How Does the Quality of U.S. Health Care Compare Internationally?

August 2009 - Taken collectively, the findings from international studies of healthcare quality do not in and of themselves provide a definitive answer to the question of how the United States compares in terms of the quality of its health care. While the evidence base is incomplete and suffers from other limitations, it does not provide support for the oft-repeated claim that the “U.S.health care is the best in the world.” In fact, there is no hard evidence that identifies particular areas in which U.S. health care quality is truly exceptional. #healthcare
About Jack Berlin

Elizabeth Docteur and Robert A. Berenson - About the Robert Wood Johnson Foundation - About Prizm Share
Health Care United State Quality country rate patient
About Jack Berlin

Elizabeth Docteur and Robert A. Berenson - About the Robert Wood Johnson Foundation - About Prizm Share
Health Care United State Quality country rate patient
Â 
 
How Does the Quality of U.S. Health Care Compare 
Internationally? 
Timely Analysis of Immediate Health Policy Issues  
August 2009  
Elizabeth Docteur and Robert A. Berenson  
Introduction 
There is a perception among many 
Americans that despite coverage, 
cost and other problems in the 
health care system, the quality of 
health care in the United States is 
better than it is anywhere else in 
the world and might be threatened 
by health reform. In fact, 55 
percent of Americans surveyed last 
year said U.S. patients receive 
better quality of care than do those 
in other nations, even though only 
45percent said they thought the 
United States had the worldâ€™s best 
health care system.1 And while 
Americans overwhelmingly 
support government action to 
increase coverage and reduce the 
costs of health care, a recent poll 
found that 63 percent worry that 
the quality of their own care would 
get worse if the government 
ensured health care for all.2 
Another poll found that as many as 
81percent of Americans have such 
concerns.3 
Participants in the current reform 
debate refer to the relative quality 
of U.S. health care as providing 
support for their views, and 
perceptions of health-care quality 
â€”Â what it is and where it can be 
found â€” are often at the heart of 
disagreements over what form of 
health reform the country should 
adopt. But hard facts to support 
claims are often missing, and it is 
clear that quality of care experts, 
policy makers, health care 
providers and the general public all 
have different ideas as to which 
aspects of health care signify its 
quality and which ones are most 
important. 
This brief brings together available 
evidence on how quality of care in 
the United States compares to that 
of other countries and comments 
on the implications of the evidence 
for the health reform debate. By 
exploring how the quality of our 
care compares internationally, we 
can address the underlying 
attitudes and concerns that people 
have about health reform. For 
example, if claims that the United 
States has the best quality of care 
in the world â€” overall or in 
particular respects â€” were well 
supported by the evidence, it 
would caution us against adopting 
forms of health reform that 
threaten those attributes of our 
health system  responsible for this 
standing. But if quality of care is 
not remarkable â€” or may be even 
lagging â€” there should be less 
reluctance to change. In addition, a 
more explicit need for health 
reform to address quality 
improvement would appear 
warranted.  
What constitutes high-
quality health care? 
A number of definitions of health 
care quality have been put forward 
over the years. The U.S. Institute 
of Medicineâ€™s definition, which 
has grounded expert work in the 
United States and elsewhere, 
describes quality as â€œthe degree to 
which health services for 
individuals and populations 
increase the likelihood of desired 
health outcomes and are consistent 
with current professional 
knowledge.â€4 A similar definition 
is used by the U.S. Agency for 
Healthcare Research and Quality: 
â€œQuality health care means doing 
the right thing at the right time in 
the right way for the right person 
and having the best results 
possible.â€5 Both definitions refer to 
characteristics of health care that 
are increasingly referred to as 
â€œtechnicalâ€ or â€œclinical" quality or 
â€œeffectiveness.â€6 
In the context of efforts to assess 
health system performance, the 
term â€œqualityâ€ is often used to 
encompass a range of desirable or 
positive attributes of health care 
and the overall performance of 
health-care systems. A review of 
eight country-specific and 
internationally developed 
frameworks for evaluating health 
systems found a great deal of 
commonality in how performance 
has been conceptualized.7 In 
addition to effectiveness, the 
researchers identified 14 other 
dimensions of the performance of 
health care systems: acceptability, 
accessibility, appropriateness, care 
environment and amenities, 
competence or capability, 
continuity, expenditure or cost, 
efficiency, equity, governance, 
patient-centeredness (-focus) or 
responsiveness, safety, 
sustainability, and timeliness.   
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Timely Analysis of Immediate Health Policy Issues 2 
Many of these performance 
dimensions might reasonably be 
considered to be attributes of high-
quality care (e.g., appropriateness, 
competence, timeliness). Those in 
a second group (e.g., cost, 
governance, sustainability) are 
readily observed as separate 
performance concerns. Reasonable 
people might have different views 
on whether others (e.g., 
accessibility, acceptability, 
responsiveness) are dimensions of 
quality or closely related concepts, 
and indeed these are treated in 
different ways in the frameworks 
reviewed. Accessibility is 
particularly difficult to disentangle 
from considerations of health care 
quality in that it is a prerequisite to 
receipt of quality health care. 
