Trends in Avoidable Mortality in Lithuania During 2001–2008 and Their Impact on Life Expectancy

expectancy by 1.77 years (preventable by 1.12 and treatable by 0.63 years). Diversity in trends in mortality of different avoidable causes was disclosed. A declining trend in mortality caused by chronic rheumatic heart disease and lung cancer was observed for males (AAPC –22.6% and –2.1%, respectively; P<0.05). However, the mortality caused by liver cirrhosis was increasing for both genders (AAPC 16.1% for males and 17.6% for females, P<0.01) and that caused by tuberculosis – only for females (AAPC 7.8%, P<0.05). Conclusions. An increasing in avoidable mortality was observed. Deaths caused by the diseases that could have been prevented had the greatest on the increasing mortality and decreasing life expectancy.


Introduction
Signifi cant changes of national mortality indicators over time in different populations dictate the necessity to search for scientifi cally proved causes of the observed processes. In the case of Lithuania, all-cause mortality with ups and downs within a certain range before the 1990s had sharply increased after the collapse of the Soviet system reaching the peak in 1994. From the international literature, this phenomenon is known as the "transitional mortality crisis" (1). Although there is no hard scientifi c evidence that explains the observed mortality trends, nevertheless, there is a generally accepted view that gross political, social, and economic changes that occurred during that time were the major contributors to the sharp worsening of health situation in post-Soviet populations. Stabilization of political, social, and economic situation, at least in Lithuania, in addition to the investments into the health sector might be an indirect refl ection of a signifi cant improvement of national health indicators (2). Unfortunately, this improvement was halted in the year 2000, and again an increasing trend in mortality was observed until 2008 (3).
The search for arguments for possible explanation of such diverse processes requires careful consideration and adequate investment into research. One of the approaches that in broad terms might be useful to start critical thinking regarding health policy implementation could be the assessment of trends in avoidable mortality. The concept of avoidable mortality has been proposed by Rutstein with colleagues (4), which further was elaborated by Holland to measure the quality of health care (5). Avoidable deaths are those that occur due to absence or lack of preventive measures and those that occur due to improper diagnosis or inadequate treatment. Application of contemporary knowledge in health sciences and its use in daily practice demonstrate that many deaths could be prevented, avoided, or at least their number could be reduced. In other words, the level of avoidable mortality could be considered as a measure of health care quality (5). At present, it is generally accepted to assign the indicators of avoidable mortality into two groups: those that refl ect the effi ciency of health care (deaths caused by diseases that are treatable) and those that refl ect the effectiveness of health policy (preventable deaths, i.e., deaths caused by diseases that could be controlled by preventive measures) (6).
In previous studies, the issue of avoidable mortality in Lithuania has been analyzed and assessed for the periods 1970-1990 and 1991-2001 (7-9). This analysis based on the list of diseases recommended by the European Commission experts headed by Holland (6) showed a sensitivity of avoidable mortality indicators to the changes of health care system infrastructure and provision of health care services meaning that this type of indicators must be an integral part of public health monitoring. The process of restructuring the health care system in Lithuania within the last decade demonstrates the need to continue the monitoring and evaluation of changes in avoidable mortality at the population level.
The aim of this study was to analyze the level of avoidable mortality, to assess its changes within the period 2001-2008, and to demonstrate its impact on the life expectancy of Lithuanian population.

Materials and Methods
A computerized database of causes of death from the Lithuanian Department of Statistics for 2001-2008 was used for this study. Twelve causes of death as rec-ommended by the European Commission Working Group experts headed by Holland (6) were used for analysis: the fi rst group comprised deaths caused by diseases that could have been treated and the second -deaths that could have been avoided by preventive measures (Table 1). Maternal deaths and deaths during perinatal period were excluded. The causes of death were coded using the 10th revision of the International Classifi cation of Diseases and Health Problems.
The analysis performed on avoidable mortality covered the Lithuanian population aged 5-64 years for the period 2001-2008. Keeping in mind the impact of population aging on mortality changes, the mortality indicators were computed using a direct standardization by age (European population standard). The row of age-standardized mortality changes for 2001-2008 for each cause of death was expressed by the linear regression (y=a+bx). The Student's criterion was used to assess the significance of changes. To compare the speed of mortality changes for different causes of death, the average annual percent change (AAPC) was computed, which presented an average mortality change in percent. In order to control bias that occurs due to annual variations resulted by relatively small numbers of death in some nosologic groups, the AAPC was computed not from real standardized mortality indicators for 2001 and 2008, but from linear regression values using the following equation: A A P C = ( ( m 2 0 0 8 / m 2 0 0 1 ) 1 / 7 -1 ) × 1 0 0 , whe re m 2001 and m 2008 indicate standardized mortality values based on linear regression. Average life expectancy (ALE) at birth and ALE shortening due to avoidable causes of death were computed for each year from annual survival tables. The same methodology was used for computing the average ALE and

