Health inequalities gap measurement tool for England

Transcription

1 Health inequalities gap measurement tool for England User guide and technical document Contents User guide 1 Introduction Using the gap tool and understanding the results... 4 Charts based on data for five years combined 3 Line and bar charts Gap in rate chart Relative gaps chart Number of deaths and population chart Mortality profiles Charts based on annual trend data 8 Trend in rates chart Trend in rates bottom to other chart Trend in gaps chart Data table Appendix: Technical document Version 3 (June 2011) Robert Kyffin, Department of Health South East Allan Baker, London Health Observatory Andrew Hughes, South East Public Health Observatory Comment and queries: robert.kyffin@dh.gsi.gov.uk Page 1 of 22

2 Health Inequalities Gap Measurement Tool for England quick reference guide Use the map to the homepage to select one of the ten English Strategic Health Authority areas. Steps 1 & 2: Using the drop-down menus, select the primary area you want to display (step 1) and, if required, select a comparator area (step 2 you can choose the national or regional average, or another NHS or Local Authority area in the region you have selected). Step 3: Select a group (persons, males, females) and confidence level (95% or 98% for the age and sex-specific charts, but fixed at 95% for the trend charts). Step 4: Step 5: Step 6: Other functions Select a cause of death you can choose from 17 cause of death categories for the age and sex-specific charts, and from all-causes, all circulatory diseases and all cancers for the trend charts. Select the deprivation quintile(s) you want to display for your primary and (if selected) comparator area you can choose from varying combinations of the bottom (most deprived), top (least deprived), middle 3, top 4 (all quintiles except the most deprived) and all quintiles. For some of the charts you can only display certain combinations of areas and quintiles the gap tool provides instructions where appropriate. Select one of the display options depending on the combination of areas you select, you can choose from a range of displays including bar and line charts, mortality profiles and trend charts. Choosing another region: Click on the small map in the top right of the main screen this will return you to the home page where you can select another region from the large map. Resizing: Click on Help/Toolbox to reveal the Scale up/down buttons which can be used to resize the tool window. You can also increase the size of just the chart by clicking on the resize button in the top right of the chart area. Chart legend: Use the Show/hide legend button in the top right of the chart area to turn the chart legend on or off. Pop-up tips: Use the Tips on/off button in Help/Toolbox to turn on or off the tips that appear when you place the cursor over any of the drop-down menus or selection buttons. Printing and copying It is currently not possible to directly print or copy the gap tool displays as a high resolution image. However, a screenshot of the gap tool can be taken (using the Print screen button on your computer) and the resulting image pasted into your document (double-clicking on it will open the Format picture dialogue box and you can use the various options to crop or change the size of the image). Page 2 of 22

3 User guide 1 Introduction 1.1 Fair Society, Healthy Lives, the independent review of health inequalities in England led by Professor Sir Michael Marmot, highlighted the social gradient in health in England and made it clear that it is material circumstances, the social environment, psychosocial factors, behaviours and biological factors that underlie these differences in health and well-being (tinyurl.com/marmotrev). Healthy Lives, Healthy People, the public health White Paper, acknowledged the findings of the Marmot review and set out the Government s strategy for improving public health and well-being and reducing health inequalities (tinyurl.com/healthpeop). 1.2 Tackling health inequalities and their causes remains a ongoing challenge for local areas across England. The Health Inequalities Gap Measurement Tool for England (the gap tool ) has been developed by the Department of Health South East, South East Public Health Observatory and London Health Observatory to provide a standardised approach to analysing these inequalities, both between and within all NHS and local authority geographies (as of 2009) in England. How the gap tool measures health inequalities 1.3 The gap tool uses population mortality rates to measure the inequality gap. These rates have been produced separately for each of the nine regions, ten strategic health authorities, 27 counties, 125 unitary authorities, 152 primary care trusts and 201 county districts in England. For each of these areas, the constituent lower layer super output areas (LSOAs) have been ranked from the most deprived to the least deprived based on their overall Index of Multiple Deprivation 2007 score. The LSOAs have then been divided into five equally numbered groups (quintiles) with the bottom quintile containing the most deprived fifth of LSOAs and the top quintile the least deprived fifth. Mortality rates have then been calculated for each quintile; comparing these quintiles allows the within-area inequality gap to be analysed. What the gap tool shows 1.4 The gap tool includes a range of display options showing for which causes of death and in which age and sex groups the inequality gap between the deprivation quintiles is found. It also shows the trend in mortality rates for the quintiles, and all these results can be compared against those for other areas within the same region and against regional and national totals. 1.5 Specifically, for the five years 2005 to 2009 combined, the tool can be used to display: mortality rates by quinary (five year) age and sex group for 17 cause of death categories absolute and relative gaps in cause-specific mortality rates for any two areas cause-specific mortality profiles for any two areas. And for 2001 to 2009 by individual year (for all causes of death, all circulatory diseases and all cancers) the tool displays: annual trends in mortality rates annual gaps in the mortality rate between different combinations of areas. What the gap tool can be used for 1.6 The gap tool can be used to support planning and commissioning to reduce health inequalities by giving users the means to: identify the causes of death with the largest inequality gaps within areas see the age groups with the greatest absolute and relative gaps in mortality Page 3 of 22

