Why is the grass greener?
http://www.100md.com
《英国医生杂志》
1 Johns Hopkins School of Public Health, 624 North Broadway, Baltimore, MD 21205, USA bstarfie@jhsph.edu
As well as learning from each other's existing systems, US and UK researchers have potential for collaborative research into improving health care
Medical research has focused on increasing knowledge about specific diseases. Although big improvements in average levels of health have resulted from these increases in knowledge,8 9 the nature of disease is changing, with greater recognition of the phenomena of comorbidity and multimorbidity.10 New models of influence on health make it clear that diseases have no single causes (or even determinants), except, perhaps, for rare Mendelian dominant conditions. The multiple influences all interact with each other, many in as yet unknown ways, so that disease is not randomly distributed in the population.11 US researchers lead British researchers in developing methods to characterise case mix and morbidity burden in individuals and, by aggregation of individual data, in subpopulations and populations.12
This new model of illness greatly increases the potential for tailoring interventions to individuals, and subpopulations, according to their health needs. Given the recognition of the importance of primary care in the United Kingdom, greater attention to these new possibilities for understanding and management of ill health seems appropriate.
Population based clinical data systems
The considerable track record of both US and UK health services researchers makes potential collaborations an exciting possibility. The large differences between the two health systems increase the potential to shed light on new approaches. At least two areas pose new challenges: assessment and monitoring of quality of care and potential of teamwork, particularly in primary care.
Assessing quality of care
Despite over 20 years of interest in assessing the quality of care through its impact on outcomes (health status), most efforts are still focused on processes of care that are thought to be related to desired outcomes. Most clinical guidelines are of this type. Several years of experience in the implementation of evidence based medicine suggest a need for a reassessment. Firstly, the evidence base for most guidelines is inadequate. Even the most elegant randomised clinical trials lack assurance of generalisability of the evidence. Secondly, most trials, even the best ones, are not conducted under conditions of real practice. As a result, the selection of candidates for most disease oriented trials ensures that people with one or more other illnesses—the majority of people (especially the elderly population)—are not included in the trials. Thirdly, clinical trials are generally not designed to ascertain variability in response to the intervention, even when it is possible that certain sub-groups of the population differ in their responsiveness, and some assumptions of trials may make the conclusions inappropriate.20
Moreover, methods of ascertaining quality of care by its effect on health have not been implemented in any national health system. For example, the simple method of asking patients whether their health is improved after care, which proved promising in a short term evaluation,21 has apparently not been considered as a method for holding health services accountable for what they do. Well tested tools for assessing changes in health status exist but are not used.
Both the United States and the United Kingdom use techniques of evaluation that are derived frommarketing techniques to ascertain satisfaction. Too great a focus on patient satisfaction will detract from a more concerted effort to gain evidence from clinical practices, thus depriving both practitioners as well as consumers of a rational rather than a preference basis for decision making. It could be argued that need, rather than demand, should be the primary criterion for providing services, in the interest of better outcomes and more equitable distribution of resources.
Summary points
Organisational differences between the United States and United Kingdom present many possibilities for joint learning
The NHS primary care system offers many learning opportunities
The United States is ahead of the United Kingdom in research to understand the multiple determinants of disease but lags behind on equity in health
The United Kingdom could make better use of national patient data
Potential of teamwork
Both UK and US organisations employ teams of practitioners to provide primary care. In US managed care, it is common for nurse practitioners to act as frontline providers of care, with primary care doctors as back up. Because of the proprietary nature of managed care data, little is written about how decisions are made about who does what, and its impact in terms of quality and outcomes of care. This issue could well serve as a basis for a bi-national collaborative evaluation, with benefit to both countries.
This is the third in a series of articles in which we asked experts in UK and US healthcare systems to identify opportunities for learning between the two countries
Contributors and sources: This article reflects BS's experience in health services research and health policy, which derives from personal and policy contacts in many industrialised and developing nations.
Funding: This work was supported in part by Grant No 6 U30 CS 00189-05 S1 R1 of the Bureau of Primary Health Care, Health Resources and Services Administration, Department of Health and Human Services, to the Primary Care Policy Center for the Underserved at Johns Hopkins University.
Competing interests: None declared.
References
Starfield B, Shi L, Grover A, Macinko J. The role of evidence in physician workforce policy . Health Aff (Milwood) 2005;Mar.
Forrest CB, Majeed A, Weiner JP, Carroll K, Bindman AB. Comparison of specialty referral rates in the United Kingdom and the United States: retrospective cohort analysis. BMJ 2002;325: 370-1.
Forrest CB, Majeed A, Weiner JP, Carroll K, Bindman AB. Referral of children to specialists in the United States and the United kingdom. Arch Pediatr Adolesc Med 2003;157: 279-85.
Starfield B, Forrest CB, Nutting PA, von Schrader S. Variability in physician referral decisions. J Am Board Fam Pract 2002;15: 473-80.
