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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. Context. - PowerPoint PPT Presentation
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Using Summary Measures of Mortality for Community Planning
and Policy Development
Bruce Cohen, Ph.D.Director, Division of Research, Bureau of Health
Statistics, MDPHNAPHSIS Annual Meeting
June 2008
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 income—this is an important focus for use of vitals data for community needs assessment and planning
Premature Mortality Rate (PMR)
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
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
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.
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
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
Median Household Income and PMR by EOHHS Regions, Massachusetts: 2005
0
50
100
150
200
250
300
350
400
BostonRegion
Western Central Southeast Northeast Metro West
PM
R
$0
$10,000
$20,000
$30,000
$40,000
$50,000
$60,000
$70,000
$80,000
$90,000
$100,000
Med
ian
Ho
use
ho
ld I
nco
me
($)
Age adjusted Rate per 100,000 population
Median Household Income
Source: Income information from the 2000 Census.
Less than High School Education and PMR by EOHHS Regions, Massachusetts: 2005
0
50
100
150
200
250
300
350
400
BostonRegion
Western Central Southeast Northeast Metro West
PM
R
0%
2%
4%
6%
8%
10%
12%
14%
%
Les
s th
an a
Hig
h S
cho
ol
Ed
uca
tio
n
Age adjusted Rate per 100,000 population
Less than High School Education
Source: Education information from the 2000 Census.
Premature Mortality Rates by Race and Hispanic Ethnicity Massachusetts: 2006
300.5279.8
140.3
427.3
298.8
0
200
400
600
White non-Hispanic
Black non-Hispanic
Asian non-Hispanic
Hispanic Total
Dea
ths
per
100
,000
Rates are per 100,000 population. Age-adjusted to the 2000 US standard population persons ages 0-74
* Statistically higher than state rate (p<0.05)** Statistically lower than state rate (p<0.05)
*
**
Rates per 100,000 population under 75 years of age; age-adjusted to the 2000 US standard population.
CHNA PMR1. Community Health Network of Berkshire = 330.82. Upper Valley Health Web-Franklin County = 334.23. Partnership for Health in Hampshire County = 285.74. The Community Health Connection = 370.75. Community Health Network of Southern Worcester County = 354.96. Community Partners for Health = 277.17. Community Health Network of Greater Metro West = 2508. Community Wellness Coalition = 3399. Fitchburg/Gardner Community Health Network = 324.510. Greater Lowell Community Health Network = 333.411. Greater Lawrence Community Health Network = 285.612. Greater Haverhill Community Health Network = 328.113. Community Health Network North = 248.8
14. North Shore Community Health Network = 303.515. Greater Woburn/Concord/Littleton Community Health Network = 217.816. North Suburban Health Alliance = 294.517. Greater Cambridge/Somerville Community Health Network = 255.718. West Suburban Health Network = 208.219. Alliance for Community Health = 365.420. Blue Hills Community Health Alliance = 297.321. Hampshire County Partnership = 367.522. Greater Brockton Community Health Network = 349.223. South Shore Community Partners in Prevention = 31324. Greater Attleboro-Taunton Health & Education Response = 347.125. Partners for a Healthier Community = 378.426. Greater New Bedford Health & Human Services Coalition = 35127. Cape Cod & Islands Community Health Network = 295.1
45
8
24
26
22
21
25
19
1
2 9
3
27
23
20
12
1011
1416
7
6
15
13
18
17
Rates are per 100,000 persons under 75 years of age, age-adjusted to the 2000 US standard population and are calculated using MDPH population estimates for 2005, which are the most updated estimates available at the sub-state level by age groups.
PMR by CHNA
Significantly higher than state rate
Not different from state rate
Significantly lower than state rate
Premature Mortality Rates (PMR) by Community Health Network Area Massachusetts: 2006
Premature Mortality Rates (PMR) to Chronic Diseasesby Community Health Network Area (CHNA), Massachusetts: 2006
Rates per 100,000 population under 75 years of age; age-adjusted to the 2000 US standard population.
CHNA PMR1. Community Health Network of Berkshire = 220.22. Upper Valley Health Web-Franklin County = 2183. Partnership for Health in Hampshire County = 184.44. The Community Health Connection = 225.95. Community Health Network of Southern Worcester County = 242.16. Community Partners for Health = 187.67. Community Health Network of Greater Metro West = 170.78. Community Wellness Coalition = 216.69. Fitchburg/Gardner Community Health Network = 213.410. Greater Lowell Community Health Network = 220.111. Greater Lawrence Community Health Network = 192.512. Greater Haverhill Community Health Network = 226.613. Community Health Network North = 174.5
14. North Shore Community Health Network = 188.815. Greater Woburn/Concord/Littleton Community Health Network = 151.816. North Suburban Health Alliance = 197.417. Greater Cambridge/Somerville Community Health Network = 16618. West Suburban Health Network = 136.919. Alliance for Community Health = 223.520. Blue Hills Community Health Alliance = 198.921. Hampshire County Partnership = 240.522. Greater Brockton Community Health Network = 228.923. South Shore Community Partners in Prevention = 216.924. Greater Attleboro-Taunton Health & Education Response = 235.325. Partners for a Healthier Community = 240.226. Greater New Bedford Health & Human Services Coalition = 219.627. Cape Cod & Islands Community Health Network = 192.2
45
24
22
21
25
19
1
2 9
3
6
8
27
23
26
20
12
1011
1416
7
15
13
18
17
Rates are per 100,000 persons under 75 years of age, age-adjusted to the 2000 US standard population and are calculated using MDPH population estimates for 2005, which are the most updated estimates available at the sub-state level by age groups.
