Cause of Death Mortality: International Trends by Socio-Economic Group

Transcription

1 Cause of Death Mortality: International Trends by Socio-Economic Group Andrew J.G. Cairns Heriot-Watt University Edinburgh Director Actuarial Research Centre IFoA Joint work with C. Redondo D. Blake K. Dowd M. Kallestrup-Lamb C. Rosenskjold Longevity 14 Amsterdam September 2018 Andrew J.G. Cairns Cause of Death Mortality 1 / 50

2 Outline Motivation and long term goals Data Comparison of US Denmark and England England: deeper dive Andrew J.G. Cairns Cause of Death Mortality 2 / 50

3 Purpose of looking at cause of death data What are the key drivers of all-cause mortality? How are the key drivers changing over time? Which causes of death have high levels of inequality: by education; by affluence? Can we point to specific causes of death as responsible for growing inequality? Leading to: insight into mortality underpinning life insurance and pensions Andrew J.G. Cairns Cause of Death Mortality 3 / 50

4 Drivers Medical advances Health spending Public health initiatives Individual risk factors: Controllable e.g. smoking diet exercise alcohol sun drugs hygeine risky sex stress environment... leading to cohort effects Not (easily) controllable e.g. genetic affluence education character/personality traits... Andrew J.G. Cairns Cause of Death Mortality 4 / 50

5 Socio-economic datasets Cause of death data for: US (males and females) by education level: low ( high school); high Denmark (males only): by education level: low; medium; high (cohorts > 1920 only) by individual affluence: 10 deciles England (males and females) by small area income deprivation: 10 deciles by region: 9 areas Andrew J.G. Cairns Cause of Death Mortality 5 / 50

6 Cause of Death Groupings US1.1 Infectious diseases excl. HIV/AIDS US 1.2 HIV/AIDS 1 Infectious diseases 2 Cancer: mouth gullet stomach 3 Cancer: gut rectum 4.1 Cancer: larynx 4.2 Cancer: trachea 4.3 Cancer: lung bronchus 5 Cancer: breast 6.1 Cancer: uterus cervix 6.2 Cancer: ovary 6.3 Cancer: other female genital 7.1 Cancer: prostate testicular 7.2 Cancer: other male genital 8 Cancer: skin bones and certain organs 9 Cancer: lymphatic 10 Benign tumours 11 Diseases: blood 12 Diabetes 13 Mental illness 14.1 Diseases of nervous system excl. Alzh Alzheimers 15 Blood pressure + rheumatic fever 16 Ischaemic heart diseases 17 Other heart diseases 18 Diseases: cerebrovascular 19 Diseases: circulatory 20 Diseases: lungs breathing 21 Diseases: digestive (excl. alcohol: 27) 22 Diseases: urine kidney Diseases: skin bone tissue 24(DU) Senility without mental illness 25 Road/other accidents 26 Other causes 27 Alcohol liver disease 28 Suicide 29 Accidental Poisonings Detail able to separate causes with and without significant risk factors or inequality Andrew J.G. Cairns Cause of Death Mortality 6 / 50

7 Data Other Details US (Cristian Redondo Session: Mortality Modelling 5) Deaths subdivided into 30 CoD groups Single ages and born between 1914 and 1970 Single years Denmark (Carsten Rosenskjold) 29 CoD groups Age groups Five-year blocks England 34 CoD groups Age groups Single years Andrew J.G. Cairns Cause of Death Mortality 7 / 50

8 Denmark Affluence Top 10 CoD Males; Ages 71-75; s Rank Least Affluent Most Affluent 1 Ischaemic heart Skin & organ cancer 2 Respiratory Ischaemic heart 3 Lung cancer etc. Prostate cancer 4 Skin & organ cancer Respiratory 5 Other Lung cancer etc. 6 Cerebrovascular Cerebrovascular 7 Other heart Other 8 Diabetes Gut cancer 9 Gut cancer Other heart 10 Prostate cancer Alzheimers etc. Prostate: almost no inequality. Causes of death with significant controllable risk factors feature much more heavily amongst the least affluent. Andrew J.G. Cairns Cause of Death Mortality 8 / 50

