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Can the Concept of Avoidable Deaths
Complement WHO Health System
Performance?
Elena A. Varavikova, MD, PhD, MPH,
Researcher, OSD/FSP
Outline of the Presentation
• Concept of Avoidable Deaths - strengths and weaknesses
• Concept of Avoidable Death and Conditions - what additional information does it provide?
• Translating Assessment of Avoidable Deaths into Policy
How Does Medical Care Contribute to Population Health?
• Safe maternity and infant care
• Control infectious disease morbidity and mortality
• Effective screening and treatment of CNID
• Evidence based medicine
• Disease prevention and health promotion
• ……………...
• Measure of success - declining MORTALITY
Why Avoidable Deaths?• Rising mortality in Russia, and still existing
avoidable causes in developed countries
• Rising inequality
• Search for successful tool and environment for health policy prioritisation, measurement and implementation
• Social importance of death and great potential for support from the society
• Mortality was always basis for Epidemiology and evidence for health policy development
Examining contribution of health care to decline of
mortality, concept of avoidable death (1)
• Rutsein et al. - 1976, Charlton 1983 - proposed list of conditions from which death should not occur if appropriate care was provided - “unnecessary untimely deaths”, or mortality amenable to medical interventions
• Mackenbach and co-authors - estimated that in The Netherlands between 1959 - 1984 changes in death from amenable causes added a total 2.9 years to male and 3.9 to female Life Expectancy
• Beaglehole 1986 - 42% of decline in death from CVD in New Zealand 1974-1981 could be attributed to MC
• EC Atlas of avoidable death, Europe... Holland 1988,91
Examining contribution of health care to decline of mortality, concept of avoidable death (2)
• Hunnink et al. 1997 - estimated about 25% of the decline in CHD mortality in the USA 1980-90 was due to primary prevention, 72% due to secondary reduction in risk factors or improvements in treatment (comp.stimulation model)
• Capewell et al. 1999 - 40% of the decline of coronary heart disease mortality in Scotland 1975-94 could be attributed to medical care, including variety of measures of primary and secondary prevention
• WHO MONICA project data linking changes in coronary care and secondary prevention to declining adverse outcomes between mid-1980s - mid-1990
Concept of Avoidable Death
(Avoidable Illness, Condition)
Avoidable deaths (mortality)• Mortality from certain causes of death, where death
is avoidable according to current medical knowledge, practice and public health interventions in a defined age/sex group of the population
• List of avoidable deaths based on expert opinion and consensus (manageable, age, sex)
• Used as a measure of health system performance NYC, Spain, Germany (Ellen Nolte), Poland, Baltic countries, Russia
•
Early Neonatal Mortality Rates
1
2
3
4
5
6
7
8
9
10
11
12
1970 1975 1980 1985 1990 1995 2000 2005
Finland
Israel
Russia
United Kingdom
CEE average
070102 +Early neonatal mortality /1000 live births
Example “Russian Case”
PATTERNS OF avoidable mortality in Russia
Andreev-Nolte- Mckee -Shkolnikov-Varavikova
Contributions of different groups of causes of death to the life expectancy gap
between Russia and the UK: 1965-1999
55
60
65
70
75
1965
1967
1969
1971
1973
1975
1977
1979
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
Year
Life e
xpecta
ncy
Other
Causes amenable to health policy
Tuberculosis
Ischaemic heart disease
Causes amenable to medical care
Life Expecrancy in Russia
Life Expecrancy in UK
65
70
75
80
85
1965
1967
1969
1971
1973
1975
1977
1979
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
Year
Life e
xpecta
ncy
Other
Causes amenable to health policy
Tuberculosis
Ischaemic heart disease
Causes amenable to medical care
Life Expecrancy in Russia
Life Expecrancy in UK
Contributions of different groups of causes of death to the life expectancy gap between Russia and the UK: 1965-1999
The mortality from injury, trauma and poisoning (European standard), ages 0-64, Russia, 1989-2000
0
50
100
150
200
250
300
350
400
450
500
1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000
Years
Stan
dart
ized
deat
h ra
te, p
er 1
0000
0
male, urban male, rural female, urban female, rural
Life expectancy at birth in Russia, Baltic countries and the UK in 1965-2000 (both sexes)
50
55
60
65
70
75
80
1965 1970 1975 1980 1985 1990 1995 2000
Year
Estonia Latvia Lithuania Russia United Kingdom
Trends in SDRs for avoidable causes of death since 1965: Russia, Baltic countries and the UK, both sexes, per 100000
0
100
200
300
400
500
600
700
1965 1970 1975 1980 1985 1990 1995 2000
Year
Estonia Latvia Lithuania Russia United Kingdom
All avoidable causes
0
50
100
150
200
250
1965 1970 1975 1980 1985 1990 1995 2000
Year
Estonia Latvia Lithuania Russia United Kingdom
