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IntroductionSeparation from one’s child can have significant consequences for parental health and well-being. Objectives and ApproachWe aimed to investigate whether parents whose children were placed in care had higher rates of avoidable (amenable and preventable) mortality. Data were obtained from the Swedish national registers. Mortality rates among parents whose children were placed in care between 1990 and 2012 (17 505 mothers, 18 286 fathers) were compared with a 5:1 matched cohort of parents whose children were not placed. We computed rate differences and hazard ratios of all-cause and avoidable mortality. ResultsWhen compared with parents who did not have a child placed in care, there were an additional 21 avoidable deaths per 10 000-person years among mothers and an additional 27 avoidable deaths per 10 000-person years among fathers whose children were placed in care. Among mothers, death due to preventable causes were 3·83 times greater (95% CI 2·82-5·21) and deaths due to amenable causes were 3·12 times greater (95% CI 2·07-4·69) for those whose children were placed in care. Among fathers, death due to preventable causes was 1·75 times greater (95% CI 1·41-2·16) and deaths due to amenable causes were 1·52 times greater (95% CI 1·08- 2·13) for those whose children were placed in care. Avoidable mortality rates were higher among mothers whose children were young when placed in care and parents whose children were all placed in care. Conclusion/ImplicationsMothers who had a young child placed and parents whose children were all placed in care are at much higher risk of avoidable mortality than parents whose children were not placed in care. Targeted public health interventions and more attentive health care could reduce risk of avoidable mortality in this group of parents.

ObjectiveTo analyse average lifespan and quantify the effect of avoidable/amenable mortality on the difference between state-specific mortality and a low-mortality benchmark in Mexico during 1990–2015.DesignRetrospective cross-sectional demographic analysis using aggregated data.SettingVital statistics from the Mexican civil registration system.ParticipantsAggregated national data (from 91.2 million people in 1995 to 119.9 in 2015) grouped in 64 populations (32 Mexican states (including Mexico City) by sex) with cause-of-death data.Main outcome measuresCause-specific contributions to the gap in life expectancy with a low-mortality benchmark in three age groups (0–14, 15–49 and 50–84 years).ResultsInfants and children under the age of 15 years show improvements towards maximal survival in all states. However, adult males aged 15 to 49 years show deterioration after 2006 in almost every state due to increasing homicides, and a slow recovery thereafter. Out of 35 potential years, females and males live on average 34.57 (34.48 to 34.67) and 33.80 (33.34 to 34.27), respectively. Adults aged 50 to 84 years show an unexpected decrease in the low mortality benchmark, indicating nationwide deterioration among older adults. Females and males in this age group show an average survival of 28.59 (27.43 to 29.75) and 26.52 (25.33 to 27.73) out of 35 potential years, respectively. State gaps from the benchmark were mainly caused by ischaemic heart diseases, diabetes, cirrhosis and homicides. We find large health disparities between states, particularly for the adult population after 2005.ConclusionsMexico has succeeded in reducing mortality and between-state inequalities in children. However, adults are becoming vulnerable as they have not been able to reduce the burden of violence and conditions amenable to health services and behaviours, such as diabetes, ischaemic heart diseases and cirrhosis. These trends have led to large health disparities between Mexican states in the last 25 years.

Aim Retrospective case record reviews (RCRR) have been widely used to assess quality of care but evidence for their use in prehospital ambulance settings is limited. We aimed to review case records of potentially avoidable deaths related to ambulance care. Method We identified patients who were transported to hospital or died using linked ambulance-hospital-mortality data from one UK ambulance service over 6 months in 2013. Death rates (within 3 days) for patient groups (based on age, dispatch code and urgency) were determined; 3 patients calling in-hours and 3 out-of-hours were selected from categories with the lowest death rates. Five reviewers (GP, nurse, 2 paramedics and medical health service manager) assessed anonymised patient records for quality of care and avoidable mortality. Results We selected 29 linked records from 1 50 003 focussing on patients not transported to distinguish pre-hospital from hospital causes. Overall 8 cases out of 29 (27.6%) scored between 2.4 and 2.8 (1=Definitely avoidable, 2=Strong evidence of avoidability), 8 cases (27.6%) scored between 3.0 and 4.6 (3=Probably avoidable, 4=Possibly avoidable), and the remaining 13 cases (44.8%) between 4.0 and 5.8 (5=Slightly avoidable or 6=Definitely not avoidable). Variation between raters was satisfactory with ICC 0.84 (95% CI: 0.73 to 0.92). Common themes among cases with strong evidence of avoidability were symptoms or physical findings indicating a potentially serious condition and refusal by patients or their carers to be transported to hospital. RCRRs require linked ambulance, hospital and mortality data to ensure accurate assessment in light of the diagnosis and cause of death. Conclusion Retrospective case record reviews (RCRR) have been widely used to assess quality of care but evidence for their use in prehospital ambulance settings is limited. We aimed to review case records of potentially avoidable deaths related to ambulance care. Conflict of interest None Funding National Institute for Health Research, UK.

BackgroundSeparation from one’s child can have significant consequences for parental health and well-being. We aimed to investigate whether parents whose children were placed in care had higher rates of avoidable mortality.MethodsData were obtained from the Swedish national registers. Mortality rates among parents whose children were placed in care between 1990 and 2012 (17 503 mothers, 18 298 fathers) were compared with a 1:5 matched cohort of parents whose children were not placed. We computed rate differences and HRs of all-cause and avoidable mortality.ResultsAmong mothers, deaths due to preventable causes were 3.09 times greater (95% CI 2.24 to 4.26) and deaths due to amenable causes were 3.04 times greater (95% CI 2.03 to 4.57) for those whose children were placed in care. Among fathers, death due to preventable causes were 1.64 times greater (95% CI 1.32 to 2.02) and deaths due to amenable causes were 1.84 times greater (95% CI 1.33 to 2.55) for those whose children were placed in care. Avoidable mortality rates were higher among mothers whose children were young when placed in care and among parents whose children were all placed in care.ConclusionsParents who had a child placed in out-of-home care are at higher risk of avoidable mortality. Interventions targeting mothers who had a child aged less than 13 placed in care, and parents whose children were all placed in care could have the greatest impact in reducing avoidable mortality in this population.