9 Denmark: Cause of Death Data e 05 1e 04 1e 03 1e 02 1e 01 Denmark By Education Ischaemic heart diseases 1e 05 1e 04 1e 03 1e 02 1e 01 Denmark By Affluence Ischaemic heart diseases Wide gap Affluence has a wider gap than education Gap narrows with age Andrew J.G. Cairns Cause of Death Mortality 9 / 50

10 Denmark: Cause of Death Data Age Group Denmark by Education Ischaemic heart diseases Denmark by Affluence Ischaemic heart diseases 5e 04 2e 03 5e 03 2e 02 5e 04 2e 03 5e 03 2e Gap widens over time Andrew J.G. Cairns Cause of Death Mortality 10 / 50

11 Impact of Controllable Risk Factors Risk factors (controllable and not controllable) Impact on cause of death rates Some risk factors big impact on some causes e.g. smoking lung cancer e.g. several risk factors ischaemic heart disease significant inequality gaps Some causes of death: no known (significant) controllable risk factors e.g. prostate cancer Andrew J.G. Cairns Cause of Death Mortality 11 / 50

12 Denmark: Cause of Death Data e 05 1e 04 1e 03 1e 02 1e 01 Denmark By Education Cancer: prostate testicular 1e 05 1e 04 1e 03 1e 02 1e 01 Denmark By Affluence Cancer: prostate testicular Education: no differences Affluence: small differences Andrew J.G. Cairns Cause of Death Mortality 12 / 50

13 Multi-Country: 2007 Males Ischaemic Heart Disease US By Education 2007 Ischaemic heart diseases Low High Denmark By Education 2007 Ischaemic heart diseases Low Medium High Denmark By Affluence 2007 Ischaemic heart diseases Age US: wider than Denmark England by Deprivation 2007 Ischaemic heart diseases Age England similar to Denmark but higher Andrew J.G. Cairns Cause of Death Mortality 13 / 50

14 Multi-Country: Age 68 Males Ischaemic Heart Disease US by Education Age 68 Ischaemic heart diseases Denmark by Education Age 68 Ischaemic heart diseases 5e 04 2e 03 1e 02 Low High 5e 04 2e 03 1e 02 Low Medium High Denmark by Affluence Age 68 Ischaemic heart diseases England by Deprivation Age 68 Ischaemic heart diseases 5e 04 2e 03 1e 02 5e 04 2e 03 1e Significant improvements but not throughout Andrew J.G. Cairns Cause of Death Mortality 14 / 50

15 Multi-Country: Age 68 Males Prostate Cancer US by Education Age 68 Cancer: prostate testicular Denmark by Education Age 68 Cancer: prostate testicular 5e 04 2e 03 1e 02 Low High 5e 04 2e 03 1e 02 Low Medium High Denmark by Affluence Age 68 Cancer: prostate testicular England by Deprivation Age 68 Cancer: prostate 5e 04 2e 03 1e 02 5e 04 2e 03 1e No controllable risk factors; US improvements; DK vs US genetic factors? Andrew J.G. Cairns Cause of Death Mortality 15 / 50

16 Multi-Country: Age 68 Males Lung Cancer US by Education Age 68 Cancer: lung larynx.. Denmark by Education Age 68 Cancer: lung larynx.. 5e 04 2e 03 1e 02 Low High 5e 04 2e 03 1e 02 Low Medium High Denmark by Affluence Age 68 Cancer: lung larynx.. England by Deprivation Age 68 Cancer: lungs bronchus 5e 04 2e 03 1e 02 5e 04 2e 03 1e Significant inequality; improvements might be driven by smoking prevalence Andrew J.G. Cairns Cause of Death Mortality 16 / 50

