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The purpose of this paper is to analyse how socio‐economic inequalities in mortality (total and avoidable) evolved in Portugal from the 1990s onwards by looking at differences by gender, age group, poverty and cause of death. Results show that mortality in younger age groups is decreasing faster in the most deprived municipalities. Yet, avoidable deaths do not follow this pattern, particularly with respect to treatable mortality amenable to the health care services. Although total and avoidable mortality are decreasing across all age groups and both genders, decreases in treatable deaths during and after the 2011–14 economic crisis slowed down among the young, with a sharpening of socio‐economic inequalities in avoidable mortality among adults and the elderly. This provides evidence that, in some respects, focusing programmes on those living in poor circumstances has been successful over time. However, the impact of the Great Recession on health care services might have contributed to a significant increase in some treatable causes of death associated with these services.

Introduction: This study provides an economic assessment of the health effects due to exposure to particulate matter PM2.5 in three medium-size cities of northwestern Mexico: Los Mochis, Culiacan and Mazatlán. People in these cities are exposed to high pollutant concentrations that exceed limits suggested in domestic and international guidelines. PM2.5 is an air contaminant negatively associated with people’s health when is highly concentrated in the atmosphere, its diameter is below 2.5 µm and causes the air to appear hazy when levels are elevated. To account for the economic impact of air pollution, a Health Impact Assessment (HIA) was used by the means of the European Aphekom Project. We figured the cost-savings of complying with current environmental standards and computed gains in life expectancy, total avoidable premature mortality, preventable cardiovascular disease, and the economic costs of air pollution related to PM2.5. A formal analysis of air pollution epidemiology is not pursued in this paper. Results: The cost of reducing PM2.5 pollution associated with negative health outcomes was based on two different scenarios: Official Mexican Standard (NOM, Spanish acronym) and World Health Organization (WHO) environmental standards. The mean PM2.5 concentrations in 2017 were 22.8, 22.4 and 14.1 µg/m3 for Los Mochis, Mazatlán and Culiacan, respectively. Conclusions: The mean avoidable mortality for all causes associated to PM2.5 exposure in these cities was 638 for the NOM scenario (i.e., with a reduction to 12 µg/m3) compared to 739 for the WHO scenario (reduction to 10 µg/m3). Complying with the WHO guideline of 10 µg/m3 in annual PM2.5 mean would add up to 15 months of life expectancy at age 30, depending on the city. The mean economic cost per year of the PM2.5 effects on human life in these three cities was USD 600 million (NOM scenario) and USD 695 million (WHO scenario). Thus, effective public health and industrial policy interventions to improve air quality are socially advantageous and cost-saving to promote better health.

Epilepsy is a serious neurological condition which contemplates as top 5 reasons for avoidable mortality from ages 5-29 in the worldwide. The avoidable deaths due to epilepsy can be reduced by developing efficient automated epilepsy detection or prediction machines or software. To develop an automated epilepsy detection framework, it is essential to properly understand the existing techniques and their benefit as well as detriment also. This paper aims to provide insight on the information about the existing epilepsy detection and classification techniques as they are crucial for supporting clinical-decision in the course of epilepsy treatment. This review study accentuate on the existing epilepsy detection approaches and their drawbacks. This information presented in this article will be helpful to the neuroscientist, researchers as well as to technicians for assisting them in selecting the reliable and appropriate techniques for analyzing epilepsy and developing an automated software system of epilepsy identification.

The consequences of political reunification for health and mortality have the unique character of a ‘natural experiment’. This is particularly true for the formerly divided German Baltic Sea region due to its cultural and geographic commonalities. This paper ascertains the changes and differences in premature mortality at ages 0–74 in urban and rural areas of the German states of Mecklenburg–Vorpommern (MV) and Schleswig–Holstein (SH) since reunification and the contribution made by ‘avoidable’ mortality. Using official cause-of-death data, the effectiveness of health care and health policies was measured based on the concept of avoidable mortality in terms of both amenable and preventable conditions. Methods of decomposition and standardisation were employed in order to erase the compositional effect from the mortality trend. As a result, mortality differences relate primarily to men and the rural areas of the German Baltic Sea region. Whereas the mortality levels in the urban areas of MV and SH have converged, the rural areas of MV still show higher levels of preventable and amenable mortality. The results show that the accessibility and quality of medical care in the thinly populated areas of MV and the effectiveness of inter-sectoral health policies through primary prevention, particularly with regard to men, have room for improvement. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s10680-018-9496-y) contains supplementary material, which is available to authorized users.

