“[Introduction]
[..] Privileged US citizens—including thought and physician leaders—may tolerate this underperformance as applying to “others,” dismissing comparisons as mean values that do not reflect the quality of their own personal care. Privileged US citizens believe that their social connections and financial resources allow them to choose the best physicians and hospitals for their own care, thereby ensuring excellent health outcomes. One study showed that the wealthiest quintile receive 43% more health care than the poorest quintile and 23% more than middle-income US citizens. Privileged US citizens may believe that their resources ensure that they receive the world’s best health care, even if less advantaged US citizens cannot.
[..] how well would the US rank against comparison countries if every citizen in the US experienced health outcomes commensurate with privileged US citizens? We examined the following 6 health outcomes that are associated with the timeliness and quality of health care services: infant mortality; maternal mortality; 5-year survival of patients with colon cancer, breast cancer, and childhood acute lymphocytic leukemia (ALL); and 30-day case-fatality rates after acute myocardial infarction (AMI).
[Methods]
[..] In this comparative effectiveness study, conducted from January 1, 2013, to December 31, 2015, we identified the top 1% and 5% highest-income counties for White US citizens using median family income from the 2015 Census Bureau’s Small Area Income and Poverty Estimates. Statistical analysis took place from July 25, 2017, to August 29, 2020. A total of 157 of 3142 counties were included for analysis of the 5% highest-income counties, with 32 representing the 1% highest-income counties. [..] We identified 12 comparison countries—Australia, Austria, Canada, Denmark, Finland, France, Germany, Japan, the Netherlands, Norway, Sweden, and Switzerland—that span 4 continents. We obtained mean annual income, per capita health expenditures, and life expectancy variables from the Organisation for Economic Co-operation and Development (OECD).
[Results]
The 157 richest US counties have a median household income of approximately $84 000, higher than the mean annual income in Switzerland (US $62 495), Norway (US $51 663), and the other comparison countries. Per capita health care expenditures in the highest-income US counties are not available, but the US had substantially higher per capita spending in 2015 than any other country—$9491 per capita, compared with US $7570 in Switzerland and US $6239 in Norway.
[..] The infant mortality rate among White US citizens in the 1% highest income counties is 3.54 per 1000 live births, while the 5% highest-income counties have an infant mortality rate of 4.01 per 1000 live births—higher than in all 12 comparison countries. [..] Among comparison countries, the infant mortality rate is lowest in Finland, at 1.70 per 1000 live births, and highest in Canada, with 4.70 per 1000 live births. Only 2 of the top 157 highest-income counties in the US have White infant mortality rates below that of Norway, and none have rates lower than Finland.
[..] The maternal mortality rate is 26.40 per 100 000 live births among all US women. Among White US women, the maternal mortality rate is 10.05 per 100 000 births in the 1% highest-income counties and 10.85 per 100 000 births in the 5% highest-income counties. Even in California, which has implemented a major initiative to reduce maternal mortality since 2006, the mortality rate for White mothers is 7.3 per 100 000 live births. Outside of the US, the worst-performing countries are Canada, with 6.00 maternal deaths per 100 000 births, and France, with 5.10 maternal deaths per 100 000 births.
The 5-year survival rate for colon cancer among all US citizens is 64.9% (95% CI, 64.7%-65.1%). For White US citizens in the 5% highest-income US counties, the survival rate is 67.2% (95% CI, 66.7%-67.7%). This survival rate was higher than that in 7 other countries but comparable to rates for average citizens in Canada, Japan, Norway, and Switzerland. However, average Australian citizens have a higher survival rate, at 70.7% (95% CI, 70.1%-71.2%), than privileged White US citizens.
The 5-year survival rate for breast cancer among White US women in the 5% highest-income US counties is 92.0% (95% CI, 91.6%-92.4%), higher than that for all US women with breast cancer (90.2% [95% CI, 90.1%-90.4%]). Breast cancer survival is higher in the US than for average citizens in all the comparator countries; the countries with the next highest breast cancer survival rates among average citizens are Australia (89.5% [95% CI, 89.1%-90.0%]), Japan (89.4% [95% CI, 88.9%-89.9%]), and Sweden (88.8% [95% CI, 88.2%-89.4%]).
The 5-year survival rate for ALL among average US children is 89.5% (95% CI, 88.8%-90.3%). The 5-year survival rate for White children in the 5% highest-income US counties is 92.6% (95% CI, 90.7%-94.2%). The survival rate for White children in the 5% highest-income US counties is higher than the survival rate in only 1 country—Norway—and is comparable in almost all other countries. Average children in Denmark (94.0% [95% CI, 90.1%-97.9%]) and Finland (95.2% [95% CI, 91.5%-98.9%]) have higher 5-year survival rates than White children in the 5% highest-income US counties, whose rate is similar to that of average children in Canada (92.6% [95% CI, 90.7%-94.6%]).
