Applications and limitations of the concept of ‘avoidable mortality’ among immigrant groups in Europe: a scoping review

Highlights

• Health care systems may provide varying quality of care or impose barriers to care on migrant groups in Europe.

• The classical concept of avoidable mortality was introduced as an alternative way to measure quality of health care.

• Avoidable deaths refer to all those, that could be avoided through timely intervention and equal chances in health care.

• The concept of avoidable mortality appears underused, despite the availability of data and variety methods.

• Further research could indicate the potential for health care systems to contribute to reductions in health inequalities.

Abstract

Objectives

Avoidable mortality is often used as a key indicator of broader health inequalities. Health inequalities refer to unfair differences in the quality of health and wellbeing, and health care across different populations. This includes differences in the presence of disease, health outcomes, or access to health care. Migrants represent a disadvantaged and growing demographic with special health risks. This study analyses the usages of the concept of avoidable mortality as applied in studies on migrants in Europe. In doing so, the study aims to identify the strengths and limitations of the concept of avoidable mortality for comparative work.

Study design

A scoping review was conducted for the period of 1990–2011.

Methods

Publications were identified by a systematic search of PUBMED and WEB OF SCIENCE. An additional five publications were found through the search via references. A total number of 37 publications from 10 European countries were included in the analysis.

Results

The authors divided studies according to direct versus indirect usage of the concept. Studies with direct usage of the concept established a correlation between patterns of avoidable mortality and health care system performance. Additionally, they searched studies which indirectly used avoidable mortality to examine further evidence for the strengths and weaknesses of the concept. These studies used indicators of amenable mortality (at times alongside other mortality indicators) without making direct reference to the concept. Findings using both approaches identified a similar trend in principal causes of premature death. The difference between the two types of studies concerned the more detailed analysis of the causes of death in studies with direct usage categorising into treatable versus preventable causes of death, or health policy versus medical intervention.

Conclusions

The results of this article highlight the role of health care systems in contributing to migrant health outcomes: whereas mixed outcomes across a number of indicators of avoidable mortality used indirectly do arise, the large number of studies – especially those using the concept directly – evidence a higher share of premature mortality for migrants compared to host populations. These findings can provide policy makers with important insights into targeted ways of improving the access and quality of health services for marginalised populations. However, the strength and depth of such insights stand to improve, as current research on avoidable mortality is often indirect (rather than overt and systematic), thereby limiting the potential for cross-national comparison, as well as a clearer understanding of the links between health outcomes and health care system performance for a disadvantaged group.

Introduction

Mortality patterns in epidemiology are central to the goals of identifying the common criteria of health status and of assessing the overall health of one or more demographic groups. They provide a general snapshot of population health, however, without reference to or differentiation amongst causes or contributions. Consequently, researchers interested in the direct relationship between the health care system and health outcomes have developed a far more specified concept, avoidable mortality (also referred to as amenable mortality, used interchangeably here), which links the performance of the health care system to a specific catalogue of diseases that should not end in death given the current state of medical knowledge and technology.1, 2, 3 Despite its growing popularity in recent years, particularly amongst researchers interested in country specific developments in health,⁴ the concept of avoidable mortality presents a number of methodological and conceptual disadvantages. Due to the range of avoidable causes of death, as well as the choice of age limits for avoidable causes, which today extends to 75 years given current life expectancy, avoidable mortality constitutes an important proportion of overall mortality. However, a strong correlation between avoidable and overall mortality has been empirically acknowledged.⁴ One key challenge in avoidable mortality research concerns the lack of a standardised approach across studies, thereby hindering the possibility for sound cross-national observations. Criticism also surrounds the poor investigation of the link between the provision of health care and the concept of avoidable mortality as it relates to important demographic characteristics of patients such as socio-economic status, migration status or ethnicity.³ The inclusion of such information has the potential to provide powerful insight into the performance of health care systems not only in terms of quality of care, but also in terms of equity of access.

The present contribution is especially interested in the interconnections between health care performance and avoidable mortality for migrants in Europe. Terms such as migration, ethnicity, race and ancestry are highly complex and often overlapping concepts. They are usually used to subdivide populations. For epidemiological research, it is important to compare different populations and understand differences. In this spirit, the usage of the terms ‘migration, migrant background, other ethnicity or race’ reflects an interest in capturing individuals with different physical and cultural characteristics, as well as different disease patterns, specific morbidity and mortality.⁵ Research has identified a number of adverse factors affecting migrant health⁶ such as pre-existing conditions, migration history, lifestyle, stress, socio-economic standing, and predisposing genetic factors, which are often met by inequalities in access and sub-optimal services in host countries.1, 5, 7, 8 By focusing on Europe in the present study, the authors are particularly interested in identifying developments in migrant health across a broad spectrum of health care system types that are captured by European welfare states,⁹ but which are nevertheless arguably more homogeneous in kind than comparisons with North America, Australia or New Zeeland would allow. Moreover, the history and nature of migration within Europe presents a distinct set of ethnic inequalities that differ from other regions of the world.² The challenge for amenable mortality studies that focus on Europe, including that of the present review, is to identify how health care systems fare in dealing with these inequalities. Thus far, however, there has been a paucity of comparative research that captures the complexity and heterogeneity of migrants in Europe, while also uncovering their shared risks. Reliable and comparable quantitative information on the patterns of disease, access to health care, overall mortality, as well as specific mortality causes amongst migrants is still scarce.3, 4 Findings from European countries are especially lacking, despite international migrants representing 4.1% of the EU-27 population as of 2012.¹⁰

Migrants living in the EU represent a broad range of sub-groups that include various ethnicities, socio-economic backgrounds, but also legal statuses (from EU citizens to visa holders to asylum seekers to illegal migrants), but they are generally said to subsume some of the most disadvantaged members of society. Often, disadvantages may be a reflection of difficult living conditions in their country of origin or, more rarely, some predisposed genetic factors, as well as borne of the complexities associated with migration and prior health status.¹¹ However, local conditions in the country of migration also play a part in affecting health: barriers to accessing health services; poor social and economic standing in the host country; stress; and continued or adopted deleterious lifestyles stand to aggravate health risks.¹² Accordingly, applying the concept of avoidable mortality to migrants offers an important litmus test for evaluating health care system performance in terms of equity.

The goal of this review is to appraise the literature currently available on migrant health in Europe, focusing on amenable mortality. In a first step, the overall and all-cause mortality in migrant populations (defined variously by authors) was examined to map the current situation of this heterogeneous group in Europe. In a second step, the authors looked at the published literature through the prism of the concept of avoidable mortality in order to (i) verify its usage; (ii) report dominant amenable causes of death; and (iii) identify age specific diseases or health problems which might be linked to migration. By examining the link between migrants and their specific health risks and the ability of health care systems to reduce, prevent, and/or treat those risks, epidemiological research stands to enhance the decision-making capacity of local authorities. The present article provides a scoping review of the concept. As described elsewhere, “scoping studies aim to map the literature on a particular topic and to provide an opportunity to identify key concepts, gaps in the research; and types and sources of evidence to inform practice, policymaking, and research”.¹³ It is also an appropriate method for studies that represent a first attempt at synthesizing an area of research hitherto unaddressed,13, 14 which (to the authors knowledge) is the case for the present study.