commentary: approaches, strengths, and limitations of avoidable mortality

A

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Commentary

Approaches strengths and limitations ofavoidable mortality

Glograveria Peacuterezabcd Maica Rodriacuteguez-Sanzacd Eva CireraceKatherine Peacuterezacd Rosa Puigpinoacutesacd and Carme Borrellabcd

aAgegravencia de Salut Puacuteblica de Barcelona Placcedila Lesseps 1 Barcelona 08023 Spainb Universitat Pompeu Fabra Barcelona SpaincCIBER Epidemiologiacutea y Salud Puacuteblica (CIBERESP) SpaindInstitute of Biomedical Research (IIB Sant Pau) Barcelona SpaineUniversitat de Vic Vic Spain

Corresponding author

Abstract Publication of recent papers such as the one by Schoenbaum andcolleagues entitled lsquoMortality Amenable to Health Care in the United States TheRoles of Demographics and Health Systems Performancersquo has stimulated this com-mentary We discuss strengths and limitations of amenable and avoidable mortalityin health-care systemsrsquo performance and their contribution to health inequalities Toillustrate we present a case study of avoidable and amenable mortality in Spain over27 years We conclude that amenable mortality is not a good indicator of health-caresystemsrsquo performance or for determining whether it could give rise to healthinequalities To understand health problems and to assess the impact of inter-ventions affecting health requires good basic and routine monitoring of healthindicators and of socioeconomic determinants of healthJournal of Public Health Policy advance online publication 13 March 2014doi101057jphp20148

Keywords mortality avoidable mortality health-care system inequalities

Introduction

Publication of the paper by Schoenbaum et al1 entitled lsquoMortalityAmenable to Health Care in the United States The Roles of Demo-graphics and Health Systems Performancersquo in the Journal of PublicHealth Policy and of two more recent works about avoidable mortality23

has spurred us to review the concepts of amenable and avoidable morta-lity their strengths and limitations in the performance of health-care

copy 2014 Macmillan Publishers Ltd 0197-5897 Journal of Public Health Policy 1ndash14wwwpalgrave-journalscomjphp

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systems and the contribution of health-care systems to reducing healthinequalities We illustrate our thinking with a case study on the evolutionof avoidable and amenable mortality over 27 years in Spain

Health Inequalities Context

Social and economic determinants of health are the conditions intowhich people are born grow up live work and age including thehealth system4 These conditions are largely responsible for healthinequalities that is unjust and avoidable differences in health betweenpopulation groups whether defined in social economic demographicor geographical termsHealth-care systems themselves constitute a social and economic

determinant of health both influenced by and influencing the effects ofother social and economic determinants Gender education occupationincome ethnicity and place of residence are linked to access to healthcare In addition the characteristics of the health system such as the typeof funding (universal coverage or not) or territorial allocation of health-care resources depending on the needs of the population determinesaccess to health services4

Interest in Assessing Health-Care Performance

Health-care systems and health-care services represent a large expendi-ture for many countries and play an important role in the health of thepublic Health care absorbs around 10 per cent of global GDP spentmostly in high-income countries4 During the last few decades severalapproaches have been developed that attempt to quantify the contribu-tion to population health of advances in medical technology and knowl-edge In general all approaches require a complex and continuousprocess of evaluation of the efficacy and effectiveness of medicaltreatment and procedures56 In 1972 Cochrane emphasized the impor-tance of research to evaluate the efficacy of treatments in use and of newtreatments as they emerge He highlighted the difficulty of conductingsuch research to relate resources with health outcomes7 In addition hedistinguished between social outcomes (equality among social classesand regions) and therapeutic outcomes (treating disease) concludingthat the latter were much easier to assess Regarding therapeutic out-come Cochrane suggested that changes in morbidity and mortality

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could be analyzed in terms of the resources dedicated to health servicesHe also pointed to enormous difficulty in assessing quality of healthservices in terms of health outcomes ndash principally because of inefficientuse of effective treatments and considerable use of ineffective treatments

Amenable Mortality Concept and Origins

In 1976 as a tool for medical audit Rutstein et al8 identified a listof lsquoamenablersquo health conditions Deaths on this list were consideredto represent lsquountimely and unnecessary deathsrsquo and their occurrencewas an indication that the quality of health-care services might needimprovement The concept lsquoAmenablersquo mortality an indicator of theoutcome of health care has been applied widely since then Furtherstudies by Charlton et al9 led to selection of 14 conditions fromRutsteinrsquos10 original list that should be wholly amenable in the UnitedKingdom when analyzing mortality at population level Since thennumerous atlases have been published including those by Hollandet al for Europe covering from 199111 to 199712 Further researchincludes that of Westerling et al1314 Others have published scientificpapers that conclude that amenable mortality remains a good indicatorof health services quality15

