United States fares poorly in international patient survey

The country was rated first only in effectiveness of care.

By Elaine Monaghan — Posted April 24, 2006

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Washington -- Adult patients in the United States are less safe, not as well informed by their doctors and more unequally treated than people in five other developed nations that spend far less treating them, according to two studies released earlier this month by the Commonwealth Fund.

America ranked last overall when compared with Australia, Canada, Germany, New Zealand and the United Kingdom in one study, "Mirror, Mirror, on the Wall: An Update on the Quality of American Health Care Through the Patient's Lens."

This analysis compared U.S. health leaders to the vain queen in "Snow White." Too often, they excluded experiences of other countries, looking only "at our own reflection in the mirror," the report states.

Based on 2004 and 2005 surveys, it found that American patients were most likely to say they encountered a laboratory test mistake or delay in receiving abnormal results, did not get questions answered by their physician, struggled to get needed care at nights or on weekends, and failed to fill or take prescriptions due to cost.

Janet Corrigan, PhD, president and CEO of the National Quality Forum and the National Committee for Quality Health Care, said the study should not be read as an indictment of physicians, but as further evidence of the need to reform the country's disorganized health system. She noted the study's reliance on patient assessments. "You might get different results if you asked physicians or looked at medical records."

The work, which followed an Institute of Medicine framework to evaluate health care system quality, concluded that the United States ranked first in six out of 51 indicators, and last or tied for last in 27. Karen Davis, PhD, the fund's president, described this outcome as "particularly disturbing considering we lead the world in health care spending." The fund is a private health foundation that supports research into improving quality and efficiency.

To arrive at its ratings, the study used six categories:

  • Patient safety addressed wrong drugs or doses, mistakes in care, and delayed or incorrect test results.
  • Effectiveness included use of mammograms, flu shots, medication reviews, diet and exercise advice, hospital infections and follow-up visits.
  • Patient centeredness examined such issues as doctor communication, choice, time with the physician, pain management and access to records.
  • Timeliness addressed appointment wait times, emergency department lines and access to care at irregular hours.
  • Efficiency focused on ED visits due to lack of access to a physician, delays in test results and rehospitalizations for complications.
  • Equity compared barriers to care, doctor ratings, filling of prescriptions and continuity of care by income.

America ranked first in only one category -- effectiveness -- and last in four areas.

The study confirmed what physicians already know or suspect about waits for care. For example, 41% of patients in the United Kingdom had to wait four months or more for elective surgery, but only 8% did here.

Some of the gap between the United States and other countries boiled down to problems unique to America, according to the second study, "The U.S. Health Care Divide: Disparities in Primary Care Experiences by Income." Three-quarters of the uninsured had skipped needed care in the previous year due to cost, the analysis of 2004 survey data found.

The study also showed that poorer Americans overall had a far dimmer view of their doctors, with 22% of below-average income patients rating their physicians fair or poor, compared with 7% of higher income residents. By contrast, the range of such negative assessments for low- and high-income people in Australia, Canada, Germany, New Zealand and the United Kingdom was 4% to 12%.

"Our fragmented health care system and lack of a strong primary care foundation show up in performance gaps throughout the studies," Dr. Davis said. Vulnerable patients -- the sicker and the poorer -- experienced "particularly negative results."

She characterized the better showing in other countries as evidence that "more efficient, effective, safe, patient-centered and equitable" care was a real possibility.

Focus of attention

This issue is key for the American Medical Association, which lists patient safety and quality improvement as one of the six items on its advocacy agenda for this year.

The AMA says it is working to implement the patient safety law, whose passage it led last year, while promoting voluntary reporting systems with strong confidentiality protections.

It convenes the Physician Consortium for Performance Improvement, which strives to develop evidence-based quality measures. The AMA tries to help doctors reduce racial and ethnic disparities and strives to build political pressure to increase access for low-income people.

Lynne Kirk, MD, president-elect of the American College of Physicians and professor of internal medicine at the University of Texas Southwestern Medical School, said the study was further proof of the need to move to electronic records, pointing out the difficulties patients had with test results and medications.

In the United States, 13% of patients surveyed reported being given the wrong drug or dose by a doctor, nurse, hospital or pharmacist in the past two years, compared with 10% in every other country except New Zealand, at 9%.

Dr Kirk said, however, that she believed the United States would be able to move "fairly quickly" in this area and that physicians should not be depressed by the results.

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High spending, low score

The United States spends more per person on health care than any of the other five countries studied, but it ranks last overall when scores for patient safety, effectiveness, patient-centeredness, timeliness, efficiency and equity are combined.

Australia Canada Germany New Zealand United Kingdom United States
Overall ranking 4 5 1 2 3 6
Patient safety 4 5 2 3 1 6
Effectiveness 4 2 3 6 5 1
Patient-centeredness 3 5 1 2 4 6
Timeliness 4 6 1 2 5 3
Efficiency 4 5 1 2 3 6
Equity 2 4 5 3 1 6
Per capita health expenditures $2,903 $3,003 $2,996 $1,886 $2,231 $5,635

Note: Based on 2004 and 2005 International Health Policy Surveys

Source: Commonwealth Fund, April

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External links

"Mirror, Mirror on the Wall: An Update on the Quality of American Health Care Through the Patient's Lens," executive summary and video overview, Commonwealth Fund, April (link)

"The U.S. Health Care Divide: Disparities in Primary Care Experiences by Income," executive summary, Commonwealth Fund, April (link)

The AMA-convened Physician Consortium for Performance Improvement (link)

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