We performed a longitudinal, retrospective cohort study involving adults 50 to 85 years of age who were included in the Health and Retirement Study and the Survey of Health, Ageing, and Retirement in Europe between 2010 and 2022. Wealth quartiles were defined according to age group and country, with quartile 1 comprising the poorest participants and quartile 4 the wealthiest. Mortality and Kaplan–Meier curves were estimated for each wealth quartile across the United States and 16 countries in northern and western, southern, and eastern Europe. We used Cox proportional-hazards models that included adjustment for baseline covariates (age group, sex, marital status [ever or never married], educational level [any or no college education], residence [rural or nonrural], current smoking status [smoking or nonsmoking], and absence or presence of a previously diagnosed long-term condition) to quantify the association between wealth quartile and all-cause mortality from 2010 through 2022 (the primary outcome).

The volume-outcome relationship has been a commonly invoked policy initiative aimed at improving the quality of healthcare. This inverse relationship between the caseload volume of patients treated and patient mortality has been described across many health settings and in many countries. Despite the large body of literature demonstrating this favourable relationship, most studies have focused on differentiating the effects of selective referral and the true effects of volume. In comparison, there are few studies evaluating the underlying mechanism of the volume-outcome relationship, namely dynamic learning-by-doing or the static effect of economics of scale. Resolving this tension between policies that allow providers to accrue experience over time and policies that promote centralisation of services would make a more compelling argument for policies such as minimum volume standards to be firmly established.

In this retrospective study, between 2009 and 2021, avoidable mortality increased in all US states, primarily due to increases in preventable deaths, while it decreased in comparable high-income countries. Health spending was significantly negatively associated with avoidable mortality for other high-income countries but not across US states.

Americans have grown accustomed to direct-to-consumer pharmaceutical advertisements and the refrain, “If you think [this drug] is right for you, talk to your doctor.” But some recent online ads feature a new twist — a link to a clinician offering telehealth services. Several pharmaceutical companies have also launched online platforms that direct users to websites run by telehealth companies, where clinicians are available to prescribe medications after a virtual consultation.

Repeated Supreme Court cases suggest uninformed sterilization care is a persistent and contemporary issue in India. This article examines patient satisfaction ratings as a potential accountability mechanism to assess normalized forms of coercion. With a sample of over 180,000 sterilized women in India, it identifies a statistically significant relationship between exposure to coercive care and odds of reporting low quality. However, over 95 percent of women who underwent a tubal ligation procedure rated their care highly even when provided with inadequate information (a recognized form of coercion), with more pronounced discordance when a patient belonged to a historically marginalized caste. System-modifiable factors, such as conditional cash transfers (CCT) to the patient and postpartum procedure timing increased reporting discordance. Using a reproductive justice lens and building on Amartya Sen’s capabilities approach, this work examines how to identify human rights violations in the routine delivery of care.

Repeated Supreme Court cases suggest uninformed sterilization care is a persistent and contemporary issue in India. This article examines patient satisfaction ratings as a potential accountability mechanism to assess normalized forms of coercion. With a sample of over 180,000 sterilized women in India, it identifies a statistically significant relationship between exposure to coercive care and odds of reporting low quality. However, over 95 percent of women who underwent a tubal ligation procedure rated their care highly even when provided with inadequate information (a recognized form of coercion), with more pronounced discordance when a patient belonged to a historically marginalized caste. System-modifiable factors, such as conditional cash transfers (CCT) to the patient and postpartum procedure timing increased reporting discordance. Using a reproductive justice lens and building on Amartya Sen’s capabilities approach, this work examines how to identify human rights violations in the routine delivery of care.

