Transcript Slide 5 Impact: Epidemiology TNEEL-NE

M. Kay M. Judge, EdD, RN
Marjorie J. Wells, PhD, ARNP
Impact: Epidemiology
Introduction:
End-of-Life (EOL) care
To cure sometimes,
To relieve often,
To comfort always.
Anonymous physician, 16th century
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Slide 2
Impact: Epidemiology
When is the End of Life?
• End of Life (EOL) is the time period for
patients in which:
A) There is little likelihood of
cure for their disease
B) Further aggressive therapy is judged
to be futile
C) Comfort is the primary goal of
health care
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Slide 3
Impact: Epidemiology
Palliative Care
• “Palliative Care” and “End-of-Life Care” are
terms often used interchangeably.
• Palliation is defined as:
– “The relief of suffering when cure is impossible.”
Palliative Care
End-of-Life Care
(Doyle, 1998)
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Slide 4
Impact: Epidemiology
The Epidemiology of Death & Dying in
the US: Demographic & Social Trends
• Covers the following areas:
– Life and death expectancy
– Years of healthy life
– Health disparities/morbidity and mortality in
special population
•
•
•
•
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Gender differences
Racial and ethnic differences
Age differences
Income and educational differences
Slide 5
Impact: Epidemiology
Personal Impact
• Demographics and social trends:
– 2 million Americans die annually.
– This is less than 1% of our population.
– This number will increase as aging
“baby boomer” population increases.
• Less than 10% die from unexpected event
• More than 90% die from:
– Lengthy life-threatening illness (i.e., cancer).
– Illness characterized by a slow decline interrupted by
crises (congestive heart failure or emphysema).
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Impact: Epidemiology
Life & Death Expectancy
• Life Expectancy
– “The average number of years people
born in a given year are expected to live
based on a set of age-specific death rates.”
US Deaths,
20th Century
• 1900 – 1720 deaths per 100,000 population
• 1995 – 880 deaths per 100,000 population
– Less than half the number in 1900
• Age-adjusted mortality rates (which factors
in the aging population) fell steadily from
1940 to 1980 to 1995.
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DROPPING
(USDHHS, 2000)
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Impact: Epidemiology
Crude Death Rates
Crude Death Rates
2000
Deaths /
100,000
Population
1500
1720
1000
880
500
0
1900
1995
Year
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Impact: Epidemiology
Age Adjusted Mortality
Age Adjusted Mortality Rates
1200
1000
Deaths /
800
100,000
Population 600
1076.1
505.5
400
200
0
1980
1940
503.7
1995
Year
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Slide 9
Impact: Epidemiology
Life Expectancy at Birth
Past and projected female and male life expectancy at birth,
United States, 1900 – 2050.
100
90
Years of Life
Female
84.3
80
Male
79.7
70
60
50
Projection
40
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1900* 1920*
1940
1960
1980
2000
2020
2040
1910*
1930*
1950
1970
1990
2010
2030
2050
Year
(Source: U.S. Department of Commerce, Bureau of the Census)
Slide 10
Impact: Epidemiology
Life Expectancy by Country & Gender
Ranked by selected countries, 1995
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Female Top 5
Male Top 5
Country
Country
Japan (1)
Years of Life
Expectancy
82.9
Japan (1)
Years of Life
Expectancy
76.4
France (2)
82.6
Sweden (2)
76.2
Switzerland (3)
81.9
Israel (3)
75.3
Sweden (4)
81.6
Canada (4)
75.2
Spain (5)
81.5
Switzerland (5)
75.1
Female Others
Male Others
Country
Country
England (16)
Years of Life
Expectancy
79.6
England (11)
Years of Life
Expectancy
74.3
Singapore (18)
79
Singapore (15)
73.4
USA (19)
78.9
USA (25)
72.5
Slide 11
Impact: Epidemiology
Years of Healthy Life
“Years of healthy life is a combined measure developed for
the Healthy People initiative. The difference between life
expectancy and years of healthy life reflects the average
amount of time spent in less than optimal health because of
chronic or acute limitations.”
(USDHHS, 2000)
• The years of healthy life was 64.2 years in 1996, a level only
slightly higher than the 64.0 years at the beginning of the 20th
century.
– During the same period, life expectancy increased a full year.
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Slide 12
Impact: Epidemiology
Health Disparities/Morbidity &
Mortality in Special Populations
• “People in the low-income compared to
high-income households are five times more
likely to report their health as fair or poor.”
• “More women report their health as fair or
poor compared to men.”
