General practice care and patients' priorities in Europe: an international comparison.

Insight into patients' priorities with respect to health care should complement the views of professionals and policy makers on what is thought to be appropriate health care. To determine the strengths and weaknesses of general practice care from patients' perspectives written surveys were performed among patients in Denmark, Germany, Israel, Netherlands, Norway, Portugal, Sweden and United Kingdom (n = 3540). The potential quality problems identified were spread over the different countries: the low involvement of general practitioners in out-of-hours services in Portugal; the low provision of routine screening in Sweden, Norway and The Netherlands; the lack of a defined patient population in Germany; the lack of a formal gatekeeper role to secondary care in general practice in Germany and Sweden; and the low number of home visits in Sweden.     

Improving performance using indicators. Recent experiences in the United States, the United Kingdom, and Australia.

This article describes recent national performance improvement initiatives in the United States, United Kingdom, and Australia. This comparison is of particular interest because each of these three countries faces similar challenges in delivering health care and improving health. Each has elevated a focus on safety and quality improvement to a national level. Marked differences in the organization and financing of health care across these three countries provide a unique opportunity to compare and contrast approaches. Drawing on the experience of the authors in each of the three countries and publicly available data sources about specific national initiatives, we describe the national context for improvement and outline recent performance improvement initiatives and emerging issues and challenges. Similarities and differences in the current evolution of national performance initiatives are described and conclusions are drawn about challenges that all three countries face, particularly in terms of developing meaningful sets of national indicators of health system performance. The challenges for future work include the importance of information infrastructure, the paucity of accurate and accessible clinical data, the need for effective performance measurement processes at a local level to capture useful data, and the tensions of balancing accountability and improvement agendas for measurement.     

Use of 13 disease registries in 5 countries demonstrates the potential to use outcome data to improve health care's value

As health care systems worldwide struggle with rising costs, a consensus is emerging to refocus reform efforts on value, as determined by the evaluation of patient outcomes relative to costs. One method of using outcome data to improve health care value is the disease registry. An international study of thirteen registries in five countries (Australia, Denmark, Sweden, the United Kingdom, and the United States) suggests that by making outcome data transparent to both practitioners and the public, well-managed registries enable medical professionals to engage in continuous learning and to identify and share best clinical practices. The apparent result: improved health outcomes, often at lower cost. For example, we calculate that if the United States had a registry for hip replacement surgery comparable to one in Sweden that enabled reductions in the rates at which these surgeries are performed a second time to replace or repair hip prostheses, the United States would avoid $2 billion of an expected $24 billion in total costs for these surgeries in 2015.     

The proposal of policies aimed at tackling health inequalities in Korea]

Although the New National Health Promotion Plan 2010 target to reduce health inequalities, whether the program will be effective for reducing the health inequalities in Korea remains quite unclear. More and more developed countries have been started to concentrate on comprehensive policies for reducing health inequalities. The health policies of the UK, Netherlands, and Sweden are the most wellknown. I propose that a comprehensive blueprint for tackling health inequalities in Korea should be made and that it must contain five domains: a target, structure and process, life-course approach, area-based approach, and reorganization of health care resources. The target should be based on determinants of health and more attention should be paid to socioeconmic factors. The structure and process require changes from the national health care policy based on medical services to the national health policy that involves the establishment of a Social Deputy Prime Minister and the strengthening multidisciplinary action. A life-course approach especially focused on the early childhood years. Area-based approach such as the establishment of healthy communities, healthy schools, or healthy work-places which are focused on deprived areas or places is also required. Finally, health care resources should be a greater investment on public resources and strengthening primary care to reduce health inequalities. The policy or intervention studies for tackling health inequalities should be implemented much more in Korea. In addition, it is essential to have political will to encourage policy action.     

The development of quality circles/peer review groups as a method of quality improvement in Europe. Results of a survey in 26 European countries

BACKGROUND: Peer review groups (PRGs) and quality circles (QCs) commenced in The Netherlands and have grown to become an important method of quality improvement in primary care in several other European countries. OBJECTIVE: Our aim was to provide an overview of QC/PRG activities and exemplary programmes in European countries. METHODS: A survey was performed in three consecutive steps by EQuiP (European Working Party on Quality in Family Practice), which is a representative association of experts from 26 European countries. The national representatives initially completed a structured questionnaire documenting the number and objectives of QCs/PRGs, sources of support and special programmes in their countries (step 1). In step 2, these sources were used to extend and validate the expert statements. Step 3 studied paradigmatic initiatives in depth. RESULTS: Step 1 took place in 2000; the response rate was 100% (26 countries). QCs/PRGs were very active in 10 countries; 16 countries showed little or no activity. Participation ranged from <2 to 86% of all GPs. Step 2 concentrated upon the countries with a high level of activity. Development appeared to be associated with establishment in private practice and the portion of GPs with vocational training. Eight programmes from six countries describing the establishment and the targeting of QC/PRG work are presented as case reports (step 3). CONCLUSION: In the last 10 years, substantial development of QCs/PRGs has taken place in The Netherlands, the UK, Denmark, Belgium, Ireland, Sweden, Norway, Germany, Switzerland and Austria. Further evaluation is needed to clarify the impact on quality of care.     

