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 .