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How Does the Quality of U.S. Health Care CompareInternationally?
Timely Analysis of Immediate Health Policy Issues
August 2009
Elizabeth Docteur and Robert A. Berenson
Introduction
There is a perception among manyAmericans that despite coverage,cost and other problems in thehealth care system, the quality of health care in the United States isbetter than it is anywhere else inthe world and might be threatenedby health reform. In fact, 55percent of Americans surveyed lastyear said U.S. patients receivebetter quality of care than do thosein other nations, even though only45percent said they thought theUnited States had the world’s besthealth care system.
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And whileAmericans overwhelminglysupport government action toincrease coverage and reduce thecosts of health care, a recent pollfound that 63 percent worry thatthe quality of their own care wouldget worse if the governmentensured health care for all.
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 Another poll found that as many as81percent of Americans have suchconcerns.
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 Participants in the current reformdebate refer to the relative qualityof U.S. health care as providingsupport for their views, andperceptions of health-care quality
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what it is and where it can befound
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are often at the heart of disagreements over what form of health reform the country shouldadopt. But hard facts to supportclaims are often missing, and it isclear that quality of care experts,policy makers, health careproviders and the general public allhave different ideas as to whichaspects of health care signify itsquality and which ones are mostimportant.This brief brings together availableevidence on how quality of care inthe United States compares to thatof other countries and commentson the implications of the evidencefor the health reform debate. Byexploring how the quality of ourcare compares internationally, wecan address the underlyingattitudes and concerns that peoplehave about health reform. Forexample, if claims that the UnitedStates has the best quality of carein the world
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overall or inparticular respects
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were wellsupported by the evidence, itwould caution us against adoptingforms of health reform thatthreaten those attributes of ourhealth system responsible for thisstanding. But if quality of care isnot remarkable
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or may be evenlagging
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there should be lessreluctance to change. In addition, amore explicit need for healthreform to address qualityimprovement would appearwarranted.
What constitutes high-quality health care?
A number of definitions of healthcare quality have been put forwardover the years. The U.S. Instituteof Medicine’s definition, whichhas grounded expert work in theUnited States and elsewhere,describes quality as “the degree towhich health services forindividuals and populationsincrease the likelihood of desiredhealth outcomes and are consistentwith current professionalknowledge.”
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A similar definitionis used by the U.S. Agency forHealthcare Research and Quality:
 
“Quality health care means doingthe right thing at the right time inthe right way for the right personand having the best resultspossible.”
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Both definitions refer tocharacteristics of health care thatare increasingly referred to as“technical” or “clinical" quality or“effectiveness.”
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 In the context of efforts to assesshealth system performance, theterm “quality” is often used toencompass a range of desirable orpositive attributes of health careand the overall performance of health-care systems. A review of eight country-specific andinternationally developedframeworks for evaluating healthsystems found a great deal of commonality in how performancehas been conceptualized.
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Inaddition to effectiveness, theresearchers identified 14 otherdimensions of the performance of health care systems: acceptability,accessibility, appropriateness, careenvironment and amenities,competence or capability,continuity, expenditure or cost,efficiency, equity, governance,patient-centeredness (-focus) orresponsiveness, safety,sustainability, and timeliness.
 
 
Timely Analysis of Immediate Health Policy Issues 2
Many of these performancedimensions might reasonably beconsidered to be attributes of high-quality care (e.g., appropriateness,competence, timeliness). Those ina second group (e.g., cost,governance, sustainability) arereadily observed as separateperformance concerns. Reasonablepeople might have different viewson whether others (e.g.,accessibility, acceptability,responsiveness) are dimensions of quality or closely related concepts,and indeed these are treated indifferent ways in the frameworksreviewed. Accessibility isparticularly difficult to disentanglefrom considerations of health carequality in that it is a prerequisite toreceipt of quality health care.Availability of providers andservices, coverage, benefits andaffordability all come into play aspotential explanations for differentuser experiences with the healthcare system and the outcomesattained. Finally, (technical)efficiency is a function of thequality and quantity of servicesproduced at a given cost.Efficiency, or value for money, is aperformance consideration of greatinterest to public authorities andpurchasers, although only modestheadway in measuring efficiencyin health care has been made todate, reflecting limitations in thecapacity to measure the quality of health care.It is evident from the U.S. reformdebates that popular conceptions of what constitutes good qualityhealth care encompass a range of dimensions. Although obviouslyhigh quality implies superiorhealth outcomes, other attributesconsidered indicative of qualityappear to underlie popularexpressions of U.S. health caresuperiority, including a belief thatAmericans with good insurancecoverage uniquely benefit fromprompt availability andaccessibility of cutting-edgemedical procedures, medicines,and devices, as well as highlyeducated and well-trained healthcare professionals, who know andconsistently do what is best fortheir patients. On the other hand,those who assert that we haveinferior quality of care point to ourrelatively poor population healthstatus,
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and factors such as barriersto access for those withoutadequate insurance coverage orlimited health plan providernetworks and insufficientcoordination among providers inthe fragmented health care deliverysystem.All of these aspects of quality andbroader health system performanceare important and legitimateconsiderations; therefore, we cast arelatively wide net in this brief.Specifically, we focus oneffectiveness (or “technical” or“clinical” quality) and consideradditional dimensions of quality orhealth system performance that aremost closely related:appropriateness, safety,accessibility, acceptability, andresponsiveness.
What is the evidence onhow quality of care inthe United Statescompares to othercountries?
To make an informed assessmentabout the quality of care in onehealth system versus another, it isimportant to look at a wide rangeof indicators. Because health careinvolves a complex array of activities, and because there aremany holes in our knowledge of the relative quality in many areas,it is impossible to use a singlemeasure as a meaningful proxy.Measures that reflect multipledimensions of quality have acertain appeal as performanceindicators for policy-makers,although more specific or narrowmeasures have the advantage of being more actionable foradministrators and clinicians. Andeven with a broad set of comparative measures, people maydiffer on which measures are mostimportant, for example, thosefocusing on the level of typical oraverage care for commonconditions versus the careavailable for unusual, life-threatening conditions.The evidentiary basis for cross-country comparisons of qualitycould be strengthened byadditional studies andimprovements in methods anddata. Nonetheless, a number of comparative studies on the qualityof care have been published.Below we review some of the keyfindings from recent research thatprovide insight on how the qualityof care in the United Statescompares to the quality of carein other nations. We explorequality as assessed by measuresbased upon population healthstatus, measures of processesand outcomes of care for particularconditions, measures of patientsafety, and indicators basedon patients’ experience withhealth services. In each area,we put forward the evidencewe could find on how theattribute in question stacks up(or fails to do so).
 