4 compare the overall mortality profiles for different areas view the direction of travel for mortality rates and the local inequality gap. 1.7 The gap tool can be used alongside the Health Inequalities Intervention Toolkit (tinyurl.com/hitoolkit) and the Health Inequality Indicators for Local Authorities and Primary Care Organisations (tinyurl.com/hiindicators) to provide a comprehensive overview of the nature and extent of health inequalities at a local level across England. 2 Using the gap tool and understanding the results Using the gap tool 2.1 A quick reference guide for the gap tool is provided on page 2 of this document. The tool has been designed to allow users to quickly and easily explore the different facets of the local inequality gap, and the various parameters (area, deprivation quintile, sex, cause of death, display option) can be changed at any point. More detailed information on each of the different display options is contained in the sections which follow. Copying the gap tool displays into Microsoft Word and PowerPoint It is not possible at present to copy the gap tool displays as a high resolution image file directly into Microsoft Word or PowerPoint. However, a screenshot of the gap tool can be taken (using the Print screen button on your computer) and the resulting image pasted into your document (double-clicking on it will open the Format picture dialogue box and you can use the various options to crop or change the size of the image). System requirements 2.2 The gap tool is a web-based resource developed using Adobe Flash v10 or later. You will need to ensure that the Flash Player is available on your computer in order to use the tool ( The data used in the gap tool 2.3 The gap tool is straightforward to use, but correctly interpreting the results requires an understanding of the data it uses and precisely what is being displayed. It may be helpful to think of the gap tool as an amalgamation of two distinct data sets and associated groups of display options: the age and sex-specific charts and the mortality profiles (described in sections 3 to 7 of this user guide) are based on aggregated data for the five year period 2005 to 2009 combined the trend charts (described in sections 8 to 10) are based on mortality rates for the period 2001 to 2009 by individual year. 2.4 Five years worth of data is used for the age and sex-specific charts and the mortality profiles to increase the reliability of the age, sex, cause of death and deprivation quintile-specific mortality rates and avoid excessively wide confidence intervals. The trend charts, in contrast, are based on single years to provide the maximum amount of information regarding the yearon-year direction of travel. Detailed information on the data sources and calculations performed by the gap tool are contained in the technical appendix to this user guide. How the deprivation quintiles are constructed 2.5 The primary focus of the gap tool is on measuring within-area health inequalities. Key to this are the deprivation quintiles. These have been produced separately and for each individual area in the gap tool (ie. England, nine regions, ten strategic health authorities, 27 counties, 125 unitary authorities, 152 primary care trusts and 201 county districts) by ranking all the LSOAs in each area from the most to the least deprived based on their overall Index of Multiple Deprivation 2007 score. Once ranked, the LSOAs were divided into five groups (quintiles) containing equal numbers of these small areas. The bottom quintile Page 4 of 22

5 therefore contains the fifth most deprived fifth of LSOAs within an area and the top quintile contains the least deprived fifth. 2.6 In other words, the quintiles are all relative and within-area in their construction, rather than based on a common absolute scale. So the most deprived quintile in Hart CD (the least deprived local authority area in England) is not directly equivalent in absolute terms to the most deprived quintile in Liverpool UA (the most deprived local authority area). 2.7 In the interests of brevity, the deprivation quintiles have been labelled as follows: bottom=the most deprived quintile in the area middle 3=the middle three quintiles top=the least deprived quintile top 4=all quintiles except the most deprived all=all quintiles combined. Page 5 of 22

