Unwarranted Variations in Health Care

1
Unwarranted Variations in Health Care

• Presentation by John Wennberg
• Citizens Health Care Working Group
• Salt Lake City, Utah
• July 22, 2005

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The 3 Categories of Unwarranted Variations

Variation not explained by illness, patient
preference or medical evidence
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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
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.)
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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
Shape of the Benefit-Utilization CurveEffective
Care Patient Safety
U.S. is
some-
where
in this
zone
Benefit to Patients
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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 Patients Own
  Preferences
• But Provider Opinion Often Determines Which
  Treatment is Used

9
Pattern of Variation and SCV for Hip Fracture,
Hip and Knee Replacement and Back Surgery
(2000-01)
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Surgical Signatures for Three Florida Regions
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Relationship Between Supply of Orthopedic
Surgeons (1999) and Knee Replacement Rates
(2000-01)
12
Relationship Between Knee Replacement Rates in
1992-93 and 2000-01
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Shape of the Benefit-Utilization
CurvePreference-Sensitive Care (e.g. Surgery)
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Reducing misuse for preference-sensitive care
Information therapy is essential

• Major focus shared decision making

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The BPH Treatment DecisionWhat 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 dont
  correlate with symptom level
• Learning which rate is right depends on sorting
  this all out at the micro-level of the
  doctor-patient relationship

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Impact of improved decision quality on surgery
rates BPH
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of BPH Patients Choosing Surgery under Shared
Decision Making by Symptom Level
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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
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Reducing misuse for preference-sensitive care
Information therapy is essential

• Major focus shared decision making
• New focus report cards measuring decision
  quality

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(No Transcript)
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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 dont work

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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 dont work
• Major impediment adverse economic incentives

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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 frequency of use

25
Association between hospital beds per 1,000 and
discharges per 1,000 among Medicare Enrollees
306 Hospital Regions
26
Association between cardiologists and visits per
person among Medicare Enrollees 306 Regions
(Under the More is Better Assumption, Capacity
Determines Need)