Improving Health Care Delivery: Lessons From a Five-Country Survey

By Michael Devitt

Last year, the Commonwealth Fund conducted the seventh in a series of international surveys intended to paint a better picture of the way health care is provided in different countries. The 2004 survey focused on two critical elements of health care - primary care and ambulatory care experiences - and evaluated the experiences of adults utilizing such care in five countries - the United States, Australia, Canada, New Zealand, and the United Kingdom. Results of the survey, published in a recent issue of Health Affairs,1 indicate that each country is lacking in some areas, with the United States performing particularly poorly in certain areas of the survey. The survey also offers a series of opportunities the U.S. and other countries can utilize to improve the delivery of primary care, and details ways in which they can pursue these improvements.

The survey consisted of a series of telephone interviews with a random sampling of adults in each of the five countries, in which participants were asked about recent experiences with access to care, emergency care, doctor-patient relationships, and other variables. The survey also questioned the adults about their opinions on choice of provider, access to medical records, e-mail communication with doctors, and current health care systems. A total of 8,672 adults were surveyed; key findings are summarized as follows:

General View of the Health System

  • In all five countries, a majority of those surveyed called for significant health reforms. However, the U.S. earned the honor of having the most negative view on health care delivery in the survey. One third of the adults questioned said that the U.S. had to "rebuild completely" its health system, a sentiment echoed in 1998; another 47 percent said that "fundamental changes" were needed. In contrast, no more than 23 percent of the adults in any of the other countries suggested that their health system be rebuilt.
  • In terms of out-of-pocket expenses, more Americans (either insured or uninsured) spent more money to pay for health care costs than residents of any other country. Twenty-six percent of U.S. adults reported spending more than $1,000 in out-of-pocket health-related costs in the past year, compared to 12 percent of Canadian adults and 4 percent of adults in the United Kingdom.

Access to Care

  • The majority of patients in all five countries reported either having a regular doctor that they saw for treatment, or a regular place of care. In the U.S., however, 17 percent of adults had no regular doctor. In addition, in the other countries, at least half of all the adults surveyed had been a patient of the same doctor for a minimum of five years; in the U.S., only 37 percent of adults reported having a long-term doctor-patient relationship.
  • Sixty-three percent of U.S. adults said it was "very or somewhat difficult" to get access to care on nights, weekends or holidays without having to go to an emergency room for treatment. Only 23 percent said it was "very or somewhat easy."
  • Costs appeared to have a direct influence on patient access to care. Of the five countries surveyed, adults in the United States were the most likely to state that they did not see a doctor even though were sick, did not have a prescription filled, skipped a medical test, or missed a follow-up appointment due to costs. Income levels also played a factor: Fifty-seven percent of American adults whose income fell below the national median reported going without some type of care due to costs.

Emergency-Room Care

  • Adults in the U.S. and Canada were more likely to have visited an emergency room in the past two years (34 percent and 38 percent, respectively) than adults in Australia, New Zealand and the U.K. Adults from these two countries were also more likely to go to the ER for a condition that could have been treated by their regular doctor, had the doctor been available to provide care.
  • Of those who visited an emergency room at least once, a majority of adults in Australia, the U.K., and New Zealand rated the care they received as "excellent" or "very good" (55%, 53% and 51%, respectively). In the U.S., 47% rated ER care very good or excellent; 34 percent considered the care either "fair" or "poor"; in Canada, only 45% rated ER services as "excellent" or "very good."
  • Wait times in the ER presented considerable concern among all countries. Between 27 percent and 48 percent of all adults reported waiting a minimum of two hours before being treated, with the highest incidence of long wait times reported among Canadian adults.

Coordination of Care

  • Seeing multiple health care providers appeared to be the norm in all five countries: Between 40 and 50 percent of the respondents reported seeing at least three or more doctors and other health professionals in the past two years.
  • Approximately 40 percent of all adults in the survey were taking at least one prescription medication on a regular basis. The U.S. had the highest percentage of adults taking two or more different prescriptions (34 percent); multiple prescription use in the other countries varied between 25 percent and 30 percent.
  • Overnight hospitalization rates varied between 13 percent and 19 percent per country. The U.S. fared better than the other countries in that a patient's regular doctor was more likely to seem "informed" and up-to-date about plans for follow-up care after the patient left the hospital.