Availability of providers and 
services, coverage, benefits and 
affordability all come into play as 
potential explanations for different 
user experiences with the health 
care system and the outcomes 
attained. Finally, (technical) 
efficiency is a function of the 
quality and quantity of services 
produced at a given cost. 
Efficiency, or value for money, is a 
performance consideration of great 
interest to public authorities and 
purchasers, although only modest 
headway in measuring efficiency 
in health care has been made to 
date, reflecting limitations in the 
capacity to measure the quality of 
health care.  
It is evident from the U.S. reform 
debates that popular conceptions of 
what constitutes good quality 
health care encompass a range of 
dimensions. Although obviously 
high quality implies superior 
health outcomes, other attributes 
considered indicative of quality 
appear to underlie popular 
expressions of U.S. health care 
superiority, including a belief that 
Americans with good insurance 
coverage uniquely benefit from 
prompt availability and 
accessibility of cutting-edge 
medical procedures, medicines, 
and devices, as well as highly 
educated and well-trained health 
care professionals, who know and 
consistently do what is best for 
their patients. On the other hand, 
those who assert that we have 
inferior quality of care point to our 
relatively poor population health 
status,8 and factors such as barriers 
to access for those without 
adequate insurance coverage or 
limited health plan provider 
networks and insufficient 
coordination among providers in 
the fragmented health care delivery 
system. 
All of these aspects of quality and 
broader health system performance 
are important and legitimate 
considerations; therefore, we cast a 
relatively wide net in this brief. 
Specifically, we focus on 
effectiveness (or â€œtechnicalâ€ or 
â€œclinicalâ€ quality) and consider 
additional dimensions of quality or 
health system performance that are 
most closely related: 
appropriateness, safety, 
accessibility, acceptability, and 
responsiveness.   
What is the evidence on 
how quality of care in 
the United States 
compares to other 
countries?  
To make an informed assessment 
about the quality of care in one 
health system versus another, it is 
important to look at a wide range 
of indicators. Because health care 
involves a complex array of 
activities, and because there are 
many holes in our knowledge of 
the relative quality in many areas, 
it is impossible to use a single 
measure as a meaningful proxy. 
Measures that reflect multiple 
dimensions of quality have a 
certain appeal as performance 
indicators for policy-makers, 
although more specific or narrow 
measures have the advantage of 
being more actionable for 
administrators and clinicians. And 
even with a broad set of 
comparative measures, people may 
differ on which measures are most 
important, for example, those 
focusing on the level of typical or 
average care for common 
conditions versus the care 
available for unusual, life-
threatening conditions.    
The evidentiary basis for cross-
country comparisons of quality 
could be strengthened by 
additional studies and 
improvements in methods and 
data. Nonetheless, a number of 
comparative studies on the quality 
of care have been published. 
Below we review some of the key 
findings from recent research that 
provide insight on how the quality 
of care in the United States 
compares to the quality of care  
in other nations. We explore 
quality as assessed by measures 
based upon population health 
status, measures of processes  
and outcomes of care for particular 
conditions, measures of patient 
safety, and indicators based 
on patientsâ€™ experience with  
health services. In each area, 
we put forward the evidence  
we could find on how the  
attribute in question stacks up   
(or fails to do so). 
 
 
 
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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 furnished 
elsewhere. Most studies of technical quality or effectiveness draw on data compiled from disease registries, medical 
records or administrative data. Such studies generally focus on a particular condition, such as coronary heart disease 
or specific forms of cancer, and they differ in the extent to which they endeavor to account for factors outside the 
control 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 part 
of regular monitoring activities include an ongoing Organisation for Economic Co-operation and Development 
(OECD) initiative, which builds on initial work by the Commonwealth Fund and a coalition of Nordic countries. To 
date, the OECD has formulated, tested and validated a relatively small number of quality measures for use in 
international comparisons, with other measures in development.55 Initial results have been published showing cross-
country differences based on data obtained from national sources, but with caveats as to factors making comparisons 
indicative, rather than absolute. Limitations include differences in data sources used in measurement, different 
reporting periods, and limited ability to adjust for age and other factors (not reflecting quality of care differences) that 
can explain apparent cross-national differences.  
Beyond this, surveys of citizens, patients and health care providers in five or more countries have been produced 
annually since 1998 by the Commonwealth Fund.56 These provide information on how health care is perceived as well 
as how the experience of health care differs internationally in relation to public expectations. Surveys can explore 
aspects of health care and quality dimensions for which other forms of data do not exist in comparable form. Their 
limitations include cross-country differences in the interpretation of questions and concepts, which could affect how 
countriesâ€™ 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 health 
outcomes, such as socioeconomic status, lifestyle, and disease incidence or prevalence. Similarly, quality of care 
measures could be affected by differential access to care across a population, reflecting coverage gaps in the United 
States as well as shortfalls in supply or financial barriers presented by cost-sharing requirements here and in other 
countries. 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-country 
differences in life 
expectancy and 
mortality indicative of 
differences in health 
care quality? 
