• The total mortality rate (crude rate) is the total number of deaths from the selected disease relative to the total population (per 100,000) over a specified period of time.
• Age-specific mortality rate for a selected chronic disease is the number of deaths in a given age group from the selected disease per 100,000 population in that age group over a specified period of time.
• Age-standardized mortality rate (SRATE) for a selected chronic disease is the number of deaths from the selected disease that would occur if the population had the same age distribution as the 1991 Canadian population (per 10,000 or 100,000) over a specified period of time.
• Standardized mortality ratio (SMR) for a selected chronic disease is the ratio of observed deaths to the number expected if the population had the same age-specific death rates as Ontario over a specified period of time.

• Total mortality rate, age-specific mortality rate, age-standardized mortality rate and standardized mortality rate for:

o Cardiovascular disease
o Ischemic heart disease
o Cerebrovascular disease
o Stroke
o Respiratory disease
o Chronic obstructive pulmonary disease (COPD)
o Chronic lower respiratory tract disease
o Asthma
o Diabetes

Ontario Public Health Standards (OPHS)

The Ontario Public Health Standards (OPHS) establish requirements for the fundamental public health programs and services carried out by boards of health, which include assessment and surveillance, health promotion and policy development, disease and injury prevention, and health protection. The OPHS consist of one Foundational Standard and 13 Program Standards that articulate broad societal goals that result from the activities undertaken by boards of health and many others, including community partners, non-governmental organizations, and governmental bodies. These results have been expressed in terms of two levels of outcomes: societal outcomes and board of health outcomes. Societal outcomes entail changes in health status, organizations, systems, norms, policies, environments, and practices and result from the work of many sectors of society, including boards of health, for the improvement of the overall health of the population. Board of health outcomes are the results of endeavours by boards of health and often focus on changes in awareness, knowledge, attitudes, skills, practices, environments, and policies. Boards of health are accountable for these outcomes. The standards also outline the requirements that boards of health must implement to achieve the stated results.

Link to OPHS
http://www.ontario.ca/publichealthstandards

Protocol Requirements Related to this Indicator

• The board of health shall collect or access the following types of population health data and information: Mortality, including death by cause (Population Health Assessment and Surveillance Protocol, 1b)

Goal Related to this Indicator

• To reduce the burden of preventable chronic diseases of public health importance (Chronic disease prevention).* 

* Chronic diseases of public health importance include cardiovascular diseases, cancer, respiratory diseases, and type 2 diabetes

  
Corresponding Indicators from Statistics Canada and CIHI

• All circulatory disease deaths; ischaemic heart disease deaths; cerebrovascular disease deaths; all respiratory disease deaths; bronchitis, emphysema and asthma deaths.
  http://www.statcan.ca/bsolc/english/bsolc?catno=82-221-X 
  Click on "view" beside "Free", "Latest issue".
  Click on "Data tables and maps" on the left side menu.
  Click on the indicator "Influenza immunization" under Health system performance, Accessibility.
• National Indicators are based on three years of data in both numerator and denominator. Three years of death data are divided by three times the mid-year population estimate. The title refers to the middle year.
• National Indicators may vary on the basis of geographic categories. Mortality data for 1996 and later years have been linked to health regions (public health units in Ontario) using postal codes and converted to Enumeration Area and then aggregated to health region.

Comparable health indicators: [Select "View" under latest issue then "Data tables"]
http://www.statcan.ca/bsolc/english/bsolc?catno=82-401-XIE

• Mortality rate for acute myocardial infarction (AMI)
• Mortality rate for stroke

Data Sources

Numerator: Mortality Data
Original source: Ontario Office of Registrar General (ORG)
Distributed by: Ontario Ministry of Health and Long-Term Care: IntelliHEALTH ONTARIO
Suggested citation (see Data Citation Notes): Ontario Mortality Data [years], Ontario Ministry of Health and Long-Term Care, IntelliHEALTH ONTARIO, Date Extracted: [date].

Denominator: Population Estimates
Original source: Statistics Canada
Distributed by: Ontario Ministry of Health and Long-Term Care: IntelliHEALTH ONTARIO
Suggested citation (see Data Citation Notes): Population Estimates [years]*, Ontario Ministry of Health and Long-Term Care, IntelliHEALTH ONTARIO, Date Extracted: [date].
* Note: Use the total years of the estimates, including the most recent year, even if not all were used in the analysis. The years used in the analysis should be included in the report itself.
 
