International comparisons of surgical procedures

There are large cross-country variations in the population level rates of some common operations - in particular, coronary bypass and angioplasty surgeries, hip and knee replacements and caesarean sections. For all these procedures it is difficult to determine what the right absolute level should be. However, trends and variations can inform us about potential problems in the quality of care provided.

How does the rate of cardiac procedures compare internationally and over time?

Heart diseases are a leading cause of hospitalisation and death in OECD countries, even though rates of ischemic heart disease (IHD) mortality have been declining in most countries since the 1990s (OECD, 2013).

Both coronary artery bypass grafts and angioplasty have been essential in treating patients with IHD. Over time, we can observe a declining trend in bypass surgeries, the more invasive form of treatment, while there has been an upward trend in angioplasties, the less invasive procedure. However, the two procedures are not direct substitutes (McGuire et al., 2014).

The United States and Germany have the highest rates of coronary artery bypass graft (CABG) and angioplasty. Data from United States is reported differently to other countries included, please see 'About this data' below for more information. For both procedures, the UK follows the trends of other countries, but has significantly fewer procedures, especially for the less invasive angioplasty.

Large variations in the rates of procedures do not seem to be closely related to the incidence of IHD, as measured by IHD mortality (OECD, 2013). For example, UK and Germany have very similar IHD mortality, yet Germany has the highest rate of revascularisation procedures. Differences in capacity to pay for and deliver these procedures, differences in treatment guidelines and physician practices, and coding and reporting practices may explain these variations (OECD, 2013).

How does the rate of hip and knee replacements compare internationally and over time?

Joint replacement surgery, including for hips and knees, is considered the most effective intervention for severe osteoarthritis (OECD, 2013). This is especially for patients who have severe pain or their mobility is affected. The two graphs show that rates of both procedures have been increasing in most countries since 2000, with generally a faster increase for knee replacements. Germany carries out the most hip and knee replacements even though the increase seems to have levelled off since 2008/9. The UK's rate of hip replacements is very similar to rates in Australia and Italy. For knee replacements, the UK has rates similar to Sweden's and Italy's. Differences in population structure and age-standardisation only explain some of the cross-country variation (OECD, 2013).

OECD, Health Statistics 2013

How does the rate of caesarean sections compare internationally and over time?

It is difficult to determine the appropriate rate of caesarean sections (C-sections) and the necessity to have C-sections rather than a normal vaginal delivery has also been controversial. While it is medically required in some situations, overuse of C-sections in Western countries has been linked to adverse outcomes for the mother and the child and is also unnecessarily costly (Gibbons et al, WHO, 2010). The graph shows that there are significant cross-country variations between the selected OECD countries. Finland and the Netherlands have one of the lowest rates while Italy is an outlier with over 350 C-sections per 1000 live births between 2000 and 2012. Apart from Italy, UK has high and increasing C-section rates relative to the Nordic countries. Some countries have stabilised the C-section rates (e.g. Canada, Spain, France) or reversed the trend, as in Italy. There are several reasons that can explain high rates of C-sections, including C-sections being considered less risky, malpractice liability concerns, scheduling convenience or patient preference, difference between a private and public facility, increase in first births among older women and multiple births, among others (OECD, 2013).

Further in depth analysis is required for all these surgical indicators. For example, for C-sections and angioplasty it would be important to disaggregate into emergency and elective procedures and for C-sections to look at the relationship with staffing (e.g. consultant cover, midwife to birth ratio).

OECD, Health Statistics 2013
About this data

These indicators are prepared by the Organisation for Economic Co-operation and Development (OECD) as part of their Health at a Glance edition. Definition and comparability notes from OECD Health at a Glance 2013

Cardiac procedures: data for most countries covers both inpatient and outpatient day cases, with the exception of the United States, where only inpatient cases are included. This results in under-estimation of coronary angioplasties but does not affect the number of coronary artery bypasses as most patients stay at least one night in the hospital. In the UK and New Zealand the data only includes activities in publicly funded hospitals, resulting in an under-estimation. Data for Spain only partially include activities in private hospitals. 

Knee and hip replacement: classification systems and registration practices vary across countries and may affect the comparability of the data. Most countries also include practical hip replacement in the figures. In New Zealand and the UK, the data only include activities in publicly-funded hospitals, which may result in underestimation (an estimated 15% of all hospital activity is undertaken in private hospitals). Data for Spain only partially include activities in private hospitals. 

The caesarean section rate is the number of caesarean deliveries per 1000 live births. 


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