No.15: Toward Higher-Performance Health Systems: Adults’ Health Care Experiences In Seven Countries

Cathy Schoen, Robin Osborn, Michelle M. Doty, Meghan Bishop, Jordon Peugh, and Nandita Murukutia. Health Affairs – Web Exclusive, October 31, 2007.

Background: Previous e-rounds have examined international surveys of OECD countries. This month’s e-round reviews the care experiences of adults in seven health care systems in 2007, to elucidate system-wide problems in these countries. While the focus by no means is on Canada, this review attempts to shine a light on access, quality, safety, and efficiency in our healthcare system, and where and how these variables could be improved.

Methods and Limitations: This is another international survey in an annual series, by the Commonwealth Fund in New York, which looks at comparative health system organization and performance. Approximately 12,000 adults in Australia, Canada, Germany, the Netherlands, New Zealand, the U.K. and the U.S. were surveyed in 2007 to assess their health care experience [n=1000 (Australia, New Zealand)]; [n=1500 (Germany, the Netherlands, U.K.)]; [n=2500 (U.S.)]; and, [n=3000 (Canada)]. The Canadian sample was expanded with the support of the Health Council of Canada. Interviews were by phone and lasted an average of 17 minutes. The analysis weighted final samples to reflect distribution of the adult population. The analysis attempted to examine the role of a “medical home” – a composite variable representing adults with a primary care source that is accessible, where their medical history is known, and that helps coordinate care. The survey examined access, quality, safety and efficiency.

The value of international surveys may be constrained by limitations in the representativeness of those surveyed or in the weight attached to their responses. While these may influence the precision of pursuant results, it is far less likely to influence the direction of those results. Accordingly, it is useful to see such findings as opportunities for improvement, as opposed to rigorous comparative results of performance. Moreover, these are patients’ opinions of their experiences and have not been otherwise verified. Finally, these countries have different insurance systems and vary in the extent to which primary care plays a coordinating role.

Analysis: Canadian physicians are the least likely to use electronic health records. The U.K. has the most comprehensive coverage, while Canada is comprehensive for physicians but has demonstrable gaps in prescription coverage, aside from those who are elderly or have low income. Public opinions about overall system performance in Canada and New Zealand have become more positive in the past decade and are now comparable to Australia and the U.K., while public views of the U.S. system have deteriorated. The most rapid access to elective surgery is in the U.S. and Germany, the slowest access in Canada and the U.K. Whereas in most countries a wait of a year is rare, of those waiting for elective surgery in Canada and the U.K, 8% wait for a year (15% wait six months or more). In terms of primary care access, 84% of Canadians report having a G.P., but Canada (38%), Australia (34%), the UK (29%) and the U.S. (38%) are notable with more than one-third of the surveyed adults responding that their regular physicians are very difficult to reach outside of regular 9 to 5 work hours. Canadians (22%) and Americans (30%) were the least likely to report same day access and most likely (Canadians 30% and Americans 20%) to report long waits (6 days or more) to see a doctor when sick. Not surprisingly, Canadians and Americans are most likely to use the Emergency Room and often indicate that it is in lieu of seeing their own doctor. E.R. use is particularly high in Canada for those with chronic conditions. At the same time, 46% of Canadians wait 2 or more hours to be seen in the E.R.


As for doctor-patient interactions, 59% (country range 56-73) of Canadian patients felt their doctor spent enough time with them. Additionally, 75% (country range 70-80) felt things were properly explained. As for overall quality of care, 73% of Canadian patients rate it as very good to excellent (third after New Zealand and Australia, range 52%-78%), though patients with a medical home reported significantly higher quality of care.


Summary: This study has a great deal of content, and we have provided only selected highlights. The concept of a “medical home” appears important and in all countries it was associated with more positive care experiences, more efficient and responsive care, and lower rates of patient-reported errors. In both Canada and the US, waits for primary care and the utilization of ERs after hours shows “symptoms of a primary care system under stress.” Cross-country comparisons show that insurance design and coverage directly impact access and experiences. The fragmented multi-payer system in the U.S. provides a “note of caution” to other countries, such as the Netherlands, “seeking to introduce competing insurance entities as part of strategies to improve.”

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