Is US Health Really th the Best in the World? Barbara Stacia, MD, MPH [NFORMATION CONCERNING THE DEFICIENCIES OF USM comulating, The fact hat more eno health insurance is w ost of the health care system i s to be tolerated unde: from more expensive es indicating that 2 ranyas 10% to 30% of patien:sreceive contraindicated cae! In addition, with the release ofthe Institute of Medicine (OM) report “To Err Is Human," millions of Americans learned, fo the first time, that an estimated 44000 to 98009 among them die each year asa result of medical errors The fact is that the US population does not have any- where nea the best the world. OF 13 co ed States ranks com) for 16 avail Sweden, Canada, France, Ausra Spin, Finland the rlands. the United Kingdom, Denmark, Belgium, the United ‘Sates, and Germany. Rankings of the United Staces on the seperate indicators? are * 13th (last) for low-birth-weight percentages + 13th for neonatal morality and infant mortaiy overall + 1th for posineonatal moruality + 13ch for years of potential life lost (excluding ext 1 year for femaks, 12th for mal at 15 years for females, 40 years for females Sth for males SSyears for females, 7th for males + rc forlife expectancy at 60 years for females, 3ed for males + 10th for age-adjusted morality The poor performance of the United States was recenty ‘confirmed by the World Health Organization, which used different indicators. Using data on disability-adjusted life expectancy, child survival to age 5 years, experiences with the health care system, disparities across social groups in experiences wi care system, and equal iy curol-pock sures for health care (regardless report ranked the United S countries *T ‘res regarding the poor pesition ofthe United States in heal worldwide mast and not dependent on the pa ‘measures used. Common explanations for this poor perfor ‘mance fail to implicate the health system. The percep: the American public “behaves badly” by smo} ed perpetrating violence. The data show ot ted Sins rons ith best Thus, although baccouse and alcohol use in excess are clearly harmful to health, they dio not aceount for the relatively poor pestion of the United es on these health indicators. The data on years of po- exclude external causes associaced with deaths 13 industrialized countries.” ‘The real explanation for relatively poor health in the United States is undoubtedly complex and multifactorial. From 2 health system viewpoint Ii possible thatthe historic fll ted with primary care performance 2 top of the average health ranking. fis of access accrues only whe I pt of primary care? The health care system also m contribute to poor health through its adverse effects. For example, US estimates!” of the combined effect of errors and adverse effects that occur because of fatrogentc dam: age not associated with recognizable error include: ‘= 12000 deathstyear from unnecessary su deathsyear from mediCOMMENTARY + 8000 hospitals 106000 deaths/yeer from nonerror, adverse effects ‘These total to 225000 deaths per year from iatrogenic causes, Three caveats should be noted. First, most of the dats are derived from studies in hospitalized petients. Second, hese estimates are for deaths only and do not include ad- verse effects that are associated with disability or discom- fort. Third, the estimates of death due to ertor are lower than 105¢ in the 1OM report! Ifthe higher estimates are used, he deaths ine to‘atrogenic causes would range from 250000 0 284200. In any case, 225000 deaths per year constitute third leading cause of death in the United State, ef deaths from heart disease and seneer. Even if these figures are overestimated, there is a wide margin herween these nam bers of deaths and the next leading cause of death (cere- brovascular disease) Oneanalysis overcomes some of these limitstion: by 2 tingadverse effects in outpatient care and including ad- se effects other than death." It concluded that becween sand 18% of consecutive patients experience adverse ef fn owrpatiens settings, with 116 million extes physi 77 million extra prescriptions, 17 milion emer- gency department visits, 8 millfon hospitalizations, 3 million long-term admissions, 199000 additional deaths, and billionin extra costs (equivalent tothe aggregate cos of patients with diabetes). jother possible contributor to the poor the United States on health indicators isthe high degree of| income inequality in this country. An extensive literarure documents the enduring adverse effects of low socioeco- tion on health; newer and accumulating ture suggests the adverse effects not only of low social po- sition but. especially, low relative social position in industrialized countries. Among the 13 countries in ded in the international comparison mentioned above, theUSposition on income inequality is llth (third worst) s ton inceme equality (when income es and including social transfers), mich ing its high position for health indicators. There is an iim perfect relationship beween rankings on income inequal ty and health, although the United Satesisthe only co ina poor position on both (B.S., unpublished da: Anintriguing aspect of the data isthe differences for the differene age groups. US chil deaths/year from nosocomial infections in Judging from the data on life expeciancyatdffeeatages the US population becomes less disadvantaged as ito but even the relatively advantaged position of sons in the United States is slipping. Tae US relat tion for life expectancy in the oldest age group was bet {nthe 19806 thenin the 1990s, The long-enisting pocr rane ingofthe United States wih regard toinfantmariality “has been a cause for concern: itis nota result of the high per 9e su4a, jy 25, 200061 266,50. ¢ tages low birth weight end infant mortality