 8 . 6 5. B r i g h t ' s d i s e a s e 4 . 7 4 . N e p h r i t i s 8 . 0 ( c h r o n i c n e p h r i t i s ) 5 . C e r e b r a l hemorrhage 7 . 1 6 . A c c i d e n t s 4 . 5 6. T u b e r c u l o s i s 6. 3 7. Con g e s t i o n and b r a i n hemorrhage 4 . 2 7. A c c i d e n t s ( e x c e p t motor 3 . 1 8 . Disease of e a r l y i n f a n c y 4 . 2 v e h i c l e ) , s u i c i d e 9. Cancer and o t h e r m a l i g n a n t 3 . 7 8. Di s e a s e s o f e a r l y i n f a n c y 4 . 4 tumors 9. Motor v e h i c l e a c c i d e n t s 2. 4 10. D i p t h e r i a 2 . 3 10. D i a r r h e a and e n t e r i t i s 2 . 3 1970 1. Heart d i s e a s e 38 . 3 2. Cancer 17. 2 3. Str o k e 10. 8 4 . Influenza-pneumoni a-bronchi t i s 3. 6 5 . A c c i d e n t s (except motor v e h i c l e ) , s u i c i d e 3. 1 6 . Motor v e h i c l e a c c i d e n t s 2 . 8 7 . Di s e a s e s of e a r l y i n f a n c y 2 . 3 8 . Diabetes 2 . 0 9. A r t e r i o s c l e r o s i s 1 . 7 10. C i r r h o s i s of the l i v e r 1 . 6 Source: Omran, Abdel R., 1977. E p i d e m i o l o g i c a l T r a n s i t i o n i n the U.S. P o p u l a t i o n B u l l e t i n 3 2 ( 2 ) : 3-42. - 13 -by 1970 the t h r e e major k i l l e r s were h e a r t d i s e a s e , cancer and s t r o k e . These l a s t t h r e e d i s e a s e s a l o n e accounted f o r a p p r o x i m a t e l y t w o - t h i r d s of a l l deaths i n the U n i t e d S t a t e s d u r i n g 1970. There has been an obvious s h i f t i n the l a s t s e v e r a l decades from i n f e c t i o u s to d e g e n e r a t i v e d i s e a s e s . T h i s p a t t e r n was a l s o f o l l o w e d i n Canada and, by 1971, i s c h a e m i c h e a r t d i s e a s e s accounted f o r 31.1% of a l l d e a t h s , cancer f o r 18.2%, s t r o k e s f o r 10.2%, w h i l e motor v e h i c l e and o t h e r a c c i d e n t s and s u i c i d e s accounted f o r 9.2% ( L a l o n d e , 1974). These deaths alone accounted f o r almost 70% of a l l Canadian d e a t h s . The average age o f death has a l s o changed i n the l a s t s e v e r a l decades. Whereas the i n f e c t i o u s d i s e a s e s s t r i k e the young, the man-made and d e g e n e r a t i v e d i s e a s e s m a i n l y a f f e c t the e l d e r l y (Thomlinson, 1976), except f o r motor v e h i c l e a c c i d e n t s , which m a i n l y a f f e c t young males between 16 and 35. For example, d u r i n g 1971 i n Canada, h e a r t a t t a c k s m a i n l y a f f e c t e d those 40 y e a r s of age and o l d e r , s t r o k e s a f f e c t e d those 65 and o l d e r , cancer a f f e c t e d those between 40 and 50, and above, and motor v e h i c l e a c c i d e n t s a f f e c t e d those o f a l l ages, but e s p e c i a l l y young males ( L a l o n d e , 1974). The net e f f e c t of these changes i n m o r t a l i t y , by cause and by age, has been both an i n c r e a s e i n l i f e e x pectancy and an i n c r e a s e i n the r e l a t i v e p r o p o r t i o n of - 14 -persons s u r v i v i n g i n t o the e l d e r l y age groups. "Over the l a s t f o r t y y e a r s , e x p e c t a t i o n of l i f e at b i r t h has improved s t e a d i l y i n both s e x e s , such t h a t l i f e expectancy i n Canada i s almost 70 ye a r s f o r males and 77 y e a r s f o r fem a l e s . The main r e a s o n f o r the o v e r a l l i n c r e a s e i n l i f e expectancy d u r i n g the l a s t few decades i s the drop i n i n f a n t m o r t a l i t y . " (McWhinnie, et a l , 1976) Omran (1977) notes t h a t changing m o r t a l i t y r a t e s have a f f e c t e d females and males d i f f e r e n t l y . For example, whereas t u b e r c u l o s i s was a k i l l e r o f young women, i t i s now a k i l l e r of o l d men. In g e n e r a l , males have h i g h e r death r a t e s than females at a l l ages. T h i s r e s u l t s i n d i f f e r e n t i a l l i f e e xpectancy. For example, males had a l i f e e x pectancy of a p p r o x i m a t e l y 70 and females 77 i n Canada d u r i n g 1971. One e x p l a n a t i o n g i v e n f o r t h i s d i f f e r e n t i a l i s t h a t males have s u b s t a n t i a l l y r i s k i e r l i f e s t y l e s than females and t h a t t h e i r o c c u p a t i o n s tend to put them at r i s k more so than f e m a l e s . T'a'blee2.2 d r a m a t i c a l l y i l l u s t r a t e s the above p o i n t s . In p a r t i c u l a r , death r a t e s i n c r e a s e w i t h age, and males have s i g n i f i c a n t l y h i g h e r death r a t e s than females at a l l ages. The h i s t o r i c a l change i n d i s e a s e p a t t e r n s and deaths i s a change i n m o r t a l i t y from acute k i l l e r s of the young, s p e c i f i c a l l y i n f e c t i o u s d i s e a s e s , t o c h r o n i c k i l l e r s and d i s a b l e r s of the o l d , s p e c i f i c a l l y man-made and - 15 -TABLE 2.2 PROBABILITY TABLE OF DEATHS IN THE NEXT TEN YEARS  MALES AND FEMALES AGES 15-80 CANADA 1971 AGE MALE FEMALE 15 1582 572 20 1622 602 25 1671 745 30 1905 1091 35 2860 1682 40 4568 2524 45 7264 3771 50 11282 5764 55 16988 8720 60 25032 13243 65 35354 20496 70 48446 31941 75 63467 48276 80 80403 71580 Source: H e a l t h and W e l f a r e Canada. Branch. Non-Medical Use of 1971 . H e a l t h Drugs. P r o t e c t i o n Mimeographed, - 16 -d e g e n e r a t i v e d i s e a s e s . The l i t e r a t u r e on the n a t u r e of causes behind them, and the t i o n age s t r u c t u r e s . f o l l o w i n g s e c t i o n i n v e s t i g a t e s c u r r e n t d i s e a s e p a t t e r n s , the impact on l i f e s p a n and p o p u l a -2.2 I S S U E S L a f r a m b o i s e (1973) was f i r s t to i d e n t i f y f o u r major h e a l t h f i e l d s which c o u l d be used f o r h e a l t h p o l i c y a n a l y s i s and program development. These now famous f i e l d s are L i f e s t y l e , Environment, H e a l t h Care O r g a n i z a t i o n , and B a s i c Human B i o l o g y . T h i s s y s t e m a t i c approach p e r m i t t e d the a n a l y s i s o f c u r r e n t p a t t e r n s of m o r b i d i t y and m o r t a l i t y on the b a s i s of o t h e r than m e d i c a l models of d i s e a s e and c u r e . C a l l b e c k (1977) i d e n t i f i e d t h a t the HealthTCare-O r g a n i z a t i o n I l l n e s s - C a r e - S y s t e m r e c e i v e d a d i s p r o p o r t i o n a t e share of a l l e x p e n d i t u r e s on h e a l t h c a r e a l t h o u g h the o t h e r f i e l d s had s i g n i f i c a n t impact on h e a l t h r e l a t e d v a r i a b l e s . T h i s work e s p e c i a l l y noted the importance of l i f e s t y l e and s e l f - i m p o s e d r i s k s on the h e a l t h s t a t u s o f i n d i v i d u a l s . Dever (1976) a l s o r e c o g n i z e d t h a t c u r r e n t d i s e a s e p a t t e r n s o f c h r o n i c and d e g e n e r a t i v e d i s e a s e s r e q u i r e an a l t e r n a t e model f o r a n a l y s i s because v a c c i n e s and a n t i -b i o t i c s have v i r t u a l l y e l i m i n a t e d the major k i l l e r s of p r e v i o u s decades. He notes t h a t the new k i l l e r s , which a f f e c t m a i n l y the e l d e r l y , are the r e s u l t of s e v e r a l - 17 -i n t e r r e l a t e d c a u s a l f a c t o r s from the f o u r h e a l t h f i e l d s . H i s a n a l y s i s a l l o w s the causes to be broken i n t o manage-ab l e components so t h a t a more d e f i n i t i v e q u a n t i t a t i v e model i s p o s s i b l e . Dever (1976) compiled f i g u r e s a l l o c a t i n g the r e l a t i v e e f f e c t of each of the f o u r h e a l t h f i e l d s on the n i n e major causes of death i n G e o r g i a . H i s a n a l y s i s i n d i c a t e s t h a t l i f e s t y l e alone i s r e s p o n s i b l e f o r over 50% of the deaths caused by h e a r t d i s e a s e , c e r e b r o v a s c u l a r d i s e a s e , motor v e h i c l e a c c i d e n t s , a c c i d e n t s ( o t h e r c a u s e s ) , and h o m i c i d e s . O v e r a l l , the average a l l o c a t i o n of m o r t a l -i t y a t t r i b u t a b l e to l i f e s t y l e f o r the d i s e a s e a n a l y s e d was 43%, much l a r g e r than to any of the f o u r o t h e r f i e l d s . Lalonde (1974) has i n d i c a t e d t h a t the r e c o g n i t i o n of l i f e s t y l e and environment as s i g n i f i c a n t causes of m o r t a l i t y and m o r b i d i t y i n Canada d i c t a t e s t h a t t h e r e be a r e a l i g n m e n t of h e a l t h c a r e r e s o u r c e s i n o r d e r to d i r e c t more a t t e n t i o n to the l i f e s t y l e and environment h e a l t h f i e l d s . T h i s a n a l y s i s a l s o i n d i c a t e s t h a t t h e r e i s s i g n i -f i c a n t room f o r improvement i n the avoidance of premature m o r t a l i t y due to s e l f - i m p o s e d r i s k s and improvements of the env ironment. I t i s not o n l y death which i s a s i g n i f i c a n t c o n s i d e r a t i o n . Dickenson (1948) i d e n t i f i e d t h a t y e a r s of l i f e l o s t and y ears of work l i f e l o s t are a l s o i m p o r t a n t - 18 -c o n s i d e r a t i o n s . Years of l i f e l o s t are equal to l i f e e xpectancy minus the age of dea t h , and work y e a r s l o s t i s equal to 65 minus the age of death. In 1945, Dickenson (1948), i l l u s t r a t e d t h a t a l t h o u g h a c c i d e n t s were the f o u r t h l e a d i n g cause of death i n 1945, they were the second cause of ye a r s o f l o s t l i f e and the f i r s t cause o f work years l o s t . Romeder (1977) c a l c u l a t e d p o t e n t i a l y e a r s of l i f e l o s t f o r Canada i n 1974. In t h i s a n a l y s i s , 70 ye a r s of age i s u t i l i z e d to c a l c u l a t e y ears o f l i f e r a t h e r than average l i f e e xpectancy. Table 2.3 r e p r e s e n t s Romeder's . d a t a . The m a j o r i t y of p o t e n t i a l y e a r s of l i f e l o s t are a l s o due to " p r e v e n t a b l e " c o n d i t i o n s . S i m i l a r to Dickenson's f i n d i n g s , motor v e h i c l e a c c i d e n t s are the major cause of p o t e n t i a l y e a r s of l i f e l o s t . McKeown (.1971) has t i e d p a s t and p r e s e n t f i n d i n g s t o g e t h e r when he s t a t e s : " S i n c e the time of K e p l e r and Harvey, m e d i c a l thought has been dominated by the b e l i e f t h a t improvements i n h e a l t h must r e l y l a r g e l y on an e n g i n e e r i n g approach, based on u n d e r s t a n d i n g of the s t r u c t u r e and f u n c t i o n of the body and of d i s e a s e p r o c e s s e s which a f f e c t i t . In f a c t , man's h e a l t h o f f e r s o n l y l i m i t e d scope f o r t h i s approach. Past improvements have been due m a i n l y to m o d i f i c a t i o n of b e h a v i o u r and changes i n the environment and i t i s to these same i n f l u e n c e s t h a t we must look p a r t i c u l a r l y f o r f u r t h e r advances." (McKeown, 1971) TABLE 2.3 PYLL1 AND DEATHS BETWEEN AGES 1 AND 70 BY MAJOR CAUSES2 CANADA 1974 2 Cause PYLL (1-70) Deaths (1-70) Total % % Total A l l Causes 1,312,675 100 100 77,440 Motor Vehicle Accidents (AE138) 23,288.5 18.2 8.0 5 ,864 Ischaemic Heart Disease (A83) 198 ,327.5 15.1 26.2 19,205 Other Accidents (AE139-146) 165,264.5 12.6 6.5 4,795 Suicide (AE147) 84,195 6.4 3.7 2,716 Cancer of Digest. Organs (A46-49, 58A) 56,667 4.3 7.1 5,186 Respiratory Diseases (A89-96) 50,264 3.8 4.7 3,425 Cancer of Respir. Organs (A50,51,58B) 48,079.5 3.7 6.1 4,444 Cerebrovascular Diseases (A85) 45,418 3.5 5.5 4,068 Cirrhosis of Liver (A102) 34,954 2.7 3.0 2,204 Breast Cancer (A54) 30,919.5 2.4 2.9 2,108 Dis. of Nervous System & Sense Organs (A72-79) 29,634 2.3 1.5 1,119 Potential Years of Life Lost between ages 1 and 70. 2 Causes responsible for more than 2% of t o t a l PYLL, with codes of the A l i s t of the International C l a s s i f i c a t i o n of Diseases, 8th revision (ICD-8). Source: Romeder, J . M., and McWhinnie, J. R. The Development of Potential Years of L i f e Lost as an Indicator of Premature Mortality. Ottawa: Health and Welfare Canada, 1977. - 20 -Dis e a s e can be p r e v e n t e d , but death can u l t i m a t e l y o n l y be postponed. The r e s u l t i n the p o s t -ponement of death i s an i n c r e a s e i n l i f e expectancy w i t h the r e s u l t t h a t more persons a c h i e v e b i o l o g i c a l maximum age. However, some a u t h o r s b e l i e v e t h a t t h i s age has almost been a c h i e v e d . For example, Bogue (1969) s t a t e s , " m o r t a l i t y r a t e s are so low t h a t they are o n l y a p o i n t or two from what most p h y s i o l o g i s t s would c o n s i d e r the i r r e d u c i a b l e b i o l o g i c a l minimum under m e d i c a l s c i e n c e as i t i s known today". H i s t o r i c a l l y , Table:2.4 p r e s e n t s i n c r e a s e s i n l i f e e x p ectancy over time. TABLE 2.4 HISTORICAL PATTERNS OF AVERAGE LIFE EXPECTANCY I r o n Age 18 Age o f C h r i s t 22 M i d d l e Ages England 33 1850 England 40 1900 U n i t e d S t a t e s 50 1970 U n i t e d S t a t e s 70 Sourc e: D u b l i n , L o u i s I . , L o t k a , A l f r e d J . and Spiegelman, M o r t i m e r . Length of L i f e . New York: Ronald P r e s s , 1949. - 21 -C o l b u r n (1974) has noted i n r e g a r d to r e c e n t i n c r e a s e s i n l i f e expectancy t h a t male l i f e e x p ectancy a f t e r age 40 has i n c r e a s e d v e r y s l i g h t l y i n the l a s t 40 y e a r s . Spiegelman (1965) i n h i s a n a l y s i s of m o r t a l i t y r a t e s i n s e v e r a l c o u n t r i e s noted t h a t the r a t e of r e d u c t i o n i n death r a t e s was s l o w i n g of l a t e , and Lew (1970) notes t h a t t h e r e has been a l e v e l l i n g o f f of age s p e c i f i c m o r t a l i t y r a t e s . These data i n d i c a t e t h a t e i t h e r the maximum l i f e s p a n i s b e i n g approached or t h a t t r a d i t i o n a l methods to reduce death r a t e s have l i m i t e d impact on e l d e r l y p e r s o n s . The demographic t e c h n i q u e u t i l i z e d to study e x i s t i n g and f o r e c a s t p a t t e r n s of m o r t a l i t y i s the l i f e t a b l e . A l i f e t a b l e " i s the death h i s t o r y of a hypo-t h e t i c a l group of p e o p l e who throughout t h e i r l i v e s would have the a g e - s e x - s p e c i f i c death r a t e s of the year f o r which the t a b l e was computed" (Thomlinson, 1976). A l i f e t a b l e p r o v i d e s s e v e r a l demographic v a r i a b l e s f o r a n a l y s i s , f o r example, l i f e e x pectancy at b i r t h or at any s p e c i f i c age, s u r v i v a l r a t e s from a g i v e n age to another g i v e n age. L i f e t a b l e d a t a can a l s o be used f o r p o p u l a t i o n p r o j e c t i o n s , and to compare s t a n d a r d death r a t e s between p o p u l a t i o n s . A l t h o u g h l i f e t a b l e s d e a l w i t h h y p o t h e t i c a l p o p u l a t i o n s , they are based on c u r r e n t d a t a . The l i f e t a b l e i s i n v a l u -a b l e f o r l i f e i n s u r a n c e u n d e r w r i t e r s and i n f a c t the p r i c e of b i l l i o n s o f d o l l a r s worth of i n s u r a n c e i s determined on - 22 -the b a s i s of l i f e t a b l e d a t a . B i r t h s and deaths are the major v a r i a b l e s u t i l i z e d i n the p r o d u c t i o n of l i f e t a b l e s . For some p o p u l a t i o n p r o j e c t i o n s , m i g r a t i o n f a c t o r s must a l s o be c o n s i d e r e d . However, i n d e a l i n g w i t h i n t e r n a l p o p u l a t i o n a n a l y s i s o n l y b i r t h s and deaths are r e l e v a n t . By u t i l i z i n g l i f e t a b l e t e c h n i q u e s , i t i s p o s s i b l e to a n a l y z e h i s t o r i c a l p a t t e r n s of m o r t a l i t y and to observe the e f f e c t of changing m o r t a l i t y r a t e s at s p e c i f i c ages. For example, deaths a v o i d e d by persons under the age of 45 yea r s are l i k e l y to r e s u l t i n a net ga i n i n p o p u l a t i o n , s i n c e t h e s e persons are i n the p r o d u c t i v e age groups, but f o r persons over age 45 who d e l a y m o r t a l i t y , the net r e s u l t w i l l be an aging of the p o p u l a t i o n and a change i n i t s s t r u c t u r e ( C o a l e , 1972). I t i s t h i s l a t t e r p a t t e r n of postponed m o r t a l i t y which c h a r a c t e r i z e s the age of d e g e n e r a t i v e and man-made d i s e a s e s , s i n c e immuniza-t i o n and a n t i b i o t i c s have e l i m i n a t e d the m a j o r i t y of deaths of those under the age of 45 ( C o a l e , 1972). As the causes of premature m o r t a l i t y are i d e n t i -f i e d and s t e p s taken to a l l e v i a t e them, i t i s p o s s i b l e to a n t i c i p a t e maximum l i f e e xpectancy which man can a c h i e v e . A v a r i e t y of a u t h o r s have c o n s i d e r e d t h i s i s s u e , and t o g e t h e r produce a suggested range o f v a l u e s f o r maximum - 23 -l i f e e xpectancy. These are: Thomlinson (1976) - 120; H a y f l i c k (1975) - 110 y e a r s (determined on the b a s i s of average c e l l d o u b l i n g s ) ; P r e s s a t (1970) - 100; Kurtzman (1976) - 100 to 110; F r i e s (1980) - 85; and Comfort (1964) - 80. In r e f e r e n c e to the d a t a p r e s e n t e d i n Table 2.2 the h i g h death r a t e s o f the e l d e r l y i n d i c a t e s t h a t b i o l o g i c a l l i f e s p a n l i k e l y l i e s between the ages of 80 and 100. There have been s e v e r a l suggested e x p l a n a t i o n s f o r the l i m i t s to l i f e e xpectancy. For example, S t r i k l e r (1960), h y p o t h e s i z e s t h a t , by p r e v e n t i n g deaths of persons w i t h "low v i t a l i t y " at younger ages, the average v i t a l i t y of s u r v i v o r s i n l a t e r l i f e i s lowered which.. causes m o r t a l i t y r a t e s to i n c r e a s e . He a l s o i n d i c a t e s t h a t o t h e r f a c t o r s are . l i k e l y to be g e n e t i c , e n v i r o n m e n t a l , and the p e r s o n a l assumption of i n c r e a s e d r i s k . Comfort (1964), i n a r e v i e w of the l i t e r a t u r e on a g i n g , noted the f o l l o w i n g f a c t o r s as r e l a t e d to the b i o l o g i c a l l i m i t s o f l i f e : g e n e t i c , b i o l o g i c a l c l o c k , i n n a t e energy l e v e l s , d i e t -l i f e s t y l e f a c t o r s , and p s y c h o l o g i c a l f a c t o r s such as s t r e s s and sense of worth. I t i s l i k e l y t h a t l i f e s p a n i s d etermined f o r an i n d i v i d u a l on the b a s i s of a c o m b i n a t i o n of the f a c t o r s noted. The o v e r a l l e f f e c t of i n c r e a s e s i n l i f e s p a n i s t h a t s u r v i v o r s h i p i n c r e a s e s and, t h e r e f o r e , the age s t r u c t u r e of the p o p u l a t i o n changes. S p e c i f i c a l l y , the - 24 -e l d e r l y age group beg i n s to comprise a h i g h e r p r o p o r t i o n of the t o t a l p o p u l a t i o n . Table 2.5 p r e s e n t s the r e l a t i v e d i s t r i b u t i o n of p o p u l a t i o n i n the U n i t e d S t a t e s f o r s e l e c t e d years from 1850 with, a p r o j e c t i o n to 2000. TABLE 2.5 PERCENTAGE DISTRIBUTION OF THE POPULATION OF THE UNITED STATES BY YEAR AND AGE GROUP YEAR AGE <_5 5-19 1850 15.1 37.4 1900 12.1 32.3 1950 7.7 21.1 2000 6.0 19.7 20-44 45-64 65+ 35.1 9.8 2.6 37.8 13.7 4.1 38.2 24.7 8.3 34.6 26.5 13.2 Source: D u b l i n , L o u i s I . , L o t k a , A l f r e d J . and Spiegelman, Mo r t i m e r . Length of L i f e . New York: Ronald P r e s s , 1949. The p r o p o r t i o n of t o t a l p o p u l a t i o n who were e l d e r l y (+65) thus i s expected to i n c r e a s e more than f i v e times between 1850 to 2000, 2.6% to 13.2%. O f f s e t t i n g t h i s i s the decrease i n the p r o p o r t i o n of those under f i v e , from 15.1% i n 1850 to 6.0% i n 2000. A s i m i l a r r e d u c t i o n i s p r o j e c t e d i n the age group 5 to 19. In the p r o d u c t i v e age groups the t o t a l p o p u l a t i o n between ages - 25 -20 and 64 remains the most n e a r l y c o n s t a n t w i t h a t o t a l of 44.9% i n 1850 and a t o t a l of 61.1% i n 2000. O v e r a l l the dependency r a t i o has d e c r e a s e d , but t h e r e has been a s u b s t a n t i a l s h i f t from young dependent persons to o l d dependent persons. The U n i t e d N a t i o n s (World Bank ,..1,9.7 6) i n d i c a t e s t h a t the a g i n g of the/ p o p u l a t i o n eis '.Jar- worldwide trend.: In 1977 5.7% of the w o r l d ' s p o p u l a t i o n was over the age of 65. The p e r c e n t a g e of e l d e r l y i n North America was 10.2% and i n Europe i t was 12.3%. The lower North American r a t e r e f l e c t s p a t t e r n s of i m m i g r a t i o n of younger age groups. The r e l a t i v e l y low p e r c e n t a g e of e l d e r l y of the t o t a l w o r l d p o p u l a t i o n i s the r e s u l t of v e r y s m a l l numbers of e l d e r l y i n underdeveloped c o u n t r i e s . U n l i k e the young, the e l d e r l y dependent are becoming wards of the s t a t e . A l t h o u g h t r a d i t i o n a l l y the c a r e f o r the e l d e r l y has been the r e s p o n s i b i l i t y of the f a m i l y , t h i s i s now s h i f t i n g to become a r e s p o n s i b i l i t y of s o c i e t y (Verzuh, 1980). A r e c e n t r e p o r t by S t a t i s t i c s Canada ( L e f e b v r e , 1979) p r e d i c t s t h a t , by the year 2031, the e l d e r l y w i l l c o n s t i t u t e a p p r o x i m a t e l y 20% of the p o p u l a t i o n . The r e p o r t a l s o i n d i c a t e s t h a t the e l d e r l y are the predominant u s e r s of h o s p i t a l s and t h a t the f o r e -c a s t growth of t h i s segment of the p o p u l a t i o n w i l l r e s u l t i n a t r i p l i n g of the demand f o r acute c a r e f a c i l i t i e s u n l e s s a l t e r n a t i v e s are found. - 26 -S i m i l a r l y , B o u v i e r (1980), w r i t i n g on the American s i t u a t i o n has i n d i c a t e d t h a t the e l d e r l y u t i l i z e r e s o u r c e s a t t h r e e times the r a t e of younger age groups. He a l s o p r e d i c t s severe p r e s s u r e s on e x i s t i n