Avoidable mortality across Canada from 1975 to 1999
BMC Public Health volume 6, Article number: 137 (2006)
The concept of 'avoidable' mortality (AM) has been proposed as a performance measure of health care systems. In this study we examined mortality in five geographic regions of Canada from 1975 to 1999 for previously defined avoidable disease groups that are amenable to medical care and public health. These trends were compared to mortality from other causes.
National and regional age-standardized mortality rates for ages less than 65 years were estimated for avoidable and other causes of death for consecutive periods (1975–1979, 1980–1985, 1985–1989, 1990–1994, and 1995–1999). The proportion of all-cause mortality attributable to avoidable causes was also determined.
From 1975–1979 to 1995–1999, the AM decrease (46.9%) was more pronounced compared to mortality from other causes (24.9%). There were persistent regional AM differences, with consistently lower AM in Ontario and British Columbia compared to the Atlantic, Quebec, and Prairies regions. This trend was not apparent when mortality from other causes was examined. Injuries, ischaemic heart disease, and lung cancer strongly influenced the overall AM trends.
The regional differences in mortality for ages less than 65 years was attributable to causes of death amenable to medical care and public health, especially from causes responsive to public health.
Rising health care costs and concern regarding the performance of health services has led to the development of various indicators of health care quality. In 1976, the Working Group on Preventable and Manageable Diseases proposed using "unnecessary untimely deaths" as an indicator of medical care quality . The Working Group presented lists of conditions for which deaths may be amenable if appropriate medical care is provided in a timely fashion. The 'avoidable' mortality (AM) concept has since been applied in various investigations examining differences in mortality between regions and over time.
Temporal trend analyses have demonstrated remarkable declines in AM over the past decades that were much more pronounced when compared to mortality from other causes [2–5]. In the Netherlands, Mackenbach et al demonstrated that declines in mortality from avoidable causes of death were preceded by the introduction of successful medical interventions for those causes. These observations have been used to argue that improvements in medical care have contributed to mortality declines. Following this reasoning, regional comparisons of AM have been conducted in order to highlight areas with excess mortality and stimulate further inquiry so that appropriate measures can be taken [7, 8]. More recently, the AM concept has been extended to include causes of death amenable to public health [9, 10]. AM has been proposed as a population-based performance measure for Canada's health care system[11, 12].
The objective of this study was to examine mortality trends from avoidable causes of death in Canada. We examined mortality from 1975–1979 to 1995–1999 in five geographic regions of Canada. These trends were compared to mortality from other causes of death not classified as avoidable. In addition, we investigated the contribution of each avoidable condition to all-cause mortality in Canada.
Mortality data were obtained from the Canadian Mortality Database. The selection of avoidable causes of death was based on disease and age groups proposed by the Concerted Action of the European Community on "Avoidable Deaths" with the addition of lung cancer and injuries (see Table 1)[13, 11]. The conditions were categorized as causes amenable to medical care or public health. Deaths amenable to medical care are those for which it is reasonable to expect deaths to be averted after the condition has developed. This list includes causes such as appendicitis and asthma, where the medical nature of the intervention is evident. This list also includes causes such as cervical and breast cancer, where deaths are preventable through early detection and effective treatment. Deaths amenable to public health are those for which medical care may be less effective for treating the condition, but where there are interventions that are known to prevent the condition from occurring. This group includes deaths from lung cancer, which are mainly amenable to lifestyle changes (mainly tobacco use), and deaths from injuries, which are influenced by social safety programs and legislative measures. Ischaemic heart disease (IHD) was categorized separately because both medical care and public health can contribute to reducing deaths from IHD . Evidence demonstrating that the causes of death are amenable to health care interventions are referenced. The deaths that were not classified as avoidable were classified as deaths from other causes.
