We found that two-thirds of the increase in life expectancy at birth since 2002 were due to declines in mortality among those aged 65 and over, and that these declines reflect a period rather than a cohort effect, suggesting that the causal factor or factors started to act with a short rather than with a long delay. Striking accelerations or even reversals of mortality trends occurred for various causes of death, many of which are typical for old-age such as stroke, pneumonia, dementia, and symptoms and ill-defined conditions. Favorable changes in mortality determinants coinciding with the acceleration of mortality decline mainly occurred within the health care system. Health care expenditure rose rapidly after 2001, and was accompanied by a sharp rise of elderly persons seeing a specialist, using prescribed drugs, being admitted to hospital, and undergoing surgical procedures. This included sharp rises in drug and surgical treatment for cardiovascular conditions, the cause-of-death group contributing most to the rise of life expectancy. A decline of deaths following non-treatment decisions is consistent with a change in physicians’ attitudes towards more active, life-prolonging treatment of elderly patients.
The results suggest that the sharp upturn of life expectancy in the Netherlands was at least partly due to a sharp increase in health care for the elderly, and has been facilitated by a relaxation of budgetary constraints in the health care system. That a more liberal administration to elderly patients of life-prolonging treatments has played a role in mortality decline is consistent with the decline in one-year case fatality among hospital patients which has been observed in the Netherlands . Between 2001 and 2005, mortality within 1 year after hospital admission declined for many conditions. Among those aged 80 years and over, the average decline (for all conditions combined) was about 14% (from 26 to 22%). This decline occurred for many conditions, including ischemic heart disease (where one-year case fatality declined from 34 to 28%) and stroke (where one-year case fatality declined from 52 to 45%) . Because there was a simultaneous increase in the hospital admission rate (Fig. 3), the decline in case fatality may also, at least partly, reflect a shift towards less severely ill patients. In the case of stroke, a plausible explanation for the decline of the one-year case fatality rate (and for the acceleration of mortality) is more rapid and more aggressive treatment for stroke in specialized stroke units, which were implemented on a large scale from about 2000 onwards .
In the case of pneumonia, dementia, and symptoms and ill-defined conditions, a more active approach towards the treatment of seriously ill elderly patients may have played a role too. Changes in mortality from these conditions are often regarded as indicative of “artefacts” of certification or coding, but these also reflect changes in physicians’ attitudes. As coding practices within Statistics Netherlands have not been systematically documented it is difficult to exclude changes in coding practice as an explanation. To the extent that they reflect changes in certification of causes of death, however, they suggest that physician attitudes have changed over time. Deaths certified as being caused by “pneumonia” can also be interpreted as a decision by the physician not to search for a better diagnosis, or if a better diagnosis is available not to treat the patient for this disease, but to let him or her die from what has always been considered the “old man’s friend” . The same applies to dementia, which as long as its complications are adequately treated will in itself not lead to death. If a death is being certified as caused by dementia, the physician has probably decided that further treatment is useless. For this very reason, dementia has long not been accepted as a possible “underlying” cause of death .
That the upturn of life expectancy may at least partly be due to a more liberal administration to elderly patients of life-prolonging treatments is also consistent with the results of end-of-life surveys in the Netherlands. These surveys show a strong decline in the proportion of deaths among the elderly in which life-prolonging treatment had been withheld or withdrawn (Table 3). For example, less withholding of treatment with antibiotics may have contributed to the reversal in the trend of mortality from pneumonia (Fig. 2). In these surveys, physicians were asked to estimate the amount of time by which life was shortened, and this was generally small but largest for withholding or withdrawing of life-prolonging treatment . The decline of the latter practice may therefore also have had a direct effect on survival rates in the population. An international survey has shown that Dutch physicians used to have higher frequencies of making end-of-life decisions than their colleagues in other European countries [25, 26], and we have shown elsewhere that the proportion of deaths with one of these end-of-life decisions was positively correlated with mortality rates among the elderly .
