report 4 pdfing - School of Medicine - Trinity College Dublin

INEQUALITIES IN HEALTHIN IRELAND - HARD FACTSJoe Barry – Hamish Sinclair – Alan Kelly– Ros O’Loughlin – Deirdre Handy – Tom O’DowdDepartment of Community Health & General Practice, Trinity College, DublinSeptember 2001

INEQUALITIES IN HEALTHIN IRELAND - HARD FACTSJoe Barry – Hamish Sinclair – Alan Kelly– Ros O’Loughlin – Deirdre Handy – Tom O’DowdDepartment of Community Health & General Practice, Trinity College, DublinSeptember 2001

THIS REPORT IS DEDICATED TO DR FIONA BRADLEYFRONT COVER IMAGE: Paul Seawright, Tangled Trees 2DETAILS:Courtesy of the Kerlin Gallery, DublinColour type C print on aluminium (edition of 6) PS08600Further copies of this report are available from the Department of Community Health & General Practice,Trinity College, Dublin. Price a20

CONTENTSACKNOWLEDGEMENTSFOREWORDSUMMARYLIST OF FIGURESLIST OF TABLESGLOSSARY OF TERMSCHAPTER 1INTRODUCTIONHOW WE DID ITCHAPTER 24578111316171922RESULTS:SECTION 1 - NATIONAL MORTALITY DATASECTION 2 - PERINATAL REPORTING SYSTEMSECTION 3 - NATIONAL PSYCHIATRIC INPATIENT REPORTING SYSTEMSECTION 4 - HOSPITAL IN-PATIENT ENQUIRYSECTION 5 - NATIONAL DRUG TREATMENT REPORTING SYSTEMSECTION 6 - UNKNOWNSCHAPTER 3REPORTS GATHERING DUSTNATIONAL HEALTH INFORMATION STRATEGY - END OF UNHEALTHY DATA?CHAPTER 4RECOMMENDATIONSREFERENCESAPPENDICESA. TECHNICAL ANNEXB. DATA INPUT FORMS:1. PERINATAL REPORTING SYSTEM2. HOSPITAL IN-PATIENT ENQUIRY3. NATIONAL PSYCHIATRIC INPATIENT REPORTING SYSTEM4. NATIONAL DRUG TREATMENT REPORTING SYSTEM22344050546068697172737476768082838485

PAGE 5ACKNOWLEDGEMENTSThis work has been funded by the Health Research Board. We are particularly grateful to thecustodians and managers of the various datasets that have been analysed, in particular:National Mortality DatasetHugh Magee - Department of Health and ChildrenPerinatal Reporting SystemHugh Magee - Department of Health and ChildrenHospital In-Patient EnquiryAnne Clifton - Economic and Social Research InstituteNational Psychiatric InPatient Reporting SystemCiaran Browne, Antoinette Daly - Health Research BoardNational Drug Treatment Reporting SystemRos Moran, Mary O'Brien - Health Research BoardPAGE 5

PAGE 6FOREWORDI am delighted to be asked to write the foreword to this most important report on "Inequalities inHealth in Ireland – Hard Facts" from the Department of Community Health and General Practice inTrinity College, Dublin.Among the issues which have come to the forefront in recent times in the debate on health isthat of "health inequalities", a concept which describes the differentials in health experiencebetween different sections of our population by reference to such indicators as morbidity andpremature mortality. Related to this also is the problem of inequitable access to health servicesbased on need.This report, while it recognises the genuine difficulties presented by incomplete and inadequateroutine data, nevertheless confirms the broad international experience of significantly highermortality rates for people from lower socio-economic groups for all causes and for ischaemic heartdisease, cancer and injuries and poisonings. In the context in which the general Irish experience inthis regard is significantly inferior to that of the rest of the European Union, the experience of poorIrish people must be regarded as intolerable.Other indicators in the area of psychiatric admissions, perinatal health and drug treatment all point tothe same differentials in experience as between the poorer and better off sections of our population.While certain important conclusions can be drawn from the data, the report identifies the limitationsof the routine data sets available. It suggests that routine data sets need to be altered so that healthinequalities can be measured by reference to these data sets (a recommendation also made in the1999 CMO’s Report) and also that once-off major epidemiological studies from time to time wouldbe appropriate. The report also suggests that these data and information deficits can best beaddressed in the context of the emerging National Health Information Strategy.To address the serious problems identified in this report, decisions need to be taken at the broadintersectoral policy level and also at health policy level. The existing partnership process and theNational Anti-Poverty Strategy process within it, provide a platform and opportunity for broad policyaction and the forthcoming Health Strategy will provide a framework for health sector responses.Those interested in further analysing and, in particular, doing something about health inequalitieswill be grateful for this report and its authors are to be congratulated on its publication.Dr. James KielyChief Medical OfficerDepartment of Health and ChildrenPAGE 6

PAGE 8SUMMARYThe following are the principal findings of this report:• In 1996 unskilled manual men were twice as likely to die as higher professionalmen (standardised ratio 122 versus 64).• In 1996 unskilled manual men were eight times more likely to die from an accidentalcause than higher professional men (standardised ratio 136 versus 17).• In 1996 you were almost four times as likely to be admitted to hospital for the firsttime for schizophrenia if you were in the unskilled manual category than if youwere a higher professional (standardised ratio of 130 versus 35).• In the early 1990s women in the unemployed socio-economic group were overtwice as likely to give birth to low birth weight babies as women in thehigher professional group (standardised ratio of 140 versus 66).• Persons with socio-economic group ‘unskilled manual’ have worse healththan professional groups in all years and for all the conditions which are analysedin this report.• Persons with socio-economic group ‘unknown’ have consistently worse health thanthose in socio-economic group ‘unskilled manual’.• The proportion of persons where socio-economic group is unknown is growingin each database.• Mortality seems to be worse in medium sized towns than in cities or in rural areas.• Data from the Perinatal Reporting System has not been published for eight years.• HIPE is of practically no use in making comment on socio-economic differences.PAGE 8

PAGE 9LIST OF FIGURESNational Mortality DataFigure 1.1Figure 1.2Figure 1.3Figure 1.4Figure 1.5Figure 1.6Figure 1.7Figure 1.8Standardised mortality ratios (SMRs) and 95% confidence intervals forall causes (males 15-64 years) by socio-economic group, Ireland 1996Standardised mortality ratios (SMRs) and 95% confidence intervals forall causes (males 15-64 years) for unskilled manual and professional(higher + lower) socio-economic groups, Ireland 1981,1986, 1991, 1996Standardised mortality ratios (SMRs) and 95% confidence intervalsfor ischaemic heart disease (ICD codes 410-414) (males 15-64 years)by socio-economic group, Ireland 1996Standardised mortality ratios (SMRs) and 95% confidence intervals for ischaemicheart disease (ICD codes 410-414) (males 15-64 years) for unskilled manualand professional (higher + lower) socio-economic groups, Ireland 1981,1986, 1991, 1996Standardised mortality ratios (SMRs) and 95% confidence intervals forneoplasms (ICD codes 140-239)(males 15-64 years) by socio-economicgroup, Ireland 1996Standardised mortality ratios (SMRs) and 95% confidence intervals forneoplasms (ICD codes 140-239)(males 15-64 years) for unskilled manual andprofessional (higher + lower) socio-economic groups, Ireland 1981,1986, 1991, 1996Standardised mortality ratios (SMRs) and 95% confidence intervals forinjuries and poisonings (ICD codes 800-999) (males 15-64 years) bysocio-economic group, Ireland 1996Standardised mortality ratios (SMRs) and 95% confidence intervals forinjuries and poisonings (ICD codes 800-999)(males 15-64 years) for unskilledmanual and professional (higher + lower) socio-economic groups,Ireland 1981,1986, 1991, 1996Perinatal Reporting SystemFigure 2.1Figure 2.2Standardised perinatal mortality ratios and 95% confidence intervals bysocio-economic group, Ireland 1990-1993Standardised perinatal mortality ratios and 95% confidence intervals for unskilledmanual and professional (higher + lower) socio-economic groups, Ireland 1986-1993PAGE 9

PAGE 10Figure 2.3Figure 2.4Figure 2.5Standardised low birth weight ratios and 95% confidence intervals bysocio-economic group, Ireland 1990-1993Standardised low birth weight ratios and 95% confidence intervals for unskilledmanual and professional (higher + lower) socio-economic groups, Ireland 1986-1993Percentage of births to single teenagers aged15-17 as a proportion of allbirths by year, 1986-1993National Psychiatric InPatient Reporting SystemFigure 3.1Figure 3.2Figure 3.3Figure 3.4Figure 3.5Figure 3.6Figure 3.7Figure 3.8Figure 3.9Figure 3.10Standardised discharge ratios and 95% confidence intervals for all 1st psychiatricadmissions (males 15-64 years) by socio-economic group, Ireland 1996Standardised discharge ratios and 95% confidence intervals for all 1stpsychiatric admissions (males 15-64 years) for unskilled manual andprofessional (higher + lower) socio-economic groups, Ireland 1991 and1996Standardised discharge ratios and 95% confidence intervals for schizophrenia1st admissions (males 15-64 years) by socio-economic group, Ireland 1996Standardised discharge ratios and 95% confidence intervals for schizophrenia1st admissions (males 15-64 years) for unskilled manual and professional(higher + lower) socio-economic groups, Ireland 1991 and1996Standardised discharge ratios and 95% confidence intervals for depressivedisorders 1st admissions (males 15-64 years) by socio-economic group, Ireland 1996Standardised discharge ratios and 95% confidence intervals for depressivedisorders 1st admissions (males 15-64 years) for unskilled manual andprofessional (higher + lower) socio-economic groups, Ireland 1991 and 1996Standardised discharge ratios and 95% confidence intervals for alcoholicdisorders 1st admissions (males 15-64 years) by socio-economic group, Ireland 1996Standardised discharge ratios and 95% confidence intervals for alcoholicdisorders 1st admissions (males 15-64 years) for unskilled manual andprofessional (higher + lower) socio-economic groups, Ireland 1991 and1996Standardised discharge ratios and 95% confidence intervals for personalitydisorders 1st admissions (males 15-64 years) by socio-economic group, Ireland 1996Standardised discharge ratios and 95% confidence intervals for personalitydisorders 1st admissions (males 15-64 years) for unskilled manual andprofessional (higher + lower) socio-economic groups, Ireland 1991 and1996PAGE 10

PAGE 11National Drug Treatment Reporting SystemFigure 5.1Figure 5.2Figure 5.3Trends in measures of education and employment for first time treatmentcontacts (opiates) 1990-1996, Dublin onlyPlot of the relationship between a DED’s deprivation level and the meanstandardised first treatment contact ratio (SFTCR) value, with 95% confidenceintervals, for opiate misuse 15-34 year olds in the greater Dublin area, 1995-1996Map of greater Dublin area district electoral divisions (DEDs) with bothsignificantly high standardised first treatment contact ratios (SFTCR)and high deprivationUnknown socio-economic groupFigure 6.1Figure 6.2Figure 6.3Figure 6.4Figure 6.5Figure 6.6Figure 6.7Figure 6.8Percentages of persons with unknown socio-economic group, NationalMortality Dataset (males 15-64) 1981 and 1996, Perinatal Reporting System(females) 1986 and 1993, National Psychiatric InPatient Reporting System(males 15-64) 1991 and 1996Percentage of male deaths (15-64 years) in the ‘unknown’ socio-economicgroup compared to all other socio-economic groups by county, Ireland 1996(National Mortality Dataset)Marital status within the ‘unknown’ socio-economic group compared to allother socio-economic groups (National Mortality Dataset)Percentage of women in the ‘unknown’ socio-economic group comparedto all other socio-economic groups by age, Ireland 1986-1993(Perinatal Reporting System)Percentage of women in the ‘unknown’ socio-economic group comparedto all other socio-economic groups by county, Ireland 1986-1993(Perinatal Reporting System)Percentage of males (15-64 years) in the ‘unknown’ socio-economic groupcompared to all other socio-economic groups by age, Ireland 1996 (NationalPsychiatric InPatient Reporting System)Percentage of males (15-64 years) in the ‘unknown’ socio-economic groupcompared to all other socio-economic groups by county, Ireland 1996 (NationalPsychiatric InPatient Reporting System)Marital status within the ‘unknown’ socio-economic group comparedto all other socio-economic groups, Ireland 1996 (National PsychiatricInPatient Reporting System)PAGE 11

PAGE 12LIST OF TABLESTable 0.1Table 0.2Routine health datasets analysed for this reportContent of the datasetsNational Mortality DataTable 1.1Table 1.2Table 1.3Table 1.4Standardised mortality ratios (SMRs) and total deaths for all causes,by county, Ireland 1994-1996Standardised mortality ratios (SMRs) and total deaths for ischaemic heartdisease (ICD codes 410-414), by county, Ireland 1994-1996Standardised mortality ratios (SMRs) and total deaths for neoplasms (ICDcodes 140-239), by county, Ireland 1994-1996Standardised mortality ratios (SMRs) and total deaths for injuries andpoisonings (ICD codes 800-999), by county, Ireland 1994-1996Table 1.5 Standardised mortality ratios (SMRs) and total deaths for all causes, for 88rural and urban districts and county boroughs, Ireland 1994-1996Table 1.6Table 1.7Table 1.8Standardised mortality ratios (SMRs) and total deaths for ischaemic heartdisease (ICD codes 410-414), for 88 rural and urban districts and countyboroughs, Ireland 1994-1996Standardised mortality ratios (SMRs) and total deaths for neoplasms (ICD codes140-239), for 88 rural and urban districts and county boroughs, Ireland 1994-1996Standardised mortality ratios (SMRs) and total deaths for injuries andpoisonings (ICD codes 800-999), for 88 rural and urban districts and countyboroughs, Ireland 1994-1996Perinatal Reporting SystemTable 2.1Table 2.2Standardised perinatal mortality ratios (SPMRs) and perinatal deaths bycounty, Ireland 1986-1993Standardised low birth weight ratios (SLBWRs) and number of low birthweight births, by county, Ireland 1986-1993Table 2.3 Age standardised incidence (ASI) of births to single teenagers aged 15-17by county, 1986-1993PAGE 12

