Me asu r es o f

Dise ase s
Fr equency(2 )

Gao Hongcai
Email: gaohc2005@163.com
School of Public Health, Jining Medical
College

1
Mortality Frequency
Measures

2
 Mortality Measures
 Crude Mortality Rate : is a measure of the
frequency of occurrence of death in a defined
population during a specified interval.
 i.e. for a defined population over a specified period
of time
Death occurring during a given time period
Crude MR = ×k
Total mid population among the deaths occurred

k =1,000 or
100,000
 The crude mortality rate is the mortality rate from
all causes of death for a population.
3
 Mortality Measures

Example: In 2001, there were 12,000 deaths from

all causes among 2 million population of Atlanta,
Georgia.

12000
Crude MR = ×1000 = 6 deaths per 1000 population per year
2000000

4
 Mortality Measures
 Case Fatality Rate: is the proportion of
persons with a particular condition (cases) that
die from the condition. It is usually expressed in
percent.
Number of deaths due to a disease
CaseFatalityRate = ×k
Number of people with the same disease

k =100

 It is simply the ratio of cause-specific deaths to

cases during a specified time,
 It requires that the deaths in the numerator be
limited to the cases in the denominator. 5
 Mortality Measures
 Example: in Richmond city, there were 500
cases of colon cancer, of whom five died
within a year after their initial diagnosis. The
case fatality rate for colon cancer in
Richmond city was:

5/500 x 100 = 1%

6
 Mortality Measures
 Age-specific MR = is a mortality
rate limited to a particular age group.
 The numerator is the number of deaths
in that age group;
 the denominator is the number of

persons in that age group in the

population.
 Some specific types of age-specific
mortality rates are neonatal, postneonatal,
and infant mortality rates. 7
 Mortality Measures
 Infant Mortality Rate : is one of the most
commonly used measures for comparing
health service among nations.

Number of infant deaths less than one year of age

IMR = ×k
Total number of live births during the same year

k =1000

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 Mortality Measures
 Infant Mortality Rate
 The numerator is the number of deaths
among children under 1 year of age
reported during a given time period,
usually a calendar year.
 The denominator is the number of live
births reported during the same time
period.
 The infant mortality rate is usually
expressed per 1,000 live births. 9
 Mortality Measures
Is the infant mortality rate a
proportion?
 Technically, it is a ratio but not
a proportion.
 Why?

10
 Mortality Measures
An example:
 Consider the U.S infant mortality rate for

1988. In 1988, 38,910 infants died and 3.9

million children were born,
 for an infant mortality rate of 9.95 per

1,000 .
 Undoubtedly, some of these deaths

occurred among children born in 1987, but

the denominator includes only children
born in 1988. 11
 Mortality Measures
 Example: Denver, Colorado, with a
population of 2.37 million, reported a
total of 270 infant deaths and 30,000
live births in 1981.
 IMR = (270/30,000) x 1000 = 9 infant
deaths per 1000 live births per year.

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 Mortality Measures
 Neonatal Mortality Rate : The neonatal
period is defined as the period from birth up
to 28 days.
number of deaths among children under 28 days of age during a given time period
NMR = ×k
Total number of live births during the same year

k =1000

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 Mortality Measures
 E.g. Memphis, Tennessee, with a population
of 1.37 million, reported a total number of
150 neonatal deaths and 30,000 live births in
1982.
 calculate NMR.
NMR = (150/30,000 )x 1000 =
5%
Five neonatal deaths per 1000 live births
per year.

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 Mortality Measures
 Post neonatal mortality rate : The post
neonatal period is defined as the period from 28
days of age up to but not including 1 year of age.
Notice: is the number of deaths among
children from 28 days up to but not
including 1 year of age during a given
time period.

