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Harvard Quality Colloquium

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1 Harvard Quality Colloquium
Taking the Pulse of the U.S. Health Care System Quality, Safety and Efficiency International and National Perspectives Cathy Schoen Senior Vice President August 21, 2006 Harvard Quality Colloquium

2 US Health System: International and National Experiences
U.S. highest cost health system in the world yet often fails to deliver high quality, high value care Quality varies widely despite centers of excellence Access is of increasing concern Uninsured and underinsured International view of safety, quality and access from patients’ perspectives US rarely a leader US stands out for poor care coordination, safety concerns and access barriers due to cost Shared challenges in managing transitions and chronic care Opportunities and targets to improve care

3 Taking the Pulse 2005 Survey of “Sicker” Adults in Six Countries
Telephone survey of sicker adults ages 18 and older in Australia, Canada, Germany, New Zealand, U.K., and U.S. Adults met at least one of the following criteria: Self reported health status is fair or poor Serious illness in the past 2 years Hospitalized or had major surgery in the past 2 years Survey sample included 7,000 “sicker” adults: 702 Australia, 751 Canada, 1,503 Germany, 704 New Zealand, 1,770 United Kingdom, and 1,527 United States Conducted by Harris Interactive March 2005 to June 2005 Focus on safety, coordination, patient-physician communication and access experiences 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults

4 Hospital Stay and Discharge Experiences
Missed opportunities to discuss risks with patients Medication review Care coordination Need to improve transition care at discharge

5 Did Doctors and Nurses Involve You as Much as You Wanted in Care Decisions?
Base: Hospitalized in past 2 years Percent NOT involved as much as would like SOURCE: 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults (Schoen et al. Taking the Pulse of Health Systems, Health Affairs November 2005)

6 Were Risks Explained Before A Hospital Procedure in an Understandable Way?
Base: Hospitalized in past 2 years Percent said risks were NOT explained 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults

7 Failure to Discuss Medications Used Before Hospitalized on Discharge
Percent of patients with new prescription who said prior medications were not reviewed at discharge 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults

8 Deficiencies in Transition Planning When Discharged from the Hospital
Base: Hospitalized in past 2 years Percent who reported when discharged: AUS CAN GER NZ UK US Did NOT receive instructions about symptoms to watch and when to seek further care 18 17 23 14 26 11 Did NOT know who to contact with questions about condition or treatment 9 12 8 Hospital did NOT arrange for for follow-up visits 30 50 19 27 % any of the above 36 41 60 33 37 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults

9 Readmitted to a Hospital or Went to ER as a Result of Complications after Discharge
Base: Hospitalized in past 2 years Percent readmitted or ER visit due to complications 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults

10 U.S. Variations in Patient-Centered Hospital Care: Staff Managed Pain, Responded When Needed Help, and Explained Medicines, 2005 Percent of patients reporting “always” * ** *** *Patient’s pain was well controlled and hospital staff did everything to help with pain **Patient got help as soon as wanted after patient pressed call button and in getting to the bathroom/using bedpan ***Hospital staff told patient what medicine was for and described possible side effects in a way that patient could understand SOURCE: 2005 CAHPS Hospital Survey results for 254 hospitals. National CAHPS Benchmarking Database

11 U.S. Heart Failure Patients Given Written Instructions or Educational Materials When Discharged, 2004 Percent of heart failure patients discharged home with written instructions or educational material* Discharge instructions must address all of the following: activity level, diet, discharge medications, follow-up appointment, weight monitoring, and what to do if symptoms worsen SOURCE: A. Jha and A. Epstein, Harvard University analysis of Hospital Quality Alliance national reporting system; State estimates – Hospital Compare database at

12 U.S. Hospital 30-Day Readmission Rates, Medicare Variations by State, 2003
Rate of hospital readmission within 30 days Source: G. Anderson and R. Herbert for the Commonwealth Fund, Medicare Standard Analytical File 5% 2001 data.

13 Coordinated Care Across Sites of Care Makes a Difference Care Transition Measure Scores,* Emergency Department Use, and Hospital Readmissions Emergency Department Use Hospital Readmissions p=0.01 * When I left the hospital, I had a good understanding of the things I was responsible for in managing my health; when I left the hospital, I clearly understood the purpose for taking each of my medications; The hospital staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left the hospital. Source: E.A. Coleman, “Windows of Opportunity for Improving Transitional Care,” Presentation to The Commonwealth Fund Commission on a High Performance Health System, March 30, 2006.