• “Rural area adult residents are 36 percent
more likely to report their health status as
fair or poor than are urban adults”
(USDHHS, 2000)
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Impact: Epidemiology
Health Disparities:
Low Income vs. High Income
Percentage of persons with perceived fair or poor health status by
household income, United States, 1995.
Persons with perceived fair or poor health status
25%
20%
15%
10%
5%
0%
Less than $15,000
$15,000-$24,999
$25,000-$34,999
$50,000 or more
$35,000-$49,999
Household income
(Source: U.S. Department of Commerce, Bureau of the Census)
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Impact: Epidemiology
Gender Differences
• Men have a life expectancy 6 years less than
women and have higher death rates for
each of the 10 leading causes of death.
• Men are twice as likely than women to
die from unintentional injuries.
• Death rates for women have increased in
the 1990s in areas men have decreases
(such as lung cancer).
• Women are at greater risk for Alzheimer’s
disease and twice as likely to be affected
by major depression than men.
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Slide 15
Impact: Epidemiology
Racial & Ethnic Differences
• “Current information about the biologic and genetic
characteristics of African Americans, Hispanics,
American Indians, Alaska Natives, Asians, Native
Hawaiians, and Pacific Islanders does not explain
the health disparities experienced by these groups
compared with the white, non-Hispanic population in
the United States. These disparities are believed to be
the result of the complex interaction among genetic
variations, environmental factors, and specific health
behaviors.”
(USDHHS, 2000)
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Impact: Epidemiology
African Americans
• Several disparities between white and black Americans:
– Twice the age adjusted mortality rates for black males
compared to white males.
– For black females, the age adjusted rate of death is more
than a 1.5 times that of white females.
– African American infant death rate is still more than
double that of whites.
– African Americans experience heart disease death rates
greater than 40 percent higher than the rate for whites.
– “The death rate for all cancers is 30 percent higher for
African Americans than for whites.”
(USDHHS, 2000)
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Impact: Epidemiology
Hispanics
• The leading causes of death for Hispanic males:
– Heart disease, cancer, unintentional injuries, and HIV.
• Hispanics living in the United States die as a result of
diabetes at nearly twice the rate as non-Hispanic
whites.
• Hispanics account for 20 percent of the new cases of
tuberculosis despite the fact that they constituted only
about 11 percent of the total population in 1996.
• This group also has higher rates of high blood pressure
and obesity than non-Hispanic whites.
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Impact: Epidemiology
American Indians & Alaska Natives
• The infant death rate in this population is almost
double that for whites.
• The rate of diabetes is more than twice that for
whites.
• The Arizona Pima Indians have one of the highest
rates of diabetes in the world.
• This groups also has disproportionately high death
rates from unintentional injuries and suicide.
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Impact: Epidemiology
Asians, Native Hawaiians &
Pacific Islanders
• On average, Asians and Pacific Islanders, are one of
the healthiest population groups in the United States.
• However, there is great diversity within this group
especially for specific segments of it:
– For example, women of Vietnamese origin have a cervical
cancer rate nearly five times the rate for white women.
– New cases of hepatitis and tuberculosis are also higher in
U.S. Asians and Pacific Islanders than in whites.
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Impact: Epidemiology
Income & Educational Differences
• “Inequalities in income and education underlie many
health disparities in the United States. Income and
education are intrinsically related and often serve as
proxy measures for each other. In general, population
groups that suffer the worst health status [and
therefore higher death rates] also are those that have
the highest poverty rates and the least education. …
Higher incomes … increase the opportunity to
engage in health-promoting behaviors.”
(USDHHS, 2000)
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Impact: Epidemiology
Income & Educational Differences II
Relationship between education and median household income among
adults aged 25 years and older, by gender, United States, 1996
$70,000
$66,690
Median Household Income
$60,000
Male
$50,000
$47,944
$30,000 $24,386
$20,000
Female
$43,628
$40,000
$40,000
$62,050
$35,300
$18,200
$10,000
$0
Less than
12 years
12 years
13-15 years
Educational Level
16 or
more years
(Source: U.S. Department of Commerce, Bureau of the Census)
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Impact: Epidemiology
Leading Causes of Death in
Advanced Countries: Chronic Illness
• Leading causes of death are used frequently to
describe the health status of the nation.
• Over the past 100 years, the US has seen a great deal
of change in the leading causes of death.
• Beginning of the 1900s:
– Infectious diseases (e.g., influenza, tuberculosis, and
diphtheria) topped the leading causes of death worldwide.
• Today:
– A century later, we control many infectious agents.
– Chronic diseases (lifestyle diseases e.g., heart disease,
cancer, and stroke) top the list.
