Saturday, October 19, 2013

With All That Said...How m'I Doing??

Since we have all now read and slept on (literally under your pillows, right?) the points discussed in "Walk With Me, We've Got a lot to Talk About", I'll boldly (foolishly) assume that we've all been brought up to speed on some of the more pressing matters in national health care reform pending implementation of the Patient Protection & Affordable Care Act (ACA) and proceed with taking us to our next stop; in what I will call a more "empirical dimension". By empirical here, I am referring to a process that disregards opinion or how we may feel about our efforts and instead focuses our objective lenses toward direct observation and statistical analysis.

Regardless of your natural inclination toward numbers of all kind, it's hard to ignore the importance of statistics in our society. In our fast-paced present day, it seems like the world is becoming increasingly more bloated with information thanks to the advent of the internet and "Big Data". To make sense of all that swirls around us, we must enlist a myriad of quantitative metrics to test our findings collected through observation. This process of basic scientific inquiry, when calibrated appropriately, can yield impressively accurate and useful results.

On the Leading (w)Edge, we stress and much prefer this sort of scientific approach using statistics to measure complex systems (in increasingly complex ways, thanks to computers and human ingenuity!), placing our valiant attempts toward improving quality of life under the microscope to be checked and verified/rejected. In other words, for the case of health care, we ask and objectively test the following question: Is our country doing a sufficient job of caring for our population's ailments/needs while simultaneously promoting healthy living standards and behavior?

One question, in one sense being so easy to ask is in another sense incredibly difficult to test with accuracy. Our battalion of public health experts call on an army of metrics to attempt to get to the question's root and uncover a comprehensive sense of our performance (so how m'I doing??). A few of the chief measures, that you'll likely see cited time and again in public health studies and articles covering the matter, and as a result are worth familiarizing yourself with, include: life expectancy, disability-adjusted life expectancy (DALE), health-adjusted life expectancy (HALE), infant mortality, percentage covered by insurance, equitable distribution of resources, cost of health care (% of GDP or per capita), preventable deaths, death due to various illnesses...the list literally goes on, and as you can tell it's a pretty morbid list.

Not all metrics get so technical however. Can you recall having seen this image before at your doctor's office?

If only it were this easy to measure our population's health...image courtesy of NPR
The above image, however amusing, serves to remind us of how difficult it can be to remain objective when measuring a qualitative thing like health or pain. Even though the "pain scale" uses numbers (0-10), it's ultimately up to the patient to decide how much pain they're truly in at that moment. With no universal way of determining our own pain (being it a sample size of one), we resort to pictures and quick descriptions in an effort to attain a true universal scale for pain. Similar to pain, health and quality of life are equally as difficult to measure objectively, though you should note it's not for a lack of trying- as we've seen, unlike pain, we have many metrics at our disposal.

In that same vein, one thing that I will encourage we keep in mind when looking at the following reports on health care performance/outcomes, is that these measures should not to be confused with the actual aim of the measure(!). In other words, the metric is arbitrary (we created it), whereas the actual condition of the system is implicit or independent of our measure. In our case, we could say we're using these metrics to try to quantify the extent to which our people suffer from health complications, the extent to which our health care network helps or hurts (the latter known as quaternary prevention) and the extent to which our people tend to live lives of high quality.

Numerous attempts have been made to measure the quality of health care systems- below I have cherry picked a few of the more widely cited and useful. Since all rankings are not created equal, please be mindful while you peruse.


Without further ado:

World Health Organization's (WHO) The World Health Report 2000 [Full pdf], "the first ever analysis of the world's health systems" [Press Release], surveys and ranks the health systems of 193 of the world's countries and, not without a healthy amount of controversy, serves as the standard for such studies. Which leads me to wonder...what would a 193-step podium look like???



Thanks to the one and only Wikipedia for use of their table!

TOSS-UP: What kind of material would you use to compose the 37th place medal? [Best comment wins a prize!]*

One thing you may have noticed is that there are some tiny nations included in the WHO rankings (with San Marino and Andorra both being populated by less than 100,000 people), begging the question, what if instead of focusing on all 193 countries, we focused exclusively on the 34 countries in the Organization for Economic Cooperation and Development (OECD)- how would the U.S. rank?

Well, let's take a look shall we...


Seemingly an improvement from 37th, but remember in this case a "jump" to 34th would be dead last.

Though still some smaller countries remain, as a quick Google search will show that two of the top 10, Iceland and Luxembourg, have populations well below one million. Given that the U.S. has a population nearly 1000 times that of Iceland, it's fair to say that maybe the latter doesn't serve as the safest companion for the former in this type of study. Luckily, there's a more recent study, this time from the Commonwealth Fund, to which we can turn that focuses on seven major countries: Australia, Canada, Germany, Netherlands, New Zealand, U.K., and U.S. See chart below from their 2010 report.

Save for New Zealand at 4.5 million, all of the other nations have populations greater than 15 million.

[AUS = 22.7 mil, CAN = 34.9 mil, GER = 81.9 mil, NED = 16.8 mil, UK = 63.2 mil, US= 314 mil].

Are you starting to see a pattern here? It appears that no matter what way you cut it, the U.S. has some significant catching up to do if it wants to improve it's system of health and win a seat at the table among the other top tier countries in this regard.

Still not convinced? We turn to an even more recent analysis reported in August of this year (2013) from The Journal of the American Medical Association's (JAMA) titled "The State of the U.S. Health, 1990-2010- Burden of Diseases, Injuries, and Risk Factors" [Abstract], which attempts to measure the relative hardship suffered in each of the 34 OECD countries via a list of illnesses.

As esteemed health policy analyst John McDonough of Harvard School of Public Health noted in his coverage of the JAMA article in his running Boston Globe column "Health Stew", "the U.S. has the highest number of reds and the lowest number of greens of any nation in this selection of nations belonging to the OECD," which in short means we're pretty subpar on most all accounts.

My intent for sharing all of this data and analysis is not to induce an all-out pity party for the U.S. health care system; it's actually quite the opposite. With all the great progress set to be made with the implementation of the ACA (quoted as the most significant piece of federal legislation on health care since the New Deal), it's important to realize that we'll still likely have much more room to improve. And that's OK. With health systems it's not about reaching some ultimate end because there is none; what health systems call for is the need for continuous quality improvement- and as Dr. Donald Berwick will emphasize, this is quite different from quality assessment. I'll leave that one for you to think about.

For all you curious cats out there, feel free to check out the link below for more analysis on global trends in health. Enjoy!

IHME Global Burden of Death Report 2012 - this interactive diagram displays the changes in leading causes and risk factors for death between 1990 and 2010. You can see how each cause and risk rank for the global population or you can choose to select for specific sub-sets of the population based on gender, age range and world region. Additionally, you have the option of selecting what metric you will use for the rankings and exactly how many causes/risks you want to rank. This tool is simply amazing! IHME, standing for The Institute of Health Metrics and Evaluation, is a research center at the University of Washington in Seattle, WA.

*the prize spoken of above need not be anything of material use- i.e. a "shout out" could be awarded and may even be more rewarding!

No comments:

Post a Comment