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Premature Mortality Rate _PMR_

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					 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
                       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
Premature Mortality Rate (PMR)
               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
                       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


    1Eyles 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
       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.
             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
        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:
      HIV/AIDS;
      increased motor vehicle deaths in rural areas;
      heart attack deaths in persons 45-64 in suburbia;
      violence
        Median Household Income and PMR by
        EOHHS Regions, Massachusetts: 2005

                                           Age adjusted Rate per 100,000 population
      400                                                                                   $100,000
                                           Median Household Income
                                                                                            $90,000
      350
                                                                                            $80,000




                                                                                                       Median Household Income ($)
      300
                                                                                            $70,000
      250
                                                                                            $60,000
PMR




      200                                                                                   $50,000

                                                                                            $40,000
      150
                                                                                            $30,000
      100
                                                                                            $20,000
       50
                                                                                            $10,000

        0                                                                                   $0
               Boston      Western        Central        Southeast   Northeast Metro West
               Region
      Source: Income information from the 2000 Census.
       Less than High School Education and PMR by
          EOHHS Regions, Massachusetts: 2005


                                       Age adjusted Rate per 100,000 population
      400                                                                                14%
                                       Less than High School Education




                                                                                               % Less than a High School Education
      350                                                                                12%

      300
                                                                                         10%
      250
                                                                                         8%
PMR




      200
                                                                                         6%
      150
                                                                                         4%
      100

       50                                                                                2%


        0                                                                                0%
            Boston   Western        Central      Southeast      Northeast   Metro West
            Region
                     Source: Education information from the 2000 Census.
                        Premature Mortality Rates by Race and
                        Hispanic Ethnicity Massachusetts: 2006


                        600

                                              *
                                             427.3
   Deaths per 100,000




                        400
                                298.8                                 279.8                            300.5


                        200                                 **
                                                          140.3



                          0
                              White non-   Black non-   Asian non-   Hispanic                           Total
                               Hispanic     Hispanic     Hispanic
                                                                         * Statistically higher than state rate (p<0.05)
                                                                         ** Statistically lower than state rate (p<0.05)

Rates are per 100,000 population. Age-adjusted to the 2000 US standard population persons ages 0-74
                      Premature Mortality Rates (PMR) by Community
                        Health Network Area Massachusetts: 2006

                                                                                                                                                             12
                                                                                                                                                    11
                                                                                                                                      10                          13
                                                                  2
                                                                                                             9
                                                                                                                                                        16 14
                                                                                                                                            15
                        1                                                                                                                           17
                                                              3
                                                                                                                                7             18        19
                                                                                                            8
                                                                   21                                                                                              20
                                                                                             5
                                                                       4                                                  6
                                                                                                                                                             22
                                                                                                                                                                       23
                                    PMR by CHNA                                                                                                   24
                                               Significantly higher than state rate
                                               Not different from state rate                                                                                                27
                                                                                                                                                        25        26
                                               Significantly lower than state rate
             CHNA PMR                                                           14. North Shore Community Health Network = 303.5
             1. Community Health Network of Berkshire = 330.8                   15. Greater Woburn/Concord/Littleton Community Health Network = 217.8
             2. Upper Valley Health Web-Franklin County = 334.2                 16. North Suburban Health Alliance = 294.5
             3. Partnership for Health in Hampshire County = 285.7              17. Greater Cambridge/Somerville Community Health Network = 255.7
             4. The Community Health Connection = 370.7                         18. West Suburban Health Network = 208.2
             5. Community Health Network of Southern Worcester County = 354.9   19. Alliance for Community Health = 365.4
             6. Community Partners for Health = 277.1                           20. Blue Hills Community Health Alliance = 297.3
             7. Community Health Network of Greater Metro West = 250            21. Hampshire County Partnership = 367.5
             8. Community Wellness Coalition = 339                              22. Greater Brockton Community Health Network = 349.2
             9. Fitchburg/Gardner Community Health Network = 324.5              23. South Shore Community Partners in Prevention = 313
             10. Greater Lowell Community Health Network = 333.4                24. Greater Attleboro-Taunton Health & Education Response = 347.1
             11. Greater Lawrence Community Health Network = 285.6              25. Partners for a Healthier Community = 378.4
             12. Greater Haverhill Community Health Network = 328.1             26. Greater New Bedford Health & Human Services Coalition = 351
             13. Community Health Network North = 248.8                         27. Cape Cod & Islands Community Health Network = 295.1
     Rates are per 100,000 persons under 75 years of age, age-adjusted to the 2000 US standard population and are calculated using MDPH population estimates for 2005,
     which are the most updated estimates available at the sub-state level by age groups.
Rates per 100,000 population under 75 years of age; age-adjusted to the 2000 US standard population.
            Premature Mortality Rates (PMR) to Chronic Diseases
       by Community Health Network Area (CHNA), Massachusetts: 2006
                      Massachusetts PMR to Chronic Diseases= 203.2