Background Reducing the gaps in health inequality at a regional level and improving health equity have been emphasized in Korea, it is essential to accurately measure the burden of disease by region. This study aimed to estimate years of life lost (YLLs) in 17 Si and Do of Korea from 1997 to 2015 and determine the trends of regional differences in health status and disease structure. Methods YLL was calculated by subtracting the age at death from the life expectancy. Data on the region, gender, and age-stratified cause-specific death were obtained from the Korean Statistical Information Service of Statistics Korea. Results Age-standardized YLLs per 100,000 population decreased by year in all regions from 1997 to 2015 by 27.4% (27.5% for men; 27.2% for women). Despite the decline in YLLs, the regions with the highest and lowest YLLs did not change between 1997 and 2015. The diseases showing regional differences were caused by injury, often classified as avoidable mortality. We also confirmed that YLLs were higher in the regions with a higher deprivation index. Conclusion The present study identified that YLLs differed by regions in Korea with specific causes. The findings of this study can be used by decision-makers to prioritize the reduction of regional gaps in premature deaths., Graphical Abstract

Objective The aim of this study was to measure income-related inequalities in avoidable, amenable and preventable mortality in Norway over the period 1994–2011. Methods We undertook a register-based population study of Norwegian residents aged 18–65 years between 1994 and 2011, using data from the Norwegian Income Register and the Cause of Death Registry. Concentration indices were used to measure income-related inequalities in avoidable, amenable and preventable mortality for each year. We compared the trend in income-related inequality in avoidable mortality with the trend in income inequality, measured by the Gini coefficient for income. Results Avoidable, amenable and preventable deaths in Norway have declined over time. There were persistent pro-poor socioeconomic inequalities in avoidable, amenable and preventable mortality, and the degree of inequality was larger in preventable mortality than in amenable mortality throughout the period. The income-avoidable mortality association was positively correlated with income inequalities in avoidable mortality over time. There was little or no relationship between variations in the Gini coefficient due to tax reforms and socioeconomic inequalities in avoidable mortality. Conclusions Income-related inequalities in avoidable, amenable and preventable mortality have remained relatively constant between 1994 and 2011 in Norway. They were mainly correlated with the relationship between income and avoidable mortality rather than with variations in the Gini coefficient of income inequality.

Ziel der Studie: Regionale Merkmale finden in Studien zu den Determinanten von Gesundheit und Gesundheitsversorgung zunehmend Berucksichtigung. Eine systematische Beobachtung und Einbeziehung regionaler Besonderheiten in strategische Planungs- und Finanzierungsentscheidungen wurde bisher jedoch vernachlassigt. Zudem werden in den vorliegenden Studien Veranderungen auf regionaler Ebene uber die Zeit meist nicht berucksichtigt. In diesem Beitrag sollen daher sowohl Niveaus als auch Trends potentiell vermeidbarer Sterbefalle auf Kreisebene dargestellt und ein Benchmark erstellt werden, der die theoretisch zu erreichende Reduktion der vermeidbaren Sterbefalle fur die Kreise aufzeigt. Methodik: Auf Basis der Todesursachenstatistik der Statistischen Amter der Bundeslander werden die potentiell vermeidbaren Sterbefalle geschlechterspezifisch und altersstandardisiert fur jeden der 413 deutschen Kreise und kreisfreien Stadte im Zeitraum von 2000 bis 2008 ermittelt. Berucksichtigt werden Sterbefalle durch Lungenkrebs und alkoholbedingte Erkrankungen, da diese als potentiell durch Primarpravention vermeidbar gelten. Die kreisspezifischen Werte fur das Benchmark werden in 2 linearen, hierarchisch geschachtelten Modellen ermittelt und anhand eines F-Tests auf Signifikanz uberpruft. Ergebnisse: Insgesamt nimmt die Lungenkrebsmortalitat bei Mannern im betrachteten Zeitraum ab, wahrend sie fur Frauen sukzessive ansteigt. Der Benchmark fur Sterbefalle durch Lungenkrebs fur Frauen zeigt, dass der Anstieg der Sterblichkeit vor allem in westdeutschen und urbanen Kreisen zu finden ist. Bezuglich der alkoholbedingten Sterblichkeit beobachten wir ein Ost-Westgefalle mit hoheren Raten in Ostdeutschland. Schrumpfende Kreise in Ostdeutschland konnten in den letzten Jahren jedoch einen starken Ruckgang der Raten verzeichnen. Eine ungunstige Trendentwicklung der alkoholbedingten Mortalitat lasst sich fur Frauen vor allem in landlichen Gebieten Bayerns beobachten. Schlussfolgerung: Die Analyse bietet Entscheidungstragern die Moglichkeit Regionen mit verstarktem Handlungsbedarf bezuglich Praventionsmasnahmen zu lokalisieren. Die steigenden Lungenkrebsmortalitatsraten von Frauen in Stadten weisen bspw. auf einen erhohten Bedarf von Anti-Rauch-Kampagnen in urbanen Gegenden hin. Fur alkoholbedingte Erkrankungen konnte neben den ostdeutschen Kreisen auch in einigen Kreisen Bayerns ein erhohter Bedarf fur zielgruppenspezifische Pravention identifiziert werden.

Mortality is a vital indicator of epidemiological transition, and mortality study of a region can provide valuable insights for evolving appropriate health policy to enable future reductions in avoidable mortality and disease burden. This article attempts to study the major features of Goa’s mortality transition over the last three decades. By using the deaths data from the International Classification of Diseases (ICD) in the Annual Reports of Registrar of Births and Deaths in Goa, an attempt is made here to understand the major causes of mortality influencing Goa’s epidemiological transition. Age structure of mortality, changes in cause composition of age-specific mortality, male-female mortality differences and disease death patterns are also studied. It emerges from the article that Goa has witnessed a phase of gradual reduction of infectious and communicable deaths and increasingly been facing non-communicable type of mortality. The age structure of mortality reflects reductions in the share of children’s deaths over a period of time and a shift towards older age mortality. The epidemiological transition shows that circulatory deaths, respiratory deaths and cancer deaths have increased their relative contributions in mortality, and the disease-wise death patterns indicate increasing prominence of lifestyle-related diseases. This suggests that the state needs to embark on a planned approach towards evolving a time-bound health policy with a clear focus on specific aspects of mortality and disease.

