Declining amenable mortality: a reflection of health care systems?

Gianino et al. BMC Health Services Research (2017) 17:735 DOI 10.1186/s12913-017-2708-z RESEARCH ARTICLE Open Access Declining amenable mortality: a reflection of health care systems? Maria Michela Gianino1*, Jacopo Lenzi2, Maria Pia Fantini2, Walter Ricciardi3 and Gianfranco Damiani3 Abstract Background: Some studies have analyzed the association of health care systems variables, such as health service resources or expenditures, with amenable mortality, but the association of types of health care systems with the decline of amenable mortality has yet to be studied. The present study examines whether specific health care system types are associated with different time trend declines in amenable mortality from 2000 to 2014 in 22 European OECD countries. Methods: A time trend analysis was performed. Using Nolte and McKee’s list, age-standardized amenable mortality rates (SDRs) were calculated as the annual number of deaths over the population aged 0–74 years per 100,000 inhabitants. We classified health care systems according to a deductively generated classification by Böhm. This classification identifies three dimensions that are not entirely independent of each other but follow a clear order: the regulation dimension is first, followed by the financing dimension and finally service provision. We performed a hierarchical semi-log polynomial regression analysis on the annual SDRs to determine whether specific health care systems were associated with different SDR trajectories over time. Results: The results showed a clear decline in SDRs in all 22 health care systems between 2000 and 2014 although at different annual changes (slopes). Regression analysis showed that there was a significant difference among the slopes according to provision dimension. Health care systems with a private provision exhibited a slowdown in the decline of amenable mortality over time. It therefore seems that ownership is the most relevant dimension in determining a different pattern of decline in mortality. Conclusions: All countries experienced decreases in amenable mortality between 2000 and 2014; this decline seems to be partially a reflection of health care systems, especially when affected by the provision dimension. If the private ownership is maintained or promoted by health systems, these findings might be considered when thinking about regulation policies to control factors that might influence health care performance. Keywords: Amenable mortality, Healthcare systems, European countries Background Amenable mortality is defined as premature death from a set of conditions that should not occur in the presence of timely and effective health care [1]. Adequate health care may prevent mortality due to a variety of causes by means of preventive or therapeutic measures [2]. This concept was originally developed by Rutstein et al., who created a list of conditions that were considered either treatable or preventable based on current medical * Correspondence: 1 Department of Public Health Sciences and Pediatrics, Università di Torino, Via Santena 5 bis -, 10126 Turin, Italy Full list of author information is available at the end of the article knowledge and technology [3]. Subsequently, the concept of amenable mortality was explored widely, especially in Europe [4–7] and has been adopted as an indicator of the performance of health care systems by organizations such as the England Department of Health [8] and the Organisation for Economic Cooperation and Development (OECD) [8]. Levels and trends of amenable mortality have been widely documented [2, 9–13]. Most researchers have shown that levels of amenable mortality have substantially decreased over the past years. Nolte and McKee [2] conducted a comprehensive study in 19 OECD countries between 1997/1998 and 2002/2003 and found a reduction © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Gianino et al. BMC Health Services Research (2017) 17:735 in amenable mortality in all countries. The average reduction rate was 14% in females and 17% in males. More recently, Gay et al. [9] measured the average annual change in amenable mortality in 31 OECD countries between 1997 and 2007 and concluded that amenable mortality declined in all OECD countries; the average annual decline was 3.7%. Some studies have analyzed the associations of health care systems variables, such as health service resources [7] or expenditures, with amenable mortality [14], but the association of types of health care systems with the decline of amenable mortality has yet to be studied. The present study builds on the aforementioned findings and examines whether specific health care system types are associated with different time trend declines in amenable mortality from 2000 to 2014. The study includes 22 OECD European countries that are associated with different types of health care systems. Methods A time trend analysis was performed using secondary data from 22 European OECD countries during the period 2000 to 2014. The mortality and population data for this study came primarily from the World Health Organization (WHO) Mortality Database [15], in which causes of death are coded according to the ICD-9 or ICD-10. If reference populations were not available in the WHO Mortality Database, the data were extracted from the 2012 Revision of the World Population Prospects (WPP) [16] (see Additional file 1 for the list of countries included in the study). Nolte and McKee [2, 17, 18] and Tobias and Yeh [19] prepared two different lists of causes of death that are amenable to health care. These two lists were used by the OECD to generate estimates of amenable mortality for 31 countries [9]. After reviewing the two sets of estimates of amenable mortality for the OECD countries provided by Nolte and McKee’s and Tobias and Yeh’s lists, we decided to choose Nolte and McKee’s because it provides, on average, more conservative figures (see Additional file 2, which includes Nolte and McKee’s list of causes of death amenable to health care). Many health care system classifications exist. We adopted the typology that was presented by Rothgang and Wendt [20, 21] and modified by Böhm [22] because it attempts a deductive construction of health care system types and allows for a more precise classification of health care systems. The health care system is defined by three dimensions that are not entirely independent of each other but fol (...truncated)