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Unwarranted Variations in Health Care

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.

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Unwarranted Variations in Health Care

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  1. Unwarranted Variations in Health Care Presentation by John Wennberg Citizens’ Health Care Working Group Salt Lake City, Utah July 22, 2005

  2. The 3 Categories of Unwarranted Variations* *Variation not explained by illness, patient preference or medical evidence

  3. Effective Care Refers to: • Services of Proven Effectiveness • Services that involve no significant tradeoffs--all with specific needs should receive them • Failure to Provide Effective Care to Patient in Need is a Medical Error--An Error of Omission

  4. 70.0 60.0 % Receiving Eye Exam (1999-2000) 50.0 40.0 30.0 There is Extensive Underuse of Effective Care Throughout the United States: Diabetic Medicare Enrollees Annual Eye Exam (1999-2000) (Each dot represents one of the 306 regions.)

  5. 10.0 9.0 8.0 7.0 6.0 5.0 4.0 3.0 2.0 1.0 0.0 Patient Safety / Failure of effective care among regions Major leg amputation/1000 (1998-2001) Non-Black Males Black Males Non-Black Females Black Females

  6. % Use of Effective Care Shape of the Benefit-Utilization CurveEffective Care & Patient Safety U.S. is some- where in this zone Benefit to Patients

  7. Reducing underuse of effective care • Major focus: improving provider performance through data feed back, infra-structure building and “paying for performance”

  8. Preference-Sensitive Care • Involves Tradeoffs--More than one treatment exists and the outcomes are different • Evidence sometimes good, sometimes not • Decisions should be based on the Patient’s Own Preferences • But Provider Opinion Often Determines Which Treatment is Used

  9. Hip Fracture (13.8) Knee Replacement (55.0) Hip Replacement (67.2) Back Surgery (93.6) Pattern of Variation and SCV for Hip Fracture, Hip and Knee Replacement and Back Surgery (2000-01)

  10. 2.0 1.67 1.66 1.48 1.45 1.5 1.20 1.12 0.92 0.95 Ratio to U.S. Average 0.87 1.0 0.5 0.0 Fort Myers Bradenton Tampa Knee Replacement Hip Replacement Back Surgery Surgical Signatures for Three Florida Regions

  11. 12.0 10.0 8.0 Knee Replacement 6.0 4.0 2.0 R2 = 0.00 0.0 0.0 3.0 6.0 9.0 12.0 15.0 Orthopedic Surgeons Relationship Between Supply of Orthopedic Surgeons (1999) and Knee Replacement Rates (2000-01)

  12. 12.0 10.0 8.0 Knee Replacement (2000-01) 6.0 4.0 2.0 R2 = 0.75 0.0 0.0 2.0 4.0 6.0 8.0 10.0 12.0 Knee Replacement (1992-93) Relationship Between Knee Replacement Rates in 1992-93 and 2000-01

  13. UNKNOWN Benefit to Patients Units of Discretionary Care Shape of the Benefit-Utilization Curve:Preference-Sensitive Care (e.g. Surgery)

  14. Reducing misuse for preference-sensitive care: Information therapy is essential • Major focus: shared decision making

  15. The BPH Treatment Decision:What is at Stake for the Patient? • Tradeoff between urinary tract and sexual function • Degree of bother versus objective level of symptoms • Traditional tests of urinary tract function don’t correlate with symptom level • Learning which rate is right depends on sorting this all out at the micro-level of the doctor-patient relationship

  16. Knowledge of relevant treatment options and outcomes Concordance between patient values and care received Impact of improved decision quality on surgery rates: BPH

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

  18. Impact of improved decision quality on surgery rates: CHD Knowledge of relevant treatment options and outcomes Concordance between patient values and care received Toronto trial

  19. Reducing misuse for preference-sensitive care: Information therapy is essential • Major focus: shared decision making • New focus: report cards measuring decision quality

  20. Reducing misuse for preference-sensitive care: Information therapy is essential • Major focus: shared decision making • New focus: report cards measuring decision quality • Traditional provider-focused appropriateness guidelines don’t work

  21. Reducing misuse for preference-sensitive care: Information therapy is essential • Major focus: shared decision making • New focus: report cards measuring decision quality • Traditional provider-focused appropriateness guidelines don’t work • Major impediment: adverse economic incentives

  22. Supply-Sensitive Care • The frequency of use is governed by the assumption that resources should be fully utilized, i.e. that more is better • Specific medical theories and medical evidence play little role in governing frequency of use • In the absence of evidence and under the assumption that more is better, available supply governs frequencyof use

  23. 400 All Medical Conditions R2 = 0.54 350 300 250 Discharge Rate 200 150 100 Hip Fracture R2 = 0.06 50 0 1.0 2.0 3.0 4.0 5.0 6.0 Acute Care Beds Association between hospital beds per 1,000 and discharges per 1,000 among Medicare Enrollees: 306 Hospital Regions

  24. 2.5 2.0 1.5 Number of Visits to Cardiologists 1.0 0.5 R2 = 0.49 0.0 0.0 2.5 5.0 7.5 10.0 12.5 15.0 Number of Cardiologists per 100,000 Association between cardiologists and visits per person among Medicare Enrollees: 306 Regions (Under the More is Better Assumption, Capacity Determines Need)

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