How Does the Quality of U.S. Compare Internationally? Timely Analysis of Immediate Health Policy Issues August 2009 Elizabeth Docteur and Robert A. Berenson

Introduction aspects of health care signify its individuals and populations quality and which ones are most increase the likelihood of desired There is a perception among many important. health outcomes and are consistent Americans that despite coverage, with current professional cost and other problems in the This brief brings together available knowledge.”4 A similar definition health care system, the quality of evidence on how quality of care in is used by the U.S. Agency for health care in the United States is the United States compares to that Healthcare Research and Quality: better than it is anywhere else in of other countries and comments “Quality health care means doing the world and might be threatened on the implications of the evidence the right thing at the right time in by health reform. In fact, 55 for the health reform debate. By the right way for the right person percent of Americans surveyed last exploring how the quality of our and having the best results year said U.S. patients receive care compares internationally, we possible.”5 Both definitions refer to better quality of care than do those can address the underlying characteristics of health care that in other nations, even though only attitudes and concerns that people are increasingly referred to as 45percent said they thought the have about health reform. For “technical” or “clinical" quality or United States had the world’s best example, if claims that the United “effectiveness.”6 health care system.1 And while States has the best quality of care Americans overwhelmingly in the world — overall or in In the context of efforts to assess support government action to particular respects — were well health system performance, the increase coverage and reduce the supported by the evidence, it term “quality” is often used to costs of health care, a recent poll would caution us against adopting encompass a range of desirable or found that 63 percent worry that forms of health reform that positive attributes of health care the quality of their own care would threaten those attributes of our and the overall performance of get worse if the government health system responsible for this health-care systems. A review of ensured health care for all.2 standing. But if quality of care is eight country-specific and Another poll found that as many as not remarkable — or may be even internationally developed 81percent of Americans have such lagging — there should be less frameworks for evaluating health 3 concerns. reluctance to change. In addition, a systems found a great deal of more explicit need for health commonality in how performance Participants in the current reform 7 reform to address quality has been conceptualized. In debate refer to the relative quality addition to effectiveness, the of U.S. health care as providing improvement would appear warranted. researchers identified 14 other support for their views, and dimensions of the performance of perceptions of health-care quality What constitutes high- health care systems: acceptability, — what it is and where it can be quality health care? accessibility, appropriateness, care found — are often at the heart of environment and amenities, disagreements over what form of A number of definitions of health competence or capability, health reform the country should care quality have been put forward continuity, expenditure or cost, adopt. But hard facts to support over the years. The U.S. Institute efficiency, equity, governance, claims are often missing, and it is of Medicine’s definition, which patient-centeredness (-focus) or clear that quality of care experts, has grounded expert work in the responsiveness, safety, policy makers, health care United States and elsewhere, sustainability, and timeliness. providers and the general public all describes quality as “the degree to have different ideas as to which which health services for

Many of these performance superiority, including a belief that many holes in our knowledge of dimensions might reasonably be Americans with good insurance the relative quality in many areas, considered to be attributes of high- coverage uniquely benefit from it is impossible to use a single quality care (e.g., appropriateness, prompt availability and measure as a meaningful proxy. competence, timeliness). Those in accessibility of cutting-edge Measures that reflect multiple a second group (e.g., cost, medical procedures, medicines, dimensions of quality have a governance, sustainability) are and devices, as well as highly certain appeal as performance readily observed as separate educated and well-trained health indicators for policy-makers, performance concerns. Reasonable care professionals, who know and although more specific or narrow people might have different views consistently do what is best for measures have the advantage of on whether others (e.g., their patients. On the other hand, being more actionable for accessibility, acceptability, those who assert that we have administrators and clinicians. And responsiveness) are dimensions of inferior quality of care point to our even with a broad set of quality or closely related concepts, relatively poor population health comparative measures, people may and indeed these are treated in status,8 and factors such as barriers differ on which measures are most different ways in the frameworks to access for those without important, for example, those reviewed. Accessibility is adequate insurance coverage or focusing on the level of typical or particularly difficult to disentangle limited health plan provider average care for common from considerations of health care networks and insufficient conditions versus the care quality in that it is a prerequisite to coordination among providers in available for unusual, life- receipt of quality health care. the fragmented health care delivery threatening conditions. Availability of providers and system. services, coverage, benefits and The evidentiary basis for cross- affordability all come into play as All of these aspects of quality and country comparisons of quality potential explanations for different broader health system performance could be strengthened by user experiences with the health are important and legitimate additional studies and care system and the outcomes considerations; therefore, we cast a improvements in methods and attained. Finally, (technical) relatively wide net in this brief. data. Nonetheless, a number of efficiency is a function of the Specifically, we focus on comparative studies on the quality quality and quantity of services effectiveness (or “technical” or of care have been published. produced at a given cost. “clinical” quality) and consider Below we review some of the key Efficiency, or value for money, is a additional dimensions of quality or findings from recent research that performance consideration of great health system performance that are provide insight on how the quality interest to public authorities and most closely related: of care in the United States purchasers, although only modest appropriateness, safety, compares to the quality of care headway in measuring efficiency accessibility, acceptability, and in other nations. We explore in health care has been made to responsiveness. quality as assessed by measures based upon population health date, reflecting limitations in the What is the evidence on capacity to measure the quality of status, measures of processes health care. how quality of care in and outcomes of care for particular the United States conditions, measures of patient It is evident from the U.S. reform compares to other safety, and indicators based debates that popular conceptions of countries? on patients’ experience with what constitutes good quality health services. In each area, health care encompass a range of To make an informed assessment we put forward the evidence dimensions. Although obviously about the quality of care in one we could find on how the high quality implies superior health system versus another, it is attribute in question stacks up health outcomes, other attributes important to look at a wide range (or fails to do so). considered indicative of quality of indicators. Because health care appear to underlie popular involves a complex array of expressions of U.S. health care activities, and because there are