The aim of this report from the Expert Group (see Box 1) on Health Systems Performance Assessment (HSPA) is to establish a comprehensive definition of low-value care in line with the concept of valuebased healthcare and from a health system perspective, and to identify low-value care indicators and measures to facilitate the reduction of low-value care for national HSPA practices. To achieve this aim, a “value-based healthcare” working group was established as a subgroup of the Expert Group with country representatives from Belgium, Czechia, Estonia, France, Germany, Hungary, Italy, Poland, Portugal, Romania and Slovenia as well as the European Observatory on Health Systems and Policies, the Organisation for Economic Co-operation and Development (OECD) and the DirectorateGeneral for Health and Food Safety (DG SANTE)

Total knee arthroplasty (TKA) is an effective treatment for patients with end-stage knee osteoarthritis but some patients exhibit a discrepancy between patient-reported outcomes (PROs) and patient satisfaction (PS). This study aims to identify predictors for patients reporting unfavorable PROs but high PS and vice versa.

Patient harm remains an important concern in hospital care,1 urging a reprioritisation of patient safety and healthcare quality.2 The past 20 years have been characterised by indispensable quality developments,3 including accreditation and public reporting providing foundations for monitoring and promoting healthcare organisation performance.4 Yet, the quality progress appears unsustainable in the long term, as indicated by, for example, nosocomial infections rising in the aftermath of the COVID-19 pandemic,5 6 or mortality reductions being abolished weeks after accreditation survey visits.7 A resilient safety culture with quality truly embedded into everyday practice can only occur after increased awareness of hospital-wide safety risks.3 8

In Belgium, the setting of this study, there is a lack of systematic hospital-wide quality monitoring, despite indications of important differences in patient outcomes between hospitals persisting over time.9 It has been shown for urology patients10 that outcomes such as mortality, readmissions and prolonged length of stay vary to a great extent between hospitals, largely impacting healthcare equity and patient safety.11 12 No data exist on variation in patient outcomes across all patient service lines and across multiple patient outcomes. By recognising which patient service lines are most prone to between-hospital variation and by identifying which hospitals have the highest potential for quality improvement (QI), targeted initiatives can be established. Such focused efforts are highly required in times of scarce financial and human resources and poor outcome prevalence.

The primary aim of this study was to examine inter-hospital variability in in-hospital mortality, unplanned 30-day readmissions and prolonged length of hospital stay (pLOS) across all Major Diagnostic Categories (MDCs) for all Belgian acute-care hospitals. Second, we aimed to estimate the number of outcomes potentially avoidable if successful QI policies could be established. Finally, we aimed to identify a set of high-impact-opportunity hospitals where policymakers can stimulate QI initiatives set to improve patient outcomes.

Health systems experience difficult trade-offs when paying for new drugs. In England, funding recommendations by the National Institute for Health and Care Excellence (NICE) for new drugs might generate health gains but inevitably result in forgone health as the funds cannot be used for alternative treatments and services. We aimed to evaluate the population health impact of NICE recommendations for new drugs during 2000–20.

The Inflation Reduction Act instructs Medicare to negotiate prices of top-selling drugs and sets statutory upper limits (“ceilings”) on negotiated prices. Medicare can negotiate prices below the ceilings based on how prices and clinical benefits of these drugs compare with those of therapeutic alternatives. In August 2024, Medicare published the negotiated prices for the first 10 drugs selected for negotiation; these prices will come into effect in 2026 and will apply to all Medicare Part D plans. We analyzed how negotiated prices in the US compared with net prices before negotiation, ceiling prices, and list prices in 6 other high-income countries.

Biologics approved by the US Food and Drug Administration (FDA) receive 12 years of guaranteed protection from biosimilar competition compared with 5 years of protection from generic competition for new small-molecule drugs. Under the 2022 Inflation Reduction Act, biologics are exempt from selection for Medicare price negotiation for 11 years compared with 7 years for small-molecule drugs. Congress codified these differing legal protections on the premise that biologics require more time and resources to develop and have weaker patent protection, necessitating additional protections for manufacturers to recoup their development costs and generate adequate returns on investment.

Launching Lifelong Health by Improving Health Care for Children, Youth, And Families presents a vision for transforming the child and adolescent health care system. This report also examines how the health care system can be better positioned to equitably address the needs of all children and families and leverage community supports. This requires transforming key components, such as health care financing, public health investment, community partnerships, and accountability strategies, to encourage team-based care delivery models and attention to and health promotion, prevention, and root causes of health disparities.

