International and global news. International comparisons

Citation

(2003), "International and global news. International comparisons", International Journal of Health Care Quality Assurance, Vol. 16 No. 7. https://doi.org/10.1108/ijhcqa.2003.06216gab.003

International and global news. International comparisons

International and global news

International comparisons

Keywords: Commonwealth Fund, Medical system, Health care, Quality, Errors

A new study, the 2002 "Commonwealth Fund international health policy survey of sicker adults in the USA, Canada, the UK, Australia, and New Zealand", reports the recent experiences of adults in each country with either ongoing health-care needs or recent intensive use of the medical system with respect to care coordination, physician-patient interaction, medical errors, prescription drug issues, and access to needed care. The survey is the fifth in a series, begun in 1998, of these five English-speaking countries.

The study shows that, despite clear structural differences among thesystems, there is consistent dissatisfaction among the surveyed populations with general health system quality, stemming from problems associated with medical errors, inadequate patient-physician communication, and insufficient coordination of care.

Findings

System views: Sizeable minorities in each country had negative views of their country's health-care system: The proportion saying that they were "not very" or "not at all" satisfied ranged from nearly a third in the UK (31 per cent) to more than two out of five adults in New Zealand (48 per cent) and the USA (44 per cent). Those saying they were very satisfied ranged from 14 per cent in New Zealand and 15 per cent in Australia to 25 per cent in the UK.

Major problems: When asked to name the two biggest problems facing their respective systems, respondents' answers varied markedly across countries. Cost and inadequate coverage concerns led the US list, although respondents may mean different things when they say that cost is the biggest problem: costs to themselves, which could be either the high cost of insurance or gaps in coverage, or costs to the health-care system overall. Shortages of health professionals/hospital beds and waiting-times were named as the leading problems in Canada, Australia and the UK, although in slightly differing proportions. In New Zealand, waiting-times were clearly the most highly rated, with inadequate government funding in second place, closely followed by shortages of health professionals or hospital beds.

Recommendations: About a third of respondents in all countries exceptthe USA identified increased public spending on health care as the single most important thing that government could do to improve care. Otherresponses in these countries indicated support for increased investment in the supply of health professionals or hospitals, which is a similar finding to concerns expressed by physicians in these four countries in 2000, with more than half of those surveyed saying that there were too few hospital beds and more than 30 per cent that there were too few specialists. US opinions were more divided. Thesingle policy action endorsed most frequently was to improve coverage of services or people, but only one-fifth named this policy step; anequal proportion said that they were "not sure" what the government should do.

Quality of care: This was the main focus of the survey and, to assess views on the direction of recent changes in the performance of the health-care system, respondents were asked whether they thought thatthe quality of care had improved, worsened or stayed the same overthe previous two years. Two-thirds or more in all five countries saw little recent change; the proportions in all countries except Canada saying it had improved or worsened were roughly equal, ranging respectively from 12 to 15 per cent and from 11 to 15 per cent. A total of 24 per cent of Canadians reported that quality of care had worsened, compared with 7 per cent who thought it had improved.

Coordination of care: Three or more physicians had cared for a sizable majority of respondents in all countries during the past two years and their experiences indicate frequent problems with coordination of care. Approximately half (range 47-57 per cent) of the respondents had had to repeat their health story to multiple health professionals, and approximately 20 per cent (range 19-26 per cent) had received conflicting information from different doctors or other professionals. One in five US and Canadian respondents reported that they had been sent for duplicate tests or procedures by different professionals, rates significantly higher than the 13 per cent in Australia and the UK. Care coordination problems were particularly frequent among people seeing multiple physicians. Those seeing three or more physicians were more than twice as likely as those seeing fewer physicians to report receiving conflicting information. Similarly, those seeing three or more physicians were about twice as likely to report duplicate tests by different health-care professionals.

Pharmaceuticals: The survey revealed heavy reliance on medications with two-thirds or more of respond-ents in each country saying that they rely on prescription medications on a regular basis. Prescription drugs can have serious side-effects and interact with other medications, yet, despite the high proportions of adults who were taking multiple prescription drugs, 30 per cent (USA) to 46 percent (UK) of respondents said that their physician had not reviewedand discussed all of the medications with them in the past two years. Medication-related side-effects are not always discussed between doctors and patients. A total of 17-19 per cent of respondents said that they had stopped taking a prescription medication without a doctor's advice because of side effects, and about one in ten reported that they had experienced serious side-effects about which the doctor did not tell them.

