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RESEARCH AND PRACTICE |
Douglas G. Manuel is with the Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada, and the Department of Public Health Sciences, University of Toronto. Yang Mao is with the Laboratory Centre for Disease Control, Health Canada, Ottawa, Ontario, Canada.
Correspondence: Requests for reprints should be sent to Douglas G. Manuel, MD, MSc, FRCPC, Institute for Clinical Evaluative Sciences G-119, 2075 Bayview Ave, Toronto, ON M4N 3M5, Canada (e-mail: doug.manuel{at}ices.on.ca).
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INTRODUCTION |
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 TOP INTRODUCTION METHODSRESULTSDISCUSSIONReferences |
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In 1976, Rutstein et al. proposed "avoidable mortality" as a simple and practical population-based method of counting "untimely and unnecessary deaths" from diseases for which effective public health and medical interventions are available.6 An excess of such deaths could be viewed as a signal of possible shortcomings in the health care system that warranted further investigation. For a sentinel disease to be defined as avoidable, there must be identifiable, effective interventions and available health care providers. Use of the avoidable mortality measure became common in Europe following refinements in the original Rutstein et al. disease groups by Charlton in the disease groups by Charlton et al.7 and subsequently the European Community Concerted Action Project on Health Services and "avoidable mortality" (ECCAP).8
In this study we examined avoidable mortality in the United States and Canada from 1980 to 1996. We postulated that there may be differences in avoidable mortality between the 2 countries, and that, if differences existed, avoidable mortality might be a useful population-based outcome measure that would encourage further evaluation and improvement of health care systems.
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METHODS |
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TOPINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Avoidable mortality was classified according to the ECCAP disease and age groups (Table 1
),8 with the following differences: appendicitis, cholelithiasis, and cholecystitis were combined into a single surgical disease group; and rheumatic heart disease deaths from all respiratory diseases for children aged 1 through 14 years were excluded. Maternal and perinatal mortality were compared only from 1985 to 1989 because of incomplete data for other years. Standardized mortality ratios (SMRs) were calculated to adjust for the different age and sex composition of the countries. Previously defined ECCAP working disease classifications were used to allow an unbiased comparison of the national health care systems. We used the European Community 1985–1989 as the reference population to allow comparisons with the previously published European Community estimates.8
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RESULTS |
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TOPINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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shows avoidable deaths in the United States and Canada for the reference period 1985–1989. During this time, there were 800 000 avoidable deaths in the United States and 83 000 in Canada. In both countries, ischemic heart disease accounted for approximately one quarter of all deaths in persons aged 15–64 years and more than one half of all avoidable deaths. Compared with Canada, the United States had higher mortality ratios for 9 of the 11 disease groups. Breast cancer mortality was marginally lower in the United States than in Canada (rate ratio 0.98, P < .005); there was no difference between the 2 countries in mortality from peptic ulcer. In Canada, the lowest mortality ratios were observed for asthma, cervical cancer, hypertension and cerebrovascular disease, tuberculosis, and maternal mortality. For these conditions, public health and primary care are usually the responsible health care sectors (Table 1
). With the notable exception of asthma mortality in the United States, mortality for all avoidable disease groups decreased during the study period in both Canada and the United States (Figure 1). For most disease groups, the rate of decline was more rapid in Canada than in the United States.
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DISCUSSION |
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TOPINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Avoidable mortality disease groups were specifically selected to reflect outcomes of the health care system, but deaths from these conditions were undoubtedly affected by other factors that were not controlled in ou-Hill et al. suggested that adjusting avoidable mortality for underlying disease incidence should control for many of these environmental and host factors.11 Avoidable mortality differences between geographic areas have been shown to persist in studies that were able to control for disease incidence or proxies for disease incidence such as socioeconomic status.7,12,13 Notwithstanding, it could be argued that avoidable mortality should not be "overcontrolled" for disease incidence, given that reducing disease is an important goal of the health care system (i.e., public health).
Similarly, socioeconomic status is associated with access to effective medical interventions—a component of health care performance that is captured in unadjusted avoidable mortality measures but not in hospital-specific measures such as survival following medical procedures.14,15 Hisnanick and Coddington suggested that comprehensive health care incorporating health promotion and disease prevention accounted for a 57% decrease in avoidable mortality among Native Americans between 1972 and 1987.16 Other possible causes of variation in mortality data, such as errors in coding of deaths, are unlikely to account for the observed differences between the 2 countries for the 11 disease groups.