17 Variation in Reporting Practice: e.g. Mental Illness US By Education 2007 Mental illness Low High Denmark By Education 2007 Mental illness Low Medium High Denmark By Affluence 2007 Mental illness Age England by Deprivation 2007 Mental illnesses Age Alcohol & drug abuse; mental disorders; vascular dementia Andrew J.G. Cairns Cause of Death Mortality 17 / 50

18 Deaths of Despair: A Growing Problem? 2002/07/12 US By Education 2002 Alcohol > liver Low High Denmark By Education 2002 Alcohol > liver Low Medium High Denmark By Affluence 2002 Alcohol > liver Age Affluence a much bigger driver England by Deprivation 2002 Alcohol related liver disease Age Andrew J.G. Cairns Cause of Death Mortality 18 / 50

19 Deaths of Despair: A Growing Problem? 2002/07/12 US By Education 2007 Alcohol > liver Low High Denmark By Education 2007 Alcohol > liver Low Medium High Denmark By Affluence 2007 Alcohol > liver Age England by Deprivation 2007 Alcohol related liver disease Age Andrew J.G. Cairns Cause of Death Mortality 19 / 50

20 Deaths of Despair: A Growing Problem? 2002/07/12 US By Education 2012 Alcohol > liver Low High Denmark By Education 2012 Alcohol > liver Low Medium High Denmark By Affluence 2012 Alcohol > liver Age US: possible cohort effect England by Deprivation 2012 Alcohol related liver disease Age Andrew J.G. Cairns Cause of Death Mortality 20 / 50

21 England: Income Deprivation versus Region North East North West Yorkshire & Humber East Midlands West Midlands East of England London South East South West Not in dataset: Scotland Wales Northern Ireland Andrew J.G. Cairns Cause of Death Mortality 21 / 50

22 England: Males (40-89) ASMR and ADSMR Inequality ASMR (log scale) Age Standardised Mortality Rates Males By Income for All Causes ASMR for age range ASMR (log scale) Age Standardised Mortality Rates Males By Region for All Causes ASMR for age range North East North West Yorkshire and The Humber East Midlands West Midlands East of England London South East South West ADSMR (log scale) Age & Deprivation Standardised Mortality Rates Males By Region for All Causes ADSMR for age range London Income Region Region: standardised ADSMR adjusts for different income deprivation mix by region Andrew J.G. Cairns Cause of Death Mortality 22 / 50

23 England: Females (40-89) ASMR and ADSMR Inequality ASMR (log scale) Age Standardised Mortality Rates Females By Income for All Causes ASMR for age range ASMR (log scale) Age Standardised Mortality Rates Females By Region for All Causes ASMR for age range North East North West Yorkshire and The Humber East Midlands West Midlands East of England London South East South West ADSMR (log scale) Age & Deprivation Standardised Mortality Rates Females By Region for All Causes ADSMR for age range London Males and Females: Clear London Effect. Greater improvements in healthcare?? Greater improvements in GDP?? Andrew J.G. Cairns Cause of Death Mortality 23 / 50

24 Lung Cancer: Males England Males ADSMR By Region Cancer: lungs bronchus England Males ASMR By Income Cancer: lungs bronchus ADSMR (log scale) North East North West Yorkshire and The Humber East Midlands West Midlands East of England London South East South West ASMR (log scale) Significant variation between income deciles ( smoking prevalence) Significant variation between regions (after standardisation) 1.5 variation by region; 2.5 by income decile London effect; Northern regions very poor Andrew J.G. Cairns Cause of Death Mortality 24 / 50

25 Lung Cancer: Females England Females ADSMR By Region Cancer: lungs bronchus England Females ASMR By Income Cancer: lungs bronchus ADSMR (log scale) North East North West Yorkshire and The Humber East Midlands West Midlands East of England London South East South West ASMR (log scale) Slight worsening smoking prevalence rising Same northern regions do badly Wider regional spread London effect Andrew J.G. Cairns Cause of Death Mortality 25 / 50

