summarize The four countries are increasingly interested in using analytic tools such as evidence-based medicine, technology assessment, report cards, and cost-effectiveness analysis to evaluate and improve their health systems. New agencies like the National Institute for Clinical Excellence in Great Britain and the ANAES in France are leading these evaluative studies. Policymakers have realistic expectations of these tools, but their influence could grow through various means, such as tying improved performance to increased provider pay, or using evidence of service overuse to justify more assertive care management. In the United States, where many of these tools originated, there is high expectation but also significant resistance to implementing practice guidelines and confusion over how to use analytic findings. As cost pressures increase, the US and the four countries may find common ground in this area