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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 countries’ 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 mortality) show the United States both men and women at age 65 is to be among the worst performers. above the Organisation for differences in life Economic Co-operation and expectancy and The United States is not among top Development (OECD) average, but mortality indicative of performers in terms of life below what the top countries have differences in health expectancy, an indicator achieved, particularly for women.9 influenced by factors outside the care quality? health system in addition to health Among 19 countries included in a care. We rank among the lower recent study of amenable While U.S. life expectancy is at or 10 below the average in comparison third of developed countries in life mortality, the United States had with that of other developed expectancy at birth. Life the highest rate of deaths from countries, findings from research expectancy at age 65 may be a conditions that could have been that has adjusted mortality to better indicator of U.S. health care prevented or treated successfully. account for deaths not related to performance because all older The extent to which differences health care (so-called amenable Americans have reasonably good across countries in the prevalence insurance coverage through of particular conditions may . U.S. life expectancy for explain the poor U.S. showing in

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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, health system ranked somewhat survival rates for individuals with although studies in which it was better (16 of 19) among its peers in particular conditions. Such possible to adjust for such minimizing amenable mortality. In measures are less sensitive to differences found that the greatest the years between the two studies, differences across countries in part of regional differences in there was an average reduction in disease prevalence. mortality for certain conditions amenable mortality for men of 17 were explained by differences in percent across all countries Below we review available disease prevalence.11 A recent included in the study, compared evidence on U.S. quality of care in study comparing the United States with only a 4 percent reduction in a variety of clinical areas, in and 10 European countries found the rate of amenable mortality for comparison with other countries. that the United States had a much men in the United States. The overall evidence is mixed, higher prevalence of nine of 10 indicating that the United States conditions, including cancer, heart Studies of processes has neither the best nor the worst disease, and stroke, in its and outcomes of care for quality of health care for particular population over age 50.12 particular conditions conditions among developed However, it is unlikely that relative countries. In certain cases where reveal differences in U.S. quality appears low relative to differences across countries in the health-care quality prevalence of disease changed that of other countries — in the areas of prevention and care for during the five years that had Measures specifically designed to 13 chronic conditions, for example passed since an earlier study by assess technical/clinical quality of — the same authors using the same care focus on health services and access barriers experienced by the methodology, in which the U.S. health outcomes, such as five-year uninsured and the underinsured may contribute to the results seen.

