nos-trum. pronunciation: \nos'-trum\. noun. Etymology: Latin, neuter of noster our, ours.
1. a medicine of secret composition recommended by its preparer but usually without scientific proof of its effectiveness.
2. a usually questionable remedy or scheme.
See here for more discussion.

Wednesday, June 23, 2010

Commonwealth Fund Blasts US Health Care: Helpful, But Subject To Criticism

US comes in last on Commonwealth Fund study of seven countries' health care systems.

There are some good points for the US system, but not many.  You can go here to see an interactive chart of the comparison criteria.

If you examine the study, ask yourself whether the comparisons are valid.  It's not easy to know for sure.

I've written more than once on how the longevity data misinforms as a measure of long and healthy lives:  when you take out death by violence and auto accidents (which are not issues of health care infrastructure or policy), the US moves from 31st to the top in one famous study.  See my post on's analysis here.  FactCheck agrees, but says the violence and auto data should be left in (presumably because it keeps the results where they would like them to be; i.e., the US does poorly).

The same thing applies to data on prematurity and infant mortality, a common comparison made between the US and other countries that shows the US to be lagging behind.  In that instance, several countries do not count certain births as "live" if less than a certain weight, or date of birth, or length--despite the fact that the newborn is breathing and moving.  A couple of countries make no effort to resuscitate the severely premature, and others don't count a living neonate as a live birth until they reach the age at which they would have been born if they reached full term. This allows them to not count those newborns in their mortality data if they don't survive.  This skews prematurity and mortality data in favor of those other countries.  See my post on this.

Quality data can also be misleading because it measures performance on a statistical basis, but says nothing about how individual patients experience their care.  For instance, low infection rates on hip replacements don't tell the story if many people are waiting up to a year to get it done, suffering pain and disability every day.

It's going to take me a week or more to go through all of this report to find out how evenly the authors applied the criteria between the countries' health care systems.  So, more on this later.

But for now, consider just one criterion.  As a hospital CEO, I was always being evaluated on how good my access and quality were.  As you might imagine, budget reviews--whether I was staying on target--were continual.  So I've seen every one of these criteria before, andI  know how people who worked for me, and other hospitals, tried to wicker the data to show they were doing better than they really were.
So, as I say, take one criterion as an example: 
"Percent of primary care practices who report almost all patients who request same- or next-day appointments can get one."
1.  The first dodge is to jinky around when the "day" clock starts.  Is it when the patient first calls, or when you call them back, or does the clock begin at the next business day and run until the second morning  (the Post Office, UPS, and FEDEX all play around with this in claiming 2-day service)?
2.  Is the data on appointing available for review centrally, or is the practice providing the data?  If the latter, this gives them a way to judge whether something meets the criteria (remember our "jobs created or saved database", with the examples of created jobs where current employees just got a raise, but it was reported as new jobs?)
3.  What if someone wants a same-day appointment and you arrange it somewhere else, or through the emergency room, so the data shows they WERE seen same-day (just elsewhere)?
4.  What type of appointments do you have?  Are a lot of people being funneled into 5-minute "refill" appointments so you can crank out the demand, even if some of them would have been better served by a real appointment?
5.  If a same-day appointment is available, but the patient doesn't accept it (they have a conflict, say), does that go into the "criterion not met" category?

The list goes on and on, and given the state of data collection world-wide, I doubt that many of these criteria are fully explored by the Commonwealth Fund's study.  When I was looking into the infant mortality claims, I found that in Canada birth registration data is missing for tens of thousands of births.  I'll hold fire for now.

Caveat:  We have a long way to go in this country to improve access, cost, and quality.  But advocacy group studies need to be examined carefully.  That's what Nostrums is all about:  to peel away the surface of articles and studies that are meant to persuade us.

Doc D

No comments:

Post a Comment


What I'm Reading - Updated 3 May

Blog Archive