Trends in ‘Avoidable’ Mortality by Neighbourhood Income in Urban Canada from 1971 to 1996 Paul...
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Transcript of Trends in ‘Avoidable’ Mortality by Neighbourhood Income in Urban Canada from 1971 to 1996 Paul...
Trends in ‘Avoidable’ Mortality by Trends in ‘Avoidable’ Mortality by NeighbourhoodNeighbourhood Income in Urban Income in Urban
Canada from 1971 to 1996Canada from 1971 to 1996
Paul James
Department of Epidemiology and Community Medicine
University of Ottawa
OutlineOutline
• Mortality inequalities in Canada
• ‘Avoidable’ mortality concept and studies
• Thesis objective and methods
• Results
• Limitations
• Conclusions
The poorer the neighbourhood, the shorter The poorer the neighbourhood, the shorter the life expectancy of its residents.the life expectancy of its residents.
Source: Wilkins R, Berthelot JM and Ng E. Trends in mortality by neighbourhood income in urban Canada from 1971 to 1996. Health Reports. 2002.
Deaths from conditions for which effective medical and/or public health interventions are available
Proposed by Rutstein et al. in 1976• Potential health care performance indicator• Signal areas that warrant further study
European Community Action Project on Heath Services and “Avoidable Mortality” (ECCAP)
CIHI?
‘‘Avoidable’ DeathsAvoidable’ Deaths
CausesCauses ICD8 CodeICD8 Code ICD9 CodeICD9 Code Age GroupAge Group
Tuberculosis 010-019 010-018, 137 5-64
Malignant neoplasm of uterus body (except cervix)
182 179, 182 15-54
Malignant neoplasm of the cervix 180 180 15-64
Malignant neoplasm of the breast 174 174 25-64
Hodgkin’s disease 201 201 5-64
Chronic rheumatic heart disease 393-398 393-398 5-44
All respiratory diseases(except Asthma)
460-492, 500-519 460-492, 494-519 1-14
Asthma 493 493 5-44
Peptic Ulcers 531-534 531-534 25-64
Appendicitis 540-543 540-543 5-64
Abdominal hernia 550-553 550-553 5-64
Cholelithiasis and cholecystitis 574-575 574-575.1, 576.1 5-64
Ischaemic heart disease 410-414 410-414, 429.2 35-64
Hypertension and cerebrovascular disease 400-404, 430-438 401-405, 430-438 35-64
Maternal deaths 630-678 630-676 0-74
Perinatal deaths 760-779 760-799 --
Holland and ECCAP, 1997Holland and ECCAP, 1997
‘‘Avoidable’ MortalityAvoidable’ Mortality• Temporal trends
– Declines in mortality from avoidable causes were more pronounced compared to mortality from other causes
• Regional comparisons– Highlight areas with excess mortality and stimulate
further inquiry
• Socioeconomic comparisons– What has been the contribution of health care to
mortality inequalities?
Previous StudiesPrevious Studies
British ColumbiaBritish Columbia (Wood et al. Soc Sci Med 1999)
• Mortality amenable to medical intervention was higher in men of lower occupational classes for the period 1981-1991(RR 1.8, 95%CI 1.4-2.2)
ObjectiveObjective
To examine changes in neighbourhood income-related differences in ‘avoidable’, and other cause, mortality in urban Canada from 1971 to 1996.