The indicators’ values of health condition of the Slovak citizens significantly lag behind the most developed countries. The issue of healthy inhabitants is more connected with a treatment of bad health condition than with a non-health prevention, which is believed to be caused by social and political development over the last decades. Measuring the influence of health system on inhabitants’ health is very difficult due to the influences of various factors, such as wealth, socio-economic status, citizen's lifestyle, quality of environments, etc. Consequently, an amenable mortality indicator is used to evaluate the health system except of the life expectancy indicator. It defines a mortality that should not have occurred in case of effective and early treatment. It only takes into consideration those diagnoses, where effective treatment exists before a certain age limit (75 years) according to experts. The number of these deaths is standardized on 100,000 citizens. The amenable mortality indicator has a great significance for standard comparisons, however, its application also causes methodological issues, such as data quality of mortality, choice of diagnoses, weight of diagnoses, etc. In the international comparing, it is very often deduced from a fact that each country spends different amount of funds on health, while the differences may be connected with a different effectiveness of invested funds in the health systems. The article reflects on the given facts and its aim is to evaluate the development of amenable mortality in Slovakia over the last ten years, as well as to compare the development of this indicator in the EU countries. Similarly, it assesses the significant methodological issues that are related to indicator's application and defines the causes of extreme differences that were found out by the results on the basis of the given outputs.

Actualmente la muerte es un hecho inevitable, sin embargo, la esperanza de vida ha cambiado de forma importante en el tiempo y aún en nuestros días difiere ampliamente entre grupos humanos. El avance de la tecnología sanitaria ha permitido que ciertas muertes puedan controlarse, postergarse o evitarse. Por ello, el objetivo de este artículo es medir el impacto que tienen las causas de muerte evitable, sobre las variables demográficas en la región Caribe colombiana, 1999-2014. Para lograrlo, se utilizó el método de eliminación hipotética de causas de muertes usando tablas de vidas. Los resultados indican que si en el periodo de estudio se hubiesen evitado algunas muertes a causa de enfermedades del sistema circulatorio y causas externas de mortalidad, la esperanza de vida de esta población se hubiera prolongado significativamente. Currently death is an inevitable fact, however, the life expectancy has changed significantly in time and even in our days it differs widely among human groups. The advancement of health technology has allowed certain deaths can be controlled, postponed or avoided. Therefore, the The objective of this article is to measure the impact of causes of avoidable death, on the demographic variables in the region Colombian Caribbean, 1999-2014. To achieve this, the method was used of hypothetical elimination of causes of death using tables of lives The results indicate that if during the study period they would have avoided some deaths due to diseases of the circulatory system and external causes of mortality, the hope of life of this population would have been significantly prolonged.

Objective To determine the risk of death from two potentially avoidable causes with different aetiologies: respiratory tract infection (RTI) and sudden unexplained death (SUD) in children with and without chronic conditions. Design Whole-country, birth cohort study using linked administrative health databases from Scotland. Setting and participants Children aged 2 months to less than 5 years in Scotland between 2000 and 2014. Main outcome measures Relative risk of death (expressed as the HR) related to RTIs or SUD, in children with and without chronic conditions. We separately analysed deaths at ages 2–11 months and at 1–4 years and adjusted for birth characteristics, socioeconomic status and vaccination uptake using Cox regression. Results The cohort comprised 761 172 children. Chronic conditions were recorded in 9.6% (n=72 901) of live births, 82.4% (n=173) of RTI-related deaths and 17.4% (n=49) of SUDs. Chronic conditions were very strongly associated with RTI mortality (2–11 months: HR 68.48, 95% CI (40.57 to 115.60), 1–4 years: HR 38.32, 95% CI (23.26 to 63.14)) and strongly associated with SUD (2–11 months: HR 2.42, 95% CI (1.67 to 3.63), 1–4 years: HR 2.53, 95% CI (1.36 to 4.71)). Conclusions The very strong association with chronic conditions suggests that RTI-related mortality may sometimes be a consequence of a terminal decline and not possible to defer or prevent in all cases. Recording whether death was expected on death certificates could indicate which RTI-related deaths might be avoidable through healthcare and public health measures.

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.

Introduction Monitoring hospital mortality using retrospective case record review (RCRR) is being adopted throughout the National Health Service (NHS) in England with publication of estimates of avoidable mortality beginning in 2017. We describe our experience of reviewing the care records of inpatients who died following admission to hospital in four acute hospital NHS Foundation Trusts in the North-East of England. Methods RCRR of 7370 patients who died between January 2012 and December 2015. Cases were reviewed by consultant reviewers with support from other disciplines and graded in terms of quality of care and preventability of deaths. Results were compared with the estimates published in the Preventable Incidents, Survival and Mortality (PRISM) studies, which established the original method. Results 34 patients (0.5%, 95% CI 0.3% to 0.6%) were judged to have a greater than 50% probability of death being preventable. 1680 patients (22.3%, 95% CI 22.4% to 23.3%) were judged to have room for improvement in clinical, organisational (or both) aspects of care or less than satisfactory care. Conclusions Reviews using clinicians within trusts produce lower estimates of preventable deaths than published results using external clinicians. More research is needed to understand the reasons for this, but as the requirement for NHS Trusts to publish estimates of preventable mortality is based on reviews by consultants working for those trusts, lower estimates of preventable mortality can be expected. Room for improvement in the quality of care is more common than preventability of death and so mortality reviews contribute to improvement activity although the outcome of care cannot be changed. RCRR conducted internally is a feasible mechanism for delivering quantitative analysis and in the future can provide qualitative insights relating to inhospital deaths.