6 Charts based on data for 2005 to 2009 combined 3 Age and sex-specific line and bar charts Available for ANY combination of quintiles What the chart shows 3.1 There are four age and sex-specific line and bar chart displays in the gap tool which show the age and sex-specific mortality profile for the selected area(s), cause of death and deprivation quintile(s). 3.2 The line and bar charts display age and sex-specific mortality rates per 100,000 population. The rates can be displayed on either an arithmetic or logarithmic scale. As mortality increases with age, the log scale option is helpful in compressing the absolute differences in rates across the age and sex-specific groups to make clear the gaps that exist between the deprivation quintiles in younger age bands. 3.3 The 95% or 98% confidence intervals for the age and sex-specific rates can be displayed, and the Show/hide legend button can be used to turn the chart legend on or off. Placing the cursor over any of the line points/bars will display the mortality rate for that age and sexspecific group. Interpreting the results 3.4 The line and bar charts show the distribution of mortality rates across 18 age groups. When two or more areas/quintiles are compared, the charts show the age and sex-specific groups in which the inequality gap exists. This information can be used to help target services at those groups with the greatest need. 3.5 When interpreting the line and bar charts, it is important to take account of the confidence limits. Where the age and sex-specific rate limits do not overlap then any differences can be said to be statistically significant at the selected level. Page 6 of 22

7 4 Mortality rate gaps chart Available for any TWO QUINTILES only What the chart shows 4.1 The mortality rate gaps chart displays the absolute difference in age and sex-specific mortality rates between any TWO quintiles. The gap is the absolute difference in the mortality rate in the selected primary area deprivation quintile minus the rate in the comparator area quintile a positive gap means the rate in the primary area is worse than in the comparator area. 4.2 You can also select two quintiles from the primary area only or the comparator area only. In this case, the sequence of the quintiles follows the order in which they are displayed in the tool. In other words, if you select the bottom (most deprived) quintile and the top (least deprived) quintile for the primary area, then the gap displayed for each age and sex-specific group is the rate in the bottom quintile minus the rate in the top quintile. 4.3 In the example below, the gap in the mortality rates between the bottom and top quintiles (2,800 and 1,591 all-cause deaths per 100,000 population respectively) for the South East region for persons aged for 2005 to 2009 combined is 1,209 deaths per 100,000 population (ie. 2,800 1,591=1,209). Interpreting the results 4.4 The mortality rate gaps chart displays the absolute gap in mortality rates across 18 age groups for the two areas/quintiles selected. This chart provides more precise information on the age and sex-specific inequality gap revealed by the line and bar charts. 4.5 When interpreting the mortality rate gaps chart, it is important to take account of the confidence limits. Where the age and sex-specific mortality rate gap limits do not cross zero then the gap can be said to be statistically significant at the selected level. Page 7 of 22

8 5 Relative mortality rates gap chart Available for any TWO QUINTILES only What the chart shows 5.1 The relative mortality rates gap chart is similar to the mortality rate gaps chart, but displays the relative rather than absolute gap in the age and sex-specific mortality rates for any TWO quintiles. The relative gap is the ratio of the rate in the primary area deprivation quintile divided by the rate in the comparator area quintile for example, a ratio of 1.5 indicates that the rate in the primary quintile is 1.5 times greater than in the comparator quintile. 5.2 You can also select two quintiles from the primary area only or the comparator area only. In this case, the sequence of the quintiles follows the order in which they are displayed in the tool. In other words, if you select the bottom (most deprived) quintile and top (least deprived) quintile for the primary area, then the gap displayed for each age and sex-specific group is the ratio of the rate in the bottom quintile divided by the rate in the top quintile. 5.3 In the example below, the relative gap in the rates between the bottom and top quintiles (2,800 and 1,591 all-cause deaths per 100,000 population respectively) for the South East region for persons aged for 2005 to 2009 combined is 1.8 (ie. 2,800/1,591=1.8). Interpreting the results 5.4 The relative mortality rates gap chart can used alongside the mortality rate gaps chart to provide a more complete overview of the inequality gap while the largest absolute differences in mortality rates (shown by the mortality rate gaps chart) tend to occur in the older age groups, the largest relative differences are often found at younger ages. 5.5 When interpreting the relative mortality rates gap chart, it is important to take account of the confidence limits. Where the age and sex-specific rate gap limits do not cross 1 then the gap can be said to be statistically significant at the selected level. Page 8 of 22

