16 January 2008

Liver transplant outcomes better in UK

Maggie Mahar, author of one of the best books on our health care mess, Money-Driven Medicine: The Real Reason Health Care Costs So Much, has a good article at her blog on cherry picking numbers to "prove" that the U.S. has best health care in the world.

Mahar researched the numbers behind the Wall Street Journal column on Nataline Sarkisyan, the 17-year-old California girl who died last month after her insurance company refused to pay for a transplant. That column's author referred to an unnamed British medical journal study on survival rates for transplants for people suffering from chronic liver disease and acute liver disease.

Mahar begins her rebuttal by asking whether fact that we perform a greater number of transplants on seriously ill patients is reason to claim that U.S. health care is better — "or does it simply mean that we are more inclined to experiment on our sickest patients?"
It all depends on how well the average patient who is plucked out of the ICU to undergo a liver transplant fares. If he or she goes on to enjoy several years of high quality life, one would be inclined to say “yes”—our more aggressive care equals better care. But if too many patients suffer complications and then die in great pain twelve or 15 months later, it would be much harder to argue that “doing more” makes U.S. healthcare “better”—especially when both the money and the liver could have been spent on another patient who had a better chance of surviving.
She found the study used by the WSJ writer. She writes that indeed it found that patients' five-year mortality after transplants for acute liver failure, the type from which Ms. Sarkisyan presumably suffered, was about 5% higher in the U.K. and Ireland than the U.S. The WSJ author also cherry picked this statistic: "in the period right after surgery, death rates were as much as 27% higher in the U.K. and Ireland than in the U.S., although differences in longer-term outcomes equilibrated once patients survived the first year of their transplant.”

Meaning that by the end of the first year, the differences canceled each other out. Mahar writes:
Begin with how the patients were faring during the first 90 days... during this time, mortality rates in the U.S. were lower (regardless of whether patients had originally suffered from acute or chronic liver diseases.) This is, in large part, the article suggests, due to lower nurse/patient ratios in the U.S. and more intensive care during the first weeks following surgery.

But what Gottlieb omits is the crucial fact that, when the researchers went back and looked at “patients who survived the first post-transplant year,” they discovered that “patients who had suffered from chronic liver disease in the U.K. and Ireland had a lower overall risk-adjusted mortality” than patients in the U.S. In other words, survival rates for patients who had a chronic disease before the transplant were better in the U.K. and Ireland. As for patients suffering from acute liver disease, longer-term survival rates past one year were just as good in the U.K. and Ireland as in the U.S. Moreover, if you checked patients in the interval between 90 days and one year, outcomes were similar in the two health care systems.
So in fact, "Outcomes in the U.K./Ireland were just as good for one group and decidedly better for the second... "

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