PAGE 13National Psychiatric InPatient Reporting SystemTable 3.1Table 3.2Table 3.3Table 3.4Table 3.5Standardised discharge ratios (SDRs) and total discharges for all 1st psychiatricadmissions (male and female) by county, Ireland 1991 and 1996 combinedStandardised discharge ratios (SDRs) and total discharges for all 1st admissionsfor schizophrenia (male and female) by county, Ireland 1991 and 1996 combinedStandardised discharge ratios (SDRs) and total discharges for all 1stadmissions for depressive disorders (male and female) by county, Ireland 1991and 1996 combinedStandardised discharge ratios (SDRs) and total discharges for all 1stadmissions for alcoholic disorders (male and female) by county,Ireland 1991 and 1996 combinedStandardised discharge ratios (SDRs) and total discharges for all 1stadmissions for personality disorders (male and female) by county,Ireland 1991 and 1996 combinedHospital In-Patient Reporting SystemTable 4.1Table 4.2Table 4.3Table 4.4Standardised discharge ratios for ischaemic heart disease (ICD codes410-414) by county, Ireland 1997Standardised discharge ratios for neoplasms (ICD codes 140-239) bycounty, Ireland 1997Standardised discharge ratios for injuries and poisonings (ICD codes800-999) by county, Ireland 1997Standardised discharge ratios for coronary artery bypass graft bycounty, Ireland 1997Table 4.5 Standardised discharge ratios for angioplasty by county, Ireland 1997Unknown socio-economic groupTable 6.1Assorted standardised ratios for ‘unknown’ category, National MortalityDataset (1996), Perinatal Reporting System (1993) and National PsychiatricInPatient Reporting System (1996)PAGE 13

PAGE 14GLOSSARY OF TERMSConfidence Interval (95%)The range of values in which the true value of a parameter (e.g. proportion) is likely to be found.By convention a 95% confidence interval is usually calculated i.e. the range that will include thetrue value 95% of the time.DatabaseA collection of values, usually containing several variables, which is constantly maintainedand updated.Health inequalitiesHealth inequality is the "differences in the prevalence or incidence of health problems betweenindividual people of higher and lower socio-economic status."Reference: World Health Organisation. City Health Profiles. Geneva 1998.Health inequitiesIt is important to note that inequity is not the same as or synonymous with inequality. Healthinequalities count as inequities only when they are avoidable, unnecessary, and unfair.Reference: Goran Dahlgren and Margaret Whitehead, Policies and Strategies to Promote Social Equality in Health(Stockholm: Institute of Future Studies, 1991).Hospital In-Patient Enquiry (HIPE)The Hospital In-patient Enquiry scheme records details on deaths and discharges for all the acutepublic hospitals in the country. Information is collected on principal diagnoses and principalprocedures performed.National Mortality DatasetDeaths classified by year of death, excluding late registrations but including deaths of nonresidents.The Ninth Revision of the International Classification of Diseases, Injuries and Causes ofDeath (ICD-9) has been used to classify deaths in Ireland by cause since 1979. The CentralStatistics Office is responsible for compiling registered deaths in computerised format.National Psychiatric InPatient Reporting SystemThis system records information on discharges for all in-patient psychiatric admissions in thecountry through all public hospitals and some private hospitals. It gathers information by principalpsychiatric diagnosis.PAGE 14

PAGE 15National Drug Treatment Reporting System (NDTRS)The NDTRS is an epidemiological database providing information on treated drug misuse in theRepublic of Ireland. Drug misuse which occurs outside the treatment context is not included. Thedatabase is maintained by the Drug Misuse Research Division of the Health Research Board.Reporting began in 1990 and for the first five years covered treated drug misuse in Dublin only. In1995 the Reporting System was expanded to cover the entire country. Drug misuse in the NDTRSis defined as the taking of an illegal and/or legal drug or drugs (excluding alcohol other than as asecondary drug of misuse and tobacco) which harms the physical, mental or social well-being ofthe individual, the group or society.Perinatal mortality rateNumber of stillbirths plus number of liveborn babies who die before the end of the first seven daysof life per annum divided by total number of live and stillbirths.Perinatal periodThe time from 28 weeks gestation (28 weeks of pregnancy) or when the foetus reaches a weightof 500 grammes whichever occurs first, to 1 week after birth. In 1995 the definition changed andthe relevant gestation period became 24 weeks.Perinatal Reporting SystemThis system comprises a notification of birth form filled out by all maternity hospitals on the birth ofeach baby, collecting information on the mother, the pregnancy and the infant. These data form thePerinatal Reporting System database.Qualitative researchSocial research which is carried out in the field (natural settings) and analysed largely in nonstatisticalways.Quantitative researchThe measurement and analysis of observations in a numerical way.Routine data sourcesThis refers to data which are continually collected by various sources e.g. Perinatal ReportingSystem, Hospital In-Patient Enquiry (HIIPE), National Psychiatric InPatient Reporting System,National Mortality Dataset.Social classSegments of the population sharing broadly similar types and levels of resources, broadly similarstyles of living and some shared perception of their collective condition.PAGE 15

PAGE 16Socio-economic group (SEG)A classification system used to bring together persons with similar social and economic status onthe basis of the level of skill or educational attainment acquired. SEG of those 15 years and overis determined by their occupational and employment status. Persons on home duties or atschool/college, who are members of a family unit are generally classified to the SEG of the personin the family on whom they were deemed dependant. SEG of married women is often determinedby their husband’s occupation.Standardised mortality ratio (SMR)Method of comparing mortality of one population with that of another. It is obtained by calculatingthe expected number of deaths in a given population (if the population had the same mortality as thestandard population) and dividing the observed number of deaths by the expected number. Otherstandardised ratios (e.g. standardised low birth weight ratios) are calculated in the same way.UnknownsThe Irish socio-economic group (SEG) classification is a nominal grouping of occupationscomprising 11 categories plus a residual 'unknown' category for individuals who cannot be codeddue to insufficient information. Occupations are grouped in each SEG on the basis that they aregenerally similar as regards the level of skill or educational attainment acquired. A major weaknessof the Irish SEG classification is the lack of ordinality in the scaling of occupations and in particularthe grouping of all farmers in one category irrespective of farm size or income accruing from thefarm. It is also felt that some categories of the Irish SEG classification contain an inappropriatecombination of occupations. (O'Hare 1991)VariablesMeasures of interest that vary across individuals, groups or geographic areas, for example, age,sex, socio-economic group, mortality rate.PAGE 16

CHAPTER ONE

PAGE 18INTRODUCTIONFairness is good for health and unfairness is bad for healthConcerns about the health of the poor have existed in Ireland since the early 1800s. Structureswere put in place through the Poor Law in 1838 and the Dispensary Service from 1851 toprovide limited healthcare for poor people. The services fell far short of the needs of the peopleand the political debate about the Health Act of 1970 expressed concerns about ‘injustice’ inhealthcare provision. Over the last two decades an international debate has moved frominjustice to inequalities. There is now compelling international research indicating that healthinequalities occur throughout the industrialised world. 1 Such inequalities are directly related toincreased ill health and early death among significant numbers of our citizens. Medicine ingeneral is beginning to realise that it can do little about inequalities in society without a widerpolitical debate. However, commentators increasingly focus on equity in healthcare whichintroduces the concept of fairness in the distribution of medical care (Shaping a HealthierFuture 1994). 2 Ireland is a good place to investigate the issue of fairness as it has wellestablished systems of public and private medical care existing side by side. Such systems arerevealing anecdotal cases of inequities where patients with similar illnesses only receive promptcare on the basis of ability to pay. Spending on health is important as in countries which spendmuch more on their health than Ireland, the better off live several years longer and have fewerillnesses than the poor. Indeed there is now evidence that health spending in the private sectorin Ireland is above the EU average while spending in the public sector continues to lag behindthe EU average (OECD). 3 Politicians have not welcomed research on inequalities in health aswas famously demonstrated when the seminal, British Government funded 'Black Report' oninequalities was released on an August bank holiday Monday in 1980 in restricted numbers toa restricted audience by Mrs. Thatcher’s government. 4The Black Report on inequalities in health presented evidence of marked differentials in healthoutcomes "…from birth to old age those at the bottom of the social scale have much poorer healthand quality of life than those at the top … gender, area of residence and ethnic origin also have adeep impact". Ten years later researchers had concluded that socio-economic inequalities in healthoutcome had widened and "….suggest that further widening of mortality differentials may beexpected." 5,6 The existence of wide and widening socio-economic differences in health shows howextraordinarily sensitive health remains to socio-economic circumstances. 7,8There is also evidence that unless medical care is targeted appropriately, that it may contribute towidening of differences between socio-economic groups because of the greater capacity of welloff people to obtain medical care. 9Approaches to policy in Ireland - insufficient actionWhile the debate about inequalities in the United Kingdom has become polarised and politicised,in the Netherlands cross party agreement has led to a consensus based approach to addressinginequalities in health. 10 The Dutch have set up a five year research programme with the aim ofraising consciousness among the scientific community, to increase knowledge of inequalities andtheir causes and, crucially, to have an effect on health policy.PAGE 18

PAGE 19The Dutch have set up a five year research programme withthe aim of raising consciousness among the scientificcommunity, to increase knowledge of inequalities and theircauses and, crucially, to have an effect on health policy.The approach in Ireland has taken the Dutch rather than the UK approach, but without the robuststructure to move from policy to action. In fairness there appears to be a seriousness of purposethat is severely handicapped by poor information systems, lack of research and difficulties inmedium to long term planning. The Department of Health and Children’s widely accepted strategydocument Shaping a Healthier Future 2 has set the scene by defining the principles of equity, qualityand accountability for the development of our health services. Considerable attention was drawnin the document to inequalities in health in selected sub-groups of the Irish population and indeedsince the publication of the strategy the reduction in inequalities in healthcare has been a priority.The first ever Chief Medical Officer’s report 11 builds on this theme and acknowledges that researchis urgently required to establish the extent of health inequality in Ireland and its complex causes. Inthe policy document Programme for Prosperity and Fairness 12 one objective is "to improve accessto quality healthcare services in order to strengthen social inclusion and cohesion and also tomonitor socio-economic health inequalities". The Programme document devotes further attentionto marginalised groups and inequalities and states "resources will be allocated to health researchas part of a comprehensive approach to ensuring adequate medium and long term planning ofhealth provision. Data systems will be adapted to enable dis-aggregation of health access andoutcomes across National Anti-Poverty Strategy target groups. This data will be monitored andreported on at national level." The Health Research Board's consultation document MakingKnowledge Work for Health 13 emphasises that epidemiological information needs to be availableand translated into measures for the health of the population. The real test is, however, not in doingthe research but in translating it into effective policy and action as an expression of our society’scommitment to equity in healthcare.This research ……In 1998, through a Health Research Board grant, we obtained access to a range of databasesfrom the Irish health services with a view to examining inequalities in health and healthcare inIreland. Some databases make socio-economic differentiation possible; in others, data ondifferences in health are only examinable at a geographic level. Unfortunately no databaseprovides analysis by social class.Our project has two principal objectives. Using routine health information systems:• To look for and present evidence of inequalities in health and healthcare in Ireland over thepast twenty years.• To make recommendations on data collection so that routine health information systemscan be used to measure changes in health status and healthcare uptake, particularly indifferent social groups of the population.PAGE 19

PAGE 20HOW WE DID ITOn receipt of the Health Research Board grant the managers or custodians of five datasets werewritten to, stating the objectives of our exercise and seeking permission to access the data. In allcases permission was forthcoming. The datasets differ widely in their construction, their objectives,their legal status and their size. Five datasets are cited in this report. These are:• National Mortality Dataset• Perinatal Reporting System• National Psychiatric InPatient Reporting System• Hospital In-Patient Enquiry• National Drug Treatment Reporting SystemThere is a risk with access to such large datasets that the data processing and analysis itself couldtake an inordinate length of time. Therefore data for each year for each dataset were not sought.A summary description of each dataset is given in Table 0.1 and an outline of the variables that canshow inequalities, collected in each dataset, is given in Table 0.2. A more detailed account of theanalytical methods used and the reasons for using them are given in the Technical Annex, appendixA. A copy of the data entry sheet for four of the datasets is given in appendix B.PAGE 20

PAGE 21Table 0.1 Routine health datasets analysed for this reportDATABASEORGANISATIONMAINTAININGDATABASEAPPROXENTRIESPER ANNUMANNUALREPORTAVAILABLEMOST RECENTYEAR FORWHICH PRINTEDREPORT ISAVAILABLEYEARSANALYSED INTHIS PROJECTNATIONALMORTALITYDATASETCENTRALSTATISTICSOFFICE30,000YES19971981, 1986,1991,1994,1995, 1996PERINATALREPORTINGSYSTEMECONOMIC &SOCIALRESEARCHINSTITUTE:(UP TO 1994 DEPTOF HEALTH)53,000YES19931986 - 1993NATIONALPSYCHIATRICINPATIENTREPORTINGSYSTEMHEALTHRESEARCHBOARD7,500(1ST ADMISSIONS)YES19981991, 1996HOSPITALIN-PATIENTENQUIRYECONOMIC &SOCIALRESEARCHINSTITUTE675,000NO–1997NATIONALDRUGTREATMENTREPORTINGSYSTEMHEALTHRESEARCHBOARD5,000YES19981990 - 1996PAGE 21

