Aging, Health Systems and Health Outcomes: The World Cities Project

Cadenza Symposium on Age-Friendly World Cities & Environment

October 8-9, 2010

Victor G. RodwinProfessor of Health Policy and Management

Wagner School, New York University

Growth of Urbanization Worldwide

Virtually all population growth projected by UN between 2010 until 2030 will be concentrated in cities.

In 2000, 47% of world’s population lived in cities; in 2030, 60% will live in cities.

Growth of Megacities

2000 - 20 “Megacities” Over 10Million People

All in Developing World Except NYC and Tokyo

In 2015, there will be 23 Megacities

Tokyo, New York, London and Paris: Units of

Analysis

New York City 8.0 million (2000); 65+ = 937,857

Central Tokyo 8.1 million (2000)65+ =1,336, 289

Paris and First Ring 6.2 million (1999)65+ = 848,723

Greater London 7.3 million (2000)65+ = 908,175

4.74.72.62.6 2.12.16.06.0

4.04.0 2.12.1

Hauts-de-Seine

Val-de-Marne

Seine-SaintDenis

Bronx

ManhattanQueens

BrooklynStaten Island

1.51.5

6.56.5

InnerTokyo

OuterToky

o

OuterLondon Inner

London

Manhattan

Inner London

Paris Inner Tokyo

# of teaching hospitals

19 13 25 9

# of medical schools

5 4 7 7

Acute hospital beds per1000 population

5.5 (2002) 4.1 (1990) 7.0 (2002)

12.8 (2000)1

Physicians per 10,000Population

85.5 (2004) 36.9 (2000) 85 (2002) 70.0 (2000)

Health Care Resources: Manhattan, Inner London, Paris

and Tokyo (1995-2000)

Life Expectancy at 65 Years

(Male)

Life Expectancy at 65 Years (Female)

New York City (2000) US (2000)

17.0

16.3

20.1

19.2 Tokyo 23 wards (2000) Japan (2000)

17.7

17.5

22.2

22.5 Paris+First Ring (1999) France

17.7

16.5

21.7

21.0 Greater London (1997-99) UK (1999-2001)

15.6

15.7

19.2

18.9

Source: Rodwin, Gusmano, Montero(2003) Etudes et Résultats, DRESS, Paris.

LE at 65: National and City Levels

Men & Women 85+ Living Alone: Manhattan, Paris, Inner London, & Inner Tokyo

Institutional Long-Term Care Beds Per 1,000 Persons Over

65+

Urban Core First Ring

London (2001) 9.9 12.5

New York (2000)

33.3 48.4

Paris (2001) 13.3 22.3

Tokyo (1997) 9.7 12.3

Nursing Home Care: Similarities

• Nursing home rates are lower in the urban cores than in the first rings

• High price of real estate in the urban cores tends to restrict investment in institutional long-term care facilities compared to first ring

• In NYC and Paris, persons over 65 who live alone have higher levels of educational attainment than those who live in institutions

Home Help Users 65 Years and Home Help Users 65 Years and Over Over

London, New York, Paris and London, New York, Paris and TokyoTokyo

(2000-2002)(2000-2002) Urban Core First Ring Total

London (2001)

8.1% 4.7% 5.8%

New York (2000)

7.4% 7.0% 7.1%

Paris (2002)

6.0% 5.8% 5.7%

Tokyo (2002)

7.3% 6.5% 6.8%

Globalization and policy Globalization and policy convergence??

• Evidence of convergence: significant and growing inequalities of income, housing, health and health care within all four cities.

• Evidence that “politics matters”: Japan’s LTCI; France’s recent expansion of home care services

• Evidence captured by neither: New York, the “hardest” global city provides twice as many nursing home beds and as much home help as the “soft” cities in our analysis

Challenges and Lessons

• Can we afford to allow frail older persons to remain in the urban core of world cities?

