1

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

2

‘‘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

3

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)

4

…… 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’