PAGE 22Table 0.2 Content of the datasetsDATABASEMETHOD OF DATA COLLECTIONTYPE OF DATACOLLECTEDVARIABLES THAT CANSHOW INEQUALITIESNATIONALMORTALITYDATASETINFORMATION IS COLLECTEDON FOOT OF A DEATHCERTIFICATE COMPLETED BYTHE ATTENDING DOCTOR.DEMOGRAPHIC,CLINICALOCCUPATION (SEG),LOCAL DISTRICTPERINATALREPORTINGSYSTEMTHE PERINATAL REPORTINGSYSTEM COLLECTSINFORMATION THROUGH EVERYMATERNITY UNIT IN THECOUNTRY ON HEALTH FACTORSRELATED TO THE MOTHER, THEPREGNANCY AND THE INFANT.DEMOGRAPHIC,PROCESS OFCARE,OUTCOMESOCCUPATION (SEG),COUNTYHOSPITALIN-PATIENTENQUIRYTHE HOSPITAL IN-PATIENTENQUIRY SCHEME RECORDSDETAILS ON DEATHS ANDDISCHARGES FOR ALL THEACUTE PUBLIC HOSPITALS INTHE COUNTRY.DEMOGRAPHIC,DIAGNOSTIC,PROCEDURALCOUNTY,GMS STATUSNATIONALPSYCHIATRICINPATIENTREPORTINGSYSTEMTHIS SYSTEM RECORDSINFORMATION ON DISCHARGESFOR ALL IN-PATIENTPSYCHIATRIC ADMISSIONS INTHE COUNTRY THROUGH ALLPUBLIC HOSPITALS AND SOMEPRIVATE HOSPITALS.DEMOGRAPHIC,DIAGNOSTICOCCUPATION (SEG),COUNTYNATIONALDRUGTREATMENTREPORTINGSYSTEMTHIS SYSTEM RECORDSINFORMATION ON ALLTREATMENT CONTACTS INDRUG TREATMENT CENTRESDEMOGRAPHIC,CLINICAL,BEHAVIOURALDISTRICT ELECTORALDIVISIONPAGE 22

CHAPTER TWOSection 1- Results from National Mortality Dataset

PAGE 24NATIONAL MORTALITY DATASETDeaths classified by year of death, excluding late registrations but including deaths of nonresidents.The Ninth Revision of the International Classification of Diseases, Injuries andCauses of Death (ICD-9) has been used to classify deaths in Ireland by cause since 1979. TheCentral Statistics Office is responsible for compiling registered deaths in computerisedformat.The results are presented in two formats;(i)socio-economic mortality for males aged 15-64 over a fifteen year timespan,using five year intervalsand(ii)geographic variations in mortality for both sexes combined, using 3 years’ aggregateddata (1994-1996), using the 26 counties of the Republic of Ireland and the 88 localdistricts as the units of analysis.The measure of mortality used is the Standardised mortality ratio (SMR).The standardised mortality ratio is a method of comparing death rates in different populations, suchas amongst different socio-economic groups in Ireland. When using the standardised mortalityratio, the average for the whole population is 100. Any SMR greater than 100 means that thatgroup has a higher mortality than the average and when the SMR is less than 100 it means thatthat group has a lower mortality than the average. We have used 95% confidence intervals in thisreport. If the 95% confidence interval does not include the value 100, it means that the SMR forthat particular occupational group or county is statistically above or below the average. Thestandard population used is the male population of Ireland aged 15 to 64.Occupation can be used as a proxy for socio-economic grouping in relation to mortality data onlyfor males because occupation of females is not well recorded. It is also difficult to use thisclassification in persons over 65 because most people have retired from work by this age. Forsimilar reasons mortality in the under 15 age group is not used. Accordingly the socio-economicmortality data that is presented relates to males aged 15-64. The data are presented for all causesand for specific named causes. The causes used are taken from the International Classification ofDiseases (9th version) and include: all causes, ischaemic heart disease (410-414), neoplasms(140-239) and injuries and poisonings (800-999).PAGE 24

PAGE 25Figure 1.1Standardised mortality ratios (SMRs) and 95% confidence intervals for allcauses (males 15-64 years) by socio-economic group, Ireland 1996COMMENT: In 1996 there was a wide variation in the range of standardised mortality ratios among the socioeconomicgroup with the lower SMRs occurring in professional and non-manual workers and also farmers. Thehighest SMR by a very large margin occurred in those men for whom a socio-economic group could not be assignedbecause it was not recorded on the data.Figure 1.2Standardised mortality ratios (SMRs) and 95% confidence intervals for allcauses (males 15-64 years) for unskilled manual and professional (higher +lower) socio-economic groups, Ireland 1981,1986, 1991, 1996COMMENT: The trends over time (Figure 1.2) give the appearance of some convergence between the unskilledmanual group and the combined professional group. However, the proportion of unknowns over this time has grownand the unknowns also have very high mortality. Further investigation is required to characterise better this unknowngroup before any inference could be drawn about a narrowing of the gap.PAGE 25

PAGE 26Figure 1.3Standardised mortality ratios (SMRs) and 95% confidence intervals forischaemic heart disease (ICD codes 410-414) (males 15-64 years) bysocio-economic group, Ireland 1996COMMENT: In 1996 the professional and non-manual groups and farmers have SMRs mostly under 100, whereasthe unskilled manual groups, except the skilled manual group, have SMRs over 100. The highest SMR is in theunknown category.Figure 1.4Standardised mortality ratios (SMRs) and 95% confidence intervals for ischaemicheart disease (ICD codes 410-414) (males 15-64 years) for unskilled manual andprofessional (higher + lower) socio-economic groups, Ireland 1981,1986, 1991, 1996COMMENT: When looked at over the 15 year time interval, the SMR for the professional group is in the range of 50-60 but there has been a steady drop in the SMR for the unskilled manual group. However, we know that over thesame time period, the proportion of those with ‘unknown’ socio-economic group has grown and we also know thatthe SMR in this group is considerably in excess of the next highest SMR. Therefore, until further characterisation ofthe unknown group is determined, the rising number of unknowns is a plausible explanation for the drop in the SMRof the unskilled manual group in the period 1981-1996.PAGE 26

PAGE 27Figure 1.5Standardised mortality ratios (SMRs) and 95% confidence intervals for neoplasms(ICD codes 140-239)(males 15-64 years) by socio- economic group, Ireland 1996COMMENT: In 1996 farmers have the lowest SMR for neoplasms and the unknown category has the highest. By andlarge the professional groups are below SMR 100 and the unskilled manual and manual workers have SMRs greaterthan 100.Figure 1.6Standardised mortality ratios (SMRs) and 95% confidence intervals for neoplasms(ICD codes 140-239)(males 15-64 years) for unskilled manual and professional(higher + lower)socio-economic groups, Ireland 1981,1986, 1991, 1996COMMENT: Over the 15 year interval 1981-1996 there has been a trend for the SMR in the professional groups tomove from values of around 50 in the 1980s up to between 70 and 80 during the 1990s. There is no discernabletrend in the SMR in the unskilled manual group which has been mostly in the range of 125 to 140.PAGE 27

PAGE 28Figure 1.7Standardised mortality ratios (SMRs) and 95% confidence intervals for injuriesand poisonings (ICD codes 800-999) (males 15-64 years) by socio-economicgroup, Ireland 1996COMMENT: In 1996 apart from the unknown group whose SMR is almost 350, the next highest is amongst thecategory ‘other agricultural and fishermen’. Professional groups have very low SMRs for injuries and poisonings.There is a health and safety issue to be addressed here.Figure 1.8Standardised mortality ratios (SMRs) and 95% confidence intervals for injuries andpoisonings (ICD codes 800-999)(males 15-64 years) for unskilled manual andprofessional (higher + lower) socio-economic groups, Ireland 1981,1986, 1991, 1996COMMENT: In the time interval from 1981-1996 SMR in the professional groups has been consistently low, in therange 30-50. In the unskilled manual group SMR has dropped from a relatively high 150 in 1981 to 130 in 1996. Forunskilled manual groups however, there may be a transfer from unskilled manual to unknown in recent yearsexplaining this apparent drop..PAGE 28

PAGE 29Table 1.1 Standardised mortality ratios(SMRs) and total deaths for all causes, bycounty, Ireland 1994-1996Table 1.2 Standardised mortality ratios(SMRs) and total deaths for ischaemic heartdisease (ICD codes 410-414), by county,Ireland 1994-1996ALL CAUSE MORTALITYThe figures show ranked age/sex standarised mortalityratios (SMR) and total numbers of deaths for all causes in1994-96 by county. National average SMR is 100.Rank SMR Deaths1 Kilkenny 90.7 18712 Meath 91.4 22863 Galway 93.8 51214 Clare 93.9 25685 Roscommon 94.2 18286 Cavan 94.8 16327 Laois 94.9 13618 Donegal 96.1 39299 Waterford 97.6 245110 Sligo 98.6 176711 Dublin 98.9 2372012 Monaghan 99.1 145213 Wicklow 99.7 245014 Longford 100.1 94315 Kerry 100.6 407916 Offaly 100.8 156317 Limerick 102.4 425118 Louth 103.3 228819 Kildare 103.8 245620 Cork 104.0 1148821 Mayo 104.8 425122 Wexford 105.9 294623 Tipperary 106.2 409024 Westmeath 108.5 179825 Leitrim 110.1 109126 Carlow 114.4 1163Sig. Low Non Sig. Sig. HighISCHAEMIC HEART DISEASEThe figures show ranked age/sex standarised mortalityratios (SMR) and total numbers of deaths for IschaemicHeart Disease (ICD 410-414) in 1994-96 by county.National average SMR is 100.Rank SMR Deaths1 Sligo 82.8 3482 Clare 87.2 5713 Dublin 88.1 55984 Laois 93.1 3395 Limerick 94.1 10036 Kilkenny 95.9 5087 Kildare 95.9 6228 Waterford 96.9 6269 Offaly 97.6 39710 Wicklow 97.8 61711 Louth 99.4 58912 Meath 103.3 66713 Cavan 103.7 43614 Westmeath 104.6 44715 Galway 104.7 134216 Wexford 105.8 75217 Cork 108.3 304218 Tipperary 108.7 106119 Leitrim 109.4 24720 Longford 109.5 25021 Donegal 110.0 101822 Carlow 110.2 29823 Kerry 110.3 106024 Mayo 111.5 100425 Roscommon 130.6 57826 Monaghan 133.2 476Sig. Low Non Sig. Sig. HighCOMMENT: There is no obvious trend, i.e. East-West, North-South, in the overall county distribution of mortality. Inthe all cause mortality, there is no obvious explanation for why two neighbouring counties, Kilkenny and Carlowshould be at opposite ends of the national mortality ratios. The SMR for Carlow at 114 is an outlier as the nexthighest, Leitrim, is 110. This is quite a large gap. If there has been some systematic coding of Kilkenny residents toCarlow, it would explain the pattern that is given in Table 1.1.PAGE 29

PAGE 30Table 1.3 Standardised mortality ratios(SMRs) and total deaths for neoplasms(ICD codes 140-239), by county, Ireland1994-1996Table 1.4 Standardised mortality ratios(SMRs) and total deaths for injuries andpoisonings (ICD codes 800-999), by county,Ireland 1994-1996NEOPLASMSThe figures show ranked age/sex standarised mortality ratios(SMR) and total numbers of deaths for Neoplasms (ICD140-239) in 1994-96 by county. National average SMR is 100.Rank SMR Deaths1 Roscommon 81.2 3622 Clare 81.6 5193 Kilkenny 83.7 4134 Galway 88.7 11175 Meath 88.8 5326 Kerry 89.1 8407 Monaghan 89.5 3078 Longford 90.9 2019 Offaly 91.2 34210 Wicklow 91.9 53411 Sligo 92.1 38212 Donegal 94.7 88013 Waterford 97.4 58314 Cavan 98.7 39915 Laois 98.7 33916 Leitrim 99.3 22617 Westmeath 100.4 39818 Tipperary 100.6 92019 Mayo 100.6 92320 Louth 101.5 54321 Limerick 101.6 100222 Wexford 105.0 69223 Cork 105.3 275624 Carlow 107.1 26425 Kildare 109.6 63026 Dublin 109.7 6309Sig. Low Non Sig. Sig. HighINJURIES AND POISONINGSThe figures show ranked age/sex standarised mortalityratios (SMR) and total numbers of deaths for Injuries andPoisonings (ICD 800+) in 1994-96 by county. Nationalaverage SMR is 100.Rank SMR Deaths1 Dublin 81.5 9942 Wicklow 86.4 1013 Roscommon 87.9 594 Limerick 92.5 1805 Kilkenny 92.6 826 Sligo 93.3 647 Tipperary 97.6 1568 Waterford 99.2 1119 Kildare 99.3 14410 Donegal 100.5 15911 Laois 104.7 6512 Cork 106.0 52713 Offaly 109.5 7514 Kerry 111.5 17415 Wexford 113.6 13916 Cavan 113.8 7417 Clare 114.5 12918 Mayo 115.2 16319 Galway 115.2 26320 Meath 116.5 14321 Louth 117.7 12422 Monaghan 127.4 7823 Westmeath 128.1 9424 Longford 130.4 4825 Leitrim 136.0 4526 Carlow 152.0 73Sig. Low Non Sig. Sig. HighCOMMENT: The range of SMRs is highest among injuries and poisonings, mainly due to the fact that there are smallernumbers of deaths from this cause. ‘Injuries and Poisonings’ are the ICD codes for what are more commonly referredto as accidents. The county with the lowest SMR from injuries and poisonings by a considerable margin, is Dublinand the county with the highest, again by a considerable margin, is Carlow. More detailed analysis of the primarydata might help to elucidate the causes of these resultsPAGE 30

