If you do not understand the problem with the data adjustment for IHD, I am not going to spend my time catching you up on a lifetime of data analysis skills. Desperately wanting this study to be true and of high quality does not make it so. Suffice it to say that the folks who conducted the study, by halving all the numbers, changed only the weighting of IHD in the total index, they did not in any way, shape, or form correct for any variations in incidence rate. I suppose that you could say that reducing the weighting of a faulty variable makes the study better, but then by that logic they should have left it out entirely.

At the end of the day, to draw the conclusions they want to draw, the only way to do this study is to show each country with a numerator of total deaths from set X of diseases and a denominator of total incidents of set X of diseases, ideally corrected for differences in population age, etc.

The study does indeed show that other countries are healthier, say on the heart disease measure. It tells us nothing about why. The conclusion that the difference is in the differences in health care systems is not at all supported by the methodology or the data. In fact, data from other sources should make us strongly suspicious that differences in death rates has MUCH more to do with lifestyles and incidence rates and to some extent even differences in reporting methodologies.

By the way, I challenge anyone who has lived in both the UK or France AND the US to argue that the US health care is of substantially inferior quality to its European counterparts in terms of keeping one alive. It just does not pass the smell test. You might argue that the US system is more of a hassle, or carries more financial risks, but to say that it is worse quality certainly does not fit my experience from being in multiple countries.

Perhaps without reduction the results would have been ludicrous, v. just outrageous (difference between being usable by Mr. Friedman v. not).

We should also insist that studies that inform health policy meet, at a minimum, the every higher drug pharma bar. i.e. double blind tests, independent analysis, effectively 10 year cooling off periods. (only half in jest). What’s good for the goose, …

You are confused, perhaps in part because you are talking about numbers of mortalities rather than mortality rates. If the contribution of lifestyle to the U.S. IHD mortality rate is, say, 30% of the total, and the contribution of lifestyle to the French IHD mortality rate is, say, 20% of the total, then to control for the contribution of lifestyle for each country you must reduce the U.S. rate by 30% but the French rate by only 20%. I don’t think this is exactly hard to grasp.

A: 100 people per million die from IHD in the US, and only 20 per million in France.

B: That is bullshit, most of the difference could be from lifestyle issues.

A: Fine, we will attribute 50 deaths per million from the US numbers and 10 deaths per million from the French numbers to lifestyle-related causes, and deduct them from our numbers.

B: This is bullshit! You just reduced both numbers by 50%! Surely a greater proportion of US deaths should be because of lifestyle-related reasons.

C: This is bullshit! You attributed 5 times as many US deaths to lifestyle reasons as you did French deaths! How can you say lifestyle has so big an influence in the US compared to France?

I don’t find either argument more compelling than the other. Therefore, I can only conclude that the adjustment is a reasonable thing to do.

Your criticism is interesting but you fail to explain why the other 18 countries saw greater improvement in amenable mortality than the U.S. I hope you would concede that this relative non-improvement by the U.S. is clearly relevant and quite damning.

It’s not damning at all. It could be any number of things that have nothing to do with the health care system. It could largely be a matter of diminishing returns.

And although the 50% reduction in IHD is hardly the best method to correct for lifestyle you make it sound like it has no effect on the results when it quite obviously does effectively making IHD less of a factor in the total number and thus being a correction of sorts for the totals.

No, it’s not a correction of any sort. It’s nonsense. The whole point of lifestyle and other variables is that they are variable. Their contribution differs between different countries. So just reducing the contribution attributed to health care by the same percentage for each country is meaningless as a correction for other variables influencing mortality.