Unwarranted Variations in Health Care Presentation by John Wennberg Presentation by John Wennberg Citizens Health Care Working Group 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

Effective Care Refers to: Effective Care Refers to: Services of Proven EffectivenessServices of Proven Effectiveness Services that involve no significant tradeoffs--all with specific needs should receive themServices 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 OmissionFailure to Provide Effective Care to Patient in Need is a Medical Error--An Error of Omission

There is Extensive Underuse of Effective Care Throughout the United States: Diabetic Medicare Enrollees Annual Eye Exam ( ) (Each dot represents one of the 306 regions.)

Patient Safety / Failure of effective care among regions Major leg amputation/1000 ( ) Patient Safety / Failure of effective care among regions Major leg amputation/1000 ( ) Non-Black Males Black Males Non-Black Females Black Females

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

Reducing underuse of effective care Major focus: improving provider performance through data feed back, infra-structure building and paying for performanceMajor focus: improving provider performance through data feed back, infra-structure building 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 Patients Own PreferencesDecisions should be based on the Patients Own Preferences But Provider Opinion Often Determines Which Treatment is UsedBut Provider Opinion Often Determines Which Treatment is Used

Pattern of Variation and SCV for Hip Fracture, Hip and Knee Replacement and Back Surgery ( ) HipFracture(13.8)KneeReplacement(55.0)HipReplacement(67.2)BackSurgery(93.6)

Surgical Signatures for Three Florida Regions Fort Myers BradentonTampa Ratio to U.S. Average Knee ReplacementHip ReplacementBack Surgery

Relationship Between Supply of Orthopedic Surgeons (1999) and Knee Replacement Rates ( )

Relationship Between Knee Replacement Rates in and

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

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

The BPH Treatment Decision: What is at Stake for the Patient? Tradeoff between urinary tract and sexual functionTradeoff between urinary tract and sexual function Degree of bother versus objective level of symptomsDegree of bother versus objective level of symptoms Traditional tests of urinary tract function dont correlate with symptom levelTraditional 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 relationshipLearning which rate is right depends on sorting this all out at the micro-level of the doctor-patient relationship

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

% of BPH Patients Choosing Surgery under Shared Decision Making by Symptom Level* Symptom Score Symptom Score % Choosing Surgery Mild (N=107) Mild (N=107) 0.9% 0.9% Moderate (N=209) Moderate (N=209) 10.5% 10.5% Severe (N=87) Severe (N=87) *Barry et al, Med. Care 21.8% 21.8%

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

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

Reducing misuse for preference-sensitive care: Information therapy is essential Major focus: shared decision makingMajor focus: shared decision making New focus: report cards measuring decision qualityNew focus: report cards measuring decision quality Traditional provider-focused appropriateness guidelines dont workTraditional provider-focused appropriateness guidelines dont work

Reducing misuse for preference-sensitive care: Information therapy is essential Major focus: shared decision makingMajor focus: shared decision making New focus: report cards measuring decision qualityNew focus: report cards measuring decision quality Traditional provider-focused appropriateness guidelines dont workTraditional provider-focused appropriateness guidelines dont work Major impediment: adverse economic incentivesMajor impediment: adverse economic incentives

Supply-Sensitive Care The frequency of use is governed by the assumption that resources should be fully utilized, i.e. that more is betterThe 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 useSpecific 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 useIn the absence of evidence and under the assumption that more is better, available supply governs frequency of use

Association between hospital beds per 1,000 and discharges per 1,000 among Medicare Enrollees: 306 Hospital Regions

Association between cardiologists and visits per person among Medicare Enrollees: 306 Regions ( Under the More is Better Assumption, Capacity Determines Need)