Your health system can kill you: the concept of amenable mortality

Everyone knows what “mortality” is: a fatal outcome, or in a word, death. Then what is “amenable mortality?” It’s mortality that can be averted by good health care. Poverty, race, hospital readmission rates, and care for chronic disease are factors that can prevent death in America, according to a study by researchers from The Commonwealth Fund, Mortality Amendable to Health Care in the United States: The Roles of Demographics and Health Systems Performance.

Amenable mortality is based on the concept that deaths from certain causes should not occur in the presence of timely and effective health care, particularly in people under age 75 years of age. In studies comparing amenable mortality in the U.S. to other countries, America has fallen short in health system performance indicators, such as care outcomes for people with asthma and diabetes. In a study of 19 nations in the Organization for Economic Cooperation and Development (the OECD), the U.S. scored a 110 compared to France, with the low index of 65.

That’s outside of U.S. borders compare with the U.S. overall. But within U.S. borders, it’s striking that amenable mortality substantially varies between Minnesota versus, say, Mississippi and Washington, DC.

Controlling for race and poverty, several health system indicators negatively impacting amenable mortality were statistically significant in the U.S. vs. other health systems:

• Percent of adult diabetics receiving recommending preventive care
• Adult asthmatics with an ER or urgent care visit in the past year
• Hospital admissions of Medicare enrollees for ambulatory care-senstive conditions
• Hospital readmissions of Medicare and nursing home patients.

The Commonwealth Fund has studied State-level differences, the latest report of which was Aiming Higher: Results from a State Scorecard on Health System Performance, 2009.

Health Populi’s Hot Points: Geography is destiny when it comes to health outcomes in the U.S., in the current state of health care delivery. Where we live in America sets the context for personal access to health care services and the quality of that care, which together drive individual health outcomes and, in the aggregate, public health. If you’ve been diagnosed with asthma or diabetes, it’s better to live in Minnesota than Mississippi.

One aspect of health reform in the Affordable Care Act that seeks to address inter-state differences in health system performance is Section 3205, the hospital readmissions program. First focusing on Medicare readmissions for heart failure, pneumonia and acute myocardial infarction, the strategy’s aim is to improve coordination of care from the inpatient setting to the home and keep patients stable once at home. This is one measure of health system performance that can impact amenable mortality.

An aspect of health system performance not often mentioned is the role of the patient. Patient engagement in self-care is another ingredient to averting mortality and morbidity. When a health citizen is activated in their own care and self-efficacy increases, trips to the emergency department can be averted and quality of life bolstered. The Chronic Care Model speaks to this, shown in the illustration. While the health care system, health IT and community policies impact health, it takes an informed, activated patient partnering with a health team (doctor, nurse, allied health professionals like diabetes educators, community health workers and “promotores”) to pull off optimal health outcomes.

Don’t blame all health outcomes on the health system’s failures (which are, clearly, many). Patients must play their role in personal health responsibility, too.