The data analyses were restricted to deaths under 65 years of age, since health care can have the greatest impact on preventing deaths in this group. Deaths from other causes were calculated as the difference between all-cause deaths and avoidable deaths. There are various conditions that are amenable to health care but have not previously been included in avoidable deaths classification lists. Although this is partly due to data availability and/or accuracy issues, this also reflects differences in opinions regarding the preventability of certain causes of death as well as the role of public health and medical care in avoiding deaths[15, 16]. For this study, causes of death were selected according to an established and widely disseminated list of avoidable deaths created by the European Community.
The trends in age-standardized mortality from avoidable and other causes of death were estimated for five geographic regions of Canada for consecutive periods (1975–1979, 1980–1985, 1985–1989, 1990–1994, and 1995–1999). The Atlantic region included the provinces Prince Edward Island, Newfoundland, Nova Scotia and New Brunswick. The Prairies region consisted of the provinces Manitoba, Saskatchewan and Alberta. Age-standardized mortality rates (ASMRs) were derived using the direct method with Canada 1991 as the reference population.
Mortality trends are presented with 95% confidence intervals assuming that the number of deaths in each age group follow a Poisson distribution.
Figure 1 shows the avoidable and other cause mortality trends in Canada from 1975–1979 to 1995–1999. During this time, mortality from avoidable and other causes decreased. However, the decline in AM (46.9%) was more pronounced from 1975–1979 to 1995–1999 compared to mortality from other causes (24.9%).
Figure 2 illustrates avoidable and other cause mortality trends in the five regions of Canada. For AM, there was a persistent difference between the highest and lowest Canadian region since 1980–1984. Ontario and British Columbia had consistently lower AM trends than the other regions. For other causes, there was a narrowing of provincial differences over the study period. By 1990–1994 provincial differences for other causes was small.
Table 2 and Table 3 describe the mortality trends from each avoidable cause of death for males and females in Canada and the proportion of all-cause mortality under 65 years of age attributable to each avoidable cause. With the exception of lung cancer, mortality from these causes decreased from 1975–1979 to 1995–1999. The relative decrease in mortality from avoidable causes from 1975–1979 to 1995–1999 was similar between males and females. Lung cancer mortality increased by 79.7% in females but decreased from 1980–1984 onward in males for an overall decrease of 21.5%.
From 1975–1979 to 1995–1999, the proportion of all-cause mortality attributable to avoidable causes of death decreased for males (63.3% to 52.6%) and females (54.4% to 50.2%). During 1995–1999, the avoidable causes that contributed the most to all-cause under 65 mortality were injuries, ischaemic heart disease and lung cancer, together contributing 41.3% to all-cause mortality. For females, breast cancer accounted for 10.6% of under 65 mortality during 1995–1999. Hypertension and cerebrovascular disease and perinatal mortality also contributed considerably to all-cause mortality during 1995–1999 (3.0% and 2.3%, respectively).
Figures 3, 4, 5, 6, 7 and 8 present the time trends for mortality from the avoidable causes of death that contributed at least 1% to all-cause mortality under 65 years of age in Canada during 1995–1999. Cause-specific mortality for both sexes was combined, except for deaths from lung cancer (figure 3) and breast cancer (figure 4). The largest regional differences were for injuries (figure 5) and lung cancer (males). Lung cancer for women was the only avoidable cause where mortality differences had increased over time, with increasing mortality in the Quebec and Prairies regions compared to decreasing mortality since 1990–1994 in all other regions. Large differences in regional mortality from ischaemic heart disease (figure 6) continued throughout the study period, although these differences narrowed over time.
This study shows that, while AM has decreased considerably from 1975 to 1999 and regional differences in AM have narrowed, there continues to exist important regional disparities in AM across Canada. Consistently lower AM trends were observed in Ontario and British Columbia – the regions with the highest life expectancy. Ontario experienced the lowest mortality from injuries. British Columbia experienced the lowest mortality from IHD. Both Ontario and British Columbia shared the lowest lung cancer mortality experience with the Prairies. By 1995–1999, these regions showed only small differences in mortality from other causes.
