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Unwarranted Variation: Expanding the Agenda for Rebuilding the Health Care system in Louisiana January 16, 2007 REDESIGNING 10 th Annual Health Care Forum on Health Care Effectiveness LSU
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Unwarranted Variation: Expanding the Agenda for Rebuilding the Health Care system in Louisiana
January 16, 2007
REDESIGNING
10th Annual Health Care Forum on Health Care Effectiveness
LSU
2
Backdrop
3
Agenda
Unwarranted Variations
From Regions to Hospitals in Baton Rouge and New Orleans
Pushing the envelope
4
Unwarranted Variation Defined
Unwarranted? Variations that cannot be explained by:– Illness, need, dictates of evidence based medicine or patient
preferences
Categories of variation– Effective and safe care
– Preference sensitive care
– Supply sensitive services
Causes and remedies differ for each category
5
Dartmouth Atlas of Health Care:United States Hospital Referral Regions (HRR)
6
Shape of the Benefit-Utilization Curve: Effective Care & Patient Safety
Benefit to Patients
Intensity of Effective Care
U.S. Is Somewhere in This Zone
7
Percent of “Ideal” AMI Patients Receiving Beta Blockers at Discharge Following AMI
0.0
20.0
40.0
60.0
80.0
100.0
Percent of “Ideal” Patients Receiving Beta Blockers
at Discharge
8
9
Shape of the Benefit-Utilization Curve: Preference-Sensitive Care (e.g. Revascularization)
Benefit to Patients
Intensity of Preference Sensitive Care
10
Rates of Coronary Artery Revascularization Procedures Compared to Ontario, Canada
3.0
6.0
9.0
12.0
15.0
18.0
21.0
Cardiac Revascularization
(1994-95)
Ontario Benchmark
11
Randomized Trial of the Coronary Artery Disease Shared Decision Making (SDM) Video, Ontario, Canada
58%
75%
CAD-SDM Controls
Revascularization Decision (p = 0.01)
% Choosing Revascularization
Morgan MW, et al., JGIM. 2000; 15:685-93.
12
Shape of the Benefit-Utilization Curve: Supply-Sensitive Services
Benefit to Patients
Intensity of Supply Sensitive Care
U.S. Is Somewhere in
This Zone
13
Hospital Utilization and Local Capacity: Effective Care (Hip Fracture) vs Supply-Sensitive Services (Medical Conditions)
0
50
100
150
200
250
300
350
400
1.0 2.0 3.0 4.0 5.0 6.0Acute Care Beds
Discharge Rate
All Medical ConditionsR2 = 0.54
Hip FractureR2 = 0.06
14
Is more better?
15
Effective Care: Ratio of Rates in Highest vs Lowest Spending Regions
1.00 1.5 2.00.5 25 3.0
1.00 1.5 2.00.5 25 3.0
Reperfusion in 12 hours for AMI
Beta Blockers at admissionAspirin at admission
Beta Blockers at dischargeAspirin at Discharge
Acute MI
Mammogram, Women 65-69
Flu shot during past yearPap Smear, Women 65+
Pneumococcal Immunization (ever)
General Population
Lower in High Spending Regions Higher in High Spending Regions
Exercise Test w/in 30 d
16
Preference-Sensitive Care: Highest vs Lowest Spending Regions
1.00 1.5 2.00.5 25 3.0
1.00 1.5 2.00.5 25 3.0
Coronary Artery Bypass Surgery (CABG)Coronary Angioplasty
Procedures after AMI
Cholecystectomy
Hernia RepairCataract Extraction
Total Hip Replacement
Major Surgery (all cohorts combined)
Total Knee ReplacementBack SurgeryCarotid Endarterectomy
Lower in High Spending Regions
Higher in High Spending Regions
AngiographyAngiography among appropriate cases
17
Supply-Sensitive Care : Highest vs Lowest Spending Regions
1.00 1.5 2.00.5 25 3.0
1.00 1.5 2.00.5 25 3.0
Office Visits
Initial Inpatient Specialist ConsultationsInpatient Visits
Psychotherapy Visits% of Patients seeing 10 or more MDs
Physician Visits
Electrocardiogram
Ambulatory ECG (Holter)Echocardiogram
Diagnostic Cardiology Procedures
Lower in High Spending Regions
Higher in High Spending Regions
Chest X-ray
Ventilation Perfusion ScanCT / MRI Brain
Imaging Tests
18
Supply-Sensitive Care : Highest vs Lowest Spending Regions
1.00 1.5 2.00.5 25 3.0
1.00 1.5 2.00.5 25 3.0
Discharges
Inpatient Days in ICU or CCUTotal Inpatient Days
Hospital Utilization
Inpatient Days
Feeding Tube PlacementICU or CCU days
Emergency Intubation
Care in Last Six Months of Life
Vena Cava Filter
Lower in High Spending Regions
Higher in High Spending Regions
Upper GI Endoscopy
Pulmonary Function TestBronchoscopy
Electroencephelogram (EEG)
Specialist Procedures
19
Relative Risk of Death across Quintiles of Supply Sensitive Services
Decreased Risk
