On Preventable Death

public health

A new study released in Health Affairs found that out of nineteen industrialized nations, the U.S. ranked dead last in preventable deaths. Here is the Abstract:

We compared trends in deaths considered amenable to health care before age seventy-five between 1997–98 and 2002–03 in the United States and in eighteen other industrialized countries. Such deaths account, on average, for 23 percent of total mortality under age seventy-five among males and 32 percent among females. The decline in amenable mortality in all countries averaged 16 percent over this period. The United States was an outlier, with a decline of only 4 percent. If the United States could reduce amenable mortality to the average rate achieved in the three top-performing countries, there would have been 101,000 fewer deaths per year by the end of the study period.

While the reasons for the U.S. performance are many, IMO one of the primary factors is that the U.S. does not allocate adequate resources to preventive medicine and public health. We have noted before on this blog the 2006 statistics that 96% of U.S. health care dollars are spent on acute care and biomedical research, with only 1-2% expended on preventive medicine and public health. Almost by definition, acute care does little to prevent morbidities that over time are productive of higher mortality.

This study adds to the copious data finding that the U.S. health care system is mediocre at best as compared to other industrialized nations. Some of this data is methodologically flawed, but there remains ample evidence to conclude that as to overall population health, the U.S. has much room for improvement. And a significant portion of the improvement, IMO, ought to come in increased resources and attention paid to preventive medicine and public health, since there is excellent evidence that such interventions are likely to have a much greater effect on population health than acute care interventions.

UPDATE: Tyler Cowen links to this methodological critique of the study at Coyote Blog.

Coyote has some points to make that are worth reading:

The study makes a big point of saying that France is much better than the US, so we will use those two countries. In 2003, France has an “amenable disease” death rate 56 points lower than the US. But we can see that almost this whole gap, or 42 points of it, comes from heart and circulatory diseases. The incidence of these diseases are highly related to diet and lifestyle. In fact, it is well established that the US has a comparatively high incidence rate of these diseases, much higher than France. This makes it entirely possible that this mortality difference is entirely due to lifestyle differences and disease incidence rates rather than the relative merits of health care systems. In fact, this study is close to meaningless.

I disagree. Whatever flaws admit in the methods, it is not meaningless. Notwithstanding the merits of Coyote’s points, even he admits that the difference may be in the higher incidence of ischemic heart disease. But, as I’ve argued on this blog before, any policy analysis that stops there is limited.

This is because the rates of cardiovascular and circulatory disease are connected to social conditions. Brunner and Marmot demonstrate that “[m]easures of social and economic status, including occupation, are extremely powerful predictors of premature heart disease.” Further, metabolic syndrome, which is prevalent in the U.S. (~ 47 million), is an evidence-based predictor of diabetes and coronary disease (Brunner & Marmot 2006). Metabolic syndrome follows a nice social gradient in the Whitehall II study, and obesity is associated with low SES.

The point, then, is that even if Coyote is right that the higher U.S. incidence of coronary and circulatory disease accounts for the large difference between France and the U.S., it is hardly sufficient to stop there and conclude there are no significant health-related differences between France and the U.S.

Moreover, if the relevant disease burdens are significantly influenced by socioeconomic conditions, Daniels, Kennedy, and Kawachi’s analysis suggests that the wider socioeconomic disparities in the U.S. may go some length to explaining the greater burdens of these socially determined disease.

acute care

The income inequality data supports this thesis, as France’s Gini is 32 compared to the U.S.’s 41, which is well on the higher end (deVogli 2005; Wilkinson 2006). de Vogli et al. conclude that “[c]ountries having lower levels of income inequality such as Japan and Sweden enjoy a better health compared with countries of high income inequality such as the USA and Portugal.”

This also provides some answer to Tyler’s comment that “[t]he biggest surprise is Japan — a country whose health care institutions are not generally popular — at number two.” Given the lower socioeconomic disparities, Japan’s performance may not be all that surprising. Admittedly, however, the most recent statistics (Download JPN.pdf ) for Japan’s health expenditures don’t indicate any profound commitment to prevention and public health, as ratios of preventive and public health spending to inpatient care are roughly equivalent to U.S. ratios (1:20).

I do not want to be accused of reductionism. The causes of disease incidence and prevalence across nations are complicated, but there is good evidence that social conditions are primary but obviously not exclusive determinants.

All of this implies that whatever the methodological problems with the study, the idea that France, which boasts smaller socioeconomic disparities as well as a widely-praised health system, could boast better health outcomes and even less preventable deaths is hardly facially implausible.

Given the social determinants of coronary and circulatory disease, one would expect the U.S. with its growing income inequality to have much higher incidences of each, which in fact it does. This is not as much a fatal flaw in the study as capturing an important determinant in thinking about health cross-culturally.

Finally, whatever the familiar critiques of the error reporting system in the U.S. vs. other OECD nations, the IOM — hardly a bastion of liberalism — has declared on several occasions that the error rates in the U.S. are unacceptably high. And these rates are hardly explained by reporting differences, especially where rates of MRSA infection in the U.S., many cases of which can be prevented by observing simple hygiene measures.

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