Sunday, October 5, 2008

Comparing Medical Care for Pain and End-Of-Life

I just saw a report that graded the United States on how we are doing taking care of people when we are seriously ill and dying. There is a whole specialty in medicine for this, called Palliative Care. It focuses on relief of the pain and other symptoms of serious illness.

We are not doing too well. The entire United States earned a "C" and several states completely failed! This got me thinking - how is this graded? and how does it compare to other countries, specifically to Costa Rica?

Well, the grading website ( references the Journal of Palliative Medicine, which is only available by subscription, so I can't judge the methodology. But the summary of the methodology looks extremely tailored - it excludes small hospitals, facilities for psychiatric treatment, chronic care, rehabilitation, ENT, pediatrics, and federally controlled facilities. What's left? (Setting aside the nature of studies, even ones you could drive a truck through. Maybe that's too harsh? it is a professional journal, after all.) I looked at the results and looked for what I could compare. I came away with the fact that it is difficult enough to find consistency from state to state. There are no numbers or factors I could see that I could use to compare to another country.

So, I looked for a world report (, and found one from Help the Hospices and the National Hospice and Palliative Care Organization (NHPCO) from 2006.

This study looks like it is done every year. It categorizes countries around the world by their approach to palliative care.
The four groups are:
1) no known hospice-palliative care activity
2) capacity building activity (but no service yet)
3) countries with localized provision of hospice-palliative care, and
4) countries where hospice and palliative care activities are approaching integration with the wider health system. (defined further at the bottom of this post)

Both the USA and Costa Rica are in Group 4, and so are at the highest level defined. Now, if the USA is not doing too well, but it is at the highest level, it is clear that the world as a whole has a long row to hoe.

Here is a brief history of palliative care for each country:

In the USA, the Connecticut Hospice provided the first home care service for the dying in 1974. The forerunner of the National Hospice and Palliative care organization (NHPCO) was founded in 1978. Reimbursement for hospice patients through the Medicare program was enacted in 1983, and by 2005, NHPCO estimated that 1.2 million patients were being cared for nationwide within hospice programs. To find a report for a specific state:

Costa Rica is a small country with an established health system committed to providing good quality care at a reasonable price to every citizen. With a government-sponsored network of 29 hospitals and more than 250 clinics throughout the country, the Caja Costarricense de Seguro Social (CCSS) has primary responsibility for providing low cost health services to its 4 million inhabitants. The Clinic for Pain and Palliative Care was established in the Calderón Guardia Hospital in the early 1990s and later became recognized as the National Center for Pain Control and Palliative Care (1999). A national pain control and palliative care policy was adopted in 2001.

The report compares several factors in evaluating the level of the country - Human Development Index, Crude Death Rates, Gross Domestic Product, and Ratio of services to population.

The human development index (HDI) gives a multiple measure of a country’s development, based on: longevity, knowledge, and standard of living. There is a strong association between palliative care and human development, as 83% of Group 4 countries have a high index (1-57), and another 14% with a medium index (58-145).
HDI rank / index:
Costa Rica = 47
USA = 10

2006 Crude Death Rates (CDR) are the total number of deaths per thousand persons which occur in the same year. These ranged from 3.7 to 13.4 among Group 4 countries. The correlation between CDR and palliative care is difficult to state, since the ranges for the groups overlap, and CDR is under-reported. However, the study states that the countries with the lowest CDR in Group 4 are distinctly lower than those in the other groups.
Costa Rica = 3.8
USA = 8.4

Gross domestic product (GDP) per capita is indicative of a country’s wealth; it is the market value of the total final output of goods and services produced in a country over a specific period. There appears to be no relationship between a country’s wealth (GDP per capita) and palliative care development, since high and low income countries are represented in each of the four groups of countries.

The comparison of the ratio of palliative care services to population, and rank in the Americas, shows little difference between the two, especially given the wide range around the world.
Costa Rica (ranked 5th) = 26 services => 166 per 1000
USA (ranked 4th) = 4000 services => 75 per 1000

Studies are interesting in that they try to level the playing field and give an objective look at an issue. These usually involve numbers and statistics. However, the cultural effect, especially on the field of medicine, is stripped. To balance this, think of the differences between a visit to your doctor in the states and to your doctor in Costa Rica. The Costa Rican doctor is trained (culturally and medically) to put you at ease. If you are in pain, you get the pain taken care of, *then* deal with fixing things. Caring for the patient as a person, and showing that you care is a natural part of the Costa Rican medical profession. It seems to me then that palliative care is regarded as just another normal part of medical training. It would seem a little strange to have a specialty just for this. But in the USA culture, where doctors are pushed towards spending less time with patients, and tackling illnesses as an entity separate from the patient, this specialty makes sense. It addresses the built-in lack in treating the patient as a whole in the states.

--- Some more details ---
World Health Organization interviewed Dr. Isaias G. Salas-Herrera, chief of the National Pain and Palliative Care Center, in San Jose, and his assistant Dr. Rigoberto Monestel. They discuss Costa Rica's national policy for pain control and palliative care.
The national health policy is here (in Spanish)
Note that you can enter this URL in Google's translation tool to read it in English:

Group 4 activities are defined further as:

(breakdown of "Capacity Building" as in Group 2)
• Presence of sensitized personnel
• Expressions of interest with key organizations (eg APCA, HAU, IAHPC, Hospice Information)
• Links established (international) with service providers
• Conference participation
• Visits to hospice-palliative care organizations
• Education and training (visiting teams)
• External training courses undertaken
• Preparation of a strategy for service development
• Lobbying: policymakers/ health ministries

(breakdown of "Localized Activities" as in Group 3)
• Critical mass of activists in one or more locations
• Service established – often linked to home care
• Local awareness/ support
• Sources of funding established (though may be heavily donor dependent and relatively isolated from one another, with little impact on wider health policy)
• Morphine available
• Some training undertaken by the hospice organization

(additional activities specific to Group 4)
• Critical mass of activists countrywide
• Range of providers and service types
• Broad awareness of palliative care
• Measure of integration with mainstream service providers
• Impact on policy
• Established education centers
• Academic links
• Research undertaken
• National Association


Christian Sinclair, MD said...

You can get the actual journal article free online at the Journal of Palliative Medicine Website.

Thanks for covering this. Your exploration of the international data is intriguing. I am not sure why there has not been another HWO world report on palliative care access recently.

Julie said...

Thanks for the link and comment, Christian.

I suspect you have to join and be logged in to read the article.

Nice to see that Kansas, Missouri, and N.Carolina all earned a "B" :).

If you haven't experienced it, I highly recommend the medical treatment in Costa Rica - not that you want to plan on a medical emergency on vacation, but if you're there, and you need it, you'll see how very caring the doctors are.