The concept of mortality amenable to medical care was introduced in the early 1970s by Rutstein. His working group selected over 90 conditions as “sentinel health events” from which disease, disability or death “should not occur in the presence of timely and effective care”. Revisions of the aforementioned list undertaken in 1977 and 1980[2, 3] have formed the basis for practically all subsequent studies on avoidable mortality. Charlton was the first to apply the concept at the population level in England and Wales in 1974–78, also introducing the terms “avoidable deaths” and “conditions amenable to medical intervention”. He narrowed the concept by excluding deaths that were not directly linked to medical care, e.g. deaths avoided by policies on tobacco control, and the concept was developed further within the Health Services Research Program of the European Community in the 1980s. This collaborative action resulted in a European Community atlas of avoidable mortality in which the work of Charlton and colleagues was extended and the boundaries of health services were interpreted as encompassing primary care, hospital care and collective health services. In 2001 Tobias and Jackson produced an updated list of conditions derived from an expert consensus exercise in which the relative avoidability of death was distributed according to primary, secondary and tertiary actions.
The usefulness of the concept of avoidable mortality is based on the assumption that such causes of death are related to the functioning of medical care. This association has been studied in the past[7–9]. Avoidable causes of death can point at possible deficiencies in the delivery of medical care. Although their direct and simple use as indicators of quality of medical care in international comparisons is questionable, avoidable mortality represents the fraction of overall mortality that is more responsive to medical interventions and therefore offers insights into the scope for improvement of medical care. The link between the concept of avoidable mortality and research on health inequalities is based on the fact that medical care plays a role for the origin and reduction of socioeconomic inequalities in health and mortality[11, 12]. The latter can be explained by differences in access and use of medical care by socioeconomic group. Therefore the analysis of socioeconomic differences in avoidable causes of death can offer important lessons for tackling health inequalities. Following this reasoning, studies have looked at social differences in avoidable mortality and whether access to medical care explains socioeconomic differences in avoidable mortality.
We combine the avoidable mortality approach with an analysis of mortality on the small area level because the socio-spatial context of the small area has been shown to be an important determinant of health and health inequality that goes beyond the effect of individual characteristics on health. This socio-spatial epidemiological framework has been proposed on the general conceptional level of “place” as a determinant of health[16, 17], on the more specific level of the city[18, 19], but also on the small area level as unit of analysis. Studying health inequalities in small city areas is useful because, first, the percentage of urban population is increasing, second, health inequalities tend to be larger in cities than in rural areas because city areas tend to contain a concentration of deprivation, poverty or affluence, and third, some policies and interventions aiming at the reduction of health inequalities are approved and implemented at the city level. Therefore the monitoring of and intervening on health inequalities and its determinants at the city and small area level are especially appropriate. For these reasons the use of spatial analysis of health outcomes and their predictors have been increasing in the past years. Likewise, the development of spatial methods for epidemiological analysis has rapidly improved[22, 23].
In principal, the link between the socio-spatial concept of health determinants and avoidable mortality has been already established by studies observing geographical variations of avoidable mortality[4, 24] but very few studies have applied this concept to the level of small areas[25, 26]. While mortality differences in small areas of Spanish cities are relatively well studied[25, 27], studies showing geographical patterns of socioeconomic indicators and cause-specific mortality by small area in a large number of European cities are scarce and no study has used avoidable mortality for such a comparison on an international scale. This is the first study presenting spatial patterns of avoidable mortality in small areas of several cities of different European countries and its dependence on area-level social deprivation.
We have studied 14 avoidable causes of death, first, to estimate smoothed Standardised Mortality Ratios (SMR) for the small areas of 15 European cities in the early 21th century by gender, and to represent them on maps and, second, to estimate inequalities in the level of avoidable mortality between small areas with different level of deprivation.
In this paper we analyse (1) whether levels of mortality from avoidable causes of death are higher in deprived small areas and (2) whether the magnitude of these social inequalities in mortality differs between European cities, regions and gender.