[..] The age-standardized and sex-standardized 30-day case-fatality rate for AMI among White US citizens 65 years or older in the wealthiest 1% of counties is 12.7%, somewhat above the 12.4% case-fatality rate for the top 5% of counties by income. These rates are significantly lower than for the general US population (13.4%) but substantially higher than in Norway (10.2%) and Denmark (10.7%).
As a sensitivity analysis, we considered case-fatality rates for White individuals in the Medicare program aged 65 years or older living in the top 5% of zip codes by income; for these patients, whose mean zip code income is $117 401, the case-fatality rate is 12.0%, which is less than the case-fatality rate for the 5% of counties with the highest income but, again, greater than in Norway and Denmark. For people in the lowest 5% of zip code income, the case-fatality rate is 14.7%, well above the US national mean. [..]
[Discussion]
The health outcomes of privileged White US citizens for 6 health outcomes are better than those for average US citizens; however, the health outcomes of privileged White US citizens for infant mortality, maternal mortality, and AMI are not consistently better than the outcomes of average residents in many other developed countries. For health conditions for which the outcomes are associated with the quality of health care, privileged US citizens—those who have high incomes and are White—do not always experience the best outcomes. Four points need emphasizing.
First, being well-off and White in the United States is associated with better health outcomes than those experienced by average US citizens. [..] In general, within the US, social and economic capital is able to “buy” more health care services and better health outcomes for conditions that may be improved by medical interventions. This is consistent with the well-established finding that being well-off in the US and other countries is associated with longer life expectancy and better survival for certain health outcomes.
[..] However, being a White US citizen living in the 1% or 5% highest-income counties does not guarantee the world’s best health outcomes; in general, the outcomes for these individuals are no better than for average citizens in many other developed countries, and for infant, maternal, and AMI mortality, privileged White US citizens often fare worse. The pattern with cancer is more complicated. Privileged White US citizens appear to have the best outcome in the world for breast cancer. That outcome is very likely due to the high rate of mammogram screening in the US, which is associated with higher rates of diagnosis of small cancers. However, if undetected, most of these small cancers would not have progressed to large cancers and caused death. Consequently, there is a high 5-year survival rate but not a lower overall breast cancer mortality rate because mammography does not increase detection of larger tumors. In the case of colon cancer, privileged White US citizens had better survival than average citizens in most of the comparator countries; for childhood ALL, survival rates were similar across countries.
Third, many US citizens equate high-quality care with freedom of choice. They believe that having choice will engender better care, reflected by their higher satisfaction and increased access to services compared with individuals living in low-income countries. This study suggests that this belief may be true in a relative sense, in that wealth can improve the outcomes for some conditions compared with lower-income US citizens, but not in an absolute sense, as wealth does not guarantee the world’s best outcomes. The improvements produced by choice can be small, as in breast cancer; in other cases, such as for AMI, a patient may not even be able to exercise much choice because they are taken quickly to whichever hospital is nearby. Thus, choice may not be sufficient to ensure the best outcomes.
Fourth, even if the dramatic and pervasive inequalities in the provision of US health care across race/ethnicity and socioeconomic status were resolved, so that every US citizen experienced health outcomes consistent with those of privileged US citizens, the US would still not rank among the best of comparison countries. This finding makes it critically important to ask why well-off White US citizens do not have measurably better outcomes—and sometimes have worse outcomes—than average people in other developed countries. Our results suggest—but do not prove—that health outcomes depend on the system of care, rather than the performance of individual physicians or hospitals. For example, Chen et al found that the US lagged far behind other countries in infant and maternal mortality primarily because of adverse events, such as respiratory disease and accidents, occurring during the postneonatal period, well after the mother and baby have left the hospital.
Similarly, research indicates that harmful adverse events that qualify as malpractice are not the result of bad actions by a single physician or nurse but rather are caused by substandard processes and organization of care. Good care is less likely to be a matter of any one outstanding physician, and more the result of excellent systems of care. It is not an individual physician, for example, who “saves” a patient with AMI, but rather the coordinated response by emergency medical technicians, emergency department physicians, specialists trained in percutaneous cardiac interventions, and nurses and other clinicians in coronary care units. Similarly, excellent care for colon cancer depends on surgeons, medical oncologists, pharmacists, infusion nurses, and many other health care professionals in both the acute and postacute settings.
Furthermore, avoiding hospital-acquired infections and other mistakes while being treated for these conditions does not depend on the care of a single physician. Therefore, choosing a concierge cardiologist or a hospital ranked highly by U.S. News & World Report may ensure prompt service and personalized attention, which have value, but it does not ensure the world’s best clinicians at each stage of care, at whatever facility is providing care, and does not ensure the best outcomes. A well-off US citizen cannot “buy out” of the uneven quality of care provided by the US health care system. To ensure the world’s best health outcomes requires improving care systematically, for all people at all facilities.”
Full article, Emanuel EJ, Gudbranson E, Parys JV et al. JAMA Internal Medicine 2020.12.28