What Can We Learn from Studies of Medical Care in Other Countries?

Forty years ago I was shown proprietary data from a pharmaceutical company that listed the 10 most popular drugs in several European countries and the United States. The striking finding was how little overlap there was among the different countries. In the United States it was antibiotics, antidepressants, and tranquilizers. The German list was dominated by suppositories. Italy had hormonal preparations for both men and women. The most popular French drugs focused on the liver. This was my first lesson on the benefits of cross-national research. It was important to realize that the French seemed to get along perfectly well without all these antibiotics we prescribed, and we did not appear to suffer from our lack of liver medications. It showed me that the practice of medicine, as opposed to the practice of science, was in large part culturally determined. After several decades of globalization, that is less true today than in the 1980s, but the benefits of cross-national research remain.

The report by Pfaff and colleagues¹ in this issue of JAMDA describes a post-acute care trajectory for frail older adults very different from that found in the United States. First off, their cohort start with older patients discharged from Swedish geriatric hospitals, an entity no longer found in the United States.² These geriatric hospitals treat both acute and chronic problems. Admissions can come directly from the community, or via transfer from hospitals that treat higher acuity patients. Thus, the Swedish geriatric hospital has some characteristics similar to what we call skilled nursing facilities, but with the capacity to care for sicker patients.

From the geriatric hospital, 11% of the cohort go to nursing homes, 35% are discharged home with no home care, and the remainder go home with home care, consisting of personal care and housekeeping. The amount of home care was based on need, with a median of 51 hours provided each month. The major finding was that those with higher amounts of in-home services had lower readmission rates. This finding makes sense, and the analyses that produced it had the appropriate controls. Furthermore, the association of higher in-home services with lower readmission rates flies in the face of large selection biases—sicker patients tend to get more home care and also tend to get readmitted—which strengthens the argument for causality. That is a very important finding. Providing personal assistance—the type a family might provide—prevents readmissions.

The post-acute care system in Sweden described by Pfaff et al is so very different from the US (and Canadian) systems, and it led me to read more about the systems in other countries. What follows is a list of lessons I learned in reviewing selected systems for providing in-home care around the globe.

One lesson is that it is important when evaluating medical systems to distinguish between the limits of a particular system from the limits of funding. A well-designed system will still fail if underfunded. I have long admired the organizational structure of the National Health Service in Great Britian,³ but years of underfunding have rendered it dysfunctional. The model of care is not to blame.

A second lesson is that coordination of care after hospitalization must be very difficult, because fragmentation of care is a common complaint even with well-designed, well-funded systems.^4–8 In Sweden, help in the home is funded by municipalities whereas health care services are funded regionally.¹ This can lead to all the problems stemming from poor coordination, including duplication of services and missed opportunities for effective intervention.⁴

Another lesson is the enormous administrative costs associated with home care in the United States. Administration eats up 40% of total expenditures on home care in the United States, $38.5 of the $97 billion spent on home care by different insurers.⁹ This 40% can be compared to a 13% rate of administrative costs in Canada. We do not provide much by way of home care services in the United States, but we administer the heck of it, as many of us and our patients and their families can attest.¹⁰ That comes to about $26 billion in excess administrative costs, compared to Canada, for home care in the United States. Readers are invited to imagine alternative, more impactful uses for those funds.

The last and most important lesson is that some countries understand that in-home care is all about the caregiving. There are clear limits to the medical model in caring for very old, very frail individuals.¹¹ In the United States, we have little problem sending out a physical therapist twice a week, and that is good, but our recently hospitalized patients are mostly on their own when it comes to shopping, or cooking, or remembering to take their pills, and that is bad. What allows some frail individuals to stay at home are help with taking their pills, meal preparation, shopping and companionship. The various European systems I reviewed provide those services for those who need them.⁴ In general, the United States does not, particularly in the post-hospital setting.

Perhaps the report by Phaff et al will nudge some of the many state, federal, and commercial funders of medical care toward a more human understanding of what goes on after sick, frail older individuals are discharged home, and toward an understanding of the value of the mundane but absolutely essential interventions that help keep them at home.