Editore"s Note
Tilting at Windmills

Email Newsletter icon, E-mail Newsletter icon, Email List icon, E-mail List icon Sign up for Free News & Updates

January 8, 2008
By: Kevin Drum

BEST HEALTHCARE IN THE WORLD, BABY....A pair of researchers has just published an update that compares various countries on their rates of "amenable mortality," defined as deaths that are "potentially preventable with timely and effective health care." In 1997, the United States ranked 15th out of 19 industrialized countries. So how are we doing now?

Answer: we're now 19th out of 19. The rest of the countries have improved their performance by an average of 16%, while the U.S., that well-known engine of healthcare innovation, has improved by only 4%. So now we're in last place.

But there's a bright side: at least our healthcare isn't funded by the government, like it is in France. Keep that in mind if someone you know dies of preventable causes. Their odds would have been a whole lot better in Paris, but who'd want to live in a socialist hellhole like that anyway?

Kevin Drum 6:15 PM Permalink | Trackbacks | Comments (59)

Bookmark and Share
 
Comments

But don't forget we have a higher standard of living than England and we have for well over 100 years.

What?????

Oh never mind.

Posted by: neil wilson on January 8, 2008 at 6:21 PM | PERMALINK

Doing a bit of math tells us that approximately 135,000 lives could be saved every year if the U.S. had a healthcare system equivalent to France's...

Posted by: Howard on January 8, 2008 at 6:24 PM | PERMALINK

Howard: Pretty good guess. The authors estimate 75-101,000.

Posted by: Kevin Drum on January 8, 2008 at 6:28 PM | PERMALINK

Howard: the original article said 101,000/year. One every 5.2minutes!

Posted by: bigTom on January 8, 2008 at 6:29 PM | PERMALINK

The chart fails because it presupposes there is a defined industry called health care. A lot of thing decrease mortality, and the value of mortality is not always more than the cost to preserve it.

For example, back to the shoe industry. I can make a chart that shows how poorly we do in providing low cost shoes, but it proves nothing about our shoe expertise, it just says that our value system puts shoes at a lower level.


Posted by: Matt on January 8, 2008 at 6:30 PM | PERMALINK

Insert random bogus anecdote about France or Canada here. We're waiting, Al.

Posted by: Gore/Edwards 08 on January 8, 2008 at 6:31 PM | PERMALINK

Didn't click through to the original article [Note to Self: Do that next time], but here's my math: Difference in mortality rate between France and U.S. is 45 per 100,000. U.S. population is 300 million. Thus, 45 X 3,000 = 135,000 preventable deaths per year if U.S. healthcare was equivalent to socialist France.

Posted by: Howard on January 8, 2008 at 6:35 PM | PERMALINK

The analysis, o Matt, is of deaths preventable with timely and effective healthcare. Hence, your argument is a non-sequitur.

Also, most people do argue that there is an industry called healthcare, which is why there are health insurance companies, halthcare providers, and so forth.

On the other hand, why am I bothering with this?

Posted by: Carol on January 8, 2008 at 6:39 PM | PERMALINK

I know that the UK government (NHS) provides the care (true "socialized" care) instead of just insuring the public. They didn't really do all that hot either. It would be kind of neat to be able to click on each country and get a brief synopsis of the system they use, so you can get a feel for any possible correlation between the type of health system in place vs. the preventable death numbers. I believe the French system is a mix of public/private health *providers*, is that correct?

Posted by: Doc at the Radar Station on January 8, 2008 at 6:42 PM | PERMALINK

What annoys me about this presentation is the Orwellian term "health care".

We are, notwithstanding this odious term, talking here about medical care provided by physicians, surgeons, and all the assorted medical paraprofessionals. This is about care for sick and dying people. If you deny a major proportion of ANY population access to medical care on a routine basis, you get this revolting result. Note that anywhere in the developed world you will get more or less adequate care provided you get past the gatekeepers. Treatment is most prompt and most effective in France. Elsewhere, rationing of various sorts administers triage. What is immoral about the US situation is that triage is done on the basis of the size of your personal hoard of liquid and beneficial assets. Medieval is as medieval does. Best stop doing it; the numbers can only get worse without universal single payer coverage with progressive subsidies for the bottom 40% of the income distribution. Then teach people it is their right to ask for care when ill and that there is no stigma attached at all. Can be done; has been done.

Posted by: anon on January 8, 2008 at 6:47 PM | PERMALINK

Found a link that explains in relative detail about how the French health care system works.

