WSJ Editorial on Liver Transplants Cherry-Picks the Numbers

Dr. Scott Gottlieb, a resident fellow at the conservative American Enterprise Institute, published an op-ed in the Wall Street Journal last week that returned to the much-exploited story of Nataline Sarkisyan, the 17-year-old Californian who died before receiving a liver transplant. Gottlieb used the story to make the argument that “the U.S. has the best health care in the world.”

Gottlieb is squaring off against John Edwards, who has been suggesting that if Nataline had lived in a European country she might have lived.  Edwards blames CIGNA, her for-profit insurer, for refusing to cover the procedure. Dr.  Gottlieb, who is a former FDA official, responds with a double-barreled argument: “Americans are more likely than Europeans to get an organ transplant, and more likely to survive it too.”  He sounds confident, and at first glance, his argument seems persuasive.

But a closer look reveals that Gottlieb makes his case by carefully culling the numbers that fit his argument, while omitting those that don’t. Unfortunately, too many people involved in the healthcare debate play fast and loose with the facts. Everyone interested in reform should be on the look-out for those who don’t cite solid evidence for their assertions. If they don’t give you their source, it may be because they don’t want you to look it up—and because they realize that they are cherry-picking the numbers.

Before engaging Gottlieb’s argument, I should acknowledge that, as I have said in an earlier post, I think Edwards has picked a bad case to make his argument for healthcare reform. I am not at all certain that the transplant would have helped this particular patient.  And while Edwards puts all of the blame on CIGNA, Nataline’s insurer, I am bothered by the fact that the hospital asked for a $75,000 down payment on the surgery and then refused to go forward without it. As one physician/blogger from the very same hospital where Nataline was treated asked: “Why didn’t the hospital simply perform the surgery and defer payment from the family or CIGNA [Nataline’s insurer] until later? If it was such a great idea, why didn’t they exhibit the outrage and strength of conviction to go ahead regardless of CIGNA’s assessment?”

That said, I agree with Edwards and other proponents of health care reform that, in other countries, decisions about whether or not to pay for expensive procedures like transplants are not based on whether the patient has the money or the insurance to pay for the operation. Instead, in other developed countries, such decisions turn on whether the benefits of the treatment outweigh the risks—and whether the procedure is cost-effective.

After all, in every country (including the U.S), we all pay for high-priced procedures, either in the form of spiraling insurance premiums or steeper taxes.  Thus, it makes sense to ask: “if we go ahead with this procedure, are we wasting resources on a futile treatment, or using money that could be used for the preventive care that would extend other lives?

Following this line of thinking, European countries put more money into preventive care and are less likely to give liver transplants to patients who are seriously ill—or appear close to death.  Gottleib himself points out that a 2004 study published in Liver Transplantation shows that “no transplant patients in the U.K. were in intensive care before transplantation, one marker for how sick patients are, compared with 19.3% of recipients in the U.S. . . . On the whole,” he notes, “the U.S. also performs more transplants per capita, giving patients better odds of getting new organs…In 2002… U.S. doctors performed 18.5 liver transplants per one million Americans. This is significantly more than in the U.K. or in single-payer France, which performed 4.6 per million citizens, or in Canada, which performed 10 per million.”

But– is the fact that we perform more transplants on sicker patients proof that we have a superior healthcare system?

Here, let me acknowledge that Dr. Gottlieb is generally more enthusiastic about experimental, long-odds medical treatments than I am. As the Seattle Times pointed out, when Gottlieb was appointed to  a  high-powered job at the FDA in 2005,  he came to the agency from Wall Street, where he “promoted hot biotech stocks to investors. Now Gottlieb holds the No. 2 job at the federal agency . . . that approves new drugs, oversees their safety and affects the fortunes of companies he once touted. Wall Street likes the appointment of Gottlieb, 33, who believes in faster drug approval and fewer news-release warnings to the public about potential side effects of drug,” the Seattle paper observed. “But some medical experts are shocked by his July 29 appointment, coming at a time when the public is increasingly concerned about the safety of popular medicines.”  (When Gottlieb left the FDA he returned to the American Enterprise Institute and started the Forbes / Gottlieb Medical Technology Report.)

