Caution needed for country-specific cancer survival

Incidence of prostate cancer and net survival by grade in a geriatric population: A population-based study in a French administrative entity from 1991 to 2013

BACKGROUND

Prostate cancer is the leading type of cancer among men in more developed countries. Incidence trends and survival rates could differ by age groups considering potential differences in the frequency of PSA testing, types of cancers and medical management. Our objective was to compare incidence trends and survival rates of prostate cancer between men aged ≥75 and 60-74 years.

METHOD

We analyzed data from a population-based cancer registry in Isère, France. All men aged ≥60 years diagnosed with an incident prostate cancer during the 1991-2013 period were included. Incidence and mortality rates were computed as well as net survival rates.

RESULTS

In 2013, observed incidence rates were 557.6 and 568.7 per 100,000 for men aged 60-74 and ≥75, respectively, with high grades cancers more frequent among elderly men. The incidence and mortality trends among men aged ≥75 included a period of stability followed by a decreasing trend from 2003, whereas a peak of incidence was observed in 2005 for men aged 60-74. For both age groups, net survival rates increased with period of diagnosis and 8-year net survival remained higher than 70% for cases diagnosed in the 2000-2004 period. Lower survival rate of 51% (95%CI: 42%; 60%) was observed for high grades cancers diagnosed among men aged 75-84 in 2000-2004.

CONCLUSION

The epidemiology of prostate cancers among men aged ≥75 include a decrease of incidence and mortality rates from 2003, an important proportion of high grade cancers and a relatively good prognosis except for high grade cancers.

Impact of clinical registries on quality of patient care and clinical outcomes: A systematic review

BACKGROUND

Clinical quality registries (CQRs) are playing an increasingly important role in improving health outcomes and reducing health care costs. CQRs are established with the purpose of monitoring quality of care, providing feedback, benchmarking performance, describing pattern of treatment, reducing variation and as a tool for conducting research.

OBJECTIVES

To synthesise the impact of clinical quality registries (CQRs) as an 'intervention' on (I) mortality/survival; (II) measures of outcome that reflect a process or outcome of health care; (III) health care utilisation; and (IV) healthcare-related costs.

METHODS

The following electronic databases were searched: MEDLINE, EMBASE, CENTRAL, CINAHL and Google Scholar. In addition, a review of the grey literature and a reference check of citations and reference lists within articles was undertaken to identify relevant studies in English covering the period January 1980 to December 2016. The PRISMA-P methodology, checklist and standard search strategy using pre-defined inclusion and exclusion criteria and structured data extraction tools were used. Data on study design and methods, participant characteristics attributes of included registries and impact of the registry on outcome measures and/or processes of care were extracted.

RESULTS

We identified 30102 abstracts from which 75 full text articles were assessed and finally 17 articles were selected for synthesis. Out of 17 studies, six focused on diabetes care, two on cardiac diseases, two on lung diseases and others on organ transplantations, rheumatoid arthritis, ulcer healing, surgical complications and kidney disease. The majority of studies were "before after" design (#11) followed by cohort design (#2), randomised controlled trial (#2), experimental non randomised study and one cross sectional comparison. The measures of impact of registries were multifarious and included change in processes of care, quality of care, treatment outcomes, adherence to guidelines and survival. Sixteen of 17 studies demonstrated positive findings in their outcomes after implementation of the registry.

CONCLUSIONS

Despite the large number of published articles using data derived from CQRs, few have rigorously evaluated the impact of the registry as an intervention on improving health outcomes. Those that have evaluated this impact have mostly found a positive impact on healthcare processes and outcomes.

TRIAL REGISTRATION

PROSPERO CRD42015017319.