Posted by: Doc at the Radar Station on January 8, 2008 at 6:51 PM | PERMALINK

Actually, most countries have a mix of public and private healthcare, including the United States, which is about 45% public and 55% private.

In Britain and Canada the state runs the healthcare system and employs the doctors. In all of the other countries on this chart the state pays for healthcare for all citizens but doesn't actually employ the doctors. (Much like Medicare in the U.S.) However, they don't pay for everything, and supplemental insurance is usually part of the system too. The end result is that in most countries healthcare funding is about 80% from the state and 20% from private sources. The details are quite different from country to country, but that's the 100,000 foot view.

Posted by: Kevin Drum on January 8, 2008 at 7:01 PM | PERMALINK

Gosh, there is nothing like quality science, with studies measuring such obvious objective standards like "deaths that are potentially preventable with timely and effective health care."

I gave up long ago having any hope that social "scientists" would ever live up to the name

Posted by: coyote on January 8, 2008 at 7:23 PM | PERMALINK

Thanks Kevin for the statistics. Prior to the Clinton healthcare proposal in 1994, it looks like Nixon tried it.

I hope the same crap doesn't happen yet again:

Nixon had trouble gaining support for his proposal for National Health Insurance. The employer mandates and the offer of substandard care for poor Americans did not fare well in Congress. (Starr:1982)

The combination of a national recession and a rise in inflation stalled the passage of healthcare. Also, the distractions of the Watergate scandal negatively affected the healthcare campaign. The media and public shifted their interest from healthcare and focused on the scandal. Watergate decreased trust and credibility in the government. By the end of 1973, Nixon's Congressional support on legislation had dropped to the lowest of any president on record. Oil prices rose by over three hundred fifty percent and inflation jumped eleven percent. The war in Vietnam had no end in sight (Quadagno 2005: 120). Because of this, the Nixon Administration was unable to make progress in healthcare reform.

Posted by: Doc at the Radar Station on January 8, 2008 at 7:24 PM | PERMALINK

Matt is right in that if we had a healthier shoe industry we might have a better amenable mortality score.

Posted by: AJ on January 8, 2008 at 7:44 PM | PERMALINK

I encourage anyone who is really frightened by these stats to read page 67 from the Health Affairs article in which it was published, the section on data problems. These guys are IDIOTIC. They may know everything in the world about medicine but they know zippo about statistical methods.

Here is an example. They (rightly) state that there have always been huge differences in heart disease rates (the largest single part of the "amenable mortality" numbers) between countries based on diet, genetics, and lifestyle. The US, for example, would have higher numbers irrespective of medical system employed, and the authors recognize this.

Here is the absurd part: To "fix" this problem, they halve all the heart disease numbers they put in the index. Their logic is maybe about half are preventable and half are lifestyle. WTF? This doesn't correct the problem, it just reduces its weighting by half. If it is true that the half of heart disease in the US is preventable and the rest from lifestyle and such, then something less than half of heart disease in other countries with healthier habits must be from lifestyle. You would need to remove half of the US, but less than half from other countries, though how you would get this latter number is unknown to me.

The authors sell this study as if they have sorted through patient files and scored them somehow for which deaths are preventable. They have not. They simply include all deaths in each country that are from a disease that they have called preventable. That does not mean the death was actually preventable, or that the death was due to flaws in the health care system. It just means the deaths are in a category of diseases arbitrarily called "preventable." If you don't know the difference, then you might consider not blindly trusting this kind of garbage social science just because it supports your policy agenda.

Posted by: coyote on January 8, 2008 at 8:10 PM | PERMALINK

but who'd want to live in a socialist hellhole like that anyway?

Me, right next to Michael Moore.

Posted by: Xanthippas on January 8, 2008 at 8:16 PM | PERMALINK

George Bush advocates the use of Emergency Rooms to provide health care to the poor. In addition to costing far more than alternative means of providing healthcare, this creates the obvious problem that many emergency rooms in the U.S. are too crowded to deal effectively with emergencies. What a great healthcare system. What a wise and insightful leader. Not!!!!

Posted by: fafner1 on January 8, 2008 at 8:27 PM | PERMALINK

In Britain and Canada the state runs the healthcare system and employs the doctors.

