Census 2011 - Demographic planning for public health

The voluntary census of 2011 is beginning to trickle out its results.   Bookmark the home page for direct access to information as it is being released Census 2011 data. 

This weeks  released on age and sex contains two bits of information for future planning.  First and to noone’s surprise, the proportion of persons over the age of 65 is continuing to grow, having reached 14.8% of the population. Good news for geriatric specialities, but perhaps not as notable as it is being made to sound.  Consider the large countries with a seniors ratio that exceeds 20%, including Japan, Germany and Italy.  Sweden, Greece, Bulgaria, Austria, Portugal, Belgium, Finland, Spain – in fact most of Europe have proportions in the upper teens.   14.8% actually puts Canada 42^nd of 230 countries globally. While some of the European countries may be economically challenged, and a portion of that caused by social programming – economic prosperity is not well related to the age structure of the population.  Enlightened countries look to the ageing population as an asset, not a liability. 

Subtly in the release of the data was the other hidden gem.  The baby boomerang generation (babies of the Baby boomers) are themselves having babies.  In fact the population aged 0-4 has gone up 11% in the past 5 years. What the census doesn’t capture is that the annual birth cohort after slowly decreasing for a couple of decades has continued to expand for the past 6-7 years.   Schools continue to see decreasing student populations and will do so for about the next 7 years, but school planners should be ramping up kindergarten opportunities and elementary schools in anticipation of the surge.  Not a tsunami of kids, but certainly growth can be anticipated. (of interest will be whether the recent recession has slowed family choices on having children or the number of children per family)

From a health system perspective, it is the perfect storm converging.  The seniors population in need of services continues to grow and will do so as the Baby boomers who are now just reaching retirement years begin to expect and need increased health services, and demand is placed on the two other groups that frequently utilize health services, the expanding child population and their new mothers.  

Baby boomers have come to know and expect ready access to health services, and an analysis by cohort demonstrate that a significant proportion of growth on health service utilization is based on expectation and not on need.

Of course, in our myopic health system planners may well review this from an absolute increase requirement of the things we are already doing.  Better clarity on defining expectations, training on health service utilization, self management, and diversification of providers can mitigate the absolute numbers needed,  but are rarely incorporated into planning models and sacred cows not to be touched politically.  Megalomaniac administrators and politicians may well look at the growth opportunities that absolute demand places on the system.  So,  regrettably, expect more of the same.   

Health indicators – who is the best?

The CIHI report https://secure.cihi.ca/free_products/health_indicators_2012_en.pdf  introduced in the previous blog provides the richness of information that can be a guidance for health improvement.  Of course, improvement to what is a good question since currently immortality is a fantasy.  So here are the best of the health regions, best province and how much better could the worst of the provinces and regions do if they were to get to the best practices in Canada.  Except for the one rate to celebrate, the territories were omitted from the analysis and oftentimes have poorer health indicators than the worst health region.  PEI is treated as a single health region as well as a province.

Indicator	Best region and rate	Best province and rate	Improvement if worst province could align with the best	Improvement if the worst region could align with the best
Age standardized mortality (per 100,000 population)	Richmond BC (155)	BC  (244)	a reduction of 66 or 21% of the current rate)	a reduction of 211 or 58% of the current rate
Potential years of life lost	Richmond BC 2707	Ontario 4182	A reduction of 1849 or of 31%	A reduction of 5017 or of 65% of the current rate
Cancer incidence		Alberta 399.8	186.6 or 32%
Youth body mass index (25 or greater)		BC 16.4	Reduction of 15.8 or 52% of the current level
High blood pressure		Yukon, NWT and Nunavut with ranges of 9-11.6	Current highest level is 24.6% of population
Injury hospitalization per 100,000 population	Central ON 306	Ontario 407	302 or 48% reduction to be achieved	A reduction of 790 or 71% of the current rate
Acute myocardial infarction hospitalization	South Vancouver Island BC 118	BC 163	157 or a 48% reduction	260 or a reduction of 69%
Smoking		BC 17.4	5.8 or a 25% reduction
5+ fruits or vegetables per day		Quebec 50.4%	21.8% or a 76% increase required
Potentially avoidable mortality	Richmond BC 113	BC 172	46 or a 20% reduction	159 or a 58% reduction
Avoidable mortality from preventative causes	Richmond BC 70	Ontario 110	33 or a 23% reduction	114 or a 61% reduction

The point here is consistently the better to do provinces are 25% better than those that are not so well off, and the better health region are a whopping 3 times worse off than those that are well off.  To which the reminder must be issued that the rates for the territories are often worse that the poorest of the health regions on many indicators.

In Canada, inequity is alive.  The CIHI report begins to at least unmask some of the disparities that are in place at home.  

