1. Back to Basics, 2016 POPULATION HEALTH : Vital & Health Statistics Dr. Nicholas Birkett School of Epidemiology, Public Health and Preventive Medicine

2. LMCC Links Links to three objectives: 03/20162 78.2Assessing and Measuring Health Status at the Population Level 78.1Concepts of Health and its Determinants 78.7Health of Special Populations

3. 03/20163 Important Questions What are the main causes of illness or death in Canada? –Common things are common using epidemiology can help you run a better clinical practice Hippocrates

4. 03/20164 Important Questions 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) –Lots of information on mortality

5. 03/20165 TOPICS Demography, population dynamics Mortality Morbidity Summary measures of population health Aboriginal health Many slides present information on key diseases and causes of death

6. 03/20166 Population Dynamics, 2007 CanadaNfldNunavut % aged >6514% Total fertility1.7 Birth rate/1,00011.3 Death rate/1,0007.3 Rate of Natural Increase/1,000 4.0 CanadaNfldNunavut % aged >6514%15% Total fertility1.71.5 Birth rate/1,00011.38.9 Death rate/1,0007.38.9 Rate of Natural Increase/1,000 4.00 CanadaNfldNunavut % aged >6514%15%3% Total fertility1.71.53.0 Birth rate/1,00011.38.925.8 Death rate/1,0007.38.94.3 Rate of Natural Increase/1,000 4.0021.5

7. 03/20167 Some definitions Dependency ratio –a measure of the degree to which a population ‘dependent’ –Usually based on the number under age 15 and over age 65 –Compares to the number between age 15 and 65. Total Fertility rate –Average number children expected to be born to a women IF: Current fertility patterns hold throughout her lifetime.

8. World Health Report, 2012 (data mostly from 2009) Population (x 1,000) Growth (%) Dependency ratio % % aged > 60 Total Fertility rate LE at birth (both sexes) P dying < 5 yrs (per 1000) Afghan- istan Canada34,0171.056201.7816 China France Japan USA Population (x 1,000) Growth (%) Dependency ratio % % aged > 60 Total Fertility rate LE at birth (both sexes) P dying < 5 yrs (per 1000) Afghan- istan Canada34,0171.056201.7816 China France Japan USA310,3840.961182.1798 Population (x 1,000) Growth (%) Dependency ratio % % aged > 60 Total Fertility rate LE at birth (both sexes) P dying < 5 yrs (per 1000) Afghan- istan 31,4123.210046.348149 Canada34,0171.056201.7816 China France Japan USA310,3840.961182.1798 Population (x 1,000) Growth (%) Dependency ratio % % aged > 60 Total Fertility rate LE at birth (both sexes) P dying < 5 yrs (per 1000) Afghan- istan 31,4123.210046.348149 Canada34,0171.056201.7816 China France Japan126,5360.175301.4833 USA310,3840.961182.1798 Population (x 1,000) Growth (%) Dependency ratio % % aged > 60 Total Fertility rate LE at birth (both sexes) P dying < 5 yrs (per 1000) Afghan- istan 31,4123.210046.348149 Canada34,0171.056201.7816 China1,348,9320.645121.67418 France Japan126,5360.175301.4833 USA310,3840.961182.1798 Population (x 1,000) Growth (%) Dependency ratio % % aged > 60 Total Fertility rate LE at birth (both sexes) P dying < 5 yrs (per 1000) Afghan- istan 31,4123.210046.348149 Canada34,0171.056201.7816 China1,348,9320.645121.67418 France62,7870.670232.0814 Japan126,5360.175301.4833 USA310,3840.961182.1798 03/20168

9. 9

10. 10 Population Pyramids

11. 03/201611 Population Pyramids Canada, 1901-2001 Ontario 1901-2001 Newfoundland 1949-2001 Yukon 1901-2001

12. Some measures of population health 1203/2016

13. 13 Measures of Population Health (1) Mortality rates –crude Overall all-cause mortality rate –specific mortality rate for a specific group (men), disease (lung cancer), etc. –standardized Mortality rate adjustment to take account of the aging population 03/2016

14. 14 Mortality data Life expectancy: –average age at death if current mortality rates continue. Derived from a life table. Potential Years of Life Lost (PYLL): –subtract age at death from some “acceptable” age of death. –Sum up over a group estimates ‘potential’ years of life lost due to early death Places more emphasis on causes that kill at younger ages. 03/2016