More recently complementary approaches have been developed16

introducing the concept of lsquoavoidablersquo mortality ndash meaning causes ofdeaths considered amenable to both medical intervention and healthpolicy Thus causes of death are classified into deaths due to causesavoidable through primary prevention (certain causes of death relatedto lifestyles and inter-sectoral policies) through secondary prevention(screening programs) and mortality avoidable by improving diagnosisand medical treatment Of particular importance is the contributionof Nolte et al17 to the definition and uses of avoidable mortality as anoverall indicator (For a more complete review of the uses of avoidablemortality see Castelli and Nizalova18)

Potential Usefulness of Amenable Mortality in AssessingHealth-Care Performance

In recent years interest in use of amenable mortality for assessing theperformance of health systems has grown ndash surely stimulated by theWorld Health Report 200019 a powerful tool for politicians to classify

Commentary

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health-care systems and countries However the latest developmentsin the field have introduced a degree of uncertainty about causal attribu-tion of causes of death to the quality of health careThe WHO report erroneously attributed low mortality in Southern

European countries to the effectiveness of their medical care Thosecountries traditionally have good health indicators with long lifeexpectancies They have different types of health services but theirpublic expenditures in health-care systems as a percentage of grossnational product are among the lowest in the European Union20

The mistaken assumption overestimation of the effectiveness of medicaland health care has not been taken into consideration and a numberof national and international scientific organizations continue to explorehow avoidable mortality can be used for regular monitoring andcomparing health systemsDeath from any cause is the final outcome in a complex chain of

events and deciding which causes of death are to be considered avoid-able by different kinds of interventions remains a problem Note thatmost of the indicators of avoidable mortality must be partitioned intoa proportion to which reductions are attributable ndash as primary second-ary or tertiary actions21 The intervention for example that mostreduces maternal mortality is improving access to and use of healthcare22 but this intervention could not be classified as a result only oreven principally of health care because opening such services is a socialeconomic and political intervention Once women are regularly ableto use health services including prenatal and delivery care maternalmortality will decline23

As noted by Mackenbach et al15 the list of causes of death defined aspotentially avoidable has varied ndash by including or excluding a particularcause of death ndash depending on relevance in each study region and theavailability of mortality data In most cases these reasons have not beenmade explicit and may limit the comparability between countries orregions In Spain some studies have highlighted difficulty in assessinggeographical inequalities by studying amenable mortality aggregated bysmall areas24 Furthermore progress in health care or in public healthpolicies may have rendered the value of some conditions questionableeven when they had previously been considered to be relatively impor-tant indicators of the quality of health care2526 Despite such limitationsmany studies have been conducted272829 comparing avoidable mortal-ity across countries303132 or trends within a country33343536

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Case Study Avoidable Mortality in Spain

We present a case study as a way to describe the evolution of amenableand avoidable mortality in Spain We highlight difficulties in relating theevolution of amenable and avoidable mortality to health-care systemandor inter-sectoral services and policy interventions We used Spanishmortality data provided by the National Institute of Statistics that coversa period of 27 years We selected the list of causes of death based onvarious studies162134 and classified them according to whether theywere considered responsible for

1 Deaths amenable through health service interventions employing abroad definition of the health-care system including primary carespecialized care and community health services

2 Deaths avoidable through inter-sectoral health policy interventionsdefined as primary prevention implemented in contexts other than thehealth-care system The main causes of death in this group werecancer of trachea bronchus and lung AIDS and HIV disease andmotor vehicle-related injuries

3 Deaths avoidable through public health programs defined as mortal-ity avoidable by screening and public health programs such asimmunization The main causes of death were female breast cancerand diseases that can be prevented through vaccination This groupof avoidable causes of death has sometimes been included in the inter-sectoral group

Note the difficulty involved in classifying certain causes of death ina specific group (for instance AIDSndashHIV diseases could be regarded asavoidable through interventions corresponding to all three groups)The trend of global mortality in Spain over 27 years shows the same

declining pattern and similar magnitude as global avoidable mortalityamong men (Figure 1) Among women global mortality is higher thanglobal avoidable mortality This shows that causes of death includedin the list of avoidable causes of mortality may not reflect the maincauses of death in women (Figure 2)Whereas mortality amenable through the health-care system

decreases mortality avoidable through health programs remains con-stant over time Mortality avoidable by inter-sectoral health interven-tions increases until the midpoint of the period followed by anobservable decline over the last decade (Figures 1 and 2)

