INTERNATIONAL/QUALITY: U.S., Canada heart-failure mortality compared

This one’s from last week, but well worth a quick look. A study in the Archives of Internal Medicine compared heart-failure mortality in the U.S. and Canada

Two findings emerged from a recent Archives of Internal Medicine report on heart-failure mortality rates. One affirms the notion that the U.S. is a leader in acute care, but the other finding offers evidence that there’s room for improvement in the management of chronic conditions.The report, which was released Nov. 28, compared 30-day and one-year mortality rates of American and Canadian heart-failure patients measured between 1998 and 2001. The findings: after risk standardization, the 28,521 U.S. Medicare beneficiaries studied had a lower 30-day mortality rate than the 8,180 similarly aged patients at hospitals in Ontario, Canada (8.9% vs. 10.7%), but one-year adjusted mortality rates were essentially the same (32.2% in the U.S. vs. 32.3% in Canada).

So in other words we spend a lot more here and there some short-term benefits, but soon enough the differences disappear (but of course the money is still gone!).  I was struck by this particularly because Vic Fuchs did a study back in the 1980s at Stanford hospital comparing the outcomes of patients admitted to the same hospital by the faculty versus community doctors. Compared to the community doctors the faculty doctors supplied more services and spend more money on patients with similar acuity (i.e. similarly sick patients). And in the short term their patients had better  results, but after several months outcomes were the same. When Fuchs talked to them with the results, both sets of physicians thought that their type of care (i.e. more intensive versus less intensive) was better for the patients.

The health economists, though, amongst us tend to believe that there’s precious little point paying a lot more money to keep very sick people alive slightly longer, when within a year they’re going to be as dead as the rest of them. And that appears to be the way it works in Canada too. Anyone really surprised?  Of course with the Dartmouth data we also know that the same variation is exactly the case between different parts of the US.

6 replies »

  1. Ike is right when it comes to allocating resources out of one public pot.
    The problem is no matter how you divvy them up, it is driven by politics and leaves lots of people unhappy. Witness the current debate on Katrina reconstruction. Or anti-terrorism grants to Wyoming. Or Alaska’s infamous “bridge to nowhere”. Or Soviet-style central planning.
    Of course, healthcare is too fragile to entirely throw to the wolves of the free market. But a private system alongside with a public one is the only way to let off some pressure.

  2. OK. but I remind you all about what Eisenhower said “Every gun that is made, every warship launched, every rocket fired signifies, in the final sense, a theft from those who hunger and are not fed, those who are cold and are not clothed.” Same thing is true for every unneccessary CABG.

  3. theorajones, you nailed it. This is exactly how the right consumer-directed healthcare system should look like:
    1) Universal safety-net baseline, funded by as much as the wisdom / generosity of “health economists” allows
    2) Option for consumers / employers to add as much coverage / services as they want at extra cost
    This would be better than what we have now (uninsured) and better than Canada (government monopoly).

  4. Re: “The health economists, though, amongst us tend to believe that there’s precious little point paying a lot more money to keep very sick people alive slightly longer, when within a year they’re going to be as dead as the rest of them.”
    A little insensitive. If it’s me or my father or my grandfather being kept alive, the time is precious and the point of such care very important. The difference between this approach and the callous they’re-going-to-be-as-dead-as-the-rest-of-them mentality is the difference between individualist and collectivist thinking. The limiting factor should be personal choice and willingness to make tradeoffs for care (with the government appropriately subsidizing incomes to enable such trades for certain people). The limiting factor should not be an economist’s judgement about the value of other people’s lives.

  5. Eh, I guess what I disagree with here is that this is a call the health care economists should be making.
    This data indicates that there is an important question to be asked: do patients want the tradeoff of more intensive (and often more physically painful, degrading and isolating) treatment initially for marginally better short-term results but still be dead in 6 months, or would they rather have a less intensive approach and have a 2% less chance of death the short-term but no less chance of death in the the medium term?
    So, we should be figuring out how to put this question in front of patients (or their decisionmakers) in a way they can understand. We shouldn’t be saying that it’s a great place to save money because we don’t think short-term outcomes are important.
    I’d rather not trade the practice paternalism of physicians for the practice paternalism of healthcare economists–I think it makes a hell of a lot more sense for them to be focusing on the healthcare ROI of various administrative pursuits that our system encourages (patient turfing, market segmentation, etc), because I think that’s the truly “wasteful” spending. Consumer preferences matter, and I think that artificially curtailing those really shouldn’t be looked at until we’ve exhausted every other possibility for cost containment.

  6. Matthew- on a related rationing note- several areas of the UK will no longer be allowing people with a body mass index (BMI) >30 to have hip or knee replacements. A BMI of 30 is the low end for ‘obese’- a condition for which as many as 50% of adults would qualify. The reason- concern for poorer outcomes with greater risk- but, really, budget constraints. Your thoughts?