asthmahttp

1http://www.
youtube.
com/watchv=joaAfBr9tAE2EDITORIALWorld'sBestMedicalCareManyAmericansareunderthedelusionthatwehave"thebesthealthcaresystemintheworld,"asPresidentBushseesit,orprovidethe"bestmedicalcareintheworld,"asRudolphGiulianideclaredlastweek.
Thatmaybetrueatmanytopmedicalcenters.
Butthedisturbingtruthisthatthiscountrylagswellbehindotheradvancednationsindeliveringtimelyandeffectivecare.
MichaelMoorestruckanerveinhisnewdocumentary,"Sicko,"whenheextolledthevirtuesofthegovernment-runhealthcaresystemsinFrance,England,CanadaandevenCubawhiledeploringthefailuresofthelargelyprivateinsurancesysteminthiscountry.
ThereisnoquestionthatMr.
Mooreoverstatedhiscasebymakingforeignsystemslookalmostflawless.
Butthereisagrowingbodyofevidencethat,byanarrayofpertinentyardsticks,theUnitedStatesisalaggardnotaleaderinprovidinggoodmedicalcare.
Sevenyearsago,theWorldHealthOrganizationmadethefirstmajorefforttorankthehealthsystemsof191nations.
FranceandItalytookthetoptwospots;theUnitedStateswasadismal37th.
Morerecently,thehighlyregardedCommonwealthFundhaspioneeredincomparingtheUnitedStateswithotheradvancednationsthroughsurveysofpatientsanddoctorsandanalysisofotherdata.
Itslatestreport,issuedinMay,rankedtheUnitedStateslastornext-to-lastcomparedwithfiveothernations—Australia,Canada,Germany,NewZealandandtheUnitedKingdom—onmostmeasuresofperformance,includingqualityofcareandaccesstoit.
OthercomparativestudiesalsoputtheUnitedStatesinarelativelybadlight.
Insurancecoverage.
Allothermajorindustrializednationsprovideuniversalhealthcoverage,andmostofthemhavecomprehensivebenefitpackageswithnocost-sharingbythepatients.
TheUnitedStates,toitsshame,hassome45millionpeoplewithouthealthinsuranceandmanymoremillionswhohavepoorcoverage.
Althoughthepresidenthasblithelysaidthatthesepeoplecanalwaysgettreatmentinanemergencyroom,manystudieshaveshownthatpeoplewithoutinsurancepostponetreatmentuntilaminorillnessbecomesworse,harmingtheirownhealthandimposinggreatercosts.
Access.
Citizensabroadoftenfacelongwaitsbeforetheycangettoseeaspecialistorundergoelectivesurgery.
Americanstypicallygetprompterattention,althoughGermanydoesbetter.
Therealbarriersherearethecostsfacinglow-incomepeoplewithoutinsuranceorwithskimpycoverage.
ButevenAmericanswithabove-averageincomesfinditmoredifficultthantheircounterpartsabroadtogetcareonnightsorweekendswithoutgoingtoanemergencyroom,andmanyreporthavingtowaitsixdaysormoreforanappointmentwiththeirowndoctors.
Fairness.
TheUnitedStatesranksdeadlastonalmostallmeasuresofequitybecausewehavethegreatestdisparityinthequalityofcaregiventoricherandpoorercitizens.
Americanswithbelow-averageincomesaremuchlesslikelythantheircounterpartsinotherindustrializednationstoseeadoctorwhensick,tofillprescriptionsortogetneededtestsandfollow-upcare.
Healthylives.
WehaveknownforyearsthatAmericahasahighinfantmortalityrate,soitisnosurprisethatweranklastamong23nationsbythatyardstick.
Buttheproblemismuchbroader.
Weranknearthebottominhealthylifeexpectancyatage60,and15thamong19countriesindeathsfromawiderangeofillnessesthatwouldnothavebeenfataliftreatedwithtimelyandeffectivecare.
Thegoodnewsisthatwehavedoneabetterjobthanotherindustrializednationsinreducingsmoking.
Thebadnewsisthatourobesityepidemicistheworstintheworld.
3Quality.
