1. Trends in ‘Avoidable’ Mortality by Neighbourhood Income in Urban Canada from 1971 to 1996 Paul James Department of Epidemiology and Community Medicine University of Ottawa

2. Outline Mortality inequalities in Canada ‘Avoidable’ mortality concept and studies Thesis objective and methods Results Limitations Conclusions

3. The poorer the neighbourhood, the shorter the life expectancy of its residents. Source: Wilkins R, Berthelot JM and Ng E. Trends in mortality by neighbourhood income in urban Canada from 1971 to 1996. Health Reports. 2002.

4. Deaths from conditions for which effective medical and/or public health interventions are available  Proposed by Rutstein et al. in 1976 Potential health care performance indicator Signal areas that warrant further study  European Community Action Project on Heath Services and “Avoidable Mortality” (ECCAP)  CIHI? ‘Avoidable’ Deaths

5. Causes ICD8 Code ICD9 Code Age Group Tuberculosis010-019010-018, 1375-64 Malignant neoplasm of uterus body (except cervix) 182179, 18215-54 Malignant neoplasm of the cervix180 15-64 Malignant neoplasm of the breast174 25-64 Hodgkin’s disease201 5-64 Chronic rheumatic heart disease393-398 5-44 All respiratory diseases (except Asthma) 460-492, 500-519460-492, 494-5191-14 Asthma493 5-44 Peptic Ulcers531-534 25-64 Appendicitis540-543 5-64 Abdominal hernia550-553 5-64 Cholelithiasis and cholecystitis574-575574-575.1, 576.15-64 Ischaemic heart disease410-414410-414, 429.235-64 Hypertension and cerebrovascular disease400-404, 430-438401-405, 430-43835-64 Maternal deaths630-678630-6760-74 Perinatal deaths760-779760-799-- Holland and ECCAP, 1997

6. ‘Avoidable’ Mortality Temporal trends –Declines in mortality from avoidable causes were more pronounced compared to mortality from other causes Regional comparisons –Highlight areas with excess mortality and stimulate further inquiry Socioeconomic comparisons –What has been the contribution of health care to mortality inequalities?

7. Previous Studies British Columbia British Columbia (Wood et al. Soc Sci Med 1999) Mortality amenable to medical intervention was higher in men of lower occupational classes for the period 1981-1991(RR 1.8, 95%CI 1.4-2.2)

8. Objective To examine changes in neighbourhood income-related differences in ‘avoidable’, and other cause, mortality in urban Canada from 1971 to 1996.

9. Data Death registration and populations for census metropolitan areas (CMAs) for the years 1971, 1986, 1991 and 1996  Canadian Mortality Database  Population censuses Deaths were previously coded to census tract and grouped into CMA-based neighbourhood income quintiles Excluded  Institutional residents  Deaths over 74 yrs  Q1=richest, Q5=poorest, QT=total population (all quintiles)

10. Analysis Classified ‘avoidable’ deaths  7 Classification lists  “Master list”: Medical intervention, public health, ischaemic heart disease and other causes Age Standardized  Potential Years of Life Lost (SPYLL)  Period Expected Years of Life Lost (SEYLL) Life expectancy of the least poor quintile (Q1) Compared Q5-Q1 and QT-Q1  Rate ratios  Rate differences  95% Confidence Intervals

11. Results

12. 1. Regardless of the list, ‘avoidable’ SEYLL disparity decreased from 1971 to 1996

14. 2. SEYLL disparity from medical care and public health causes decreased from 1971 to 1996

16. 3. Ischaemic heart disease, Lung cancer, Perinatal conditions and Cerebrovascular disease contributed the most to SEYLL disparity. Cause MalesFemales Ischaemic heart disease (35-74)14.1415.95 Lung Cancer (0-74)8.7010.92 Perinatal conditions5.726.32 Cerebrovascular disease (35-74)3.644.25 Percent of all-cause QT-Q1 SEYLL rate difference, 1996

17. 4a. In general, SEYLL disparity from ‘avoidable’ causes decreased from 1971 to 1996.

19. 4b. Exceptions: Lung Cancer

20. Some Limitations Data: Death certification and coding Underlying cause of death versus multiple causes of death ‘Avoidable’ mortality: No information on quality of life, condition severity, morbidity Not shown to be associated with health services SES trend: Healthy Immigrant effect Institutional population Ecologic fallacy? Health selection

21. Conclusions 1.Deaths amenable to public health and medical intervention were associated with the reduction of mortality disparities in urban Canada from 1971 to 1996 2.The largest SEYLL disparities in 1996 were related to deaths from ischaemic heart disease, lung cancer, perinatal conditions and cerebrovascular disease 3.The unchanging and increasing mortality disparities related to some causes warrant further investigation

22. Thank you! Health Analysis and Measurement Group Institute of Clinical Evaluative Sciences Centre for Global Health  Russell Wilkins (HAMG)  Doug Manuel (ICES)  Peter Tugwell (CGB)