Premature avoidable deaths by road traffic injuries in Belgium: Trends and geographical disparities

Transcription

1 European Journal of Epidemiology 17: , Ó 2002 Kluwer Academic Publishers. Printed in the Netherlands. Premature avoidable deaths by road traffic injuries in Belgium: Trends and geographical disparities A. Leveque, P.C. Humblet & R. Lagasse Department of Health Policies and Health Systems Research, School of Public Health, Universite Libre De Bruxelles (ULB), Brussels, Belgium Accepted in revised form 12 February2002 Abstract. Road traffic injuries are a major public health problem. In this study, we chose Years of Potential Life Lost (YPLL) to analyse the trends during the period and the relative impact of the traffic injuries death on total mortalityand on total avoidable mortalityin Belgium. We analysed the geographical trends over a 20-year period at the district level. The YPLL age-adjusted rates were analysed for four successive 5-year periods: , , , and the ratios of YPLL rates were used to describe changes between 1974 and 1994 at district level. The YPLL rates decrease for all causes mortality, total avoidable causes and road traffic injuries. This trend can be observed during the four periods of 5 years. A slowing down of the decrease of the YPLL rates for road traffic injuries, both for men and women is observed: 11.7% between periods 2 and 1, and only3% between periods 4 and 3 for men (16.2 and 7.5% for women). The geographical analysis shows marked differences between districts. Even though a favourable trend is observed for the traffic injuries deaths in Belgium it is important to highlight the important slowing down of this trend during the most recent years. It is also necessary to underline the importance of geographical disparities in the distribution of YPLL rates within the entire population. Key words: Avoidable death, Belgium, Road traffic injury, Time trends, YPLL Introduction In manyindustrialized countries, traffic injuries are the leading causes of death in children, adolescents and young adults. Among elderly people injury death rates are even higher than among young ones but overshadowed bydeath from cancer and other degenerative diseases [1, 2]. Classical methods of measuring mortality, including crude rates, age- and sex-specific rates or agestandardised death rates provide an indication of the relative magnitude of the problem. However, theyare not the best measures of the actual health impact due to road traffic injuries. The use of premature mortalityhas been advised since it takes into account age at death and then give a better indicator of the burden of traffic injuries in the population. The Years of Potential Life Lost (YPLL) prior to age 65 is a health indicator measuring the total number of life years lost due to premature death. It is calculated in order to compare the importance of the causes of death with public health significance in a population [3, 4]. Deaths from traffic injuries are avoidable or partly avoidable with treatment or with preventive measures or both. As described byhaddon [5], there are three major stages in the sequence of injuryevents during which countermeasures can be undertaken. For these reasons, deaths from traffic injuries are undoubtedly premature and avoidable. In this study, we chose YPLL (age-standardized rates) to analyse the trends in and the relative impact of the traffic injuries death on total mortalityand on total avoidable mortalitybetween 1974 and 1994 in Belgium separatelyin women and men. We analysed the geographical trends over a 20-year period at district level. This geographical comparison is aimed at producing results and indicators for health monitoring and health promotion programs at the corresponding level of public health decisions in Belgium [6]. Methods National data on deaths were obtained from the National Institute of Statistics (NIS). The Eighth Revision of the International Classification of Diseases (ICD-8) was used during the period. The Ninth Revision (ICD-9) was introduced in 1979 in Belgium. We decided to skip 1979 for problems in coding practices. Since 1980 till 1998 mortalitystatistics have been coded with the ICD-9. The avoidable death indicators used in this study to obtain the age-adjusted YPLL rates from all avoidable causes are the same as those in the list

