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Background: More than 5 million patients in the United States and 15 million patients in Europe are currently living with heart failure, with the rate of new cases projected to rise each year. Heart failure is a devastating and costly disease that accounts for over $39 billion dollars in health care expenditures in the United States and 2% of the overall national expenditures on healthcare in Europe. In a controversial assessment conducted by the World Health Organization in 2000, France was ranked as the number one healthcare system in the world, with the United States ranking at a distant 38. While the United States is in a transitional stage between private insurance and government health insurance via the Affordable Care Act, French citizens receive government insurance through a system of social security that covers nearly 100% of healthcare costs for chronic disease. Although the U.S. and French healthcare systems differ on many aspects, care coordination has seen as a major component within high performance healthcare systems. In addition to these facts, it has been argued that better care coordination has the potential of improving health system performance, not only in terms of quality but also cost-efficiency. One of the major failures in care coordination is the poor transmission of information between providers that has led to a suboptimal provision of care. In the U.S., for instance, less than half of patients with heart failure leave the hospital with clear instructions and follow-up care procedure. Hence, understanding what main drivers of success and failure in terms of care coordination in heart failure can potentially result in a more effective and efficient provision of care.
Methods: This study utilized a multi-site mixed-methods research approach to compare the U.S. and French healthcare systems in terms of their care coordination capabilities. A multidisciplinary team composed of nursing and engineering scientists and professionals was put in place to design and conduct the multi-site study. The framework used was divided into four main phases: 1) Conducting in-situ observations to the Hershey Medical Center in Pennsylvania and Henri Mondor in Paris; 2) Qualitative semi-structured interviews along with focus groups with key healthcare stakeholders including physicians, nurses, nurse practitioners, case managers, and social workers at the two sites; 3) Quantitative questionnaires including multiple choice and Likert’s scales with different healthcare stakeholders, and 4) Initial assessment of the findings using quality improvement tools to categorize and identify main strengths, weaknesses, and barriers of care coordination at both sites. The results provide a baseline for sharing best practices and lessons learned across the U.S. and French healthcare systems.
Results: The United States and France have vastly different approaches to tackling heart failure care delivery and coordination. With recent penalties instituted by Medicare for heart failure readmissions within 30 days, much attention has been dedicated to addressing the care coordination of heart failure patients in the United States. Cardiologists and heart failure clinics manage the majority of heart failure care. Advanced practice nurses have a bigger role than ever in managing outpatient care via clinic visits, transitional care programs, and the use of telehealth. In France, nurses are employed as civil servants and are viewed as more vocational than as college educated professionals. Staffing ratios in France are starkly different, with approximately 35 patients being managed by three nurses and two nurse’s aides. A beginning nurse’s salary in France ranges from approximately $1,300 to $1,400 per month, after taxes, and French physicians make around 60% of what American physicians are paid. Additionally, mild to moderate cases of heart failure are generally managed by the primary care physician in France as opposed to a cardiologist. However, the French healthcare system allows citizens to choose their physician without the constraints of an insurance network, so physicians, specialists, and facilities must be increasingly mindful of their performance in order to stay competitive. Cardiologists are one of the most populous specialties in France, so wait times for appointments are often less than a week. Therefore, French patients have easy access to specialists and hospitals and are less likely to forgo healthcare than an under-insured American.
Conclusions and Implications: Both countries have much to learn from each other regarding healthcare delivery and care coordination of heart failure patients. Our approach serves as the baseline or roadmap for process and care coordination improvement. Heart failure is a major public health problem in both countries, with cases continuously on the rise. Although the structure of the French healthcare system allows for easy access and high reimbursements of medical costs, there is increased recognition that the cost of heart failure is too high in relation to hospitalizations and the duration of inpatient stay. This could potentially be addressed by increasing the role of nurses and by adding more educational references for the French public. France does not have internet sites dedicated to heart failure education the way the United States so commonly does. Conversely, the United States would benefit from a government insurance system in which every citizen was provided with healthcare coverage and the ability to choose their providers. This could increase the number of visits for preventative care rather than the majority of healthcare dollars going to emergency and inpatient visits.
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