To think the US paediatrician system is weird

[shaniahoo]

I'm on a few parenting groups that are American and the way they talk about their pediatrician is so alien to me. The ped seems to have a lot of power. Like, the hard line of these groups is that you always follow your ped's advice and nobody is allowed to question what a poster's pediatrician told them. But a lot of it seems like non-medical parenting advice? Everyone has their ped tell them when to start solids and they follow that - so they might tell you to start at 4 months so you do that or if they tell you to start at 6 months you do that. And everyone has to have their paediatrician "clear" their baby to start solids before they start. And the ped "clears" you to start sleep training or tells you you must do it or must not do it, and you do what they say. I suppose the equivalent here is the HV but you don't see them nearly so much and there's no sense among parents that you must do whatever your HV says.
AIBU to think this takes autonomy away from parents? Or is it great that they have so much advice and support?

@Aphrathestorm I would be delighted to look at any comparative data you have to back up this statement. It doesn’t mean anything without that. Sadly I also agree that American outcomes are dragged down by the uninsured. That does not include low income people (or those living on benefits) who make proper use of Medicaid.

As horrific as gun violence in schools is, statistically in such a large country it is small potatoes. Just like our own problem with knife violence amongst a much smaller population. I hope you have something more substantive.

Perhaps it's a class/privilege thing. Very obviously not all families are going to have access to this, but for ones who do or who have very expansive health insurance this is the norm.

We had excellent healthcare that didn't cost hardly anything, as did my my friends. We had access to all doctors/specialties as needed.
I have found there are many Uk mums who seem to need a hand hold all the time, they use the GP, the midwife and the health visitor for permissions. These are the same kind of parent who would ask the Paed for permission and info constantly.
I don't think it's a US thing at all.
There were no midwives (where we lived) and no health visitors to check with about anything at all.

"The United States ranks lower than 38 other countries on measurements of children’s survival, health, education and nutrition"

edition.cnn.com/2020/02/18/health/children-health-rankings-unicef-who-lancet-report/index.html

"The United States has poorer child health outcomes than other wealthy nations despite greater per capita spending on health care for children. To better understand this phenomenon, we examined mortality trends for the US and nineteen comparator nations in the Organization for Economic Cooperation and Development for children ages 0–19 from 1961 to 2010 using publicly available data. While child mortality progressively declined across all countries, mortality in the US has been higher than in peer nations since the 1980s. From 2001 to 2010 the risk of death in the US was 76 percent greater for infants and 57 percent greater for children ages 1–19. During this decade, children ages 15–19 were eighty-two times more likely to die from gun homicide in the US. Over the fifty-year study period, the lagging US performance amounted to over 600,000 excess deaths. Policy interventions should focus on infants and on children ages 15–19, the two age groups with the greatest disparities, by addressing perinatal causes of death, automobile accidents, and assaults by firearm."

www.healthaffairs.org/doi/10.1377/hlthaff.2017.0767

"In this comparative effectiveness study of 6 health outcomes, White US citizens in the 1% and 5% highest-income counties obtained better health outcomes than average US citizens but had worse outcomes for infant and maternal mortality, colon cancer, childhood acute lymphocytic leukemia, and acute myocardial infarction compared with average citizens of other developed countries."

www.ncbi.nlm.nih.gov/pmc/articles/PMC7770612/

So all those annual health checks are not leading to better health outcomes.
I am a great believer in evidence based medicine. Often what the public thinks is good healthcare, is not necessarily the best healthcare when we look at the actual evidence.

I've had a look at the last study. Between the fact that it's 2013-2015, when there were fewer people with insurance in even the wealthy counties and the authors' cited limitations, I'd call it an interesting read, but not terribly conclusive. There are also some fairly surprising findings there, i.e. Switzerland's very high infant mortality rate. I'd also note that the UK is not one of the comparison countries.

I think gun violence and car accidents need to be taken out of this discussion as, yes, they're endemic problems, but not related to the health care system other than tangentially in that more mental health provision might have some (limited) effect.