14 Safety: Medication, Medical and Diagnostic Test Errors

15 Medical Mistake or Medication Error In Past Two Years
Percent reporting either mistake or medication error 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults

16 Medical Mistake or Medication Error Occurred Outside the Hospital
Base: Experienced medical mistake or medication error Percent saying error occurred outside the hospital 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults

17 Incorrect Lab/Diagnostic Test or Delay in Receiving Abnormal Test Results
Percent reporting either lab test error in past two years 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults

18 Any Error: Medical Mistake, Medication Error or Test Error in Past 2 Years
Percent 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults

19 Mistake Any Error By Number of Doctors Seen in Past 2 Years
Percent 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults

20 Care Coordination and Patient-Doctor Communication

21 U.S. Patients Less Likely to Have Continuity and Long Term Relationships with Doctors
Percent: AUS CAN GER NZ UK US Has Regular Doctor 92 97 94 96 84 Less than 2 years 16 12 6 19 14 17 5 years or more 56 60 76 57 66 42 No regular doctor 8 3 4 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults

22 Care Coordination Percent saying in the past 2 years: AUS CAN GER NZ UK US Test results or records not available at time of appointment 12 19 11 16 23 Duplicate tests: doctor ordered test that had already been done 10 20 9 6 18 Percent who experienced either coordination problem 24 26 21 33 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults

23 Coordination Problems by Number of Doctors
Percent *Either records/results did not reach doctors office in time for appointment OR doctors ordered a duplicate medical test 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults

24 Missed Opportunities to Engage Patient with Chronic Conditions in Care
Base: Adults with chronic disease Percent saying doctor:* AUS CAN GER NZ UK US Does NOT give you clear instructions 19 24 18 15 27 Does NOT make goals and plans clear 21 16 25 Does NOT tell you about treatment choices or ask your opinions 45 38 39 51 49 *Doctor only sometimes, rarely or never 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults

25 Prescription Medications
Base: Adults with chronic disease on regular medications Percent saying doctor:* AUS CAN GER NZ UK US Does NOT review all medications taking, including prescribed by other doctors 46 38 35 42 40 Does NOT explain side effects 36 47 33 48 49 *Doctor only sometimes, rarely or never 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults

26 Doctor Gives You Plan for Self-Management
Base: Adults with chronic disease Percent given self-management plan 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults

27 Doctor’s Office Has a Nurse Regularly Involved in Care Management
Base: Adults with chronic disease Percent have nurse involved 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults

28 Received Recommended Care for Chronic Condition
Percent received recommended care: AUS CAN GER NZ UK US Hypertension* 78 85 91 77 72 Diabetes** 41 38 55 40 58 56 *Blood pressure and cholesterol checked **Hemoglobin A1C and cholesterol checked, and feet and eyes examined 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults

29 Adults with Diabetes Who Received Recommended Care, by Self-Management Plan or Nurse Involvement
Includes Hemoglobin A1C and cholesterol checked, and feet and eyes examined *Sample size too small for subgroups for Australia, Canada and New Zealand 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults

30 Access

31 Cost-Related Access Problems
Percent in past year due to cost: AUS CAN GER NZ UK US Did not fill prescription or skipped doses 22 20 14 19 8 40 Had a medical problem but did not visit doctor 18 7 15 29 4 34 Skipped test, treatment or follow-up 12 21 5 33 Percent who said yes to at least one of the above 26 28 38 13 51 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults

32 Out-of-Pocket Medical Costs in the Past Year
Percent AUS CAN GER NZ UK US AUS CAN GER NZ UK US 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults

33 Waiting Time to See Doctor When Sick or Need Medical Attention, Sicker Adults in Six Countries, 2005
Last time you were sick or needed medical attention, how quickly could you get an appointment to see a doctor? Percent of adults SOURCE: 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults (Schoen et al. Taking the Pulse of Health Systems, Health Affairs November 2005)

34 Difficulty Getting Care on Nights, Weekends, Holidays Without Going to The ER
Percent Saying “Very” or “Somewhat Difficult” 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults

35 Went to the ER for Condition that Could Have Been Treated by Regular Doctor if Available
Percent 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults

36 Waiting Time for Elective or Non-Emergency Surgery
Base: Needed non-emergency or elective surgery Percent AUS CAN GER NZ UK US AUS CAN GER NZ UK US SOURCE: 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults

37 International View Summary
U.S. an outlier on cost barriers with evidence of poorly coordinated fragmented care, lack of primary care access Gaps in insurance and benefit designs undermine patient adherence and follow up care Lack of timely access affects quality and efficiency Medical Errors: High rates in multiple areas US highest over all error rate. Notably high for patients seeing multiple physicians Majority of patients reported errors occur outside the hospital Shared challenges across countries Coordination: Failures to coordinate and integrate care across sites of care, especially during transitions Chronic Care: Gaps in engaging patients and use of teams to help manage care Opportunities to learn from exchange THE COMMONWEALTH FUND

38 Overall View of the US Health Care System
Markedly higher health care expenditures but variable performance in international comparisons Wide variations in quality and costs Access of increasing concern Fragmented insurance and care systems Need to improve Access, Quality and Efficiency