While U.S. life expectancy is at or 
below the average in comparison 
with that of other developed 
countries, findings from research 
that has adjusted mortality to 
account for deaths not related to 
health care (so-called amenable 
mortality) show the United States 
to be among the worst performers. 
The United States is not among top 
performers in terms of life 
expectancy, an indicator 
influenced by factors outside the 
health system in addition to health 
care. We rank among the lower 
third of developed countries in life 
expectancy at birth. Life 
expectancy at age 65 may be a 
better indicator of U.S. health care 
performance because all older 
Americans have reasonably good 
insurance coverage through 
Medicare. U.S. life expectancy for 
both men and women at age 65 is 
above the Organisation for 
Economic Co-operation and 
Development (OECD) average, but 
below what the top countries have 
achieved, particularly for women.9 
Among 19 countries included in a 
recent study of amenable 
mortality,10 the United States had 
the highest rate of deaths from 
conditions that could have been 
prevented or treated successfully. 
The extent to which differences 
across countries in the prevalence 
of particular conditions may 
explain the poor U.S. showing in 
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Timely Analysis of Immediate Health Policy Issues 4 
What do life expectancy and mortality data tell us about the quality and effectiveness of 
health care? 
Health status measures based on mortality and life expectancy data have been used to assess the overall effectiveness 
of the health system, reflecting the quality and accessibility of services, as well as environmental factors. Examples of 
such measures include crude mortality rates for defined populations; disability-adjusted life years (DALY), an 
indicator developed by the World Health Organization to assess the burden of disease; health-adjusted life expectancy 
(HALE), which can be used to assess whether increases in longevity are accompanied by compression of morbidity; 
and potential years of life lost (PYLL), a summary measures of premature mortality that assigns greater weight to 
deaths that are further away from a defined benchmark (such as age 70).  
Although very interesting as indicators of health status, all fall short as measures of health care quality because they 
tend to be significantly influenced by factors other than health care. For example, of the 30 OECD countries, only 
Hungary does worse than the United States in female premature mortality, as measured by PYLL, and only three 
countries exceed the U.S. rate of male premature mortality. However, accidents, suicides and homicides play a large 
role in explaining this finding, as the U.S. homicide rate is more than five times the OECD average.57   
More sophisticated mortality measures set aside those deaths that cannot be attributed to the effectiveness of health 
care. So-called amenable mortality is an indicator that aims to cast light on the relative effectiveness of health systems 
by calculating the rate of deaths prior to a certain age which are considered by experts to be avoidable through 
appropriate health care. As with other measures of mortality, amenable mortality is affected by differences in the 
prevalence of particular conditions across populations being compared. Thus, two health care systems could have 
identical rates of failing to provide adequate care for a condition that should not be fatal; however, if one of the two 
countries has a higher rate of prevalence of the condition among its population, its amenable mortality rate will also 
be higher. Nevertheless, amenable mortality does a better job than crude mortality data in assessing the effectiveness 
of health care delivery in improving health.   
the recent study is unknown, 
although studies in which it was 
possible to adjust for such 
differences found that the greatest 
part of regional differences in 
mortality for certain conditions 
were explained by differences in 
disease prevalence.11 A recent 
study comparing the United States 
and 10 European countries found 
that the United States had a much 
higher prevalence of nine of 10 
conditions, including cancer, heart 
disease, and stroke, in its 
population over age 50.12 
However, it is unlikely that relative 
differences across countries in the 
prevalence of disease changed 
during the five years that had 
passed since an earlier study13 by 
the same authors using the same 
methodology, in which the U.S. 
health system ranked somewhat 
better (16 of 19) among its peers in 
minimizing amenable mortality. In 
the years between the two studies, 
there was an average reduction in 
amenable mortality for men of 17 
percent across all countries 
included in the study, compared 
with only a 4 percent reduction in 
the rate of amenable mortality for 
men in the United States. 
Studies of processes 
and outcomes of care for 
particular conditions 
reveal differences in 
health-care quality 
Measures specifically designed to 
assess technical/clinical quality of 
care focus on health services and 
health outcomes, such as five-year 
survival rates for individuals with 
particular conditions. Such 
measures are less sensitive to 
differences across countries in 
disease prevalence.  
Below we review available 
evidence on U.S. quality of care in 
a variety of clinical areas, in 
comparison with other countries. 
The overall evidence is mixed, 
indicating that the United States 
has neither the best nor the worst 
quality of health care for particular 
conditions among developed 
countries. In certain cases where 
U.S. quality appears low relative to 
that of other countries â€” in the 
areas of prevention and care for 
chronic conditions, for example â€” 
access barriers experienced by the 
uninsured and the underinsured 
may contribute to the results seen. 