Comparing UK and 20 Western countries' efficiency in reducing adult (55-74) cancer and total mortality rates 1989-2010: Cause for cautious celebration? A population-based study

Objective

Every Western nation expends vast sums on health, especially for cancer; thus, the question is how efficient is the UK in reducing adult (55–74) cancer mortality rates and total mortality rates (TMR) compared to the other Western nations in the context of economic-input to health, the percentage of Gross-Domestic-Product-expenditure-on-Health.

Design

WHO mortality rates for baseline 3 years 1989–1991 and 2008–2010 were analysed, and confidence intervals determine any significant differences between the UK and other countries in reducing the mortalities. Efficiency ratios are calculated by dividing reduced mortality over the period by the average % of national income.

Setting

Twenty-one similar socio-economic Western countries.

Participants

The 21 countries’ general population.

Main outcome measures

Cancer mortality rates, total mortality rates Gross Domestic Product and Efficiency Ratios.

Results

Economic Input: In 1980, UK national income was 5.6% and the European average was 7.1%. By 2010, UK national income was 9.4% being equal 17th of 21 averaging 7.1% over the period. Europe’s 1980–2010 average of 8.4% yields a UK to Europe ratio of 1:1.18.

Clinical output 1989–2010: UK Cancer Mortality Rates was the sixth highest, but equal sixth biggest fall, significantly greater than 14 other countries. UK Total Mortality Rates was the fifth highest but third biggest decline, significantly greater than 17 countries. UK’s cancer Efficiency Ratios is largest at 1:301 and second biggest for Total Mortality Rates at 1.1341; the USA ratios were 1:152 and 1:525, respectively.

Conclusions

UK reduced mortalities indicate that the NHS achieves proportionally more with relatively less, but UK needs to match European average Gross-Domestic-Product-expenditure-on-Health to meet future challenges.

RELATIVE EFFECTIVENESS IN BREAST CANCER TREATMENT: A HEALTH PRODUCTION APPROACH

Background: Pharmaceuticals’ relative effectiveness has come to the fore in the policy arena, reflecting the need to understand how relative efficacy (what can work) translates into added benefit in routine clinical use (what does work). European payers and licensing authorities assess value for money and post-launch benefit–risk profiles, and efforts to standardize assessments of relative effectiveness across the European Union (EU) are under way. However, the ways that relative effectiveness differs across EU healthcare settings are poorly understood.

Methods: To understand which factors influence differences in relative effectiveness, we developed an analytical framework that treats the healthcare system as a health production function. Using evidence on breast cancer from England, Spain, and Sweden as a case study, we investigated the reasons why the relative effectiveness of a new drug might vary across healthcare systems. Evidence was identified from a literature review and national clinical guidance.

Results: The review included thirteen international studies and thirty country-specific studies. Cross-country differences in population age structure, deprivation, and educational attainment were consistently associated with variation in outcomes. Screening intensity appeared to drive differences in survival, although the impact on mortality was unclear.

Conclusions: The way efficacy translates into relative effectiveness across health systems is likely to be influenced by a range of complex and interrelated factors. These factors could inform government and payer policy decisions on ways to optimize relative effectiveness, and help increase understanding of the potential transferability of data on relative effectiveness from one health system to another.

How many cancer deaths could New Zealand avoid if five-year relative survival ratios were the same as in Australia?

AIM

To determine how many Māori and non-Māori deaths might have been avoidable if cancer survival in New Zealand were as high as in Australia.

METHODS

Age-sex-tumour specific five-year relative survival ratios were calculated for cancer patients diagnosed with 27 tumour sites (representing about 92% of all cancers) in 2006-10. These were used to estimate the number of Māori, non-Māori and total deaths (and proportion of excess deaths) that would have been avoidable within five years of diagnosis had New Zealand's relative survival been equivalent to Australia's.