9 6 Number of deaths and population chart Available for any ONE QUINTILE only What the chart shows 6.1 This chart displays the number of deaths and population by age and sex-specific group for any ONE deprivation quintile for the selected cause of death (in other words, it shows the numerator and denominator for the age and sex-specific mortality rates displayed in the line and bar charts). 6.2 The number of deaths is the five year combined total for the selected cause and quintile for the period 2005 to 2009; the population number is the single year average of the ONS mid-year population estimates for 2005 to 2009 for the selected quintile. 6.3 Placing the cursor over any of the bars will display the specific number of deaths (on the right y-axis) or the population count (on the left y-axis). In the example below, the combined number of deaths among persons aged in the South East region bottom (most deprived) quintile over the five year period 2005 to 2009 was 7,698. Interpreting the results 6.4 The number of deaths and population chart displays the basic numerators and denominators used to produce the age and sex-specific mortality rates presented in the line and bar charts. This information is helpful in clarifying the absolute numbers of deaths underlying the inequality gap between areas/quintiles. Page 9 of 22

10 7 Mortality profiles Available for any TWO QUINTILES only What the chart shows 7.1 The two mortality profile stacked bar charts show the relative contribution of ten different causes of death to overall mortality for any TWO deprivation quintiles. There are two display options: the mortality profile can be shown using directly age-standardised rates per 100,000 population (mortality profile - rates chart) or as percentages (mortality profile - percentages chart) (deaths under age 1 are included in the other causes category for both options see point below). 7.2 Placing the cursor over any of the stacked bars will display the age-standardised mortality rate or the percentage of deaths for the selected cause and area/quintile. In the example below, the age-standardised mortality rate for all cancers in the South East region top (least deprived) quintile for 2005 to 2009 combined is per 100,000 persons. 7.3 The cause-specific age-standardised mortality rates sum to the total all-age, all-cause mortality rate for the selected deprivation quintiles. Interpreting the results 7.4 The mortality profile - rates chart is helpful in showing the overall inequality gap between two areas/quintiles and the absolute contribution of different causes of death to the gap. The mortality profile - percentages chart, in contrast, shows the relative contribution of different causes of death to the overall all-age, all-cause mortality rate. Page 10 of 22

11 Charts based on annual trend data for 2001 to Trends - mortality rates chart Available for ANY combination of quintiles What the chart shows 8.1 The trends - mortality rates chart displays the directly age-standardised mortality rate per 100,000 population for the selected area(s)/deprivation quintile(s) for each year between 2001 to Exponential projections based on the 2001 to 2009 trend are also presented for 2010 to The trends - mortality rates chart is only available for all causes of death, all circulatory diseases and all cancers. Trends are not available for other causes of death as the comparatively small numbers involved can result in substantial year-on-year variability in the rates and produce very wide confidence limits % confidence limits can be displayed for the 2001 to 2009 trend data, but are not available for the projected 2010 to 2012 rates. Interpreting the results 8.4 The trends - mortality rates chart shows the direction of travel for the cause-specific mortality rates and is helpful in gauging both the year-on-year within-area trend for the selected area(s)/quintile(s) and the trend in the inequality gap between areas/quintiles. 8.5 When interpreting the trend, it is important to take account of the confidence limits. Where these do not overlap either from year-to-year for a single area/quintile or between different areas/quintiles then any differences can be said to be statistically significant at the 95% level. Page 11 of 22

12 9 Trends - bottom to other mortality rate gaps chart Available for the PRIMARY AREA only the BOTTOM QUINTILE must also be selected What the chart shows 9.1 The trends - bottom to other mortality rate gaps chart augments the trends - mortality rates chart by displaying the trend in the within-area inequality gap. The gap is the absolute difference in the directly age-standardised mortality rate for the bottom (most deprived) quintile minus the rate for the other selected quintile(s) for the primary area only. Linear projections based on the 2001 to 2009 gap trend are also presented for 2010 to In the example below, deaths per 100,000 population is the gap in the all-cause mortality rate for the South East region bottom quintile minus the all-cause mortality rate in the South East top quintile for The trends - bottom to other mortality rate gaps chart is only available for all causes of death. Trends are not available for other causes of death as the comparatively small numbers involved can result in substantial year-on-year variability in the rates and produce very wide confidence limits % confidence limits can be displayed for the 2001 to 2009 gap trend, but are not available for the projected 2010 to 2012 rates. Interpreting the results 9.5 The trends - bottom to other mortality rate gaps chart shows the nine year trend and precise absolute annual inequality gap between the bottom and other selected quintiles. 9.6 When interpreting the gap trend, it is important to take account of the confidence limits. Where the year-on-year limits do not overlap then any changes can be said to be statistically significant at the 95% level. Page 12 of 22