Kevin: This is true for Britain, but not for Canada, where the state limits its role mostly to paying bills. In Canada most medical services are delivered by private, not-for-profit hospitals (similar to the US), or sometimes by small for profit companies (lab tests, etc.). And most physicians in Canada work for private, for profit medical practices -- again, similar to the US. I tend to think of Canada's healthcare system as being similar to that of France, with the exception that unlike in France, private insurance is not widely utilized, but is either discouraged or is defacto illegal.

Posted by: Jasper on January 8, 2008 at 8:42 PM | PERMALINK

Jasper, do you think that having a *somewhat* pared-down public single-payer system coupled with a significant but minority role of private insurers and subsidy for the poor that France has would be better than having a purely public system? I ask because the info I got about the French system show: "The public health insurance system covers about 75% of total health expenditures. Half of the outstanding amount is covered by patients' out-of-pocket payments and the other half is paid by private health insurance companies. These supplementary health insurance policies can be taken out by individuals or groups.

About 85% of the population own such policies."

Posted by: Doc at the Radar Station on January 8, 2008 at 8:50 PM | PERMALINK


Yeah, better dead than red.

So what does Al think?

t

Posted by: t on January 8, 2008 at 9:01 PM | PERMALINK

Jasper, do you think that having a *somewhat* pared-down public single-payer system coupled with a significant but minority role of private insurers and subsidy for the poor that France has would be better than having a purely public system?

In a word, yes.

My mom lives in Nova Scotia, Canada, and, while I'd say their system is preferable to the US, I reckon France's is better than either. The French system seems to consistently rate as one of the planet's very best. Canada, from what I read, has too many capacity/rationing and lack of choice issues for my taste. The hardline systemic hostility in Canada to allowing the participation of private capital in the provision of healthcare -- while grounded in the admirable goal of equity -- simply wouldn't work in the US.

Posted by: Jasper on January 8, 2008 at 9:11 PM | PERMALINK

Doc at the Radar Station: France has a number of other rather nice innovations; the entire country is linked by a state provided EMR, national healthcare cards allow timely compensation to providers, and (probably most importantly) the social safety net of allied support services is extensive.

Posted by: J Bean on January 8, 2008 at 9:25 PM | PERMALINK

J Bean: France has a number of other rather nice innovations ...

But is it worth living in a country where people speak without using consonants?

Posted by: alex on January 8, 2008 at 9:27 PM | PERMALINK

But is it worth living in a country where people speak without using consonants?

Yes, but they make up for it with an excessive number of vowels.

Posted by: J Bean on January 8, 2008 at 9:34 PM | PERMALINK

By the way, reading this further, I have found two other things in addition to my comments above

1. The difference between the US and France is 95% attributable to heart disease and circulatory problems. This study does not correct for higher incidence rates, as noted in my post above. All this study says is that the US has a less healthy lifestyle than France. This study might justify fascistic government control of our eating habits, but it says nothing about relative health care systems, no matter how much the authors and Mr. Drum would like it to. This study only covers a few conditions, and is dominated by heart disease, circulatory problems, and diabetes, all diseases related to lifestyle. A far more honest way to present this data would be to compare countries on what percentage of sufferers of a certain condition actually die.

2. The study notably leaves out a lot of very large sources of mortality. For example, the authors apparently do not consider cancer to be "mortality amenable to care" since cancer is not included. Why? Well, a couple of thoughts. First, the US kicks everyone's butt in this category, so it makes me suspicious that they have an agenda in leaving it out. In countries like France, the government does just give up on cancer patients to save money so it may indeed not be amenable to care in France. But in the US, I would indeed consider it amenable to care.

Posted by: coyote on January 8, 2008 at 9:40 PM | PERMALINK

First, the US kicks everyone's butt in this category, so it makes me suspicious that they have an agenda in leaving it out. In countries like France, the government does just give up on cancer patients to save money so it may indeed not be amenable to care in France. But in the US, I would indeed consider it amenable to care.

Um, coyote, do you have some data to back up those statements?

Posted by: J Bean on January 8, 2008 at 9:43 PM | PERMALINK

My bad, sortof. They do include some cancers in the study in a category called neoplasms. Sorry, that is the problem with my commenting in real time. However, this study shows the US ahead of these countries in mortality on neoplasms, and ahead of France and UK, DESPITE having a higher incidence rate. So we have higher incidence but lower mortality.