RESULTS

A total of 3,631 cancer deaths (726/year; 13.4% of excess deaths) could have been avoidable. Among 25 tumours where ethnic-specific results were estimated, there were 851 potentially avoidable deaths in Māori (24.9%) and 2,758 in non-Māori (11.8%). Breast, bowel, lung and prostate tumours made up 64% of avoidable deaths. Those with the highest proportions of avoidable deaths were thyroid (44.7%), prostate (35.5%), breast (30.0%) and uterus (23.5%). More than 50% of Māori melanoma, prostate, testis and thyroid cancer deaths were avoidable.

CONCLUSION

A significant number of cancer deaths could be avoidable if New Zealand achieved Australia's relative survival ratios. The proportion is much higher for Māori than for non-Māori.

IMPLICATIONS

There is considerable scope to improve cancer outcomes in New Zealand.

Convergence with SEER database achieved by a breast cancer network: a longitudinal benchmark of 5-year relative survival

PURPOSE

To benchmark outcomes of a German breast cancer network with the Surveillance Epidemiology and End Results programme (SEER) of the USA from a longitudinal point of view.

METHODS

All women receiving primary breast cancer therapy of three hospitals in a rural district of Marburg-Biedenkopf (Germany) of time intervals 1996-1997 and 2003-2004 were used to define local benchmark objects. Data from SEER-programme contributed longitudinal benchmark objects from national level (1988-2004). All benchmark objects were compared with the time-fixed benchmark reference of SEER (2004). Stage distributions and 5-year relative survival ratios were combined to estimate standardized screening-, case-mix-, work-up-, treatment- and relative overall performance index.

RESULTS

From the entry cohort of 877 German women, 97.7 % of the patients accounted for the institutional sample (N = 857) and 65.8 % accounted for the regional sample (N = 577). Stage distributions, relative survival ratios and indices of the German breast cancer network improved over time. Developed indices converged with SEER (2004).

CONCLUSIONS

Effectiveness gap between one exemplary German breast cancer network and international benchmark defined by SEER has been closed. Reasons are manifold, and further research is recommended.

Cancer incidence, survival and mortality: explaining the concepts

Cancer incidence, survival and mortality are essential population-based indicators for public health and cancer control. Confusion and misunderstanding still surround the estimation and interpretation of these indicators. Recurring controversies over the use and misuse of population-based cancer statistics in health policy suggests the need for further clarification. In our article, we describe the concepts that underlie the measures of incidence, survival and mortality, and illustrate the synergy between these measures of the cancer burden. We demonstrate the relationships between trends in incidence, survival and mortality, using real data for cancers of the lung and breast from England and Sweden. Finally, we discuss the importance of using all three measures in combination when interpreting overall progress in cancer control, and we offer some recommendations for their use.

Comparative cancer survival in European countries

BACKGROUND

Survival for patients with cancer varies widely across Europe. This review is an attempt to explore some of the factors that influence this variation.

SOURCES OF DATA

The data on cancer survival come from EUROCARE-5 and a recent OECD report. These figures have been analysed together with data from a variety of other sources: other OECD data sets; EUROSTAT; The World Bank; Gallup and the World Health Organisation.

AREAS OF AGREEMENT

This study confirms the importance of national socio-economic factors in influencing the outcomes for patients with cancer.

AREAS OF CONTROVERSY

The usual suspects (limited access to expensive new cancer drugs; delayed diagnosis and late presentation) may have less influence on cancer survival than is usually assumed.

GROWING POINTS

Disparities in outcomes challenge systems of health care to re-evaluate their strategies. The key point is that these new strategies need to be informed by facts, rather than suppositions.

AREAS TIMELY FOR DEVELOPING RESEARCH

The role and scope of national cancer registries should be enhanced. We need to record more detailed information on each patient with cancer and, in an era of linked data, cancer registries are ideally placed to collect and curate such information.

Is serum human epididymis protein 4 ready for prime time?