In contrast to bilateral aid, aid disbursed from multilateral institutions increased significantly at the onset of the COVID-19 pandemic. Yet, at a time when a coherent and effective multilateral response is needed most, the COVID-19 pandemic revealed a shifting landscape of donor agencies that struggle with basic functions, such as cross-national coordination. While multilaterals are uniquely positioned to transcend national priorities and respond to pandemics, functionally we find official development assistance (ODA) from these entities may increasingly mimic the attributes of bilateral aid. We explore three important, but not comprehensive, attributes of aid leading up to and during the COVID-19 pandemic: (1) earmarking, (2) donor concentration and (3) aid modality.

While the effectiveness of patient-reported outcome measures (PROMs) as an intervention to impact patient pathways has been established for cancer care, it is unknown for other indications. We assessed the cost-effectiveness of a PROM-based monitoring and alert intervention for early detection of critical recovery paths following hip and knee replacement.

The intervention significantly improved patient outcomes at lower costs in patients with hip replacements when compared with standard care. Further it showed a nonsignificant cost reduction in knee replacement patients. This reinforces the notion that PROMs can be utilised as a cost-effective instrument for remote monitoring in standard care settings.

The study underscores the importance of understanding and addressing variation in acute care utilization for mental health conditions, including the differential effect of COVID-19, across different health care systems. Further research is needed to elucidate the extent to which factors such as workforce capacity, access barriers, financial incentives, COVID-19 preparedness, and community-based care may contribute to these variations.

In this study we investigated the epidemiology, clinical presentation, and outcomes of the mpox outbreak related to clade IIb in the EMR. We raise concerns about the accuracy and completeness of the data, given that the number of cases reported to the WHO from EMR countries appears to be significantly lower than the number of cases documented within the region. This discrepancy could impact the reliability of the reported figures and the region's response strategies. Despite these challenges, collaborative efforts across EMR countries have laid the groundwork for effective outbreak response, underscoring the importance of ongoing regional cooperation to enhance future preparedness strategies.

Little is known about how long it takes for new medicines to reach countries with different income levels. We analyzed data, sourced from IQVIA, on the timing of new drug launches in seventy-five low-, middle-, and high-income markets from 1982 to 2024. The sample captured the majority of essential medicines (as designated by the World Health Organization in the twenty-third Model List of Essential Medicines) that first came into medical use anywhere globally from 1982 onward. Kaplan-Meier estimates were used to quantify delays in launches across countries. Our analysis comprised 119 medicines with 6,871 observed launches. Nearly three-quarters (74 percent) of first launches occurred in just eight countries (in order of the most first launches, the US, the Netherlands, Sweden, Switzerland, the United Kingdom, France, Germany, and Japan). From the first launch globally, the median time to availability was 2.7 years for high-income countries, 4.5 years for upper-middle-income countries, 6.9 years for lower-middle-income countries, and 8.0 years for low-income countries. The gap between richer (high- and upper-middle-income) and poorer (lower-middle- and low-income) countries remained largely unchanged over time. Strategies to address the disparities highlighted by this analysis are urgently needed.

Over the last two decades, comparative health systems research has gained significant traction as policymakers and researchers seek to better understand how to improve the effectiveness and efficiency of health-care systems worldwide. While most studies undertaken to achieve these goals continue to be predominantly at the national or sub-national levels, the role and importance of cross-country comparison research is increasingly being acknowledged. Recent challenges such as the COVID-19 pandemic, inflationary pressures, rising health-care costs globally, climate change, and decreasing life expectancy among several high-income countries have increased the importance and urgency of this work. Collaborative research efforts across disciplines and countries are therefore needed to identify focused solutions that health systems can apply to the challenges they currently face, and those that may arise in the future.

In this editorial, we summarize the current state of cross-country comparison work at a high level, outline research gaps that remain, and discuss the contribution to this literature of research contained in this special section on international comparisons.