I stand by the rest. The vast majority of the mortality in this study is due to Circulatory and cardiovascular diseases plus diabetes, all ones where the US has a higher mortality because it has a higher incidence rate. Show me the same country comparison of mortality as a percentage of incidence, and not total population, and then you will have a better point about relative health care systems. The key data for all this is on page 66 of the health affairs article. It is gated but if you navigate to the pdf through the press release it will let you get to the pdf for free.

Again, this study may be fairly damning about lifestyles, and if you are for government micro-control of our everyday decisions, it backs you up. But it really has little to say about the relative merits of health care systems

Posted by: coyote on January 8, 2008 at 10:03 PM | PERMALINK

a couple of points ...

Here is the absurd part: To "fix" this problem, they halve all the heart disease numbers they put in the index. Their logic is maybe about half are preventable and half are lifestyle. WTF? This doesn't correct the problem, it just reduces its weighting by half. If it is true that the half of heart disease in the US is preventable and the rest from lifestyle and such, then something less than half of heart disease in other countries with healthier habits must be from lifestyle. You would need to remove half of the US, but less than half from other countries, though how you would get this latter number is unknown to me.

Actually, what you would do is compute the mortality risk for heart disease per country AFTER adjusting for smoking, diet, BMI, etc, THEN calculate the attributable risk per country, and then ADJUST the above model to account for that.

Across-the-board assignment of 50% will skew the model, I agree. And while misunderstanding the statistics yourself, this remains, as of yet, the only accurate thing you've stated on this thread.


The authors sell this study as if they have sorted through patient files and scored them somehow for which deaths are preventable. They have not. They simply include all deaths in each country that are from a disease that they have called preventable. That does not mean the death was actually preventable, or that the death was due to flaws in the health care system. It just means the deaths are in a category of diseases arbitrarily called "preventable." If you don't know the difference, then you might consider not blindly trusting this kind of garbage social science just because it supports your policy agenda.
Posted by: coyote

The authors did no such thing: the authors picked standard causes of death "based on the concept of "amenable mortality," referring to deaths from certain causes that should not occur in the presence of timely and effective health care. Originally developed in the 1970s in the United States, the concept was subsequently adopted and updated by many researchers, especially in Europe, where it has been used to assess the quality of health care systems.


1. The difference between the US and France is 95% attributable to heart disease and circulatory problems.

You do not have the data to say this. France saw a 20% decline in preventable deaths from IHD, the US 2%. Unless you happen to know the numbers for the OTHER causes of preventable death, and their relative contributions to the aggregate (16% vs 4%), then your statement is false.


This study might justify fascistic government control of our eating habits, but it says nothing about relative health care systems, no matter how much the authors and Mr. Drum would like it to.

The study compares mortalities across 19 countries, all of which saw large drops. Therefore, the only thing it says is that rates fell everywhere for certain conditions, but in America they fell the least. The data themselves actually makes no statement about mechanism, but the better access to universal healthcare in the majority of the other examples is telling.


This study only covers a few conditions, and is dominated by heart disease, circulatory problems, and diabetes, all diseases related to lifestyle. A far more honest way to present this data would be to compare countries on what percentage of sufferers of a certain condition actually die.

You seem fixated on cardiovascular disease and lifestyle, presumably because you mistakenly think it strengthens your point. It doesn't. Furthermore, a study such as yours would show a 100% mortality rate, since that is the percentage of people that actually die from anything. Except for the Rapture, I suppose.

2. The study notably leaves out a lot of very large sources of mortality. For example, the authors apparently do not consider cancer to be "mortality amenable to care" since cancer is not included.

I will give you the benefit of the doubt and say you maybe had just misread the Methods section:

"In brief, for this paper we considered conditions such as bacterial infections, treatable cancers, diabetes, cardiovascular and cerebrovascular disease, and complications of common surgical procedures."

Why? Well, a couple of thoughts. First, the US kicks everyone's butt in this category, so it makes me suspicious that they have an agenda in leaving it out. In countries like France, the government does just give up on cancer patients to save money so it may indeed not be amenable to care in France. But in the US, I would indeed consider it amenable to care.
Posted by: coyote

Honestly, a statement like that is simply begging for some data, or at least a link to wikipedia, to back it up. Throw me a fucking bone here!

Posted by: Lurker on January 8, 2008 at 10:16 PM | PERMALINK

To a lot of the Ayn-al/Neocon/Plutocrat/Libertdystopian "philosophers", it literally is more important to do things the ideologically "pure" or "moral" way in their view, than for people to live, to be happy, to be prosperous, be healthy, etc.