Results
The data taken from the WHO European "Health for All" database (10) present the trends of all-cause mortality in the Lithuanian population between 1980 and 2008 in comparison with the EU, 2 other Baltic States, and the Commonwealth of Independent States (CIS) (Fig.). The presented analysis of trends in all-cause mortality demonstrates several important issues. Firstly, contrary to steady declining mortality rates in the EU populations, the Baltic and CIS populations experienced a dramatic increase in age-standardized mortality rates (SMRs) after 1990s, peaking in 1994, and then a signifi cant decline until 2000, at least in the Baltic States. However, while the SMRs in Latvia and especially in Lithuania leveled off since 2000, in Estonia mortality rates continued to decline. Secondly, mortality rates in Lithuania for a long time being the lowest in the Baltic context (even in a health crisis situation) have lost this position after 2004. There must be some important reasons for this transformation. Finally, although with obvious differences in the level of mortality rates, the trend changes in the Baltic and CIS populations followed similar patterns still remaining considerably higher in the CIS populations after 2004. Moreover, signifi cant differences in mortality rates remain comparing the Baltic and EU populations.
Assessing the changes in mortality trends by analyzing the patterns of avoidable mortality might provide some explanation for the effects of national health policy implementation. In Lithuania, 112 117 deaths were registered in the population aged 5-64 years during the study period. The proportion of deaths of 12 avoidable causes under study accounted for 22.9% in this age group, i.e., almost one-fourth of all deaths. Among them, deaths the causes of which could have been avoided by treatment made up 40% and deaths that could have been avoided by effective prevention measures made up 60%.
During the analyzed period, the all-cause SMR in the population aged 5-64 years ( Table 2) was signifi cantly increasing (AAPC 1.7%, P<0.05), as was the case for female population (AAPC 1.6%, P<0.01). The avoidable mortality was increasing more substantially than the overall mortality (AAPC 3.0%, P<0.05). The most signifi cant increase was observed for avoidable mortality in the female population (AAPC 4.0%, P<0.05). An increase in avoidable mortality caused by preventable diseases was observed for both genders and a considerable increase was recorded for females (AAPC 4.6% for both genders, P<0.05, and 9.4% for females, P<0.01). A trend in the increasing avoidable mortality that could have been treated was not statistically signifi cant.
The observed negative changes in avoidable mortality were refl ected in the values of ALE. Due to premature deaths before the age of 65, the overall ALE within 2001-2008 was shortened by 8.8 years. The impact of deaths due to avoidable causes was less signifi cant -the ALE was shortened by 1.77 years. The shortening of ALE by avoidable deaths for males was 2.18 years. Although this shortening for females was only 1.12 years, its annual change reached 3.8% (P<0.05). The impact of avoidable deaths caused by treatable and preventable diseases on ALE was considerably different. The ALE within 2001-2008 was shortened by 0.63 year by deaths caused by treatable diseases, and this impact practi- (1) (6) (4) (5) cally remained unchanged during the entire period of observation. At the same time, the deaths caused by preventable diseases shortened ALE as much as twice (1.12 years), and their impact on the shortening of ALE remained signifi cant over the entire period under study (AAPC 3.6%, P<0.05). Genderrelated analysis demonstrated that although male ALE was shortened for 1.5 years due to prevent-able diseases, the annual change of that shortening was not signifi cant. In contrast, although ALE shortening for females was only 0.5 year, the annual change of that shortening was statistically significant (AAPC 8.4%, P<0.01).
The avoidable mortality by individual disease categories during the period under study was different (Tables 3 and 4  Mortality caused by motor vehicle accidents showed also a trend of decline within the period under study, however, not reaching statistical signifi cance.