The National Institute for Health and Clinical Excellence (NICE) guidelines have sparked hot debate regarding the role of carbohydrate antigen 125 (CA-125) for ovarian cancer (OC) detection. Recent literature and evidence calls into question the use of CA-125 in diagnostic algorithms, given the better performance of human epididymis protein 4 (HE4) vs. CA-125 to rule OC. This is an important consideration since combined measurements are not cost-effective. The quality of this evidence is, however, threatened by important gaps related to study design, enrolled populations and analytical issues. For instance, despite the clinical need to prioritize the evaluation of biomarker performance in early stage tumours, sound evidence on this cannot be provided. In addition, results should be cautiously interpreted due to wide differences in the type of employed assays and in adopted diagnostic thresholds for HE4. Comparability among results obtained by different commercially available HE4 assays, together with an objective establishment of analytical goals is essential for the optimal clinical application of this marker.

Using relative survival measures for cross-sectional and longitudinal benchmarks of countries, states, and districts: the BenchRelSurv- and BenchRelSurvPlot-macros

Background

The objective of screening programs is to discover life threatening diseases in as many patients as early as possible and to increase the chance of survival. To be able to compare aspects of health care quality, methods are needed for benchmarking that allow comparisons on various health care levels (regional, national, and international).

Objectives

Applications and extensions of algorithms can be used to link the information on disease phases with relative survival rates and to consolidate them in composite measures. The application of the developed SAS-macros will give results for benchmarking of health care quality. Data examples for breast cancer care are given.

Methods

A reference scale (expected, E) must be defined at a time point at which all benchmark objects (observed, O) are measured. All indices are defined as O/E, whereby the extended standardized screening-index (eSSI), the standardized case-mix-index (SCI), the work-up-index (SWI), and the treatment-index (STI) address different health care aspects. The composite measures called overall-performance evaluation (OPE) and relative overall performance indices (ROPI) link the individual indices differently for cross-sectional or longitudinal analyses.

Results

Algorithms allow a time point and a time interval associated comparison of the benchmark objects in the indices eSSI, SCI, SWI, STI, OPE, and ROPI. Comparisons between countries, states and districts are possible. Exemplarily comparisons between two countries are made. The success of early detection and screening programs as well as clinical health care quality for breast cancer can be demonstrated while the population’s background mortality is concerned.

Conclusions

If external quality assurance programs and benchmark objects are based on population-based and corresponding demographic data, information of disease phase and relative survival rates can be combined to indices which offer approaches for comparative analyses between benchmark objects. Conclusions on screening programs and health care quality are possible. The macros can be transferred to other diseases if a disease-specific phase scale of prognostic value (e.g. stage) exists.

Valid comparisons and decisions based on clinical registers and population based cohort studies: assessing the accuracy, completeness and epidemiological relevance of a breast cancer query database

Background

Data accuracy and completeness are crucial for ensuring both the correctness and epidemiological relevance of a given data set. In this study we evaluated a clinical register in the administrative district of Marburg-Biedenkopf, Germany, for these criteria.

Methods

The register contained data gathered from a comprehensive integrated breast-cancer network from three hospitals that treated all included incident cases of malignant breast cancer in two distinct time periods from 1996–97 (N=389) and 2003–04 (N=488). To assess the accuracy of this data, we compared distributions of risk, prognostic, and predictive factors with distributions from established secondary databases to detect any deviations from these “true” population parameters. To evaluate data completeness, we calculated epidemiological standard measures as well as incidence-mortality-ratios (IMRs).

Results

In total, 12% (13 of 109) of the variables exhibited inaccuracies: 9% (5 out of 56) in 1996–97 and 15% (8 out of 53) in 2003–04. In contrast to raw, unstandardized incidence rates, (in-) directly age-standardized incidence rates showed no systematic deviations. Our final completeness estimates were IMR=36% (1996–97) and IMR=43% (2003–04).

Conclusion

Overall, the register contained accurate, complete, and correct data. Regional differences accounted for detected inaccuracies. Demographic shifts occurred. Age-standardized measures indicate an acceptable degree of completeness. The IMR method of measuring completeness was inappropriate for incidence-based data registers. For the rising number of population-based health-care networks, further methodological advancements are necessary. Correct and epidemiologically relevant data are crucial for clinical and health-policy decision-making.