This is a descriptive study using time-series analyses to quantify the annual effect of the COVID-19 pandemic on non-COVID-19 hospitalizations for 20 diagnostic categories and 15 surgical procedures. We compared expected hospitalizations had the pandemic never occurred in 2020–2021, estimated using autoregressive integrated moving average modeling with data from 2010 to 2019, with observed hospitalizations. Observed-to-expected ratios and missed hospitalizations were computed as measures of COVID-19 impact. Mixed linear models were employed to examine associations between hospitalization observed-to-expected ratios and covariates. There was marked cross-country variability in disruptions to hospitalizations and ambulatory care. Certain health system characteristics appeared to be more protective, such as insurance coverage, and number of inputs including healthcare workforce and beds.

Health systems should be designed to withstand emerging shocks and challenges such as the COVID-19 pandemic, and economic and social crises. The ability for a health system to sustain its performance, or even improve it, in the face of a shock can inform policymakers as to how resilient it is. The WHO’s Health System Performance Assessment (HSPA) Framework for Universal Health Coverage (UHC) offers policymakers a conceptual tool for a comprehensive assessment of health system performance. Specifically, it provides a framework from which to examine the performance of the health system itself, but also of the four health system functions - governance, resource generation, financing and service delivery - that make up health systems. The HSPA framework can thus aid policymakers and researchers in examining health systems and considering how shocks may influence the outcomes they produce, as well as the necessary structures that are required for it to produce and sustain performance. In this chapter, we present in detail how the framework can be used to examine how resilient health system performance is to different types of shocks. We consider through a series of case studies both how to use the framework to assess the vulnerabilities of the four key health system functions to different shocks and also how this may translate into changes in performance.

Many studies have documented differences in maternal health outcomes across high-income countries, noting higher and growing maternal mortality in the US. However, few studies have detailed the journeys of care that may underlie or influence differences in outcomes. This study explores how maternity care entitlements and experiences vary among the US and five high-income countries, to study variations in child delivery care practices. Health systems with different organizational structure, insurance coverage and with known differences in maternal care delivery and maternal health outcomes were selected. Data was collected using a structured questionnaire, comparison of secondary data, and literature scan. We find that, while prenatal care approaches were broadly similar across all six countries, there were some important differences in maternity care provision among the comparator countries: (1) the US has more fragmented coverage during pregnancy than comparator countries (2) there were differences with regards to the main provider delivering care, the US relied primarily on physician specialists rather than midwives for prenatal care and delivery which was more common in other countries, (3) the intensity of labor and delivery care varied, particularly with regards to rates of epidural use which were highest in the US and France and lowest in Japan, and (4), there was large variation in the use of postnatal home visits to assess health and wellbeing, notably lacking in the US. The US’ greater use of specialists and more intensive labor and delivery care may partially explain higher costs of care than in comparator countries. Moreover, US maternal mortality is concentrated in the pre- and postnatal periods and thus may be related to poorer access to prenatal care and the lack of an organized, community-based approach to postnatal care. Given the increase in maternal mortality across countries, policy makers should look across countries to identify promising models of care delivery, and should consider investing in more comprehensive coverage in pre- and postnatal care.

More than two decades ago, the Agency for Healthcare Research and Quality developed its Patient Safety Indicators (PSIs) to monitor potentially preventable and severe adverse events within hospitals. Application of PSIs outside the US was explored more than a decade ago, but it is uncertain whether they remain relevant within Europe, as no up-to-date assessments of overall PSI-associated adverse event rates or interhospital variability can be found in the literature. This article assesses the nationwide occurrence and variability of thirteen adverse events for a case study of Belgium. We studied 4,765,850 patient stays across all 101 hospitals for 2016–18. We established that although adverse event rates were generally low, with an adverse event observed in 0.1 percent of medical hospital stays and in 1.2 percent of surgical hospital stays, they were higher than equivalent US rates and were prone to considerable between-hospital variability. Failure-to-rescue rates, for example, equaled 23 percent, whereas some hospitals exceeded nationwide central line–associated bloodstream infection rates by a factor of 8. Policy makers and hospital managers can prioritize PSIs that have high adverse event rates or large variability, such as failure to rescue or central line–associated bloodstream infections, to improve the quality of care in Belgian hospitals.