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Similar results on mortality avoidable through health care have beenobserved in other studies in Spain2627 and in other countries1517 eventhough these investigators used different lists of causes of death

020406080

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MR Global mortality per 100000

Avoidable mortality Health service interventions

Health inter-sectorial interventions Global mortality

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20

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1981

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MR per 100000

Cancer of trachea bronchus and lung Motor vehicle-related injuriesAIDS and VIH Cerebro-vascular diseaseHeart ischaemic disease

1981

1982

1983

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2007

a

b

Figure 1 (a) Evolution of age standardized avoidable mortality rate (SMR) in men in Spain 1981ndash2007 SMR of global and avoidable mortality (b) Evolution of SMR of specific causes of death

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As some authors have stated17 cerebrovascular mortality andischemic heart disease mortality have relatively large impacts on thetrend of mortality amenable through health care as these causes account

020406080

100120140160180200220240260280300320340

a

19811982

19831984

19851986

19871988

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19911992

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20012002

20032004

20052006

2007

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MR per 100000

0

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MR global mortality per 100000


Health inter-sectorial interventions Health programs

Global mortality

0

10

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1981

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2005

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2007

Years

MR per 100000

Cancer of trachea bronchus and lung Motor vehicle-related injuries

AIDS and VIH Breast cancer

Cerebro-vascular disease Ischaemic heart disease

b

Figure 2 (a) Evolution of age standardized avoidable mortality rate (SMR) in women in Spain1981ndash2007 SMR of global and avoidable mortality (b) Evolution of SMR of specific causes of death

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for most deaths in the group The potential impact of health care oncerebrovascular mortality or ischemic heart disease mortality could bemeasured in terms of increasing survival by advances in treatment of riskfactors such as hypertension37 among others38 and by management ofacute episodes3940

Breast cancer is included in the group of mortality avoidable throughprograms Breast cancer mortality in Spain has declined faster in the lastdecade a phenomenon observed in other countries4142 along with anincrease of survival because of advances in treatments including insurgical techniques43

The relatively slow or non-existent decline in mortality from causesof death considered avoidable through inter-sectoral interventionscould again be influenced by the specific causes listed such as lungcancer AIDSndashHIV disease and vehicle-related injuries Mortality due tothese three causes has evolved differently during our period of studybecause of changes in prevention measures diagnosis and treatmentimplemented as well as political measures adopted Campaigns toprevent smoking or to prevent HIVAIDS are not solely attributable tohealth care initiatives in contrast to the case of HIV infection wherehealth services have been shown to be effective parts of an HIVprevention strategy44 Motor vehicle-related injuries illustrate a politicalcontribution to reducing mortality Spain established road safety as apolitical priority principally to achieve a 40 per cent reduction in roadfatalities from 2003 to 2008 An evaluation of the effectiveness of suchmeasures showed positive results45

Our case study shows that it can be difficult to assign a cause of deathto only one of the above three groups because the evolution of mortalitydue to some causes may be affected by health services interventionsor by health prevention and promotion strategies or by inter-sectoralpolicies46

State of the Art Today

New research12 and even a new atlas3 about avoidable mortalityhave been published recently Schoenbaum et al1 demonstrate therelationship between poverty and ethnicity and amenable mortalityacross the United States Schoenbaum and colleagues state that scientificpapers have been published describing similar relationships between

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poorer health outcomes death being one of them and the social andeconomic status of the populationThey also present evidence for an interaction between poverty

and lack of health insurance coverage In the discussion they clearlyidentify social and economic factors that determine inequitable accessto health care in the United States They also showed a relationshipbetween amenable causes of death and indicators of poor health systemperformance But the final recommendation of Schoenbaum et al1 wasto lsquohellip encourage states to adopt goals to improve health-systemindicators associated with amenable mortalityrsquo The authors forget thatimproving access to health care improves health ndash but this is a politicalchange that would not therefore be classified as attributable to healthsystem performanceIn June 2012 the United States Supreme Court upheld a law enacted

by the United States Congress in 2010 to reform health-care insurancePolitical changes in the model of health care in the United States willsurely improve the access to health services for the previously uninsuredpopulation47 As a consequence of this political change better healthindicators can be expected in the next few years including a reduction ofmortalityTo illustrate geographical and social variations in avoidable and

amenable mortality within and between Australia and New Zealandan atlas has been published3 using those causes of death consideredpotentially avoidable given available knowledge about social andeconomic policy impacts health behaviors and health care As the atlasrsquoauthors state in their introduction avoidable mortality cannot providea definitive indicator of the performance of a health service or of thehealth system although they believe that avoidable mortality couldprovide an indication that performance is poor ndash but without identify-ing the problems with performance They justify the use of avoidablemortality lsquogiven the ease and low cost with which avoidable andamenable mortality can be monitoredrsquoRecently advances have been proposed in an effort to connect specific

health-care improvements and avoidable mortality The AMIEHS project(Avoidable Mortality in the European Union) for example specificallyselects causes of death based only on the effectiveness of interventions inpreventing deaths4849 In the final report AMIEHS researchers state thatof 14 conditions selected in the study variations in mortality reflectvariations in the effectiveness of health care only for 3 (colorectal cancer