Returning to my question: Is the fact that we perform a greater number of transplants on seriously ill patients reason to claim that U.S. health care is “superior”—or does it simply mean that we are more inclined to experiment on our sickest patients?

It all depends on how well the average patient who is plucked out of the ICU to undergo a liver transplant fares.  If he or she goes on to enjoy several years of high quality life, one would be inclined to say “yes”—our more aggressive care equals better care.   But if too many patients suffer complications and then die in great pain twelve or 15 months later, it would be much harder to argue that “doing more” makes U.S. healthcare “better”—especially when both the money and the liver could have been spent on another patient who had a better chance of surviving.

Gottlieb realizes that everything hinges on outcomes. And so he points to “one recent study” which  “found that patients’ five-year mortality after transplants for acute liver failure, the type from which Ms. Sarkisyan presumably suffered, was about 5% higher in the U.K. and Ireland than the U.S. ”  Moreover, he observes, “the same study also found that in the period right after surgery, death rates were as much as 27% higher in the U.K. and Ireland than in the U.S., although differences in longer-term outcomes equilibrated once patients survived the first year of their transplant.”

Wait a minute—what is he saying in the last part of that final sentence: “differences in longer-term outcomes equilibrated once patients survived the first year?”

“Equilibrated” is a not a verb I would normally choose to use. It’s just one of those very ugly words that fairly bristle on the page; you know there must be a simpler, clearer way to say whatever you are trying to say. And indeed there is. “Equilibrated” means “came into equilibrium” or “canceled each other out.”  In other words, Gottlieb seems to be saying, once patients survived the first year, the differences between outcomes in the U.K. and the U.S. disappeared.

When people use $10 words that are hard on the ear, I become suspicious that they they’re trying to hide behind jargon. I also was bothered that Dr. Gottleib didn’t name the journal where the outcomes study was published.  In the preceding paragraph where he talked about how many more liver transplants the U.S. does, he did cite his source (“a study published in 2004 in the journal Liver Transplantation.”) Why didn’t he name his source when contrasting outcomes?

I decided to do a little research. It turns out that Gottlieb is referring to research that appeared in GUT online, a journal published by BMJ (formerly the British Medical Journal), on March 13, 2007 comparing survival rates for transplant patients in the U.K/Ireland to outcomes for patients in the U.S. (Patients in the two groups were similar in term so age, gender and race and the comparisons adjusted for risk.)

By reading the study I discovered what Gottlieb had left out. First, the researchers looked at how the patients were doing at three points in time: during the 90 days immediately following the transplant, one year after the transplant, and five years after the transplant. Secondly, they followed patients suffering from two types of disease: chronic liver disease and acute liver disease.

Begin with how the patients were faring during the first 90 days. As Gottlieb points out, during this time, mortality rates in the U.S. were lower (regardless of whether patients had originally suffered from acute or chronic liver diseases.) This is, in large part, the article suggests, due to lower nurse/patient ratios in the U.S. and more intensive care during the first weeks following surgery.

But what Gottlieb omits is the crucial fact that, when the researchers went back and  looked at “patients who survived the first post-transplant year,” they discovered that  “patients who had suffered from chronic liver disease in the U.K. and Ireland had a lower overall risk-adjusted mortality” than patients in the U.S.  In other words, survival rates for patients who had a chronic disease before the transplant  were better in the U.K. and Ireland. As for patients suffering from acute liver disease, longer-term survival rates past one year were just as good in the U.K. and Ireland as in the U.S. Moreover, if you checked patients in the interval between 90 days and one year, outcomes were similar in the two health care systems.