                                                                                                                                                             12
                                                                                                                                                    11
                                                                                                                                      10                          13
                                                                  2
                                                                                                             9
                                                                                                                                                        16 14
                                                                                                                                            15
                        1                                                                                                                           17
                                                              3
                                                                                                                                7             18        19
                                                                                                            8
                                                                   21                                                                                              20
                                                                                             5
                                                                       4                                                  6
                                                                                                                                                             22
                                                                                                                                                                       23
                            PMR to Chronic Diseases by CHNA                                                                                       24
                                     Significantly higher than state rate
                                     Not different from state rate                                                                                                          27
                                                                                                                                                        25        26
                                     Significantly lower than state rate
             CHNA PMR                                                           14. North Shore Community Health Network = 188.8
             1. Community Health Network of Berkshire = 220.2                   15. Greater Woburn/Concord/Littleton Community Health Network = 151.8
             2. Upper Valley Health Web-Franklin County = 218                   16. North Suburban Health Alliance = 197.4
             3. Partnership for Health in Hampshire County = 184.4              17. Greater Cambridge/Somerville Community Health Network = 166
             4. The Community Health Connection = 225.9                         18. West Suburban Health Network = 136.9
             5. Community Health Network of Southern Worcester County = 242.1   19. Alliance for Community Health = 223.5
             6. Community Partners for Health = 187.6                           20. Blue Hills Community Health Alliance = 198.9
             7. Community Health Network of Greater Metro West = 170.7          21. Hampshire County Partnership = 240.5
             8. Community Wellness Coalition = 216.6                            22. Greater Brockton Community Health Network = 228.9
             9. Fitchburg/Gardner Community Health Network = 213.4              23. South Shore Community Partners in Prevention = 216.9
             10. Greater Lowell Community Health Network = 220.1                24. Greater Attleboro-Taunton Health & Education Response = 235.3
             11. Greater Lawrence Community Health Network = 192.5              25. Partners for a Healthier Community = 240.2
             12. Greater Haverhill Community Health Network = 226.6             26. Greater New Bedford Health & Human Services Coalition = 219.6
             13. Community Health Network North = 174.5                         27. Cape Cod & Islands Community Health Network = 192.2
     Rates are per 100,000 persons under 75 years of age, age-adjusted to the 2000 US standard population and are calculated using MDPH population estimates for 2005,
     which are the most updated estimates available at the sub-state level by age groups.
Rates per 100,000 population under 75 years of age; age-adjusted to the 2000 US standard population.
           Premature Mortality Rates (PMR) to Non-Chronic Diseases
       by Community Health Network Area (CHNA), Massachusetts: 2006
                 Massachusetts PMR to non Chronic Diseases= 107.9

                                                                                                                                                             12
                                                                                                                                                       11
                                                                                                                                      10                          13
                                                                  2
                                                                                                             9
                                                                                                                                                        16 14
                                                                                                                                            15
                        1                                                                                                                              17
                                                              3
                                                                                                                                7             18        19
                                                                                                            8
                                                                   21                                                                                              20
                                                                                             5
                                                                        4                                                 6
                                                                                                                                                             22
                                                                                                                                                                       23
                    PMR to Non-Chronic Diseases by CHNA                                                                                           24
                                   Significantly higher than state rate
                                   Not different from state rate                                                                                                            27
                                                                                                                                                        25        26
                                   Significantly lower than state rate
             CHNA PMR                                                           14. North Shore Community Health Network = 114.6
             1. Community Health Network of Berkshire = 110.6                   15. Greater Woburn/Concord/Littleton Community Health Network = 66.0
             2. Upper Valley Health Web-Franklin County = 116.2                 16. North Suburban Health Alliance = 97.1
             3. Partnership for Health in Hampshire County = 101.2              17. Greater Cambridge/Somerville Community Health Network = 89.6
             4. The Community Health Connection = 144.8                         18. West Suburban Health Network = 71.4
             5. Community Health Network of Southern Worcester County = 112.8   19. Alliance for Community Health = 141.9
             6. Community Partners for Health = 89.5                            20. Blue Hills Community Health Alliance = 98.4
             7. Community Health Network of Greater Metro West = 79.3           21. Hampshire County Partnership = 127.0
             8. Community Wellness Coalition = 122.5                            22. Greater Brockton Community Health Network = 120.3
             9. Fitchburg/Gardner Community Health Network = 111.1              23. South Shore Community Partners in Prevention = 96.1
             10. Greater Lowell Community Health Network = 113.3                24. Greater Attleboro-Taunton Health & Education Response = 111.8
             11. Greater Lawrence Community Health Network = 93.1               25. Partners for a Healthier Community = 138.2
             12. Greater Haverhill Community Health Network = 101.6             26. Greater New Bedford Health & Human Services Coalition = 131.4
             13. Community Health Network North = 74.3                          27. Cape Cod & Islands Community Health Network = 102.9

