• How do we rate the quality of the US health care system – Available Technology

    If you haven’t read the introduction, go back and read it now.  That introductory post also includes links to all the posts in this series on how we can rate the quality of the US health care system.  Each of these pieces will discuss another way to look at quality, and how the US compares to comparable countries in that domain.

    One way to measure quality, at least to some, is to note how much technology is available.  The thinking is that more technology means more advances, or at least better outcomes.  In other words, better health care systems have more technology.  So measures of a system’s technology are metrics that can be used to measure quality.

    For each of these, I will present OECD data on the G8 countries, without the Russian Federation, which does not submit comparative data.  I present the G8 countries because of all countries, these are the ones whose relative wealth and standing in the world should make them most likely to compete with us.  And, for each of these measurements, I will present all available data from 1990 onwards, lest you accuse me of cherry picking a year.  To make it easy to read these graphs, when I am making charts from OECD data, I will always make the United States a nice red line.  I should note, up front, that data on these topics are not as complete as others.  I will show you everything I could find, though.

    Let’s start with CT scanners.  These devices are used to look at the body in ways that x-rays often can’t.  They got a lot of press when Oprah started recommending full body CT scans.  I don’t recommend those, but CT scanners are important, and useful devices.  Do we have a lot of them?

    We do.  In fact, we have more, per million people, than almost any other country in the world.  Japan, however, makes us look deficient.  They have about three times as many as we do.  To be honest, I have no idea why.

    How about MRI machines?  These scanners are even more advanced (and more expensive) than CT scanners.  Do we have many of them?

    Once again, we do.  More than almost all other countries, yet fewer than Japan.  They sure do like their scanners in Japan.

    But diagnosis isn’t the only technology that is important to people.  Access to high-tech procedures is considered a metric of quality as well.  So let’s look at many of those, specifically transplants.

    We’ll go in in alphabetical order, starting with bone marrow transplants:

    Well, we’re not the worst, but not the best either.  Middle of the road here.  I should note that Japan is down at the bottom.  Maybe that’s because they spent too much on scanners, or maybe they choose to treat patients in other ways.

    How about heart transplants?

    We are number one here.  We do more heart transplants per 100,000 people than any comparable country.  The differences aren’t huge at a population level, but to those that receive new hearts, the difference may be life saving.

    Kidney transplants:

    We are solidly number one here.  More kidney transplants are performed in the United States per 100,000 people than in any comparable country.  For people on dialysis, this can be a life saving, or massively life improving procedure.

    Finally, how about liver transplants?

    As with other solid organ transplants, you are more likely to get one in the United States than comparable countries.  Score for the US.

    I feel compelled to present one more metric.  One of the common memes presented about the US compared to other countries is that people who need dialysis may see it withheld because of rationing.  So you’d expect to see much higher rates of dialysis in the US than in other countries:

    There are far more patients on dialysis per 100,000 in Japan than in any of the other countries; this may be because of their low rates of kidney transplants.  But the US uses dialysis more commonly than the rest of the G8 countries.  This doesn’t mean rationing is necessarily occurring, but it does mean that dialysis is less common in those other countries.

    So, overall, the United States is a great place to be with respect to both scanning technology and for high tech interventions, like transplants.  If that’s where you measurement of quality ends, then we do look really great.

    More importantly, however, does this technology translate into better outcomes?  More on that tomorrow.

    Here’s the second scorecard:

    And here’s the running total for the series:

    A further explanation of these charts can be found here.

    • “But the US uses dialysis more commonly than the rest of the G8 countries.”

      Does higher usage translate into “better?”

      For example, the dialysis usage… is that because a health care system is better able to provide the serivce, or because the service is more in demand because of poorer health, possibly due to limitations elsewhere in the system?

    • @Ken Hamer

      I don’t necessarily disagree with you. I’d similarly say having more CT or MRI scanners doesn’t necessarily mean the system is better.

      But this is how some people define quality, and I am really trying to give a breadth of measures. If you care about the availability of technology, the US is pretty good.

      Disease Care, which is tomorrow, is a harder outcome.

      • @Ken, Aaron – Part of the challenge here is that “quality” is not and cannot be defined in as precise a degree as “spending.” Perhaps it would be more accurate to view the “quality” series as really addressing the question, “What do we get for what we spend?” Getting more per dollar is, in a narrow sense, a better value. That is not the same thing as saying it implies better health.

    • Question as this relates to cost — were transplant surgeries and follow-up sequelae considered in the column on cost of technology in health care?

    • In my conversations with doctors regarding the health care challenge, we will go jovially round and round in circles on why costs are high, what could be changed, and whether or not malpractice insurance is a big factor — but when quality is comes up, they put their feet down. They dismiss my cross-populational statistics (like those mentioned in the Population post), and maintain that in terms of top care, the United States is still the place to be. If your daughter is sick or injured, they argue, it is the top care metrics that you are looking at, not the national averages. And the best care, they argue, is in the United States. This argument seems to me to be anecdotal, but I am wondering if there is any statistical backing for it…. Have you heard this before?

    • re: CT’s and MRI’s, according to the National Imaging Association, 1 in 3 tests paid for by Medicare are unnecessary ); worth pointing out…

      also, related, have you guys checked out Capretta’s, “What’s Ailing Health Care?” He references some interesting research from Arnold Kling from, “Crisis of Abundance: Rethinking How We Pay for Health Care.”

    • T.R. Reid talked a bit about the Japanese in his book. They are pretty obsessive about getting CT scans. There was high demand form patients for them. They responded by building ultra cheap CT scanners, and MRIs according to Reid.


    • I believe I read in T. R. Reid’s “The Healing of America” (an excellent read, BTW) that the reason Japan has a lot of scanners is that their physicians wanted to use them, found their health care not covering them, which drove their technologists to create a lower cost scanner. Imagine that. Now, with lower cost scanners, they can scan more. Hopefully it is paying off for all involved (and not causing false positives that drive additional investigations, etc., especially if something about the lower-cost machines means that the incidence of false positives increases). And if lower cost machines are really available, I certainly hope they are being marketed in America to see the power of the market at work.

    • Oops… Steve beat me to the punch! 🙂

    • ken,

      just coming to this info late.

      i’m a canadian who spends a lot of time in japan. actually in nara prefecture national hospital in nara as write this. my (japanese) wife is dying of lung, lymph node and brain cancer.

      was wondering if lifestyle–i.e. the number of morbidly obese americans–has anything to do with the dialysis. demand caused by the citizens’ obesity.

      the mri and ct scan stats are certainly true. scads of ’em here.

      bruce picken

    • FWIW, there are two factors limiting transplants in Japan. The main one is that the population is not comfortable with the concept of brain death (or with trusting doctors to make that determiniation), and is largely unwilling to sign organ donor cards. This is changing, but very slowly. The other one is that they have fewer auto fatalities, and thus fewer possible donors. This results in an ever increasing number of patients in need of dialysis. (Statistics on life expectancy of patients on dialysis without transplant would be interesting.)

      The vast numbers of scanners in Japan may be for private, not covered by national insusance clinics. My impression is that the prices for scanner services are actually quite reasonable. My wife had tooth problems and her dentist recommended a non-covered head scan, and it wasn’t insanely expensive. A fellow translator had headaches, and got a scan at an off-insurance headache clinic, and also reports that it wasn’t off-the-wall expensive. In the US$150 to $300 or so in both cases. There may also be some protect-the-home market Japan Inc. export-supporting sleaze (of the type common in the pre-bubble era) going on here, where there are incentives for local purchases of Japanese-made scanners.