Injuries leading to death include falls, motor vehicle accidents, drowning, burns, bicycle crashes and suicide. Since deaths from these causes can potentially be prevented, various Canadian authors have advocated for the development of co-ordinated injury prevention and safety promotion policies [17, 18]. Surveillance and research aimed at determining risk factors associated with injuries in Canada have also been recommended. Bicycle safety legislation represents a good example of a successful intervention for reducing injuries. Using data from the Canadian Institute for Health Information, Macpherson et al  demonstrated that bicycle-related head injury rates were found to decrease significantly (45% reduction) in provinces where bicycle helmet legislation had been adopted compared to those provinces and territories where it had not been adopted (27% reduction).
Regional variations in deaths from ischemic heart disease have been shown to be associated with differences in the prevalence of smoking, obesity, hypertension and physical inactivity [21, 22]. Thus future efforts aiming to reduce the regional burden of heart disease should include individual and community-based strategies targeting the reduction of these risk factors. Modifying these risk factors also offers the potential for even larger gains in reducing the total burden of disease because heart disease risk factors are also associated with deaths from other chronic conditions, such as diabetes and cancer.
Tobacco use accounts for the majority of deaths from lung cancer. Trends in lung cancer mortality reflect the smoking behaviour of the population two decades earlier. Among women, smoking rates peaked in the 1970s and lung cancer deaths continued to increase during the 1990s. Among men, however, smoking rates peaked in the 1960s and lung cancer death rates peaked in the 1980s, falling consistently since then.
In addition to traditional risk factors, broader determinants of health, such as income status, employment and education have been shown to be associated with mortality from injuries, IHD and lung cancer[21, 22, 17, 25]. For example, Filate et al have shown that regional death rates from ischaemic heart disease in Canada are significantly associated with regional differences in postsecondary education, unemployment rate and low income rate. Brownell, Frisen and Mayer demonstrated that geographic variations in childhood injury mortality and hospitalizations in Manitoba were strongly influenced by regional differences in neighbourhood income.
A common characteristic of these causes is the potential contribution of public health in their control. Injuries, along with tobacco-related causes of death, may be the most significant deaths that could be prevented through public health initiatives in Canada . Wigle et al  estimated that about half of the annual premature deaths in Canada may be avoidable through the control of smoking, diet, elevated serum cholesterol, hypertension, diabetes, and alcohol. The notable regional mortality disparities related to these causes present a warning signal to the Canadian health care system and warrants further investigation.
AM can be considered a useful tool that can provide insights into health care and indicate where further research is warranted [1, 27, 28]. As others have stated, several characteristics of AM suggest that it is a useful measure of health care performance[29, 30]. First, AM one of the few measures that can be measured over time and for different regions both nationally in Canada and internationally. Second, death is an important outcome. This study's findings support the use of AM as a performance measure, particularly when used to compare health regions in Canada. We show that AM in Canada appears to be a surprisingly sensitive measure – one that has considerable variation over time and across regions, and that it likely reflects observed underlying mortality risks that are amenable to public health and health care interventions.
However, AM trends should be interpreted with caution. The definition of avoidable deaths varies between studies and it has recently been shown that observed AM trends are influenced by the list of avoidable deaths applied. In addition, in this study there was a large reduction in mortality not defined avoidable. Many deaths from these conditions were likely amenable to health care interventions. We elected to replicate a previously established list of avoidable deaths to reduce the potential bias of selecting causes of death that would favour one region over another. Future studies should include standard lists of avoidable deaths that are periodically updated as proven health care interventions are effectively introduced.
The AM concept implies that deaths from the selected avoidable causes could have been avoided by optimum health care alone. This is questionable as mortality can be viewed as a long-term outcome that is affected by many factors, including disease incidence, disease severity and risk factors. Additionally, it is difficult to clearly attribute AM trends to specific aspects of health care. It is also important to note that some death that were classified as avoidable may not have been preventable due to factors such as the presence of co-morbidity or treatment complications[13, 14]. A meaningful association between AM levels and health care performance and accessibility is lacking[32, 30], and thus the validity of AM as an indicator of health care effectiveness is unproven. Furthermore, there are many important functions of the health care services (such as reducing avoidable morbidity and improving quality of life) that cannot be measured using mortality statistics [29, 27].