In amenable mortality--deaths avoidable through health care--progress in the US lags that of three European countries

We examined trends and patterns of amenable mortality-deaths that should not occur in the presence of timely and effective health care-in the United States compared to those in France, Germany, and the United Kingdom between 1999 and 2007. Americans under age sixty-five during this period had elevated rates of amenable mortality compared to their peers in Europe. For Americans over age sixty-five, declines in amenable mortality slowed relative to their peers in Europe. Overall, amenable mortality rates among men from 1999 to 2007 fell by only 18.5 percent in the United States compared to 36.9 percent in the United Kingdom. Among women, the rates fell by 17.5 percent and 31.9 percent, respectively. Although US men and women had the lowest mortality from treatable cancers among the four countries, deaths from circulatory conditions-chiefly cerebrovascular disease and hypertension-were the main reason amenable death rates remained relatively high in the United States. These findings strengthen the case for reforms that will enable all Americans to receive timely and effective health care.

Diabetes and cancer (2): evaluating the impact of diabetes on mortality in patients with cancer

In this paper we address methodological aspects of aetiological importance in the link between diabetes and mortality in patients with cancer. We identified nine key points on the cancer pathway at which confounding may arise-cancer screening use, stage at diagnosis, cancer treatment selection, cancer treatment complications and failures, peri-treatment mortality, competing risks for long-term mortality, effects of type 2 diabetes on anti-cancer therapies, effects of glucose-lowering treatments on cancer outcome and differences in tumour biology. Two types of mortality studies were identified: (1) inception cohort studies that evaluate the effect of baseline diabetes on cancer-related mortality in general populations, and (2) cohorts of patients with a cancer diagnosis and pre-existing type 2 diabetes. We demonstrate, with multiple examples from the literature, that pre-existing diabetes affects presentation, cancer treatment, and outcome of several common cancer types, often to varying extents. Diabetes is associated with increased all-cause mortality in cancer patients, but the evidence that it influences cancer-specific mortality is inconsistent. In the absence of data that address the potential biases and confounders outlined in the above framework, we caution against the reporting of cancer-related mortality as a main endpoint in analyses determining the impact of diabetes and glucose-lowering medications on risk of cancer.

Finding needles in a haystack: annual low-dose computed tomography screening reduces lung cancer mortality in a high-risk group

Lung cancer is a global health issue. Compared with other common malignancies, the prognosis is poor as many patients present with advanced disease. The National Lung Screening Trial (NLST) aimed to identify and treat early lung cancers using annual low-dose computed tomography (CT) screening in a high-risk group. When compared with chest x-ray screening, low-dose CT screening reduced lung cancer mortality by 20%; the NLST is the first lung cancer screening trial to demonstrate such a mortality benefit. However, we must wait for cost-effectiveness data from the NLST, as well as the results of ongoing European studies comparing low-dose CT with observation alone, before firm conclusions can be drawn regarding the overall benefits of introducing a CT screening program to clinical practice.

Comparing cancer mortality and GDP health expenditure in England and Wales with other major developed countries from 1979 to 2006

BACKGROUND

Cancer and gross-domestic-product on health expenditure (GDPHE) are critical issues for major developed countries (MDC). Each country's economic input, GDPHE 1980-2005 is contrasted with clinical outputs, cancer mortality rates (CMRs), to compare their efficiency and effectiveness in reducing CMR.

METHODS

World Health Organization's CMR data for baseline years (1979-1981) are compared with 2004-2006 by sex and age. The χ(2)-tests are used to determine differences between MDC. Efficiency is analysed by calculating a ratio of average GDPHE to reduced CMR over the period.

