Different health systems – Different mortality outcomes? Regional disparities in avoidable mortality across German-speaking Europe, 1992–2019

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Abstract

Background

Evaluating the impact of health systems on premature mortality across different countries is a very challenging task, as it is hardly possible to disentangle it from the influence of contextual factors such as cultural differences. In this respect, the German-speaking area in Central Europe (Austria, Germany, South Tyrol and large parts of Switzerland) represents a unique ‘natural experiment’ setting: While being exposed to different health policies, they share a similar culture and language.

Methods

To assess the impact of different health systems on mortality differentials across the German-speaking area, we relied on the concept of avoidable mortality. Based on official mortality statistics, we aggregated causes of death below age 75 that are either 1) amenable to health care or 2) avoidable through primary prevention. We calculated standardised death rates and constructed cause-deleted life tables for 9 Austrian, 96 German, 1 Italian and 5 Swiss regions from 1992 to 2019, harmonised according to the current territorial borders.

Results

There are strong north-south and east-west gradients in amenable and preventable mortality across the studied regions to the advantage of the southwest. However, the Swiss regions still show significantly lower mortality levels than the neighbouring regions in southern Germany. Eliminating avoidable deaths from the life tables reduces spatial inequality in life expectancy in 2017/2019 by 30% for men and 28% for women.

Conclusions

The efficiency of health policies in assuring timely and adequate health care and in preventing risk-relevant behaviour has room for improvement in all German regions, especially in the north, west and east, and in eastern Austria as well.

Highlights

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Strong north-south and east-west gradients across the studied area.
•

Swiss regions and South Tyrol show the lowest outcomes of avoidable mortality.
•

Even best-performing regions of Germany and Austria are above Swiss level.
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Spatial pattern related to varying effectiveness of health care and health policies.
•

Avoidable deaths explain approx. 30% of regional variation in life expectancy.

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Most cited references 74

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Measuring the quality of medical care. A clinical method.

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We outline the implementation of a new method of measuring the quality of medical care that counts cases of unnecessary disease and disability and unnecessary untimely deaths. First of all, conditions are listed in which the occurrence of a single case of disease or disability or a single untimely death would justify asking, "Why did it happen?" Secondly, we have selected conditions in which critical increases in rates of disease, disability, or untimely death could serve as indexes of the quality of care. Finally, broad categories of illness are noted in which redefinition and intensive study might reveal characteristics that could serve as indexes of health. We describe how these inth of the general population and the effects of economic, political, and other environmental factors upon it, and to evaluate the quality of medical care provided both within and without the hospital to maintain health and to prevent and treat disease.

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Statutory health insurance in Germany: a health system shaped by 135 years of solidarity, self-governance, and competition.

Franz Knieps, Miriam Blümel, Till Bärnighausen … (2017)

Bismarck's Health Insurance Act of 1883 established the first social health insurance system in the world. The German statutory health insurance system was built on the defining principles of solidarity and self-governance, and these principles have remained at the core of its continuous development for 135 years. A gradual expansion of population and benefits coverage has led to what is, in 2017, universal health coverage with a generous benefits package. Self-governance was initially applied mainly to the payers (the sickness funds) but was extended in 1913 to cover relations between sickness funds and doctors, which in turn led to the right for insured individuals to freely choose their health-care providers. In 1993, the freedom to choose one's sickness fund was formally introduced, and reforms that encourage competition and a strengthened market orientation have gradually gained importance in the past 25 years; these reforms were designed and implemented to protect the principles of solidarity and self-governance. In 2004, self-governance was strengthened through the establishment of the Federal Joint Committee, a major payer-provider structure given the task of defining uniform rules for access to and distribution of health care, benefits coverage, coordination of care across sectors, quality, and efficiency. Under the oversight of the Federal Joint Committee, payer and provider associations have ensured good access to high-quality health care without substantial shortages or waiting times. Self-governance has, however, led to an oversupply of pharmaceutical products, an excess in the number of inpatient cases and hospital stays, and problems with delivering continuity of care across sectoral boundaries. The German health insurance system is not as cost-effective as in some of Germany's neighbouring countries, which, given present expenditure levels, indicates a need to improve efficiency and value for patients.

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Medicine and epidemiology currently dominate the study of the strong association between socioeconomic status and mortality. Socioeconomic status typically is viewed as a causally irrelevant "confounding variable" or as a less critical variable marking only the beginning of a causal chain in which intervening risk factors are given prominence. Yet the association between socioeconomic status and mortality has persisted despite radical changes in the diseases and risk factors that are presumed to explain it. This suggests that the effect of socioeconomic status on mortality essentially cannot be understood by reductive explanations that focus on current mechanisms. Accordingly, Link and Phelan (1995) proposed that socioeconomic status is a "fundamental cause" of mortality disparities-that socioeconomic disparities endure despite changing mechanisms because socioeconomic status embodies an array of resources, such as money, knowledge, prestige, power, and beneficial social connections, that protect health no matter what mechanisms are relevant at any given time. We identified a situation in which resources should be less helpful in prolonging life, and derived the following prediction from the theory: For less preventable causes of death (for which we know little about prevention or treatment), socioeconomic status will be less strongly associated with mortality than for more preventable causes. We tested this hypothesis with the National Longitudinal Mortality Study, which followed Current Population Survey respondents (N = 370,930) for mortality for nine years. Our hypothesis was supported, lending support to the theory of fundamental causes and more generally to the importance of a sociological approach to the study of socioeconomic disparities in mortality.

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Author and article information

Contributors

Michael Mühlichen

Journal

Journal ID (nlm-ta): Soc Sci Med

Journal ID (iso-abbrev): Soc Sci Med

Title: Social Science & Medicine (1982)

Publisher: Pergamon

ISSN (Print): 0277-9536

ISSN (Electronic): 1873-5347

Publication date PMC-release: 1 July 2023

Publication date (Print): July 2023

Volume: 329

Electronic Location Identifier: 115976

Affiliations

[a ]Federal Institute for Population Research (BIB), Friedrich-Ebert-Allee 4, 65185, Wiesbaden, Germany

[b ]Swiss Federal Institute of Technology in Lausanne (EPFL), Route Cantonale, 1015, Lausanne, Switzerland

Author notes

[∗ ]Corresponding author. michael.muehlichen@ 123456bib.bund.de

Article

Publisher Item ID: S0277-9536(23)00333-7 Publisher ID: 115976

DOI: 10.1016/j.socscimed.2023.115976

PMC ID: 10357323

PubMed ID: 37356189

SO-VID: 94f03c60-1975-463b-98c6-668ca2f6c62b

License:

This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

History

Date received : 9 January 2023

Date revision received : 8 May 2023

Date accepted : 18 May 2023

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Different health systems – Different mortality outcomes? Regional disparities in avoidable mortality across German-speaking Europe, 1992–2019

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Abstract

Background

Methods

Results

Conclusions

Highlights

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Most cited references 74

Measuring the quality of medical care. A clinical method.

Statutory health insurance in Germany: a health system shaped by 135 years of solidarity, self-governance, and competition.

"Fundamental causes" of social inequalities in mortality: a test of the theory.

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Contributors

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Cited by 6