Gauging the health of our health care system
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* Noralou P. Roos

David Zitner suggests that it is unacceptable that only 50% of Canadians said that the medical care they or their family had received was very good or excellent. It is important to put this statistic into perspective. Statistics from the neighbours to the south suggest that the Canadian health care “industry” is not doing that badly. That is, 52% of Americans “completely agree” that “there is something seriously wrong with [the US] health care system” and an additional 27% agree somewhat with this statement.1 Another 49% of Americans agree completely (and 25% agree somewhat) that “quality care is often compromised by insurance companies to save money.” 

Although it is true that in another series of polls 59% of Canadian generalist physicians reported that things have “gotten worse” relative to their ability to provide quality care, 56% of US generalist physicians made the same assessment about their system.2 Perhaps the most revealing comparisons relate to physicians' concerns for the future. Canadian physicians were more concerned that “patients will wait longer than they should for medical treatment” than American physicians (74% v. 43%) On the other hand, American physicians were more concerned that “patients will not be able to afford the care they need” (54% of American physicians v. 32% of Canadian physicians). And since so many Americans feel that their system puts profits ahead of people, it is clear that many patients in the United States do not even trust their physicians to do what is in their best interests — a situation that erodes the core of the physician–patient relationship.

Ralph Hawkins is right that death rates have been declining steadily for decades in the United States, the United Kingdom, Western Europe and Australia. Hawkins fails to mention that acute care capacity has also been declining dramatically in all of these jurisdictions, just as it did in British Columbia. For example, between 1985 and 1995, days of care in US short-stay hospitals declined by 38%.3 Declines in the United Kingdom, Western Europe and Australia have been similarly steep. The same pattern —decrease in acute care beds and improvement in health — has occurred across Canada, including British Columbia.4 For example, mortality rates fell 7.4% in Manitoba between 1987 and 1996; over the same period, hospital days per capita decreased by 23%. Changes in Ontario were even more dramatic: mortality rates fell 10.7% over a period when hospital use was essentially cut in half.

Following Hawkins' logic, should we conclude that the “obvious answer” is that a decline in acute care capacity has a demonstrably beneficial effect on population health? Obviously not. Hawkins' letter criticizing the piece by Sheps and colleagues5 is precisely the type of untempered claim on the part of the stakeholders that leads to the disconnect between the headlines and the facts.6 Rather than assumptions that the Canadian health care system can't get it right, that more medical care must be better and that any decrease in medical spending represents a threat to life and limb, we need collaboration between medical professionals and health care researchers to better understand how well or poorly the system is working, and more importantly, the actual role of medical care in making and keeping people healthy.

## References

1.  1. National Coalition on Health Care. How Americans perceive the health care system: a report on a national survey. J Health Care Finance 1997; 23(4):12–20.
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=9211148&link_type=MED&atom=%2Fcmaj%2F164%2F3%2F325.2.atom) 

2.  2. *The Commonwealth Fund 2000 international health policy survey of physicians*. New York: The Commonwealth Fund; 2000.
    
    

3.  3. National Center for Health Statistics. *Health, United States, 1998 with socioeconomic status and health chartbook*. Hyattsville (MD): The Center; 1998.
    
    

4.  4. Statistics Canada. Average stay in hospitals: day's stay in hospital, separations, and average length of hospital stay by chapter (diagnostic 19), age groups (6) and sex (3), for Canada, provinces and territories, 1969–70 to 1996–97. In: Health indicators [computer file]. Ottawa: Statistics Canada, Health Statistics Division; 1999.
    
    

5.  5. Sheps SB, Reid RJ, Barer ML, Krueger H, McGrail KM, Green B, et al. Hospital downsizing and trends in health care use among elderly people in British Columbia. CMAJ 2000;163(4): 397-401.
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czo5OiIxNjMvNC8zOTciO3M6NDoiYXRvbSI7czoyMjoiL2NtYWovMTY0LzMvMzI1LjIuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

6.  6. Roos NP. The disconnect between the data and the headlines [commentary]. CMAJ 2000;163(4): 411-2.
    
    [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czo5OiIxNjMvNC80MTEiO3M6NDoiYXRvbSI7czoyMjoiL2NtYWovMTY0LzMvMzI1LjIuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9)