So “equilibrated” wasn’t just a dodgy piece of jargon; it was inaccurate. When researchers checked on  patients more than a year after they had the transplant, outcomes in the U.K/Ireland and the U.S. weren’t in perfect balance (or in equilibrium) with results in the U.S.  Outcomes in the U.K./Ireland were just as good for one group and decidedly better for the second —assuming that if you go through the trauma of a liver transplant, the outcome you are hoping for is to live more than a year, rather than just 90 days.

Why is chronic care better in the U.K. in the years following surgery? Because the “primary care infrastructure” is stronger in the U.K. and Ireland, the article explains. Add in the fact that patients have “equal access” to health care and that the cost of care is “lower,” and this helps explain superior long-term results.  As the researchers point out, “the 2002 Commonwealth Fund International Health Policy Survey found that sicker adults in the US are far more likely than those in the UK to forgo medical care and fail to comply with recommended follow-up and treatment because of costs. In the U.S., it seems, outcomes tend to turn on whether the patient has money.

Finally, what about outcomes after five years? What Gottlieb forgot to mention is that survival rates for patients who had originally suffered from chronic liver disease were similar in the two countries, while mortality rates for patients suffering from acute liver disease were higher in the U.K. and Ireland.

But when summing up their findings, the researchers underlined the importance of survival rates during the first 90 days and after one year. “These results highlight interesting differences between two health systems funded by entirely different mechanisms,” one of the report’s authors told Reuters Health. “A predominantly privately funded healthcare system, such as the one in the United States, was demonstrated to have a better short-term outcome for liver transplantation, but a system of universal publicly funded healthcare, as in the U.K. had a better outcome after the first post-transplant year.”

“Our results therefore could have important implications for health policymakers in those countries and beyond,” he concluded.

Maggie Mahar is an award winning journalist and author. A frequent contributor to THCB, her work has appeared in the New York Times, Barron’s and Institutional Investor. She is the author of  “Money-Driven Medicine: The Real Reason Why Healthcare Costs So Much,” an examination of the economic forces driving the health care system. A fellow at the Century Foundation, Maggie is also the author the increasingly influential HealthBeat blog, one of our favorite health care reads, where this piece first appeared.

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12 replies »

  1. Dr Bipin Vibhute and team offers all kind of liver treatments in all over India. He is currently a senior consultant & Hepato-Pancreatic and Biliary (HPB) Oncosurgeon at the Sahyadri group of hospitals in Pune. He has great experience in liver transplantation. He has performed more than 600 liver transplant in India.

    Now Dr Bipin Vibhute is providing liver transplant in India. He has 20 years of experience in liver transplant, completed more than 600 liver transplant surgeries across India, completed successfully 250 liver transplant as a primary surgeon, completed more than 100 liver transplant in India in one and half year. For more information please go to http://www.livertransplantpune.com/liver-transplant-india/

  2. At what age do we say dialysis (or another such effective and proven treatment) should no longer be paid for? It then becomes a financial question of what Medicare can afford (or what taxpayers will support). Inevitably, ethical questions/concerns arise as value judgments are assigned as to what is worthwhile or “cost-effective” and what is not.
    Should we tell all men: “Don’t bother getting your prostate cancer treated, even though the annual death rate from metastatic prostate cancer is 27,000 per year, and a randomized trial from Scandinavia shows an overall survival benefit of treatment versus observation at 10 years out?” (reference Bill-Axelson A, et.al.,NEJM, 2005, 352(19):1977-84)
    Patient choice still has to be respected, but on the other hand patient/consumer/citizen “rights” to healthcare are not unbridled. (The “right” to healthcare indeed is worthy of an explicit definition.)
    NHS in England certainly does not give British citizens access to many of the newer (effective and proven) targeted chemotherapy agents such as Avastin for breast cancer. To make matters worse, NHS will not even allow patients to buy Avastin on their own, or else risk losing NHS coverage for the rest of their cancer treatment altogether. (Link below)

  3. jms–
    I think Medicare should refuse to cover ineffective and unproven treatments (except, of course, Medicare should cover unproven treatmetns in clinical trials. But those clnical trials should be being overseen by reserachers who have no financial stake in the outcome.

