Thinking Beyond Our Borders

Thinking Beyond Our Borders: What We Can Learn about Improving

Care from Other Countries

Dr. Lisa Simpson

President and CEO

April 24, 2012

Outline

Introduction

What do international studies tell us about

health and health care in the U.S.?

Leading Approaches in Other Countries

Burgeoning Field of Implementation Science

Concluding Thoughts

AcademyHealth: Improving

Health & Health Care AcademyHealth is a leading national organization serving the fields of health

services and policy research and the professionals who produce and use this

important work.

Together with our members, we offer programs and services that support the

development and use of rigorous, relevant and timely evidence to:

1. Increase the quality, accessibility and value

of health care,

2. Reduce disparities, and

3. Improve health.

A trusted broker of information, AcademyHealth

brings stakeholders together to address the current

and future needs of an evolving health system,

inform health policy, and translate evidence into action.

3

Leveraging >4,500 Diverse,

Expert Members & Organizations

3

Behavioral Health Services Research

Child Health Services Research

Disability Research

Disparities

Gender and Health

Health Economics

Health Information Technology

Health Workforce

Interdisciplinary Research Group on Nursing Issues

Long-Term Care

Public Health Systems Research

Quality & Value

Translation & Communications

State Health Research and Policy

AcademyHealth Interest Groups

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Mission and Programs Methods and professional skill-building

seminars, methods council

Electronic Data Methods (EDM) Forum

Changes in Health Care Financing and

Organization (HCFO)

Multi-payer Claims Database (MPCD)

Annual Research Meeting

Address the current and future needs of an evolving health system

Translate evidence into action

AHRQ Knowledge Transfer Initiative

Beacon Evaluation and Innovation Network

National Library of Medicine’s HSRProj

National Health Policy Conference

Public Health Services Research

AHRQ Healthcare Innovations Exchange

State Coverage Initiatives

AHRQ Medicaid Medical Director’s

Learning Network

Advocacy and Public Policy

Inform health policy

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Conferences

Annual Research Meeting (ARM)

– June 24-26, 2012 in Orlando, FL

– Over 2,000 attendees

Health Policy Orientation

– October 22-25, 2012 in Washington DC

– Limited to 50 participants

National Health Policy Conference

(NHPC)

– February 4 – 5, 2013 in DC

– Over 800 attendees

AcademyHealth Focus

2012-2014

Fundamental program areas

– Generate new knowledge

– Move knowledge into action

Strategic priority areas

– Health care costs and value

– Delivery system transformation

– Public and population health

Push audiences

– Delivery system leaders

– States

ARM Opportunities for

Students

Registration and hotel discounts

Scholarships

Meet-the-expert breakfast

Networking events

Career Coaches

Awards for best dissertation & poster

Declaring My Biases!

1. The US is far too insular

in its approach to the

world!

2. There is much to be

learned from other

countries as we struggle

to improve health and

health care.

3. Others in the audience

know far more than I do!

Agenda

Introduction

What do international studies tell us about

health and health care in the U.S.?

Dimensions of Comparison

Health and outcomes

Health care costs

Health care utilization

Adults Who Report Being Daily Smokers, 2009

28.0 26.2

24.9

21.9 21.5 21.5 21.0 20.4 19.0 18.1

16.6 16.2 16.1 14.3

0

10

20

30

40

NETH FR* JPN GER UK OECDMedian

NOR SWIZ** DEN NZ** AUS** CAN US SWE

Percent

* 2008.

** 2007.

Source: OECD Health Data 2011 (June 2011).

THE

COMMONWEALTH

FUND

33.8

26.5 24.6 24.2

23.0

14.7

11.8 11.2 11.2 10.0

8.1

3.9

0

5

10

15

20

25

30

35

40

US* NZ** AUS** CAN* UK GER NETH FR* SWE NOR* SWIZ** JPN

Obesity (BMI>30) Prevalence Among Adult Population, 2009

Note: Body-mass index (BMI) estimates based on national health interview surveys (self-reported data)

are usually significantly lower than estimates based on actual measurements.

Percent

Measured Self-reported

THE

COMMONWEALTH

FUND

* 2008.

** 2007.


Breast Cancer Five-Year Relative Survival Rate,

2002–2007 (or nearest period)

90.5 87.1 86.1 85.2

82.4 82.1 81.9 78.5

0

20

40

60

80

100

US CAN SWE NETH DEN NZ NOR UK

Source: OECD Health Care Quality Indicators Data 2009.

Percent

THE

COMMONWEALTH

FUND

* 2006.

