From: CurtAdams@aol.com
Date: Sat Apr 03 1999 - 15:19:52 MST
In a message dated 99-04-03 13:26:54 EST, hanson@econ.berkeley.edu (Robin
Hanson) writes:
> But maybe most treatment is optional or speculative. If so, maybe we could
> spend 1/3 what we do now and be just as healthy.
In terms of mortality, I would think so. The overwhelming portion of medical
care
I and my family have recieved has been directed at disability, discomfort, or
even
appearance (orthodontics). In terms of improvements to my life expectancy I
suspect most of the benefit comes from my childhood vaccinations to smallpox,
diptheria, polio, german measles, and whooping cough. I think that would be
less than $100.
>>It's implausible that the medicine we get (as opposed to additional
treatment
>>we don't normally get) doesn't help. People get things like appendicitis,
>>pneumonia in the young, and gangrene which were major risks in the past
>>but very rarely die of them.
>Sure we are lots healthier now than in the past. The question is how much
>credit medicine deserves for that. Lots of other things have changed besides
>medicine.
That's why I picked those. Gangrene and appendicitis still have nearly 100%
mortality if not treated. Pneumonia is generally survivable by the young but
still often lethal if not treated.
>>That sounds like a biased sample. People who die within six months are
>>people for whom treatment has failed. If medical treatment works, they
>>won't show up in the sample. Am I missing something?
>I gave the URL for it - take a look for yourself:
>http://nberws.nber.org/papers/W6513
The abstract doesn't answer my questions; the paper has to be paid for.
I wouldn't expect survival from a specific cause to be related to
last-six-months
spending; treated survivors are excluded while patients with other disease
are included. So you have a lot more noise and a lot less signal even for
a real affect. Statistical significance is a real problem with medical
studies;
some require hundreds of thousands of patients. Reducing signal/noise
ratio increases the necessary sample size by the square of the ratio change.
Even for heart disease, mortality is less that 30% and proportion of medical
costs less than a third so the ratio is about 10:1 That would drive the
number
of deaths needed into the tens of millions and that's too much even for a
countrywide survey.
My concern with excluding survivors remains. The most effective medical
treatments result in nearly 100% survivability (e.g. gangrene, appendicitis,
and pneumonia in the young). Hence the measurement by definition
excludes patients for whom medical treatment is highly effective.
(from the abstract)
>regional survival rates following acute conditions like AMI (heart attacks),
stroke, >and gastrointestinal bleeding were not correlated with more
intensive health care >spending.
I don't know about GI bleeding, but I'd kind of expect that for AMI and
stroke.
There really aren't any treatments for stroke yet - some marginal improvements
with thrombolytics in a few percent of patients, and that's it. For AMI,
there's
thrombolytics (which are cheap), nitroglycerin and heparin (which are very
cheap)
and coronary bypass (which is universal in those cases where it improves
mortality). So any excess spending necessarily goes to things of no proven,
and probably little, mortality benefit.
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