 
ICD Codes

• Cardiovascular disease: Diseases of the circulatory system (ICD-9: 390-459); (ICD-10-CA: I00-I99)
• Ischemic heart disease (ICD-9: 410-414); Ischemic heart diseases (ICD-10-CA: I20-I25)
• Cerebrovascular disease (ICD-9: 430-434,436-438); (ICD-10-CA: I60-I69)
• Stroke (ICD-9: 430, 431, 434, 436); (ICD-10 I60, I61, I63, I64)
• Hypertensive disease (ICD-9: 401-405); (ICD-10: I10-I15)
• Respiratory disease: Diseases of the respiratory system (ICD-9:460-519); (ICD-10-CA: J00-J99)
• Chronic Obstructive Pulmonary Disease (ICD-9: 490-492, 496); (ICD-10-CA: J40-J44)
• Chronic lower respiratory tract disease
• ICD-9 490, 496
• Bronchitis (490, 491)/empysema (492)/asthma (493)/bronchiectasis (494)/chronic airways obstruction, not elsewhere classified (496)
• (excluded 495, extrinsic allergic alveolitis)
• ICD-10-CA J40-J47
• Bronchitis, chronic and unspecified (J40-J42)/emphysema (J43)/other chronic obstructive pulmonary disease (J44)/asthma (J45)/bronchiectasis (J47)
• Asthma (ICD: 493); (ICD-10-CA: J45-J46)
• Diabetes (ICD-9: 250); (ICD-10-CA: E10-E14)   

• Consider aggregation of data values and/or cell suppression when dealing with small numbers to avoid risk of confidentiality breach. A new resource is currently under development to provide more detailed information on this issue.
• Use Deaths data source from the Vital Statistics folder in IntelliHEALTH, select # ON Deaths measure (number of deaths for Ontario residents who died in Ontario). Note: deaths for Ontario residents who died outside the province are not captured in Vital Statistics.
• Select appropriate geography from Deceased Information folder (public health unit or LHIN). Include other items, depending on your requirements (ICD10 Chapter, Lead Cause Group, age group, sex, etc.).
• For population estimates, use the Population Estimates County PHU Municipality or the Population Estimates and Projections LHIN data source in the Populations folder in IntelliHEALTH; select the # people measure and the appropriate geography (PHU or LHIN), age group(s), and sex.

Method of Calculation
 

Basic Categories

• Age groups for age-specific rates: <1-19, 20-44, 45-64, 65-74, 75+, total. (Age Group (CD) in IntelliHEALTH)
• Sex: male, female
• Geographic areas: public health unit, LHIN, census division, census sub-division