PAGE 31Table 1.5 Standardised mortality ratios (SMRs) and total deaths for all causes, for 88 rural andurban districts and county boroughs, Ireland 1994-1996ALL CAUSESThe figures show ranked Bayesian-adjusted age/sex standarisedmortality ratios (SMR) and total numbers of deaths for all causes in1994-96 by urban/rural district. National average SMR is 100.ALL CAUSES continuedRank SMR Deaths1 Meath RD Rural 63.5 14372 Louth RD Rural 71.8 7523 Tipperary NR RD Rural 72.7 9074 Tipperary SR RD Rural 77.3 11025 Galway CB Urban 79.7 9426 Offaly RD Rural 79.8 9517 Kilkenny RD Rural 80.1 14378 Wexford RD Rural 80.6 17579 Clare RD Rural 81.3 200810 Monaghan RD Rural 82.4 90411 Cork RD Rural 82.8 553412 Mayo RD Rural 84.8 290613 Kerry RD Rural 85.4 268514 Wicklow RD Rural 85.8 134215 Dublin - Fingal Urban 86.5 211316 Dublin - Belgard Urban 87.8 253117 Galway RD Rural 88.2 359418 Sligo MB Urban 89.6 46319 Dun L - Rathdown Urban 89.7 444020 Donegal RD Rural 91.5 343421 Longford RD Rural 93 78822 Limerick RD Rural 93.2 266223 Kildare RD Rural 93.7 185924 Cavan RD Rural 93.7 153225 Roscommon County Rural 94.2 182826 Westmeath RD Rural 94.6 133127 Laois County Rural 95 136128 Waterford CB Urban 95.7 97029 Waterford RD Rural 96.6 122030 Wicklow UD Urban 96.8 13631 Buncrana UD Urban 101.4 10332 Sligo RD Rural 102.6 130433 Youghal UD Urban 103.2 18034 Monaghan UD Urban 106 17435 Dublin CB Urban 106.8 1463636 Drogheda MB Urban 108.6 59337 Leitrim County Rural 110.1 109138 Carlow RD Rural 111.2 81439 Dungarvan UD Urban 113.8 26140 Cavan UD Urban 117.5 10041 Cork CB Urban 118.3 391142 Carlow UD Urban 123 34943 Limerick CB Urban 123.1 158944 Arklow UD Urban 124.8 23745 Tralee UD Urban 126.5 623Rank SMR Deaths46 Clonakilty UD Urban 127.5 17047 Letterkenny UD Urban 128.8 22548 Bray UD Urban 131.1 73549 Castleblayney UD Urban 138.8 14350 Castlebar UD Urban 139.5 39251 Cobh UD Urban 145.7 23052 Tipperary UD Urban 147.7 23253 Clonmel MB Urban 151 48654 Naas UD Urban 151.9 32755 Dundalk MB Urban 152.6 94356 Wexford MB Urban 154.8 45657 Athy UD Urban 160.8 27058 Tullamore UD Urban 162.1 36959 Cashel UD Urban 163.4 17660 Kilkenny MB Urban 163.5 43461 Longford UD Urban 165 15562 Killarney UD Urban 172 49063 Kilrush UD Urban 174.5 18764 Carrick-on-Suir UD Urban 180.3 23565 New Ross UD Urban 180.6 26766 Templemore UD Urban 181.2 11667 Clones UD Urban 184.1 7168 Birr UD Urban 186.7 24369 Athlone UD Urban 186.8 46770 Kinsale UD Urban 193.6 10371 Thurles UD Urban 194.5 45872 Midleton UD Urban 203.9 23873 Macroom UD Urban 208.9 20474 Listowel UD Urban 209.7 28175 Fermoy UD Urban 231.6 19476 Nenagh UD Urban 237.9 37877 Ennis UD Urban 239 37378 Trim UD Urban 244.4 13179 Westport UD Urban 257.1 34880 Carrickmacross UD Urban 261.1 16081 Skibbereen UD Urban 271.2 19682 Bundoran UD Urban 287.2 16783 Ballina UD Urban 287.9 60584 Enniscorthy UD Urban 292.3 46685 Ballinasloe UD Urban 293.5 58586 Mallow UD Urban 298.8 52887 Kells UD Urban 362.9 24188 Navan UD Urban 407.7 477Sig. Low Non Sig. Sig. HighPAGE 31COMMENT: For all cause mortality among the 88 districts in the country, those with the highest SMRs are all mediumsized towns. Most of the rural districts in the country have low SMRs. This is combined data for the years 1994-1996and most of the towns have absolute numbers of deaths in the range of 200-500. One explanation for this urban/ruraldifference is that it is real and that people who live in towns have higher mortality than people who live in the countryside.However, when one looks at the rural district with the lowest SMR in the country, it is by a considerable margin, Meath,and when one looks at the towns with the highest mortality, the top two, again by considerable margins, are Navan andKells. It could well be that for some reason residents of Meath are given an urban address when they die. We can seefrom Table1.1 that overall Meath has a low SMR (91), the second lowest in the country. Checking of the primary datais necessary to clarify this.

PAGE 32Table 1.6 Standardised mortality ratios (SMRs) and total deaths for ischaemic heart disease (ICDcodes 410-414), for 88 rural and urban districts and county boroughs, Ireland 1994-1996ISCHAEMIC HEART DISEASEThe figures show ranked Bayesian-adjusted age/sex standarised mortalityratios (SMR) and total numbers of deaths for Ischaemic Heart Disease (ICD410-414) in 1994-96 by urban/rural area. National average SMR is 100.Rank SMR Deaths1 Dublin-Belgard Urban 64.1 5732 Louth RD Rural 68.8 1883 Tipperary NR RD Rural 69.8 2224 Dublin-Fingal Urban 71.8 5055 Meath RD Rural 72.2 4226 Clare RD Rural 73.3 4317 Sligo MB Urban 77.3 858 Offaly RD Rural 78.4 2519 Dun L-Rathdown Urban 80.3 102410 Wexford RD Rural 81.1 46111 Wicklow RD Rural 83.4 34312 Galway MB Urban 83.9 24713 Sligo RD Rural 86.1 26314 Westmeath RD Rural 86.6 31615 Kilkenny RD Rural 86.8 39716 Mayo RD Rural 87.5 67617 Tipperary SR RD Rural 87.9 32218 Limerick RD Rural 88.1 62719 Kildare RD Rural 88.6 48920 Cork RD Rural 88.7 149321 Waterford CB Urban 89.5 23522 Laois County Rural 93.5 33923 Wicklow UD Urban 95.7 3424 Waterford RD Rural 99.3 32525 Kerry RD Rural 100.1 73926 Dublin County Borough Urban 100.7 349627 Galway RD Rural 101.8 95528 Drogheda MB Urban 103.3 15329 Cavan RD Rural 103.5 41430 Donegal RD Rural 104.9 88531 Buncrana UD Urban 105.2 2332 Carlow UD Urban 106.2 8033 Youghal UD Urban 107.0 4434 Longford RD Rural 107.4 21835 Limerick CB Urban 107.5 37636 Templemore UD Urban 109.3 1737 Cavan UD Urban 109.3 2238 Leitrim County Rural 110.0 24739 Monaghan RD Rural 111.1 30240 Arklow UD Urban 111.2 6241 Carlow RD Rural 112.3 21842 Cork CB Urban 114.6 100443 Wexford MB Urban 121.4 9344 Naas UD Urban 121.7 7445 Tralee UD Urban 121.9 151ISCHAEMIC HEART DISEASEThe figures show ranked Bayesian-adjusted age/sex Standarised MortalityRatios (SMR) and total numbers of deaths for Ischaemic Heart Disease (ICD410-414) in 1994-96 by urban/rural area. National average SMR is 100.ISCHAEMIC HEART DISEASE continuedRank SMR Deaths46 Dungarvan UD Urban 124.7 6647 Longford UD Urban 129.4 3248 Roscommon County Rural 130.6 57849 Letterkenny UD Urban 139.4 6350 Cobh UD Urban 139.5 5851 Clonmel MB Urban 141.9 11952 Bray UD Urban 143.2 17853 Killarney UD Urban 145.5 9854 Monaghan UD Urban 147.3 6255 Dundalk UD Urban 147.8 24856 Carrick-on-Suir UD Urban 152.5 5557 Tullamore UD Urban 153.2 8758 Kilkenny MB Urban 155.8 11159 Kinsale UD Urban 156.7 2560 Tipperary UD Urban 157.1 5961 Castlebar UD Urban 159.7 8062 Athy UD Urban 168.1 5963 Clones UD Urban 177.8 1964 Middleton UD Urban 197.8 5265 Ennis UD Urban 205.5 9066 Athlone UD Urban 208.9 13167 Birr UD Urban 213.9 5968 Nenagh UD Urban 217.3 9269 Kilrush UD Urban 229.3 5070 Thurles UD Urban 229.7 12171 Clonakilty UD Urban 237.2 5672 New Ross UD Urban 238.0 7873 Castleblayney UD Urban 238.4 4474 Listowel UD Urban 247.4 7275 Cashel UD Urban 247.8 5476 Skibereen UD Urban 255.6 4677 Fermoy UD Urban 255.7 5178 Westport UD Urban 256.7 8479 Trim UD Urban 261.2 3980 Ballinasloe UD Urban 286.8 14081 Carrickmacross UD Urban 295.4 4982 Mallow UD Urban 300.9 14183 Bundoran UD Urban 313.6 4784 Ballina UD Urban 352.8 16485 Macroom UD Urban 359.3 7286 Enniscorthy UD Urban 364.0 12087 Kells UD Urban 411.8 7288 Navan UD Urban 456.9 134Sig. Low Non Sig. Sig. HighCOMMENT: For ischaemic heart disease, Navan is the highest mortality town in the country followed by Kells. Meathrural district is fifth lowest. There is a similar pattern with most urban districts, representing medium sized towns, havingmuch higher SMRs than rural districts. It could well be that for some reason residents of Meath are given an urbanaddress when they die. Checking of the primary data is necessary to clarify this.PAGE 32

PAGE 33Table 1.7 Standardised mortality ratios (SMRs) and total deaths for neoplasms (ICD codes 140-239), for 88 rural and urban districts and county boroughs, Ireland 1994-1996ALL NEOPLASMS CAUSESThe figures show ranked Bayesian-adjusted age/sex standarised Standarised mortalityMortality ratios (SMR) Ratios and (SMR) total numbers and total of numbers deaths for of Neoplasms deaths for (ICD140-239) all causes in in1994-96 by urban/rural area. district. National average average SMR SMR is 100. is 100.Rank SMR Deaths1 Meath RD Rural 62.6 3382 Louth RD Rural 66.1 1653 Offaly RD Rural 68.2 1974 Clare RD Rural 68.7 3945 Tipperary NR RD Rural 68.9 2036 Kerry RD Rural 71.0 5177 Tipperary SR RD Rural 71.0 2408 Kilkenny RD Rural 73.3 3119 Monaghan RD Rural 77.0 19810 Cork RD Rural 77.2 122011 Wexford RD Rural 79.4 41312 Galway RD Rural 80.7 75213 Wicklow RD Rural 81.6 30714 Roscommon County Rural 81.6 36215 Galway MB Urban 82.4 22716 Longford RD Rural 83.1 16317 Mayo RD Rural 83.7 65418 Youghal UD Urban 85.6 3219 Limerick RD Rural 87.5 58720 Arklow UD Urban 89.2 4221 Donegal RD Rural 89.4 76122 Waterford CB Urban 89.9 21523 Westmeath RD Rural 90.2 30324 Sligo MB Urban 92.4 10525 Sligo RD Rural 92.8 27726 Dublin-Fingal Urban 93.8 56927 Kildare RD Rural 94.7 45928 Dublin-Belgard Urban 95.5 70929 Waterford RD Rural 97.8 29830 Monaghan UD Urban 98.4 3731 Cavan RD Rural 98.9 38032 Laois County Rural 99.0 33933 Leitrim County Rural 100.2 22634 Carlow RD Rural 100.4 17835 Dun L-Rathdown Urban 101.0 118636 Wicklow UD Urban 101.6 3337 Cavan UD Urban 103.0 1938 Drogheda MB Urban 118.0 15639 Dublin County Borough Urban 119.2 384540 Letterkenny UD Urban 122.8 5141 Buncrana UD Urban 122.9 2842 Bray UD Urban 124.2 15243 Tralee UD Urban 124.7 14544 Carlow UD Urban 125.7 8645 Clonakilty UD Urban 130.7 36ALL NEOPLASMS CAUSES continuedRank SMR Deaths46 Limerick CB Urban 132.8 41547 Dungarvan UD Urban 133.3 7048 Cork CB Urban 136.4 108249 Clonmel MB Urban 140.6 10950 Castlebar UD Urban 143.0 8351 Clones UD Urban 146.3 1452 Dundalk UD Urban 147.6 22253 Templemore UD Urban 148.3 2354 Cobh UD Urban 150.2 5755 Castleblayney UD Urban 154.8 3356 Kilkenny MB Urban 156.9 10257 Athlone UD Urban 159.9 9558 Longford UD Urban 160.4 3859 Carrick-on-Suir UD Urban 160.7 5260 Tipperary UD Urban 164.0 6061 Naas UD Urban 165.8 9062 Carrickmacross UD Urban 166.9 2563 Kilrush UD Urban 168.3 3964 Tullamore UD Urban 170.5 9265 Wexford MB Urban 175.2 12566 Killarney UD Urban 175.6 11767 Cashel UD Urban 176.5 4268 Birr UD Urban 179.7 5369 New Ross UD Urban 181.4 6070 Thurles UD Urban 195.7 10471 Skibereen UD Urban 201.4 3572 Trim UD Urban 203.2 2873 Listowel UD Urban 203.9 6174 Westport UD Urban 207.4 6675 Macroom UD Urban 211.3 4676 Kinsale UD Urban 216.4 3177 Ennis UD Urban 216.5 8678 Athy UD Urban 218.1 8179 Nenagh UD Urban 221.3 8780 Middleton UD Urban 222.2 6081 Fermoy UD Urban 240.9 4882 Mallow UD Urban 253.7 10983 Ballina UD Urban 258.1 12084 Bundoran UD Urban 265.9 4085 Enniscorthy UD Urban 270.6 9486 Ballinasloe UD Urban 289.9 13887 Kells UD Urban 337.9 5688 Navan UD Urban 391.0 110Sig. Low Non Sig. Sig. HighCOMMENT: Of the 88 districts in the country, the highest 20 in terms of mortality from neoplasms are all medium sizedtowns. The lowest 13 are all rural districts. The county with the lowest standardised mortality ratio, by a considerabledistance, is Meath while the 2 towns with the highest standardised mortality ratios, again by a considerable distance,are Navan and Kells. It would be necessary to check in all counties, but in particular in Meath, whether, on death,persons who would have actually resided in a rural district, are ascribed to an urban district when mortality statistics arebeing compiled.PAGE 33