No. of deaths among children between 28 days and 1 yr. of age

PNMR = ×k
Number of live births during the same time period

k =1000
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 Mortality Measures
 The postneonatal mortality rate is usually
expressed per 1,000 live births. Live
Infant deaths births

 Example: In Oakland California there were 2

million births in 1995, of which 10,000 died
before they reach their first birth day. 7,500
of the infant died within the first 28 days.
Neonatal
deaths
Calculate the IMR, NMR and PNMR
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 Mortality Measures
• Live births
2,000,000
• Infant deaths 10,000
• Neonatal deaths 10,000-7,500
7,500 = 2,500
• Post-neonates
 IMR = 10,000/2,000,000 x 1,000 = 5 per 1,000 live
births
 NMR =7,500/2,000,000 x 1000 = 4 per 1,000 live
births
 PNMR 2,500/2,000,000 x 1000 = 1 per 1,000 live
= births
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Maternal mortality rate
 The maternal mortality rate is really a
ratio used to measure mortality
associated with pregnancy.
 The numerator is the number of
deaths assigned to causes related to
pregnancy during a given time period.

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Maternal mortality rate
 The denominator is the number of live
births reported during the same time
period.
 Because maternal mortality is much
less common than infant mortality, the
maternal mortality rate is usually
expressed per 100,000 live births.
 e.g. In 1988, the maternal mortality rate
was 8.4 per 100,000 live births (7). 19
Cause-specific mortality rate
 The cause-specific mortality rate is the
mortality rate from a specified cause for a
population.
 The numerator is the number of deaths
attributed to a specific cause.
 The denominator remains the size of the
population at the midpoint of the time
period.
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Sex-specific mortality rate
 A sex-specific mortality rate is a

mortality rate among either males

or females.
 Both numerator and denominator

are limited to the one sex.

21
Race-specific mortality rate
 A race-specific mortality rate is a

mortality rate limited to a specified

racial group.
 Both numerator and denominator

are limited to the specified race.

22
Combinations of specific mortality
rates
 Mortality rates can be further refined
to combinations that are cause-
specific, age-specific, sex-specific,
and/or race-specific.

23
Combinations of specific mortality rates
For example,
 the mortality rate attributed to HIV among
25- to 44-year-olds in the United States in
1987 was 9,820 deaths among 77.6 million
25- to 44-year olds, or 12.7 per 100,000.
 This is a cause- and age-specific mortality
rate, because it is limited to one cause (HIV
infection) and one age group (25 to 44
years).
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Age-adjusted mortality rates

 Often, we want to compare the

mortality experience of different
populations. However, since mortality
rates increase with age, a higher
mortality rate in one population than in
another may simply reflect that the
first population is older than the 25
Age-adjusted mortality rates
 Statistical techniques are used to
adjust or standardize the rates in the
populations to be compared which
eliminates the effect of different age
distributions in the different
populations.
 Mortality rates computed with these
techniques are called age-adjusted or
age-standardized mortality rates. 26
Example
 A total of 2,123,323 deaths were
recorded in the United States in 1987.
 The mid-year population was estimated
to be 243,401,000.
 HIV-related mortality and population
data by age for all residents and for
black males are shown in Table 3.

27
Table 3.

28
 We will use these data to calculate the
following four mortality rates:
 a. Crude mortality rate
 b. HIV-(cause)-specific mortality rate for
the entire population
 c. HIV-specific mortality among 35- to
44-year-olds
 d. HIV-specific mortality among 35- to
44-year-old black males
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 a. Crude mortality rate
= (Number of deaths in the U.S./Total
population) × 100,000
= (2 123 323/243 401 000) × 100,000
= 872.4 deaths per 100,000 population

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 b. HIV (cause)-specific mortality rate for the en

Number of HIV deaths

= × 10n
Population

= ( 13 468/243 401 000) ×100,000

= 5.5 HIV-related deaths per 100,000
population

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  c. HIV-related mortality rate among 35- t

Number of HIV deaths in 35 - to 44 - year -× 10n

= olds Population of 35 - to 44 - year – olds

= 4 794 × 10n
34 305 000
= 14.0 HIV-related deaths per 100,000 35- to 44-year-olds

