Les inégalités de santé: Congres National des ORS

Transcription

1 Les inégalités de santé: comparaisons nationales et urbaines Congres National des ORS 16 octobre, 2008 Victor G. Rodwin Michael K. Gusmano Daniel Weisz Wagner School/New York University October 16, 2008

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3 Inegalités entre départements pour les indicateurs de santé

4 La carte des femmes titulaires du baccalauréat ressemble celle de l espéreance de vie!

5 Manhattan: Infant Mortality Highest (red): Community Districts: 5, 10, and 11. Lowest (blue): Community Districts: 1, 2, and 8.

6 Infant Mortality Rate in Paris By Arrondissement Highest Arrondissements: (red): II, V, and VIII Lowest (blue): Arrondissements: III, IV, and VI Source: Rodwin and Neuberg, Infant Mortality and Income. American Journal of Public Health

7 A quoi sert-il de soigner les maladies Pour ensuite les renvoyer dans les memes contextes sociaux qui les ont rendus malades? des gens COMMISSION ON SOCIAL DETERMINANTS OF HEALTH Chair: Professor Sir Michael Marmot; set up by the World Health Organization; launched in Santiago, Chile, March 2005

8 Population Health vs. Health Care Is it the health system or the social determinants that matter? If social determinants, then does universal coverage matter? If not, then what? If so, what is to be done? If health system is not key driver of population health, then should we still fix it?

9 A Rare Example of Regional Variation that Reflects Illness: Hospitalization for Hip Fracture 1.30 or More (0) 1.10 to < 1.30 (56) 0.90 to < 1.10 (204) 0.75 to < 0.90 (45) 0.65 to < 0.75 (1) Not Populated Ratio of Rates of Hip Fracture to the U.S. Average ( ) 96) among the 306 hospital referral regions

10 Variation in Rates of Hospitalization for Common Conditions Hip Fracture C.H.F.

11 Variations in Rates of Surgical Procedures and Causes of fhospitalization ti Source: Dartmouth hatlas of Health Care Rates refer to the number of procedures per 1,000 Medicare enrollees per year in hospital referral regions nationwide. Hospital referral regions are healthcare markets defined geographically by the correlation between zip codes in which care is delivered and zip codes in which the majority of residents are consumers of care being delivered. Data adjusted for age, sex, and race.

12 Defining Amenable/Avoidable Mortality Premature death (prior to 75 years) from diseases amenable to screening and medical intervention Examples include: ischemic heart disease several malignancies: breast, colon, cervix, skin tuberculosis Maternal deaths

13 Avoidable Hospitalization: A Measure of Access to Primary Care Avoidable Hospital Marker Conditions Conditions Examples: Pneumonia Congestive Heart Failure Asthma Cllli Cellulitus Examples: Acute Myocardial Infarction Appendicitis GI obstruction Hip fracture We use the list of ICD-9/ICD-10 Codes from the definition used by Dr. Joel Weissman and colleagues

14 Source: Nolte and McKee 2008: Exhibit 5 on page 65.

15 Avoidable Mortality in Five World Cities Age-adj justed ra ate/ New York Paris London Tokyo Hong Kong Average rates,

16 Age-Adjusted Rates of Amenable Mortality per 1000 in New York City by Borough of Residence, New York City Staten Island Bronx Brooklyn Manhattan Queens Source: New York City Department of Health and Mental Hygiene, Birth and Death Files

17 Sources: France - PMSI, 2004.; Germany Federal Office of Statistics, 2005; England HES, and ; U.S. - National Hospital Discharge Survey, 2004 and *Age Standardized, United Nations Standard Population, 2005

18 Hospital Discharges for Avoidable Hospital Conditions and Marker Conditions: Manhattan, Paris and Inner London average es/ ted Rate lation 1 e Adjust popul Age AHC marker conditions Manhattan Paris Inner London

19 Age-Adjusted Rates of Avoidable Hospital Conditions per 1000 Persons 20+ in New York City by Borough of Residence, Years New York City Staten Island Bronx Brooklyn Manhattan Queens Data Table New City York Staten Island Bronx Brooklyn Manhattan Queens (99,216) (5,488) (20,734) (31,326) (18,239) (22,490) Source: SPARCS,

20 Odds of AHC Discharge by Insurance Status in Manhattan Uninsured Medicaid Medicare

21 Odds of AHC Discharge by Race/Ethnicity in Manhattan African American Hispanic

22 Sources: France - PMSI, 2005.; Germany Federal Office of Statistics, 2005; England HES, and ; U.S. - National Hospital Discharge Survey, 2004 and *Age Standardized, United Nations Standard Population, 2005