It has been suggested that differences in medically amenable mortality rates may reflect differences in disease incidence. Some authors have attempted to address this potential limitation. For example, Treurniet et al found that regional differences in medically amenable mortality in the Netherlands persisted after adjusting for incidence variations. Some authors have argued that AM trends should not be adjusted for disease incidence or risk factors, since they related to the population's health needs and are within the responsibility of the health system.
Future research should seek to understand the relationship between AM levels and health care interventions. Thus far, the association between AM and health care variables have has been characterized as weak and inconsistent. However, the studies conducted in this area used ecological data and considered crude measures of health care. Further, in many countries, mortality trends are taken into account when allocating health care resources. As suggested by Mackenbach et al, individual-level data will be necessary in order to determine whether avoidable deaths can be linked to deficiencies in the organization, quality or accessibility of health care services.
Setting age-restrictions for each cause of death is a crude approach to defining avoidable deaths. A useful alternative approach would be to perform sensitivity analyses by comparing trends using alternative age-limits. Furthermore, calculating the proportion of avoidable deaths that are attributable to specific health care interventions may provide more meaningful information for health care decision-makers regarding which interventions would have the greatest impact on improving health and reducing inequalities. For example, in New Zealand, Tobias and Jackson  weighted cause-specific mortality trends by the extent to which deaths could be avoided through primary, secondary and tertiary interventions. This expansion of the AM concept can be used to estimate the potential contribution of specific health care interventions to future population health gain.
Although regional AM differences across Canada have decreased, there continues to exist important regional AM disparities that are mainly attributable to causes of death (injuries, IHD and lung cancer) mainly preventable through public health initiatives.
Rutstein DD, Berenberg W, Chalmers TC, Child CGD, Fishman AP, Perrin EB: Measuring the quality of medical care. A clinical method. N Engl J Med. 1976, 294: 582-8.
Charlton JR, Velez R: Some international comparisons of mortality amenable to medical intervention. Br Med J. 1986, 292: 295-301.
Poikolainen K, Eskola J: The effect of health services on mortality: decline in death rates from amenable and non-amenable causes in Finland, 1969-81. Lancet. 1986, 1: 199-202. 10.1016/S0140-6736(86)90664-1.
Westerling R: Trends in "avoidable" mortality in Sweden, 1974-1985. JECH. 1992, 46: 489-93.
Desmeules M, Semenciw R: The impact of medical care on mortality in Canada, 1959-1988. Can J Public Health. 1991, 82: 209-11.
Mackenbach JP, Looman CW, Kunst AE, Habbema JD, van der Maas PJ: Post-1950 mortality trends and medical care: gains in life expectancy due to declines in mortality from conditions amenable to medical intervention in The Netherlands. Soc Sci Med. 1988, 27: 889-894. 10.1016/0277-9536(88)90278-X.
Mackenbach JP, Kunst AE, Looman CW, Habbema JD, van der Maas PJ: Regional differences in mortality from conditions amenable to medical intervention in The Netherlands: a comparison of four time periods. JECH. 1988, 42: 325-32.
Kunst AE, Looman CW, Mackenbach JP: Medical care and regional mortality differences within the countries of the European community. Eur J Popul. 1988, 4: 223-245. 10.1007/BF01796895.
Humblet PC, Lagasse R, Leveque A: Trends in Belgian premature avoidable deaths over a 20 year period. J Epidemiol Community Health. 2000, 54: 687-691. 10.1136/jech.54.9.687.
Westerling R, Smedby B: The European Community 'avoidable death indicators' in Sweden 1974-1985. Int J Epidemiol. 1992, 21: 502-10.
Manuel DG, Mao Y: Avoidable mortality in the United States and Canada, 1980-1996. Am J Public Health. 2003, 93: 186-187.
Manuel DG, Goel V: 2002, Toronto, Ontario Hospital Association, Population Health Indicators for Measuring Health System Performance Hospital Report 2001
Manuel DG, Mao Y: Avoidable mortality in the United States and Canada, 1980-1996. Am J Public Health. 2002, 92: 1481-1484.
