Does Health Care Save Lives? The role of the health care system

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

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 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)

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 1970/74-1985/89 (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)

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’