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.

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On Smaller Class Size

acute care

Via Slate comes word of a new study released in the November 2007 issue of American Journal of Public Health. The study tracked the role of class size on a number of outcomes including projected earnings, welfare payments, crime costs, quality-of-life scores, and mortality.

Remarkably, the authors found that, when targeted to low-income students, smaller class size produced savings of approximately $200,000, and a net gain of 1.7 QALYs.

acute care interventions

Notwithstanding my dislike of QALYs, this study concludes that reducing class-size could conceivably have a greater effect on socioeconomic disparities and on mortality than most acute care interventions. I have been beating the drum on this general point for some time now, that increasing access to acute care interventions is not an evidence-based way of improving health and ameliorating illness.

Changing the way we conceive of the causes of health and illness is, IMO, the fundamental barrier to improving public health in the U.S. As important as access to care is in a moral paradigm, the evidence, already robust, is mounting that public health policies geared towards the social determinants of health are far and away the most effective means of improving health.

improving health