Unwarranted Variations in Health Care Unwarranted Variations in Health Care

Presentation by John WennbergPresentation by John Wennberg

Citizens’ Health Care Working GroupCitizens’ Health Care Working Group

Salt Lake City, UtahSalt Lake City, UtahJuly 22, 2005July 22, 2005

The 3 Categories of Unwarranted Variations*The 3 Categories of Unwarranted Variations*

*Variation not explained by illness, patient preference or medical evidence*Variation not explained by illness, patient preference or medical evidence

Effective Care Refers to:Effective Care Refers to:

• Services of Proven EffectivenessServices of Proven Effectiveness

• Services that involve no significant tradeoffs--all with Services that involve no significant tradeoffs--all with specific needs should receive themspecific needs should receive them

• Failure to Provide Effective Care to Patient in Need is a Failure to Provide Effective Care to Patient in Need is a Medical Error--An Error of OmissionMedical Error--An Error of Omission

There is There is Extensive Underuse of Effective CareExtensive Underuse of Effective Care Throughout the Throughout the United States: Diabetic Medicare Enrollees Annual Eye Exam United States: Diabetic Medicare Enrollees Annual Eye Exam (1999-2000) (Each dot represents one of the 306 regions.)(1999-2000) (Each dot represents one of the 306 regions.)

30.030.0

40.040.0

50.050.0

60.060.0

70.070.0%

Rec

eiv

ing

Ey

e E

xam

(19

99

-20

00)

% R

ece

ivin

g E

ye

Ex

am (

199

9-2

00

0)

0.00.0

1.01.0

2.02.0

3.03.0

4.04.0

5.05.0

6.06.0

7.07.0

8.08.0

9.09.0

10.010.0

Patient Safety / Failure of effective care among regions Patient Safety / Failure of effective care among regions

Major leg amputation/1000 (1998-2001) Major leg amputation/1000 (1998-2001)

Non-BlackMales

BlackMales

Non-BlackFemales

BlackFemales

Ben

efit

to

Pat

ien

tsB

enef

it t

o P

atie

nts

% Use of Effective Care% Use of Effective Care

U.S. issome-wherein thiszone

Shape of the Benefit-Utilization CurveShape of the Benefit-Utilization CurveEffective Care & Patient SafetyEffective Care & Patient Safety

Reducing underuse of effective careReducing underuse of effective care

• Major focus: improving provider performance Major focus: improving provider performance through data feed back, infra-structure building through data feed back, infra-structure building and “paying for performance”and “paying for performance”

Preference-Sensitive Care Preference-Sensitive Care

• Involves Tradeoffs--More than one treatment exists and the outcomes are differentInvolves Tradeoffs--More than one treatment exists and the outcomes are different

• Evidence sometimes good, sometimes notEvidence sometimes good, sometimes not

• Decisions should be based on the Patient’s Own PreferencesDecisions should be based on the Patient’s Own Preferences

• But Provider Opinion Often Determines Which Treatment is But Provider Opinion Often Determines Which Treatment is UsedUsed

Pattern of Variation and SCV for Hip Pattern of Variation and SCV for Hip Fracture, Hip and Knee Replacement and Fracture, Hip and Knee Replacement and

Back Surgery (2000-01)Back Surgery (2000-01)

0.2

1.0

4.0

HipHipFractureFracture

(13.8)(13.8)

KneeKneeReplacementReplacement

(55.0)(55.0)

HipHipReplacementReplacement

(67.2)(67.2)

BackBackSurgerySurgery

(93.6)(93.6)

Surgical Signatures for Three Florida RegionsSurgical Signatures for Three Florida Regions

1.48

1.12

0.95

1.45

1.20

0.87

1.67

1.66

0.92

0.00.0

0.50.5

1.01.0

1.51.5

2.02.0

Fort MyersFort Myers BradentonBradenton TampaTampa

Rat

io t

o U

.S.

Ave

rag

eR

atio

to

U.S

. A

vera

ge

Knee Replacement Hip Replacement Back Surgery

Relationship Between Supply of Orthopedic Relationship Between Supply of Orthopedic Surgeons (1999) and Knee Replacement Rates Surgeons (1999) and Knee Replacement Rates

(2000-01)(2000-01)

R2 = 0.000.00.0

2.02.0

4.04.0

6.06.0

8.08.0

10.010.0

12.012.0

0.00.0 3.03.0 6.06.0 9.09.0 12.012.0 15.015.0

Orthopedic SurgeonsOrthopedic Surgeons

Kn

ee R

epla

cem

ent

Kn

ee R

epla

cem

ent

Relationship Between Knee Replacement Relationship Between Knee Replacement Rates in 1992-93 and 2000-01Rates in 1992-93 and 2000-01

0.00.0

2.02.0

4.04.0

6.06.0

8.08.0

10.010.0

12.012.0

0.00.0 2.02.0 4.04.0 6.06.0 8.08.0 10.010.0 12.012.0

Knee Replacement (1992-93)Knee Replacement (1992-93)

Kn

ee R

epla

cem

ent

(200

0-01

)K

nee

Rep

lace

men

t (2

000-

01)

R2 = 0.75

Ben

efit

to

Pat

ien

tsB

enef

it t

o P

atie

nts

UNKNOWN

Units of Discretionary CareUnits of Discretionary Care

Shape of the Benefit-Utilization Curve:Shape of the Benefit-Utilization Curve:Preference-Sensitive Care (e.g. Surgery)Preference-Sensitive Care (e.g. Surgery)

Reducing misuse for preference-sensitive Reducing misuse for preference-sensitive care: Information therapy is essentialcare: Information therapy is essential

• Major focus: shared decision making Major focus: shared decision making

The BPH Treatment Decision:The BPH Treatment Decision:What is at Stake for the Patient?What is at Stake for the Patient?

