Health Affairs carries results from a survey of primary care doctors in ten countries regarding care from complex patients with multiple chronic conditions. (HA Article) The countries included in the survey were the US, Canada, Australia, Norway, Sweden, Germany, the Netherlands, New Zealand, Switzerland and the UK. In any country, a relatively few patients account for a substantial fraction of total health spending and they tend to be these patients with complex conditions. As populations age, there are more of these patients and more of them tend to have brain diseases, which makes it harder for these patients to do self-care or self-management, much less participate in decision-making about their treatment. Primary care physicians tend to have large patient pools and this makes it difficult for them to find the time to adequately care for the complex subgroup. The survey asked doctors about several aspects of attempting to manage complex patients. In most countries, a substantial majority of primary care doctors said their practice was prepared to effectively manage complex care patients, with a range from 66% in Sweden to 88% in Germany and the Netherlands, with a 76% positive response in the United States. The sense of preparedness, however, was significantly lower for certain subsets of these patients. For example, in many countries, a majority felt unprepared to handle patients with dementia, with 47% stating that they were in the United States. Doctors in Germany were most likely to say they could effectively treat these patients, at 67%, and doctors in New Zealand and Canada the least likely, at around 42%.
Countries vary widely in how much they use nurses or case managers to help manage these patients and whether this staff is employed by the practice or contracted outside of it. In Germany, for example, only 20% of doctors use such case managers as part of the practice and 7% hire outside case managers, while in the UK, 87% of practices have employed case managers and 8% use outside resources. In the United States, 43% of doctors have employed case managers and 24% rely on contracted ones. The use of home visits also has wide variance, from 6% of doctors in the US to 88% in the Netherlands and 84% in the UK. One area in which the US has a substantial lead is patients ability to view, download or transmit medical record information; with 60% of US primary care doctors saying their practice has this capability, with the next highest country being the UK at 28%. In no country is their extensive satisfaction with communication across a patient’s care sources. Primary care doctors often don’t feel they get timely communication from specialists and a significant majority is not notified when a patient is discharged from the hospital or seen in an ER. Use of an EHR was very high in many of the countries, Switzerland was lowest with only 56% of primary care physicians reporting use of one compared to several countries with usage in 90% plus range. The US is low middle of the pack at 84%. Use of these systems for sophisticated care management purposes, however, is much lower. In general, many physicians have low perceptions of their health system. The most positive attitudes are in Norway and New Zealand and the least in the US, the UK and Sweden. Many physicians find their job stressful and many feel they spend too much time on administrative issues, and not just in the US.