Inacomparisonwithfiveothercountries,theCommonwealthFundrankedtheUnitedStatesfirstinprovidingthe"rightcare"foragivenconditionasdefinedbystandardclinicalguidelinesandgaveitespeciallyhighmarksforpreventivecare,likePapsmearsandmammogramstodetectearly-stagecancers,andbloodtestsandcholesterolchecksforhypertensivepatients.
Butwescoredpoorlyincoordinatingthecareofchronicallyillpatients,inprotectingthesafetyofpatients,andinmeetingtheirneedsandpreferences,whichdroveouroverallqualityratingdowntolastplace.
Americandoctorsandhospitalskillpatientsthroughsurgicalandmedicalmistakesmoreoftenthantheircounterpartsinotherindustrializednations.
Lifeanddeath.
Inacomparisonoffivecountries,theUnitedStateshadthebestsurvivalrateforbreastcancer,secondbestforcervicalcancerandchildhoodleukemia,worstforkidneytransplants,andalmost-worstforlivertransplantsandcolorectalcancer.
Inaneight-countrycomparison,theUnitedStatesrankedlastinyearsofpotentiallifelosttocirculatorydiseases,respiratorydiseasesanddiabetesandhadthesecondhighestdeathratefrombronchitis,asthmaandemphysema.
Althoughseveralfactorscanaffecttheseresults,itseemslikelythatthequalityofcaredeliveredwasasignificantcontributor.
Patientsatisfaction.
Despitethedeclarationsoftheirpoliticalleaders,manyAmericansholdsurprisinglynegativeviewsoftheirhealthcaresystem.
PollsinEuropeandNorthAmericaseventonineyearsagofoundthatonly40percentofAmericansweresatisfiedwiththenation'shealthcaresystem,placingus14thoutof17countries.
InrecentCommonwealthFundsurveysoffivecountries,Americanattitudesstandoutasthemostnegative,withathirdoftheadultssurveyedcallingforrebuildingtheentiresystem,comparedwithonly13percentwhofeelthatwayinBritainand14percentinCanada.
ThatmaybebecauseAmericansfacehigherout-of-pocketcoststhancitizenselsewhere,arelessapttohavealong-termdoctor,lessabletoseeadoctoronthesamedaywhensick,andlessapttogettheirquestionsansweredorreceiveclearinstructionsfromadoctor.
Ontheotherhand,Galluppollsinrecentyearshaveshownthatthree-quartersoftherespondentsintheUnitedStates,inCanadaandinBritainratetheirpersonalcareasexcellentorgood,soitcouldbehardtomotivatethesepeopleforthewholesalechangesoughtbythedisaffected.
Useofinformationtechnology.
Shockingly,despiteourvauntedprowessincomputers,softwareandtheInternet,muchofourhealthcaresystemisstilloperatinginthedarkagesofpaperrecordsandhandwrittenscrawls.
Americanprimarycaredoctorslagyearsbehinddoctorsinotheradvancednationsinadoptingelectronicmedicalrecordsorprescribingmedicationselectronically.
Thismakesithardertocoordinatecare,spoterrorsandadheretostandardclinicalguidelines.
Top-of-the-linecare.
Despiteourpoorshowinginmanyinternationalcomparisons,itisdoubtfulthatmanyAmericans,facedwithalife-threateningillness,wouldratherbetreatedelsewhere.
Wetendtothinkthatourverybestmedicalcentersarethebestintheworld.
Butwhetherthisisarealisticassessmentormerelyaculturalpreferenceforthehometeamisdifficulttosay.
Onlywhenbettermeasuresofclinicalexcellencearedevelopedwilldiscerningmedicalshoppersknowforsurewhoisthebestofthebest.
WithhealthcareemergingasamajorissueinthepresidentialcampaignandinCongress,itwillbeimportanttogetbeyondemptyboaststhatthiscountryhas"thebesthealthcaresystemintheworld"andturninsteadtofixingitsveryrealdefects.
Themaingoalshouldbetoreducethehugenumberofuninsured,whoareamajorreasonforourpoorstandingglobally.
Butthereisalsoplentyofroomtoimproveourcoordinationofcare,ouruseofcomputerizedrecords,communicationsbetweendoctorsandpatients,anddozensofotherfactorsthatimpairthequalityofcare.
Theworld'smostpowerfuleconomyshouldbeabletoprovideahealthcaresystemthatreallyisthebest.