23 Sources: France - PMSI, 2005.; Germany Federal Office of Statistics, 2005; England HES, and ; U.S. - National Hospital Discharge Survey, 2004 and *Age Standardized, United Nations Standard Population, 2005

24 Ratio of Age-Adjusted Rates of Revascularization : Age-Adjusted Rate of AMI in New York City by Borough of Residence, Years New York City Staten Island Bronx Brooklyn Manhattan Queens Source: SPARCS,

25 Characteristics of Residents by Income Quartile of Neighborhood Socioeconomic i Status: t Manhattan, Inner London, Paris Manhattan Total Population Education Level 1 Median Household Income Range Deprivation Score Q1 529, % $20,111 - $27,693 N/A Q2 320, % $41,335 - $54,051 N/A Q3 304, % $57,597 - $65,038 N/A Q4 371, % $68,355 - $73,816 N/A Paris Q1 778, % 20,061-22,470 N/A Q2 417, % 22,575-25,971 N/A Q3 566, % 26,506-28,551 N/A Q4 361, % 28,572-36,161 N/A Inner London Q1 642, % N/A Q2 903, % N/A 42.6 Q3 612, % N/A Q4 607, % N/A Sources: U.S. Census 2000; French Census 1999; National Office of Statistics, UK 2001

26 Health Status by Income Quartile of Neighborhood: Mortality Age-Adjusted Premature Mortality Rate Age-Adjusted Diabetes Mortality Rate Manhattan Ratio: Q1:Q4 Paris Ratio: Q1:Q4 Inner London Ratio: Q1:Q4 Sources: Manhattan - Bureau of Vital Statistics of the New York City Department of Health and Mental Hygiene, ; Paris - The Institut National de la Santé et de la Recherche Médicale (INSERM), ; Inner London - The United Kingdom Office of National Statistics,

27 Age Adjusted Hospital Discharges per 100,000 Total and Myocardial a Infraction (AMI) Age-Adjusted Total Age-Adjusted Acute Myocardial Infarction (AMI) Manhattan Ratio: Q1:Q Q4 Paris Ratio: Q1:Q4 Inner London Ratio: Q1:Q4 Sources: Manhattan - Statewide Planning and Research Cooperative System (SPARCS), ; Paris - French Ministry of Health s Hospital Reporting System: Programme pour la Médicalisation des Systèmes d Information (PMSI) (PMSI), ; Inner London: Hospital Episode Statistics (HES),

28 Access to Primary Care by Income Quartile of Neighborhood Avoidable Hospital Conditions per 100,000 Avoidable Hospital Conditions per 100, Avoidable Hospital Conditions per 100, Manhattan Ratio: Q1:Q4 Paris Ratio: Q1:Q4 Inner London Ratio: Q1:Q4 Sources: Manhattan - Statewide Planning and Research Cooperative System (SPARCS), ; Paris - French Ministry of Health s Hospital Reporting System: Programme pour la Médicalisation des Systèmes d Information (PMSI) (PMSI), ; Inner London: Hospital Episode Statistics (HES),

29 Access to Specialty Care by Income Quartile of Neighborhood Age-Adjusted Discharge Rate for Revascularizations per 100,000 (35+) Age-Adjusted Lower Joint Replacement Rate Manhattan Q1:Q4 Paris Q1:Q4 Inner London Q1:Q4 Age-Adjusted Breast Reconstruction Rate Sources: Manhattan - Statewide Planning and Research Cooperative System (SPARCS), ; Paris - French Ministry of Health s Hospital Reporting System: Programme pour la Médicalisation des Systèmes d Information (PMSI) (PMSI), ; Inner London: Hospital Episode Statistics (HES),

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31 Ne faudrait-il pas concentrer les interverventions ti sur les populations et les zones géographiques àhaut risque?

32 NHS Healthy World Cities Consortium

33 HWCI Research Themes Inequality in access to health h care How do rates of mortality amenable to health care compare across different city neighborhoods h ranked by SES? How does access to primary care and specialty services compare among these neighborhoods? Inter-sectoral action to promote population health Policies to curb smoking Congestion pricing Chronic disease dsease

34 Healthy World Cities Initiative Activities Healthy world cities web presence Relational database enabling inter as well as intra city comparisons, available on the web site Targeted and applied health policy and social research Meetings A Healthy World Cities Academy

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