2 842 Table 1. Avoidable mortalityindicators: ICD codes (8th and 9th revision) ICD-8 ICD-9 Tuberculosis , 137 Malignant neoplasm of the breast Malignant neoplasm of the cervix/uterus body180, , 182 Malignant neoplasm of the testis Hodgkin s disease Chronic rheumatic heart disease Hypertensive an cerebrovascular disease , , Asthma Peptic ulcers Appendicitis Abdominal hernia Cholelithiasis and cholecystitis , Maternal mortality Malignant neoplasms of the trachea, bronchus and lung Malignant neoplasm of the skin (non melanoma) Ischaemic heart disease , Cirrhosis of liver Motor vehicle accidents E E published bythe EC studygroup [7, 8] (Table 1). The age-adjusted YPLL rates are calculated along the Romeder procedure [3]. We worked with the limits of age 1 64, and expressed the rate per 100,000 persons. We used the direct standardization method to produce YPLL age-adjusted rates using Belgium s population in the 5-year period as the reference population. The YPLL age-adjusted rates were analysed for four successive 5-year periods: , , and The ratios of YPLL rates were used to describe changes between 1974 and 1994 (1994 vs. 1974) at district level. The geographical distribution of YPLL ratio by sex and bydistricts (43 Belgian districts) is mapped, based on a sextile grouping method. We also compared the relative magnitude of YPLL rates for road traffic injuries with YPLL for all causes mortalityand with YPLL for total avoidable causes byusing percentages. Results Table 2 shows the total number of deaths bygender and categories (all deaths/avoidable deaths/road traffic injurydeaths) during the four periods of 5 years. The YPLL rates indicate a favourable development for all causes mortality, total avoidable causes and traffic injuries. The total decrease between periods P1 and P4 is greater for total avoidable causes and even more so in men (65.8%). The ratios for traffic injuries are more favourable for women than for men (respectively69.2 and 74.9%). This favourable trend can be observed during the four periods of 5 years: a certain slowing down of the decrease of the YPLL rates for road traffic injuries, both for men and women. The decrease was 11.7% between periods 2 and 1, and only 3% between periods 4 and 3 for men. It was 16.2 and 7.5% for women (Table 3). The relative magnitude of YPLL rates for traffic injuries out of all causes of death remains relatively steadythroughout the four periods of time: respectively18 19% and 10 11% for men and women. On the other hand the relative importance of YPLL rates for traffic injuries in all avoidable causes of death YPLL age-adjusted rates increase from 40.5 to 46% throughout the four periods for men. On the contrary, the proportion is stable (25 27%) for women (Table 4). The changes in YPLL rates for traffic injuries between and are analysed geographicallyat district level (43 districts in Belgium; Flanders: 22, Wallonia: 20 and Brussels region: 1). Figures 1 and 2 and Table 5 illustrate the districts patterns of YPLL rate ratios (P4/P1) for men and Table 2. Total number of deaths (age standardized, 1 64 years) during the four periods by gender and category (P1) (P2) (P3) (P4) Traffic injuries Men Women Total avoidable causes Men Women All causes Men Women

3 843 Table 3. YPLL rates and YPLL ratios (in %) between the 5-year periods over time for women and men YPLL (age standardized rates/100,000) YPLL rate ratios (%) between periods (P1) (P2) (P3) (P4) P2/P1 P3/P2 P4/P3 P4/P1 Traffic injuries Men Women Total avoidable causes Men Women All causes Men Women Table 4. Relative magnitude of YPLL rates for traffic injuries over time for women and men (P1) (P2) (P3) (P4) Traffic injuries vs. total avoidable causes (%) Men Women Traffic injuries vs. All causes (%) Men Women Figure 1. Road traffic injuries (men): ratio of YPLL rates between and at the district level (Brussels Region: number 4; Flanders: numbers 1 3, 5 21, 33 35; Wallonia: numbers 22 32, 36 43). Figure 2. Road traffic injuries (women): ratio of YPLL rates between the periods and at the district level (Numbers indicate districts of Belgium. See Figure 1). women separately. For men, all the districts except three (22, 28, 32) present a decrease of YPLL rates. These three exceptions are in Wallonia. For women, six districts among the 43 (10, 18, 22, 23, 32, 41) present an increase of YPLL rates up to 60% (district 32). Among these six, four are in Wallonia (22, 23, 32, 41) and two in Flanders (10, 17). Two Walloon districts present an increase in both sexes (22, 32). Discussion The YPLL method is arbitraryin the choice of the upper limit for premature death [9, 10]. We chose the age of 64 years in adequation with EC avoidable indicators methodology[8]. During this period of 20 years, the YPLL rates for road traffic injuries decreased by30 and 25% among women and men re-

