**5. Discussion about conceptual problems**

While avoidable mortality seems to be an innovative indicator for measuring the effectiveness of medical services, it has number of limitations resulting from the data sets relevance, as well as the concept itself. It is very important to clearly distinguish between the meaning of the avoidable, amenable and preventable mortality. These terms are often mixed up what lead to the confusion in their interpretation. For example, interpreting the decrease in avoidable mortality only such as observing a positive impact of treatment can mask an effective introduction of public health interventions.

Since health care system characteristics as well as their levels of accessibility vary from country to country, there is an absence of international agreement on the uniform selection of causes of death and age limit in the cross‐country comparison. Although the methodologies strictly do not distinguish causes of death or age limits for men and women separately, it would be useful to further develop the concept of avoidable mortality differentiating age limits for males and females to reflect the greater longevity of women. In our complementary analyses [29, 30], we found that amenable mortality is generally higher in men than in women, irrespective of the four concept used. The differences between men and women are much higher in countries with higher amenable mortality than in countries with lower amenable death rates. These facts are consistent with the findings of a research project AMIEHS. It declares that the disparity between male and female premature mortality is partially determined by the provision of health care.

This concept does not take into account the fact that different countries do not have the same health care resources needed for effective treatment, such as available new required technologies, medical skills or sufficient number of professionals. Additionally, it is not monitored whether countries secure distribution and dissemination of the necessary resources. For this reason, avoidable mortality should be interpreted in the context of many other available characteristics of health care system performance in the country. Hence, avoidable mortality can be an effective indicator in the assessment of progress achieved by the country in a certain time period.

additional causes of death included in the EUROSTAT's list accounted for 12.1%. A largest share in both lists is presented by ischaemic heart disease representing 44.9% under the AMIEHS's list and 40% in the EUROSTAT's list. However, standardised death rate of ischaemic heart disease has not changed when comparing the two lists. The other circulatory disease reported the statistically significant decrease of standardised death rates by 14.1% in the EUROSTAT's list contrary to the AMIEHS's list that was due to the exclusion of heart failure from the group. However, heart failure represented a substantial cause accounted for 14.1% in the group of other circulatory disease under the AMIEHS's list. In spite of the fact that infectious disease reflected the lowest numbers of deaths in the both lists, they recorded the largest statistically significant increase under the EUROSTAT's list because of the additional causes of death (tuberculosis, hepatitis C, selected invasive bacterial and protozoal infections) to the HIV contained in the AMIEHS's list. Moreover, in the HIV cause group, there was the extension of the age limit on the all age groups, whereas the age limit 0–74 years was included in the AMIEHS's list. In the neoplasms cause group, there was a statistically significant increase in the number of deaths by 15% mainly because of the addition of malignant neoplasms of skin and bladder cancer to the EUROSTAT's list and the shortness of the upper age limit of leukaemia. Finally, the standardised death rates for the surgical, congenital and perinatal conditions increased significantly under the EUROSTAT's list by 69.1 and 59%, respectively, mainly due to the inclusion of some surgical conditions (acute abdomen, appendicitis, intestinal obstruction, etc.) and the extension

of the scope of congenital malformations to the overall 17 chapters of ICD‐10.

While avoidable mortality seems to be an innovative indicator for measuring the effectiveness of medical services, it has number of limitations resulting from the data sets relevance, as well as the concept itself. It is very important to clearly distinguish between the meaning of the avoidable, amenable and preventable mortality. These terms are often mixed up what lead to the confusion in their interpretation. For example, interpreting the decrease in avoidable mortality only such as observing a positive impact of treatment can mask an effective introduction

Since health care system characteristics as well as their levels of accessibility vary from country to country, there is an absence of international agreement on the uniform selection of causes of death and age limit in the cross‐country comparison. Although the methodologies strictly do not distinguish causes of death or age limits for men and women separately, it would be useful to further develop the concept of avoidable mortality differentiating age limits for males and females to reflect the greater longevity of women. In our complementary analyses [29, 30], we found that amenable mortality is generally higher in men than in women, irrespective of the four concept used. The differences between men and women are much higher in countries with higher amenable mortality than in countries with lower amenable death rates. These facts are consistent with the findings of a research project AMIEHS. It declares that the disparity between male and female premature mortality is partially deter-

**5. Discussion about conceptual problems**

of public health interventions.

86 Advances in Health Management

mined by the provision of health care.

The lack of resources can lead to the increase of disease prevalence that is not adjusted in the amenable mortality indicator. For example, based on our previous study [31], Slovakia has gained the worst values of standardised mortality rate of ischaemic heart disease (above 500 deaths per 100,000) across the European countries in the long term. In this case, we should find out whether incidence or prevalence of ischaemic heart disease was not significantly increased in the examined time period, otherwise, we might interpret mistakenly a decrease of the quality of health care by an ineffective treatment of ischaemic heart disease or prevention programs in Slovakia. It is useful to assess the individual diagnosis in the given countries, as the countries with high levels of avoidable mortality tend to have a high level of mortality in individual cases.

Additionally, we see a disadvantage of variations in diagnostic practices and cause of death coding between countries, what also impacts both on international comparison and national level assessment of amenable mortality. We found out that by 2009, causes of death were coded at the third digit level (e.g. B17), while since 2010 at the fourth digit level (e.g. B171). These discrepancies may have led to the distortion of comparison of causes of death over time. The use of EUROSTAT's list before 2010 could overvalue the number of deaths, since the whole group of 'other acute viral hepatitis' (B17) would have been considered instead of 'hepatitis C' (B171).

One of the reasons for the benefits of composing the avoidable mortality concept at the national level, supported by previous studies of AMIEHS and Office for National Statistics, may be a time lag between the improved of health care services or introduction of a public health prevention program and a corresponding decrease of amenable mortality. Based on AMIEHS, a time lag was 7 years, while the Office for National Statistics in England suggests that selection of avoidable causes of death should be updated every 3 years.

We have to realise that variations in avoidable mortality are also influenced by socio‐economic factors, which can mask the impact of health care system effectiveness. We consider as the main limitation of the concept of avoidable mortality the fact that many factors beyond the health system influence mortality and an indicator of avoidable mortality does not capture many of them. Therefore, cross‐country comparison based only on this indicator can be biased. Other complementary indicators such as health services supply, health expenditures or gains in quality of life should be used in combination with avoidable mortality indicators to assess the effectiveness of the health care system.

Permanent evaluation of the concept based on the epidemiological studies, availability of health technologies and interventions supported by empirical evidence could help create an effective tool for measurement avoidable mortality mainly at the national level.