Posted by: Neil B. on January 8, 2008 at 10:21 PM | PERMALINK

My bad, sortof. They do include some cancers in the study in a category called neoplasms. Sorry, that is the problem with my commenting in real time. However, this study shows the US ahead of these countries in mortality on neoplasms, and ahead of France and UK, DESPITE having a higher incidence rate. So we have higher incidence but lower mortality.

The study says nothing about the incidence of these diseases, so again, I'm not sure where that statement came from.

As for better mortality, Exhibit 6 showing Death Rates shows a 1-3/100,000 mortality difference between the US and UK wrt cancers, and 0.2/100,000 between US and France, while showing an over 20/100,000 mortality difference between the US and France wrt cardiovascular disease. I don't see how the ridiculously small difference between cancer mortality is ALL due to superior American medical knowhow, and the MASSIVE difference in cardiovascular mortality is somehow ALL lifestyle.

I stand by the rest. The vast majority of the mortality in this study is due to Circulatory and cardiovascular diseases plus diabetes, all ones where the US has a higher mortality because it has a higher incidence rate.

again, you really need to show me this magical place where you got these incidence rates from, because I have a hard time seeing you as a specialist who just happens to know them offhand.


Again, this study may be fairly damning about lifestyles, and if you are for government micro-control of our everyday decisions, it backs you up. But it really has little to say about the relative merits of health care systems
Posted by: coyote

At the risk of descending into ad hominem, this is a level of delusion which should be medicated.

Posted by: Lurker on January 8, 2008 at 10:29 PM | PERMALINK

But does this mean we have bad healthcare, or is it just another consequence of the fact American's kill each other at a greater rate than anywhere else in the developed world? Surely he have more "amenable" death per capita to begin with, since we're so much more busy than the competition shotting and stabbing each other.

Posted by: mattg on January 8, 2008 at 10:32 PM | PERMALINK

Per the request above, here is the 5-year cancer survival rates in US that dwarf those in most of Europe.

Here is a post on my blog with the comments above cleaned up and expanded on. The specific data and text from the study I refer to is included, in case you can't get through the gated site.

Posted by: coyote on January 8, 2008 at 10:50 PM | PERMALINK

Per the request above, here is the 5-year cancer survival rates in US that dwarf those in most of Europe.
Posted by: coyote

OK ... after reading some of your blog, I understand your position somewhat. I had mistakenly thought you were responding to Kevin's actual posting on this blog, with the data available, as opposed to being an ideologue with a consistent agenda against effective medical care.

My bad.

It is amusing, however, to note that your cancer mortality statistics originate from 1998, which is actually the first year represented by the study in this posting, and that since every other country has apparently improved its amenable mortality statistics by a factor of 4x MORE SO than did the US, so it would be instructive to see you post the same graph using data more recent than 10 years old.

Posted by: Lurker on January 8, 2008 at 11:15 PM | PERMALINK

Re. cancer survival rates: according to a 2006 summary of reports that compare Canadian and US health care and that was prepared by Nicholas Skala (http://www.pnhp.org/single_payer_resources/CAN_Comparison_Sheet.pdf), in 2004 Canada had a higher survival rate for colorectal cancer, Canada and the US were virtually tied for cervical cancer (with a slight lead for the US), and the US had a higher survival rate for breast cancer.

It's interesting to note that according to Skala's report, Canadians kidney patients were twice as likely to receive a transplant than Americans, who were much more likely to remain on dialysis. Skala conjectures that this is because continuing dialysis is more profitable than doing a transplant (the monthly costs of treatment for kidney patients were $503 higher in the US than in Canada).

Posted by: otherpaul on January 9, 2008 at 12:13 AM | PERMALINK

The data from this study show that organ donation is lower in Canada than the US by >50%. Spain has the highest rate, btw.
So otherpaul needs to find another argument. What I see in the US is a conflict between dialysis centers, who want to keep their patients, and insurance companies, who want to save money with transplants.

Posted by: natural cynic on January 9, 2008 at 1:58 AM | PERMALINK

"Their odds would have been a whole lot better in Paris, but who'd want to live in a socialist hellhole like that anyway?"

I guess Spinal Tap was right: you really are better off living in a hellhole.

Posted by: FreakyBeaky on January 9, 2008 at 2:12 AM | PERMALINK

It's been said a lot on similar healthcare related threads, but one remedy for this is to tie insurance reimbursements to outcomes, rather than individual "treatments". There's too much unnecessary treatment in our system and not enough attention paid to whether anybody actually gets well or not. No wonder our numbers on this count are so crappy.