g h e a l t h and s o c i a l s e r v i c e systems as the number of e l d e r l y i n c r e a s e i n the v e r y near fut~ure. S i m i l a r l y , H a y f l i c k (1976), has s t a t e d t h a t many g e r o n t o l o g i c a l p h y s i o l o g i s t s b e l i e v e t h a t the i n c r e a s e of the e l d e r l y p o p u l a t i o n due to an i n c r e a s e i n l i f e e xpectancy of as l i t t l e as f i v e y e a r s , would produce a c o l l a p s e o f e x i s t i n g h e a l t h and s o c i a l s e r v i c e s systems. The o n l y m i t i g a t i n g view of the i n c r e a s e of the e l d e r l y p o p u l a t i o n i s t h a t the change w i l l be i n c r e m e n t a l and, t h e r e f o r e , amenable to accommodation through s t r u c t u r e d changes i n support s e r v i c e s ( L e f e b v r e , 1979). The "gloom-and-doom" p r e d i c t i o n s o f the i n c r e a s i n g need f o r s e r v i c e s to care f o r the e l d e r l y are based on h i s t o r i c a l p r o j e c t i o n s o f h e a l t h c a r e u t i l i z a t i o n . Should the needs of the e l d e r l y change then i t i s l i k e l y t h a t the per c a p i t a demand f o r s e r v i c e may decr e a s e . For example, Sjogrem (1959), i n an a n a l y s i s of changing age s t r u c t u r e on demands f o r mental i l l n e s s , noted t h a t between 1906 and 1952 the i n c i d e n c e o f mental i l l n e s s i n West Germany decreased f o r the age group 60 to 66 y e a r s . Should l i f e s p a n s c o n t i n u e to i n c r e a s e , i t i s p o s s i b l e t h a t f u r t h e r demands w i l l be p l a c e d on the - 27 -I l l n e s s Care System as the a b s o l u t e and r e l a t i v e number of e l d e r l y i n c r e a s e . H a v i g h u r s t (1976) has a n a l y s e d the s p e c i f i c changes i n l i f e e xpectancy f o r those over 65. He determined t h a t i n the U n i t e d S t a t e s s i n c e 1950 l i f e e x p e c tancy of t h i s age had i n c r e a s e d o n l y two y e a r s . While he a l s o noted t h a t t h e r e are p r o s p e c t s o f l e n g t h e n i n g l i f e as the o v e r a l l v i g o r of e l d e r l y persons i n c r e a s e s , he i s d o u b t f u l t h a t o v e r a l l l i f e s p a n w i l l i n c r e a s e s u b s t a n -t i a l l y , s i n c e a f t e r the age of 40 death r a t e s a p p r o x i m a t e l y double every e i g h t y e a r s . R e i l l y (1968) notes t h a t the h e a l t h of o l d people may be h i g h e r now than at any time i n h i s t o r y . However, she a l s o s t a t e s t h a t t h e r e i s the p o s s i b i l i t y t h a t many e l d e r l y p e o p l e e n t e r o l d age w i t h c h r o n i c c o n d i t i o n s . She h y p o t h e s i z e s t h a t , i f l e s s h e a l t h y persons a v o i d premature m o r t a l i t y , many s u r v i v o r s w i l l be weaker and s u b j e c t to h i g h e r l e v e l s of m o r b i d i t y when they be come o1d e r . R e i l l y (1968) a l s o notes t h a t a p p r o x i m a t e l y 40% of a l l persons between the ages of 65 and 75 have a c h r o n i c c o n d i t i o n or impairment of f u n c t i o n and t h a t a f t e r the age of 75 the r a t e i n c r e a s e s to more than 60%. She ranks the f o l l o w i n g c h r o n i c c o n d i t i o n s as the major d e b i l i t a t o r s of the e l d e r l y : a r t h r i t i s and rheumatism, h e a r t c o n d i t i o n s , h i g h b l o o d p r e s s u r e , asthma/hay f e v e r , d i a b e t e s and b r o n c h i t i s. - 28 -The l i t e r a t u r e on the f u t u r e m o r b i d i t y of the e l d e r l y i s not a l l p e s s i m i s t i c . F r i e s (1980), a f t e r examining r e c e n t t r e n d s i n l i f e e xpectancy at s e l e c t e d age groups, h y p o t h e s i z e s t h a t the maximal l i f e s p a n of man i s f i x e d at about 85 years and t h a t i f persons can a v o i d c h r o n i c d i s e a s e s , of which the m a j o r i t y are s e l f - i n f l i c t e d , t hey can expect to l i v e a f u l l and p r o d u c t i v e l i f e w i t h o n l y a s h o r t p e r i o d of m o r b i d i t y p r i o r to death. He terms t h i s phenomenon the "compression of m o r b i d i t y " . He a l s o s t a t e s , i n d e f e r e n c e to R e i l l y , t h a t the age of onset o f an i n f i r m i t y can be postponed through improvements i n l i f e s t y l e . I f a c o n d i t i o n can be postponed long enough, an i n d i v i d u a l might d i e o f another c o n d i t i o n b e f o r e the c h r o n i c c o n d i t i o n man-i f e s t s i t s e l f . I f t h i s o c c u r s , the c o n d i t i o n i s not o n l y postponed, but a l s o p r e v e n t e d . F i g u r e 1 p r e s e n t s F r i e s ' (1980) s u r v i v a l c u r v e s f o r the U n i t e d S t a t e s . These curves d r a m a t i c a l l y i l l u s -t r a t e the " r e c t a n g u l a r i z a t i o n " of s u r v i v a l . E s s e n t i a l l y , what i s o c c u r r i n g i s t h a t more people are a t t a i n i n g b i o l o g -i c a l age. At t h i s p o i n t death r a t e s i n c r e a s e d r a m a t i c a l l y and t h e r e i s a sudden d r o p - o f f i n the number o f s u r v i v o r s . He a l s o a s s e r t s t h a t t h e r e w i l l be a concomitant r e c t a n g -u l a r i z a t i o n o f m o r b i d i t y c u r v e s as persons s u r v i v e i n t o the e l d e r l y age groups i n a h e a l t h i e r c o n d i t i o n . The major f a c t o r behind t h i s p r o j e c t e d improvement i n h e a l t h i s the p o s i t i v e a l t e r a t i o n of l i f e s t y l e s and the abatement of e n v i r o n m e n t a l h a z a r d s . - 29 -FIGURE 1 SURVIVAL CURVES 0 10 20 30 40 50 60 70 80 90 100 AGE Figure 1: The Increasingly Rectangular Survival Curve. About 80 percent (stippled area) of the difference between the 1900 curve and the ideal curve (stippled area plus hatched area) had been eliminated by 1980. Trauma i s now the dominant cause of death i n early l i f e . Source: Fries, James F. 1980. A g i n g , n a t u r a l death, and the compression of m o r b i d i t y . The New England J o u r n a l of M e d i c i n e , 303 (3):130-135. - 30 -T h e r e f o r e , t h e r e are two p o i n t s o f view i n terms of f u t u r e p a t t e r n s of m o r b i d i t y of the e l d e r l y ; a p e s s i m i s t i c one f a v o r i n g i n c r e a s e d l e v e l s of m o r b i d i t y and an o p t i m i s t i c view p r e d i c t i n g improved h e a l t h s t a t u s o f the e l d e r l y w i t h a decreased need f o r i l l n e s s c a r e s e r v i c e s . 2.3 MEASUREMENT M o r t a l i t y d a t a and i t s a p p l i c a t i o n f o r the p r o j e c t i o n of l i f e e x pectancy were, f i r s t used! i n Rome f o r the purpose o f v a l u i n g a n n u n i t i e s . A Roman j u r i s t , U l p i a n , developed the f i r s t l i f e t a b l e i n 220 A.D. (Gesner, 1978). S i n c e t h a t time a major u s e r of p r e d i c t i o n s of p a t t e r n s of m o r t a l i t y has been i n s u r a n c e companies, who use s o p h i s t i c a t e d p r o j e c t i o n s of e x p e c t a t i o n s of death to determine l i f e i n s u r a n c e premiums. Of c o u r s e , o t h e r major u s e r s of r a t e s o f m o r t a l i t y are e p i d e m i o l o g i s t s and o t h e r s who study the p r o c e s s o f d i s e a s e , l i f e , and death i n man. Robbins (1977), i n summarizing the h i s t o r y of the development of H e a l t h Hazard A p p r a i s a l , notes t h a t Mountain, i n v e s t i g a t i n g h e a r t a t t a c k s i n 1947 and G e l l e r , i n v e s t i g a t i n g cancer i n 1957, r e c o g n i z e d t h a t the a n a l y s i s o f h i s t o r i c a l p a t t e r n s and causes o f death c o u l d p r o v i d e " a n t i c i p a t o r y " c o n t r o l s t r a t e g i e s f o r d i s e a s e c o n t r o l . - 31 -T h e r e f o r e , by s t u d y i n g the n a t u r a l h i s t o r y of the d i s e a s e i t i s p o s s i b l e to i d e n t i f y f a c t o r s which, when p r e s e n t or a bsent, i n f l u e n c e the r a t e of death from the s p e c i f i c d i s e a s e . Such f a c t o r s are termed r i s k f a c t o r s . The s t u d y of i n d i v i d u a l causes of death l e a d G e l l e r to d e v e l o p 10 year s u r v i v o r s h i p e s t i m a t e s f o r s p e c i f i c d i s e a s e s and s e l e c t e d age groups (Robbins, 1975). The f o c u s f o r the development of a q u a n t i t a t i v e d a t a base f o r the e s t i m a t i o n of the impact of s p e c i f i c r i s k f a c t o r s on the causes o f death was the H e a l t h Hazard A p p r a i s a l program of the M e t h o d i s t H o s p i t a l o f I n d i a n a (Robbins, 1970). T h i s p r o j e c t l e a d to the p r e p a r a t i o n o f the " G e l l e r - G e s n e r T a b l e s " . These t a b l e s q u a n t i f i e d the impact of r i s k f a c t o r s on an i n d i v i d u a l ' s chance o f s u r v i v i n g the next t e n - y e a r p e r i o d . H a l l (1980) s t a t e s "the p r o g n o s t i c c a t e g o r i e s ( l i f e s t y l e ) o f each i n d i v i d u a l can be used to q u a n t i t a t i v e l y show v a r i a n c e s between average r i s k f o r a group and the i n d i v i d u a l " (Gesner Tables) . T h e r e f o r e , i t i s p o s s i b l e by u s i n g the t a b l e s to measure the impact of changed l i f e s t y l e s on an i n d i v i d u a l or p o p u l a t i o n due to an improvement i n l i f e s t y l e or an abatement of a r i s k f a c t o r . The i d e a l method o f d e t e r m i n i n g the impact of a s p e c i f i c l i f e s t y l e on a cause of death i s through p r o s p e c -t i v e s t u d i e s . However, f o r e t h i c a l and economic reasons t h i s i s not always p r a c t i c a l . Gesner (1978) notes t h a t - 32 -"the u l t i m a t e v a l i d a t i o n o f H e a l t h Hazard A p p r a i s a l w i l l be d etermined from a c t u a l e x p e r i e n c e w i t h the program". Lack of p r e c i s i o n i n the G e l l e r - G e s n e r Table has caused some a u t h o r s to q u e s t i o n i t s r e l i a b i l i t y . For example, F u l l e r t o n (1977) i d e n t i f i e s the f o l l o w i n g v a r i a b l e s which are not a d e q u a t e l y d e a l t w i t h by the p r e s e n t G e l l e r - G e s n e r T a b l e s : socio-economic s t a t u s , n u t r i t i o n / d i e t , l i f e s t r e s s / l i f e change, workplace/work s t r e s s , and f i t n e s s (as i t r e l a t e s to a c t i v i t i e s o f d a i l y l i v i n g ) . S i m i l a r l y , Imrey (.1978) q u e s t i o n s the r e l i a b i l i t y of H e a l t h Hazard A p p r a i s a l based on observed g e o g r a p h i c a l d i f f e r e n c e i n m o r t a l i t y , the s e l e c t i v i t y of p o p u l a t i o n s s t u d i e d to determine r i s k f a c t o r v a l u e s , and the complex r e l a t i o n s h i p s caused by m u l t i p l e r i s k f a c t o r s . However, the G e l l e r - G e s n e r Tables s t i l l remain the best source o f q u a n t i t a t i v e data r e l a t i n g i n d i v i d u a l r i s k f a c t o r s and t h e i r c o m b i n a t i o n s on an i n d i v i d u a l ' s r e l a t i v e chances f o r s u r v i v a l . W i n k e l s t e i n (1979) and F u l l e r t o n (1977) suggest t h a t the H e a l t h Hazard A p p r a i s a l d a t a base be expanded to i n c l u d e m o r b i d i t y i n f o r m a t i o n . W i n k e l s t e i n (1979) l i s t s t h r e e reasons f o r t h i s : f i r s t , " t h e r e are a number of i m p o r t a n t d i s e a s e s i n which m o r t a l i t y i s not a major end p o i n t " ; second, "... the case f a t a l i t y r a t i o s f o r v a r i o u s d i s e a s e s are d i f f e r e n t , so t h a t the r e l a t i v e v a l u e of the s c o r i n g systems f o r v a r i o u s d i s e a s e s are not comparable"; t h i r d , "... our fundamental purpose i s to p r e v e n t d i s e a s e not j u s t death, and i f we are - 33 -going to approach the m a t t e r q u a n t i t a t i v e l y , we s h o u l d be as a c c u r a t e as p o s s i b l e " . T h e r e f o r e , a l t h o u g h i t i s p o s s i b l e to e s t i m a t e the r e l a t i v e impact of changed l i f e -s t y l e s on m o r t a l i t y r a t e s , the o v e r a l l e f f e c t on m o r b i d i t y i s not a v a i l a b l e . The l i f e t a b l e i s the s t a t i s t i c a l and demo-g r a p h i c t e c h n i q u e u t i l i z e d i n the a n a l y s i s of changes i n m o r t a l i t y r a t e s and t h e i r e f f e c t on p o p u l a t i o n s . K e y f i t z (1971), i n a t e x t b o o k on demography, notes t h a t changes i n m o r t a l i t y r a t e s i n a p o p u l a t i o n over time w i l l r e s u l t i n changes i n the p o p u l a t i o n ' s age s t r u c t u r e and o v e r a l l s i z e . He has compiled computer programs to g enerate l i f e t a b l e s and p o p u l a t i o n p r o j e c t i o n s based on r e a d i l y a v a i l a b l e demographic d a t a ( K e y f i t z , 1971). These programs a l s o a l l o w the m o d i f i c a t i o n of m o r t a l i t y r a t e s i n o r d e r to a s s e s s t h e i r e f f e c t s on f u t u r e p o p u l a t i o n s . Robbins & H a l l ' s (1970) work i n the f i e l d of p r o s p e c t i v e m e d i c i n e i s based on the assumption t h a t chang i n l i f e s t y l e s w i l l r e s u l t i n d e c r e a s e s of m o r t a l i t y . I t i s p o s s i b l e to e s t i m a t e the f u t u r e expected p a t t e r n o f m o r t a l i t y i n a p o p u l a t i o n which m o d i f i e s i t s l i f e s t y l e and, t h e r e f o r e , decreases i t s o v e r a l l m o r t a l i t y r a t e . Unfor t u n a t e l y , as Milsum (1980) i n d i c a t e s , c u r r e n t data and a n a l y s i s do not s u pport c a u s a l r e l a t i o n s h i p s between m o d i f i e d l i f e s t y l e s and decreased m o r t a l i t y r a t e s . However, as he a l s o n o t e s , t h e r e i s a s u b s t a n t i a l body of - 34 -a s s o c i a t i v e e v idence s u p p o r t i n g these hypotheses. The assumptions c o n c e r n i n g l i f e s t y l e r e l a t i o n -s h i p to m o r t a l i t y seem r e a s o n a b l e , s i n c e , f o r example, i n p o p u l a t i o n s who have l e s s hazardous l i f e s t y l e s the m o r t a l i t y i s lower than w i t h o t h e r s . Lyon (1978) r e p o r t s t h a t the non-smoking Mormons of Utah had 35% l e s s m o r t a l i t y than average U n i t e d S t a t e s r a t e s f o r c a r d i o v a s c u l a r d i s e a s e . These f i n d i n g s support the r e l a t i o n s h i p between c i g a r e t t e smoking and m o r t a l i t y from c a r d i o v a s c u l a r d i s e a s e . T h e r e f o r e , a l t h o u g h the impact of l i f e s t y l e and m o r t a l i t y have not been d e f i n i t i v e l y proven, t h e i r r e l a t i o n s h i p and the d i r e c t i o n of change are c l e a r l y e v i d e n t . Sheppard (1975) c a u t i o n s t h a t the e f f e c t of m o d i f y i n g l i f e s t y l e s i s not c o n s i s t e n t f o r a l l i n d i v i d u a l s w i t h i n a p o p u l a t i o n . He notes t h a t a p o p u l a t i o n i s comprised of groups of i n d i v i d u a l s at d i f f e r e n t l e v e l s o f i n n a t e r i s k . T h e r e f o r e , i n d i v i d u a l s who mod i f y t h e i r l i f e s t y l e s may e x p e r i e n c e d i f f e r e n t p a t t e r n s of m o r t a l i t y r e d u c t i o n s dependent on t h e i r i n n a t e l i k e l i h o o d of c o n t r a c t i n g s p e c i f i c d i s e a s e s i n q u e s t i o n . He a l s o i n d i c a t e s t h a t i n d i v i d u a l s may be grouped i n t o c a t e g o r i e s such as " c o n s t i t u t i o n a l l y weak" and "normal". He argues t h a t i n d i v i d u a l s who are c o n s t i t u t i o n a l l y weak have m o r t a l i t y r a t e s h i g h e r than normal groups, and hence, s h o u l d they a v o i d premature m o r t a l i t y , t h e i r chance o f d y i n g from an a l t e r n a t e cause i s h i g h e r than t h a t of the - 35 -normal group. K e y f i t z (1977) c o i n e d the term "Taeuber Paradox" to r e f e r to the phenomenon t h a t when an i n d i v i d u a l a v o i d s m o r t a l i t y due to a s p e c i f i c cause, he i s then s u b j e c t to a l l o t h e r causes of m o r t a l i t y at the same r a t e as the average p o p u l a t i o n . In s i m p l e terms, s i n c e death can o n l y be postponed, p r e v e n t i n g premature m o r t a l i t y w i l l o n l y d e l a y death u n t i l the i n d i v i d u a l d i e s from another cause. Romeder (1977) r e f e r s to t h i s phenomenon as competing m o r t a l i t y . In h i s a n a l y s e s of p o t e n t i a l y e a r s o f l i f e l o s s due to s e l e c t e d p r e v e n t a b l e c o n d i t i o n s , he determined t h a t the competing m o r t a l i t y had o n l y minimal impact up to age 70. A l t h o u g h the l i t e r a t u r e i s v e r y l i m i t e d i n t h i s a r e a , i t would appear t h a t p o p u l a t i o n s who improve t h e i r l i f e s t y l e s and a v o i d premature m o r t a l i t y , do not have m o r t a l i t y r a t e s h i g h e r than average d u r i n g the remainder o f t h e i r l i f e span. T h i s data s u p p o r t s F r i e s ' (1980) assumption t h a t i n d i v i d u a l s who have h e a l t h y l i f e s t y l e s are l i k e l y to e x p e r i e n c e f u l l and p r o d u c t i v e l i f e spans w i t h o n l y a s h o r t p e r i o d of m o r b i d i t y and d i s a b i l i t y p r i o r to dea t h . At t h i s time, however, i t i s i m p o s s i b l e to t e s t the v a l i d i t y of these assumptions, s i n c e as Milsum (1980) n o t e s , f o r e t h i c a l and t e c h n i c a l reasons p r o s p e c t i v e s t u d i e s i n t h i s a r e a are v i r t u a l l y i m p o s s i b l e . - 36 -T s a i (1978) a n a l y z e d the e f f e c t of r e d u c t i o n s i n p r e v e n t a b l e causes of d e a t h and p o t e n t i a l g a i n s i n l i f e e xpectancy. He u t i l i z e d l i f e t a b l e a n a l y s e s to c a l c u l a t e the added y e a r s of l i f e g a i n e d by a p o p u l a t i o n which had reduced i t s m o r t a l i t y r a t e from c a r d i o v a s c u l a r d i s e a s e , motor v e h i c l e a c c i d e n t s , and m a l i g n a n t neoplasms. H i s d a t a i n d i c a t e t h a t i f these t h r e e d i s e a s e s had been reduced by 50% the o v e r a l l g a i n i n l i f e e xpectancy i n a p o p u l a t i o n would have been a p p r o x i m a t e l y o n l y f i v e y e a r s . S i m i l a r l y , he determined t h a t the p o t e n t i a l g a i n s f o r working ages'(15 to 65) f o r a 50% e l i m i n a t i o n o f these d i s e a s e s i s l e s s than one year on the average. His d a t a s u p p o r t s the assumption t h a t p r e v e n t a b l e c o n d i t i o n s p r i m a r i l y a f f e c t the e l d e r l y age group who have h i g h r a t e s of m o r t a l i t y from competing causes. S i m i l a r l y , K e y f i t z (1977) determined t h a t the e l i m i n a t i o n o f cancer as a cause o f death i n the U n i t e d S t a t e s would i n c r e a s e l i f e e x pectancy by o n l y 2.3 y e a r s . The r e d u c t i o n i n m o r t a l i t y r a t e s of p r e v e n t a b l e c o n d i t i o n s as i l l u s t r a t e d by T s a i (1978) and K e y f i t z (1977) i n d i c a t e s t h a t even s u b s t a n t i a l r e d u c t i o n s i n p r e v e n t a b l e causes of m o r t a l i t y are not l i k e l y to l e a d to s u b s t a n t i a l i n c r e a s e s i n l i f e expectancy. T h e r e f o r e , i t would appear t h a t the major b e n e f i t s of r e d u c i n g p r e v e n t a b l e m o r t a l i t y would be to i n c r e a s e the number of persons who a c h i e v e b i o l o g i c a l maximum age and to reduce the f r e q u e n c y of i l l n e s s e p i s o d e s p r i o r to an e p i s o d e of i l l n e s s l e a d i n g to - 37 -d e a t h . Gupta (.1973) i n an a n a l y s i s o f the e l i m i n a t i o n of d i f f e r e n t causes of death on the e x p e c t a t i o n of l i f e i n I n d i a has found t h a t the major i n c r e a s e s i n the e x p e c t a -t i o n o f l i f e would be due to the e l i m i n a t i o n of T u b e r c u l o s i s and epidemic d i s e a s e s . T h i s i s because the younger age groups i n I n d i a s t i l l s u f f e r from these i n f e c t i o u s d i s e a s e s , v i r t u a l l y unknown i n w e s t e r n c o u n t r i e s . However, i t i s a l s o i n t e r e s t i n g to note t h a t h e a r t a t t a c k s have the second most i m p o r t a n t impact on i n c r e a s i n g l i f e e xpectancy. The l i t e r a t u r e i s v i r t u a l l y s i l e n t on s t u d i e s c a r r i e d out to i n v e s t i g a t e the impact of improved l i f e -s t y l e s on the decrease i n a p o p u l a t i o n ' s o v e r a l l l e v e l o f m o r b i d i t y . A l t h o u g h W i n k e l s t e i n (1979) a s s e r t s t h a t H e a l t h Hazard A p p r a i s a l s h o u l d be expanded to i n c l u d e m o r b i d i t y r i s k s , t h i s has not taken p l a c e . The reasons are v e r y c l e a r - c o s t , t i m e , and e f f o r t r e q u i r e d would be s u b s t a n t i a l . Thus, i t would appear t h a t f o r t h i s p r e s e n t work the b e s t e s t i m a t e of r e d u c t i o n i n m o r b i d i t y i s t h a t i t would be p r o p o r t i o n a t e to r e d u c t i o n s i n m o r t a l i t y . For example, B e r n s t e i n (1979) makes the p l a u s i b l e but u n t e s t e d assumption t h a t r i s k i n d i c a t o r s o p e r a t e i n the same manner f o r m o r b i d i t y as they do f o r m o r t a l i t y . He a l s o n otes t h a t i n i t i a l a n a l y s i s i s t a k i n g p l a c e i n the area o f cancer and c a r d i o v a s c u l a r m o r b i d i t y . - 38 -Twaddle (1968) i l l u s t r a t e s the type o f i n f o r -m a t i o n now bei n g u t i l i z e d f o r the a n a l y s i s of f u t u r e p a t t e r n s o f m o r b i d i t y . In h i s a n a l y s i s o f the impact o f an aging p o p u l a t i o n on the i n c r e a s e o f persons w i t h c h r o n i c d i s e a s e s , he u n d e r t a k e s a s t r a i g h t - 1 i n e p r o j e c t i o n of p r e s e n t r a t e s o f c h r o n i c m o r b i d i t y by age and a p p l i e s these r a t e s to f u t u r e p r o j e c t e d p o p u l a t i o n s . L e f e b v r e (1979) a l s o makes the assumption t h a t f u t u r e p a t t e r n s o f m o r b i d i t y l e a d i n g to h o s p i t a l i z a t i o n w i l l be at c u r r e n t r a t e s . 