In This Issue

March 2012 | Bradford H. Gray

The health care and policy experiences of different countries are receiving increasing attention from researchers and policymakers because analyses of such experiences are often revelatory. This issue of The Milbank Quarterly begins with such a study. In “Cervical Cancer Screening in the United States and the Netherlands: A Tale of Two Countries,” Dik Habbema and Inge de Kok, from the Erasmus MC University Medical Center in Rotterdam, and Martin Brown, from the National Cancer Institute, present data on whether screening practices and outcomes differ in the two countries. The U.S. Preventive Services Task Force’s proposal to change screening guidelines for breast and prostate cancer has generated a great deal of controversy, including charges that with less screening, more lives would be lost. A comparison of different countries’ screening policies and practices is thus of interest. Habbema and his colleagues report that although rates of cervical cancer screening are three to four times higher in the United States than in the Netherlands, the two countries’ mortality rates are similar.

No single study, especially one based on observational data, can definitively answer questions about the wisest screening policies, but as Jane Kim notes in one of two commentaries on the article, this study “lends support to the suspicion that cervical cancer screening in this country is overly aggressive and inefficient.” She also cautions, however, that screening practices are only one of several factors that affect mortality from cervical cancer. In a second commentary, Brenda Sirovich makes similar points, supplementing them with relevant personal experience as a doctor and calling for more discussion with patients and in policy circles about the benefits and harms of screening.

The second article in this issue presents a new approach to systematic literature reviews. Australian researchers Leonie Segal, Rachelle Sara Opie, and Kim Dalziel sought to understand why various studies of the effects of home visiting programs to reduce child maltreatment had different results. The answer is revealed in the title of their article: “Theory! The Missing Link in Understanding the Performance of Neonate/Infant Home-Visiting Programs to Prevent Child Maltreatment: A Systematic Review.” Their literature review captures the usual characteristics of the studies that met their screening criteria, but they also examined whether these home-visiting programs were based on theory. They found that those programs with a theoretical underpinning that linked them to the target population were much more likely to be effective than were programs without a theoretical match with the target population. Their article thus not only provides a valuable overview of programs aimed at an important problem—the maltreatment of children—but it also describes a way to increase the value of systematic reviews themselves.

The use of theory is also the subject of the next article in this issue. In “Health Insurance Coverage and Take-Up: Lessons from Behavioral Economics,” Katherine Baicker, William Congdon, and Sendhil Mullainathan address the question of why some people with access to health insurance—often at low cost—do not enroll. Economic factors play a role, of course, but the authors argue that a fuller understanding can be gained from behavioral economics, the field that uses insights from psychology to inform economic analyses. They argue that ideas from behavioral economics help explain both people’s failure to buy insurance and the efficacy of different policies aimed at increasing coverage, and they advocate using “behaviorally informed policy design” to address this issue. In view of the provisions in the Affordable Care Act aimed at increasing health insurance coverage in the United States, their analysis is particularly important.

The next article in this issue contributes to our understanding of how change occurs in medical practice and the factors that produce change. The article, “What We Talk about When We Talk about Risk: Refining Surgery’s Hazards in Medical Thought,” is a collaboration between an anesthesiologist, Mark Neuman, and a sociologist, Charles Bosk. In this case, the change was in how surgeons conceptualize and assess risk to surgical candidates, and the factor that stimulated this change was a new method of assessing surgical risk. Using guidance provided in surgery textbooks as their measure of surgical practice, Neuman and Bosk found that before 1977, risk was thought of in global terms: a patient was either a “good” or a “poor” risk for surgery. Then in 1977, an influential article proposed a new surgical risk-stratification index focusing on the probability of specific organ systems’ dysfunction after surgery. By the early 1980s, surgical textbooks had adopted the new approach, which seemed to be a more scientific and standardized way of judging the risk of surgery. This new approach to risk assessment, the authors suggest, was also more permissive regarding surgical intervention and may conflict with policy goals of promoting more cost-effective decisions to proceed with surgery.

This issue concludes with a pair of empirical studies. The article by Matthew McHugh, Margo Brooks Carthon, Douglas M. Sloane, Evan Wu, Lesly Kelly, and Linda H. Aiken, “Impact of Nurse Staffing Mandates on Safety-Net Hospitals: Lessons from California,” addresses the policy concern that the legislatively based nurse-staffing requirements implemented for California hospitals in 2004 would have an adverse effect on that state’s safety-net hospitals and the patients they serve. The particular concern was that because safety-net hospitals tend to have limited resources, they would fulfill the new requirements by substituting lesser-trained staff for registered nurses.

But McHugh and his colleagues report that the staffing mandate resulted instead in significant staffing improvements, with the greatest increase in those hospitals with the lowest staffing levels at the outset. Although a slight increase in skill mix was found in the non-safety-net hospitals, no such change was found in the safety-net hospitals. The authors conclude that the nurse-staffing mandate resulted in improvements and was not, as had been feared, at the cost of reducing nursing skills.

The final article in this issue, “Metropolitan Fragmentation and Health Disparities: Is There a Link?” by Malo André Hutson, George Kaplan, Nalini Ranjit, and Mahasin Mujahid, focuses on a heretofore unexamined possible source of racial differences in mortality in the United States. Previous research has found that residential racial segregation contributes to health disadvantages in a minority population (Schulz et al. 2002; Williams and Collins 2001). Among the mechanisms suggested to explain this, Hutson and his colleagues explore the possibility that metropolitan fragmentation—the total number of governmental units within a metropolitan statistical area—may play a role.

Hutson and his colleagues report data that show black-white mortality differences tend to be higher in the more fragmented cities. They suggest several reasons that might help explain this. One puzzling observation is that the association between racial differences in mortality and fragmentation was not found in the population aged sixty-five and older. Nevertheless, the finding of a link between mortality and the way in which metropolitan areas are organized suggests a new path for examining the determinants of population health.

Bradford H. Gray


Schulz, A.J., D.R. Williams, B.A. Israel, and L.B. Lempert. 2002. Racial and Spatial Relations as Fundamental Determinants of Health in Detroit. The Milbank Quarterly 80(4):677–707.

Williams, D.R., and C. Collins. 2001. Racial Residential Segregation: A Fundamental Cause of Racial Disparities in Health. Public Health Reports 116(5):404–16.

Author(s): Bradford H. Gray

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Volume 90, Issue 1 (pages 1–4)
DOI: 10.1111/j.1468-0009.2011.00651.x
Published in 2012