12 January 2008

Single-payer & Nataline Sarkisyan

Christopher M. Hughes, MD, has a wonderful post in his blog, Single-Payer Healthcare Blog. Dr. Hughes replies to what has evidently become a backlash against the outcry against what happened to Nataline Sarkisyan. He writes:
The staunchest advocates for Single Payer Healthcare never, ever, disparage American medicine's ability to deliver the best care in the world in areas such as organ transplant, trauma, intensive care and other high tech endeavors. But these areas are only a sliver of overall clinical outcomes. Even at the quoted 18.5 liver transplants per million done in the US annually, this is only 5000 or so patients. So, while not being dismissive of these patients, they are not reflective of healthcare outcomes of our population. They only reflect what we already know: We spend tons of money on advancing high tech medicine and we are darn good at it. As I view the transition to single payer, I see no reason, other than "conservatives" wailing about unnecessary spending on healthcare as the system matures, for us to continue to do well in our "American specialty" of bleeding edge healthcare.

It looks like Dr. Hughes began his blog about the same time I launched Ave Cassandra, maybe a month later, and that he posts about a dozen times a month. And that he's smart. I added his blog to Ave Cassandra links.

In that Wall Street Journal commentary, I was struck by the numbers —
In 2002 -- a year comparative data is available -- U.S. doctors performed 18.5 liver transplants per one million Americans. This is significantly more than in the U.K. or in single-payer France, which performed 4.6 per million citizens, or in Canada, which performed 10 per million.

What about the differences in outcomes between ours and single-payer systems, an issue Mr. Edwards hasn't directly addressed? One recent study 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 Irleand than the U.S. The same study also found that 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.

These findings aren't confined to transplanted livers. A study in the Journal of Heart and Lung Transplantation compared statistics on heart transplants over the mid 1990s. It found patients were more likely to receive hearts in the U.S., even when they were older and sicker. The rate was 8.8 transplants per one million people, compared to 5.4 in the U.K. Over the same period, about 15% of patients died while waiting for new hearts in the U.K. compared to 12% in the U.S. In 2006, there were 28,931 transplants of all organ types in the U.S., 96.8 transplants for every one million Americans. There were 2,999 total organ transplants in the U.K., 49.5 transplants for every one million British citizens.
When you read the Commonwealth Fund studies, the analysts there often say that no one country is better than others in outcomes overall — we're best at some stuff, France is best at some things, Britain for something else... but that the U.S. falls down completely when the fact that we spend so much and exclude so many is taken into account.

Unless there is other data that the WSJ author (a physician and right-wing American Enterprise Institute resident fellow) is leaving out, one would assume that transplants are one of the areas in which the U.S. is ahead in terms of practice and outcomes.

I'd be interested in knowing what else goes into these transplant numbers — for instance, the rate of donated organs and their availability, the need for transplants, whether some of our transplants are done on patients that get some other kind of treatment there, and the average age of transplant recipients in the various countries.

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