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U.S. Primary Care Underdeveloped in Some Respects

By John Reichard, CQ HealthBeat Editor

November 2, 2006 -- Is the U.S. the puny kid on the primary care block? Whatever the disadvantages of health systems abroad, a lack of health information technology among primary care physicians does not appear to be among them. Neither does a lack of access to primary doctors outside of normal working hours nor the use of teams of physicians to better coordinate the care of patients with chronic diseases.

Those are among the findings of a new survey that assesses how primary care in the U.S. stacks up against six other nations: the United Kingdom, Canada, Australia, New Zealand, Germany, and the Netherlands.

Despite U.S. per capita outlays for health care of almost twice that of any of the other six countries, U.S. primary care practices "are more limited than the leading countries in information capacity, provide less patient access outside of 'normal' work hours, and are among the least likely to use teams or to receive financial rewards for quality," said the study, led by Commonwealth Fund Senior Vice President Cathy Schoen. Overall, U.S. primary care has "less capacity to ensure accessible, high quality, or patient-centered care," concludes the study, which was posted on the policy journal Health Affairs' Web site Thursday.

IT's Better Abroad
Researchers conducted surveys of primary care doctors in the seven countries from late February though July of this year to draw comparisons. While only 28 percent of U.S. physicians said they use electronic medical records in their practices, 98 percent of doctors in the Netherlands said they did so, as did 92 percent of doctors in New Zealand and 89 percent of doctors in the United Kingdom.

Ninety-three percent of Dutch doctors said they receive computerized prompts or alerts about a potential problem with a drug dosage or adverse drug interaction, compared with 23 percent of U.S. doctors.

Fifty-three percent of British doctors said they receive computerized alerts to provide patients with test results, compared with 15 percent of U.S. doctors.

Ninety-three percent of doctors in New Zealand and 83 percent of doctors in the United Kingdom said they use computer systems to send patients reminder notices for preventive or follow-up care, compared with 18 percent of U.S. doctors.

Eighty-two percent of doctors in New Zealand and 64 percent of doctors in Germany said it was easy for them to generate lists of patients who are due or overdue for tests or preventive care, while 20 percent of U.S. doctors said so.

Altogether, 87 percent of doctors in New Zealand and 83 percent of doctors in the United Kingdom said they had computerized systems to perform seven or more functions assisting them with clinical care, compared with 19 percent in the U.S.

Health IT is more concentrated in larger physician practices in the U.S., but less so in a number of the other countries. In four of the seven countries, user rates for electronic medical records and electronic prescribing are high in both solo and larger practices, while those rates were low in small practices in the U.S. and Canada.

"The data show that U.S. primary care doctors find it difficult or impossible to perform tasks that doctors in other countries find easy; they also practice without basic decision supports that could improve health outcomes and reduce costs," Schoen said.

Instructions and Teams
In Germany, 63 percent of the doctors said they routinely give patients with chronic diseases written instructions about how to manage their care at home, compared with 33 percent in the U.S. and 14 percent in Canada. In the United Kingdom, 81 percent of doctors said their practices routinely used multidisciplinary teams to coordinate the care of the chronically ill, compared with 29 percent of doctors in the U.S.

Eighty-five percent of doctors in the Netherlands and 80 percent in Germany said they offered office hours before 8:30 a.m., compared with 40 percent in the U.S. Seventy-four percent of doctors in Germany said they offer office hours after 6 p.m., compared with 38 percent of doctors in the U.S. But those early risers in Holland close up shop early; only 4 percent said they offer hours after 6 p.m.

Ninety-five percent of Dutch doctors and 81 percent of Australian doctors said their practices have an arrangement where a patient can see a doctor or nurse (not at the emergency room) if the practice is closed, while 40 percent of U.S. doctors did so.

But the U.S. outdistanced the competition when it came to waiting times for diagnostic tests and hospital care. Only 9 percent of U.S. doctors said their practices often had long waiting times for diagnostic tests, compared with 57 percent of doctors in the United Kingdom and 51 percent in Canada. And only 9 percent of U.S. doctors said they often had long waiting times for elective surgery or hospital care, compared with 85 percent in New Zealand, 69 percent in Australia, and 62 percent in the United Kingdom.

U.S. doctors also didn't have to wait long to receive reports from hospitals on their discharged patients. Half or more of doctors in Canada, Germany, the Netherlands and the United Kingdom said they had to wait 14 days or longer for those reports, while 40 percent or more of doctors in the United States and New Zealand said they received those reports within four days.

Overall, the study highlights a number of areas where the U.S. can improve, the study said. "Cohesive, broad-based policy changes" could lead to improvement, the study found. The U.S. lags in health IT in particular because, unlike the other nations, it lacks a national implementation plan, the researchers said.

A number of other nations excel in health IT because they have national health systems and "strong central leadership," Stephen Schoenbaum, the Commonwealth Fund's executive vice president for programs, said in an interview. "They are much more centrally controlled."

The Bush administration "has made significant efforts to develop standards," but significant issues remain in making sure that systems work together and are "interoperable," he said. "We are at an early stage, and we are behind the curve."

The U.S. could get on a better track through "even stronger leadership that does need to be national," Schoenbaum said. However, "that doesn't mean we end up with a national system," he added. It means better incentives akin to those that increased reporting by hospitals on quality of care to include virtually all hospitals, when just a few reported such data initially. Higher Medicare payments did the trick in that sector and a similar approach could work in primary care, Schoenbaum suggested.

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