Results

The YPLL method revealed large variations in the EC avoidable mortality indicators for women and men between 1974 and 1994. The YPLL ratios indicated a favourable development, as they were under 100% (table 2). Compared with the YPLL ratios of all causes mortality, the ratios of the total avoidable causes indicated a more favourable development. This was especially the case in men (ratio of 65.8% compared with 76.1%), but also in women (ratio of 71.8% compared with 73.3%). In men, the more favourable development was largely attributable to the overall curative indicator that decreased even more (ratio=47.0%).

Analysis of the relative importance of the EC avoidable causes of death separately for women (table 3) and men (table 4) over the different periods of time detected substantial gender related differences. In women (table 3), the rank of malignant neoplasm of the breast as the second leading cause of premature death in 1974–78 was maintained during 1980–84, but rose to the first ranked in 1985–1989 and 1990–1994, where it contributed then to more years of YPLL loss than motor vehicle accidents. Malignant neoplasm of the trachea, bronchus and lung, which ranked seventh in YPLL rates during the first two periods, rose to the fifth place in the period 1990–94, replacing malignant neoplasm of the cervix/uterus, which fell to the seventh rank. The YPLL ratio of all causes indicated a favourable development of premature mortality (ratio=73.3%). However, according to YPPL, between 1974 and 1994, the relative importance of the total “EC avoidable causes” for women accounted for more or less 40% of all causes and this ratio remained unchanged over the four periods covered by this study (table 3).

In contrast with women, the ranking order of the top three causes for men did not change between 1974 and 1994: motor vehicle accidents, ischaemic heart disease and malignant neoplasm of the trachea, bronchus and lung respectively (table 4). The rate for cirrhosis of the liver increased between 1974–78 and 1980–84 and decreased afterwards, and these movements changed the ordering from the fifth to the fourth rank. The YPLL ratio for all causes mortality indicated a less favourable development for men (ratio=77.6%) than for women, and unlike women, when looking at the YPLL, the relative importance of the total EC avoidable causes in all causes deaths decreased for men from 46.9% in 1974–78 to 39.6% in 1990–94.

The particular case of malignant neoplasm of the trachea, bronchus and lung showed a decreasing YPLL rate between 1974 and 1994 for men while it increased in women (table 3 and table 4). The changes in YPLL rates were analysed geographically for the preventive indicators at the district level (Flanders=22 districts; Wallonia=20; Brussels Region=1). Regionally, the trends between 1974 and 1994 were expressed in separate male and female YPLL ratios for each district (figs 1 and 2). More favourable trends were noted in Flanders than in Wallonia. At the district level, three districts with increasing YPLL rates for both men and women were situated in Wallonia (numbers 23; 24; 30), while seven districts with decreasing YPLL rates for both men and women were found in Flanders (numbers 2; 10; 13; 14; 15; 20; 21) but only one in Wallonia (number 22).

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Figure 1

Malignant neoplasm of the trachea, bronchus and lung (men): ratio of YPLL rates between 1974–78 and 1990–94 at the district level (Regions: Brussels Region: number 4; Flanders: numbers 1–3, 5–21, 33–35; Wallonia: numbers 22–32, 36–43).

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Figure 2

Malignant neoplasm of the trachea, bronchus and lung (women): ratio of YPLL rates between 1974–78 and 1990–94 at the district level (Regions: Brussels: number 4; Flanders: numbers 1–3, 5–21, 33–35; Wallonia: numbers 22–32, 36–43).

Discussion

The use of YPLL to measure the trends and level of the EC avoidable mortality indicators over a 20 year period needed some adaptations. The age limits of the indicators were adapted to fit the YPLL method requirements of setting common limits. In the YPLL method, the choice of 65, 70 or 75 years as the upper limit for premature death is considered rather arbitrary.13 14 We chose the upper age of 64 years, because it was recognised in the EC indicators as a limit related to the assumption of avoidability. This was the case of all EC indicators, except those concerning children under 15 (table 1). For intestinal infections (0–14), leukaemia (0–14) and respiratory diseases (1–14), the assumption of their avoidability made by the EC study group for the ages of 0 or 1 year to 14 years was not necessarily relevant between ages 1 and 64. They were removed from the YPLL analysis on the grounds that choosing to calculate their YPLL with an upper age of 64 years like the other ones would have introduced a large overestimation and an alteration of the avoidable indicator concept.

