Tracking MedicineTracking Medicine

A Lecture by Jack WennbergA Lecture by Jack Wennberg

GroupHealth Innovation ConferenceGroupHealth Innovation Conference

March 25March 25thth 2011 2011

Understanding Variations in the Way Medicine is PracticedUnderstanding Variations in the Way Medicine is Practiced

The Vermont StoryThe Vermont Story

The Maine StoryThe Maine Story

The Dartmouth Atlas ProjectThe Dartmouth Atlas Project

New Hampshire

Massachusetts

New York

Quebec

From From “Science,”“Science,” December 14, 1973.December 14, 1973.

Vermont Map from “Science”Vermont Map from “Science”

Morrisville and Waterbury CenterMorrisville and Waterbury Center

Tonsillectomy Rate per 10,000 Children Among 13 Tonsillectomy Rate per 10,000 Children Among 13 Vermont Hospital Service AreasVermont Hospital Service Areas

00

5050

100100

150150

200200

250250

300300

350350

400400

450450MorrisvilleMorrisville

19691969

Stages of Facing RealityStages of Facing Reality

• Stage 1. “The data are wrong.”Stage 1. “The data are wrong.”• Stage 2. “The data are right, but it’s not a Stage 2. “The data are right, but it’s not a

problem.”problem.”• Stage 3. “The data are right; it is a problem; but it Stage 3. “The data are right; it is a problem; but it

is not my problem.”is not my problem.”• Stage 4. “I accept the burden of improvement.”Stage 4. “I accept the burden of improvement.”

Tonsillectomy Rate per 10,000 Children Among 13 Tonsillectomy Rate per 10,000 Children Among 13 Vermont Hospital Service AreasVermont Hospital Service Areas

00

5050

100100

150150

200200

250250

300300

350350

400400

450450

MorrisvilleMorrisville

MorrisvilleMorrisville

19691969 19731973

1.5-2 x

2-3 x

1.5-2 x

2-3 x

Table 2.1. A Test of Consumer Contribution to Small Area Variations in Health Care Delivery: Randolph and Middlebury, VT (continued)

Middlebury Randolph,

Vermont VermontAccess to physician Contact with physician within year 73% 73%

“Post-access” utilization of health care Hospital discharges per 1,000 132 220 Surgery discharges per 1,000 49 80 Medicare Part B spending per Enrollee ($) 92 142

Source: Adapted from Wennberg, J and Fowler, FJ. 1977. A Test of Consumer Contributions to Small Area Variations in Health Care Delivery. Journal of the Maine Medical Association. 68(8):275-279.

Science, 14 December, 1973Science, 14 December, 1973

“ “ Given the Magnitude of these variations, theGiven the Magnitude of these variations, the

possiblty of too much medical care and and the possiblty of too much medical care and and the attendant likelihood of iatrogenic illness is attendant likelihood of iatrogenic illness is presumably as strong as the possibilty of not presumably as strong as the possibilty of not enough services and unattended morbidity and enough services and unattended morbidity and mortality”mortality”

Understanding Variations in the Way Medicine is PracticedUnderstanding Variations in the Way Medicine is Practiced

The Vermont StoryThe Vermont Story

The Maine StoryThe Maine Story

Which rate is right? Impact of improved Which rate is right? Impact of improved decision quality on surgery rates: BPHdecision quality on surgery rates: BPH

Knowledge of relevant treatment

options and outcomes

Concordance between patient values

and care received

Learning what works and what patients wantLearning what works and what patients want

The Vermont StoryThe Vermont Story

The Maine StoryThe Maine Story

The Dartmouth Atlas ProjectThe Dartmouth Atlas Project

The Dartmouth Atlas Project: 306 hospital referral regionsThe Dartmouth Atlas Project: 306 hospital referral regionsOngoing Study of Traditional Medicare Population USAOngoing Study of Traditional Medicare Population USA

Unwarranted Variation in Health Care Delivery:Unwarranted Variation in Health Care Delivery:

Variation that can’t be explained by illness Variation that can’t be explained by illness

or patient preferencesor patient preferences

The Three Categories of Unwarranted The Three Categories of Unwarranted Variation in Health Care DeliveryVariation in Health Care Delivery

Effective CareEffective CareEE

vviiddeennccee--bbaasseedd ccaarree tthhaatt aallll wwiitthh nneeeedd sshhoouulldd rreecceeiivvee

Preference-Sensitive CarePreference-Sensitive Care

Supply-Sensitive CareSupply-Sensitive Care

Preference-Sensitive Care Preference-Sensitive Care

• Involves tradeoffs -- more than one treatment exists Involves tradeoffs -- more than one treatment exists and the outcomes are differentand the outcomes are different

