How does the United States compare with other countries on measures of patient-centered care and on patient views of the need for health care reform?

Among eight measures of patient-centered care included on a 2005 survey of sicker patients in six developed countries, the United States ranked first on only one measure and ranked last or tied for last place on six measures. Patients in the U.S. and Germany expressed the most negative views of their health systems.

Why is this important?

Many developed nations are seeking to improve the responsiveness or patient-centeredness of health care (OECD Health Project 2004). Understanding how patients perceive their health care experience is important "because that experience, as much as the technical quality of care, will determine how people use their health care system and how they benefit from it" (Gerteis et al. 1993). Likewise, patients' views of the need for health care system reform provide one means of gauging their overall satisfaction with current health care arrangements.

Findings

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 (Schoen et al. 2005). On four measures of physician communication and engagement with patients, the United States ranked last on two measures and tied with the United Kingdom for last place on two measures. Specifically:

• One-half (50%) of U.S. and U.K. patients, as compared with a little more than one-third (37%) of New Zealand patients, reported that their regular doctor did not always discuss treatment choices and ask for the patient's opinion.
• More than one of four U.S. patients (27%–28%), as compared with one of six New Zealand patients (16%), reported that their regular doctor did not always clearly communicate the specific goals for treatment and give clear instructions about self-monitoring and follow-up.
• Almost one of four U.S. patients (24%), as compared with almost one of six U.K. patients (15%), reported that they had left a doctor's appointment without getting important questions asked in the past two years.

Among those who were hospitalized in the past two years, self-reported experiences of U.S. patients were mixed in comparison with other countries. U.S. patients were less likely to report poor discharge coordination or that they were not told about the risks of treatments or procedures. On the other hand, U.S. patients also were less likely to report that hospital staff did everything they could to control their pain.

• U.S. and German patients were less likely than Canadian patients to report that they were not told about the risks of treatments or procedures.
• U.S. and New Zealand patients were less likely than Canadian and German patients to report poor discharge coordination.
• U.S. patients were less likely than patients in most other countries to report that hospital staff did everything they could to control their pain.

When asked about the need for health system reform, only a minority of patients in any country (e.g., 16 percent in Germany, 23 percent in the U.S., and 30 percent in the U.K.) said that only minor changes are needed. Almost one-third of patients in the U.S. and Germany indicated strong dissatisfaction by saying that the system needs to be completely rebuilt (twice the proportion as in the U.K.).

Implications

Gaps in patient experience are pervasive across surveyed countries, with no country achieving consistently better results across all measures of patient-centered care. A separate analysis (not shown) found that patient's views about the need for health system reform were related to their care experiences (Schoen et al. 2005).

Improvement Ideas and Resources

Given widely reported gaps in hospital discharge coordination, hospitals may find it helpful to use patient surveys, such as the Care Transitions Measure, to gauge their own performance in patient communication. Some interventions to improve care transitions have been shown to reduce subsequent emergency visits and/or rehospitalizations (Coleman et al. 2006; Naylor et al. 2004). These include:

• using tools to ensure communication of critical patient information during patient "hand-offs" across sites of care;
• coaching patients to be more assertive in communicating their needs and preferences; andproviding care management and home follow-up services to patients with congestive heart failure.

Case studies of eight U.S. hospital leaders identified several promising practices associated with successful efforts to improve patient-centered communication with vulnerable patient populations (Wynia and Matiasek 2006):

1. Encourage champions throughout the organization;
2. Collect information to demonstrate needs;
3. Engage communities to share information and resources;
4. Develop workforce diversity and communication skills;
5. Involve patients every step of the way;
6. Be aware of cultural diversity;
7. Provide effective language assistance services; and
8. Be aware of low health literacy and use clear language.

See the Snapshot on Patient Perceptions of Physician Interpersonal Quality of Care for additional recommendations to improve physician–patient communication.

Measure:

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).

Limitations:

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.

Source:

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).

References:

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

Coleman, E. A., C. Parry, S. Chalmers et al. 2006. The Care Transitions Intervention: Results of a Randomized Controlled Trial. Archives of Internal Medicine 166 (17): 1822–8.

Gerteis, M., S. Edgman-Levitan, J. Daley et al., Eds. 1993. Through the Patient's Eyes: Understanding and Promoting Patient-Centered Care. San Francisco, Calif.: Jossey-Bass Publishers.

Naylor, M. D., D. A. Brooten, R. L. Campbell et al. 2004. Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial. Journal of the American Geriatrics Society 52 (5): 675–84.

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

* 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.

Wynia, M., and J. Matiasek. 2006. Promising Practices for Patient-Centered Communication with Vulnerable Populations: Examples from Eight Hospitals. New York: The Commonwealth Fund and the American Medical Association Institute for Ethics.