Optimising your surgical device and equipment market strategy in the US, Japan and Europe

In this article, we will compare the US (with around 325 m inhabitants), Japan (130 m) and the largest European market, Germany (85 m), in terms of surgical practices, and assess the effects of the differences between these countries on the respective medtech markets.

It’s fair to state that all countries have comparable patient buying power, quality and scope of healthcare infrastructure and sophistication of clinical practices.

Nevertheless, the differences at operating room level, i.e. on the operating floor, are substantial.

Demographics, national healthcare structure, market access for new technologies, and clinical practice, create greater differences than similarities
Bart Van den Mooter, CEO TforG Group

Differences in Hospital Provisions

Following are a few examples to illustrate the structural differences between our three focal markets, US, Japan and Germany. (Source: TforG myToolsforGrowth – surgical procedures).

Striking are the differences in HC infrastructure and how patients flow through the respective HC systems, as can be inferred by the varying averages of hospital stay-duration and nationwide hospital bed volumes.


Green cells mark notably lower volumes and blue cells mark substantially higher volumes.

As the comparison above highlights, Japan has almost twice as many hospital beds per million inhabitants than Germany does, and 4 times the beds/capita count as in the US. Japan also has close to 3 times longer hospital stays compared to Germany, and 3.6 times longer than the US.


Looking at ORs per million inhabitants, Japan beats the US by 50 more operating rooms/m, and Germany by almost double the volume.

Most impressive here, is the difference between surgeons in Japan and the US; Japan having 2.5 more surgeons per million than the US has. Keeping in mind that the US population is generously more than double the size of Japan, this raises the pressure upon this more limited count of surgeons by millions of potentially underserved patients. This alters the way that surgeons handle patient volumes, how protocols are set up, and how hospitals (and the healthcare system overall) handle patient care tracks.

The most formidable discrepancy can be seen in the volumes of surgical robots; the US has 10 times more robotic arms than Japan, and a whooping 25 times more surgical robots than the German healthcare system.

Differences in Surgical Procedure Volumes

The number of surgical procedures differs substantially between our 3 focal markets.

For this exercise, we selected 3 high revenue driving specialisms, which are also particularly prone to growth due to their correlation to chronic disease trends and ageing populations.


The USA, in comparison to Japan and Germany, performs markedly less insertions of drug-eluting coronary artery stents (less than 40% the volume of Germany). What alternative procedures are used in the USA to treat the relative clinical indication? What other medtech would they require to perform such treatments?

Simultaneously, we learn that the market for stents in Germany must be particularly interesting to stent-manufacturers and suppliers.


Close to 70% less intracranial pressure monitoring is applied in the US in comparison to Japan. Again, we ask ourselves, what protocols define the usage of such a technique, how does this impact our product marketing, and what type of technologies are most successful/demanded in which countries?


Over 5 times more spinal fusions are performed in the US than in Germany. What does this mean for the marketing of your spinal surgery product? Explore the myToolsforGrowth databases to learn what other trends/volumes exist for various procedures and specialisms, and which treatments and respective medtech is most in demand in which countries.

Differences in Protocols and Treatments in Oncology, Stroke Management and Cardiac Surgery across Different National Healthcare Systems

Oncology – Gastric Cancer

There are substantial differences in the outcomes of patients who have gastric cancer in the Japan, the US and Germany. Differences in biology, surgical and adjuvant treatment, the histology, tumor location, environmental exposures, dietary factors and levels of Helicobacter pylori status account for these discrepancies. E.g., endoscopic mucosal resection and extended lymph node dissection are routinely practiced in the Japan, and much less in Germany and the US.

Stroke management

The guidelines for treating ischemic and hemorrhagic strokes differ between Japan and the US (and in most European countries), resulting in different approaches to certain aspects of ischemic stroke management.

Cardiac surgery

Cardiovascular surgery in Japan is characterized by a high rate (60%) of off-pump coronary bypass (OPCAB) grafting, in comparison to a rate of 15–20% in the US. This is interesting to observe, since the OPCAB approach requires higher surgical skills. Respectively, training and selecting surgeons in Japan is substantially different from the US and Germany, leading to different surgical practices.

Differences in Protocols and Treatments in Oncology, Stroke Management and Cardiac Surgery across Different National Healthcare Systems

Conclusion: Different countries, different HC structures, different marketing needs

The examples above clearly illustrate that several parameters such as demographics, national health care structure, physicians’ training, patient preference, surgical practice etc. affect the market structure and dynamics. This leads to substantial differences in market sizes and country specific characteristics in the 3 countries of our comparative review.

Apart from concrete statistics informing us of the most common to least common treatments, which allows us to estimate product market sizes and trends, there is also the matter of procurement itself. How do countries -and in particular, how do hospitals- procure the medical devices and supplies they need for their treatments and for the delivery of the nation’s healthcare? In the next blog we will explore procurement and the regulatory frameworks of the US, Japan and Germany; reiterating the KSF of understanding both subtle and vast differences within healthcare protocols and sourcing, in order to optimise your market strategy.

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About Bart Van den Mooter

Bart is the founder of TforG and works closely together with over 50 global companies such as Abbott, Baxter, GE, J&J, Medtronic, Philips, Stryker and Covidien. In this function, he spends a lot time with Key Opinion Leaders and Health Policy makers in Europe and in Emerging Markets. He graduated at the Polytechnic University of Leuven with a Master of Engineering and has an MBA (Flanders Business School).