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
eivi
ng E
ye E
xam
(199
9-20
00)
% R
ecei
ving
Eye
Exa
m (1
999-
2000
)
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 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
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 to
U.S
. Ave
rage
Rat
io to
U.S
. Ave
rage
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 15.015.0Orthopedic SurgeonsOrthopedic Surgeons
Kne
e R
epla
cem
ent
Kne
e 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 12.012.0Knee 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
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)
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 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
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
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)