International Journal of Epidemiology, Vol 28, 225-232, Copyright © 1999 by International Epidemiological Association
HF Treurniet, CW Looman, PJ van der Maas and JP Mackenbach
BACKGROUND: Variations in 'avoidable' mortality may reflect variations in
the quality of care, but they may also be due to variations in incidence or
severity of diseases. We studied the association between regional
variations in 'avoidable' mortality and variations in disease incidence.
For a selection of conditions we also analysed whether the proportion of
in-hospital deaths can explain the regional variations in
incidence-adjusted mortality. METHODS: Relative risks for mortality,
incidence, incidence-adjusted mortality and in-hospital mortality (1984-
1994) were calculated by log-linear regression. Linear regression was used
to examine the relationship between mortality and incidence on the one
hand, and between incidence-adjusted mortality and in-hospital mortality on
the other. RESULTS: Significant regional mortality variations were found
for cervical cancer, cancer of the testis, hypertensive and cerebrovascular
disease, influenza/pneumonia, cholecystitis/lithiasis, perinatal causes and
congenital cardiovascular anomalies. Regional mortality differences in
general were only partly accounted for by incidence variations. The only
exception was cervical cancer, which no longer showed significant
variations after adjustment for incidence. The contribution of inhospital
mortality variations to total cause-specific mortality variations varied
between conditions: the highest percentage of explained variance was found
for mortality from CVA (60.1%) and appendicitis (29.2%). CONCLUSIONS:
Incidence data are a worthy addition to studies on 'avoidable' mortality.
It is to be expected that the incidence-adjusted mortality rates are more
sensitive for quality-of-care variations than the 'crude' mortality
variations. Nevertheless, further research at the individual level is
needed to identify possible deficiencies in health care delivery.
ARTICLES
Variations in 'avoidable' mortality: a reflection of variations in incidence?
Erasmus University, Department of Public Health, Rotterdam, The Netherlands.
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