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cervical cancer and cerebrovascular disease)50 Moreover the AMIEHSprincipal investigators conclude that lsquoin the current state of knowledgebetween country differences in the absolute levels of mortality fromamenable conditions cannot be recommended for use in routine surveil-lance of health-care performancersquo2

Schonbaum et al1 also identified difficulty involved in comparingcountries based on avoidable and amenable mortality implying a similardifficulty in using atlases of avoidable mortality for this purpose Suchatlases however may still be useful for describing avoidable mortalitywithin a given country

The Way Forward

As we demonstrate in our case study global indicators of avoidablemortality tend to mask the shape and magnitude of trends in specificcauses of death Moreover some causes of death included in the groupof mortality avoidable through health care may sometimes also beincluded in the group of mortality avoidable through inter-sectoralinterventions (and conversely some in the inter-sectoral interventionsgroup also avoidable by health care) as was revealed by the analysisof avoidable mortality in SpainRecent studies allow us to conclude that avoidable mortality does

not seem to appear to be a good indicator for analyzing the performanceof health-care systems or for determining whether these systems maygive rise to health inequalitiesTo understand health problems and to assess the impact of inter-

ventions requires good basic and routine monitoring of health indi-cators and social determinants This approach is consistent with thestatement from the Institute of Innovation and Improvement of theBritish National Health Service51 lsquoIf you are not sure if the indicatorsyou are proposing actually measure what they claim to measure thendo not proceed until the proposed indicators have been tested (ievalidated)rsquo The analysis of mortality due to specific causes of deathshould be examined separately by sex age social class incomeethnicity and territory (area of residence) This will help us understandpossible influences of interventions over time Thus a new approach tothe lsquoavoidabilityrsquo in mortality is needed an approach that would takeinto account the contextual framework of social and economic determi-nants of health

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Acknowledgements

This study was partly funded by CIBER Epidemiologiacutea and SaludPuacuteblica of Spain by theMinisterio de Sanidad y Consumo Observatoriode Salud de la Mujer Direccioacuten General de la Agencia de Calidad andby the Ministerio de Ciencia e Innovacioacuten Instituto de Salud Carlos IIIof Spain The program of lsquoIntensificacioacuten de la actividad investigadora(Carme Borrell)rsquo was funded by the Instituto Carlos III and the Depart-ment of Health Generalitat de Catalunya Spain We also thank DaveMacfarlane for editing and reviewing the manuscript

About the Authors

Glograveria Peacuterez MD PhD works in the Health Information SystemsService at the Agegravencia de Salut Puacuteblica de Barcelona and is an AssistantProfessor at the Universitat Pompeu Fabra Barcelona Spain and theJohns Hopkins University Baltimore USA

Maica Rodriacuteguez-Sanz MPH is a statistician and the Head of MortalityRegister of Barcelona in the Health Information Systems Service ofAgegravencia de Salut Puacuteblica de Barcelona She is a researcher at theSpanish Research Network on Epidemiology and Public Health andshe is an Assistant Professor at theUniversitat Pompeu Fabra BarcelonaSpain

Eva Cirera MPH is a Professor of Statistics and Epidemiology inUniversitat de Vic in Vic Spain and is working in her dissertationin Biomedicine on Population Health and Injuries

Katherine Peacuterez MPH and PhD is a psychologist working in theHealth Information Systems Service at the Agegravencia de Salut Puacuteblicade Barcelona Spain She is responsible for the Health InformationSystem on Injuries in Barcelona

Rosa Puigpinoacutes MPH and PhD is a biologist working at the Agegravenciade Salut Puacuteblica de Barcelona Spain She is coordinator of the TechnicalOffice of the Population of Breast Cancer Screening Program inBarcelona

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Carme Borrell MD and PhD works at the Agegravencia de Salut Puacuteblicade Barcelona Spain and is an Assistant Professor at the UniversitatPompeu Fabra there and the Johns Hopkins University in BaltimoreUSA She is the main coordinator of SOPHIE project (7th frameworkof European Union)

References

1 Schoenbaum SC Schoen C Nicholson JL and Cantor JC (2011) Mortality amenable tohealth care in the United States The roles of demographics and health systems performanceJournal of Public Health Policy 32(4) 407ndash429