RESULTS

Inputs: All the countries GDPHE grew substantially. For the United Kingdom this reached 9.3%, which is below the MDC average (10%). Outputs: CMR fell substantially (>20%) in six of the ten countries. The male average (15-74 years) CMR in England and Wales had been third highest but by 2004-2006 was sixth, a 31% reduction, which was significantly greater than seven other countries. Initially England and Wales female average CMR was the highest of all countries and is now the second highest. There were significantly greater reductions for the 55-64 and 65-74 years old than in seven and four countries, respectively. GDPHE reduced CMR ratios--the average GDPHE:reduced CMR ratio of England and Wales was 1:120, greater than all MDC and double that in four countries.

CONCLUSION

Comparing GDPHE input with CMR output showed that relatively the NHS achieved more with proportionately less than other MDC.

Survival of women with breast cancer in central and northern Denmark, 1998-2009

Objective

Breast cancer is the most common cancer among women worldwide. The Nordic countries have relatively high survival, but Denmark has a lower survival than neighboring countries. A breast cancer screening program was introduced in 2007 and 2008 in the northern and central regions of Denmark respectively. We aimed to examine possible changes in survival of Danish breast cancer patients in central and northern Denmark in the period 1998–2009.

Materials and methods

From the northern and central Denmark regions, we included all women (n = 13,756) with an incident diagnosis of breast cancer, as recorded in the Danish National Registry of Patients during the period January 1, 1998 through December 31, 2009. We calculated age-stratified survival and used Cox proportional hazard regression to estimate mortality rate ratios (MRRs) for all breast cancer patients.

Results

Median age was 62 years (21–102 years). The overall 1-year survival improved steadily over the period from 90.9% in 1998–2000 to 94.4% in 2007–2009, corresponding to a 1-year age adjusted MRR of 0.68 in 2007–2009 compared with the reference period 1998–2000. We estimated the 5-year survival to improve from 70.0% in 1998–2000 to 74.7% in 2007–2009, corresponding to a 5-year age adjusted MRR of 0.82 in 2007–2009 compared with the reference period 1998–2000. For middle-aged women (50–74 years) 1-year survival increased from 92.8% in 1998–2000 to 96.6% in 2008–2009, and 5-year survival was expected to increase from 73.9% in 1998–2000 to 80.2% in 2007–2009. Among younger women (15–49 years) and elderly women (>75 years), 1-year survival and 5-year predicted survival did not change over the two time periods.

Conclusion

Survival of breast cancer patients has improved in Denmark over the period 1998–2009, and this change was most distinct in women aged 50–74 years. Survival improved even before the implementation of a formal breast cancer screening program.

Survival of patients with colon and rectal cancer in central and northern Denmark, 1998-2009

Objective

The prognosis for colon and rectal cancer has improved in Denmark over the past decades but is still poor compared with that in our neighboring countries. We conducted this population-based study to monitor recent trends in colon and rectal cancer survival in the central and northern regions of Denmark.

Material and methods

Using the Danish National Registry of Patients, we identified 9412 patients with an incident diagnosis of colon cancer and 5685 patients diagnosed with rectal cancer between 1998 and 2009. We determined survival, and used Cox proportional hazard regression analysis to compare mortality over time, adjusting for age and gender. Among surgically treated patients, we computed 30-day mortality and corresponding mortality rate ratios (MRRs).

Results

The annual numbers of colon and rectal cancer increased from 1998 through 2009. For colon cancer, 1-year survival improved from 65% to 70%, and 5-year survival improved from 37% to 43%. For rectal cancer, 1-year survival improved from 73% to 78%, and 5-year survival improved from 39% to 47%. Men aged 80+ showed most pronounced improvements. The 1- and 5-year adjusted MRRs decreased: for colon cancer 0.83 (95% confidence interval CI: 0.76–0.92) and 0.84 (95% CI: 0.78–0.90) respectively; for rectal cancer 0.79 (95% CI: 0.68–0.91) and 0.81 (95% CI: 0.73–0.89) respectively. The 30-day postoperative mortality after resection also declined over the study period. Compared with 1998–2000 the 30-day MRRs in 2007–2009 were 0.68 (95% CI: 0.53–0.87) for colon cancer and 0.59 (95% CI: 0.37–0.96) for rectal cancer.

