1. Can the Concept of Avoidable Deaths Complement WHO Health System Performance? Elena A. Varavikova, MD, PhD, MPH, Researcher, OSD/FSP

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. Early Neonatal Mortality Rates

9. 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

10. Contributions of different groups of causes of death to the life expectancy gap between Russia and the UK: 1965-1999

12. Life expectancy at birth in Russia, Baltic countries and the UK in 1965-2000 (both sexes)

13. Trends in SDRs for avoidable causes of death since 1965: Russia, Baltic countries and the UK, both sexes, per 100000

14. Ischemic Heart Disease, Selected Countries, 1970-1998

15. Mortality from Cerebrovascular Disease, Selected Countries, 1970-1998

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

19. 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

20. 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)

21. 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

22. 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.