 
Timely Analysis of Immediate Health Policy Issues 3
How strong is the evidence base for comparing health care quality across countries?
There is modest research literature comparing the quality of care in the United States with the quality of care furnishedelsewhere. Most studies of technical quality or effectiveness draw on data compiled from disease registries, medicalrecords or administrative data. Such studies generally focus on a particular condition, such as coronary heart diseaseor specific forms of cancer, and they differ in the extent to which they endeavor to account for factors outside thecontrol of the health care provider and system that could affect the results.Efforts to identify a set of indicators for use in making international comparisons across a range of conditions as partof regular monitoring activities include an ongoingOrganisation for Economic Co-operation and Development(OECD) initiative, which builds on initial work by the Commonwealth Fund and a coalition of Nordic countries. Todate, the OECD has formulated, tested and validated a relatively small number of quality measures for use ininternational comparisons, with other measures in development.
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Initial results have been published showing cross-country differences based on data obtained from national sources, but with caveats as to factors making comparisonsindicative, rather than absolute. Limitations include differences in data sources used in measurement, differentreporting periods, and limited ability to adjust for age and other factors (not reflecting quality of care differences) thatcan explain apparent cross-national differences.Beyond this, surveys of citizens, patients and health care providers in five or more countries have been producedannually since 1998 by the Commonwealth Fund.
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These provide information on how health care is perceived as wellas how the experience of health care differs internationally in relation to public expectations. Surveys can exploreaspects of health care and quality dimensions for which other forms of data do not exist in comparable form. Theirlimitations include cross-country differences in the interpretation of questions and concepts, which could affect howcountries’ health systems fare relative to one another, as well as standard survey research problems like recall bias.An important issue in health care quality measurement, as in other types of research that attempt to ascertain causality,is that it is very difficult to adjust for factors outside the health care system which contribute to particular healthoutcomes, such as socioeconomic status, lifestyle, and disease incidence or prevalence. Similarly, quality of caremeasures could be affected by differential access to care across a population, reflecting coverage gaps in the UnitedStates as well as shortfalls in supply or financial barriers presented by cost-sharing requirements here and in othercountries. Thus, the quality of care obtained by those with unfettered access might differ considerably from that of those who face obstacles to getting needed care.
Are cross-countrydifferences in lifeexpectancy andmortality indicative ofdifferences in healthcare quality?
While U.S. life expectancy is at orbelow the average in comparisonwith that of other developedcountries, findings from researchthat has adjusted mortality toaccount for deaths not related tohealth care (so-called amenablemortality) show the United Statesto be among the worst performers.The United States is not among topperformers in terms of lifeexpectancy, an indicatorinfluenced by factors outside thehealth system in addition to healthcare. We rank among the lowerthird of developed countries in lifeexpectancy at birth. Lifeexpectancy at age 65 may be abetter indicator of U.S. health careperformance because all olderAmericans have reasonably goodinsurance coverage throughMedicare. U.S. life expectancy forboth men and women at age 65 isabove the Organisation forEconomic Co-operation andDevelopment (OECD) average, butbelow what the top countries haveachieved, particularly for women.
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 Among 19 countries included in arecent study of amenablemortality,
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the United States hadthe highest rate of deaths fromconditions that could have beenprevented or treated successfully.The extent to which differencesacross countries in the prevalenceof particular conditions mayexplain the poor U.S. showing in
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