DOES HEALTH CARE SAVE LIVES? AVOIDABLE MORTALITY REVISITED Ellen Nolte Martin McKee Foreword by John Wyn Owen CB The authors Dr Ellen Nolte is a Lecturer in Public Health in the European Centre on Health of Societies in Transition at the London School of Hygiene and Tropical Medicine and Research Fellow at the European Observatory on Health Care Systems. Professor Martin McKee is Professor of European Public Health in the European Centre on Health of Societies in Transition at the London School of Hygiene and Tropical Medicine and Research Director at the European Observatory on Health Care Systems. ISBN 1-902089-94-4 © The Nuffield Trust, 2004 Published by The Nuffield Trust 59 New Cavendish Street London WIG 7LP Telephone: 020 7631 8450 Facsimile: 020 7631 8451 E-mail: TABLE OF CONTENTS List of tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 List of figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 List of boxes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Executive summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 PART I: THE CONCEPT OF ‘AVOIDABLE’ MORTALITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15-61 Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Evolution of the concept of ‘avoidable’ mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Empirical studies of ‘avoidable’ mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Scope and nature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33 Variation between places . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Variation between social groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Variation over time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Conceptual problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Relationship to health care inputs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Interpreting trends in deaths from amenable mortality over time . . . . . . . . . . . . . . . . . . . . . . 44 Selection of ‘avoidable’ conditions and the attribution of health outcomes . . . . . . . . . . . . 47 The changing concept of avoidability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Treatment or prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Contribution of amenable conditions to overall mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52 Underlying disease incidence and disease severity at presentation . . . . . . . . . . . . . . . . . . . . . 53 Other limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Alternative approaches to assess the contribution of medical care to population health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Future directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 PART II: AVOIDABLE MORTALITY IN THE EUROPEAN UNION . . . . . . . . . . . . . . . . . 63-99 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63 Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Selection of causes of death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 3 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 Trends in life expectancy at birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68 Amenable mortality in the 1980s and 1990s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 Trends in temporary life expectancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 The contribution of amenable mortality to changing life expectancy . . . . . . . . . . . . . . . . 92 Next steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 PART III: EMPIRICAL STUDIES OF ‘AVOIDABLE’ MORTALITY . . . . . . . . . . . . . . . . 101-123 Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 LIST OF TABLES Table 1 Amenable causes of death: Charlton et al. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20 Table 2 Amenable causes of death: Poikolainen & Eskola . . . . . . . . . . . . . . . . . . . . . . . . . .21-22 Table 3 Amenable causes of death: European Community atlas of ‘avoidable death’ 23-25 Table 4 Amenable causes of death: Mackenbach et al . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Table 5 Amenable causes of death: Westerling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Table 6 Amenable causes of death: Nolte et al. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Table 7 Amenable causes of death: Simonato et al. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Table 8 Amenable causes of death: Tobias & Jackson . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32-33 Table 9 Changes in amenable mortality over time: Summary of results from selected studies of ‘avoidable’ mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39-41 Table 10 Causes of death considered amenable to health care . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 Table 11 Life expectancy at birth in selected European countries in 1980, 1989, 1990 and 1998 (in years) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Table 12 Life expectancy between birth and age 75 in selected European countries in 1980, 1989, 1990 and 1998 (in years) . . . . . . . . . . . . . . . . . . . . . . . . . . . .69 Table 13 Selected measures of population health outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .93 Table 14 Age-standardised death rates (per 100 000) for selected causes and cause groups in EU countries in 1980, 1990 and 1998: age 0-74 . . . . . . . .95 Table 15 Age- and cause specific contributions (in years) to changes in temporary life expectancy in selected countries of the European Union between 1980 and 1989 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96-97 Table 16 Age- and cause specific contributions (in years) to changes in temporary life expectancy in selected countries of the European Union between 1990 and 1998 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98-99 4 LIST OF FIGURES Figure 1 Mortality from respiratory tuberculosis in England and Wales . . . . . . . . . . . . . . 11 Figure 2 Death rates from tuberculosis in successive years between 1945 and 1955 in England and Wales by age group1 . . . . . . . . . . . . . . . . . . . . . . . . . .12 Figure 3 Age- and cause specific contributions to changes in temporary life expectancy in Austria: 1980-1989 and 1990-1998 . . . . . . . . . . . . . . . . . . . . . . . . . 71 Figure 4 Age- and cause specific contributions to changes in temporary life expectancy in Denmark: 1980-1989 and 1990-1998 . . . . . . . . . . . . . . . . . . . . . . . 72 Figure 5 Age- and cause specific contributions to changes in temporary life expectancy in Finland: 1980-1989 and 1990-1998 . . . . . . . . . . . . . . . . . . . . . . . 74 Figure 6 Age- and cause specific contributions to changes in temporary life expectancy in France: 1980-1989 and 1990-1998 . . . . . . . . . . . . . . . . . . . . . . . . . 