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States came in below average in a Measuring the technical quality or effectiveness of health care: field where one-third of OECD A brief primer countries have rates above 95 percent. The science of health care quality measurement has been developed over the course of several decades. Quality measures include those to assess Quality of care for chronic health care processes (what was done), outcomes (what was achieved) and conditions structural measures that evaluate the capacity to do what needs to be done. Findings on the quality of U.S. Process measures can be further categorized as measures of overuse (when care for several chronic conditions patients get services that are inappropriate for their medical condition, also provide a mixed picture. subjecting them to unwarranted risk and/or expense), underuse (when patients do not receive care that is indicated based on their medical Among 30 OECD countries, the condition) and misuse (when a service is provided in a technically United States ranked below incorrect manner), although the bulk of the measures used regularly for average in adult asthma care. Adult comparison relate to underuse of services considered medically necessary hospital admission rates for in defined circumstances. asthma, an indicator of inadequate care for the condition, were second Quality can be assessed objectively (against standards defined by evidence highest among 17 countries or professional agreement) or subjectively (against patients’ expectations reporting (12 per 10,000 U.S. or experiences, or reviewer judgment, for examples). Assessment draws versus 5.8 OECD average) and upon empirical data, such as administrative and medical records or patient U.S. asthma mortality, double the registries and the perceptions of those involved in health care (surveys, OECD average rate, was fifth testimonials). Quality is evaluated for populations and sub-groups within highest among 25 countries the population, as there is a particular interest in evaluating whether and reporting.17 how differences in health care contribute to observed disparities in health status. A handful of studies undertaken in the 1990s18 have compared outcomes for U.S. and Canadian Quality of preventive care average mammography rates (61 patients with end-stage renal percent U.S. versus 55 percent disease and found that Canadians The evidence on how the United OECD), although was far below have longer survival times while in States compares to other developed the best performers (82-98 percent hemodialysis or peritoneal dialysis countries in terms of the quality of in four countries). However, the programs, and after receipt of its preventive care is quite mixed. United States had the highest kidney transplant, even when cervical cancer screening rate (83 In a report that summarized survey extensive adjustment for percent) among 22 countries research comparing quality of care comorbidity is done. in five countries, Davis et al.14 reporting data to OECD. A survey of patients in six concluded that the United States Among 30 OECD countries, the countries19 found that more than had relatively high-quality United States had above-average half of U.S. diabetics had received preventive care. 85 percent of rates of flu vaccination for senior four recommended services, a rate American women reported having citizens (65 percent U.S. versus 55 comparable to the UK and had a Pap smear within the last percent OECD average and 80 Germany, and higher than the rate two years and 84 percent of percent in top-performing seen in Australia, Canada and New American women age 50 to 64 Australia). However, childhood Zealand. The same survey found reported having received a vaccination rates were below the that 85 percent of U.S. mammogram within the last two OECD average.16 The U.S. hypertension patients reported years, the highest shares among the pertussis vaccination rate stood at having received two recommended countries included in the survey. 86 percent in 2005; only Austria tests, a rate identical to Canada and Perhaps reflecting differences in and Canada reported lower rates. 15 exceeded only by Germany (91 data sources, the OECD found Even with a 92 percent childhood percent). that the United States had above- measles vaccination, the United

