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The concept of The concept of ‘‘avoidableavoidable’’
mortality mortality Progress on developing a common listProgress on developing a common list
Ellen Nolte
RAND Europe
London School of Hygiene & Tropical Medicine
9 October 2009
‘‘AvoidableAvoidable’’ mortality (1)mortality (1)
� Rutstein et al. “unnecessary, untimely deaths” (1976)
� Conditions from which, in the presence of timely and
effective medical care, premature death should not
occur
� Single case of death (illness/disability): Why did it happen?
� Rate: not every single case preventable/ manageable � reduction of incidence
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‘‘AvoidableAvoidable’’ mortality (2)mortality (2)
� immunisation, e.g. measles
� early detection, e.g. cervical cancer
� medical treatment, e.g. hypertension
� surgery, e.g. appendicitis
Systematic reviewSystematic review
� Tracing the evolution of the
concept & how it has changed over
time
� Methodological critique
� Alternative approaches
� Compilation of annotated review of
work that has been undertaken
worldwide so far (3/2003)
� Revise concept of avoidable
mortality in light of advances of
health care and increasing
expectations of life
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Empirical studies of Empirical studies of ‘‘avoidable avoidable
mortalitymortality’’
� 70 studies (of 72)
� Variation in
� Selection of avoidable conditions
� Methodology, study region, time period, explanatory variables….
� Terminology
� avoidable, preventable, treatable
� medical care indicator vs. health policy indicator
� amenable/treatable: health care
� preventable: health policy ‘avoidable’
What is medical care? What is medical care?
“the application of all relevant medical knowledge […], the services of all medical and allied health personnel, institutions and laboratories, the resources of governmental, voluntary, and social agencies, and the co-operative responsibility of the individual himself”
(Rutstein et al. 1976)
“the application of biomedical knowledge through a personal service system”
(Mackenbach et al. 1988)
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…… health care services? health care services?
= medical care?
“primary care, hospital care, and collective health services such as screening and public health programmes, e.g. immunisation”
� “identifiable effective interventions and health care providers”
(EC Concerted Action Project 1988)
Variation between placesVariation between places
� Is there a link between amenable mortality and
indicators of health services?
� Generally weak and inconsistent
� No association between amenable mortality and health care
expenditure in EC (Mackenbach 1990)
� Range of indicators of health services explained only 10% of
geographical variation in amenable mortality in E&W (Buck
& Bull 1986)
� Positive association between mortality from TB and hospital
beds in NL (Mackenbach et al. 1998)
� Strong(er) association with socio-economic indicators
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Variation between social groupsVariation between social groups
� Consistent findings of inequalities
� African-Americans vs. white Americans, US
� Excess mortality from hypertension, cervical cancer,
diabetes, peptic ulcer (Woolhander et al. 1985)
� 4.5 times higher death rates from amenable conditions
(Schwartz et al. 1990)
� Maori vs. non-Maori in New Zealand
� Little change over time: ratio M/N-M at 2.3 in 1967 and 2.0
in 1987 (Malcolm & Salmond 1993)
� Low SES vs. high SES
� Health services can contribute to the reduction of
health inequalities
US State Scorecard on Health System US State Scorecard on Health System
Performance, 2007Performance, 2007
