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International Comparison: Access & Timeliness

How does the United States compare with other countries on patient-reported access problems, continuity of care, and waiting times?

In a 2005 survey of sicker patients conducted in six developed countries, the United States ranked last on four measures of continuity of care and access problems reported by patients. The U.S. patients reported relatively longer waiting times for doctor appointments when they were sick, but relatively shorter waiting times to be seen at the emergency department, see a specialist, and have elective surgery.

Slide For International Comparison: Access & Timeliness
Slide For International Comparison: Access & Timeliness
Slide For International Comparison: Access & Timeliness

Why is this important?

Many developed nations are interested in measuring and improving the quality of health care for their citizens. Comparing quality of care internationally might help identify factors giving rise to better performance and stimulate cross-national learning and collaboration to improve quality.

  • Cross-national comparisons suggest that health care systems with stronger primary care infrastructure provide better access to care and achieve superior health outcomes at lower cost (Macinko et al. 2003; Starfield and Shi 2002).
  • Waiting times are a key measure of health system responsiveness and can influence care-seeking behaviors, such as visiting a hospital emergency department (ED) rather than a physician's office (Galbraith et al. 2004) or leaving the ED without being seen for urgent problems (Rowe et al. 2006).
  • Although there is little evidence that moderate waiting for elective (nonemergency) surgery harms patient health (Hurst and Siciliani 2004), some research suggests that prolonged waiting for certain procedures such as hip replacement may reduce patients' quality of life, their productivity at work, and their likelihood of achieving good outcomes (Fielden et al. 2005; Garbuz et al. 2006; Ostendorf et al. 2004).


The Commonwealth Fund collaborated with five other developed nations—Australia, Canada, Germany, New Zealand, and the United Kingdom—to survey patients who had a high incidence of chronic illness and made recent intensive use of health care.

The U.S. ranked last among these six nations on four measures of access and continuity of care. Specifically:

  • U.S. patients were less likely than patients in the other five countries to have a regular doctor (84% v. 92%–97%). Among those with a regular doctor, U.S. patients were less likely to have continuity with the same doctor for five years or more (50% v. 61%–78%).
  • U.S. patients were more likely than patients in the other five countries to report not filling a prescription, not visiting a doctor when sick, and/or not getting a test or follow-up care recommended by a doctor because of cost in the past two years (51% v. 13%–38%).
  • U.S. patients were more likely than patients in four other countries (except Australia) to report that it was very difficult to get care on nights, weekends, or holidays without going to the emergency department (39% v. 11%–29%) (Schoen et al. 2005)
U.S. patients reported relatively longer waiting times for doctor appointments when they were sick, but relatively shorter waiting times to be seen at the ER, see a specialist, and have elective surgery. Specifically:
  • The percentage of U.S. patients who waited six days or more for a doctor appointment when sick was not significantly different from the rate in Canada (23% v. 36%), the worst-performing country.
  • Only 47 percent of U.S. patients were able to see a doctor on the same or next day when sick, versus 61 percent to 81 percent of patients in the four better-performing nations.
  • U.S. patients were less likely than patients in Canada (12% v. 24%) but more likely than patients in Germany (4%) to wait four hours or more to be seen in the emergency department.
  • U.S. patients were less likely than patients in four countries (except Germany) to wait four weeks or longer to see a specialist (23% v. 40%–60%) or to wait four months or longer for elective surgery (8% v. 19%–41%) (Schoen et al. 2005).


The United States' relatively worse performance on primary care access measures may reflect, in part, the barriers to care faced by the 16 percent of Americans who do not have health insurance, the relatively higher cost of care, and the relatively weaker primary care infrastructure in the U.S. as compared with other countries (Starfield and Shi 2002). On the other hand, many patients in countries with stronger primary care infrastructure perceive waiting times to be a serious problem with their health care system (Blendon et al. 2003).

The German health care system bears some similarities to the U.S. in terms of a mixed public–private model. Germany achieved relatively higher performance on six of eight of these access measures, suggesting that it might offer lessons on how to structure health care delivery to improve the accessibility and timeliness of care.