More health care may not only have reduced old-age mortality through more in-hospital treatment and/or more active treatment of severely ill patients, but also through more liberal administration in an outpatient setting of drugs which may prevent severe illness. The increase in prescription of lipid- and blood pressure lowering drugs to elderly people may have contributed to mortality decline because both types of drugs have been shown to reduce mortality, and to do so within a few years after start of treatment [28, 29]. Liberalization of preventive drug treatment can be traced in professional guidelines, which have gradually relaxed or abolished age-limits in the prescription of these drugs. For example, in 1999, the guideline of the Dutch Society of General Practice (NHG) for prescribing cholesterol lowering drugs still included an upper age-limit of 70 years for men and 75 years for women. In 2006, the new guideline on cardiovascular risk management no longer had age-limits for cholesterol lowering or blood pressure lowering drugs . In this case, the guidelines have apparently formalized changes which had already started to occur in the practice of health care.
We believe that the evidence for a contribution of increased health care delivery to the upturn of life expectancy in the Netherlands is compelling, but acknowledge that parallel trends in population-wide health care delivery and mortality indicators do not prove that one has led to the other. Individual level data, if they can be found, could be used to check whether the increases in survival really occurred among people who had received more health care, e.g. lipid-lowering drugs or PTCAs. The same applies to international comparisons of trends in determinants and trends in life expectancy.
The expansion of health care for the elderly coincided with a clear-cut change in growth of health care expenditure in the Netherlands. Long-term trends in health care spending in the Netherlands show a very distinct pattern, characterized by rapid growth in the 1960s and 1970s, relatively slow growth in the 1980s and 1990s, and rapid growth again in the first years of the new millennium. In terms of the volume of care annual growth rates were 4% in the 1970, 2% in the 1980s, 2% in the 1990s, and almost 6% in the period 2001–2007. Expressed as a proportion of Gross National Product, health care expenditure rose from about 4% in 1960 to about 9% in 1980, remained more or less stable until the year 2000, and then rapidly increased again to slightly above 10% in 2008. The annual growth rate of health care expenditure (in constant prices, i.e. adjusted for inflation) peaked in 2001, 2002, and 2003. It was 3.1% in 1999, 3.6% in 2000, 5.4% in 2001, 4.4% in 2002, 4.3% in 2003, 3.2% in 2004, 2.9% in 2005, 2.6% in 2006, and 3.1% in 2007 .
The sudden rise in health care expenditure after 2001 was due to a conscious decision by the Dutch government to relax the budgetary restraints of the 1980s and 1990s. During these two decades the Dutch government had successfully limited the growth of health care expenditure, first by a strict regulation of supply (hospital beds, expensive equipment, specialized personnel, …), then by imposing budget constraints for in-patient care. As a result, the proportion of GDP spent on health care in the Netherlands rose less than in many other high-income countries. As shown in Table 4, health care expenditure rose more rapidly during the 1980s and 1990s in Belgium, France, Germany, Switzerland, the United Kingdom and the United States. The only other countries with similar stagnation in the proportion of GDP spent on health care were Denmark (which also experienced a stagnation in life expectancy) and Sweden . By 2001 public dissatisfaction with waiting lists and other problems of access to the health care system had become so wide-spread in the Netherlands that the government decided to remove budgetary restraints. In the plan “Zorg verzekerd” (“Care insured (or ensured)”) the government promised that all necessary treatments would be eligible for reimbursement . As a result, health care costs rose sharply, until new but less tight restrictions were re-imposed around 2004.
It is difficult to say whether the relaxation of budgetary constraints directly caused the expansion of health care, or only facilitated a change that had its own momentum. Conceivably, these simultaneous changes in health care delivery and health care financing reflected a change towards less complacent attitudes to health care which were shared by both professionals and policy-makers. The early years of the new millennium were not only a period of rapid economic growth which made budgetary constraints less acceptable, but also of profound changes in public opinion, accelerated by the murder of Dutch politician Pim Fortuyn in 2001. Increased responsiveness of the health care system to consumer needs therefore may have been part of broader cultural changes as well.
In conclusion, although important questions remain a plausible hypothesis for explaining the sudden reversal of old-age mortality trends in the Netherlands is more health care for the elderly, which was at least facilitated by a sudden relaxation of budgetary restraints.