Using Summary Measures of Mortality for Community Planning and Policy Development

1
Using 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

2
Context

• 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

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Premature Mortality Rate (PMR)
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PMR 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

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PMR 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
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PMR 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.

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PMR 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

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PMR 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

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Median Household Income and PMR by EOHHS Regions,
Massachusetts 2005
Source Income information from the 2000 Census.
10
Less than High School Education and PMR by EOHHS
Regions, Massachusetts 2005
Source Education information from the 2000
Census.
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Premature 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
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Premature Mortality Rates (PMR) by Community
Health Network Area Massachusetts 2006
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Premature 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
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Premature 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.


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PMR 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.)

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PMR 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.

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Mortality Amenable to Health Care
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Amenable 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

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Amenable 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)

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Amenable 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)

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List 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

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List 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

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List 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

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Reasons Considered Amenable
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Reasons Considered Amenable
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Percent Amenable Deaths Massachusetts 2006
All Deaths
Deaths Persons Ages 0-74
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Mortality 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
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Mortality 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
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Premature 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
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Uses 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.

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The 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.)

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Infant Mortality Rate by Race and Education
Mothers Ages 25, Massachusetts 2000-2006
Significantly Different from White Non-Hispanic
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Infant Mortality Rate by Percent in Poverty and
Race-Hispanic Ethnicity
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Infant Mortality Rate by Race-Hispanic Ethnicity
and Percent in Poverty
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LBW by Percent in Poverty and Race-Hispanic
Ethnicity
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Smoking During Pregnancy by Percent in Poverty
and Race-Hispanic Ethnicity
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Smoking During Pregnancy by Race-Hispanic
Ethnicity and Percent in Poverty
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Concluding 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