4 844 Table 5. Changes in YPLL for traffic injuries between (P1) and (P4) [(P4/P1) 100%] at the district level for men and women in Belgium No. Arrondissement Men Women 1 Antwerpen Mechelen Turnhout Brux-bruss Halle-vilv Leuven Nivelles Brugge Diksmuide Ieper Kortrijk Oostende Roeselaere Tielt Veurne Aalst Dendermond Eeklo Gent Oudenaarde St-niklaas Ath Charleroi Mons Mouscron Soignies Thuin Tournai Huy Liege Verviers Waremme Hasselt Maaseik Tongeren Arlon Bastogne Marche Neufchat Virton Dinant Namur Philippev spectively. It is rather comparable with the reduction observed for all causes of deaths (respectively27 and 24%). The comparison of the patterns of trend for YPLL rates bytraffic injuries and by total avoidable causes of death point out the slowing down of the positive evolution of YPLL rates since This deceleration is verymarked for traffic injuries in men. Indeed, the reduction is only3% between the periods and The proportion of YPLL bytraffic injuries as compared to all causes of death YPLL rates remains stable over the 20 years period (18% for men and 10 11% for women). On the other hand, the YPLL bytraffic injuries in the total avoidable causes of death increases regularlyin men from 40.5% during the to 46% during the periods. In the context of a favourable global evolution, the geographical analysis shows marked differences between districts. For men, three Walloon districts (22, 28, 32) present an increase of YPLL rates bytraffic injuries (with a maximum of 28%). For all the others the magnitude of reduction is nearly50% for two of them located in Flanders (9, 17) and between 30 and 40% for 14 of them (seven in Flanders, six in Wallonia and Brussels). For women, four Walloon (22, 23, 32, 41) and two Flemish (10, 18) districts present an increase of YPLL rates bytraffic injuries (with a maximum of 63%) between the and the periods. All the others present a reduction of their rates: eight of them decrease for more than 50% (four in Flanders and four in Wallonia), six for more than 40% (four in Wallonia and two in Flanders), seven for more than 30% (six in Flanders and Brussels). These differences could be treated as a starting point for in-depth studies on gender and geographical variations [11] but also as warning signals for health planners [12, 13]. Since 1986 the communities are in charge of coding and verifying the causes of deaths separately. On this basis differences in coding practice between the two communities are to be suspected. But different coding exercises have shown that the impact on mortalitystatistics comparabilitybetween regions is far from explaining the whole difference observed [14]. A better health situation in Flanders than in Wallonia has been regularlyobserved [15, 16]. The same conclusion was found in previous studies on EC avoidable mortalityindicators [17, 18]. Even though a favourable trend is observed for the traffic injuries deaths in Belgium [6] as in other countries [19, 20], it is important to highlight the important slowing down of this trend during the most recent years in Belgium. Several assumptions can explain the deceleration of this favourable trend: among those, lack of passengers adhesion to the wearing of seat belt at the back of vehicles (however obligatorysince 1991) and an increase of injurydeath among lorry(less than 3.5 tons) drivers (more than 20% between 1980 and 1999). It is also necessaryto underline in some countries the importance of geographical [14, 21] and socioeconomic [21 23] disparities in the distribution of YPLL rates within the entire population. It is suggested that the development of a method of mortalityanalysis based on the space and temporal axis provide relevant informations and indicators for health planners and for policydecision makers at the regional and local levels in adequacywith the health priorityidentification and health promotion strategies in the Belgian context.

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