75 Figure 7 Age- and cause specific contributions to changes in temporary life expectancy in west Germany: 1980-1989 and 1990-1998 . . . . . . . . . . . . . . . . .77 Figure 8 Age- and cause specific contributions to changes in temporary life expectancy in Greece: 1980-1989 and 1990-1998 . . . . . . . . . . . . . . . . . . . . . . . . . 78 Figure 9 Age- and cause specific contributions to changes in temporary life expectancy in Italy: 1980-1989 and 1990-1998 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Figure 10 Age- and cause specific contributions to changes in temporary life expectancy in The Netherlands: 1980-1989 and 1990-1998 . . . . . . . . . . . . . . .82 Figure 11 Age- and cause specific contributions to changes in temporary life expectancy in Portugal: 1980-1989 and 1990-1998 . . . . . . . . . . . . . . . . . . . . . . . . 84 Figure 12 Age- and cause specific contributions to changes in temporary life expectancy in Spain: 1980-1989 and 1990-1998 . . . . . . . . . . . . . . . . . . . . . . . . . . .86 Figure 13 Age- and cause specific contributions to changes in temporary life expectancy in Sweden: 1980-1989 and 1990-1998 . . . . . . . . . . . . . . . . . . . . . . . . .87 Figure 14 Age- and cause specific contributions to changes in temporary life expectancy in the United Kingdom: 1980-1989 and 1990-1998 . . . . . . . . . . .89 Figure 15 Comparison of rankings based on DALE and amenable mortality rates . . . . . . .93 LIST OF BOXES Box 1 Health care related factors influencing health outcome . . . . . . . . . . . . . . . . . . . . .17-18 Box 2 The decline in stroke mortality and its explanations . . . . . . . . . . . . . . . . . . . . . . . 45-46 Box 3 Confidential enquiries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48 Box 4 The changing meaning of perinatal mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49-50 5 FOREWORD The question of how much health care contributes to the health of populations has been debated for several decades. Writing in the 1970s, Professor Thomas McKeown argued that its contribution had been minor, as much of the decline in mortality in industrialised countries took place before effective health care was available. Instead, he emphasised the role of broader social policies, leading to changes such as better nutrition and cleaner water. However, as several commentators have noted, McKeown was describing a period in which health care still had relatively little to offer. It was only in the 1960s and 1970s that safe and effective drugs for many chronic diseases became widely available. In the 1980s, several researchers, including Professor Walter Holland, the Nuffield Trust’s 1997 Rock Carling lecturer, began work on what was variously termed avoidable or amenable mortality. This involved looking at deaths that should not occur in the presence of effective and timely health care. This work suggested that health care was indeed having an impact on premature mortality at the population level. While this work led to much interest at the time, the concept of avoidable mortality has recently received rather less attention. Yet there are now several reasons why we should revisit it. One is the growing international interest in comparing the performance of health systems, exemplified by the World Health Organization’s 2000 World Health Report, with its controversial rankings of health systems. Another is the growing interest in the complex relationship between the health and wealth of nations, exemplified by the report of the Commission on Macro-Economics and Health. The Nuffield Trust's purpose is to communicate evidence and encourage an exchange around developed or developing knowledge in order to illuminate recognised and emerging issues. As such, it is entirely appropriate that it should contribute to these discussions. One way that it has done this is by publishing this important book, which describes the findings of a study co-funded by the Trust and by Merck & Co., in association with the European Observatory on Health Care Systems. The authors, Ellen Nolte and Martin McKee, have done an excellent job in assembling the extensive literature that now exists on avoidable mortality, bringing the definitions up to date, and then applying them to patterns of mortality in a range of industrialised countries. They confirm that health care has made an appreciable difference to population health, while showing that the impact varies among countries. This work bridges two of the Trust’s key themes, public health and quality in health care, and I commend it to health service researchers and health policy makers interested in benchmarking the performance of health systems. John Wyn Owen C.B. Secretary, Nuffield Trust February 2004 6 ACKNOWLEDGEMENTS This report was made possible by an unrestricted educational grant by Merck, Sharp & Dohme (MSD). We are especially grateful to Melinda Hanisch of MSD for her continuing support, encouragement and interest in this work, as well as to Heather Richmond and Jeffrey Sturchio. We are also grateful to the Nuffield Trust for their additional support of our work on health systems, and in particular to John Wyn Owen. Further we would like to thank Professor Walter W. Holland, London School of Economics, Professor Johan P. Mackenbach, Erasmus University Rotterdam, Professor Reinhard Busse, Technical University Berlin, and Dr Chris Bain, University of Queensland, for their very helpful comments and suggestions on an earlier draft. Ellen Nolte is a Lecturer in Public Health at the London School of Hygiene and Tropical Medicine, funded by the Nuffield Trust and the European Observatory on Health Care Systems. Martin McKee is Professor of European Public Health at the London School of Hygiene and Tropical Medicine and a research director of the European Observatory on Health Care Systems. The Observatory is a partnership of the World Health Organisation, World Bank, European Investment Bank, Open Society Institute, the governments of Greece, Norway and Spain, the London School of Hygiene and Tropical Medicine and the London School of Economics and Political Science. For further information please see www.observatory.dk The views expressed in this report are those of the authors alone and should not be taken as representing those of any of the organisations mentioned. 