1. 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

2. 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

3. Premature Mortality Rate (PMR)

4. 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

5. 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 1 Eyles 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

6. 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.

7. 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

8. 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: n HIV/AIDS; n increased motor vehicle deaths in rural areas; n heart attack deaths in persons 45-64 in suburbia; n violence

9. Median Household Income and PMR by EOHHS Regions, Massachusetts: 2005 Source: Income information from the 2000 Census.

10. Less than High School Education and PMR by EOHHS Regions, Massachusetts: 2005 Source: Education information from the 2000 Census.

11. Premature Mortality Rates by Race and Hispanic Ethnicity Massachusetts: 2006 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) * **

12. Premature Mortality Rates (PMR) by Community Health Network Area Massachusetts: 2006

15. Premature Mortality Rate by Race/Ethnicity Chronic Diseases 1, Massachusetts: 2006 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

16. Premature Mortality Rate by Race/Ethnicity Non Chronic Conditions/Diseases, Massachusetts: 2006 Age-adjusted to the 2000 US standard population under 75 years of age. (*) Statistically different from State (p ≤.05)

17. 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.)

18. 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.

19. Mortality Amenable to Health Care

20. 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 1 Nolte 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. 2 Nolte E and McKee CM. Does Health Care Save Lives? Avoidable Mortality Revisited. The Nullfield Trust. 2004. London, England

21. 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)

22. Amenable Mortality: Background  Operationalized as a set of 33 cause of death codes for persons under age 75 1  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 )http://content.healthaffairs.org/cgi/content/full/27/1/58/DC1

23. 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

24.  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)

25.  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)

26. Reasons Considered Amenable

28. Percent Amenable Deaths Massachusetts: 2006 All Deaths Deaths Persons Ages 0-74

29. Mortality Rates for Causes Amenable to Health Care by Race and Ethnicity Massachusetts: 2000 and 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) **

30. 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

31. Premature Mortality Rates & Amenable Mortality by Race and Ethnicity, Massachusetts: 2006 Rates are per 100,000 population. Age-adjusted to the 2000 US standard population persons ages 0-74

32. 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.

33. 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.)

34. Infant Mortality Rate by Race and Education Mothers Ages 25+, Massachusetts – 2000-2006 * Significantly Different from White Non-Hispanic

35. Infant Mortality Rate by Percent in Poverty and Race-Hispanic Ethnicity

36. Infant Mortality Rate by Race-Hispanic Ethnicity and Percent in Poverty

37. LBW by Percent in Poverty and Race- Hispanic Ethnicity

38. Smoking During Pregnancy by Percent in Poverty and Race-Hispanic Ethnicity

39. Smoking During Pregnancy by Race- Hispanic Ethnicity and Percent in Poverty

40. 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