Patient-centered care Sweden Docteur

Granskar vård och omsorg

Myndigheten för vårdanalys 7/3/12 Sid 1

Patient-centeredness in Sweden’s
health system – an external
assessment and six steps
for progress


Elizabeth Docteur

•  Independent health policy consultant with 20 years’ experience
•  Positions in the U.S. federal government, the international arena,
the private sector and civil society.
•  Previous Deputy Head of the Health Division at the Organization for
Economic Cooperation and Development (OECD)
•  Previous Vice President and Director of Policy Analysis at the Center
for Studying Health Systems Change


Angela Coulter

•  Director of Global Initiatives at the Foundation for Informed Medical
Decision Making, Boston
•  Senior Research Scientist at the Department of Public Health,
University of Oxford
•  Previous Chief Executive of Picker Institute Europe
•  Previous Director of Policy and Development at the King’s Fund

Professor Coulter has published more than 250 research papers and reports and
several books including Engaging Patients in Healthcare (2011) and The
Autonomous Patient (2002)
In January the Donabedian Foundation at Barcelona University awarded her the
2012 Donabedian International Award in health care quality for her work on patient-
centered care.


Patient-centeredness in Sweden’s
health system – an external
assessment and six steps
for progress


What is patient-centered care
and why is it important?

•  Patient-centered care anticipates and responds to the needs and
expectations of individual users and potential users of health services.
•  Patient-centered care produces better patient experiences and is
associated with better health outcomes. Can also assist in reducing
costs via channels such as better patient compliance with prescribed
treatments and fewer errors, duplication, problems; shorter hospital
stays; quicker return to work.
•  Making health systems more patient-centered is increasingly recognized
as a critical performance goal (OECD, WHO), one of six aims for quality
improvement put forward by US Institute of Medicine


Objectives of this study:
The questions from Vårdanalys

•  What framework can be used to assess the extent to which Sweden’s
health care system is patient-centered?
•  To what extent is Sweden’s health care system patient-centered?
•  What changes in policy could help to strengthen patient-centeredness in
Sweden’s health care system?


The framework - what we did:
Phase 1 – Select framework for assessment and operational plan

•  Review work on patient-centered health care by researchers,
international organizations, patient groups
•  Define an appropriate framework for assessing and benchmarking
performance in Sweden and internationally
•  Identify indicators and data to use
•  Obtain input and feedback from expert advisory group


The assessment – what we did:
Phase 2 – Conduct assessment of patient-centeredness in
Sweden’s health system

•  Interview 34 Swedish experts (patient representatives, government
officials, academic and other experts)
•  Analyze data on patient experiences from Sweden’s National Patient
Survey and International Health Policy Survey
•  Review academic research and policy literature, government reports
and relevant laws
•  Develop policy recommendations driven by main conclusions
•  Obtain input and feedback from expert advisory group


Framework for assessment


Overall assessment

“Overall, our assessment revealed a number of shortfalls in
terms of achieving patient-centered care in Sweden’s
health system. At the same time, we found evidence of
progress in a number of areas. Also, the system benefits
from a number of strengths that provide a good foundation
on which to build when making needed effort to accelerate
progress. Yet there are barriers that have impeded
progress; tackling these can help to accelerate change.”


Dimension 1:
Empowering patients through information and education

Sweden has made good recent progress in strengthening
and improving legislation pertaining to patient information
and education. Nevertheless, important gaps in information
and education are evident, in terms of how well those
efforts have paid off in patients’ understanding and
satisfaction with the information and education obtained.


Dimension 1:

100% Percentage of patients
answering the most preferable
90% answer on each question
concerning information and
education (unweighted index).
80%
79% Source: IHP International
77% 77% Survey of Sicker Adults (2011)
70%
72% 71% 70%
69%
60% 65%
60%
58%
50%
53%

40%

30%

20%

10%

0%
ia a s y ce n y
UK nd US an
d al ad nd an an de wa
la al tr n la m Fr we or
er us Ca er er S
itz Ze A eth G N
Sw ew N
N


Dimension 1:

•  Legal obligation to provide individually tailored
information about condition and available treatments,
choice of provider and guarantee is often not met.
•  Swedish patients more likely than others to say their
doctors do not spend enough time with them, do not
present options for treatment, do not give them
opportunities to ask questions.
•  Swedish patients say doctors often fail to tell patients
about the side effects of their medicines and the danger
signals to watch out for.
•  Large cross-county variation in psychiatric care, inpatient
specialist care.


Dimension 1:

•  Relatively good telephone access
•  Information portals (internet and telephone) are
improving, being used.