Posted by: jonas on January 9, 2008 at 2:46 AM | PERMALINK

I will never yield to the cruel tyranny of mandates no matter what the cost in lives.

Posted by: crazy Republican or healthy Obama supporter? on January 9, 2008 at 2:59 AM | PERMALINK

Coyote pointed something similar out above, but I think this needs to be made explicit:

The study calculates the preventable rate of death from heart disease at 50% of all deaths listed as such. This rate is used in every country with no adjustments and no real justification for the standardization.

In the US, there are 217 deaths from heart disease per 100K per year. (That's a total of 652,486, source CDC)

By comparison, most estimates of French heart disease deaths come out close to 85 per 100K per year. I had trouble finding a reliable source, but most of the estimates I saw put it in that ballpark.

Taht's a lifestlye issue, not a healthcare issue, and it accounts for the vast majority of the so-called preventable deaths, and more than accoutns for the difference. (If you remove heart disease, France comes out to approximately 20 preventable deaths per 100K per year, and the US toabout 6)

Please note that the above numbers don't suggest that the US is (mirabile dictu) superior to France. They simply indicate that this is a truly terrible study. It really is a comparison of heart attack rates across countries, with a bit of hand-waving tacked on to boost its publishability.

Meaningless drivel, in other words.

Posted by: heedless on January 9, 2008 at 4:22 AM | PERMALINK

Posts like these really hit home hard. I lost my mother last July after a very preventable error in a highly routine surgery followed by six months of preventable error after preventable error. The whole situation is parodic and sickening. And the hospital's behavior since her death belies an understanding of what poor care they gave.

Posted by: Jack on January 9, 2008 at 8:17 AM | PERMALINK

Natural Cynic: I didn't intend to make a very general argument. I just cited some figures to indicate that different systems fare better at different procedures, with the result that Canada outperforms the US in some areas but the US outperforms Canada in others. So it's difficult to draw sweeping conclusions about whether one system is better (across the board), or even whether one system is better when it comes to all forms of cancer.

The study you cite indicates that "the rate of organ transplantation in the United States was 150% that of Canada in 2002." That's a claim about all transplants. By contrast, I made a point just about kidney transplants, which differ from some other kinds of transplant in that kidney transplants compete against a different, eventually more expensive procedure (dialysis).

It's unfair to compare Spain's organ 'donation' rates with those of any anglo country. Spain, along with several other EU states, has a system of presumed consent, which means you're donating your organs unless you fill out a form saying that you don't want to. By contrast, Canada, the US and other anglophone countries use presumed refusal, which means you're not donating organs unless you indicate that you wish to do so.

Posted by: otherpaul on January 9, 2008 at 8:50 AM | PERMALINK

If more people in the US are dying of preventable ailments, does that necessarily reflect poorly on the healthcare system? Or could it be attributed to culture? That is, could it be that Americans are less likely to seek out preventative care than people in other countries?

Posted by: Derek James on January 9, 2008 at 10:01 AM | PERMALINK

could it be that Americans are less likely to seek out preventative care than people in other countries?

Yeah, 'cause they can't afford it.

Posted by: Vicente Fox on January 9, 2008 at 11:06 AM | PERMALINK

If more people in the US are dying of preventable ailments, does that necessarily reflect poorly on the healthcare system?

Yes.

Or could it be attributed to culture? That is, could it be that Americans are less likely to seek out preventative care than people in other countries?

Americans are less likely to seek out preventative care because they can't afford it, not because of "culture" (what culture would that be, exactly?), and that fact is a direct result of the failed healthcare system we have.

Posted by: Stefan on January 9, 2008 at 11:16 AM | PERMALINK

"However, this study shows the US ahead of these countries in mortality on neoplasms, and ahead of France and UK, DESPITE having a higher incidence rate. So we have higher incidence but lower mortality."

Be very, very wary of anyone who compares cancer incidence and survival rates in the US and other countries. The US employs a widespread screening regime for colon and prostate cancer; other nations do not. This means that you are exponentially more likely to be diagnosed with these cancers in the US, even though many (most, in the case of prostate cancer) cancers would not be terminal (i.e., you'd probably die of something else before the cancer became life threatening).