13 10 Trends - any two mortality rate gaps chart Available for ANY combination of quintiles What the chart shows 10.1 While the trends - bottom to other mortality rate gaps chart provides information on the within-area inequality trend for the primary area only, the trends - any two mortality rate gaps chart allows any two deprivation quintiles to be compared. Linear projections based on the 2001 to 2009 gap trend are also presented for 2010 to In the example below, deaths per 100,000 population is the gap in the all-cause mortality rate for all quintiles in the South East region (501.0 deaths per 100,000 persons) minus the all-cause mortality rate for all quintiles in England (547.3 deaths per 100,000 persons) for In other words, the all-cause mortality rate for the South East is better than the rate for England as whole The trends - any two mortality rate gaps chart is only available for all causes of death. 95% confidence limits can be displayed for the 2001 to 2009 gap trend, but are not available for the projected 2010 to 2012 rates. Interpreting the results 10.4 The trends - any two mortality rate gaps chart shows the trend and precise absolute annual inequality gap between any two quintiles and allows local mortality rate trends to be compared with other areas or against national, regional or SHA benchmarks When interpreting the gap trend, it is important to take account of the confidence limits. Where the year-on-year limits do not overlap then any changes can be said to be statistically significant at the 95% level. Page 13 of 22

14 11 Mortality profile data table Available for any ONE QUINTILE only What the table shows 11.1 The mortality profile data table option provides further information to support the mortality profile - rates chart by specifying the number of deaths, cause-specific directly agestandardised mortality rates and 95% confidence limits for the selected deprivation quintile This table can be copied from the gap tool by clicking the Export data button. To load the resulting CSV file into Microsoft Excel, save the file to your computer, open Excel, use File > Open > Files of type > Text files (*.csv) to locate and open the file, then from the import wizard options select Original data type > Delimited, click next and finally ensure that the Delimiters > Comma tickbox is selected. Page 14 of 22

15 Appendix: Technical document Introduction 12.1 This technical document describes the methods used to create the data sets employed in the Health Inequalities Gap Measurement Tool for England (the gap tool ) and the calculations performed on them. It also describes related issues such as how the deprivation quintiles are constructed. This document does not, however, describe in detail all the statistical methods used in the gap tool as most are generic to epidemiological analysis and are well-described elsewhere such as in the user guide to the Compendium of Clinical and Health Indicators (in particular, Annex 3: Explanations of statistical methods used in the Compendium see and in the technical briefings and analytical tools produced by the English Public Health Observatories (particularly Technical Briefing 3: Commonly used public health statistics and their confidence intervals see tinyurl.com/photools). Data sources and lookup files used in the gap tool 12.2 The gap tool uses the following data sources and lookup files; their specific use is detailed in the sections which follow: Office for National Statistics Mortality File Extract for Public Health Observatories, 2001 to 2009 Office for National Statistics Lower Layer Super Output Area Experimental Mid-Year Population Estimates (Revised), 2001 to 2009 NHS Postcode Directory (Gridall November 2010 issue) from the Connecting For Health Organisation Data Service (nww.connectingforhealth.nhs.uk/ods/downloads) LSOA to deprivation quintile lookup table based on the Index of Multiple Deprivation 2007 produced by London Health Observatory. How the deprivation quintiles are constructed 12.3 The deprivation quintiles used by the gap tool are derived using the Index of Multiple Deprivation 2007 (IMD07) produced by the Department of Communities and Local Government ( Separately for each individual area in the gap tool (ie. England, nine regions, ten Strategic Health Authorities, 27 counties, 125 Unitary Authorities, 152 Primary Care Trusts and 201 county districts), the constituent LSOAs have been divided into five groups (quintiles) based on their overall IMD07 rank. The top quintile contains the least deprived LSOAs in the area and the bottom quintile the most deprived LSOAs Where the number of LSOAs in an area is exactly divisible by five, the quintiles contain equal numbers of LSOAs. For areas with a number of LSOAs which is not exactly divisible by five, an algorithm was used to allocate the extra areas in a systematic way. First, the number of LSOAs was divided by five to gain the mod value (the number after the decimal point) for the area. This value was then used in conjunction with the table below to allocate the extra LSOAs to the quintiles, with the allocation weighted towards the most deprived quintile rather than the least. For example, in a region with 2,503 LSOAs the mod value is six (ie. 2,503/5=500.6) meaning that the three extra areas were assigned to the first, second and fourth quintiles: Mod value Deciles allocated extra LSOAs ,3 6 1,2,4 8 1,2,3, The aggregated deaths and population counts for the LSOAs making up each of the quintiles provide the basic numerator and denominator data used by the gap tool. It is important to note that the deprivation quintiles are relative rather than absolute in their construction. In Page 15 of 22