Dimension 2:
Respecting patients’ individual needs, preference and values

Sweden’s health care system very often fails to anticipate
and respond to patients as individuals with particular
needs, values and preferences. Failure to meet patient
expectations can have demonstrable costs to patients, the
health system and the public purse.


Dimension 2:

90% answer on each question
concerning preferences and
needs (unweighted index).
80%
Source: IHP International
70% 74% Survey of Sicker Adults, 2011.
71%
69%
60% 65% 64%
62% 61%
57%
50%
51%
40% 46%
42%

30%

20%

10%

0%
ia a s y ce n
UK nd US d l ad nd an ay de
la an tra n la an w e
er al us Ca er er
m Fr or Sw
i tz Ze A eth G N
Sw ew N
N


Dimension 2:

•  In international comparisons, Swedish patients are least
likely to be engaged by their health care providers in their
care and treatment decisions. The concept of shared-
decision making has yet to take root in Sweden and there
is little use of decision aids.
•  Low patient engagement is associated with worse
outcomes, including medical errors.
•  Patients are not viewed as a source of expertise and
information regarding their condition and needs.
•  Swedish health care is said to be organized for
administrative convenience, rather than convenience of
patients (and providers).
•  Psychiatric patients are particularly dissatisfied with their
experience.


Dimension 2:

Swedish patients report that their health care
providers treat them with respect and
listen to them.


Dimension 3:
Coordinating care across service providers and
ensuring continuity of care

Inadequate coordination care across health-care providers
is an important weakness in Sweden’s health system. Such
problems are likely to have a negative impact on health
outcomes and costs, in addition to having a negative
impact on patient experienced quality of service.


Dimension 3:

answer on each separate
90%
question concerning
coordination and continuity
80% (unweighted index).

SOURCE: IHP International
70% 74% Survey of Sicker Adults (2011).
69%
60% 65% 64%
62%
60%
57%
50% 54%
52%
50% 49%
40%

30%

20%

10%

0%
a ia s ay e en y
UK US nd nd ad al nd nc d n
la al
a an str la or
w
Fr
a
we ma
er Au er er
itz Ze C
eth N S G
Sw ew N
N


Dimension 3:

•  Poor international performance with respect to
coordination; mediocre performance in terms of poor
outcomes associated with coordination problems
•  Inadequate cooperation among health care providers and
between health and social services
•  Technical problems in the function of electronic medical
records that impede their full use for coordination
•  Problems for vulnerable populations, such as the sickest
elderly, patients with rare conditions.


Dimension 4:
Taking a holistic approach to patients as people with medical,
social, emotional, psychological and spiritual needs

Some problems in taking a sufficiently holistic approach to
patient care are evident, with relatively little variation in
performance across counties.


Dimension 4:
Taking a holistic approach to patients as people with medical,
social, emotional, psychological and spiritual needs

•  Specialist physicians, hospital staff, and hospital
administrators can do more to take a sufficiently holistic
view of patients, so as to better meet their needs.
•  Need to look at how well spiritual needs are met (some
evidence of problems) and how best to meet needs in a
secular, multicultural society.
•  Relatively low performance variation across counties
suggests that this may not be an area in which the
administration of health care services by the county
councils has a particular impact.


Dimension 5:
Involving family and close friends in the health care experience

While evidence regarding patients’ experiences in involving
family and close friends in their health care is relatively
limited in depth and scope, available data suggests that
there is room for improvement in this area. Several types of
potential problems benefiting from further exploration were
identified in the course of the present study.


Dimension 5:
Involving family and close friends in the health care experience


Facilitators and barriers
to a more patient-centered health care in Sweden

•  Achievements of Sweden’s health care system support a
focus on patients
•  Potential to exploit an impressive array of patient data
•  Patient-centeredness is a public priority
•  Developing efforts to track performance in achieving
patient-centeredness



•  Enhanced choice may spur a more patient-centered care,
but will not suffice for all patients
•  Existing patient protections and guarantees are valuable,
but need to be strengthened and enforced
•  Local administration of health services has both benefits
and disadvantages for patient-centeredness



•  Evident challenges from cost-containment pressure
(e.g., constraints on time spent with patients)
•  Need to accelerate attitudinal changes


Policy recommendations:
Six steps toward a more patient-centered care

1  Ensure compliance with existing “patients’ rights”
2  Establish patients as full partners with their providers with a role in
health and care decisions
3  Engage and involve patients and their representatives in health policy
and administrative decisions
4  Sustain efforts to facilitate coordination and continuity of care (through
remuneration changes, improvement of health ICT, etc…)
5  Define a model of patient-centered health care that reflects the
priorities of Swedish patients
6  Strengthen efforts to assess and track patient centeredness


Patient-centered care Sweden Docteur

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