2.4 CONCLUSIONS The a c t u a l l i t e r a t u r e on p r o j e c t i n g changed l i f e s t y l e s l e a d i n g to change m o r b i d i t y and m o r t a l i t y r a t e s has been found to be m i n i m a l . R e l a t e d l i t e r a t u r e c o n c e r n i n g demographic a n a l y s e s , H e a l t h Hazard A p p r a i s a l , and examples of e x i s t i n g s t u d i e s has been r e v i e w e d . The l i t e r a t u r e i s s t r o n g l y committed to the concept o f p r e v e n t i o n and the postponement o f i l l n e s s and dea t h . However, no body of q u a n t i t a t i v e a n a l y s i s adequate to support these f i n d i n g s i s c u r r e n t l y a v a i l a b l e . A l t h o u g h Crawford (1977) has r a i s e d p o l i t i c a l and e t h i c a l reasons f o r the c a u t i o u s a p p l i c a t i o n o f b e h a v i o u r m o d i f i c a t i o n t e c h n i q u e s on the improvement of l i f e s t y l e s , the m a j o r i t y o f a u t h o r s b e l i e v e t h a t w i t h the - 39 -p r a c t i c a l l i m i t s of medicine now be i n g a c h i e v e d , the f u t u r e major improvement of h e a l t h and w e l l - b e i n g of p o p u l a t i o n s w i l l l i k e l y be through the abatement of s e l f - i m p o s e d r i s k s . U n f o r t u n a t e l y , as y e t , t h e r e has been no q u a n t i f i c a t i o n o f these assumptions. - 40 -METHODOLOGY 3.1 BASELINE DEMOGRAPHIC DATA In t h i s c h a p t e r the methodology used t o a n a l y z e the impact o f improved l i f e s t y l e s o f Canadians on f u t u r e h o s p i t a l use and i t s c o s t s i s p r e s e n t e d . The methods r e s o l v e ' t h e problems o u t l i n e d i n S e c t i o n 1.2 i n the I n t r o d u c t i o n . The p o p u l a t i o n chosen f o r the a n a l y s i s i s t h a t of Canada 1971. Table 3.1 p r e s e n t s a summary of the d a t a , showing t o t a l p o p u l a t i o n , deaths and b i r t h s . The p o p u l a t i o n and number of deaths i s d i s a g g r e g a t e d i n t o c o h o r t s c h a r a c t e r i z e d by sex (male and female) and n i n e t e e n age groups. B i r t h s are r e c o r d e d by age of mother because these data are used i n the p o p u l a t i o n model t o determine female a g e - s p e c i f i c f e r t i l i t y r a t e s . Deaths r e p r e s e n t the p a t t e r n of m o r t a l i t y e x p e r i e n c e d by the 1971 Canadian p o p u l a t i o n . These m o r t a l i t y r a t e s are m o d i f i e d i n the model's p r o j e c t i o n s , as the r e s u l t of assumptions c o n c e r n i n g changes i n the p o p u l a t i o n l i f e s t y l e s . T o t a l p o p u l a t i o n i n 1971 was 21,568,400. The t o t a l deaths e x p e r i e n c e d were 157,256. T h i s r e p r e s e n t s TABLE 3.1 POPULATION AND DEATHS BY SELECTED AGE GROUPS AND SEX, AND BIRTH BY AGE OF MOTHERS - CANADA 1971 AGE POPULATION BIRTHS DEATHS AGE MALE FEMALE MALE FEMALE 0 186,600 173,700 0 3, 71. 2 2, 644 0 1 743,000 712,900 0 679 551 1 5 1,152,400 1,101,600 0 641 424 5 10 1, 181,400 1,129,300 303 589 365 10 15 1,074,400 1,040,000 41,723 1,489 579 15 20 941, 800 947,600 129,063 1, 697 559 20 25 800,700 783,400 112,985 1,176 485 25 30 660,900 644,600 50,640 1,090 565 30 35 645,000 618,800 21,147 1,416 815 35 40 640,800 621,800 5, 947 2,310 1 , 290 40 45 613,400 625,600 347 3,523 1 , 901 45 50 518,900 533,600 5 4, 838 2,480 50 55 472,400 482,300 0 6,886 3,477 55 60 381,700 395,300 0 8,753 4, 345 60 65 296,100 323,900 0 10,277 5 ,614 65 70 205,600 251,800 0 10,661 7,138 70 75 140,000 185,500 0 11,056 8,930 75 80 85,700 118,500 0 10,180 9,762 80 85 54,600 82,800 0 10,836 13,523 85 UNKNOWN 0 0 0 0 0 UNKNOWN TOTAL, 10,795,400 10,773,000 362,187 91,809 65,447 by Sex TOTAL 21,568,400 157,256 - 42 -a crude death r a t e of 7.3 per thousand p e r s o n s . T o t a l b i r t h s were 362,187 which r e p r e s e n t s a crude b i r t h r a t e of 16.8 b i r t h s per thousand p e r s o n s . In the subsequent a n a l y s i s t h i s p o p u l a t i o n i s assumed to be c l o s e d ; t h a t i s , the p o p u l a t i o n does not e x p e r i e n c e e i t h e r i n or out m i g r a t i o n . A l t h o u g h t h i s assumption i s c l e a r l y i n c o r r e c t , i t i s r e q u i r e d i n o r d e r to a s s e s s the impact of l i f e s t y l e changes i n i s o l a t i o n o f e x t e r n a l m i g r a t i o n f a c t o r s . Thus the p o p u l a t i o n chosen i s a h y p o t h e t i c a l one and i t s p r o -j e c t i o n s h o u l d not be viewed as a p r e d i c t i o n of the f u t u r e p o p u l a t i o n of Canada. 3.2 CAUSES OF PREVENTABLE DEATHS I t i s n e c e s s a r y to i d e n t i f y s i g n i f i c a n t causes of p r e v e n t a b l e deaths to i n c l u d e i n the a n a l y s i s . The c r i t e r i a a p p l i e d are t o t a l deaths caused, p o t e n t i a l y e a r s of l i f e l o s t , and t o t a l days of h o s p i t a l i z a t i o n . In a d d i t i o n , i n o r d e r to determine causes of death i t i s n e c e s s a r y to choose a p p r o p r i a t e m o d i f i a b l e l i f e s t y l e f a c t o r s . The l i f e s t y l e f a c t o r s are chosen on the b a s i s of t h e i r p r e d i c t i v e impact on m o r t a l i t y , t h e i r p r o p e n s i t y to be m o d i f i e d , and t h e i r r e l a t i o n s h i p to the s e l e c t e d d i s e a s e s under study. The l i f e s t y l e f a c t o r s chosen are - 43 -Smoking, A l c o h o l Consumption, E x e r c i s e , Overweight, and S e a t b e l t Usage. Table 3.2 p r e s e n t s a m a t r i x which i d e n t i f i e s major m o d i f i a b l e r i s k f a c t o r s a s s o c i a t e d w i t h g i v e n d i s e a s e s which are major causes of m o r t a l i t y . Table 3.3 ranks the d i s e a s e s under a n a l y s i s i n terms o f t o t a l d e a t h s , p o t e n t i a l y e a r s of l i f e l o s t , and t o t a l days of h o s p i t a l i z a t i o n . 3.3 CHANGING MORTALITY RATES The m o r t a l i t y a s s o c i a t e d w i t h the 1971 Canadian p o p u l a t i o n i s e x t r a c t e d from S t a t i s t i c s Canada p u b l i c a t i o n on the causes o f d e a t h , by sex and age ( S t a t i s t i c s Canada, Causes o f Death, 1972). Table 3.4 p r e s e n t s the causes of death i n a l p h a b e t i c a l o r d e r , the ICDA Codes a s s o c i a t e d w i t h each ( N a t i o n a l Centre f o r H e a l t h S t a t i s t i c s , 1967) and the numbers o f deaths, by sex, a t t r i b u t a b l e to each cause d u r i n g 1971. There were 81,452 deaths a t t r i b u t a b l e to the s e l e c t e d causes used i n the study. T h i s r e p r e s e n t s 52.4% of a l l deaths d u r i n g 1971. These d i s e a s e s accounted f o r 56.1% o f male deaths and 47.3% of a l l female deaths. f i c a t i o n The e f f e c t o f changed l i f e s t y l e s on the modi-of m o r t a l i t y r a t e s i s a s s e s s e d by a d a p t i n g TABLE 3.2 LIFESTYLE FACTORS AND CAUSE OF DEATH MATRIX LIFESTYLE FACTOR Over Seatbelt Smoking Alcohol Exercise Weight Usage B r o n c h i t i s § Emphysema X Cancer o f the Lung X C i r r h o s i s o f the L i v e r X Ischemic Heart D i s e a s e X X X Motor V e h i c l e A c c i d e n t s X X S t r o k e X Source: Adapted from Robbins, Lewis C. and Jack H. Hall (1970). How to Practice Prospective Medicine „ Indianapolis: Methodist Hospital of Indiana. - 45 -TABLE 3.3 CAUSE OF DEATH AND RANKING  FOR DEATHS, POTENTIAL YEARS OF LIFE LOST, AND TOTAL DAYS OF HOSPITALIZATION Deaths Potential Years of Li f e Lost Total Days Hospitalization B r o n c h i t i s § Emphysema * * 7 Cancer o f the Lung C i r r h o s i s of L i v e r Ischemic Heart D i s e a s e Motor V e h i c l e A c c i d e n t s S t r o k e Refers to a l l Respiratory Disease Refers to a l l accidents Source: John R. McWhinnie and others, Health F i e l d Indicators. 1976. Ottawa: Department of National Health § Welfare. - 46 -TABLE 3.4 MORTALITY BY SELECTED CAUSES CANADA 1971 ICDA Code* Male DEATHS Female Total Bronchitis § Emphysema 490-493 2,785 697 3,482 Cancer of the Lung 162.1 4,583 792 5,375 Cirrhosis of the Liver 571 1,287 650 1,937 Ischemic Heart Disease 410-414 30,186 18,789 48,975 Motor Vehicle Accidents E810-819 4,029 1,587 5,616 Stroke 430-438 7,618 8,449 16,067 P a r t i a l Total 50,488 30,964 81,452 A l l Other Causes 40,321 34,483 74,804 Total 90,809 65,447 156,256 * National Center for Health S t a t i s t i c s , Eighth Revision International C l a s s i f i c a t i o n of Diseases, Volume 1. Washington: U.S. Department of Health Education and Welfare, 1967. Source: S t a t i s t i c s Canada. Causes of Death 1971, Catalogue 84-203. Ottawa: Information Canada, 1972. - 47 -Robbins' and H a l l ' s r i s k f a c t o r s ( G e s s n e r - G e l 1 e r Tables) to p r e d i c t the changing p a t t e r n o f m o r t a l i t y brought about by s e l e c t i v e changes i n l i f e s t y l e s . M o d i f i c a t i o n i n each l i f e s t y l e f a c t o r i d e n t i -f i e d r e p r e s e n t s a " t r i a l " , i n t h i s p r e s e n t work. These are Smoking, 'S'; A l c o h o l Consumption, 'A'; E x e r c i s e , 'X'; Overweight, 'W; and S e a t b e l t Usage, 'B'. In o r d e r to a l s o a s s e s s the s y n e r g i s t i c e f f e c t s o f l i f e -s t y l e changes, c o m b i n a t i o n s of r i s k f a c t o r s are a l s o s t u d i e d . F i n a l l y , an i d e a l i z e d c o n d i t i o n , of a l l f i v e f a c t o r s , was assumed; Smoking, A l c o h o l Consumption, E x e r c i s e , Overweight, and S e a t b e l t Usage. T h i s i d e a l s t a t e i s when a r i s k f a c t o r i s lowered t o i t s minimum v a l u e by e l i m i n a t i n g the r i s k . For example, i n the i d e a l s t a t e everyone would be a non-smoker, n o n - d r i n k e r , e x e r c i s e r e g u l a r l y , be an i d e a l weight, and always wear s e a t b e l t s . The r i s k f a c t o r s t h e r e f o r e assume t h e i r l o w e s t p o s s i b l e v a l u e s . - 48 -TABLE 3.5 RISK FACTOR TRIALS Standard Run w i t h P r e s e n t L i f e s t y l e s 'P' Smoking »S' A l c o h o l Consumption 'A' E x e r c i s e 'X' Overweight 'W S e a t b e l t Usage 'B' Smoking/Alcohol Consumption 'SA' •E x e r c i s e / O v e r w e i g h t 'XW1 Smoking/Alcoho1 C o n s u m p t i o n / E x e r c i s e / 'SAXW' Overweight Smoking/Alcoho1 C o n s u m p t i o n / E x e r c i s e / 'SAXWB' O v e r w e i g h t / S e a t b e l t Usage Smoking/Alcohol C o n s u m p t i o n / E x e r c i s e / 'SAXWB-I' O v e r w e i g h t / S e a t b e l t U s a g e - I d e a l When Table 3.5 and Table 3.2 are compared i t i s p o s s i b l e to i d e n t i f y the d i s e a s e s a f f e c t e d by s p e c i f i c r i s k f a c t o r s and t r i a l s . For example, smoking a f f e c t s a l l the d i s e a s e s c o n s i d e r e d except c i r r h o s i s o f the l i v e r and motor v e h i c l e a c c i d e n t s ; a l c o h o l a f f e c t s c i r r h o s i s o f the l i v e r and motor v e h i c l e a c c i d e n t s ; o v e r w e i g h t a f f e c t s eschemic h e a r t d i s e a s e , e t c . The i d e a l s t a t e , 'SAXWB-I', was s t u d i e d i n o r d e r to i n d i c a t e the magnitude of the e f f e c t o f r e d u c i n g p r e v e n t a b l e premature m o r t a l i t y to l e v e l s a s s o c i a t e d w i t h i d e a l i z e d - 49 -r e d u c t i o n of the r i s k f a c t o r s . 3.4 QUANTIFICATION OF DECREASED MORTALITY Having chosen the causes of death and a p p r o p r i a t e r i s k f a c t o r s to study, we must c a l c u l a t e the e f f e c t of r e a s o n a b l y m o d i f y i n g the l i f e s t y l e s to p r e d i c t f u t u r e expected p a t t e r n s o f m o r t a l i t y . T h i s i s a c c o m p l i s h e d by u t i l i z i n g the G e s s n e r - G e l l e r Tables (Robbins, 1970). T h i s a l l o w s the e s t i m a t i o n o f the expected p a t t e r n o f m o r t a l i t y f o r 1971 assuming t h a t the p o p u l a t i o n had p r a c t i s e d improved l i f e s t y l e . Robbins and H a l l (1970) p r o v i d e the f o l l o w i n g d e f i n i t i o n : " R i s k F a c t o r : the m o r t a l i t y r a t i o o f a group w i t h a p a r t i c u l a r p r o g n o s t i c c h a r a c t e r i s t i c as compared to the po p u l a -t i o n average. I f d a t a does not show t h i s d i r e c t l y i t can be c a l c u l a t e d from t h e m o r t a l i t y r a t i o of a group w i t h the prog-n o s t i c c h a r a c t e r i s t i c as compared to a group w i t h o u t the c h a r a c t e r i s t i c . " "Composite R i s k F a c t o r : the m o r t a l i t y r a t i o f o r a p a r t i c u l a r cause of death f o r a s p e c i f i c age, sex, r a c e which c o v e r s a l l p r o g n o s t i c c h a r a c t e r i s t i c s i n use i n H e a l t h Hazard A p p r a i s a l . I t i s n e c e s s a r y to determine the composite r i s k f a c t o r by f o r m u l a i f d a t a f o r such a c o m b i n a t i o n i s not a v a i l a b l e . " - 50 -The composite r i s k f a c t o r , namely the p r o d u c t and sum o f i n d i v i d u a l r i s k f a c t o r s as c a l c u -l a t e d from the G e s s n e r - G e l l e r T a b l e s , i s used to determine the p r o b a b i l i t y of an i n d i v i d u a l s u r v i v i n g ten y e a r s , g i v e n the average r i s k of d y i n g f o r h i s a g e - c o h o r t . Given i n d i v i d u a l s w i l l have g r e a t e r , e q u a l , or l e s s e r r i s k of d y i n g than o t h e r numbers o f t h e i r c o h o r t , but i t i s assumed t h a t the o v e r a l l r i s k f a c t o r w i l l be 1 u n l e s s a change i s i n t r o d u c e d . That i s , p a t t e r n s o f m o r t a l i t y would remain at the 1971 l e v e l s . For the purpose o f the s t u d y , i t i s assumed t h a t s e l e c t e d r i s k f a c t o r s would be a r b i t r a r i l y reduced by 25%. I t i s , t h e r e f o r e , assumed t h a t the a g e - s p e c i f i c m o r t a l i t y r a t e s a t t r i b u t a b l e to the p o p u l a t i o n i n 1971 c o u l d be reduced p r o p o r t i o n a t e l y i n accordance w i t h the p r e d i c t e d p a t t e r n o f m o r t a l i t y e x p r e s s e d by Gessner-G e l l e r T a b l e s . S i n c e these data are c a l c u l a t e d on a t e n - y e a r c o h o r t t h e r e i s a c e r t a i n i n h e r e n t anomaly s i n c e the assumption i s a c o n s t a n t annual r a t e - o f - d e a t h . In a c t u a l terms, the p a t t e r n o f m o r t a l i t y i s n o n - l i n e a r w i t h an i n c r e a s i n g p a t t e r n o f m o r t a l i t y towards the l a t t e r y e a r s o f the t e n - y e a r time-frame. However, s i n c e i t i s i m p r a c t i c a l to c a l c u l a t e an annual m o r t a l i t y r a t e , i t i s assumed t h a t the annual m o r t a l i t y r a t e would be reduced p r o p o r t i o n a t e l y . - 51 -The c a l c u l a t i o n of m o r t a l i t y r e d u c t i o n f a c t o r , and c o n s e q u e n t l y of number of l i v e s saved from a 25% improvement i n l i f e s t y l e r i s k f a c t o r proceeds as f o l l o w s . The example uses Motor V e h i c l e A c c i d e n t s (MVA) as the cause of deat h , w i t h A l c o h o l Consumption (A) and S e a t b e l t Usage (B) as the r e l e v a n t , r e d u c i b l e r i s k f a c t o r s . By d e f i n i t i o n the average r i s k f a c t o r s f o r the p o p u l a t i o n equal 1. However i n t h i s d i s c u s s i o n we r e s t r i c t t h i s d e f i n i t i o n to the r i s k f a c t o r a p p l i c a b l e t o the p o p u l a t i o n of the year 1971. Then i f the whole p o p u l a t i o n were s u b s e q u e n t l y t o reduce such r i s k f a c t o r s t o t h e i r lowest l e v e l s (RF, . , RF„ . ) , the maximum amounts A, mm . B , mm, of r i s k f a c t o r r e d u c t i o n (RFR. , RFR" . , , , A,max. B,max.) would be gi v e n by RF R = (1 - RF . )* A,max. A,mm. However, w i t h the more modest assumption t h a t o n l y 25% of these maximum r i s k f a c t o r r e d u c t i o n s are a c h i e v e d , the a c t u a l l e v e l s of- r i s k f a c t o r r e d u c t i o n become RFR = 0.25 RFR = 0.25(1 - RF . ) A A, max . A, mm . For s i m p l i c i t y o n l y the f o r m u l a f o r A i s g i v e n . - 52 -In o r d e r to assess impact on m o r t a l i t y , the r e v i s e d r i s k f a c t o r s equal the p r e s e n t average l e v e l (1) minus these amounts of r i s k f a c t o r r e d u c t i o n (RFR., R F R D ) . RF = 1 - RFR. = 1 - 0.25(1 - RF. . ) A A A, mm. In the p r e s e n t example o f r i s k f a c t o r s f o r death by MVA, RF. . = 0.5, T h e r e f o r e , RFR. = 0.25(1 - 0.5) = 0.125 A ,mm. ' A and RF A = 1 - RFR^ = 0.875 and RFg^'min. =0. 8. T h e r e f o r e , RFR g = 0.25(1 - 0.8) = 0.05 and RFg = 0.95 T h e r e f o r e , the new r i s k f a c t o r s r e s u l t i n g from a 25% r e d u c t i o n i n A l c o h o l Usage and a 25% i n c r e a s e i n S e a t b e l t Usage are .875 and .950 r e s p e c t i v e l y . Conse-q u e n t l y t h e r e i s a 12.5% r e d u c t i o n i n deaths a t t r i b u t a b l e to the r i s k f a c t o r S e a t b e l t Usage. In o r d e r to determine the new m o r t a l i t y r a t e when the e f f e c t s o f the two r i s k f a c t o r s , A l c o h o l and S e a t b e l t Usage, are combined, the f o l l o w i n g f o r m u l a f o r combined R i s k F a c t o r (RF^B' o r CRF) i s used (Robbins § H a l l , 19 70). - 53 -CRF - R F A B = R F A . RF B and t h e r e f o r e , i n t h i s example R F A g = 0.875 . 0.95 = 0.831 In o r d e r to c a l c u l a t e the m o d i f i e d number of deaths due to motor v e h i c l e a c c i d e n t s , M^y A, f o r any g i v e n r i s k f a c t o r r e d u c t i o n X(X = A,B, or AB), the e x i s t i n g number o f de a t h s , D^y A, i s s i m p l y m u l t i p l i e d by the r e v i s e d r i s k f a c t o r , RF A MVA X * UMVA C o r r e s p o n d i n g l y , the number of l i v e s "saved" (or deaths d e f e r r e d ) , L M y A , i s g i v e n by LMVA = ^ ~ R F X ^ °MVA Table 3.6 i l l u s t r a t e s the c a l c u l a t i o n of both reduced m o r t a l i t y and o f l i v e s saved, f o r males, due to a 25% r e d u c t i o n i n the r i s k f a c t o r s , A l c o h o l and S e a t b e l t Usage, f o r each o f 19 age groups, as w e l l as f o r the whole p o p u l a t i o n . - 54 -TABLE 3.6 EXAMPLE CALCULATION  MODIFIED MORTALITY RATES FOR MOTOR VEHICLE ACCIDENTS; FOR 25% REDUCTION IN ALCOHOL $ SEATBELTS RISK FACTORS; MALES 1 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-T o t a l DMVA 16 87 203 17 7 668 797 378 257 218 195 201 177 165 135 132 95 66 47 21 4,035 RF A RF, RF AB 875 950 .831 M MVA 13 72 , i 169 147 555 662 314 214 181 162 167 147 137 112 110 79 55 39 17 3, 352 MVA 3 15 34 30 113 135 64 43 37 33 34 30 28 23 22 16 11 8 4 683 - 55 -For each of the t r i a l s noted i n Table 3.5 the a g e - s p e c i f i c m o r t a l i t y a s s o c i a t e d w i t h each age group i s reduced a c c o r d i n g to the t o t a l l i v e s saved as a r e s u l t of a 25% improvement i n a l l r e l e v a n t l i f e s t y l e r i s k f a c t o r s . S i n c e t h e s e are t r i a l s w i t h m u l t i p l e d i s e a s e s , i t i s n e c e s s a r y to c a l c u l a t e the l i v e s saved per i n d i v i d u a l d i s e a s e and then add the t o t a l l i v e s saved to determine the number of deaths to be reduced by such t r i a l s . The p a t t e r n s o f m o r t a l i t y e x p e r i e n c e d , when s e l e c t e d l i f e s t y l e improvements are made, are a l l l e s s than the o r i g i n a l p a t t e r n s o f m o r t a l i t y . Table 3.7 i n d i c a t e s t h a t the most s i g n i f i c a n t l i f e s t y l e f a c t o r s i n o r d e r o f importance are Smoking, w i t h r e d u c t i o n i n t o t a l d eaths, 3.4%; E x e r c i s e , 2.3%; Weight C o n t r o l , 1.5%; A l c o h o l Use, 0.7%; and f i n a l l y S e a t b e l t Usage, 0.2%. I t s h o u l d be noted t h a t t h i s c a s t s s e a t b e l t s i n a poor l i g h t i n r e f e r e n c e to t o t a l d eaths, however, s i n c e motor v e h i c l e a c c i d e n t s r e p r e s e n t the major cause of p o t e n t i a l y ears of l i f e l o s t i t i s e v i d e n t t h a t each l i f e saved due to an a u t o m o b i l e a c c i d e n t i s l i k e l y to produce a s i g n i f i c a n t t o t a l number of a d d i t i o n a l y ears o f l i f e . The i d e a l i z e d t r i a l S A X W B - 1 J assumes t h a t the f i v e r i s k f a c t o r s are reduced to an i d e a l s t a t e , and the a n a l y s i s shows t h a t t h i s would reduce the o v e r a l l m o r t a l i t y by 24.0%. T h e r e f o r e , i t i s e v i d e n t t h a t the u l t i m a t e a b i l i t y o f the improvement o f l i f e s t y l e to e f f e c t d ecreased m o r t a l i t y r a t e s 56 TABLE 3.7 TOTAL DEATHS FOR SELECTED TRIALS 1971 - HYPOTHETICAL POPULATION TRIAL TOTAL DEATHS % REDUCTION" (S) (A) (X) (WD (B) (SA) (XW) (SAXW) CSAXWB) (SAXWB-1) 2 STANDARD 1971 (P) 151,871 156,121 153,667 154,862 156,973 150,736 151,166 146,107 145,868 119,456 157,256 3 . 4 0.7 2 . 3 1 . 5 0 . 2 4 . 2 3 . 9 7.1 7 . 2 24 . 0 0.0 % R e d u c t i o n from Standard (P) R e d u c t i o n of r i s k f a c t o r to I d e a l S t a t e - 57 -by s e l e c t e d age groups i s s u b s t a n t i a l . The more r e a l i s t i c tria1, 1SAXWB' w i t h a 25% r e d u c t i o n i n r i s k f a c t o r s r e s u l t s i n a r e d u c t i o n of m o r t a l i t y by 7.2%. 