09 January 2008

Best Care Anywhere?

Not in the US.

In France. Or Japan. Or Australia.

In fact, any one of the 18 other industrialized nations ranked by the journal Health Affairs (subscription required) in a recent study, as cited by Reuters.

The study looked at what they called "preventable deaths," defined as "deaths before age 75 from numerous causes, including heart disease, stroke, certain cancers, diabetes, certain bacterial infections and complications of common surgical procedures." By this metric, France had the highest quality care with 64.8 preventable deaths per 100,000 people. Japan and Australia lagged with 71.2 and 71.3.

The United States came in dead last with 109.7 "preventable" deaths per 100,000 people. By this measure, somewhere north of 100,000 Americans die prematurely every year.

The study's lead author was quoted as saying "I wouldn't say it (the last-place ranking) is a condemnation, because I think health care in the U.S. is pretty good if you have access. But if you don't, I think that's the main problem, isn't it?"

You can quibble with the details of this study -- the definition of "preventable deaths" is always controversial and open to debate. And there are differences between the populations in terms of general health and the incidence of certain diseases. But the findings provide a reasonable comparison between countries, and it's not unreasonable to conclude that this provides at least a partial index of the overall quality of the health care system. Further, since this reproduces the results from multiple other studies showing that the US has, on aggregate, the worst health outcomes in the industrialized world, further credibility would be added to this result.

And for this, we pay $7000 per capita. Again, we pay the most, and get the least.


  1. It's sad, isn't it? We're spending billions of dollars in Iraq while our own people are dying here at home because they can't access the health care system.

  2. I think it is sad that we are spending billions of dollars in Iraq.

    I think it is sad that people do not have access to health care.

    But, why does this study measure the effectiveness of the health care system and not the healthiness of the citizens? Seems to me that fewer people in France dying prematurely may be cause by fewer people in France being morbidly obese, or fewer people in France driving cars, or fewer people in France working 80 hours a week. Am I missing something?

  3. Take a look at this analysis of the study and tell me what you think.

    It seems to me the author of that blog makes some pretty convincing arguments that this study is pretty close to meaningless or at least is not measuring what it says it is.

  4. The ones with insurance spend the most. Unlimited access to all the health care you could ever want.

    For a fraction of your buy in cost.

    It's called Medicare.

    When people talk about "getting their TKA done", in the same sentence as, "renovating my kitchen", one has to wonder why I'm paying for their elective surgery when they have $40K to renovate their house.

    It's all screwed up

  5. I am French and I have been living in the US for 15 years.
    My two cents:
    Yes, the Europeans do have a healthier lifestyle: there is no room for drive throughs, parking spots next door to your destination. You walk. A lot. Food, until the arrival of McDonald's and their peers was pretty healthy.
    However, I am stunned every time I go back to France to see the new generation of obese youngsters that the country is developing.
    Give it another 20 to 30 years, and health problems will be identical in both countries.

    France and the US both have a high quality of healthcare with well trained physicians.

    Overall, I tend to agree with the author of the article, that access to equal healthcare is what makes the difference.
    Just think of all the families in the US who have financial hardship because of medical expenses. Some working, insured people forgo treatment because of the poor insurance coverage. Older patients have to decrease the dosage of their meds, so they can make it through the month.
    This should not happen.

  6. Jim,

    No, it's not purely a measure of the efficacy of the health care system. There's the whole "we eat too many cheeseburgers" logic, which is to some degree a player, as well as other phenomena, such as more teen/low-birthweight babies, a higher incidence of colon cancer, etc etc etc. These are some of the confounding factors I referred to.

    It is also, to say the very minimum, controversial to what degree the lack of meaningful access that 80 million americans have (uninsured + medicaid) to care plays into this data.

    The real point here is not *just* that there are too many preventable/premature deaths in the US. The point is that our health care system costs us twice as much and delivers poorer outcomes. If we eat too many cheeseburgers and have more heart attacks, but if we're paying a lot more, and doing more heart caths, why are more people still dying of heart disease? Is it the poor access to primary care, poor screening, poor "wellness care" and prevention, or is it just that all this gee-whiz technology just doesn't really work at preventing deaths?

    One shouldn't read this study as purporting to provide definitive answers, but it continues, as many other studies have, to raise serious questions about how we allocate our national resources.

  7. Well said. We certainly are not managing our assets well... just wait, in four years 20% of our GDP will go to health care and we'll still be scoring low. Even more people will be without health insurance.
    I hope that one of the presidential candidates changes this. Otherwise, we need a REVOLUTION.

  8. Sorry, but the underlying data (from WHO) is at best questionable. From the WHO's site itself:

    Although the International Classification of Diseases is intended to provide a standard way of recording underlying cause of death, comparison of cause of death data over time and across countries should be undertaken with caution. Several new features and changes from ICD9 to ICD10 have great impact on the interpretation of the statistical data. The implications of these changes in ICD10 should be taken into account when making trend comparisons and estimates for causes of death. ICD10 is more detailed with about 10 000 conditions for classifying causes of death compared to around 5 100 in ICD9. The rules for selecting the underlying cause of death have been re-evaluated and sometimes changed. Accuracy in diagnosing causes of death still varies from one country to another. In addition the process of coding underlying causes of death involves some extent of misattribution or miscoding even in countries where causes are assigned by medically qualified staff. Main reasons are incorrect or systematic biases in diagnosis, incorrect or incomplete death certificates, misinterpretation of ICD rules for selection of the underlying cause, and variations in the use of coding categories for unknown and ill-defined causes.

    In short, every country has their own definitions of everything, and change them at will. You cannot use data like that to make the kind of assessments that WHO, and especially the Commonwealth Fund, try to all the time.

    They don't mind, though: The US' data is probably the most accurate, and using it places the US consistently worse than the rest of the socialist world

  9. People can afford the health care system if they want to... maybe if they would spend money more wisely they could afford the stuff they need...such as health care...

  10. How can we have the best care anywhere when a new study shows show hospitals lax in use of anti-microbials for catheters
    A new national study indicates that fewer than one in three hospitals are using either bladder scanners or anti-microbial catheters to prevent urinary tract infection and less than one in 10 are using daily reminders that prompt doctors to “review the need for a catheter.”

  11. In my humble opinion, it takes a certain amount of self-loathing to be an American who works every day in the health care system and simultaneously proclaims our care to be "the worst."

    We have so many immigrants who come here with previously untreated chronic conditions (htn, type II diabetes---the stuff you can't treat when you live in the mountains in a war-torn SE Asian country and have never seen a doctor). They show up, we give them 100%-paid-for medical care, and then they die early anyway from the CHF/stroke from 20 years of untreated htn borne in their own country. See it everyday.

    Maybe we shouldn't let them in---will goof up our "stats."

    It would be best to only include preventable deaths from native people, people born in the country being studied if you want to use it as a measure of the "quality" of the overall health care system.

  12. Nurse K,

    Self loathing? No, it would take willful blindness to not see the failings in our system, self-delusion to continue to proclaim it the "best in the world," and criminal indifference not to advocate for improvement.

    And in this, I am proud that there is agreement from the left and the right. The Happy Hospitalist, KevinMD, and many others. Sure, we focus on different ways in which the system is broken, and we disagree on the best solution. But I cannot think of another soul working in healthcare who doesn't think the system is coming apart at the seams.

    Self-loathing, indeed.

  13. Yeah, my website is full of rainbows, smiles, and joyful portrayals of our health care system. *sigh*

    Read. Between. The. Lines.


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