** 2005.

*** Among countries shown.

36

21

16

13 12 12 12

11 11 11 9

0

10

20

30

40

US* DEN SWIZ* FR NZ Median*** SWE CAN NETH** NOR UK

Diabetes Lower Extremity Amputation Rates

per 100,000 Population Age 15 and Older, 2007


THE

COMMONWEALTH

FUND

* In-hospital case-fatality rates within 30 days of admission.

** 2006.

*** 2005.

Mortality After Admission for Acute Myocardial Infarction*

per 100 Patients, 2007

6.6 6.3

5.1

4.2

3.3 3.2 2.9 2.9

0

2

4

6

8

NETH** UK US* CAN NZ NOR DEN SWE


THE

COMMONWEALTH

FUND

$2,983 $3,445 $3,487

$3,722 $3,978

$4,218 $4,363

$4,914 $5,144

$5,352

$7,960

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

$8,000

NZ(10.3%)

AUS(8.7%)*

UK(9.8%)

SWE(10.0%)

FR(11.8%)

GER(11.6%)

CAN(11.4%)

NETH(12.0%)

SWIZ(11.4%)

NOR(9.6%)

US(17.4%)

Health Spending per Capita, 2009 Adjusted for Differences in Cost of Living

* 2008.


% GDP

Dollars

THE

COMMONWEALTH

FUND

18 Health Care Spending per Capita by Source of Funding, 2009 Adjusted for Differences in Cost of Living

3,795 4,501

3,072 3,081 3,242 3,100 3,033 2,935 2,342 2,400 2,325

3,189

43

504 646 424 587 69 188

476 184 99

976

808

1,568 636 552 291

620 364 627

399 454

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

US NOR SWIZ CAN GER FR SWE UK AUS* NZ JPN*

Out-of-pocket spending

Private spending

Public spending

* 2008.

Dollars

7,960

4,363 4,218 3,978

3,722 3,487 3,445

2,878 2,983

5,352 5,144


THE

COMMONWEALTH

FUND

0

1000

2000

3000

4000

5000

6000

7000

8000

1980 1984 1988 1992 1996 2000 2004 2008

US

NOR

SWIZ

NETH

CAN

DEN

GER

FR

SWE

UK

AUS

NZ

JPN


Average Health Care Spending per Capita, 1980–2009 Adjusted for differences in cost of living

19

Dollars

THE

COMMONWEALTH

FUND

Out-of-Pocket Spending and Problems Paying Medical Bills in Past Year

Percent

1 5 6

11 12 13 16

24

35 36 39

0

10

20

30

40

50

60

More than US$1,000 in

out-of-pocket costs

1 4 5 6 7 8 8 8

11 14

27

Serious problems paying or

unable to pay medical bills

Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

THE

COMMONWEALTH

FUND

21 Average Annual Number of Physician Visits per Capita, 2009

13.2

8.2

6.9 6.5 6.3

5.7 5.5 5.0

4.6 4.3 4.0 3.9

2.9

0

2

4

6

8

10

12

14

JPN* GER FR AUS OECDMedian

NETH CAN* UK DEN NZ** SWIZ** US* SWE

* 2008.

** 2007.


THE

COMMONWEALTH

FUND

Patients with a Regular Doctor versus a Medical Home

99 99 99 91

99 99 97 96 97 100 95

74 70

65

56 53 52 51 49 48 48

33

0

20

40

60

80

100

UK SWIZ NZ US NOR FR AUS CAN GER NETH SWE

Has a regular doctor or place of care

Has a medical homePercent

Patients with a medical home have a regular practice who is

accessible, knows them, and helps coordinate their care


THE

COMMONWEALTH

FUND

Rated Quality of Care in Past Year as “Excellent” or “Very Good,”

by Medical Home

79

72

49

35

44

83

65 62

72

88

77

56

46

38

27 26

59

34

44

57 60

43

0

20

40

60

80

100

AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US

Medical home No medical home

Percent


THE

COMMONWEALTH

FUND

Waited Less Than a Month to See Specialist

92 88

81 80 79

68 67 63

59 52

47

0

20

40

60

80

100

SWIZ US NETH UK GER NZ FR SWE AUS CAN NOR

Percent

Base: Saw or needed to see a specialist in the past two years.


THE

COMMONWEALTH

FUND

Shared Decision-Making with Specialists

80 79 72

67 67 64 61

50 48

40 37

0

20

40

60

80

100

SWIZ UK NZ NETH US AUS CAN GER SWE NOR FR

Percent reporting positive shared decision-making experiences with specialists*

* Reported specialist always/often: 1) Gives opportunities to ask questions about recommended treatment;

2) Tells you about treatment choices; and 3) Involves you as much as you want in decisions about your care.