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Quality of care for certain early postoperative events. The United States for patients age 65 or acute conditions United States and Manitoba older at diagnosis. In the case of used a more advanced surgical stomach cancer, the U.S. survival Studies of diverse conditions method for cataract removal as rate for patients under age 45 was ranging from heart disease, hip compared with Barcelona or below those of many European fracture and vision impairment Denmark.24 nations, but similar among the also are mixed in terms of their older patients. Other studies (e.g., findings as to how U.S. quality Quality of cancer care Coleman, et al. 2008)26 have also compares to that of other countries. While interpreting the available found that U.S. survival rates for • Yusuf et al.20 studied patients evidence is challenging in the light certain cancers, particularly undergoing invasive cardiac of different screening protocols prostate cancer, are among the procedures in six countries and across countries, it does suggest best. Among 30 OECD countries, found that higher rates of that the United States as one of the United States had one of the invasive and revascularization several world leaders in providing best five-year survival rates for patients with breast or colorectal procedures in United States high-quality cancer care. 27 and Brazil were associated cancer. A study by Gatta and colleagues,25 with lower rates of refractory There is an important link between angina or readmission for looked at five-year cancer survival rates for the United States and 17 survival rates and screening rates unstable angina, no apparent for many cancers (e.g., melanoma, reduction in cardiovascular European countries. The United States had the highest survival prostate cancer, breast cancer, death or myocardial infarction, colorectal cancer). Many cancers but higher rates of stroke. Tu rates for cancer of the colon, 21 rectum, lung, breast, and prostate. are more amenable to treatment et al. found that short-term, when caught early. But it is also but not long-term, cardiac U.S. survival rates were also among the highest for melanoma true that in countries with higher outcomes were better in the screening, more cancers will be United States than Ontario. (fourth), uterine (second) and ovarian (fifth) cancer, cervical diagnosed early, and survival rates • Ho et al.22 found that inpatient cancer (sixth), Hodgkins disease in those countries will be higher hip fracture mortality was (third) and non-Hodgkins simply because there are more higher in Canada (Manitoba lymphoma (fourth). The United patients in the denominator with less advanced disease. Thus, Gatta and Quebec) than in the United States was ninth in survival of 28 States (California and stomach cancer. Although average et al. found that those countries Massachusetts). Canadians had survival differences between the with the highest breast cancer longer waits for surgery, United States and Europe as a incidence rate (share of population although this was found not to whole were in some cases large, newly diagnosed with the disease explain the difference in the difference between the United in a given year) also had the mortality observed. States and the other countries with highest survival rates. relatively high five-year survival 23 Differing national commitments to • Norregaard et al. found rates were generally small screening becomes an issue, similar postoperative visual (approximately 3 to 4 percent for particularly, in the case of prostate acuity for cataract patients many cancers) and (due to small cancer, where U.S. incidence rates across four countries studied, sample sizes) usually not are double those of Europe including the United States, statistically significant. The study because aggressive screening despite considerable also looked at cross-country uncovers cancers at a very early differences in the organization differences by population group, stage. The implications for quality of care and patterns of clinical finding that survival rates for are complicated, in that cancer practice. The United States had colon, breast and uterine cancer detection has instigated more fewer adverse intra-operative were similar in the United States treatments with serious risk of events than the other three and Europe for patients under 45 quality of life deterioration for a sites studied but, along with years, but were much better in the condition that is very slow to Manitoba, had higher rates of

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develop. In 2008, the U.S. U.S.-Canada does not vary across countries with Preventive Services Task Force comparisons more often different service rates. updated its screening advice, find Canadian quality is recommending that known risks of The degree of variation in the screening outweigh potential better share of populations receiving benefits for older men, and that particular services is greater than A significant share of the academic what would be expected based on informed patient preferences research studies comparing the should serve as a determinant of population health status outcomes and effectiveness of differences, raising a question as to appropriate care in younger men. health care across countries Other countries, such as Denmark, whether there is underuse of the consists of U.S./Canada procedure in countries with had recommended against comparisons, perhaps reflecting widespread use of the test as early relatively low rates or overuse in policy interest, data availability or the countries with relatively high as 1990 (cited in Coleman et al. other factors. Although studies 2008).29 rates. For example, OECD findings go in both directions, the countries’ rates of caesarean Differences across countries in bulk of the research finds higher sections per 100 live births range access to diagnostic and treatment quality of care in Canada. from 13.6 to 37.9, with U.S. rates services explain most of the A review of the evidence on among the highest in the OECD. observed differences in cancer Although determining the extent to 30 quality differences between the survival rates. Better survival United States and Canada found which the procedure is overused rates are associated with higher that each of the two countries requires investigation of patient national income levels, higher performed better in different characteristics, including age and levels of expenditure on health, studies. Guyatt et al.32 identified 38 comorbidities, the World Health and higher investment in health studies comparing populations of Organization has stated that rates technology, as proxied by above 15 percent offer no benefits patients in Canada and the United 33 indicators such as the rate of CT States. Studies addressed diverse in terms of population health. scanners per person. The problems, including cancer, The United States also has the relationship between cancer coronary artery disease, chronic highest rates of coronary survival and level of expenditure illnesses and surgical procedures. revascularization procedures, with on diagnosis and treatment has yet Of 10 studies that included more than double the rates of other to be fully explored, due to data countries with similar mortality extensive statistical adjustment and 34 limitations, although some cross- enrolled broad populations, five rates from heart disease. country differences in expenditure favored Canada, two favored the have been documented. Using an However, relying on assessment of United States, and three showed performance against evidence- approach to assess relative equivalent or mixed results. 35 spending across nations with based criteria, McGlynn et al. different income levels, OECD Overuse of health found comparable rates of found that the United States spent inappropriate use of coronary services not linked with angiography and CABG, when between 41 and 62 percent of its service volume per capita GDP on the first six comparing New York State and Canada, despite different rates of months of breast cancer treatment Although there have been use of service in the areas studied. following diagnosis for each relatively few studies comparing Findings from studies by Bernstein patient, while Canada and France the rates of overuse of health 36 37 et al. and Gandjour et al. also spent about one-third of their services, the limited available suggest that rates of inappropriate respective per capita GDPs for evidence suggests that higher rates 31 services are not dependent on the treatment during the initial phase. of certain surgeries and procedures frequency of the procedure. in the United States put more Despite performing relatively few Americans at risk, in comparison cardiovascular procedures, in with their counterparts, even if it is comparison with the United States, the case that the share of the rates of inappropriate surgeries procedures that are inappropriate