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Timely Analysis of Immediate Health Policy Issues 5 
Measuring the technical quality or effectiveness of health care: 
A brief primer 
The science of health care quality measurement has been developed over 
the course of several decades. Quality measures include those to assess 
health care processes (what was done), outcomes (what was achieved) and 
structural measures that evaluate the capacity to do what needs to be done. 
Process measures can be further categorized as measures of overuse (when 
patients get services that are inappropriate for their medical condition, 
subjecting them to unwarranted risk and/or expense), underuse (when 
patients do not receive care that is indicated based on their medical 
condition) and misuse (when a service is provided in a technically 
incorrect manner), although the bulk of the measures used regularly for 
comparison relate to underuse of services considered medically necessary 
in defined circumstances. 
Quality can be assessed objectively (against standards defined by evidence 
or professional agreement) or subjectively (against patientsâ€™ expectations 
or experiences, or reviewer judgment, for examples). Assessment draws 
upon empirical data, such as administrative and medical records or patient 
registries and the perceptions of those involved in health care (surveys, 
testimonials). Quality is evaluated for populations and sub-groups within 
the population, as there is a particular interest in evaluating whether and 
how differences in health care contribute to observed disparities in health 
status. 
Quality of preventive care 
The evidence on how the United 
States compares to other developed 
countries in terms of the quality of 
its preventive care is quite mixed. 
In a report that summarized survey 
research comparing quality of care 
in five countries, Davis et al.14 
concluded that the United States 
had relatively high-quality 
preventive care. 85 percent of 
American women reported having 
had a Pap smear within the last 
two years and 84 percent of 
American women age 50 to 64 
reported having received a 
mammogram within the last two 
years, the highest shares among the 
countries included in the survey. 
Perhaps reflecting differences in 
data sources, the OECD15 found 
that the United States had above-
average mammography rates (61 
percent U.S. versus 55 percent 
OECD), although was far below 
the best performers (82-98 percent 
in four countries). However, the 
United States had the highest 
cervical cancer screening rate (83 
percent) among 22 countries 
reporting data to OECD. 
Among 30 OECD countries, the 
United States had above-average 
rates of flu vaccination for senior 
citizens (65 percent U.S. versus 55 
percent OECD average and 80 
percent in top-performing 
Australia). However, childhood 
vaccination rates were below the 
OECD average.16 The U.S. 
pertussis vaccination rate stood at 
86 percent in 2005; only Austria 
and Canada reported lower rates. 
Even with a 92 percent childhood 
measles vaccination, the United 
States came in below average in a 
field where one-third of OECD 
countries have rates above 95 
percent.  
Quality of care for chronic 
conditions 
Findings on the quality of U.S. 
care for several chronic conditions 
also provide a mixed picture. 
Among 30 OECD countries, the 
United States ranked below 
average in adult asthma care. Adult 
hospital admission rates for 
asthma, an indicator of inadequate 
care for the condition, were second 
highest among 17 countries 
reporting (12 per 10,000 U.S. 
versus 5.8 OECD average) and 
U.S. asthma mortality, double the 
OECD average rate, was fifth 
highest among 25 countries 
reporting.17 
A handful of studies undertaken in 
the 1990s18 have compared 
outcomes for U.S. and Canadian 
patients with end-stage renal 
disease and found that Canadians 
have longer survival times while in 
hemodialysis or peritoneal dialysis 
programs, and after receipt of 
kidney transplant, even when 
extensive adjustment for 
comorbidity is done. 
A survey of patients in six 
countries19 found that more than 
half of U.S. diabetics had received 
four recommended services, a rate 
comparable to the UK and 
Germany, and higher than the rate 
seen in Australia, Canada and New 
Zealand.  The same survey found 
that 85 percent of U.S. 
hypertension patients reported 
having received two recommended 
tests, a rate identical to Canada and 
exceeded only by Germany (91 
percent). 
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Timely Analysis of Immediate Health Policy Issues 6 
Quality of care for certain 
acute conditions 
Studies of diverse conditions 
ranging from heart disease, hip 
fracture and vision impairment 
also are mixed in terms of their 
findings as to how U.S. quality 
compares to that of other countries. 
â€¢ Yusuf et al.20 studied patients 
undergoing invasive cardiac 
procedures in six countries and 
found that higher rates of 
invasive and revascularization 
procedures in United States 
and Brazil were associated 
with lower rates of refractory 
angina or readmission for 
unstable angina, no apparent 
reduction in cardiovascular 
death or myocardial infarction, 
but higher rates of stroke. Tu 
et al.21 found that short-term, 
but not long-term, cardiac 
outcomes were better in the 
United States than Ontario.  