  
Indicator Comments

• Significant discontinuities can be found in cause of death trends from the last year of ICD-9 use to the first year of ICD-10 use (between 1999 and 2000 for mortality data). In particular, decreases should be expected in deaths due to acute myocardial infarction (I21-I22) and increases for ischemic heart disease as a larger grouping (I20-I25). Additionally, increases should be expected in deaths due to cerebrovascular disease, chronic obstructive lung disease, chronic obstructive pulmonary disease, bronchitis, emphysema and asthma as well as diabetes.¹
• Cardiovascular disease is a term that refers to more than one disease of the circulatory system including the heart and blood vessels, whether the blood vessels are affecting the lungs, the brain, kidneys or other parts of the body. The Public Health Agency of Canada identifies six types of cardiovascular disease: ischemic heart disease, cerebrovascular disease (stroke), peripheral vascular disease, heart failure, rheumatic heart disease, and congenital heart disease.²
• Cardiovascular disease (CVD) is the leading cause of mortality in Canada. Age-standardized death rates from CVD have decreased dramatically since the 1950s. Men have higher mortality rates than women but the difference has narrowed in recent years.³
• Although stroke and cerebrovascular disease are often used interchangeably, stroke is more specific. Cerebrovascular disease includes more unspecified and ill-defined ICD codes as well as late effects of cerebrovascular disease. Users should choose one or the other and clearly document the codes they have used.
• the APHEO definition of stroke excludes ICD-10-CA code I62 (i.e., "other non-traumatic intracranial maemorrhage") and is therefore different from the Canadian Institute for Health Information (CIHI) definition of stroke. Although patients with "other traumatic intracranial haemorrhage"may present with stroke-like symptoms, the etiology is different than stroke and definitive diagnosis depends on technology which may be less available in smaller regions and hospitals. CIHI includes I62 in their calculations, recognizing that this approach will result in some false positives, but rates based on total counts will be more comparable between regions across Canada.
• The ICD-10-CA codes included in the APHEO 'hypertensive diseases' specific indicator correspond to those used by both CIHI and Public Health Agency of Canada (PHAC).
• The respiratory disease category includes mostly chronic but some acute diseases as well. Influenza and pneumonia are included but lung cancer is not. Approximately 8% of deaths in Canada in 2004 were due to respiratory diseases, primarily COPD and influenza and pneumonia.⁴
• Although Chronic Obstructive Lung Disease (COLD) and Chronic Obstructive Pulmonary Disease (COPD) are often used interchangeably, COLD includes asthma, bronchiectasis, and extrinsic allergic alveolitis, whereas COPD does not. COPD consists only of bronchitis, emphysema, and chronic airways obstruction not elsewhere classified. Since some data systems use the COLD grouping of 490-496 but refer to it as COPD, users should check documentation closely. COPD is used by Health Canada and is recommended in this indicator. The chapter on respiratory disease in Public Health and Preventive Medicine, 11th Edition, John Last (Ed.) notes that the term COLD was introduced in the 1960s.⁵ It states "comparisons between different countries using different diagnostic criteria may be more valid when the separate categories are combined. But for most purposes, every effort should be made to use precise, clearly defined diagnostic criteria".
• 'Chronic lower respiratory disease' specific indicator, which includes 'other chronic obstructive pulmonary diseases' (J44) and bronchiectasis (J47) has replaced the 'bronchitis/emphysems/asthma' specific indicator. Bronchiectasis is characterized by permanent dilatation of the bronchi and bronchioles and secretion retention, and often accompanied by shortness of breath, recurrent lung infection, and reduced general health status.⁶ Bronchiectasis may be a comorbid condition in a substantial proportion of those with COPD and may become a more signifcant problem as COPD prevalence rises.^7,8 Prevalence of bronchiectatasis has been found to be higher in indigenous communities globally, ^9,10,11 possibly related to higher prevalence of lower respiratory tract infections related to living conditions in these communities.¹²
• Co-morbidity contributes uncertainty to classifying underlying cause of death.
• Rates due to diabetes may be underestimated due to other diseases being specified as the underlying cause of death. A Statistics Canada study of all deaths from 1990 to 1993 found that diabetes was coded as "underlying cause of death" in only 28% of cases in which diabetes was mentioned on death certificates. In the remaining 72%, diabetes was mentioned as a contributing cause. Compared with all causes of death, diabetes had a very high ratio of mentions on the death certificate to selections as the underlying cause of death. Thus, using underlying cause of death alone will capture fewer than one third of all diabetes-related deaths. This study did not include deaths related to diabetes that were not coded on the death certificate.¹³
• Most data sources do not differentiate between Type 1 and Type 2 diabetes.¹³
• To best understand mortality or disease trends in a population, it is important to determine crude rates, age-specific rates and age-standardized rates (SRATES) and/or ratios (SMRs, SIRs). Although the crude death (or disease) rate depicts the "true" picture of death/disease in a community, it is greatly influenced by the age structure of the population: an older population would likely have a higher crude death rate. Age-specific rates can best describe the "true" death/disease pattern within particular age groups of a community, and allow for comparison of age groups across populations that have different age structures.
• Since many age-specific rates are cumbersome to present, age standardized rates have the advantage of providing a single summary number that allows different populations to be compared; however, they present an "artificial" picture of the death /disease pattern in a community. For more information about standardization, refer to the Resources section: Standardization of Rates.

Definitions

• Cardiovascular Diseases - All diseases of the circulatory system including congenital and acquired diseases such as acute myocardial infarction (heart attack), ischemic heart disease, valvular heart disease, peripheral vascular disease, arrhythmias, high blood pressure, and stroke.¹⁴
• Chronic Obstructive Pulmonary Disease (COPD) - A chronic disease with shortness of breath, cough and sputum production, also referred to as chronic bronchitis and emphysema.⁴

Cross-References to Other Indicators

• All-Cause Mortality (Mortality, Morbidity and Health-Related Quality of Life - Section 3)
• Potential Years of Life Lost (75) (Mortality, Morbidity and Health-Related Quality of Life - Section 3)
• Cancer Mortality (Cancer Incidence and Early Detection of Cancer - Section 4B)
• Child and Adolescent Mortality (asthma) (Child and Adolescent Health – Section 6C)
• Chronic Disease Hospitalization (Chronic Disease and Injuries - Section 4A)
  

