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European Health Forum Gastein, 5 October 2005. Does Health Care Save Lives? The role of the health care system. Ellen Nolte Martin McKee London School of Hygiene & Tropical Medicine. Thomas McKeown and the role of medicine. Source: McKeown, 1979. Revisiting McKeown. - PowerPoint PPT Presentation
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Does Health Care Save Does Health Care Save Lives? The role of the Lives? The role of the health care system health care system
Ellen NolteMartin McKee
London School of Hygiene & Tropical Medicine
European Health Forum Gastein, 5 October 2005
Thomas McKeown and the role Thomas McKeown and the role of medicineof medicine
Source: McKeown, 1979
Revisiting McKeownRevisiting McKeown
[C]urative medical measures played little role in mortality decline prior to mid-20th century
(Colgrove 2002)
The situation by the end of the The situation by the end of the 1960s1960s Clear evidence of life saving interventions Rapid change was on its way
Cancer chemotherapy Newer antibiotics Improved antihypertensives Thrombolytics The emergence of evidence-based medicine
-100 -80 -60 -40 -20 0
NorwaySwedenAustriaUKDenmarkFinlandSwitzerlandItalyIrelandGermanyNetherlandsGreeceFranceJapanCzech RepublicUSAHungaryPolandSpainBulgaria
Source: Levi et al., 2001
Changing death rates from testicular Changing death rates from testicular cancer age 20-44: 1975-9 to 1995-9cancer age 20-44: 1975-9 to 1995-9
Dramatic reductions in western Europe
Smaller changes in eastern Europe
Improvements in neonatal Improvements in neonatal mortalitymortality
0
5
10
15
20
25
1970 1975 1980 1985 1990 1995 2000
de
ath
s /
10
00
live
bir
ths
Portugal
FinlandEU 15
Sweden
Source: HFA database
Falling mortality from Falling mortality from ischaemic heart diseaseischaemic heart disease
0
100
200
300
400
500
600
1970 1975 1980 1985 1990 1995 2000
SD
R
Spain
Finland
EU 15 Sweden
United Kingdom
Source: HFA database
Falling mortality from Falling mortality from ischaemic heart diseaseischaemic heart disease
New Zealand: 42% of CVD decline 1974-81 attributable to medical care (Beaglehole 1986)
Netherlands: 46% of IHD decline 1978-85 due to medical intervention (eg CABG, post-infarction treatment), 44% due to primary prevention (eg smoking cessation, hypertension treatment) (Bots & Grobee 1996)
USA: 72% of IHD decline 1980-90 due to secondary prevention & treatment (Hunink et al. 1997)
Scotland: 40% of IHD decline 1975-94 attributable to medical care (Capewell et al. 1999)
‘‘Avoidable’ mortality (1)Avoidable’ mortality (1)
Rutstein et al. “unnecessary, untimely deaths” (1976)
Conditions from which, in the presence of timely and effective medical care, premature death should not occur Single case of death (illness/disability): Why did it happen? Rate: not every single case preventable/ manageable
reduction of incidence
‘‘Avoidable’ mortality (2)Avoidable’ mortality (2)
immunisation, e.g. measles
early detection, e.g. cervical cancer
medical treatment, e.g. hypertension
surgery, e.g. appendicitis
‘‘Avoidable’ mortality (3)Avoidable’ mortality (3)
Mackenbach et al. (1988): Impact of specific treatments observable as
accelerating falls in mortality from conditions they were intended to treat
Between 1950 & 1984 changes in deaths from conditions responsive to medical treatment in the Netherlands added 2.9 years to life expectancy at birth in men (women: 3.9 years)
EC Concerted Action Project on Health
Services and ‘Avoidable Deaths’
“provide warning signals of potential shortcomings in
health care delivery “
(4 volumes:1988,1991,1993, 1997)
‘‘Avoidable’ Mortality (4)Avoidable’ Mortality (4)
Treatable (or amenable) mortality Deaths from causes sensitive to health care (primary &
hospital care, collective health interventions eg screening) selected cancers (breast, colorectal, testes, cervix), diabetes <50,
hypertension/stroke, surgical conditions, maternal mortality, perinatal conditions etc.
