As good as it gets?

“No man ever reached to excellence in any one art or profession without having passed through the slow and painful process of study and preparation”
(Horace, 65BC – 8BC)

Health policy makers and managers around the world are striving to secure improvements in the quality of care. The routine measurement of quality indicators and the subsequent reporting of results has become commonplace within healthcare systems. These performance measurement frameworks are generally based on a broad definition of quality, which includes effectiveness, access and timeliness, safety, patient responsiveness and equity.

Recent years have seen a growing interest in moving beyond the measurement and reporting of quality of care indicators within countries or healthcare systems, towards comparing performance across countries. International comparisons are increasingly regarded as a valuable source of information for decision-makers, particularly as a means to facilitate benchmarking efforts and contextualising system performance, to provide opportunities to learn from other systems’ achievements and problems and to inform priority setting and policy themes.

Benchmarking

International comparisons provide a yardstick to contextualise the performance of any given healthcare system. Although national data can provide an historical account of achievements in quality of care over time, it is often difficult to interpret any changes in performance without some external comparison. By providing a sense of scale, and a basis on which to assess achievements and deficiencies, international comparisons can help with the interpretation of quality data.

The value of international comparisons can be illustrated by an examination of data on circulatory disease mortality rates. Figure 1 (below) shows that between 1993 and 2005, mortality rates from circulatory disease in England fell markedly: by 43 per cent in men and by 40 per cent in women. Taken at face value, these figures suggest significant improvements in outcomes and by implication, in the performance of English healthcare.

Figure 1: Mortality rates from circulatory disease, England (source: NCHOD)

However, when viewed in the context of international performance the achievements appear somewhat less impressive, with the UK lagging behind many other developed countries in terms of mortality rates (see Figure 2). It should be noted that international data releases lag behind the UK releases and this chart therefore does not include changes that may have occurred since 2002.

Figure 2: Mortality from circulatory disease, international comparison (source: OECD)

Clearly, mortality rates are compounded by factors outside the control of healthcare systems, such as diet and lifestyle. Nevertheless, comparative data such as these can highlight the scale of potential improvement and provide an impetus for concerted change in policy and investment and in clinical care processes.

Learning from other systems

International comparisons can also act as catalysts for analysis and exploration of underlying problems in the quality of care. On the basis of fair comparisons of performance, it is possible to explore underlying reasons for variations in quality. For example, the international data in Figure 3 shows that the UK has a relatively high rate of MRSA infections. In response to this, the National Audit Office undertook a review of hospital-acquired infections in 2004 to identify the reasons for the difference in infection rates. They found that the Netherlands attributed their low MRSA infection rates to the strict application of screening and isolation guidelines, along with stringent antibiotic policies – a so-called ‘search and destroy’ approach.

Figure 3: Learning from other systems – MRSA (source: EARSS)

It’s not all doom and gloom for UK healthcare, however. The NHS is often held up as an international model of how to deliver healthcare equitably. Figure 4 shows data from an international survey conducted in 2005 by the Commonwealth Fund, which asked patients whether cost concerns had prevented them from seeking medical care. The UK easily outperforms other developed countries in this area. These findings could prompt countries seeking to improve equity in their healthcare systems to explore which elements of the UK health service might be applied in their own systems.

Figure 4: Patient survey data: not accessing care because of cost concerns (source: Commonwealth Fund)

Informing priorities

Evidence-based policy – currently a popular concept – requires reliable information about what works in different contexts. By highlighting deficiencies in quality and prompting the study of high achieving systems, international comparisons provide valuable information for policymaking, priority setting and healthcare management. International data can help decision makers answer the three key questions that underpin all improvement efforts: where are we? where do we want to get to? and how do we get there?

Limitations of international comparisons

International comparisons provide an insight into the relative strengths and weaknesses of individual healthcare system and can illustrate what is achievable given sufficient energy, innovation and resources. However, they are not without limitations. Healthcare systems are diverse and complex, reflecting their historical and cultural contexts. Each system has its own traditions, values, priorities, funding arrangements, control mechanisms and processes for accountability. This diversity means that although international comparisons can help guide improvement in healthcare systems, there can never be a ‘one size fits all’ solution to healthcare problems.

Furthermore, comparing national level data can mask considerable variation within countries. For example the US, with its strong reliance on market forces and drive for technological excellence, delivers extremely effective healthcare to those who can afford it. However, despite spending almost $2 trillion per year on healthcare (which corresponds to $6,700 per person - more than twice that of any other major industrialised country), some 46 million US citizens are uninsured and struggle to gain access to basic healthcare services.

A third problem with international comparisons lies in the way that quality data is often divorced from cost data. In order to make sensible policy decisions, it is essential to know the costs of improving quality in different areas.

Moving forward

To date, interest in the measurement and reporting of quality of care has largely been focused within healthcare systems, either at the national, organisational, regional or professional level. More recently there has been increased effort to develop internationally agreed indicators which share definitions and rules for collection. This allows international comparisons such as the OECD Health Care Quality Indicators Project. Such efforts will form the basis for significant learning across participating countries and provide valuable insights into what incentives and institutional arrangements work best to promote good quality healthcare.

The process of agreeing common data definitions and priority areas for international indicators is not straightforward. Individual countries have established processes and data that are not always easily amenable to change. However, the rewards for establishing a shared set of performance indicators are significant, providing information to guide policy and managerial decisions. International comparisons can provide insights into what is possible and feasible in improving the quality of care.