3.5 POPULATION PROJECTION The major purpose of the a n a l y s i s i s to determine how a f u t u r e p o p u l a t i o n ' s u t i l i z a t i o n of h o s p i t a l s e r v i c e s i s changed based on t h a t p o p u l a t i o n h a v i n g an o v e r a l l improvement i n l i f e s t y l e . T h e r e f o r e , f o r reasons now d i s c u s s e d , i t i s d e s i r a b l e t o p r o j e c t the p o p u l a t i o n over both s h o r t - and l o n g - t e r m p e r i o d s . The l i f e t a b l e model chosen to p r o j e c t the p o p u l a t i o n i s the K e y f i t z Model (1971), which b a s i c a l l y produces a l i f e t a b l e . P r o d u c i n g a l i f e t a b l e i s a method by which a p o p u l a t i o n w i t h a g i v e n p a t t e r n of m o r t a l i t y i s t r a n s l a t e d i n t o a s t a n d a r d p o p u l a t i o n of 100,000 persons w i t h e q u i v a l e n t m o r t a l i t y r a t e s a p p l i e d to i n d i v i d u a l age c o h o r t s to produce a v a r i e t y o f demo-g r a p h i c v a r i a b l e s . For example, the l i f e t a b l e w i l l i n d i c a t e f o r any g i v e n age c o h o r t the average l i f e e x p ectancy o f members w i t h i n t h a t c o h o r t . S i n c e the l i f e t a b l e i s dependent on a g e - s p e c i f i c m o r t a l i t y r a t e s i t i s an obvious v e h i c l e f o r the a n a l y s i s o f changing m o r t a l i t y w i t h i n a p o p u l a t i o n . In a d d i t i o n , the K e y f i t z - 58 -Model uses the output o f the l i f e t a b l e program as i n p u t i n t o another program which produces a p o p u l a t i o n p r o j e c t i o n . T h i s p r o j e c t i o n uses c o n s t a n t a g e - s p e c i -f i c m o r t a l i t y r a t e s as determined by the l i f e t a b l e ; a l s o f e r t i l i t y r a t e s are h e l d c o n s t a n t on the b a s i s o f age and number of mothers. T h i s p o p u l a t i o n p r o j e c t i o n produces expected p o p u l a t i o n s f o r 1976, 1981, 1986, 1991, and 1996 f o r males and females by s e l e c t e d age groups. In a d d i t i o n , the p r o j e c t i o n c a r r i e s the popu-l a t i o n f i v e hundred years i n t o the f u t u r e i n o r d e r to demonstrate the n a t u r e o f a s t a b l e e q u i v a l e n t to the o r i g i n a l p o p u l a t i o n which i s produced somewhere d u r i n g t h i s i n t e r v a l ; t h a t i s , g i v e n c o n s t a n t p a t t e r n s o f m o r t a l i t y and f e r t i l i t y , and w i t h m i g r a t i o n e x c l u d e d , the s i z e o f i n d i v i d u a l c o h o r t s w i l l remain c o n s t a n t t h e r e a f t e r . T h e r e f o r e , the p o p u l a t i o n ceases to change i n i t s o v e r a l l c o m p o s i t i o n . While t h i s p r o j e c t i o n by i t s v e r y n a t u r e i s h y p o t h e t i c a l i t does p r o v i d e a u s e f u l t o o l f o r the a n a l y s i s of the impact o f changed m o r t a l i t y r a t e s i n the l o n g e r term. The p r o j e c t i o n a l s o i n d i c a t e s the u l t i m a t e a g i n g of the p o p u l a t i o n and the r e l a t i v e d i s t r i b u t i o n o f s p e c i f i c age groups of the s p e c i f i e d p o p u l a t i on. The programs p r e s e n t e d by K e y f i t z (1971) were m o d i f i e d to r u n at the U n i v e r s i t y o f B r i t i s h Columbia's Computing C e n t r e . These programs are i n c l u d e d as - 59 -Appendix 1 and Appendix 2. The K e y f i t z Programs were v e r y c o n v e n i e n t f o r the a n a l y s i s i n q u e s t i o n , s i n c e the i n p u t data are r e l a t i v e l y s i m p l e . Table 3.8 p r e s e n t s the i n p u t data to the l i f e t a b l e f o r the s t a n d a r d p o p u l a t i o n t r i a l p e r i o d . L i n e 1 i n d i c a t e s the t r i a l . L i n e 2 i n d i c a t e s the year i n q u e s t i o n , the t o t a l p o p u l a t i o n , the t o t a l deaths-, the t o t a l b i r t h s , t o t a l ' male b i r t h s and t o t a l female b i r t h s . L i n e s 3 and 4 c o n t a i n d a t a on the male p o p u l a t i o n by 19 s p e c i f i c age groups: 0, 1-4, 5-9, ... , 85+. L i n e s 5 and 6 c o n t a i n data on the female p o p u l a t i o n i n the same 19 age groups. L i n e s 7 and 8 c o n t a i n data on b i r t h s by age o f mother. L i n e s 9 and 10 c o n t a i n data on male deaths by the same age groups, and l i n e s 11 and 12 on female d e a t h s . Each l i n e r e p r e s e n t s an 80 c h a r a c t e r computer c a r d . For the purpose o f the a n a l y s i s , i t i s assumed t h a t f e r t i l i t y r a t e s remain c o n s t a n t at 1971 l e v e l s . For each t r i a l i t "was n e c e s s a r y t o modify '•' l i n e s 9, 10, 11, and 12, which d e f i n e the male and female deaths by s e l e c t e d age groups. The a c t u a l number o f deaths i s determined on the b a s i s of the o r i g i n a l p a t t e r n o f m o r t a l i t y minus the l i v e s saved as the r e s u l t o f l i f e -s t y l e changes, as has been d i s c u s s e d i n S e c t i o n 3.4. In a d d i t i o n to the s t a n d a r d r u n , a s e p a r a t e run i s made TABLE 3.8  INPUT DATA  KEYFITZ " LTF PROGRAM" STANDARD 1971 1971 Canada 971 21568400 157256 362187 186646 L75541 186600 743000 1152400 1181400 1074400 941800 800700 660900 645000 640800 613400 518900 472400 381700 296100 205600 140000 85700 54600 0 173700 712900 1101600 1129300 1040000 947600 783400 644600 618800 621800 625600 533600 482300 395300 323900 251800 185500 118500 82800 0 0 0 0 303 41723 129063 112985 50640 21117 5947 374 5 0 0 0 0 0 0 0 0 3712 679 641 589 1489 1697 1176 1090 1416 2310 3523 4838 6886 8753 10277 10661 11056 10180 10836 0 2644 551 424 365 579 559 485 565 815 1290 1901 2480 3477 4345 5614 7138 8930 9762 13523 0 - 61 -f o r each of the ten t r i a l s as noted. At the same time t h a t the l i f e t a b l e i s p r e p a r e d i t i s p o s s i b l e t o s i m u l t a n e o u s l y run the p o p u l a t i o n p r o j e c t i o n s i n c e , as not e d , the i n p u t t o the p o p u l a t i o n p r o j e c t i o n i s i n f a c t o utput from the l i f e t a b l e programs. The o t h e r use o f the l i f e t a b l e i s to make a v a i l a b l e l i f e expectancy both by sex and by s e l e c t e d age group. These data are s u b s e q u e n t l y a n a l y z e d to determine the e f f e c t on i n c r e a s e d l o n g e v i t y o f the v a r i o u s l i f e s t y l e f a c t o r s under a n a l y s i s . 3.6 FORECASTING HOSPITAL UTILIZATION I t i s n e c e s s a r y to determine r a t e s o f h o s p i t a l u t i l i z a t i o n by s p e c i f i c age groups and sex f o r the t r i a l p o p u l a t i o n s i n o r d e r to determine f u t u r e p a t t e r n s o f h o s p i t a l u t i l i z a t i o n . The c u r r e n t p a t t e r n of h o s p i t a l u t i l i z a t i o n was r e c o r d e d by S t a t i s t i c s Canada, H o s p i t a l M o r b i d i t y (1974) . For the purpose o f t h i s a n a l y s i s i t i s assumed t h a t the p a t t e r n o f h o s p i t a l u t i l i z a t i o n i n the f u t u r e w i l l resemble p r e s e n t u t i l i z a t i o n by age and sex except f o r those decreases brought about by improved l i f e s t y l e . The d i s e a s e s i n q u e s t i o n are the same as p r e s e n t e d i n Table 3.4 and s i m i l a r ICDA Codes are used so t h a t the m o r t a l i t y and m o r b i d i t y r a t e s are d i r e c t l y - 62 -comparab1e. The S t a t i s t i c s Canada P u b l i c a t i o n p r o v i d e s data based on a l l ICDA Codes needed except f o r a c c i d e n t s , E810-819. In the case of a c c i d e n t s , mor-b i d i t y i s r e c o r d e d by S t a t i s t i c s Canada i n terms o f the p r i m a r y d i a g n o s i s . For example, a motor v e h i c l e a c c i d e n t i n which a broken l e g was i n v o l v e d would be coded as a f r a c t u r e and not as a motor v e h i c l e a c c i d e n t . Hence, i t i s n e c e s s a r y to f i n d another method to e s t i m a t e h o s p i t a l i z a t i o n due to motor v e h i c l e a c c i d e n t s . There i s a d e a r t h of i n f o r m a t i o n a v a i l a b l e i n t h i s a r e a . However, B r i t i s h Columbia compiles e x c e l l e n t s t a t i s t i c s c o n c e r n i n g motor v e h i c l e a c c i d e n t s and r e l a t e d m o r b i d i t y and m o r t a l i t y ( B r i t i s h Columbia H o s p i t a l Insurance S e r v i c e , 1972). S t a t i s t i c s are c o m p i l e d both f o r t o t a l m o r t a l i t y by s p e c i f i c age groups f o r motor v e h i c l e a c c i d e n t s , and f o r h o s p i t a l i z a t i o n by s p e c i f i c age groups. By u s i n g t h i s i n f o r m a t i o n i t i s p o s s i b l e to determine the number o f h o s p i t a l days per motor v e h i c l e death i n B r i t i s h Columbia. The data compared f a v o r a b l y w i t h the Nova S c o t i a s t u d y of a s i m i l a r time p e r i o d (Chapman, 19 73). Table 3.9 p r e s e n t s d a t a c o n c e r n i n g the number of motor v e h i c l e a c c i d e n t s and r e l a t e d days s t a y f o r 63 TABLE 3.9 DEATHS AND DAYS OF HOSPITALIZATION DUE TO MOTOR VEHICLE ACCIDENTS BRITISH COLUMBIA 1972 DAYS DAYS HOSPITALIZATION/ HOSPITALIZATION # DEATHS DEATH 0-19 M 28,356 146 194 F 13,939 48 290 20-64 M 44,869 283 159 F 22,676 93 244 65-74 M 3,997 31 129 F 3,205 19 169 75 + M 3 ,406 22 155 F 2,171 15 145 TOTAL M $ F 122,619 657 187 Source: B r i t i s h Columbia H o s p i t a l Insurance S e r v i c e . 1972. S t a t i s t i c s of H o s p i t a l i z e d A c c i d e n t s : B r i t i s h Columbia, 1972. V i c t o r i a ; Department o f H e a l t h . - 64 -s e l e c t e d age groups, i n 1972. I t i s i n t e r e s t i n g to note the lower number of h o s p i t a l days per death among the e l d e r l y which, however, may r e f l e c t h i g h e r immediate m o r t a l i t y per a c c i d e n t r a t h e r than d e c r e a s e d l e n g t h of s t a y f o r e l d e r l y p e r s o n s . S i m i l a r l y , the l a r g e 1 e n g t h - o f - s t a y f o r females may a l s o be a r e s u l t o f them f r e q u e n t l y b e i n g passengers i n the s o - c a l l e d " s u i c i d e s e a t " where many major motor v e h i c l e i n j u r i e s o c c u r . To determine the t o t a l h o s p i t a l i z a t i o n by s e l e c t e d age groups f o r 1971, Canada, i t i s assumed t h a t the average number of h o s p i t a l days per death i n Canada i s s i m i l a r to the B r i t i s h Columbia e x p e r i e n c e . T h e r e f o r e , the c a l c u l a t i o n i s made by m u l t i p l y i n g the number o f motor v e h i c l e deaths r e c o r d e d i n Canada f o r 1971, f o r s e l e c t e d age groups and sex, by the average days of h o s p i t a l i z a t i o n . Table 3.10 p r e s e n t s t o t a l h o s p i t a l i z a t i o n r e l a t e d to s e l e c t e d d i s e a s e s , and d i s a g g r e g a t e d by sex and s e l e c t e d age groups (0-19, 20-64, 65-74, and 75+). These age g r o u p i n g s are chosen because p a t t e r n s of h o s p i t a l i z a t i o n v a r y by the age of the p a t i e n t . E s p e c i a l l y i m p o r t a n t are the d r a m a t i c i n c r e a s e s i n h o s p i t a l use by e l d e r l y p e r s o n s . Hence, the two groupings f o r those over 65 y e a r s of age. - 65 -TABLE 3.10 TOTAL DAYS OF HOSPITALIZATION BY SELECTED DISEASES BY SEX AND BY SELECTED -AGE-GROUPS - 1971 0-19 20-64 65-74 75 + B r o n c h i t i s § M 184,879 133,076 111,985 Emphysema F 140,472 5 2,280 42,116 Cancer of the M 108,369 83,888 42,394 Lung F 29,010 15,374 9, 302 C i r r h o s i s of M 94,002 21,141 9,592 the L i v e r F 48,211 11,843 6, 863 Ischemic Heart M 708,150 356,934 482,570 Disease F 298,332 344,140 718,833 Motor V e h i c l e M 223,294 401,157 29,283 20,770 A c c i d e n t s F 165,590 195,932 21,463 12,470 S t r o k e M 244,314 288,626 458,656 F 183,399 444,305 738,739 Source: Chipman, Mary L. 1973. " H o s p i t a l i z a t i o n a f t e r motor ^ .. v e h i c l e a c c i d e n t s i n Nova S c o t i a . " Canadian J o u r n a l o f P u b l i c H e a l t h , 64(2):133-140. S t a t i s t i c s Canada. 1974. H o s p i t a l M o r b i d i t y 1971. Cata l o g u e 82-206; I n f o r m a t i o n Canada. Ottawa. - 66 -Table 3.11 p r e s e n t s both the t o t a l days of h o s p i t a l i z a t i o n e x p e r i e n c e d by the Canadian p o p u l a t i o n d u r i n g 1971 and the days d i s t r i b u t e d by the same s e l -e c t e d age groups. Table 3.12 g i v e s data c o n c e r n i n g t o t a l days o f h o s p i t a l i z a t i o n by s e l e c t e d age groups f o r p r e v e n t a b l e c o n d i t i o n s ( d i s e a s e s / c a u s e s - o f - d e a t h under a n a l y s i s , Table 3.2). In o r d e r to as s e s s the o v e r a l l impact o f postponed m o r t a l i t y on h o s p i t a l u t i l i z a t i o n , t h r e e c o n d i t i o n s were i n v e s t i g a t e d : the Sta n d a r d P o p u l a t i o n 'P', 'SAXWB', and 'SAXWB-I'. These are chosen because the l a t t e r two r e p r e s e n t e d the most s i g n i f i c a n t r e d u c t i o n s i n m o r t a l i t y and, t h e r e f o r e , would b e t t e r i l l u s t r a t e the d i r e c t i o n o f change from decreased m o r t a l i t y . In o r d e r to determine the o v e r a l l r e d u c t i o n i n h o s p i t a l u t i l i z a t i o n i t was assumed, f o r the s t a n d a r d t r i a l 'P', t h a t the r a t e o f h o s p i t a l i z a t i o n per person i n f u t u r e y e a r s would be e q u i v a l e n t to the per c a p i t a r a t e i n 1971 and i t was assumed, f o r the o t h e r t r i a l s , t h a t h o s p i t a l u t i l i z a t i o n would be decreased p r o p o r -t i o n a t e l y to the decrease i n m o r t a l i t y . I t i s n e c e s s a r y to make t h i s assumption because i t i s i m p o s s i b l e t o i d e n t i f y , i n a p o p u l a t i o n a d o p t i n g an o v e r a l l improve-ment i n i t s l i f e s t y l e , whether h o s p i t a l e p i s o d e s would oc c u r e i t h e r a t decreased or a t s i m i l a r r a t e s , and s i m i l a r l y whether or not a p o p u l a t i o n w i t h an o v e r a l l 67 TABLE 3.11 TOTAL DAYS OF HOSPITALIZATION BY SEX AND BY SELECTED-AGE-GROUPS - CANADA 19 71 0-19 20-64 65-74 75 + T o t a l M 3,333,676 8,222,057 3,073,746 3,518,753 18,148,232 F 3,135,835 12,122,725 3,063,973 4, 757, 548 23,080,081 T 6,469,511 20,344,782 6,137,719 8,276,301 41,228,313 % 15.69 49 . 35 14 . 89 20.07 100.00 Source: S t a t i s t i c s Canada. 1974. H o s p i t a l M o r b i d i t y 1971 TABLE 3.12 TOTAL DAYS OF HOSPITALIZATION FOR PREVENTABLE  CONDITIONS BY SEX AND BY SELECTED-AGE-GROUPS 1971 0-19 20-64 65-74 75+ T o t a l M 223,294 1,740,871 912,951 1,125,967 4,003,083 F 165,590 895,356 889,405 1,528,323 3,478,674 T 388,884 2,636,227 1,802,356 2,654,290 7,481,757 5.20 35.24 24.09 35.48 100.00 * S ourc e: S t a t i s t i c s Canada. 1974. H o s p i t a l M o r b i d i t y 1971. - 68 -improved l i f e s t y l e would e x p e r i e n c e lower o v e r a l l 1 e n g t h s - o f - s t a y per e p i s o d e . The next s t e p determines the r e l a t i v e decrease i n h o s p i t a l i z a t i o n by s p e c i f i c age groups and sex f o r the s e l e c t e d d i s e a s e s . Table 3.13 p r e s e n t s an example o f t h i s c a l c u l a t i o n f o r the d i s e a s e B r o n c h i t i s and Emphysema. The r a t e o f r e d u c t i o n i s c a l c u l a t e d on the b a s i s of the number of deaths p r e v e n t e d over the t o t a l number of deaths. T h i s c a l c u l a t i o n i s made f o r t r i a l s 'SAXWB' and 'SAXWB-I'. T h i s d a t a i s p r e s e n t e d i n Chapter 4. For the Standard P o p u l a t i o n 'P', the u t i l i z a t i o n r a t e r e c o r d e d i n 1971 i s used, as a l r e a d y noted. Table 3.14 p r e s e n t s an example c a l c u l a t i o n of the r e d u c t i o n of the h o s p i t a l u t i l i z a t i o n i n 1971for 3 s e l e c t e d age groups, by a p p l y i n g the 'SAXWB' reduc-t i o n s of Table 3.13. The t o t a l days o f h o s p i t a l i z a t i o n ' i n 1971 are c a l c u l a t e d by m u l t i p l y i n g the t o t a l number of h o s p i t a l days r e c o r d e d by (1 - r a t e o f r e d u c t i o n ) . In a r r i v i n g a t the t o t a l days of h o s p i t a l i z a t i o n , these c a l c u l a t i o n s are c a r r i e d out f o r a l l s e l e c t e d d i s e a s e s . In o r d e r to determine the o v e r a l l u t i l i z a t i o n r a t e , i n 1971, w i t h the assumed changes, by s p e c i f i c age groups and sex, i t i s n e c e s s a r y to sum the t o t a l days of h o s p i t a l i z a t i o n f o r the s e l e c t e d d i s e a s e s , expected as the r e s u l t o f the improved l i f e s t y l e , p l u s the t o t a l * f o r B r o n c h i t i s and Emphysema - 69 -TABLE 3.13 EXAMPLE CALCULATION RATE OF REDUCTION OF HOSPITAL UTILIZATION 1971 'SAXWB1- BRONCHITIS AND EMPHYSEMA DEATHS Male 20-64 65-74 75 + Standard Run 'P' 697 967 1 , 098 Prevented 130 192 219 Rate .187 .199 .199 Female 20-64 65- 74 75 + 221 175 280 11 6 7 050 034 025 TABLE 3.14 EXAMPLE CALCULATION REDUCTION OF HOSPITAL UTI LIZAT I ON 1971 Male Female SAXWB' BRONCHITIS AND EMPHYSEMA 20-64 65-74 75 + 20-64 65-74 75 + T o t a l Days 'P' 184,879 133,076 111,985 140,472 52,280 42 ,116 T o t a l Days 'SAXWB1 150,397 106,654 89,650 133,481 50,487 41 , 063 - 70 -u t i l i z a t i o n from a l l o t h e r causes. Once the t o t a l h o s p i t a l i z a t i o n i s e s t a b l i s h e d i t i s n e c e s s a r y t o c a l c u l a t e a g e - s p e c i f i c , p e r - c a p i t a u t i l i z a t i o n r a t e s . To a c c o m p l i s h t h i s the t o t a l number of h o s p i t a l days by sex and s e l e c t e d age-group i s d i v i d e d by the pop-u l a t i o n of t h e s e same c a t e g o r i e s f o r 1971. There r e s u l t s an age- and s e x - s p e c i f i c u t i l i z a t i o n r a t e which can be a p p l i e d to the p r o j e c t e d p o p u l a t i o n s g e n e rated by the K e y f i t z model. Table 3.15 p r e s e n t s the p r o j e c t e d u t i l i z a t i o n r a t e s f o r the 'P', 'SAXWB', and 'SAXWB-I' p o p u l a t i o n s . H o s p i t a l u t i l i z a t i o n expected w i t h f u t u r e p o p u l a t i o n s i s p r o j e c t e d by m u l t i p l y i n g the a g e - s p e c i f i c h o s p i t a l u t i l i z a t i o n r a t e by the t o t a l p o p u l a t i o n of the age groups i n the p r o j e c t i o n . Table 3.16 p r e s e n t s an example of t h i s c a l c u l a t i o n f o r the 1996 p o p u l a t i o n w i t h c o n d i t i o n •SAXWB'. Having c a l c u l a t e d the t o t a l h o s p i t a l u t i l i z a -t i o n e xpected by the p r o j e c t e d p o p u l a t i o n s , i t i s then p o s s i b l e t o c a l c u l a t e the o v e r a l l burden on s o c i e t y which would r e s u l t due to an i n c r e a s i n g number of persons s u r v i v i n g i n t o the e l d e r l y age group. This p r o j e c t i o n becomes o f i n t e r e s t i n the f u t u r e as the p r o p o r t i o n o f the e l d e r l y i n c r e a s e s . To a c c o m p l i s h t h i s the p r o d u c t i v e p o p u l a t i o n , i n the age group 20-64, i s determined f o r 71 TABLE 3.15 TOTAL HOSPITAL UTILIZATION RATES BY SEX  SELECTED-AGE-GROUPS, AND TRIALS F i g u r e s r e p r e s e n t h o s p i t a l d a y s / p e r s o n - y e a r STANDARD 'P' 0-19 20-64 65-74 75 + MALE 0.76852 1.44867 6. 12666 12 . 55352 FEMALE 0 .75426 2 .14448 5.32217 12.29976 'SAXWB' 0-19 20-64 65-74 75 + 0.75980 1.39736 5.873-16 12.05892 0.74742 2.12676 5.21600 12.01592 'SAXWB-I' 0-19 20-64 65-74 75 + 0 . 73761 1.27103 5.21215 10.81428 0.73040 2.08020 5 . 01670 11 .44865 72 TABLE 3.16 EXAMPLE CALCULATION OF TOTAL HOSPITAL UTILIZATION FOR TRIAL 'SAXWB' IN 1996 Mai e 0-19 20-64 65-74 75 + POPULATION 4,484,177 7, 885, 270 845,585 504,711 UTILIZATION RATE - DAYS/ PERSON-YEAR 0 . 7 5 980 1 . 39736 5 . 87316 12.05892 UTILIZATION DAYS 3,407,078 11,018,560 4,966,256 6,086,270 Female 0-19 20-64 65-74 75 + 4,243,881 7,825,430 1,006,974 801,523 0. 74742 2.12676 5 .21600 12.01592 3,171,962 16,642,811 5,252,376 9,631,036 T o t a l H o s p i t a l i z a t i o n : 60,176,349 - 73 -the t h r e e h o s p i t a 1 - u t i 1 i z a t i o n t r i a l s . When t h i s popu-l a t i o n i s d i v i d e d i n t o the t o t a l u t i l i z a t i o n i t i s p o s s i b l e to c a l c u l a t e the number of h o s p i t a l days s t a y per p r o d u c t i v e p e r s o n . T h i s i s d e f i n e d as BSR i n Table 3.17. Table 3.17 p r e s e n t s - t h i s d ata f o r 1971 and 1996 and f o r the s t a b l e p o p u l a t i o n p r o j e c t e d i n 2471. 3.7 FORECASTING HOSPITAL COSTS The f i n a l a s pect o f the a n a l y s i s i s to determine the c o s t a s s o c i a t e d w i t h t h e s e f u t u r e p a t t e r n s of h o s p i t a l u t i l i z a t i o n , based on changing l i f e s t y l e s of the p o p u l a -t i o n . S i n c e s u r v i v o r s h i p i n c r e a s e s s i g n i f i c a n t l y when reduced m o r t a l i t y r a t e s a p p l y , the r e s u l t i n g i n c r e a s e i n h o s p i t a l i z a t i o n r a t e s i n d i c a t e s t h a t t h e r e w i l l l i k e l y be a concomitant i n c r e a s e i n o v e r a l l h o s p i t a l c o s t s . The t o t a l c o s t s are c a l c u l a t e d based on the average t o t a l o p e r a t i n g expenses per p a t i e n t day f o r a d u l t s and c h i l -d ren d u r i n g 1971, $65.67 ( S t a t i s t i c s Canada, H o s p i t a l S t a t i s t i c s , 1974). Table 3.18 p r e s e n t s the c a l c u l a t i o n of t o t a l c o s t s i n c o n s t a n t d o l l a r s f o r the s e l e c t e d t r i a l s . Of course the use of 1971 c o n s t a n t d o l l a r s w i l l not h e l p much i n p r e d i c t i n g f u t u r e h o s p i t a l u t i l i z a t i o n c o s t s , s i n c e the c o s t s of l a b o u r - i n t e n s i v e h o s p i t a l - 74 -TABLE 3.17 HOSPITALIZATION  BURDEN ON SOCIETY RATES (BSR)* SELECTED TRIALS STANDARD P, 1971 Pop., 20-64 M & F U t i 1 i z a t i o n (BSR) 1971 11,328,600 41,228,313 3 . 6393 1996 15,661,408 59,973,987 3 .8294 2471 16,422,353 75,600,138 4 . 6035 'SAXWB' Pop., 20-64 M £ F U t i 1 i z a t i on (BSR) 15,710,700 60,176,349 3 .8303 16,477,983 76,496,469 4 . 