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Variation over timeVariation over time
� Mortality from amenable conditions declined more
rapidly than mortality from ‘non-amenable’ conditions
since 1960s
� Average decline of 6% per year between 1950 and 1984 in NL
vs. 2% or no change (men) (Mackenbach et al. 1988)
� Acceleration of decline during 1970s & 1980s� E&W: average decline of 2.7% per year between 1955/59 &
1970/74 vs. 3.6% in 1970/74-1985/89 (Boys et al. 1991)
� Similar findings from CEE but lower pace� Average decline of 1-2% per year 1970s/1980s vs. no
change/increase in non-amenable mortality (Boys et al. 1991)
‘‘AmenableAmenable’’ mortality EUmortality EU--27, 1990/91 & 27, 1990/91 &
2000/02: men2000/02: men
0 50 100 150 200 250 300
Sweden
Netherlands
France
Spain
Italy
UK
Germany
Ireland
Finland
Austria
Slovenia
Lithuania
Portugal
Poland
Czech Republic
Estonia
Latvia
Hungary
Bulgaria
Romania
deaths / 100,000
1990/91
2000/02
Source: Newey et al. 2004
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‘‘AmenableAmenable’’ mortality EUmortality EU--27, 1990/91 27, 1990/91 & &
2000/02: women2000/02: women
0 50 100 150 200 250
France
Sweden
Spain
Netherlands
Italy
Finland
Germany
Austria
Ireland
UK
Slovenia
Portugal
Lithuania
Poland
Czech Republic
Estonia
Latvia
Hungary
Bulgaria
Romania
deaths / 100,000
1990/91
2000/02
Source: Newey et al. 2004
0 40 80 120 160
FranceCanada
AustraliaSpain
ItalyJapan
SwedenNetherlan
GreeceNorway
DenmarkGermany
N.ZealandUSA
AustriaUK
FinlandPortugal
Ireland
Age-standardised death rate 0-74 (per 100,000)
1997/98
2002/03
men
‘‘AmenableAmenable’’ mortality OECD, 1997/98 & mortality OECD, 1997/98 &
2002/032002/03
Source: Nolte & McKee 2008
0 40 80 120 160
JapanFranceSpain
SwedenAustralia
ItalyCanadaGreeceNorwayFinlandAustria
NetherlandsGermany
USANew Zealand
PortugalDenmark
IrelandUK
Age-standardised death rate 0-74 (per 100,000)
1997/98
2002/03
women
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Conceptual problems (I)Conceptual problems (I)
� Relationship to health care inputs� Focus: health care resources or supply
� Available data reflect only what is measurable
� Relationship between quantity and quality is likely to be inexact
� Geographical level of analysis
� Time lag between changes in resources and changes in amenable mortality
� Analysis of more specific aspects of health care delivery in terms of organisation, quality, access etc. potentially useful
Conceptual problems (II)Conceptual problems (II)
� Interpreting deaths from amenable mortality over time
� Possible confounding by changes in disease incidence; cohort
effects
� Accelerated fall in mortality from conditions following
introduction of specific interventions intended to treat them
� contributed 2.9 yrs to male life expectancy at birth in NL 1950-
1984 (women: 3.9 yrs) (Mackenbach et al. 1988)
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Per cent decline Per cent decline ‘‘amenableamenable’’ vs. vs. ‘‘otherother’’
mortality 75 years OECD, 1997/8 mortality 75 years OECD, 1997/8 -- 2002/032002/03
Source: Nolte & McKee 2008
0 5 10 15 20 25
USA
Greece
Spain
Japan
Denmark
Canada
Sweden
France
Germany
Netherlands
Italy
New Zealand
Portugal
Finland
Australia
UK
Norway
Ireland
Austria
per cent decline
amenable causes
other
men
-5 0 5 10 15 20 25
USA
Sweden
Denmark
Japan
France
Spain
Canada
Norway
Netherlands
New Zealand
Germany
Italy
Greece
Australia
Portugal
Finland
Austria
UK
Ireland
per cent decline
amenable causes
other
women
Conceptual problems (III)Conceptual problems (III)
� Selection of ‘avoidable’ conditions and attribution of health outcomes� Any list to some extent arbitrary
� Which condition does reflect performance of health care?