Irene Papanicolas and colleagues consider the potential of alternatives to quality-based pay-for-performance systems and the remaining challenges

Over the past two decades most healthcare systems have modified the way they pay providers to attach financial incentives directly to quality of care. This type of payment, often referred to as pay for performance, gained momentum in the early 2000s, following several studies highlighting concerns about the quality and safety of healthcare systems.1 However, the evidence suggests they have been largely ineffective in improving quality. In response, health payers in various countries have introduced alternative payment models that encourage more effective, efficient, and integrated healthcare. We examine the early evidence on these alternative models and consider what they can realistically achieve.

Comparing health policy measures before elections and identifying potential gaps in the health policy debate can be challenging. We explored the use of the Health System Performance Assessment for Universal Health Coverage framework to analyse health policy proposals by classifying health policy measures outlined in political manifestos into four health system functions: governance, financing, resource generation and service delivery. As a case study, we analysed the political manifestos of all Portuguese parties with parliamentary representation ahead of the election in March 2024. We calculated the share of measures per health system function for individual political manifestos and identified potential gaps in the health policy debate. When required, we used additional classification criteria and local expertise on political and institutional knowledge.

Wealth-related inequalities in self-reported health status are strong and persistent across countries. Our results suggest that there is meaningful variation across high-income countries in health-wealth dynamics that merits further investigation to better understand whether certain health or welfare systems are more equitable. They also highlight the need to consider social policy and wealth redistribution mechanisms as strategies for improving population health among the less wealthy, in the United States and elsewhere.

Using satisfaction ratings without nuanced approaches in value-based purchasing programmes may mask poor-quality interpersonal services, particularly for historically marginalized patients. Surveys should be designed to accurately capture true levels of dissatisfaction, ensuring that patient concerns are not hidden.

The articles in this issue highlight the importance of regular health systems performance assessment to inform policies that advance progress on health system objectives globally, and offer insights on associated data, methods and applications.

Heterogeneity in national SARS-CoV-2 infection surveillance capabilities may compromise global enumeration and tracking of COVID-19 cases and deaths and bias analyses of the pandemic’s tolls. Taking account of heterogeneity in data completeness may thus help clarify analyses of the relationship between COVID-19 outcomes and standard preparedness measures. Results support the pre-pandemic hypothesis that countries with greater pandemic preparedness capacities have larger SARS-CoV-2 infection and mortality data completeness rates and lower COVID-19 disease burdens. More high-quality data of COVID-19 impact based on direct measurement are needed.

Researchers and policy-makers have long compared health system performance. International comparisons raise awareness of health systems’ relative strengths and shortcomings, prompting policy debates and informing policy decisions. Yet determining how these international comparisons can be used to improve health system performance is challenging. Health systems can differ in many ways, including how they are governed, how they are funded, how they generate and deploy resources, and how they deliver services. While the international health community widely agrees that these functions influence health system performance, understanding of how much they matter, which ones matter most, and how they are affected by the context in which they operate remains limited. To gain relevant and meaningful insights from health systems comparisons that offer lessons for policy, we must agree on how to compare health systems. In this article, we argue that doing so requires collecting better, more granular data on a broad range of health system characteristics and using those data to choose the most appropriate health system comparators.

Analysis of interhospital variation highlights important outcome differences that are not explained by known patient or hospital characteristics. Targeting variation is therefore a promising strategy to improve cardiovascular care. Considering their treatment in multidisciplinary teams, policy makers, and managers should prioritize heart failure, hypertension, cardiac arrest, and angina pectoris improvements by targeting guideline implementation outside the cardiology department.

