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Monday, October 26, 2009

Physician Responses to Apples are Apples Post

I posted my "Apples are Apples and Oranges are Oranges..." post on Sermo for commentary from real doctors in the trenches--not from the AMA.

dximgr Radiology
Edited Oct 25, 2009 at 8:11 PM
Dr. Virgil: There are several reasons to cast doubt on the WHO rankings. But this is not one of them: "I then pointed out to them that the average population of the European nations they had compared us to was about 50 million (ranging from 9 to 87 million) compared to 350 million in the US and that it was rather disingenuous to compare economies of scale in delivering and administering health care between countries with 9 to 87 million people (Sweden, Spain, France, England, and Germany) and ours with 350 million."Economies of scale allow one to SAVE money as the number of units increases. So if economies of scale played a role (and as I've expressed elsewhere on Sermo I don't think they do), it would lead one to assume the US, with its larger population, would have a lower cost per capita, not a higher one.So unless I'm completely misunderstanding your point, I don't think your reasoning works.

bpoterjoy Pediatrics
Posted Oct 25, 2009 at 8:18 PM
DrJ Your post here is a much longer version of a discussion I have had in non-professional forums. I have grown tired of continually hammering stat-quoters who really have no background in statistics, or who have had no formal instruction in critiquing data. So as to not rehash your well written post, I will simply say I fully agree with your comments. The one thing you left out is this- any meaningful comparison of the US v anyone is difficult not simply on population size, but on demographics- economics, race, social environment, etc. How does one compare the US, with a landmass the size of Europe and a more diverse population to, let's say Norway? I just don't think any comparison is valid. The dilemma is that the average person most likely does not have any exposure to an academic approach to data analysis, and is left with whatever he/she reads online or in the paper, or hears on television, and then quotes the data as if it is gospel.....sort of like the college student writing a term paper....or a med student doing journal club. Speaking for myself, it has taken a decade in medicine to get to reading the hypothesis, methods, and results...

rarmstrong Surgery, General
Posted Oct 25, 2009 at 8:43 PM
John, this subject has, of course been recognized and thoughtfully debated by many here on Sermo. To expect the media, politicians, pundits and others to be educated and honest about these numbers is kind of refreshing but as you have presented, is naive. So, how do you win a debate about health care in America with an uneducated, uninformed and easily inflamed public? You use statistics to lie, dramatize and support your opinion. This is operative, everywhere you look. If you are trying to sort it out...excellent! More of us should work to sort it out. Then, maybe we could form a rational informed opinion on how to proceed. You will not find this type of analysis in abundance inside of the beltway.

lawdoc Psychiatry
Posted Oct 25, 2009 at 9:49 PM
I would like a link to the reference that the editor was concerned about the methodology of the UN. I have often found the statistics problematic, but I have not seen the criticism you reference.Thanks.

theesist Anesthesiology
Posted Oct 25, 2009 at 9:53 PM
I don't know if you ran across these articles when researching for your blog, but here are a couple more that dispute our

slatosky Family Medicine
Posted Oct 26, 2009 at 9:09 AM
it is about expenditure not outcomes. if you take a country that has no medical care and everyone with breast cancer dies from it quickly and compare them to a country with great cancer survival rates you can then conclude that the country with no medical care has a lower percentage of people with breast cancer with a much lower expenditure. this is what was done in this study. If you were a patient with breast cancer where would you want to be.

rosevoran Internal Medicine
Posted Oct 26, 2009 at 9:36 AM
Power & Idealogy, this is what "Health Care Reform" is all about. Rarmstrong is right, statistics are used to lie.... This administration's goal is a socialist makeover of America. Controlling medical care is pivotal in this quest. There is no debating with them. Have you ever wondered why every one concerned (patients, physicians, pharmaceutical companies, DME companies, etc) will take a huge hit with the Obama plan...all except lawyers. There is no debate, this is a power grab.

