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‘The U.S. spends more per person on health care than any other country, but in overall quality, its care ranks 37th in the world, says a World Health Organization (WHO) analysis.’ N Y Times June 20, 2000
"The American healthcare system is at once the most expensive and the most inadequate system in the developed world," Dr. Marcia Angell, editor of the New England Journal of Medicine (1999;340:48) The following comments are specific to the USA health system but the trends in terms of cost and quality of clinical decision making substantially characterise the Australian and European systems as well. Health CostsThe USA health system is in serious trouble with rapidly escalating costs. Insurance companies are currently estimating an annual increase of 15% in medical costs, when the USA already spends approx. 16.5% of GDP on health compared to many other developed countries where figures are of the order of 8-9% of GDP.Quality in Healthcare
In contrast to the cost of healthcare, only recently has public attention been focused on the question of quality, an important issue in its own right but also one of the major contributors to health costs. The central problem is clinical decision making. The current appalling average level of clinical decision making was most recently disclosed in the March 1, 2001 US Government sponsored Washington Institute of Medicine (WIM) survey of health care in America. The report was titled ‘Crossing the Quality Chasm’ and was endorsed by every major medical group in the USA. It surprised many outside of the health field for the first time. The report quantitatively confirmed Dr Angell’s above evaluation and the WHO analysis. The following excerpt is from Associated Press’s summary of the report on March 2, 2001 `The frustration levels of both patients and clinicians have probably never been higher,'' the report said. ``Health care today harms too frequently and routinely fails to deliver its potential benefits.'' Among the most alarming findings: It can take 17 years for important medical discoveries to become accepted and used by the average doctor. For example, heart medicines called beta blockers were proved more than 10 years ago to increase significantly a person's chances of survival after a heart attack. But nearly half of heart attack victims still do not receive them, said Dr. Lucian Leape of Harvard University, a co-author of the report.’ The world’s foremost medical journal, The Lancet, on Sept 29, 2000 reported a large outcome analysis on women who’d had lumpectomies for breast cancer. It was a follow up study of 143,000 women who had received breast cancer treatment in America between 1983 and 1995. Clearly patients or their relatives at the time were unaware of the very substantial research that reflected on this critical decision making. Some 35 % of them had not had lymph node biopsies or radiation treatment, very important concurrent treatments, well documented since 1980. Without these, the breast cancer recurrence rate doubles. THE COST OF POOR CLINICAL DECISION MAKINGApart from the enormous significance for human morbidity and mortality no one has ever quantified the cost to the USA of this inadequate clinical decision making. The best estimate probably comes from the leading expert on health quality in America, Dr Donald Berwick. The following is from a National Press Club speech by David Lawrence, MD, chairman and CEO, Kaiser Foundation Health Plan & Hospitals, July 14, 1999‘Improvements in patient safety should pay for themselves. Dr. Donald Berwick, president of the Institute for Healthcare Improvement, estimates that we would reduce the nation's health care bill by 30% (a saving of $333 billion in 1999) if we applied across the health care system what we already know. The evidence is persuasive: just as in other sectors of our economy, it costs less to do things right for our patients than to fix the consequences. Our science, our technology, our medical care, our understanding of what works and what doesn't in medicine are the best in the world and getting better. But the care which is delivered in this country is compromised by the delivery system through which most Americans receive it. That century old system can no longer do the job. It is obsolete.’ The way that poor clinical decision making drives costs is through-
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