International Healthcare Quality

I got an email forward the other day about everything wrong with the Obama administration. Of course these emails never stop, no matter who is president. The content just changes based on which issues the current president is campaigning. Obviously, health care is a huge topic nowadays, with the introduction of the PPACA (even though we're still yet to see any real changes from the impact of the law). That aside, the Right is absolutely furious with the Left for their desire to implement a national health system. or the US version of national health care, since really a national health system varies greatly from country to country. This is of course something all those opposed to the new PPACA refuse to acknowledge. They instead prefer to deal in absolutes- "National Health Care is Bad,"  instead of maybe "This specific National Health program in this country is Bad."  

Oh well.  You can really only do so much when educating people about the various international health systems and their successes or failures. The bottom line is, many, many things affect each country's healthcare delivery system, such as politics, culture, the system itself, the list is never ending; but this is an extremely hard thing to explain to someone who is really only interested in backing his or her political leanings and has little interest in the actual quality of healthcare a certain system may offer.

Anyways- here's the part of the email that pertains to healthcare:

There are actually two messages here.  The 1st points out the incredible benefits of “Universal Healthcare” and is very interesting; the 2nd is absolutely astounding - and explains a lot.


1.A recent "Investor's Business Daily" article provided very interesting statistics from a survey by the United Nations International Health Organization.

Percentage of men and women who survived a cancer five years after diagnosis:
U.S.      65%
England       46%
Canada   42%

Percentage of patients diagnosed with diabetes who received treatment within six months:
U.S.      93%
England       15%
Canada   43%

Percentage of seniors needing hip replacement who received it within six months:
U.S. 90%
England   15%
Canada   43%

Percentage referred to a medical specialist
who see one within one month:
U.S.      77%
England   40%
Canada    43%

Number of MRI scanners (a prime diagnostic tool) per million people:
U.S.      71
England       14
Canada   18

Percentage of seniors (65+), with low income, who say they are in "excellent health":
U..S.  12%
England       02%
Canada    06%

What a bleak outlook. You'd think people in England and Canada are just sitting in the streets waiting to die after reading an email like that!

Now, I have to say, I have no idea whether those statistics are accurate. I tried to google that report and couldn't locate one that produced those same numbers, but for all I know it could be accurate. Let's assume it is (I doubt it, but let's just assume..) - there's still one big problem with this email.  If the point of that part of the email was (and it was)  to suggest that National Health Care results in poorer quality than the United States' current health system, they've made a crucial mistake:  more countries besides England and Canada have national health care, and not only that, but they have much higher quality healthcare systems than the US does. 

This  is one of my favorite reports on the comparison of health care systems internationally. It's not the newest report (at about ten years old),  but it is my favorite for the amount of countries in the comparison as well as the graphs it uses. Speaking of which...

So here we see the MRI scanners available per million of the population.  This rather puts that MRI statistic included in the email into perspective, does it not?  Yes- the US is leading England and Canada. However, it is so to speak having it's butt kicked by Japan- a country with a national healthcare system.

This is just one example.  The report does not include statistics on hip replacements or treatment availability of diabetes, but it does include numerous other statistics in which the US is trailing a pack of other countries that have national healthcare systems. 

As stated above, it is very difficult to not only measure and compare these systems that are so different for so many reasons, but to then rank them and explain which is best and why. One of the most common things you hear those in favor of resisting national healthcare in the US say, is that "our system is the best,"  but what does this mean? What does "best"  really represent here? Best at what?  Best at spending money? Absolutely.

As you can see, the US spends more than double the ten country average- and this was ten years ago.  The costs have soared in the past ten years, I shudder to think what this graph would look like today. Based on this graph, you would think we must have the best healthcare, after we spent all that money on it!  Not quite.

And there you have it- the United States, trailing the pack.

Now, these are only statistics from one report, a reputable one no less, but that's not to say that the United States couldn't have improved it's healthcare delivery in the past decade. We do know however, that the US still spends more on healthcare than any other country, and we are still not leading the pack. 