Background Despite concerns about the degree of compassion in contemporary healthcare, there is a dearth of evidence for health service managers about how to promote compassionate healthcare. This paper reports on the implementation of the Creating Learning Environments for Compassionate Care (CLECC) intervention by four hospital ward nursing teams. CLECC is a workplace educational intervention focused on developing sustainable leadership and work-team practices designed to support team relational capacity and compassionate care delivery. Objectives To identify and explain the extent to which CLECC was implemented into existing work practices by nursing staff, and to inform conclusions about how such interventions can be optimised to support compassionate care in acute settings. Methods Process evaluation guided by normalisation process theory. Data gathered included staff interviews (n=47), observations (n=7 over 26 hours) and ward manager questionnaires on staffing (n=4). Results Frontline staff were keen to participate in CLECC, were able to implement many of the planned activities and valued the benefits to their well-being and to patient care. Nonetheless, factors outside of the direct influence of the ward teams mediated the impact and sustainability of the intervention. These factors included an organisational culture focused on tasks and targets that constrained opportunities for staff mutual support and learning. Conclusions Relational work in caregiving organisations depends on individual caregiver agency and on whether or not this work is adequately supported by resources, norms and relationships located in the wider system. High cognitive participation in compassionate nursing care interventions such as CLECC by senior nurse managers is likely to result in improved impact and sustainability.

The paper published in the January 2015 issue of this journal by Gusmano and colleagues entitled "Shanghai rising: health improvements as measured by avoidable mortality since 2000" has spurred this commentary. We discuss controversial issues surrounding the concept of avoidable mortality in health service research in general and Gusmano’s study in particular. The impact of overall social development on mortality may be underappreciated in Gusmano’s report; the innovative efforts of healthcare professionals to use cutting-edge technology and evidence-approved preventive strategies to reduce healthcare cost and improve the life quality of community members may not necessarily come to fruition in death reduction, and might be undervalued, too. More critically, the shape and magnitude of emerging health issues in Shanghai, such as accidents and injuries, pollution-related cancers, may be camouflaged in Gusmano’s report. We conclude this commentary by suggesting the most urgent questions to be addressed in the future studies.

Article disponible en ligne à l'adresse : http://ijhpm.com/article_2963_616.html; International audience; Investments in the extension of health insurance coverage, the strengthening of public health services, as well as primary care and better hospitals, highlights the emerging role of healthcare as part of China’s new growth regime, based on an expansion of services, and redistributive policies. Such investments, apart from their central role in terms of relief for low-income people, serve to rebalance the Chinese economy away from export-led growth toward the domestic market, particularly in megacity-regions as Shanghai and the Pearl River Delta, which confront the challenge of integrating migrant workers. Based on the paper by Gusmano and colleagues, one would expect improvements in population health for permanent residents of China’s cities. The challenge ahead, however, is how to address the growth of inequalities in income, wealth and the social wage.

