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Cathy Schoen, Robin Osborn, Sabrina K.H. How, Michelle M. Doty, and Jordon Peugh In Chronic Condition: Experiences Of Patients With Complex Health Care Needs, In Eight Countries, 2008 Health Affairs, January/February 2009; 28(1): w1-w16. [Abstract] [Full Text] [Figures Only] [PDF] [Reprints & Permissions]

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Questions About Study Results

Kathleen M. McInnis, MS, RN   ( 17 November 2008 )

Interpreting Survey Results

Carmel M. Martin   ( 2 December 2008 )

Questions About Study Results 17 November 2008
Kathleen M. McInnis, MS, RN, Legal Nurse Consultant Professional Legal Nurse Consulting Send comment to journal: Re: Questions About Study Results katmci{at}frontier.net Kathleen M. McInnis, MS, RN	As a nurse studying health policy, I read the Reuters article reporting your study with interest. I had many questions about the study, so I found the entire article in Health Affairs online. I still have comments. (1) How can you generalize these study results to the entire United States with such a small study sample? Even though your sample was randomized, that number is minuscule when considering that the U.S. population is 300 million and that 45 percent of the population has a major chronic illness (Partnership to Fight Chronic Disease, 2008). (2) In your original article, you state that all countries in the study have strengths and weaknesses and that all countries need to improve in some areas. In the Reuters article, the strengths of the United States are left out, as are the weaknesses of the other countries. While this study highlights problems and indicates the need for further study, and the U.S. has some major weaknesses in its health care system, I was disappointed that the Reuters article appeared so biased. It did not recognize or report that these results may not be representative of the whole population.
Interpreting Survey Results 2 December 2008
Carmel M. Martin, Associate Professor Northern Ontario School of Medicine Send comment to journal: Re: Interpreting Survey Results carmelmarymartin{at}gmail.com Carmel M. Martin	Congratulations to the Commonwealth Fund for this second survey of sicker adults in 8 countries in 2008. However, that does not mean that results can be immediately generalised as evidence for health system performance in the participating countries. As a Health Services Researcher and a practising Family Physician who has trained in the U.K. and Australia, and recently worked in clinical practice in Canada, the U.K., and Australia, it is clear to me that cultural differences among patients and contextual differences in health systems are very entrenched and important considerations. These may be overlooked in indicator surveys. For example, Australian patients have highly developed consumer awareness, having a history of being able to shop around for the care they want. In contrast, U.K. patients have had little choice and have what I perceive to be lower expectations and an apparent passive acquiescence to what the health system has to offer. Similarly many constructs examined in the survey, such as "access," are different in different contexts. While people in the U.K. may have apparently easier access, that may be because of the way the system is engineered, and may conceal other access barriers. In many U.K. practices, the ability to make a follow-up appointment after a chronic care or any other GP visit is limited, so that people with chronic conditions have to ring up close to their appointment date and make a follow-up appointment. This is compared to Australia and Canada, where people can make an appointment at the time of the visit. Other areas that need closer analysis and examination of underlying assumptions include the use of the Chronic Care Model uncritically as a service template rather than as a conceptual framework for chronic care. The list goes on. Again, I think that this survey is an excellent barometer or indicator of what is happening in complex chronic care. However, I have fears that decisionmakers with health service entrepreneurs take the findings at face value to shift health care in individual countries in accordance with a particular agenda of health system control. It is important to build change and improvement on local culture and existing system contexts and successes, based on in-depth analysis of existing strengths as well as apparent shortcomings. In my experience, this is particularly the case for Australia, where patients have high expectations with a strong health care consumer philosophy. Governments and leading academics see a U.K.-type model or a U.S. managed care version of the Chronic Care Model as a panacea for reform, without understanding also the many unintended consequences concealed behind statistics. Indicators are a warning light that draw our attention to areas of concern, but they need detailed study, often additional in-depth research, and very careful interpretation, before they are evidence for policy change.