It's important to understand the definition of quality, and how we determine whether a healthcare system is high quality or not.  To do this, let's remember the six aims of quality as defined by Berwick:

Now; other international systems aside- how does our own system achieve these aims? 

Safe-  given the colossally high rate of nosocomial infections occurring at hospital's everyday, I'm not quite confident that we can say we have a very safe healthcare delivery system here in the US.

Efficient- I don't need to say anything here. Our system is anything but efficient at this point, unfortunately.

Timely- the people sitting in ER waiting rooms for hours on end may not feel our delivery system is very timely. Then again, if the email except above has any merit, wait times in England and Canada aren't so hot either.

Patient Centered-  I feel if you ask many patients about their experiences with a doctor or medical professional, I doubt many of them would say they felt valued or in control. Typically most patients leave a doctor's office feeling confused and annoyed after having waited an hour in the waiting room and then another hour in the office to see the physician, only to be rushed back out onto the street after five minutes with a prescription they can't read.

Equitable- With 50.7 million Americans uninsured, I'm not sure that you could consider our health system equitable.



So where does this leave us (besides maybe depressed)?    To be honest, it's hard to say.  Are the other countries out there with better healthcare than us? Absolutely. Will their system work here?  Maybe, maybe not.  Looking at statistics, Japan has some of the highest ranking healthcare available today- but look at their country, look at their people.  Statistics used to rank healthcare often include mortality and morbidity- Japan's culture is that of a healthy population:  they have long lifespans, healthy eating habits, etc.  This certainly could have an effect on the success of their healthcare delivery system.  Their people are also notoriously hardworking; could this be part of why their largely employer-based insurance system is so successful?  Possibly.  

 The truth is, there are numerous factors that play a role in measuring the healthcare quality of a nation, but there are some undeniably truths that we cannot avoid.  The bottom line is, healthcare in the United States has huge room for improvement, and continuing on with the current system is simply not a viable economic option.  Whether or not they like the idea of National Healthcare, Americans will be forced in the near future to accept that maybe their system isn't the "best" as they like to believe. Hopefully going forward we will see less emails like the one above, and more viable solutions offered to try and solve our healthcare problems.

(I won't be holding my breath though)

Patient Perspective

Today's Writing prompt: In your own words, explain why or why not the perspective of the patient is the most important determinant as to whether an adverse event has occurred


Ever since I was little I have had an issue with authority. Most people wouldn't guess that- I have never been grounded or punished by my parents, gotten detention at school; actually I had never even been tardy to class until I went away to college and learned the joys of the snooze button.  My issue with authority wasn't an unruly teenager flipping the bird at her parents behind their backs- it was a mischievous little girl quietly flouting authority in small unnoticeable ways yet significant (at least to her).   I don't have an issue with authority itself or the idea of obedience, I simply take issue with the idea of following an order that may not be the best thing for me.  I have always been of the opinion that I know  me  best.  Notice I did not say I know what's best for me, but that I know myself better than anyone else. Some may say that's a semantics argument. I disagree- I think there is an important difference between the two.

This is something I think people lose sight of, and especially in healthcare. Patients' complaints about their doctors not listening to them or taking them seriously are a dime a dozen, and are often ignored because of the idea that doctors clearly know more about medicine than the people paying them do.  I wouldn't argue that fact- surely the people who went to medical school for eight or so years are more knowledgeable about medicine than the person wearing the hospital gown; yet could the patients have a point?   The person wearing the hospital gown has had a pretty close relationship with themselves for years- maybe decades; the doctor probably just met them five minutes ago.   There is a legitimate argument to be had that sometimes doctors lose sight of this fact when they are working with patients and making diagnoses. 

When it comes to an adverse health event- which is more important, the patient's perspective, or the doctors?  There can be arguments made for both sides; the patient is the one experiencing the effects and having to tolerate the symptoms, yet the doctor is the one knowledgeable in all of the effects as well as likely why the event occurred, and if  it might happen again or trigger another adverse health event. 