Background Analyses of children and young people mortality continue to be an important component of health monitoring of this population. Such analyses provide the basis to assess the overall trends, the structure of the causes of death over longer periods, and the differences between Poland and other countries. Purpose The purpose of the current study is to present the current status and the direction of changes since 2000 with regard to the level and underlying causes of mortality in children and adolescents aged 1-19 years in Poland on the background of statistics for leading European countries. Material and methods Interactive databases available online: the National Demographic Database provided by the Central Statistical Office and the International WHO-MDB Database were used. Poland, constantly belonging to Eur-B category, was compared with the combined group of 27 leading countries, classified as a very low total mortality group (Eur-A) according to WHO. Linear trends of overall and cause-specific mortality in 2000–2013 were estimated. The causes of death have been presented according to the main classes of the 10th Revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10). External and other causes were adopted as the two principal categories. Results In 2015, 1471 deaths of persons aged 1-19 were recorded in Poland (19.9 per 100 000, 25.4 and 14.2 for boys and girls, respectively). Changes in children and adolescents mortality by age have a nonlinear nature (U-shaped), and the lowest level is recorded at the age of 5-9 years. According to 2014 data, 50.2% of deaths of children and adolescents aged 1-19 years occurred due to external causes, including non-intentional and intentional ones. This percentage increased from 18.4% in the 1-4 age group to 68.6% at the age of 15-19 years. Apart from external causes, the dominating causes of death are malignant neoplasms, congenital defects, or nervous system and respiratory system diseases. The ranking of those causes of death changes in successive age groups and over time. When age is considered, a higher proportion of congenital defects and respiratory system diseases was found in mortality younger children and a higher proportion of circulatory system diseases and undefined cases in mortality of adolescents. When trends were studied, a continuing elimination of infectious diseases was observed together with growing impact of rare diseases in all age groups. The excess mortality of Polish population at age 1-19 by comparison to Eur-A countries increased from 21% in 2000 to 56% in 2013, mainly due to unfavourable trends in adolescents. The rate of decline in the mortality of young children (1-4 years) was greater than in Eur-A countries, both in case of external and other causes. In the age group 5-14 years the higher rate of change was sustained only with regard to external causes. Among adolescents and young adults, the distance between Poland and Eur-A countries increased during the studied period. The shape of trend in the 15-24 age group was unfavourable for Poland, mainly with respect to external causes. This observation could be in part explained by increasing suicide trend in Poland since 2008, coexisting with rather constant level in Eur-A countries. Conclusions The mortality rate among the population aged 1-19 years in Poland is systematically decreasing, but it still exceeds the average level recorded in leading European countries, particularly in relation to adolescents. When assessing the ability to reduce mortality in Poland to the level of Eur-A countries, attention must be paid to the causes considered as avoidable. Further studies ought to focus on the trends and international comparisons only foreshadowed in this study with regard to individual diagnoses, discussing possible preventive measures. Introduction of an ICD-11 classification will enable more accurate coding of causes of death, including a more precise analysis of the burden of rare diseases, which are an increasing challenge to public health in the population at the developmental age.

Background National levels of personal health-care access and quality can be approximated by measuring mortality rates from causes that should not be fatal in the presence of effective medical care (ie, amenable mortality). Previous analyses of mortality amenable to health care only focused on high-income countries and faced several methodological challenges. In the present analysis, we use the highly standardised cause of death and risk factor estimates generated through the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) to improve and expand the quantification of personal health-care access and quality for 195 countries and territories from 1990 to 2015. Methods We mapped the most widely used list of causes amenable to personal health care developed by Nolte and McKee to 32 GBD causes. We accounted for variations in cause of death certification and misclassifications through the extensive data standardisation processes and redistribution algorithms developed for GBD. To isolate the effects of personal health-care access and quality, we risk-standardised cause-specific mortality rates for each geography-year by removing the joint effects of local environmental and behavioural risks, and adding back the global levels of risk exposure as estimated for GBD 2015. We employed principal component analysis to create a single, interpretable summary measure–the Healthcare Quality and Access (HAQ) Index–on a scale of 0 to 100. The HAQ Index showed strong convergence validity as compared with other health-system indicators, including health expenditure per capita (r=0·88), an index of 11 universal health coverage interventions (r=0·83), and human resources for health per 1000 (r=0·77). We used free disposal hull analysis with bootstrapping to produce a frontier based on the relationship between the HAQ Index and the Socio-demographic Index (SDI), a measure of overall development consisting of income per capita, average years of education, and total fertility rates. This frontier allowed us to better quantify the maximum levels of personal health-care access and quality achieved across the development spectrum, and pinpoint geographies where gaps between observed and potential levels have narrowed or widened over time. Findings Between 1990 and 2015, nearly all countries and territories saw their HAQ Index values improve; nonetheless, the difference between the highest and lowest observed HAQ Index was larger in 2015 than in 1990, ranging from 28·6 to 94·6. Of 195 geographies, 167 had statistically significant increases in HAQ Index levels since 1990, with South Korea, Turkey, Peru, China, and the Maldives recording among the largest gains by 2015. Performance on the HAQ Index and individual causes showed distinct patterns by region and level of development, yet substantial heterogeneities emerged for several causes, including cancers in highest-SDI countries; chronic kidney disease, diabetes, diarrhoeal diseases, and lower respiratory infections among middle-SDI countries; and measles and tetanus among lowest-SDI countries. While the global HAQ Index average rose from 40·7 (95% uncertainty interval, 39·0–42·8) in 1990 to 53·7 (52·2–55·4) in 2015, far less progress occurred in narrowing the gap between observed HAQ Index values and maximum levels achieved; at the global level, the difference between the observed and frontier HAQ Index only decreased from 21·2 in 1990 to 20·1 in 2015. If every country and territory had achieved the highest observed HAQ Index by their corresponding level of SDI, the global average would have been 73·8 in 2015. Several countries, particularly in eastern and western sub-Saharan Africa, reached HAQ Index values similar to or beyond their development levels, whereas others, namely in southern sub-Saharan Africa, the Middle East, and south Asia, lagged behind what geographies of similar development attained between 1990 and 2015. Interpretation This novel extension of the GBD Study shows the untapped potential for personal health-care access and quality improvement across the development spectrum. Amid substantive advances in personal health care at the national level, heterogeneous patterns for individual causes in given countries or territories suggest that few places have consistently achieved optimal health-care access and quality across health-system functions and therapeutic areas. This is especially evident in middle-SDI countries, many of which have recently undergone or are currently experiencing epidemiological transitions. The HAQ Index, if paired with other measures of health-system characteristics such as intervention coverage, could provide a robust avenue for tracking progress on universal health coverage and identifying local priorities for strengthening personal health-care quality and access throughout the world. Funding Bill & Melinda Gates Foundation.

Little is known about the effectiveness of health care in reducing inequalities in health. We assessed trends in inequalities in mortality from conditions amenable to health care in seventeen European countries in the period 1980-2010 and used models that included country fixed effects to study the determinants of these trends. Our findings show remarkable declines over the study period in amenable mortality among people with a low level of education. We also found stable absolute inequalities in amenable mortality over time between people with low and high levels of education, but widening relative inequalities. Higher health care expenditure was associated with lower mortality from amenable causes, but not from nonamenable causes. The effect of health care expenditure on amenable mortality was equally strong, in relative terms, among people with low levels of education and those with high levels. As a result, higher health care expenditure was associated with a narrowing of absolute inequalities in amenable mortality. Our findings suggest that in the European context, more generous health care funding provides some protection against inequalities in amenable mortality.

