Rome is Burning

bfeedback on Saturday, November 23, 2019 – 03:56 pm

Forums:

Other Stuff

November 18, 2019

BY: ROBERT CALIFF, MD, MACC

Healthcare in the United States has long been viewed by the public as “the best in the world”; a view defended by American politicians who often rebuke those who question it.[1] However, increasingly comprehensive data illuminate both the health of global populations and the functioning of the healthcare systems that serve them, and these analyses yield a strikingly different picture.[2] Dissembling and deflection are no longer possible, as numerous recent reports highlight alarming health challenges now unfolding in the United States—challenges that demand the focused attention of the national healthcare system, its leaders and clinicians, and American society at large.

National trends toward increasing degrees of segregation between people with current and projected poor health outcomes and those who are experiencing unparalleled longevity and quality of life has led to a pernicious dissociation, whereby privileged pockets of society lack a sense of urgency about taking action to bridge this gap. As a result, we find ourselves at a critical juncture: either we actively deal with the underlying factors driving these outcomes, or face what will likely be devastating results for the future of the United States.

The Downward Trajectory of American Health

The United States has now seen 5 years of steady decline in average life expectancy.[3] Compared with the average of economically developed countries, we fall short by more than 2 years, and almost 4 years short of countries with highest life expectancy.[4] Life expectancy continues to climb among all 18 highest-income countries—all except for the United States, and more recently, the United Kingdom.[5],[6]Last among peers in terms of life expectancy, the United States is also seeing a widening gap between its outcomes and those of the next-to-last country on the list. This pattern is particularly alarming when we consider that regression to the mean would tend to make the U.S. look better over time relative to other countries.

However, this wide-angle view based on global comparisons tells only part of the story. Murray and colleagues’ landmark “Eight Americas” paper[7] shows that when Americans are examined by sex, race, and ethnicity, major differences in life expectancy appear. More recent data[8] confirms that wealth, education, sex, and race account for a high proportion of variability in life expectancy. Contemporary trends now show modest narrowing of racial differences, albeit with disturbing widening of differences as a function of wealth and education.[9] We have long known known that these social factors are primary determinants of health,[10] and an examination of outcomes using a geospatial framework provides a clear picture of variation that tracks with these factors. At the level of regions, states, counties, and neighborhoods, combinations of these factors are associated with lower life expectancy, increased disease prevalence, and reduced functional status.

Because these outcomes are driven by multidimensional factors, they resist simple categorization. For example, middle-aged white men in the middle swath of the U.S. from Oklahoma to West Virginia8 have experienced a dramatic deterioration of life expectancy with concerning indicators of poor future outcomes. But at the same time, non-Hispanic Black women have an appallingly elevated risk of pregnancy-related death that is not wholly explained by sociodemographic characteristics[11]—a persistent disparity that contributes to the United States’ recent poor overall maternal health statistics.[12]

In general, the public health in rural areas is deteriorating, while urban areas and university towns continue to see overall improvements in life span and function. In urban areas, wealthier neighborhoods fare better, with projections of increasing dissociation from poor ones as people with higher educational status sort themselves into areas where wealth and good health outcomes are already concentrated. In short, demographic trends point to increasing segregation of neighborhoods by income and education, while race remains an important factor.[13],[14]

What Can Be Done?

Amid these ominous trends, we also see cause for hope. Many of these differences in social factors are manifested in familiar biological measures— hypertension, elevated LDL cholesterol, smoking, lack of exercise, elevated blood glucose levels/diabetes, and obesity—that can be modified by the use of readily available, inexpensive therapies.8 People who can regulate and limit these risk factors have better health outcomes regardless of wealth or education, while those in whom these factors are not adequately controlled have worse outcomes.

The issues of drug overdose, opioid addiction, depression, and suicide deserve intensive national attention, as they are among the most significant drivers of negative survival trends. The particular role that the proliferation of guns plays with regard to suicide rates also merits serious evaluation,[15] because attempted suicide is much more likely to have a lethal outcome when guns are used as the method. While the etiology of these negative outcomes and the uptick in cardiometabolic disease is complex, these trends are undoubtedly rooted to some extent in a constellation of behavioral determinants termed “diseases of despair.”[16]

A common American response to this information is initial disbelief, followed by a reaction that dismisses the problem as too big for individuals or health systems to address. Even leaders of large institutions and corporations tend to stay in their lanes, focusing on optimizing institutional operations within the financial rules that govern their policies and their missions. However, a different kind of action is needed—swiftly, and at multiple levels—that will require leaders to reach beyond their organizations’ usual practices.