16 other words, the bottom (most deprived) quintile in one area will not be equally deprived in absolute terms compared to the bottom quintile in another area. However, different quintiles can still be directly compared to help gauge the health inequality gap between them. How the gap tool compares with the Health Inequalities Intervention Toolkit 12.6 In common with the Health Inequalities Intervention Toolkit (tinyurl.com/hitoolkit), the gap tool has been produced to support local work aimed at reducing health inequalities. There are some overlaps between the two, but where the gap tool focuses on providing detailed information on the nature and extent of local inequality gaps and trends, the intervention toolkit allows users to model the impact of different interventions Both the gap tool and the intervention toolkit employ deprivation quintiles to measure the within-area inequality gap. However, the intervention toolkit differs from the gap tool in using just the Income Domain of the Indices of Deprivation 2007, rather than the overall IMD07 score, to construct the deprivation quintiles. The tools also differ in the metric used: the gap tool uses mortality rates while the intervention toolkit is based on life expectancy. How the gap tool compares with the Slope Index of Inequality 12.8 The Slope Index of Inequality (SII, part of the Health Inequality Indicators for Local Authorities and Primary Care Organisations) represents the gap in years of life expectancy between the least deprived and most deprived populations within an area, based on a statistical analysis of the relationship between life expectancy and deprivation scores across the whole area (tinyurl.com/hiindicators) The SII provides similar, but not directly comparable, information to the gap tool. The SII is a composite score based on life expectancy for deprivation deciles. In contrast, the gap tool is based on mortality rates for deprivation quintiles and provides a wider range of information on the nature of the inequality gap in an area. How the gap tool compares with the Compendium of Clinical and Health Indicators While employing essentially the same data sources, there are some differences between the gap tool and the Compendium of Population Health Indicators which mean that the mortality rates produced by the two may not match exactly in all instances The quinary age group charts and the mortality profiles in the gap tool have no direct equivalent in the Compendium, but the gap tool trend charts are comparable to the Compendium trend tables. These trends may differ slightly as different postcode lookup files have been used to assign deaths to geographical areas. The gap tool was also constructed by aggregating data for LSOAs. In areas where LSOAs are split between PCTs, these have been assigned to a single PCT using a best-fit approach. By contrast, in the Compendium deaths in these areas are assigned using the postcode of usual residence Population data for the gap tool were also aggregated from LSOAs, which in some years differ slightly from the local authority and PCT estimates used in the Compendium (eg. LSOA estimates for 2001 to 2003 were disclosure controlled before release). The Compendium also includes post-neonatal deaths in its circulatory disease and cancer mortality rates, but these have been excluded from the cause-specific trends contained in gap tool. How the age-specific mortality rates are calculated Relates to: age and sex-specific line and bar charts The age and sex-specific line and bar chart displays in the gap tool are based on age and sexspecific mortality rates for 2005 to 2009 combined. The method for calculating these rates is described in the box below. Five years data has been used to increase the reliability of the age, sex, cause and deprivation quintile-specific mortality rates and avoid excessively wide confidence limits (although for the age and sex-specific groups in which the numbers of deaths are low, and for the less frequently occurring causes of death, some of the confidence limits remain unavoidably large). This does make the line and bar chart displays less responsive to any recent changes in mortality rates, but using fewer years would have resulted in very few statistically significant differences between areas/quintiles. Page 16 of 22

17 12.14 The line and bar charts do not display deaths under age 1. While postneonatal deaths (deaths after 28 days of life but under one year) do have a cause of death recorded, neonatal deaths (within 28 days of birth) do not. As neonatal deaths account for more than two-thirds of deaths under age 1, no infant deaths are included in the line and bar charts as the small numbers involved would produce unreliable rates and wide confidence limits. However, infant deaths are included in the mortality profiles (as part of the other category) and in the allcauses trend charts displays. Metadata: Age and sex-specific mortality rates 1. Numerator data Description Aggregated count of the number of deaths by quinary age group (1-4, , 85+), sex (persons, males, females), area, deprivation quintile and cause of death category for 2005 to 2009 combined Source Office for National Statistics. Mortality File Extract for Public Health Observatories, 2005 to 2009 Method of calculation 1 Mortality records selected for 2005 to 2009 based on year of registration 2 Each mortality record allocated a LSOA based on the postcode of the usual place of residence using the NHS Postcode Directory 3 Each mortality record allocated a cause of death code based on the underlying cause of death (UCOD) field using a UCOD-tocause of death lookup file (see point 12.16) 4 Each mortality record allocated an England, region, SHA, PCT and LA-specific deprivation quintile based on a LSOA-to-IMD07 lookup file (see point 12.6) 5 Summed count of the number of deaths derived for each quinary age group, sex, area, deprivation quintile and cause of death category 2. Denominator data Description Aggregated population count by quinary age group (1-4, , 85+), sex (persons, males, females), area and deprivation quintile for 2005 to 2009 combined Source Office for National Statistics. Lower Layer Super Output Area Experimental Mid-Year Population Estimates (Revised), 2005 to 2009 Method of calculation 1 Each LSOA allocated an England, region, SHA, PCT and LA-specific deprivation quintile based on a LSOA-to-IMD07 lookup file (see point 12.6) 2 Summed population count derived for each quinary age group, sex, area and deprivation quintile 3. Measure and calculation Description Age-specific mortality rate per 100,000 population Method of calculation 1 Mortality rate calculated for each age, sex, area, deprivation quintile and cause of death category using method described in PHO Technical Briefing 3 (tinyurl.com/photools) (rate = number of deaths / population * 100,000) 2 Confidence intervals calculated using Byar s approximation as described in Technical Briefing 3 Page 17 of 22