6423 'SAXWB-I• Pop., 20-64 M £ F U t i l i z a t i o n (BSR) 15,833,796 60,675,651 3 .8320 16,614,630 79,065,711 4.7588 * D e f i n e d on p. 73 -75 TABLE 3.18 TOTAL COSTS OF HOSPITAL UTILIZATION BY SELECTED TRIALS, 1971 CONSTANT DOLLARS* Day's H o s p i t a l i z a t i o n Costs OOP's 1971 'P* 41,228,313 2,703,340.4 1996 'P' 59,973,987 3,932,494.3 'SAXWB' 60,176,349 3,945,763.2 'SAXWB-I* 60,675,651 3,978,502.4 2471 'P' 75,600,138 4,957,101.0 •SAXWB' 76,496,469 5,015,873.4 'SAXWB-I' 79,065,711 5,184,338.6 Costs = 1971 Average t o t a l o p e r a t i n g expenses per p a t i e n t day f o r a d u l t s and c h i l d r e n j $65.57. - 76 -s e r v i c e s w i l l l i k e l y i n c r e a s e at a r a t e f a s t e r than the o v e r a l l r a t e of i n f l a t i o n . Thus, i n r e a l d o l l a r s the c o s t s o f h o s p i t a l i z a t i o n w i l l i n c r e a s e even more s u b s t a n t i a l l y . Baumal and Oates (1972) have noted t h a t our i n a b i l i t y to i n c r e a s e p r o d u c t i v i t y o f l a b o u r - i n t e n s i v e p e r s o n a l s e r v i c e s at an e q u i v a l e n t r a t e to t h a t i n o t h e r s e c t o r s o f the economy means t h a t the r e l a t i v e r a t e o f i n c r e a s e o f these c o s t s are d i s p r o p o r t i o n a t e l y h i g h e r than o v e r a l l c o s t i n c r e a s e s . The f u l l a n a l y s i s of t h i s d ata and r e s u l t s f o l l o w i n the next c h a p t e r . - 77 -RESULTS AND DISCUSSION 4.1 INTRODUCTION The Methodology c h a p t e r p r e s e n t s the q u a n t i -t a t i v e t e c h n i q u e s used to produce the r e s u l t s r e q u i r e d to answer the r e s e a r c h q u e s t i o n s . T h i s c h a p t e r d i s c u s s e s the r e s u l t s of the computations and makes i n f e r e n c e s u s e f u l i n t h e i r i n t e r p r e t a t i o n . I t s h o u l d be kept i n mind t h a t t h i s work cannot p r e d i c t a c t u a l f u t u r e p a t t e r n s of h o s p i t a l u t i l i z a t i o n , but r a t h e r i n d i c a t e s the l i k e l y s h i f t i n p a t t e r n s of u t i l i z a t i o n as a r e s u l t of improvements i n the average l i f e s t y l e of Canadians. The i m p l i c a t i o n of an e v o l v i n g age s t r u c t u r e of the p o p u l a t i o n and t h e i r f u t u r e use of h o s p i t a l s e r v i c e s i s noted. The p o l i c y i m p l i c a t i o n s and s u g g e s t i o n s f o r f u r t h e r a n a l y s i s are p r e s e n t e d i n the c o n c l u d i n g c h a p t e r . 4.2 THE POPULATION The p o p u l a t i o n used i n c o n j u n c t i o n w i t h the m o d i f i e d K e y f i t z program i s r e p r e s e n t e d by the 1971 Canadian V i t a l S t a t i s t i c s Data as a l r e a d y g i v e n i n Table 3.1. These d a t a p r o v i d e the i n i t i a l p o p u l a t i o n p r o f i l e from which the s t a n d a r d t r i a l i s made. In subsequent t r i a l s the o n l y change i n t h i s i n p u t data - 78 -was i n "male d e a t h s " and "female d e a t h s " , which r e s u l t e d from assumed improvements i n l i f e s t y l e . The 1971 Canadian p o p u l a t i o n comprised 21,568,400 p e r s o n s , of which a p p r o x i m a t e l y h a l f were male and h a l f were female. The age d i s t r i b u t i o n o f the p o p u l a t i o n was: 0-19 39.4% 20-64 52.5% 65+ 8.1% This age s t r u c t u r e r e p r e s e n t s a young p o p u l a t i o n i n terms of developed c o u n t r i e s . For example, the World Bank (1976) r e p o r t e d t h a t the Canadian p o p u l a t i o n was made up of 8.0% persons aged 65 or more i n 1970. Of the t h i r t y f r e e -market economies which had per c a p i t a income i n excess of $1,000, Canada ranked twenty-second i n terms of the r e l a t i v e p e r c e n t a g e o f the e l d e r l y . S i n c e o v e r a l l im-provements i n l i f e e x pectancy are i n f l u e n c i n g p o p u l a t i o n age d i s t r i b u t i o n i t i s l i k e l y t h a t the Canadian popu-l a t i o n w i l l age n a t u r a l l y i n l i n e w i t h o t h e r n a t i o n s . In comparison, note t h a t Sweden had 13.7% of i t s pop-u l a t i o n over 65 i n 1970. - 79 -4.3 CRUDE DEATH RATES The 1971 r e c o r d e d deaths were m o d i f i e d f o r each t r i a l based on the l i k e l y e f f e c t o f improvements i n l i f e s t y l e . S i n c e the 1971 o r i g i n a l p o p u l a t i o n i s the s t a r t i n g p o i n t f o r each p r o j e c t i o n , the m o d i f i e d death f i g u r e s can be used to c a l c u l a t e c o m p a t i b l e crude m o r t a l i t y r a t e s . Table 4.1 p r e s e n t s crude death r a t e s and t h e i r r a n k i n g by t r i a l , f o r males and females s e p a r a t e l y , and f o r both. The o v e r a l l e f f e c t of r e d u c i n g deaths i n any s e l e c t e d age groups i s c l e a r l y t o reduce the o v e r a l l death r a t e . The 'P' t r i a l has a crude t o t a l death r a t e of 7.29 per thousand p e r s o n s . The minimal e f f e c t on o v e r a l l deaths o c c u r s w i t h 'B', S e a t b e l t Usage a l o n e , f o r which the r a t e o n l y reduces to 7.28, whereas the most profound e f f e c t i s i n the i d e a l t r i a l 'SAXWB-l', namely 5.54. In a l l cases the combining of s e v e r a l r i s k f a c t o r r e d u c t i o n s i n a s i n g l e t r i a l produces g r e a t e r d e c r e a s e s i n m o r t a l i t y than f o r any s i n g l e r i s k f a c t o r r e d u c t i o n s , except f o r ' E x e r c i s e ' and 'Over Weight' f o r males, 8.11, compared w i t h 'Smoking' a l o n e , 8.08. Of the f i v e r i s k f a c t o r s a l o n e , the most s i g n i f i c a n t r e d u c e r of m o r t a l i t y i s 'Smoking', 7.04, f o l l o w e d by ' E x e r c i s e ' , 7.12, 'Over Weight', 7.18, ' A l c o h o l ' , 7.24, and f i n a l l y ' S e a t b e l t Usage', 7.28. - 80 -TABLE 4.1 CRUDE DEATH RATES AND RANKING  BY TRIAL "1971" (CANADA)  FOR MALE, FEMALE, AND TOTAL MALE 1 RANK FEMALE RANK TOTAL SAXWB-I' 5. 84 (1) 5 . 23 (1) 5. 54 (1) SAXWB1 7. 73 (2) 5 . 80 (2) 6. 76 (2) SAXW' 7 . 74 (3) 5 .80 (2) 6.77 (3) XW1 8.11 (6) 5 . 91 (4) 7 .01 (5) SA 1 8 . 01 (4) 5.97 (5) 6.99 (4) B 1 8.49 (10) 6 . 07 (10) 7 . 28 (10) W» 8. 37 (8) 5 .99 (6) 7.18 (8) X' 8 . 26 (7) 5 .99 (6) 7.12 (7) A' 8.43 (9) 6. 04 (9) 7 . 24 (9) S ' 8 .08 (5) 6.00 (8) 7 . 04 (6) P' 8 .50 (11) 6. 08 (11) 7 .29 ( I D - 81 -The r e d u c t i o n i n m o r t a l i t y r a t e s i s g r e a t e r f o r males than females. T h i s i s because the r i s k f a c t o r s i n v e s t i g a t e d had c o r r e s p o n d i n g l y a much more profound impact on the d i s e a s e s i n males. T h i s may be due i n p a r t to the f a c t t h a t the o v e r a l l average r i s k f o r males w i t h i n a l l s e l e c t e d c a t e g o r i e s i s h i g h e r than f o r f e m a l e s . The net e f f e c t i s t h a t when the improvements of l i f e -s t y l e are a p p l i e d e q u a l l y to both males and f e m a l e s , the males are a f f e c t e d more s i g n i f i c a n t l y , and t h e r e f o r e t h e i r m o r t a l i t y r a t e reduced more g r e a t l y . Table 4.2 shows the a b s o l u t e and p ercentage r e d u c t i o n s i n m o r t a l i t y r a t e s d e r i v e d from Table 4.1, f o r the s t a n d a r d and some s e l e c t e d t r i a l s . Thus the o v e r a l l r e d u c t i o n i n m o r t a l i t y v e r y s t r o n g l y f a v o r s males over females and i s most pronounced i n the i d e a l i z e d t r i a l 'SAXWB-l'. Whereas t h i s t r i a l showed a r e d u c t i o n i n m o r t a l i t y r a t e o f almost 24.0%, the t r i a l 'SAXWB' showed a r e d u c t i o n o f o n l y 7.3% and t r i a l 'S* of o n l y 3.4%. The crude death r a t e i s a g r o s s way of i n t e r p r e t i n g death r a t e s . For example, the s m a l l d e c r e a s e i n deaths r e s u l t i n g from the use o f s e a t b e l t s i s o n l y 0.01 below the s t a n d a r d . However, improvement i n t h i s l i f e s t y l e f a c t o r may be r a t h e r e a s i l y g a i n e d . F u r t h e r , improved s e a t b e l t use would d r a m a t i c a l l y reduce - 82 -TABLE 4.2 ABSOLUTE AND PERCENTAGE REDUCTIONS IN MORTALITY RATES BY SELECTED TRIALS AND STANDARD M F T Absolute % Absolute % Absolute % •Standard' 0 0 0 0 0 0 •Seatbelt Usage' .01 0,12% .01 0.16% .01 0.14% 'Smoking' 0.42 4.9% 0.08 1.3% 0.25 3.4% 'SAXWB* 0.77 9.1% 0.28 4.6% 0.53 7.3% 'SAXWB-I' 2.66 31.3% 0.85 14.0% 1.75 24.0% - 83 -p o t e n t i a l y e a r s of l i f e l o s t because deaths from t h i s cause a f f e c t the young to a g r e a t e r e x t e n t than the e l d e r l y . Indeed, a l t h o u g h not i n c l u d e d i n the a n a l y s i s , the m o r b i d i t y c o s t s due to n o n - f a t a l a c c i d e n t s p r o b a b l y g r e a t l y exceed the r e l a t i v e l y t r i v i a l m o r t a l i t y c o s t i n economic terms. 4.4 LIFE EXPECTANCY The r e s u l t of d ecreases i n a g e - s p e c i f i c m o r t a l i t y r a t e s , as premature deaths are a v e r t e d , i s an i n c r e a s e i n o v e r a l l l i f e e xpectancy. Table 4.3 p r e s e n t s the l i f e expectancy at b i r t h and at ages 20, 45 and 65 r e s p e c t i v e l y f o r the 1971 s t a n d a r d p o p u l a t i o n and f o r the v a r i o u s t r i a l s . T able 4.4 summarizes these r e s u l t s c o m p a c t l y , by p r e s e n t i n g the net i n c r e a s e i n l i f e e xpectancy i n years between s e l e c t e d t r i a l s and s t a n d a r d . T h i s r e p r e s e n t s the d i f f e r e n c e between the l i f e e xpectancy i n the 'P' t r i a l and l i f e expectancy of the s e l e c t e d t r i a l s . I t i s not s u r p r i s i n g t h a t the p a t t e r n of i n c r e a s e s i n l i f e e xpectancy m i r r o r the p a t t e r n o f d e creases i n m o r t a l i t y r a t e s . The t r i a l ' S e a t b e l t 84 TABLE 4.3 LIFE EXPECTANCY MALE § FEMALE AT SELECTED AGES BY TRIAL AGE 0 AGE 20 SAXWB-I 1 SAXWB1 SAXW' XW' SA' B' W1 X* A' S 1 P' M 74.4 70. 7 70. 7 70. 1 70. 3 69 . 6 69 . 7 69 . 9 69.7 70 . 1 69. 5 F 78 . 5 77.2 77. 2 77. 0 76 . 9 76. 7 76. 8 76 . 8 76.8 76 . 8 76. 7 M 56. 7 53 . 1 53.0 52.4 52.6 51 . 9 52.0 52 . 2 52.0 52.5 51 . 8 F 60. 2 59.0 59.0 58.8 58 . 7 58.5 58.6 58.6 58.6 58 . 6 58.5 - 85 -TABLE 4.5, . cont. LIFE EXPECTANCY MALE § FEMALE AT SELECTED AGES BY TRIAL AGE 45 AGE 65 M F_ M F 'SAXWB-I' 55.6 56.5 17.2 19.1 'SAXWB' 30.1 35.2 14.7 18.2 'SAXW' 30.1 35.2 14.7 18.2 'XW' 29.5 35.0 14.5 18.1 'SA' 29.6 54.9 14.4 17.9 'B' 28.9 54.7 15.9 17.7 ' W' 29.1 54.8 14.0 17.9 'X' 29.5 54.8 14.1 17.9 'A' 29.0 54.7 15.9 17.8 'S' 29.6 54.8 14.4 17.9 'P* 28.9 54.7 15.9 17.7 86 TABLE 4.4 OVERALL INCREASE ABOVE STANDARD LIFE EXPECTANCY WITH SELECTED TRIALS, BY AGE GROUP § SEX, IN YEARS 0 2_0 4_5 6_5_ , rB' M 0.185 0.034 0.009 .003 F 0.023 0.013 0.007 .002 'S' M 0.600 0.621 0.656 0.485 F 0.143 0.146 0.118 0.116 •SAXWB' M 1.221 1.212 1.178 0.804 F 0.555 0.537 0.485 0.443 'SAXWB-I' M 4.884 4.860 4.734 3.363 F 1.815 1.747 1.629 1.343 - 87 -Usage' has the s m a l l e s t e f f e c t , as b e f o r e . Among the t r i a l s i n v o l v i n g one l i f e s t y l e change o n l y , 'Smoking' has the l a r g e s t e f f e c t , w h i l e any c o m b i n a t i o n o f t r i a l s g e n e r a l l y i n c r e a s e s l i f e e xpectancy more than any s i n g l e v a r i a b l e . The i n c r e a s e s i n l i f e e x pectancy are not n e a r l y as d r a m a t i c as d e c r e a s e s i n m o r t a l i t y . For example, the 25% decrease i n m o r t a l i t y r a t e f o r the i d e a l t r i a l , 'SAXWB-I', f o r males, c o r r e s p o n d s to a net g a i n o f l e s s than f i v e y e a r s (4.884) i n l i f e e x p e c t a n c y , or approx-i m a t e l y 7% i n c r e a s e from 'P'. For the more r e a s o n a b l e t r i a l rSAXWB' the i n c r e a s e i s i n the o r d e r o f one year (1.221) f o r males and o n e - h a l f year (0.555) f o r f e m a l e s . Once a g a i n , f o r t r i a l s w i t h a s i n g l e l i f e s t y l e change, ' S e a t b e l t Usage' has the s m a l l e s t e f f e c t on i n c r e a s i n g l o n g e v i t y , and 'Smoking' the h i g h e s t . The e f f e c t i s noted most s t r o n g l y f o r males and l e a s t s t r o n g l y f o r f e m a l e s . The net e f f e c t i s a r e d u c t i o n o f the o v e r a l l d i f f e r e n c e between l i f e e x pectancy f o r males and fe m a l e s . Table 4.5 p r e s e n t s the l i f e e xpectancy d i f f e r e n c e s between males and females f o r the v a r i o u s t r i a l s and at v a r i o u s ages. The d i f f e r e n c e i n l i f e e x p ectancy r e d u c t i o n i s most n o t i c e a b l e f o r persons 65 and o l d e r where the pe r c e n t a g e d i f f e r e n c e drops by over 50% between 'SAXWB-I' and *P' ( v i z . f o r - 88 -TABLE 4.5 LIFE EXPECTANCY DIFFERENCE BETWEEN MALE AND FEMALE, BY AGE GROUP $ TRIAL; IN YEARS 0 2J) 4_5 65_ • S A X W B - I 1 4.090 3.526 2.690 1.852 •SAXWB' 6.493 5.964 5.103 3.511 'SAXW' 6.517 5.984 5.108 3.511 *XW' 6.914 6.382 5.485 3.732 'SA* 6.620 6.094 5.231 3.497 'B' 7.135 6.618 5.762 3.871 'W' 7.130 6.607 5.727 3.877 •X' 6.968 6.439 5.550 3.768 'A' 7.080 6.572 5.741 3.867 •S' 6.702 6.164 5.257 3.503 •P' 7.159 6.639 5.795 3.872 - 89 -d i f f e r e n c e s o f 3.9 and 1.9 ye a r s r e s p e c t i v e l y ) . The l a r g e s t d i f f e r e n c e i s obser v e d a t b i r t h and decreases g r a d u a l l y f o r the age groups s i n c e premature m o r t a l i t y a f f e c t s males to a g r e a t e r e x t e n t than f e m a l e s . The na t u r e o f p r e v e n t a b l e c o n d i t i o n s and i n c r e a s e d m o r t a l i t y f o r males i n d i c a t e s t h a t the arguments s u p p o r t i n g b i o l o g i c a l supremacy f o r females due to l o n g e r l i f e e x pectancy may be erroneous s i n c e i t may o n l y be an a r t i f a c t o f p r e v e n t a b l e m o r t a l i t y and not i n n a t e b i o -l o g i c a l s u p e r i o r i t y . 4.5 FERTILITY The p o p u l a t i o n model determines the number of b i r t h s and t h e r e f o r e a l l new e n t r i e s i n t o the po p u l a -t i o n d u r i n g each time p e r i o d based on the a g e - s p e c i f i c f e r t i l i t y r a t e o f the i n i t i a l female p o p u l a t i o n i n 1971. As the number o f women i n the p r o d u c t i v e age c o h o r t s v a r i e s over t i m e , so does the a b s o l u t e number o f b i r t h s . However, the o v e r a l l female a g e - s p e c i f i c r a t e s remain unchanged i n t h i s a n a l y s i s . S i n c e r e d u c t i o n i n m o r t a l i t y due to p r e v e n t a b l e c o n d i t i o n s a f f e c t males to a l a r g e r e x t e n t than females and the o l d to a l a r g e r e x t e n t than the young, t h e r e w i l l not be a d r a m a t i c i n c r e a s e i n the number o f female - 90 -s u r v i v o r s i n the p r o d u c t i v e age groups. T h e r e f o r e , the l i k e l y t o t a l p o p u l a t i o n growth o c c u r r i n g due to improved l i f e s t y l e s s h o u l d be moderate. The f o l l o w i n g a n a l y s i s o f the p o p u l a t i o n age s t r u c t u r e i n d i c a t e s t h a t t h i s e x p e c t a t i o n i s i n f a c t r e a l i z e d . 4.6 POPULATION AGE STRUCTURE The most d r a m a t i c e f f e c t o f m o d i f y i n g m o r t a l i t y r a t e s i s the e v o l u t i o n o f changed p o p u l a t i o n s t r u c t u r e s . For the purpose of t h i s a n a l y s i s the p o p u l a t i o n s are grouped as f o l l o w s : Males ) Females j 0-19, 20-64, and 65+ T o t a l ) The group, 0-19 y e a r s , r e p r e s e n t s young dependents; the group 20-64 r e p r e s e n t s p r o d u c t i v e age groups; and the group 65+ r e p r e s e n t s the e l d e r l y dependent. In t h i s c o n t e x t , the r e s u l t s of the t r i a l s f o r 1996 ( s h o r t term) and 2471 ( l o n g term) are p r e s e n t e d i n Tables 4.6 and 4.7. These t a b l e s p r e s e n t the po p u l a -t i o n p r o j e c t i o n s r e s u l t i n g from the s t a n d a r d p o p u l a t i o n (.1971) b e i n g p r o j e c t e d 25 years i n the s h o r t term (.1996) and 500 years i n the l o n g term (2471). The d i f f e r e n c e s i n each t r i a l by sex and age are due to the - 91 -TABLE 4.6A DISTRIBUTION BY AGE § SEX 1996 MALES 0-19 20-64 65 + TOTAL *SAXWB-I• 4,492,300 7,983,249 1,656,059 14,131,608 1SAXWB' 4,484,177 7,885,270 1,350,296 13,719,743 1SAXW1 4,483,434 7,881,764 1,349,631 13,714,829 •xw 1 4,481,018 7,857,530 1,302,414 13,640,962 'SA' 4,483,370 7,871,389 1,312,279 13,667,038 'B» 4,481,942 7,849,557 1,249,930 13,581,429 t W t 4,481,014 7,849,390 1,267,140 13,597,544 'X' 4,481,014 7,853,938 1,281,934 13,616,886 •A' 4,483,370 7,858,666 1,253,799 13,595,835 •S1 4,481,019 7,858,115 1,307,580 13,646,714 i p i 4,481,014 7,845,415 1,249,322 13,575,751 1971 4,337,800 5,675,600 782,000 10,795,400 - 92 -TABLE 4.6B DISTRIBUTION BY AGE § SEX 1996 FEMALES 0-19 20-64 65+ TOTAL •SAXWB-I* 4,250,572 7,850,547 1,907,166 14,008,285 •SAXWB' 4,243,881 7,825,430 1,808,497 13,877,808 •SAXW' 4,243,254 7,824,362 1,808,123 13,875,739 •xw 4,241,264 7,817, 731 1,792,302 13,851,297 •SA' 4,243,196 7,822,630 1,778,492 13,844,318 •B' 4,242,031 7,817,425 1,762,702 13,822,158 'W' 4,241,259 7,816,864 1,777,466 13,835,589 •X' 4,241,259 7,816,864 1,777,466 13,835,589 'A' 4,243,195 7,820,841 1,765,345 13,829,381 'S' 4,241,266 7,817,787 1,775,316 13,834,369 'P* 4,241,259 7,815,993 1,762,285 13,819,537 1971 4,157,500 5,653,000 962,500 10,773,000 - 93 -TABLE 4.6C DISTRIBUTION BY AGE § SEX 1996 MALES § FEMALES 0-19 20-64 65+ TOTAL 1SAXWB-I» 8,742,872 15,833,763 3,563,225 28,139,870 'SAXWB' 8,728,058 15,710,700 3,158,793 27,597,551 'SAXW' 8,726,688 15,706,126 3,157,754 27,590,568 *XW' 8,722,282 15,675,261 3,094,716 27,492,259 •SA' 8,726,566 15,694,019 3,090,771 27,511,356 'B' 8,723,973 15,666,982 3,012,632 27,403,587 •w 8,722,273 15,666,254 3,044,606 27,433,133 'X' 8,722,273 15,670,802 3,059,400 27,452,475 •A' 8,726,565 15,679,507 3,019,144 27,425,216 'S' 8,722,285 15,675,902 3,082,896 27,481,083 i p i 8,722,273 15,661,408 3,011,607 27,395,288 1971 8,495,300 11,328,600 1,744,500 21,568,400 TABLE 4.6D PERCENTAGE DISTRIBUTION BY AGE S SEX 1996 M 0-19 20-64 1SAXWB- I' 'SAXWB' »SAXW' •XW1 • SA' • B • ' W» 'X' •A* * S' .p. 1971 31. 8 32. 7 32. 7 32. 8 32. 8 33.0 33. 0 32. 9 33. 0 32. 8 33. 0 40. 2 56. 5 57.4 57.5 57.6 57.6 57.8 57.7 57.7 57.8 57.6 57.8 52.6 65 + 11.7 9. 8 9. 8 9 . 5 9.6 9. 2 9. 3 9.4 9. 2 9.6 9. 2 7.2 0-19 20-64 30. 3 30.6 30. 6 30. 6 30.6 30. 7 30 . 7 30. 7 30. 7 30 . 7 30.7 38 . 6 56 . 0 56.4 56.4 56 . 4 56. 5 56.6 56 . 5 56. 5 56 . 6 56.5 56 . 6 52.5 65 + 13.6 13.0 13 . 0 12.9 12.8 12. 8 12.8 12 . 8 12.8 12.8 12.8 8 . 9 0-19 M & F 20-64 65 + 31.1 31. 6 31 . 6 31.7 31 . 7 31.8 31 . 8 31.8 31 . 8 31.7 31 . 8 39 . 4 56 . 3 56 . 9 56.9 57.0 57.0 57 . 2 57.1 57.1 57.2 57.0 57.2 52.5 12.7 11 .4 11.4 11.3 11.2 11.0 11.1 11.1 11.0 11.2 11.0 8 . 1 - 95 -TABLE 4.7A DISTRIBUTION BY AGE § SEX 24 71 MALES 0- 19 20-64 65 + TOTAL 'SAXWB-I' 4,205,963 8,437,663 2 , 626, 8 75 15,270,501 'SAXWB' 4,205,362 8,317, 740 2,072,278 14,595,380 * SAXW' 4,205,149 8,313,962 2,070,455 14,589,566 ' XW' 4,205,048 8,285,415 1,986,804 14,477,267 ' SA' 4,204,745 8,299,045 2,005,207 14,508,997 *B' 4,204,637 8,271,740 1,897,568 14,373,945 ' W' 4,204,951 8,274,012 1,926,332 14,405,295 ' X' 4, 204, 95 1 8,280,255 1,951,689 14,436,895 •A' 4,205,128 8, 282, 199 1,905,975 14,393,302 • S ' 4,205,087 8,286,320 1,994,969 14,486,376 ' P* 4,204,951 8,268,513 1,896,080 14,369,544 1971 4,337,800 5,675,600 782,000 10,795,400 TABLE 4 . 7 B DISTRIBUTION BY AGE £ SEX 2471 FEMALES 0-19 20-64 65 + TOTAL 1SAXWB-I' 3,979,636 8,176,967 2,958,148 15,114,751 •SAXWB' 3,980,006 8,160,243 2,782,882 14,923,131 'SAXW' 3,979,878 8,160,082 2,782,679 14,922,639 •xw 3,980,063 8,156,438 2,755,405 14,891,906 •SA1 3,979,497 8,157,032 2,729,609 14,866,138 •B' 3,979,575 8,153,077 2,701,849 14,834,501 t W i 3,979,971 8,155,050 2,728,926 14,863,947 'X' 3,979,971 8,155,050 2,728,926 14,863,947 'A' 3,979,859 8,155,334 2,706,233 14,841,426 'S' 3,980,100 8,156,536 2,725,492 14,862,128 .p. 3,979,971 8,153,840 2,701,973 14,835,784 1971 4,157,500 5,653,000 962,500 10,773,000 - 97 -TABLE 4.7C DISTRIBUTION BY AGE § SEX 2471 MALES 5 FEMALES 0-19 20-64 65+ TOTAL •SAXWB-1' 8,185,599 16,614,630 5,585,023 30,385,252 'SAXWB' 8,185,368 16,477,983 4,855,160 29,518,511 •SAXW' 8,185,027 16,474,044 4,853,134 29,512,205 'XW' 8,185,111 16,441,853 4,742,209 29,369,173 'SA' 8,184,242 16,456,077 4,734,816 29,375,135 'B' 8,184,212 16,424,817 4,599,417 29,208,446 •W' 8,184,922 16,429,062 4,655,258 29,269,242 'X' 8,184,922 16,435,305 4,680,615 29,300,842 'A' 8,184,987 16,437,533 4,622,208 29,234,728 'S' 8,185,187 16,442,856 4,720,461 29,348,504 i p . 8,184,922 16,422,353 4,598,053 29,205,328 1971 8,495,300 11,328,600 1,744,500 21,568,400 TABLE 4.7D PERCENTAGE DISTRIBUTION BY AGE $ SEX 2471 M 0-19 20-64 'SAXWB-I' 'SAXWB' 'SAXW' •XW' •SA' 'B' 'W' 'X' 'A' *S' .pi 1971 27.5 28.8 28.8 29.0 29.0 29.3 29.2 29.1 29.2 29.0 29.3 40.2 55.3 57.0 57.0 57.2 57. 2 57.5 57.4 57.4 57.5 57.2 57.5 52.6 65+ 17.2 14.2 14.2 13. 7 13.8 13.2 13.4 13.5 13. 2 13.8 13.2 7.2 0-19 20-64 26.3 26.7 26.7 26.7 26.8 26.8 26.8 26.8 26.8 26.8 26.8 38.6 54.1 54.7 54.7 54.8 54.9 55. 0 54.9 54.9 54.9 54.9 55.0 52.5 65+ 19.6 18.6 18.6 18.5 18.4 18.2 18.4 18.4 18.2 18.3 18.2 8.9 M § F 0-19 20-64 26.9 27.7 27.7 27.9 27.9 28.0 28.0 27.9 28.0 27.9 28.0 39.4 54.7 55.8 55.8 56.0 56.0 56.2 56.1 56.1 56.2 56.0 56.2 52.5 65+ 18.4 16.4 16.4 16.1 16.1 15. 