More than half of Americans with chronic illnesses did not fill prescriptions, skipped doses of their medications, or didn't see a doctor for a medical problem because they could not afford to, a new study showed.

In a survey of some 7,500 people with chronic diseases in eight industrial nations, 54% of U.S. respondents said they had skimped on recommended care during the previous two years because of costs, reported Cathy Schoen, M.S., of the Commonwealth Fund here, and colleagues online in Health Affairs.

But the U.S. respondents were also much less likely than residents of other countries to report waiting two months or longer to see a specialist.

"The United States continues to stand out for more negative patient experiences, ranking last or low for access, care coordination/efficiency, and patient-reported safety concerns," wrote Schoen and colleagues.

"The United States did comparatively well on measures of transitional care during hospital discharge, and responses were more positive on some items related to patient-centered care (for example, setting goals and priorities)," the researchers added. "Yet U.S. patients often cannot afford to follow recommended care."

The other countries included in the study were Australia, Canada, France, Germany, the Netherlands, New Zealand, and Great Britain. The survey was based on telephone interviews conducted earlier this year.

Results were adjusted to reflect the published demographic distributions in each country.

Among the 1,007 U.S. respondents with chronic diseases, the following percentages reported specific cost-related access problems in the previous two years:
* Did not fill a prescription or skipped doses: 43%
* Did not visit a doctor for an incident medical problem: 36%
* Did not get a recommended test, treatment, or follow-up evaluation: 38%
In each category, the U.S. figure was significantly higher than in any other country (P<0.05).

The rate of unfilled prescriptions and skipped doses was more than double that of any other country. The nation with the next highest percentage was Australia at 20%. Dutch citizens appeared to have the least problems with cost-related barriers to care, with only 7% of respondents saying they had reduced or avoided seeking care because of the expense.

The survey also confirmed that Americans pay more out-of-pocket for healthcare than people in other developed countries. Some 41% of U.S. respondents said they had more than $1,000 in out-of-pocket expenses, compared with 4% to 25% elsewhere (P<0.05 for all).

Americans were also more likely than anyone except Australians and Canadians to say they had sought care at an emergency room for a problem that could have been treated elsewhere.

Among U.S. respondents, 19% said they had gone to an emergency room for non-urgent care, compared with 23% of Canadians (P<0.05), 17% of Australians (not significant), and from 6% to 9% of residents of the other five nations (P<0.05 relative to the U.S.).

Americans were also more likely to report having experienced problems in several categories of patient-perceived medical errors, the researchers said. About 14% of American said they had received the wrong drug or the wrong dose -- significantly (P<0.05) more than European and Canadian respondents.

Delays in notification of abnormal test results were also more commonly reported in the U.S. than elsewhere, at 16% versus 5% to 13% (P<0.05 except for Australia, which was second to the U.S. at 13%).

Coordination between different types of providers also seemed to be poorer in the U.S., the researchers found.

For example, American patients were substantially more likely to say records and test results were not available at a scheduled appointment and that they were given duplicate tests.

Perhaps contributing to the coordination problems was a high rate of polypharmacy among American respondents.

Nearly half of American patients (48%) reported taking four or more prescription medications, substantially more than any other country except Britain (50%). Next highest was Canada, where 41% of respondents said they had that many prescriptions.

But the U.S. also fared better against the other nations in important respects.

For example, only 10% of American respondents said they had to wait two months or more for a specialist appointment, compared with 20% to 42% in the other seven countries (P<0.05). Long waits were most common in Canada (42%), Great Britain (33%) and New Zealand (33%).

In addition, U.S. patient satisfaction with their care after discharge from a hospital was relatively high. Only 38% identified gaps in care or communication after discharge, lower than any other nation in the survey (50% to 71%).

And just 9% of Americans who had been hospitalized said they did not receive a written care plan at discharge, compared with 31% to 43% of respondents elsewhere.

Nevertheless, the authors took an overall dim view of the U.S. system.

"U.S. patients appear at particularly high risk as a result of coverage gaps and poorly organized care," they wrote. "Chronically ill patients in countries with strong primary care infrastructures tend to fare better."

But Schoen and colleagues also noted that every country had problems of one sort or another.

"Canada continues to face capacity restraints in both primary care and access to specialists," they noted.

They also pointed out that, although the Netherlands had the lowest cost-related barriers to care, post-hospitalization care seemed relatively neglected there, as seen in high rates of complications and readmissions following discharge.

The authors noted that the study was limited by its reliance on respondents' self-reports of diagnoses, medication usage, and problems.