New International Survey of Primary Care Physicians: Most U.S. Doctors Unable to Provide Patients Access to After-Hours Care; Half Lack Access to Drug Safety Alert Systems

Washington, DC, November 2, 2006—Primary care doctors in the U.S. are less likely than those in several other countries to be able to offer patients access to care outside regular office hours or to have systems that alert doctors to potentially harmful drug interactions. U.S. primary care physicians are also less likely to receive financial incentives for improving patient care, according to the Commonwealth Fund 2006 International Health Policy Survey published today on the Web site of the journal Health Affairs.

The survey of more than 6,000 primary care physicians in Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States reveals that primary care physicians in the U.S. do not have the tools or support to provide the best care possible to patients. "In an era of advanced computer systems, it's disturbing that the vast majority of primary care doctors in the U.S. don't have the tools to electronically prescribe medications, access patients' test results, or know when patients are overdue for essential care," said Commonwealth Fund Senior Vice President Cathy Schoen, lead author of the article. "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."

The U.S. primary care system trails other countries in several areas:

• Adoption of health information technology that can improve quality and patient safety. Only about a quarter of primary care doctors in the U.S. (28%) and Canada (23%) use EMRs, compared with a large majority of primary care doctors in the Netherlands, (98%), New Zealand (92%), the U.K. (89%) and Australia (79%).
• Receipt of computerized alerts for potential harmful drug doses or interactions. Less than a quarter of U.S. primary care doctors (23%) receive these computerized alerts. By contrast, 93% of primary care doctors in the Netherlands, 91% in the U.K., 87% in New Zealand, 80% in Australia, and 40% in Germany have computerized alert systems. Among the surveyed countries, only in Canada (10%) do primary care physicians make less use of computerized alerts than do U.S. primary care physicians. Almost half (47%) of U.S. primary care physicians have no system, computerized or manual, for alerting them to potential drug-related hazards.
• Ability to offer care to patients other than during working hours, which can prevent unnecessary emergency room visits. Just 40% of U.S. primary care doctors report they are able to offer such access; in the Netherlands the rate is 95%, and in the U.K. it is 87%.
• Access to resources for managing complex chronic conditions at a time when more and more patients are suffering from these conditions. Use of multi-disciplinary teams varied widely, from a high of 81% in the U.K to lows of 29% to 32% in the U.S., Canada, Australia and New Zealand.

Information Technology and Systems to Ensure Quality Care
In "On the Front Lines of Care: Primary Care Doctors' Office Systems, Experiences, and Views in Seven Countries," the authors find that primary care doctors in the U.S. and Canada lag well behind other countries in information technology. In fact, the survey reveals strikingly wide differences between primary care doctors' access to information systems with the potential to improve patient care and efficiency, such as alerts and tracking test results, drug interactions, or electronic medical records.

Further, 40% or more of U.S. and Canadian primary care doctors say it is difficult or impossible for them to identify patients who are overdue for a test or preventive care, compared with 19% or less in the other countries. Overall, fewer than one of five U.S. and Canadian primary care doctors have access to robust information systems that provide a foundation to ensure high-quality patient care.

Among the seven countries, the U.K stands out for having systems to track medical errors, with 79% of U.K primary care doctors able to document all adverse events, compared with between 7% and 41% in other countries (37% in the U.S.).

U.S. Performs Poorly in Access After-Hours
Primary care doctors in the U.S. (40%) were least likely to say that their practice had arrangements for after-hours care to see a nurse or doctor without going to an emergency room, and about half (47%) of Canadian primary care doctors have such arrangements. In contrast, almost all primary care doctors in the Netherlands (95%), New Zealand (90%), the U.K (87%), and Germany (76%) have after-hours care arrangements. The authors note that the Netherlands stands out because it has implemented a system in which almost all family doctors participate in large-scale cooperative arrangements to provide after-hours coverage by a doctor or nurse.

U.S. primary care doctors are also the most likely to report patients have difficulty paying for care. Half (51%) of U.S. primary care physicians report that patients often have difficulty paying for medications, compared with between 7% and 27% in the other countries.

These results are consistent with a Commonwealth Fund 2005 survey of patients, in six of these countries (all except the Netherlands) in which U.S. patients were the least likely to have access to after-hours care, the most likely to use the emergency room when other care was not available, and the most likely to go without needed care because of costs. Findings from the 2005 survey were published on the Health Affairs Web site on November 3rd, 2005.

Financial Incentives to Improve Quality: the U.K. Rates High, the U.S. Rates Low
Despite growing interest in the U.S. in providing financial incentives and support to improve performance, U.S. primary care doctors are among the least likely to receive incentives targeting quality. Just 30% of U.S. primary care doctors report receiving or having the potential to receive any incentives for managing chronic disease, achieving clinical quality targets, enhancing preventive care, or any other quality improvement activities. Reports of opportunities to receive financial incentive were also relatively low in Canada (41%) and Germany (43%) compared with the other four countries.

The U.K. stands out as a leader in providing payments for quality improvement: 95% of primary care doctors in the U.K. report receiving or having the potential to receive financial incentives for efforts to improve performance.

"Although the U.S. pays more for health care than any other country, we are under-investing in our primary care system," said Commonwealth Fund President Karen Davis. "Other countries have made high-quality primary care a priority by putting into place the financial and technological systems that support access to, and delivery of, such care. New U.S. national policies are essential to support system-wide initiatives to improve patient care."

Variations in Use of Teams and Systems to Care for Patients with Chronic Illnesses
In the critically important dimension of managing chronic illness, a high proportion of primary care doctors in all countries (25% to 30% or more) except Germany (7%) say they are not well prepared to care for patients with multiple chronic conditions. The survey revealed wide variations in use of teams and systems known to improve outcomes for such patients. The percent of primary care doctors using non-physician clinicians on teams to care for patients with chronic disease was low in Canada, the U.S. and Australia (25% to 38%) and high in Germany (62%) and the U.K (73%) with rates also relatively high in New Zealand (57%) and the Netherlands (46%).

Clinical systems to manage care well also varied widely: use of patient registries by diagnosis was low in Canada and the U.S., as were reminders about preventive or follow-up care or systems to make it easy to list medications taken by patients, including those prescribed by other doctors. In the U.S. only 8% of primary care doctors reported receiving incentives to manage patients with complex, chronic diseases compared with 24% to 79% in the other countries.

Overall, the survey points to the importance of system-wide approaches to provide a foundation for delivering well-coordinated, safe, and high-quality care.

You can read the Health Affairs article at http://content.healthaffairs.org/cgi/content/abstract/hlthaff.25.w555.