Is Quality of Care Better in Canada?

Americans like to think that our healthcare quality is second to none. But how does the United States compare with other countries—particularly with our neighbor to the north: Canada?

A new review of the evidence on quality differences between the U.S. and Canada finds that each country performs better in different quality-related studies. But overall, the bulk of the research gives the edge to Canada, the researchers say. So how can this be?

Making the comparisons in the first place is challenging, according to one of the study's authors, Robert Berenson, MD, an institute fellow at the Urban Institute in Washington, DC. In looking at quality in the U.S., as compared to other countries, including Canada, "We found that the evidence was mixed as to where the U.S. stands on quality," he wrote in his blog.

"There was no objective evidence that the U.S. has the best quality in the world—although personal testimonials of exceptional care in particular circumstances should not be dismissed," Berenson said. "Overall, there is a lot of room for improvement [in the U.S.]."

Here's how it breaks down:

Overuse vs. Underuse. While only a small number of studies have compared the rates of overuse of health services, 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," according to the study.

When the degree of variation among populations receiving particular services is greater than what would be expected, this raises a question on whether there is underuse of certain procedures in countries with relatively low rates or overuse in the countries with relatively high rates?

For example, several industrialized countries' rates of Caesarean sections per 100 live births range from 13.6% to 37.9%, with American rates among the highest. However, the World Health Organization has stated that rates above 15% offer no benefits in terms of population health.

Higher rates of surgery may have both a positive and negative impact of health outcomes, the researchers said. On one hand, the surgery could have positive benefits in terms of life expectancy and morbidity associated with the underlying condition. On the other hand, greater rates of heart surgery may contribute to the higher rates of mortality due to surgical and medical errors in the U.S.

Patient Safety. Problems with patient safety appear more prevalent in the U.S. However, few studies have compared patient safety at an international level. Available evidence, though, suggests that patients could be at greater risk of safety problems in the U.S. than elsewhere, including Canada.

Some international comparisons on mortality related to surgical and medical errors show that the U.S. has relatively high rates, in comparison with other countries. But the rates still could be problematic due to differences in reporting accuracy across countries.

Access Barriers and Uninsurance. Barriers to access that are encountered by those without health insurance raise another dilemma. Close to a fifth of the U.S. population under age 65 is uninsured. The U.S. is one of the few larger countries (with Mexico and Turkey), which have a sizeable share of their population lacking coverage. In Canada, coverage is universal.

Many of today's measures capture problems of "underuse" by the uninsured population—where they fail to receive the screening or treatment indicated, based on agreed medical practice standards.

Life Expectancy and Mortality. The U.S. is not among top performers in terms of life expectancy. However, the researchers note that this rate is influenced by factors both inside and outside the healthcare system.

While U.S. life expectancy is at or below average in comparison with other developed countries, the higher rates of death not related to healthcare (such as suicide or gun-related) show the United States to be among the worst performers.

Quality of Care for Chronic Conditions. Findings on the quality of U.S. care for several chronic conditions also provide a mixed picture. Among industrialized countries, the United States ranked below average in adult asthma care when looking at hospital admission rates and mortality rates.

When looking at outcomes related to patients with end stage renal disease, Canadians had longer survival times while in hemodialysis or peritoneal dialysis programs, and after receipt of kidney transplant—even when extensive adjustment for comorbidity is done.

In the long run, it appears that the U.S. is among the best in some areas, such as cancer outcomes, "and nowhere near the best in others, such as prevention, and deaths from preventable or manageable illnesses," Berenson said.

"In other words, we may do better when people are already quite sick: the U.S. seems to emphasize 'rescue care,'" he said. "But we are not doing well in helping people not to get so sick in the first place. Ultimately, our life expectancy is nowhere near stellar when compared to what other industrialized countries have achieved."