The US is unique among its industrialised country peers in that it has no universal health coverage, fragmented provision of care and a hybrid system in which most health care is delivered privately, even where it is publicly financed. Some 27.3m Americans were uninsured in the first quarter of 2016, equivalent to 8.6% of the population, down from 9.1% in 2015.1 The federal government accounted for 28% of spending while state and local governments accounted for 17%.2
The Economist Intelligence Unit created an eight-country scorecard, which contains indicators of importance to the management of atopic dermatitis, a chronic skin disease that can have psychological impacts on patients. The Atopic Dermatitis (AD) Scorecard looked at 12 policy indicators, addressing a range of factors, including the provision of care and support for patients and caregivers (see below for the full scorecard results for the US).
The US was the only one of the countries surveyed for which statistics on “lifetime prevalence” of AD were unavailable (although other types of prevalence data are available). Estimates of lifetime prevalence of AD range from 3.2%, based on analysis of healthcare claims data from the public and private sectors,4 to 4.9% in a study using web-based surveys.5
Health providers have guidelines from the American Academy for Dermatology (AAD) for assessing the severity of AD,6 but these have yet to be validated. There have been efforts to determine the economic impact of the disease on patients, with one recent study finding that the total mean annual per-patient direct medical costs were US$9,782 higher for patients with AD than for those in a non-AD control group.7 The study also found that AD patients had a significantly increased risk for arthritis, asthma and nasal allergies.
AD patients can face a range of other burdens because of their condition, including increased rates of anxiety and depression, especially in those with severe AD.4 These co-morbidities contribute to high cost burdens for emergency room visits, prescriptions and over-the-counter treatments, as well as the broader impact of reduced work productivity and health-related quality of life.
According to the scorecard, the US system lagged most sharply behind other countries in the provision of primary healthcare training and awareness programmes, and patient education programmes. By contrast, it performed better in the areas of quality of life measurement and in the number of dermatologists serving the population. As the scorecard shows, the US does better in recommending the use of guidelines for measuring quality of life for AD patients, receiving the top score in this category.6
Provision of care
Although it has 3.6 dermatologists per 100,000 population, one of the higher proportions of the eight countries studied, the US scores in the middle of the survey group with regards to multidisciplinary care, with AAD guidelines merely referring to the need for a multidisciplinary approach. This is despite the fact that studies have showed some improvement in both adult and child AD patients involved in multidisciplinary treatment programmes.8
Despite the comparatively high number of dermatologists, however, the average wait times for a dermatology appointment is 32.3 days, according to one estimate,9 with significant regional discrepancies.
As the waiting times mentioned earlier reflect, making an appointment with a dermatology specialist can be challenging. Some have argued that the demand for cosmetic dermatology is filling many of the time slots for dermatology specialists, who prefer the procedures because they are generally not covered by insurers and require patients to pay up front.9
Awareness and advocacy
Primary healthcare professional training on AD has been identified as a key factor in boosting patient outcomes and quality of life.10 Yet, in common with most of the other countries surveyed, the US performs poorly in this category, receiving a score of zero. While US medical schools require an average of ten hours of dermatology training, this accounts for less than 0.3 % of the total curriculum; the Accreditation Council of Graduate Medical Education requires exposure to dermatology as part of its Family Medicine residency curriculum, but no similar requirement exists for internal medicine residents, with only 14% of this group receiving at least a month of clinical dermatology training.11 Although the AAD website contains a number of discussions and learning modules related to the basic dermatology curriculum, it wasn’t immediately clear how much of this covers AD in particular, or is targeted towards primary care.12
There have been some pilot projects aimed at providing training and other resources to primary care providers.13 One group of researchers designed an algorithm to help primary care providers learn more about AD and manage the condition in paediatric patients; researchers concluded that the model helped to improve physician knowledge, although the study included only a small sample group.14
Advocacy organisations also seem to devote few resources to educating health providers. The National Eczema Association provides medical professionals accessing its website with a series of brief fact sheets on the condition, with more of the information oriented primarily toward patients and carers.15
The US does substantially better in the area of AD patient advocacy and support, receiving the highest score in this category.16
Full scorecard results for The US are available in the downloadable article
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