To use an example, assume two countries (A and B), each with a population of 100. Ten people in each country will have non-prostate/colon cancer. Five of them will die from their cancer. Now assume another 10 will have prostate/colon cancer, but, left untreated, only two will die from it (we'll assume that they could be saved if diagnosed reasonably early).

Country A tests for colon/prostate cancer. They catch all 10 colon/prostate cancers and save those patients. So, you get an incidence rate of 20%, and a mortality rate of 5%.

Country B doesn't test. The two colon/prostate cancers are diagnosed after it is too late, so the incidence rate is 12%, and the mortality rate is 7%.

Do you see how this skews things? It looks like the survival rate in Country A is 75% and the survival rate in Country B is around 40% -- yet the main reason for this is that Country A was able to identify 10% of its population with a probably benign condition. This is why mortality across the population (5% v. 7% here) is the ONLY good number to use.

(And keep in mind, of course, that for the two prostate/cancer patients who die, there are eight patients who are treated "unnecessarily" -- meaning a colostomy bag or impotence in many of those cases. It would be a legitimate policy choice for a medical system to "sacrifice" the two lives to drastically improve QOL in the other eight, though I'm not sure I'd pick it.)

Posted by: Joe on January 9, 2008 at 11:58 AM | PERMALINK

Preventative care is vastly cheaper than treatment after the patient has already contracted a disease. E.g., it's far cheaper to prevent heart disease than it is to treat it.

And by culture, I mean large-scale, identifiable trends in behavior based on the society they live in. I'm not claiming it is so, but it could be that Americans, on average, are less likely to get yearly check-ups (which are not prohibitively expensive).

It's simply poor reasoning to necessarily attribute the cause of preventable deaths to the quality of the health care system.

Posted by: Derek James on January 9, 2008 at 12:07 PM | PERMALINK

And by culture, I mean large-scale, identifiable trends in behavior based on the society they live in.

Yes, but what trend would it be? What is supposedly so unique about American culture that it would discourage doctor visits? What is the actual, identifiable value in our society that would cause this? You can't just say "it's culture" without specifically identifying the cultural value that is supposedly at play.

I'm not claiming it is so, but it could be that Americans, on average, are less likely to get yearly check-ups (which are not prohibitively expensive).

They are indeed prohitibitively expensive for many American families, especially if you add in the cost of diagnostic tests. And even if the check-up wasn't expensive, what's the use of it if it reveals a condition that the patient, lacking adequate insurance, can't afford to treat?

It's simply poor reasoning to necessarily attribute the cause of preventable deaths to the quality of the health care system.

No, it's simply delusional and/or dishonest not to attribute the cause of preventable deaths to the quality of the health care system. That's like saying "it's simply poor reasoning to necessarily attribute the cause of preventable car crashes to the automobile industry."

Posted by: Stefan on January 9, 2008 at 12:55 PM | PERMALINK

Their odds would have been a whole lot better in Paris, but who'd want to live in a socialist hellhole like that anyway?

Moi, si vous plait!

Posted by: "Fair and Balanced" Dave on January 9, 2008 at 1:40 PM | PERMALINK

That's like saying "it's simply poor reasoning to necessarily attribute the cause of preventable car crashes to the automobile industry."

Wow, thanks for making my point for me, Stefan. Do you really place the blame for all car crashes on the automobile industry? So when people drink and drive and hit someone, that's Honda's fault?

Posted by: Derek James on January 9, 2008 at 3:08 PM | PERMALINK

Wow, thanks for making my point for me, Stefan. Do you really place the blame for all car crashes on the automobile industry? So when people drink and drive and hit someone, that's Honda's fault?

All? No. Some? Of course. It would be ridiculous to claim that the automobile industry didn't bear some responsibility for automobile safety due to their design of cars (for example, designing SUVs liable to roll-over, or making SUVs so ungainly that they have a harder time maneuvering out of potential accidents as smaller cars).

(Not to mention the fact that their lobbying on behalf of funds for the highway system at the expense of public transportation has the effect of putting more cars on the roads, which directly increases the number of auto fatalities).

Similarly, in the healthcare industry you cannot solely blame individual action without also considering the broader economic and systemic disincentives discouraging Americans from seeking medical care.

Posted by: Stefan on January 9, 2008 at 4:30 PM | PERMALINK

This kind of argument moves no votes.

The "best healthcare in the world" folks really mean "best healthcare in the world for folks like me who can pay for it." They don't care about averages, because averages count all the poor people who don't matter to them.