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 d.
HIV-related mortality rate among 35- to 44-year-old black
(cause-, age-, race-, and sex-specific mortality rate)
Number of HIV deaths in 35 - to 44 - year - old black
= males × 10n
Population of 35 - to 44 - year - old black males
= 1 212 × 10n
1 663 000
= 72.9 HIV-related deaths per 100,000 35- to 44-year-old
black males

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 Death-to-case ratio
 The death-to-case ratio is the number

of deaths attributed to a particular

disease during a specified time period
divided by the number of new cases of
that disease identified during the same
time period:
Number of deaths of particular diseases during specified period
Death - to - case ratio = ×k
Number of new cases of the disease identified during same period

34
Death-to-case ratio
 The figures used for the numerator and
denominator must apply to the same
population.
 However, The deaths in the numerator are
NOT NECESSARILY included in the
denominator, because some of the deaths
may have occurred in persons who developed
the disease before the specified period.
35
 For example, 22,517 new cases of
tuberculosis were reported in the
United States in 1987(2). During the
same year, 1,755 deaths occurred
that were attributed to tuberculosis.

36
 Presumably, many of the deaths occurred in
persons who had initially contracted
tuberculosis years earlier. Thus, many of the
1,755 in the numerator are not among the
22,517 in the denominator.
 Therefore, the death-to-case ratio is a ratio
but not a proportion. The tuberculosis
 death-to-case ratio for 1987 is:

37
 We can calculate the number of deaths
per 100 cases by dividing the
numerator by the denominator (10n =
100 for this calculation):

 1.755 ÷ 22,517 × 100 = 7.8 deaths per 100 new

cases

38
 Alternatively, we can calculate the number
of cases per death by dividing the
denominator by the numerator (10n = 1 for
this alculation):
 22,517 ÷ 1,755 = 12.8
 Therefore, there was 1 death per 12.8 new
cases.
 It is correct to use either expression of the
ratio. 39
 Proportionate mortality
 Proportionate mortality describes the
proportion of deaths in a specified
population over a period of time attributable
to different causes.
 Each cause is expressed as a percentage of
all deaths, and the sum of the causes must
add to 100%.
 These proportions are not mortality rates,
since the denominator is all deaths, not the
40
population in which the deaths occurred.
 For a specified population over a specified
period,
Deaths due to a particular cause
Proportionate mortality = × 100
Deaths from all causes

41
Table
4.

42
 Sometimes we compare the
proportionate mortality in one age
group or occupational group to the
entire population, either for deaths
from all causes or from a specific
cause.

 The resulting ratio is called a

proportionate mortality ratio, or PMR 43
 Mortality Measures
 Years of Potential Life Lost (YPLL)
is a measure of the impact of
premature mortality on a population.

 Premature death = when a death occurs

earlier than expected if disease were not
present.

44
 It is calculated as the sum of the differences
between some predetermined end point and
the ages of death for those who died before
that end point.
 The two most commonly used end points
are age 65 years and average life
expectancy.
 Because of the way in which YPLL is
calculated, this measure gives more weight
to a death the earlier it occurs.
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Calculating YPLL from a line listing
 1. Eliminate the records of all persons
who died at or after the end point (e.g.,
age 65 years).
 2. For each person who died before the
end point, identify that individual’s YPLL
by subtracting the age at death from the
end point.
 3. Sum the YPLL’s. 46
 The Years of Potential Life Lost Rate
represents years of potential life lost per
1,000 population below the age of 65
years (or below the average life
expectancy).
 YPLL rates should be used to compare
premature mortality in different
populations, since YPLL does not take into
account differences in population sizes.
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The formula for a YPLL rate is as follows:

Years of potential life lost

YPLL rate = ×k
Population under age 65 years

48
Two end points are in common use,
 The first, age 65. The 65-year end point
assumes that everyone should live at least
to age 65, and any death before that age is
premature.
 It ignores deaths after age 65.
 Thus, the 65-year end point emphasizes
causes of death among younger persons.
49
 The second end point commonly used is
life expectancy remaining at the time of
death.
 Years of potential life lost for each death
is calculated by subtracting the age at
death (or age group midpoint) from the
remaining life expectancy at that age.
 The remaining life expectancy is available
from an abridged life table published
annually by the National Center for Health
50
 For example, in 1984, the remaining life
expectancy for a 60-year-old was 20.4
years, and the remaining life expectancy
for the age group 75 to 84 years was 8.2
years. Since deaths at older ages are far
more numerous, the life-expectancy
method for calculating years of potential
life lost places less emphasis on deaths
at early ages, and more closely
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 Mortality Measures
survival rate
 Indicate the percentage of people in a study or

treatment group who are alive for a certain period

of time after they were diagnosed with or treated
for a disease (such as cancer).
 The survival rate is often stated as a five-year

survival rate, which is the percentage of people in

a study or treatment group who are alive five
years after diagnosis or treatment.
52
 Mortality Measures
 Survival rates are important for
prognosis; for example, whether a
type of cancer has a good or bad
prognosis can be determined from its
survival rate.

53
Mortality Measures
 Patients with a certain disease can die
directly from that disease or from an
unrelated cause such as a car accident.
 When the precise cause of death is not
specified, this is called the overall
survival rate or observed survival
rate.

54
 Mortality Measures
 Doctors often use mean overall survival
rates to estimate the patient's prognosis.
This is often expressed over standard time
periods, like one, five, and ten years.
 For example, prostate cancer has a much
higher one year overall survival rate than
pancreatic cancer, and thus has a better
prognosis.
55
Mortality Measures
 When someone is more interested in
how survival is affected by the disease,
there is also the net survival rate,
which filters out the effect of mortality
from other causes than the disease.
 The two main ways to calculate net
survival
 relative survival
 cause specific survival or disease
specific survival.
56
 Mortality Measures
 Relative survival is calculated by
dividing the overall survival after
diagnosis of a disease by the survival
as observed in a similar population
that was not diagnosed with that
disease.
 A similar population is composed of
individuals with at least age and
gender similar to those diagnosed with 57
 Mortality Measures
 Cause specific survival is calculated by
treating deaths from other causes than
the disease as withdrawals from the
population that don't lower survival,
comparable to patients who are not
observed any longer, e.g. due to
reaching the end of the study period.

58
Mortality Measures
 Relative survival has the
advantage that it does not depend
on accuracy of the reported cause
of death;
 cause specific survival has the
advantage that it does not depend
on the ability to find a similar
population of people without the
disease. 59
Natality Frequency
Measures

60
 In epidemiology, natality measures
are used in the area of maternal and
child health and less so in other areas.
 Table 5 shows a summary for some
frequently used measures of natality.

61
Table 5.

62
Adjusted Rates

63
 Adjusted Rates
 A statistically manipulated rate
controlling for the factor of interest
(age, race, etc)
 Specific rates give more valuable
information when comparing rates
between sub-groups.
 However, specific rates do not provide
accurate comparison with other population. 64
 Adjusted Rates
 Adjusted rates provide a summary
statistic that corrects for differences in age
or other factors in populations – making
comparisons possible between different
populations
 The computational process for adjusted
rate is called “standardization” or
adjustment .
65
 Adjusted Rates
 Advantages
 Provides summary statement
 Differences in groups removed to permit
unbiased comparisons
 Disadvantages
 Statistically manipulated rates (fictional)
 Absolute magnitude dependent on
choice of reference population
66
Adjusted Rates
 Two methods of adjustment:
 1) Direct
 2) Indirect
 Direct Method is commonly utilized
in practice
 But is this necessarily the most
accurate?

67
 Adjusted Mortality Rates
 Example:
 You are a primary care practitioner in a

suburb of a medium-sized city.