18 How the directly age standardised rates are calculated Relates to: mortality profiles, trends - mortality rates, trends - bottom to other mortality rate gaps, trends - any two mortality rate gaps Both the mortality profiles and the trend charts are based on directly age-standardised mortality rates. They differ, however, in the time periods which they cover: the mortality profiles are based on data for the five years 2005 to 2009 combined while the trend charts are based on data for 2001 to 2009 by year. But while the data on which these display options are based differs, the method of calculation (described in the box below) is essentially the same Point above describes the rationale for using five years data for the mortality profile displays. In contrast, the trend charts are based on data for the period 2001 to 2009 by year to make the gap tool more responsive to annual changes in mortality rates. This does mean, however, that there are relatively few statistically significant changes in the mortality rates for most areas/deprivation quintiles from year-to-year The mortality profiles include ten cause of death categories. The trend charts, in contrast, are only available for all-causes, all circulatory diseases and all cancers. Trends are not presented for other causes of death as the smaller numbers involved produce less reliable rates and wide confidence limits. The all-cause mortality rate trend chart does include infant deaths, but the circulatory disease and cancer rate options do not (see point 12.11). Metadata: Directly age-standardised mortality rates 1. Numerator data Description Mortality profiles Aggregated count of the number of deaths by quinary age group (<1, 1-4, , 85+), sex (persons, males, females), area, deprivation quintile and cause of death category for 2005 to 2009 combined Trend charts Count of the number of deaths by quinary age group (<1, 1-4, , 85+), sex (persons, males, females), area, deprivation quintile and cause of death category (all-causes, all circulatory diseases and all cancers) for 2001 to 2009 by year Source Office for National Statistics. Mortality File Extract for Public Health Observatories, 2001 to 2009 Method of calculation Mortality profiles 1 Mortality records selected for 2005 to 2009 based on year of registration 2 Each mortality record allocated a LSOA based on the postcode of the usual place of residence using the NHS Postcode Directory 3 Each mortality record allocated a cause of death code based on the underlying cause of death (UCOD) field using a UCOD-tocause of death lookup file (see point 12.16) 4 Each mortality record allocated an England, region, SHA, PCT and LA-specific deprivation quintile based on a LSOA-to-IMD07 lookup file (see point 12.6) 5 Summed count of the number of deaths derived for each quinary age group, sex, area, deprivation quintile and cause of death category Trend charts 1 Mortality records selected for 2001 to 2009 based on year of registration 2 Each mortality record allocated a LSOA based on the postcode of the usual place of residence using the NHS Postcode Directory Page 18 of 22