‘avoidable’ deaths should not be interpreted as absolute measures of outcome, they “do not provide definitive
evidence that a particular service is wrong”(Holland & Breeze 1988)
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Conceptual problems (IV)Conceptual problems (IV)
� The changing concept of avoidability� Most studies set in the 1970s/1980s; however, substantial
advances in scope and quality of health care since
� IHD: 40-70% of decline in mortality since mid-1970s poss. attributable to medical care (secondary prevention, treatment)
� Tobias & Jackson (2001): quantitative attribution of health outcomes to specific components of health care (IHD: 50% -25% - 25%)
� Possible? - multifactorial nature of many chronic diseases
� Desirable? – suggests degree of accuracy unlikely to be achieved
Source: Nolte, Bain, McKee in press
Percentage of the decline in IHD mortality attributable to treatment and to risk factor reductions in selected study populations
Country Period Risk factors Treatment
Auckland, New Zealand (Beaglehole, 1986)
1974-1981 - 40%
Netherlands (Bots and Grobee, 1996)
1978-1985 44% 46%
USA (Hunink et al., 1997)
1980-1990 50% 43%
Scotland (Capewell et al., 1999)
1975-1994 55% 35%
Finland (Laatikainen et al., 2005)
1982-1997 53% 23%
Auckland, New Zealand (Capewell et al., 2000)
1982-1993 54% 46%
USA (Ford et al., 2007)
1980-2000 44% 47%
Ireland (Bennett et al., 2006)
1985-2000 48% 44%
England & Wales (Unal et al., 2007)
1981-2000 58% 42%
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International classification of diseases Cause of death considered amenable to health
care Age 9th revision 10th revision
Intestinal infections 0-14 001-9 A00-9
Tuberculosis 0-74 010-8, 137 A15-9,B90
Other infections (diphtheria, tetanus, septicaemia, poliomyelitis)
0-74 032,037,038, 045 A36,A35,A80
Whooping cough 0-14 033 A37
Measles 1-14 055 B05
Malignant neoplasm of colon and rectum 0-74 153-4 C18-21
Malignant neoplasm of skin 0-74 173 C44
Malignant neoplasm of breast 0-74 174 C50
Malignant neoplasm of cervix uteri 0-74 180 C53
Malignant neoplasm of cervix uteri and body of uterus
0-44 179,182 C54, C55
Malignant neoplasm of testis 0-74 186 C62
Hodgkin’s disease 0-74 201 C81
Leukaemia 0-44 204-8 C91-5
Diseases of the thyroid 0-74 240-6 E00-7
Diabetes 0-49 250 E10-4
Epilepsy 0-74 345 G40-1
Chronic rheumatic heart disease 0-74 393-8 I05-9
Hypertensive disease 0-74 401-5 I10-3,I15
Ischaemic heart disease: 50% of deaths 0-74 410-4 I20-5
Cerebrovascular disease 0-74 430-8 I60-9
All respiratory diseases (excl. pneumonia, influenza) 1-14 460-79,488-519 J00-9,J20-99
Influenza 0-74 487 J10-1
Pneumonia 0-74 480-6 J12-8
Peptic ulcer 0-74 531-3 K25-7
Appendicitis 0-74 540-3 K35-8
Abdominal hernia 0-74 550-3 K40-6
Cholelithiasis and cholecystitis 0-74 574-5.1 K80-1
Nephritis and nephrosis 0-74 580-9 N00-7,N17-9, N25-7
Benign prostatic hyperplasia 0-74 600 N40
Misadventures to patients 0-74 E870-6,E878-9 Y60-9,Y83-4
Maternal death 0-74 630-76 O00-99
Congenital cardiovascular anomalies 0-74 745-7 Q20-8
Perinatal deaths, all causes, excluding stillbirths 0-74 760-79 P00-96,A33
Causes of Causes of death death considered considered amenable to amenable to health care (1)health care (1)
Source: Nolte & McKee 2008
Conceptual problems (V)Conceptual problems (V)
� Treatment or prevention?
� Contribution of amenable conditions to overall mortality
� Underlying disease incidence/severity
� Others
� Cause of death certification and coding
� Focus on mortality
� Negative consequences of medical care
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Treatment or prevention?Treatment or prevention?
� Amenable (treatable) conditions: it is reasonable to expect death to be averted even after the condition has developed
� tuberculosis: although acquisition is driven by socio-economic factors timely treatment is effective in preventing mortality
� Preventable: there are effective measures that prevent a given condition from occurring in the first place
� lung cancer: largely preventable through appropriate policies on smoking (others: liver cirrhosis; injuries caused by traffic accidents)
� HIV/AIDS? Suicide? Melanoma?
Causes of Causes of death death considered considered amenable to amenable to health care (2)health care (2)
Source: James et al. 2007
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Causes of Causes of death death considered considered amenable to amenable to health care (3)health care (3)
Source: Stirbu et al. 2006
Treatment or prevention?Treatment or prevention?