â€¢ Ho et al.22 found that inpatient 
hip fracture mortality was 
higher in Canada (Manitoba 
and Quebec) than in the United 
States (California and 
Massachusetts). Canadians had 
longer waits for surgery, 
although this was found not to 
explain the difference in 
mortality observed.  
â€¢ Norregaard et al.23 found 
similar postoperative visual 
acuity for cataract patients 
across four countries studied, 
including the United States, 
despite considerable 
differences in the organization 
of care and patterns of clinical 
practice. The United States had 
fewer adverse intra-operative 
events than the other three 
sites studied but, along with 
Manitoba, had higher rates of 
early postoperative events. The 
United States and Manitoba 
used a more advanced surgical 
method for cataract removal as 
compared with Barcelona or 
Denmark.24 
Quality of cancer care 
While interpreting the available 
evidence is challenging in the light 
of different screening protocols 
across countries, it does suggest 
that the United States as one of 
several world leaders in providing 
high-quality cancer care. 
A study by Gatta and colleagues,25 
looked at five-year cancer survival 
rates for the United States and 17 
European countries. The United 
States had the highest survival 
rates for cancer of the colon, 
rectum, lung, breast, and prostate. 
U.S. survival rates were also 
among the highest for melanoma 
(fourth), uterine (second) and 
ovarian (fifth) cancer, cervical 
cancer (sixth), Hodgkins disease 
(third) and non-Hodgkins 
lymphoma (fourth). The United 
States was ninth in survival of 
stomach cancer. Although average 
survival differences between the 
United States and Europe as a 
whole were in some cases large, 
the difference between the United 
States and the other countries with 
relatively high five-year survival 
rates were generally small 
(approximately 3 to 4 percent for 
many cancers) and (due to small 
sample sizes) usually not 
statistically significant. The study 
also looked at cross-country 
differences by population group, 
finding that survival rates for 
colon, breast and uterine cancer 
were similar in the United States 
and Europe for patients under 45 
years, but were much better in the 
United States for patients age 65 or 
older at diagnosis. In the case of 
stomach cancer, the U.S. survival 
rate for patients under age 45 was 
below those of many European 
nations, but similar among the 
older patients. Other studies (e.g., 
Coleman, et al. 2008)26 have also 
found that U.S. survival rates for 
certain cancers, particularly 
prostate cancer, are among the 
best. Among 30 OECD countries, 
the United States had one of the 
best five-year survival rates for 
patients with breast or colorectal 
cancer.27  
There is an important link between 
survival rates and screening rates 
for many cancers (e.g., melanoma, 
prostate cancer, breast cancer, 
colorectal cancer). Many cancers 
are more amenable to treatment 
when caught early. But it is also 
true that in countries with higher 
screening, more cancers will be 
diagnosed early, and survival rates 
in those countries will be higher 
simply because there are more 
patients in the denominator with 
less advanced disease. Thus, Gatta 
et al.28 found that those countries 
with the highest breast cancer 
incidence rate (share of population 
newly diagnosed with the disease 
in a given year) also had the 
highest survival rates.  
Differing national commitments to 
screening becomes an issue, 
particularly, in the case of prostate 
cancer, where U.S. incidence rates 
are double those of Europe 
because aggressive screening 
uncovers cancers at a very early 
stage. The implications for quality 
are complicated, in that cancer 
detection has instigated more 
treatments with serious risk of 
quality of life deterioration for a 
condition that is very slow to 
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Timely Analysis of Immediate Health Policy Issues 7 
develop. In 2008, the U.S. 
Preventive Services Task Force 
updated its screening advice, 
recommending that known risks of 
screening outweigh potential 
benefits for older men, and that 
informed patient preferences 
should serve as a determinant of 
appropriate care in younger men. 
Other countries, such as Denmark, 
had recommended against 
widespread use of the test as early 
as 1990 (cited in Coleman et al. 
2008).29 
Differences across countries in 
access to diagnostic and treatment 
services explain most of the 
observed differences in cancer 
survival rates.30 Better survival 
rates are associated with higher 
national income levels, higher 
levels of expenditure on health, 
and higher investment in health 
technology, as proxied by 
indicators such as the rate of CT 
scanners per person. The 
relationship between cancer 
survival and level of expenditure 
on diagnosis and treatment has yet 
to be fully explored, due to data 
limitations, although some cross-
country differences in expenditure 
have been documented. Using an 
approach to assess relative 
spending across nations with 
different income levels, OECD 
found that the United States spent 
between 41 and 62 percent of its 
per capita GDP on the first six 
months of breast cancer treatment 
following diagnosis for each 
patient, while Canada and France 
spent about one-third of their 
respective per capita GDPs for 
treatment during the initial phase.31 
 
U.S.-Canada 
comparisons more often 
find Canadian quality is 
better  
A significant share of the academic 
research studies comparing the 
outcomes and effectiveness of 
health care across countries 
consists of U.S./Canada 
comparisons, perhaps reflecting 
policy interest, data availability or 
other factors. Although studies 
findings go in both directions, the 
bulk of the research finds higher 
quality of care in Canada. 