• Tradeoff between urinary tract and sexual Tradeoff between urinary tract and sexual functionfunction

• Degree of bother versus objective level of Degree of bother versus objective level of symptomssymptoms

• Traditional tests of urinary tract function don’t Traditional tests of urinary tract function don’t correlate with symptom levelcorrelate with symptom level

• Learning which rate is right depends on sorting Learning which rate is right depends on sorting this all out at the micro-level of the doctor-patient this all out at the micro-level of the doctor-patient relationshiprelationship

Impact of improved decision quality on surgery Impact of improved decision quality on surgery rates: BPHrates: BPH

Knowledge of relevant treatment

options and outcomes

Concordance between patient values

and care received

% of BPH Patients Choosing Surgery under % of BPH Patients Choosing Surgery under Shared Decision Making by Symptom Level*Shared Decision Making by Symptom Level*

Symptom Score Symptom Score % Choosing Surgery% Choosing Surgery

Mild (N=107)Mild (N=107) 0.9%0.9%

Moderate Moderate (N=209)(N=209)

10.5%10.5%

Severe (N=87)Severe (N=87)

*Barry et al, Med. *Barry et al, Med. CareCare

21.8%21.8%

Knowledge of relevant treatment

options and outcomes

Concordance between patient values

and care receivedToronto trial

7.28

0.852.01

10.78

1.182.52

16.75

2.17

4.55

0

5

10

15

20

1 or 2 vesseldisease, w/o PLAD

disease

2 vessel + PLAD or3 vessel

left main disease

20-64 yrs65-74 yrs>=75 yrs

Impact of improved decision quality on surgery Impact of improved decision quality on surgery rates: CHDrates: CHD

Reducing misuse for preference-sensitive Reducing misuse for preference-sensitive care: Information therapy is essentialcare: Information therapy is essential

• Major focus: shared decision makingMajor focus: shared decision making• New focus: report cards measuring decision New focus: report cards measuring decision

qualityquality

Reducing misuse for preference-sensitive Reducing misuse for preference-sensitive care: Information therapy is essentialcare: Information therapy is essential

• Major focus: shared decision makingMajor focus: shared decision making• New focus: report cards measuring decision New focus: report cards measuring decision

qualityquality• Traditional provider-focused appropriateness Traditional provider-focused appropriateness

guidelines don’t workguidelines don’t work

Reducing misuse for preference-sensitive Reducing misuse for preference-sensitive care: Information therapy is essentialcare: Information therapy is essential

• Major focus: shared decision makingMajor focus: shared decision making• New focus: report cards measuring decision New focus: report cards measuring decision

qualityquality• Traditional provider-focused appropriateness Traditional provider-focused appropriateness

guidelines don’t workguidelines don’t work• Major impediment: adverse economic incentivesMajor impediment: adverse economic incentives

Supply-Sensitive Care Supply-Sensitive Care

• The frequency of use is governed by the assumption that The frequency of use is governed by the assumption that resources should be fully utilized, i.e. that more is betterresources should be fully utilized, i.e. that more is better

• Specific medical theories and medical evidence play little role in Specific medical theories and medical evidence play little role in governing frequency of usegoverning frequency of use

• In the absence of evidence and under the assumption that more is In the absence of evidence and under the assumption that more is

better, available supply governs frequencybetter, available supply governs frequency of useof use

Hip FractureR2 = 0.06

All MedicalConditionsR2 = 0.54

00

5050

100100

150150

200200

250250

300300

350350

400400

1.01.0 2.02.0 3.03.0 4.04.0 5.05.0 6.06.0Acute Care BedsAcute Care Beds

Dis

cha

rge

Rat

eD

isch

arg

e R

ate

Association between hospital beds per 1,000 and discharges Association between hospital beds per 1,000 and discharges per 1,000 among Medicare Enrollees: 306 Hospital Regionsper 1,000 among Medicare Enrollees: 306 Hospital Regions

R2 = 0.49

Nu

mb

er

of

Vis

its

to C

ard

iolo

gis

tsN

um

be

r o

f V

isit

s to

Ca

rdio

log

ists

0.00.0

0.50.5

1.01.0

1.51.5

2.02.0

2.52.5

0.00.0 2.52.5 5.05.0 7.57.5 10.010.0 12.512.5 15.015.0

Number of Cardiologists per 100,000Number of Cardiologists per 100,000

Association between cardiologists and visits per person Association between cardiologists and visits per person

among Medicare Enrollees: 306 Regionsamong Medicare Enrollees: 306 Regions ( (Under the More Under the More is Better Assumption, Capacity Determines Need)is Better Assumption, Capacity Determines Need)