Making sense of mortality

The black-white suicide paradox: possible effects of misclassification

This research addresses the paradox that the crude and age-adjusted suicide rates of United States blacks are less than half those of whites despite similar risks. Upper and lower limits for true suicide rates are estimated to assess the potential for differential suicide misclassification by race. Construction of these two rate scenarios respectively incorporate one or all of the three cause-of-death categories identified in the literature as most prone to obscure suicides: injury of undetermined intent and unintentional poisonings and drownings. The data source is the US Centers for Disease Control and Prevention's Web-based Injury Statistics Query and Reporting System, and the observation period is 1999-2002. We found that as in the official rates, the racial suicide gap persists within the lower and upper limit scenarios. However, there is marked shrinkage under the upper limit scenario. That scenario even generates rate crossovers for males ages 45-54 years and females ages 85 years and older. Suicide data appear relatively more deficient for black females than for black males. Racial data disparities are minimal for youth and young adults, and maximal for middle-aged males and the oldest and younger middle-aged females. Results strongly indicate greater susceptibility of medico-legal authorities to misclassify black suicides than white suicides. To demystify the racial suicide paradox, research is needed on medical histories and other biographical information that are accessible by the authorities in equivocal cases. To meet the standards of evidence-based medicine and public health, high-quality suicide data are an imperative for risk group delineation; risk factor identification; policy formulation; program planning, implementation, and evaluation; and ultimately, effective prevention.

Inpatient care quality: analyzing Swedish hospitals with stroke as a tracer

Mortality statistics are an important source of information concerning variations in time and place, identification of risk factors and the evaluation of treatment programs. In this study, a new death certificate was completed "blind" on the basis of hospital records from the last episode of care, across a random sample of 1,376 cases. The results showed that the overlap between the official register's underlying cause of death and that of a panel was 72 per cent at the three-digit level. The official underlying cause of death from cerebrovascular diseases (CVD) was 72 cases in this sample, while 93 were deemed to have CVD by a panel. Additionally, of the 1,233 cases originally reported as non-CVD, the panel deemed non-CVD to be the true underlying cause in 1,176 cases. The paper concludes that CVD was most often correctly reported as the underlying cause of death in the investigated ages up to 75 years but plain differences were found between specialities and in different hospital size.

Assumptions of the QALY procedure

The Quality Adjusted Life Year (QALY) has been proposed as a useful index for those managing the provision of health care because it enables the decision-maker to compare the 'value' of different health care programmes and in a way which, potentially at least, reflects social preferences about the appropriate pattern of provision. The index depends on a combination of a measure of morbidity and the risk of mortality. Methodological debate has tended to concentrate on the technicalities of producing a scale of health; and philosophical argument has concentrated on the ethics of interpersonal comparison. There is little recognition of the fragility of the theoretical assumptions underpinning the proposed combination of morbidity and risk of mortality. The context in which the proposed indices are being developed is examined in Section 2. Whilst most working in the field of health measurement eschew over-simplification, it is clear that the application of micro-economics to management is greatly facilitated if a single index can be agreed. The various approaches to combining morbidity and mortality are described in Section 3. The crucial assumptions concern the measurement and valuation of morbidity; the procedures used for scaling morbidity with mortality; and the role of risk. The nature of the valuations involved are examined in Section 4. It seems unlikely that they could ever be widely acceptable; the combination with death and perfect health poses particular problems; and aggregation across individuals compounds the problem. There are also several technical difficulties of scaling and of allowing for risk which have been discussed elsewhere and so are only considered briefly in Section 5 of this paper.(ABSTRACT TRUNCATED AT 250 WORDS)

The inequalities in health debate: a critical review of the issues

There has been an ongoing dispute about inequalities in health ever since the suppressed publication of the Black Report in 1980. It has recently been given a new edge by three publications: the proceedings of an SSRC Workshop held in November 1983 and the Registrar General's Decennial Supplement for 1979-1983, and another half-suppressed report, this time from Health Education Council. The first and third broadly claim that inequalities in health are widening; the second that they are irrelevant. This paper reviews the debate since 1980 around the issues of measurement (how to assess differences between social groups and how to compare across time) and the four kinds of explanation examined by the Black Report. The concluding discussion emphasises the essentially political nature of the debate over the 'trends' but concludes that, whilst most agree on the importance of materialist/structuralist variables, there are differences in the policy implications of the different explanatory positions. However, on the whole these will not be resolved by 'further research': the time is long overdue for a redistribution of resources to eradicate poverty.