Controlling health care costs while improving health care outcomes remains a global challenge, regardless of health system ownership or payer type. Scorecards released by several international organizations, including the World Health Organization and the Organization for Economic Cooperation and Development, highlight global disparities in the quality and cost of health care among developed nations. While country-level comparisons hold interest for policy makers, high-level comparison measurement alone is not sufficient for quality improvement. Comparison work is needed at the clinical process level that informs efforts at real change.

Comparisons of health care performance are one important mechanism being used increasingly today by policy makers to benchmark their health care system's performance against their peers at the local, national, and international levels. Comparisons can also provide a basis for learning, decision making on resource allocation, promoting stewardship, and transferring health services technology to lesser-developed countries.

We know that international performance comparisons have been done for some time in health care settings. Such comparisons have particular value when in-country comparisons are insufficient. A review of published literature would suggest that most international comparative work being done begins and ends with the measurement comparison. Berwick et al1 have argued that measurement is necessary but not sufficient for quality improvement. Wennberg and Thomson have noted that "while research into practice variation has improved our understanding of unwarranted variations and how they may be reduced, this knowledge has had only modest effects."2 In this spirit, the goal then of performance comparisons should be to uncover actionable opportunities for shared learning and innovation in health care.

To achieve improved health care performance, opportunities exist to improve the conduct of international health system comparisons so that they are actionable by the health systems. Comparability issues tied to the cultural, legal, and ethical standards of each society, as well as the risk factors common to patients in both countries, must be understood and addressed. At the care level, documenting the specific clinical processes of both organizations, including differences in the care approach, use of clinical guidelines, resource utilization levels, and seemingly mundane issues such as the calibration of laboratory measures, must be done to evaluate comparability between organizations. Challenges with existing data used for comparisons must also be understood and addressed. This can include variation in (1) definitions of important terms, (2) classification structures for coding clinical encounters, (3) coding practices, and (4) the purpose for which data are captured. All of these impact the measurement basis used by the comparing organizations and represent barriers to conducting high-quality comparisons.

Collaborative international networks are forming around specific conditions and diseases to increase the value generated through comparative work. One recent example is the International Network for Evaluation of Outcomes (iNEO) of Neonates Collaborative. More recent collaboratives such as iNEO are designed to be more action-oriented-promoting evidence-based practice change at the clinical care level.3

Through the Intermountain Institute for Healthcare Delivery Research, Intermountain Healthcare ("Intermountain") is advancing international comparative analysis and quality improvement, working in close collaboration with quality improvement leaders from Sweden. The objective of this collaborative is to conduct high-quality, condition-specific comparative analysis with a goal to advance the translation of health care delivery quality improvement between countries. The first step in advancing this work was the development by the Collaborative of a Framework for International Comparative Data Analysis, specifically designed as a purposeful effort to uncover opportunities for shared learning and innovation in health care (the "Framework"). The 3 phases of the Framework include (1) setting collaboration terms, (2) identifying transferable improvement opportunities for high-quality comparisons, and (3) taking action and disseminating learnings. In setting collaboration terms, we agreed jointly on 10 specific disease areas for individual comparative analysis, beginning with diabetes, heart failure, and breast cancer.

Thirty-day readmission for heart failure was an area of particular interest for the Collaborative, given evidence that high readmissions signal a breakdown in care quality and are being linked with performance penalties. Fiscal and operating decisions regarding health care delivery in Sweden, including taxing authority, are generally owned and managed at the county level. Uppsala County, which includes Uppsala University Academic and Enkoping hospitals, was identified as having strong performance in 30-day readmissions for heart failure among all counties in Sweden. To continue to learn and improve, Uppsala County looked beyond its national borders for health systems having success with innovative approaches to heart failure care.

Through the Collaborative, a high-quality analytic comparison was conducted examining heart failure readmission rates between Uppsala University Academic Hospital, where most heart failure cases in the county are treated, and the Intermountain Medical Center (IMC), which supports heart failure care for patients living in Salt Lake County, Utah, including Salt Lake City. Both hospitals are tertiary referral centers for heart failure care, with significant heart failure encounters annually. Standards of care, including available treatment technologies, were deemed similar between the 2 hospitals.

Guided by the Framework, comparability issues effecting reported comparisons were identified and addressed. Specific differences included understanding (1) definitions of planned/unplanned readmissions, (2) the nature and use of observation stays, (3) reporting of discharge against medical advice, (4) the use of CPT (Current Procedural Terminology) codes, and (5) the counting of readmissions with 24 hours of discharge. One important similarity that reminded participants that we were more similar than not was the ever-present challenge of addressing readmissions that occur outside the health system.

Adjusted comparisons revealed an opportunity for shared learning between the 2 organizations. The IMC had both lower readmission rates and mean length of stay for patients older than 65 years. In contrast, Uppsala had better results when looking at patients younger than 65 years.

Armed with this information, a two-day heart failure conference of care delivery leaders from Intermountain and Uppsala was held at the IMC. The goal of this conference was to examine the underlying care processes for patients with heart failure within both organizations and to highlight specific transferable mechanisms associated with improved readmission outcomes for patients with heart failure. Five targeted improvement opportunities were identified during this two-day conference. Ongoing meetings are now planned to monitor the progress of both organizations, with a follow-up conference planned for the next year.

Executing the Framework phases was not without challenges. Collaborative members needed time to understand how each health system operated and to characterize the implications that contextual differences between systems had on the care process and on measurement. Several iterations were required to gain the necessary understanding. Once understood, stakeholder engagement had to be carried out at the right level within both organizations to ensure the right clinical care and clinical data people were available to support the more detailed evaluation. Despite some of these challenges, we remain optimistic about the long-term benefits to both organizations of conducting a high-quality, disease-specific, process-level comparison.

Based upon Intermountain's experience with both national comparisons such as the High-Value Healthcare Collaborative and international health care performance comparisons including the Sweden/Intermountain collaboration, we believe that well-executed collaboratives remain a viable approach for identifying actionable opportunities for quality improvement. Organizations interested in collaborating together must (1) remain focused on an end goal-to improve individual patient care and to maintain or lower per patient cost; (2) move beyond measurement alone, engaging clinical leaders, decision makers, and data stewards at the clinical care level to understand the process of care; and (3) use the PDSA (Plan/Do/Study/Act) cycle or similar methodology to drive specific quality improvement at the care process level.

Innovation in health systems is often constrained by the inertia of a system's existing culture, values, and practices. As a result, internal health system performance comparisons can have limited value for organizations pursuing truly innovative approaches delivering care. Well-executed, high-quality external performance comparisons provide an important tool in efforts to identify transferable improvement opportunities between health systems.

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