In their Letter to the Editor, Olivença and colleagues question the benefit of adopting health technology assessment (HTA) in the US, and suggest it could result in fewer drugs being available to patients. They raise 3 main critiques of our study.1

First, Olivença et al note that patients in countries with HTA have voiced concerns about inadequate access to new therapies, citing 5 media reports from negative coverage decisions in England. The extent to which these reports represent the broader views of society is unclear. Recent decades have seen global consensus that universal health coverage is desirable for health care systems. Achieving universal coverage requires decisions about which services should be made available to maximize population health. As many new drugs offer little or no added therapeutic value,2 no coverage may be acceptable unless pharmaceutical companies offer reasonable prices (otherwise, funds would not be available to pay for other health services). In our study, we observed good coverage in all countries of high-value drugs following HTA review.

Total hip arthroplasty (THA) is among the most commonly performed elective surgeries in high-income countries, and wait times for THA have frequently been cited by US commentators as evidence that countries with universal insurance programs or national health systems “ration” care. This novel qualitative study explores processes of care for hip replacement in the United States and 6 high-income countries with a focus on eligibility, wait times, decision-making, postoperative care, and payment policies. We found no evidence of rationing or government interference in decision-making across high-income countries. Compared with the 6 other high-income countries in our study, the United States has developed efficient care processes that often allow for a same-day discharge. In contrast, THA patients in Germany stay in the hospital 7–9 days and receive 2–3 weeks of inpatient rehabilitation. However, the payment per THA in the United States remains far above other countries, despite far fewer inpatient days.

The choice of price index has major implications for comparative analysis. Despite their widespread use internationally, general price indices likely underestimate the contribution of price growth to overall health expenditure growth. We find that in addition to its reputation for having high health price levels compared to other high-income countries, the United States also faces health price growth for goods and services paid for by government and households in excess of general price growth. Furthermore, US households are exposed to greater health price growth than households in comparator countries.

Medical crowdfunding is a key source of finance for individuals facing high out of pocket costs, including organ transplant candidates. However, little is known about racial disparities in campaigning activity and outcomes, or how these relate to access to care. In this exploratory nationwide cross-sectional study, we examined racial disparities in campaigning activity across states and the association between U.S. campaigners’ race and ethnicity and crowdfunding outcomes using a novel database of organ-transplant related campaigns, and an algorithm to identify race and ethnicity based on name and geographic location. This analysis suggests that there are racial disparities in individuals’ ability to successfully raise requested funds, with Black and Hispanic campaigners fundraising lower amounts and less likely to achieve their monetary goals. We also find that crowdfunding among White, Black, and Hispanic populations exhibit different patterns of activity at the state level, and in relation to race specific uninsurance and wait list additions, highlighting potential differences in fundraising need across the three groups. Policy efforts should consider not only how inequalities in fundraising ability for associated costs influences accessibility to care, but also how to identify clinical need among minorities.

Most high-income countries except the US rely on health technology assessment (HTA) to ensure that prices paid for new medicines reflect the value they provide.1,2 Health technology assessment bodies assess the relative clinical or economic impact of new drugs to guide pricing and coverage decisions. These assessments usually occur after marketing authorization by a medicines regulatory body (eg, European Medicines Agency), and patients may have little or no access to therapies not assessed favorably by HTA bodies. As Medicare considers using comparative effectiveness data to negotiate drug prices, examining HTA decisions abroad can inform US policymakers about how HTA affects the availability and coverage of new medicines.3 We analyzed HTA outcomes and review times in 6 countries (Australia, Canada, England, France, Germany, and Switzerland) for novel therapeutic agents approved by the US Food and Drug Administration (FDA).

In low- and middle-income countries, many believe that telehealth services could significantly expand access to doctors by offering remote access at low cost. Yet, despite its convenience, telehealth care is limited by the absence of physical examination, point-of-care testing, or immediate treatment. Hence it is unclear how individuals value such options compared to standard face-to-face care. We study this issue in South Africa with general practitioners who today mostly practice in the private sector and are geographically located in wealthier areas with higher health insurance coverage. We use an incentive-compatible method to elicit robust measures of willingness-to-pay (WTP) for telehealth and face-to-face consultations with general practitioners in a sample of uninsured individuals. We find that only 36% of respondents are willing to pay the prevailing market price for a telehealth consultation. We find average WTP for in-person consultations is only 10% higher than that of telehealth. Additionally, individuals with higher health needs are willing to pay a premium for face-to-face consultations, while others are indifferent. Our findings suggest that private telehealth services are better suited for more minor health needs, but are unlikely to expand access to a majority unless cheaper models are introduced.