La progression de l’espérance de vie au Québec reflète l’amélioration de la santé de la population. Toutefois, des décès continuent à survenir prématurément avant l’âge de 75 ans. Une part de cette mortalité prématurée est potentiellement évitable. L'objectif de ce mémoire est d’estimer la mortalité évitable au Québec de 1981-1985 à 2005-2009. Pour cela, la méthode de Tobias et Jackson (2001) a été appliquée sur des données de décès, fournies par l’Institut national de santé publique du Québec, pour estimer les taux de mortalité évitable totale et pour chacun des sexes. Cette approche nous a, par ailleurs, permis d’estimer des taux de mortalité évitable selon trois paliers de prévention : primaire, secondaire et tertiaire. Nos résultats démontrent une tendance à la baisse de la mortalité évitable à travers le temps. Cette baisse a été enregistrée chez les deux sexes, mais des disparités de mortalité évitable existent entre les hommes et les femmes. En effet, la mortalité évitable des hommes est plus élevée que celle des femmes et cet écart de mortalité est principalement dû à la mortalité évitable associée à la prévention primaire. L’analyse de la mortalité évitable par cause de décès fait ressortir que le cancer du poumon est la principale cause de décès évitable tant chez les hommes que chez les femmes en 2005-2009. Durant cette même période, le cancer du sein et les cardiopathies ischémiques étaient la deuxième cause de décès évitable respectivement chez les femmes et chez les hommes., The upward trend observed in Quebec’s life expectancy in past years suggests that population health has continued to improve. However, a number of deaths continue to occur prematurely before the age of 75 years. A part of this premature mortality is potentially avoidable. The objective of this paper is to estimate avoidable mortality rates in Quebec from 1981-1985 to 2005-2009. Avoidable mortality rates were obtained by applying the method of Tobias and Jackson (2001) to mortality data made available to us by the Institut national de santé publique du Québec. Furthermore, this approach allowed us to evaluate avoidable mortality rates by three levels of prevention: primary, secondary and tertiary. Our results show a downward trend in avoidable mortality from 1981-1985 to 2005-2009. This decline was observed for the whole population and also for both sexes. Differences in male’s and female’s avoidable mortality trends are however noticed. Indeed, avoidable mortality is higher for men than women and a large part of this difference is associated to primary prevention. The analysis by cause of death revealed that lung cancer was the leading cause of avoidable death in both men and women in 2005-2009. During this same period, the second leading cause of avoidable mortality is breast cancer and ischemic heart diseases in females and males respectively.

