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)