1. Does Health Care Save Lives? The role of the health care system
European Health Forum Gastein, 5 October 2005
Ellen Nolte Martin McKee London School of Hygiene & Tropical Medicine
Does Health Care Save Lives? The role of the health care system

2. Thomas McKeown and the role of medicine
Source: McKeown, 1979

3. Revisiting McKeown
[C]urative medical measures played little role in mortality decline prior to mid-20th century
(Colgrove 2002)

4. The situation by the end of the 1960s
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

5. Changing death rates from testicular cancer age 20-44: 1975-9 to 1995-9
Dramatic reductions in western Europe
Smaller changes in eastern Europe
Source: Levi et al., 2001

6. Improvements in neonatal mortality
Source: HFA database

7. Falling mortality from ischaemic heart disease
Source: HFA database

8. Falling mortality from ischaemic heart disease
New Zealand: 42% of CVD decline attributable to medical care (Beaglehole 1986)
Netherlands: 46% of IHD decline 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 due to secondary prevention & treatment (Hunink et al. 1997)
Scotland: 40% of IHD decline attributable to medical care (Capewell et al. 1999)

9. ‘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

10. ‘Avoidable’ mortality (2)
immunisation, e.g. measles
early detection, e.g. cervical cancer
medical treatment, e.g. hypertension
surgery, e.g. appendicitis

11. ‘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)

12. 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)

13. ‘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

14. Variation 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/ /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)

15. Variation over time
“at least part of the mortality decline from amenable conditions is due to improvements in health care”
(Mackenbach et al. 1990)

16. Age standardised death rates(0-74) from treatable causes, 1980 & 1998
men
Source: Nolte & McKee 2004

17. Age standardised death rates(0-74) from treatable causes, 1980 & 1998
women
Source: Nolte & McKee 2004

18. ‘Avoidable’ mortality in selected countries, 2000
men
women
Treatable causes
Preventable causes
Source: Nolte, unpublished

19. Age-standardised death rates(0-74) from treatable causes, 1990/91 & 2000/02
men
Source: Newey, Nolte et al. 2004

20. Age-standardised death rates(0-74) from treatable causes, 1990/91 & 2000/02
women
Source: Newey, Nolte et al. 2004

21. Age-standardised death rates(0-74) from preventable causes, 1990/91 & 2000/02
men
Source: Newey, Nolte et al. 2004

22. Age-standardised death rates(0-74) from preventable causes, 1990/91 & 2000/02
women
Source: Newey, Nolte et al. 2004

23. Age-standardised death rates(0-74) from preventable causes, 2000/02
Source: Newey, Nolte et al. 2004

24. Variation 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

25. Summary
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’