The COVID-19 pandemic was associated with increased mental health visits for parents of young children. This raises concerns about mental health impacts and highlights the need to address these concerns.

Study results raise concerns over prolonged high rates of mental health use during the pandemic, particularly in female adolescents and young women, and highlights the need to better monitor and identify mental health outcomes associated with COVID-19 containment measures and to develop policies to address these concerns.

Report identifies striking lack of progress relative to peer countries.

Jonathan Cylus and colleagues argue that inflationary pressures mean the NHS may have reached the limit on its ability to contain costs for goods and staff without affecting care.

The need for cardiac transplantation (CT) in eligible patients with advanced heart failure has continued to grow, with a substantial mismatch between organ availability and demand. As the demand for transplantable organs has risen in the United States,1 so has the prevalence of major cardiometabolic risk factors, including diabetes mellitus (DM), among the current and emerging pool of potential donors.2 Although the cardiovascular complications of DM are well recognized, donor DM status has not been shown to adversely impact post-CT outcomes in older analyses.3 However, this has not been evaluated in the contemporary era or over longer-term follow-up.

One of the most pressing challenges facing most health care systems is rising costs. As the population ages and the demand for health care services grows, there is a growing need to understand the drivers of these costs across systems. This paper attempts to address this gap by examining utilization and spending of the course of a year for two specific high-need high-cost patient types: a frail older person with a hip fracture and an older person with congestive heart failure and diabetes. Data on utilization and expenditure is collected across five health care settings (hospital, post-acute rehabilitation, primary care, outpatient specialty and drugs), in six countries (Canada (Ontario), France, Germany, Spain (Aragon), Sweden and the United States (fee for service Medicare) and used to construct treatment episode Purchasing Power Parities (PPPs) that compare prices using baskets of goods from the different care settings. The treatment episode PPPs suggest other countries have more similar volumes of care to the US as compared to other standardization approaches, suggesting that US prices account for more of the differential in US health care expenditures. The US also differs with regards to the share of expenditures across care settings, with post-acute rehab and outpatient speciality expenditures accounting for a larger share of the total relative to comparators.

Although there are cross-country differences in the availability and structure of data sources, countries had the ability to effectively identify comparable HNHC personas for international study. This work serves as the methodological paper for six accompanying papers examining differences in spending, utilization, and outcomes for these personas across countries.

Across seven countries, we find important variations in end-of-life care for patients who sustained a hip fracture, with some differences explained by sex and age. Our work sheds important insights that may help ongoing health policy discussions on equity, efficiency, and reimbursement in health care systems.

Distribution of health care consumption in different settings varies within countries, but there are also some common treatment patterns across all countries. Clinicians and policy makers need to look into these differences in care utilization by sex and care setting to determine whether they are justified or indicate suboptimal care.

In this comparison of LTC services following a hip fracture, we found international differences in total use of institutional and noninstitutional care, longevity, and total expenditures. There exist opportunities to organize postacute care differently to maximize independence and mitigate costs.

Across 11 countries, there are meaningful differences in health system outcomes for two types of patients.

Across 11 countries, there is substantial variation in health care spending and utilization for a complex multimorbid persona with heart failure and diabetes. Drivers of spending vary across countries, with the United States being the most expensive country due to high prices and higher use of facility-based rehabilitative care.

The United States spent approximately twice as much as other high-income countries on medical care, yet utilization rates in the United States were largely similar to those in other nations. Prices of labor and goods, including pharmaceuticals, and administrative costs appeared to be the major drivers of the difference in overall cost between the United States and other high-income countries. As patients, physicians, policy makers, and legislators actively debate the future of the US health system, data such as these are needed to inform policy decisions.