4MEASURINGOVERALLHEALTHSYSTEMPERFORMANCEFOR191COUNTRIESAjayTandonChristopherJLMurrayJeremyA.
LauerDavidB.
EvansGPEDiscussionPaperSeries:No30EIP/GPE/EQCWorldHealthOrganizationhttp://www.
who.
int/entity/healthinfo/paper30.
pdfThisstudyisbasedonthecompositemeasureofhealthcaredelivery,COMP.
56789THECOMPARATIVEEFFICIENCYOFNATIONALHEALTHSYSTEMSINPRODUCINGHEALTHANANALYSISOF191COUNTRIESDavidB.
EvansAjayTandonChristopherJLMurrayJeremyA.
LauerGPEDiscussionPaperSeries:No29EIP/GPE/EQCWorldHealthOrganizationhttp://www.
who.
int/entity/healthinfo/paper29.
pdfThisstudyisbasedonthemeasureofdisabilityadjustedlifeexpectancy,DALE.
10111213EuropeansPerformHighestInRankingofWorldHealthByPHILIPJ.
HILTSPublished:June21,2000TheWorldHealthOrganizationissuedfiguresyesterdaythatrankhealthcaresystemsaroundtheworldforthefirsttime.
TheyindicatethatEuropeanhealthsystemsaregenerallyperformingbestandthattheUnitedStatesislaggingbehind,largelybecauseofinequaldistributionofhealthcareservices.
TherankingsarecontainedintheWorldHealthReport2000.
Thereportmeasurednotjustoverallspendingonhealthbutalsohowhealthcarewasdistributedamongdifferentgroupsineachofthe191nationsthataremembersoftheWorldHealthOrganization.
Thecountrieswerejudgedaccordingtofivehealth-carecategoriesthatW.
H.
Osurveysfoundtobemostimportanttothepeopleinvariousnations.
Untilnow,argumentoverhowwellhealthsystemsandpoliciesareworkinghasbeenbasedonanecdotesandfractionalbitsofdata,saidDr.
JeffreyKoplan,directoroftheUnitedStatesCentersforDiseaseControlandPrevention.
Hesaidthereportwasthefirstattempttoputtheargumentsonafactualfooting.
Accordingtothereport,thefivetopnationsforhealthcarewereFrance,Italy,SanMarino,AndorraandMalta.
Onesurpriseinthefindings,saidDr.
DavidEvansoftheW.
H.
O.
'sGlobalProgramonEvidenceforHealthPolicy,wasthegoodrankingsforsouthernEuropeancountriessuchasItalyandSpain.
''Peopleinthosecountriesdon'tbelievetheirhealthsystemsaredoingverywell,''hesaid.
OmanrankedNo.
8,asurprisebecauseitshealthcaresystemwasinashamblesinthe1970's,withveryhighinfantmortality,andbecauseithasarelativelysmallbudgetforhealth.
Itsspendingpercapitaonhealthisone-ninthofthatoftheUnitedStates,forexample.
Dr.
ChristopherJ.
L.
Murray,aninternationalhealtheconomistfromtheHarvardSchoolofPublicHealth,whoisoneoftwoleadersoftheproject,saidOmandemonstratesthatgreatchangesinacountry'shealthcanbeproducedinashortperiodoftime.
AnothersurprisewasChina'srankingofNo.
144.
Alittlemorethanadecadeago,Chinahadapublichealthcaresystem,butithascollapsed,andnowpeopletherepayforvirtuallyalltheircareoutofpocket.
ItwasrankedNo.
188infairnessoffinancing.
TheUnitedStatesoutspendstheworldandranksnearthetopinaveragehealthmeasures,butfailstodelivergoodhealthcaretoalargeproportionofitspopulationanddistributesthecostrelativelyunfairly,accordingtothereport'smeasures,leavingitatnumber37intherankings.
Usingthemeasure''healthlifeexpectancy''--thatis,lifeexpectancyminusyearsofsicknessanddisability,therearecountiesintheUnitedStateswhereNativeAmericanchildrenatbirthcanlookforwardtoonlyabout50yearsofhealthlifeonaverage,whilesomeAsianminoritiesinsuburbanNewYorkcanexpectmorethan90yearsofhealthylife,Dr.