PAGE 34Table 1.8 Standardised mortality ratios (SMRs) and total deaths for injuries and poisonings (ICDcodes 800-999), for 88 rural and urban districts and county boroughs, Ireland 1994-1996ALL INJURIES CAUSES AND POISONINGSThe figures show ranked Bayesian-adjusted age/sex standarised Standarised mortalityMortality ratios (SMR) Ratios and (SMR) total numbers and total of numbers deaths for of Injuries deaths and for Poisonings all causes in (ICD1994-96 800+) in 1994-96 by urban/rural by urban/rural district. National area. National average average SMR SMR is 100. is 100.Rank SMR Deaths1 Tipperary NR RD Rural 61.2 292 Dublin-Belgard Urban 62.1 1343 Dun L-Rathdown Urban 66.6 1494 Dublin-Fingal Urban 70.2 1175 Galway MB Urban 79.8 516 Limerick RD Rural 80.1 1057 Wexford RD Rural 81.0 798 Waterford CB Urban 83.4 409 Mayo RD Rural 83.5 9710 Wicklow RD Rural 84.3 6411 Tipperary SR RD Rural 85.4 5112 Sligo MB Urban 85.8 1713 Meath RD Rural 86.9 9714 Arklow UD Urban 87.4 715 Kildare RD Rural 87.7 10816 Roscommon County Rural 89.6 5917 Kilkenny RD Rural 89.7 6918 Cork RD Rural 89.7 27019 Westmeath RD Rural 92.9 5820 Tipperary UD Urban 93.5 421 Donegal RD Rural 94.3 13422 Kerry RD Rural 95.7 11323 Wicklow UD Urban 97.0 624 Monaghan RD Rural 97.9 4625 Dublin County Borough Urban 98.4 59426 Drogheda MB Urban 99.3 2627 Clare RD Rural 100.6 10228 Sligo RD Rural 101.5 4729 Templemore UD Urban 102.1 230 Louth RD Rural 102.2 4931 Clonakilty UD Urban 102.4 332 Offaly RD Rural 102.7 5433 Laois County Rural 105.7 6534 Listowel UD Urban 107.8 435 Bray UD Urban 110.7 2436 Cork CB Urban 112.0 17237 Kinsale UD Urban 112.5 238 Waterford RD Rural 113.6 6039 Cavan RD Rural 115.1 7040 Cavan UD Urban 116.7 441 Wexford MB Urban 117.3 1442 Galway RD Rural 118.1 18343 Longford RD Rural 120.9 3944 Kilkenny MB Urban 122.4 1345 Limerick CB Urban 123.5 75ALL INJURIES CAUSES AND continued POISONINGS continuedRank SMR Deaths46 Buncrana UD Urban 124.1 547 Dungarvan UD Urban 124.2 1148 Letterkenny UD Urban 126.5 1149 Naas UD Urban 126.9 1950 Birr UD Urban 130.9 651 Leitrim County Rural 134.2 4552 Youghal UD Urban 140.2 1053 Tullamore UD Urban 141.1 1554 Carrick-on-Suir UD Urban 142.1 955 Carlow RD Rural 146.6 5156 Tralee UD Urban 147.9 3457 Carlow UD Urban 151.7 2258 Monaghan UD Urban 155.0 1159 Nenagh UD Urban 157.1 1160 Castlebar UD Urban 161.3 1561 Dundalk UD Urban 163.9 4962 Middleton UD Urban 166.5 863 Clonmel MB Urban 168.2 2464 Cashel UD Urban 173.1 765 Trim UD Urban 173.5 566 Longford UD Urban 176.4 967 Clones UD Urban 177.7 468 Macroom UD Urban 190.3 869 Cobh UD Urban 192.4 1670 Thurles UD Urban 200.3 1971 Killarney UD Urban 203.1 2372 Castleblayney UD Urban 208.3 873 Ennis UD Urban 208.9 1774 Kilrush UD Urban 225.1 1075 Skibereen UD Urban 231.2 876 Mallow UD Urban 234.2 2077 Fermoy UD Urban 245.9 1078 Athy UD Urban 247.2 1779 Carrickmacross UD Urban 261.5 980 Westport UD Urban 287.3 1881 Bundoran UD Urban 292.9 982 New Ross UD Urban 304.6 2283 Athlone UD Urban 338.0 3684 Ballina UD Urban 345.7 3385 Ballinasloe UD Urban 348.6 2986 Kells UD Urban 371.6 1487 Enniscorthy UD Urban 415.0 2488 Navan UD Urban 485.2 27Sig. Low Non Sig. Sig. HighCOMMENT: The pattern for injuries and poisonings is not the same as for the natural causes examined. While mediumsized towns are at the top end of the SMR table, with Navan again having the highest SMR in the country, 3 of thelowest 4 places are occupied by Dublin districts, which is consistent with the fact that when comparing all counties(Table 1.4) Dublin has the lowest injuries and poisonings mortality in the country. Checking of the primary data isnecessary to clarify if the high SMR for Navan is due to coding errors.PAGE 34

CHAPTER TWOSection 2 - Results from Perinatal Reporting System

PAGE 36PERINATAL REPORTING SYSTEMThis system comprises a notification of birth form filled out by all maternity hospitals on the birth ofeach baby, collecting information on the mother, the pregnancy and the infant. These data form thePerinatal Reporting System database.From the perinatal reporting system the outcome measures which are analysed are perinatalmortality and low birth weight. This has been done for all counties and for socio-economic groups.Indirectly standardised rates have been calculated. There are increasing difficulties in using thefather’s occupation as the marker of socio-economic group for the infant, particularly with the risingproportion of births to single mothers and births to mothers with their own jobs and careers. Therising trend in births to mothers under the age of 18 and the county distribution of this phenomenonare also presented.The best predictor of outcome in perinatal epidemiology is birth weight. In this report, low birthweight is defined as birth weight less than 2.5 kilogrammes. International research has shown thaton an aggregate level, babies born with low birth weight have poorer health outcomes in the longterm than babies of normal weight. Perinatal mortality is an internationally accepted measure of thequality of maternity services.PAGE 36

PAGE 37Figure 2.1Standardised perinatal mortality ratios and 95% confidence intervals bysocio-economic group, Ireland 1990-1993Farmers (n=92)Other agricultural & fishermen (n=27)Higher professional (n=33)Lower professional (n=27)Employers & managers (n=73)Salaried employees (n=27)Intermediate non-manual (n=111)Other non-manual (n=109)Skilled manual (n=196)Semi-skilled manual (n=57)Unskilled manual (n=66)Unemployed (n=65)Unknown (n=242)Missing (n=21)0 50 100 150 200 250 300Figure 2.2Standardised perinatal mortality ratios and 95% confidence intervals for unskilledmanual and professional (higher + lower) socio-economic groups, Ireland 1986-1993Higher & LowerProfessionalsUnskilled manual2502001501005001986 1987 1988 1989 1990 1991 1992 1993COMMENT: Professional and salaried persons have lower standardised mortality ratios for perinatal mortality, and thehighest is in the unemployed category followed by the unskilled manual. There is some evidence of a convergencefrom 1986-1993 when the SMRs of the unskilled manual were compared to the combined professional. The highSMR in the unemployed, unknown and miscellaneous groups would need to be examined further to determinewhether this would account for the drop in the SMR in the unskilled manual category in the early 1990s.PAGE 37

PAGE 38Figure 2.3Standardised low birth weight ratios and 95% confidence intervals by socioeconomicgroup, Ireland 1990-1993Farmers (n=476)Other agricultural & fishermen (n=120)Higher professional (n=197)Lower professional (n=205)Employers & managers (n=494)Salaried employees (n=155)Intermediate non-manual (n=614)Other non-manual (n=604)Skilled manual (n=1341)Semi-skilled manual (n=363)Unskilled manual (n=377)Unemployed (n=320)Unknown (n=1990)Missing (n=70)0 50 100 150COMMENT: The unknown category has the highest SMR for low birth weight and the various professional groupsand managerial categories together with farmers, have the lowest SMRs. Apart from the unknowns, the unemployedand unskilled manual categories are the only other two categories with SMRs statistically significantly above thenational average.Figure 2.4Standardised low birth weight ratios and 95% confidence intervals for unskilledmanual and professional (higher + lower) socio- economic groups, Ireland 1986-1993Higher & LowerProfessionalsUnskilled manual2001501005001986 1987 1988 1989 1990 1991 1992 1993COMMENT: Over the time interval 1986-1993 the SMRs for the combined professional groups was in the range of50-80, whereas the SMR range for the unskilled manual group was, between 1986 and 1991 within the range of115-140; within the last 2 years of the time period examined, it had just tipped below 100 in 1992 and had just risenagain above 100 in 1993. This phenomenon could be explained by a transfer from those who might be in the unskilledmanual group into the unknown group.PAGE 38

PAGE 39Table 2.1 Standardised perinatal mortalityratios (SPMRs) and perinatal deaths by county,Ireland 1986-1993Table 2.2 Standardised low birth weight ratios(SLBWRs) and number of low birth weightbirths, by county, Ireland 1986-1993PERINATAL MORTALITYThe figures show ranked age standarised perinatal mortalityratios (SPMR) and total numbers of perinatal deaths between1986 and 1993. National average SPMR is 100.LOW BIRTH WEIGHT (LBW)The figures show ranked age standarised ratio of LBW(SLBWR) and total numbers of low birth weight births in1991 and 1996. National average SMR is 100.Rank SPMR Deaths1 Galway 68 912 Leitrim 85 153 Limerick 89 1124 Cork 91 2735 Meath 95 806 Clare 96 647 Kildare 96 1028 Dublin 97 7529 Kilkenny 97 5310 Sligo 100 4011 Tipperary 100 9512 Waterford 100 6513 Mayo 102 8014 Donegal 104 10315 Louth 104 6916 Roscommon 104 3517 Monaghan 106 3918 Westmeath 108 5219 Laois 109 4220 Offaly 112 4821 Longford 115 2622 Cavan 118 4823 Carlow 125 4424 Wicklow 126 10225 Kerry 127 10426 Wexford 145 118Rank SLBWR No.1 Monaghan 78 1652 Donegal 83 4783 Mayo 83 3714 Kilkenny 89 2815 Meath 89 4336 Kildare 91 5637 Cavan 92 2178 Kerry 92 4379 Leitrim 93 9510 Carlow 94 19011 Longford 94 12212 Wicklow 94 44013 Roscommon 95 18314 Galway 96 74815 Laois 96 21316 Limerick 96 70117 Cork 98 170618 Sligo 98 22619 Westmeath 98 27320 Tipperary 100 55021 Waterford 100 37722 Clare 101 38723 Offaly 102 25124 Wexford 104 49125 Louth 109 41726 Dublin 112 5044Sig. Low Non Sig. Sig. HighSig. Low Non Sig. Sig. HighCOMMENT: Only one county, Galway, is significantlybelow the national average with three counties,Wicklow, Kerry and Wexford significantly above.COMMENT: Six counties; Monaghan, Donegal, Mayo,Kilkenny, Meath and Kildare are significantly belowthe national average in terms of standardised ratiosof low birth weight and one county, Dublin, issignificantly abovePAGE 39

PAGE 40Table 2.3 Age standardised incidence (ASI)of births to single teenagers aged 15-17by county, 1986-1993COMMENT: There is a marked geographic variationin the standardised ratio of single teenage births withthe counties of the western seaboard having much lowerincidence than the counties of the eastern half ofthe country.BIRTHS TO SINGLE TEENAGERS AGED 15-17The figures show ranked age standarised incidence (ASI) of birth ratesand total numbers of births among single girls aged 15, 16 and 17between 1986-1993 by county. National average ASI is 100.Rank ASI Births1 Leitrim 6 22 Roscommon 24 183 Mayo 43 724 Monaghan 50 375 Kerry 51 916 Galway 54 1467 Sligo 58 468 Clare 65 909 Kilkenny 66 7310 Cavan 69 5211 Cork 71 42012 Offaly 76 7213 Laois 77 5814 Tipperary 78 16015 Westmeath 82 8116 Longford 82 3617 Donegal 90 17318 Waterford 97 13319 Kildare 113 21420 Wicklow 114 16721 Louth 117 16222 Limerick 119 29623 Wexford 124 18624 Meath 130 21725 Dublin 146 203926 Carlow 153 92Sig. Low Non Sig. Sig. HighFigure 2.5Percentage of births to single teenagers aged 15-17 as a proportion of allbirths by year, 1986-19936Percentage single teenager births per year54321086 87 88 89 90 91 92 93YearCOMMENT: There was a gradual increase in the percentage of births to single teenagersbetween 1986 and 1991 in each of the years under investigation.PAGE 40

CHAPTER TWOSection 3 - Results from National PsychiatricInPatient Reporting System

PAGE 42NATIONAL PSYCHIATRIC INPATIENT REPORTING SYSTEMThis system records information on discharges for all in-patient psychiatric admissions in thecountry through all public hospitals and some private hospitals. It gathers information by principalpsychiatric diagnosis.Data from the National Psychiatric InPatient Reporting System in 1991 and 1996 were examined.All first admission data were analysed and this is used as a proxy for incidence of severe mentalillness. All acute admissions were examined and data are presented for four subsets of this;schizophrenia, depressive disorders, alcoholic disorders and personality disorder. In all psychiatricconditions there is an increasing socio-economic gradient in incidence from professional tounskilled manual. However, the gradient is not as steep as with mortality or perinatal events andindeed employers generally have the lowest SMRs for psychiatric illness. What is more marked inthe psychiatric database is that the proportion where the socio-economic status is unknown isgreater than with the other datasets and the SDRs for psychiatric conditions for socio-economicgroup ‘unknown’ are very high.In all psychiatric conditions there is an increasingsocio-economic gradient in incidence from professional tounskilled manual.PAGE 42

PAGE 43Figure 3.1Standardised discharge ratios and 95% confidence intervals for all 1stpsychiatric admissions (males 15-64 years) by socio-economic group, Ireland 1996Farmers (n=199)Other agricultural & fishermen (n=90)Higher professional (n=101)Lower professional (n=115)Employers & managers (n=105)Salaried employees (n=77)Intermediate non-manual (n=236)Other non-manual (n=287)Skilled manual (n=426)Semi-skilled manual (n=190)Unskilled manual (n=368)Unknown (n=1170)0 100 200 300 400 500 600Figure 3.2Standardised discharge ratios and 95% confidence intervals for all 1stpsychiatric admissions (males 15-64 years) for unskilled manual and professional(higher + lower) socio-economic groups, Ireland 1991 and1996Higher & LowerProfessionals300Unskilled manual20010001991 1996COMMENT: Discharge ratios for all psychiatric conditions among males are statistically below average forprofessional groups and above average for unskilled manual in 1996. The category with the greatest number in it isthe ‘unknown’ and the standardised discharge ratio for these is almost 500. The drop in the standardised ratio forthe unskilled manual between 1991 and 1996 could be explained by the increase in ‘unknowns’, together with thevery high standardised ratio for the unknowns.PAGE 43