All causes amenable by medical care
0
20
40
60
80
100
120
140
160
180
1965 1970 1975 1980 1985 1990 1995 2000
Year
Estonia Latvia Lithuania Russia United Kingdom
Causes amenable to medical care: hypertensive disease and cerebrovascular disorders
0
2
4
6
8
10
12
14
16
1965 1970 1975 1980 1985 1990 1995 2000
Year
Estonia Latvia Lithuania Russia United Kingdom
Tuberculosis
0
50
100
150
200
250
300
1965 1970 1975 1980 1985 1990 1995 2000
Year
Estonia Latvia Lithuania Russia United Kingdom
Ischeamic heart disease
0
20
40
60
80
100
120
1965 1970 1975 1980 1985 1990 1995 2000
Year
Estonia Latvia Lithuania Russia United Kingdom
Causes amenable to health policy
Ischemic Heart Disease, Selected Countries, 1970-1998
100
150
200
250
300
350
400
450
1970 1975 1980 1985 1990 1995 2000 2005
Finland
Israel
Russia
United Kingdom
CEE average
090202 +SDR,ischaemic heart disease,all ages/100000
Mortality from Cerebrovascular Disease, Selected Countries, 1970-1998
50
100
150
200
250
300
1970 1975 1980 1985 1990 1995 2000 2005
Finland
Israel
Russia
United Kingdom
CEE average
090302 +SDR,cerebrovascular disease,all ages/100000
10
20
Moscow citi
St. Petersburg
Kaliningrad region Republic of Karelia
Leningrad regionPskov region
Novgorod region
Vologda region
Arkhangelsk region
Republic of Komi
Kirov regionKomi-Permyatzky autonomous district
Perm region
Tver region
Yaroslavl region
Ivanovo region
Nizhny Novgorod region
Kostroma region
Smolensk region
Moscow regionVladimir region
Republic of Mariy ElChuvash republic
Bryansk regionKaluga region
Tula regionOryol regionKursk region
Belgorod regionVoronezh region
Rostov regionKrasnodar territoryRepublic of Adygeya
Karachaev-Circassian republicStavropol territoryKabardian-Balkar republicRepublic of North OssetiaChechen and Ingush republics
Republic of Dagestan
Republic of KalmykiaAstrakhan region
Volgograd regionSaratov region
Penza regionTambov region
Lipetzk regionRyazan region
Republic of Mordovia
Ulyanovsk region
Samara region
Orenburg region
Republic of TatarstanUdmurt republic
Republic of BashkortostanChelyabinsk regionKurgan region
Sverdlovsk region
Chechen republicIngush republic
Murmansk Oblast
Nenets Autonomous Okrug
52 & 56
1013
111312
5
4
3266
65
25
27
17
33
19
24
21
16
29
31
1518
262237
35
36
5957
50
54 58
53
55
51
4143
44 47
45
39
3823
30
48
46
64
42
62
61
68 63
67
5652
10
20
7
8
6
St. Petersburg
Moscow
< 12
12 - 16
16 - 20
20 - 24
> 24
SDR per 10000 from tuberculosis, both sexes
The mortality of thetuberculosis (European standart), Russia, 1989-2000
0
5
10
15
20
25
30
35
40
45
50
1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000
Years
Stan
dart
ized
deat
h ra
te, p
er 1
0000
0
male, urban male, rural female, urban female, rural
Avoidable Death Survey , RF
• Moscow, Tver, St. Petersburg, Cheliabinsk
• Russian List of Avoidable Death
• Age groups
• Promotion and prevention
• Education
Improving Health System Performance using Concept of Avoidable Conditions
• Measure population health, health outcomes of the services, patient safety
• Develop consensus on avoidable conditions and legislative support, (Dubna municipality)
• Program development and implementation for the control of mortality and non-fatal avoidable health outcomes
• Quality management (Netherlands, Finland)• Attention to health promotion and disease prevention • Injuries and trauma
Problems and Questions • Eligibility of some ‘avoidable conditions’ as performance
indicators for health services (Walworth-Bell &Allen, 1988 - cancer of cervix and hypertansion) {EBM}
• Overstatement of if impact of health services (small portion of mortality) - {age 65, 75 or 80?, SHEP and Syst-Eur, female breast cancer}
• Absence of a clear link at sub-national level with other measures of health care provision (Carr-Hill et al.) {modern studies CVD}
• No account of differences in the underlying prevalence or severity of a disease {incidence-adjusted mortality rates, Netherlands}
• Avoidable death and non-fatal health outcomes (and coverage) are qualitatively different
• Quality of mortality data { List }
• To effect change, policies need to be specific and based on disaggregated data + sub national level (RF, Japan, Hungary, USA)
Avoidable Mortality is a Tool for Prioritisation in Health Policy,
Measure of success in the Reform process
• Strategic Analysis (population approach)
• Regional comparison• Sub-national level
• Monitoring of quality and effectiveness of Health System
• Analysis of causes• Access, coverage• Quality control,
Patient safety
What Concept of Avoidable conditions
could add to Public Health practice ?
• Evidence on the effectiveness of health system reforms
• A consistent framework for specifying goals and measuring outcomes
• Clear base for societal and legislative support
• Informed concern and demand for research and implementation
• Evidence-based ‘Library’ for implementations to control avoidable conditions
• Tool for implementation .