39 International Comparison of Spending on Health, 1980–2004
Average spending on health per capita ($US PPP) Total expenditures on health as % GDP Source: OECD Health Data 2005 and 2006

40 Percent of Adults Ages 18–64 Uninsured by State
WA OR ID MT ND WY NV CA UT AZ NM KS NE MN MO WI TX IA IL IN AR LA AL SC TN NC KY FL VA OH MI WV PA NY AK MD ME VT NH MA RI CT DE DC HI CO GA MS OK NJ SD 19%–22.9% Less than 14% 14%–18.9% 23% or more 1999–2000 2003–2004 SOURCE: Two-year averages 1999–2000 and 2003–2004 from the Census Bureau’s March 2000, 2001 and 2004, 2005 Current Population Surveys. Estimates by the Employee Benefit Research Institute.

41 46 Million Uninsured in 2004; Increasing Steadily Since 2000
Millions uninsured 46 Increase of 4 million revivals the increases that triggered last national debate on need for federal policy action Notable that about half the increase in the past two years in income groups above poverty. . All of the increase from decline in private coverage. Public still expanding in the last 2 years.. 2013 Projected *1999–2003 estimates reflect the results of follow-up verification questions and implementation of Census 2000-based population controls. Note: Projected estimates for 2004–2013 are for nonelderly uninsured based on T. Gilmer and R. Kronick, “It’s the Premiums, Stupid: Projections of the Uninsured Through 2013,” Health Affairs Web Exclusive, April 5, 2005. Source: U.S. Census Bureau, March CPS Surveys 1988 to 2005.

42 U.S. Adults Without Insurance Are Less Likely to Be Able to Manage Chronic Conditions
Percent of adults ages 19–64 with at least one chronic condition* * Hypertension, high blood pressure, or stroke; heart attack or heart disease; diabetes; asthma, emphysema, or lung disease. Source: The Commonwealth Fund Biennial Health Insurance Survey (2005).

43 “Underinsured” and Uninsured Adults Experience High Rates of Access Problems and Financial Stress
Percent adults 19-64, 2003 * Did not fill a prescription; did not see a specialist; skipped recommended care; or did not see doctor when sick because of costs. Source: C. Schoen, et al., “Insured but Not Protected: How Many Adults Are Underinsured?” Health Affairs Web Exclusive, June 14, 2005.

44 Cost-Sharing Reduces Use of Both Essential and Less Essential Drugs and Increases Risk of Adverse Events Percent reduction in drugs per day Percent increase in incidence per 10,000 Source: R. Tamblyn et al., “Adverse Events Associated With Prescription Drug Cost-Sharing Among Poor and Elderly Person,” JAMA 285, no. 4 (2001): 421–429.

45 Inadequate Clinical Information Systems U. S
Inadequate Clinical Information Systems U.S. Doctors Electronic Access to Test Results, Medical Records and Electronic Ordering Percent who “routinely/occasionally” use the following: * Electronic ordering of tests, procedures, or drugs. Source: A. Audet, M. Doty, J. Peugh et al., “Information Technologies: When Will They Make It Into Physicians' Black Bags?” Medscape General Medicine, December 7, 2004.

46 Quality and Medicare Spending Vary Across U.S. States, 2000–2001
Sources: K. Baicker and A. Chandra, “Medicare Spending, The Physician Workforce, and Beneficiaries’ Quality of Care,” Health Affairs Web Exclusive, April 7, 2004.

47 Implications for Physician Leaders and Care Executives
Consensus on performance measures Sharing best practices and innovations Re-design practices to achieve improved access, safety, quality and efficiency Partnering with other providers and sites of care to improve coordination, disease management, and transitional care Developing standards for advanced primary care and more integrated delivery systems Fostering the growth of accountable health care organizations

48 Take Away Messages We should expect more given the resources committed to health care. We should be a leader on access, quality and efficiency There is unacceptably wide variation in the quality and cost of care Patient experiences as well as clinical indicators provide targets for improvement Coordination is a key aspect of safety and effective care This includes across sites of care Insurance and access are essential for improving quality and safety Physician leadership is critical

49 Visit the Fund at: www.cmwf.org
Acknowledgements With appreciation to: Co-Authors: Robin Osborn, Phuong Trang Huynh, Michelle Doty, Kinga Zapert, Jordan Peugh and Karen Davis For 2005 Six Country of Sicker Adults and 2004 Five Country Survey of Primary Care All Adults see: Schoen et al. “Taking the Pulse of Health Care Systems: Experiences of Patients with Health Problems in Six Countries, Health Affairs, November 3, 2005 Schoen et al. “ Primary Care and Health System Performance: Adults’ Experiences in Five Countries” Health Affairs October 28, 2004. For international and national studies on U.S. quality and care Visit the Fund at: THE COMMONWEALTH FUND

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