PAGE 44Figure 3.3Standardised discharge ratios and 95% confidence intervals for schizophrenia1st admissions (males 15-64 years) by socio-economic group, Ireland 1996Farmers (n=28)Other agricultural & fishermen (n=20)Higher professional (n=8)Lower professional (n=13)Employers & managers (n=9)Salaried employees (n=7)Intermediate non-manual (n=33)Other non-manual (n=30)Skilled manual (n=51)Semi-skilled manual (n=27)Unsilled-manual (n=56)Unknown (n=224)0 100 200 300 400 500 600 700Figure 3.4Standardised discharge ratios and 95% confidence intervals for schizophrenia1st admissions (males 15-64 years) for unskilled manual and professional (higher+ lower) socio-economic groups, Ireland 1991 and1996Higher & LowerProfessionals300Unskilled manual20010001991 1996COMMENT: The professional groups are statistically below the average for schizophrenia and no group is above theaverage apart from the unknowns where the standardised rate is almost 600 i.e. 6 times higher than average. Almosthalf of all discharges had an unknown socio-economic category. The drop in the standardised ratio for the unskilledmanual between 1991 and 1996 could be explained by the increase in ‘unknowns’, together with the very highstandardised ratio for the unknowns.PAGE 44

PAGE 45Figure 3.5Standardised discharge ratios and 95% confidence intervals for depressive disorders1st admissions (males 15-64 years) by socio-economic group, Ireland 1996Farmers (n=56)Other agricultural & fishermen (n=16)Higher professional (n=26)Lower professional (n=29)Employers & managers (n=18)Salaried employees (n=19)Intermediate non-manual (n=42)Other non-manual (n=93)Skilled manual (n=88)Semi-skilled manual (n=39)Unskilled manual (n=53)Unknown (n=245)0 100 200 300 400 500 600Figure 3.6Standardised discharge ratios and 95% confidence intervals for depressivedisorders 1st admissions (males 15-64 years) for unskilled manual andprofessional (higher + lower) socio-economic groups, Ireland 1991 and 1996Higher & LowerProfessionals300Unskilled manual20010001991 1996COMMENT: The standardised discharge ratio for depressed males with unknown socio-economic categorisation wasover 500 in 1996. The drop in the standardised ratio for the unskilled manual between 1991 and 1996 could beexplained by the increase in ‘unknowns’, together with the very high standardised ratio for the unknowns.PAGE 45

PAGE 46Figure 3.7Standardised discharge ratios and 95% confidence intervals for alcoholic disorders1st admissions (males 15-64 years) by socio-economic group, Ireland 1996Farmers (n=56)Other agricultural & fishermen (n=32)Higher professional (n=33)Lower professional (n=41)Employers & managers (n=53)Salaried employees (n=23)Intermediate non-manual (n=96)Other non-manual (n=88)Skilled manual (n=161)Semi-skilled manual (n=62)Unskilled manual (n=159)Unknown (n=282)0 100 200 300 400 500Figure 3.8Standardised discharge ratios and 95% confidence intervals for alcoholicdisorders 1st admissions (males 15-64 years) for unskilled manual andprofessional (higher + lower) socio-economic groups, Ireland 1991 and1996Higher & LowerProfessionals300Unskilled manual20010001991 1996COMMENT: The unskilled manual group is the only socio-economic group with a discharge ratio significantlystatistically greater than 100 apart from the unknown category where it is over 400. The standardised ratio for theprofessional groups is almost unchanged between 1991 and 1996. The drop in the standardised ratio for theunskilled manual between 1991 and 1996 could be explained by the increase in ‘unknowns’, together with the veryhigh standardised ratio for the unknowns.PAGE 46

PAGE 47Figure 3.9Standardised discharge ratios and 95% confidence intervals for personality disorders1st admissions (males 15-64 years) by socio-economic group, Ireland 1996Farmers (n=8)Other agricultural & fishermen (n=4)Higher professional (n=6)Lower professional (n=4)Employers & managers (n=1)Salaried employees (n=6)Intermediate non-manual (n=10)Other non-manual (n=11)Skilled manual (n=26)Semi-skilled manual (n=11)Unskilled manual (n=16)Unknown (n=80)0 200 400 600Figure 3.10Standardised discharge ratios and 95% confidence intervals for personalitydisorders 1st admissions (males 15-64 years) for unskilled manual andprofessional (higher + lower) socio-economic groups, Ireland 1991 and1996Higher & LowerProfessionals300Unskilled manual20010001991 1996COMMENT: Numbers with a diagnosis of personality disorder are small. The highest discharge ratio is in theunknown category where it is just over 500. Almost 60% of all discharges for this diagnosis have ‘unknown’ socioeconomiccategorisation. The drop in the standardised ratio for the unskilled manual between 1991 and 1996 couldbe explained by the increase in ‘unknowns’, together with the very high standardised ratio for the unknowns.PAGE 47

PAGE 48Table 3.1Standardised discharge ratios (SDRs) and total discharges for all 1st psychiatricadmissions (male and female) by county, Ireland 1991 and 1996 combinedALL PSYCHIATRIC CONDITIONSThe figures show ranked age/sex Standarised standarised Discharge dischargeRatios ratios (SDR) for all 1st psychiatric admissions discharges (male andfemale) and total numbers of discharges in 1991 and 1996.National average SDR is 100.Rank SDR Discharges1 Mayo 46 1982 Monaghan 62 1213 Laois 70 1424 Kildare 76 3885 Offaly 80 1796 Meath 84 3487 Leitrim 85 848 Wexford 86 3439 Cork 87 143210 Kilkenny 87 25311 Sligo 92 20112 Wicklow 96 37713 Kerry 97 47714 Carlow 104 16515 Clare 104 37616 Donegal 106 52017 Limerick 106 68018 Louth 107 37919 Dublin 107 449720 Longford 108 12421 Waterford 110 40322 Galway 119 87023 Cavan 119 24224 Westmeath 120 29025 Roscommon 134 27126 Tipperary 142 733Sig. Low Non Sig. Sig. HighCOMMENT: There is no discernible geographic pattern for discharges for all psychiatric conditions. The county withthe highest discharge ratio is Tipperary and the county with the lowest is Mayo.PAGE 48

PAGE 49Table 3.2 Standardised discharge ratios(SDRs) and total discharges for all 1stadmissions for schizophrenia (male and female)by county, Ireland 1991 and 1996 combinedTable 3.3 Standardised discharge ratios(SDRs) and total discharges for all 1stadmissions for depressive disorders (male andfemale) by county, Ireland 1991 and 1996 combinedALL SCHIZOPHRENIAPSYCHIATRIC CONDITIONSThe figures show ranked age/sex Standarised standarised Discharge dischargeRatios ratios (SDR) of for patients all 1st with psychiatric schizophrenia discharges (male and (male female) andfemale) and total and numbers total numbers of discharges of discharges in 1991 and in 1991 1996. and National 1996.National average SDR average is 100. SDR is 100.Rank SDR Discharges1 Mayo 31 182 Laois 46 133 Carlow 62 144 Offaly 63 205 Louth 64 326 Wicklow 72 407 Cork 76 1788 Meath 79 469 Westmeath 79 2710 Monaghan 81 2211 Donegal 82 5612 Wexford 84 4713 Waterford 88 4614 Kildare 98 7215 Kilkenny 99 4016 Roscommon 102 2817 Kerry 104 7118 Galway 107 11119 Limerick 108 9920 Dublin 118 72021 Tipperary 118 8522 Longford 126 2023 Clare 131 6624 Sligo 172 5225 Cavan 179 5026 Leitrim 195 26ALL DEPRESSION PSYCHIATRIC CONDITIONSThe figures show ranked age/sex Standarised standarised Discharge dischargeRatios ratios (SDR) of for patients all 1st with psychiatric depression discharges (male and (male female) andfemale) and total and numbers total numbers of discharges of discharges in 1991 and in 1991 1996. and National 1996.National average SDR average is 100. SDR is 100.Rank SDR Discharges1 Leitrim 47 142 Mayo 51 663 Laois 69 414 Monaghan 75 435 Kildare 78 1146 Kilkenny 79 677 Wexford 84 998 Kerry 86 1259 Donegal 86 12610 Clare 87 9211 Offaly 91 6012 Sligo 91 5913 Meath 95 11414 Dublin 96 117815 Wicklow 97 11216 Longford 100 3417 Cavan 104 6218 Limerick 109 20319 Louth 109 11320 Carlow 110 5121 Westmeath 111 7922 Galway 113 24323 Waterford 115 12424 Cork 116 55925 Roscommon 147 8926 Tipperary 175 265Sig. Low Non Sig. Sig. HighSig. Low Non Sig. Sig. HighCOMMENT: Only four counties have a standardiseddischarge ratio statistically greater than average; Leitrim,Cavan, Sligo and Dublin. Counties with a dischargeratio statistically less than average are Mayo, Laois,Carlow, Offaly, Louth, Wicklow and Cork.COMMENT: There is no discernible county pattern. Thetwo counties with the lowest discharge ratios are Mayoand Leitrim and two with the highest ratios are Tipperaryand Roscommon.PAGE 49

PAGE 50Table 3.4 Standardised discharge ratios (SDRs)and total discharges for all 1st admissions foralcoholic disorders (male and female) by county,Ireland 1991 and 1996 combinedTable 3.5 Standardised discharge ratios (SDRs)and total discharges for all 1st admissions forpersonality disorders (male and female) bycounty, Ireland 1991 and 1996 combinedALL ALCHOLIC PSYCHIATRIC DISORDERS CONDITIONSThe figures show ranked age/sex Standarised standarised Discharge dischargeRatios ratios (SDR) of for patients all 1st with psychiatric alcoholic discharges disorders (male andfemale) and total numbers of discharges in 1991 and 1996.National average SDR is 100.Rank SDR Discharges1 Monaghan 48 242 Mayo 51 553 Kildare 68 934 Laois 68 365 Cork 69 2916 Meath 82 907 Cavan 84 448 Clare 89 849 Offaly 90 5210 Wexford 92 9511 Limerick 94 15512 Dublin 97 103213 Wicklow 98 10114 Sligo 98 5415 Kilkenny 103 7816 Waterford 111 10517 Kerry 112 14218 Carlow 114 4719 Louth 115 10520 Leitrim 119 3021 Longford 141 4222 Galway 144 26723 Tipperary 149 19824 Roscommon 158 8225 Westmeath 163 10126 Donegal 174 216ALL PERSONALITY PSYCHIATRIC DISORDERS CONDITIONSThe figures show ranked age/sex Standarised standarised Discharge dischargeRatios ratios (SDR) of for patients all 1st with psychiatric personality discharges disorders (male andfemale) and total numbers of discharges in 1991 and 1996.National average SDR is 100.Rank SDR Discharges1 Sligo 19 32 Leitrim 28 23 Laois 29 44 Mayo 31 105 Offaly 33 56 Cork 35 417 Clare 35 98 Donegal 37 149 Meath 46 1310 Monaghan 49 711 Kerry 51 1812 Kildare 59 2013 Kilkenny 60 1214 Roscommon 60 915 Cavan 70 1016 Wexford 74 2117 Waterford 80 2118 Limerick 80 3719 Carlow 82 920 Wicklow 89 2521 Dublin 89 26622 Galway 92 4923 Tipperary 100 3724 Westmeath 107 1825 Longford 109 926 Louth 135 33Sig. Low Non Sig. Sig. HighSig. Low Non Sig. Sig. HighCOMMENT: Monaghan has the lowest ratio andDonegal has the highest.COMMENT: The numbers of discharges with personalitydisorder for most counties is quite small. The lowestratio is in Sligo and the highest is in LouthPAGE 50

CHAPTER TWOSection 4 - Results from Hospital In-Patient Enquiry

PAGE 52HOSPITAL IN-PATIENT ENQUIRY (HIPE)The Hospital In-patient Enquiry scheme records details on deaths and discharges for all the acutepublic hospitals in the country. Information is collected on principal diagnoses and principalprocedures performed. It is the largest volume morbidity database in Ireland but it does not collectinformation on socio-economic group.The interpretation of the HIPE data is more difficult than the interpretation of the mortality,perinatal or psychiatric data because it is more difficult to use HIPE as a proxy for incidence ofillness. It is also more difficult to use HIPE for commenting on inequalities because socioeconomicgroup is not collected in HIPE. GMS status is collected but we decided that, as entrycriteria are discretionary where a person has an illness, interpretation would be compromised.The unit of analysis which we have chosen is the county and five tables are presented showingdischarge and procedure data for ischaemic heart disease and discharge data for neoplasmsand injuries and poisonings.Of all the databases we examined, HIPE is the most difficultto interpret and it contributes least to the demonstration ofinequalities. Private hospitals do not contribute to HIPE data.PAGE 52

