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A comparison of British and US mortality outcomes

VOL: 102, ISSUE: 48, PAGE NO: 33-34

Colin Pritchard, PhD, MA, AAPSW, FRSA; Kathleen Galvin, PhD, BSc, RGN

Colin Pritchard, PhD, MA, AAPSW, FRSA, is emeritus professor at the School of Medicine, University of Southampton, and research professor in psychiatric social work; Kathleen Galvin, PhD, BSc, RGN, is professor of health research, Institute of Health and Community Studies, Bournemouth University.

ABSTRACT: Pritchard, C. et al (2006) A comparison of Britishand US mortality outcomes. www.nursingtimes.net.

ABSTRACT: Pritchard, C. et al (2006) A comparison of Britishand US mortality outcomes. www.nursingtimes.net.AIM: In response to American colleagues’ concerns about the state of the NHS, we undertook a comparison of deaths in England and Wales and the US. METHOD: Figures for 1974-2000 were obtained from World Health Organization data on all-cause and cancer mortality rates. RESULTS: Overall rates fell substantially in all three countries but there was a more significant drop in England and Wales over the period. The reduction in deaths in England and Wales was also economically more effective. CONCLUSION: This finding is a credit to the NHS and should be a boost for patient and staff morale.
During a recent visit to the US we were startled by our American colleagues’ views on the state of the NHS. A series of negative media reports led them to ask whether the NHS in the UK was collapsing and they negatively compared ‘your socialised medicine’ with the US health system. We were somewhat despondent and asked ourselves how much worse the NHS was than the US health system. For many years the US has spent a considerably higher proportion of its national wealth gross domestic product (GDP) on healthcare than Britain. In 1970 it spent 9.5%, which had increased to 13.9% by 2001. In comparison, the UK spent 5.6% in 1970, which had risen to 7.6% in 2001 (US Bureau, 2005) and continues to rise. The ultimate outcome measure of any health service is the reduction in deaths. We decided to compare all-cause mortality between the two countries in the years 1974-2000. Despite the knowledge that rates of death from cancer have long been higher in Britain than the US (Evans and Pritchard, 2000) we also compared deaths from cancer between England and Wales and the US for the same years. MethodsTo ensure uniformity and reliability of data, we used the latest available standardised World Health Organization mortality statistics for all-cause death rates per million (pm) of the population and for all cancers (WHO, 2005). Using rates of mortality allows for comparability between nations of different size over time. Adult age groups were examined from 15-24 years to 75 years and over and by gender. Baseline years for comparison were three-year average mortality rates for 1974-1976 and 1998-2000. The start date of 1974-1976 was chosen because it followed the 1973 oil crisis, which led to structural unemployment and carried health consequences for the western world (Singh et al, 2005). Ratios of change were calculated for each country and the ratio of change was then compared between the two time periods. For example, in 1974-1976 cancer death rates for 45-54-year-old males in England and Wales were 1,911pm but fell to 1,342pm, a ratio of 1:0.62, equivalent to a decline of 38%. Such an approach resolves the problems inherent in international comparisons and has been successfully used in many comparative international studies, such as deaths from diabetes and neurological disorders (Pritchard et al, 2004a; Pritchard and Peveler, 2003). A series of chi-square tests were carried out by age and gender on the mortality rates for the period 1974-2000. This spans three WHO international classification of diagnosis editions (ICD 8, 9, and 10) but in general categories of all-cause and cancer deaths, there are few differences in reporting (USDHHS, 2005). There are marked differences between England and Wales and US GDP expenditure on health (US Bureau, 2005), which is briefly reviewed to place the changes in context. ResultsAll-cause deathsIn England and Wales the all-cause death rate for men of all ages was 9,589pm in 1974-1976 falling to 7,746pm by 1998-2000, a ratio of change of 0.81, or a 19% decline. Women’s rates fell from 9,302pm to 8,343pm, a ratio of 1:0.90, equivalent to a 10% decline. In the US, all-cause death rates in men of all ages fell from 8,246pm to 6,587pm, a decline of 20%, while women’s rates actually rose from 6,200pm to 6,724pm, a ratio of 1:1.08, or an 8% rise (Table 1). Table 1. All cause deaths by age and gender % +/- (rates per million) p value for significance.