Of the things looked at in this study, the infant mortality rate is surprisingly bad, but notable that Canada, Denmark, France and Switzerland also have surprisingly high rates. When I did a search for 2015, the UK infant mortality rate was 3.7 per 1,000 births, which puts it behind the richest 1% counties in the US, ahead of the 5% richest, on even par with Denmark and France, ahead of Canada and Switzerland, and behind everyone else. It's hard to know what to take from this. Would be interesting to know if maternal age and rates of assisted/higher risk pregnancies are higher in these areas.

As to the rest, of the areas looked at, I would classify colon and breast cancer as areas where the discussed annual health checks potentially come into play, and when it comes to 5 year survival rates, the US leads for breast cancer and only lags behind Australia and Japan for colon cancer. For childhood ALL, which I something unlikely to be flagged up on an annual health check as it tends to have sudden onset symptoms, the US lags only behind Denmark and Finland and only thing I could find on UK survival rates is 'over 90%', so I'd guess roughly on a par.

As for heart attacks, here's a chart that does include the UK

Sorry, forgot to add, the chart is the 30 day fatality rate for heart attacks.
eFigure. Adjusted Case Fatality Rate for Comparison Countries and the US for Overall, Top 1% and Top 5% Counties by Income, 2013-14

@OutofEverything

So, in conclusion, it makes interesting reading, but it's hardly actual evidence. There's too much that's not controlled for.

You are cherry picking. Yes there was an issue highlighted in 2015 about the 30 day survival rate from heart attacks in the UK and recommendations were made to improve treatment which have been enacted.

Mortality from ischaemic heart disease is higher in the US than any other high income country.

www.ncbi.nlm.nih.gov/pmc/articles/PMC3819990/

Interesting stats about breast cancer by country
www.wcrf.org/cancer-trends/breast-cancer-statistics/

I want evidence based medicine.
With cancer the real scandal is how survival rates have hardly increased at all with the types of cancer the public are less interested in e.g. lung cancer.

Infant mortality rates in the US are much worse than the UK. Look at the countries the US has similar infant mortality rates to. It is pretty shocking.
All the research I have read says it is largely to do with very poor and a lack of pre and post natal checks.

You are confusing correlation and causation.

American children have worse health outcomes largely because of greater inequality and poverty. You can't look at American children en masse, the fact that we have paediatricians in primary care, and then conclude that primary care paediatrics is inferior. You need to compare matched groups, see actual access to care, etc. This is one of the biggest flaws in the American system: the government does not spend money on social programmes and then dumps the result on the health system. The issue is often not the direct care the doctors are providing.

there are structural issues in the USA beyond insurance. In principle, almost all American children should have access to health insurance, whether through their parents, Medicaid, or S-CHIP, though in practice it's not quite that good--both because of some gaps in the system, because some parents don't enroll their children, etc. (Surprise: Massachusetts has only 1% of children uninsured while Texas is nearly 12%.)

But then you have to get parents to engage with the system, take their kids for checkups, listen to the advice doctors give. There are Americans who are basically culturally conditioned not to go to the doctor, sometimes because they believe it's too expensive, sometimes because they've done so long without that even though they can afford it now they're used to not going.

Infant mortality is all deaths to age 1--it's not all down to post-natal checks. Again, women are actually supposed to get these checks. There's set dates you're supposed to return to your obstetrician or midwife and dates to take the baby to the paediatrician. One real obstacle to this is that traditionally, pregnancy Medicaid terminates 2 weeks after childbirth. There's a push to make it extend to 1 year to ensure proper postnatal care. So again, the problem isn't what doctors recommend people do, it's making sure they're actually able to access it.

So again, the problem isn't what doctors recommend people do, it's making sure they're actually able to access it.

@knitnerd90 I agree with this, it’s all about access. Sadly, access is also getting harder in the UK due to the staffing shortages. Both systems have many problems right now.

Also, there are various committees that evaluate evidence quality in the US and make recommendations.

What is interesting is the response to that. For example several years ago the USPSTF recommended decreasing mammography frequency from annual to biannual and discontinuing the screening programme for ages 40-49 for women not at risk of cancer. There was a massive outcry with women claiming their lives had been saved by annual mammography. Insurance companies were forced to continue covering annual mammograms for all women over 40, despite the USPSTF recommendation.

