INATTENTION TO THE FIDELITY OF HEALTH CARE DELIVERY IS COSTING LIVES

Leroy et al.1 examined what we call the fidelity of health care delivery, the extent to which the system provides patients with the interventions they need, delivered properly and precisely when they need them.2 According to their analysis of interventions for children in 42 low-income countries, improving fidelity rather than the technology of care (e.g., new drugs) would save almost 3 times as many lives. They reported that research on child mortality in developing countries deals overwhelmingly with technological advances, giving comparatively little attention to delivery and utilization.1

This imbalance is hardly unique to developing countries. We reached the same conclusion in our analysis of research priorities in the United States, where the fidelity of health care delivery also is deficient.2 Americans receive only 55% of recommended treatments, and those who do receive care are often dissatisfied with its quality,3 yet most research is directed at finding new treatments.4 We described a break-even point2 after which incremental improvements in the efficacy of biotechnology saved fewer lives than did improving systems to deliver those treatments to patients. For example, we found that the billions of dollars invested in developing anti-platelet agents more potent than aspirin may have prevented fewer strokes than simply ensuring that all at-risk persons took aspirin.

Our view—and presumably that of Leroy et al.—is not that biomedical research should be abandoned but that it should not receive disproportionate priority while the infrastructure for delivering care languishes. Lives are lost in developed and developing countries by concentrating too many resources on advancing biotechnology and concentrating too few on the fidelity of health care delivery. We found that such an imbalance in priorities produced inferior health outcomes in the United States, and Leroy et al. found the same for the developing world, where they estimated that the same resource imbalance claims 4 million children’s lives each year.

We also contend that biomedical advances save fewer lives than modifying the social conditions that influence health. We have estimated that for every life saved in the United States by such advances, 5 lives would be saved if Blacks experienced the mortality rates of Whites and 8 lives would be saved if adults with lesser education experienced the mortality rates of college-educated adults.5^,6

These ratios are subject to some imprecision, but the size of the ratios makes it unlikely that greater precision would result in biomedical advances exceeding fidelity. Leroy et al. reached the same conclusion. These studies collectively paint a clear picture for policymakers: overspending on biotechnology at the expense of other priorities is costing lives.