Title: Using Summary Measures of Mortality for Community Planning and Policy Development
1Using Summary Measures of Mortality for Community
Planning and Policy Development
- Bruce Cohen, Ph.D.
- Director, Division of Research, Bureau of Health
Statistics, MDPH - NAPHSIS Annual Meeting
- June 2008
2Context
- Many public health practitioners feel that
mortality data are not very useful death is too
late of end-point to use for policy, targeting
interventions, and evaluation of health care
delivery - There are summary, non disease-specific measures
that have been developed to enhance the utility
of mortality data to identify potential system
changes - Two such measures are
- premature mortality (PMR)
- mortality Amenable to Health Care (AM)
- As an additional issue, briefly present data on
the interaction of race and incomethis is an
important focus for use of vitals data for
community needs assessment and planning
3Premature Mortality Rate (PMR)
4PMR Background
- Almost 2 out of 3 deaths in Massachusetts occur
to people age 75 and older - Although quality of life for our older citizens
is important, we wanted to use a measure that
focused on the health of younger persons - Why? The rationale is that the vast majority of
deaths to persons age 75 and older are due to
chronic conditions associated with aging - By examining deaths to persons younger than 75,
it is possible to identify many issues that are
more amenable to systematic public health
approaches to health promotion and disease
prevention
5PMR Background
- THE PMR is considered an excellent, single
measure that reflects the health status of a
population, and the need for systematic public
health approaches to health promotion and disease
prevention.1,2 - Sometimes used as an indicator of health care
need
1Eyles J, Birch S. A population needs-based
approach to health care resource allocation and
planning in Ontario A link between policy goals
and practice. Can J Public Health 1993 84(2)
112-117. 2 Carstairs V., Morris R. Deprivation
and Health in Scotland. Aberdeen Scotland
Aberdeen University Pres, 1991
6PMR Attractive Properties...
- Data used to calculate the PMR are readily
available (mortality and age of population) - PMR is easily understandable and intuitive
- PMR provides a mechanism to summarize the burden
of multiple adverse conditions creating a broader
community perspective.
7PMR Definition
- The number of deaths to persons age 0-74 divided
by the population age 0-74 (per 100,000) - Age adjusted to the 2000 US standard population,
age 0-74
8PMR related to many factors
- Health care is certainly one of these factors,
but not the only factor - PMR may be related to socioeconomic status and
its correlates potential issues such as
environmental conditions, housing, education,
stress, higher rates of smoking, substance abuse,
violence, obesity, and lack of access to care - Other possible reasons for high PMRs specific
sub-populations of younger persons at risk such
as - HIV/AIDS
- increased motor vehicle deaths in rural areas
- heart attack deaths in persons 45-64 in suburbia
- violence
9Median Household Income and PMR by EOHHS Regions,
Massachusetts 2005
Source Income information from the 2000 Census.
10Less than High School Education and PMR by EOHHS
Regions, Massachusetts 2005
Source Education information from the 2000
Census.
11Premature Mortality Rates by Race and Hispanic
Ethnicity Massachusetts 2006
Statistically higher than state rate
(plt0.05) Statistically lower than state rate
(plt0.05)
Rates are per 100,000 population. Age-adjusted
to the 2000 US standard population persons ages
0-74
12Premature Mortality Rates (PMR) by Community
Health Network Area Massachusetts 2006
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15Premature Mortality Rate by Race/EthnicityChronic
Diseases1, Massachusetts 2006
() Statistically different from State (p .05)
Age-adjusted to the 2000 US standard population
under 75 years of age.
1 Includes Cancer, heart disease, stroke, CLRD,
nephritis, chronic liver disease, diabetes,
Parkinson, and other chronic diseases
16Premature Mortality Rate by Race/EthnicityNon
Chronic Conditions/Diseases, Massachusetts 2006
() Statistically different from State (p .05)
Age-adjusted to the 2000 US standard population
under 75 years of age.
17PMR Limitations
- PMR does not identify specific reasons why some
areas may be high or low - summary measures may sometimes obscure important
subgroup differences - mortality might not be a good measure of
important public health issues (e.g. arthritis,
poor housing, etc.)
18PMR summary
- The PMR is a useful tool
- to begin discussions that allow policy makers,
community advocates, public health professionals,
and cities and towns to consider more effective
and cost efficient approaches to improving the
quality of life and health of the public - to focus on the inter-connected roots of early
death and direct us towards considering the
overall health of our communities.