(on the flip side: the NHS refusal to cover varicella vaccination, claiming that chicken pox is only an economic problem; this makes the NHS an outlier in refusing to vaccinate for it, even for people who have not had chicken pox by the time they are teens. They also claim it will cause a rise in shingles cases, but everywhere is seeing that--including the UK. It's easy to dismiss the US for vaccinating for varicella; it's harder when Canada, Australia, and multiple European countries do it.)

No, you're cherry picking. What's the attribution for that chart? What year? Where have you read that it's largely to do with 'very poor and a lack of pre and post natal checks'? That's a very general analysis for someone who keeps banging on about evidence based medicine, not to mention unclearly worded. Do you mean poor people, as in people living in poverty, or do you mean poor medical care? It's unclear.

By the way, here's the definition for evidence based medicine, which you keep talking about but don't seem to understand. So far literally nothing you've posted has been evidence based medicine proving that routine checks, as are common in the US, don't lead to better outcomes.

Source: BMJ

Evidence-based medicine (EBMa) refers to the application of the best available research to clinical care, which requires the integration of evidence with clinical expertise and patient values. [1] [2] By best available research, we mean clinically relevant (i.e., patient oriented) research that:

Illuminates the accuracy and precision of diagnostic tests,
Highlights the importance of prognostic markers,
Establishes the efficacy and safety of therapeutic, rehabilitative, or preventive healthcare strategies, or
Seeks to understand the patient experience.

As to infant mortality, here's some data from the World Bank for 2020. Oh, look, US and UK not all that far apart. Also, you would do well to bear in mind that there are differences in the way countries count infant mortality, with the US more likely to count infants on the threshold of viability as live births than many other countries which are more likely to count them as miscarriages or stillbirths.

This chart is very interesting because if you scroll down it has data by income level

data.worldbank.org/indicator/SP.DYN.IMRT.IN?name_desc=true&locations=GB

With cancer the real scandal is how survival rates have hardly increased at all with the types of cancer the public are less interested in e.g. lung cancer.

That's a totally different and unrelated conversation, having to do, I believe with the fact that people tend to not be diagnosed while the cancer is still localised. Surely even you can see that there's a link to that being a cancer we don't routinely screen for and therefore increase the odds of catching in an early stage as opposed to breast and colon?

(on the flip side: the NHS refusal to cover varicella vaccination, claiming that chicken pox is only an economic problem; this makes the NHS an outlier in refusing to vaccinate for it, even for people who have not had chicken pox by the time they are teens. They also claim it will cause a rise in shingles cases, but everywhere is seeing that--including the UK. It's easy to dismiss the US for vaccinating for varicella; it's harder when Canada, Australia, and multiple European countries do it.)

Yes, and in fact the evidence seems to show that the vaccination reduces shingles overall.

From Scientific American (2019)

Approximately 38 per 100,000 children vaccinated against chickenpox developed shingles per year, compared with 170 per 100,000 unvaccinated children, researchers found. Furthermore, shingles infection rates were lower in children who received both recommended doses of the chickenpox vaccine compared with those who only got the first dose.

The NHS do not vaccinate for chickenpox as they are trying to reduce the incidence of shingles. There is lots of evidence that having some chickenpox circulating in the community reduces shingles severity and incidence for older people.
But I know vaccination would eventually reduce shingles as well as people age.

I know many mothers in the US do not get post natal check ups. Charging for access to healthcare has that consequence.

It doesn't have to be either/or with chicken pox and shingles.

The Shingrex vaccine is incredibly effective in preventing shingles and is recommended for everyone over age 50 in the US. The old live virus Zostavax is ineffective and outdated.

Of course Zostavax is cheaper.

You jump around a lot and don't seem interested or able to reply to anything that is refuted or questioned, @OutofEverything

Re shingles, sure, but there is currently a very effective vaccine against shingles. Why not give that routinely to anyone too old to have been vaccinated against chicken pox and vaccinate all children for chicken pox? A two prong approach that, ultimately, will save the system a lot of money. That's part of the problem with the NHS, imo, it's a system that is constantly playing catch-up rather than engaging in forward thinking and preventative care for a long term gain.

