1. In Healthcare, Is More Always Better? Thérèse Stukel Institute for Clinical Evaluative Sciences, Toronto Dartmouth Medical School, US Graham Woodward Cancer Care Ontario Canadian Health Services Research Foundation October 15, 2008 Researcher on Call

2. Common Assumptions Higher spending is due to greater use of treatments of proven benefit to sick patients. More is better. — Wennberg, Gittelsohn. Science (1973)

3. 0.2 1.0 5.0 Hip Fracture Heart Failure Huge U.S. regional variations exist in hospitalization rates for common conditions

4. Hip Fracture R 2 = 0.06 All Medical Conditions R 2 = 0.54 0 50 100 150 200 250 300 350 400 1.02.03.04.05.06.0 Discharge Rate U.S. regional hospitalization rates are strongly related to hospital bed supply Acute Care Beds

5. Huge U.S. regional variations exist in spending intensity during L6M* L6M $ per capita Total Medicare $ per capita 9,0743,922 10,6364,439 11,5594,940 12,5985,444 14,6446,304 (r = 0.81) *L6M = Last 6 months of life

6. Costs reflect health care resource availability Comparison of Highest & Lowest 20 th -percentile Spending Regions Lowest 20th Percentile Spending Highest 20th Percentile Spending Ratio Highest- Lowest Regional Medicare spending (per capita) $3,963$6,2981.59 Regional supply of health care resources (per capita) Hospital beds per 10002.43.21.33 Physician supply (per 100K) – Medical specialists 28441.59 – General Internists 23371.63 – Family practitioners/GPs 35270.75 – Surgeons 44561.27 – Other specialists 59781.32

7. Rates of evidence-based care were lower or similar in high spending regions (RR<1)* 1.001.52.00.5253.0 1.01.52.00.5253.0 Reperfusion in 12 hours for AMI Beta blockers at admission Aspirin at admission Beta blockers at discharge Aspirin at discharge Acute MI Mammogram, Women 65-69 Flu shot during past year Pap smear, Women 65+ Pneumococcal immunization General Population Lower in High Spending Regions (RR<1)Higher in High Spending Regions (RR>1) *RR=Relative Rate

8. Rates of Physician-Driven Care were higher in high spending regions (RR>1)* 1.001.52.00.5253.0 1.01.52.00.5253.0 Office visits Initial inpatient specialist consultations Inpatient visits Psychotherapy visits % of patients seeing 10 or more MDs Physician Visits Chest X-ray Ventilation perfusion scan CT / MRI brain Imaging Tests Upper GI endoscopy Pulmonary function test Bronchoscopy Electroencephelogram (EEG) Diagnostic Tests/Procedures Ambulatory ECG (Holter) monitor Lower in high spending regions (RR<1)Higher in high spending regions (RR>1) *RR=Relative Rate

9. Rates of Hospital-Driven care were higher in high spending regions (RR>1)* 1.001.52.00.5253.0 1.01.52.00.5253.0 Inpatient days in ICU or CCU Discharges Total inpatient days Hospital Utilization Feeding tube placement Inpatient days ICU or CCU days Emergency intubation Care in Last Six Months of Life Vena cava filter Lower in high spending regions (RR<1)Higher in high spending regions (RR>1) *RR=Relative Rate

10. Conclusions Higher intensity of spending and care due to use of high-tech services (hospital beds, specialists) and lack of coordination. Higher intensity is associated with more care, not better care. Higher intensity associated with a small increased risk of death.

11. Ontario regional hospitalization rates are strongly related to hospital bed supply

12. System Misalignment: Ontario regional AMI admission rates are inversely related to cardiology supply

13. Probability of death after lung cancer surgery varies 1-8% depending where you get care

14. Key health policy questions How can we improve information on the outcomes of specific interventions? How can we overcome the public’s perception that “in health care, more is always better.” How can we manage the growth of health care resource capacity? How can we improve both the quality and efficiency of care? How can we ensure the residents receive appropriate care?

15. Current thinking on fostering highly efficient systems (e.g. Large U.S. Multispecialty Physician Group Practices) Performance measurement and feedback to motivate change Shared physician – hospital accountability for patients Organizational culture and systems to support improvement Strong primary care (PC) systems Chronic disease management programs Engagement of multiple health professionals Focus on longitudinal efficiency – total experience of a patient over a defined period of time Limited policy success:  Pay for performance (P4P)  Individual physician profiling  Technical quality measures (discrete, episodic, silo care)

16. Attributes of High-Performing Teams Effective leadership Patient focus Team is multidisciplinary and interdependent Shared culture Wise use of information technology Change based on performance measurement and process improvement Organizational support Trust Nelson, EC et al. Journal of Quality Improvement 2002: 28(9): 472

17. Attributes of High-Performing Organizations Investment in information technology (IT) to improve MD communication Implementation of patient safety, quality improvement programs Re-engineering of care systems based on what is learned about high performing teams and organizations. Use of benchmarks to manage capacity.

18. Just like more services, more providers is not always a good thing. For some procedures, the quality of care can be related to volume –higher volumes = better outcomes Two examples where Cancer Care Ontario is addressing the volume-outcome relationship: –Colonoscopy: 200+ per endoscopist »Fewer missed cancers, fewer bowel perforations –Lung cancer surgery: 150+ per hospital »Better outcomes, fewer deaths

19. Currently, 1/3 of physicians do not meet the standard of 200+ colonoscopies per year.

20. Too many hospitals provide lung cancer surgery: Cancer Care Ontario is reducing this to 10-15 hospitals

21. Where to go? Begin to measure efficiency – even with imperfect data – since opportunities for improvement are large and sustainability issues are urgent Engage hospitals, physicians and policy- makers in discussions of how to align practice and integrate care across sectors Build trusted relationships