Adolescence is a period of initiation to drug consumption, at the forefront of which are alcohol and tobacco. In 2011, 28% of European adolescents had consumed tobacco over the last 30 days, and 57% alcohol. Beer was the most consumed alcoholic beverage (46%), followed by spirits (38%). However, alcohol and tobacco consumption constitute health, social and economic issues for the European Union. Tobacco is the leading cause of avoidable mortality, killing 625,000 smokers each year and with a social cost estimated between 1.04 and 1.39% of the GDP, while alcohol, each year, is responsible for 195,000 deaths and a cost amounting to between 0.9 and 2.4% of the GDP incurred by the European Union. In addition, the joint consumption of alcohol and tobacco increases the risk of cancers of the upper digestive and respiratory tracts, and therefore the risk of mortality. In order to stop future premature mortality, prevention policies are used in order to deter young people from starting to consume alcohol and tobacco. Among these policies, taxation represents the most effective tool to reduce alcohol and tobacco consumption, but its level varies between European countries.

Background National levels of personal health-care access and quality can be approximated by measuring mortality rates from causes that should not be fatal in the presence of effective medical care (ie, amenable mortality). Previous analyses of mortality amenable to health care only focused on high-income countries and faced several methodological challenges. In the present analysis, we use the highly standardised cause of death and risk factor estimates generated through the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) to improve and expand the quantification of personal health-care access and quality for 195 countries and territories from 1990 to 2015. Methods We mapped the most widely used list of causes amenable to personal health care developed by Nolte and McKee to 32 GBD causes. We accounted for variations in cause of death certification and misclassifications through the extensive data standardisation processes and redistribution algorithms developed for GBD. To isolate the effects of personal health-care access and quality, we risk-standardised cause-specific mortality rates for each geography-year by removing the joint effects of local environmental and behavioural risks, and adding back the global levels of risk exposure as estimated for GBD 2015. We employed principal component analysis to create a single, interpretable summary measure-the Healthcare Quality and Access (HAQ) Index-on a scale of 0 to 100. The HAQ Index showed strong convergence validity as compared with other health-system indicators, including health expenditure per capita (r= 0.88), an index of 11 universal health coverage interventions (r= 0.83), and human resources for health per 1000 (r= 0.77). We used free disposal hull analysis with bootstrapping to produce a frontier based on the relationship between the HAQ Index and the Socio-demographic Index (SDI), a measure of overall development consisting of income per capita, average years of education, and total fertility rates. This frontier allowed us to better quantify the maximum levels of personal health-care access and quality achieved across the development spectrum, and pinpoint geographies where gaps between observed and potential levels have narrowed or widened over time. Findings Between 1990 and 2015, nearly all countries and territories saw their HAQ Index values improve; nonetheless, the difference between the highest and lowest observed HAQ Index was larger in 2015 than in 1990, ranging from 28.6 to 94.6. Of 195 geographies, 167 had statistically significant increases in HAQ Index levels since 1990, with South Korea, Turkey, Peru, China, and the Maldives recording among the largest gains by 2015. Performance on the HAQ Index and individual causes showed distinct patterns by region and level of development, yet substantial heterogeneities emerged for several causes, including cancers in highest-SDI countries; chronic kidney disease, diabetes, diarrhoeal diseases, and lower respiratory infections among middle-SDI countries; and measles and tetanus among lowest-SDI countries. While the global HAQ Index average rose from 40.7 (95% uncertainty interval, 39.0-42.8) in 1990 to 53.7 (52.2-55.4) in 2015, far less progress occurred in narrowing the gap between observed HAQ Index values and maximum levels achieved; at the global level, the difference between the observed and frontier HAQ Index only decreased from 21.2 in 1990 to 20.1 in 2015. If every country and territory had achieved the highest observed HAQ Index by their corresponding level of SDI, the global average would have been 73.8 in 2015. Several countries, particularly in eastern and western sub-Saharan Africa, reached HAQ Index values similar to or beyond their development levels, whereas others, namely in southern sub-Saharan Africa, the Middle East, and south Asia, lagged behind what geographies of similar development attained between 1990 and 2015. Interpretation This novel extension of the GBD Study shows the untapped potential for personal health-care access and quality improvement across the development spectrum. Amid substantive advances in personal health care at the national level, heterogeneous patterns for individual causes in given countries or territories suggest that few places have consistently achieved optimal health-care access and quality across health-system functions and therapeutic areas. This is especially evident in middle-SDI countries, many of which have recently undergone or are currently experiencing epidemiological transitions. The HAQ Index, if paired with other measures of health-systemcharacteristics such as intervention coverage, could provide a robust avenue for tracking progress on universal health coverage and identifying local priorities for strengthening personal health-care quality and access throughout the world., Bill & Melinda Gates Foundation.

The World is undergoing rapid urbanization, with 70% of the World population expected to live in urban areas by 2050. Nevertheless, nationally representative analysis of the health differences in the leading causes of avoidable mortality disaggregated by urbanization level is lacking. We undertake a study of temporal trends in mortality rates for deaths considered avoidable by the Concerted Action of the European Community on Avoidable Mortality for four different levels of urbanization in Taiwan between 1971 and 2008. We find that for virtually all causes of death, age-standardized mortality rates (ASMRs) were lower in more urbanized than less urbanized areas, either throughout the study period, or by the end of the period despite higher rates in urbanized areas initially. Only breast cancer had consistently higher AMSRs in more urbanized areas throughout the 38-year period. Further, only breast cancer, lung cancer, and ischemic heart disease witnessed an increase in ASMRs in one or more urbanization categories. More urbanized areas in Taiwan appear to enjoy better indicators of health outcomes in terms of mortality rates than less urbanized areas. Access to and the availability of rich healthcare resources in urban areas may have contributed to this positive result.

Background: The Italian Society of Environmental Medicine has performed a preliminary assessment of the health impact attributable to road freight traffic in Italy. Methods: We estimated fine particulate matter (PM10, PM2.5) and nitrogen oxides (NOx) generated by road transportation of goods in Italy considering the number of trucks, the emission factors and the average annual distance covered in the year 2016. Simulations on data concerning Years of Life Lost (YLL) attributable to PM2.5 (593,700) and nitrogen oxides NO2 (200,700) provided by the European Environmental Agency (EEA) were used as a proxy of healthcare burden. We set three different healthcare burden scenarios, varying from 1/5 to 1/10 of the proportion of the overall particulate matter attributable to road freight traffic in Italy (about 7% on a total of 2262 tons/year). Results: Road freight traffic in Italy produced about 189 tons of PM10, 147 tons of PM2.5 and 4125 tons of NOx in year 2016, resulting in annual healthcare costs varying from 400 million up to 1.2 billion EUR per year. Conclusion: Road freight traffic has a relevant impact on air pollution and healthcare costs, especially if considered over a 10-year period. Any solution able to significantly reduce the road transportation of goods could decrease avoidable mortality due to air pollution and related costs.