among the black population, because the international ranking hardly changes when date for the white population only are used Whereas definitive explanstions for the elatively pocr po. sition of the United States continue to be elusive, there se slffcient hints as to their nacure to provide the basis consideration of neglected factors: (2) The nanue and operation of the health care system, Jn the United States, in contrast to many other countries, the extent to which receipt of services ftom primary care physicians vs specialists affects overall healeh and survival has not been considered. While available data indicate thet specialty care isassociated with better quality of care for spe- fic conditions in the purview of dhe specialist the data con general medical care suggest otherwise. National sur voysalmoast al fall to obzain data on the extent to which the cate received fulfils the criteria for primary care. soit is not possitle to examine the relationships beoween individual and community heelth characteristics and the type of ear (2) The relationship between tatrogentc effects (inclu ing both error and nonerror adverse events) and «ype of care received. The results of international surveys dogument high availability of technology in the United Seales. Among 29 countres, che Uniied States is second only to Japan in availabilty of magnetic resonance imaging unttsand com puted tomography scanners per million population.” Ja- Dan, however, ranks highest on health, whereas the Uni States ranks among the lowest. 1 is possible that the high of technology in Japan is limited ts diagnostic tecknol- ogy not matched by high rates of treatment, whereas in the United States, high use of diz linked tothe “ca of employees per bed full-time equivalents) in Scates is highestamong the countries ranked. whereas they are very low in Japan'”~far lower than can be accounted for bby the common practice of having family members rather al stall provide the amenities of hospi use of death and outpatient diagnoses does not facilitate an understanding of the extent 0 which fatrogenic causes of health are operative. Consistent ust (of E” codes (extemal causes of injury and poisoning) would ‘raprove the likelihood of their recognition becanse these ICD (international Classification of Diseases) codes permit attribution of eause of effec: to “Drugs, Medicinal, and Bic logical Substances Causing Adverse Effects in Therapeutic Use.” More consistent use of codes for “Comphcations of Surgical end Medical Cere” (ICD codes 950-979 and 986- (999) might improve the recognition of the magnitude of th effect; currently, most deaths resulting from these und! Iying causes are likely ro be coded according to the imme- diace cause of death (such as organ failure). The sugges: tone of the IOM document on maadstory reporting of adverse eflects might improve reporting in hospital setfor ited sich wuld Bio- ale sof 196. her jer sof tings, but it is unlikely ro allect underreporting of adverse events in noninstitutional setings Only berter record keer ing, with documentation ofall intervenuions and resultin, health status (including symptoms and signs), is likely t improve the current ability to understand both the adverse and positive effects of health care. G) The relationships among income inequality, social dis advantage, and characteristics of health systems, including therelative contributions of primary eare and cave ing physician-to-papulation ratios (as proxy for unavailable data on actual receipt of health scr viees according to their type) have chown chat the higher the primary care physician-to-population ratio in a siate, health outcomesare.™ The influence o cialty physician-to-population ratios and of sp primary care physician ratios has not been ade ‘ed, bur preliminary and retatively superficial anal the converse may be the case. Inclusion of equality variables in the analysis does not liminate the posi- liveeffeer ofprimary care Furthermore, states thathave mor equitable distributions of incomealso are more likely to have Detter primary care resource availability, thus raising ques- Honsabout therelationshipsamongahosto! social and policy characteristics that determine what and hor sources are avallable Recognition of the harmful effects of health ventions, and the likely possibility that they accou substantial proportion af the excess ceaths in the United States compared with other compar Hons, sheds new light on imperatives for research an: special EDITORIAL ‘COMMENTARVEDITORIAT -¢ explanations for these realities deserve intensive exploration, ieee, Toms woman Burg Stereath fon OC Nabend cada Pes 1699. Usberay Pres 1098 75 2000 5 trl Cnptsoso! aeons in Me. & dN, Wey nea disease moray istow in aie ste Cries ong Annu Ree Pub het slog tendon elas, Gunnte la neers leslave spins JCan ton ti Sex and Cyberspace—Virtual Networks Leading to High- Risk : Sex Kathlecn E Toomey. MD.MPH Richard B. Rothenberg, MD \N ADDITION TO 175 POWER AND REACH FOR RAFIO ‘mation exchange, the Internet has generated a new-de- bate: does it fundamentally change the way we lead om lives? That the Intemet has revolutionized commun: cations and business practices worldwide is clearly recog: nized, That the Internet may have some paychological ef fects on individual behavior, molded perhaps by the See also pp 443 and 447, ology isl has now been notsd.N iy described be al disorders possibly linked to Internet use include Internet-related depression'? and cybersex addiction.” Re- rts have suggested that fully one third of adult ln- ts are directed to sexually ariented Web sites, chet and news groups," where Internet users ean ob- sual images o1 participate in online sexual discu: Ben $76, Ais, Ca 38905 5082 (em ke JINR, uy 26,2000