7 15.9 16.0 15.8 16.1 15.7 8.1 - 99 -m o d i f i e d m o r t a l i t y r a t e s r e s u l t i n g from assumed improvements i n l i f e s t y l e s . Another purpose o f these t a b l e s i s to examine the d i f f e r e n c e s i n dependency r a t i o s r e s u l t i n g from changes i n p o p u l a t i o n s t r u c t u r e s . T h e r e f o r e , Tables 4.6 and 4.7 p r e s e n t the t o t a l p r o j e c t e d p o p u l a t i o n by t r i a l f o r 1996 and 2471 by s e l e c t e d age groups and sex; and t h e i r p e r c e n t a g e d i s t r i b u t i o n . ( T a b 1es 4.6D and 4.7D) In t o t a l numbers i n 1996 (Table 4.6) the s t a n d a r d p o p u l a t i o n 'P' i n c r e a s e s to 27,395,288, whereas the t r i a l "SAXWB-1* i n c r e a s e s to 28,139,870 (Table 4.6). The net growth between the two i s 744,582 or a p p r o x i -m a t e l y 2.7%. S i m i l a r l y , i n 2471 (Table 4.7) the s t a n d a r d p o p u l a t i o n 'P' i n c r e a s e s to 29,205,328, whereas the t r i a l 'SAXWB-1' i n c r e a s e s to 30,385,252. The net growth between the two i s 1,179,924 or a p p r o x i m a t e l y 4.0%. In 2471 the s t a n d a r d male p o p u l a t i o n i n c r e a s e s to 14,369,544 and 'SAXWB-1' to 15,270,501, a 6.3% i n c r e a s e . The s t a n d a r d female p o p u l a t i o n i n c r e a s e s t o 14,835,784 and 'SAXWB-1' to 15,114,751, a 1.9% i n c r e a s e . T h e r e f o r e , the a b s o l u t e growth of the p o p u l a t i o n i s not l a r g e even f o r i d e a l t r i a l 'SAXWB-1', and what growth t h e r e i s can be a t t r i b u t a b l e m a i n l y to males. The most s a l i e n t f e a t u r e of Tables 4.6 and 4.7 i s t h a t the o v e r a l l age d i s t r i b u t i o n of the p o p u l a t i o n - 100 -does not v a r y d r a m a t i c a l l y . However, s i n c e the p r o j e c t e d p o p u l a t i o n s remain f a i r l y c o n s t a n t i n a b s o l u t e terms, y e t have m o d i f i e d m o r t a l i t y r a t e s , i t i s e v i d e n t t h a t the p o p u l a t i o n age s t r u c t u r e must be changing to some degree. These t a b l e s p r o v i d e e v i d e n c e t h a t the e f f e c t of r e d u c i n g m o r t a l i t y i s t h a t the r e l a t i v e p e r c e n t a g e of p r o d u c t i v e persons remains f a i r l y c o n s t a n t w h i l e the young-dependent group decreases and the o1d-depend ent group i n c r e a s e s . For example, i n the 2471. s t a b l e p o p u l a t i o n the s t a n d a r d p r o j e c t i o n i n d i c a t e d t h a t 15.7% o f the p o p u l a t i o n would be over 65, w h i l e the t r i a l 'SAXWB' . i n d i c a t e s t h i s would have r i s e n to 18.4%. In more r e a l i s t i c terms o f comparison between 'P' and 'SAXWB-l', however, the r e l a t i v e growth o f the e l d e r l y i s o n l y .7%, t h a t i s , from 15.7% to 16.4%. This i s c o n s i s t e n t w i t h the r e l a t i v e l y s m a l l i n c r e a s e s of l i f e e x p e ctancy o c c u r r i n g because of these m o r t a l i t y r e d u c t i o n s . The net e f f e c t i s t h a t the h i g h l e v e l s of the competing causes o f m o r t a l i t y among the e l d e r l y s t i l l r e s u l t i n h i g h r a t e s of m o r t a l i t y which l i m i t the o v e r a l l growth o f the o l d e r age groups. Once again the impact o f the a n a l y s i s a f f e c t s males to a l a r g e r e x t e n t than f e m a l e s . For example, by 2471 the "male 65+" age group i s 1% l a r g e r i n 'SAXWB' than i n 'P', whereas the d i f f e r e n c e f o r the s i m i l a r female t r i a l s i s o n l y 0.4%. In the case o f - 101 -t r i a l s i n v o l v i n g a s i n g l e r i s k f a c t o r the d i f f e r e n c e of growth i n the e l d e r l y p o p u l a t i o n i n a l l cases i s much l e s s than 1% f o r both male and f e m a l e s . T h i s f a c t o r has a p r o f o u n d e f f e c t on the assumption t h a t p r e v e n t e d m o r t a l i t y w i l l d r a m a t i c a l l y i n c r e a s e the e l d e r l y age groups beyond the c a p a c i t y o f the p r o d u c t i v e age groups to s u p p o r t them. From the d a t a p r e s e n t e d i t would appear t h a t the decreases i n m o r t a l i t y have r e l a t i v e l y s m a l l e f f e c t on the o v e r a l l number of dependent persons and i n f a c t when c o n s i d e r e d w i t h the d e c r e a s e d number o f young t h e r e i s a c t u a l l y v e r y l i t t l e d i f f e r e n c e i n the dependency r a t i o . For example, i n 2471 the t o t a l p r o d u c t i v e age group v a r i e s a t most, by .4% f o r t r i a l 'SAXWB' compared w i t h 'P' (56.2% - 55.8% = . 4 % ) . In the t r i a l » S A X W B - l 1 the decrease i n the p r o d u c t i v e age group i s 1.5% (.56.2% - 54.7% = 1.5%). Thus, the p o p u l a t i o n d i s t r i b u -t i o n i n the s h o r t term which i s p r e s e n t e d i n Table 4.6 does not j u s t i f y f a r - r e a c h i n g c o n c l u s i o n s s i n c e i t r e p r e s e n t s o n l y s h o r t term changes i n p o p u l a t i o n age s t r u c t u r e s . The u l t i m a t e e f f e c t o f m u l t i g e n e r a t i o n a l changes can o n l y be e x p r e s s e d through s t a b l e p o p u l a t i o n a n a l y s i s . However, the r e s u l t s i d e n t i f i e d f o r 2471 are a l s o e v i d e n t i n the s h o r t term, f o r example, the o v e r a l l i n c r e a s e o f the e l d e r l y i s f o l l o w i n g a s i m i l a r p a t t e r n to t h a t o f the s t a b l e p o p u l a t i o n . The a b s o l u t e - 102 -growth i n the p o p u l a t i o n i n the s h o r t term i s r e l a t i v e l y s m a l l and the changes i n the age s t r u c t u r e are m i n i m a l . This would i n d i c a t e t h a t t h e r e would not l i k e l y be profound s o c i a l or economic problems r e s u l t i n g from improved l i f e s t y l e s i n s h o r t term s i n c e the p r o d u c t i v e age groups are m a i n t a i n e d at a. c o n s i s t e n t l y h i g h p ercentage the t o t a l p o p u l a t i o n . Table 4.8 summarizes the d i f f e r e n c e s i n p o p u l a t i o n growth between 'SAXWB-1 and 'P' f o r the 2471 p r o j e c t i o n . I t f a c i l i t a t e s the a n a l y s i s of the l a r g e amount of data c o n c e r n i n g the growth o f po p u l a -t i o n and the changes i n age s t r u c t u r e which were p r e s e n t e d i n Tables 4.6 and 4.7. These data i n d i c a t e t h a t the t o t a l growth o f the p o p u l a t i o n between 'P' and 'SAXWB-1' i s a p p r o x i m a t e l y 1.2 m i l l i o n or a per c e n t a g e growth of 4%. However, t h i s growth r a t e i s not d i s t r i b u t e d e q u a l l y between the s e l e c t e d age groups. For example, the age group 0-19 grew at o n l y 0.008% and i n f a c t d e c l i n e d f o r f e m a l e s , -0.084%. The c o h o r t 20-64 grew o n l y 1.17% and the b u l k o f t h i s growth o c c u r r e d i n the age group, p r o d u c t i v e males. By f a r the most s i g n i f i c a n t i n c r e a s e i n p o p u l a -t i o n was made by the e l d e r l y age group, 65+. O v e r a l l i t grew 21.5% w i t h males a c c o u n t i n g f o r 38.5% growth and females f o r a l e s s d r a m a t i c but s i g n i f i c a n t 9.48 growth. - 103 -TABLE 4.8 POPULATION GROWTH *P' TO ' SAXWB-I-' 2471 MALE FEMALE TOTAL # % # % # % 0-19 1,012 0.024 -335 -0.084 677 0.008 20-64 169,150 2.05 23,127 0.28 192,277 1.17 65+ 730,795 38.5 256,175 9.4.8 986,970 21.51 TOTAL 900,957 6.27 278,967 1.88 1,179,924 4.04 - 104 -Thus, of the t o t a l r e l a t i v e growth i n p o p u l a t i o n between the two t r i a l s , 83.6% i s a t t r i b u t a b l e to the o l d e r p o p u l a t i o n . Not s u r p r i s i n g l y , t h a t i s , the net e f f e c t o f a v o i d i n g premature m o r t a l i t y w i l l be i n c r e a s e d numbers of e l d e r l y p e r s o n s . However, because of the r e l a t i v e l y s m a l l s i z e of t h i s c o h o r t o f the t o t a l pop-u l a t i o n the r a t h e r d r a m a t i c growth a f f e c t s o v e r a l l p o p u l a t i o n s t r u c t u r e l e s s s i g n i f i c a n t l y as noted i n Table 4.7. I t s h o u l d be kept i n mind t h a t these data are f o r the i d e a l t r i a l , 'SAXWB-1', and t h a t f o r o t h e r t r i a l s w i t h l e s s l i f e s t y l e change, the d i r e c t i o n o f growth would be s i m i l a r but i t s a b s o l u t e magnitude s i g n i f i c a n t l y l e s s e n e d . In summary, the net e f f e c t of r e d u c i n g m o r t a l i t y w i l l show v e r y l i t t l e o v e r a l l impact on changing age s t r u c t u r e of the p o p u l a t i o n . The most s i g n i f i c a n t change o c c u r s i n the a b s o l u t e and r e l a t i v e growth of the e l d e r l y age groups. However, i t must be kept i n mind t h a t i t i s p r e v e n t e d m o r t a l i t y which i n c r e a s e s the e l d e r l y component. Th i s p r e v e n t e d m o r t a l i t y i s not the r e s u l t o f h e r o i c and e x p e n s i v e l i f e s a v i n g t e c h n i q u e s but r a t h e r r e l a t i v e l y i n e x p e n s i v e or even l e s s e x p e n s i v e p r e v e n t i v e i n t e r v e n -t i o n s . For example, the t r i a l 'Smoking' i n d i c a t e s a d r a m a t i c r e d u c t i o n i n m o r t a l i t y through decreased smoking which i n h e r e n t l y i n v o l v e s a net s a v i n g to s o c i e t y r a t h e r than a net c o s t . The f o l l o w i n g s e c t i o n now - 105 -d i s c u s s the e f f e c t of t h i s changed p o p u l a t i o n on the use of h o s p i t a l f a c i l i t i e s . 4.7 HOSPITAL UTILIZATION The p r o j e c t e d i n c r e a s e s i n the a b s o l u t e number of e l d e r l y , and p a r t i c u l a r l y t h e i r i n c r e a s e i n the p r o p o r t i o n o f the p o p u l a t i o n may not bode w e l l f o r persons i n the p r o d u c t i v e age groups who must su p p o r t t h i s p o p u l a t i o n . The f o l l o w i n g d a t a and a n a l y s i s p r e s e n t s the p r o j e c t e d p a t t e r n o f h o s p i t a l u t i l i z a t i o n f o r 2471 w i t h the 'P*, 'SAXWB', and 'SAXWB-1* t r i a l s . The t e c h n i q u e s used and assumptions made are d e s c r i b e d i n the Methodology c h a p t e r . These t r i a l s are chosen because they p e r m i t the o b s e r v a t i o n o f the w i d e s t p o s s i b l e range o f h o s p i t a l i z a t i o n , t h a t i s , w i t h s i g n i f i c a n t d e c reases i n m o r t a l i t y a t one end, and w i t h more p r a c -t i c a l assumptions c o n c e r n i n g changes o f l i f e s t y l e s a t the o t h e r . In the case o f the 'P' t r i a l , u t i l i z a t i o n r a t e s were h e l d c o n s t a n t at 1971 l e v e l s . However, f o r 'SAXWB' and SAXWB-1', u t i l i z a t i o n r a t e s were reduced p r o p o r t i o n -a t e l y w i t h r e d u c t i o n s i n m o r t a l i t y as d i s c u s s e d i n S e c t i o n 3. A l s o , because of the dr a m a t i c i n c r e a s e of per c a p i t a h o s p i t a l u t i l i z a t i o n by the v e r y o l d , the - 106 -dependent e l d e r l y p o p u l a t i o n was f u r t h e r s u b d i v i d e d i n t o two c o h o r t s , 65-74 and 75+. Table 4.9 p r e s e n t s the c a l c u l a t e d a g e - s p e c i f i c and s e x - s p e c i f i c u t i l i z a t i o n r a t e s . Note t h a t the r a t e i s e s t a b l i s h e d based on the 1971 p o p u l a t i o n , i t s exper-i e n c e of m o r b i d i t y by s e l e c t e d ages, and subsequent r e d u c t i o n o f t h a t m o r b i d i t y based on the r a t e o f decrease of m o r t a l i t y . The r a t e s are c a l c u l a t e d on a p e r - c a p i t a b a s i s and t h e r e f o r e are s t a n d a r d i z e d , thus a l l o w i n g t h e i r a p p l i c a t i o n to f u t u r e p o p u l a t i o n s w i t h d i f f e r e n t age s t r u e t u r e s . Per c a p i t a h o s p i t a l u t i l i z a t i o n i s d i r e c t l y r e l a t e d to the age o f the p e r s o n . For example, i n 1971, the v e r y e l d e r l y , 75+, used h o s p i t a l s e r v i c e s a t a r a t e s i x t e e n times t h a t o f persons i n the age group 0-19. High l e v e l s o f u t i l i z a t i o n are r e t a i n e d i n the s e l e c t e d t r i a l s a l t h o u g h the a b s o l u t e r a t e of u t i l i z a t i o n per person i s d e c r e a s e d . Table 4.9 p r e s e n t s the o v e r a l l impact o f r e d u c i n g h o s p i t a l u t i l i z a t i o n r a t e s c o n s i s t e n t w i t h d e c r e a s e s i n m o r t a l i t y and Table 4.10 p r e s e n t s the r e l a t i v e decreases i n h o s p i t a l u t i l i z a t i o n by the s e l e c t e d t r i a l s . Once a g a i n the r e l a t i v e r e d u c t i o n i n - 107 -TABLE 4.9 HOSPITAL UTILIZATION RATES BY SELECTED AGE GROUPS AND BY SEX FOR SELECTED TRIALS; IN HOSPITAL DAYS/PER CAPITA PER YEAR 2471 SAXWB SAXWB-I* 0- 19 M F 0.76852 0.75426 0.75980 0.74742 0.73761 0.73040 20-64 M F 1 .44867 2 . 14448 1 . 39736 2.12676 1.27103 2.08020 65-74 M F 6.12666 5.32217 5 .87316 5 . 21600 5.21215 5.01670 75 + M F 12.55352 12.29976 12.05892 12.01592 10.81428 11.44865 TABLE 4.10 PERCENTAGE REDUCTION IN HOSPITAL UTILIZATION  BY AGE AND BY SEX FOR SELECTED TRIALS 2471 0-19 20-64 65-74 75+ M F M F M F M F 'SAXWB' 1.13 0.91 3.54 J ,0.83 4.14 1.99 3.94 2.31 •SAXWB-I' 4.02 3.16 12.3 3.00 14.9 5.74 13.9 6.92 - 108 -h o s p i t a l u t i l i z a t i o n i s h i g h e r f o r males than f o r females and i t a l s o i n c r e a s e s by age. The most s i g n i f i c a n t r e d u c t i o n i s w i t h the v e r y e l d e r l y (75+), i n t h a t the u t i l i z a t i o n r a t e was reduced i n the i d e a l t r i a l 'SAXWB-I1 f o r males by 13.9% and f o r males 'SAXWB' by 3.94% i n 2471. The s m a l l e s t r e d u c t i o n was observed f o r the age group 0-19. Th i s was because t h i s age group's m o r t a l i t y was reduced o n l y through decreases i n deaths caused by motor v e h i c l e a c c i d e n t s . I t i s a l s o i n t e r e s t i n g to compare the r e s u l t s o f Table 4.10 w i t h Table 4.2 to asses s the o v e r a l l impact of improved l i f e s t y l e s on h o s p i t a l u t i l i z a t i o n . A l t h o u g h Table 4.2 i s not a g e - s p e c i f i c , i n a l l age groups i n Table 4.10 f o r both males and females the percentage r e d u c t i o n of h o s p i t a l i z a t i o n i s lower than the pe r c e n t a g e r e d u c t i o n o f m o r t a l i t y i n Table 4.2. I t i s apparent t h a t the r e l a t i v e decrease i n m o r t a l i t y i s s i g n i f i c a n t l y l a r g e r than the r e l a t i v e d e c r ease i n m o r b i d i t y . One e x p l a n -a t i o n f o r t h i s i s t h a t many causes o f h o s p i t a l i z a t i o n which produce l a r g e number o f days of h o s p i t a l i z a t i o n , do not have h i g h r a t e s o f m o r t a l i t y a s s o c i a t e d w i t h them, f o r example, female d e l i v e r i e s , and c h r o n i c c o n d i t i o n s such as rheumatism, a r t h r i t i s and d i a b e t e s . In a n a l y z i n g h o s p i t a l u t i l i z a t i o n r a t e s i t sh o u l d be kept i n mind t h a t the Taeuber Paradox i s s t i l l o p e r a t i v e . In the same way t h a t a person who - 109 -a v o i d s d y i n g of any one cause i s s u b j e c t to s i m i l a r r i s k s o f h i s age c o h o r t from a l l o t h e r causes, a person who a v o i d s h o s p i t a l i z a t i o n due to a p r e v e n t a b l e c o n d i -t i o n i s a l s o s u b j e c t t o competing r i s k of h o s p i t a l i z a -t i o n from o t h e r causes. T h e r e f o r e , the a c t u a l h o s p i t a l -i z a t i o n r a t e s f o r the s p e c i f i e d t r i a l s may w e l l under-e s t i m a t e the a c t u a l r a t e o f h o s p i t a l i z a t i o n i f s u r v i v o r s are above average u s e r s of h o s p i t a l s e r v i c e s . However, i t s h o u l d a l s o be kept i n mind t h a t the s y n e r g i s t i c r e l a t i o n s h i p s between the improved l i f e s t y l e s and o t h e r causes o f m o r b i d i t y may i n f a c t reduce m o r b i d i t y i n the o t h e r d i r e c t i o n by d e c r e a s i n g f u r t h e r the o v e r a l l r a t e s o f h o s p i t a l i z a t i o n . With our p r e s e n t i g n o r a n c e t h e r e i s no way of a d e q u a t e l y q u a n t i f y i n g the above assump-t i o n s and t h e r e f o r e p r o p o r t i o n a t e r a t e s are u t i l i z e d . When the r a t e s noted i n Table 4.9 are a p p l i e d to the p r o j e c t e d p o p u l a t i o n s i n 1996 and 2471, the t o t a l expected h o s p i t a l i z a t i o n i n days r e s u l t s . Tables 4.11, 4.12 and 4.13 p r e s e n t t h i s i n f o r m a t i o n . In the 'P' t r i a l f o r 1971 the days o f h o s p i t a l u t i l i z a t i o n are the a c t u a l days u t i l i z e d by the i n i t i a l p o p u l a t i o n d u r i n g 1971. S u b s e q u e n t l y f o r years 1996 and 2471 the h o s p i t a l u t i l i z a t i o n i s p r o j e c t e d based on the c a l c u l a t e d per c a p i t a u t i l i z a t i o n r a t e s . I t i s not - 110 -TABLE 4.11 HOSPITAL UTILIZATION BY AGE AND SEX FOR 'P' TRIAL, IN DAYS 1971 0-19 20-64 65-74 75 + T o t a l M 3,333,676 8,222,057 3,073,746 3,518,753 18,148,232 3,135,035 12,122,725 3,063,973 4,757,548 23,080,081 TOTAL M § F - 41,228,313 1996 0-19 3,443,749 20-64 11,365,417 65-74 4,929,259 75+ 5,583,341 T o t a l 25,321,766 TOTAL M § F - 59,973,987 3,170,002 16,761,240 5,304,713 9,416,266 34,652,221 2471 0-19 20-64 65-74 75 + T o t a l 3,231,589 11,978,346 7,030,973 9,396,021 31,686,929 3,001,933 17,485,746 7,443,002 16,032,528 43,963,209 TOTAL M & F - 75,600,138 - I l l -TABLE 4.12 HOSPITAL 'UTILIZATION BY AGE AND SEX  FOR TRIAL ' S A X W B I N DAYS 0-19 3,407,078 3,171,962 20-64 11,018,560 16,642,811 65-74 4,966,256 5,252,376 75+ 6,086,270 9,631,036 T o t a l 25,478,164 34,698,185 TOTAL M S F - 60,176,349 0-19 3,195,234 2,974,736 20-64 11,622,877 17,354,878 65-74 7,098,477 7,366,369 75+ 10,414,662 16,469,236 T o t a l 32,331,250 44,165,219 TOTAL M & F - 76,496,469 - 112 -TABLE 4.13 HOSPITAL UTILIZATION BY AGE AND SEX FOR TRIAL 'SAXWB-I' IN DAYS M F 1996 0-19 3,313,565 3,104,618 20-64 10,146,948 16,330,707 65-74 4,971,359 5,163,704 75+ 7,594,404 10,050,346 T o t a l 26,026,267 34,649,375 TOTAL M § F - 60,675,651 2471 0-19 3,102,360 2,906,726 20-64 10, 724, 522, 17, 009, 726 65-74 7,142,652 7,234,267 75+ 13,588,034 17,357,424 T o t a l 34,557,568 44,508,148 TOTAL M § F - 79,065,711 - 113 -s u r p r i s i n g to note t h a t t h e r e i s some i n c r e a s e i n u t i l i z a t i o n from 'P' to 'SAXWB1 and from 'SAXWB' to 'SAXWB-I', even though the i n c r e a s e i s s m a l l . This i n p a r t r e f l e c t s the i n c r e a s e d p o p u l a t i o n s which r e s u l t i n the l a t t e r t r i a l s . However, the net r e s u l t can be e x p r e s s e d i n a n o n - s t a n d a r d i z e d f a s h i o n by o b s e r v i n g the annual p e r - c a p i t a h o s p i t a l u t i l i z a t i o n f o r the v a r i o u s t r i a l s . Table 4.14 p r e s e n t s these p e r - c a p i t a u t i l i z a t i o n r a t e s . I t i s worthy o f note t h a t , a l t h o u g h the popu-l a t i o n i s ageing s i g n i f i c a n t l y as premature deaths are av o i d e d i n 'SAXWB' and. 'SAXWB-I', the o v e r a l l annual p e r - c a p i t a h o s p i t a l u t i l i z a t i o n n e v e r t h e l e s s i s p r o j e c t e d to remain f a i r l y c o n s t a n t a t 2.2 days f o r 1996 and 2.6 days f o r 2471. In the s h o r t term, p e r - c a p i t a u t i l i z a -t i o n d e creases v e r y s l i g h t l y as the number o f p r e v e n t a b l e deaths d e c r e a s e s . Howev e r , by 2471 t h i s t r e n d i s r e v e r s e d as the p e r - c a p i t a u t i l i z a t i o n i n c r e a s e s v e r y s l i g h t l y due to the ageing p o p u l a t i o n . T h i s can be e x p l a i n e d by the f a c t t h a t the age s t r u c t u r e o f the s h o r t term pop-u l a t i o n i s younger than t h a t o f the s t a b l e p o p u l a t i o n o f 2471. Another method of d e t e r m i n i n g the o v e r a l l impact o f h o s p i t a l i z a t i o n on the p o p u l a t i o n i s to c a l c u l a t e the r e l a t i v e burden t h a t t o t a l h o s p i t a l i z a t i o n causes on - 114 -TABLE 4.14 ANNUAL PER CAPITA PROJECTED HOSPITAL UTILIZATION BY YEAR FOR SELECTED TRIALS IN DAYS 19 71 1996 2471 1 P' 1.92 2.19 2.59 'SAXWB' 2.18 2.59 * SAXWB-I• 2.16 2.60 - 115 -the p r o j e c t e d age groups. T h i s i s a c c o m p l i s h e d by d i v i d i n g the t o t a l annual h o s p i t a l u t i l i z a t i o n by the t o t a l number of persons i n the p r o d u c t i v e age groups, (.20-64 male and f e m a l e ) . Table 4.15 p r e s e n t s the burden on s o c i e t y through h o s p i t a l u t i l i z a t i o n o f a l l age groups, and Table 4.16 the d i f f e r e n c e s between the t r i a l s and 'Standard'. I t i s e v i d e n t from these t a b l e s t h a t the u l t i m a t e burden on s o c i e t y caused by i n c r e a s e d h o s p i t a l u t i l i z a t i o n by the e l d e r l y even f o r t r i a l 'SAXWB-I' i s q u i t e s m a l l . When these d i f f e r e n c e s i n days are m u l t i p l i e d by the 1971 average c o s t p e r p a t i e n t day of $65.57 i t i s p o s s i b l e to determine an a n n u a l , p e r - c a p i t a burden on s o c i e t y . For the t r i a l 'SAXWB' t h i s amounts to a s i x cent i n c r e a s e i n 1996 and $2.54 i n c r e a s e i n . 2 4 7 1 ; f o r t r i a l 'SAXWB-I' the d i f f e r e n c e amounts to a seventeen cent i n c r e a s e i n 1996 and $10.18 i n c r e a s e i n 247.1. This c o s t c o u l d be l o o k e d on e i t h e r as the net p e r - c a p i t a c o s t f o r the i n c r e a s e d number of persons s u r v i v i n g i n t o the e l d e r l y age groups, or e q u a l l y as the same c o s t f o r the number of persons whose deaths are postponed through p r e v e n t i o n . T h e r e f o r e , a l t h o u g h the improvements of l i f e s t y l e have i n c r e a s e d both the a b s o l u t e number o f the e l d e r l y , s i g n i f i c a n t l y , and t h e i r p r o p o r t i o n a t e share of t o t a l p o p u l a t i o n , i t w i l l have v e r y l i t t l e impact on a l t e r i n g the expected p a t t e r n of h o s p i t a l u t i l i z a t i o n . - 116 -TABLE 4.15 BURDEN ON SOCIETY HOSPITAL UTILIZATION, BY SELECTED TRIALS, IN DAYS PER CAPITA OF PRODUCTIVE AGE 1971 3.693 SAXWB SAXWB-I' 1996 3.8294 3.8303 3.8320 2471 4.6035 4.6423 4.7588 TABLE 4.16 BURDEN ON SOCIETY HOSPITAL UTILIZATION BY SELECTED TRIALS DIFFERENCE FROM 'P' IN DAYS 1996 2471 'SAXWB + . 009 + . 039 'SAXWB-I ' + . 003 + . 