Barbara Starfield, MD, MPH
Information concerning the deficiencies of US healthcare have been accumulating. The fact that more than 40 million people have no health insurance at all is well known. The high cost of the healthcare system is considered to be a deficit, but seems to be tolerated under the assumption that better health results from more expensive care, despite evidence that as many as 20% to 30% of patients receive contraindicated care. In addition, with the release of the Institute of Medicine report (IOM) 'To Err Is Human,' millions of Americans learned for the first time that an estimated 44 000 to 98 000 among them die each year as a result of medical errors.
The fact is that the US population does not have anywhere near the best health in the world. Of 13 countries in a recent comparison, the US ranks an average of 12th (second bottom) for 16 available health indicators. Countries in order of their average ranking on the health indicators (with the best being first are): Japan, Sweden, Canada, France, Australia, Spain, Finland, The Netherlands, The UK, Denmark, Belgium, The US and Germany. The poor performance of the US was recently confirmed by the World Health Organisation. Their report ranked the US 15th among 25 industrialised countries. Thus, the figures regarding the poor position of the US in health worldwide are robust and not dependent on the particular measures used. Common explanations for this poor performance fail to implicate the health system. The perception is that the US public 'behaves badly' by smoking, drinking and perpetrating violence. The data shows otherwise, at least relatively. The proportion of females who smoke is fifth best in the US at 24%.. For males it is third best at 24%. The data for alcohol consumptions is similar. The US ranks fifth. Thus although excess alcohol and tobacco use is clearly harmful to health, they do not account for the relatively poor position of the US on these health indicators. The data on years of potential life excludes external causes associated with motor accidents and violence, and it is still the worst among 13 countries. Dietary differences have been demonstrated to be related to differences in mortality across countries, but the US has relatively low consumption of animal fats and the third lowest mean cholesterol concentrations among men between the age of 50 and 70 in 13 industrialised countries.
The real explanation for relatively poor health in the US is undoubtedly complex and multifactorial. From a health system perspective it is possible that the historic failure to build a strong primary care infrastructure could play some role. A wealth of evidence documents the benefits of characteristics associated with primary care performance. Of the seven countries in the top of the health ranking, five have strong primary care infrastructures. Although better access to care including universal health insurance is widely considered to be the solution, there is evidence that the major benefit of access accrues only when it facilitates receipt of primary care. The health care system itself may also contribute to poor health through its adverse effects. For example, US estimates of the combined effect of errors and adverse effects that occur because of iatrogenic damage not associated with recognisable error include:
12 000 deaths a year from unnecessary surgery
7000 deaths a year from medication errors in hospitals
20 000 deaths a year from other errors in hospital
80 000 deaths a year from non socomial infections in hospital
106 000 deaths a year from non error adverse effects of medication
These total to 225 000 deaths per year from iatrogenic causes. Three caveats should be noted. First, most of the data is derived from hospitalised patients. Second, these estimates are for deaths only and do not include adverse effects that are associated with disability or discomfort. Third, the estimates of death due to error are lower than those in the IOM report. If the higher estimates are used, the deaths due to iatrogenic causes would range from 230 000 to 284 000. In any case, 225 000 deaths a year constitutes the third leading cause of death in the US after heart disease and cancer. There is also a wide margin between these figures and the next leading cause of death which is cerebrovascular disease.
One analysis overcomes some of these limitations by estimating adverse effects in outpatient care and including adverse effects other than death. It concluded that between 4% and 18% of consecutive patients experience adverse effects in outpatient settings, with 116 million extra physician visits, 77 million extra prescriptions, 17 million emergency department visits, 8 million hospitalisations, 3 million long term admissions, 199 000 additional deaths and $77 billion in extra costs (equivalent to the aggregate cost of care pf patients with diabetes).
