Excess Cardiovascular Mortality in Latvia: A Novel Approach Based on Patient-Level Data to Estimate the Separate Contributions of Primary Prevention, Accessibility and Quality of Hospital Care

Background: Because quantifying the relative contributions of prevention and medical care to the decline in cardiovascular mortality is controversial, at present mortality indicators use a fifty-fifty allocation to fraction avoidable cardiovascular deaths as being partly preventable and partly amenable. The aim of this study was to develop a dynamic approach to estimate the contributions of preventable versus amenable mortality, and to estimate the proportion of amenable mortality due to non-utilisation of care versus suboptimal quality of care. Methods: We calculated the contribution of primary prevention, healthcare utilisation and healthcare quality in Latvia by using Emilia-Romagna (ER) (Italy) as the best performer reference standard. In particular, we considered preventable mortality as the number of cardiovascular deaths that could be avoided if Latvia had the same incidence as ER, and then apportioned non-preventable mortality into the two components of non-utilisation versus suboptimal quality of hospital care based on the presence of hospital admissions in the days before death. This calculation was possible thanks to the availability of the unique patient identifier in the administrative databases of Latvia and ER. Results: 41.5 people per 100 000 population died in Latvia in 2016 from cardiovascular causes amenable to healthcare; about half of these (21.4 per 100 000) had had no contact with acute care settings, while the other half (20.1 per 100 000) had accessed the hospital but received suboptimal-quality healthcare. Another estimated 26.8 deaths per 100 000 population were due to lack of primary prevention. Deaths attributable to suboptimal quality or non-utilisation of hospital care constituted 60.7% of all avoidable cardiovascular mortality. Conclusion: If research is undertaken to understand the reasons for differences between territories and their possible relevance to lower performing countries, the dynamic assessment of country-specific contributions to avoidable mortality has considerable potential to stimulate cross-national learning and continuous improvement in population health outcomes.