A review of the evidence on 
quality differences between the 
United States and Canada found 
that each of the two countries 
performed better in different 
studies. Guyatt et al.32 identified 38 
studies comparing populations of 
patients in Canada and the United 
States. Studies addressed diverse 
problems, including cancer, 
coronary artery disease, chronic 
illnesses and surgical procedures. 
Of 10 studies that included 
extensive statistical adjustment and 
enrolled broad populations, five 
favored Canada, two favored the 
United States, and three showed 
equivalent or mixed results.  
Overuse of health 
services not linked with 
service volume  
Although there have been 
relatively few studies comparing 
the rates of overuse of health 
services, the limited available 
evidence suggests that higher rates 
of certain surgeries and procedures 
in the United States put more 
Americans at risk, in comparison 
with their counterparts, even if it is 
the case that the share of 
procedures that are inappropriate 
does not vary across countries with 
different service rates.  
The degree of variation in the 
share of populations receiving 
particular services is greater than 
what would be expected based on 
population health status 
differences, raising a question as to 
whether there is underuse of the 
procedure in countries with 
relatively low rates or overuse in 
the countries with relatively high 
rates. For example, OECD 
countriesâ€™ rates of caesarean 
sections per 100 live births range 
from 13.6 to 37.9, with U.S. rates 
among the highest in the OECD. 
Although determining the extent to 
which the procedure is overused 
requires investigation of patient 
characteristics, including age and 
comorbidities, the World Health 
Organization has stated that rates 
above 15 percent offer no benefits 
in terms of population health.33 
The United States also has the 
highest rates of coronary 
revascularization procedures, with 
more than double the rates of other 
countries with similar mortality 
rates from heart disease.34 
However, relying on assessment of 
performance against evidence-
based criteria, McGlynn et al.35 
found comparable rates of 
inappropriate use of coronary 
angiography and CABG, when 
comparing New York State and 
Canada, despite different rates of 
use of service in the areas studied. 
Findings from studies by Bernstein 
et al.36 and Gandjour et al.37 also 
suggest that rates of inappropriate 
services are not dependent on the 
frequency of the procedure. 
Despite performing relatively few 
cardiovascular procedures, in 
comparison with the United States, 
the rates of inappropriate surgeries 
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Timely Analysis of Immediate Health Policy Issues 8 
in the UK and Germany were 
comparable. 
Higher rates of surgery may have 
both positive and negative impact 
of health outcomes. On the one 
hand, when performed on 
appropriate candidates, surgery 
will tend to have positive benefits 
in terms of life expectancy and 
morbidity associated with the 
underlying condition. On the other, 
greater per capita rates of heart 
surgery may contribute to the 
higher rates of mortality due to 
surgical and medical errors in the 
United States. 
Patient safety problems 
appear more prevalent in 
the United States 
Few studies have compared patient 
safety at an international level, as 
data and indicators for use within 
countries are still in development. 
Notwithstanding such limitations, 
available evidence suggests that 
patients may be at greater risk of 
safety problems in the United 
States than they are elsewhere. 
Data are available for cross-
national comparisons on mortality 
due to surgical and medical 
errors.38 These data show that the 
United States has relatively high 
rates, in comparison with other 
OECD countries, but the rates may 
be problematic as quality 
indicators due to differences in 
reporting accuracy across countries 
and the relative infrequency of this 
outcome. 
Surveys provide another source of 
information on relative safety. A 
six-country survey of patients with 
a high incidence of chronic illness 
and recent intensive use of the 
health care system found that 
patients in the United States were 
more likely than patients in other 
countries to report mistakes or 
adverse events and gaps in expert-
recommended safe medication 
management practices.39 A survey 
of chronically ill or intensively ill 
patients in eight countries40 found 
that the United States had the 
highest reported rates of problems 
such as being given the wrong 
medication or dosage, 
experiencing a medical error, 
receiving incorrect test results, or 
facing delays in hearing about 
abnormal test results. Patient 
reports of these types of problems 
were lowest in the Netherlands (17 
percent), France (18 percent), and 
Germany (19 percent) and highest 
in the United States (34 percent). 
Physician and patient 
perceptions of health 
care quality suggest 
strengths and 
weaknesses of U.S. care 
As with most of the indicators 
described above, physician and 
patient reports suggest some areas 
of strength, but as a general matter 
do not distinguish American health 
care as providing especially high 
quality compared to the health care 
provided in other countries. 
A survey of physicians in five 
countries41 found that U.S. 
physicians were more likely than 
physicians in other countries to 
report that interventions in patient 
care geared towards cost control 
were threatening the quality of 
care they could provide to their 
patients. U.S. physicians were less 
likely to report that community 
resources were inadequate, but 
more likely to say that limitations 
on the medicines they could 
prescribe posed a problem. 