15. 15 Impact of different causes of death in Canada 2001: Mortality rates and PYLL Source: Statistics Canada 03/2016

16. 16 Measures of population health (2) Mortality is a ‘crude’ measure of population health Need to consider –morbidity –quality of life –disability –and so on. 03/2016

17. 17 Measures of population health (3) Many other measures have been developed Quality Adjusted Life Years (QALYs) –Years lived are weighted according to quality of life, disability, etc. Two ‘classes’ of these types of measures: –Health expectancies point up from zero –Health gaps point down from ideal 03/2016

18. Some more theory 03/201618

19. 19 Standardization (1) The (made-up) mortality from prostate cancer was: –1950: 50/100,000 –2000: 100/100,000 Were men dying from prostate cancer at twice the rate in 2000? NO! 03/2016

20. 20 Standardization (2) Population is older in 2000 than 1950. Distorts the comparison. Standardization adjusts for age differences Always should be used when presenting incidence and mortality trends in a population BUT NOTE: twice as many men will need treatment for prostate cancer in 2000 03/2016

21. 21 Standardization (3) The essential idea –If only the two populations had the same age distribution, we’d be OK –Let’s fake things out. –Define a standard population –For each of your two populations, figure out how many deaths would have occurred if only the population were the same as the standard one. –Now, compare the two rates 03/2016

22. 22 Standardization (4) Direct: –yields age-standardized rate (ASMR) Indirect: –yields standardized mortality ratio (SMR) You don’t need to know how to do this 03/2016

23. 23 Attributable Risks (1) Would like to know the amount of a disease which might be prevented if we eliminate a risk Tricky area since there are several measures with similar names. –Attributable risk –Attributable fraction –Population Attributable Risk –and so on Gives an upper limit on amount of disease which we can prevent. Meaningful only if association is causal. 03/2016

24. 24 Attributable Risks (2) Two main targets for these measures The amount of disease due to exposure in the exposed subjects. The same as the risk difference. The proportion of risk attributed to the exposure in the general population –depends on Risk due to exposure How common the exposure is. 03/2016

25. 25 Attributable risks (3) ExpUnexp Risk Difference or Attributable Risk I exp I unexp RD = AR = I exp - I unexp 03/2016

26. Attributable risks (3) Exp Unexp Attributable Risk, population I exp I unexp Population I pop

27. Attributable risks (4) Exp Unexp Attributable Risk, population I exp I unexp Population I pop Exposure is uncommon

28. Attributable risks (5) Exp Unexp Attributable Risk, population I exp I unexp Population I pop Exposure is common

29. Attributable risks (6) Risk in the population is a weighted average of –risk in exposed people –risk in unexposed people. The weight is the prevalence of the risk factor in the population:

30. 30 Attributable risks (4) ExpUnexp Population Attributable Risk I exp I unexp I pop Population 03/2016

31. General (All-Causes) Mortality

32. 03/201632 # deaths in Canada from 1979-2004; men and women. Population got: Bigger Older

33. 03/201633 # deaths in Canada from 2000-2012; men and women.

34. 03/201634 Mortality RATES in Canada from 1979-2004; men and women.

35. 03/201635 Mortality RATES in Canada from 2000-2012; men and women.

36. 03/201636 Infant Mortality, 1935-2005

37. 03/201637 Infant Mortality, 1935-2005

38. 03/201638

39. 03/201639

40. 4003/2016

41. 41 Rectangularization of the mortality curve

42. Cause-Specific Mortality

43. 03/201643 Leading causes of death (2009) Cause20042009 Cancer3029.8 - Lung9(M); 8(F)7.8 - Breast5 (F)4.2 (F) - Prostate3 (M)3.1 (M) Cardiovascular2826.6 - Ischemic heart1715.5 - Other circulatory55.2 - Stroke65.9 Respiratory disease77.0 Injuries44.3 Diabetes42.9 Alzheimer’s disease22.6 Suicide1.6

44. 03/201644 CANCER: 30.3% Circ Disease: 27.6% † † Pneumonia & influenza grouped with respiratory disease. Would increase infectious % to about 3.4%.