    ” .. This leads many observers to suspect that the difference might be that they have a better health care system which emphasizes preventive care and offers equal access to all, rich or poor ..”
    This leads many observers to suspect that politics cognitively frames perception and might be behind theoretical thinking that posits unlimited spending will change people’s behavior and improve their health.
    It is like those who have their stomachs stapled. Five years later, a significant percentage are still overweight.
    Of course, people should not excessively eat, drink alcohol, smoke, couch-potato, etc. That is obvious.
    But they do. Whose problem is that? Who is doing the enabling?
    Thoughtless, aimless, and reckless spending never solves anything. Except bankrupt the working class.

  5. First– Thank you all for your comments:
    Rick and rbaer– I think palliative care really is the answer to many of the grasping-for-straw-after-the–straw procedures that we do. Palliative care specialists are very good at talking to patients and families, compassionately and realistically, about what their options are–and the likely outcomes. They are also very good at talking to surgeons who have been trained to “do everything possible” and who often want to go back in after a surgery (like Nataline’s bone marrow transplant) goes sour. They feel terrible–and want to try to make it right.
    But that may not be possible, and may not be what is best for the patient.
    Palliative care specailists sometimes act as the patient’s advocate–explaining to the doctor (and sometimes part of the family) that the patient really doesn’t want yet another procedure.
    Why don’t we have more palliative care in our hospitals? (You find many more of these specailists in the U.K. and other European countries.) Because, like primary care docs, or others who practice cognitive medicine (talking to and listening to the patient), they are not very well paid. Students emerging from our med schools with $150,000 or more in loans are often reluctant to go into a specialty where they know they will have a hard time paying off the loans, buying a home, having kids, etc.
    I’d urge Medicare to increase what it pays palliative care specialists along with other “generalists” while lowering reimbursements for some of the most aggressive procedures–particuarly in areas where we know we do too many procedures.
    Barry– You write: ” I’m a sick patient who could potentially benefit from a liver transplant, the two most relevant questions in comparing healthcare systems as it relates to this issue are (1) did I get a liver transplant or not and (2) am I alive five years later or not? On both metrics, it appears that I would be better off in the U.S., at least if I have insurance. Whether the cost of the operation was money well spent from the system’s perspective is a separate issue and discussion.”
    First you would be better off in the U.S. only if you had one type of liver disease. If you had the other type, it makes no difference. And the chances that you would die between 1 year after the transplant and five years are greater in the U.S.
    More importantly, saying that “whether or not the cost of the operation was money well spent from Society’s Perspective is a
    separate issue” makes it clear that you see “me” and “we” as two distinct groups.
    But the fact is that you that you are part of “we.” We all pay for everyone else’s procedures in the form of higher insurance premiums, higher Medicare deductibles, higher taxes. In order to make ethical decisions about how our society’s resources are going to be allocated, we have to ask ourselves: “If I was about to be born and didn’t know where I was going to land in society–rich or poor, sick or healthy–what would I think would be a fair distribution of resources?”
    Last Friday the Happy Hospitalist posted an excellent piece titled “Turning me into we.” Kevin MD thought it was the best healthcare post of the week, and I agree. You should take a look at it. http://thehappyhospitalist.blogspot.com/2008/01/turning-me-into-we.html
    All of the “me” thinking is at the root of what is wrong with our health care system. In other countries, people think collectively because their is more solidarity. They realize that their neighbor’s health is as important as their own.
    As for comparative effectiveness reserach,
    Bev is right.
    Bev– I agree, the CBO paper is excellent–and, as you point out, it doesn’t say that we can’t do anything for 10 years. There is already a lot of data out there which suggests that we’re doing things that aren’t effective. Start with PSA tests for early-stage prostate cancer. And all of the treatments (surgery and radiation) for early stage prostate cancer. The National Cancer Society says that there is no evidence that the testing and treatment in any way “alters the course of the disease.” The American Cancer Society doesn’t recommend it.