2 Mackenbach JP et al (2013) Using lsquoamenable mortalityrsquo as indicator of healthcare effective-ness in international comparisons Results of a validation study Journal of Epidemiology andCommunity Health 67(2) 139ndash146

3 University of Adelaide (2006) Australian and New Zealand atlas of avoidable mortality httpwwwpublichealthgovaupublicationsaustralian-and-new-zealand-atlas-of-avoidable-mortalityhtml accessed January 2013

4 Commission on Social Determinants of Health (CSDH) (2008) Closing the gap in a generationHealth equity through action on the social determinants of health Final Report of the Commissionon Social Determinants of Health Geneva World Health Organization httpwwwwhointsocial_determinantsthecommissionfinalreportenindexhtml accessed September 2012

5 McDaid D and Cookson R on behalf of the ASTEC group (2003) Evaluating health careinterventions in the European Union Health Policy 26(2) 133ndash139

6 Donabedian A (2003) An Introduction to Quality Assurance in Health Care New YorkOxford University Press

7 Cochrane AL (1985) Eficacia y eficiencia Reflexiones al azar sobre los servicios sanitarios[Effectiveness amp Efficiency Random Reflections on Health Services] Originally published inEnglish in 1972 Barcelona Salvat in Spanish

8 Rutstein DD Berenberg W Chalmers TC Child CG Fishman AP and Perrin EB(1976) Measuring the quality of medical care A clinical methodNew England Journal of Medicine294(11) 582ndash588

9 Charlton JR Hartley RM Silver R and Holland WW (1983) Geographical variation inmortality from conditions amenable to medical intervention in England and Wales Lancet1(8326 Pt 1) 691ndash696

10 Rutstein DD Berenberg W Chalmers TC Child CG Fishman AP and Perrin EB(1977) Measuring the quality of medical care Revision of tables of indexes New EnglandJournal of Medicine 297(9) 508

11 Holland WW (ed) (1991) EC Working Group on Health Services and Avoidable DeathsEuropean Community Atlas of lsquoAvoidable Deathrsquo Oxford Oxford University Press

12 Holland WW (ed) (1997) EC Working Group on Health Services and Avoidable DeathsEuropean Community Atlas of lsquoAvoidable Deathrsquo Oxford Oxford University Press 1985ndash1989

13 Westerling R (1992) lsquoAvoidablersquo causes of death in Sweden 1974ndash85Qual Assur Health Care4(4) 319ndash328

14 Westerling R and Rosen M (2002) lsquoAvoidablersquo mortality among immigrants in SwedenEuropean Journal of Public Health 12(4) 279ndash286

15 Mackenbach JP Bouvier-Colle MH and Jougla E (1990) lsquoAvoidablersquo mortality and healthservices A review of aggregate data studies Journal of Epidemiology and Community Health44(2) 106ndash111

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16 Simonato L Ballard T Bellini P and Winkelmann R (1998) Avoidable mortality in Europe1955ndash1994 A plea for prevention Journal of Epidemiology and Community Health 52(10)624ndash630

17 Nolte E and McKee M (2004) Does Health Care Save Lives Avoidable Mortality RevisitedLondon Nuffield Trust

18 Castelli A and Nizalova O (2011) Avoidable mortality What it means and how it is measuredhttpwwwyorkacukmediachedocumentspapersresearchpapersCHERP63_avoidable_mortality_what_it_means_and_how_it_is_measuredpdf accessed January 2013

19 World Health Organization (2000) Health Systems Improving Performance Geneva Switzer-land WHO

20 Navarro V (2000) Assessment of the World Health Report 2000 The Lancet 356(9241)1598ndash1601

21 Tobias M and Jackson G (2001) Avoidable mortality in New Zealand 1981ndash97 Australianand New Zealand Journal of Public Health 25(1) 12ndash20

22 Sundari TK (1992) The untold story How the health care systems in developing countriescontribute to maternal mortality International Journal of Health Services 22(3) 513ndash528

23 Jowett M (2000) Safe motherhood interventions in low-income countries An economicjustification and evidence of cost effectiveness Health Policy 53(3) 201ndash228

24 Vegara M Benach J Martiacutenez JM Buxoacute M and Yasui Y (2009) Avoidable and nonavoidable mortality Geographical distribution in small areas in Spain (1990ndash2001) [Spanish]Gaceta Sanitaria 23(1) 16ndash22