1.00 1.05 1.100.95
ColorectalCancer
Q1Q2Q3Q4Q5
Hip Fracture Q1Q2Q3Q4Q5
MyocardialInfarction
Q1Q2Q3Q4Q5
Increased Risk
20
Decreased Risk
Change in relative risk of death per 10% increment in regional practice intensity: Acute Myocardial Infarction Cohort
1.00 1.02 1.040.98
1.00 1.02 1.040.98
Age < 80Age > 80
Increased Risk
FemaleMale
BlackNon-black
Other location
Non-Q MIAnterior MIInferior MI
Low risk (<15% 1yr)Moderate (15-30%)High Risk (> 30%)
21
Agenda
Unwarranted Variations
From Regions to Hospitals in Baton Rouge and New Orleans
Pushing the envelope
Copyright © Health Dialog Services Corporation 2006. All rights reserved. 22
23
Red Dots Indicate U.S. News’ “Ten Best Geriatric Hospitals”
Supply Sensitive Care: Total Medicare Payments per Decedent During the Last Six Months of Life (1998-2000)
11,000
16,000
21,000
26,000
31,000
36,000
24
Physician Visits During the Last Six Months of Life Among Patients Assigned to Selected Academic Medical Centers
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
NYU Medical Center 76.2
UCLA Medical Center 43.9NY Presbyterian Hospital 40.3Mass. General Hospital 38.8
Cedars-Sinai Medical Center 66.2
Mount Sinai Hospital 53.9
Brigham & Women's Hospital 31.9Boston Medical Center 31.5Beth Israel Deaconess 29.2UCSF Medical Center 27.2Stanford University Hospital 22.6
25
Association Between Hospital Day Rates in the Last Six Months of Life Among 77 Hospital Cohorts for Chronic Conditions
R2 = 0.73 5.0
10.0
15.0
20.0
25.0
30.0
35.0
5.0 10.0 15.0 20.0 25.0 30.0 35.0
Cancer cohort
Con
gesti
ve H
eart
Failu
re c
oh
ort
26
Association Between Total Medicare Payments 18-24 Months and 0-6 Months Before Death
R2 = 0.795,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
1,500 3,500 5,500 7,500
Total Payments 19-24 Mos. Before Death
Total Payment in Last 6 Months
27
R2 = 0.7510
20
30
40
50
60
100 150 200 250 300 350 400
Medicare Medical Admissions
Adult Medical Admissions
Relationship Between Medicare and Health Plan X All Adult Medical Admission Rates
28
Hospital days (Part A) per decedent during the last six months of life (1999-2003)
27.0
18.0
15.0
12.0
9.0
21.0
24.0
National benchmark
Hospital Rates
Lane Memorial Hospital 16.7
North Oaks Medical Center 16.4
Hood Memorial Hospital 16.3
Prevost Memorial Hospital 15.2
Summit Hospital 14.1
National Benchmark 13.9
St Elizabeth Hospital 13.8
Lallie Kamp Regional Medical Center 13.8
Our Lady of the Lake Regional Medical Center 13.6
Pointe Coupee General Hospital 13.3
Baton Rouge General Medical Center 13.1
River West Medical Center 11.4
St Helena Parish Hospital 11.0
Earl K. Long Medical Center 10.8
29
Total physician visits (Part B) per decedent during the last six months of life (2000-2003)
81.0
72.0
45.0
36.0
27.0
18.0
54.0
63.0
National benchmark
Hospital Rates
North Oaks Medical Center 38.5
Summit Hospital 34.3
National Benchmark 33.5
Our Lady of the Lake Regional Medical Center 33.5
Baton Rouge General Medical Center 33.1
Lane Memorial Hospital 30.3
30
Hospital days (Part A) per decedent during the last six months of life (1999-2003)
27.0
24.0
15.0
12.0
9.0
18.0
21.0
National benchmark
Hospital Rates
Chalmette Medical Center 18.0
Pendleton Memorial Methodist Hospital 15.9
Lakeland Medical Center 15.8
Memorial Medical Center – New Orleans 15.2
National Benchmark 13.9
Touro Infirmary 13.9
Ochsner Foundation Hospital
13.1
Tulane University Hospital 12.8
Meadowcrest Hospital 11.5
West Jefferson Medical Center 11.5
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Total physician visits (Part B) per decedent during the last six months of life (2000-2003)
81.0
72.0
45.0
36.0
27.0
18.0
54.0
63.0
National benchmark
Hospital Rates
Chalmette Medical Center 72.7
Lakeland Medical Center 59.9
Touro Infirmary 58.0
Pendleton Memorial Methodist Hospital 52.8
Memorial Medical Center – New Orleans 46.1
West Jefferson Medical Center 43.9
Meadowcrest Hospital 43.6
National Benchmark 33.5
Tulane University Hospital 29.9
Ochsner Foundation Hospital
25.2
Copyright © Health Dialog Services Corporation 2006. All rights reserved. 32
Implications of Katrina in Regards to Unwarranted Variation
The impact of Hurricane Katrina on the heath care infrastructure within New Orleans presents a unique opportunity to design out unwarranted variation.
