Saturday, April 28, 2007

Canada’s health care is at least as good as in the U.S., and that’s evidence based!

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.


Greg P said...

The biggest fear that I, and I suspect many, have is that creating some kind of single-payor system will create a massive bureaucracy which will be horribly inefficient and underfunded, in the end perhaps getting less of its intended resources to the end result of delivering health care than the current system.
The current system, largely with private companies paying the bills, is based on each of these companies taking risk, then being allowed to take profits based on that risk.
The biggest problem is that there is an ever-increasing greed in this system. We might do better to limit profits, limit executive compensation, while having the government help with the risk aspect so that people of all levels of income can be guaranteed the right and ability to obtain health insurance.
The precedent for the government doing this is the regulations and restrictions that we have as health care providers -- all sorts of barriers for us as physicians to set up companies that profit from the orders for medicines, equipment, and other services. As a rehab physician, I probably order millions of dollars worth of equipment for patients every year, yet I am barred from owning a company that I might do business with - conflict of interest.
Why should health insurance companies profit from denying health care services? Isn't that a similar conflict of interest?

Dean Giustini - blogger said...

Hi Dr. R.W.,

My name is Dean Giustini, and I am the OM blogger.

I think it's important for you to share some of your ideas over at the OM blog - we can have a debate. My sense is that there
are demonstrable differences between the appearance of conflict and actual conflicts of interest. Further, would you agree that there is a measurable difference
between someone's political views resulting in bias, and actual scientific bias? The Guyatt article is not, as you suggest, favouring Canada's health
system because he is left-wing but, rather, because the systematic review he and his international group of researchers did found that to be a reasonable conclusion arising from 38 studies.

I believe that positive or negative statements regarding actual conflicts of interest are sufficient to alert readers to potential biases within studies.

Dean Giustini, Associate Editor, OM Blogger

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