Age-bands and yearsEngland&WalesMaleUSMaleEngland&WalesFemaleUSFemale
All-age1974-761998-2000% change9,5897,74619%-8,2466,57820%-9,3028,34310%-6,2006,7248%+
E&W vs US n.sig <0.001
15-24 years1974-19761998-2000% change92565130%-1,5421,16724%-38728127%-60343827%-
E&W vs US n.sig n.sig
25-34 years1974-19761998-2000% change77484810%+1,8471,36626%-59732718%-70055321%-
E&W vs US <0.001 # n.sig
35-44 years1974-19761998-2000% change1,6501,24924%-2,9692,23224%-84555535%-1,3161,01223%-
E&W vs US n.sig p<0.03
45-54 years1974-19761998-2000% change5,230267549%-6,692409938%-2,2431,21846%-2,8011,85634%-
E&W vs US P<0.001 P<0.001
55-64 years1974-19761998-2000% change13,8976,77351%-15,2528,37645%-6,1463,32846%-6,5634,55231%-
E&W vs US P<0.001 p<0.001
65-74 years1974-19761998-2000% change37,39919,45347%-34,26820,51330%-19,45312,11138%-16,92312,8210.24%
E&W vs US P<0.001 P<0.001
75+1974-19761998-2000% change134,909100,15126%-112,44090,22620%-99,47782,47017%-80,86676,6625%-
  p<0.02 P<0.001

# All significant differences are ‘in favour’ ofEnglandandWalesexcept marked #All chi-square tests 1 d/f. n.sig = not significantIn both countries, for both genders, there was a reduction in death rates in all the age bands from 25-64, some of which were substantial (20% or more). For example, in men aged 45-74 in England and Wales, all-cause rates fell by more than 47% and, in women aged 45-74, deaths fell by more than 38%. In the US, rates for men aged 45-74 fell more than 30%, with rates for women falling 10-30%. In all three countries, reductions in mortality in women were not as pronounced as for men. There were significantly bigger reductions in all-cause mortality rates for men aged 24-74 and for women aged 35-74 in England and Wales than in the US. All-cause death rates in England and Wales were lower than the US for men aged 15-74 and for women aged 15-64, with more significant improvements for in women in England and Wales in the 35-74 age group over the period. Cancer deathsThere was little change in male cancer death rates in England and Wales across all age ranges, falling from 2,795pm to 2,687pm, a decline of 4%. In women, the rate rose by 6%, from 2,282pm to 2,419pm. In the US, rates of male cancer deaths rose by 6% and in women from 1,553pm to 1,878pm, a 21% increase. In England and Wales, there were impressive falls in cancer death rates among the 25-34 age group at 47% for men and 29% for women. For the 35-44 age group there were falls of 42% and 34% respectively. The 45-54 age group had a reduction in cancer death rates of more than 30% for both men and women while, in the 55-64 age band, cancer deaths fell 31% for men and 18% for women. In men aged 65-74, rates fell by 20% - but there was a slight rise for women of 5%. In the US, cancer deaths in men aged 15-54 fell by 48% and by more than 17% in those aged 55-74. In US women, cancer deaths in those aged 15-24 fell by 43% and by 30% in those aged 25-54, again women doing less well than males. Improvements in rates of cancer deaths were significantly greater in England and Wales than the US for all ages for men and women (p<0.004), for the 55-64-year-olds (p<0.001) and for the 65-74-year-olds (p<0.001) (Table 2). It is worth noting that, while cancer rates fell more in England and Wales than in the US, rates for women in every age band were consistently higher. This was not true for men. Table 2. Cancer deaths by age and gender % +/- (rates per million) p value for significance.

Age-bands and yearsEngland&WalesMaleUSMaleEngland&WalesFemaleUSFemale
All-age1974-19761998-2000% change2,7952,687-4%1,9572,1188%+2,2822,4196%+1,5531,87821%+
E & W v US P<0.004 P<0.003
15-24 years1974-19761998-2000% change925531%-855338%-663547%-553743%-
E&W vs US n.sig n.sig
25-34 years1974-19761998-2000% change1739147%_15010238%-16411629%-15710930%-
E&W vs US n.sig n.sig
35-44 years1974-19761998-2000% change46326942%-48833638%-65643634%-59741231%-
E&W vs US n.sig n.sig
45-54 years1974-19761998-2000% change1,9091,23035%-1,9111,34238%-2,0841,39433%-1,7941,26130%-
E&W vs US n.sig n.sig
55-64 years1974-19761998-2000% change5,9204,09431%-5,2374,31617%-4,0533,31218%-3,6523,27210%-
E&W vs US P<0.001 P<0.01
65-74 yrs1974-19761998-2000% change13,40010,69120%-10,62410,2623%-6,6777,0125%+5,7616,71817%+
E&W vs US P<0.0001 p<0.001
75+1974-19761998-2000% change22,20122,1871%-18,10119,2797%+11,48512,77112%+9,78111,67319%+
E&W vs US n.sig n.sig

# All significant differences are in ‘favour’ ofEnglandandWalesexcept marked #All chi square tests 1 d/f. n.sig = not significant.GDP expenditure on healthBut what has been the cost of these very substantial improvements? Between 1980 and 2001, spending on health in England and Wales and the US grew substantially, with 36% growth from 5.6% to 7.6% GDP in England and Wales and 46% growth from 9.5% to 13.9% in the US. The differences in the proportion of GDP spent on healthcare in the countries was fairly stable, with the US spending an average 83% more every year than England and Wales. However, the total GDP expenditure hides marked differences between the two countries. In England and Wales, public expenditure on healthcare is five times that on private healthcare. The reverse is true in the US, where private healthcare spending was on average more than 20% above public expenditure. Table 3. Percentage of GDP expenditure on health 1980-2001