Compared with doctors in 
Australia, Canada, New Zealand 
and the United Kingdom, 
American doctors were less likely 
to agree that their health care 
system works well and more likely 
to consider that the system needs 
complete rebuilding. A 2003 
survey of hospital executives 
yielded a similar finding; half of 
American hospital executives said 
they were not satisfied with the 
performance of their countryâ€™s 
health care system, compared with 
between 4 and 12 percent of 
hospital executives in four other 
countries.42 
Davis43 reviewed findings from 
multi-country surveys conducted 
in 2004 and 2005 that examined 
patientsâ€™ satisfaction and 
experience with their health care. 
Patients assigned the U.S. health 
system mixed marks in terms of 
whether their health care providers 
communicated needed 
information. U.S. patients were 
less satisfied than patients in other 
countries with the quality of 
communication relating to doctorâ€™s 
office visits, but more satisfied 
than other patients with the quality 
of communication relating to 
hospitalization.  On the other hand, 
U.S. patients were less satisfied 
than patients in other countries 
with how much their physicians 
engaged them in making health 
care decisions. In terms of 
satisfaction with the level of 
choice of doctor, Americans were 
less satisfied than patients from 
New Zealand and more satisfied 
that Canadian patients. Finally, in 
terms of timeliness, American and 
German patients reported 
relatively short waiting times for 
seeing a specialist or obtaining 
elective surgery. But Americans 
were less likely to say they could 
get medical attention when needed 
Â 
 
Timely Analysis of Immediate Health Policy Issues 9 
and could readily obtain care on 
nights and weekends. Considering 
timeliness measures as a whole, 
German patients were more 
satisfied than American patients, 
and British and Canadian patients 
were least satisfied. 
Is the average quality of 
care in the United States 
negatively affected by 
access barriers faced by 
the uninsured? 
When comparing the quality of 
care in the United States to that of 
other countries it is impossible to 
ignore one stark difference â€” the 
fact that close to one-fifth of the 
U.S. population under age 65 is 
uninsured. The United States is 
one of only three countries in the 
OECD, together with Mexico and 
Turkey, which has a sizeable share 
of its population lacking coverage.  
It stands to reason that some of the 
gap between United States and 
other countries in average quality 
may well be related, in at least 
some part, to the insurance 
coverage problem in this country. 
Most of todayâ€™s measures capture 
problems of â€œunderuse,â€ or the 
share of a population that receives 
the screening or treatment 
indicated, based on agreed medical 
practice standards. For many such 
measures, quality and access are 
intrinsically linked.  
There is, in fact, some suggestive 
evidence of a quality-coverage 
relationship. In their updated study 
of amenable mortality, Nolte and 
McKee44 suggest that an increase 
in the share of Americans 
uninsured between the two study 
periods may be responsible for the 
failure of the United States to 
improve its performance apace 
with other countries studied, 
resulting in the United States 
dropping from 16th to 19th place 
over five years. Furthermore, the 
findings showing that the United 
States does better than Europe in 
cancer survival for the over-65 
population suggests a possible role 
for insurance status as an 
explanatory factor, especially since 
working age and retirees have the 
same coverage in most European 
countries. 
In addition, there is evidence to 
suggest that access barriers are an 
issue affecting U.S. performance, 
in particular. As compared with the 
residents of other countries, many 
more Americans â€” and 
chronically ill Americans â€” say 
they skip medicines or medical 
appointments due to cost.45 46 Such 
behavior, which may reflect 
problems of underinsurance as 
well as uninsurance, may result in 
impaired health outcomes. By 
contrast, the types of access 
problems reported in other 
countries â€” mainly longer waits 
for elective surgeries â€” are likely 
to affect perceptions of service 
quality and reduced quality of life 
during the waiting period without 
impact on clinical outcomes.47 
Based on a comprehensive review 
of the relevant research literature, 
the Institute of Medicine48 
concluded that the uninsured have 
worse health and higher mortality 
than the insured population in the 
United States. Population based 
studies have shown that uninsured 
Americans have shorter survival 
times for conditions such as cancer 
of the breast, colorectum and 
prostate than those with 
insurance.49 A review of the 
research literature over the past 25 
years by Hadley50 found that the 
uninsured receive fewer preventive 
and diagnostic services, tend to be 
more severely ill when diagnosed, 
and receive less therapeutic care. 
He concluded that insurance 
coverage could reduce mortality by 
an estimated 4 to 25 percent, 
depending on the condition.  
But all of this does not necessarily 
mean that the uninsured have 
worse quality of care, as measured 
by provision of evidence-based, 
recommended processes of care 
that are likely to improve patient 
outcomes.  In fact, a study by Asch 
et al.51 found that health insurance 
status was largely unrelated to the 
quality of care as measured by 
adherence to professionally 
recommended standards of care, 
among those with at least one 
contact with the health care system 
within a two-year period. This 
somewhat surprising finding 
suggests that the access barriers 
experienced by the uninsured may 
not result in differential treatment 
once an uninsured person succeeds 
in engaging with the health care 
delivery system. 
