The Metrics of Health System Performance do not Measure Efficiency
US health care: A reality check on cross-country comparisons
H.E. Frech, Stephen T. Parente, John Hoff
The Organisation for Economic Co-operation and Development (OECD) uses mortality metrics to measure health care system performance, but these data do not adequately indicate health status differences and do not accurately judge health care system efficiency. . .
This Outlook offers a brief critical assessment of international health system performance metrics. We will focus on three statistics that the OECD delves into in its report: infant mortality, life expectancy, and premature death. The strengths and weaknesses of these measures are illuminated through brief examples that ultimately demonstrate that the measures do not reflect the efficiency of any country’s health system. Given that organizations such as the OECD continually try to evaluate countries’ health systems, US policymakers and analysts must understand the limitations of such exercises. We conclude with suggested changes in approach and a road map for improved research.
Before describing the key metrics for international comparison, it is useful to recall the relatively recent origin of international health statistics. The OECD was created in 1948 as the Organisation for European Economic Co-operation (OEEC) to administer funds made available by the US Marshall Plan for the reconstruction of Europe after World War II. Later, the OEEC’s membership was extended beyond Europe. In 1961, it was reformed into the OECD. Today, its members are thirty-four developed countries.. . .
Health Status Metrics
A common misconception is that people value health care in and of itself. In reality, people value the improved health status that they hope to gain from receiving health care. Indeed, using most health care is unpleasant. Health status is not directly measurable; it can only be approximated through related factors that can be measured.
The OECD report focused on observable measures as proxies of health status to provide comparative statistics. A depressing reality is that these observable measures are all some derivative of mortality. The OECD expects all its member states to provide death registers as part of a planned, one-hundred-year public health mission to identify sources of death and time of death to track epidemiological emergencies such as those resulting from infectious diseases. In the service of OECD, mortality metrics are outcome measures that are meant to proxy health status and the output of health care systems, rather than the consumption of health services.
The OECD uses infant mortality, life expectancy, and premature death as measures of mortality in their report. The validity of each one of these measures as proxies for health system performance is examined below.
Infant Mortality. There are three overlapping OECD infant mortality measures: infant, neonatal, and perinatal mortality. Infant mortality is the number of deaths in the first year per one thousand live births. Neonatal mortality is the number of deaths in the first twenty-eight days per one thousand live births. Perinatal mortality is the number of deaths in the first week after birth, plus fetal deaths after twenty-eight weeks of gestation or fetuses that exceed a weight of one thousand grams.
Partly based on an argument by Nixon and Ullmann, the OECD report states that these infant mortality measures are less influenced by factors unrelated to the health care system than are other possible measures. However, we believe that the opposite is true. One major concern is that the basic definitions of infant mortality are not consistent across countries.
For example, babies who are not viable and who die quickly after birth are more likely to be classified as stillbirths in countries outside the United States, especially in Japan, Sweden, Norway, Ireland, the Netherlands, and France. This is especially likely for babies who die before their birth is legally registered. In the United States, however, nonviable births are often recorded as live births, making the US infant mortality rate appear misleadingly high. In a detailed study of medical records and birth and death certificates in Philadelphia, Gibson and colleagues found that infant mortality had been overstated by 40 percent, merely as a result of these nonviable births that were recorded as live births.
There is another problem with using infant mortality to represent health care efficacy. US physicians often go to great efforts—at the prenatal and postnatal stages—to save a baby with poor survival chances. The additional prenatal care an American doctor provides may improve the odds of the live birth of a baby with poor survival chances, who is then likely to require extensive neonatal care. Accordingly, the US uses substantially more neonatal intensive care units (NICU) than other industrialized countries. In this case, the additional health care may actually worsen reported infant mortality rates and misleadingly suggest poor care in the United States. Similarly, US physicians are more likely to resuscitate very small premature babies, many of whom nevertheless die and many others of whom live with serious and expensive medical problems. This practice also raises measured infant mortality rates for the United States.
The combination of higher delivery costs because of greater NICU use and the unique way the United States counts live births could lead one to erroneously conclude that the United States is highly inefficient compared to other industrialized nations. Furthermore, infant mortality is strongly and immediately affected by external influences such as the mother’s age, behavior, and lifestyle (meaning factors such as obesity and use of tobacco, alcohol, and illicit drugs). Infant mortality is strongly linked to birth weight and gestational age, which are highly, but not perfectly, correlated. Indeed, the correlation is high enough that researchers will often use one or the other measure according to conveniences. In any case, both measures are largely a result of parental lifestyles.
Teenage mothers are more likely to have preterm, low-birth-weight babies. The mortality rate for infants born to US teenage mothers is 1.5 to 3.5 times as high as the rate for infants born to mothers ages twenty-five to twenty-nine. The US rate of births for teenage mothers is very high—2.8 times that of Canada and 7.0 times that of Sweden and Japan. If the United States had the same birth weights as Canada, its infant mortality rate—adjusting for this variable alone—would be slightly lower than Canada’s (5.4 versus 5.5 per one thousand births).
Turning to gestational age, MacDorman and Mathews calculate that if the United States had the same distribution of gestational ages as Sweden, its recorded infant mortality rate would drop by 33 percent, tying it with France as the fifth lowest rate out of twenty-one developed countries. Moreover, in the United States, mortality rates for infants born to unwed mothers were about twice as high as for infants born to married women.
Overall, these lifestyle and socioeconomic factors may reflect poorly on some aspects of society in the United States in comparison to other countries. It is inappropriate, however, to conclude that the root cause is the US health care system rather than societal factors in a dynamic heterogeneous society. Infant mortality is a particularly misleading metric by which to grade country-specific health system performance and to make international comparisons. . .
Read more about the other variables, Life Expectancy and Premature Mortality which makes the comparisons even more invalid at http://www.aei.org/outlook/health/global-health/us-health-care-a-reality-check-on-cross-country-comparisons/
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