No. 10: On the Front Lines of Care: Primary Care Doctors’ Office Systems, Experiences and Views in Seven Countries

Cathy Schoen, Robin Osborn, Phuong Trang Huynh, Michelle Doty, Jordan Peugh, and Kinga Zapert. Health Affairs (web exclusive): 555-571, November 2006

Background: Countries worldwide are pursuing initiatives focused on improving primary care practice and supporting high quality, efficient care. A variety of approaches and emphases are apparent, including financial incentives, practice re-design, information technology support, and patient-centered teams. This e-Rounds examines the experiences and views of primary care physicians in Australia, Canada, Germany, New Zealand, the Netherlands, the UK, and the US.

Objectives: To examine variations among countries in their primary care practices, as a means of elucidating opportunities to learn, to improve outcomes, and to increase efficiency.

Methods: A survey took place in 7 countries with representative samples of primary care physicians answering a common questionnaire. Practising physicians were randomly selected from lists available through private or government sources. Physicians were surveyed by mail or telephone between February – July 2006. The sampling technique was weighted to take into account the distribution of physicians by region of the country, sex, primary care ‘specialty’ and, in the United States, whether office- or hospital-based.

Results: The distribution of age and sex was similar across countries, with approximately 1/3 being female and 1/2 age 50 years or older. Primary care doctors in Australia, Netherlands, New Zealand, and the UK have the most widespread and multifunctional clinical information technology systems, whilst Canada and the United States’ doctors lag well behind. Nearly all doctors in the Netherlands and the vast majority in Australia, New Zealand and the UK use electronic medical records. Only 23% of Canadian physicians reported doing so. The prevalence of electronic prescribing and electronic retrieval of test results is well below that of leading countries. Access to prescription alerts, prompts, and electronic patient reminders also lags in the US and in Canada. To determine overall clinical information system capacity, the study used a summary variable for IT use. Most physicians in Australia, the UK, and New Zealand reported use of 7 or more of 14 specified IT functions. The majority of physicians from Canada and the US reported 2 or fewer functions. Canadian doctors report that medical records are not available at the time of an appointment. Moreover, about half or more physicians in Canada report that they wait 15 days or longer to receive reports. The survey also looked at access to primary care and waiting times. After-hours coverage arrangements vary remarkably, with 3 of 5 US and half of Canadian doctors saying that they have no after-hours arrangements. In contrast, at least 3/4 of physicians in other countries, including nearly all Dutch physicians, reported having these arrangements. As for waiting times, Australian and US doctors were the least likely, and Canadian and UK doctors the most likely, to say that their patients confront long waits for diagnostic tests. Physicians report that waiting for elective surgery appears to be the norm in New Zealand, occurs often in Australia, Canada, the Netherlands and the U.K, but is rare in Germany and the US. The US stands out for the high percentage of physicians reporting that patients have difficulty paying for care and medications, even among insured patients. This is in contrast to U.K. and Dutch physicians who are the least likely to cite affordability concerns. Overall, the US has less capacity to ensure accessible, high-quality care, or patient-centered primary care, leading to poorer clinical outcomes.

Limitations: All multi-country international surveys raise questions about the representativeness of responses. Weighted sampling techniques are used to ensure responses are not disproportionately different by country, sex, and nature of office practice. Although such weighting is essential, the sampling technique can clearly influence the results. US responses about shorter waiting times for elective surgery appear not to consider the predicament of uninsured patients. 

Conclusion: Primary care redesign is occurring extensively throughout the world. Variations seen in this study point to definite opportunities for improvement. Just as we have come to understand that wide variability in practice often points to opportunities for improved management and to the presence of inappropriate or wasteful care, so too, wide country variations suggest that the capacity to manage disease in primary care practices varies widely. Such studies point clearly to where there are opportunities for improvement in Canada.

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