11/09/2011 12:17 EST | Updated 01/08/2012 05:12 EST

'Medical home' concept growing, but Canada lags some other countries: report

TORONTO - Chronically and seriously ill adults who receive care through "medical home" practices are less likely to report medical errors, test duplication and gaps in co-ordinated care, a survey of patients in Canada and 10 other countries has found.

The Commonwealth Fund survey, published Wednesday in the journal Health Affairs, also found that patients connected with such primary-care practices had better relationships with their doctors and gave their overall medical care higher marks.

"In all countries, we find that having a connection and an attachment to a primary-care practice that serves as a medical home makes a difference," said lead author Cathy Schoen, the foundation's senior vice-president for policy, research and evaluation.

More than 18,000 "sicker" patients in Canada, Australia, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom and the United States took part in the survey.

They included people who were in fair or poor health, had undergone surgery or been hospitalized in the past two years, or had received care for a serious or chronic illness, injury or disability in the previous year.

Patients were identified as having a medical home if they reported having a regular provider who was aware of their medical history, was accessible and helped co-ordinate care from other providers or specialists.

In Canada, 96 per cent of the almost 4,000 patients surveyed reported having a regular doctor — but just 49 per cent described their care meeting the definition of a medical home.

Canada fell far below top-rated U.K. and Switzerland, where nearly three-quarters of patients reported being attached to practices with characteristics of a medical home. In the other eight high-income countries, about 33 to 65 per cent of patients reported having such co-ordinated care.

"Canada does relatively well, it's in the middle of the spectrum," Schoen said during a teleconference Tuesday.

Co-author Robin Osborn said there have been signs of growing improvement in the Canadian health-care system's responsiveness to patients over the last seven years, with a higher percentage of respondents to the annual survey saying only minor changes are needed.

"I think it has to do with a combination of the waiting times initiative and improvements there on elective surgery," said Osborn, director of the fund's international program in health policy and innovation.

"But I also think in many of the provinces standing out — for instance, Ontario with family health teams, with family health groups, the same in B.C. with the advanced medical home practices that are in place — there's starting to be a very dramatic shift and transformation of primary care.

"And I think people are really beginning to experience much more of a medical-home effect."

The survey found that U.K. and Swiss patients reported more positive health-care experiences than those in the other countries: they were more likely to get a same-day or next-day appointment when ill and to have easy access to after-hours care; they also were less likely to experience poorly co-ordinated care.

Canadian patients weren't so complimentary: while 51 per cent reported getting an appointment with their provider on the same or following day, 23 per cent said they had to wait six days or more after falling ill to see their doctor or a nurse; and 63 per cent of Canadian respondents said after-hours care was "somewhat or very difficult" to access.

One-third or more of sicker adults in all 11 countries had visited an emergency department in the past two years. Emergency department use was significantly higher in Canada, Sweden, the U.S., Australia, and New Zealand than the other countries, with Canadian patients leading the pack for ER visits.

"If you look at Canada, one of the things we see in this survey is that after-hours are often problematic without going to the emergency room," said Schoen. "We've been observing higher rates of emergency room use and difficulty getting after-hours care for several years now in Canada.

"But it is getting better ... I think the good news is that the trend has been improvement in Canada."

Sholom Glouberman, president of the Patients' Association of Canada, believes the overall structure of Canada's health-care system is not geared to patients with chronic illnesses like diabetes or cardiovascular disease or to those with disabling conditions.

"We need a huge amount more of primary care," he said in an interview. "It's in primary care that you have continuity, that you have a family doctor and a nurse practitioner who can keep track of you over a longer period of time and know who you are.

"That's the notion of the medical home."

The report showed the U.S. had the highest rate of patients going without needed care because of cost, with 42 per cent reporting they had not visited a doctor, filled a prescription or sought recommended care in the previous year because it wasn't affordable. U.S. patients also had among the highest rates of self-reported medication, lab or medical errors, as well as gaps in co-ordination of care.

"Despite spending far more on health care than any other country, the United States practically stands alone when it comes to people with illness or chronic conditions having difficulty affording health care and paying medical bills," said Commonwealth Fund president Karen Davis.

"This is a clear indication of the urgent need for Affordable Care Act reforms geared toward improving coverage and controlling health-care costs," she said, referring to the U.S. health-care overhaul signed into law last year by President Barack Obama.

The results from the telephone survey, conducted between March and June, highlight the importance of patient-centred primary care as a foundation for a high-performing health system in every country, said Schoen.

"There clearly is room to improve in all countries."