Can the Concept of Avoidable Deaths Complement WHO Health System Performance?

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Can the Concept of Avoidable DeathsComplement
WHO Health System Performance?

• Elena A. Varavikova, MD, PhD, MPH,
• Researcher, OSD/FSP

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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

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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

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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

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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

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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

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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

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Early Neonatal Mortality Rates
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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
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Contributions of different groups of causes of
death to the life expectancy gap between Russia
and the UK 1965-1999
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Life expectancy at birth in Russia, Baltic
countries and the UK in 1965-2000 (both sexes)
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Trends in SDRs for avoidable causes of death
since 1965 Russia, Baltic countries and the UK,
both sexes, per 100000
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Ischemic Heart Disease, Selected Countries,
1970-1998
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Mortality from Cerebrovascular Disease,
Selected Countries, 1970-1998
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Avoidable Death Survey , RF

• Moscow, Tver, St. Petersburg, Cheliabinsk
• Russian List of Avoidable Death
• Age groups
• Promotion and prevention
• Education

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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

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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)

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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

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• 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
  .