Fireman B, Bartlett J, Selby J. Can disease management reduce health care costs by improving quality? Health Aff (Milwood) 2004;23: 63-75.
Ham C, York N, Sutch S, Shaw R. Hospital bed utilisation in the NHS, Kaiser Permanente, and the US Medicare programme: analysis of routine data. BMJ 2003;327: 1257.
National Committee for Vital and Health Statistics. Information for health: a strategy for building the national health information infrastructure. Washington, DC: US Department of Health and Human Services, 2001.
Nolte E, McKee M. Measuring the health of nations: analysis of mortality amenable to health care. BMJ 2003;327: 1129.
Bunker J. Medicine matters after all: measuring the benefits of medical care, a healthy lifestyle and a just social environment. London: Nuffield Trust, 2001.
Van den Akker M, Buntinx F, Roos S, Knottnerus JA. Problems in determining occurrence rates of multimorbidity. J Clin Epidemiol 2001;54: 675-9.
Starfield B. New paradigms for quality in primary care. Br J Gen Pract 2001;51: 303-9.
Salem-Schatz S, Moore G, Rucker M, Pearson SD. The case for case-mix adjustment in practice profiling. When good apples look bad. JAMA 1994;272: 871-4.
Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. Part 1: the content, quality, and accessibility of care. Ann Intern Med 2003;138: 273-87.
Baicker K, Chandra A. Medicare spending, the physician workforce, and beneficiaries' quality of care . Health Aff (Milwood) 2004; Apr 7. http://content.healthaffairs.org/cgi/reprint/hlthaff.w4.184v1.pdf (accessed 24 Feb 2004).
Wennberg JE. Perspective: Practice variations and health care reform: connecting the dots. Health Aff 2004;Suppl: VAR-140-VAR-144.
Majeed A, Evans N, Head P. What can PACT tell us about prescribing in general practice? BMJ 1997;315: 1515-9.
US Department of Health and Human Services. Healthy People 2010. 2nd ed. Washington, DC: US Government Printing Office, 2000.
Black D. Inequalities in health: report of a research working group. London: Department of Health and Social Security, 1980.
Acheson D. Independent inquiry into inequalities in health: report. London: Stationery Office, 1998.
Senn S. Individual response to treatment: is it a valid assumption? BMJ 2004;329: 966-8.
Mushlin AI, Appel FA. Testing an outcome-based quality assurance strategy in primary care. Med Care 1980;18: 1-100.(Barbara Starfield, university distinguis)
As well as learning from each other's existing systems, US and UK researchers have potential for collaborative research into improving health care
Medical research has focused on increasing knowledge about specific diseases. Although big improvements in average levels of health have resulted from these increases in knowledge,8 9 the nature of disease is changing, with greater recognition of the phenomena of comorbidity and multimorbidity.10 New models of influence on health make it clear that diseases have no single causes (or even determinants), except, perhaps, for rare Mendelian dominant conditions. The multiple influences all interact with each other, many in as yet unknown ways, so that disease is not randomly distributed in the population.11 US researchers lead British researchers in developing methods to characterise case mix and morbidity burden in individuals and, by aggregation of individual data, in subpopulations and populations.12
This new model of illness greatly increases the potential for tailoring interventions to individuals, and subpopulations, according to their health needs. Given the recognition of the importance of primary care in the United Kingdom, greater attention to these new possibilities for understanding and management of ill health seems appropriate.
Population based clinical data systems
The considerable track record of both US and UK health services researchers makes potential collaborations an exciting possibility. The large differences between the two health systems increase the potential to shed light on new approaches. At least two areas pose new challenges: assessment and monitoring of quality of care and potential of teamwork, particularly in primary care.
Assessing quality of care
Despite over 20 years of interest in assessing the quality of care through its impact on outcomes (health status), most efforts are still focused on processes of care that are thought to be related to desired outcomes. Most clinical guidelines are of this type. Several years of experience in the implementation of evidence based medicine suggest a need for a reassessment. Firstly, the evidence base for most guidelines is inadequate. Even the most elegant randomised clinical trials lack assurance of generalisability of the evidence. Secondly, most trials, even the best ones, are not conducted under conditions of real practice. As a result, the selection of candidates for most disease oriented trials ensures that people with one or more other illnesses—the majority of people (especially the elderly population)—are not included in the trials. Thirdly, clinical trials are generally not designed to ascertain variability in response to the intervention, even when it is possible that certain sub-groups of the population differ in their responsiveness, and some assumptions of trials may make the conclusions inappropriate.20
Moreover, methods of ascertaining quality of care by its effect on health have not been implemented in any national health system. For example, the simple method of asking patients whether their health is improved after care, which proved promising in a short term evaluation,21 has apparently not been considered as a method for holding health services accountable for what they do. Well tested tools for assessing changes in health status exist but are not used.
