Saturday, April 24, 2010

National Health Outcome Rankings: It’s the Culture Stupid!

Deciphering That 2000 WHO “Zombie Number” Ranking the U.S. 37th in the World

Philip Musgrove, PhD, who was editor-in-chief of the 2000 World Health Report, Health Systems: Improving Performance, says the report, published under his editorship, ranking the U.S. 37th in the world was a mistake (“Health Care Rankings, “ Letter to the Editor, New England Journal of Medicine, April 22, 2010). “It is long past time,” he says,” for this zombie number to disappear from circulation.”

Musgrove was responding to a New England Journal article critical of U.S. health care by two medical academics, Murray, C;l. and Frenk, J.: Ranking 37th – Measuring The Performance of the U.S. Health Care System,” N Engl J Medic 2010, 362:98-88.

Mosgrove argues that 37 is a”zombie number”because it predisposes national health outcomes depend only on access and ignore cultural, geographic, and historical factors.

I’m with Mosgrove. These examples supporting his position spring to mind.

• Medical care accounts only for about 15 percent of the health status of any given population (Leonard Sagan, The Health of Nations: True Causes of Sickness and Well-Being, 1987). Life style accounts for 20 percent to 30 percent, and income differences, and lack of social cohesion for the other 55 percent(D. Satcher, and R, Pamies, Multicultural Medicine and Health Differences, 2006).

• If one were to eliminate violence and accidents from the statistics, the U.S. would rank near the top in longevity. John Holcomb, M.D., the U.S. Army’s top trauma surgeon is fond of quoting the statistic, that, among U.S. civilians, trauma leads all diseases in terms of life-years lost, more than heart disease or cancer. That’s a useful statistic to keep in mind when comparing national health systems. If one takes trauma and violence into consideration, U.S. longevity statistics are comparable to any other country. Civilian trauma and deaths are largely beyond the health system’s reach.

• The U.S. is the number one destination for the world’s immigrants. The U.S. receives some 85 percent of the world’s immigrants. Because of such things as poverty, cultural differences, poor prenatal care, and discrimination, the non-white population, a disproportionate number of whom are immigrants, have lower life expectancies as follows; whites 81.0 years, black 63.6 years, Hispanic 74.0 years, Asian 75.2 years. (Abstract of the United States, 200-2004). From 1993 to 2003, the U.S. population exploded by 12.3 percent, due in large part to newly arrived immigrants with and their subsequent fecundity. This unexpected growth contributed to the physician shortage, lack of access to care, and dismal statistics.

• Life expectancy in the United States, a vast continental nation, depends on where you live . If you are black man in Harlem, your chances of surviving past 40 are less than if you lived in Bangladesh or other third world countries. If you live in Minnesota, you will live on average to 80.5 years. If you live in Mississippi, you are likely to die by 73.9 years. These various statistics are largely due to socioeconomic factors beyond the reach of health care professionals, who do not control what goes on in the streets or immigration patterns.

Top-down health care social engineering is a fine and wonderful bundle of good intentions worth pursuing, but it has its limitations - such as achieving uniform improved outcomes across all cultural groups.


HaynesBE said...

Thank you for bringing attention to this worthless but oft quoted statistic.

The calculation of life expectancy is of course dependent on infant morality figures. I have read that different countries define live birth, neonatal and infant mortality in different ways and that the US is one of the most inclusive in its consideration of what to record as a live birth. Requirements and methods for reporting also vary greatly between countries.
Additionally, the US has a much larger proportion of teen mothers (certainly a cultural phenomenon) and consequently more low birth weight and pre-term infants. These factors all lead to a higher infant mortality which then brings down life expectancy.

I would love to see an article which compares live birth definitions and discusses the accuracy of data collection between various countries. Without that information to provide a full context for the statistics, the numbers are meaningless. When used to denigrate the remnant of freedom in the US health care system, they are worse than useless; they are harmful.

Richard L. Reece, MD said...

In Other Words

When using statistics to rank how well nations,
And health systems influence outcomes of patients.
Always keep in mind the tricky logistics,
Of how countries count birth statistics.
The beginnings distort the final summations

L. Harris said...

Any useful comparison of health care systems is a complex undertaking that involves gathering a large collection of measures (mostly objective) and weighting them by importance (largely subjective).

Life expectancy is only one of those measures. You can spend pages explaining why our lower life expectancy is not indicative of issues in our health care system, but at the end of the day you'll have only addressed one measure.

The WHO ranking is not a life expectancy ranking. There are many, many measures by which we do not compare favorably with countries that have some of the better universal health care systems, and to ignore all of those measures to dismiss a poor ranking seems disingenuous.

The 37th ranking reflects some biases in the weighting of some measures, which is an inherently subjective process. WHO gives a lot of weight to access, and since we don't have universal health care, we will not rank well by that measure, for example.

The WHO ranking aside, there are many measures by which we compare poorly. One would be the percentage of people who forego some kind of care because of cost. 45% of respondents to a survey by the Commonwealth Fund reported that they had foregone some kind of recommended care in 2007 because of cost. You won't find that in Canada, France, Germany, Norway, and so on.

It's estimated that up to 45,000 people die annually here because they postponed getting care for some kind of problem because they felt they couldn't afford it. Gallup reported in 2007 that "The Nov. 11-14 survey shows that 30% of Americans say they or a family member have put off medical treatment because of cost, up from 22% in 1991, when Gallup first asked the question."

Hundreds of thousands of Americans face bankruptcy over medical debt annually. More see their savings wiped out or lose their homes after mortgaging them to pay medical bills. One in four cancer patients or their families said they used up all or most of their savings to pay for treatment.

I could many more measures by which we perform poorly compared to other countries, but the point is you can't legitimately dismiss any ranking of health care systems with an argument that focuses on a single measure, or even two.