Nolte E, Scholz R, Shkolnikov V, McKee M: The contribution of medical care to changing life expectancy in Germany and Poland. Soc Sci Med. 2002, 55: 1905-1921. 10.1016/S0277-9536(01)00320-3.
Charlton JR, Hartley RM, Silver R, Holland WW: Geographical variation in mortality from conditions amenable to medical intervention in England and Wales. Lancet. 1983, 1: 691-6. 10.1016/S0140-6736(83)91981-5.
Holland WW, EC Working Group on Health Services and 'Avoidable Death': European Community Atlas of 'Avoidable Death'. 1997, Oxford, Oxford University Press
Brownell M, Friesen D, Mayer T: Childhood injury rates in Manitoba: socioeconomic influences. Can J Public Health. 2002, 93 Suppl 2:S50-6: S50-S56.
Mo F, Choi BCK, Clottey C, LeBrun B, Robbins G: Characteristics and risk factors for accident injury in Canada form 1986 to 1996: An analysis of the Canadian Accident Injury Reporting and Evaluation (CAIRE) database. Injury Control and Safety Promotion. 2002, 9: 73-81. 10.1076/icsp.18.104.22.16801.
Cusimano MD, Mukhida K: Acute injuries research in Canada. 2003, Canadian Institute for Health Research, 1-23.
Macpherson AK, To TM, Macarthur C, Chipman ML, Wright JG, Parkin PC: Impact of mandatory helmet legislation on bicycle-related head injuries in children: A population-based study. Pediatrics. 2005, 110: 60-65. 10.1542/peds.110.5.e60.
Filate WA, Johansen HL, Kennedy CC, Tu JV: Regional variations in cardiovascular mortality in Canada. Can J Cardiol. 2003, 19: 1241-1248.
Tanuseputro P, Manuel DG, Leung M, Nguyen K, Johansen H: Risk factors for cardiovascular disease in Canada. Can J Cardiol. 2003, 19: 1249-1259.
Manuel DG, Leung M, Nguyen K, Tanuseputro P: Burden of cardiovascular disease in Canada. Can J Cardiol. 2003, 19: 997-1004.
Illing EMM, Kaiserman MJ: Mortality attributable to tobacco use in Canada and its regions, 1994 and 1996. Chronic Dis Can. 1999, 20: 111-117.
Wilkins R, Berthelot JM, Ng E: Trends in Mortality by Neighbourhood Income in Urban Canada from 1971 to 1996. Health Rep. 2002, 13: 45-71.
Wigle DT, Mao Y, Semenciw R, McCann C, Davies JW: Premature deaths in Canada: impact, trends and opportunities for prevention [published erratum appears in Can J Public Health 1991 Jan-Feb;82(1):26]. Canadian Journal of Public Health-Revue Canadienne De Sante Publique. 1990, 81: 376-81.
Holland WW, Fitzgerald AP, Hildrey SJ, Phillips SJ: Heaven can wait. J Public Health Med. 1994, 16: 321-30.
Charlton JR, Bauer R, Lakhani A: Outcome measures for district and regional health care planners. Community Med. 1984, 6: 306-15.
Holland W: Avoidable death as a measure of quality. Quality Assurance in Health Care. 1990, 2: 227-33.
Mackenbach JP, Bouvier-Colle MH, Jougla E: Avoidable mortality and health services: a review of aggregate data studies. JECH. 1990, 44: 106-11.
French KM, Jones K: Impact of definition on the study of avoidable mortality: geographical trends in British deaths 1981-1998 using Charlton and Holland's definitions. Soc Sci Med. 2006, 62: 1443-1456. 10.1016/j.socscimed.2005.08.002.
Carr-Hill RA, Hardman GF, Russell IT: Variations in avoidable mortality and variations in health care resources. Lancet. 1987, 1: 789-92. 10.1016/S0140-6736(87)92810-8.