PAGE 53Table 4.1 Standardised discharge ratios forischaemic heart disease (ICD codes 410-414) by county, Ireland 1997.ALL ISCHAEMIC PSYCHIATRIC HEART CONDITIONSDISEASEThe figures show ranked age/sex age/sex Standarised standarised Discharge dischargeratios (SDR) and total numbers of cases for Ischaemic HeartRatios (SDR) for all 1st psychiatric discharges (male andDisease (ICD 410 - 414) in 1997 by county. National averagefemale)SDR is 100.and total numbers of discharges in 1991 and 1996.National average SDR is 100.Rank SDR Discharges1 Kerry 55 7142 Mayo 73 8863 Wicklow 74 6174 Kilkenny 79 5515 Galway 80 13836 Leitrim 82 2507 Tipperary 84 10818 Clare 86 7579 Carlow 91 32210 Donegal 92 115511 Roscommon 93 55212 Waterford 102 86513 Dublin 102 837414 Cavan 103 57115 Cork 107 395316 Wexford 107 100117 Laois 109 52518 Longford 113 34219 Meath 114 98320 Kildare 118 100821 Offaly 120 63322 Sligo 125 70523 Limerick 127 177424 Westmeath 132 73625 Monaghan 138 65426 Louth 143 1095Sig. Low Non Sig. Sig. HighTable 4.2 Standardised discharge ratios forneoplasms (ICD codes 140-239) by county,Ireland 1997.NEOPLASMSThe figures show ranked age/sex standarised dischargeratios (SDR) and total numbers of neoplasms (ICD 140-239)in 1997 by county. National average SDR is 100.Rank SDR Discharges1 Clare 73 16962 Roscommon 83 12023 Leitrim 85 6044 Monaghan 85 10715 Meath 86 21446 Mayo 88 26427 Waterford 88 20268 Kerry 89 29089 Limerick 91 353510 Kilkenny 92 170511 Sligo 92 132812 Kildare 92 256613 Wicklow 92 219514 Cavan 94 129615 Dublin 96 2322016 Tipperary 98 326417 Wexford 101 252718 Galway 102 468019 Louth 105 225820 Offaly 106 150821 Longford 107 82522 Laois 109 140423 Carlow 111 108624 Westmeath 115 174325 Donegal 122 395126 Cork 130 13140Sig. Low Non Sig. Sig. HighCOMMENT: The county with the lowest discharge ratiofor Ischaemic Heart Disease is Kerry. The ratio issignificantly below the national average. The higheststandardised discharge ratio in the country is in Louth.COMMENT: The highest ratio in the country fordischarge for neoplasms is Cork and the lowest isClare. Because of the large numbers, the ratios arestatistically significant in all except four counties.Table 4.3 Standardised discharge ratios for injuries and poisonings (ICD codes 800-999) bycounty, Ireland 1997.ALL INJURIES PSYCHIATRIC AND POISONINGS CONDITIONSThe figures figures show show ranked ranked age/sex age/sex standarised Standarised discharge Discharge ratios(SDR) and total numbers of cases of injuries and poisoningsRatios (SDR) for all 1st psychiatric discharges (male and(ICD 800+) in 1997 by county. National average SDR is 100.female) and total numbers of discharges in 1991 and 1996.Rank National average SDR is 100. SDR Discharges1 Kerry 79 20302 Donegal 84 22523 Clare 85 16204 Limerick 87 28715 Dublin 88 180606 Laois 91 9757 Cork 92 76778 Meath 94 20339 Kildare 98 254010 Roscommon 98 107011 Wicklow 104 210612 Galway 108 410113 Leitrim 111 590ALL INJURIES PSYCHIATRIC AND POISONINGS CONDITIONS contd.The figures show ranked age/sex Standarised DischargeRank SDR DischargesRatios (SDR) for all 1st psychiatric discharges (male and14 Sligo 111 1266female) and total numbers of discharges in 1991 and 1996.15National averageWaterfordSDR is 100.112 211216 Tipperary 113 304917 Mayo 116 270318 Cavan 117 128119 Offaly 120 142220 Kilkenny 121 183221 Carlow 123 102122 Wexford 126 262623 Louth 131 238424 Longford 144 89525 Monaghan 152 158326 Westmeath 162 2048Sig. Low Non Sig. Sig. HighCOMMENT: The lowest discharge ratio for injuries and poisonings is in Kerry and the highest is in Westmeath.PAGE 53

PAGE 54Table 4.4 Standardised discharge ratios forcoronary artery bypass graft by county,Ireland 1997Table 4.5 Standardised discharge ratios forangioplasty by county, Ireland 1997ALL CORONARY PSYCHIATRIC ARTERY CONDITIONSBYPASS GRAFTThe figures show ranked age/sex Standarised standarised Discharge dischargeRatios ratios (SDR) and for total all 1st numbers psychiatric of cases discharges of Coronary (male Artery andfemale) Bypass Grafts and total (CABG) numbers (ICD of 9 discharges CM 36.1 - in 36.19) 1991 in and 1997 1996. byNational county. National average average SDR is SDR 100. is 100.Rank SDR Discharges1 Kilkenny 38 92 Mayo 49 193 Laois 55 94 Carlow 56 75 Leitrim 61 66 Clare 61 187 Meath 63 198 Kerry 66 289 Offaly 66 1210 Donegal 68 2811 Kildare 68 2112 Westmeath 73 1413 Wexford 74 2414 Waterford 75 2215 Galway 77 4416 Wicklow 80 2317 Monaghan 82 1318 Roscommon 83 1619 Sligo 92 1720 Limerick 101 4921 Tipperary 105 4622 Cavan 114 2123 Louth 120 3224 Dublin 120 34525 Longford 149 1526 Cork 173 219ALL ANGIOPLASTY PSYCHIATRIC CONDITIONSThe figures show ranked age/sex Standarised standarised Discharge dischargeRatios ratios (SDR) and for total all 1st numbers psychiatric of cases discharges of Angioplasty (male(ICDandfemale) 9 CM 36.00 and total - 36.09) numbers in 1997 of discharges by county. in National 1991 and average 1996.National SDR is 100. average SDR is 100.Rank SDR Discharges1 Mayo 11 52 Kerry 22 113 Galway 25 174 Clare 29 105 Roscommon 50 116 Limerick 56 327 Carlow 62 98 Laois 63 129 Cork 70 10410 Kilkenny 72 2011 Donegal 73 3512 Monaghan 76 1413 Leitrim 81 914 Tipperary 83 4215 Wicklow 89 3116 Sligo 107 3717 Louth 107 3418 Waterford 107 2319 Cavan 109 2320 Kildare 110 4221 Wexford 110 4222 Longford 137 1623 Offaly 146 3124 Meath 147 5325 Westmeath 165 3726 Dublin 165 572Sig. Low Non Sig. Sig. HighSig. Low Non Sig. Sig. HighCOMMENT: The wide range in the standardisedincidence ratios for coronary artery bypass graftscould be a reflection of service provision rather thandegree of need. In particular the two major urbancentres in the country, Cork and Dublin are in the topthree in terms of coronary artery bypass graftscarried out.COMMENT: The county with the highest ratio isDublin which may reflect access to provision. The sixcounties with the lowest ratios are all in the westernhalf of the country.PAGE 54

CHAPTER TWOSection 5 - Results from The National Drug TreatmentReporting System

PAGE 56THE NATIONAL DRUG TREATMENT REPORTING SYSTEM (NDTRS)The NDTRS is an epidemiological database providing information on treated drug misuse in theRepublic of Ireland. Drug misuse which occurs outside the treatment context is not included. Thedatabase is maintained by the Drug Misuse Research Division of the Health Research Board.Reporting began in 1990 and for the first five years covered treated drug misuse in Dublin only. In1995 the Reporting System was expanded to cover the entire country. Drug misuse in the NDTRSis defined as the taking of an illegal and/or legal drug or drugs (excluding alcohol other than as asecondary drug of misuse and tobacco) which harms the physical, mental or social well-being ofthe individual, the group or society.The NDTRS is a smaller database than the other four analysed in this report and the units ofanalysis are educational achievement and district electoral division of residence. For this report,first treatment contacts for opiates have been analysed.PAGE 56

PAGE 57Figure 5.1Trends in measures of education and employment for first time treatmentcontacts (opiates) 1990-1996, Dublin only10075%502501990 1991 1992 1993 1994 1995 1996YearEarly school leaver Received secondary education UnemployedCOMMENT: There was an increase in educational attainment but a decrease in employment ratePAGE 57

PAGE 58Figure 5.2Plot of the relationship between a DED’s deprivation level and the meanstandardised first treatment contact ratio (SFTCR) value, with 95% confidenceintervals, for opiate misuse 15-34 year olds in the greater Dublin area, 1995-1996400300SFCTR20010001 2 3 4 5LowDeprivation levelHighCOMMENT: There is a very steep gradient of the probability of entering treatment for drug misuse as onemoves from a district electoral division with a low deprivation level to one with a high deprivation level. Areadeprivation was measured using the Small Area Health Research Unit deprivation index, which is an index ofmaterial deprivation. It is scaled from 1 to 5 where 5 is the highest level of deprivation.PAGE 58

PAGE 59Figure 5.3Map of greater Dublin area district electoral divisions (DEDs) with both significantlyhigh standardised first treatment contact ratios (SFTCR) and high deprivationCOMMENT: Fifty one District Electoral Divisions have both high first treatment contact ratios and high deprivation.PAGE 59

CHAPTER TWOSection 6 - Unknowns - Results from National MortalityDataset, Perinatal Reporting System & NationalPsychiatric InPatient Reporting System

PAGE 62‘UNKNOWNS’In the previous sections we have highlighted where possible differences in health between well-offand poor people, mainly by comparing men aged 15-64 in the professional socio-economic groupwith men of the same age in the unskilled manual group. A number of patterns emerge. In alldatasets for all the years those in the unskilled manual category have worse health status thanthose in the professional category. There has been an increase in the proportion of people who arein the ‘unknown’ category as time has gone on, in each of the three datasets where this informationis recorded. The ‘unknown’ category is also the category with the worst health index in nearly allanalyses. What we present in this chapter is a summary of the disease ratios for the ‘unknown’category together with a demonstration of the increased proportion of the unknowns in the lateryears of the analyses and some categorisation of the unknowns from the three datasets.The ‘unknowns’ are growing, they have the worst healthof all and single males in Dublin are over-represented in thiscategory.PAGE 62

PAGE 63Table 6.1Assorted standardised ratios for ‘unknown’ category, National Mortality Dataset(1996), Perinatal Reporting System (1993) and National Psychiatric InPatientReporting System (1996)NATIONAL MORTALITY DATASET (1996)Compared with average forthe country of 100SMR all causes277SMR ischaemic heart disease233SMR neoplasms186SMR injuries & poisonings340PERINATAL REPORTING SYSTEM (1993)Standardised perinatal mortality ratio122Standardised low birth weight ratio156NATIONAL PSYCHIATRIC INPATIENT REPORTINGSYSTEM (1996)SDR all 1st admissions (males)480SDR schizophrenia (males)589SDR depressive disorders (males)513SDR alcoholic disorders (males)408SDR personality disorder (males)520PAGE 63

PAGE 64Figure 6.1Percentages of persons with unknown socio-economic group , National MortalityData (males 15-64) 1981 and 1996, Perinatal Reporting System (females) 1986 and1993, National Psychiatric InPatient Reporting System (males 15-64) 1991 and 199619961996198119931991198614% 24%9%29% 16% 35%Mortality Perinatal PsychiatricCOMMENT: There is a considerable increase in the percentage of persons with unknown socio-economic group ineach database as time has gone on.PAGE 64

PAGE 6550Figure 6.2Percentage of male deaths (15-64 years) in the ‘unknown’ socio-economic groupcompared to all other socio-economic groups by county, Ireland 1996(National Mortality Dataset)40%3020100DublinCorkGalwayLimerickKerryMayoKildareDonegalWexfordMeathWaterfordClareLouthWicklowTipperary SRSligoOffalyWestmeathKilkennyTipperary NRCarlowCavanLaoisRoscommonMonaghanLongfordLeitrimAll other SEG groupsUnknown SEG groupCOMMENT: Almost half of all deaths in the unknown socio-economic group occurred in Dublin in 1996.Figure 6.3Marital status within the ‘unknown’ socio-economic group compared to all othersocio-economic groups (National Mortality Dataset)Single3%4%MarriedOther36%35%61%60%Unknown SEG GroupAll other SEG groupsCOMMENT: The majority of deaths in the unknown socio-economic group were single whereas for all other socioeconomicgroups the majority were married.PAGE 65

PAGE 66Figure 6.4Percentage of women in the ‘unknown’ socio-economic group compared to allother socio-economic groups by age, Ireland 1986-1993 (Perinatal Reporting System)5040%302010015-19All SEGs20-24 25-29 30-34 35-39 40-44 45-49Unknown SEGCOMMENT: The women in the ‘unknown’ SEG were more likely to be in the younger age groups.Figure 6.5Percentage of women in the ‘unknown’ socio-economic group compared to all othersocio-economic groups by county, Ireland 1986-1993 (Perinatal Reporting System)5040%3020100DublinCorkGalwayLimerickKildareDonegalTipperaryKerryMayoMeathWexfordWicklowClareLouthWaterfordKilkennyWestmeathOffalyCavanSligoLaoisMonaghanRoscommonCarlowLongfordLeitrimAll SEGsUnknown SEGCOMMENT: Almost half of all women in the unknown socio-economic group were resident in Dublin.PAGE 66

PAGE 67Figure 6.6Percentage of males (15-64 years) in the ‘unknown’ socio-economic groupcompared to all other socio-economic groups by age, Ireland 1996 (NationalPsychiatric InPatient Reporting System)All other SEGs201996Unknown SEG15%105015-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64COMMENT: The men in the ‘unknown’ SEG were more likely to be in the younger age groups.Figure 6.7All others SEGsUnknown SEGPercentage of males (15-64 years) in the ‘unknown’ socio-economic groupcompared to all other socio-economic groups by county, Ireland 1996 (NationalPsychiatric InPatient Reporting System)45403530%2520151050DublinCorkTipperaryGalwayDonegalLimerickKerryLouthClareWestmeathMeathWexfordMayoOffalyKilkennyCarlowKildareWicklowLongfordLaoisSligoWaterfordRoscommonCavanMonaghanLeitrimCOMMENT: Almost half of all males in the unknown socio-economic group were resident in Dublin. Over two thirdsof all persons in the unknown socio-economic group were single, whereas for other socio-economic groups it wasjust over one half.Figure 6.8Marital status within the ‘unknown’ socio-economic group compared to all other socioeconomicgroups, Ireland 1996 (National Psychiatric InPatient Reporting System)SingleMarried19%Other55%34%11%70%11%PAGE 67All other SEG groupsUnknown SEG Group

