The law of diminishing returns La ley de los rendimientos decrecientes MGH's Inpatient Mortality Rate (Brown) and Adjusted Cost per Patient Who Was Discharged Alive (in 2010 MGH's Inpatient Mortality Rate (Brown) and Adjusted Cost per Patient Who Was Discharged Alive (in 2010 Dollars; Blue), 1821–2010. Dollars; Blue), 1821–2010. The law of diminishing returns La ley de los rendimientos decrecientes MGH's Inpatient Mortality Rate (Brown) and Adjusted Cost per Patient Who Was Discharged Alive (in 2010 Dollars; Blue), 1821–2010. Seems to be characterized by diminishing returns, with growth in costs far outpacing reductions in inpatient mortality. Treatment of severely ill patients with increasingly complex conditions contributes to this phenomenon, but that fact does little to mitigate the reality that for the first time, improvements in inpatient mortality may be coming at unsustainable increases in cost. Close examination of our past clarifies just how daunting is the challenge we face today Two Hundred Years of Hospital Costs and Mortality — MGH and Four Eras of Value in Medicine Gregg S. Meyer, M.D., Akinluwa A. Demehin, M.P.H., Xiu Liu, M.S., and Duncan Neuhauser, Ph.D. N Engl J Med 2012; 366:2147-2149 7-2149.

Regional differences in Medicare spending are largely explained by the more inpatient-based and specialist oriented pattern of practice observed in high-spending regions. Neither quality of care nor access to care appear to be better for Medicare enrolees in higher-spending regions. The Implications of Regional Variations in Medicare Spending. Part 1:The Content, Quality, and Accessibility of Care Elliott S. Fisher, MD, MPH; Ann Intern Med. 2003;138:273-287. 28 December 2018

Does more $ per capita improve care?

[Cuidado de la salud es inalcanzable en todo el mundo] HEALTH CARE IS UNAFFORDABLE! [NEJM 2012]-WORLDWIDE [Cuidado de la salud es inalcanzable en todo el mundo] Health Expenditures as a Percentage of Gross Domestic Product (GDP) in Selected OECD Countries, 1960–2009. Figure 2. Health Expenditures as a Percentage of Gross Domestic Product (GDP) in Selected OECD Countries, 1960–2009. Data for all OECD countries appear in the Supplementary Appendix. Fineberg HV. N Engl J Med 2012;366:1020-1027.

Time to tackle unwarranted variations in practice THE VARIATION PHENOMENON “The variation phenomenon in modern medicine -the observation of differences in the way apparently similar patients are treated from one health care setting to another.” D. Blumenthal. Editorial NEJM 331:1994;1017-8 Much of the variation in use of healthcare is accounted for by the willingness and ability of doctors to offer treatment rather than differences in illness or patient preference. Variation that cannot be explained on the basis of illness, patient preferences or the dictates of evidence-based medicine. [APPROPRIATE AND INAPPROPRIATE VARIATION-Brent James] Identifying and reducing such variation should be a priority for providers. (John Wennberg 2011-Dartmouth Institute)

Reasons for practice variation Complexity: How many factors can the human mind simultaneously balance to optimize an outcome? Lack of valid and poor access to clinical knowledge -(poor evidence) Subjective judgment / uncertainty Subjective evaluation is notoriously poor across groups or over time and enthusiasm for unproven methods Brent James summary of the the reasons for practice variation. All these factors involve complex decision making in an information rich environment. Human error- -- humans are inherently fallible information processors- -- Clem MacDonald, PhD

CCDSS IMPROVING RESOURCE UTILISATION, OUTCOMES $3 million per year savings ~$64bUS(1995) (2013- $tr) Tierney’s study into the use of of a longitudinal CBPR to reduce resource utilization. (Refer to the Johns and Blum study on costs, resource utilization, and clinical decision making) Physician inpatient order writing on microcomputer workstations-effects on resource utilisation. WM Tierney and others. JAMA 1993;269:379-383 28 December 2018

COSTS/QUALITY/OUTCOMES/RESEARCH “The plural of anecdote is not data” CCDSS(EHR) 1996 COSTS/QUALITY/OUTCOMES/RESEARCH “The plural of anecdote is not data” 160,000 patient over 4 years Overall antibiotic use: decreased 22.8% Mortality rates: decreased from 3.65% to 2.65% Antibiotic-associated ADE: decreased 30% Antibiotic resistance: remained STABLE Appropriately timed preoperative a/biotics: 40% to 99.1% Antibiotic costs per treated patient: decreased $122.66 to $51.90 Acquisition costs for antibiotics: fell 24.8% to 12.9% ($987,547) to ($612,500) Our Case-Mix index which measures patient acuity levels INCREASED during this period, meaning we were treating sicker and sicker patients while better utilizing the delivery of antibiotics. (******WENNBERG 2012) Pestotnik, S. L. Classen, D. C. Evans, R. S. Burke, J. P. Implementing antibiotic practice guidelines through computer-assisted decision support: clinical and financial outcomes.Ann Intern Med 1996 May 15 28 December 2018

PricewaterhouseCoopers LLP (PwC) switch to electronic medical records (EMR) by family doctors from across Canada between 2006 and 2012 $800 million $584 million 28 December 2018