Let's say for example that a patient experiences an adverse health event. The doctor is concerned about this event that has occurred and recommends to the patient that he seek such and such a treatment in order to prevent this from occurring again. However, let's say in this situation that the patient has been experiencing these ongoing symptoms for some time, but is not bothered by them or the fact that they happen, and does not want to follow the treatment plan the doctor has provided. Who is right?   On the one hand, the patient knows their own body better than the doctor does- and is the one experiencing everything firsthand; however, the doctor is the one with the training and may know that if the patient does not seek treatment conditions may worsen and danger may be present.

I think when it comes to adverse health events, neither the patient perspective or the doctor perspective is the most important in deciding whether an event has occurred.  Patient perspective is absolutely important, and should not be disregarded.  Who hasn't suffered the unpleasant experience of being questioned endlessly about how you are feeling, when you continuously repeat that you are feeling fine?  Nobody knows you better than you do after all. However, someone with eight years of medical training can undoubtedly identify a medical issue better than someone without years of medical training. Is it not possible for someone to be suffering an affliction of some sort yet present no symptoms currently? As healthcare professionals we know all too well that someone can feel fine one minute and be barely alive the next.  For this reason, I would have to say the patient perspective is not the most important determinant when decided whether an adverse health event has occurred- because both perspectives are important. There is no "most important"  perspective or person, rather both patient and provider should work together.

Health Literacy- fact or fiction?

Lately I've been hearing a lot of people talk about not understanding what is actually wrong with them after going to the doctor. I know the feeling- a lot of times I leave the office in a literally fog (flu season gets me every year!)  and I barely remember the directions he or she has given me to follow, let alone the scientific terms and proper names for all of the parts of my body that were identified.    However, you have to wonder whether or not this is really significant to people getting better  and whether it affects the quality of our healthcare.

Kaiser Health News did an article on this titled Health Care Quality Issues: the Disconnect Between Patients and Experts (which can be found here )  They defined "health literacy" as follows:

This literacy is "the limited ability to understand the technical jargon, the orders, the prescriptions and the forms coming from doctors, nurses, pharmacists and insurance companies. This failure to communicate leads to missed doctor appointments, medications taken incorrectly, instructions ignored — all contributing to worsening health."

Now obviously, this is a real and observable fact. For example- let's say you visit the doctor because you are sick and are coughing up mucus, and the doctor says you have bronchitis. The anatomy of the lung as explained by PubMed Health states that

"When air is inhaled through the nose or mouth, it travels down the trachea to the bronchus, where it first enters the lung. From the bronchus, air goes through the bronchi, into the even smaller bronchioles and lastly into the alveoli."

 Now let's be honest- your doctor will very likely mention at least one of these scientific terms when explaining bronchitis to you, however, how many of us would raise our hands in a classroom if we could point out where in our bodies the bronchioles are?  Probably not many. And at that moment in time when your head is in a fog and you feel like death, understanding the advanced explanation of what is causing your body to feel the way it does at that moment is not high on your list of things to worry about.  All you care about in that moment, is what you are going to do to feel better, and what the doctor can give to you.  

It is for this reason that I always, always, always have a notepad with me when I go to the doctors, to write down what he or she is saying, because I know (and you know)  that once I leave that office, the details are slowly going to leak out of my head while I wander up and down the aisles of Walgreens miserably waiting for my Z-pack prescription to be filled. Completely human- however, this is an issue that is affecting healthcare quality.   There are several issues at play- one issue is that if the patient doesn't fully understand their prognosis, they may later on down the line make mistakes with following the directions on their medication, or follow up treatments.   Even further than this issue, is an overall literacy issue period, with patients being unable to read and understand the directions printed on the medications they are taking.  

