April 13, 2011 Back to Basics, 2011 POPULATION HEALTH : Vital & Health Statistics Presented by Robert Spasoff, MD Epidemiology & Community Medicine 1

April 13, : VITAL STATISTICS INFORMATION What are the key causes of illness or death in Canada? Common things are common – using epidemiology can help you run a better clinical practicekey causes of illness or death How have disease incidence and mortality changed in Canada in the past 20 years? –Little good information on disease incidence except for reportable diseases and cancer (cancer registries) 2

April 13, 2011 TOPICS Demography, population dynamics Mortality, and inequalities therein Morbidity Summary measures of population health Aboriginal health 3

April 13, 2011 Population Dynamics, 2007 CanadaNfldNunavut % aged 65+14%15%3% Total fertility Crude Birth rate Crude Death rate Rate of Natural Increase

World Health Report, 2006 (data mostly from 2004) Population (x 1,000) Growth (%) Dependency ratio % % aged > 60 Total Fertility rate LE at birth (both sexes) P dying < 5 yrs (per 1000) Canada31, USA295, France60, Japan127, China1,315, Afghan- istan 28, April 13, 20115

Canadian Historical Population Pyramids roducts/analytic/companion/age/cda01pymd.cfmhttp://www12.statcan.ca/english/census01/p roducts/analytic/companion/age/cda01pymd.cfm April 13, 20116

Standardization An older method of adjusting for confounding (usually used for differences in age between two populations) Refers observed events to a standard population, producing hypothetical values Direct: yields age-standardized rate (ASMR) Indirect: yields standardized mortality ratio (SMR) 7

April 13, 2011 Mortality data Three ways to summarize them Mortality rates (crude, specific, standardized) PYLL: subtracts age at death from some “acceptable” age of death. Emphasizes causes that kill at younger ages. Life expectancy: average age at death if current mortality rates continue. Derived from life table. 8

General (All-Causes) Mortality April 13, 20119

10 Annual NUMBER of Deaths, by Sex, Canada,

April 13, 2011 Age-Standardized Mortality RATES, Canada,

April 13, 2011 Infant Mortality,

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Income Inequalities in Health April 13,

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Income adequacy quintiles Remaining Life Expectancy at age 25. Based on 10-year follow-up to 1991 census April 13,

Remaining life expectancy at age 25 (conditional on surviving to age 25), MenWomen Total, all quintiles Quintile 1 (lowest) Quintile Quintile Quintile Quintile 5 (highest) Difference Q5-Q April 13,

Probability of survival to age 75 (conditional on surviving to age 25), MenWomen Total, all quintiles Quintile 1 (lowest) Quintile Quintile Quintile Quintile 5 (highest) Difference Q5-Q April 13,

Cause-Specific Mortality April 13,

April 13, 2011 Leading causes of death –Cardiovascular disease: 37% Heart disease: 20% Other circulatory disease: 10% Stroke 7% –Cancer: 28% Lung cancer: 9% (M); 6% (W) Breast cancer: 4% (W) Prostate cancer: 4% (M) –Respiratory Disease: 10% –Injuries: 6% –Diabetes: 3% –Alzheimer’s: 1% 22

April 13, 2011 Impact of different causes of death in Canada 2001: Mortality rates and PYLL Source: Statistics Canada 23

April 13, 2011 CANCER: 30.3% Circ Disease: 27.6% †† † † Pneumonia & influenza grouped with respiratory disease. Would increase infectious % to about 3.4%. 24

April 13, 2011 CANCER: 29.8% Circ Disease: 29.0% † † † Pneumonia & influenza grouped with respiratory disease. Would increase infectious % to about 3.5%. { EXTERNAL CAUSES: 4.8%+ 25

April 13, 2011 CANCER: 31.6% Circ Disease: 27.3% † † † Pneumonia & influenza grouped with respiratory disease. Would increase infectious % to about 3.3%. { EXTERNAL CAUSES: 3.4%+ 26

Deaths due to Cardiovascular Disease and Cancer, Canada, : Sex ratio (M/F) April 13,

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April 13, 2011 Overall trends in mortality from Cancer : rates and numbers 32

April 13, 2011 Overall trends in mortality : rates and numbers 33

April 13, 2011 Cancer and Age Age-Specific Incidence Rates for All Cancers by Sex, Canada, 2003 Surveillance Division, CCDPC, Public Health Agency of Canada 34

April 13, 2011 Cancer and Age Age-Specific Mortality Rates for All Cancers by Sex, Canada, 2003 Surveillance Division, CCDPC, Public Health Agency of Canada 35

April 13, 2011 Time trends in Males IncidenceMortality 36

April 13, 2011 Time trends in Females IncidenceMortality 37

Summary Measures of Population Health April 13,

April 13, 2011 Summary measures of population health Combine mortality and morbidity statistics, in order to provide a more comprehensive population health indicator, e.g., QALY Years lived are weighted according to quality of life, disability, etc. Two types: –Health expectancies point up from zero –Health gaps point down from ideal (Japan) 39

April 13, 2011 Summary Measures of Population Health Indicator Type Life (Survival)Health-Adjusted Life (Survival) GapYears of Life Lost (YLL) Disability-Adj Life Years (DALY) ExpectancyLife Expectancy (LE) Health-Adj Life Expectancy (HALE) 40

April 13, Life Expectancy and Health-Adjusted Life Expectancy Gender Indicator MalesFemalesDifference LE HALE Difference HALE always < LE Females live longer (but gap is narrowing) Females suffer more morbidity 41

