US Falls Behind Other Countries in Avoidable Deaths

This transcript has been edited for clarity. 

Welcome to Impact Factor, your weekly dose of commentary on a new medical study. I’m Dr F. Perry Wilson from the Yale School of Medicine.

It doesn’t really matter what metric you choose. When you compare healthcare outcomes in the United States with other developed nations, we don’t stack up too well.

Among the 38 countries in the Organization for Economic Co-operation and Development (OECD), the US ranks #1 in healthcare expenditure per capita, #1 in healthcare expenditure as a percentage of GDP, and #1 in the percent of overweight or obesity. And that’s basically it for our superlatives.

We rank 33 out of 38 in infant mortality. We are 29 out of 38 for life expectancy at age 65, between Greece and Estonia. 

We do a bit better for cancer mortality — 10^th — better than Costa Rica, worse than Sweden.

People can take issue with all of these metrics. They all have their flaws, and of course none of them really captures the big question — the whole picture — which is basically “how good is our country at taking care of the health of its population?”

There’s one metric, though, that does a better job than most at answering that question: the avoidable death rate. I’ll explain exactly what that means in a minute, but suffice it to say that based on that metric, the United States is doing really, really badly. 

OK, what is an “avoidable” death? It feels a bit meta-physical, doesn’t it? But we actually don’t have to worry about the vicissitudes of the universe or the nature of causality here, because epidemiologists already have a very well-defined framework for how to count various deaths — and what they define as avoidable is actually quite broad. Their definition basically categorizes a death as avoidable if it could potentially not have happened in a perfect world, for lack of a better phrase.

There are two types of avoidable deaths. The first are deaths that are preventable, in theory. These are things like traffic-deaths or deaths due to smoking or obesity-related deaths or drug abuse.

The idea here is not that every single car accident is avoidable or that every single case of lung cancer in a smoker could be prevented but that, broadly, if we delivered perfect public health and perfect medical interventions, we could potentially save this life using technology available to us today. So we’ve got these deaths that we basically say we “failed to prevent”. 

And then we have treatable deaths. These are deaths that occur due to inadequate medical care. Think deaths from sepsis for example, or even deaths due to poor management of chronic diseases like hypertension or diabetes. Like, if we had a perfect healthcare system, using current technology and meds with perfect patient adherence, we can say that a death due to complications from diabetes could have been avoided.

If you think about “avoidable deaths” in this way — you realize quickly that almost every death is avoidable. There are exceptions. Death from old age is, for now at least, not avoidable. Deaths from currently incurable diseases — genetic disorders, Huntington’s disease or something — are not avoidable. But, if we’re talking about a population under age 75 say, the vast majority of deaths really are, in theory, avoidable. This is the “we can do better” metric. And that’s what I like about it so much.

Avoidable deaths are on my mind this week for a few reasons, including the quite-clearly avoidable deaths that have occurred in the latest measles outbreak, but equally as importantly because of this study, just published in JAMA Internal Medicine, which ranks the United States against other OECD countries in terms of avoidable deaths. It isn’t pretty.

Let’s start with the big picture. In 2019, prior to the pandemic, the United States ranked somewhere between the Czech Republic and Croatia in terms of avoidable mortality. Considering that we spend five-fold more per capita on healthcare than these countries, that is a real indictment on our system of care.

But this study goes a bit deeper than just the country level. They actually break down all of this by state. This is really important because states vary quite a bit in how they deliver healthcare and what they prioritize. Some states engaged in Medicaid expansion, for example, while others didn’t. States have different policies regarding gun control, abortion access, vaccination and so on. So we might expect there to be a fair amount of variability in this metric state-by-state.

And there is, certainly. But look at what happens when we break down avoidable deaths by state — almost all the US states, in red, from our best-performing Minnesota to our worst-performing Mississippi, perform worse than the majority of OECD countries, in blue. 

It gets worse.

From 2009 to 2019, nearly every OECD country had a decrease in avoidable mortality rates. Every single US state had an increase. Every one. While the rest of the world was saving lives, we were saving fewer. And that’s before the pandemic. We’ll get to the pandemic in a minute.

But first, where did all these avoidable deaths come from? Were they preventable or treatable? Far and away the place we lost ground was in preventable deaths. 76% of the change in avoidable deaths in the US were from preventable deaths. And of those preventable deaths, just over 70% were from drug overdoses.

In contrast, the other OECD countries were reducing preventable deaths over this time frame. 

Now I don’t want to cast all the blame on drug overdoses here — US states, by and large, also saw an increase in preventable deaths due to traffic accidents, homicides and suicides and an increase in treatable deaths due to cancers. But still, if there’s an elephant in the room here, it is the epidemic of drug abuse over the past decade in this country. Something we, quite clearly, have failed to address. 

I said I’d address the COVID pandemic, and as you might expect, nearly every country in the OECD saw an increase in the avoidable death rate during COVID — the only exceptions were Denmark and Australia. The avoidable death rate increased across all US states during COVID, and at a rate that exceeded most OECD countries. The worst-performing state, Mississippi, had an increase in avoidable deaths just under Bulgaria and Mexico. The best performing state, Massachusetts, still had an avoidable death rate higher than 15 OECD countries. You can see in red here that the vast majority of the increase in avoidable deaths were due to deaths from COVID-19.

Does spending more money avoid more deaths? In most of the world, the answer seems to be yes. This graph plots health expenditures per capita against the avoidable death rate and the trend is clear — more money, less deaths. 

But let’s add the US states to the plot. Virtually no relationship. 

You have states that spend relatively little money on healthcare (by US standards) but have a lower rate of avoidable deaths — like Utah. And you have states that spend a lot but don’t seem to avoid deaths because of it — like West Virginia. In the US, in contrast to the rest of the world, healthcare spending is dissociated from outcomes.

This implies that the solution to our poor health outcomes in the United States is not to simply “throw money at it” — we’ve been doing that for a long time now. It doesn’t seem to be working. Even state-by-state, we don’t see a real bang-for-the-buck signal. What that means is that there are overarching, national issues that drive these outcomes. I think that drug overdoses are a symptom of these overarching issues. 

So what is different about the United States as a whole compared to the rest of the world? The first thing that comes to mind is that we don’t have universal health care, in contrast to basically every other developed country. It’s hard to prevent deaths or treat diseases when people can’t access the care they need. The United States also doesn’t really have a public health service — not in the way other European countries do. Instead, we rely on a patchwork of state and local officials with limited national coordination. This hinders national responses to national threats — like COVID-19, or the opioid epidemic. 

Those of you who know me know I am a believer in American exceptionalism, but this is not the way I want to be exceptional. If metric after metric — avoidable deaths, infant mortality, maternal mortality, life expectancy — are all telling us we’re doing a bad job delivering healthcare to our community, it becomes more and more difficult to excuse this as due to the quirks of American history and culture. It’s time we own up to the fact that these results, these bad results, are themselves the results of choices we have made. As a people. As a country. And these choices, thankfully, are not set in stone. Perhaps with some changes, falling further behind other developed nations can be avoided.

F. Perry Wilson, MD, MSCE, is an associate professor of medicine and public health and director of Yale’s Clinical and Translational Research Accelerator. His science communication work can be found in the Huffington Post, on NPR, and here on Medscape. He posts at @fperrywilsonand his book, How Medicine Works and When It Doesn’t, is available now.