� Lethality of serious criminal assault in the USA has dropped substantially since 1960 despite a simultaneous increase in assault rates
� Time-series data on criminological data on murder, manslaughter and assault along with health data and data on medical resources and facilities
� Contemporary American homicide rates would be up to five times higher than they would have been in the absence of advances in medical technology and related health care support
(Harris et al. 2002)
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Contribution of amenable conditions to Contribution of amenable conditions to
total mortality <75 years OECD, 2002/03total mortality <75 years OECD, 2002/03
Source: Nolte & McKee 2008
0 100 200 300 400 500 600
Australia
Japan
Sweden
Italy
Norway
Canada
New Zealand
Greece
Netherlands
Spain
UK
Austria
Ireland
France
Germany
Finland
Denmark
Portugal
USA
Age-standardised death rate per 100,000
Amenable causes
IHD (50%)
Other causes
men
0 50 100 150 200 250 300 350
Japan
Spain
Greece
Italy
Australia
France
Finland
Sweden
Austria
Norway
Germany
Canada
Portugal
Netherlands
Ireland
New Zealand
UK
USA
Denmark
Age-standardised death rate per 100,000
Amenable causes
IHD (50%)
Other causes
women
0% 20% 40% 60% 80%
Sweden
Netherlands
Norway
Ireland
Greece
Italy
New Zealand
Australia
UK
Canada
Austria
Denmark
Spain
Japan
Portugal
Germany
Finland
France
USA
men
women
Proportion Proportion of deaths of deaths under 75 of under 75 of all deaths, all deaths, 20032003
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Aggregate nature of the measure: Aggregate nature of the measure: Amenable mortality (SDRAmenable mortality (SDR00--7474) and diabetes M:I ) and diabetes M:I ratio (1998)ratio (1998)
0
25
50
75
100
125
150
Gre
ece
Italy
Spain U
K
Swed
en
Can
ada
Franc
e
New
Zea
land
Net
herla
nds
Austra
lia
Austri
a
Nor
way
Finland
Ger
man
y
Portu
gal
Den
mar
kUSA
Japa
n
Ireland
0
0.02
0.04
0.06
0.08
0.1
0.12
0.14
0.16
SDR0-74
M:I
SD
R 0
-74 M
:I
Source: Nolte, unpublished
Is Is ‘‘avoidableavoidable’’ mortality still a useful mortality still a useful
concept?concept?
� critics asked it to be a definitive source of evidence of differences in effectiveness of health care
� never intended to be more than an indicator of potential weaknesses in health care that can then be investigated in more depth
� Important limitations: comparability of data, attribution of causes, coverage of the range of health outcomes
“[A]voidable deaths provide a valuable measure of quality […] It has a valuable part to play in observing changes in performance over time […] This technique can provide indicators of areas where future research is necessary.”
(Holland 1990)
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The AMIEHS projectThe AMIEHS project
� Avoidable Mortality in the European Union: towards better
Indicators for the Effectiveness of Health Systems
� Aim: To develop a set of avoidable mortality-based indicators
that can be used in future surveillance of the performance of health systems in Europe
� April 2008 – March 2011, funded under the Public Health Programme
� Partners in 7 Countries
� Coordinator: Erasmus MC, NL
Partners: LSHTM, UK; Uppsala University, Sweden; Institut National
de la santé et de la recherche médicale (Inserm), France; University of
Tartu, Estonia; NRW Institute of Health and Work (Liga), Germany;
and University of Valencia, Spain)
� http://amiehs.lshtm.ac.uk
The AMIEHS project: ScopeThe AMIEHS project: Scope
� Systematic review of literature to assess to which extent causes of death can be considered avoidable
� Gather in-depth information on introduction of medical innovations in 7 countries
� Develop an agreed set of avoidable mortality-based indicators
� Prepare an electronic atlas of avoidable mortality in 25-30 countries in Europe (EU, candidate countries, EFTA)
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The AMIEHS projectThe AMIEHS projectProgress to dateProgress to date
� Defining the desired properties of avoidable mortality (AM) indicators
� Boundaries of the health care system: primary care, hospital care, and collective health services (e.g. cancer screening), and public health programmes (e.g. immunisation)
� Observable mortality decline of 30% over 30 year period
� Minimum number of deaths per year (here: 100)
� Preventability by contemporary interventions (here: 5 years)
� Plausible intervention
� Direct evidence of improved survival
� Preliminary list of ~ 20 conditions considered ‘amenable’
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SummarySummary
� There is increasing evidence that health can make a considerable contribution to population health
� The concept of “avoidable mortality” offers a way to measure this contribution, and to compare the relative performance of countries and over time
� Measures at aggregate level (such as avoidable mortality) are limited as they do not indicate which elements of the health system perform ‘sub-optimal’