CrossNational Comparison of Primary Care

1
Cross-National Comparison of Primary Care

• Andrew B. Bindman MD
• Professor Medicine, Health Policy, Epidemiology
  and Biostatistics
• University of California San Francisco

2
Interpreting the Findings

• Survey on patients perceptions of primary care
• What is primary care?
• Does primary care contribute to performance of
  health care system?
• Where does primary care fit in healthcare
  re-design

3
Is Primary Care Simply the Activities of Primary
Care Doctors?
4
Number and Percent Primary Care Doctors by Country
5
Primary Care Doctor Role

• All but US have a single primary care physician
  specialty and a primary care led health service
• Primary care gatekeeping in all countries except
  US where tried in managed care but in decline
• Information technology and systems of care being
  developed to support or perform some primary care
  functions

6
Definition of Primary CareInstitute of Medicine

• Accessibility
• Communication
• Comprehensiveness
• Coordination
• Longitudinality

7
Commonwealth Fund International Health Survey

• Unique insights into patients perceptions of
  primary care in their own country
• Countries vary in meeting different domains of
  primary care

8
Accessibility / Longitudinality

• UK has the least financial barriers to access and
  longest primary care relationships
• Australia/New Zealand provide most rapid access
  for sick patients (capacity)
• US/Canada have heaviest reliance upon emergency
  rooms and patients dont like care there

9
Communication

• Australia/New Zealand providers best explainers
• UK patients most adherent to advice
• Least likely to have unanswered questions
• Least likely to report cost a barrier to
  following advice
• US patients least adherent to advice
• Most likely to have unanswered questions
• Most likely to report cost a barrier to following
  advice

10
Comprehensiveness

• All countries have much room for improvement in
  health promotion and self-management
• US patients report most health promotion and
  self-management for chronic disease
• US also leader in cancer screening but all
  countries in 80-90 range

11
Coordination

• Ambulatory setting less coordinated in US
• patients more likely to report test results
  lacking or duplicate tests performed
• More integration between hospital and ambulatory
  care in US
• Fewer US patients report regular doctor
  uninformed about hospitalizations
• Emergency room care poorly integrated in all
  countries
• Approximately 1 in 3 of patients in each country
  reported primary care doctor uninformed about ER
  visits

12
Validity of the Results

• Patients perceptions may not match reality
• Patient reports of rarely or never enough time
  with doctor
• USgtUKgtNew ZealandAustralia
• Physician reports of visit length (minutes)
• US 16.8
• UK 9.4
• New Zealand 15.0
• Australia 14.9

13
Other Cross-National Measures of Primary Care

• No standardized reporting of primary care
• CMWF findings consistent with separate composite
  primary care scores by Starfield
• Health care systems ranked from most to least
  primary care oriented
• UKgtAustralia/New ZealandgtCanadagtUS
• Rankings positively associated with health
  outcomes and value

14
The Use of Computers in Primary Care Practice
15
Where Does Primary Care Fit in Health Care System
Re-Design

• Cross-national interest in improving equity,
  quality and value of health care systems
• Consider whether strategies designed to meet
  these goals re-enforce or undermine primary care
  principles
• Consider whether health care re-design should
  build upon or replace primary care providers
• Cross-national comparisons reveal variation in
  approach and an important learning opportunity