Years & Rank1980199019951998199920002001
UKPublicPrivateTotal5.00.65.65.01.06.05.91.17.05.61.16.75.81.47.25.91.47.36.21.47.6
USPublicPrivateTotal3.64.18.74.77.211.96.37.613.96.17.513.66.17.113.05.87.313.16.27.713.9
Total UK as ratio of US1.551.981.992.021.811.791.83

DiscussionThere are three main findings:

  • Although there were substantial reductions in both countries for all-cause and cancer deaths, the results for England and Wales were significantly better than the US;
  • Outcomes for women were not as good as for men in both countries;
  • England and Wales achieved bigger reductions with less spending.

The results raise some interesting questions, which cannot be answered by this study and require further research:

  • Why has England and Wales done relatively better than the US?
  • Why have rates for women not improved as much as those for men?
  • Why for most age groups are all cause mortality rates lower in England and Wales than in the US?
  • Why are rates of cancer deaths lower in men in England and Wales than in the US?
  • Do the differences in private and public health expenditure contribute to the significant differences in mortality rates?

There is little doubt that US healthcare is among the best in the world and that the country spends proportionally more on health than any other (US Bureau, 2005). Bearing this in mind, the finding that England and Wales did significantly better was unexpected. There is evidence of poorer health and welfare services for certain sections of the US general population, with marked socioeconomic disparities in a range of mortality figures (Mensah et al, 2005; Singh et al, 2005). However, differences between health outcomes between social groups can also be found in Britain (Neale and Alagar, 2005), which justifies the continued increase of GDP in England planned over the next three years. The results suggest that although England and Wales started from a lower financial base, the NHS was able to achieve clinically more, with comparatively less. Nonetheless, for both countries there are grounds for celebration in the reduction of mortality. ConclusionThe variations in mortality between the countries may reflect differences in health service delivery, while the record levels of GDP expenditure seem justified by the all time lows in adult deaths, not least for deaths from cancer. This study is evidence that while healthcare costs have increased, public health measures and active treatment and care have yielded better outcomes with respect to reducing deaths. Furthermore, public and political concern about the cost of healthcare often ignores the fact that positive health outcomes yield economic benefits (Pritchard et al, 2004b). This study adds further evidence that health and community services can also be seen as ‘wealth-producing’, both in terms of lives-saved and by enabling those of working age to continue to contribute to the general economy. These results should be a boost for the morale of patients, their families and staff, offsetting the spate of negative media images of the NHS which so undermine confidence in the service. These results enable us to claim that the NHS mortality outcomes are as good as the world’s best, and, the NHS continues to be one of the world’s leading health services. Staff in the NHS, public health and community services should feel proud of their achievements and can look forward to even greater results. ReferencesEvans, B., Pritchard, C. (2000) Cancer survival rates and GDP expenditure on health: comparison of England and Wales and Denmark, Finland, France, Germany, Italy, Spain, Switzerland and the US. Public Health; 114: 5, 336-339. Mensah, G.A. et al (2005) State of disparities in cardiovascular health in the United States. Circulation 2005; 111: 10, 1233-1241. Neal, R.D., Allgar, V. (2005) Sociodemographic factors and delays in the diagnosis of six cancers: analysis of data from the national survey of NHS patients: Cancer. British Journal of Cancer; 92: 11, 1971-1975. Pritchard, C. et al (2004a) Changing patterns of adult (45-74 years) neurological deaths in the major Western world countries 1979-1997. Public Health; 118: 4, 268-283. Pritchard, C. et al (2004b) Two-year prospective study of psychosocial outcomes and a cost-analysis of ‘treatment-as-usual’ versus an ‘enhanced’ (specialist liaison nurse) service for aneurysmal sub arachnoid haemorrhage (ASAH) patients and families. British Journal of Neurosurgery; 18: 4, 347-356. Pritchard, C., Pevler, R. (2003) Changing patterns of diabetic deaths in youth and young adults by gender in the major Western countries. International Journal of Adolescent Medicine and Health; 15: 169-177. Singh, G.K. et al (2005) Persistent area socio-economic disparities in US incidence of cervical cancer, mortality, stage and survival 1975-2000. Cancer; 101: 1051-1057. US Bureau of Statistics (2005) Statistical Abstract of the United States (120th edn). WashingtonDC: USBS. US Department of Health and Human Services (2001) National Vital Statistics Reports: Comparability of Cause of Death Between ICD 9 and ICD 10: Preliminary Estimates. Washington: DHHS. WHO (2005) World Statistics Annual 1974-2002. www.who.int/whosis/mort/table1_process.cfm.

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