(USDHHS, 2000)
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Impact: Epidemiology
Causes of Death/Mortality:
20th Century
Leading Causes of Death, 1900
Pneumonia
Tuberculosis
Diarrhea and
enteritis
Heart disease
Liver disease
Injuries
Cancer
Senility
Diphtheria
0
5
10
15
20
25
30
Percent of all deaths
(Source: Centers for Disease Control and Prevention)
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Impact: Epidemiology
Causes of Death/Mortality:
20th Century
Leading Causes of Death, 1997
Heart disease
Cancer
Stroke
Chronic obstructive
pulmonary disease
Unintentional injuries
Pneumonia/influenza
Diabetes
Suicide
Kidney disease
Chronic liver disease
and cirrhosis
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0
5
10
15
20
25
30
35
Percent of all deaths
(Source: Centers for Disease Control and Prevention)
Slide 25
Impact: Epidemiology
Age Differences
• A different image emerges for different populations:
– Unintentional injuries, mainly motor vehicle accidents:
• The fifth leading cause of death for the total population.
• #1 cause of death for those from 1 to 44 years of age.
– HIV/AIDS
• The 14th leading cause of death for the total population.
• #1 cause of death for African American men aged 25 to 44 years.
• In the US, leading causes of death generally result
from a variety of factors:
– Injury, violence, other factors, and the unavailability or
inaccessibility of quality health care services.
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Impact: Epidemiology
All Age Groups
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Slide 27
Impact: Epidemiology
Leading Causes of Death by
Age Group
Number of Deaths
Under 1 Year
Birth defects
Disorders related to premature birth
Sudden infant death syndrome
6,178
3,925
2,991
45-64 Years
Cancer
Heart disease
Unintentional Injuries
131,743
101,235
17,521
65 Years and Older
Heart disease
Cancer
Stroke
606,913
382,913
140,366
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Impact: Epidemiology
Injury & Violence
• More than 400 Americans die each day from injuries
due primarily to motor vehicle crashes, firearms,
poisonings, suffocation, falls, fires, and drowning.
• Most persons sustain a significant injury at some
time during their lives.
• Motor vehicle crashes are most common:
– In 1998, there were 15.6 deaths from motor vehicle
crashes per 100,000 persons.
• Homicide is a reliable indicator of all violent crime:
– In 1998, the US murder rate fell to its lowest level in three
decades — 6.5 homicides per 100,000 persons.
(USDHHS, 2000)
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Impact: Epidemiology
Motor Vehicle Accidents
• Death rates associated
with motor vehicle-traffic
injuries are highest in the
age group 15 to 24 years.
• In 1996, teenagers accounted for only 10 percent of
the U.S. population but 15 percent of the deaths from
motor vehicle crashes.
• Those aged 75 years and older had the second
highest rate of motor vehicle-related deaths.
• Nearly 40 percent of traffic fatalities in 1997 were
alcohol related.
(USDHHS, 2000)
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Impact: Epidemiology
Homicides
• In 1997, 32,436 individuals died
from firearm injuries
– 42 percent were victims of homicide.
• In 1997, homicide was the third
leading cause of death for children
aged 5 to 14 years.
• In 1996, more than 80 percent of infant homicides
were considered to be fatal child abuse.
• Males are most often the victims and the perpetrators
of homicides. African Americans are more than five
times as likely as whites to be murdered. (USDHHS, 2000)
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Impact: Epidemiology
Motor Vehicle & Homicide Deaths
(Source: Centers for Disease Control and Prevention)
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Impact: Epidemiology
Sites of Death & Dying
• Technical advances and societal changes have
radically altered the dying process.
• Improved efficacy of health care interventions
lengthens the dying process.
– The mobility of today’s society isolates the experience.
• Since the turn of the last century, there has been a
major change in where people die:
– A migration from dying at home with family members in
attendance to dying in an institution often attended only by
professional caregivers.
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Impact: Epidemiology
Sites of Death & Dying II
Where Death Occurs (1992 Statistics)
6%
Hospitals
20%
Nursing Homes
Residences
57%
17%
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Elsewhere (including
those who were dead
on arrival at hospitals)
Slide 34
Impact: Epidemiology
Sites of Death & Dying III
Sites of Death and Dying in the United States 1900-1980
Sites of Death & Dying
% Occurred in
Institutions
80%
70%
74.0%
60%
50%
40%
30%
20%
10%
0%
60.9%
49.5%
60.5%
% of Death in
Other Institutions
Besides Hospitals
47.6%
39.5%
% of Death in
Hospitals
1%
1900
1949
1958
1980
Year
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