We are grateful to our many colleagues who took the time to respond to our analysis of Shanghai’s declining “avoidable mortality.”1 The range of their perspectives across 5 recent commentaries reassures us that the topic is worthy of sustained study. Indeed, the presumption behind our comparative research on healthcare in world cities2 is that the city is a strategic unit of analysis for understanding the health sector and that world cities share a host of important characteristics. Contrary to Cheng’s3 comment that we compared “disparate cities whose only common characteristic is that they are of mega-size,” we have relied on a “most similar systems” approach to comparative analysis.4 World cities are characterized by high population size and density, similar commuting patterns between their outer rings and urban cores, and similar functions in the realms of international finance, culture, media, and provision of tertiary and quaternary medical care. Likewise, they exhibit flagrant socio-economic inequalities, share many of the same strengths and weaknesses, but exist within nations with strikingly different health policies. Thus, comparisons among these cities, as well as within them (across neighborhoods), can shed light on the implications of national health policy for access to care, as well as on the importance of urban health policies for grappling with local health challenges. We agree with Ren’s comment5 that it would have been preferable to compare our data from New York City, Paris (and first ring) and Greater London to Shanghai City with a population of 10 million. Indeed, we attempted to do so, but the Shanghai Municipal Center for Disease Control and Prevention (SCDC) provided disaggregated mortality data, by cause, only for all of Shanghai. This problem reflects a broader issue in comparative urban health services research. While international comparisons are typically conducted across nation states with data assembled by leading international organizations (UN, OECD, WHO), there is no international association of large cities that provides comparable data for urban areas, their central cores, outer rings, let alone neighborhoods within them. This problem is well illustrated in the commentary by Yip and Chen6 where they present 2 graphs comparing life expectancy at birth across 6 cities. London, New York City and Hong Kong are comparable in terms of population size, but once again Shanghai probably refers to the whole city, Tokyo probably reflects the entire Prefecture that extends way beyond the most heavily urbanized areas, and Paris (if they did not include the first ring) includes only the 2.1 million population living in the dense and historic urban core. The problem of inadequate data at the city-level is also the reason why Yip and Chen’s6 suggestion that we assess health-adjusted life expectancy (HALE) and disability adjusted life years (DALY) for Shanghai is not practical. Putting aside the considerable ethical problems raised by how to weight different states of health, even in New York City for which we have a great deal of information about population health at the local level, we do not have sufficient data on prevalence of disease necessary to calculate such measures. Surely, as the world becomes increasingly urban, the demand for databases across world cities, as well as smaller ones, will increase and make it possible to deepen the kinds of research we began more than a decade ago.7,8 There is a final issue provoked by the indicator on which we based our analysis – amenable mortality (AM). We propose to address this issue in more detail because three of the commentaries raised it in different ways. Yan and Zhang9 note the “unavoidable limitations of the concept of AM.” They state – correctly in our judgment – that “it might be disputable to jump to the conclusion that: ‘investments in public health infrastructure and increasing access to health services in megacities – both in China and worldwide – can produce significant mortality declines.’” Likewise, Cheng3 notes that our hypothesis is “data compatible… and plausible” but that we “cannot rule out alternative, plausible hypotheses on other factors that may have driven the decline in AM in Shanghai.” Finally, Yip and Chen6 criticize us for not producing empirical data to “demonstrate a direct link for (the) causal relationship” between the decline in AM and improvement in Shanghai’s healthcare system. In fact, we do provide some evidence of substantial investments in the healthcare system and Fabre’s10 commentary highlights the emerging role of healthcare investments as part of China’s new growth regime. We are surprised by these reactions because they misconstrue the purpose of our analysis. We did not seek to validate the AM indicator. There is an extensive literature on this score including a recent analysis by Heijink and colleagues11 that finds a statistically significant relationship between healthcare spending and AM. All indicators are subject to limitations and caveats that must be examined before making claims about causality. Indeed, that is why they are called “indicators.” We relied on the indicator, AM, because there is strong evidence in the literature we cited that this indicator tells us something important about one dimension of healthcare system performance. To suggest, as our critics have, that there are other important factors, aside from access to effective healthcare, that have contributed to health improvements in Shanghai is indisputable. To imply that we should have disentangled the relative importance of these factors in the case of Shanghai simply because we relied on the AM indicator is unreasonable. It is, as if we relied on life expectancy at birth or infant mortality to compare levels of well-being and were told that there are many other factors to consider before making causal claims! For all those who recognize the overwhelming importance of social determinants of health (SDH) in explaining population health status, we share your view. But for those who refuse to recognize that the AM indicator has something to add in assessing an important dimension of healthcare system performance, we recommend that you read Allin and Grignon’s12 incisive defense of the indicator. Needless to say, we recognize that the use of comparative rates of AM to estimate gains in health from improved health system performance is limited by lack of available data to assess more directly health system performance (eg, hospital readmission rates or admission rates for ambulatory care sensitive conditions or use of recommended primary and secondary clinical and preventive services. Similarly, without the collection of small-area socio-demographic measures, the influence of such factors as poverty cannot be determined. In our comparisons of world cities2 , we have emphasized the extent to which New York City reflects national policy in the United States of not sufficiently (in our judgment) reducing inequities in the SDH, but also because the United States – even after passage of the Affordable Care Act (ACA) – has not come close to eliminating financial barriers in access to healthcare. Most other studies of these problems either emphasize the decisive impact of SDH or the importance of healthcare access. We have chosen a middle ground in which we pay attention to the consequences of poor social conditions, as well as access barriers to healthcare services that can prevent disease, improve health, reduce avoidable hospitalizations, and ultimately reduce premature mortality amenable to healthcare.13 It is for these reasons that we rely on the AM indicator, among others, to provide preliminary assessments of urban healthcare systems. Our purpose in collaborating with colleagues in Shanghai was to show how analysis of available data on one important indicator of healthcare system performance can be used to provide a comparative perspective on achievements to date and to stimulate discussion of next steps in promoting useful research on how Shanghai’s healthcare system can continue to improve. At the end of the day, we are convinced that it is not sufficient simply to state that health reforms have improved the healthcare system.14 Saying so does not make it so! Also, as we note in our paper and as all of the commentaries have reiterated, without data on the health status of Shanghai’s migrant population, it is impossible to make legitimate claims about Shanghai’s population health and its healthcare system. Finally, it will be important to conduct neighborhood-level analyses of population health and access to healthcare services to advance our capacity to assess the performance of Shanghai’s healthcare system and make more meaningful comparisons with other world cities.

Health reforms that emphasize public health and improvements in primary care can be cost-effective measures to achieve health improvements, especially in developing countries that face severe resource constraints. In their paper "Shanghai rising: health improvements as measured by avoidable mortality since 2000," Gusmano et al suggest that Shanghai’s health policy-makers have been successful in reducing avoidable mortality among Shanghai’s 14.9 million (2010) registered residents through these policy measures. It is a plausible hypothesis, but the data the authors cite also would be compatible with alternative hypotheses, as the comparison they make with trends in amenable mortality-rate (AM) in large cities in other parts of the world suggests.