25 Vergara M (2009) Causas de lsquomortalidad prematura evitablersquo Estrategias de clasificacioacuten yaplicacioacuten al anaacutelisis de la desigualdad geograacutefica en Espantildea [Causes of lsquoavoidable prematuremortalityrsquo Strategies classification and analysis application geographical inequality in Spain]PhD dissertation httpwwwtdxcatbitstreamhandle108037204tmvpdfjsessionid=2C34927F17CBB49B93A96C818E0850D1tdx2sequence=1 accessed January 2013

26 Goldberger N and Haklai Z (2012) Mortality rates in Israel from causes amenable to healthcare regional and international comparison Israel Journal of Health Policy Research 1 41

27 Bernat-Gil LM and Rathwell T (1989) The effect of health services on mortality Amenableand non-amenable causes in Spain International Journal of Epidemiology 18(3) 652ndash657

28 Benavides FG Orts R and Perez S (1992) Adding years to life Effect of avoidable mortalityon life expectancy at birth Journal of Epidemiology and Community Health 46(4) 394ndash395

29 Albert X Bayo A Alfonso JL Cortina P and Corella D (1996) The effectiveness of healthsystems in influencing avoidable mortality A study in Valencia Spain 1975ndash90 Journal ofEpidemiology and Community Health 50(3) 320ndash325

30 Kunst AE Looman CWN and Mackenbach JP (1988) Medical care and regionalmortality differences within the countries of the European Community European Journal ofPopulation 4(3) 223ndash245

31 Manuel DG and Mao Y (2002) Avoidable mortality in the United States and in Canada1980ndash1996 American Journal of Public Health 92(9) 1481ndash1484

32 Treurniet HF Boshuizen HC and Harteloh PP (2004) Avoidable mortality in Europe(1980ndash1997) A comparison of trends Journal of Epidemiology and Community Health 58(4)290ndash295

33 Chung JI Song YM Choi JS and Kim BM (2008) Trends in avoidable death over20 years in Korea Journal of Korean Medical Science 23(6) 975ndash981

34 James PD Manuel DG and Mao Y (2006) Avoidable mortality across Canada from 1975to 1999 BMC Public Health 23(6) 137

35 Gispert Magarolas R et al (2006) Health system interventions assessment in Spain Anapproach through the analysis of the time trends and the geographical variability of avoidablemortality between 1986ndash2001 [Spanish] Revista Espantildeola de Salud Puacuteblica 80(4) 139ndash155

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36 Nolasco A et al (2009) Preventable avoidable mortality Evolution of socioeconomic inequal-ities in urban areas in Spain 1996ndash2003 Health amp Place 15(3) 732ndash741

37 Derby CA Lapane KL Feldman HA and Carleton RA (2000) Trends in validated casesof fatal and non-fatal stroke stroke classification and risk factors in Southeastern NewEngland 1980 to 1991 Data from the Pawtucket heart health program Stroke 31(4) 875ndash881

38 Geacutervas J Peacuterez-Fernaacutendez M Palomo-Cobos L and Pastor-Saacutenchez R (2005) Twenty yearsof reform of primary care in Spain Ministerio Sanidad y Consumo httpwwwmscesaccessed 26 May 2010

39 Vartiainen E Sarti C Tuomilehto J and Kuulasmaa K (1995) Do changes in cardiovascularrisk factors explain changes in mortality from stroke in Finland British Medical Journal310(6984) 901ndash904

40 Loacutepez-Valcaacutercel BG and Pinilla J (2008) The impact of medical technology on healthA longitudinal analysis of ischemic heart disease Value in Health 11(1) 88ndash96

41 Schopper D and de Wolf C (2009) How effective are breast cancer screening programmes bymammography Review of the current evidence European Journal of Cancer 45(11) 1916ndash1923

42 Pons-Vigueacutes M Puigpinoacutes R Cano-Serral G Mariacute-DellrsquoOlmo M and Borrell C (2008)Breast cancer mortality in Barcelona following implementation of a city breast cancer-screeningprogram Cancer Detection and Prevention 32(2) 162ndash167

43 Clegraveries R Ribes J Esteban L Martiacutenez JM and Borragraves JM (2006) Time trends of breastcancer mortality in Spain during the period 1977ndash2001 and Bayesian approach for projectionsduring 2002ndash2016 Annals of Oncology 17(12) 1783ndash1791

44 Auerbach J (2009) Transforming social structures and environments to help in HIV preven-tion Health Affairs (Millwood) 28(6) 1655ndash1665

45 Novoa AM et al (2011) Road safety in the political agenda The impact on road trafficinjuries Journal of Epidemiology and Community Health 65(3) 218ndash225

46 Villalbiacute JR Guarga A and Pasariacuten MI (1999) Evaluation of primary care reform impact onhealth [Spanish] Atencion Primaria 24(8) 468ndash474