Patient safety: medication and medical errors: About one in ten patients in each country reported a time in the past two years when they were given the wrong medication or wrong dose by a doctor, hospital, or pharmacist and about 20 per cent in all countries except the UK (13 per cent) believed a medical mistake was made in treatment or care. Of those who reported either type of error, the majority in each of the five countries (51-63 per cent) said that the mistake caused serious health problems. The incidence of reported medical errorsincreased among those who saw three or more physicians and the rates of medication errors rose with thenumber of medications takenregularly.

Doctor-patient communication: Significant proportions in all countries, ranging from 47 per cent in the USA and New Zealand to 67 per cent in the UK, reported that their regular physician does not ask for their ideas or opinions about treatment and care and there are also significant numbers, ranging from 20 per cent in the USA to 38 per cent in the UK, who said that their physicians do not make clear the specific goals for treatment. The survey also found that one in five respondents or more in each country reported a time when they had left their doctor's office without getting important questions answered. Considerable emotional strain oftenaccompanies serious or chronic illnesses yet the majority of respondents in all countries said that their regular doctor had not discussed theemotional burden of coping with their illness in the past two years. Despite this evidence of communicationfailures, the majority of respondents in all five countries rated their physician highly (excellent or very good) on questions about care relationships: listening to their health concerns, treating them with dignity andrespect, being accessible, spending enough time with them, or diagnosing their problems correctly. Ratings of "excellent" or "very good" tended tobe highest in New Zealand, with Australia a close second and significantly lower ratings in both the USA and the UK.

Access to care and waiting-times: Half of Canadians and more than one third of respondents in Australia, New Zealand and the UK said that it was difficult to see a specialist when needed, citing waits for appointments as the dominant reason. Two in five US respondents also reported difficulties seeing a specialist when needed. The survey also asked whether waits to be admitted into the hospital or to see a doctor or delays in surgery because of cancellation had posed problems in the past two years. The proportion saying that waiting for hospital admission was a "big" problem was highest in Canada (28 per cent) and lowest in the USA (13 per cent). The majority of respondents in all countries reported that there was no problem with waits to get an appointment with their regulardoctor, although significant minorities in Canada (24 per cent) and the UK (21 per cent) reported that it was a big problem. In most countries cost can be a problem for access to care. Respondents in the USA were most likely to say that they had not filled a prescription (35 per cent) or followed up on recommended tests or treatment (26 per cent) because of costs, and UK respondents were the least likely to report these problems. Respondents in New Zealand (26 per cent) and the USA (28 per cent) were the most likely to say that they did not get needed medical care because of cost. Cost for dental care was the most significant deterrent in all countries, ranging from 21 per cent in the UK to 44 per cent in Australia.

Overall, the survey indicates that patients of the type surveyed are likely to be at high risk for deficiencies in care coordination, communication failures, and medical care errors and the authors say that it finds notable areas of common concern as well as varying performance across the five nations. They acknowledge that they are unable to assess what proportion of the differences can be attributed to variations in cultural expectations but, despite this limitation, the similarities in problems of coordination, communication, medication problems, and errors are striking. The survey shows that in all five countries failure to coordinate care can result in duplicate tests, delays in care, wasted patient and medical staff time, and conflicting information. Deficiencies in patient-doctor communication can compound such concerns because of failure to involve patients in decision making. The survey indicates frequent failures of physicians during patient visits to exchange information and answer questions, to discuss care goals and options, and to review medication regimens. Access concerns also exist in all five countries, but sources and types of barriers vary widely.

The authors say that their findings indicate that, as countries seek to redesign their care systems, interventions that target patients who see multiple physicians or depend on multiple medications could be particularly effective. Tracking systems, shared electronic medical records, or electronic prescribing of medications offer potential pay-offs. Better monitoring of prescriptions could help to prevent medication-related adverse interactions, side-effects, and prescription errors and could work toward controlling high pharmaceutical costs.

Karen Davis, president of The Commonwealth Fund, said:

"Frequent error, miscommunication, and wasted resources from duplicate tests, delays, and conflicting information are common problems in the health systems of all the countries studied. These findings highlight serious problems with quality ofcare and wasted resources, and make a compelling case for implementing interventions that we know will make a difference, including electronicmedical records and computerized systems for physician ordering of prescription drugs."

Further information: The survey, by Commonwealth Fund/Harvard/Harris Interactive, 2002, Commonwealth Fund international healthpolicy survey of sicker adults, is reported in the May/June issue of Health Affairs (Blendon, R.J., Schoen, C,. Des Roches, C., Osborn, R. and Zapert, K., 2003), "Common concerns amid diverse systems: health-care experiences in five countries",Health Affairs, Vol. 22 No. 3, May/June 2003, pp. 106-21, and can be accessed through the Commonwealth Fund Web site at www.commonwealthfund.org