26 Respiratory Diseases: Males England Males ADSMR By Region Respiratory diseases England Males ASMR By Income Respiratory diseases ADSMR (log scale) North East North West Yorkshire and The Humber East Midlands West Midlands East of England London South East South West ASMR (log scale) Flatter but otherwise similar pattern to lung cancer males Andrew J.G. Cairns Cause of Death Mortality 26 / 50

27 Respiratory Diseases: Females England Females ADSMR By Region Respiratory diseases England Females ASMR By Income Respiratory diseases ADSMR (log scale) North East North West Yorkshire and The Humber East Midlands West Midlands East of England London South East South West ASMR (log scale) Similar pattern to lung cancer females Andrew J.G. Cairns Cause of Death Mortality 27 / 50

28 Ischaemic Heart Disease: Males ADSMR (log scale) England Males ADSMR By Region Ischaemic heart diseases North East North West Yorkshire and The Humber East Midlands West Midlands East of England London South East South West ASMR (log scale) England Males ASMR By Income Ischaemic heart diseases Success story: major improvements Deterioration: widening gap and regional inequality Females: similar picture Andrew J.G. Cairns Cause of Death Mortality 28 / 50

29 Story So Far Causes of death with significant risk factors: Significant inequalities by income deprivation Significant additional inequalities by region Bigger income inequality bigger regional inequality Mostly the same regions are worse Andrew J.G. Cairns Cause of Death Mortality 29 / 50

30 Breast Cancer: An Equality Success Story England Females ADSMR By Region Cancer: breast England Females ASMR By Income Cancer: breast ADSMR (log scale) 2e 04 3e 04 5e 04 7e 04 North East North West Yorkshire and The Humber East Midlands West Midlands East of England London South East South West ASMR (log scale) 2e 04 3e 04 5e 04 7e Limited controllable risk factors Success story: no significant inequality Andrew J.G. Cairns Cause of Death Mortality 30 / 50

31 Ovarian Cancer: A Regional Lottery? England Females ADSMR By Region Cancer: ovary England Females ASMR By Income Cancer: ovary ADSMR (log scale) North East North West Yorkshire and The Humber East Midlands West Midlands East of England London South East South West ASMR (log scale) Limited controllable risk factors Limited income effect Significant regional effect Andrew J.G. Cairns Cause of Death Mortality 31 / 50

32 Diabetes: Males England Males ADSMR By Region Diabetes England Males ASMR By Income Diabetes ADSMR (log scale) North East North West Yorkshire and The Humber East Midlands West Midlands East of England London South East South West ASMR (log scale) Significant inequality Widening inequality gap by income deciles Worsening mortality after about 2010 Andrew J.G. Cairns Cause of Death Mortality 32 / 50

33 Alzheimers: Females (no clear risk factors) ADSMR (log scale) 1e 04 2e 04 3e 04 5e 04 England Females ADSMR By Region Alzheimers North East North West Yorkshire and The Humber East Midlands West Midlands East of England London South East South West e 04 2e 04 3e 04 5e 04 England Females ASMR By Income Alzheimers Modest income effect; Strong regional effect?? health migration Deterioration (2 )?? evidence for non-independence of causes of death improvements elsewhere?? more frail survivors in old age ASMR (log scale) Andrew J.G. Cairns Cause of Death Mortality 33 / 50

34 Further remarks US Denmark: Need to factor in changing levels of educational attainment Is it possible to decompose improvements into medical advances and changes in risk taking? E.g. Can we link smoking prevalence to e.g. lung cancer mortality? What are the causes of the London Effect? Andrew J.G. Cairns Cause of Death Mortality 34 / 50

35 Summary Affluence or income deprivation is better than education for all CoD if you have the data Impact of affluence/education/region varies with CoD Significant levels of inequality for most of the big CoD s CoD absolute levels vary between countries: local practice(?) But degree of inequality by CoD is consistent from country to country Second order differences between countries may be due to healthcare systems England: Regional differences in addition to income effects Consistent patterns by CoD connected to controllable risk factors Andrew J.G. Cairns Cause of Death Mortality 35 / 50