Doctor-Patient Communication

  • When asked to rate the quality of care from their doctor in the past 12 months, most adults considered the care they received "excellent" or "very good"; however, fewer adults in the U.S. gave their doctors such high ratings. A higher percentage of American adults rated the care they received as only "fair or poor" than adults in the other countries.
  • Based on survey responses, American doctors fared the worst of any country in terms of listening, providing a clear explanation and spending enough time with patients. U.S. doctors also appeared to fare the worst at clarifying the specific goals and plans for patient treatment; giving clear instructions so that patients knew what to do or what symptoms or side-effects to watch out for; and telling patients about other treatment choices and asking for their ideas or opinions.
  • American adults who had seen a doctor in the past two years were more likely than those in other countries to leave the doctor's office without getting "important" questions answered. They were also more likely to not follow the doctor's advice or treatment plan.

Preventive Care and Health Promotion

  • American doctors were more likely to check a patient's blood pressure during an office visit (86 percent) than doctors in the other countries. Seventy-two percent of American doctors provided their elderly patients (ages 65 and older) with a flu shot in the past year. Among female patients, U.S. women were more likely than women in other countries to receive a Pap test at the recommended interval. Women in the U.S. were as likely as women in the other countries to receive a mammogram at the recommended interval.
  • Doctors in the U.S. also did a better job at providing reminders for preventive care than their counterparts in other countries. Fifty-two percent of U.S. doctors provided advice or counseling on weight, nutrition or exercise to their patients in the past two years; only 33 percent of doctors in New Zealand and 28 percent of doctors in the U.K. provided the same type of advice.
  • American doctors appeared more competent at providing ways patients could manage their conditions. Sixty-four percent of American adults reported that their doctor had given them a plan to manage their care at home. Only 45 percent of doctors in the U.K. and 57 percent of doctors in Australia provided the same type of plan to their adult patients.

Choice and Information

  • Seventy-eight percent of American adults said they were "very satisfied" or "somewhat satisfied" with their choice of doctors, ranking the U.S. just behind Australia and the United Kingdom.
  • Fifty-one percent of adults in the U.S. reported having access to their own medical records - the highest percentage of any country in the survey. Of those who did not have current access to their medical records, 75 percent of adults in the United States indicated that they would like access - again, the highest percentage of any country in the survey.
  • A significant number of American adults (20 percent) reported being able to communicate with their doctor via e-mail. Interestingly, another 21 percent reported that they were unable to communicate due to a lack of Internet access. Of those who could not e-mail their doctor, 42 percent of American adults indicated that they would like to be able to.

Implications on Future Health Care Policy

In a discussion of their results, the authors noted that primary care "is fundamental to a high-performance health care system," and that it "also influences public confidence in the system." Yet in each country, the survey found that there were "shortfalls in delivering safe, effective, patient-centered, timely, efficient, and equitable care." As a result, the authors suggest that the survey's findings provide opportunities for countries to take action and learn from other nations' health care systems.

One example the researchers cited concerned the performance of U.S. doctors in terms of preventive care and health promotion. Performance in these areas suggested that factors such as "policy leadership, clear guidelines and market pressures" could make a significant difference in the quality of health care. In another example, the researchers commended the ability of doctors in Australia and New Zealand to see a patient the same day the patient wanted an appointment, and to treat emergency room patients more quickly than in other countries. According to the authors, these results suggest that "it is possible to design systems to enable rapid response" and that "more timely access to primary care could help ease demands on ERs and improve the continuity of care."

In addition to the suggestions above, the authors noted a number of options that could be used to improve primary care based on their analysis of the survey, including:

  • "innovative payment systems" that would reward high-quality performance and team-based approaches to care;
  • "learning collaboratives" that could help redesign methods of health care delivery and improve patient outcomes;
  • improving after-hours coverage of patients, which would ease patient concerns, ease stresses placed on emergency rooms and ER physicians, and improve patient access to primary care providers;
  • lowering costs to make both preventive care and primary care more accessible, especially to people of lower incomes and the uninsured;
  • improving stability in the insurance industry, which would help to ensure long-term relationships between patients and providers;
  • investing in information technology, which could reduce medical errors, remind patients and doctors about follow-up visits, and facilitate the sharing of information.

"Although it is beyond the limits of the study to attribute performance to particular policy initiatives, promising initiatives under way in each country warrant further study and tracking over time," conclude the authors. "The challenge in all five countries is finding the right combination to improve primary care and move to a high-performance care system."


  1. Schoen C, Osborn R, Huynh PT, et al. Primary care and health system performance: adults' experiences in five countries. Health Affairs, Oct. 28, 2004. Web Exclusive: W4-487-502.

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