Aging, Health Systems and Health Outcomes: The World Cities Project Cadenza Symposium on Age-Friendly World Cities & Environment October 8-9, 2010 Victor G. Rodwin Professor of Health Policy and Management Wagner School, New York University

Growth of Urbanization Worldwide Virtually all population growth projected by UN between 2010 until 2030 will be concentrated in cities. In 2000, 47% of world’s population lived in cities; in 2030, 60% will live in cities.

Growth of Megacities  “Megacities” Over 10 Million People All in Developing World Except NYC and Tokyo In 2015, there will be 23 Megacities

Tokyo, New York, London and Paris: Units of Analysis

New York City 8.0 million (2000); 65+ = 937,857 Central Tokyo 8.1 million (2000) 65+ =1,336, 289 Paris and First Ring 6.2 million (1999) 65+ = 848,723 Greater London 7.3 million (2000) 65+ = 908, Hauts-de- Seine Val-de- Marne Seine-Saint Denis Bronx Manhattan Queens Brooklyn Staten Island Inner Tokyo Outer Tokyo Outer London Inner London

ManhattanInner London ParisInner Tokyo # of teaching hospitals # of medical schools5477 Acute hospital beds per 1000 population 5.5 (2002)4.1 (1990)7.0 (2002)12.8 (2000) 1 Physicians per 10,000 Population 85.5 (2004)36.9 (2000)85 (2002)70.0 (2000) Health Care Resources: Manhattan, Inner London, Paris and Tokyo ( )

Source: Rodwin, Gusmano, Montero(2003) Etudes et Résultats, DRESS, Paris. LE at 65: National and City Levels

Men & Women 85+ Living Alone: Manhattan, Paris, Inner London, & Inner Tokyo

Institutional Long-Term Care Beds Per 1,000 Persons Over 65+

Nursing Home Care: Similarities Nursing home rates are lower in the urban cores than in the first rings High price of real estate in the urban cores tends to restrict investment in institutional long-term care facilities compared to first ring In NYC and Paris, persons over 65 who live alone have higher levels of educational attainment than those who live in institutions

Home Help Users 65 Years and Over London, New York, Paris and Tokyo ( )

Globalization and policy ? Globalization and policy convergence? Evidence of convergence: significant and growing inequalities of income, housing, health and health care within all four cities. Evidence that “politics matters”: Japan’s LTCI; France’s recent expansion of home care services Evidence captured by neither: New York, the “hardest” global city provides twice as many nursing home beds and as much home help as the “soft” cities in our analysis

Challenges and Lessons Can we afford to allow frail older persons to remain in the urban core of world cities? Local policies fill the residuals left by higher levels of government Local administrative discretion is significant Cities cope with diverse older persons Providing information to older persons and giving them greater voice Supporting the oldest old living alone and identifying the most isolated and vulnerable

- Life expectancy at birth - Probability of survival given diseases - Premature Mortality - Avoidable Mortality - Access to Primary Care - Access to Specialty Care Health Outcomes and Health System Performance

Premature Mortality Rate per 1,000 by Neighborhood Quartile Age-Standardized, UN World Population 2004

Defining “Avoidable Mortality” “Avoidable Mortality” premature death (prior to 75 years) from diseases amenable to screening and medical intervention Examples include: –ischemic heart disease –several malignancies: breast, colon, cervix, skin –tuberculosis –Maternal deaths

Average rate, From Chau, PH, Woo, J et. al. Avoidable Mortality Pattern..European J. Public Health

Avoidable Hospital Conditions Examples: Pneumonia Congestive Heart Failure Asthma Cellulitus Marker Conditions Examples: Acute Myocardial Infarction Appendicitis GI obstruction Hip fracture Comparing Access to Primary Care We use the list of ICD-9/ICD-10 Codes from the definition used by Dr. Joel Weissman and colleagues. The Weissman definition includes the following conditions: pneumonia, congestive heart failure, asthma, cellulitis, perforated or bleeding ulcer, pyelonephritis, diabetes with ketoacidosis or coma, ruptured appendix, malignant hypertension, hypokalemia, immunizable conditions, and gangrene.

Characteristics of Residents by Income Quartile of Neighborhood Socioeconomic Status: Manhattan, Inner London, Paris Total PopulationEducation Level 1 Median Household Income Range Deprivation Score Manhattan Q1529, %$20,111 - $27,693N/A Q2320, %$41,335 - $54,051N/A Q3304, %$57,597 - $65,038N/A Q4371, %$68,355 - $73,816N/A Paris Q1778, %€ 20,061 - € 22,470N/A Q2417, %€ 22,575 - € 25,971N/A Q3566, %€ 26,506 - € 28,551N/A Q4361, %€ 28,572 - € 36,161N/A Inner London Q1642, %N/A58.26 Q2903, %N/A42.6 Q3612, %N/A34.97 Q4607, %N/A Bachelors degree or higher Sources: U.S. Census 2000; French Census 1999; National Office of Statistics, UK 2001

Avoidable Hospital Conditions per 1,000 by Neighborhood Quartile Age-Standardized, UN World Population 2004

Revascularizations per 100,000 (35+), by Neighborhood Quartile Age-Standardized, UN World Population 2004

Lower Joint Replacement Rate per 100,000 by Neighborhood Quartile Age-Standardized, UN World Population 2004