36 Thank You! Questions? E: W: andrewc/arcresources Andrew J.G. Cairns Cause of Death Mortality 36 / 50

37 The Actuarial Research Centre (ARC) A gateway to global actuarial research The Actuarial Research Centre (ARC) is the Institute and Faculty of Actuaries (IFoA) network of actuarial researchers around the world. The ARC seeks to deliver cutting-edge research programmes that address some of the significant global challenges in actuarial science through a partnership of the actuarial profession the academic community and practitioners. The Modelling Measurement and Management of Longevity and Morbidity Risk research programme is being funded by the ARC the SoA and the CIA. Andrew J.G. Cairns Cause of Death Mortality 37 / 50

38 England: Income Deprivation versus Region United Kingdom: Regions 2011 Orkney Islands Shetland Islands Northern Ireland Scotland North East Key Regions Boundaries shown in England are effective as follows: Regions at 31st December 2011 (see note below). Government Offices for the Regions closed at the end of March The former Government Office Regions (England) are now referred to as 'regions' for statistical purposes. Scotland Northern Ireland and Wales are not regions but are often used as equivalents for the purpose of representing statistics that cover the whole of the UK. Please visit the ONS Geography web pages for the latest information: North West Yorkshire and The Humber East Midlands Wales West Midlands East of England London South West South East Contains Ordnance Survey data Crown copyright and database right 2012 Produced by ONS Geography GIS & Mapping Unit Andrew J.G. Cairns Cause of Death Mortality 38 / 50

39 Denmark Males: Statistical Significance For each cause of death (29) and age group (13) Rank the death rates for the 10 groups i = For each year group t R(i t) = rank of m(i t) out of m(1 t)... m(10 t) Rank 1: highest death rate Rank 10: lowest death rate Data (i R(i t)) ( ) Test statistic S = cor i R(i t) Under H 0 the ranks are a random permutation of Under H 0 S is approximately N(0 σ 2 ) where σ = One-sided test: Reject H 0 if S > σφ 1 (α) Large S low affluence high CoD mortality Andrew J.G. Cairns Cause of Death Mortality 39 / 50

40 Cause of Death Inequaility: Income vs Region Inequality Between Regions Comparison of Inequality Between Income Groups and Between Regions (Standardised) Alzheimers Inequality = ASMR(worst) / ASMR(best) Alzheimers Cancer: lungs bronchus Respiratory diseases Cerebrovascular diseasesischaemic heart diseases Ischaemic heart diseases Cerebrovascular diseasesrespiratory Cancer: diseases lungs bronchus Cancer: ovary Cancer: skin bones internal organs Cancer: skin bones internal organs Cancer: prostate Cancer: breast Cancer: uterus cervix Males Females Major Cause of Death Minor Cause of Death Inequality Between Income Groups Inequality=A(D)SMR(worst)/A(D)SMR(best) Region: best=london; worst=n.w. Income Deprivation: best=10; worst=1 Andrew J.G. Cairns Cause of Death Mortality 40 / 50

41 Cause of Death Inequaility: Income vs Region Inequality Between Regions Comparison of Inequality Between Income Groups and Between Regions (Standardised) Alzheimers Inequality = ASMR(worst) / ASMR(best) Alzheimers Cancer: lungs bronchus Respiratory diseases Cerebrovascular diseasesischaemic heart diseases Ischaemic heart diseases Cerebrovascular diseasesrespiratory Cancer: diseases lungs bronchus Cancer: ovary Cancer: skin bones internal organs Cancer: skin bones internal organs Cancer: prostate Cancer: breast Cancer: uterus cervix Males Females Major Cause of Death Minor Cause of Death Inequality Between Income Groups London: not always the best for individual causes of death. Andrew J.G. Cairns Cause of Death Mortality 41 / 50