CIHI 2012 Health Indicators report released

There is an annual tradition for which we owe a debt of gratitude to MacLean’s magazine.  It is the release of the comparison indicators between health regions in Canada by the Canadian Institute of Health information. health indicators report 2012  or if the link does not work, access through the CIHI site and download for free at CIHI store 

The document does what the provinces have long feared, makes some direct comparisons combeined with celebrating the cumulative accomplishments of health improvement in the country.   Considerable focus is on the impact of the health care system on wellbeing, a calling deaths as avoidable and preventable – then listing where the system is not working. 

The actual document which compares health regions is embedded starting at page 45 – perhaps another message of how the document has impacted perceptions.  Most notably though is while there are reams of statistics, the presentation is standard geographic format and you will need to study the information before drawing any conclusions.  So much so that while regions may be marked as statistically different, you may find yourself asking if the finding is higher or lower than the national rate, and statistically testing does not appear to have been applied to provincial data – leaving the impression that perhaps there is no statistical difference when clearly there is.

And when will the health system learn that it has a huge impact on the determinants of health and that these are inappropriately called the “non-medical” determinants of health?  The document defines these as factors outside of the health system that affect health.   And yet, right up front in the document the health system is defined as "by the World Health Organization in 2000, includes “all activities whose primary purpose is to promote, restore or maintain health.” Therefore, in addition to the provision of care, the health system also includes public health activities of health promotion and disease prevention and other policy initiatives such as road and environmental safety  improvement, access to clean water, support for good nutrition and housing.”

Such inconsistencies are reflective of biases and prejudices of some of the members of the CIHI board who might be obvious when reviewing the names, but will not be shamed publically here. Thankfully the more rationale heads of the likes of Brian Postl, Vivek Goal, Corey Neudorf, and Luc Boileau who bring strong public health thinking to the table have influenced the remainder of the document. Thanks to these broad thinking directors of CIHI we have such a worthwhile document. 

The data are a major contribution to determining how well health regions and provinces are performing.  DrPHealth would welcome your interpretations of any particular section – if you don’t analyze it, don’t expect that the report will have made what is inherently obvious to you, something that others would recognize (write your piece and send to drphealth@gmail.com)   

Prostate screening recommendations - First, do no harm

The main topic of the week on the wires is the US preventative task for recommendation (USPTF) against PSA screening for prostate cancer.   Timely given this sites discussion on overscreening a week previous overscreening - a new public health risk.  DPHealth takes no credit for the wisdom of the  USPTF. prostate screening recommendations .  The Canadian task force came under similar scrutiny for its enlightened view of breast cancer screening CTF breast cancer screening ,  CTF has yet to comment on prostate cancer screening. 

The USPTF short version – PSA screening may benefit the reduction in death from prostate cancer by 0-1 men per 1000 screened. 

80% of PSA positive tests are false positive - that is they do not reflect cancer, but they will likely result in at least a discomforting biopsy. 

Screening leads to an upwards 50% increase in detection of what otherwise would have been clinically non-relevant cancers (ie asymptomatic and would not contribute to the individual’s subsequent health)

1/3^rd of men who have prostate surgery develop significant post surgical discomfort, 5 in 1000 die post surgery, and 10-70 will have significant complications.

On the balance sheet the harms are roughly the same, or slightly more than the benefit.  

As Hippocrates wrote into the oath taken by physicians – "first, do no harm".  One of the four pillars of modern medical ethics is this principle of non-maleficence. Kudos to the USPTF for staying true to the Hippocratic oath.  

To celebrate the Canadian contribution, the Canadian Task Force on the periodic health examination was founded in 1976 and formed the model for the USPTF that followed in 1984.  The CTF developed the methodology that has been emulated numerous times in assessing quality of evidence review and the synthesis into grading of recommendations.   Both bodies as well as other national bodies modelled after the CTF are designed to look carefully at the evidence for applying population level interventions.  The current iteration of the task force was revived in 2010 after a 5 year disbanding and one only hopes survives the scythe which is swinging in Ottawa these days.  

Flu report card launched by the Lung Association fails grade.

A few weeks ago the lung associations from BC and Quebec released a report card on influenza in Canada BC Lung association link.  Last Friday the American Public Health Association picked up on the report card and gave Canada an overall failing grade.  APHA link.

On the surface, it made for good media coverage and much mileage CBC report on report card.  Probably made the folks in BC feel good, and provided fodder for Quebecers to tighten up their influenza vaccination program.

Here’s where the critical public health mind needs to go to work and read the fine print.  You can find on the original release that the study was based on a 3 day telephone blitz of 1019 residents for Canada.  It provides some level of stability on a national level, but start breaking that down into provincial data, and your confidence intervals are such that even the difference between BC and Quebec likely becomes not-significant. And then to draw a conclusion about recall on influenza like illness to suggest that certain provincial policies are better than others is a bit of a stretch.

Of course, look to the Canada community health survey for more accurate data – buried in reams of paper and not user friendly.  From 2007/08 (please let us know if there is comparable data for 2010 yet available anywhere).  Turns out that total population coverage rates has Canada at 30.5%, Nova Scotia doing the best at 38.9% and Newfoundland and Labrador in the basement at 23% (BC at 29.3% and Quebec at 25.2%). 

