Amenable mortality as an indicator of health care services performance at a sub-national level

Background: Mortality amenable to health care services has been defined as “premature deaths that should not occur in the presence of timely and effective health care” or as “conditions for which effective clinical interventions exist”. Originally developed in the 1970s in the United States the concept of amenable mortality has been revitalized recently as potentially useful to assess the quality and performance of health systems and analyse changes over time. This study examined amenable mortality in Italy and analysed regional variability in health care services using amenable mortality as a performance indicator. We also estimated the contribution of amenable mortality to the total mortality gap between Northern and Southern Italy. Methods: We analyzed age standardized rates of amenable morality under age 75 (SMR) per 100,000 inhabitants, stratified by gender and region, over the years 2006-2008. Results: Amenable mortality constitutes an important proportion of total mortality, accounting, in 2006-08, for an average of 18.9% of total mortality under age 75 among males and 31.4% among females. During the study period, the SMR in Italy was 62.6 per 100,000 inhabitants: 66.0 per 100,000 for males and 59.1 per 100,000 for females. A significant regional variation in SMRs was found, ranging from 54.1 per 100,000 in Alto Adige to 76.3 per 100,000 in Campania. Southern Italy generally had higher SMRs than Northern Italy. The contribution of amenable mortality to the total mortality gap between Northern and Southern Italy was estimated using the ratio of the standardized mortality rate differences (SRD amenable / SRD all causes) between the groups of interest. In 2006-2008 amenable mortality contributed 35.8% and 54.1% to the North-South total mortality gap for males and females respectively. Conclusions: The Italian National Health Care System shows a general good performance although Southern health care services display a poorer performance, as assessed by the concept of amenable mortality. Despite its limitations, amenable mortality is a scientifically sound and feasible indicator that can be used to inform policy decision making processes in decentralizing health care systems and monitoring their effectiveness and equity.