An overview of existing mesothelioma registries worldwide,and the need for a US Registry

The association between asbestos exposure, mainly in occupational settings, and malignant mesothelioma has been well established; this has prompted several countries to establish mesothelioma epidemiologic surveillance programs often at the request of national agencies. This review compares currently existing mesothelioma registries worldwide to develop a concept model for a US real-time case capture mesothelioma registry. Five countries were identified with a mesothelioma specific registry, including Italy, France, UK, Australia, and South Korea. All, except the UK, used interviews to collect exposure data. Linkage with the national death index was available or was in future plans for all registries. The registries have limited information on treatment, quality of life, and other patient-centered outcomes such as symptoms and pain management. To thoroughly collect exposure data, “real-time” enrollment is preferable; to maximize the capture of mesothelioma cases, optimal coverage, and a simplified consent process are needed.     

A comparison of approaches to health service quality in the UK, USA & Sweden and of the use of organizational audit frameworks

Health care reforms in the UK, USA and Sweden are leading healthproviders and purchasers to pay more attention to quality. Thispaper considers different approaches to proving and improvingquality before and after 1990 in these three countries. Thesecond part of the paper describes different frameworks forauditing health service quality, such as the ISO 9000 and USMalcum Baldridge award. It considers how purchasers can usethese frameworks in purchasing services, and how providers canuse the frameworks to assess and improve their own service quality.     

The Picker Patient Experience Questionnaire: development and validation using data from in-patient surveys in five countries.

OBJECTIVE: The purpose of this study was to develop and test a core set of questions to measure patients' experiences of in-patient care. Questions were selected from the bank of items developed for use in in-patient surveys undertaken by the Picker Institute for the purposes of assessing the quality of care. DESIGN: The data reported here come from surveys of patients who had attended acute care hospitals in five countries: the United Kingdom, Germany, Sweden, Switzerland, and the USA. Questionnaires were mailed to patients' homes within 1 month of discharge, either to all patients, or to a random sample, discharged during a specified period. SAMPLE: A total of 62 925 questionnaires were returned, with response rates of 65% (UK), 74% (Germany), 63% (Sweden), 52% (Switzerland), and 46% (USA). RESULTS: Fifteen items were selected from the bank of questions included in the Picker in-patient questionnaires. These items have a high degree of face validity and when summed to an index they show a high degree of construct validity and internal reliability consistency. DISCUSSION: Fifteen items derived from the longer form Picker in-patient survey have been found to provide a meaningful picture of patient experiences of health care, and constitute the 15-item Picker Patient Experience Questionnaire. These questions comprise a core set that should be measured in all in-patient facility surveys. The Picker Patient Experience Questionnaire represents a step forward in the measurement of patient experience as it provides a core set of questions around which further optional modules may be added. Scores are easy to interpret and actionable. CONCLUSION: This small set of questions could be incorporated into in-patient surveys in different settings, enabling the comparison of hospital performance and the establishment of national or international benchmarks.     

医疗不良事件报告系统的国际比较及启示

世界各国卫生保健系统都在寻找减少不良事件和医疗差错、提高医疗质量的可行方法。通过研究英国、瑞典、丹麦、美国、澳大利亚以及我国医疗不良事件报告与学习系统应用现状,总结发达国家的先进经验,并从报告数量、报告应用、学习现状3方面进行比较,提出应建立我国医疗不良事件学习和报告系统,并从以下5方面开展工作:强化政府主导,开展系统上报试点工作;委托专业机构,提高分析结果的准确性;加强科学管理,注重个人隐私与信息安全;强化宣传引导,对上报单位进行预培训;重视信息反馈,促进质量持续改进。     

Primary medical care in the United kingdom

Since 1948 health care in the United Kingdom (UK) has been centrally funded through the National Health Service (NHS). The NHS provides both primary and specialist health care which is largely free at the point of delivery. Family practitioners are responsible for registered populations of patients and typically work in groups of 4-6 self-employed physicians. They hire nurses and a range of other ancillary staff, and act as gatekeepers to specialist care. Recent reforms include a wide range of national quality improvement initiatives and a pay for performance scheme that accounts for around 25% of family practitioners' income. These reforms have been associated with some major improvements in quality, including improved chronic disease management and reduced waiting times for specialist care. The four countries of the UK differ in some important aspects of health care organization: proposed reforms in England would move towards a more market-driven system, with family practitioners acting as payers for specialist care and controlling 70% of the NHS budget. The other countries (Scotland, Wales and Northern Ireland) focus more on trying to create area-based integrated systems of care.     