DataData• Death registration and populations for census metropolitan areas
(CMAs) for the years 1971, 1986, 1991 and 1996
Canadian Mortality Database Population censuses
• Deaths were previously coded to census tract and grouped into CMA-based neighbourhood income quintiles
• Excluded Institutional residents Deaths over 74 yrs
Q1=richest, Q5=poorest, QT=total population (all quintiles)
AnalysisAnalysis• Classified ‘avoidable’ deaths
7 Classification lists “Master list”: Medical intervention, public health, ischaemic heart disease and
other causes
• Age Standardized Potential Years of Life Lost (SPYLL)Period Expected Years of Life Lost (SEYLL)
• Life expectancy of the least poor quintile (Q1)
• Compared Q5-Q1 and QT-Q1Rate ratios Rate differences95% Confidence Intervals
ResultsResults
1. Regardless of the l1. Regardless of the listist, ‘avoidable’ SEYLL , ‘avoidable’ SEYLL disparity decreased from 1971 to 1996disparity decreased from 1971 to 1996
Males
0
1000
2000
3000
4000
5000
6000
Charlton 1983 Poikolainen1986
Mackenbach1988
Holland 1988 Holland 1997 Humblet 2000 Nolte 2002
Classification List
Q5
-Q1
SE
YL
L D
iffe
ren
ce
(pe
r 1
00
00
0)
1971 1986 1991 1996
1. Regardless of the l1. Regardless of the listist, ‘avoidable’ SEYLL , ‘avoidable’ SEYLL disparity decreased from 1971 to 1996disparity decreased from 1971 to 1996
Females
0
1000
2000
3000
4000
5000
6000
Charlton 1983 Poikolainen1986
Mackenbach1988
Holland 1988 Holland 1988 Humblet 2000 Nolte 2002
Classification List
Q5
-Q1
SE
YL
L D
iffe
ren
ce
(pe
r 1
00
00
0)
1971 1986 1991 1996
2. SEYLL disparity from medical care and public 2. SEYLL disparity from medical care and public health causes decreased from 1971 to 1996health causes decreased from 1971 to 1996
Males
0
1000
2000
3000
4000
5000
Medicalintervention
Public health Ischaemic heartdisease
Other causes
Cause Category
Q5
-Q1
SE
YL
L D
iffe
ren
ce
(pe
r 1
00
00
0)
1971 1986 1991 1996
2. SEYLL disparity from medical care and public 2. SEYLL disparity from medical care and public health causes decreased from 1971 to 1996health causes decreased from 1971 to 1996
Females
0
1000
2000
3000
4000
5000
Medicalintervention
Public health Ischaemicheart disease
Other causes
Cause Category
Q5
-Q1
SE
YL
L D
iffe
ren
ce (
pe
r 1
00
00
0)
1971 1986 1991 1996
3. Ischaemic heart disease, Lung cancer, Perinatal 3. Ischaemic heart disease, Lung cancer, Perinatal conditions and Cerebrovascular disease contributed conditions and Cerebrovascular disease contributed the most to SEYLL disparity.the most to SEYLL disparity.
Cause Males Females
Ischaemic heart disease (35-74) 14.14 15.95
Lung Cancer (0-74) 8.70 10.92
Perinatal conditions 5.72 6.32
Cerebrovascular disease (35-74) 3.64 4.25
Percent of all-cause QT-Q1 SEYLL rate difference, 1996
4a. In general, SEYLL disparity from ‘avoidable’ 4a. In general, SEYLL disparity from ‘avoidable’ causes decreased from 1971 to 1996causes decreased from 1971 to 1996..
Ischaemic heart disease (35-74), males
0
1000
2000
3000
4000
5000
6000
1971 1976 1981 1986 1991 1996
Year
SE
YL
L (p
er
10
0 0
00
)
Q1Q2Q3Q4Q5
4a. In general, SEYLL disparity from ‘avoidable’ 4a. In general, SEYLL disparity from ‘avoidable’ causes decreased from 1971 to 1996causes decreased from 1971 to 1996..
Cervical cancer (15-74), females
0
50
100
150
200
250
300
350
400
1971 1976 1981 1986 1991 1996
Year
SE
YL
L (p
er
10
0 0
00
)
Q1Q2Q3Q4Q5
4b. Exceptions: 4b. Exceptions: Lung CancerLung Cancer
Lung cancer (0-74), females
0
100
200
300
400
500
600
700
800
900
1000
1971 1976 1981 1986 1991 1996
Year
SE
YL
L (p
er
10
0 0
00
)
Q1Q2Q3Q4Q5
Some LimitationsSome LimitationsData:• Death certification and coding• Underlying cause of death versus multiple causes of death
‘Avoidable’ mortality:• No information on quality of life, condition severity, morbidity• Not shown to be associated with health services
SES trend:• Healthy Immigrant effect• Institutional population• Ecologic fallacy?• Health selection
ConclusionsConclusions
1. Deaths amenable to public health and medical intervention were associated with the reduction of mortality disparities in urban Canada from 1971 to 1996
2. The largest SEYLL disparities in 1996 were related to deaths from ischaemic heart disease, lung cancer, perinatal conditions and cerebrovascular disease
3. The unchanging and increasing mortality disparities related to some causes warrant further investigation
Thank you!Thank you!
Health Analysis and Measurement Group
Institute of Clinical Evaluative Sciences
Centre for Global Health
Russell Wilkins (HAMG) Doug Manuel (ICES) Peter Tugwell (CGB)