 Some of your patients lately have been

older men with cardiac chest pain, and

after appropriate testing you have decided
that several of them should undergo
coronary artery bypass surgery.
 There are 2 groups of surgeons and you

want to send your patients to the group

with lowest mortality rate. 68
 Direct Comparison of Mortality
Rate

Clinic A Clinic B

Age group
Surgeries Operative Operative Surgeries Operative Operative
Death Mortality Death Mortality

45-54 500 6 300 3

55-64 300 15 300 12

65-74 200 20 400 36

Total 45-74 1000 41 1000 51

69
 Adjusted Rates
 Step 1: Calculate age-specific rates in the populations
you want to compare

Clinic A Clinic B

Age group
Surgeries Operative Operative Surgeries Operative Operative
Death Mortality Death Mortality

45-54 500 6 1.2% 300 3 1%

55-64 300 15 5% 300 12 4%
65-74 200 20 10% 400 36 9%

Total 45-74 1000 41 4.1% 1000 51 5.1%

70
 Adjusted Rates
 Step 2 : Choose a reference population
whose age composition is known.

• US 2000 standard population

• 45-54 years 134,834
• 55-64 years 87,247
• 65-74 years 66,037

71
 Adjusted Rates
 Step 3: Calculate Expected deaths in
reference population if the Clinic A specific
rates were the true rates

72
Adjusted Rates
Expected # of deaths in
Operative Mortality ref pop using rates
No. in ref from
Age group
pop (1)
Clinic A Clinic B
Clinic A(2) Clinic B(3)
(1)*(2) (1)*(3)
45-54 134,834 1.2% 1% 1618.0 1348.3

55-64 87,247 5% 4%

65-74 66,037 10% 9%

Total 45-74 4.1% 5.1% 12584.1

73
 Adjusted Rates
 Step 4. Add up the total number of deaths expected
in the reference population under each clinic's set
of rates.
Expected # of deaths in ref
Operative Mortality
pop using rates from
No. in ref pop
Age group
(1)
Clinic A Clinic B
Clinic A(2) Clinic B(3)
(1)*(2) (1)*(3)

45-54 134,834 1.2% 1% 1618.0 1348.3

55-64 87,247 5% 4% 4362.35 3489.88

65-74 66,037 10% 9% 6603.70 5943.33

Total 45-74 4.1% 5.1% 12584.1 10781.5

74
 Adjusted Rates
 Step 5 Calculate the age adjusted
operative mortality rate for each study
group by dividing the sum of expected
deaths by the total size of the reference
population:
Expected # of deaths
Total size of the ref. pop.
x 100

75
 Adjusted Rates
 Clinic A: 12,584.1 / 288,118 * 100% = 4.37 / 100
surgeries

 Clinic B: 10,781.5 / 288,118 * 100% =3.74 / 100

surgeries
Which clinic would you recommend
now?

76
 Summary
 Counts of disease and other health events
are important in epidemiology.
 Counts are the basis for disease
surveillance and for allocation of
resources.
 However, a count alone is insufficient for
describing the characteristics of a
population and for determining risk. For
these purposes we use ratios, 77
 Summary
 Ratios and proportions are useful for
describing the characteristics of
populations.
 Proportions and rates are used for
quantifying morbidity and mortality.
 From these proportions we can infer risk
among different groups, detect high-risk
groups, and develop hypotheses about
causes
78
 i.e., why these groups are at increased risk.
 Summary
 The two primary measures of morbidity
are incidence rates and prevalence.
 Incidence rates reflect the occurrence of
new disease in a population;
 prevalence reflects the presence of
disease in a population.

79
 Summary
 To quantify the association between
disease occurrence and possible risk
factors or causes, we commonly use two
measures, relative risk and odds ratio.
(these will be discussed in later lessons )

80
 Summary
 Mortality rates have long been the
standard for measuring mortality in a
population. Recently, years of potential
life lost and years of potential life lost
rates have gained in popularity because
they focus on premature, and mostly
preventable, mortality.
 All of these measures are used when we
perform the core epidemiologic task
known as descriptive epidemiology.
81
Table 2. shows a summary of the formulas for
frequently used morbidity measures.

82
 Table 3 summarizes the formulas
of frequently used mortality
measures.

83
Table 3

84
 Table 1 shows several morbidity
measures.

85
Question?

86