Treurniet HF, Looman CWN, van der Maas PH, Mackenbach JP: Variations in "avoidable" mortality: a reflection of variations in incidence?. Int J Epidemiol. 1999, 28: 225-232. 10.1093/ije/28.2.225.
Mackenbach JP, Bouvier-Colle MH, Jougla E: "Avoidable" mortality and health services: a review of aggregate data studies. J Epidemiol Community Health. 1990, 44: 106-111.
Tobias M, Jackson G: Avoidable mortality in New Zealand, 1981-97. Aust N Z J Public Health. 2001, 25: 12-20.
Linke A, Erbs S, Hambrecht R: Exercise and the coronary circulation-alterations and adaptations in coronary artery disease. Prog Cardiovasc Dis. 2006, 48: 270-284. 10.1016/j.pcad.2005.10.001.
Reiffel JA: Practical algorithms for pharmacologic management of the post myocardial infarction patient. Clin Cardiol. 2005, 28: I28-I37.
Faxon DP: Coronary interventions and their impact on post myocardial infarction survival. Clin Cardiol. 2005, 28: I38-I44.
Courville KA, Lavie CJ, Milani RV: Lipid-lowering therapy for elderly patients at risk for coronary events and stroke. Am Heart Hosp J. 2005, 3: 256-262.
Boodhwani M, Rubens FD, Sellke FW, Mesana TG, Ruel M: Mortality and myocardial infarction following surgical versus percutaneous revascularization of isolated left anterior descending artery disease: a meta-analysis. Eur J Cardiothorac Surg. 2006, 29: 65-70. 10.1016/j.ejcts.2005.07.020.
Mercado N, Wijns W, Serruys PW, Sigwart U, Flather MD, Stables RH, O'Neill WW, Rodriguez A, Lemos PA, Hueb WA, Gersh BJ, Booth J, Boersma E: One-year outcomes of coronary artery bypass graft surgery versus percutaneous coronary intervention with multiple stenting for multisystem disease: a meta-analysis of individual patient data from randomized clinical trials. J Thorac Cardiovasc Surg. 2005, 130: 512-519. 10.1016/j.jtcvs.2004.12.049.
Dye C, Watt CJ, Bleed DM, Hosseini SM, Raviglione MC: Evolution of tuberculosis control and prospects for reducing tuberculosis incidence, prevalence, and deaths globally. JAMA. 2005, 293: 2767-2775. 10.1001/jama.293.22.2767.
Lalloo UG, Naidoo R, Ambaram A: Recent advances in the medical and surgical treatment of multi-drug resistant tuberculosis. Curr Opin Pulm Med. 2006, 12: 179-185. 10.1097/01.mcp.0000219266.27439.52.
Jatoi I, Miller AB: Why is breast-cancer mortality declining?. Lancet Oncol. 2003, 4: 251-254. 10.1016/S1470-2045(03)01037-4.
Ringash J: Preventive health care, 2001 update: screening mammography among women aged 40-49 years at average risk of breast cancer. CMAJ. 2001, 164: 469-476.
Dang CT: Drug treatments for adjuvant chemotherapy in breast cancer: recent trials and future directions. Expert Rev Anticancer Ther. 2006, 6: 427-436. 10.1586/1473722.214.171.1247.
Witherby SM, Muss HB: Update in medical oncology for older patients: focus on breast cancer: management of early breast cancer. Cancer J. 2005, 11: 506-517.
Sigurdsson K, Sigvaldason H: Effectiveness of cervical cancer screening in Iceland, 1964-2002: a study on trends in incidence and mortality and the effect of risk factors. Acta Obstet Gynecol Scand. 2006, 85: 343-349.
Taylor R, Morrell S, Mamoon H, Wain G, Ross J: Decline in cervical cancer incidence and mortality in New South Wales in relation to control activities (australia). Cancer Causes Control. 2006, 17: 299-306. 10.1007/s10552-005-0515-z.
Carey MS, Gawlik C, Fung-Kee-Fung M, Chambers A, Oliver T: Systematic review of systemic therapy for advanced or recurrent endometrial cancer. Gynecol Oncol. 2006, 101: 158-167. 10.1016/j.ygyno.2005.11.019.