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in the UK and Germany were more likely than patients in other Australia, Canada, New Zealand comparable. countries to report mistakes or and the United Kingdom, adverse events and gaps in expert- American doctors were less likely Higher rates of surgery may have recommended safe medication to agree that their health care both positive and negative impact management practices.39 A survey system works well and more likely of health outcomes. On the one of chronically ill or intensively ill to consider that the system needs hand, when performed on patients in eight countries40 found complete rebuilding. A 2003 appropriate candidates, surgery that the United States had the survey of hospital executives will tend to have positive benefits highest reported rates of problems yielded a similar finding; half of in terms of life expectancy and such as being given the wrong American hospital executives said morbidity associated with the medication or dosage, they were not satisfied with the underlying condition. On the other, experiencing a medical error, performance of their country’s greater per capita rates of heart receiving incorrect test results, or health care system, compared with surgery may contribute to the facing delays in hearing about between 4 and 12 percent of higher rates of mortality due to abnormal test results. Patient hospital executives in four other surgical and medical errors in the reports of these types of problems countries.42 United States. were lowest in the Netherlands (17 Davis43 reviewed findings from problems percent), France (18 percent), and Germany (19 percent) and highest multi-country surveys conducted appear more prevalent in in the United States (34 percent). in 2004 and 2005 that examined the United States patients’ satisfaction and Physician and patient experience with their health care. Few studies have compared patient perceptions of health Patients assigned the U.S. health safety at an international level, as care quality suggest system mixed marks in terms of data and indicators for use within whether their health care providers countries are still in development. strengths and communicated needed Notwithstanding such limitations, weaknesses of U.S. care information. U.S. patients were available evidence suggests that less satisfied than patients in other As with most of the indicators patients may be at greater risk of countries with the quality of described above, physician and safety problems in the United communication relating to doctor’s patient reports suggest some areas States than they are elsewhere. office visits, but more satisfied of strength, but as a general matter than other patients with the quality Data are available for cross- do not distinguish American health of communication relating to national comparisons on mortality care as providing especially high hospitalization. On the other hand, due to surgical and medical quality compared to the health care 38 U.S. patients were less satisfied errors. These data show that the provided in other countries. than patients in other countries United States has relatively high with how much their physicians rates, in comparison with other A survey of physicians in five 41 engaged them in making health OECD countries, but the rates may countries found that U.S. care decisions. In terms of be problematic as quality physicians were more likely than satisfaction with the level of indicators due to differences in physicians in other countries to choice of doctor, Americans were reporting accuracy across countries report that interventions in patient less satisfied than patients from and the relative infrequency of this care geared towards cost control New Zealand and more satisfied outcome. were threatening the quality of care they could provide to their that Canadian patients. Finally, in Surveys provide another source of patients. U.S. physicians were less terms of timeliness, American and information on relative safety. A likely to report that community German patients reported six-country survey of patients with resources were inadequate, but relatively short waiting times for a high incidence of chronic illness more likely to say that limitations seeing a specialist or obtaining and recent intensive use of the on the medicines they could elective surgery. But Americans health care system found that prescribe posed a problem. were less likely to say they could patients in the United States were Compared with doctors in get medical attention when needed