April 13, 2011 Disability-Adjusted Life-Years Lost, by Disease Group 42

April 13, 2011 Which Chronic Diseases? 43

April 13, 2011 Impact of Chronic Diseases CategoryMortalityMorbidity Cancer85%15% Cardiovascular79%21% Diabetes37%63% Respiratory33%67% Neuropsychiatric8%92% Musculoskeletal7%93% Sense organs0%100% 44

April 13, 2011 Deaths vs Prevalence, Canada 45

LE vs HALE, Canada April 13,

Aboriginal Health April 13,

Population Pyramids April 13,

April 13, 2011 Canadian population pyramids A. First Nations and overall population compared B. Animated display, showing changing Canadian population Link to Statistics Canada 49

Age-specific Fertility Rates April 13,

Percentage of Live Births by Age Group of Mother April 13,

First Nations: Birth Weights as % of Live Births April 13,

. Crude Mortality Rate April 13,

Life Expectancy at Birth in Years, by Sex April 13,

Leading Causes of Death (crude rates) April 13,

Leading Causes of Death (age- standardized) April 13,

Potential Years of Life Lost (PYLL) April 13, 2011 First NationsCanada 57

Age-standardized Potential Years of Life Lost (PYLL) by Cause of Death April 13,

April 13, 2011 Vital & Health Statistics Multiple Choice Questions for discussion 59

April 13, 2011 Which of the following statements regarding the measurement of health and disease in a population is true? a) a rate is the number of times an event has occurred during a certain time interval divided by the number of persons at risk during the same interval b) when calculating a ratio, the numerator is a portion of the denominator c) a ratio is the number of times an event has occurred during a certain time interval multiplied by the number of times an event has not occurred during the same interval d) when calculating a rate, the numerator is not a portion of the denominator e) none of the above 60

April 13, 2011 Which of the following statements regarding the measurement of health and disease in a population is true? a) a rate is the number of times an event has occurred during a certain time interval divided by the number of persons at risk during the same interval YES, APPROXIMATELY (DENOMINATOR IS PERSON- YEARS) b) when calculating a ratio, the numerator is a portion of the denominator NOT NECESSARILY c) a ratio is the number of times an event has occurred during a certain time interval multiplied by the number of times an event has not occurred during the same interval NO, THIS IS ODDS d) when calculating a rate, the numerator is not a portion of the denominator NO, IT IS PART OF THE DENOMINATOR e) none of the above 61

April 13, 2011 In describing the leading causes of death in Canada, two very different lists emerge, depending on whether proportional mortality rates or person- years of life lost (PYLL) are used. This is because: a) one measure uses a calendar year and the other a fiscal year to calculate annual experience b) one measure includes morbidity as well as mortality experience c) both rates exclude deaths occurring over the age of 70 d) different definitions of “cause of death” are used e) one measure gives greater weight to deaths occurring in younger age groups 62

April 13, 2011 In describing the leading causes of death in Canada, two very different lists emerge, depending on whether proportional mortality rates or person- years of life lost (PYLL) are used. This is because: a) one measure uses a calendar year and the other a fiscal year to calculate annual experience NO, IT HAS NOTHING TO DO WITH MONEY b) one measure includes morbidity as well as mortality experience NO, THIS SOUNDS LIKE SUMMARY MEASURES OF POPULATION HEALTH c) both rates exclude deaths occurring over the age of 70 NO, ALTHOUGH PYLL MIGHT, IN A WAY d) different definitions of “cause of death” are used NO e) one measure gives greater weight to deaths occurring in younger age groups YES, PYLL DOES THAT 63

April 13, 2011 All of the following statements are true EXCEPT: a) one indirect measure of a population’s health status is the percentage of low birth weight neonates b) accidents are the largest cause of potential years of life lost in Canada c) the Canadian population is steadily undergoing rectangularization of mortality d) morbidity is defined as all health outcomes excluding death e) the neonatal mortality rate is the number of infant deaths divided by the number of live births multiplied by

April 13, 2011 All of the following statements are true EXCEPT: a) one indirect measure of a population’s health status is the percentage of low birth weight neonates TRUE, ALTHOUGH INFANT MORTALITY IS USUAL b) accidents are the largest cause of potential years of life lost in Canada YES THEY ARE…..? c) the Canadian population is steadily undergoing rectangularization of mortality TRUE UP TO ABOUT AGE 85, BUT THE VERY OLD ARE LIVING LONGER d) morbidity is defined as all health outcomes excluding death NOT USUALLY DEFINED THAT WAY, BUT IT AMOUNTS TO THAT e) the neonatal mortality rate is the number of infant deaths divided by the number of live births multiplied by 1000 NO, IT IS THE NUMBER OF NEONATAL DEATHS 65

April 13, 2011 In 1981, the crude birth rate in Ontario was approximately 14 per 1000 and the crude death rate was 7 per The estimated rate of net migration was –1 per The growth rate of the province, per 1000 population was: a) 6 b) 7 c) 8 d) 20 e) 22 66

April 13, 2011 In 1981, the crude birth rate in Ontario was approximately 14 per 1000 and the crude death rate was 7 per The estimated rate of net migration was –1 per The growth rate of the province, per 1000 population was: a) 6 YUP, 14 – 7 -1 = 6 b) 7 NO, THAT IS RATE OF NATURAL INCREASE c) 8 EPIDEMIOLOGIC AND ARITHMETIC NONSENSE d) 20 DITTO e) 22 DITTO 67