47 Hisnanick JJ and Coddington DA (1995) Measuring human betterment through avoidablemortality A case for universal health care in the USA Health Policy 34(1) 9ndash19

48 AMIEHS (2009) Avoidable mortality in the European Union Towards better indicators for theeffectiveness of health systems httpamiehslshtmacuk accessed 21 February 2011

49 Hoffman R Plug I Khoshaba B McKee M and Mackenbach JP AMIEHS wrokinggroup (2013) Amenable mortality revisited The AMIEHS study Gaceta Sanitaria 27(3)199ndash206

50 AMIEHS Project (2012) Avoidable mortality in the European Union final report httpamiehslshtmacukpublicationsreportsAMIEHS20final20report20VOL20Ipdf accessedJuly 2012

51 NHS Institute for Innovation and Improvement (2007) The Good Indicators Guide Under-standing How to Use and Choose Indicators Coventry UK University of Warwick Campus

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systems and the contribution of health-care systems to reducing healthinequalities We illustrate our thinking with a case study on the evolutionof avoidable and amenable mortality over 27 years in Spain

Health Inequalities Context

Social and economic determinants of health are the conditions intowhich people are born grow up live work and age including thehealth system4 These conditions are largely responsible for healthinequalities that is unjust and avoidable differences in health betweenpopulation groups whether defined in social economic demographicor geographical termsHealth-care systems themselves constitute a social and economic

determinant of health both influenced by and influencing the effects ofother social and economic determinants Gender education occupationincome ethnicity and place of residence are linked to access to healthcare In addition the characteristics of the health system such as the typeof funding (universal coverage or not) or territorial allocation of health-care resources depending on the needs of the population determinesaccess to health services4

Interest in Assessing Health-Care Performance

Health-care systems and health-care services represent a large expendi-ture for many countries and play an important role in the health of thepublic Health care absorbs around 10 per cent of global GDP spentmostly in high-income countries4 During the last few decades severalapproaches have been developed that attempt to quantify the contribu-tion to population health of advances in medical technology and knowl-edge In general all approaches require a complex and continuousprocess of evaluation of the efficacy and effectiveness of medicaltreatment and procedures56 In 1972 Cochrane emphasized the impor-tance of research to evaluate the efficacy of treatments in use and of newtreatments as they emerge He highlighted the difficulty of conductingsuch research to relate resources with health outcomes7 In addition hedistinguished between social outcomes (equality among social classesand regions) and therapeutic outcomes (treating disease) concludingthat the latter were much easier to assess Regarding therapeutic out-come Cochrane suggested that changes in morbidity and mortality