155 - 117 -Table 4.17 can be used to answer the f i n a l q u e s t i o n suggested i n the I n t r o d u c t i o n ; what are the u l t i m a t e c o s t s o f h o s p i t a l i z a t i o n g e n e r a t e d by f u t u r e p o p u l a t i o n s ? Such c o s t s can be p r o j e c t e d on the b a s i s o f 1971 c o n s t a n t d o l l a r s and the c o s t o f a day of h o s p i t a l c a r e i s h e l d a t the 1971 r a t e o f $65.57. Of course c o s t s w i l l i n e v i t a b l y r i s e , but i t i s i m p o s s i b l e to c a r r y out a r e a s o n a b l e p r o j e c t i o n o f such r i s e f o r the l o n g time p e r i o d s s t u d i e d h e r e . Indeed at t h i s w r i t i n g , 1980, Canadian per diem h o s p i t a l c o s t s are more than double 1971 l e v e l s . TABLE 4.17 TOTAL PROJECTED COSTS OF HOSPITAL UTILIZATION BY SELECTED TRIALS 1971 CONSTANT DOLLARS 000's 1971 1996 2471 •P1 2,703,340.4 3,932,494.3 4,957,101.0 1SAXWB' 3,945,763.2 5,015,873.4 'SAXWB-I 1 3, 978, 502.4 5, 184, 338.6 The e f f e c t of changed m o r t a l i t y r a t e s i n 1996 r e s u l t s i n an i n c r e a s e i n h o s p i t a l c o s t s o f 13.3 m i l l i o n f o r 'SAXWB' and 46.0 m i l l i o n f o r 'SAXWB-I'. S i m i l a r l y , - 118 -the c o s t i n c r e a s e f o r 2471 by 58.8 m i l l i o n f o r 'SAXWB1 and 227.2 m i l l i o n f o r 'SAXWB-I'. I t s h o u l d be kept i n mind t h a t these c o s t s r e f l e c t both changes i n h o s p i t a l u t i l i z a t i o n and the i n c r e a s e of p o p u l a t i o n between t r i a l s . T h e r e f o r e , i t i s i m p o r t a n t to keep i n mind t h a t the p e r - c a p i t a - c o s t d i f f e r e n t i a l i s o n l y a p p r o x i m a t e l y $10.00 p e r - c a p i t a even f o r the i d e a l t r i a l d u r i n g 2471. This completes our p r e s e n t a t i o n and d i s c u s s i o n o f the r e s u l t s . - 119 -CONCLUSIONS 5.1 BACKGROUND This t h e s i s has attempted to determine the e f f e c t of a b a t i n g u n h e a l t h y l i f e s t y l e s on f u t u r e use and c o s t o f h o s p i t a l i n - p a t i e n t care i n Canada. This a n a l y s i s stems from u n c e r t a i n t y r e g a r d i n g the long-term p o s i t i v e or n e g a t i v e e f f e c t s which m o d i f i e d l i f e s t y l e s w i l l have i n changing m o r t a l i t y r a t e s , m o r b i d i t y r a t e s , and the p o p u l a t i o n ' s age s t r u c t u r e . The study s h o u l d a l s o p r o v i d e guidance f o r l o n g - t e r m p o l i c y development, h e a l t h p l a n n i n g , and the a l l o c a t i o n o f r e s o u r c e s to s p e c i f i c segments of the h e a l t h and i l l n e s s care system i n Canada. Four s t e p s were i d e n t i f i e d which would p r o v i d e the n e c e s s a r y i n f o r m a t i o n t o answer the q u e s t i o n : 1) development o f a methodology f o r r e d u c i n g m o r t a l i t y r a t e s based on improved l i f e s t y l e s . T h i s was ac c o m p l i s h e d by a p p l y i n g G e l l e r - G e s n e r Tables as r e p o r t e d by Robbins and H a l l to Canadian 1971 census and m o r t a l i t y d a t a . 2) d e t e r m i n a t i o n o f an a p p r o p r i a t e p o p u l a t i o n model. - 120 -T h i s was a c c o m p l i s h e d by u s i n g K e y f i t z ' s L i f e Table and P o p u l a t i o n P r o j e c t i o n models which produced both s h o r t - t e r m (25 y e a r s ) and l o n g - t e r m (500 y e a r s ) p o p u l a t i o n p r o j e c t i o n s . 3) development of a methodology f o r the r e d u c t i o n o f h o s p i t a l u t i l i z a t i o n r a t e s a s s o c i a t e d w i t h changed l i f e s t y l e s . This was a c c o m p l i s h e d by assuming t h a t a decrease i n h o s p i t a l u t i l i z a t i o n f o r s p e c i f i c age groups and s e l e c t e d d i s e a s e s under study would be d i r e c t l y p r o p o r t i o n a t e to decreases i n m o r t a l i t y r a t e s as c a l c u l a t e d . 4) development of a methodology f o r p r o d u c i n g c o m p a r a t i v e c o s t s o f f u t u r e use of h o s p i t a l s and the consequent 'burden on s o c i e t y ' . T his was a c c o m p l i s h e d by m u l t i p l y i n g the p r o j e c t e d p a t t e r n o f h o s p i t a l u t i l i z a t i o n by the 1971 per diem c o s t o f h o s p i t a l care i n Canada. The 'burden on s o c i e t y ' was a measure c a l c u l a t e d by d i v i d i n g the t o t a l c o s t o f h o s p i t a l care i n a year by the number of persons i n the p r o d u c t i v e age group (20-64). - 121 -5.2 FINDINGS - INTERPRETATIONS 5.2.1 MORTALITY The m o r t a l i t y r a t e of each s e l e c t e d age group decreased as the r e s u l t of improvements i n l i f e s t y l e . The p a t t e r n o f deaths a v e r t e d v a r i e d i n s e v e r a l ways. The m a j o r i t y of postponable deaths o c c u r a t advanced ages. The o n l y e x c e p t i o n was t h a t s e a t b e l t use had i t s most s i g n i f i c a n t impact on younger age groups. Males were spared more o f t e n than females and the l a r g e s t r e d u c t i o n i n m o r t a l i t y r a t e s o c c u r r e d when s e v e r a l r i s k f a c t o r s were reduced at the same t i m e . A l t h o u g h many deaths were a v e r t e d i n the e l d e r l y age groups, the t o t a l deaths and r e l a t e d m o r t a l i t y r a t e s remained v e r y h i g h f o r the e l d e r l y . T h is meant t h a t when an i n d i v i d u a l postponed death at a younger age, he would s t i l l f a c e an i n c r e a s e d chance of dy i n g as he aged. T h i s aspect o f the p a t t e r n o f mor-t a l i t y i s r e f e r r e d to as competing m o r t a l i t y . That i s , as an i n d i v i d u a l a v o i d s d y i n g from a s p e c i f i c cause, he i s s t i l l s u b j e c t to the r i s k of d y i n g from a l l o t h e r causes. - 122 -The changing p a t t e r n o f m o r t a l i t y was found to a f f e c t o v e r a l l l i f e e x pectancy i n a l i m i t e d way. Male l i f e e xpectancy i n c r e a s e d to a l a r g e r e x t e n t than female but competing m o r t a l i t y l i m i t e d the p o p u l a t i o n ' s o v e r a l l g a i n s i n l i f e e x pectancy. The net e f f e c t was t h a t t h e r e were g r e a t e r numbers of persons advancing i n t o the e l d e r l y age groups but o v e r a l l l i f e e x pectancy i n c r e a s e d o n l y m a r g i n a l l y . The t h e s i s tends to support the h y p o t h e s i s t h a t t h e r e may be b i o l o g i c a l l i m i t s to l i f e e x pectancy because of the s i g n i f i c a n c e o f causes of m o r t a l i t y which are not amenable to p r e v e n t i o n or postponement. The t h e s i s a l s o determined t h a t the d i f f e r e n c e i n l i f e e x p ectancy between males and females was reduced by i m p r o v i n g l i f e s t y l e . A l t h o u g h females s t i l l had the h i g h e r l i f e e x pectancy the h y p o t h e s i s o f the b i o l o g i c a l supremacy of females based on l o n g e r l i f e s p a n i s c a l l e d i n t o q u e s t i o n . 5.2.2 POPULATION STRUCTURE Reducing premature m o r t a l i t y r e s u l t e d i n both a s l i g h t i n c r e a s e i n the s t a b l e p o p u l a t i o n ' s t o t a l s i z e and the p r o p o r t i o n o f e l d e r l y i n the p o p u l a t i o n . S i n c e few deaths were postponed i n the female p r o d u c t i v e age - 123 -groups, the p o t e n t i a l growth i n t o t a l p o p u l a t i o n s i z e was l i m i t e d . The h i g h r a t e s of competing m o r t a l i t y f o r the e l d e r l y meant t h a t the numbers of e l d e r l y were h e l d i n check. As the p o p u l a t i o n moved to a s t a b l e s t a t e , the p r o p o r t i o n of the young (0-19) d e c r e a s e d . There-f o r e the i n c r e a s e s i n the e l d e r l y age groups (65+) were o f f s e t by d ecreases i n the young and the pro-d u c t i v e (20-64) age group remained f a i r l y c o n s t a n t i n p e r c e n t a g e terms. A l t h o u g h the dependency r a t i o :.•u. remained r e l a t i v e l y c o n s t a n t , a h i g h e r number of dependent e l d e r l y emerged who would tend to c o s t s o c i e t y more than the young. 5.2.3 HOSPITAL UTILIZATION The i n t r o d u c t i o n i d e n t i f i e d two p o s s i b l e s c e n a r i o s f o r f u t u r e p a t t e r n s of h o s p i t a l u t i l i z a -t i o n i n a p o p u l a t i o n which improved i t s l i f e s t y l e . An o p t i m i s t i c one s u g gests t h a t a p o p u l a t i o n e x p e r i e n c i n g reduced r a t e s of m o r b i d i t y would have decreased use of h o s p i t a l s e r v i c e s . The p e s s i m i s t i c view i s t h a t the aging p o p u l a t i o n , i n which h o s p i t a l use i s at a r a t e s e v e r a l times t h a t i n younger ages, would i n c r e a s e d r a m a t i c a l l y and p l a c e an extreme burden - 124 -on the p r o d u c t i v e age group. I t was found t h a t the l i t e r a t u r e d i d not p r o v i d e evidence as to which s c e n a r i o was more p l a u s i b l e . The a n a l y s i s i n d i c a t e d t h a t per c a p i t a h o s p i t a l use i n each age group decreased. However, the s l i g h t i n c r e a s e i n l i f e e x pectancy and consequent i n c r e a s e i n the number and p r o p o r t i o n of e l d e r l y and t h e i r i l l n e s s e s caused u t i l i z a t i o n to i n c r e a s e . The net e f f e c t was t h a t one o f f s e t the o t h e r . The o v e r a l l per remained f a i r l y c o n s t a n t , s c e n a r i o s c o n t a i n a g r a i n c a p i t a h o s p i t a l u t i l i z a t i o n Thus i t appears t h a t both of t r u t h . I t was n o ted i n Chapter 2 t h a t a t h e o r y i s d e v e l o p i n g c o n c e r n i n g the compression of m o r b i d i t y : s i m p l y s t a t e d , i f l i f e e x pectancy i s assumed to be b i o l o g i c a l l y f i x e d , and i f s i c k n e s s and d i s a b i l i t y can be postponed, then the p e r i o d o f i l l n e s s and d i s a b i l i t y p r i o r to death can be s h o r t e n e d or even e l i m i n a t e d . The data s u p p o r t s the i d e a t h a t t h e r e i s a maximum l i f e -span, not much beyond c u r r e n t expectancy, but i n the case of m o r b i d i t y i t was determined t h a t those who postpone t h e i r deaths through improvements i n l i f e -s t y l e s are s t i l l s u b j e c t to many morbid c o n d i t i o n s which, a l t h o u g h not l e a d i n g to death, i n v o l v e s i g n i -- 125 -f i c a n t p e r i o d s of h o s p i t a l c a r e . T h i s p a t t e r n of h o s p i t a l use c o u l d be r e f e r r e d to as competing m o r b i d i t y . 5.2.4 COSTS S i n c e h o s p i t a l c o s t s are p r o j e c t e d i n 1971 c o n s t a n t d o l l a r s , they f o l l o w the same p a t t e r n as h o s p i t a l u t i l i z a t i o n . The d e c l i n e i n per c a p i t a a g e - s p e c i f i c h o s p i t a l u t i l i z a t i o n r e s u l t s i n a d e c l i n e of p e r c a p i t a a g e - s p e c i f i c c o s t s . However, i n the same way t h a t the i n c r e a s e d number of e l d e r l y meant a s l i g h t o v e r a l l i n c r e a s e i n h o s p i t a l use, the o v e r a l l c o s t of care a l s o i n c r e a s e d m a r g i n a l l y . T h e r e f o r e the t h e s i s has determined t h a t h e a l t h promotion by i t s e l f w i l l not have a s i g n i f i c a n t e f f e c t on e i t h e r i n c r e a s i n g or d e c r e a s i n g c o s t s of h o s p i t a l care i n the lon g term. The r e l a t e d c o s t s f o r n o n - h o s p i t a l i l l n e s s care and su p p o r t s e r v i c e s have not been i n c l u d e d and are d i f f i c u l t to p r e d i c t . The l a r g e r number of e l d e r l y w i l l be h e a l t h i e r but s t i l l r e q u i r e the s p e c i a l i z e d s e r v i c e s f o r n o n - p r e v e n t a b l e c o n d i t i o n s - f o r example, 126 -extended m e d i c a l - n u r s i n g care f a c i l i t i e s , n u r s i n g homes and home c a r e . I t i s p r o b a b l e t h a t i n the same way t h a t per c a p i t a decrease i n the use of h o s p i t a l s e r v i c e s was o f f s e t by the i n c r e a s e of the number of aged, a s i m i l a r b a l a n c e would occur f o r these types of c a r e . I t s h o u l d be kept i n mind t h a t i l l n e s s i s a c t u a l l y o n l y one f o r c e d r i v i n g up h e a l t h care c o s t s ; o t h e r s are p r o v i d e r s , o v e r - u t i l i z i n g - e o n s u m e r s , expanding t e c h n o l o g y , and the d e c r e a s i n g r o l e of f a m i l y and community i n the p r o v i s i o n o f b a s i c h e a l t h s e r v i c e s . T h e r e f o r e , a l t h o u g h h e a l t h promotion appears to have m a r g i n a l b e n e f i t i n r e d u c i n g h e a l t h c o s t s , i t s t i l l a c h i e v e s the fundamental h e a l t h o b j e c t i v e o f i n c r e a s i n g l i f e e x pectancy and d e c r e a s i n g i l l n e s s a t v e r y l i t t l e expense. 5.3 IMPLICATIONS R e g a r d l e s s o f the impact of h e a l t h promotion programs, i t has been i l l u s t r a t e d t h a t the Canadian p o p u l a t i o n w i l l age c o n s i d e r a b l y i n the v e r y near f u t u r e and t h a t t h i s c o u p l e d w i t h low b i r t h r a t e s w i l l r e s u l t i n a s i g n i f i c a n t i n c r e a s e i n the a b s o l u t e number of e l d e r l y Canadians. These persons r e q u i r e - 127 -s i g n i f i c a n t amounts of i l l n e s s care s e r v i c e . T h e i r needs are c u r r e n t l y met through h o s p i t a l s , extended care f a c i l i t i e s , n u r s i n g homes, and a v a r i e t y o f home care s e r v i c e s . The mix o f these types o f s e r v i c e s and the r e s u l t a n t c o s t w i l l be p r i m a r i l y d etermined by the c h a r a c t e r of the p o p u l a t i o n they are to s e r v e . T h e r e f o r e , t h e r e w i l l be s i g n i f i c a n t changes i n h e a l t h manpower needs, i n s t i t u t i o n a l mixes, and even new s e r v i c e types f o r t h i s b u rgeoning age group. S i n c e these new demands f o r s e r v i c e are o c c u r r i n g a t a time of decreased r e s o u r c e a v a i l a b i l i t y , t h e r e w i l l be i n c r e a s i n g p r e s s u r e s to develop l o w - c o s t a l t e r n a t i v e s e r v i c e s to meet these needs. A l t h o u g h h e a l t h promotion has been suggested as a major f a c t o r i n t h i s r e g a r d , a more r e a l i s t i c assessment i n d i c a t e s t h a t h e a l t h promotion w i l l modify demands but not e l i m i n a t e them. T h e r e f o r e , persons r e s p o n s i b l e f o r a l l o c a t i n g h e a l t h care r e s o u r c e s w i l l be f o r c e d to p r o v i d e a d d i t i o n a l s e r v i c e s or lower the o v e r a l l q u a l i t y and s e r v i c e a v a i l a b i l i t y to the e l d e r l y , , or seek low c o s t a l t e r n a t i v e s . H e a l t h promotion per se i s not a panacea f o r the i l l n e s s care system, nor i s i t w i t h o u t m e r i t . R a t h e r , h e a l t h promotion i s a v i a b l e s t r a t e g y which at v e r y l i t t l e expense w i l l postpone a s i g n i f i c a n t pro-p o r t i o n o f premature m o r t a l i t y , a l l o w more persons to a t t a i n o l d age, and r e s u l t i n a more v i g o r o u s p o p u l a t i o n . In the f i n a l a n a l y s i s , b e n e f i t s appear to outweigh the c o s t . - 128 -The q u e s t i o n r emains, i s t h e r e a p r i c e to p r e v e n t i n g o r a t l e a s t d e l a y i n g m o r t a l i t y ? Many i l l n e s s p r e v e n t i o n and h e a l t h promotion a c t i v i t i e s have v e r y s m a l l c o s t s and i t has been shown t h a t i n f a c t abatement i o f many r i s k s would c o n s t i t u t e a d e f i n i t e s a v i n g even i f s l i g h t . T h e r e f o r e , the i n c r e a s e d number o f p r o d u c t i v e y e a r s o f l i f e brought about through p o s i t i v e l i f e s t y l e change and r e s u l t i n g i n c r e a s e i n l i f e e xpectancy w i l l be a c c o m p l i s h e d a t v e r y l i t t l e c o s t . 5 . 4 FUTURE RESEARCH A l t h o u g h h e a l t h promotion i s a worthy o b j e c t i v e i n and of i t s e l f , t h e r e i s s t i l l i n c r e a s i n g p r e s s u r e to reduce i l l n e s s - c a r e c o s t . In o r d e r t h a t a more d e f i n i t e r e l a t i o n s h i p be e s t a b l i s h e d between h e a l t h p r o motion and h o s p i t a l u t i l i z a t i o n t h e r e i s a need f o r p r o s p e c t i v e l o n g - t e r m s t u d i e s to as s e s s the net f i n a n c i a l impact o f h e a l t h promotion programs. However, more p r o d u c t i v e r e s e a r c h e f f o r t s would be d i r e c t e d towards f i n d i n g o p t i m a l methods to modify and improve l i f e s t y l e s f o r the purpose of i m p r o v i n g q u a l i t y o f l i f e ( i . e . i r r e s p e c t i v e o f c o s t c o n c e r n ) . Such r e s e a r c h s h o u l d have e v a l u a t i v e components and have - 129 -long time-frames to a n a l y z e more f u l l y the t o t a l impact of b e h a v i o r a l changes. Such r e s e a r c h i s a l s o v e r y n e c e s s a r y i n orde r to prove to those who a l l o c a t e s c a r c e h e a l t h and i l l n e s s care r e s o u r c e s t h a t an investment i n h e a l t h promotion w i l l have a p o s i t i v e impact on h e a l t h and t h e r e f o r e a c h i e v e h e a l t h s e r v i c e s o b j e c t i v e s . U n t i l now h e a l t h promotion has been m a i n l y d i r e c t e d towards the postponement o f death and, t o a c e r t a i n e x t e n t ^ d i s a b i l i t y There i s a d e f i n i t e need to broaden t h i s p e r s p e c t i v e to i n c l u d e the abatement o f i l l n e s s , h o s p i t a l use, and c h r o n i c d i s a b i l i t y . S i m i l a r l y , t h e r e i s a need to u n d e r s t a n d more f u l l y the r e l a t i o n s h i p between h i g h l e v e l s o f w e l l - b e i n g and such v a r i a b l e s as worker p r o d u c t i v i t y , l e v e l s o f w e l l - b e i n g , and q u a l i t y of l i f e . U l t i m a t e l y the long run importance o f h e a l t h p r o m o t i o n as a component o f the h e a l t h c a r e system w i l l be determined on grounds o f both i t s h e a l t h impact, i n terms o f w e l l n e s s and l o n g e v i t y , and i t s economic impact, i n terms o f a v e r t e d i l l n e s s care c o s t s and i n c r e a s e s i n p r o d u c t i v i t y . There i s s u f f i c i e n t e v i d e n c e to c o n c l u d e t h a t h e a l t h promotion s h o u l d be advanced as a v i a b l e and n e c e s s a r y component of h e a l t h systems. - 130 -BIBLIOGRAPHY Baumal, W. J . , and W. E. Oates. 1972. "The c o s t d i s e a s e of the p e r s o n a l s e r v i c e s and the q u a l i t y of l i f e . " S k a n d i n a v i s k a E n s k i l d a Banken Q u a r t e r l y Review, S p r i n g : p. 44-54. 1! Bennett, James E., and Jacques Krasny. 1977. H e a l t h c a r e i n Canada: a s e r i e s on the n a t i o n s h e a l t h . R e p r i n t of s e r i e s . 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Trends and D i f f e r e n t i a l s i n M o r t a l i t y . New York, M i l b a n k Memorial Fund. S t a t i s t i c s Canada. 1972. Causes of death 1971. Catalogue 84-203; I n f o r m a t i o n Canada. Ottawa. S t a t i s t i c s Canada. 1973. H o s p i t a l s t a t i s t i c s . Volume 6, H o s p i t a l E x p e n d i t u r e s . Catalogue 83-215; I n f o r m a t i o n Canada. Ottawa. S t a t i s t i c s Canada. 1973. V i t a l S t a t i s t i c s 1971. Catalogue 84-201; I n f o r m a t i o n Canada. Ottawa. S t a t i s t i c s Canada. 1974. H o s p i t a l M o r b i d i t y 1971. Catalogue 82-206; I n f o r m a t i o n Canada. Ottawa. S t a t i s t i c s Canada. 1974. V i t a l S t a t i s t i c s . Volume 1, B i r t h s 1971. Catalogue 84-204; I n f o r m a t i o n Canada. Ottawa. S t r i k l e r , Bernard L., and A l b e r t S. M i l d v a n . 1960. " G e n e r a l t h e o r y o f m o r t a l i t y and a g i n g . " S c i e n c e , 132(3418):14-20. Thomlinson, Ralph. 1976. P o p u l a t i o n dynamics. New York, Random House. p.79-153. Thornton, David A., B e t t y MacGregor, and Lynn Hawkins. 1978. E v a l u a t i o n of h e a l t h h a z a r d a p p r a i s a l u s e r ' s s u r v e y . Ottawa, H e a l t h and W e l f a r e Canada. T s a i , Shan Pore, Eun S u l Lec, and Robert J . Hardy. 1978. "The e f f e c t of a r e d u c t i o n i n l e a d i n g causes of death: p o t e n t i a l g a i n s i n l i f e e x p e c t a n c y . " American J o u r n a l of P u b l i c H e a l t h , 68(10):966-971. - 135 -Twaddle, Andrew C. 1968. "Aging p o p u l a t i o n growth and c h r o n i c i l l n e s s . " J o u r n a l o f C h r o n i c D i s e a s e s , 21:417-422. Verzuh, Ron. 1980. " E l d e r l y c o u l d f l o o d h o s p i t a l s by 2031." P e r c e p t i o n , 3 ( 4 ) : 3 5 . W i n k e l s t e i n , Warren. 1979. "An e p i d e m i o l o g i c a l look at the methodology of the h e a l t h h a z a r d a p p r a i s a l . " In P r o c e e d i n g s of the F i f t e e n t h Annual M e e t i n g on P r o s p e c t i v e M e d i c i n e . Bethesda, H e a l t h and E d u c a t i o n Resources. World Bank. 1976. World bank t a b l e s . Washington. Wrong, Dennis H. 1969. P o p u l a t i o n and s o c i e t y . 3rd ed. T o r o n t o , Random House. L I F E READS I N P U T , CHECKS I TS C O N S I S T E N C Y , AND PUNCHES A STANDARD DECK FOR USE AS INPUT TO OTHER P R O G R A M S . . ALSO C A L L S L 1 F , WHICH COMPUTES AND P R I N T S A L I F E TABLE A NO PUNCHES ' LL ( X ) • * INPUT STARTS WITH 12 CARDS AS TOLLOWS T I T L E CARD ( 1 9 A M ) T O T A L S CARD IN FORMAT (11 , 5X , I 9 , 5 F 9 . 0 ) C O N T A I N I N G THE YEAR ( I D A T E ) IN COLUMNS I-<4 TOTAL P O P U L A T I O N I I T P P ) IN COLUMNS 1 0 - 1 6 TOTAL DEATHS (TDD) IN COLUMNS 1 9 - 2 7 TOTAL B I R T H S ( T B B ) I N COLUMNS 2 8 - 3 6 MALE B I R T H S ( T B 6 M ) IN COLUMNS 3 7 - 4 5 F E M A L E B I R T H S ( T B B F ) IN COLUMNS 4 6 - 5 4 THE NUMBER OF YEARS TO WHICH THE B I R T H AND DEATH DATA A P P L Y ( Y E A R S ) IN COLUMNS 5 5 - 6 3 . IF THE NUMBER OF YEARS I S NOT P U N C H E D , THE DEFAULT VALUE I S ONE Y E A R . MALE P O P U L A T I O N BY AGE (PPM ( 1 ) 1 , 2 CARDS IN FORMAT ( 1 0 F 8 . 