Another possible contributor to the poor performance in US health indicators is the high degree of income inequality in this country. Extensive literature documents the enduring effects of low socioeconomic position on health; a newer and accumulating field of literature suggests the adverse effects of not only low socioeconomic position but especially, low relative social position in industrialised countries. Among the 13 countries included in the international comparison mentioned above, the US position on income inequality is 11th (third worst). Sweden ranks the best on income equality, matching its high position for health indicators. There is an imperfect relationship on matches between income inequality and health, although the US is the only country in a poor position on both.
US children are particularly disadvantaged whereas elderly persons are much less so. Judging on the data from life expectancy at different ages, the US population becomes less disadvantaged as it ages, but even the relatively advantaged position of elderly persons in the US is slipping. The US relative position for life expectancy in the oldest age group was better in the 1980s than the 1990s. The long existing poor ranking of the US with regard to infant mortality has been a cause for concern. It is not a result of high percentages of low birth weight and infant mortality among the black population, because the international ranking hardly changes when data for the white population only is used. Whereas definitive explanations for the relatively poor position of the US continue to be elusive, there are sufficient hints as to their nature to provide the basis for consideration of neglected factors:
1.The nature and operation of the healthcare system. In the US, in contrast to many other countries, the extent to which receipt of services from primary care physicians versus specialists affects overall health and survival has not been considered. While data available suggests that specialty care is associated with better quality of care for specific conditions in the purview of specialist, the data on general medical care suggests otherwise. National data fail to obtain data on the extent to which the care received fulfills the criteria for primary care, so it is not possible to examine the relationship between individual and community health chracteristics and the type of care received.
2. The relationship between iatrogenic events (including both error and nonerror adverse events) and type of care received. The results of international surveys document the high availability of advanced technological systems in the US. Among 29 countries, the US is second only to Japan in the availability of magnetic resonance imaging units and computed tomography scanners per million population. Japan, however, ranks the highest on health whereas the US ranks among the lowest. It is possible that the high use of technology in Japan is limited to diagnostic technology not matched by high rates of treatment, whereas in the US, high use of diagnostic technology may be linked to the 'cascade effect' and further treatment. Supporting this possibility are data showing that the number of employees per bed (full time equivalents) in the US is highest among the countries ranked, whereas they are very low in Japan; far lower than can be accounted for by the common practice of having family members rather than hospital staff provide the amenities of hospital care.
How cause of death and outpatient diagnoses are coded does not facilitate an understanding of the extent to which iatrogenic causes of ill health are operative. Consistent use of 'E' codes (external use of injury and poisoning) would improve the likelihood of their recognition because these ICD (international classification of diseases) codes permit attribution of cause of effect to 'Drugs, Medicinal and Biological Substances causing Adverse Effects in Therapeutic Use.' More consistent use of codes for 'Complications of Surgical and Medical Care' might improve the recognition of the magnitude of their effect; currently, most deaths resulting from these underlying causes are likely to be coded according to the immediate cause of death (such as organ failure). The suggestions of the IOM document on mandatory reporting of adverse effects might improve reporting in hospital settings, but it is unlikely to affect under reporting in noninstitutional settings. Only better record keeping with documentation of all interventions and resulting health status (including symptoms and signs) is likely to improve the current ability to understand both the adverse and positive effects of healthcare.
3. The relationships among income inequality, social disadvantage and characteristics of health systems, including the relative contributions of primary care and specialty care. Recent studies using physician to population ratios (as a proxy for unavailable data on actual receipt of health services according to their type) have shown that the higher the primary care physician to population ration in a state, the better most health outcomes are. The influence of specialty physician to population ratio and of specialist to primary care physician ratios has not been adequately studied but preliminary data suggests that the converse may be the case. Inclusion of income inequality variables does not eliminate the positive effects of primary care. Furthermore, states that have more equitable distribution of income are also more likely to have better primary care resource availability, this raising questions about the relationship among a host of social and health policy characteristics that determine what and how resources are available.
Recognition of the harmful effects of healthcare intervention and the likely possibility that they account for a large portion of excess deaths in the US compared with other comparably industrialised nations, sheds new light on imperatives for research and health policy. Alternative explanation for these realities deserve intensive exploration.