Get some statistics, or even anecdotes, that show that middle- and upper-class employed Americans also suffer from the status quo.

How about that cardiologist in Redding a few years ago, who did unnecessary heart catheterizations on a bunch of folks with excellent insurance, killing some and permanently disabling others? They never would have received this great "treatment" had they not been well-insured. Or stats that show that Americans with health insurance get *worse* emergency care (and outcomes) than the uninsured?

Our system can kill you either way. And we'd better realize that people are pretty selfish on this issue. So don't expect to convince them with arguments from altruism. Get them where they live--or die.

Posted by: Nancy Irving on January 10, 2008 at 6:08 AM | PERMALINK

"Honestly, a statement like that is simply begging for some data, or at least a link to wikipedia, to back it up. Throw me a fucking bone here!"

How about the dolts who wrote the original report from the Commonwealth Fund being a bit more open with what they used for data and/or criteria, and then I will determine, for myself, what the conclusions are, instead of having some organization with an agenda outright telling me that what I've currently got is shit and I'd be better off if were just like everyone else's stuff.

Piss off, Lurker!

Posted by: theirritablearchitect on January 10, 2008 at 10:45 AM | PERMALINK

I refer theirritablearchitec to the Methods section of the paper, and the referenced articles. Can't access them? Then get an account to Medline or pay for the article from the source.

Posted by: Lurker on January 10, 2008 at 12:35 PM | PERMALINK

Did it, and read the fine print too!

Kiss off!

Posted by: theirritablearchitect on January 10, 2008 at 1:27 PM | PERMALINK

It's called lying through intentional omission, and it appears as though there are a bunch of people who don't know what that means.

Posted by: theirritablearchitect on January 10, 2008 at 1:36 PM | PERMALINK

Lurker,

Actually, what you would do is compute the mortality risk for heart disease per country AFTER adjusting for smoking, diet, BMI, etc, THEN calculate the attributable risk per country, and then ADJUST the above model to account for that.

Do you have an analysis that controls for the differences between the countries in smoking, diet, BMI and every other lifestyle or environmental influence on "amenable mortality?" Of course not. There is no such analysis. As an indicator of the performance or effectiveness of different nations' health care systems, the study is meaningless, for the reasons coyote explains.

It is amusing, however, to note that your cancer mortality statistics originate from 1998, which is actually the first year represented by the study in this posting, and that since every other country has apparently improved its amenable mortality statistics by a factor of 4x MORE SO than did the US, so it would be instructive to see you post the same graph using data more recent than 10 years old.

The most recent data I'm aware of come from Eurostat-4 report published in the Lancet Oncology August 2007, which provides data for the period 2000-2002. This data also clearly shows much better 5-year cancer survival rates for the U.S. compared with Europe. See here for details.

Bottom line: If you get cancer, your chances of survival are much better in the U.S. than in Europe.

Posted by: Jason on January 12, 2008 at 10:41 PM | PERMALINK

Stefan,

No, it's simply delusional and/or dishonest not to attribute the cause of preventable deaths to the quality of the health care system.

What utter nonsense. Smoking, diet, exercise, accident rates, crime rates and about a thousand other variables have a much greater effect on the rate of preventable deaths than the health care system. You cannot possibly draw any meaningful conclusions from preventable death rates about the performance of the health care system without controlling for these other variables.

That's like saying "it's simply poor reasoning to necessarily attribute the cause of preventable car crashes to the automobile industry."

It IS simply poor reasoning to attribute the cause of preventable car crashes to the automobile industry. Apparently, you think the skills and attention of the drivers, the quality of highways and road signs, the number of vehicles on the roads, and so on, have no effect.

Seriously Stefan, try THINKING for thirty seconds before writing, then you might not embarrass yourself so often.

Posted by: Jason on January 12, 2008 at 10:51 PM | PERMALINK

Gioca ai giochi del casino online in un ambiente virtuale sano e sicuro, sapendo di avere accesso a tutti i manuali ed ai libri di strategia, così come alle offerte di Bonus gratuiti e ad altri vantaggi offerti dai casinò online.

casino online - http://www.quellefromage.com/ Posted by: casino online on January 31, 2008 at 8:48 AM | PERMALINK




 

 

Read Jonathan Rowe remembrance and articles
Email Newsletter icon, E-mail Newsletter icon, Email List icon, E-mail List icon Sign up for Free News & Updates

Advertise in WM



buy from Amazon and
support the Monthly