Copyright © Health Dialog Services Corporation 2006. All rights reserved. 33
Health Dialog Project for the Louisiana Health Care Redesign Collaborative
1. Create a unified data set combining pre-Katrina:• Commercial data • Medicaid data• Medicare data• Uninsured data• VA data
2. Analyze integrated data-set (at patient, market areas – tertiary and primary, and payer (including none)
• Disease prevalence/patterns• Utilization patterns• Cost patterns• Quality patterns
3. Examine geographic differences both within Louisiana, and compared to national benchmarks
4. Data warehouse will serve as an important tool as decisions are made regarding what and where to rebuild, as well as an ongoing asset to be updated with current data
34
63%12%
25%
Proportion of Health Care Costs Attributed to Unwarranted Variation
Preference Sensitive Care
Effective Care
Supply Sensitive Care
Copyright © Health Dialog Services Corporation 2006. All rights reserved. 35
Agenda
Unwarranted Variations
From Regions to Hospitals in Baton Rouge and New Orleans
Pushing the envelope on redesign
Copyright © Health Dialog Services Corporation 2006. All rights reserved. 36
Shape of the Benefit-Utilization Curve: Effective Care & Patient Safety
Benefit to Patients
Intensity of Effective Care
U.S. Is Somewhere in This Zone
Copyright © Health Dialog Services Corporation 2006. All rights reserved. 37
Unwarranted Variations: expanding the agenda for redesign
Variation Cause Expanding the Agenda
Effective care and patient safety
Poorly understood care processes
Failure to learn
Inadequate systems to support delivery
Measures are expanded and transparency continues
Capital investment (HIT, safe design)
Operational investment (medical home, team based care, care management systems)
Provider payments include performance on measures of effective care
Copyright © Health Dialog Services Corporation 2006. All rights reserved. 38
Shape of the Benefit-Utilization Curve: Preference-Sensitive Care
Benefit to Patients
Intensity of Preference Sensitive Care
Copyright © Health Dialog Services Corporation 2006. All rights reserved. 39
Variation Cause Expanding the Agenda
Effective care andpatient safety
Poorly understood care processes
Develop systems of care capable of improvement
Preference-sensitive care Physician-dominated decisions
Decision quality measures developed and expanded
Shared decision making support for patients within and outside the practice
Provider payments include performance on ‘decision quality’
Unwarranted Variations: expanding the agenda for redesign
Copyright © Health Dialog Services Corporation 2006. All rights reserved. 40
Shape of the Benefit-Utilization Curve: Supply-Sensitive Services
Benefit to Patients
Intensity of Supply Sensitive Care
U.S. Is Somewhere in This Zone
Copyright © Health Dialog Services Corporation 2006. All rights reserved. 41
Variation Cause Expanding the Agenda
Effective care andpatient safety
Poorly understood care processes
Develop systems of care capable of improvement
Preference-sensitive care Physician-dominated decisions
Shared decision-making
Supply-sensitive care Variations in supply
Assumption that more is better
Efficiency is a measure of quality
Transparency
Benchmark-based capital investment (beds, MRIs, specialists, etc.)
Provider payments reward efficiency
Unwarranted Variations: expanding the agenda for redesign
Copyright © Health Dialog Services Corporation 2006. All rights reserved. 42
Unwarranted Variations: expanding the redesign agenda