19Mortality Amenable to Health Care
20Amenable Mortality Background
- Definition deaths from certain causes that
should not occur in the presence of timely and
effective health care.1,2 - Originally developed in US in 1970s adopted and
updated by many researchers especially in
Europe.2 - This concept has been revitalized and used to
assess the quality of health care systems - Potentially useful tool to assess performance of
health care systems and track changes over time.1 - 1Nolte E and McKee CM. Measuring The Health of
Nations Updating An Earlier Analysis. Health
Affairs 2008 Vol 27, Number 1 58-71 Jan/Feb
2008. - 2Nolte E and McKee CM . Does Health Care Save
Lives? Avoidable Mortality Revisited. The
Nullfield Trust. 2004. London, England
21Amenable Mortality Background
- Causes amenable to secondary prevention through
early detection and treatment this includes
causes where screening and treatment are
effective for example breast, cervical, and skin
cancer - Causes amenable to improved treatment and medical
care this group includes infectious diseases
causes that respond to antibiotic treatments and
immunizations as well as causes that require
direct medical and/or surgical intervention such
as appendicitis and hypertension or causes that
rely on efficient medical care delivery (accurate
and timely diagnosis, transport, and treatment.) - (Adapted from Does Health Care Save Lives? p.30)
22Amenable Mortality Background
- Operationalized as a set of 33 cause of death
codes for persons under age 751 - Subset of PMR
- 1 Online data supplement to Nolte and McKee,
Measuring the Health Of Nations. Health Affairs.
Vol. 27, no. 1. (http//content.healthaffairs.org/
cgi/content/full/27/1/58/DC1)
23List of Causes of Death Considered Amenable to
Health care
- Intestinal infections
- Tuberculosis
- Other infectious (Diphtheria, Tetanus,
Poliomyelitis) - Whooping cough
- Septicemia
- Measles
- Malignant neoplasm of colon and rectum
- Malignant neoplasm of skin,
- Malignant neoplasm of breast,
- Malignant neoplasm of cervix uteri
- Malignant neoplasm of cervix uteri and body of
the uterus - Malignant neoplasm of testis
24List of Causes of Death Considered Amenable to
Health care (continued)
- Hodgkins disease
- Leukemia
- Diseases of the thyroid
- Diabetes mellitus
- Epilepsy
- Chronic rheumatic heart disease
- Hypertensive disease
- Ischemic heart disease
- Cerebrovascular disease
- All respiratory diseases (excl.
pneumonia/influenza) - Influenza
25List of Causes of Death Considered Amenable to
Health care (continued)
- Pneumonia
- Peptic ulcer
- Appendicitis
- Abdominal hernia
- Cholelithiasis cholecystitis
- Nephritis and nephrosis
- Benign prostatic hyperplasia
- Maternal deaths
- Congenital cardiovascular anomalies
- Perinatal deaths, all causes excluding
stillbirths - Misadventures to patients during surgical and
medical care
26Reasons Considered Amenable
27Reasons Considered Amenable
28Percent Amenable Deaths Massachusetts 2006
All Deaths
Deaths Persons Ages 0-74
29Mortality Rates for Causes Amenable to Health
Care by Race and Ethnicity Massachusetts 2000
and 2006
Statistically lower than 2000 rate (plt0.05)
Rates are per 100,000 population. Age-adjusted
to the 2000 US standard population persons ages
0-74
30Mortality Rates for Causes Amenable to Health
Care by GenderMassachusetts 2000 and 2006
Statistically lower than 2000 rate (plt0.05)
Rates are per 100,000 population. Age-adjusted
to the 2000 US standard population persons ages
0-74
31Premature Mortality Rates Amenable Mortality
by Race and Ethnicity, Massachusetts 2006
Rates are per 100,000 population. Age-adjusted
to the 2000 US standard population persons ages
0-74
32Uses of Amenable Mortality
- Amenable mortality is a useful tool
- to begin discussions that allow policy makers,
community advocates, and public health
professionals, to consider more effective and
cost efficient approaches to improving the
quality of life and health of the public - to move us away from considering only individual
diseases, and directs us towards considering the
overall health and access issues.
33The Interaction between race and poverty
examples from natality analyses
- No direct measure of income on the birth
certificate - Education is useful, but teens havent completed
schooling and foreign born have different
educational experiences - Is it race? (surrogate for unequal treatment,
cultural differences, linguistic isolation, etc.)
OR - Is it poverty? (lack of financial access to
purchase medical care, other necessities,
surrogate for other detrimental exposures such as
higher pollution, crime, stress, etc.)
34Infant Mortality Rate by Race and Education
Mothers Ages 25, Massachusetts 2000-2006
Significantly Different from White Non-Hispanic
35Infant Mortality Rate by Percent in Poverty and
Race-Hispanic Ethnicity
36Infant Mortality Rate by Race-Hispanic Ethnicity
and Percent in Poverty
37LBW by Percent in Poverty and Race-Hispanic
Ethnicity
38Smoking During Pregnancy by Percent in Poverty
and Race-Hispanic Ethnicity
39Smoking During Pregnancy by Race-Hispanic
Ethnicity and Percent in Poverty
40Concluding thoughts
- We should be as creative as possible making our
statistics and analyses vital for public health
policy development and community uses - There are emerging frameworks that allow for use
of vital statistics in these wayswe should be
standardizing and promoting these applications