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and could readily obtain care on with other countries studied, uninsured receive fewer preventive nights and weekends. Considering resulting in the United States and diagnostic services, tend to be timeliness measures as a whole, dropping from 16th to 19th place more severely ill when diagnosed, German patients were more over five years. Furthermore, the and receive less therapeutic care. satisfied than American patients, findings showing that the United He concluded that insurance and British and Canadian patients States does better than Europe in coverage could reduce mortality by were least satisfied. cancer survival for the over-65 an estimated 4 to 25 percent, population suggests a possible role depending on the condition. Is the average quality of for insurance status as an care in the United States explanatory factor, especially since But all of this does not necessarily negatively affected by working age and retirees have the mean that the uninsured have worse quality of care, as measured access barriers faced by same coverage in most European countries. by provision of evidence-based, the uninsured? recommended processes of care In addition, there is evidence to that are likely to improve patient When comparing the quality of suggest that access barriers are an outcomes. In fact, a study by Asch care in the United States to that of 51 issue affecting U.S. performance, et al. found that health insurance other countries it is impossible to in particular. As compared with the status was largely unrelated to the ignore one stark difference — the residents of other countries, many quality of care as measured by fact that close to one-fifth of the more Americans — and adherence to professionally U.S. population under age 65 is chronically ill Americans — say recommended standards of care, uninsured. The United States is they skip medicines or medical among those with at least one one of only three countries in the appointments due to cost.45 46 Such contact with the health care system OECD, together with Mexico and behavior, which may reflect within a two-year period. This Turkey, which has a sizeable share problems of underinsurance as somewhat surprising finding of its population lacking coverage. well as uninsurance, may result in suggests that the access barriers It stands to reason that some of the impaired health outcomes. By experienced by the uninsured may gap between United States and contrast, the types of access not result in differential treatment other countries in average quality problems reported in other once an uninsured person succeeds may well be related, in at least countries — mainly longer waits in engaging with the health care some part, to the insurance for elective surgeries — are likely delivery system. coverage problem in this country. to affect perceptions of service Most of today’s measures capture quality and reduced quality of life Summary and problems of “underuse,” or the during the waiting period without conclusions 47 share of a population that receives impact on clinical outcomes. Taken collectively, the findings the screening or treatment Based on a comprehensive review from international studies of health indicated, based on agreed medical care quality do not in and of practice standards. For many such of the relevant research literature, the Institute of Medicine48 themselves provide a definitive measures, quality and access are answer to the question of how the intrinsically linked. concluded that the uninsured have worse health and higher mortality United States compares in terms of There is, in fact, some suggestive than the insured population in the the quality of its health care. While evidence of a quality-coverage United States. Population based the evidence base is incomplete relationship. In their updated study studies have shown that uninsured and suffers from other limitations, of amenable mortality, Nolte and Americans have shorter survival it does not provide support for the McKee44 suggest that an increase times for conditions such as cancer oft-repeated claim that the “U.S. in the share of Americans of the breast, colorectum and health care is the best in the uninsured between the two study prostate than those with world.” In fact, there is no hard periods may be responsible for the insurance.49 A review of the evidence that identifies particular failure of the United States to research literature over the past 25 areas in which U.S. health care improve its performance apace years by Hadley50 found that the quality is truly exceptional.

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Instead, the picture that emerges information technology, other developed countries achieve from the information available on differences in the coordination of comparable quality of care while technical quality and related care and the fragmentation of devoting at most two-thirds the aspects of health system health care delivery, variations in share of their national income. performance is a mixed bag, with reliance of incentives for providers the United States doing relatively and consumers to provide and Faced with the evidence, one well in some areas — such as select care based on consideration might well ask why it is that assertions of the superiority of cancer care — and less well in of quality). We do know, however, U.S. health care are so common. others — such as mortality from from a five-country survey of 52 Technical definitions and popular conditions amenable to prevention primary care physicians that U.S. conceptions of quality include and treatment. Many Americans physicians’ practices are more many different dimensions and would be surprised by the findings limited in information capacity, there may not be agreement about from studies showing that U.S. provide less patient access outside which dimensions are most health care is not clearly superior of traditional work hours, and are important. For example, people to that received by Canadians, and among the least likely to work in who make the claims that the that in some respects Canadian teams or to receive financial United States has the “best quality care has been shown to be of rewards for quality, all factors that of care” in the world may be higher quality. could bear on the quality of primary care furnished. prioritizing a degree of access to To be sure, there are limitations to medical technology and innovation the current evidence base. In Taken together, these studies do which they believe to be unique to particular, there is no data or provide a strong basis for the United States. Perhaps media evidence by which to answer the determining whether proposed attention paid to outcomes for a question of whether the United health reform initiatives might select few (e.g., multiple organ States is a place where one finds threaten or, alternatively, transplant recipients, high-risk health care that exceeds the quality strengthen the current level of U.S. delivery of multiple births) has of the best care available quality. While evidence is not cast into shadow the average elsewhere in the world — in other conclusive, it is clear that the outcomes of the majority of words, whether the “best U.S. argument that reform of the U.S. Americans with more routine, yet health care is the best in the health system stands to endanger serious, conditions and other world.” Although it is often held “the best health care quality in the health care needs. that the U.S. strength lies in state- world” lacks foundation. Like other countries, the United States But a less-than-fully informed of-the-art, technically oriented public comes at a cost in that care, especially focused on has been found to have both strengths and weaknesses in terms assertions of excellence divert “rescue” care, rather than care for attention from the need to inspire more routine acute and chronic of the quality of care available, and the quality of care the population and foster systematic quality conditions, studies typically do not improvement activities. compare the “best” care offered in receives. The main ways in which the United States differs from Furthermore, there seems to be a different countries. Further, there routine genuflection to the remain other aspects of health care other developed countries are in the very high costs of its health widespread belief of U.S. quality for which we have no quality excellence, even among experts. In measures or inadequate data for care and the share of its population that is uninsured. an environment where even comparisons. insured Americans receive only Existing studies also fail to tell us In the light of the fact that the about half of the services that much at all about the reasons for United States spends twice as experts consider necessary, there is the apparent differences in quality much per person on health care as a strong argument for placing observed across countries, its peers, those who question the quality firmly on the health reform 53 although numerous hypotheses value for money obtained in U.S. agenda. In short, health reform have been put forward (e.g., health expenditures are on a firm can be seen as an opportunity to differences in the use of health footing. The evidence suggests that systematically improve quality of