The lowest mortality ratios in Canada were for disease groups in which public health or primary care was expected to play a major role (asthma, cervical cancer, hypertension and cerebrovascular disease, tuberculosis, and maternal mortality), as opposed to those most often treated in a hospital (Hodgkin disease, appendicitis, cholecystitis, abdominal hernia, and peptic ulcer). One of the most frequently cited differences between Canada and United States is the degree to which comprehensive health care is freely available at the point of use.17 Another difference is the Canadian emphasis on primary care, demonstrated by a higher per capita proportion of primary care physicians than in the United States.18
Rutstein et al. originally intended that measures of avoidable mortality merely provide a warning sign of possible health care system shortcomings6; therefore, it would be unwise to conclude, solely on the basis of differences in mortality, that the Canadian health care system performs better than the United States system. Yet the differences in avoidable mortality between the United States and Canada warrant further investigation, given that reducing mortality is a major objective of the health care system. Whether use of the avoidable mortality measure can ultimately stimulate improvement in health care systems remains largely to be seen. There are an increasing number of examples of high levels of avoidable mortality having led to further investigations of underlying influences8; however, it is not clear whether these investigations have led to health system improvements. Further, measures of avoidable mortality have not yet been subjected to the kinds of evaluative reviews that have been conducted for other performance measures, such as procedure-specific report cards.19
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Footnotes |
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D. G. Manuel planned the study, analyzed the data, and wrote the article. Y. Mao assisted with the study design, supervised the data analyses, and contributed to the writing of the article.
Human Participant Protection
No protocol approval was needed for this study.
Accepted for publication October 4, 2001.
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References |
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TOPINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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2. Bodenheimer T. The American health care system—the movement for improved quality in health care. N Engl J Med. 1999;340:488–492.
3. Baker GR, Pink GH. A balanced scorecard for Canadian hospitals. Healthc Manage Forum. 1995;8:7–21.[Medline]
4. Donabedian A. The quality of care. How can it be assessed? JAMA. 1988;260:1743–1748.[Abstract]
5. Mulligan J, Appleby J, Harrison A. Measuring the performance of health systems. BMJ. 2000;321:191–192.
6. Rutstein DD, Berenberg W, Chalmers TC, Child CG 3rd, Fishman AP, Perrin EB. Measuring the quality of medical care: a clinical method. N Engl J Med. 1976;294:582–588.[Abstract]
7. Charlton JR, Hartley RM, Silver R, Holland WW. Geographical variation in mortality from conditions amenable to medical intervention in England and Wales. Lancet. 1983;1(8326 Pt 1):691–696.[Medline]
8. Holland WW and the EC Working Group on Health Services and "Avoidable Death," eds. European Community Atlas of Avoidable Death 1985–1989. 3rd ed. Oxford: Oxford University Press; 1997.
9. CDC WONDER [search program]. Available at: http://wonder.cdc.gov/#aboutWonder.
10. Hoyert D. Perinatal mortality in the United States. Vital Health Stat 20. 1995;No. 26.
11. Carr-Hill RA, Hardman GF, Russell IT. Variations in avoidable mortality and variations in health care resources. Lancet. 1987;1(8536):789–792.[Medline]
12. Bauer RL, Charlton JR. Area variation in mortality from diseases amenable to medical intervention: the contribution of differences in morbidity. Int J Epidemiol. 1986;15:408–412.
13. Treurniet HF, Looman CW, van der Maas PJ, Mackenbach JP. Variations in ‘avoidable’ mortality: a reflection of variations in incidence? Int J Epidemiol. 1999;28:225–232.
14. Andersen R, Aday LA. Access to medical care in the US: realized and potential. Med Care. 1978;16:533–546.[Medline]
15. Gorey KM, Holowary EJ, Fehringer G, et al. An international comparison of cancer survival: Toronto, Ontario, and Detroit, Michigan, metropolitan areas. Am J Public Health. 1997;87:1156–1163.
16. Hisnanick JJ, Coddington DA. Measuring human betterment through avoidable mortality: a case for universal health care in the USA. Health Policy. 1995;34:9–19.[Medline]
17. Weale A. Rationing health care. BMJ. 1998;316:410.
18. Sullivan RB, Watanabe M, Whitcomb ME, Kindig DA. The evolution of divergences in physician supply policy in Canada and the United States. JAMA. 1996;276:704–709.[Abstract]
19. Thomas JW, Hofer TP. Research evidence on the validity of risk-adjusted mortality rate as a measure of hospital quality of care. Med Care Res Rev. 1998;55:371–404.
20. Health Indicators [program]. Cat No. 82-221-XDE version. Statistics Canada, Ottawa; 1996.
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