The Commonwealth Fund 2024: New Zealand Healthcare Performance Analysis

Criteria for Selecting Health Indicators

Choosing a proper measure is essential when evaluating health outcomes, access, quality, equity, or efficiency within a health system. To be effective, a good indicator must meet the following four criteria:

1. Clearly related to the concept: The measurement must directly reflect the specific aspect of health or care being studied.

2. Measurable: The indicator must be quantifiable with available tools and data.

3. Controllable by the health system: The variables being measured should be within the influence or control of health policy and practice.

4. Consistent data collection: Data must be gathered in a uniform way over time and across different regions to allow for valid comparisons.

Conceptual Example: Measuring Speed

To illustrate the complexity of measurement, the lecture poses a rhetorical question: "What's the best measure of the speed of a car?" This serves to highlight that even seemingly simple concepts require specific, standardized metrics to be useful.

Case Study: Maternal Mortality Measurement Challenges

A critical example of measurement failure and its consequences is the reported maternal mortality rate, defined as the reported annual death rate from maternal conditions per $100,000$ women and girls.

United States vs. International Trends

• Statistics based on the WHO Mortality Database ($2022$) show that between $2003$ and $2017$, maternal mortality appeared to more than double in the United States, while remaining static in other countries such as Canada, the United Kingdom, and France.

• The Reporting Issue: This spike in the US was largely attributed to shifts in data collection methods rather than a sudden decline in clinical safety. Specifically, the introduction of a "pregnancy checkbox" on death certificates led to the capture of data that was previously missed by standard death certificate narratives.

• Data Limitations:

  • Reported figures often include late maternal deaths occurring up to $1$ year after the end of pregnancy.

  • Official statistics likely represent a lower number than the true total due to limited reporting.

  • Metrics are age-standardized to allow for cross-country and temporal comparisons, yet not all deaths in every country are registered with an official cause of death.

Overview of the Commonwealth Fund

Organizational Background

• Origins: Despite the name, it is not related to the Commonwealth of Nations (the group of former British colonies). It was founded in $1918$ by Anna Harkness, an American philanthropist.

• Mission: The fund was established to improve healthcare in the United States, with a specific focus on low-income individuals, the uninsured, and racial minorities.

• Historical Impact: The fund supported significant medical advancements, including the development of the Pap test for cervical cancer.

Methodology: International Surveys

The Commonwealth Fund conducts surveys both within the US and internationally. International reports have been issued in $2007$, $2010$, $2014$, $2017$, $2021$, and $2024$.

• Target Groups: Surveys target the general public, specific groups of sicker patients, and healthcare professionals (doctors and others).

• Participating Countries: Australia, Canada, France, Germany, Netherlands, New Zealand, Sweden, Switzerland, United Kingdom, and USA.

• Temporal Context: The $2024$ report focuses on data collected since $2020$, which means findings are heavily influenced by the global impacts of COVID-$19$.

New Zealand Performance: Quality of Care Processes

Quality is measured through four sub-categories: Preventive Care, Safe Care, Coordinated Care, and Engagement/Patient Preferences.

Measured Metrics

• Preventive: Discussions about smoking cessation or health risks of alcohol; mammography screening for women aged $50$-$69$.

• Safe: Patient access to online test results; medication review for those on $2$ or more prescriptions.

• Coordinated: Timeliness of specialist reports to primary care physicians (PCPs); coordination with social/community services.

• Engagement: Whether doctors spend enough time and explain things clearly; discussions of goals/priorities with chronically ill patients.

Findings for New Zealand

• The Good:

  • $46\%$ of patients talked with providers about smoking risks/quitting.

  • $20\%$ discussed alcohol use with providers.

  • $78\%$ had a regular review of medications.

  • $84\%$ initial COVID-$19$ vaccination rate.

  • $89\%$ feel regular doctors treat them with respect.

  • $85\%$ of PCPs are notified when a patient is seen in the Emergency Department (ED).

• The Bad:

  • Measles vaccination for children (aged <$1$ year) is low at $90\%$.

  • $16\%$ of patients felt treated unfairly or that concerns were not taken seriously.

  • $70\%$ of PCPs reported feeling burned out.

  • $77\%$ of PCPs report the quality of care has worsened since COVID-$19$.

  • Only $11\%$ of PCPs frequently communicate with home-based nursing providers.

New Zealand Performance: Access to Care

Access is split into Affordability (cost-related problems) and Availability (timeliness and after-hours care).

Findings for New Zealand

• The Good:

  • Only $6\%$ report issues with insurance not paying as much as expected.

  • $90\%$ of primary care practices have arrangements for after-hours care.

• The Bad:

  • $48\%$ of New Zealanders reported cost-related access problems for medical or dental care in the last year.

  • Only $11\%$ of patients wait less than one week for a specialist appointment.

New Zealand Performance: Administrative Efficiency

Efficiency measures the burden of paperwork, disputes, and system-level hurdles experienced by both doctors and patients.

Findings for New Zealand

• The Good:

  • Only $38\%$ of doctors report significant problems securing treatment for their patients.

  • Only $5\%$ of doctors complain about excessive time spent on paperwork or billing disputes.

• The Bad:

  • $33\%$ of patients visited the ED for a condition that could have been handled by a regular doctor if they had been available.

New Zealand Performance: Equity

Equity measures the gap between below-average and above-average income earners regarding quality and access, as well as experiences based on race/ethnicity.

Findings for New Zealand

• The Good: No clear issues found regarding equity between men and women compared to other countries.

• The Bad:

  • New Zealand has the highest income-related differences in reported cost-access for low-income people.

  • Low-income patients report doctors are less likely to know their medical history and less likely to take their concerns seriously.

  • $45\%$ of PCPs report unfair treatment of patients by ethnicity.

  • $59\%$ of PCPs report that patients have told them their concerns were ignored or they were treated unfairly due to ethnicity.

  • Affordability issues are significantly larger for rural residents compared to urban New Zealanders.

New Zealand Performance: Health Outcomes

Outcome measures include life expectancy, avoidable mortality, and excess deaths.

Findings for New Zealand

• The Good: Very low excess deaths associated with COVID-$19$.

• The Bad: Treatable mortality (deaths that could have been avoided through timely and effective healthcare) is higher in New Zealand than in most other surveyed countries.