Humber C, Tierney J, Symonds P, Collingwood M, Kirwan J, Williams C, Green J: Chemotherapy for advanced, recurrent or metastatic endometrial carcinoma. Cochrane Database Syst Rev. 2005, CD003915-
Connors JM, Klimo P, Adams G, Burns BF, Cooper I, Meyer RM, O'Reilly SE, Pater J, Quirt I, Sadura A, Shustik C, Skillings J, Sutcliffe S, Verma S, Yoshida S, Zee B: Treatment of advanced Hodgkin's disease with chemotherapy--comparison of MOPP/ABV hybrid regimen with alternating courses of MOPP and ABVD: a report from the National Cancer Institute of Canada clinical trials group. J Clin Oncol. 1997, 15: 1638-1645.
Meyer RM, Gospodarowicz MK, Connors JM, Pearcey RG, Bezjak A, Wells WA, Burns BF, Winter JN, Horning SJ, Dar AR, Djurfeldt MS, Ding K, Shepherd LE: Randomized comparison of ABVD chemotherapy with a strategy that includes radiation therapy in patients with limited-stage Hodgkin's lymphoma: National Cancer Institute of Canada Clinical Trials Group and the Eastern Cooperative Oncology Group. J Clin Oncol. 2005, 23: 4634-4642. 10.1200/JCO.2005.09.085.
Gospodarowicz MK, Sutcliffe SB, Clark RM, Dembo AJ, Fitzpatrick PJ, Munro AJ, Bergsagel DE, Patterson BJ, Tsang R, Chua T, .: Analysis of supradiaphragmatic clinical stage I and II Hodgkin's disease treated with radiation alone. Int J Radiat Oncol Biol Phys. 1992, 22: 859-865.
Chaturvedi S, Bruno A, Feasby T, Holloway R, Benavente O, Cohen SN, Cote R, Hess D, Saver J, Spence JD, Stern B, Wilterdink J: Carotid endarterectomy--an evidence-based review: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2005, 65: 794-801.
Briel M, Studer M, Glass TR, Bucher HC: Effects of statins on stroke prevention in patients with and without coronary heart disease: a meta-analysis of randomized controlled trials. Am J Med. 2004, 117: 596-606. 10.1016/j.amjmed.2004.04.022.
Wardlaw JM, Warlow CP, Counsell C: Systematic review of evidence on thrombolytic therapy for acute ischaemic stroke. Lancet. 1997, 350: 607-614. 10.1016/S0140-6736(97)03022-5.
Sidebotham HJ, Roche WR: Asthma deaths; persistent and preventable mortality. Histopathology. 2003, 43: 105-117. 10.1046/j.1365-2559.2003.01664.x.
Suissa S, Ernst P: Inhaled corticosteroids: impact on asthma morbidity and mortality. J Allergy Clin Immunol. 2001, 107: 937-944. 10.1067/mai.2001.115653.
Leontiadis GI, Sharma VK, Howden CW: Proton pump inhibitor treatment for acute peptic ulcer bleeding. Cochrane Database Syst Rev. 2006, CD002094-
Lunevicius R, Morkevicius M: Systematic review comparing laparoscopic and open repair for perforated peptic ulcer. Br J Surg. 2005, 92: 1195-1207. 10.1002/bjs.5155.
Katkhouda N, Mason RJ, Towfigh S, Gevorgyan A, Essani R: Laparoscopic versus open appendectomy: a prospective randomized double-blind study. Ann Surg. 2005, 242: 439-448.
Cox MR, McCall JL, Toouli J, Padbury RT, Wilson TG, Wattchow DA, Langcake M: Prospective randomized comparison of open versus laparoscopic appendectomy in men. World J Surg. 1996, 20: 263-266. 10.1007/s002689900041.
Arregui ME, Young SB: Groin hernia repair by laparoscopic techniques: current status and controversies. World J Surg. 2005, 29: 1052-1057. 10.1007/s00268-005-7968-9.
