Different health systems - Different mortality outcomes? Regional disparities in avoidable mortality across German-speaking Europe, 1992-2019

Abstract

Background: Evaluating the impact of health systems on premature mortality across different countries is a very challenging task, as it is hardly possible to disentangle it from the influence of contextual factors such as cultural differences. In this respect, the German-speaking area in Central Europe (Austria, Germany, South Tyrol and large parts of Switzerland) represents a unique 'natural experiment' setting: While being exposed to different health policies, they share a similar culture and language.

Methods: To assess the impact of different health systems on mortality differentials across the German-speaking area, we relied on the concept of avoidable mortality. Based on official mortality statistics, we aggregated causes of death below age 75 that are either 1) amenable to health care or 2) avoidable through primary prevention. We calculated standardised death rates and constructed cause-deleted life tables for 9 Austrian, 96 German, 1 Italian and 5 Swiss regions from 1992 to 2019, harmonised according to the current territorial borders.

Results: There are strong north-south and east-west gradients in amenable and preventable mortality across the studied regions to the advantage of the southwest. However, the Swiss regions still show significantly lower mortality levels than the neighbouring regions in southern Germany. Eliminating avoidable deaths from the life tables reduces spatial inequality in life expectancy in 2017/2019 by 30% for men and 28% for women.

Conclusions: The efficiency of health policies in assuring timely and adequate health care and in preventing risk-relevant behaviour has room for improvement in all German regions, especially in the north, west and east, and in eastern Austria as well.

Keywords: Amenable mortality; Cause-deleted life tables; German-speaking Europe; Long-term trends; Preventable mortality; Spatial differences.

Fig. 1

Amenable and preventable mortality in Austrian, German and Swiss regions by sex from 1992/1994 to 2017/2019 (moving averages); standardised death rates (deaths per 100,000 inhabitants); minimum and maximum values by country.

Fig. 2

Amenable and preventable mortality across German-speaking regions by sex in 1992–1994; standardised death rates (deaths per 100,000 inhabitants).

Fig. 3

Amenable and preventable mortality across German-speaking regions by sex in 2017–2019; standardised death rates (deaths per 100,000 inhabitants).

Fig. 4

Life expectancy at birth before and after removing avoidable deaths from life tables across German-speaking regions by sex in 1992–1994. Note: Same scale used for panels a and b (men) and for panels c and d (women) to make differences clearer. In panels a and b, there are no regions in the range from 75.2 to 77.5.

Fig. 5

Life expectancy at birth before and after removing avoidable deaths from life tables across German-speaking regions by sex in 2017–2019. Note: Same scale used for panels a and b (men) and for panels c and d (women) to make differences clearer.

Fig. 6

Selected regions: 9 Austrian federal states (‘Bundesländer’), 96 German spatial planning regions (‘Raumordnungsregionen’), 1 Italian province and 5 Swiss major regions (‘Grossregionen’) Note: For visibility, we mostly used the names of the central cities instead of the regions' names. Abbreviations: Hung. = Hungary; Li. = Liechtenstein; Lux. = Luxemburg; Slov. = Slovakia.

Fig. 7

Amenable and preventable mortality in selected Austrian, German and Swiss regions and South Tyrol by sex from 1992/1994 to 2017/2019 (moving averages); standardised death rates (deaths per 100,000 inhabitants). Notes: For visibility, we dropped confidence intervals and used different y-scales for each panel. We chose regions that represent different geographical areas and different mortality levels.

Fig. 8

Premature mortality from ‘non-avoidable’ causes across German-speaking regions by sex in 1992–1994 and 2017–2019; standardised death rates (deaths per 100,000 inhabitants).