The use of somewhat modified avoidable indicators is far from being exceptional. The EC indicators are characterised by some variability in definition. The method's sensitivity to the selection of causes of death in the studies on avoidable mortality trends was emphasised,7 just as the fact that variability in avoidable mortality's definition had an impact on the assessment of its contribution to total mortality.15 Converging lists of causes of death are used as indicators of curative care whereas there is some diversity for the primary and secondary prevention indicators. For instance, the particular case of malignant neoplasm of the trachea, bronchus and lung divides: some authors have included it in the preventive indicators,7 15 16 18-20 but others have not.3-5 21 22

In this study of Belgium, a faster decline than all causes premature mortality was observed for men and women in the EC indicators. It was especially true for the overall “curative indicators” in men, but it was also the case for the overall “preventive indicators” in men and women. However, dividing the indicators into two categories was less effective with regard to the magnitudes of the losses. The largest gains in YPLL rates over the periods came from the preventive indicators in men too. The genders experienced different evolutions. Genders differed according to the importance of the different avoidable death causes. In women, one “curative indicator” and one “preventive indicator” are becoming more important: malignant neoplasm of the breast contributed more years of YPLL loss than motor vehicle accidents in 1990–94, and the rank of malignant neoplasm of the trachea, bronchus and lung was rising regularly. These differences of trends could be treated as warning signals and as a starting point for in depth studies on gender health variations.

Since 1986 the Communities are in charge of coding and verifying the causes of deaths separately.23 On this basis differences in coding practice between the two Communities are to be suspected. But different coding exercises have shown that the impact on mortality statistics comparability between regions is far from explaining the whole difference observed.24

These results are coherent with those observed in studies of other countries, and support the validity of avoidable mortality statistics as health indicator. Nearly all studies described a faster decline for avoidable death indicators than for all causes mortality.15 18 21 Important decreases in avoidable mortality rates have been shown in time period comparisons for many Western and Eastern European countries22 as well as for regions such as Quebec21 or Valencia (Spain).15 The general improvement in the EC indicators led health planners to consider that a lack of improvement in these health indicators was a warning signal in itself20 or to consider that a widening gap in avoidable mortality between countries could indicate potential fields for improvement of the health systems.17 However, after having demonstrated a risk of false positive warning signals, Westerling suggested to use the indicators for monitoring, but to limit them as starting points for in depth studies.19 Indeed, the different indicators used may vary according to the weight of incidence related factors and of all other factors related to case fatality.25 26

In the studies where the EC avoidable mortality indicators have been divided into two categories, generally, the changes over time differed in the group of treatable compared with the group of preventable causes of deaths. In Sweden, during the 12 year period stretching from 1974 to 1985 inclusive, treatable causes in men declined more than total mortality, and preventable causes decreased for both sexes when malignant neoplasm of the trachea, bronchus and lung was excluded from the mortality rates.7 In Lithuania between 1970 and 1990, treatable causes mortality rates fell while preventable causes mortality increased.20 This was also the case in Valencia (Spain) between 1975 and 1990.15 In eastern European countries between 1950 and 1987, the “causes of death amenable to medical care” decreased regularly though less rapidly than in western countries, but the “causes non-amenable to medical care” exhibited worsening rates and seemed to be the more important reason for lack of improvement in all cause mortality trends from 1970 on.22

The division between curative indicators and preventive indicators is also justified for reasons rooted in health policy organisation. With the example of malignant neoplasm of the trachea, bronchus and lung, we have shown that the dynamics of change of premature avoidable mortality over time and space has played a part in bolstering the developing specific mortality patterns in Flanders and Wallonia. It has contributed to widen the national “north/south” (inter-regional) health gap between Flanders and Wallonia. Nearly all European studies showed large geographical differences.2-4 16 19 21 26 27 28 A better health situation in Flanders than in Wallonia has been regularly observed.28 29 The same conclusion was found in previous studies on EC avoidable mortality indicators.16 30

This study has shown the interest of mortality indicators that combine the avoidable death concept and premature mortality (YPLL method) into a synthetic and comparative approach. It supplies health indicators to health planners at regional and local levels. In the Belgian context, which permitted health promotion policies decentralisation, these indicators are very useful to help identify health priority problems and to prioritise and to target health promotion strategies.