Charging is not the only complicating factor in accessing care. The US is very large and many areas can be described as medical deserts as they are either too far away from medical care to access it reliably, or lacking in health care providers. I suspect the UK is well on its way to something similar. When you add this to poor maternity and family leave policies, it's not a pretty picture. Things are not nearly so black and white or simple as you seem to believe.

@Wallaw Nothing is black and white, these are complex issues. I am simply explaining why the decision was made some time ago not to roll out vaccination of children against chickenpox.
The new chickenpox vaccine has been around for just over a year and is used by the NHS in some cases, but not routinely.
The decision not to vaccinate children was after a very robust research project that found a low level of circulation of chickenpox in the community significantly reduced shingles. I have not seen any research as to whether the new vaccine provides the same level of protection. Indeed as the vaccine is so new I doubt there is any evidence available yet to show that. I know the new vaccine provides a high level of protection initially, but whether this is sustained long term still needs to be evaluated.
I don't know whether the CDC or NICE approach is best, but currently shingles is more common in the United States than the UK and the mortality rate is significantly higher in the US from shingles. If this new vaccine changes things then NICE will recommend a change of approach.

The NICE approach to shingles has certainly up till now been evidenced based at a population heath. It is about promoting the best public health. At an individual level where you want to stop your child getting chickenpox then the US approach wins out.

I'm actually heavily in favour of changing the uk system so every woman has a named gynaecologist and every child a paediatrician and taking those cases away from GPs.

What I'm vehemently against is forced medical intervention, which is the trend in USA.

Eg childbirth. I'd never give birth there. Home births are illegal in some states and no midwife led care is the norm. This is proven to have worse outcomes.

Do you mean the new shingles vaccine (Shingrix) or are you talking about the chicken pox vaccine? You seem unclear. The chicken pox vaccine was approved in 1995. Shingrix was approved in the US in 2017, where it's recommended for adults over 50, and is now recommended for all adults 70-79 in the UK. Short term protection is over 90%.

and the mortality rate is significantly higher in the US from shingles.

Where did you get this gem? Out of thin air. The statistics I was able to find are that there are roughly 50 deaths from shingles-related causes every year int he UK, and under 100 in the US.

The decision not to vaccinate children was after a very robust research project that found a low level of circulation of chickenpox in the community significantly reduced shingles.

If you're referring to the BMJ article, the authors state flat out that it's observational, and therefore, speculative. Interesting, but not conclusive. Other studies, i.e. one conducted in Canada, show the opposite, but the authors concede that they're unable to draw long-term conclusions.

I have some work to finish up and we have friends coming to dinner, but I'll eagerly await your next poorly researched conclusion later tonight.

Home births are not illegal in any state. There can be issues with midwives requiring certification (which varies from state to state), but women have the right to choose home birth.

What forced medical interventions are you referring to? I'm genuinely curious.

The NHS approach to the chickenpox vaccine is short-sighted as the vaccine greatly reduces the chance of shingles so in the future there will be far less shingles cases in countries where children are vaccinated while the level will remain the same in the UK. And that's not even taking into account the issue of serious cases of chickenpox including deaths.

@Wallaw Shingrex was approved in the US for use in Oct 2017. But I am sure the recommendation from the CDC to use shingrex was only issued late in 2021. And I meant the shingles vaccine. I am working so commenting on the hop.

CDC Website:
Almost 1 out of 3 people in the United States will develop shingles in their lifetime. Between 1 in 25 and 1 in 100 people who develop shingles have to be hospitalized for complications. Older adults and people with weakened or suppressed immune system are more likely to be hospitalized. About 30% of people hospitalized for shingles have a weakened or suppressed immune system. Shingles causes fewer than 100 deaths annually. Almost all shingles deaths are in elderly or people with compromised immune system.

In England and Wales there are about 50,000 cases of shingles in people aged 70 or above every year. Around one in four adults will experience shingles in their lifetime

The mortality rate of shingles is not statistically significant. Obviously tragic on an individual basis, but very, very few people die from a case of shingles.

Of far greater concern is preventing postherpetic neuralgia, an absolutely excruciating condition with few effective treatments. The cost in terms of quality of life as well as chronic need for medical treatment and ongoing disability is enormous.