Article Text

Download PDFPDF

Using ‘amenable mortality’ as indicator of healthcare effectiveness in international comparisons: results of a validation study
  1. Johan P Mackenbach1,
  2. Rasmus Hoffmann1,
  3. Bernadette Khoshaba2,
  4. Iris Plug1,
  5. Grégoire Rey3,
  6. Ragnar Westerling4,
  7. Kersti Pärna5,
  8. Eric Jougla3,
  9. José Alfonso6,
  10. Caspar Looman1,
  11. Martin McKee2
  1. 1Department of Public Health, Erasmus MC, Rotterdam, the Netherlands
  2. 2London School of Hygiene and Tropical Medicine, London, UK
  3. 3CépiDc, Institut National de la Santé et de la Recherche Médicale (INSERM), Le Vésinet, France
  4. 4Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
  5. 5Department of Public Health, University of Tartu, Tartu, Estonia
  6. 6Fundación de Investigación, Hospital General Universitario de Valencia, Valencia, Spain
  1. Correspondence to Professor Dr Johan P Mackenbach, Department of Public Health, Erasmus MC, P.O. Box 2040, Rotterdam 3000 CA, the Netherlands; j.mackenbach{at}


Background and study aims There is widespread consensus on the need for better indicators of the effectiveness of healthcare. We carried out an analysis of the validity of amenable mortality as an indicator of the effectiveness of healthcare, focusing on the potential use in routine surveillance systems of between-country variations in rates of mortality. We assessed whether the introduction of specific healthcare innovations coincided with declines in mortality from potentially amenable causes in seven European countries. In this paper, we summarise the main results of this study and illustrate them for four conditions.

Data and methods We identified 14 conditions for which considerable declines in mortality have been observed and for which there is reasonable evidence in the literature of the effectiveness of healthcare interventions to lower mortality. We determined the time at which these interventions were introduced and assessed whether the innovations coincided with favourable changes in the mortality trends from these conditions, measured using Poisson linear spline regression. All the evidence was then presented to a Delphi panel.

Main results The timing of innovation and favourable change in mortality trends coincided for only a few conditions. Other reasons for mortality decline are likely to include diffusion and improved quality of interventions and in incidence of diseases and their risk factors, but there is insufficient evidence to differentiate these at present. For most conditions, a Delphi panel could not reach consensus on the role of current mortality levels as measures of effectiveness of healthcare.

Discussion and conclusions Improvements in healthcare probably lowered mortality from many of the conditions that we studied but occurred in a much more diffuse way than we assumed in the study design. Quantification of the contribution of healthcare to mortality requires adequate data on timing of innovation and trends in diffusion and quality and in incidence of disease, none of which are currently available. Given these gaps in knowledge, between-country differences in levels of mortality from amenable conditions should not be used for routine surveillance of healthcare performance. The timing and pace of mortality decline from amenable conditions may provide better indicators of healthcare performance.

  • Health expectancy
  • public health
  • social epidemiology
  • demography
  • epidemiology
  • health impact assessment
  • social inequalities
  • self-rated health
  • study design
  • avoidable deaths
  • biostatistics
  • preventive medicine
  • Eastern Europe
  • international health
  • policy

Statistics from

Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

    Files in this Data Supplement:


  • Funding This paper summarises the results of the project ‘Avoidable mortality in the European Union: Towards better indicators for the effectiveness of health systems (AMIEHS)’ which was co-funded by the European Union within the framework of the Public Health Program (project number 2007106). The funding body played no role in the design, writing or decision to publish this manuscript.

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.