42 Cause of Death Inequaility: Income vs Region Inequality Between Regions Comparison of Inequality Between Income Groups and Between Regions (Standardised) Alzheimers Inequality = ASMR(worst) / ASMR(best) Alzheimers Cancer: lungs bronchus Respiratory diseases Cerebrovascular diseasesischaemic heart diseases Ischaemic heart diseases Cerebrovascular diseasesrespiratory Cancer: diseases lungs bronchus Cancer: ovary Cancer: skin bones internal organs Cancer: skin bones internal organs Cancer: prostate Cancer: breast Cancer: uterus cervix Males Females Major Cause of Death Minor Cause of Death Inequality Between Income Groups Causes of death with significant controllable risk factors: Inequality between regions (??) significant variation in risk factors between regions Andrew J.G. Cairns Cause of Death Mortality 42 / 50

43 US Males Age 63: Stagnation Males Age 63 All Cause Mortality US low education US high education? Andrew J.G. Cairns Cause of Death Mortality 43 / 50

44 US Drivers of Change Males Age 63 Low education absolute changes in mortality Absolute Change in CoD Death Rate US Males Aged 63 Low Education Changes in CoD Death Rates Accidental Poisonings Benign tumours HIV/AIDS Diseases: skin bone tissue Diseases: blood Mental illness Infectious Diseases e Diseases: Nervous system urine kidney... incl. Alzheimers Suicide Other causes Blood pressure + rheum Diseases: digestive Cancer: prostate testicular Cancer: Alcohol > liver Road/other lymphatic accidents blood forming tissue Diabetes Diseases: circulatory Cancer: mouth gullet stomach Cancer: gut rectum Cerebrovascular diseases incl. stroke Diseases: lungs breath Cancer: bones skin Other heart diseases Cancer: lung larynx.. Ischaemic heart diseases 1e 05 2e 05 5e 05 1e 04 2e 04 5e 04 1e 03 2e 03 5e 03 CoD Death Rate in (log scale) Three big gains many Andrew small J.G. Cairns losers Cause of Death Mortality 44 / 50

45 US Drivers of Change Males Age 63 High education absolute changes in mortality Absolute Change in CoD Death Rate Accidental Poisonings US Males Aged 63 High Education Changes in CoD Death Rates Diseases: skin bone tissue Benign tumours Mental illness HIV/AIDS Diseases: urine blood kidney... Other causes Alcohol Road/other Diabetes > liver accidents Diseases: circulatory Infectious Diseases excl HIV Suicide Nervous system incl. Alzheimers Diseases: Blood pressure digestive + rheumatic fever Cancer: prostate testicular Cancer: mouth gullet stomach Cerebrovascular diseases incl. stroke Cancer: lymphatic blood forming tissue Cancer: gut rectum Diseases: lungs breathing Other heart diseases Cancer: bones skin Cancer: lung larynx.. Ischaemic heart diseases 1e 05 2e 05 5e 05 1e 04 2e 04 5e 04 1e 03 2e 03 5e 03 CoD Death Rate in (log scale) Small losers small Andrew J.G. gains Cairns Cause of Death Mortality 45 / 50

46 Deaths of Despair: A Growing Problem? 2002/07/12 US By Education 2002 Accidental Poisonings Low High Denmark By Education 2002 Accidental Poisonings Low Medium High Denmark By Affluence 2002 Accidental Poisonings Age US Denmark: significant England by Deprivation 2002 Accidental poisonings Age Andrew J.G. Cairns Cause of Death Mortality 46 / 50

47 Deaths of Despair: A Growing Problem? 2002/07/12 US By Education 2007 Accidental Poisonings Low High Denmark By Education 2007 Accidental Poisonings Low Medium High Denmark By Affluence 2007 Accidental Poisonings Age England by Deprivation 2007 Accidental poisonings Age Andrew J.G. Cairns Cause of Death Mortality 47 / 50

48 Deaths of Despair: A Growing Problem? 2002/07/12 US By Education 2012 Accidental Poisonings Low High Denmark By Education 2012 Accidental Poisonings Low Medium High Denmark By Affluence 2012 Accidental Poisonings Age Growth: England > US > DK England by Deprivation 2012 Accidental poisonings Age US: evidence of a cohort effect Andrew J.G. Cairns Cause of Death Mortality 48 / 50