Peacuterez et al


A

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0

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1981

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2000

2001

2002

2003

2004

2005

2006

2007

Years

MR per 100000


1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

a

b


Peacuterez et al


A

UTHOR COPY


020406080

100120140160180200220240260280300320340

a

19811982

19831984

19851986

19871988

19891990

19911992

19931994

19951996

19971998

19992000

20012002

20032004

20052006

2007

Years

MR per 100000

0

100

200

300

400

500

600

700

800




Global mortality

0

10

20

30

40

50

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

Years

MR per 100000




b


Commentary


A

UTHOR COPY







Peacuterez et al


A

UTHOR COPY






Commentary


A

UTHOR COPY



The Way Forward




Peacuterez et al


A

UTHOR COPY

Acknowledgements


About the Authors






Commentary


A

UTHOR COPY


References
















Peacuterez et al


A

UTHOR COPY





















Commentary


A

UTHOR COPY

















Peacuterez et al


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A

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Peacuterez et al


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Commentary


A

UTHOR COPY


020406080

100120140160180200220240260280300320340

Years

MR per 100000

0

100

200

300

400

500

600

700

800

900

1000

1100

1200




0

20

40

60

80

100

120

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

Years

MR per 100000


1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

a

b


Peacuterez et al


A

UTHOR COPY


020406080

100120140160180200220240260280300320340

a

19811982

19831984

19851986

19871988

19891990

19911992

19931994

19951996

19971998

19992000

20012002

20032004

20052006

2007

Years

MR per 100000

0

100

200

300

400

500

600

700

800




Global mortality

0

10

20

30

40

50

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

Years

MR per 100000




b


Commentary


A

UTHOR COPY







Peacuterez et al


A

UTHOR COPY






Commentary


A

UTHOR COPY



The Way Forward




Peacuterez et al


A

UTHOR COPY

Acknowledgements


About the Authors






Commentary


A

UTHOR COPY


References
















Peacuterez et al


A

UTHOR COPY





















Commentary


A

UTHOR COPY

















Peacuterez et al


A

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Peacuterez et al


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A

UTHOR COPY


020406080

100120140160180200220240260280300320340

Years

MR per 100000

0

100

200

300

400

500

600

700

800

900

1000

1100

1200




0

20

40

60

80

100

120

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

Years

MR per 100000


1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

a

b


Peacuterez et al


A

UTHOR COPY


020406080

100120140160180200220240260280300320340

a

19811982

19831984

19851986

19871988

19891990

19911992

19931994

19951996

19971998

19992000

20012002

20032004

20052006

2007

Years

MR per 100000

0

100

200

300

400

500

600

700

800




Global mortality

0

10

20

30

40

50

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

Years

MR per 100000




b


Commentary


A

UTHOR COPY







Peacuterez et al


A

UTHOR COPY






Commentary


A

UTHOR COPY



The Way Forward




Peacuterez et al


A

UTHOR COPY

Acknowledgements


About the Authors






Commentary


A

UTHOR COPY


References
















Peacuterez et al


A

UTHOR COPY





















Commentary


A

UTHOR COPY

















Peacuterez et al


A

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Commentary


A

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020406080

100120140160180200220240260280300320340

Years

MR per 100000

0

100

200

300

400

500

600

700

800

900

1000

1100

1200




0

20

40

60

80

100

120

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

Years

MR per 100000


1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

a

b


Peacuterez et al


A

UTHOR COPY


020406080

100120140160180200220240260280300320340

a

19811982

19831984

19851986

19871988

19891990

19911992

19931994

19951996

19971998

19992000

20012002

20032004

20052006

2007

Years

MR per 100000

0

100

200

300

400

500

600

700

800




Global mortality

0

10

20

30

40

50

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

Years

MR per 100000




b


Commentary


A

UTHOR COPY







Peacuterez et al


A

UTHOR COPY






Commentary


A

UTHOR COPY



The Way Forward




Peacuterez et al


A

UTHOR COPY

Acknowledgements


About the Authors






Commentary


A

UTHOR COPY


References
















Peacuterez et al


A

UTHOR COPY





















Commentary


A

UTHOR COPY

















Peacuterez et al


A

UTHOR COPY


020406080

100120140160180200220240260280300320340

Years

MR per 100000

0

100

200

300

400

500

600

700

800

900

1000

1100

1200




0

20

40

60

80

100

120

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

Years

MR per 100000


1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

a

b


Peacuterez et al


A

UTHOR COPY


020406080

100120140160180200220240260280300320340

a

19811982

19831984

19851986

19871988

19891990

19911992

19931994

19951996

19971998

19992000

20012002

20032004

20052006

2007

Years

MR per 100000

0

100

200

300

400

500

600

700

800




Global mortality

0

10

20

30

40

50

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

Years

MR per 100000




b


Commentary


A

UTHOR COPY







Peacuterez et al


A

UTHOR COPY






Commentary


A

UTHOR COPY



The Way Forward




Peacuterez et al


A

UTHOR COPY

Acknowledgements


About the Authors






Commentary


A

UTHOR COPY


References
















Peacuterez et al


A

UTHOR COPY





















Commentary


A

UTHOR COPY

















Peacuterez et al


A

UTHOR COPY


020406080

100120140160180200220240260280300320340

a

19811982

19831984

19851986

19871988

19891990

19911992

19931994

19951996

19971998

19992000

20012002

20032004

20052006

2007

Years

MR per 100000

0

100

200

300

400

500

600

700

800




Global mortality

0

10

20

30

40

50

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

Years

MR per 100000




b


Commentary


A

UTHOR COPY







Peacuterez et al


A

UTHOR COPY






Commentary


A

UTHOR COPY



The Way Forward




Peacuterez et al


A

UTHOR COPY

Acknowledgements


About the Authors






Commentary


A

UTHOR COPY


References
















Peacuterez et al


A

UTHOR COPY





















Commentary


A

UTHOR COPY

















Peacuterez et al


A

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Peacuterez et al


A

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A

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The Way Forward




Peacuterez et al


A

UTHOR COPY

Acknowledgements


About the Authors






Commentary


A

UTHOR COPY


References
















Peacuterez et al


A

UTHOR COPY





















Commentary


A

UTHOR COPY

















Peacuterez et al


A

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A

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The Way Forward




Peacuterez et al


A

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Acknowledgements


About the Authors






Commentary


A

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References
















Peacuterez et al


A

UTHOR COPY





















Commentary


A

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The Way Forward




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About the Authors






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A

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References
















Peacuterez et al


A

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Peacuterez et al


commentary: approaches, strengths, and limitations of avoidable mortality

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