0 ) F E M A L E P O P U L A T I O N BY AGE ( I P P F ( I I ) , 2 CARDS IN FORMAT ( 1 0 1 8 ) B I R T H S BY AGE OF MOTHER (BB ( I ) ) , 2 CARDS IN FORMAT ( 1 0 F 8 . 0 ) MALE DEATHS BY AGE IDDM ( I ) ) , 2 CARDS IN FORMAT ( 1 0 F 8 . 0 ) F E M A L E DEATHS BY AGE (DDF I I I ) , 2 CARDS IN FORMAT ( 1 0 F 8 . O AGE G R O U P S . A R E 0 , 1 - 4 , 5 - 9 , 1 0 - 1 4 , . . . B 5 » , UNKNOWN ( 2 0 C A T E G O R I E S ) . NEXT ARE THE NUMBERS NN AND MM IN FORMAT ( 2 I < U , FOLLOWED BY NN CARDS C O N T A I N I N G THE SOURCE NOTES AND MM CARDS D E S C R I B I N G A D J U S T M E N T S . IF THERE ARE NO N O T E S , THE DATA DECK ENDS WITH A CARD PUNCHED 1 I N COLUMN 4 AND A BLANK C A R D . SETS OF THE ABOVE INPUT MAY BE R E P E A T E D I N D E F I N I T E L Y . THE PROGRAM TERMINATES E X E C U T I O N WHEN A BLANK T I T L E CAPO IS R E A D . D I M E N S I O N N A M E ( 1 9 ) , N 0 T E ( 1 9 ) , P P M ( 2 0 ) , P P F ( 2 0 ) , B B ( 2 O ) , D D M < 2 0 ) , D D F ( 2 O ) A , I A G E ( 1 9 ) , I P P M ( 2 0 ) , I P P F ( 2 0 ) , I B B ( 2 0 ) , I D D M ( 2 D ) , I D D F ( 2 0 ) COLUMNS 1 - 7 6 OF THE T I T L E CARD ARE STORED IN ' N A M E . ' COLUMNS 7 7 - 8 0 OF THE T I T L E CARD MUST ALWAYS BE B L A N K . READ 5 0 , N A M E , IE K FORMAT ( 19AM ,Ai) ) P R I N T 5 4 , N A M E FORMAT ( 1 H 1 1 9 A 4 / / I READ 5 6 , I D A T E , I T P P , T O D , T B B , T B B M , T B B F , Y E A R S FORMAT ( I 4 , 5 X , I 9 , 5 F 9 . U > READ 5 8 , I P P M , 1 P P F FORMAT I 1 0 I 8 / 1 0 1 8 / 1 U I 8 / 1 0 I 8 ) READ 5 9 , B B , 0 0 M , D D F FORMAT ( 1 0 F 8 . Q I THE DATA HAVE B E E N R E A D . READ AND P R I N T SOURCE NOTES (A MINIMUM OF ONE NOTE CARD IS R E Q U I R E D — IF THERE ARE NO NOTES IT WILL BE B L A N K ) . READ 6 0 , N N , M M NzNN+MM FORMAT ( 2 I H ) DO 62 1 = 1 , N READ S O , N O T E P R I N T 6 4 , N O T E FORMAT t l X 1 9 A 4 ) I F IN . G T . 2 3 ) P R I N T 5 1 , NAME NOTES HAVE BEEN P R I N T E D . ADJUST THE B I R T H S AND DEATHS TO A O N E - Y E A R I N T E R V A L IF THE INPUT A P P L I E S TO MORE THAN ONE Y E A R . I F ( Y E A R S . L E . 0 . 0 . O R . I F I X I Y E A R S ) . E O . 1) GO TO 68 P E C I P - 1 . O / Y E A R S TDD=TUD*RECIP T 6 B = T B B * R E C I P T B B M - T B B M * R E C I P T B B F r T B B F « R E C I P DO 66 I - 1 , 20 BB< I I = B B ( I ) * R E C I P DOM( I ) = D D M ( I ) * R E C I P D D F ( I ) = D D F ( I ) * R E C I P CHECK TO A S C E R T A I N IF EACH TOTAL EOUALS THE SUM OF THE A G E S . I T P P M : 0 I T P P F - 0 T T f? B - 0 . TDDM = 0 . TDDF - 0 . DO 70 1 = 1 . 2 0 I TPPM = I T P P M + I P P M ( 1 ) I T P P F = I T P P F * I P P F I I I T TBB - T T B B * B B ( I I TDDM = TDDM+DDM(I ) T DDF =TDDF + O D F ( I ) I D 1 = I T P P M * 1 T P P F - I T P P I D 2 - T T B B - T B B I03=TDOM<TDDF -TDD I F ( 1 A B S ( ID1 ) * I A B S ( I D 2 I • I A B S ( 1 0 3 ) . L T . 1 I GO TO 74 P R I N T 7 2 , I D 1 , I D 2 , 1 D 3 FORMAT (/// 29H D I S C R E P A N C Y IN P O P U L A T I O N I S • 1 1 0 / , B 2SH D I S C R E P A N C Y IN B I R T H S IS 110 / 25H D I S C R E P A N C Y IN DEATHS C 1 1 0 ) GO TO 96 N E X T , P R I N T THE D A T A . "-"'J F I R S T , SET UP THE STUB OF THE T A B L E . I AGE < 2)=0 DO 76 1 = 3 , 1 9 I A G E ( I ) = I A G E ( 1 - 1 1 * 5 I A G E ( 1 ) = 0 I A G E ( 2 > = 1 CONVERT THE DATA TO I N T E G E R S FOR P R I N T I N G AND P U N C H I N G . I T T B B = TTBB ITDDM = TDDM ITOOF z TODF DO 78 1 = 1 , 2 0 I B B ( I ) = B B ( I 1 E L I M I N A T E P O S S I B L E MINUS Z E R O S . I F ( I B P ( 11 . L E . 0 ) IBB ( I I =0 ; , i. I D D M ( I ) = 0DM I I ) I DDF ( I )= DDF( I ) P R I N T THE T A B L E . P R I N T 8 0 FORMAT (/// 3X 3HAGE 9X 1 0 H P 0 P U L A T I O N U X 6 H B I R T H S 1 2 X 6 H D E A T H S 12X D 3HAGE / 1 2 X MHMALE 7X 6HFE MALE 20X 4 HM ALE 7X 6HFEMALE /) P R I N T 8 2 , ( I A G E ( I > , I P P M ( I > , I P P F ( I ) , 1 B B ( I ) , I D D M ( I ) , I D D F U ) , I A G E ( I > , E 1 = 1 , 1 9 ) FORMAT ( 1 5 , 5 1 1 2 , 1 9 ) P R I N T 8 M , I P P M ( 2 0 ) , I P P F l 2 0 ) , I B B ( 2 0 ) , I D 0 M ( 2 0 ) , I D D F ( 2 0 ) FORMAT ( / I X 7HUNKN0WN I 9 , m i 2 , 5 X 7HUNKN0WN ) P R I N T 85 . I T P P M , I T P P F , I T T B B , I T D O M , I T O D F • FORMAT < 5 X , 5 ( 5 X , 7 H > / 7HD TO T A L , I 1D , <i 11 2 , 6 X , 5 HTO T AL ) CONVERT THE DATA TO R E A L S FOR D I S T R I B U T I O N OF P O P U L A T I O N . TPPM = I T P P M T P P F = I T P P F DO 8 6 I = 1 , 2 0 P P M { I I = I P P M ( I ) P P F ( I ) = I P P F I I ) -D I S T R I B U T E THE UNKNOWN CATEGORY OF P O P U L A T I O N . DO 8 7 1 = 1 , 1 9 P P M ( I ) = P P M ( I ) * T P P M / ( T P P M - P P M ( 2 0 ) ) P P F ( I ) = P P F ( I ) * T P P F / ( T P P F - P P F ( 2 0 ) ) D D M ( I ) =DDM(I ) * T D 0 M / ( T D D M - D D M ( 2 0 ) ) DDF( I )=DDF I I ) * T D D F / ( T D D F - D D F ( 2 0 ) ) I PPM( I ) =PPM{ I ) < . 5 I P P F ( I ) = P P F ( I I • . 5 PUNCH A NEW OAT A D E C K . ' I TDD = TDD I TBB = TBB ITBBM=TBBM I T B B F = T B B F I B B ( 1 8 ) = T B B M I B B ( 1 9 ) = T B B F I B B ( 2 0 ) = T B B PUNCH 5 0 , N A M E PUNCH 8 8 , I D A T E , I T P P , I T D 0 , I T B B , I T B B M , I T B B F , Y E A R S 8 8 FORMAT ( I I , 5 X 5 1 9 , F 9 . 3 ) PUNCH 9 0 , I P P M , I P P F , I B B 9 0 FORMAT ( 1 0 1 8 ) C . . C COMPUTE AND PRINT THE MALE L I F E T A B L E . P R I N T 9 2 9 2 FORMAT ( 2 1 H 1 L I F E T A B L E FOR MALES ) C A L L L I F I P P M . D D M ) C C COMPUTE AND PRINT THE F E M A L E L I F E T A B L E . P R I N T 94 94 FORMAT ( 2 3 H 1 L 1 F E T A B L E FOR F E M A L E S ) C A L L L I F ( P P F . D D F ) C C CHECK FOR ANOTHER SET OF D A T A . 9 6 READ 5 0 , N A M E DO 98 1 - 1 , 1 0 I F (NAME ( I ) • N E . I B K ) GO TO 52 C BLANK CARD AFTER L A S T STACKED DATA SET T E R M I N A T E S P R O G R A M ; 98 CONTINUE STOP END SUBROUT INE L I F ( P P . D D ) C C PRODUCES A L I F E T A B L E THAT I T E R A T E S TO THE D A T A . C C INPUT IN FORMAT ( 1 0 F 8 . 0 ) I S — C I I P O P U L A T I O N P P ( I ) FOR AGES 0 , 1 - 4 . 5 - 9 , . . . 8 5 * * AT L A S T 2) O E A T H S * D 0 ( I ) C F S R S T H E S A M E A G E G R O U P S , O V E R O N E Y E R OR T H E W A V E R A G E P E R Y E A R O F S O M E O T H E R P E R I O D (2 C A R D S ) ^ C C D I M E N S I O N P P ( 2 0 I , 0 D ( 2 0 ) , V M M ( 2 0 ) , V R ( 2 0 ) , V L ( 2 0 ) , V L L P I 2 0 ) . A I A G E ( 2 0 ) , Q X ( 2 0 ) , I P P ( 2 0 ) , I O O ( 2 0 ) , L ( 2 0 ) , L L ( 2 0 ) , N D X ( 2 0 ) , V M ( 2 0 ) , B V A ( 2 0 ) , I T T ( 2 U ) , E ( 2 0 I , T T ( 2 0 ) . C C C L I F E T A B L E V A R I A B L E S C V M M ( I ) - A G E - S P E C I F I C DEATH R A T E S C V R ( I ) : RATE OF I N C R E A S E FOR ITH AGE G R O U P - L O C A L R C SEP - S E P A R A T I O N FACTOR FOR AGE ZERO C V L d ) = NUMBER S U R V I V I N G COLUMN OF L I F E T A B L E C V L L P ( I ) - NUMBER L I V I N G I N L O C A L L Y OR S E C T I O N A L L Y S T A B L E C P O P U L A T I O N — ALSO STORES S T A T I O N A R Y P O P U L A T I O N C L L ( I ) - NUMBER L I V I N G IN S T A T I O N A R Y P O P U L A T I O N C C SET I N I T I A L V A L U E S IN A R R A Y S . 0 0 11 1 = 1 , 1 9 1 P P ( I K P P U M . 5 IF 1 1 P P ( I ) , E Q . 0 ) PP ( I > - 1 • VMM( I ) - DD( I ) / P P ( I ) 11 V R I I > = . 0 0 0 0 0 1 S E P = . 0 7 • 1 . 7 * V M M ( 1 ) V L ( 1 I = 1 0 0 0 0 0 . V L ( 2 > : V L ( 1 ) * < 1 . - SEP*VMM( 1 ) )/I 1• • t l . - S E P ) * V M M ( i ) l VL<3> = V L ( 2 ) * ( 1 . - 1 • 5 * V M M ( Z I I / I I• * 2 . 5 * V M M ( 2 I ) DO 13 1 = 3 , 1 9 V L ( I * 1 I = VL t 1 1 * ( 1 . - 2 . 5 * V M M ( I > I / < 1 . • 2 . 5*VMM(1)> 13 V L L P ( 11 ~ 2 . 5 * ( V L ( I ) * V L I I + 111 V L 1 7 = V L ( 1 7 ) C C THE F O L L O W I N G QUOTIENTS ARE COMPUTED ONCE AND STORED TO C AVOID R E - C O M P U T I N G THEM MANY T IMES IN THE D O - L O O P S A H E A D . C N S T A r l O . / 3 . C N S T B = 5 . / 1 Z . C N S T C = 6 S . / 2 4 . C N S T D = 5 . / 21 . C C THE MAIN I T E R A T I V E LOOP I S FROM HERE TO STATEMENT 2 1 . DO 21 J = l , 10 C C R E V I S E L L ( X ) FOR AGES 5 - 9 A NO 8 5 * . V L L P ( 3 ) - 2 . 5 * ( V L ( 3 ) » V L ( 4 ) / E X P ( 5 . * V R ( 3 I ) ) V L L P ( 1 9 ) r C N S T A * V L ( 1 9 I - C N S T B * V L ( 1 8 ) C V L L P U f I S USED F I R S T TO STORE THE S E C T I O N A L L Y S T A B L E C P O P U L A T I O N AND LATER THE S T A T I O N A R Y P O P U L A T I O N . C C PERFORM THE I T E R A T I O N FOR EACH AGE GROUP ( 1 0 - 1 1 , . . . 8 D - 8 M ) . DO 15 1 = 4 , 18 C C D E F I N E S AS EXP ( 5 * R ) TO AVOID R E C A L C U L A T I N G E X P O N E N T I A L S . 1 S = E X P ( 5 . * V R ( 1 ) 1 C >-, C COMPUTE THE NEW I T E R A T E FOR V L L P ( I ) . V L L P ( I ) = C N S T C * ( V L ( I > * V L t I * l ) / S ) - C N S T D * ( V L ( I - l > * S « V L ( I » 2 ) / S * * 2 ) O C COMPUTE NEW ITERATE FOR L ( X ) . I V L ( I « 1 ) = S * ( V L ( I ) - ( V M M ( I ) » V R ( I ) ) * ( V L L P ( I ) - C N S T C » V L ( I « 1 ) / S ) ) / C ( 1 . * C N S T C * ( V M M ( I ) * V R ( 1 ) ) ) C C COMPUTE NEW ITERATE FOR A G E - S P E C I F I C I N C R E A S E RATE VR( I I . W W : ( P P I I - 1 ) / V L L P ( I - 1 ) ) / ( P P ( I * 1 ) / V L L P ( I » 1 ) ) V R ( I ) = . 0 0 0 0 0 1 I F (WW . G T . 1 . 0 ) V R ( I ) = . 1 * A LOG (WW) IF ( V R ( I ) . G T . . 0 4 ) V R ( I ) = . 0 4 15 CONTINUE C C TEST FOR C O N V E R G E N C E . I F ( A B S ( V L 1 7 - V L ( 1 7 ( I . L T . 1 . ) GO TO 2 5 V L 1 7 = V L ( 1 7 ) 2 1 CONT INUE P R I N T 2 3 2 3 FORMAT ( 5 0 H O CONVERGENCE WAS NOT A T T A I N E D WITH 10 I T E R A T I O N S > RETURN C THE I T E R A T I O N FOR L I X ) I S C O M P L E T E . C C THE R E M A I N I N G COLUMNS OF THE L I F E T A B L E WILL NOW BE COMPUTED C S T A R T I N G WITH THOSE C A L C U L A T E D FROM TOP TO BOTTOM. 25 DO 27 1 = 1 , 1 9 I A G E ( I ) = 5 * I - 1 0 C X ( 1 > = 1 . D - V L 11* 1 >/VL I I > NDXI I> = VLI I > - V I ( 1 * 1 1 • 0 . 5 IF ( I . L T . 4 . O R . I . E C • 1 9 ) GO TO 2 7 V L L P ( I > = C N S T C * ( V L ( I ) » V L ( I* 1 > ) - CN S T D* I V L ( I - 1 ) • VL ( I « 2 ) I 27 CONTINUE C C SOME OF THE ABOVE COMPUTATIONS MUST BE M O D I F I E D C FOR THE LOWEST AND HIGHEST AGE G R O U P S . ': :' . N D X ( 1 9 ) = V L ( 1 9 1 * 0 . 5 0 X 1 1 9 1 = 1 . 0 I A G E ( 1 1 = 0 I A G E I 2 ) = 1 V L L P ( 1 ) = S £ P * V L ( 1 ) • l l . 0 - S E P ) * V L ( 2 ) V L L P ( 2 ) = 1 . 5 * V L ( 2 ) . 2 . 5 * V L ( 3 > V L L P ( 3 ) = 2 . 5 * < V L ( 3 ) * V L ( 4 I ) V L L P ( 1 9 ) = V L I 191/VMM( 19) T TI 1 9 ) = V L L P ( 1 9 ) C C THE NEXT LOOP COMPUTES FROM THE BOTTOM TO THE T O P ; C TO DO T H I S , INDEX I TAKES ON V A L U E S 1 9 , 1 8 , . . . 1 AS J = l i l 9 . DO 29 J = l , 19 I = 2 D - J V M ( I ) = ( V L ( I ) - V H I * 1 ) ) / V L L P ( I ) V A 1 I I = 1 V L L P ( I ) - 5 . 0 * V L ( I « 1 ) ) / ( V L I I ) - V L ( I * 1 ) ) -I F ( I . N E . 1 9 ) T T ( I > = T T ( I « l ) * V L L P ( I ) C • • , 29 E ( I ) = T T ( I ) / V L ( I ) C C A G A I N , SOME VALUES R E Q U I R E A D J U S T M E N T . V A ( 1 ) = S E P V A ( 2 ) = 1 • 5 VA ( 3 ) = 2 . 5 V A ( 1 9 ) = E ( 1 9 ) C I C I N ORDER TO S U P P R E S S D E C I M A L P O I N T S CONVERT TO I N T E G E R S C B E F O R E P R I N T I N G . '.: DO 31 1 = 1 , 1 9 1 D O ( I ) = D D ( I ) L ( I ) = V L ( I I « 0 . 5 L L ( I ) = V L L P ( I M O . 5 31 IT T ( I ) : T T ( I ) • 0 . 5 C P R I N T 33 33 FORMAT (//4 HOAGE 7 X 2 H P P 8X2HOO 8 X 4 H Q I X ) 6 X M H H X I 7 X 4 H D I X ) 5X E S H L L ( X ) 5X3HAGE /) C C P R I N T THE F I R S T S I X COLUMNS OF THE L I F E T A B L E . P R I N T 3 5 , ( I A G E ( I ) , I P P I I ) , I DDI I ) , Q X ( I ) , L ( I ) , N O X ( I I , L L ( I ) , 1 AGE( I ) , D 1 = 1 , 1 9 ) 35 FORMAT ( I X 1 3 , 1 1 1 , 1 9 , F 1 2 . 6 , 3 1 1 0 , 1 7 1 P R I N T 3 7 37 FORMAT 1///4HUAGE 6 X 4 H M ( X ) 7X4 H A ( X ) 6X 5HT T ( X) 6 X 4 H R 1 X ) 5 X 4 H E I X ) 6X F 5HMMIX) SX3HAGE /> r P R I N T THE SECOND S I X COLUMNS OF THE L I F E T A B L E ; P R I N T 3 9 . I I A G E I I I . V H I I I , V A f .1 I , I T T I I I , V R I I I , E I 11 , V M H I I 1 , _ 39 G F O R M A T I ! l X I 3 i F l l . 6 , F 10 . 3 , 1 1 2 , F 9 . <t, F 1 0 . 3 , F 1 1 . 6 , 1 6 ) C PUNCH L L < X ) FOR FUTURE P R O G R A M S - - F O R M A T 1 1 0 1 8 ) . L L < 2 0 ) = 0 PUNCH M l . L L M l FORMAT 1 1 0 1 8 ) RETURN END -P. I c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c PROJECT PROVIDES A POPULATION PROJECTION WITH FIXED A G E - S P E C I F I C RATES OF BIRTHS A NO DEATHS, AS WELL AS ULTIMATE OR I N T R I N S I C RATES OF B I R T H , DEATH AND NATURAL INCREASE, AND AGE D I S T R I B U T I O N . THE MODEL IS FEMALE DOMINANT, I . E . THE NUMBER OF BIRTHS AT EACH STAGE OF THE PROJECTION IS DETERMINED BY THE NUMBER OF WOMEN THE INPUT I S THE STANDARD DECK PROOUCED BY THE PROGRAM • L I F E * ! MODIFIED ONLY BY PUNCHING THE OESIRED TERMINAL YEAR OF THE PROJECTION I N COLUMNS 65-68 OF THE TOTALS CARD WHICH IS SECONO IN THE DECK OF 12 CARDS. IF NO PUNCH FOR TERMINAL'.'YEARt PROGRAM PRINTS OUT 25 YEARS PROJECTION I F OUTPUT OF ' L I F E * IS NOT A V A I L A B L E . THE INPUT WOULD BE MADE UP AS FOLLOWS — T I T L E CARD (1 CARD IN FORMAT 19AM) ONE CARD IN FORMAT |1M, 32X, 2 F 9 . 0 , 9 X , 15) THAT CONTAINS THE YEAR OF I N I T I A L POPULATION, TOTAL MALE B I R T H S , TOTAL FEMALE B I R T H S , AND THE DESIRED TERMINAL YEAR FOR . ' f . THE PROJECTION THE FOLLOWING F I V E D I S T R I B U T I O N S EACH CONTAINING 20 NUMBERS PUNCHED ON TWO CARDS IN FORMAT ( 1 0 F 8 . 0 ) ACCORDING TO AGE GROUPS I 0 ,1-M,5-9,...,85*, UNKNOWN) — OBSERVED MALE POPULATION OBSERVED FEMALE POPULATION BIRTHS BY AGE OF MOTHER MALE STATIONARY POPULATION L L I X ) FROM THE L I F E TABLE FEMALE STATIONARY POPULATION L U X ) FROM THE L I F E TABLE SETS OF THE ABOVE INPUT MAY BE REPEATE0 I N O E F I N I T E L Y . THE V PROGRAM TERMINATES EXECUTION WHEN A BLANK T I T L E CARD IS R E A D i ARRAYS PP=POULATION NUMBER IN 5-YEAR AGE GROUPS BB=BIRTHS TO MOTHERS IN 5-YEAR AGE GROUPS V L L = L I F E TABLE STATIONARY AGE D I S T R I B U T I O N F F = A G E - S P E C I F I C BIRTH RATES •NAME* I S USED TO STORE THE CONTENTS OF THE T I T L E CARD DIMENSION N A M E J 1 9 1 , V L L ( M O ) , P P < M 1 , 6 ) , P P 1 ( M O I , B B ( 2 0 I . F F J 2 0 ) , J J ( M 1 I , A V ( M 1 ) , I Y E A R ( 7 I , P P A ( 2 U I , P P B ( 2 0 ) , V L L A { 2 0 ) , V L L B ( 2 0 ) COLUMNS 1-76 OF THE T I T L E CARD ARE STORED IN "NAME* EQUIVALENCE I P P 1 , P P A ) , ( P P 1 1 2 1 ) ,PPB > , I V L L , V L L A ) , I V L L < 2 1 > , V L L B > C:0 •..'•, READ 1, NAME i I8K , ' 1 FORMAT (20AM) 3 PRINT 5,NAME 5 FORMAT I 1H1 19AM) READ 7 . I Y E A R U ) , T BBM , T BBF , L YE A R 7 FORMAT (IM , 3 2 X . 2 F 9 . 0 , 9 X , 1 5 I > m a 3 M 5 6 7 8 9 10 C C L E A R ARRAYS IN WHICH P R O J E C T I O N I S TO BE STOREO DO 8 1 = 1 , 4 1 DO 8 J= 1 , 6 PP ( I , J ) = D 8 CONT INUE C N I S THE NUMBER OF T W E N T Y - F I V E YEAR P R O J E C T I O N C Y C L E S C TO BE P R I N T E D N = 1 * 1 L Y E A R - I Y E A R ( 1 1 - 1 1 / 2 5 I F I L Y E A R . E Q . D ) N= l C C READ INPUT RE AO 9 , P P A , P P B , B B , V L L A , V L L B 9 FORMAT ( 1 0 F 8 . 0 ) 11 F 0 R M A T M l H 0 / 1 6 X , 5 H M A L E S , 2 U X , 7 H F E M A L E S » 1 2 X i 6 H B I R T H S ) C S IS THE SEX RAT IO AT B I R T H . S=TBBM/TBBF C C SET AGES IN ARRAY J J . J J ( 2 > = 0 DO 19 1 = 3 , 1 9 J J ( I ) = J J 1 1 — 1 1 * 5 19 J J ( I * 2 0 ) = J J 1 I ) J J ( 1 1 = 0 J J ( 2 I = 1 C C P R I N T INPUT D A T A . 21 F 0 R M A T 2 l 3 X l H X , 6 X 5 H P P ( X I , 7 X 5 H L L ( X I , 9 X 5 H P P ( X ) , 7 X 5 H L L ( X ) » 8 X 5 H B B ( X > ) D P R I N T H 2 3 ' ( J J ( I ) , P P 1 1 I ) , V L L I I > , P P 1 t I * 2 0 > , V L L I 1 * 2 0 ) , B B ( I ) , J J < I ) , E 1 = 1 , 1 9 ) 23 FORMAT t IX , 1 3 , 2 F 1 2 . 0 , F 1 4 . 0 . 2 F 1 2 . 0 , 1 5 ) P R I N T 2 5 , S , 25 FORMAT ( 1 H 0 / 2 1 H SEX R A T I O AT B I R T H = F 1 0 . 6 ) J J ( 2 ) = 0 C THE^ ARRAY J J C O N T A I N S THE I N I T I A L YEAR OF EACH 5 - Y E A R AGROUP C S T A R T I N G WITH J J I 2 I = 0 FOR MALES AND J J I 2 2 1 = 0 FOR F E M A L E S . C CHANGE I S BECAUSE AGES FOR P R O J E C T I O N OUTPUT ( 0 , , 5 i 1 0 1 C ARE S L I G H T L Y D I F F E R E N T FROM THOSE OF THE DATA INPUT I D , 1 , 5 ) C THE I N I T I A L AGE D I S T R I B U T I O N I S ENTERED I N THE F I R S T COLUMN C OF THE MATRIX PP DO 27 1 = 1 , t O 27 P P ( I , 1 ) = P P 1 ( 1 1 C THE AGE GROUPS 0 AND 1 - "4 ARE COMBINED AND P L A C E D IN THE C P O S I T I O N OF THE 1 - 4 . V L L I 2 I = V L L I 2 I • V L L U ) V L L 1 2 2 ) = V L L 1 2 2 1 • V L L I 2 1 I P P ( 2 , 1 ) = P P ( 2 , 1 > * P P ( 1 , 1 I P P ( 2 2 , 1 ) = P P 1 2 2 . 1 I * P P I 2 1 . 1 ) 11 12 1 3 I t 15 16 17 18 19 20 21 22 2 3 24 25 26 27 2 8 29 30 31 32 33 34 3 5 36 37 38 39 4 0 4 1 4 2 4 3 DO 2 9 1 = 1 , 1 2 29 F F ( I ) = B B I I l / P P l ( 1 * 2 0 ) C C T H I S COMPLETES THE P R E P A R A T O R Y WORK. NOW FOR THE C P R O J E C T I O N P R O P E R . S T A R T I N G WITH S U R V I V O R S H I P . C S U C C E S S I V E COLUMNS OF PP ARE F I L L E D WITH THE P O P U L A T I O N C P R O J E C T E D FORWARD F I V E Y E A R S , U S I N G THE L I F E T A B L E S U R V I V A L RA C C I I N O E X E S AGES C J I N D E X E S YEARS W I T H I N 2 5 - Y E A R P R O J E C T I O N C Y C L E C L I N D E X E S 2 5 - Y E A R C Y C L E S . C DO 6 7 L = 1 , 2 D 0 0 35 J = 2 , 6 DO 31 1 = 3 , 1 9 P P ( I , J ) = P P I 1 - 1 , J - l ) * V L L 1 1 ) / V L L ( I - l ) 31 P P I I « 2 0 , J > = P P I 1 * 1 9 , J - l ) * V L L ( I + 2 0 I / V L L C 1 + 19) C C THE NUMBER OF M A L E ANO F E M A L E B I R T H S DURING THE J T H 5 - Y E A R C P E R I O D THAT S U R V I V E TO THE END OF THE P E R I O D ARE S T O R E D - ' C R E S P E C T I V E L Y IN P P ( 2 , J > AND P P ( 2 2 , J > . C B I R T H S MUST BE CONVERTED INTO S U R V I V O R S TO T H E . E N D OF EACH C F I V E - Y E A R P E R I O D . P P C 2 2 . J ) =0 DO 3 3 K = 1 , 1 2 33 P P I 2 2 . J ) = P P « 2 2 i J » • . 5 * V L L I 2 2 ) * < P P t K * 2 0 , J - l > • P P I K * 2 0 , J I ) 1 * F F ( K ) / ( ( 1 . • S l * 1 0 0 0 0 0 . l P P < 2 , J > = S * P P ( 2 2 , J ) * V L L ( 2 » / V L H 2 2 ) P P ( 2 0 , J ) = 0 . 35 P P t l O . J ) = 0 . C C THE TOTAL M A L E S , TOTAL F E M A L E S , AND GRAND TOTAL ARE STORED C R E S P E C T I V E K Y IN P P ( 2 0 , J I , P P ( 4 0 , J I , A NO P P ( l l j J ) P P I 2 0 . 1 ) = 0 . P P 1 1 0 . 1 ) = 0 . 0 0 39 J = l , 6 I Y E A R t J + 1 ) = I Y E A R C J ) • 5 DO 37 1 = 2 , 1 9 . .•> P P I 2 0 . J I = P P ( 2 0 i J > + P P U . J I 37 P P ( 4 0 , J I = P P I 4 0 . J ) • P P ( I * 2 0 , J » 39 P P ( 4 1 , J I = P P 1 2 0 , J > ' • P P < 4 0 , J ) C C I F THE P R O J E C T I O N I S P A S T L Y E A R D O N ' T P R I N T I T . I F (L . G T . N) GO TO 59 P R I N T 1 1 , I I Y E A R ( J I , J = l , 6 I 11 F O R M A T ! 1 H 1 . 6 I 1 2 / I C C P R I N T F I R S T HALF OF S I X P R O J E C T I O N S P R I N T 4 3 , ( J J ( 1 ) , < P P ( I , J > , J = 1 , 6 I , J J C I I , 1 = 2 , 1 9 I 1 3 FORMAT l l X , I 2 , 6 F 1 2 . 0 f I 4 ) K = 20 C C P R I N T TOTALS FOR MALES P R I N T 4 7 , < P P ( K , J I , J = 1 , 6 ) 44 4 5 16 1 7 18 19 50 51 52 5 3 5 1 5 5 5 6 57 58 59 6 0 61 6 2 6 3 6 1 6 5 6 6 67 68 6 9 7 0 71 72 47 FORMAT < 3 H 0 T M , 6 F 1 2 . O , 4 H TM/1HO I C C P R I N T SECOND HALF OF S I X P R O J E C T I O N S P R I N T 4 3 , ( J J U ) , <PP t I , J I , J = l , 6 I , J J ( I ) , 1 = 2 2 , 39) K = 40 C C P R I N T TOTALS FOR F F M A L E S P R I N T 5 3 , I P P < K , J l , J = l , 6 I 53 FORMAT I 3 H O T F , 6 F 1 2 . 0 , 4 H TF /IHO ) , C C P R I N T GRAND TOTALS 5 5 P R I N T 5 7 , ( P P 1 4 1 j J ) , J = 1 , 6 > 57 FORMAT (3H T , 6 F 1 2 . 0 , 3 H T I C A T W E N T Y - F I V E YEAR P R O J E C T I O N C Y C L E HAS BEEN P R I N T E D C C ALAM IS C A L C U L A T E D AS THE RATIO OF THE TOTAL P R O J E C T E D C P O P U L A T I O N AT ONE T IME TO THAT F I V E YEARS B E F O R E ( I T I S ,THE C IT I S THE SAME AS THE DOMINANT ROOT OF THE P R O J E C T I O N MA TRIX I . C FROM THE L A T E S T P R O J E C T I O N , THE TOTAL P O P U L A T I O N I S C A R R I E D C BACKWARD TO THE I N I T I A L YEAR BY MEANS OF A L A M , WHICH C A P P R O X I M A T E S THE S T A B L E P O P U L A T I O N E O U I V A L E N T . 59 ALAM = P P t M l , 6 l / P P I 4 1 , 5 > A r A L A M * * ( - 5 * L 1 Q S T A R = P P ( 4 1 , 6 ) * A QrQSTAR • C C THE L A S T P R O J E C T I O N I S P L A C E D IN THE F I R S T P O S I T I O N FOR' THE C NEXT S E R I E S OF P R O J E C T I O N S . 0 0 6 5 1 =1 , 4 1 65 P P I I » 1 ) - P P ( I » 6 ) 67 I Y E A R l l l = I YE A R ( 6 ) C C THE P R O J E C T I O N I S NOW C O M P L E T E D . C WE PROCEEO TO A N A L Y S I S OF THE S T A B L E C O N D I T I O N . C C COMPUTE THE A G E - S E X - S P E C I F I C P O P U L A T I O N E O U I V A L E N T . 6 9 DO 7D 1=1 , 4 1 70 V I I I = P P ( I , 6 I * A C C THE S T A B I L I Z E D P O P U L A T I O N I S USED TO COMPUTE THE F E M A L E S T A B L E C OR I N T R I N S I C R A T E S OF B I R T H B , DEATH D , AND NATURAL I N C R E A S E R BBS=0.0 DO 71 1 = 4 , 1 2 71 BBS = BBS • P P J 1 + 2 0 , 6 ) * F F I I I / ( 1 . « S I B = B B S / P P ( 4 0 , 6 1 R = A L O G I A L A M I / 5 . 4 D = B - R C P R I N T S T A B L E OR I N T R I N S I C R A T E S . P R I N T 73 73 FORMAT ( 1H1 , 7 X , 4 O H S T A B L E E Q U I V A L E N T TO O R I G I N A L P O P U L A T I O N , / / 1 2 2 X , 5 H M A L E S , 8 X , 7 H F E M A L E S / / I P R I N T 7 5 , I J J I 1 1 , V I I > , V ( I + 2 0 1 , 1 = 2 , 1 9 1 75 FORMAT (1 O X , I 3 , 2 F 1 5 . 0 I P R I N T 7 9 , V ( 2 0 1 , V ( 4 0 ) , V I 4 1 I 73 74 75 76 77 78 79 8 0 81 82 8 3 84 8 5 86 87 88 89 9 0 9 1 9 2 9 3 94 9 5 9 6 97 9 8 99 1 0 0 79 FORMAT ( / 1 5 X , 2 H T M , F 1 1 . 0 , 2 X , 2 H T F , F 1 1 . 0 / / 1 1X , 5 H T O T A L , F 1 7 . 0 ) P R I N T 81 81 FORMAT ( 1 H 0 / 1 H 0 , 1 0 X , 1 S H I N T R I N S I C R A T E S I P R I N T 8 5 , B , D , R 8 5 FORMAT I I H U . I U X , 1 0 H B I R T H RATE , F 1 2 . 5 / 1 1 X , 1 O H D E A T H R A T E , F 1 2 . 5 / A 8X , 1 6 H N A T U R A L I N C R E A S E , F 9 . 5 ) NN - t L - 1 1 * 2 5 P R I N T 8 7 , N N 87 FORMAT I 1 HO / 11X , 3 3H8 A SE 0 ON P O P U L A T I O N P R O J E C T E D T O , 1 4 6 H Y E A R S 8 9 READ 1 ,NAME 0 0 9 1 1 = 1 , 1 0 I F I NAME 11 1 . N E . N A M E I 1 9 ) 1 GO TO 3 91 CONTINUE P R I N T 9 3 9 3 FORMAT ( 1 1 H 1 E N 0 OF JOB 1 STOP END J E X E C U T E $STOP S E N D F I L E t R U N *WATFIV S C A R O S = R I C H 5 = * S 0 U R C E * 6 = * S I N K * t S I G N O F F 1 0 1 1 0 2 1 0 3 1 0 4 1 0 5 1 0 6 1 0 7 1 0 8 1 0 9 1 1 0 111 1 1 2 1 1 3 114 1 1 5 1 1 6 1 1 7 

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