Improvement Ideas and Resources

The National Academy of Engineering and the Institute of Medicine issued a joint report, Building a Better Delivery System: A New Engineering/Health Care Partnership, which calls for health care organizations to apply proven systems engineering tools to help improve the design and performance of health care delivery systems. For example:

  • One large Midwestern hospital used the principles of flow management to improve elective surgery admissions resulting in improved efficiency, revenue, number of patients served, quality of care, and patient satisfaction (Crute 2005).
  • An emergency department in an urban academic medical center instituted a rapid entry and accelerated care at triage (REACT) process that reduced average patient waiting times by 24 minutes as well as the number of patients who left the ED before being seen (Chan et al. 2005).
An examination of international experience found that some countries have reduced prolonged surgical waiting "by raising surgical capacity and productivity, and by supporting surgeons' efforts to monitor and reprioritize patients according to clinical need" (OECD Health Project 2004).


The denominator is sicker adults, defined as those who rated their health as fair or poor; reported that they had a serious illness, injury, or disability that required intensive medical care in the past two years; or reported that in the past two years they had major surgery or had been hospitalized for something other than a normal pregnancy (Schoen et al. 2005).


Patient-reported data are subject to potential recall bias. Patient expectations for care may be influenced by cultural factors that differ from country to country. Although patient-reported waiting times are important measures of responsiveness, patient symptoms and functional status also are important when determining clinical priority for surgery (Pace et al. 2006).


The Commonwealth Fund International Health Policy Survey is a telephone survey of random, representative samples of adults in each country conducted by Harris Interactive and its affiliates (Schoen et al. 2005).


* Indicates source of data used in chart(s).

Blendon, R. J., C. Schoen, C. DesRoches et al. 2003. Common Concerns Amid Diverse Systems: Health Care Experiences in Five Countries. Health Affairs (Millwood) 22 (3): 106–21.

Chan, T. C., J. P. Killeen, D. Kelly et al. 2005. Impact of Rapid Entry and Accelerated Care at Triage on Reducing Emergency Department Patient Wait Times, Lengths of Stay, and Rate of Left Without Being Seen. Annals of Emergency Medicine 46 (6): 491–7.

Crute, S. 2005. Case Study: Flow Management at St. John's Regional Health Center. Quality Matters. New York: The Commonwealth Fund (Oct).

Fielden, J. M., J. M. Cumming, J. G. Horne et al. 2005. Waiting for Hip Arthroplasty: Economic Costs and Health Outcomes. Journal of Arthroplasty 20 (8): 990–7.

Galbraith, A. A., J. Semura, B. McAninch-Dake et al. 2004. Emergency Department Use and Perceived Delay in Accessing Illness Care Among Children with Medicaid. Ambulatory Pediatrics 4 (6): 509–13.

Garbuz, D. S., M. Xu, C. P. Duncan et al. 2006. Delays Worsen Quality of Life Outcome of Primary Total Hip Arthroplasty. Clinical Orthopaedics and Related Research 447: 79–84.

Hurst, J., and L. Siciliani. 2004. Tackling Excessive Waiting Times for Elective Surgery. In Towards High-Performing Health Systems: Policy Studies. Paris: Organisation for Economic Co-operation and Development.

Macinko, J., B. Starfield, and L. Shi. 2003. The Contribution of Primary Care Systems to Health Outcomes Within Organization for Economic Cooperation and Development (OECD) Countries, 1970–1998. Health Services Research 38 (3): 831–65.

OECD Health Project. 2004. Towards High-Performing Health Systems. Paris, France: Organisation for Economic Co-operation and Development.

Ostendorf, M., E. Buskens, H. van Stel et al. 2004. Waiting for Total Hip Arthroplasty: Avoidable Loss in Quality Time and Preventable Deterioration. Journal of Arthroplasty 19 (3): 302–9.

Pace, A., N. Orpen, H. Doll et al. 2006. Outcome Scoring System Evaluation of Knee Osteoarthritis in Patients Awaiting TKA. Journal of Knee Surgery 19 (2): 85–8.

Rowe, B. H., P. Channan, M. Bullard et al. 2006. Characteristics of Patients Who Leave Emergency Departments Without Being Seen. Academic Emergency Medicine 13 (8): 848–52.

* Schoen, C., R. Osborn, P. T. Huynh et al. 2005. Taking the Pulse of Health Care Systems: Experiences of Patients with Health Problems in Six Countries. Health Affairs Web Exclusive: W5-509–W5-525.

Starfield, B., and L. Shi. 2002. Policy Relevant Determinants of Health: An International Perspective. Health Policy 60 (3): 201–18.