healthcare outcomes: US Vs UK

Disease and Disadvantage in the United States and in England

James Banks, PhD; Michael Marmot, MD; Zoe Oldfield, MSc; James P. Smith, PhD

JAMA. 2006;295:2037-2045.

Context The United States spends considerably more money on health care than the United Kingdom, but whether that translates to better health outcomes is unknown.

Objective To assess the relative heath status of older individuals in England and the United States, especially how their health status varies by important indicators of socioeconomic position.

Design, Setting, and Participants We analyzed representative samples of residents aged 55 to 64 years from both countries using 2002 data from the US Health and Retirement Survey (n = 4386) and the English Longitudinal Study of Aging (n = 3681), which were designed to have directly comparable measures of health, income, and education. This analysis is supplemented by samples of those aged 40 to 70 years from the 1999-2002 waves of National Health and Nutrition Examination Survey (n = 2097) and the 2003 wave of the Health Survey for England (n = 5526). These surveys contain extensive and comparable biological disease markers on respondents, which are used to determine whether differential propensities to report illness can explain these health differences. To ensure that health differences are not solely due to health issues in the black or Latino populations in the United States, the analysis is limited to non-Hispanic whites in both countries.

Main Outcome Measure Self-reported prevalence rates of several chronic diseases related to diabetes and heart disease, adjusted for age and health behavior risk factors, were compared between the 2 countries and across education and income classes within each country.

Results The US population in late middle age is less healthy than the equivalent British population for diabetes, hypertension, heart disease, myocardial infarction, stroke, lung disease, and cancer. Within each country, there exists a pronounced negative socioeconomic status (SES) gradient with self-reported disease so that health disparities are largest at the bottom of the education or income variants of the SES hierarchy. This conclusion is generally robust to control for a standard set of behavioral risk factors, including smoking, overweight, obesity, and alcohol drinking, which explain very little of these health differences. These differences between countries or across SES groups within each country are not due to biases in self-reported disease because biological markers of disease exhibit exactly the same patterns. To illustrate, among those aged 55 to 64 years, diabetes prevalence is twice as high in the United States and only one fifth of this difference can be explained by a common set of risk factors. Similarly, among middle-aged adults, mean levels of C-reactive protein are 20% higher in the United States compared with England and mean high-density lipoprotein cholesterol levels are 14% lower. These differences are not solely driven by the bottom of the SES distribution. In many diseases, the top of the SES distribution is less healthy in the United States as well.

Conclusion: Based on self-reported illnesses and biological markers of disease, US residents are much less healthy than their English counterparts and these differences exist at all points of the SES distribution.


Author Affiliations: University College London and Institute for Fiscal Studies (Dr Banks), Department of Epidemiology, University College London (Dr Marmot) and Institute for Fiscal Studies (Ms Oldfield), London, England; and RAND Corp, Santa Monica, Calif (Dr Smith).




Middle aged white people are healthier in England than US
Janice Hopkins Tanne
New York
news, BMJ 2006;332:1047 (6 May),


People aged 55 to 64 in England are healthier than their counter-parts in the United States, a new study shows. This is despite the fact that the US spends $5274 (£2900; 4193) per person on medical care each year and the United Kingdom as a whole spends only $2164.

The disparity between the health of middle aged white English and American people found is so great, the study found, that the prevalence of diabetes and heart disease among Americans of the highest socioeconomic status is similar to that among the lowest status English people.

The study's authors, Michael Marmot and colleagues at University College London, found that middle aged white English people had lower rates of diabetes, hypertension, heart disease, heart attacks, strokes, lung disease, and cancer than middle aged white Americans (JAMA 2006;295: 2037-45[Abstract/Free Full Text]). The reason remains a puzzle, although the study suggests some possible reasons.

For the US data the study used information from the US health and retirement survey (4386 people), which included self reported information, and the national health and nutrition examination survey (2097 people), which included results of physical and laboratory examinations. For England the study used the English longitudinal study of ageing (3681 people), which included data from three separate years of the health survey for England (5526 people), and biological results from the 2003 health survey for England.

All four surveys included data on age, sex, household income, and education.

In both countries, people of higher socioeconomic status were healthier than those lower down the social scale, the study says.

"Americans report higher levels of disease than the English, and in most cases much higher levels," the study reports. Differences in prevalence rates between the two countries for all diseases were all significant.

Higher rates of cancer in the US may be explained by higher rates of screening, but this does not completely explain the higher prevalence in the US. Cancer mortality was higher in the UK.

In both countries about 20% of people in the study smoked.

Heavy drinking was more common in England. Obesity was much more common in the United States.

The authors considered whether lifetime access to health care could account for the differences, given that members of all socioeconomic groups in England had free access to health care. In the US people aged over 65 have health insurance in the form of the Medicare programme, but they may not have had insurance earlier in their lives. But the authors did not think this gave a full explanation, because although Americans in the highest socioeconomic status group almost always had health care their health outcomes were often worse than those of their English counterparts.