Better policies can enable significant progress in this arena. Alone among the 18 highest-income countries, the United States has not embraced the concept of healthcare as a fundamental right; it has also earned a dubious distinction for its poorly organized primary-care system. We also allocate a much smaller proportion of our healthcare-related societal investment to social services than do comparable countries, a disparity recently emphasized by the National Academy of Medicine.[17] While the Affordable Care Act (ACA) has moved the US healthcare system toward active intervention, multiple analyses indicate worse health outcomes in states that did not expand Medicaid under the ACA.[18]

In addition, the coalescence of health systems should encourage accountable care for the populations they serve. One of the most significant changes in American healthcare has been the absorption of clinicians and facilities into a limited number of health systems.[19] Loss of competition has coincided with a measurable increase in prices, but tying payment to accurately measured elements of the widely touted “quadruple aim”—better outcomes, better patient and family experience, lower costs, and improved clinician experience—could lead to sustainable improvements in outcomes at reasonable cost. Previous divides among biomedical, behavioral, and social interventions can be surmounted now that the digital age enables integration of services, and ongoing integration of social services into Medicare and Medicaid payments represents a positive move in this direction.[20],[21]

A different kind of action is needed—swiftly, and at multiple levels—that will require leaders to reach beyond their organizations’ usual practices.

Changing these national trends is a task beyond the scope of any single person or health system. On the other hand, participating in the broader social/political system and in the governance of health systems provide an opportunity to make a real difference. It will be particularly important for individuals to support efforts to change approaches to clinical care and the integration of social and medical services—and to speak out when choices driven by financial optimization are contrary to patient outcomes.

An additional area that deserves emphasis is communication. Ubiquitous internet access ensures that any question that arises about health can be instantaneously answered—whether correctly or not. Unfortunately, misinformation and disinformation are common, including purposefully damaging information on topics such as vaccines and statins.[22],[23] Combating misinformation poses distinct communications and public-engagement challenges, as scientifically valid information requires acknowledgement of uncertainty and the inevitable evolution of scientific knowledge, whereas untruthful information is often depicted as definitive. Solutions to countering medical misinformation require consensus by multidisciplinary groups, and universities with major health systems are particularly well-suited to take on this daunting issue.[24]

While current measurements in key indicators of health status suggest general directions for change, the same enhanced information capabilities enabled by the ongoing “4th Industrial Revolution” offer not only the capacity to make changes, but also to evaluate the effects of those changes and rapidly revise and optimize approaches in ways that previously were impractical or impossible. Now that almost all Americans have electronic health records, health outcomes and intermediate biological measures can be assayed at shorter intervals. In addition, the latency of available data is declining in a manner that should lead to increasingly accurate and timely dashboards that can be produced at the level of a neighborhood, voting precinct, county, or state. Involving both healthcare professionals and lay people in assessing and understanding these data may prove an especially effective way to motivate interest in new strategies and behaviors.

Matching Quality to Expectations

The United States is on a downward trajectory for multiple important health outcomes. Decisive action is needed to bend these curves; merely hoping that the situation will improve on its own will not suffice. Although underlying causes are complex, substantive engagement from healthcare systems and local leaders provides a basis for intervention at the individual, health system, and policy levels, and recent advances in digital technologies will accelerate measurement and intervention at all scales. By bringing to bear a combination of policy, health system, clinical practice, social services, and social media interventions on our country’s ongoing health challenges, we have the opportunity to transform the U.S. healthcare system into one whose actual quality matches our expectations.

DISCLOSURES

Dr. Robert Califf sits on the corporate board for Cytokinetics and is board chair for the People-Centered Research Foundation. He receives personal fees for consulting from Merck, Amgen, Biogen, Genentech, Eli Lilly, and Boehringer Ingelheim. He is also employed as an advisor by Verily Life Sciences (Alphabet).