The development of a quality information system: a case study of Mexico.

One of the primary obstacles in the implementation of continuous quality improvement (CQI) programmes in developing countries is the lack of timely and appropriate information for decentralized decision-making. The integrated quality information system (QIS) described herein demonstrates Mexico's unique effort to package four separate, yet mutually reinforcing, tools for the generation and use of quality-related information at all levels of the Mexican national health care system. The QIS is one element of the continuous quality improvement programme administered by the Secretariat of Health in Mexico. Mexico's QIS was designed to be flexible and capable of adapting to local needs, while at the same time allowing for the standardization of health care quality assurance indicators, and subsequent ability to measure and compare the quality performance of health facilities nationwide. The flexibility of the system extends to permit the optimal use of available data by health care managers at all levels of the health care system, as well as the generation of new information in important areas often neglected in more traditional information systems. Mexico's QIS consists of four integrated components: 1) a set of client and provider surveys, to assess specific issues in the quality of health services delivered; 2) client and provider national satisfaction surveys; 3) a sentinel health events strategy; and 4) a national Comparative Performance Evaluation System, for use by the Secretariate of Health for the quality assessment of state and provincial health care services (internal benchmarking). The QIS represents another step in Mexico's ongoing effort to use data for effective decision-making in the planning, monitoring and evaluation of services delivered by the national health care system. The design and application of Mexico's QIS provides a model for decentralized decision-making that could prove useful for developing countries, where the effective use of quality indicators is often limited. Further, the system could serve as a mechanism for motivating positive change in the way information is collected and used in the process of ensuring high quality health care service delivery.     

Review of performance assessment and improvement in ambulatory medical care

Health care plans often consider quality of care as a means of containing rising health costs. The assessment of physician and group practice performance has become increasingly widespread in ambulatory care. This article reviews the three main methods used to improve and assess performance: practice audits, peer-review groups and practice visits. The focus is on Europe - which countries use which methods - and on the following aspects: which authorities or bodies are responsible for setting up and running the systems, are the systems mandatory or voluntary, who takes part in assessments and what is their motivation, are patients views taken into account. Many countries run parallel systems managed by authorities working at different hierarchical levels (national, regional or local). The reasons that underlie the choice of a particular system are discussed. They are mostly related to the national health care system and to cultural factors.     

Using national electronic health care registries for comparing the risk of psychiatric re-hospitalisation in six European countries: Opportunities and limitations

Psychiatric re-hospitalisation rates have been of longstanding interest as health care quality metric for planners and policy makers, but are criticized for not being comparable across hospitals and countries due to measurement unclarities. The objectives of the present study were to explore the interoperability of national electronic routine health care registries of six European countries (Austria, Finland, Italy, Norway, Romania, Slovenia) and, by using variables found to be comparable, to calculate and compare re-hospitalisation rates and the associated risk factors. A “Methods Toolkit” was developed for exploring the interoperability of registry data and protocol led pilot studies were carried out. Problems encountered in this process are described. Using restricted but comparable data sets, up to twofold differences in psychiatric re-hospitalisation rates were found between countries for both a 30- and 365-day follow-up period. Cumulative incidence curves revealed noteworthy additional differences. Health system characteristics are discussed as potential causes for the differences. Multi-level logistic regression analyses showed that younger age and a diagnosis of schizophrenia/mania/bipolar disorder consistently increased the probability of psychiatric re-hospitalisation across countries. It is concluded that the advantage of having large unselected study populations of national electronic health care registries needs to be balanced against the considerable efforts to examine the interoperability of databases in cross-country comparisons.     

Measuring cost efficiency in the Nordic Hospitals—a cross-sectional comparison of public hospitals in 2002

The aim of this study was to compare the performance of hospital care in four Nordic countries: Norway, Finland, Sweden and Denmark. Using national discharge registries and cost data from hospitals, cost efficiency in the production of somatic hospital care was calculated for public hospitals. Data were collected using harmonised definitions of inputs and outputs for 184 hospitals and data envelopment analysis was used to calculate Farrell efficiency estimates for the year 2002. Results suggest that there were marked differences in the average hospital efficiency between Nordic countries. In 2002, average efficiency was markedly higher in Finland compared to Norway and Sweden. This study found differences in cost efficiency that cannot be explained by input prices or differences in coding practices. More analysis is needed to reveal the causes of large efficiency disparities between Nordic hospitals.     