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care, rather than as a threat to has the “best” quality of care in the health system on quality. If reform existing levels of quality. world are sometimes put forward accomplishes no more than to support views that reforms are extending insurance coverage to Health reform provides an unwarranted on quality grounds the more than 45 million opportunity to build on strengths and even risky — particularly Americans without insurance, it and correct weaknesses, work those reforms that would modify will be an important step forward, towards aims for improvement, U.S. health financing, coverage or but more is needed to ensure health such as those defined by IOM in 54 delivery arrangements in ways care quality improvement. To the Crossing the Quality Chasm, that similar to those used in other extent it is possible to improve care be safe, effective, patient- countries. health care delivery through centered, timely, efficient and reforms that strengthen incentives equitable. The IOM continues to On the basis of this review it is to apply knowledge and meet push for quality improvement safe to say that U.S. health care is quality standards, employ based on the evident gap between not pre-eminent on quality; technology to reduce errors and what is done and what should be furthermore, one can surely argue ensure appropriate care, and help done, what can be achieved and that U.S. health care quality is not consumers and patients demand what is achieved, but international at risk from the kinds of health better quality, even more might be comparisons have not played a reform proposals receiving achieved. major role in pushing forward that attention. On the contrary, our message. On the contrary, findings strengthen arguments that unsubstantiated claims that, despite reform is needed to improve the any shortfalls, the United States relative performance of the U.S.

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14 26 Notes Davis, K, C Schoen, S C Schoenbaum, AJ Coleman, Michael P., Manuela Quaresma, Audet, MM Doty, AL Holmgren, and JL Kriss, Franco Berrino, Jean-Michel Lutz, Roberta De

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The views expressed are those of the authors and should not be attributed to any campaign or to the Robert Wood Johnson Foundation, or the Urban Institute, its trustees, or its funders. About the Authors and Acknowledgements Elizabeth Docteur is an independent health policy analyst and researcher. She was formerly the deputy head of the health division at the Organization for Economic Cooperation and Development from 2005 to 2009. Robert A. Berenson is an Institute Fellow at the Urban Institute. The authors thank Stan Dorn, Kelly Devers, Elizabeth McGlynn, Sheila Leatherman, and Michael Millenson for their comments and suggestions. This research was funded by the Robert Wood Johnson Foundation. About the Urban Institute The Urban Institute is a nonprofit, nonpartisan policy research and educational organization that examines the social, economic, and governance problems facing the nation. About the Robert Wood Johnson Foundation The Robert Wood Johnson Foundation focuses on the pressing health and health care issues facing our country. As the nation’s largest philanthropy devoted exclusively to improving the health and health care of all Americans, the Foundation works with a diverse group of organizations and individuals to identify solutions and achieve comprehensive, meaningful, and timely change. For more than 35 years, the Foundation has brought experience, commitment, and a rigorous, balanced approach to the problems that affect the health and health care of those it serves. When it comes to helping Americans lead healthier lives and get the care they need, the Foundation expects to make a difference in your lifetime. For more information, visit www.rwjf.org.

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