**3. Conceptual methods**

#### **3.1. AMIEHS project from 2011**

The AMIEHS project (Amenable mortality in the European Union: toward better indicators for the effectiveness of health systems) was introduced in 2011 by researchers representing prestigious universities from seven EU countries: the Netherland, the United Kingdom, Sweden, France, Estonia, Germany and Spain.

The main aim of this project is to develop an agreed definition of amenable mortality for Europe and introduce a renewed way of selecting diseases into the lists of causes of death that are amenable by health care which can be used in assessing effectiveness of health systems. They applied strict selection process of diseases based on the consecutively conducted analyses. First, they identified 54 diseases for which mortality declined more than 30% between 1979 and 2000, and for which the number of deaths in 2000 exceeded 100 in England or Wales. These countries were selected because they disposed the most consistent data over this period. Second, they conducted a systematic review of the literature in order to identify health care interventions, which were introduced in 1970–2000 and shown as effective in reducing mortality.

Evidence of effectiveness of interventions was evaluated on a four‐point scale. The highest grade was denoted as (4)—evidence from systematic reviews or meta‐analysis; (3)—randomised controlled trial; (2)—observational studies; and (1)—consensus statements or expert opinions. Grade of evidence of the decrease in mortality of 30% or more due to effective impact of health care interventions was evaluated on a three‐point scale: (3)—evidence from population‐based registers (e.g. cancer registries) of reduction in mortality; (2)—published studies describing decline in mortality at population level where investigation has identified health care interventions as the most likely explanation; and (1)—published studies describing decline in mortality at population level where investigation has identified health care interventions as one among several explanations.

However, the strength of the evidence was variable, only few interventions had the highest grade and many interventions were supported by evidence from observational studies only. The highest levels of evidence were observed, for example, in HIV‐related mortality that between 1996 and 1998 fell by 60% in the United States due to the key intervention attributable to the azidothymidine and zidovudine applied in the late 1980s. Evidence of patient‐level studies reflected a major influence of treatment on mortality during the early 1990s. The result of these efforts was the list of 16 causes of death for which a review of the literature indicated the appropriate level of evidence of treatment (**Table 2**). Those causes of death, in which successful health care interventions were introduced before 1970, e.g. infectious diseases treated successfully with antibiotics or diabetes by insulin were eliminated from the list of amenable causes of death.

The second latest study 'Amenable mortality in the European Union: toward better indicators for the effectiveness of health systems' (AMIEHS) [18] in 2011 introduced an empirical evidence of selecting diseases into the lists of causes of death. Finally, a recent project has referred to the avoidable mortality indicators defined according to the Eurostat 'Satellite List' Task Force [19] in 2013. A common objective of these studies is to reach a consensus by countries of the European Community about the definition and selection of causes of avoidable deaths. Both studies are further described in Section 3 more specifically for the purposes of

**Table 1.** Causes of death selected in the amenable mortality list of Nolte and McKee [16] and Tobias and Yeh [17].

**Cause of death Nolte and McKee [16] ICD‐10 Tobias and Yeh [17] ICD‐10**

Maternal deaths O00–O99 Non‐classified

Congenital malformations Q20–Q28 Q00–Q99

Thyroid disorders E00–E07 E00–E07 Epilepsy G40–G41 G40–G41

*Note*: Age group used for calculation is 0–74 except if otherwise mentioned. *Source*: Own processing based on Nolte and McKee [16] and Tobias and Yeh [17].

Y60–Y69, Y83–Y84 Non‐classified

P00–P96 H311, P00, P03–P95

The AMIEHS project (Amenable mortality in the European Union: toward better indicators for the effectiveness of health systems) was introduced in 2011 by researchers representing prestigious universities from seven EU countries: the Netherland, the United Kingdom,

The main aim of this project is to develop an agreed definition of amenable mortality for Europe and introduce a renewed way of selecting diseases into the lists of causes of death that are amenable by health care which can be used in assessing effectiveness of health systems. They applied strict selection process of diseases based on the consecutively conducted analyses. First, they identified 54 diseases for which mortality declined more than 30% between 1979 and 2000, and for which the number of deaths in 2000 exceeded 100 in England or Wales. These countries were selected because they disposed the most consistent data over

our analysis.

**3. Conceptual methods**

**Misadventures to patients during surgical and medical care**

76 Advances in Health Management

Perinatal deaths, all causes (excl.

stillbirths)

**Other conditions**

**Maternal, congenital and perinatal conditions**

**3.1. AMIEHS project from 2011**

Sweden, France, Estonia, Germany and Spain.



*Note*: Age group used for calculation is 0–74 except if otherwise mentioned. *Source*: Own processing based on AMIEHS and EUROSTAT's proposals.

**Table 2.** Comparison of the AMIEHS and the EUROSTAT's list of causes of death considered amenable to health care.

For each selected cause of death, mortality trends were analysed using regression analyses to specify points in time at which the mortality trend changed significantly. They applied age limit 75 years of age. The trend analyses examined the validation of amenable mortality indicators. The results were also validated by a Delphi method where experts assessed the likelihood that variations in mortality from the pre‐selected conditions reflect variations in the effectiveness of health care. Surprisingly, the experts reached consensus on only three diseases: colorectal cancer, cervical cancer and cerebrovascular disease. These results raise doubts about availability of amenable mortality as a valid indicator of effectiveness of health systems in international comparisons. Their analyses showed that although the treatment for surgical emergencies has been known for decades, mortality has continued to decline, reflecting a combination of some other factors, for example, increasing skill in treatment or better treatment of complications. However, the AMIEHS project has proved that amenable mortality partially reflects the impact of health care innovations but must be interpreted with other analyses examining such as quality of health care utilisation or access to health care resources.