Summary and 
conclusions 
Taken collectively, the findings 
from international studies of health 
care quality do not in and of 
themselves provide a definitive 
answer to the question of how the 
United States compares in terms of 
the quality of its health care. While 
the evidence base is incomplete 
and suffers from other limitations, 
it does not provide support for the 
oft-repeated claim that the â€œU.S. 
health care is the best in the 
world.â€ In fact, there is no hard 
evidence that identifies particular 
areas in which U.S. health care 
quality is truly exceptional. 
Â 
 
Timely Analysis of Immediate Health Policy Issues 10 
Instead, the picture that emerges 
from the information available on 
technical quality and related 
aspects of health system 
performance is a mixed bag, with 
the United States doing relatively 
well in some areas â€” such as 
cancer care â€” and less well in 
others â€” such as mortality from 
conditions amenable to prevention 
and treatment. Many Americans 
would be surprised by the findings 
from studies showing that U.S. 
health care is not clearly superior 
to that received by Canadians, and 
that in some respects Canadian 
care has been shown to be of 
higher quality. 
To be sure, there are limitations to 
the current evidence base. In 
particular, there is no data or 
evidence by which to answer the 
question of whether the United 
States is a place where one finds 
health care that exceeds the quality 
of the best care available 
elsewhere in the world â€” in other 
words, whether the â€œbest U.S. 
health care is the best in the 
world.â€  Although it is often held 
that the U.S. strength lies in state-
of-the-art, technically oriented 
care, especially focused on 
â€œrescueâ€ care, rather than care for 
more routine acute and chronic 
conditions, studies typically do not 
compare the â€œbestâ€ care offered in 
different countries. Further, there 
remain other aspects of health care 
for which we have no quality 
measures or inadequate data for 
comparisons.  
Existing studies also fail to tell us 
much at all about the reasons for 
the apparent differences in quality 
observed across countries, 
although numerous hypotheses 
have been put forward (e.g., 
differences in the use of health 
information technology, 
differences in the coordination of 
care and the fragmentation of 
health care delivery, variations in 
reliance of incentives for providers 
and consumers to provide and 
select care based on consideration 
of quality). We do know, however, 
from a five-country survey of 
primary care physicians52 that U.S. 
physiciansâ€™ practices are more 
limited in information capacity, 
provide less patient access outside 
of traditional work hours, and are 
among the least likely to work in 
teams or to receive financial 
rewards for quality, all factors that 
could bear on the quality of 
primary care furnished.  
Taken together, these studies do 
provide a strong basis for 
determining whether proposed 
health reform initiatives might 
threaten or, alternatively, 
strengthen the current level of U.S. 
quality. While evidence is not 
conclusive, it is clear that the 
argument that reform of the U.S. 
health system stands to endanger 
â€œthe best health care quality in the 
worldâ€ lacks foundation. Like 
other countries, the United States 
has been found to have both 
strengths and weaknesses in terms 
of the quality of care available, and 
the quality of care the population 
receives. The main ways in which 
the United States differs from 
other developed countries are in 
the very high costs of its health 
care and the share of its population 
that is uninsured. 
In the light of the fact that the 
United States spends twice as 
much per person on health care as 
its peers, those who question the 
value for money obtained in U.S. 
health expenditures are on a firm 
footing. The evidence suggests that 
other developed countries achieve 
comparable quality of care while 
devoting at most two-thirds the 
share of their national income.   
Faced with the evidence, one 
might well ask why it is that 
assertions of the superiority of 
U.S. health care are so common. 
Technical definitions and popular 
conceptions of quality include 
many different dimensions and 
there may not be agreement about 
which dimensions are most 
important. For example, people 
who make the claims that the 
United States has the â€œbest quality 
of careâ€ in the world may be 
prioritizing a degree of access to 
medical technology and innovation 
which they believe to be unique to 
the United States. Perhaps media 
attention paid to outcomes for a 
select few (e.g., multiple organ 
transplant recipients, high-risk 
delivery of multiple births) has 
cast into shadow the average 
outcomes of the majority of 
Americans with more routine, yet 
serious, conditions and other 
health care needs. 
But a less-than-fully informed 
public comes at a cost in that 
assertions of excellence divert 
attention from the need to inspire 
and foster systematic quality 
improvement activities. 
Furthermore, there seems to be a 
routine genuflection to the 
widespread belief of U.S. quality 
excellence, even among experts. In 
an environment where even 
insured Americans receive only 
about half of the services that 
experts consider necessary, there is 
a strong argument for placing 
quality firmly on the health reform 
agenda.53 In short, health reform 
can be seen as an opportunity to 
systematically improve quality of