High-Performance Health Care: It Takes a World of Innovations

When it comes to medicine, the United States has made many important contributions to improving the health of people everywhere. Scores of advances in pharmaceuticals and medical practice have been developed in U.S. laboratories or clinics. Our medical training programs are filled with some of the world's brightest young clinicians and scientists, eager to advance their educations and use their knowledge to benefit patients around the world. The scientific meetings of our specialty organizations have become the premier global platforms for presenting promising clinical science.

But even the best teacher should never stop learning. And our health care system could benefit by studying how other countries address some of medicine's toughest problems—the ills weakening the health care system itself. Sub-optimal or inappropriate care, medical errors, inadequate access to primary care services, underuse of information technology, and huge gaps in health insurance coverage are systemic problems for which solutions may not be found in our high-tech research labs, hospitals, and classrooms.

For one example, we can look to the most recent Commonwealth Fund international survey, which asked adults with medical problems to assess their experiences with the health care systems in Australia, Canada, Germany, New Zealand, the United Kingdom, and the United States. The survey found that, while all countries had plenty of room for improvement, the U.S. stood out for having higher patient-reported error rates, inefficient coordination of care, and barriers to accessing needed services.

To be sure, many U.S. researchers are studying these problems and proposing innovative strategies to address them. But even as we search for homegrown solutions, we would do well to look beyond our borders at promising models that, in some cases, are far more advanced than our own.

Medical Errors and Variation in Quality
Our international survey focused on patients who had recently been hospitalized, had surgery, or reported health problems. Disturbingly, one-third of such U.S. patients report at least one of four errors: they believed they experienced a medical mistake in treatment or care, were given the wrong medication or dose, given incorrect results for a test, or experienced delays in being notified about abnormal test results. By comparison, three of 10 (30%) Canadian respondents reported at least one of these errors, as did one-fifth or more of patients in Australia (27%), New Zealand (25%), Germany (23%), and the U.K. (22%).

Errors aside, there is evidence of significant variation in the overall quality of U.S. health care. A recent analysis of data from the Hospital Quality Alliance—the first initiative to routinely report information on hospital performance—showed that the quality of hospital care varies widely, not only by geographic region and hospital type, but also across conditions within individual hospitals.

So what to do? We might look to the German health system, which since 2001 has relied on a national benchmarking program to monitor the safety and quality of care in hospital settings. The National Institute for Quality Measurement in Health Care provides all German hospitals with tools to measure the quality of care for 26 conditions or procedures, using 10 to 15 evidence-based indicators for each. Data are collected electronically and shared among participants, and statistics on more than 350 quality goals are made available at www.bqs-outcome.de.

Regional authorities use the performance data to identify low- and high-performing hospitals. When a quality problem is found, officials visit the hospital to study the conditions and implement an improvement process. While the effectiveness of this system differs among fields of treatment, progress has been demonstrated for most projects in whole regions and, in some cases, nationwide.

In 2007, Germany will begin a national quality benchmarking project in ambulatory care.

Access to Care
Our survey showed that ease of access to needed care—including after-hours—differs markedly across countries. Majorities of patients in Germany (72%), New Zealand (70%), and the U.K. (57%) said it was easy to secure care on nights, weekends, or holidays. But majorities of patients in the U.S. (60%), Australia (58%), and Canada (53%) said it was very or somewhat difficult to get after-hours care.

How do some countries manage to provide timely access to needed care, while reducing financial barriers and still spending less per capita than the U.S.? There are several emerging approaches, many of which rely on triage and advice centers, primary care cooperatives, and information technology support.

For example, in the Netherlands, the majority of general practitioners participate in large-scale after-hours primary care cooperatives. Most of these require patients to call ahead to speak with triage nurses, who assess the urgency of patients' problems and make decisions about appropriate actions. Triage nurses follow national guidelines, are supervised by general practitioners, and in some cases use computer-based decision support.

Denmark also operates primary care cooperatives, which provide patients with direct access to physicians. During off-hours, physicians provide telephone triage and advice services, prescribe medications, or direct patients to come in for care at off-hours clinics. If they decide to make home visits, they can access information on patients' previous treatments, tests, and medications via computer and telephone links to the triage centers.

Research is needed to monitor the effects of these round-the-clock systems on the quality and safety of care, as well as the costs.

Performance Incentives
The theory that financial incentives can encourage quality is beginning to be put into practice in the U.S.—and there have been some encouraging early results. But the U.K. is leading the way with an extraordinarily ambitious pay-for-performance initiative.

Since 2004, all U.K. general practitioners have been able to increase their practice income by up to 20 percent by meeting performance goals. The new general practitioner contracts measure performance through 147 indicators, with points and payments awarded according to the level of achievement.

To encourage practices to perform in all areas—rather than cherry-picking the more achievable or profitable goals—the quality framework also includes measures of overall achievement in clinical and other domains, as well as bonuses for providing access to health professionals within 48 hours.

Results thus far are promising: while the program is voluntary, nearly all practices have chosen to participate. In the first year, general practitioners earned most of the available bonuses and the incentives appear to be having an impact on work processes. It is too early to judge whether such changes will result in improved health outcomes, but it is an experiment worth watching.

Common Challenges
These are just a few of the innovative ways in which other nations are trying to improve health care coverage, access, and quality. Some of the promise these efforts have shown no doubt is facilitated by the countries' health care delivery and financing systems, which are quite different from our own. These initiatives would not necessarily translate well to our complex private–public health system. These nations also have different cultural experiences with medicine and health care.

But such differences should not prevent us from looking abroad for ways to improve the performance of the world's most expensive health care system. Nor should the survey data be taken as endorsing one particular system or innovation over another. Indeed, the international survey did not conclude that any one nation performed best or worst overall on the patient-reported measures. Rather, it found that industrialized nations face common challenges, including the need to ensure quality and safety, coordinate care, and treat patients as partners.

So it makes sense for American researchers and practitioners to expand their field of vision to include international experiments and innovations in their armamentarium of policy options. Doing so will benefit all of us.

As always, I'd like to hear from you. Send your feedback to kd@cmwf.org.

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November 2005


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