PMR to Chronic Diseases by CHNA
Significantly higher than state rate
Not different from state rate
Significantly lower than state rate
Massachusetts PMR to Chronic Diseases= 203.2
Premature Mortality Rates (PMR) to Non-Chronic Diseasesby Community Health Network Area (CHNA), Massachusetts: 2006
Rates per 100,000 population under 75 years of age; age-adjusted to the 2000 US standard population.
CHNA PMR1. Community Health Network of Berkshire = 110.62. Upper Valley Health Web-Franklin County = 116.23. Partnership for Health in Hampshire County = 101.24. The Community Health Connection = 144.85. Community Health Network of Southern Worcester County = 112.86. Community Partners for Health = 89.57. Community Health Network of Greater Metro West = 79.38. Community Wellness Coalition = 122.59. Fitchburg/Gardner Community Health Network = 111.110. Greater Lowell Community Health Network = 113.311. Greater Lawrence Community Health Network = 93.112. Greater Haverhill Community Health Network = 101.613. Community Health Network North = 74.3
14. North Shore Community Health Network = 114.615. Greater Woburn/Concord/Littleton Community Health Network = 66.016. North Suburban Health Alliance = 97.117. Greater Cambridge/Somerville Community Health Network = 89.618. West Suburban Health Network = 71.419. Alliance for Community Health = 141.920. Blue Hills Community Health Alliance = 98.421. Hampshire County Partnership = 127.022. Greater Brockton Community Health Network = 120.323. South Shore Community Partners in Prevention = 96.124. Greater Attleboro-Taunton Health & Education Response = 111.825. Partners for a Healthier Community = 138.226. Greater New Bedford Health & Human Services Coalition = 131.427. Cape Cod & Islands Community Health Network = 102.9
4
2625
19
1
2 9
3
56
8
27
2423
20
12
10
22
21
11
1416
7
15
13
18
17
Rates are per 100,000 persons under 75 years of age, age-adjusted to the 2000 US standard population and are calculated using MDPH population estimates for 2005, which are the most updated estimates available at the sub-state level by age groups.
PMR to Non-Chronic Diseases by CHNA
Significantly higher than state rate
Not different from state rate
Significantly lower than state rate
Massachusetts PMR to non Chronic Diseases= 107.9
Premature Mortality Rate by Race/EthnicityChronic Diseases1, Massachusetts: 2006
197.8 195.0
97.9*
146.8*
245.0*
0
50
100
150
200
250
300
White non-Hispanic
Black non-Hispanic
Hispanic Asian non-Hispanic
ALL
Dea
ths
per
100
,000
Age-adjusted to the 2000 US standard population under 75 years of age.
(*) Statistically different from State (p ≤.05)
1 Includes Cancer, heart disease, stroke, CLRD, nephritis, chronic liver disease, diabetes, Parkinson, and other chronic diseases
Premature Mortality Rate by Race/EthnicityNon Chronic Conditions/Diseases,
Massachusetts: 2006
101.0 105.5
42.4*
133.0*
182.3*
0
20
40
60
80
100
120
140
160
180
200
White non-Hispanic
Black non-Hispanic
Hispanic Asian non-Hispanic
ALL
Dea
ths
per
100
,000
Age-adjusted to the 2000 US standard population under 75 years of age.
(*) Statistically different from State (p ≤.05)
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.)
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.