Objective: Patients with schizophrenia are at a greater risk of avoidable death. Although smoking is a modifiable factor to reduce the mortality gap, the rate of quitting smoking in these inpatients is still lower than that in the general population. We examined avoidable mortality among long-stay patients with schizophrenia under different smoking-restriction environments. Methods: A total of 1998 male and 459 female patients with schizophrenia who was admitted to Taipei Veterans General Hospital, Yuli Branch, in Taiwan, received follow-ups for 11 years to be estimated for the standardized mortality ratios (SMRs) of avoidable causes of death. During that period, all the male patients had stayed in smoking-allowed wards, but all the female patients had not. Results: The mean ± standard deviation age of the patients was 57.8 ± 17.0 years. Of the 993 decedents in total, 411 died of avoidable causes (41.4%). Compared with the general population, male patients had significantly higher mortality due to avoidable causes (SMR = 1.96, 95% confidence interval [CI] = 1.77–2.16, p < 0.05) and in terms of indicators of medical care (SMR = 2.41, 95% CI = 2.17–2.67, p < 0.05); however, the female patients did not (SMR = 1.22, 95% CI = 0.67–2.05; SMR = 1.57, 95% CI = 0.86–2.64, respectively). Conclusion: Male patients had higher mortality gaps due to avoidable causes and in terms of indicators of medical care. But female patients who all had stayed in tobacco-free settings did not. Environmental smoking restriction might be related to the diminished avoidable mortality gaps in patients with schizophrenia.

We investigated the availability of health system performance indicator data in Canada’s 18 northern regions and the feasibility of using the performance framework developed by the Canadian Institute for Health Information [CIHI]. We examined the variation in 24 indicators across regions and factors that might explain such variation. The 18 regions vary in population size and various measures of socioeconomic status, health-care delivery, and health status. The worst performing health systems generally include Nunavut and the northern regions of Québec, Manitoba and Saskatchewan where indigenous people constitute the overwhelming majority of the population, ranging from 70% to 90%, and where they also fare worst in terms of adverse social determinants. All northern regions perform worse than Canada nationally in hospitalisations for ambulatory care sensitive conditions and potentially avoidable mortality. Population size, socioeconomic status, degree of urbanisation and proportion of Aboriginal people in the population are all associated with performance. The North is far from homogenous. Inter-regional variation demands further investigation. The more intermediate pathways, especially between health system inputs, outputs and outcomes, are largely unexplored. Improvement of health system performance for northern and remote regions will require the engagement of indigenous leadership, communities and patient representatives.

The decline in Avoidable Mortality (AM) and increase in life expectancy in Shanghai is impressive. Gusmano and colleagues suggested that Shanghai’s improved health system has contributed significantly to this decline in AM. However, when compared to other global cities, Shanghai’s life expectancy at birth is improving as London and New York City, but has yet to surpass that of Hong Kong, Tokyo, and Paris. Over the past decade, the reduction in AM of Shanghai is just in line with the international experience in reducing avoidable premature deaths. We suggest that a more elaborate research design is needed to examine the impact of the improvement in Shanghai’s health system on its population health status.

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.

BACKGROUND Critical congenital heart disease (CCHD) was recently added to the U.S. Recommended Uniform Screening Panel for newborns. States considering screening requirements may want more information about the potential impact of screening. This study examined potentially avoidable mortality among infants with late detected CCHD and assessed whether late detection was associated with increased hospital resource use during infancy. METHODS This was a state-wide, population-based, observational study of infants with CCHD (n = 3603) born 1998 to 2007 identified by the Florida Birth Defects Registry. We examined 12 CCHD conditions that are targets of newborn screening. Late detection was defined as CCHD diagnosis after the birth hospitalization. Deaths potentially avoidable through screening were defined as those that occurred outside a hospital following birth hospitalization discharge and those that occurred within 3 days of an emergency readmission. RESULTS For 23% (n = 825) of infants, CCHD was not detected during the birth hospitalization. Death occurred among 20% (n = 568/2,778) of infants with timely detected CCHD and 8% (n = 66/825) of infants with late detected CCHD, unadjusted for clinical characteristics. Potentially preventable deaths occurred in 1.8% (n = 15/825) of infants with late detected CCHD (0.4% of all infants with CCHD). In multivariable models adjusted for selected characteristics, late CCHD detection was significantly associated with 52% more admissions, 18% more hospitalized days, and 35% higher inpatient costs during infancy. CONCLUSION Increased CCHD detection at birth hospitals through screening may lead to decreased hospital costs and avoid some deaths during infancy. Additional studies conducted after screening implementation are needed to confirm these findings. Birth Defects Research (Part A) 97:664–672, 2013. © 2013 Wiley Periodicals, Inc.

Background: Recognizing mortality pattern and observing its trend will help us in determining health priorities, allocating health resources and priorities in health section, eliminating main factors of premature deaths and carrying out epidemiological research. Objective: The aim of this research was to determine avoidable mortality in Kerman province. Materials and Methods: The present study was carried out longitudinal. A checklist was applied for data collection. Avoidable mortalities were examined in Kerman province between 2004 and 2010. Statistical universe of this research was all deaths registered in statistical unit of health deputy of Kerman University of Medical Sciences; they were all studied through a census method. Data analysis was carried out using descriptive and analytical test by SPSS18.0. Results: Two thousand and one hundred –ninety seven deaths were examined. Of them, 210 deaths were unavoidable and 19987 were avoidable. In this study, most unavoidable deaths were due to pancreases cancer and ovary cancer. Conclusions: Relative high number of avoidable deaths indicates that performance of health system was not desirable in Kerman during the studied years. Examining trend of avoidable deaths showed that these mortalities are increasing although it is not significant nowadays. However, if this trend continues, it will be very alarming for health care authorities in this region.

a b s t r a c t All developed nations use indicators to monitor the health of their populations, but few nations provide a systematic monitoring of indicators for small regional units. The present study aims to contribute to the literature a single graph that provides a quick and comprehensive overview of the level of and trend in avoidable mortality in each German district as compared to the national average and development. Using mortality data from the German Federal Statistical Office, I calculated the age-standardized number of avoidable deaths, separately for men and women, in each of the 413 local districts in Germany between 2000 and 2008. For men, the graph illustrates that the districts with the highest rates of avoidable mortality are still located in the former East German states, but that some of these districts have improved significantly between the years 2000 and 2008 and are approaching the nationwide average. The graph for women shows slightly different results. Here, many urban areas show high rates of avoidable mortality with both favorable and unfavorable trends. Health professionals could use the graph to establish realistic benchmarks that are based on countrywide comparisons of districts to a national average and trend, which may in turn help them to identify local districts in need of primary or secondary prevention programs or a more effective provision of health care. © 2012 Elsevier Ireland Ltd. All rights reserved.

