Cathy Schoen, Robin Osborn, Phuong Trang Huynh, Michelle Doty, Kinga Zapert, Jordon Peugh and Karen Davis. Health Affairs (web exclusive) 24: 509-525, 2005

Background: Last month’s Medicare E-Rounds focused on comparative primary care in seven countries. The same authors have attempted to assess care at the front lines through the eyes of patients. Sick adults from Australia, Canada, Germany, New Zealand, the United Kingdom and the United States offered their perceptions as an informative voice to policy researchers seeking to improve the performance and quality of health care systems through redesign of care delivery, payment, and/or insurance.

Objective: To compare the experiences of sick adult patients in health care systems across six countries.

Methods: A similar survey was conducted in six countries focusing on safety, care coordination, access and chronic disease management. The telephone administered survey screened initial random samples of adults, 18 years and older, who met at least one of four criteria: 1) fair/poor self-reported health; 2) serious illness, injury or disability requiring intensive medical care in the past two years; 3) major surgery; or, 4) hospitalization in the past two years other than for normal pregnancy. In the analysis, final samples were weighted to reflect distribution of the adult population based on initial screening demographics.

Results: Final results included a sample of 702, 751 and 704, respectively from Australia, Canada and New Zealand, and 1770, 1527, 1503, respectively for the UK, the US and Germany. Two-thirds to three- quarters of respondents in each country indicated at least one diagnosis of a chronic illness. Half or more were 50 years of age or older and 40-50% had been hospitalized in the past two years.

Deficiencies in care were widely reported and widespread. Examples included one in five reporting inadequate pain management and 7-10% reporting hospital-acquired infections. Communication gaps were cited by 19-26% of patients, with at least one in six patients from each country indicating a desire for greater involvement in decisions about their care. Moreover, failure to coordinate some medications, particularly at discharge, was commonplace in all countries.

Patient-reported medical and medication errors were high in all countries, with between 17 and 22% of patients reporting perceived medical mistakes, with 61-83% reporting that their physicians did not inform them of these perceived errors. Laboratory error rates were relatively high in Canada. Using a composite variable of errors - medical, medication or lab – US patients were the most likely and UK patients the least likely to report errors, with Canada only slightly, albeit significantly (p < 0.05), lower than the US.

In terms of access, patients were less likely to report rapid access in Canada and the US. This was true for doctors’ appointments, after-hours access and emergency waiting times, the ER being used much more commonly in Canada and the US than in other countries. Access problems based on cost, in the past two years, were highest for the US, with Canadian patients reporting fewer barriers to care based on cost than all countries except the UK.

Limitations: As with all such surveys, representativeness of responses is a critical feature. A weighted sampling technique was used but by no means eliminates disproportionately higher responses by country, sex or case mix. The reliability of self-reported survey data is tenuous, introducing potential sources of error, such as recall bias, that may influence validity of results. The magnitude of these potential errors is unknown.

Conclusion: Patients in all six countries reported safety concerns, mistakes, poor care coordination and other deficiencies. No country consistently leads or lags. Weakness in transitional care was a shared concern across countries. The data point to substantial opportunities in Canada to reduce medical and medication errors, with particular emphasis on laboratory error. Moreover, rapid access to generalist and specialist care is a comparatively greater problem in Canada than in some countries, though not related to cost barriers as in the US.

Relevance: Like all health care systems, Canada’s has its share of problems balanced against considerable strengths. Of note is the fact that at the time of this survey, the percent of national income spent on health care by each country was 14.6% (US), 10.9% (Germany), 9.6% (Canada), 9.1% (Australia), 8.5% (New Zealand), and 7.7% (UK). This study points to improvements that could be made in the organization and delivery of care within the context of publicly-funded health care systems as in Germany, the UK, Australia, New Zealand and Canada, without setting up barriers to care and incurring greater costs as in the case of the US.