CHAPTER THREE

PAGE 70REPORTS GATHERING DUSTWe are conscious that in the past there have been examples of papers, reports and documentshighlighting inequalities in health and healthcare uptake in Ireland which have not been followed upby action to lessen these inequalities. Apart from the National Health Strategy in 1994 and theChief Medical Officer’s report of 1999, Nolan and colleagues in 1994 found higher rates ofperinatal mortality in infants born to mothers from poorer socio-economic groups. 14 O’Shea in 1997when examining male mortality found an excess of deaths in unskilled manual workers. 15 O’Sheaconcluded his paper by commenting on the size of the ‘unknown’ category. He had found adeterioration in the quality of the measurement of that data between 1991 and 1996. He called forthe reasons for this to be explored. We have found a pattern where the proportion of unknowns ineach dataset is increasing with passing years, for all datasets examined. While it is not possible toshow national socio-economic differentials in infant mortality, Ryan and colleagues in the SouthernHealth Board used Cork city as a proxy for deprived areas, based on SAHRU deprivation indexscores, and found higher infant mortality in deprived areas of the Southern Health Board. 16Limitations of our workWe have confined our analysis in this report to inequalities by economic group (as denoted byoccupational status) and by geographic location. The capacity of this approach to identifyinequalities is limited by the data collected.Socio-economic categories used in datasets in Ireland:• Farmers• Other agriculatural workers and fishermen• Higher professional• Lower professional• Employers and managers• Salaried employees• Intermediate non-manual• Other non-manual• Skilled manual• Semi-skilled manual• Unskilled manual• UnknownBecause our analysis is wholly quantitative we have not been able to explore the nuances whichmight explain some of the differences; these can best be determined by qualitative methods.You are better off to be better offThere is a consistency across datasets examined in this report in terms of the picture of socioeconomicdifferentials in health in Ireland. As a general rule persons with higher paid occupations,such as professional groups and employers, tend to have lower standardised ratios for all causes.They also have lower ratios than persons whose socio-economic group is lower income, such asmanual workers or unskilled manual workers. This differential has existed over the past fifteen years.PAGE 70

PAGE 71Unknowns - unclassifiable?There is one major caveat that needs to be entered when describing a possible narrowing of thegap in inequalities in health. The proportion of persons where the socio-economic group could notbe determined has increased dramatically from the 1980s to the mid-1990s. The standardisedratios in every dataset we have examined are considerably higher in the ‘unknown’ group than inany of the economic groups that have been classifiable, even ‘unskilled manual’. In-depth analysisof the category ‘unknown’ is required as a matter of urgency to determine whether or not there isa genuine narrowing of the gap between rich and poor in Ireland. The determination of what exactlythis unknown group stands for is probably the most critically important finding to be examinedfurther as a matter of urgency. It could be that it reflects just a lessening of standards in datacollection and coding or that there is a genuine increase in persons with very poor health for whomthe socio-economic group cannot be described. Equally, it could be a combination of these twofactors, but without further detailed examination this cannot be determined.The socially excluded - very unhealthyMuch public comment is being made on the concept of social exclusion. Addressing socialexclusion is one of the main challenges for the health services and for the wider social partners.People who are socially excluded are not easily catered for in the partnership model that hasevolved in Ireland in the last decade. There is a worrying and unnecessary trend in our data ofbeing unable to categorise people by socio-economic group. At the same time people who are noteasy to classify socio-economically have demonstrably poorer health and health care uptake thanthe majority of the population. This very unhealthy subset of the population could well be theproportion of the population who are being left behind by economic development and who arereferred to in literature in other countries as an underclass. Our current routine health informationsystems are not adequately describing this subset of the population beyond saying that they arevery unhealthy. Major adjustment to current routine data collection methods are required to addressthis problem.People who are socially excluded are not easily catered forin the partnership model that has evolved in Ireland in thelast decade.Females - still dependentBasing inferences on the health of different socio-economic groups in the country on the basis ofoccupational status alone means that it is difficult to quantify socio-economic differentials in thehealth status of females of whatever age. A move from a socio-economic to a social class systemof recording would mean a female’s social class in its own right could be used to show differencesin health across different social groups. The social class scale is also an ordinal scale and commenton the relative health of different sectors of the population by social class could be made if socialclass was the category analysed rather than socio-economic group.PAGE 71

PAGE 72NATIONAL HEALTH INFORMATION STRATEGY - end of unhealthy data?Our findings should inform discussions on the drafting of the National Health InformationStrategy. They are also complementary to the findings of the recently published all-Irelandmortality report from the Institute of Public Health in Ireland, which found large social gradientsin mortality between the poorest and the richest in Ireland, North and South. 17 The measurementand the elimination of inequalities in health are stated as policy objectives by the Department ofHealth and Children and were specifically highlighted in the report of the Chief Medical Officer.While much data are collected in the Irish health services, drawing of inferences on inequalitiesis not straightforward, primarily because of weaknesses in data collection systems. Routine datasources need to be adapted so that inequalities in health can be measured by analysis of thesedata sources.In some situations it may be that routine data sources are notthe ideal method of measuring inequalities in health and thatone-off epidemiological studies, from time to time, mayprovide more appropriate information.We welcome comment from any sector on our findings and interpretations. Health informationsystems will only become more accurate and useful if used and if analysis of them is published. Inparticular we would welcome comment from people who generate data in the first place, i.e.clinicians, and from data managers, data coders and those responsible for data input.We plan to put this report on our website in the next couple of months. We hope this will allowgreater access to the findings for a wider national and international audience.Website address: www.tcd.ie/Community_Health/PAGE 72

CHAPTER FOUR

PAGE 74RECOMMENDATIONS• Annual reports on datasets should be available no later than two years after the end of theyear in question.• There should be a move from socio-economic group to social class for the socialcategorisation of health related data.• Data on social class of females should be collected in such a way that it can be analysed.• Data on private healthcare usage should be incorporated into any national healthinformation system.• As a matter of urgency an investigation should be carried out to determine whetherthe ‘unknowns’ phenomenon is as a result of poor data quality or represents realdeterioration in health in socially excluded people.• The quality control of data should be a priority.• HIPE should collect data on social status.• An annual report from the HIPE dataset should be published.• We recommend that improvements to all routine datasets should be a priority for theforthcoming National Health Strategy and National Health Information Strategy.PAGE 74

PAGE 75REFERENCES1. Garcia P, McCarthy M. Measuring Health: a step in the development of city health profiles.Copenhagen: World Health Organisation Regional Office for Europe, 1998.2. Department of Health. Shaping a Healthier Future. Dublin: The Stationery Office, 1984.3. OECD Health Data 2000.4. Department of Health & Social Services. Report on Inequalities in Health ('The Black Report').London: HMSO, 1980. (OUT OF PRINT)5. Townsend P, Davidson N, Whitehead M, editors. Inequalities in Health: The Black Report andthe Health Divide. Harmondsworth, Penguin Books,1988.6. Davey Smith G, Bartley M, Blane D. The Black report on socio-economic inequalities in health10 years on. British Medical Journal 1990; 301:373-377.7. Wilkinson RG. Socio-economic determinants of health: Health inequalities - relative or absolutematerial standards? British Medical Journal 1997; 314: 591-595.8. Department of Health & Social Services. Independent inquiry into inequalities in health ('TheAcheson Report'). London: HMSO, 1998.9. Mackenbach JP, Stronks K, Kunst AE. The contribution of medical care to inequalities in health:differences between socio-economic groups in decline of mortality from conditions amenableto medical intervention. Social Science and Medicine 1989; 29(3): 369-376.10.Mackenbach JP. Socioeconomic inequalities in health in the Netherlands: impact of a five yearresearch programme. British Medical Journal 1994; 309:1487-1491.11.Department of Health and Children. Annual Report of the Chief Medical Officer 1999.Dublin: Department of Health and Children, 1999.12.Department of the Taoiseach. Programme for Prosperity and Fairness. Dublin: The StationeryOffice, 2000.13.The Health Research Board. Making Knowledge Work for Health. Dublin: The Health ResearchBoard, 2000.14.Nolan B. Perinatal Mortality and Low Birthweight by Socio-economic Background: evidencefor Ireland. Economic and Social Review 1994; 25: 321-341.15.O’Shea E. Male mortality differentials by socio-economic group in Ireland. Social Science andMedicine 1997; 45(6): 803-809.16.Ryan CA, Ryan F, Keane E, Hegarty H. Trend analysis and socio-economic differentials in infantmortality in the Southern Health Board, Ireland (1988-1997). Irish Medical Journal 2000; 93: 204-206.17.Balanda K, Wilde J. Inequalities in Mortality 1989-1998 - a report on all-Ireland mortality data.Dublin: The Institute of Public Health in Ireland, 2001.PAGE 75

APPENDIX A

PAGE 78TECHNICAL ANNEXThe basis of this report was to use routine data sources to determine the extent of inequalities andinequities in Irish health and healthcare. As each dataset is constructed differently, the methodemployed to analyse the data varies accordingly.National Mortality DatasetFor reasons given in Chapter 2 (Section 1), only data on males aged 15-64 were analysed. Trendsover four time periods were used for the socio-economic categorisation. For the geographiccategorisation three years’ pooled data were used. In this section we used the three most recentyears available.For the Census years 1981, 1986, 1991, and 1996 deaths by age, sex, region, socio-economicgroup (SEG) and cause of death were extracted from anonymised computer files obtained fromthe Central Statistics Office. The analysis was confined to men aged 15 to 64 years. Women wereexcluded because over 40% of deaths had an 'unknown' socio-economic group. Age standardisedmortality ratios (SMRs) were calculated. This is a summary measure which standardises fordiffering age composition by calculating what the expected number of deaths for a particular SEGwould be if the actual population in that SEG in each age range experienced the average deathrate over all the SEGs for that age range. The actual total of deaths for that SEG is then expressedas a percentage of the expected deaths. A SMR of over 100 means that a SEG has had more moredeaths than would be expected and vice versa.Perinatal Reporting SystemThe Perinatal Reporting System has long been used for planning maternal and infant healthcareservices and it is regrettable that no data have been published from it since 1993. For this report,eight consecutive years’ data were obtained (1986-1993). The outcome indicators chosen werelow birth weight and perinatal mortality. For some analyses the last four years were pooled and forsome others data from each year has been presented.In addition to the 12 main socio-economic groups described earlier in this report the perinatalreporting system has an additional two categories, ‘unemployed’ and ‘missing’. The fact that thebaby’s father’s socio-economic group is used to categorise the mother causes further complicationsas this is often not reflective of the mother’s socio-economic group and is often left unspecified.National Psychiatric InPatient Reporting SystemThere were changes in how data for this system were collected between the late 1980s and theearly 1990s and accordingly it was decided to confine the analysis to the data from the 1990s. Ithad been intended to use a third year’s data from the middle 90s but completeness of socioeconomicgroup data was not sufficient to enable analysis to be carried out. Therefore data fromtwo years only, 1991 and 1996, were used. We have taken first admissions as a proxy forincidences of acute psychiatric illness but varying admission criteria in different parts of the countrycould affect the validity of this approach. Repeat admissions, which accounted for 72% of thedischarges in 1991 and 1996, were excluded.PAGE 78

PAGE 79Diagnosis is recorded at both admission and discharge. There was very little difference betweenthe two recordings and as discharge diagnosis is considered to be more reflective of the truecondition, this was used for the analysis. Nine specific conditions are documented with a furthertwo categories of ‘other psychosis’ and ‘unspecified’. Four conditions were chosen for moredetailed analysis which together made up over 75% of all first admissions. These were; alcoholicdisorders, depressive disorders, schizophrenia and personality disorder.HIPEThis very large volume dataset of hospital activity is not as useful for demonstrating inequalities asno socio-economic data are collected. The possibility of using the presence or absence of a medicalcard, which is recorded in the dataset, as a proxy for lower socio-economic groups was considered.However it was thought that this would not adequately reflect socio-economic group differences,particularly as private healthcare was not generally covered by HIPE during the years analysed.Although data were obtained for three years, 1993, 1995 and 1997, only data from the most recentyear, 1997 are presented as this is sufficient to give an indication of the variability by county.Data are presented for the discharge rates of three of the main causes of hospitalisation in Ireland;ischaemic heart disease, neoplasms and accidents and poisonings. In addition, incidence of twocardiac procedures are presented; coronary artery bypass graft and angioplasty, as these werefound to vary significantly by county and other data in relation to ischaemic heart disease arepresented in the report.National Drug Treatment Reporting SystemThe National Drug Treatment Reporting System (NDTRS) is an epidemiological database providinginformation on treated drug misuse in the Republic of Ireland. Drug misuse which occurs outsidethe treatment context is not included. The database is maintained by the Drug Misuse ResearchDivision of the Health Research Board. Reporting began in 1990 and for the first five years coveredtreated drug misuse in Dublin only. In 1995 the Reporting System was expanded to cover the entirecountry. Drug misuse in the NDTRS is defined as the taking of an illegal and/or legal drug or drugs(excluding alcohol other than as a secondary drug of misuse and tobacco) which harms thephysical, mental or social well-being of the individual, the group or society. Drug treatment for thepurposes of the NDTRS is any activity which is targeted directly at people who have a problem withtheir drug use and which aims to ameliorate the psychological, medical or social state of individualswho seek help for their drug problems. For the time in question, needle exchange was notclassified as treatment.The present analysis concentrates on first treatment contacts for opiate misuse in the GreaterDublin Area for the years 1995 and 1996. A first treatment contact (FTC) is defined as a personwho receives treatment for the first time ever and who is not being treated anywhere else for theirproblem drug use. The term 'opiate' refers to opiates and opioids, both natural and synthetic. TheGreater Dublin Area was chosen because FTC addresses are coded by District Electoral Division(DED) only for this area in the NDTRS.PAGE 79

APPENDIX B

PAGE 82DATA INPUT FORMS1. PERINATAL REPORTING SYSTEM2. NATIONAL PSYCHIATRIC INPATIENT REPORTING SYSTEM3. HOSPITAL IN-PATIENT ENQUIRY (HIPE)4. NATIONAL DRUG TREATMENT REPORTING SYSTEMPAGE 82

PAGE 831. PERINATAL REPORTING SYSTEMPAGE 83

PAGE 842. NATIONAL PSYCHIATRIC INPATIENT REPORTING SYSTEMPAGE 84

PAGE 853. HOSPITAL IN-PATIENT ENQUIRY (HIPE)PAGE 85

PAGE 864. NATIONAL DRUG TREATMENT REPORTING SYSTEM(N.B. An anonymised copy of this form is submitted to the Health Research Boardpersonnel for data input)PAGE 86