Base: Seen specialist in past two years.


THE

COMMONWEALTH

FUND

Cross-Cutting Themes and Implications

Outcomes and quality have improved but there is room for

improvement in all countries

There is a clear need to contain public spending

Per capita spending has risen by 70% since the early

90’s

U.S. is an outlier on access and affordability

Cost-sharing and benefit design matters

Strong primary care “medical homes” make a difference in

all countries

Health care systems: getting more

value for money (OECD Report, 2010)

There is no health care system that performs systematically

better in delivering cost-effective health care.

On average, life expectancy at birth could be raised by more

than two years, while holding health care spending steady, if all

countries were to become as efficient as the best performers.

Health outcomes are highly disparate across individuals and

such inequalities can be reduced without sacrificing efficiency

There is no “one-size-fits-all” approach to reforming health care

systems.

By improving the efficiency of the health care system, public

spending savings would be large, approaching 2% of GDP on

average in the OECD.

Outline

Overview of AcademyHealth

How the U.S. Compares: Quality and

Outcomes


Strategies in Use

OECD:

– Reliance on market mechanisms and

regulations to steer demand and

supply

– Coverage principles to promote equity

– Budget and management approaches

to control public spending

Market Mechanisms

Users

– Price signals

– Gate keeping & limited choice among providers

Providers

– Mitigating volume incentives

– Regulating prices

– Enhancing patient choice

– User information on quality and price

Common International Trends

Standardizing and integrating health

information technology and other electronic

data innovations

Bolstering the research enterprise and

integrating CER into decision-making

Engaging patients meaningfully in their care

and shifting the perspective of research to be

patient-centered

Kalipso Chalkidou, NICE International

Engaging Patients

American patients who feel engaged by their

providers are more likely to rate their care as high

quality than engaged patients in other countries

Low income patients were less likely to feel engaged

than higher income patients

American patients are likely to report positive care

experience, even if clinical needs were not met

American patients exhibited the greatest disparities in

care and engagement

R. Osborn and D. Squires, "International Perspectives on Patient Engagement:

Results from the 2011 Commonwealth Fund Survey," Journal of Ambulatory Care

Management, April/June 2012 35(2):118–28.

Divergent Actions, Similar Trends Compared: OECD Health Care Quality Indicators

Project and the US National Healthcare Quality

Report

Found:

– Choice of breadth or priorities

– Methods must be developed to both edit indicators

and preserve core set for longitudinal study

– Communication, translation, dissemination are key

– Momentum matters

Edward T. kelley 1 , 2 , Irma Arispe 3 and Julia Holmes 3

Beyond the initial indicators: lessons from the OECD Health Care Quality Indicators

Project and the US National Healthcare Quality Report

Int J Qual Health Care (September 2006) 18 (suppl 1): 45-51. doi: 10.1093/intqhc/mzl027

http://intqhc.oxfordjournals.org/content/18/suppl_1/45.long

http://intqhc.oxfordjournals.org/search?author1=Edward+T.+kelley&sortspec=date&submit=Submit

http://intqhc.oxfordjournals.org/search?author1=Edward+T.+kelley&sortspec=date&submit=Submit







http://intqhc.oxfordjournals.org/search?author1=Irma+Arispe&sortspec=date&submit=Submit

http://intqhc.oxfordjournals.org/search?author1=Irma+Arispe&sortspec=date&submit=Submit




http://intqhc.oxfordjournals.org/search?author1=Julia+Holmes&sortspec=date&submit=Submit




US Activity vs. International Generate the right data and

evidence

– Inform patient choice as well as

traditional decision makers

– HIT, electronic data, systematic

reviews, real-world

demonstrations, measure

standardization/harmonization

Identify the right populations

and partners

– Patient- centered research

Engage both to make more

informed and creative ideas

– PCORI, patient-centered

medical homes

Generate the right data and

evidence

– Convergence of payer and

regulator use of CER

– HIT, electronic data, systematic

reviews, cost-focused analysis,

international pilots, measure

standardization/ harmonization

Identify the right populations

and partners

– Patient- centered research,

product developers, health

system professionals

Engage both to make more

informed and creative ideas

– Value-based pricing

Population Health, Patient Experience, Per

Capita Cost

HHS implementation in the US

IHI Triple Aim Partners 2011 – UK (NHS)

– Australia

– Sweden

– Singapore

– New Zealand

– Canada

http://www.ihi.org/offerings/Initiatives/TripleAi

m/Pages/Participants.aspx

Population Health is…

…the health outcomes of a group of

individuals, including the distribution

of such outcomes within the group.