7 EXECUTIVE SUMMARY Does health care save lives? Commentators such as McKeown and Illich, writing in the 1960s, argued that it played very little part, and might even be harmful. However they were writing about a period when health care had relatively little to offer compared to today. Since then, several writers have described often quite substantial improvements in death rates from conditions for which effective interventions have been introduced. But the debate continues, with some arguing that health care is making an increasingly important impact on overall levels of health while others contend that it is in the realm of broader policies, such as education, transport and housing, that we should look to for future advances in health. Inevitably this is to a considerable extent a false dichotomy. Both are important. But how much does health care contribute to population health? One way in which this question has been addressed previously is to look at deaths that should not occur in the presence of effective and timely health care, so-called ‘avoidable’ mortality. However much of this work was undertaken in the 1980s and early 1990s, since when health care has advanced considerably. In addition, ‘avoidable’ deaths were often limited to those before, for example, the age of 65, a figure that seems inappropriately low in the light of life expectancies that are now about 80 in many countries. In this review we have traced the evolution of the concept of ‘avoidable’ mortality from its inception in the 1970s. We have undertaken a detailed methodological critique of this concept, examining questions of attribution, issues relating to comparisons over time and place, and relationships with other indicators of health service provision. To help future researchers we have produced a comprehensive, annotated review of the work that has been undertaken worldwide so far. We note that ‘avoidable’ mortality was never intended to be more than an indicator of potential weaknesses in health care that can then be investigated in more depth. We describe examples of where this approach has been successful, drawing attention to problems that might otherwise have been missed. In contrast, many of the critics of ‘avoidable’ mortality, or more specifically, mortality amenable to health care (amenable mortality), have asked that it do something it was not intended to do, to be a definitive source of evidence of differences in effectiveness of health 8 E X E C U T I V E S U M M A R Y care. Thus, it is not unexpected that studies seeking to link amenable mortality with health care resources have failed to do so, especially when undertaken within countries, although it is notable that where gross differences exist, as between western and eastern Europe, the gap in amenable mortality is especially high. For these reasons, it seems justifiable to continue and extend the extensive body of research that has already been undertaken to look at ‘avoidable’ mortality, updating the list of conditions included to reflect the changing scope of health care and extending the age limit to reflect increasing expectation of life. However it must be recognised that the concept of ‘avoidable’ mortality does have important limitations, relating to comparability of data, attribution of causes, and coverage of the range of health outcomes. Comparisons of health system performance are now firmly on the international policy agenda, especially since the publication of the 2000 World Health Report. Incorporation of the concept of mortality amenable to health care into the methodology used to generate the rankings of health systems in that report would be an advance on the current situation. We show how, within Europe, this would lead to different rankings from those based on overall disability adjusted life expectancy, which is used in the current rankings. However, any approach based on aggregate data would not address one of the major criticisms of such comparisons, that they do not indicate what needs to be done when faced with evidence of sub-optimal performance. This requires a more detailed analysis of the specific issues facing health systems. Here we propose a new method, in which analyses of amenable mortality identify areas of potential concern that are then examined in more detail by studying the processes and outcomes of care for tracer conditions, selected on the basis of their ability to assess a wide range of health system components. The second part of the review applies the refined method of amenable mortality analysis to patterns of mortality in the countries of the European Union over the past two decades. This shows that deaths that could be prevented by timely and effective care were still relatively common in many countries in 1980. Reductions in these deaths contributed substantially to the overall change in life expectancy between birth and age 75 during the 1980s. The largest contribution was from falling infant mortality but in some countries reductions in deaths among the middle aged was equally or even more important. These countries were Denmark, The Netherlands, the United Kingdom, France (for men) and Sweden (for women). In contrast, during the 1990s, reductions in amenable mortality made a somewhat smaller contribution to improved life expectancy, especially in the northern European countries. However they remained important in southern Europe, especially in Portugal and Greece, where the initial death rates had been higher. These findings provide clear evidence that improvements in access to effective health care have had a measurable impact in many countries during the 1980s and 1990s, in particular through reductions in infant mortality and in deaths among the middle aged and elderly, especially women. However the scale of impact has, to a considerable extent, reflected the starting point. Thus, those countries where infant mortality was relatively high at the beginning of the 1980s, and which had the greatest scope for improvement, such as Greece 9 D O E S H E A LT H C A R E S A V E L I V E S ? A V O I D A B L E M O R T A L I T Y R E V I S I T E D and Portugal, unsurprisingly saw the greatest reductions in amenable mortality in infancy. In contrast, in countries with infant mortality rates that had already reached very low rates by the beginning of the 1990s, such as Sweden, the scope for further improvement was small. Similarly, the scope for improvement in amenable deaths in adulthood was greatest in those countries where initial rates were highest. The corollary of this is that as rates fall in all countries, the extent of variation decreases. As a consequence, it seems likely that, in the 21st century, the ability to compare health system performance using mortality data at the aggregate level is likely to be limited, simply because the differences will be relatively small. This does not, however, mean that there is not scope for analyses that use amenable mortality rates to screen for potential problems that can then be explored in more depth. It also does not exclude the use of amenable mortality to gain new insights into inequalities in access to care within populations. 10