General preferences for involvement in treatment decision making among European women with urinary incontinence

Current health care policies advocate patient participation in treatment decision making. Little evidence on possible differences between European women's preferences for involvement in this process exists. In this study we explore preferences for involvement in treatment decision making in 15 European countries in a sample of 9434 women seeking treatment for urinary incontinence in an outpatient setting. Their generally preferred role in treatment decisions was assessed using the Control Preferences Scale. Results show variations within and between countries in preferences for involvement in treatment decision making. The 'collaborative role' was the most preferred role in Austria, Belgium, Denmark, France, Germany, Ireland, Sweden, Switzerland, the Netherlands and the UK. In Greece, Portugal and Spain the 'passive role' was most preferred. Over a third of women in Denmark, Finland and Norway preferred an 'active role'. Multinominal regression analyses found that, after adjusting for case mix and factors previously associated with role preferences, country membership was strongly associated with role preferences, with women living in Southern European countries preferring a more passive role. Such clear differences are of interest in the current health care environment where active patient participation is being encouraged. Greater efforts need to be made to establish whether patient preferences are genuine or merely a learned response influenced by cultural attitudes and traditions so that a balance can be struck between assisting women to play a more active role in the treatment decision-making process without disregarding some women's genuine preferences to play a more passive role.     

Benchmarks for health expenditures, services and outcomes in Africa during the 1990s

There is limited information on national health expenditures, services, and outcomes in African countries during the 1990s. We intend to make statistical information available for national level comparisons. National level data were collected from numerous international databases, and supplemented by national household surveys and World Bank expenditure reviews. The results were tabulated and analysed in an exploratory fashion to provide benchmarks for groupings of African countries and individual country comparison. There is wide variation in scale and outcome of health care spending between African countries, with poorer countries tending to do worse than wealthier ones. From 1990-96, the median annual per capita government expenditure on health was nearly US$ 6, but averaged US$ 3 in the lowest-income countries, compared to US$ 72 in middle-income countries. Similar trends were found for health services and outcomes. Results from individual countries (particularly Ethiopia, Ghana, Côte d''Ivoire and Gabon) are used to indicate how the data can be used to identify areas of improvement in health system performance. Serious gaps in data, particularly concerning private sector delivery and financing, health service utilization, equity and efficiency measures, hinder more effective health management. Nonetheless, the data are useful for providing benchmarks for performance and for crudely identifying problem areas in health systems for individual countries.     

The role of national quality registers in the Swedish health service

This article reports on a quality movement in Sweden that has gone largely unnoticed, namely the national quality control registers. These registers represent a potentially important primary data source for comparative studies and can play an important role in a national strategy for control and improvement of health care quality. First, we review the recent health care quality initiatives in Sweden and the background of national quality control registers. Secondly, we discuss our findings from a study on the purpose, content, value and problems associated with the registers. Our findings are based on (a) interviews with physician managers of the registers, (b) questionnaires to selected hospital departments participating in the registers and (c) questionnaires to elected officials and administrators representing the local health care providers. Finally, we discuss several crucial issues related to the registers. Although some have existed for several years, the registers are still defining their roles. Traditionally, this activity has been managed by the medical profession. However, interest in register information is increasing among health care policy makers and administrators at all levels in the system. Two key issues concern register ownership and finance, but the most sensitive issue concerns the right of policy makers and the public to access register information. The registers and the information they contain illustrate the ongoing conflict between openness and consumer sovereignty in health care on the one hand and professional autonomy on the other.     

The Swedish health care system--an economist's view

This article compares the organization of the Swedish health care system with that in three other countries, the U.S., the U.K., and Canada, focussing on three main areas: (1) the provision and financing (public or private) of health insurance, including the question of the quality of the insurance protection offered; (2) the organization of the production of health services, and the economic incentives on the system's decision-makers (doctors, hospital managers, politicians, etc.). Possible answers are suggested to the question why one country (the U.K.) is able to provide health care to its population at an average cost considerably below that of the others: Differences in the quality of the insurance protection and health services; in the incentives on the system managers to exercise cost control; and in the incentives on service providers such as physicians, to consider cost-effectiveness when making treatment decisions. An attempt is made to suggest lessons for health care reform in Sweden and elsewhere.