19 3 Relevant mortality records allocated to all circulatory diseases and all cancers categories based on the underlying cause of death (UCOD) field using a UCOD-to-cause of death lookup file (see point 12.16) 4 Each mortality record allocated an England, region, SHA, PCT and LA-specific deprivation quintile based on a LSOA-to-IMD07 lookup file (see point 12.6) 5 Summed count of the number of deaths derived for each quinary age group, sex, area, deprivation quintile, relevant cause of death category and year 2. Denominator data Description Mortality profiles Aggregated population count by quinary age group (<1, 1-4, , 85+), sex (persons, males, females), area and deprivation quintile for 2005 to 2009 combined Trend charts Population count by quinary age group (<1, 1-4, , 85+), sex (persons, males, females), area and deprivation quintile for 2001 to 2009 by year Source Office for National Statistics. Lower Layer Super Output Area Experimental Mid-Year Population Estimates (Revised), 2001 to 2009 Method of calculation Mortality profiles 1 Each LSOA allocated an England, region, SHA, PCT and LA-specific deprivation quintile based on a LSOA-to-IMD07 lookup file (see point 12.6) 2 Summed population count derived for each quinary age group, sex, area, deprivation quintile and cause of death category for 2005 to 2009 combined Trend charts 1 Each LSOA allocated an England, region, SHA, PCT and LA-specific deprivation quintile based on a LSOA-to-IMD07 lookup file (see point 12.6) 2 Summed population count derived for each quinary age group, sex, area, deprivation quintile, relevant cause of death category and year for 2001 to Discrete <1 and 1-4 age group estimates not available for 2001, 2002 and 2003, so <1 and 1-4 age bands for these years derived by proportional division of the 0-4 age group (ie. <1 age band = 0-4 age band * 0.2) 3. Measure and calculation Description Directly age-standardised mortality rate per 100,000 population Method of calculation Mortality profiles 1 Directly age-standardised mortality rate for each age, sex, area, deprivation quintile and cause of death calculated using method described in PHO Technical Briefing 3 (tinyurl.com/aphotools) for 2005 to 2009 combined using the European standard population 2 Confidence intervals (displayed in the data table) calculated using Byar s approximation as described in PHO Technical Briefing 3 Trend charts 1 Directly age-standardised mortality rate for each age, sex, area and deprivation quintile calculated for all-causes, all circulatory diseases and all cancers using method described in PHO Technical Briefing 3 for 2001 to 2009 by year using the European standard Page 19 of 22

20 population 2 Confidence intervals calculated using Byar s approximation as described in PHO Technical Briefing 3 3 Projected rates for 2010 to 2012 based on exponential projection of 2001 to 2009 actual data 4. Additional notes Mortality profiles 1 The mortality rates are additive the ten cause of death categories available can be summed to derive the all-age, allcause mortality rate for the selected area/quintile 2 To ensure that the mortality profiles sum to the all-age, all-cause mortality rate, infant deaths are included in the Other cause of death category Trend charts 1 The use of different population denominators means that the gap tool and the Compendium of Clinical and Health Indicators produce slightly different results (see point 2.5), but in addition, the cancer and circulatory disease mortality rates differ further as the Compendium includes postneonatal deaths while the gap tool does not (see point 12.11) How the gap charts are calculated Relates to: mortality rate gaps chart, relative mortality rate gaps chart, trends - bottom to other mortality rate gaps, trends - any two mortality rate gaps The various mortality rate gap charts display the difference in mortality rates for varying combinations of two quintiles. Sections 4, 5, 9 and 10 of the user guide describe the operation of these charts in detail. The confidence limits for these displays were produced using the methods described by dos Santos Silva (see Appendix 6.1: Confidence intervals and significance tests for epidemiological measures, in Cancer Epidemiology: Principles and Methods; Lyon: International Agency for Research on Cancer, 1999). How the cause of death categories are constructed The gap tool uses the same cause of death categories as the Compendium of Clinical and Health Indicators. The only exception is for the all circulatory diseases trend chart where the Compendium includes infant deaths while the gap tool does not. Metadata: Gap tool cause of death categories Category All causes Diseases of the circulatory system Ischaemic heart diseases (coronary heart disease) Cerebrovascular diseases (stroke) Cancers Lung cancer Breast cancer Diseases of the respiratory system Pneumonia Bronchitis, emphysema and chronic obstructive diseases Diseases of the digestive system Mental and behavioural disorders ICD10 chapter(s) All deaths I I20-I25 I60-I69 C00-C97 C33-C34 C50 J J12-J18 J40-J44 K F Page 20 of 22

21 Diseases of the nervous system Diseases of the genitourinary system External causes of morbidity and mortality Infectious and parasitic diseases G N U50*, V-Y Other D00-D89, E, H, L, M, O- T, Z plus no UCOD code *U50 is a non-standard code used for deaths that were previously recorded to Y33.9 ( other specified events, undetermined intent unspecified place ). These are accelerated registrations where a death is registered after an inquest has been adjourned, normally to await the conclusion of legal proceedings in a higher court. Most are eventually recoded to assault or land transport accidents. How the gap tool handles City of London and Isles of Scilly City of London LB and Isles of Scilly UA only include five and one LSOAs respectively so neither area is included separately in the gap tool. However, deaths for these areas are included in the results for City & Hackney Teaching PCT and Cornwall & Isles of Scilly PCT respectively. A-B Page 21 of 22

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