Preventable mortality Deaths from causes sensitive to public health or inter-sectoral
policies Lung cancer, liver cirrhosis, transport injuries
Variation over timeVariation over time
Mortality from ‘treatable’ conditions declined more rapidly than mortality from other conditions since 1960s Average decline of 6% per year between 1950 and 1984 in NL vs. 2% or no change (men) (Mackenbach et al. 1988)
Acceleration of decline during 1970s & 1980s E&W: average decline of 2.7% per year between 1955/59 & 1970/74 vs. 3.6% in 1970/74-1985/89 (Boys et al. 1991)
Similar findings in CEE but lower pace Average decline of 1-2% per year 1970s/1980s vs. no change/increase in ‘other’ mortality (Boys et al. 1991)
Variation over timeVariation over time
“at least part of the mortality decline from amenable conditions is due to improvements in health care”
(Mackenbach et al. 1990)
Age standardised death ratesAge standardised death rates(0-74) (0-74) from from
treatable causes, 1980 & 1998treatable causes, 1980 & 1998
0
50
100
150
200
250
300
Portu
gal
Austri
a
United
Kin
gdom Ita
ly
Ger
man
y wes
t
Spain
Gre
ece
Finlan
d
Franc
e
Nether
land
s
Denm
ark
Sweden
SD
R a
me
na
ble
ca
use
s (p
er
10
0,0
00
)
1980
1998
men
Source: Nolte & McKee 2004
Age standardised death ratesAge standardised death rates(0-74) (0-74) from from
treatable causes, 1980 & 1998treatable causes, 1980 & 1998
0
50
100
150
200
250
300
Portu
gal
United
Kin
gdom
Austri
a
Gre
ece
Italy
Ger
man
y wes
t
Spain
Denm
ark
Nether
land
s
Finlan
d
Franc
e
Sweden
SD
R a
me
na
ble
ca
use
s (p
er
10
0,0
00
)
1980
1998
women
Source: Nolte & McKee 2004
‘‘Avoidable’ mortality in selected Avoidable’ mortality in selected countries, 2000countries, 2000
0 20 40 60 80 100
Sweden
E&W
Germany
USA
SDR 0- 74
womenmen
0 20 40 60 80 100
Sweden
Germany
E&W
USA
SDR 0- 74
Treatable causes Preventable causes
Source: Nolte, unpublished
men
Age-standardised death ratesAge-standardised death rates(0-74)(0-74) from treatable causes, 1990/91 & from treatable causes, 1990/91 & 2000/02 2000/02
0 50 100 150 200 250 300
Sweden
Slovenia
Lithuania
Portugal
Poland
Czech Republic
Estonia
Latvia
Hungary
Bulgaria
Romania
deaths / 100,000
1990/91
2000/02
Source: Newey, Nolte et al. 2004
women
Age-standardised death ratesAge-standardised death rates(0-74)(0-74) from treatable causes, 1990/91 from treatable causes, 1990/91 & & 2000/022000/02
0 50 100 150 200 250
Sweden
Slovenia
Portugal
Lithuania
Poland
Czech Republic
Estonia
Latvia
Hungary
Bulgaria
Romania
deaths / 100,000
1990/91
2000/02
Source: Newey, Nolte et al. 2004
men
Age-standardised death ratesAge-standardised death rates(0-74)(0-74) from preventable causes, 1990/91 from preventable causes, 1990/91 & 2000/02 & 2000/02
0 50 100 150 200 250
Sweden
Bulgaria
Portugal
Romania
Lithuania
Poland
Czech Republic
Estonia
Latvia
Slovenia
Hungary
deaths / 100,000
1990/91
2000/02
Source: Newey, Nolte et al. 2004
women
Age-standardised death ratesAge-standardised death rates(0-74)(0-74) from preventable causes, 1990/91 from preventable causes, 1990/91 & 2000/02 & 2000/02
0 20 40 60 80
Bulgaria
Sweden
Lithuania
Latvia
Estonia
France
Poland
Czech Republic
Portugal
UK
Romania
Slovenia
Hungary
deaths / 100,000
1990/91
2000/02
Source: Newey, Nolte et al. 2004
Age-standardised death ratesAge-standardised death rates(0-74)(0-74) from preventable causes, 2000/02 from preventable causes, 2000/02
0 50 100 150 200 250
SwedenIreland
UKFinland
NetherlandsGermany
AustriaItaly
PortugalSpain
BulgariaFrance
Czech RepublicPolandEstonia
SloveniaLatvia
LithuaniaRomaniaHungary
deaths / 100,000
men
women
Source: Newey, Nolte et al. 2004
Variation between social groupsVariation between social groups Consistent findings of inequalities
African-Americans vs. white Americans, US Excess mortality from hypertension, cervical cancer, diabetes, peptic ulcer (Woolhander et al. 1985) 4.5 times higher death rates from amenable conditions (Schwartz et al. 1990)
Maori vs. non-Maori in New Zealand Little change over time: ratio M/N-M at 2.3 in 1967 and 2.0 in 1987 (Malcolm & Salmond 1993)
Low socio-economic status (SES) vs. high SES Health services can contribute to the reduction of health inequalities
SummarySummary There is increasing evidence that health can make a
considerable contribution to population health The concept of “avoidable mortality” offers a way to measure
this contribution, and to compare the relative performance of countries and over time
Refinement into ‘treatable’ and ‘preventable’ mortality allows measuring the potential impact of health care from influences of policies that are outside the direct control of health care
Measures at aggregate level (such as avoidable mortality) are limited as they do not indicate which elements of the health system perform ‘sub-optimal’