Bittner R: The standard of laparoscopic cholecystectomy. Langenbecks Arch Surg. 2004, 389: 157-163. 10.1007/s00423-004-0471-1.
Khan KS, Wojdyla D, Say L, Gulmezoglu AM, Van Look PF: WHO analysis of causes of maternal death: a systematic review. Lancet. 2006, 367: 1066-1074. 10.1016/S0140-6736(06)68397-9.
Bullough C, Meda N, Makowiecka K, Ronsmans C, Achadi EL, Hussein J: Current strategies for the reduction of maternal mortality. BJOG. 2005, 112: 1180-1188.
Darmstadt GL, Bhutta ZA, Cousens S, Adam T, Walker N, de Bernis L: Evidence-based, cost-effective interventions: how many newborn babies can we save?. Lancet. 2005, 365: 977-988. 10.1016/S0140-6736(05)71088-6.
Dragnev KH, Stover D, Dmitrovsky E: Lung cancer prevention: the guidelines. Chest. 2003, 123: 60S-71S. 10.1378/chest.123.1_suppl.60S.
Kelley MJ, McCrory DC: Prevention of lung cancer: summary of published evidence. Chest. 2003, 123: 50S-59S. 10.1378/chest.123.1_suppl.50S.
Tardon A, Lee WJ, Delgado-Rodriguez M, Dosemeci M, Albanes D, Hoover R, Blair A: Leisure-time physical activity and lung cancer: a meta-analysis. Cancer Causes Control. 2005, 16: 389-397. 10.1007/s10552-004-5026-9.
Liu B, Ivers R, Norton R, Blows S, Lo SK: Helmets for preventing injury in motorcycle riders. Cochrane Database Syst Rev. 2004, CD004333-
Philippakis A, Hemenway D, Alexe DM, Dessypris N, Spyridopoulos T, Petridou E: A quantification of preventable unintentional childhood injury mortality in the United States. Inj Prev. 2004, 10: 79-82. 10.1136/ip.2003.004119.
Bunn F, Collier T, Frost C, Ker K, Roberts I, Wentz R: Traffic calming for the prevention of road traffic injuries: systematic review and meta-analysis. Inj Prev. 2003, 9: 200-204. 10.1136/ip.9.3.200.
Attewell RG, Glase K, McFadden M: Bicycle helmet efficacy: a meta-analysis. Accid Anal Prev. 2001, 33: 345-352. 10.1016/S0001-4575(00)00048-8.
Rivara FP, Thompson DC: Systematic reviews of injury-prevention strategies for occupational injuries: an overview. Am J Prev Med. 2000, 18: 1-3. 10.1016/S0749-3797(00)00134-3.
Rivara FP, Thompson DC, Cummings P: Effectiveness of primary and secondary enforced seat belt laws. Am J Prev Med. 1999, 16: 30-39. 10.1016/S0749-3797(98)00113-5.
The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/6/137/prepub
Funding for this study was provided by The Population and Public Health Branch, Health Canada and The Canadian Population Health Institute, Canadian Institute for Health Information. We are indebted to Davida Glazer for her help with the literature review.
The author(s) declare that they have no competing interests.
Paul James had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Below is a summary of the authors' contributions to this manuscript:
Study concept and design: PJ, DM, YM
Acquisition of data: DM, YM
Analysis and interpretation of data: PJ, DM
Drafting of the Manuscript: PJ, DM, YM
Critical revision of the manuscript for important intellectual content: PJ, DM, YM
Statistical analysis: PJ, DM, YM
Obtained funding: DM, YM
Administrative, technical, or material support: DM
Study supervision: DM
All authors read and approved the final manuscript.
Paul D James, Doug G Manuel and Yang Mao contributed equally to this work.
Authors’ original submitted files for images
Below are the links to the authors’ original submitted files for images.
About this article
Cite this article
James, P.D., Manuel, D.G. & Mao, Y. Avoidable mortality across Canada from 1975 to 1999. BMC Public Health 6, 137 (2006). https://doi.org/10.1186/1471-2458-6-137