Group can be defined by geography or

include other types such as employees,

ethnic groups, disabled persons, etc…

36

Source: Kindig and Stoddart. “What is Population Health?” Am J Public Health.

2003 March; 93(3): 380–383.

Population Health

Churchill had it right! – Americans will make the right choice, after…

Costs have put it on the table – Private sector focus

– ACA

Provisions in ACA for Population Health

Addresses need for systematic

approach to definition, funding, evidence

base, communication, and need for

cooperation.

The introduction of a reliable, steady

stream of funding for public health

research.

Encourages development and use of

common metrics to measure

effectiveness.

Promotes prevention in the health care

system

Source: Bovberg, et al. “What directions for Public Health under the

Affordable Care Act?” The Urban Institute Health Policy Center, November

2011.

Population Health

• “Because improvement in population health requires the attention and actions of multiple actors (legislators, managers, providers, and individuals), the field of population health needs to pay careful attention to the knowledge transfer and academic-practice partnerships that are required for positive change to occur.”

• Moves beyond current distinction between public health programs & health care delivery

• Integrated approach supported by multiple aspects of the ACA

39

Source: Kindig and Stoddart. “What is Population Health?” Am

J Public Health. 2003 March; 93(3): 380–383.

“Health in All Policies” Approach

– Increasing awareness that factors outside

of the health system affect health status

– Incorporates Social Determinant

perspective

– Policy Relevance

• Improved productivity

• Reduced health care costs (‘economic

security’)

40

Evidence-Generating Orgs

How to Act on what we Learn?

Though we are

generating new

evidence, aligning

interests and

partnering with

stakeholders… how do

we translate,

disseminate, and

implement what we

know to improve care?

Agenda



Outcomes



What is implementation science?

Research relevant to the scientific

study of methods to promote the

uptake of research findings into

routine healthcare in both clinical

and policy contexts.

http://www.implementationscience.com/

What is in a name?

Implementation science

Improvement science

Delivery system research

Dissemination and implementation research

Quality improvement research

Pipeline from research to practice to policy

The Translational Pathway

Innovation

Pilot testing

Rigorous assessment

Replication and spread

Scale-up

Focus on Adoption, the “Triple S”

Scale up, Sustainability, Spread

US

– AHRQ

– PCORI

– CMMI

– Million Hearts

– VA

– NIH – Dissemination and implementation

activities; NCATS/CTSA

International

Focus on Adoption, the “Triple S”

Scale up, Sustainability, Spread

Cochrane Effective Practice and Organisation

of Care (EPOC) Group

– Reviews of interventions designed to improve

professional practice and the delivery of effective

health services.

Health evidence Canada

– Facilitate the adoption and implementation of

effective policies/programs/interventions at the

local and regional public health decision making

levels across Canada.

A New International Society on

Research on How to Improve Care

An inclusive approach: mental health healthcare,

treatment for substance abuse, the work of allied

health professions, and preventive healthcare.

Open to researchers from all traditions: rigorous

methods, focused on improving healthcare,

knowledge that can be transferred across settings.

Improvement science, behavioral medicine,

knowledge translation

Start international debate, shared vision, seek

funding opportunities and engage stakeholders.

Now seeking comment online.

Outline



Outcomes



Concluding Thoughts

Future Challenges

Ensuring rigorous methods match policy and practice

needs.

Key requirements for creating comparable indicators

that address the needs of policy-makers are:

– appropriate methods of summarizing complex information;

– a narrative that picks out the key issues and uncertainties;

– a diagnosis of why the reported variations are arising; and

– an assessment of implications for policy action.

http://www.euro.who.int/en/what-we-do/data-and-evidence/health-

evidence-network-hen/publications/2012/health-system-

performance-comparison-an-agenda-for-policy,-information-and-

research-2012

Future Challenges (cont)

Harmonize and coordinate federal efforts to

fund research

Build a high performing comparative

effectiveness research system to achieve

rapid-learning potential of electronic health

records, databases, data sharing, networks

Support a rapid-learning culture for the US

health care system

Etheredge, Lynn. “Creating a High-Performance System

for Comparative Effectiveness Research.” Health

Affairs. 29; No. 10 (2010): 1761-1767

Wither AcademyHealth?

Continued focus on

– Evidence generation

– Evidence translation

Engage & learn from international colleagues

– Update to 2009 report on CER efforts

– Delegation to Beijing to attend 2nd Global

Symposium on Health Systems Research

– Your thoughts?

Questions?

Lisa Simpson, MB, BCh, MPH, FAAP President and CEO

Thinking Beyond Our Borders

Health & Medicine