Finally, an electronic atlas of amenable mortality was prepared that provides trends of standardised mortality rates in European countries according to the list of causes of death over the period 2001–2009 [20].

#### **3.2. Eurostat task force on satellite lists of causes of death from 2013**

**Cause of death AMIEHS (2011) ICD‐10 EUROSTAT (2013) ICD‐10**

Leukaemia C91 C91, C920 (age 0–44)

**Diabetes mellitus (type 2)** Non‐classified E10–E14 (age 0–49)

I00–I09 I01–I09

Non‐classified K35–K38, K40–K46, K80–K83, K85,

Non‐classified N13, N20–N21, N35, N40, N991

Non‐classified Y60–Y69, Y83–Y84 (all ages)

K861–K869, K915

Thyroid cancer Non‐classified C73 Hodgkin's disease C81 C81

Benign neoplasms Non‐classified D10–D36

**Ischaemic heart disease** I20–I25 I20–I25

Hypertensive heart disease I10–I13 I10–I15

Cerebrovascular diseases I60–I69 I60–I69

Influenza (including swine flu) Non‐classified J09–J11 Pneumonia Non‐classified J12–J18 Asthma Non‐classified J45–J46

Gastric and duodenal ulcer K25–K26 K25–K28

Nephritis and nephrosis N17–N19 N00–N07, N17–N19, N25–N27

Q20–Q24 Q00–99

**Table 2.** Comparison of the AMIEHS and the EUROSTAT's list of causes of death considered amenable to health care.

Complications of perinatal period P00–P96 P00–P96, A33 (all ages)

Epilepsy and status epilepticus Non‐classified G40–G41

*Note*: Age group used for calculation is 0–74 except if otherwise mentioned. *Source*: Own processing based on AMIEHS and EUROSTAT's proposals.

Heart failure I50–I51 Non‐classified

**Other circulatory disease**

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**Respiratory diseases**

**Surgical conditions**

hyperplasia

anomalies

**Other condition**

Acute abdomen, appendicitis, intestinal obstruction, cholecystitis/ lithiasis, pancreatitis, hernia

Obstructive uropathy and prostatic

**Congenital and perinatal conditions**

**Misadventures to patients during surgical and medical care**

Congenital malformations, deformations and chromosomal

disease

Rheumatic and other valvular heart

At the request of European member states, policy makers and experts in the field of public health to enhance information on specific groups of causes of death, Eurostat established a Task Force for revising a Satellite Lists of causes of death information on major public health issues. These public health themes also include the two concepts of avoidable mortality: amenable and preventable deaths. This satellite list should serve as a comprehensive information platform on at‐risk groups of population in the European countries. The Task Force had some meetings were decided to consider the list of avoidable causes of death based on the three publications by the Office for National Statistics of the United Kingdom.

First of them, the consultation document [21] from February 2011 consists of the literature review, comparative analyses of existing selections of causes and consultations with experts to agree or disagree with the proposed disease classification. A public consultation was running between February and April 2011. The second one was the 'Responses to the public consultation on definitions of avoidable mortality' [22] from August 2011. This document contains 20 responses to the consultation document from various medical experts on five key questions of revising the definition of avoidable mortality concept. These questions related to the proposed causes of death to be included in amenable or preventable mortality, agreement or disagreement with the proposals on age limits, and how they would change them. Third, the final definition of avoidable mortality was presented in a document 'Definition of avoidable mortality' [23] at the end of 2011.

The Members of Eurostat's Working Group of Public Health Statistics approved the list of diseases and age groups proposed by the Office for National Statistics of the United Kingdom. Hence, the Eurostat 'satellite lists' Task Force tested this proposed selection of causes of death by Delphi method; unfortunately, those results are not disseminated. The final EUROSTAT Satellite List defining causes of death considered as amenable or preventable is available at Eurostat web page [24]. We present the list of causes considered to be amenable in **Table 2**.

As one should notice, the development of concept of avoidable mortality has been considerably influenced by the evidence from clinical research studies or consultation that has confirmed the impact of health care or public health interventions on declining mortality. However, a considered time period has played an important role in creating the unique list of selected diseases, because medical knowledge and technology have advanced over time what subsequently has an impact on inclusion or exclusion criteria by which a list of amenable or preventable causes of death is made. Therefore, the lists of causes of death amenable to health care need to be regularly updated in relation to current medical practice.

#### **3.3. Office for national statistics in England**

Although avoidable mortality has been investigated for the last four decades, there is still small consensus among researchers about how to define it. Last precise definitions of the concept are presented by the Office for National Statistics in England [25]. Following definitions were developed through an iterative public consultation running in 2015.

#### *3.3.1. Avoidable mortality*

Avoidable deaths are all those defined as preventable, amenable (treatable) or both, where each death is counted only once; where a cause of death is both preventable and amenable, all deaths from that cause are counted in both categories when they are presented separately.

#### *3.3.2. Amenable mortality*

A death is amenable (treatable) if, in the light of medical knowledge and technology at the time of death, all or most deaths from that cause (subject to age limits if appropriate) could be avoided through good quality healthcare.

#### *3.3.3. Preventable mortality*

A death is preventable if, in the light of understanding of the determinants of health at time of death, all or most deaths from that cause (subject to age limits if appropriate) could be avoided by public health interventions in the broadest sense.
