have yet to be identified. In the first major attempt to rank health care systems, the WHO World Health Report 2000 introduced a ranking based on health attainment, equity of health outcomes, “patient responsiveness,” and “fairness of financial contributions” (World Health Organization, 2000b). The U.S. health system ranked 37th based on this methodology, but the measures, methods, and data were criticized (Jamison and Sandbu, 2001; Navarro, 2002). Another such effort is that of the Commonwealth Fund, which established a Commission on a High Performance Health System in 2005 that regularly issues a “national scorecard” based on five dimensions: quality, access, efficiency, equity, and long, healthy, and productive lives (Commonwealth Fund Commission on a High Performance Health System, 2011). In 2008, WHO identified five shortcomings in health care delivery that are found in systems around the world: inverse care, impoverishing care, fragmented and fragmenting care, unsafe care, and misdirected care (World Health Organization, 2008b). International health experts have not reached consensus on the optimal parameters for measuring and tracking the performance of national health systems.

Statistics for all these dimensions are difficult to capture. The capacity of different countries to collect appropriate data and to do so -systematically—using consistent sampling procedures, data collection techniques, coding practices, and measurement intervals (e.g., annually)—is challenging for practical reasons and limited budgets. To cite just one example, patient safety indicators for hospital care are not standardized across countries (Drösler et al., 2012). Access to medical records or administrative data is uneven across countries. International surveys face methodological challenges that introduce sampling biases. One example is survey methodology: some surveys have used a combination of landlines and mobile telephones to conduct interviews, and some countries have low response rates or mobile telephone usage. Adults with complex conditions, low income, or language barriers may be undersampled. Surveys of patients or physicians’ perceptions of the quality of care are ultimately perceptions and may not correspond with objective measures. The research challenges and priorities to address these gaps in the science are discussed further in Chapter 9, along with recommendations to remedy the problem.

Despite these limitations, the existing evidence is certainly sufficient for the panel to conclude that public health and medical systems in the United States have important shortcomings, some of which appear to be more pronounced in the United States than in other high-income countries. Subsequent chapters address the factors outside the clinic that may lead to greater illness and injury among Americans, but health problems ultimately lead most people to the health care system, or at least to attempt to obtain clinical assistance. The difficulties Americans experience in accessing these services and receiving high-quality care, as documented in this chapter, cannot be ignored as a potential contributor to the U.S. health disadvantage.

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