Avoidable Mortality Rates Decrease but Inequity Gaps Widen for Marginalized Neighborhoods: A Population-Based Analysis in Ontario, Canada from 1993 to 2014

  • Austin ZygmuntEmail author
  • Claire E. Kendall
  • Paul James
  • Isac Lima
  • Meltem Tuna
  • Peter Tanuseputro
Original Paper


Avoidable mortality (AM) is a health indicator used to examine trends in avoidable deaths amenable to public health and medical interventions. AM is more likely amongst marginalized populations. Our objective was to examine trends in AM rates by level of neighborhood marginalization. Decedents under age 75 years in Ontario from 1993 to 2014 (n = 691,453) were assigned to a quintile-level of each Ontario Marginalization (ON-Marg) Index dimension: material deprivation, residential instability, dependency, and ethnic concentration. We calculated ON-Marg Index dimension and quintile specific age- and sex-standardized AM incidence rates. We then calculated annual AM rate ratios between the most (Q5) and least (Q1) marginalized quintiles for each ON-Marg dimension. To describe the inequity gap in AM over time we calculated the absolute difference in the Q5/Q1 rate ratio between 2014 and 1993 for each dimension. AM rates in Ontario were almost halved (48.6%) from 1993 to 2014 (216 vs. 111 per 100,000 population). This decline was greater for treatable AM (75 vs. 36 per 100,000 population) than preventable AM (128 vs. 88 per 100,000 population). The inequity gap in AM Q5/Q1 rate ratios (RR) between 1993 and 2014 widened for all marginalization dimensions: dependency (RR 2.11–2.58), ethnic concentration (RR 0.59–0.48), material deprivation (RR 1.63–2.23), and residential instability (RR 2.01–2.43). To attain further declines in AM, policymakers and governments must address AM due to preventable deaths in neighborhoods highly marginalized by dependency, material deprivation, and residential instability.


Marginalization Dependency Ethnic concentration Material deprivation Residential instability Avoidable mortality 


Author Contributions

AZ conceived the study and is the lead author, corresponding author, and guarantor. AZ, CK, PJ, IL, MT, and PT contributed to study design, data interpretation, and manuscript revisions. IL and MT contributed to data analysis. AZ searched the literature. AZ, CK, PJ, IL, MT, and PT all contributed to the drafting of the manuscript. AZ had full access to all the data in the study and had final responsibility for the decision on content and publication submission. All authors have seen and approved the final text. The funder of the study had no role in the study design; data collection, analysis, or interpretation; or writing of the report.


Bruyère Research Institute through the Big Data Research Program. This study was supported by the Institute for Clinical Evaluative Sciences (ICES), which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC). The opinions, results and conclusions reported in this paper are those of the authors and are independent from the funding sources. No endorsement by ICES or the Ontario MOHLTC is intended or should be inferred.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

ICES is a prescribed entity under section 45 of Ontario’s Personal Health Information Protection Act. Section 45 authorizes ICES to collect personal health information, without consent, for the purpose of analysis or compiling statistical information with respect to the management of, evaluation or monitoring of, the allocation of resources to or planning for all or part of the health system. Projects conducted under section 45, by definition, do not require review by a Research Ethics Board. This project was conducted under section 45, and approved by ICES’ Privacy and Compliance Office.


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.School of Epidemiology and Public HealthUniversity of OttawaOttawaCanada
  2. 2.Ottawa Hospital Research InstituteOttawaCanada
  3. 3.ICES uOttawa, The Ottawa HospitalOttawaCanada
  4. 4.CT Lamont Primary Health Care Research GroupBruyère Research InstituteOttawaCanada
  5. 5.Department of Family MedicineUniversity of OttawaOttawaCanada
  6. 6.Li Ka Shing Knowledge Institute, St. Michael’s HospitalTorontoCanada
  7. 7.Department of MedicineUniversity Health Network, University of TorontoTorontoCanada
  8. 8.Division of Palliative Care, Department of MedicineUniversity of OttawaOttawaCanada

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