    Based on that evidence, other countires don’t pay for it. Why do we? Because the Academy of Urologists still favor these procedures, and they have a lobby.
    People could still have these tests and procedures if they want to pay for them, but lacking evidence there is no reason for Medicare (or private insurers) to pay for them.
    This is only the beginning of a fairly long list. Places like the Mayo Clinic have formularies of drugs they use–leaving out certain drugs that they never or only rarely use because their data shows these drugs are more expensive but no more effective–and may be risky. They stopped using Vioxx for most patients two or three years before Merck was forced to take it off the market. The VA and Kaiser also stopped using Vioxx.
    If Medicare looked at the data the VA, Kaiser, and the Mayo Clinic have they could begin excluding many over-priced and no-more-effective drugs and devices. (artifical knees made especially for women, for example, which I have written about on http://www.healthbeatblog.org.
    As Don Berwick of IHI points out, suppliers of equipment, drugs and services must “cease making profit on complexity.”
    Bev, I also agree that Medicare needs to look at cost-effectiveness and dialysis would be a good place to start. When I think of long-term dialysis for the elderly, always think of that book “Mama Would Be Better Off Dead.”
    Finally, with more research we will find that things that are not effective today might be effective tomorrow. For example, I have misgivings about Gardasil –the “vaccine” for cervical cancer that stops only 70% of the viruses that cause cervical cancer and was fast-tracked through the FDA when Merck needed a new sream of income to replace Vioxx. (Vioxx was also “fast-tracked.) We don’t know what the long-term risks of Garadsil might be for very young girls. And some researachers are worried that if girls think they are “vaccinated” they will stop going for Pap Smears–which discover close to 100% of all cases of cervical cancer . . .
    This is a case where we should certainly continue the research. Being able to stop 70% of the viruses is a major breakthrough–though I don’t know that means the vaccine is ready for primetime. In other words, I’m very uneasy that some states are requiring it unless parents object.
    . If we could continue developing the drug so that it eventually it stopped 100% or 99% of the viruses that cause the cancer that would be incredible. But I’m not sure we should be mandating Gardasil for all 12 to 13-year-old girls–or requiring states to pay for it.
    Russ– how is the U.K. like the U.S.? In many ways, it isn’t. Caucasians in the U.K. are much healthier than Caucasians in the U.S. A year or so ago a major study was done looking at both wealthy and lower-income white people in both countries, and the reserachers found that wealthier people were healthier (no surprise). They also found that wealthy white Americans were only as healthy as low-income white British people.
    Why? They couldn’t figure that out. We’re more obsese, but they smoke more. Drinking is about equal in both countries. Maybe it’s because life in the U.S. is more stressful, they said. But could it be that much more stressful?
    This leads many observers to suspect that the difference might be that they have a better health care system which emphasizes preventive care and offers equal access to all, rich or poor.
    Peter–if we go to a system that emphasizes cost-effectiveness, most of the decisions would not be made
    at the bedside by either the doctor or the hospital.
    The CBO and the three leading Democratic candidates all envision a “comparative effectiveness institute” (probably connected to the NIH) where panels of physicians, medical ethicists, etc. draw up guidelines for best practice which would include guidelines as to how sick a patient could be and still be a good candidate for a liver transplant.
    Because every case is different, these guidelines couldn’t be hard and fast rules, but hostpitals and doctors would be expected to follow them as “best practice” guidelines most of the time. If, over time, a hospital was making a large number of exceptions, Medicare would ask more questions about their patient outcomes and whether they patients were benefiting from the procedures.
    Finally, I agree that global budgets (say for hospitals in a particular region) can also be helpful in getting people to be more aware of costs and trade-offs. If you spend the money one way, you can’t spend it on something else.