     Rates are per 100,000 persons under 75 years of age, age-adjusted to the 2000 US standard population and are calculated using MDPH population estimates for 2005,
     which are the most updated estimates available at the sub-state level by age groups.
Rates per 100,000 population under 75 years of age; age-adjusted to the 2000 US standard population.
                                 Premature Mortality Rate by Race/Ethnicity
                                  Chronic Diseases1, Massachusetts: 2006

                               300

                                                   245.0*
                               250
          Deaths per 100,000




                                       197.8                                                                             195.0
                               200

                                                                         146.8*
                               150

                                                                                                97.9*
                               100


                                50


                                 0
                                     White non-   Black non-            Hispanic             Asian non-                   ALL
                                      Hispanic     Hispanic                                   Hispanic

    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
                               Premature Mortality Rate by Race/Ethnicity
                                  Non Chronic Conditions/Diseases,
                                         Massachusetts: 2006

                         200
                                               182.3*
                         180

                         160
    Deaths per 100,000




                         140                                     133.0*

                         120                                                                            105.5
                                   101.0
                         100
                          80

                          60
                                                                                42.4*
                          40
                          20

                           0
                                 White non-   Black non-        Hispanic    Asian non-                    ALL
                                  Hispanic     Hispanic                      Hispanic

Age-adjusted to the 2000 US standard population under 75 years of age.     (*) Statistically different from State (p ≤.05)
             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.)
               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.
Mortality Amenable to Health Care
            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
1Nolte 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.
2Nolte E and McKee CM . Does Health Care Save Lives? Avoidable Mortality Revisited. The Nullfield Trust.
     2004. London, England
         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)
         Amenable Mortality: Background

   Operationalized as a set of 33 cause of death
    codes for persons under age 751
   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)
List of Causes of Death Considered
      Amenable to Health care

   Intestinalinfections
   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
List of Causes of Death Considered
  Amenable to Health care (continued)

  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)

  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
Reasons Considered Amenable
Reasons Considered Amenable
         Percent Amenable Deaths
           Massachusetts: 2006



              Amena         All
                ble       Deaths
  All         Deaths      Ages 0-
Deaths         10%          74       Amena
 90%                       72%
                                       ble
                                     Deaths
                                      28%




All Deaths               Deaths Persons
                           Ages 0-74
            Mortality Rates for Causes Amenable to
              Health Care by Race and Ethnicity
                Massachusetts: 2000 and 2006
                                                                2000     2006

                            160
                                                    142.9
                                                        128.4
       Deaths per 100,000




                            120
                                   105.4                                                                     103.6

                                       82.5
                                              **                                              81.4                      **
                                                                                                                     84.0
                             80
                                                                                         64.5
                                                                              48.1
                                                                       40.6
                             40


                              0
                                  White non-       Black non-      Asian non-            Hispanic              Total
                                   Hispanic         Hispanic        Hispanic
                                                                                     ** Statistically lower than 2000 rate (p<0.05)

Rates are per 100,000 population. Age-adjusted to the 2000 US standard population persons ages 0-74
                    Mortality Rates for
          Causes Amenable to Health Care by Gender
               Massachusetts: 2000 and 2006
                           160                         2000      2006

                                 133.7
      Deaths per 100,000




                           120
                                         101.8   **                                  103.6

                                                        86.0                                  84.0**
                            80
                                                                67.6**

                            40



                             0
                                   Male                   Female                         Total

                                                                            ** Statistically lower than 2000 rate (p<0.05)

Rates are per 100,000 population. Age-adjusted to the 2000 US standard population persons ages 0-74
    Premature Mortality Rates & Amenable
                  Mortality
  by Race and Ethnicity, Massachusetts: 2006
                        600


