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Where Does the US Really Rank in Health Care Outcomes

An interesting angle in the CBS news story. It all depends on how you want to use data and information.  http://www.cbsnews.com/stories/2009/10/06/politics/washingtonpost/main5366248.shtml
 
The constant pursuit of a ‘sound bite’ causes messages to get garbled, misunderstood, and altered for a specific purpose. This is a genuine case in point. Clearly there is significant room for debate about what the data demonstrates. It demonstrates many things on many different levels.  But in the community at large there is little time to lay out the facts in a transparent manner to communicate all sides of the issue. Measures get hijacked and take on a life of their own, perhaps in unintended ways. We behave this way to make a point or in the belief that others can’t understand the data. Whatever the case, diffent points of view may and often do get shut out in the process.
 
The media, the politicians and various stakeholders are attracted to the ‘Uber Measures’.
 
The WHO data  on where the US stands relative to other developed countries on health care seems to indicate,  and there is little debate, that
  1. The US spends more than any other country on health care
  2. The US spends a greater % of its GDP on health care
The first real debate is in what we get for that expenditure. Do we get:
  1. More of the world’s advances in drugs, procedures, test, shorter waiting times to be seen, etc. that make a quality, cost and/or delivery difference versus the comparison countries?
  2. Are our outcomes significantly better than the comparision countries? The ‘Uber Measure’ of mortality might be an alluring comparision, but is it correct? Since it is an uber measure it is made up of  many inputs requiring tencity and discipline to assure commonality across countries to get equivalent data to compare.
  3. There are some significant ‘holes’ in the data analysis. SEE BELOW for some of those details.
 
The story makes the following assertion:
Up to 100,000 lives could be saved if the country’s health-care system performed as well those in nations such as France, Japan and Australia, according to the Commonwealth Fund study, which was based on World Health Organization statistics.
 
The question is performed as well as … on what? Primary care…or if we improved our accident and homicide rates an equivalent amount would we get an an even better result? So what is the practicality and cost of each?
 
However, the real initiative should be to get the measures on an equivalent basis. Presumeably based on the data we have seen we really are at or near the ‘head of the class’ AND we should strive to improve in all the individual categories — focusing on those with the best cost / benefit relationship.
 
In the meantime, Senator Conrad, at the end of the article, jumps to conclusions that haven’t been adequately demonstrated in the details of the data. He has hijacked the ‘uber measures’ to make his case.
Analysis of the WHO data —
There are many criticisms of the underlying assumptions and the methodology used by WHO to produce the rankings. It is assumed that due to concerns with the initial publication, it has not been repeated since.

Assumptions
– Creating a composite measure does not support making policy changes and knowing how to improve the health system in a country.
– The report does not look at subpopulation characteristics e.g. wealth, sex, race, ethnicity and geography and any resulting inequalities.
– Life expectancy is heavily affected by factors outside of the health system, e.g. poverty, geography, homicide rate, deaths from motor vehicle and other accidents, diet, tobacco use, level of public health measures.
Under the inequality measure a country with good care for half the population and excellent care for the rest would do worse than a country with mediocre care for everyone because it measures differences in quality, rather than the level of quality received by the worst off.
– Financial fairness is defined as all households paying the same fraction of their non-food spending on health services. This is based on a value judgement and rewards countries that finance health care according to ability to pay rather than based on consumption or willingness to pay. The factor doesn’t measure the quality of care, but rather how the costs are equaled across the population.

Methodology
– Much of the data was imputed since data was unavailable for 70-89% of the 191 countries.
– The key informants used to construct the rankings came from only 35 countries and were not representative of those. Half of them were WHO staff.
– Most of the supporting references are from non-peer reviewed WHO written documents.
– The WHO rankings combine multiple random samples and assign different weights resulting in an 80% uncertainty interval for each country, which results in considerable overlap among countries and a lack of precision in the rankings, which generally does not come through when the rankings are reported.
– The measures do not reflect differences in definition that affect the measures, e.g. infant mortality is measured differently

Removing accidents and murders from the rankings
Other studies reported in the literature indicate that when accidents and murders are removed from the life expectancy rankings the US moves up to #1 because of the disproportionate impact of these in the US and their occurrence outside of the health system. The unusually high death rates from unintentional injury among young Americans reduces the estimated life expectancy at birth in the US, but does not indicate a deficiency in the US health system. Although US society may contribute to the high homicide rate, it also does not reflect on the health system.

Road deaths
– US is 3 times higher than Sweden or UK
– 1.5 times higher than Australia, Canada, Denmark, Germany or Japan

Homicide
– US is 10 – 12 times greater than Japan or UK
– 8 times greater than France or Germany
– 5 – 6 times greater than Australia, Canada, Denmark, Italy or Sweden

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October 7, 2009 - Posted by | Federal Government, healthcare | , , ,

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