Murraysaid.
Thereportdemonstrates,Dr.
Murraysaid,''thatnoonemodelisbest,butthenumberswillgiveusthemeansovertimetotestwhichinnovationinhealthsystemsworkbestandwhicharefailing.
''Thenewratingsystembasesnationalscoresonfivemeasures,andinproducingarankingtakesintoaccountthefinancialresourcesithasavailable.
Thefivemeasuresusedare:overalllevelofhealthorlifeexpectancy;healthfairnessorlifeexpectancyasmeasuredacrossvariouspopulationswithinacountry;responsivenessorhowwellpeopleratedperformanceoftheirhealthcaresystem;fairnessinresponsivenessamongdifferentgroupsinthesamecountry;andfairnessinfinancingamongdifferentgroups,whichlookedatwhatproportionofincomeisdevotedtohealthcare.
14SomeofthePublishedWorkBasedontheWHOStudy/DataEvansD,TandonA,MurrayC,LauerJ.
Thecomparativeefficiencyofnationalhealthsystemsinproducinghealth:ananalysisof191Countries.
WorldHealthOrganization,GPEDiscussionPaper,No.
29,EIP/GPE/EQC2000a.
EvansD,TandonA,MurrayC,LauerJ.
Measuringoverallhealthsystemperformancefor191countries.
WorldHealthOrganizationGPEDiscussionPaper,No.
30,EIP/GPE/EQC2000b.
GravelleH,JacobsR,JonesA,StreetA.
Comparingtheefficiencyofnationalhealthsystems:econometricanalysisshouldbehandledwithcare.
UniversityofYork,HealthEconomics,UK.
Manuscript2002a.
GravelleH,JacobsR,JonesA,StreetA.
Comparingtheefficiencyofnationalhealthsystems:asensitivityapproach.
UniversityofYork,HealthEconomics,Manuscript,UK2002b.
Greene,W.
Distinguishingbetweenheterogeneityandinefficiency:stochasticfrontieranalysisoftheWorldHealthOrganization'spaneldataonnationalhealthcaresystems.
HealthEconomics,13,2004,pp.
959-980.
WorkingPaper03-10,DepartmentofEconomics,SternSchoolofBusiness,NewYorkUniversity2003d;(http://www.
stern.
nyu.
edu/~wgreene/heterogeneityandinefficiency.
pdf).
GreeneW.
Reconsideringheterogeneityinpaneldataestimatorsofthestochasticfrontiermodel.
JournalofEconometrics2004.
.
GreeneW.
Fixedandrandomeffectsinnonlinearmodels.
SternSchoolofBusiness,DepartmentofEconomics,WorkingPaper01-012001.
Greene,W.
EconometricAnalysis,6thEd.
.
PrenticeHallEnglewoodCliffs;2007.
HollingsworthJ,WildmanB.
Theefficiencyofhealthproduction:re-estimatingtheWHOpaneldatausingparametricandnonparametricapproachestoprovideadditionalinformation.
HealthEconomics2002;11:1-11.
NewhouseJ.
Medicalcareexpenditure:acrossnationalsurvey.
JournalofHumanResources1977;12:115-124.
WilliamsA.
ScienceofmarketingatWHOAcommentaryonWorldHealth2000.
HealthEconomics2001;10:93-100.
WorldHealthOrganization.
TheWorldHealthReport,2000,HealthSystems:ImprovingPerformance.
Geneva.
2000.
15Aug12,7:03AMEDTUSSlippinginLifeExpectancyRankingsBySTEPHENOHLEMACHERAssociatedPressWriterWASHINGTON(AP)--Americansarelivinglongerthanever,butnotaslongaspeoplein41othercountries.
Fordecades,theUnitedStateshasbeenslippingininternationalrankingsoflifeexpectancy,asothercountriesimprovehealthcare,nutritionandlifestyles.
CountriesthatsurpasstheU.
S.
includeJapanandmostofEurope,aswellasJordan,GuamandtheCaymanIslands.
"Something'swrongherewhenoneoftherichestcountriesintheworld,theonethatspendsthemostonhealthcare,isnotabletokeepupwithothercountries,"saidDr.