There is a clear and ongoing need for better indicators of the effectiveness of healthcare systems. Amenable or avoidable mortality, defined as deaths that, in theory, could be prevented by timely access to good-quality healthcare, is an appealing indicator that bears further empirical scrutiny. It is proposed as a method of measuring the contribution of healthcare to population health, using routinely collected mortality data. It has been used to compare health systems at the levels of nations, provinces or states and across socio-economic strata. We investigate its application at the level of health regions in the Canadian province of British Columbia (BC), where we might expect less dramatic differences in healthcare delivery, and in the context of relatively low mortality.

Este artigo tem como objetivo analisar as causas e taxas de mortes evitáveis em crianças com menos de um ano de idade na Bahia no período de 2000 a 2012. Para isso, realizou-se um estudo ecológico de série temporal. Foram considerados os óbitos de crianças da faixa em questão, cujas mães residiam na Bahia naquele período. A classificação de evitabilidade dos óbitos seguiu a Lista brasileira de causas de mortes evitáveis por intervenções do Sistema Único de Saúde. Os dados foram extraídos dos sistemas de informação em saúde (Sistema de Informação sobre Mortalidade, Sistema de Informação sobre Nascidos Vivos). Apesar das reduções não só da taxa de mortalidade infantil geral como daquela por causas evitáveis no período estudado, ainda persistem altas proporções dessa última em menores de um ano de idade na Bahia. Destacaram-se a diminuição das taxas de mortalidade reduzíveis por adequada assistência ao recém-nascido e o aumento das taxas de mortalidade reduzíveis por adequada atenção à mulher na gestação. Concluiu-se que a abordagem da evitabilidade é um potente avaliador da resolutividade dos serviços de saúde prestados à saúde materno-infantil.

Parental delay in recognising the significance of a non-blanching rash has been identified as a cause of avoidable mortality and morbidity in 15% of children with meningococcal disease.1 The ‘tumbler’ or ‘glass’ test is promoted in UK national guidelines as a way to address this problem – parents are encouraged to “press a glass tumbler firmly against the rash – if you can see the spots through the glass and they do not fade seek medical advice immediately”.2 A well-conducted survey from France ( in press ) reports that only 7% of parents are able to recognise a petechial rash and know about the tumbler test.3The authors conclude that public information campaigns about the significance of haemorrhagic rash and the tumbler test are needed. Front-line clinicians who routinely deal with parents phoning for advice or bringing their child for initial assessment will recognise that the issue is not so straightforward. Personal experience suggests that the test is more widely known in the UK (perhaps due to the efforts of the charitable sector), but many parents find the test difficult to perform and interpret – urgent consultations due to false positive results from the tumbler test are …

Migrants constitute a significant part of our society. Migrants differ from the general German population in health status, health risks and needs, health awareness and health behavior. These differences refer to inequalities in the presence of disease, health outcomes, or access to health care. Avoidable mortality is often used as a key indicator of broader health inequalities. To further investigate the health situation of migrants in Germany beyond the indicators of avoidable mortality, it is necessary to identify migrant populations in existing databases. The first aim of this work was to combine already applied methods with new methodological approaches for determining the vital status and the mortality of migrants from Turkey and the former Soviet Union. The second aim of this dissertation project was to analyze the health situation of migrants in the state of Bremen beyond the indicators of avoidable mortality using data from the Bremen Mortality Index. We calculated age-standardized death rates, standardized mortality ratios for premature deaths ( age 65) and years of potential life lost, and analyzed underlying causes of death contributing to premature mortality. Further in-depth methodological steps such as a qualitative approach and scoping review have been established to better understand different health situations of migrants and to examine the concept of avoidable mortality based on available current European literature. While the overall trends favour the migrant populations, the indicator of YPLL and cause-specific results indicate areas where the health care system s responsiveness may need to be improved, including preventive services. This dissertation project contributed to better determination of migration background. Specific areas have been indicated where the health care provision needs to be improved.

BACKGROUND: The Low Temperature Days (LTD) have attracted far less attention than that of High Temperature Days (HTD), though its impact on mortality is at least comparable. This lower degree of attention may perhaps be due to the fact that its influence on mortality is less pronounced and longer-term, and that there are other concomitant infectious winters factors. In a climate-change scenario, the studies undertaken to date report differing results. The aim of this study was to analyse mortality attributable to both thermal extremes in Spain's 52 provinces across the period 2000-2009, and estimate the related economic cost to show the benefit or "profitability" of implementing prevention plans against LTD. METHODS: Previous studies enabled us: to obtain the maximum daily temperature above which HTD occurred and the minimum daily temperature below which LTD occurred in the 52 provincial capitals analysed across the same study period; and to calculate the relative and attributable risks (%) associated with daily mortality in each capital. These measures of association were then used to make different calculations to obtain the daily mean mortality attributable to both thermal extremes. To this end, we obtained a summary of the number of degrees whereby the temperature exceeded (excess °C) or fell short (deficit °C) of the threshold temperature for each capital, and calculated the respective number of extreme temperatures days. The economic estimates rated the prevention plans as being 68% effective. RESULTS: Over the period considered, the number of HTD (4373) was higher than the number of LTD (3006) for Spain as a whole. Notwithstanding this, in every provincial capital the mean daily mortality attributable to heat was lower (3deaths/day) than that attributable to cold (3.48deaths/day). In terms of the economic impact of the activation of prevention plans against LTD, these could be assumed to avoid 2.37 deaths on each LTD, which translated as a saving of €0.29M. Similarly, in the case of heat, 2.04 deaths could be assumed to be avoided each day on which the prevention plan against HTD was activated, amounting to a saving of €0.25M. While the economic cost of cold-related mortality across the ten-year period 2000-2009 was €871.7M, that attributable to heat could be put at €1093.2M. CONCLUSION: The effect of extreme temperatures on daily mortality was similar across the study period for Spain overall. The lower number of days with LTD meant, however, that daily cold-related mortality was higher than daily heat-related mortality, thereby making prevention plans against LTD more "profitable" prevention plans against HTD in terms of avoidable mortality. This study was supported by grants FIS ENPY 1001/13 & SEPY 1037/14 from Spain's Health Research Fund. Sí