Ok, the years aren’t comparable and we did have a little H1N1 in between the surveys, but the rigour of the CCHS survey and the overall differences between this and the Lung Association must be noted. Likely no harm done other than the APHA headline that suggests Canada has a failing grade collectively and it would be interesting to see some international comparisons.   

Of course, kudos to the lung association for doing what PHAC and Health Canada seem so reticent to do - actually compare jurisdictional data.  McLeans magazine started the trend and over the years the McLean’s rankings carry more credence than most government reports, but isn’t this something that our major health oversight folks should be doing so that we can make decisions made on solid science?  

Cosmetic pestcide ban falls in BC - how to release politically unwanted news before the long weekend

If you are interested in how to release politically unwanted information, watch the media on the Friday before a long weekend. 

A year ago, BC’s premier indicated that she would move to regulate cosmetic use of pesticides and join the forward thinking provinces of Québec, Ontario, New Brunswick, Prince Edward Island, Alberta, Nova Scotia, and Newfoundland and Labrador in precluding the use of cosmetic pesticides.   (and in Saskatchewan and Manitoba pesticides companies are so much of the economy they might be excused).  But in tree hugging BC, known for its environmental extremism and oftentimes very insightful policies, the shocker was released on a Friday afternoon before the first major outdoor camping weekend – one can just imagine the back-to-naturists having departed their telecommuting offices for the relative wilds - when the earthquake was released.  BC cosmetic pesticide committee's collective wisdom flew in the face of the 40 existing communities and 60% of the BC population that already have voted no to cosmetic pesticides.

No wonder the report was released before the long weekend. By Tuesday, all that will be left are some echos in the blogosphere like this.  

Read the decision.  Pesticide ban committee report May 18 2012  it actually seems to make sense of many of the aspects of the rationale.  What should disturb our BC colleagues thought is that little is made to suggest that there are not health effects currently.  The decision seems more based on everything is currently hunky-dory, and that further restrictions would hurt certain industrial processes, with the kicker being on page 25 where media reports were used to demonstrate that pesticide limitations were problematic as it led to weed overrun playing turf. So while popular reporting received considerable attention by the committee, the health consequences were skimmed at best and almost accepted as trivial fact. 

Thus the committee knowingly decided not to act in the face of a potential health hazard.  Perhaps another blow for Premier Clark in controller her government.  Clearly a win for the minority industry supporters that responded in the process, and likely a win for some ultra conservative cabinet ministers who wear liberal red clothing.  

While BC’s public health community seems to have had some differences of opinion leading up to the committee deliberations, the final decision will be seen as another blow to public health in BC.   The strong advocacy efforts of the Canadian Cancer Society with many NGO partners clearly overwhelmed the committee input with supportive comments that have been ignored.  

And BC gets to stand alone – renowned for its green stances, but willing to poison its land. 

Any other May 18^th, Friday before the long weekend stories to share?   Feel free to write a piece and submit to Drphealth@gmail.com   

Pertussis – back in the news big time, but where is it in formal surveillance systems?

Several months ago this site spoke to the issue of pertussis DRPHealth a need for adult pertussis vaccine  in the face of some small outbreaks within the country.

Today’s news includes a report on nearly 1500 cases of pertussis from the state of Washington Washington department of health pertussis statistics .  Of note is a New York Times piece that specifically blames the large number of cases on state funding cuts to public health NYTimes editorial on pertussis   even though Governor Gregoire released a whopping $90,000 in additional resources to fight the outbreak.  

Undoubtably related in some fashion to Canadian exportation of pertussis from BC’s outbreak that began last fall Vancouver sun article referencing 224 BC cases since outbreak start .

There would apparently be clusters of pertussis throughout the US  - but one would not capture this by looking to CDC statistics CDC reporting on pertussis , try Twitter @pertussis for notes about Washington, Illinois, New Mexico, Wisconsin. Google adds at least Iowa and Montana.   Of course weekly US stats are published in the MMWR  MMWR morbidity stats May 11.

While Canada posts weekly influenza statistics, try finding anything more recent than 2004 on national pertussis statistics, and certainly nothing yet this year in Canada Communicable Disease Report   CCDR home page. 

Have Twitter and Google become the de facto communicable disease surveillance tools of 2012?  Try other search strategies and see how successful you are in getting an update on Canadian pertussis activity in the year, if you are lucky you will find reports of a 100 or so cases in New Brunswick, a cluster in Elgin St. Thomas health unit in Ontario, a distinct rise in cases in Quebec so far this year, and now Southern Alberta in the past week.   

The disconnect between transparent disease reporting in Canada and the US, and the use of newer means of surveillance are becoming increasingly apparent and perhaps foreboding, or perhaps a new opportunity to do things differently.  In any case pertussis remains a dangerous disease and there is a gap in public communication regarding the risk.