Estimates from the article report that this issue could cost up to $7.5  billion dollars annually- no small chunk of change.   But what can be done to insure that this issue is resolved?   speaking from personal experience, I am seeing an increase in the amount of informational pamphlets being handed out after visiting a healthcare facility. In the past three years, I have noticed that I am given handouts when leaving the healthcenter on campus, explaining  details of what I may have visited for (and this is at a college campus, where you would expect those visiting to have reached a certain level of literacy!)   However, the health center is making an important observation: You just can't assume people understand; as a health provider, it is our responsibility to make sure the patients receives and understands all pertinent information given to them.

In a world where everyone thinks they're a doctor courtesy of WebMD, it's easy to forget that not every patient who walks through the doors of a health facility has already been on line and diagnosed themselves, and is only their for a script.  In order to ensure healthcare quality continues to improve and that all patients receive the highest level of care available, healthcare providers will have to continue to keep health literacy in mind when delivering care.

Quality and what it means to me

People define things in many different ways, especially subjective terms like good or bad. Quality is one of those subjective terms- what one person might consider good quality, another person may consider sub par, and because of this a challenge is posed for companies to determine what goods or services would be considered by their consumers as high quality, and develop and bring this high quality to the market.

I can remember from a very young age my mom talking about whether something was good or bad quality while we were shopping for clothing. She would always veto whatever item I picked out saying it was "bad quality and would fall apart too quickly" or that it wouldn't last or would rip or stretch out, etc. Personally I think she was just horrified by my taste in clothes and extreme love of animal print or glitter, but she did have a point. When she would cave and allow me to buy whatever low quality outfit I had my eye on that was made for ten cents in Indonesia, inevitably it would shrink beyond recognition or rip, and I wouldn't get to wear it more than a couple times, whereas the "boring" but high quality clothes she would pick out would unfortunately last forever and I would be forced to wear them repeatedly.  In this example, the definition of quality being used was only that the clothes were durable, and that they would last, but was ignoring several other important factors, like cost, or comfort.

With that example, it is easy to see how many different aspects there are to quality, and how they all come into play. For example- the clothes I wanted to wear as a child were much less expensive than the clothes my mother wanted  me to wear, and cost is certainly part of measuring quality. Additionally, the clothes I picked out were much more aesthetically pleasing to me than the ones my mother picked, and of course things being visually appealing could also be considered an aspect of quality.

Recalling Dr. Oetjen's class last Wednesday when each person named their favorite high quality restaurant, there were many varying answers given. Some people named fast food chains, some named expensive restaurants. The degree of variation in the answers given is not only indicative of people's preference in taste, but also how they define quality. Those that chose expensive restaurants may define a quality dining experience as one with a very high level of service or a selection of gourmet food, whereas others who chose a lower cost dining location may define quality more along the lines of getting a lot of food for a reasonable price, as in good value.  Others still may have used different factors to choose, such as wait times, or a wide variety, etc.   In chapter one of our Ransom text, quality is defined as follows.

Now, let's apply these six dimensions to the restaurant example:

1- safe: this would mean that the food is not contaminated and fit for consumption, and also that the dining environment is safe and patrons are not concerned they could experience harm within the establishment.

2- effective:  meaning that the food ordered would satisfy the consumer's hunger and tastes.

3- efficient:  efficiency in this situation would mean that the food ordered is of good value- meaning that you receive a sufficient amount of food comparable to the price you pay, and that the food tastes good, etc. For example- what you pay at McDonalds would be different than what you pay at Kobe Steakhouse, however the trade off in these situations is fair because of the difference in the food that you receive.

4- timely: food should be delivered quickly, and waiters and waitresses should be attentive and respond quickly to guest's requests.

5- patient centered: service provided should be provided with the guests satisfaction in mind.

6- equitable: all patrons should receive the same level of service and quality of food. 


To me, quality means getting something of good value in return for the money you pay, and that what you receive satisfies the need and is a better option than the other alternatives, so in this situation I can relate to the people who chose a lower cost option restaurant as one of being high quality.  Despite this, it is easy to see that all six dimensions of quality must be present in order to be considered a high quality establishment. This is true of both restaurants, and more importantly, healthcare facilities. As we move forward in the semester I will be sure to keep all six dimensions in mind when thinking about or measuring quality.