Hypertension is one of the leading causes of avoidable mortality in the former Soviet Union (fSU). In previous work, the authors described patterns of irregular hypertension treatment in eight countries of the fSU in 2001. This paper presents new data on changes in the use of hypertension treatment in the same countries.Using household survey data from 18 420 (2001) and 17 914 (2010) respondents from Armenia, Azerbaijan (2010 only), Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia and Ukraine, the authors describe changes in rates of irregular treatment use (less than daily) between 2001 and 2010. Multivariate logistic regression was also used to analyse the characteristics associated with irregular treatment.Irregular treatment was extremely high at 74% in 2001 and only fell to 68% in 2010 (all countries combined). Irregular treatment remained particularly high in 2010 in Armenia (79%), Kazakhstan (73%) and Moldova (73%). Recurring characteristics associated with irregular treatment included gender (men), younger age, higher fitness levels, and consuming alcohol and tobacco.Irregular hypertension treatment continues to be a major problem in the countries of the fSU and requires an urgent response.

To evaluate the impact of avoidable mortality on the changes in life expectancy at birth in Korea. Standard life table techniques and the Arriaga method were used to calculate and to decompose life expectancy changes by age, effects and groups of causes of avoidable mortality among two periods(1990-2000 and 2000-2009). A list of causes of avoidable mortality reached by consensus and previously published in Spain was used. Mortality in young adults produced a reduction in life expectancy at birth during the 1990-2000, but there was an important increase in life expectancy at birth during the 2000-2009; in both cases, this was the result of factors amenable to health policy interventions. The highest improvement in life expectancy at birth was due to non-avoidable causes, but avoidable mortality through health service interventions showed improvements in life expectancy at birth in those elderly people than 1 year and in those younger. Making a distinction between several groups of causes of avoidable mortality and using decomposition by causes, ages and effects allowed us to better explain the impact of avoidable mortality on the life expectancy at birth of the whole population and gave a new dimension to this indicator that could be very useful in public health.

The current trends of avoidable mortality, which is an integral indicator of health system performance, were analyzed. The paper discusses the regional heterogeneity of levels and trends in avoidable mortality in the Russian Federation. Also, it contains the analysis of impact of the financial costs of public health on avoidable mortality in regions with different levels of economic development. The last 20-years period was studied, which includes a stage of crisis as well as a social recovery phase. The official data of the State Statistics Committee were analyzed. In Russia, all death cases are registered in accordance to the international classification ICD-10. Special computer program summarizes death cases from preventable causes, and calculates the standardized rates for the population aged from 5 to 64 years. The old European standard of population age structure is used. Estimates of avoidable mortality were made in accordance with the European approach, under which avoidable mortality accumulates deaths of persons aged from 5 to 64 years due to 34 causes and 4 classes of causes. These 38 causes are divided into 3 groups according to three levels of diseases prevention. The level of avoidable mortality in the different regions varies up to 8 times. That is comparable to the difference between Russia and the countries of European Union in 1994. This gap is due to the coexistence of different stages of epidemiological development among the regions in Russia. When death rates increased, it is shown that mortality from causes which are preventable by measures of primary and tertiary prevention increased to a greater extent than mortality from the causes which depend from measures of secondary prevention. Therein, the largest growth of observed mortality was due to low quality of medical care in case of males (group 3), and due to causes which are preventable by measures of primary prevention in case of females (group 1). When mortality was reduced, the rates of change for causes in groups 1 and 3 were approximately the same for both sexes. Avoidable mortality due to late detection of malignant tumors (group 2) has been changed the least. Preventable component defines over 80% of the regional differences in death rates. In 2009, the level of avoidable mortality differed more than fourfold among different regions of the Russia. Similarly, the difference in the level of unavoidable mortality was 1.3-fold and 1.7-fold, for males and females respectively. Proportion of deaths from preventable causes in the total sum of death cases varies from 40% till 75%. Funding for comprehensive programs of public health to a greater extent stimulates the reduction in mortality from preventable causes of the first group. Mortality connected with quality of medical care is more determined by socio-political situation in the country than by regional health care expenses. Based on these results, it is concluded that the action plans to reduce mortality in Russia must have a strong regional specificity, different targets and indicators. Using the proportion of preventable causes, it is possible to separate the regions into groups with different ratios of death determinants, which, therefore, require different approaches to reduce mortality.

Background: Globally, tobacco can be attributed to more than 7 million deaths each year. To address this potentially avoidable mortality, The University of Texas MD Anderson Cancer Center has engaged its Global Academic Program´s (GAP) sister institutions (SI) by conducting an inaugural tobacco control assessment survey. A similar survey was done with our University of Texas academic and health science center affiliates that led to improved adoption of tobacco control policies as well as prevention and cessation services on all campuses. The baseline data collected will serve as a mechanism to develop a tobacco prevention and control strategy within a global cancer center network. Aim: To assess SI laws and policies regarding tobacco use, existing screening and cessation services. Strategy/Tactics: Qualtrics was used to administer a 27-item survey to our GAP SI from April-October 2017. Survey questions focused on key areas of tobacco prevention and control: policy, tobacco use screening, and cessation services. A survey link was emailed to 34 institutions in 23 countries. Program/Policy process: Survey GAP SI to determine current tobacco prevention and control measures being implemented. Convene GAP SI in May 2018 to share tobacco control best practices across the network and identify resources and supports to strengthen tobacco control efforts at each institution. Build collaborations aimed at progressive actions in tobacco control policies, educational programs and cessation services culturally appropriate to the needs and resources of the GAP network. Outcomes: Of the 34 GAP SI, 26 responded to the survey (76% response rate). Key findings among the 26 responding institutions: policy - 96% are located in cities with laws regulating the sale and/or use of tobacco products by minors and 77% of the cities have laws regulating the use of tobacco in the workplace; 42% of the campuses have designated smoking areas; tobacco use screening - 65% screen for and document patients´ tobacco status, however only 27% screen “all the time”; cessation services - 19% offer telephone counseling as a cessation service; 38% offer cessation services to the community; 46% offer cessation services to employees. What was learned: The baseline assessment identified areas of institutional needs: cessation services and campus policies. Further discussion with the SI will help engage them in further efforts to address gaps in tobacco control. Collectively, we aim to develop action steps to collaborate and enhance existing services by creating a global platform in which tobacco control best practices and resources can be shared.

AMIEHS, avoidable mortality in the European Union : towards better indicators for the effectiveness of health systems