Mortality Amenable to Health Care
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 1970’s; 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
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)
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)
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
Hodgkin’s 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
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
List of Causes of Death Considered Amenable to Health care (continued)
Reasons Considered Amenable
Reasons Considered Amenable
Percent Amenable Deaths Massachusetts: 2006
All Deaths
90%
Amenable
Deaths10%
Amenable
Deaths28%
All Deaths Ages 0-
7472%
All Deaths Deaths Persons Ages 0-74
Mortality Rates for Causes Amenable to Health Care by Race and Ethnicity
Massachusetts: 2000 and 2006
105.4
142.9
40.6
103.6
64.5
84.081.4
48.1
128.4
82.5
0
40
80
120
160
White non-Hispanic
Black non-Hispanic
Asian non-Hispanic
Hispanic Total
Dea
ths
per
100
,000
2000 2006
Rates are per 100,000 population. Age-adjusted to the 2000 US standard population persons ages 0-74
**
** Statistically lower than 2000 rate (p<0.05)
**
133.7
86.0
103.6
84.0
67.6
101.8
0
40
80
120
160
Male Female Total
Dea
ths
per
100
,000
2000 2006
Rates are per 100,000 population. Age-adjusted to the 2000 US standard population persons ages 0-74
** Statistically lower than 2000 rate (p<0.05)
**
****
Mortality Rates for Causes Amenable to Health Care by Gender
Massachusetts: 2000 and 2006
Premature Mortality Rates & Amenable Mortality
by Race and Ethnicity, Massachusetts: 2006
29%34%30%
28%28%
427.3
298.8300.5
140.3
279.8
0
100
200
300
400
500
600
Total White non-Hispanic
Black non-Hispanic
Asian non-Hispanic
Hispanic
Dea
ths
per
100
,000
Rates are per 100,000 population. Age-adjusted to the 2000 US standard population persons ages 0-74
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.
The Interaction between race and poverty: examples from natality analyses
No direct measure of income on the birth certificate
Education is useful, but teens haven’t 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.)
Infant Mortality Rate by Race and Education Mothers Ages 25+, Massachusetts – 2000-2006
6.1
3.7 3.6
7.2
4.9
2.5
11.9*
9.0*
16.0*
0
2
4
6
8
10
12
14
16
18
High School or Less Some College College Graduate or More
Infa
nt D
eath
s p
er 1
,000
Liv
e B
irth
s
White, Non-Hispanic
Black, Non-Hispanic
Hispanic
* Significantly Different from White Non-Hispanic
Infant Mortality Rate by Percent in Poverty and Race-Hispanic Ethnicity
Bla
ck N
H
Bla
ck N
H
Bla
ck N
H
Bla
ck N
H
His
pan
ics
His
pan
ics
His
pan
ics
His
pan
ics
Asi
an N
H
Asi
an N
H
Asi
an N
H
Asi
an N
H
Wh
ite
NH
Wh
ite
NH
Wh
ite
NH
Wh
ite
NH
0
5
10
15
0- 4.9% 5- 9.9% 10-19.9% 20-100 %
Percent in Poverty
IMR
(p
er 1
000
live
bir
ths)
Infant Mortality Rate by Race-Hispanic Ethnicity and Percent in Poverty
0-
4.9
%
0-
4.9
%
0-
4.9
%
5-
9.9
%
5-
9.9
%
5-
9.9
%
10-1
9.9
%
10-1
9.9
%
10-1
9.9
%
20-1
00 %
20-1
00 %
20-1
00 %
0-
4.9
%
5-
9.9
%
10-1
9.9
%
20-1
00 %
0
5
10
15
White NH Black NH Hispanics Asian NH
Race-Hispanic Ethinicty
IMR
(p
er
1000 l
ive b
irth
s)
LBW by Percent in Poverty and Race-Hispanic Ethnicity
Bla
ck N
H
Bla
ck N
H
Bla
ck N
H
Bla
ck N
H
His
pan
ics
His
pan
ics
His
pan
ics
His
pan
ics
Asi
an N
H
Asi
an N
H
Asi
an N
H
Asi
an N
H
Wh
ite
NH
Wh
ite
NH
Wh
ite
NH
Wh
ite
NH
0
5
10
15
0- 4.9% 5- 9.9% 10-19.9% 20-100 %
Percent in Poverty
LB
W (
%)
Smoking During Pregnancy by Percent in Poverty and Race-Hispanic Ethnicity
Bla
ck N
H
Bla
ck N
H
Bla
ck N
H
Bla
ck N
H
His
pan
ics
His
pan
ics
His
pan
ics
His
pan
ics
Asi
an N
H
Asi
an N
H
Asi
an N
H
Asi
an N
H
Wh
ite
NH
Wh
ite
NH
Wh
ite
NH
Wh
ite
NH
0
5
10
15
20
25
0- 4.9% 5- 9.9% 10-19.9% 20-100 %
Percent in Poverty
Sm
oki
ng
Du
rin
g P
reg
nan
cy(%
)
Smoking During Pregnancy by Race-Hispanic Ethnicity and Percent in Poverty
0-
4.9
%
0-
4.9
%
0-
4.9
%
5-
9.9
%
5-
9.9
%
5-
9.9
%
10-1
9.9
%
10-1
9.9
%
10-1
9.9
%
20-1
00 %
20-1
00 %
20-1
00 %
0-
4.9
%
5-
9.9
%
10-1
9.9
%
20-1
00 %
0
5
10
15
20
25
White NH Black NH Hispanics Asian NH
Race-Hispanic Ethinicty
Sm
okin
g D
uri
ng
Pre
gn
an
cy(%
)
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 ways—we should be standardizing and promoting these applications