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Avoidable mortality by neighbourhood income in Canada: 25 years after the establishment of universal health insurance
  1. Paul D James1,
  2. Russell Wilkins2,
  3. Allan S Detsky3,
  4. Peter Tugwell4,
  5. Douglas G Manuel5
  1. 1Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada
  2. 2Health Analysis and Measurement Group, Statistics Canada, Ottawa, Ontario, Canada
  3. 3Department of Medicine, University of Toronto, Toronto, Ontario, Canada
  4. 4Centre for Global Health, Institute of Population Health, University of Ottawa, Ottawa, Ontario
  5. 5Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
  1. Correspondence to:
 Dr D G Manuel
 Institute for Clinical Evaluative Sciences, G-119, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada; doug.manuel{at}


Aim: To examine neighbourhood income differences in deaths amenable to medical care and public health over a 25-year period after the establishment of universal insurance for doctors and hospital services in Canada.

Methods: Data for census metropolitan areas were obtained from the Canadian Mortality Database and population censuses for the years 1971, 1986, 1991 and 1996. Deaths amenable to medical care, amenable to public health, from ischaemic heart disease and from other causes were considered. Data on deaths were grouped into neighbourhood income quintiles on the basis of the census tract percentage of population below Canada’s low-income cut-offs.

Results: From 1971 to 1996, differences between the richest and poorest quintiles in age-standardised expected years of life lost amenable to medical care decreased 60% (p<0.001) in men and 78% (p<0.001) in women, those amenable to public health increased 0.7% (p = 0.94) in men and 20% (p = 0.55) in women, those lost from ischaemic heart disease decreased 58% in men and 38% in women, and from other causes decreased 15% in men and 9% in women. Changes in the age-standardised expected years of life lost difference for deaths amenable to medical care were significantly larger than those for deaths amenable to public health or other causes for both men and women (p<0.001).

Conclusions: Reductions in rates of deaths amenable to medical care made the largest contribution to narrowing socioeconomic mortality disparities. Continuing disparities in mortality from causes amenable to public health suggest that public health initiatives have a potentially important, but yet unrealised, role in further reducing mortality disparities in Canada.

  • IHD, ischaemic heart disease
  • PYLL, potential years of life lost
  • SEYLL, age-standardised expected years of life lost

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  • Funding: The following organisations supported research and administrative costs of this study; these organisations were not involved in the design or conduct of this study and did not participate in data collection, analysis or interpretation: Population and Public Health Branch, Health Canada; Canadian Population Health Institute, Canadian Institute for Health Information; Canadian Population Health Initiative; and Centre for Global Health, Institute for Population Health, University of Ottawa.

  • Competing interests: None declared.

  • PDJ had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Below is a summary of the authors’ contributions to this manuscript:

  • Study concept and design: PDJ, RW, DGM. Acquisition of data: RW. Analysis and interpretation of data: PDJ, RW, ASD, PT, DGM. Drafting of the manuscript: PDJ, RW, ASD, PT, DGM. Critical revision of the manuscript for important intellectual content: PDJ, RW, ASD, PT, DGM. Statistical analysis: PDJ,RW, DGM. Obtained funding: PT, DGM. Administrative, technical or material support: RW, ASD, PT, DGM. Study supervision: RW, PT, DGM. Final approval: PDJ, RW, ASD, PT, DGM.

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