Conclusion

The survival after colon and rectal cancer has improved in central and northern Denmark during the 1998–2009 period, as well as the 30-day postoperative mortality.

Survival of patients with ovarian cancer in central and northern Denmark, 1998-2009

Objective

To examine time trends of survival and mortality of ovarian cancer in the central and northern Denmark regions during the period 1998–2009.

Study design and setting

We conducted a cohort study including women recorded with a first-time diagnosis of ovarian cancer in the Danish National Registry of Patients (DNRP) between 1998 and 2009. Patients were followed for survival through the Danish Civil Registration System. We determined survival stratified by age, and used Cox proportional hazard regression analyses to obtain mortality rate ratios (MRRs) to assess changes over time.

Results

We found no improvement in overall ovarian cancer survival between 1998 and 2009. One-year survival was 71% in 1998–2000 and 68% in 2007–2009. Three-year survival declined from 48% in 1998–2000 to 46% in 2007–2009 (predicted), and 5-year survival declined from 40% in 1998–2000 to 37% in 2007–2009 (predicted). Compared with the period 1998–2000, the age-adjusted 1-year MRR was 1.05 (95% confidence interval CI: 0.86–1.28) for the period 2007–2009, and the predicted age-adjusted 3- and 5-year MRRs were 0.96 (95% CI: 0.83–1.12) and 0.99 (95% CI: 0.86–1.14), respectively. Results are not adjusted for tumor stage as this information was not available. We also observed a decline in the annual number of incident ovarian cancer patients during the study period, most pronounced in the youngest age group.

Conclusion

The survival of ovarian cancer patients did not improve during the study period. This lack of improvement contrasts with the national cancer strategies implemented during this last decade, focusing on improving the survival of ovarian cancer patients.

Comparing the USA, UK and 17 Western countries' efficiency and effectiveness in reducing mortality

OBJECTIVES

To test the hypothesis that the USA healthcare system was superior to the NHS and 17 other Western countries in reducing feasible mortality rates over the period 1979-2005.

DESIGN

Economic inputs into healthcare, GDP health expenditure (GDPHE) were compared with clinical outputs, i.e. total 'adult' (15-74 years) and 'older' (55-74 years) mortality rates based upon three-year average mortality rates for 1979-81 vs. 2003-2005. A cost-effective ratio was calculated by dividing average GDPHE into reduced mortality rates over the period.

SETTING

Nineteen Western countries' mortality rates compared between 1979-2005.

PARTICIPANTS

Mortality of people by age and gender.

MAIN OUTCOME MEASURES

A cost-effective ratio to measure efficiency and effectiveness of healthcare systems in reducing mortality rates. Chi-square tested any differences between the USA, UK and other Western countries.

RESULTS

INPUT

The USA had the highest current and average GDPHE; the UK was 10th highest but joint 16th overall, still below the Western countries' average. Output: Every country's mortality rate fell substantially; but 15 countries reduced their mortality rates significantly more than the US, while UK 'adult' and 'older' mortality rates fell significantly more than 12 other countries. Cost-effectiveness: The USA GDPHE: mortality rate ratio was 1:205 for 'adults' and 1:515 for 'older' people, 16 Western countries having bigger ratios than the US; the UK had second greatest ratios at 1:593 and 1:1595, respectively. The UK ratios were >20% larger than 14 other countries.

CONCLUSIONS

In cost-effective terms, i.e. economic input versus clinical output, the USA healthcare system was one of the least cost-effective in reducing mortality rates whereas the UK was one of the most cost-effective over the period.