Department of Public Health and Caring Sciences, Uppsala University, Sweden.
Ragnar Westerling, Department of Public Health and Caring Sciences, Uppsala Science Park, 751 85 Uppsala, Sweden.
In the late 1970s, an American working group chaired by David D Rutstein introduced a method for measuring the quality of medical care.1 It was based on the tradition of using potentially avoidable mortality such as perinatal and maternal mortality as negative indicators of health and as a starting point for the evaluation of health care. Studies of the maternal and infant mortality rate have been useful. These rates, however, have the limitation that they only apply to mothers and infants. With the help of specialists in many fields of medicine 80 causes of death were defined as unnecessary untimely deaths. The list was based on judgements as to whether the conditions were amenable to preventive and/or therapeutic measures. An agglomeration of deaths from these causes would be warning signals indicating that the quality of medical care may need to be improved.
The list was designed for international use, not only for use in more economically developed countries. However, most of the studies applying the method have mainly been published from western industrialized countries.
There was a break-through for the concept in 1986 when Charlton and Velez showed that mortality from avoidable causes of death had decreased to a greater degree than total mortality in several industrial countries during the period 19501980.2 These trends have been confirmed in later studies from several countries.3 For many avoidable causes of death, mortality has also been shown to decline faster after the introduction of new technologies in health care, such as primary care programmes for the management of hypertension for preventing mortality from cerebrovascular disease and cervix cancer screening.
A large number of deaths in the American working group list were relatively rare in developed countries. In Sweden a limited number of causes of death accounted for most of the deaths covered by the Rutstein list.4 For a majority of the remaining causes there were few cases and for several causes, no deaths at all during a 12-year period.
In the 1980s a European Community (EC) working group was set up to prepare an atlas of avoidable mortality in the EC.5 Seventeen disease groups were agreed as avoidable death indicators, mainly selected from the Rutstein list. The general principle was that each disease has identifiable effective interventions and providers of health care intervention. Three of the conditions were considered to be indicators of the national health policy for primary prevention, usually outside the direct control of the health services. Fourteen conditions were defined as medical care indicators. These would reflect different aspects of medical care delivered by health administrative authorities, mainly curative and secondary preventive measures. Strict age limits were set for each condition to increase the validity of the outcome indicators. Several studies on the variations in avoidable death between different countries and different health administrative areas have been published using the EC working group criteria.3
In the 1990s some studies of avoidable mortality in Eastern European countries were published. Comparisons between Eastern and Western European countries have also been performed. For instance, in Lithuania death rates for avoidable death indicators were between 2 and 36 times higher than in Sweden during the years 19711990.6 For several avoidable causes of death, such as tuberculosis, appendicitis and hypertensive and cerebrovascular disease the gap was widening. The study pointed out potential fields for improvement of the health care system in Lithuania.
A study on avoidable mortality in Singapore 1965 to 1994 has been published in this issue of International Journal of Epidemiology, extending the application of the method further.7 In this study, the temporal trends in avoidable mortality have been analysed in an economically less developed country. The EC working group list of indicators was used. For ages 564 years, more than 40% of the deaths was covered by the list of avoidable causes of death. The corresponding figures for the EC countries varied between 10% and 30%. Thus, there seems to be potential to reduce mortality in Singapore considerably by health care intervention. A promising reduction in avoidable death rates was also found when compared to other causes of death. Thus, the general pattern of decreasing avoidable death rates previously found in industrialized countries seems to be valid also in developing countries.
The EC working group indicators were chosen in order to make comparisons possible with European countries. However, the original American working group list was much broader including about 80 causes of death. Many of these causes of death have been rare in industrialized countries but they may be useful as indicators in developing countries. Thus, when extending the application of the avoidable mortality method to developing countries it would be useful to make a revision of the choice of indicators.
In later avoidable mortality studies there has been concern also about the equity in outcome of health care. For instance, several studies have shown socioeconomic differences in avoidable mortality.8 Ethnic differences have also been found between white and blacks in the US.9 The Singapore study illustrates the usefulness of studying the equity in avoidable mortality also in Asian countries. Both ethnic and gender differences were found. Evaluating the equity in mortality outcome should be a major concern for further studies of avoidable mortality.
According to the original idea, an agglomeration of avoidable deaths is a warning signal motivating in-depth studies of the quality of care. Several audits of avoidable factors influencing death have been published from a variety of countries, both industrialized and developing countries. However, there is a need to define the evaluation criteria further.10 For instance, the avoidable factors examined should be explicitly classified and the sources of information and people responsible for the judgements presented.
To sum up, the avoidable mortality concept originally was developed for international use. So far, there has however been a lack of studies from developing countries. The Singapore study shows the feasibility of applying the concept also in economically developing countries.
Acknowledgments
The paper was supported by a grant from the Swedish Council for Social Research.
References
1 Rutstein DD, Berenberger W, Chalmers TC, Child GC, Fischmen AP, Perrin EB. Measuring the quality of medical care. N Engl J Med 1976; 294:58288.[Abstract]
2 Charlton JRH, Velez R. Some international comparisons of mortality amenable to medical intervention. Br Med J 1986;292:295300.[ISI][Medline]
3 Mackenbach JP, Bouvier-Colle MH, Jougla E. Avoidable mortality and health services: a review of aggregate data studies. J Epidemiol Community Health 1990;44:10611.[Abstract]
4 Westerling R. Avoidable causes of death in Sweden 197485. Qual Assur Health Care 1992;4:31928.[Medline]
5 Holland WW (ed.). European Community Atlas of Avoidable Death. Commission of the European Communities Health Services Research Series No. 3. Oxford, 1988.
6 Gaizauskiené A, Westerling R. A comparison of avoidable mortality in Lithuania and Sweden 19711990. Int J Epidemiol 1995;24:112431.[Abstract]
7
Niti M, Ng PT. Temporal trends and ethnic variations in amenable mortality in Singapore 1965 to 1994: the impact of health care in transition. Int J Epidemiol 2001;30:96673.
8 Westerling R, Gullberg A, Rosén M. Socioeconomic differences in avoidable mortality in Sweden 19861990. Int J Epidemiol 1996;25: 56067.[Abstract]
9 Woolhandler S, Himmelstein DU, Silber R, Bader M, Harnly M, Jones AA. Medical care and mortality: racial differences in preventable deaths. Int J Health Serv 1985;15:122.[ISI][Medline]
10 Westerling R. Studies of avoidable factors influencing deatha call for explicit criteria. Qual Health Care 1996;5:15965.[Abstract]
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