The inaugural issue of Open Medicine published a systematic review of health outcomes in Canada and the U.S. which purported to show that “…although Canadian outcomes were more often superior to US outcomes than the reverse, neither the United States nor Canada can claim hegemony in terms of quality of medical care and the resultant patient-important outcomes.” This despite the fact, as the authors point out, that the U.S. spends nearly twice as much per capita on health care as Canada. At face value it doesn’t speak well for the U.S. free market model. Although several bloggers jumped on this sound bite uncritically it’s worth digging deeper.
First, the conflict of interest disclosure reads “Competing interests: None declared.” That may be literally true but it’s deceptive. No conflicts were declared but they certainly do exist. Not very open for an open medical journal, I’d say. It took some serious Googling on my part to find the conflicts.
What I found was that several of the authors are political activists and staunch advocates for the Canadian model. Co-author Steffie Woolhandler, for example, was profiled thusly in the New York Times: “Her plan is simple. Get rid of the private health insurance industry and abolish Medicaid, the government's health insurance program for the poor. In their stead, set up a national health insurance system that would cover all Americans by expanding Medicare, the old-style Medicare, to include everyone from birth to death.” A co-founder of Physicians for a National Health Program, (PNHP) she’s also on their speaker’s bureau and a board member of the organization. The John Goodman Health Blog had this to say about her: “Not if you're Steffie Woolhandler, who along with her husband, David Himmelstein, has spent years urging Americans to adopt Canada's healthcare system.” Himmelstein by the way is another of the co-authors of the paper. Kevin had a few choice words about an earlier Woolhandler study here.
Lead author Gordon Guyatt appears to have a similar conflict. He’s been a political candidate for the socialist-leaning New Democratic Party which advocates for government health care and the end of privatization. He was taken to task before for not declaring this obvious competing interest.
Another of the authors, Armine Yalnizyan, has been a vigorous advocate for the Canadian model as evidenced by these writings.
The methods session of the paper is no more open than the conflict of interest statement. We are told that “Interested readers can obtain the detailed protocol for this review from the corresponding author.” That’s right; you have to email the authors to get the search strategy. It would appear, though, that the search strategy was not predetermined; rather, it was “iterative”, almost as if they made it up as they went along. Then they culled the list of retrieved citations down from 4923 down to 38. We’re not told exactly how this was done or by whom, but it appears to have been a complicated procedure, and to the reader it’s somewhat mysterious.
Even if this review is valid it’s nothing new. No one is claiming that patients in the U.S. live longer. This paper, from where I sit, smacks of activism for single payer health care disguised as research.