45. 03/201645 CANCER: 29.8% Circ Disease: 29.0% † † † Pneumonia & influenza grouped with respiratory disease. Would increase infectious % to about 3.5%. { EXTERNAL CAUSES: 4.8%+

46. 03/201646 CANCER: 31.6% Circ Disease: 27.3% † † † Pneumonia & influenza grouped with respiratory disease. Would increase infectious % to about 3.3%. { EXTERNAL CAUSES: 3.4%+

47. 03/201647 Cancer Cluster Cardio- vascular Cluster ‘Other’ Cluster

48. 03/201648 ‘Other’ Cluster

49. 03/201649 Suicide Crime

50. 03/201650

51. 03/201651 Cancer and Age Age-Specific Mortality Rates for All Cancers by Sex, Canada, 2003 Surveillance Division, CCDPC, Public Health Agency of Canada

52. 03/201652 Cancer and Age Age-Specific Incidence Rates for All Cancers by Sex, Canada, 2003 Surveillance Division, CCDPC, Public Health Agency of Canada

53. 03/201653 Time trends in Males IncidenceMortality

54. 03/201654 Time trends in Males (up to 2013) IncidenceMortality NOTE:NHL is not listed in my source for these rates. No idea why not.

55. 03/201655 Time trends in Females IncidenceMortality

56. 03/201656 Time trends in Females (up to 2013) IncidenceMortality

57. 03/201657

58. 03/201658

59. Income Inequalities in Health

60. Income Inequalities SES (socio-economic status) –Lower  worse health Life expectancy 6.6 years lower in the poorest group. –Complex causal pathway Nutrition Race Habits Environmental/occupational Access to/use of health/preventive services Political isolation Others 60 03/2016

61. 61

62. 1 2 3 4 5 1 2 3 4 5 Income adequacy quintiles Men Women Remaining Life Expectancy at age 25. Based on 10-year follow-up to 1991 census 03/201662

63. Remaining life expectancy at age 25, 1991-2001 MenWomen Total, all quintiles53.759.3 Quintile 1 (lowest) 50.6 57.1 Quintile 2 53.0 59.2 Quintile 3 54.0 59.7 Quintile 4 55.0 60.6 Quintile 5 (highest) 56.0 60.4 Difference Q5-Q15.33.3 03/2016 63

64. Probability of survival to age 75 (conditional on surviving to age 25), 1991-2001 MenWomen Total, all quintiles66.980.1 Quintile 1 (lowest) 57.0 73.3 Quintile 2 64.1 79.5 Quintile 3 67.3 81.8 Quintile 4 69.5 82.9 Quintile 5 (highest) 74.1 83.6 Difference Q5-Q117.210.3 03/2016 64

65. Summary Measures of Population Health Combine mortality and a measure of morbidity

66. 03/201666 Impact of Chronic Diseases CategoryMortalityMorbidity Cancer85%15% Cardiovascular79%21% Diabetes37%63% Respiratory33%67% Neuropsychiatric8%92% Musculoskeletal7%93% Sense organs0%100%

67. 03/201667 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)

68. 03/201668 2001 Life Expectancy and Health-Adjusted Life Expectancy Gender Indicator MalesFemalesDifference LE76.982.05.1 HALE68.370.82.5 Difference8.612.8 HALE always < LE Females live longer (but gap is narrowing) Females suffer more morbidity

69. 03/201669 Disability-Adjusted Life-Years Lost

70. 03/201670 Which Chronic Diseases? Cancer CHD Diabetes Respiratory Neuro-Psych Musculoskeletal Sensory

71. 03/201671 Deaths vs Prevalence, Canada Different scales!

72. 03/201672

73. Aboriginal Health

74. Population Pyramids 03/201674

75. Age-specific Fertility Rates 03/201675

76. Percentage of Live Births by Age Group of Mother 03/201676

77. Crude Mortality Rate 03/201677

78. Age-adjusted Mortality Rate 03/201678

79. Age-specific Mortality Ratio 03/201679

80. Life Expectancy at Birth in Years, by Sex 03/201680

81. Leading Causes of Death (age- standardized) 03/201681

82. Potential Years of Life Lost (PYLL) 03/201682 First NationsCanada

83. 03/201683