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International Comparison: Effectiveness

How does the United States compare with other countries on the provision of effective care and related health outcomes?

In comparisons among six developed countries, the United States generally ranks first or second in providing effective preventive care, such as immunizations and cancer screening, and chronic care for diabetes. The U.S. ranks in the middle on outcomes such as cancer survival. All countries exhibit gaps in quality.

Slide For International Comparison: Effectiveness
Slide For International Comparison: Effectiveness
Slide For International Comparison: Effectiveness
Slide For International Comparison: Effectiveness

Why is this important?

Many developed nations are interested in measuring and improving the quality of health care for their citizens. Comparing quality of care internationally might help identify factors giving rise to better performance and stimulate cross-national learning and collaboration to improve quality. The Commonwealth Fund has collaborated with four nations—Australia, Canada, New Zealand, and the United Kingdom—to measure and compare health system performance since 1998. Germany joined this group in 2005. The World Health Organization collects data on vaccination coverage from countries worldwide.


The six countries performed best on childhood immunizations, with most achieving coverage in the 90 percent range for specific vaccines (WHO 2005). Quality of adult preventive care was somewhat lower, reaching only about three-quarters of eligible individuals on average. Chronic care for diabetes was variable, but on average only about half of diabetic patients received all of four recommended services (Schoen et al. 2004). The United States ranked first on four of 15 process measures and second on most other measures of effective health care. In statistical significance testing (not performed for childhood immunizations or cervical cancer screening):

  • The U.S. scored significantly better than other countries on blood pressure testing and preventive care reminders, and significantly better than the worst-performing countries on diabetes blood sugar monitoring and foot exams.
  • Rates for the U.S. were not significantly different from other countries for mammograms or flu shots, and not significantly different from the best-performing country on diabetes measures except for eye exams.
For selected outcomes that reflect, in part, the effectiveness of diagnosis and treatment, the United States ranked third on average (among five countries) on cancer and transplant survival rates, and second best on average on rates of avoidable events such as suicide (Epstein et al. 2004).
  • The U.S. performed relatively well on breast cancer survival and the prevention of smoking and measles.
  • The U.S. performed relatively poorly on rates of transplant survival and the prevention of Hepatitis B infections.


Health care quality is variable within and across countries. No country consistently achieves better performance, suggesting that quality challenges are complex and multifaceted. Additional analysis is warranted to better understand how the unique attributes of each national system affect the quality of care.

Improvement Ideas and Resources

Diabetes patients who reported that they had been given a plan for disease self-management or that a nurse was involved in their care were more likely to receive recommended services (Schoen et al. 2005). Preventive care reminders can be effective but only one-half of U.S. patients reported receiving them (Schoen et al. 2004), emphasizing the need for better systems to support high-quality care.Twenty-four member-nations of the Organization for Economic Cooperation and Development are collaborating to lay the groundwork for developing a comprehensive, cross-national reporting system for quality of health care (Kelley and Hurst 2006). This effort may yield additional insights into the determinants of good quality and barriers to its achievement.


Immunization rates represent the percentage of young children (typically two-year olds) who had been vaccinated as defined by country or provincial recommendations. German rates are collected on school entry and shifted back five years to reflect coverage of the birth cohort (WHO 2005). Adult preventive care measures represent the percentage of surveyed adults of specified ages who reported receiving the service in the specified time intervals. For diabetes care measures, the denominator includes sicker adults ages 18 and older whose doctor told them that they had diabetes. Sicker adults were defined as those who rated their health as fair or poor; reported that they had a serious illness, injury, or disability that required intensive medical care in the past two years; or reported that in the past two years they had major surgery or had been hospitalized for something other than a normal pregnancy (Schoen et al. 2005).Five-year survival rates represent the percentage of cancer or transplant patients who are alive five years after their diagnosis or transplant. Relative survival rates are calculated by comparing observed survival with expected survival from a comparable set of people that do not have cancer to measure the excess mortality that is associated with a cancer diagnosis (different methods were used in different countries). Cancer survival rates were age-standardized to the OECD standard 1980 population using the direct method. Some differences in rates are due to different age-standardization methods (Epstein et al. 2004). Asthma mortality is reported for ages 5–39 "because these are the ages where an asthma cause-of-death diagnosis is considered most reliable" (Epstein et al. 2004). Smoking rates are shown as 100 minus the non-smoking rate reported in the study.


Recommended preventive care schedules and data reporting practices differ among countries (see sources for details). Patient-reported data are subject to potential recall bias. Some preventive care rates for the U.S. differ from rates reported in federal surveys (e.g., flu shot 72% v. 65%; blood pressure testing 86% v. 90%), but rates of diabetes care closely match those reported in a 2002 federal survey. U.S. cancer survival rates may not be nationally representative. More recent outcomes data are now available in some countries.



* Indicates source of data used in the chart(s).* Epstein, A. M., G. F. Anderson, A. J. Audet et al. 2004. First Report and Recommendations of the Commonwealth Fund's International Working Group on Quality Indicators. New York: The Commonwealth Fund. Kelley, E., and J. Hurst. 2006. Health Care Quality Indicators Project Conceptual Framework Paper. OECD Health Working Papers No. 23. Paris: Organization for Economic Cooperation and Development. * Schoen, C., R. Osborn, P. T. Huynh et al. 2004. Primary Care and Health System Performance: Adults' Experiences in Five Countries. Health Affairs (Millwood) Suppl Web Exclusives: W4-487–503. * Schoen, C., R. Osborn, P. T. Huynh et al. 2005. Taking the Pulse of Health Care Systems: Experiences of Patients with Health Problems in Six Countries. Health Affairs (Millwood). * WHO (World Health Organization). 2005. WHO Vaccine-Preventable Diseases Monitoring System: 2005 Global Summary. Geneva: World Health Organization, Department of Immunization, Vaccines and Biologicals.