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

    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.

    While many of you have likely heard of some of the previous metrics before, I suspect that some of the ones presented today will surprise you.  We’re going to start getting into actual performance here, as well as how the system succeeds while in action.  We’re going to look at utilization, or how much people use, or get to use, the system.

    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.

    Let’s start with some data on prevention.  Specifically, we are going to focus on immunizations.  The first is known as DTP, or diphtheria, pertussis, and tetanus.  If you want to get technical, these days it’s mostly DTaP, as we are now using acellular pertussis, but that’s besides the point.  You’re supposed to get five vaccinations by the time you enter school.  So how does the US stack up in keeping kids current by age 1-2 years ?

    Better in recent years, but still nowhere near the top.  In fact, we seem to have plateaued at around the mid 80’s.  We could do much, much better.  Data exist on more than DTP, however.  We can also look at immunizations for measles.  This series is much simpler than DTP, and only requires two vaccinations by school entry.  In the US, we try to have one dose in by 15 months of age.  How well do we do at that compared to other countries:

    Better!  In fact, in recent years, we are near the top.  Children aren’t the only population that should be immunized, however.  People over the age of 65 should be getting vaccinations against influenza each year.  How do countries compare on that metric?

    Middle of the road there.  As always, with the elderly, it’s important to remember that they function in a different system, one of effective universal coverage because of Medicare.

    Moving past preventive care, let’s head into ambulatory care.  How many times do people in the US get to see the doctor compared to other countries?

    I have to admit, this one surprised me.  Making no claims as to whether every visit in every other country is needed (remember, no one metric is perfect), knowing how much more we are spending than these other countries makes the fact that they see the doctor many more times was surprising.

    How about outpatient surgery?  Do we get more than that?

    You bet we do.  Even though there isn’t a whole lot of data for the US, we are clearly out front there.  We do a lot of same-day procedures (which we saw in the cost series).  A lot.  Is it the same for inpatient procedures?

    Still number one, but not by as great an amount.  Certainly there is no question that we are getting many more procedures than any other comparable country.

    We’ve gone from office visits to outpatient procedures to inpatient procedures.  Let’s finish up with inpatient care.  How many days does the average person stay in the hospital?

    Again, given our costs, it’s surprising that we spend the least amount of time in the hospital.  Remember, we’re doing the most procedures.  We just don’t get to stay long afterwards.  Many people don’t like that.

    We should look at this from more than one direction.  Maybe we get longer stays, but fewer of them?

    Not so much.  The average length of an inpatient stay in the US is shorter than any comparable country.

    So how do we do with actual use of the system?  With respect to prevention, we’re middling.  We hardly get to see the doctor in the office at all.  We do get a lot of procedures, both inpatient and outpatient, although we rarely get to stay in the hospital, and when we do it’s for much less time than other countries.

    Here’s your fifth scorecard:

    And here’s the running total for the series:

    A further explanation of these charts can be found here.

    UPDATE: I screwed the pooch on this one.  Thanks to Michael in the comments, I fixed it.  I got the rankings exactly backwards in the overall category and running total.  I’ve been traveling and I’m sleep deprived and I’m human.  The responsibility is mine, however, and I own the mistake.

    • i know the flag scheme isn’t meant to be scientific, nor should one draw conclusions from it alone, but it seems awfully generous to rate utilization of health care in the US as closer to ‘really great’ than ‘really bad’…

    • @Garth

      I committed to sticking to the numbers for the charts. I will offer my own thoughts on the matter (which I bet are closer to yours) in the Conclusion.

      Again, think of this as how much do we get for out money. We get a TON of procedures, which skew us toward the top. I’m not arguing that this means we have better outcomes. I am just saying that if you value quantity, we do pretty well.

    • Echoing Garth’s sentiments here.

      I’m surprised you’re weighting the *number* of inpatient and outpatient procedures much more than anything else. Surely the number of procedures points how bad we are at not preventing them? I also have a feeling that short hospital stays have something to do with the number of procedures. To make an argument from anecdata, a couple of my friends had to go back to get their stitches redone after being discharged from the hospital three days after their c-sections. What a pain!

    • *doh, I meant to write “how bad we are at preventing them”. There’s an extra “not” in my original sentence.

    • Some math problems with the aggregate measure today.

      Japan is 4/7, 4/7, 7/7, 1/7, 1/7, 1/6 on the six categories where it is ranked. Those should average to a ranking better than 6/7.

      France has the same problem.

      I’d also like to question the “more is better” underlying assumption, although I think it is safe to say “more services is less rationing”, or “more services is more access”.

    • You guys are killing me. I agree with you. But how well the quantity of utilization works should be seen in things like disease care.

      This series describes a breadth of ways to think about what we get for our money. Some people, including me and apparently you, care about the final outcomes. Others care about quantity. I will argue my points and thoughts at the end. But I will not cherry pick data throughout.

      If I didn’t present this stuff, some would point to the series and say that I ignored the fact that it’s easier to get a procedure in the US than in other countries. I am not ignoring it. It’s in this post.

      There will be something to like and hate in every post. Welcome to the health care system of the Unites States.

    • @Michael

      Some days I get more sleep than others. I totally screwed up the overall. I fixed it and the composite.

      I appreciate the number-checking!

    • Is shorter length of stay necessarily a bad thing? I’ve seen data that indicates not only is USA length of stay decreasing (from 1997 to 2007), but so is readmittance rate. This could indicate that the US is not only providing better care (lower readmittance rate (relative to itself 10 years prior)), but they are also doing it more efficiently (lower LOS). Disregarding costs for a second (which I know is stupid because this whole series is about health care costs, but…), wouldn’t this be ideal?

    • in the update and responses to other comments, you addressed what i was trying to get at (in a very confusing manner, i now realize…) in my original comment. i’ll stick to commenting after noon from now on…

    • Ah, Aaron, that makes it much more clear. I was under the impression that somehow, for this post alone, you decided to weight the subcategories to give most weight to the number of procedures for some reason. My fault, I was too lazy to check the numbers myself. sorry if you felt attacked, I certainly didn’t mean to sound like that!

    • Outside of the immunizations, which Americans do poorly on, less might be better. And yes that is even true for ambulatory visits.

    • Less might be better but should it also be more expensive?

      I think the series is intended to look at whether the United States is getting value for its money.

      I suspect the author(s) would be appalled if it were interpreted as a recommendation for patient care!

    • Hospital A provides a treatment. It will require a 45 day hospital stay, with a 20% chance of readmittance within 30 days of discharge due to ineffective treatment.

      Hospital B provides a treatment. It will require a 3 day hospital stay with 1% chance of readmittance within 30 days of discharge due to ineffective treatment.

      I think I’d be willing to pay more for treatment at Hospital B.

    • This is exactly the point. If we are spending more on healthcare we would expect either superior service, better outcomes, or both. If we are spending more and getting inferior service then we would hope for a positive effect on outcomes.

      (Service clearly has multiple parts. I am consciously assigning the effect on health to ‘outcomes’ and describing only quality of interaction in ‘service’.)

      The question is, are we seeing anything like this benefit?

      The implication often is that these interactions are short but incredibly effective relative to what other countries are getting. From the evidence on outcomes I’m not convinced. Some people seem to mistake modern American healthcare for Star Trek IV.


    • There was a post on the Health Affairs blog yesterday that talked about utilization and how we visit the doctor less and have shorter stays, yet still have higher expenditures than other countries:

      By the way, I’m a doctoral student in health services research, and I wanted to let you know that I have been getting a lot out of this series and the last one (and the blog in general). Thank you so much.