Discussion
Advantages and Shortcomings of the Study Method. The concept of avoidable mortality is in principle based on scientifi c evidence and expert consensus that allows judging how much the number of deaths in a population might be signifi cantly reduced in a given period taking into account the conditions in which the health system is functioning. However, the scope and quality of health care provision are changing over time. The list of diseases that could be effectively treated in various age groups is also changing. All these conditions have a serious impact on the proportion of deaths that could be avoided within the structure of overall mortality. On the other hand, the interpretation and practical use of avoidable mortality concept are also changing. The group of researchers headed by Rutstein, having the objective to raise community's interest in searching the answers to the questions why their members died or became disabled, proposed the list containing 90 ill-health conditions (4). The improvement of health care quality was the major task of the analysis performed. This concept was further developed by other investigators backing it up by quantifi ed indicators. Studying territorial avoidable mortality changes in England and Wales, Charlton et al. selected 14 disease entities from the Rutstein's list, which had a direct link with functioning of primary and inpatient care (11). Poikolainen and Escola studied 22 conditions; 5 of them were related to perinatal deaths in Finland. Analyzing the differences in avoidable mortality in 25 countries, the authors in their later research selected 70 avoidable and 20 "partially avoidable" disease entities, meaning that the concept of avoidable mortality again was enlarged. The European Commission Working Group headed by Holland proposed the list of 14 diseases being selected on the basis of intervention effectiveness and existing health care structures (5,6). In principle, the largest proportion of studies in the subsequent period was based on the recom-  mendations of this Working Group. Westerling was among the fi rst ones who adopted the concept of preventable and treatable avoidable mortality at the national level in Sweden and proposed to defi ne the acceptable marginal levels of avoidable mortality for each country (12). The debate is ongoing at present regarding the proposal to expand the list of avoidable deaths. The increasing number of interventions such as coronary angiography, thrombolytic therapy, and coronary bypass surgery in medical practice has a considerable impact on the survival of patients with ischemic heart disease, and the combination of surgical, chemotherapy, and radiotherapy for the treatment of malignant neoplasms considerably changes disease outcomes. Researchers suggest adding diabetes, alcohol intoxication, and suicides to the list of avoidable mortality, thus increasing the number of avoidable external causes of death (13,14). After having performed the literature review on amenable mortality as an indicator of health care quality in 2008, Kamarudeen states that there is no consensus what exactly constitutes avoidable mortality, thereby making the concept in itself imprecise (15). However, the researchers continue the studies on avoidable mortality (16)(17)(18)(19)(20). Keeping in mind the abovementioned comments and even increasing trends of some cause-specifi c mortality in Lithuania, the application of avoidable mortality method should be considered more detailed in future research in our country.
Computing the impact of avoidable deaths on ALE is another important methodological aspect to mention. The shortening of ALE in this study was assessed by eliminating avoidable deaths in the target age group under assumption that those subjects would not die from other causes in the study period. For methodological precision, it would be desirable to carry out more detailed analysis that includes the clustering of diseases. However, the chances that other causes might lead to death within the study period for subjects younger than 65 years in practice are not too big since multiple pathology at this age is unlikely to be frequent. Therefore, it is justifi ed enough to assume that this could not signifi cantly infl uence the mortality caused by avoidable deaths. On the other hand, due recognition should be given to the simplicity and quantitative assessment of the results by the methodology used, which is its obvious advantage.