  6. If we do go to a system of cost verse value then how will we administer it? From the doctor level, the hospital level? If you think John Edwards uses improper cases to make a political point then wait until we expect docs and hospitals to make those decisions. I think as long as docs and hospitals make more money with more interventions then they won’t take any chances on public outcry from trying to give grandpa another month with loved ones.
    If we had a single-pay system with actual budget limits then hosptials would be more likely to try and educate patients and their families when these decisions are necessary. At least for the non-marginal and clear cut decisions we could save some money.
    What makes me laugh is if the Nataline Sarkisyan case were brought up as happening in Canada then the American Enterprise types would be calling it an example of what Americans could expect from the scourge of socialized medicine.

  7. Barry, thanks for finding that CBO paper; it is a great one! I believe it is very well researched and does a good job of considering all the options. I did not come away from it quite as pessimistic as you did, however. It is the prospective randomized clinical trials which will take the longest and cost the most, hence the 10 year benefit estimate. However, there is a great deal of data already out there which could be systematically mined with meta-analysis and other techniques to provide some useful information sooner. Also, one has to start SOMEWHERE, even if only our kids receive the major benefit.
    As far as Medicare considering cost benefit analysis, I think it is pretty clear that they will need that power. Such power may have prevented the untold millions we have already wasted on Medicare having agreed in the ’70’s to pay for dialysis for all comers, even if you’re 105 years old – in fact, that would be the first cost benefit analysis I would recommend they undertake.
    As for liver transplants, please see my comment to Matthew’s previous post regarding Maggie and Mr. Gottleib, to the effect that non-emergency liver transplantation is becoming more and more an acceptable routine treatment thanks to ongoing research. As another example, I trained during the days when chemotherapy for cancer got, at best, a 20% response rate, almost all kids who got cancer were dying from it, and look where we are now in about 30 years – some adult cancers are curable with chemotherapy, and a substantial majority of childhood cancers are cured. Research really does work, we just have to do it more efficiently and give it time.

  8. Once thousands of “academic” studies are read, a hard question is asked —
    How the heck is the U.K. like the U.S.?
    Population? Weather? Size? MD salaries? MD unions? Any of 100,000,000 other v’bles?
    BTW, madam — which medical school did you and Matthew attend?
    Was it the medical school with the unlimited amount of taxpayer money?
    That medical school with the unlimited amount of taxpayer money should buy advertising here. It would be popular with everyone, I’m sure.

  9. Maggie,
    If I’m a sick patient who could potentially benefit from a liver transplant, the two most relevant questions in comparing healthcare systems as it relates to this issue are (1) did I get a liver transplant or not and (2) am I alive five years later or not? On both metrics, it appears that I would be better off in the U.S., at least if I have insurance. Whether the cost of the operation was money well spent from the system’s perspective is a separate issue and discussion.
    On the issue of value or money, including comparative effectiveness research, I was not encouraged after reading this paper recently published by the CBO. After 42 years in business, Medicare is generally still not allowed to take cost into account when deciding what treatments, drugs and devices to cover. Despite what MedPAC may want, it is likely to take legislation to change that. Even if CMS gets the legislative changes, the CBO suggests that any comparative effectiveness research effort is likely to take at least a decade to bear fruit and is likely to cost more money than it saves in the short to intermediate term.

  10. As long as many, if not most US middle- and upper class citizens are overly fascinated by high tech medicine, and also most of them tend to grasp for the straw AFTER the last straw, we will have too many costly high risk procedures without solid benefit. Maybe the AMA should do a campaign: “Even today, we can’t achieve everything and often know sh… about a particular disease”, just to set expectations straight.

  11. What this story reinforces the notion that we don’t do end-of-life care and decision-making very well in the U.S. Scott Gottleib’s assertion that “Americans are more likely than Europeans to get an organ transplant,” certainly appears to be true. What he fails to say is that that might not be a good thing.
    If so many of those transplant patients don’t even live a year after the procedure, perhaps palliative care would have been the better choice for them, rather than extending their lives, painfully and unnecessarily, for such a short time.