Cited References 

1. Statistics Canada. Comparability of ICD-10 and ICD-9 for Mortality Statistics in Canada. Ottawa: Ministry of Industry, 2005. Catalogue no. 84-548-XIE. URL: http://www.statcan.ca/english/freepub/84-548-XIE/84-548-XIE2005001.htm.
2. Public Health Agency of Canada. Six types of Cardiovascular Disease. Available online at: http://www.phac-aspc.gc.ca/cd-mc/cvd-mcv/index-eng.php (Accessed on June 18, 2009).
3. DG Manuel, M Leung, K Nguyen, P Tanuseputro, H Johansen.Burden of cardiovascular disease in Canada. Can J Cardiol 2003;19(9):997-1004. Available in the CCORT Canadian Cardiovascular Atlas listed below.
4. Public Health Agency of Canada. Life and Breath: Respiratory Disease in Canada. Ottawa, ON: Public Health Agency of Canada, 2007. Available at: http://www.phac-aspc.gc.ca/publicat/2007/lbrdc-vsmrc/index-eng.php.
5. Higgins I. Respiratory Disease. In: Last J (Ed.), Maxcy-Rosenau Public Health and Preventive Medicine. Eleventh Edition. New York: Appleton-Century-Crofts, New York, 1980.
6. Neves PC, Guerra M, Ponce P, Mirand J, Vouga L. Non-cystic fibrosis bronchiectasis. Interactive cardiovascular and Thoracic surgery.2011 [cited 2013 Jun 28];13:619-25. Available from: http://icvts.oxfordjournals.org/content/13/6/619.full.pdf+html.
7. Patel IS, Vlahos I, Wilkinson MA, Lloyd-Owen SJ, Donaldson GC, Wilks M, et al. Bronchiectasis, exacerbation indices, and inflammation in chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2004;170:400-7. Available from: http://www.atsjournals.org/doi/pdf/10.1164/rccm.200305-648OC.
8. Rademacher J, Welte T. Bronchiectasis - diagnosis and treatment. Dtsch Arztebl Int 2011; 108(48): 809-15.
9. Subie HA, Fitzgerald DA. Non-cystic fibrosis bronchiectasis. J Paed Child Health. 2012;48:382-8.
10. Chang AB, Grimwood K, Mulholland EK, Torzillo PJ. Bronchiectasis in indigenous children in remote Australian communities. Med J Aust. 2002 [cited 2013 Jun 28];177:200-4. Available from: https://www.mja.com.au/journal/2002/177/4/bronchiectasis-indigenous-children-remote-australian-communities.
11. Singleton R, Morris A, Redding G, Poll J, Holck P, Martinez P, et al. Bronchiectasis in Alaska native children: causes and clinical courses. Pediatr Pulmonol. 2000;29:182-7.
12. Peck AJ, Holman RC, Curns AT, Lingappa JR, Cheeck JE, Singleton RJ, et al. Lower respiratory tract infections among American Indian and Alaska Native children and the general population of U.S. children. Pediatr Infect Dis J. 2005;24:342-51.
13. Wilkins K, Wysocki M, Morin C, Wood P. Multiple causes of death. Health Reports 1997;9(2):19-29. Available at: http://www.statcan.gc.ca/studies-etudes/82-003/archive/1997/3235-eng.pdf.
14. National Statistics and Opportunities for Improved Surveillance, Prevention, and Control. Diabetes in Canada. Ottawa, ON: Public Health Agency of Canada, 1999. Available at: http://www.phac-aspc.gc.ca/publicat/dic-dac99/index-eng.php.
15. Public Health Agency of Canada. Tracking Heart Disease and Stroke in Canada. Ottawa, ON: Public Health Agency of Canada, 2009. Available at: http://www.phac-aspc.gc.ca/publicat/2009/cvd-avc/index-eng.php.

Other References

• Hux J, Booth G, Slaughter P, Laupacis A (Eds.) Diabetes in Ontario: An ICES Practice Atlas. Toronto, ON: Institute for Clinical Evaluative Sciences, 2003. Available at: http://www.ices.on.ca/webpage.cfm?site_id=1&org_id=67&morg_id=0&gsec_id=0&item_id=1312&type=atlas.
• Chronic Disease in Canada - publication of the Public Health Agency of Canada. http://www.phac-aspc.gc.ca/publicat/cdic-mcc/index-eng.php.
• WA Filate, HL Johansen, CC Kennedy, JV Tu. Regional variations in cardiovascular mortality in Canada. Can J Cardiol 2003;19(11):1241-1248. Available in the CCORT Canadian Cardiovascular Atlas listed below.
• Tu JV, Ghali WA, Pilote L, Brien S [eds]. CCORT Canadian Cardiovascular Atlas. Pulsus Group Inc and Institute for Clinical Evaluative Sciences 2006. http://www.ccort.ca/ccort/AtlasDownload/tabid/84/Default.aspx.
• Glazier RH, Booth GL, Gozdyra P, Creatore MI, Tynan, M, editors. Neighbourhood Environments and Resources for Healthy Living-A Focus on Diabetes in Toronto: ICES Atlas. Toronto: Institute for Clinical Evaluative Sciences; 2007. http://www.ices.on.ca/webpage.cfm?site_id=1&org_id=67&morg_id=0&gsec_id=0&item_id=4406&type=atlas.
• Public Health Agency of Canada. Leading Causes of Death and Hospitalization in Canada. Available at: http://www.phac-aspc.gc.ca/publicat/lcd-pcd97/index-eng.php.

Changes Made