• Local policies fill the residuals left by higher levels of government

• Local administrative discretion is significant• Cities cope with diverse older persons• Providing information to older persons and

giving them greater voice• Supporting the oldest old living alone and

identifying the most isolated and vulnerable

- Life expectancy at birth- Probability of survival given diseases- Premature Mortality- Avoidable Mortality- Access to Primary Care - Access to Specialty Care

Health Outcomes and Health System Performance

Premature Mortality Rate per 1,000 by Neighborhood Quartile

1999-2003

Age-Standardized, UN World Population 2004

Q1, 449

Q1, 280

Q1, 427

Q4, 210

Q4, 95

Q4, 314

0

50

100

150

200

250

300

350

400

450

500

Manhattan Paris Inner London

Q1

Q2

Q3

Q4

Defining “Avoidable Mortality”

• “Avoidable Mortality” premature death (prior to 75 years) from diseases amenable to screening and medical intervention

• Examples include: – ischemic heart disease– several malignancies: breast, colon, cervix, skin– tuberculosis– Maternal deaths

Avoidable Mortality in Five World Cities

1.11

0.56

0.910.85

1.27

0.0

0.4

0.8

1.2

1.6

Manhattan Paris InnerLondon

Tokyo Hong Kong

Ag

e-a

dju

ste

d r

ate

/10

00

Average rate, 1999-2003

From Chau, PH, Woo, J et. al. Avoidable Mortality Pattern..European J. Public Health

Avoidable Hospital Conditions

Examples:

• Pneumonia

• Congestive Heart Failure

• Asthma

• Cellulitus

Marker Conditions

Examples:

• Acute Myocardial Infarction

• Appendicitis

• GI obstruction

• Hip fracture

Comparing Access to Primary Care

We use the list of ICD-9/ICD-10 Codes from the definition used by Dr. Joel Weissman and colleagues. The Weissman definition includes the following conditions: pneumonia, congestive heart failure, asthma, cellulitis, perforated or bleeding ulcer, pyelonephritis, diabetes with ketoacidosis or coma, ruptured appendix, malignant hypertension, hypokalemia, immunizable conditions, and gangrene.

Hospital Discharges for Avoidable Hospital Conditions and Marker Conditions: Manhattan, Paris and Inner London

1998-2001average

4.66.9

4.8

10.2

4.1

16.1

0

5

10

15

20

AHC marker conditionsAg

e A

dju

sted

Rat

es/1

000

po

pu

lati

on

18+

Manhattan

Paris

Inner London

Characteristics of Residents by Income Quartile of Neighborhood

Socioeconomic Status: Manhattan, Inner London, Paris

 Total

Population Education Level 1 Median Household Income Range Deprivation

Score

Manhattan        

Q1 529,882 17.00% $20,111 - $27,693 N/A

Q2 320,135 48.14% $41,335 - $54,051 N/A

Q3 304,415 64.16% $57,597 - $65,038 N/A

Q4 371,749 71.09% $68,355 - $73,816 N/A

Paris        

Q1 778,982 21.71% € 20,061 - € 22,470 N/A

Q2 417,795 28.68% € 22,575 - € 25,971 N/A

Q3 566,629 23.80% € 26,506 - € 28,551 N/A

Q4 361,840 40.22% € 28,572 - € 36,161 N/A

Inner London        

Q1 642,821 28.23% N/A 58.26

Q2 903,339 38.38% N/A 42.6

Q3 612,184 39.19% N/A 34.97

Q4 607,770 47.50% N/A 21.02

1. Bachelors degree or higher

Sources: U.S. Census 2000; French Census 1999; National Office of Statistics, UK 2001

Avoidable Hospital Conditions per 1,000 by Neighborhood Quartile

1999-2003

Age-Standardized, UN World Population 2004

Q1, 19.9

Q1, 9.4Q1, 11.1

Q4, 7.2Q4, 5.3

Q4, 8.4

0

5

10

15

20

25

Manhattan Paris Inner London

Q1

Q2

Q3

Q4

Rates of Revascularization France, England and the U.S.

1998-2001 Average

630.2

167.6

327.4

1342.2

223.5

648.4

0 500 1000 1500

United States

England

France

Age Adjusted Rates Per 100,000

65+

45-64

RatioRates of Revascularization : Rates of AMI Mortality

Paris, Inner London, Manhattan1998-2001 Average

13.2

4.7

16.8

2.4

0.8

3.5

0 5 10 15 20

Manhattan

Inner London

Paris

Age Adjusted Rates Per 100,000

65+

45-64

Revascularizations per 100,000 (35+), by Neighborhood Quartile

1999-2003

Age-Standardized, UN World Population 2004

Lower Joint Replacement Rate per 100,000 by Neighborhood Quartile

1999-2003

Age-Standardized, UN World Population 2004

Q1, 121

Q1, 91

Q1, 133

Q4, 171

Q4, 74

Q4, 139

0

20

40

60

80

100

120

140

160

180

Manhattan Paris Inner London

Q1

Q2

Q3

Q4