                        500
                                                            427.3
   Deaths per 100,000




                        400
                              300.5     298.8                                                         279.8
                        300


                        200                                                    140.3

                        100
                                                             30%
                              28%         28%                                   34%                   29%
                          0
                              Total   White non-         Black non-         Asian non-           Hispanic
                                       Hispanic           Hispanic           Hispanic



Rates are per 100,000 population. Age-adjusted to the 2000 US standard population persons ages 0-74
         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.
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.)
                                            Infant Mortality Rate by Race and Education
                                           Mothers Ages 25+, Massachusetts – 2000-2006

                                            18                               White, Non-Hispanic
                                                         16.0*               Black, Non-Hispanic
                                            16
                                                                             Hispanic
     Infant Deaths per 1,000 Live Births




                                            14
                                                                                                         11.9*
                                            12

                                            10                               9.0*

                                             8                   7.2
                                                   6.1
                                             6                                      4.9
                                                                       3.7                         3.6
                                             4
                                                                                                                 2.5
                                             2

                                             0
                                                 High School or Less    Some College         College Graduate or More

* Significantly Different from White Non-Hispanic
                                    IMR (per 1000 live births)




                                                     10
                                                                 15




                                0
                                          5
                                Black NH
                                Hispanics
                                Asian NH




                     0- 4.9%
                                White NH



                                Black NH
                                Hispanics
                                Asian NH




                     5- 9.9%
                                White NH



                                Black NH



Percent in Poverty
                                Hispanics
                                Asian NH
                     10-19.9%

                                White NH



                                Black NH
                                Hispanics
                                Asian NH
                     20-100 %




                                White NH
                                                                       Infant Mortality Rate by Percent in
                                                                      Poverty and Race-Hispanic Ethnicity
                                                 IMR (per 1000 live births)




                                                                    10
                                                                              15




                                      0
                                                    5
                                      0- 4.9%
                                      5- 9.9%
                                      10-19.9%




                          White NH
                                      20-100 %



                                      0- 4.9%
                                      5- 9.9%
                                      10-19.9%




                          Black NH
                                      20-100 %



                                      0- 4.9%
                                      5- 9.9%
Race-Hispanic Ethinicty
                                      10-19.9%
                          Hispanics



                                      20-100 %



                                      0- 4.9%
                                      5- 9.9%
                                      10-19.9%
                                                                                       Ethnicity and Percent in Poverty




                          Asian NH




                                      20-100 %
                                                                                   Infant Mortality Rate by Race-Hispanic
                                                LBW (%)




                                                          10
                                                               15




                                0
                                            5
                                Black NH
                                Hispanics
                                Asian NH




                     0- 4.9%
                                White NH



                                Black NH
                                Hispanics
                                Asian NH




                     5- 9.9%
                                White NH



                                Black NH
Percent in Poverty              Hispanics
                                Asian NH
                     10-19.9%



                                White NH
                                                                            Hispanic Ethnicity




                                Black NH
                                Hispanics
                                Asian NH
                     20-100 %




                                White NH
                                                                    LBW by Percent in Poverty and Race-
                                       Smoking During Pregnancy(%)




                                               10
                                                       15
                                                                20
                                                                     25




                                0
                                       5
                                Black NH
                                Hispanics
                                Asian NH




                     0- 4.9%
                                White NH



                                Black NH
                                Hispanics
                                Asian NH




                     5- 9.9%
                                White NH



                                Black NH
                                Hispanics



Percent in Poverty
                                Asian NH
                     10-19.9%   White NH



                                Black NH
                                Hispanics
                                Asian NH
                     20-100 %




                                White NH
                                                                          in Poverty and Race-Hispanic Ethnicity
                                                                          Smoking During Pregnancy by Percent
                                  Smoking During Pregnancy(%)




                                      0
                                          5
                                                10
                                                     15
                                                          20
                                                               25
                                      0- 4.9%
                                      5- 9.9%
                                      10-19.9%




                          White NH
                                      20-100 %



                                      0- 4.9%
                                      5- 9.9%
                                      10-19.9%




                          Black NH
                                      20-100 %



                                      0- 4.9%
                                      5- 9.9%
Race-Hispanic Ethinicty               10-19.9%
                          Hispanics


                                      20-100 %



                                      0- 4.9%
                                      5- 9.9%
                                      10-19.9%
                          Asian NH




                                      20-100 %
                                                                    Smoking During Pregnancy by Race-
                                                                    Hispanic Ethnicity and Percent in Poverty
          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

				
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