Isledoc34 Pathology
Posted Oct 26, 2009 at 10:27 AM
One of my college texts was "How to Lie with Statistics". It seems to be the most popular texts in the WH today. Any good Socialist Govt. needs control, power, and money and will obtain their ends by whatever means available...lying being one of the best,

docvicolo Surgery, General
Posted Oct 26, 2009 at 10:34 AM
Nice Post and Comments. But can we really have any serious discussion about healthcare reform without showing our individual personal bias?.......... Not on Sermo. " Statistics is the art of drawing a crooked line from an unproved assumption to a foregone conclusion." (~ Emil Frankel )

jabmd1 Surgery, General
Posted Oct 26, 2009 at 11:00 AM
I think the key to the statistics is to compare the apples. When you compare surivial rates from many diseases the US is tops (especially cancers) To get high survivial you need to SPEND money. You spend the money on the screening, you spend the money on the treatment and you spend the money to find better treatments. I am in agreement with those that posted before me. This healthcare reform debate is all about power and trying to get a 50% majority vote for all time. Once a group of people have an entitlement program in place do you think any politician that wants to revoke it will garner any votes from the group that gets the entitlement.

lawdoc Psychiatry
Posted Oct 26, 2009 at 11:47 AM
Most of the time, it is not the statistics, it is the liars. There is rampant scientific illiteracy in this country, so the statistics are simply misused.Again, I would like to see the the actual comments of the editor. It should always be evident that we, in the USA, have social problems that pass as medical. When Farrakhan recently was encouraging black people to avoid the H1N1 vaccine, the outcomes will be reported as a failure of the medical "system." Why is it, that the failure to teach health as a meaningful course in the schools never gets mentioned as the main reason people don't know how to take care of themselves or know when it is appropriate to go see a doctor? Parents who don't know anything will only teach mis information to their kids.

Isledoc34 Pathology
Posted Oct 26, 2009 at 12:30 PM
Lawdoc, Re: "Why is it, that the failure to teach health as a meaningful course in the school never gets mentioned"... The schools all give sex education and hand out condums "to prevent disease" which is great Health Care. The kids also sing songs to BO which encompasses all of Health Care, doesn't it? It's disgusting, really.

drjrvigil Surgery, General
Edited Oct 26, 2009 at 1:04 PM are absolutely correct that economy of scale allows the ability of producing or supplying a commodity at a decreased price..but this hold true only to a point until discoordination occurs in management, inefficicney rises and average total cost of production increases again forming a U-shaped curve (this is called diseconomy of scale). E.g. General Motors. Hence it is ok to compare economies of scale between 9 million and 50 million, but somewhat of a stretch to go from 50 million to 350 million.

dximgr Radiology
Posted Oct 26, 2009 at 1:06 PM
That's exactly why, Dr. Vigil, I said above (and elaborated in prior Sermo comments) that I don't think "economies of scale" explains much in healthcare comparisons among nations. Economies of scale explain things at the level of the factory. When we talk about larger entities, another economic principle swamps it: Diminishing marginal returns.My point was merely theoretical. IF you believe economies of scale plays a role among national healthcare programs, THEN you'd expect the larger ones to be more economically efficient. But if I read you correctly, you were arguing the opposite: that the US, larger, doing worse than European countries, smaller, was explained by "economies of scale." My apologies if this was not your original claim.(If you wish to make some complicated "U-shaped" curve argument, than it's all an empirical question, and you'd need to provide numbers rather than just say it's all explainable by 'economies of scale'.)

drjrvigil Surgery, General
Posted Oct 26, 2009 at 1:06 PM
bpoterjoy, You hit the nail right on the fact that was one of the main reason that the WHO stopped the rankings because of the difficulties in comparing demographics, race, socioeconomic variables, and etc.

drjrvigil Surgery, General
Posted Oct 26, 2009 at 1:20 PM
lawdoc, here is the link and a summary. Judging health systems: reflections on WHO's methods Philip Musgrove PhD a Summary The attainment values in WHO's World Health Report 20001 are spurious: only 39% are country-level observations. The responsiveness indicators are not comparable across countries; and three values obtained from expert informants were discarded in favour of imputed values. Indices of composite attainment and performance are based on imputations and thus are also meaningless. Member governments were not informed of the methods and sometimes suffered unjust criticism because of the rankings. Judgments about performance should be based on real data, represent methodological consensus, be built from less aggregated levels, and be useful for policy.

drjrvigil Surgery, General
Posted Oct 26, 2009 at 1:36 PM
dximgr I think we are argiung the same thing. Diminshing marginal return is what makes the U curve slope upwards again. Economy of scale can apply to factories as well as organizations (goods vs services). My argument was that while a single payer system may--and the key word is may--work in smaller countries with populations of the European countries, that it is impossible to extrapolate or assume that that type of system would work in a country with a much larger economy of scale and that in fact, there would be the real and likely possibility that applying such a sytstem to our population would result in diseconomy of scale

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