Both the United States and the United Kingdom use techniques of evaluation that are derived frommarketing techniques to ascertain satisfaction. Too great a focus on patient satisfaction will detract from a more concerted effort to gain evidence from clinical practices, thus depriving both practitioners as well as consumers of a rational rather than a preference basis for decision making. It could be argued that need, rather than demand, should be the primary criterion for providing services, in the interest of better outcomes and more equitable distribution of resources.
Summary points
Organisational differences between the United States and United Kingdom present many possibilities for joint learning
The NHS primary care system offers many learning opportunities
The United States is ahead of the United Kingdom in research to understand the multiple determinants of disease but lags behind on equity in health
The United Kingdom could make better use of national patient data
Potential of teamwork
Both UK and US organisations employ teams of practitioners to provide primary care. In US managed care, it is common for nurse practitioners to act as frontline providers of care, with primary care doctors as back up. Because of the proprietary nature of managed care data, little is written about how decisions are made about who does what, and its impact in terms of quality and outcomes of care. This issue could well serve as a basis for a bi-national collaborative evaluation, with benefit to both countries.
This is the third in a series of articles in which we asked experts in UK and US healthcare systems to identify opportunities for learning between the two countries
Contributors and sources: This article reflects BS's experience in health services research and health policy, which derives from personal and policy contacts in many industrialised and developing nations.
Funding: This work was supported in part by Grant No 6 U30 CS 00189-05 S1 R1 of the Bureau of Primary Health Care, Health Resources and Services Administration, Department of Health and Human Services, to the Primary Care Policy Center for the Underserved at Johns Hopkins University.
Competing interests: None declared.
References
Starfield B, Shi L, Grover A, Macinko J. The role of evidence in physician workforce policy . Health Aff (Milwood) 2005;Mar.
Forrest CB, Majeed A, Weiner JP, Carroll K, Bindman AB. Comparison of specialty referral rates in the United Kingdom and the United States: retrospective cohort analysis. BMJ 2002;325: 370-1.
Forrest CB, Majeed A, Weiner JP, Carroll K, Bindman AB. Referral of children to specialists in the United States and the United kingdom. Arch Pediatr Adolesc Med 2003;157: 279-85.
Starfield B, Forrest CB, Nutting PA, von Schrader S. Variability in physician referral decisions. J Am Board Fam Pract 2002;15: 473-80.
Fireman B, Bartlett J, Selby J. Can disease management reduce health care costs by improving quality? Health Aff (Milwood) 2004;23: 63-75.
Ham C, York N, Sutch S, Shaw R. Hospital bed utilisation in the NHS, Kaiser Permanente, and the US Medicare programme: analysis of routine data. BMJ 2003;327: 1257.
National Committee for Vital and Health Statistics. Information for health: a strategy for building the national health information infrastructure. Washington, DC: US Department of Health and Human Services, 2001.
Nolte E, McKee M. Measuring the health of nations: analysis of mortality amenable to health care. BMJ 2003;327: 1129.
Bunker J. Medicine matters after all: measuring the benefits of medical care, a healthy lifestyle and a just social environment. London: Nuffield Trust, 2001.
Van den Akker M, Buntinx F, Roos S, Knottnerus JA. Problems in determining occurrence rates of multimorbidity. J Clin Epidemiol 2001;54: 675-9.
Starfield B. New paradigms for quality in primary care. Br J Gen Pract 2001;51: 303-9.
Salem-Schatz S, Moore G, Rucker M, Pearson SD. The case for case-mix adjustment in practice profiling. When good apples look bad. JAMA 1994;272: 871-4.
Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. Part 1: the content, quality, and accessibility of care. Ann Intern Med 2003;138: 273-87.
Baicker K, Chandra A. Medicare spending, the physician workforce, and beneficiaries' quality of care . Health Aff (Milwood) 2004; Apr 7. http://content.healthaffairs.org/cgi/reprint/hlthaff.w4.184v1.pdf (accessed 24 Feb 2004).
Wennberg JE. Perspective: Practice variations and health care reform: connecting the dots. Health Aff 2004;Suppl: VAR-140-VAR-144.
Majeed A, Evans N, Head P. What can PACT tell us about prescribing in general practice? BMJ 1997;315: 1515-9.
US Department of Health and Human Services. Healthy People 2010. 2nd ed. Washington, DC: US Government Printing Office, 2000.
Black D. Inequalities in health: report of a research working group. London: Department of Health and Social Security, 1980.
Acheson D. Independent inquiry into inequalities in health: report. London: Stationery Office, 1998.
Senn S. Individual response to treatment: is it a valid assumption? BMJ 2004;329: 966-8.
Mushlin AI, Appel FA. Testing an outcome-based quality assurance strategy in primary care. Med Care 1980;18: 1-100.(Barbara Starfield, university distinguis)