ChristopherMurray,headoftheInstituteforHealthMetricsandEvaluationattheUniversityofWashington.
AbabybornintheUnitedStatesin2004willliveanaverageof77.
9years.
Thatlifeexpectancyranks42nd,downfrom11thtwodecadesearlier,accordingtointernationalnumbersprovidedbytheCensusBureauanddomesticnumbersfromtheNationalCenterforHealthStatistics.
Andorra,atinycountryinthePyreneesmountainsbetweenFranceandSpain,hadthelongestlifeexpectancy,at83.
5years,accordingtotheCensusBureau.
ItwasfollowedbyJapan,Macau,SanMarinoandSingapore.
TheshortestlifeexpectancieswereclusteredinSub-SaharanAfrica,aregionthathasbeenhithardbyanepidemicofHIVandAIDS,aswellasfamineandcivilstrife.
Swazilandhastheshortest,at34.
1years,followedbyZambia,Angola,LiberiaandZimbabwe.
ResearcherssaidseveralfactorshavecontributedtotheUnitedStatesfallingbehindotherindustrializednations.
Amajoroneisthat45millionAmericanslackhealthinsurance,whileCanadaandmanyEuropeancountrieshaveuniversalhealthcare,theysay.
But"it'snotassimpleassayingwedon'thavenationalhealthinsurance,"saidSamHarper,anepidemiologistatMcGillUniversityinMontreal.
"It'snotthateasy.
"Amongtheotherfactors:-AdultsintheUnitedStateshaveoneofthehighestobesityratesintheworld.
NearlyathirdofU.
S.
adults20yearsandolderareobese,whileabouttwo-thirdsareoverweight,accordingtotheNationalCenterforHealthStatistics.
"TheU.
S.
hastheresourcesthatallowpeopletogetfatandlazy,"saidPaulTerry,anassistantprofessorofepidemiologyatEmoryUniversityinAtlanta.
"Wehavetheluxuryofchoosingabadlifestyleasopposedtohavingoneimposedonusbyhardtimes.
"-Racialdisparities.
BlackAmericanshaveanaveragelifeexpectancyof73.
3years,fiveyearsshorterthanwhiteAmericans.
BlackAmericanmaleshavealifeexpectancyof69.
8years,slightlylongerthantheaveragesforIranandSyriaandslightlyshorterthaninNicaraguaandMorocco.
-ArelativelyhighpercentageofbabiesbornintheU.
S.
diebeforetheirfirstbirthday,comparedwithotherindustrializednations.
Fortycountries,includingCuba,TaiwanandmostofEuropehadlowerinfantmortalityratesthantheU.
S.
in2004.
TheU.
S.
ratewas6.
8deathsforevery1,000livebirths.
Itwas13.
7forBlackAmericans,thesameasSaudiArabia.
16"ItreallyreflectsthesocialconditionsinwhichAfricanAmericanwomengrowupandhavechildren,"saidDr.
MarieC.
McCormick,professorofmaternalandchildhealthattheHarvardSchoolofPublicHealth.
"Wehaven'tdoneanythingtoeliminatethosedisparities.
"AnotherreasonfortheU.
S.
dropintherankingisthattheCensusBureaunowtrackslifeexpectancyforalotmorecountries-222in2004-thanitdidinthe1980s.
However,thatdoesnotexplainwhysomanycountriesenteredtherankingswithlongerlifeexpectanciesthantheUnitedStates.
Murray,fromtheUniversityofWashington,saidimprovedaccesstohealthinsurancecouldincreaselifeexpectancy.
But,hepredicted,theU.
S.
won'tmoveupintheworldrankingsaslongasthehealthcaredebateislimitedtoinsurance.
Policymakersalsoshouldfocusonwaystoreducecancer,heartdiseaseandlungdisease,saidMurray.
Headvocatesstepped-upeffortstoreducetobaccouse,controlbloodpressure,reducecholesterolandregulatebloodsugar.
"Evenifwefocusedonlyonthosefourthings,wewouldgoalongwaytowardimprovinghealthcareintheUnitedStates,"Murraysaid.
"ThestartingpointistherecognitionthattheU.
S.
doesnothavethebesthealthcaresystem.
Therearestillanawfullotofpeoplewhothinkitdoes.
"