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Unwarranted Variations in Health Care

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Unwarranted Variations in Health Care . Presentation by John Wennberg Citizens’ Health Care Working Group Salt Lake City, Utah July 22, 2005. The 3 Categories of Unwarranted Variations*. *Variation not explained by illness, patient preference or medical evidence. - PowerPoint PPT Presentation
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Unwarranted Variations in Health Unwarranted Variations in Health Care Care Presentation by John Wennberg Presentation by John Wennberg Citizens’ Health Care Working Group Citizens’ Health Care Working Group Salt Lake City, Utah Salt Lake City, Utah July 22, 2005 July 22, 2005
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Page 1: Unwarranted Variations in Health Care

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

Page 2: Unwarranted Variations in Health Care

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

Page 3: Unwarranted Variations in Health Care

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

Page 4: Unwarranted Variations in Health Care

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

eivi

ng E

ye E

xam

(199

9-20

00)

% R

ecei

ving

Eye

Exa

m (1

999-

2000

)

Page 5: Unwarranted Variations in Health Care

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

Page 6: Unwarranted Variations in Health Care

Ben

efit

to P

atie

nts

Ben

efit

to 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

Page 7: Unwarranted Variations in Health Care

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”

Page 8: Unwarranted Variations in Health Care

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

Page 9: Unwarranted Variations in Health Care

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)

Page 10: Unwarranted Variations in Health Care

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 to

U.S

. Ave

rage

Rat

io to

U.S

. Ave

rage

Knee Replacement Hip Replacement Back Surgery

Page 11: Unwarranted Variations in Health Care

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 15.015.0Orthopedic SurgeonsOrthopedic Surgeons

Kne

e R

epla

cem

ent

Kne

e R

epla

cem

ent

Page 12: Unwarranted Variations in Health Care

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 12.012.0Knee Replacement (1992-93)Knee Replacement (1992-93)

Kne

e R

epla

cem

ent (

2000

-01)

Kne

e R

epla

cem

ent (

2000

-01)

R2 = 0.75

Page 13: Unwarranted Variations in Health Care

Ben

efit

to P

atie

nts

Ben

efit

to 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)

Page 14: Unwarranted Variations in Health Care

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

Page 15: Unwarranted Variations in Health Care
Page 16: Unwarranted Variations in Health Care

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

Page 17: Unwarranted Variations in Health Care

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

Page 18: Unwarranted Variations in Health Care

% 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%

Page 19: Unwarranted Variations in Health Care

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

Page 20: Unwarranted Variations in Health Care

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

Page 21: Unwarranted Variations in Health Care
Page 22: Unwarranted Variations in Health Care

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

Page 23: Unwarranted Variations in Health Care

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

Page 24: Unwarranted Variations in Health Care

Supply-Sensitive Care Supply-Sensitive Care

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

Page 25: Unwarranted Variations in Health Care

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

char

ge R

ate

Dis

char

ge 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

Page 26: Unwarranted Variations in Health Care

R2 = 0.49Num

ber o

f Vis

its to

Car

diol

ogis

tsN

umbe

r of V

isits

to C

ardi

olog

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)


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