Comparison of Changes in Avoidable Mortality for 2001-2008 With the Previous Investigations.
As mentioned earlier, the analysis of avoidable mortality is internationally applied for indirect assessment of the effectiveness of health care at the population level. By reviewing results of avoidable mortality analysis in different periods, it is reasonable to compare the trends of these indicators in those periods. Comparing 2001-2008 data with the previous dec-ade, a negative trend was observed: while the proportion of avoidable deaths in the population under 65 in 1990-2001 was 20.6% (9), it increased up to 22.9% in 2001-2008. Since within the last period the rate of increase of avoidable mortality was higher than that of overall mortality, it is likely that the proportion of avoidable mortality in the structure of overall mortality will not decrease. This means that it is unlikely to expect positive changes in the functioning of health system in the nearest future to occur at the population level as measured by this group of indicators.
The data of previous investigation period demonstrated two important directions in mortality changes in the population under 65: a signifi cant increase in 1990-1994 (AAPC 7.3%) and a decrease in 1995-2001 (AAPC -3.8%). Similar trends in changes were observed in avoidable mortality, although statistically not signifi cant (9). Within the health policy context, it is important to consider changes in trends of treatable and preventable diseases that allows assessing the functioning of different structures of the health system. Mortality caused by the diseases that could have been treated signifi cantly increased in 1990-1994 (AAPC 6.0%) and signifi cantly decreased in 1995-2001 (AAPC -4.7%). This was related to the increase of deaths caused by hypertension and stroke as well as tuberculosis in 1990-1994 and decrease of these deaths in 1995-2001 (AAPC 5.4% and -4.5%; and 14.6% and -6.7%, respectively). The data of 2001-2008 did not show any signifi cant changes in the group of treatable diseases, although trends for cause-specifi c deaths were different. Special concern should be given to an increase in tuberculosis-associated mortality in females (AAPC 7.8%) when during 1995-2001 tuberculosis-caused mortality was declining (AAPC -7.5%). The national Programme for Prevention and Control of Tuberculosis has been operating since 2003. It goes without saying that action plan of this program for the period 2007-2011 needs to be revised.
One of the strategic tasks of the Lithuanian Health Programme -attainment of a signifi cant increase in healthy life expectancy -could not be achieved without reorientation of national health system paying more attention and investing in health promotion and disease prevention (3). During the last decade, a number of prevention programs have been endorsed and funded by the government. These programs cover areas such as tobacco and alcohol control, healthy nutrition, high cardiovascular risk detection, and screening for cervical cancer, breast cancer, and prostate cancer. It is expected that these long-term programs will bring results in due time. The monitoring of avoidable mortality might be used as one of the tools to observe and assess the implementation of these programs and to evaluate long-term results. For the time being, the avoidable mortality caused by ill-health conditions that could have been prevented was increasing (AAPC 4.6%, P<0.05). The major contribution to that was significantly increasing mortality caused by liver cirrhosis in both genders (AAPC 17.6%, P<0.01). In the previous decade, mortality caused by liver cirrhosis was 2-fold lower (AAPC 9.5%, P<0.05). The report of the Institute of Alcohol Studies in London (21) has declared that mortality caused by liver cirrhosis in the female population of England aged 35-44 years increased 10-fold during the last 30 years. In Lithuania, the increasing consumption of alcohol caused by liberalization of alcohol control policy has been refl ected in the increasing of alcohol-related mortality during 2001-2007 (22,23). For public and economic reasons, governments should play a strong role in alcohol retailing and strengthen alcohol control. Alcohol advertising was limited and decisions restricting access were adopted in Lithuania during 2007-2008. The last available data (2008) showed the decline of deaths caused by liver cirrhosis. Although liver cirrhosis is a chronic disease because of long-term excess consumption of alcohol, there are other signs of leveling-off of alcohol-related problems. Since 2008, a considerable decrease in acute alcohol-related problems, such as acute alcohol intoxication especially among teenagers, has been documented (23). Moreover, in 2008, there was a signifi cant decrease in mortality caused by traffi c accidents. All this taken together indicates that stronger alcohol control measures show the signs of improvement in health policy implementation.
Summarizing the results of comparative analysis during two study periods, it is obvious that the trends in overall avoidable mortality caused by both deaths that could have been avoided by treatment as well as by implementing the effective preventive measures were less favorable for the period 2001-2008 than the previous period. In fact, the avoidable mortality caused by treatable diseases leveled off, and mortality caused be preventable disease was increasing at a higher rate. It is likely that increasing alcohol consumption in 2001-2007 was the major contributor to the observed trend. Having in mind that an improvement in national health indicators was halted in the year 2000, and an increasing trend in total mortality was observed until 2008, systematic analysis, monitoring, and evaluation of avoidable mortality might be considered as a useful additional measure for the assessment of health policy implementation.

Conclusions
The avoidable mortality in Lithuanian population aged 5-64 years within the period 2001-2008 was increasing at a higher rate (AAPC 3.0%, P<0.05) than overall mortality (AAPC 1.7%, P<0.05). An observed increase in avoidable mortality was mainly determined by deaths that could have been prevented (AAPC 4.6%, P<0.05). Among the latter, liver cirrhosis was a major contributor to the avoidable mortality: it was increasing by 16.1% per year among males and 17.6% per year among females (P<0.01). The avoidable causes of death reduced the life expectancy by 1.77 years. The impact of deaths caused by preventable diseases was 2-fold higher than the treatable ones.