• Decisions should be based on the patient’s own Decisions should be based on the patient’s own preferencespreferences

• But Provider Opinion Often Determines Which But Provider Opinion Often Determines Which Treatment is UsedTreatment is Used

Conditions involving preference-sensitive Conditions involving preference-sensitive surgical decisionssurgical decisions

ConditionCondition Treatment Options Treatment Options

• Silent GallstonesSilent Gallstones Surgery versus watchful waiting Surgery versus watchful waiting

• Chronic Stable Angina PCI vs. surgery vs. other methodsChronic Stable Angina PCI vs. surgery vs. other methods

• Hip and Knee ArthritisHip and Knee Arthritis Joint replacement vs. pain meds Joint replacement vs. pain meds

• Carotid Artery Stenosis Surgery vs. aspirinCarotid Artery Stenosis Surgery vs. aspirin

• Herniated DiscHerniated Disc Back surgery vs. other strategies Back surgery vs. other strategies

• Early Prostate Cancer Early Prostate Cancer Surgery vs. radiation vs. waiting Surgery vs. radiation vs. waiting

• Enlarged ProstateEnlarged Prostate Surgery vs. other strategies Surgery vs. other strategies

• Early Stage Breast Cancer Lumpectomy vs. mastectomy Early Stage Breast Cancer Lumpectomy vs. mastectomy

Knee Replacement: An Example of Preference-Sensitive CareKnee Replacement: An Example of Preference-Sensitive Care

Ratio of knee replacement rates to the U.S. average (2005Ratio of knee replacement rates to the U.S. average (2005))

11.30.30 to to 11.75.75 (46)(46)11.10.10 to < to < 11.30.30 (78)(78)00.90.90 to < to < 11.10.10 (106)(106)00.75.75 to < to < 00.90.90 (53)(53)00.41.41 to < to < 00.75.75 (23)(23)Not PopulatedNot Populated

Total Knee replacement for Arthritis per 1,000 Medicare Total Knee replacement for Arthritis per 1,000 Medicare enrollees among 306 Hospital Referral Regionsenrollees among 306 Hospital Referral Regions

1.01.0

3.03.0

5.05.0

7.07.0

9.09.0

11.011.0

1992-93 2000-01

Red dot = U.S. average:Red dot = U.S. average: 4.034.03 5.64 40% increase5.64 40% increase

Relationship Between Knee Replacement Rates Among Relationship Between Knee Replacement Rates Among Hospital Referral Regions in 1992-93 and 2000-01Hospital Referral Regions 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 12.012.0

Knee Replacement (1992-93)Knee Replacement (1992-93)

Kn

ee R

epla

cem

ent

(200

0-01

)K

nee

Rep

lace

men

t (2

000-

01)

R2 = 0.75

Determining the Need for Hip and Knee Arthroplasty: Determining the Need for Hip and Knee Arthroplasty: The Role of Clinical Severity and Patients’ Preferences The Role of Clinical Severity and Patients’ Preferences

. . . Among those with severe arthritis, no . . . Among those with severe arthritis, no more than 15% were definitely willing to undergo more than 15% were definitely willing to undergo (joint replacement), emphasizing the importance (joint replacement), emphasizing the importance of considering both patients’ preference and of considering both patients’ preference and surgical indications in evaluating need and surgical indications in evaluating need and appropriateness of rates of surgeryappropriateness of rates of surgery

Seattle 4.7

Tacoma 5.9

Spokane 6.9

Everett 4.0

Wenatchee 7.9

Wenatchee 9.2

Spokane 9.1

Tacoma 8.3

Seattle 6.8

Everett 6.5

Wenatchee 9.9

Seattle 2.4

Tacoma 4.0

Spokane 6.0

Bellevue 1.7

Spokane 4.3

Tacoma 3.5

Seattle 2.5

Renton 2.2

Tacoma 8.9

Spokane 8.9

Seattle 6.4

Port Angels 5.0

Bellingham 14.9

Bellingham 19.0

Spokane 13.2

Tacoma 12.3

Seattle 8.9

Port Angels 8.2

Bottom Line Implication: Bottom Line Implication:

Clinical Appropriateness should be based on sound Clinical Appropriateness should be based on sound evaluation of treatment options (outcomes research)evaluation of treatment options (outcomes research)

To Avoid Wrong Patient Surgery, Medical Necessity To Avoid Wrong Patient Surgery, Medical Necessity should be based on Informed Patient Choice among should be based on Informed Patient Choice among Clinically Appropriate OptionsClinically Appropriate Options

Supply-Sensitive Care Supply-Sensitive Care

• The frequency of use is governed by the assumption that The frequency of use is governed by the assumption that resources should be fully utilized, i.e. that more is betterresources should 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 In the absence of evidence, and under the assumption that more is better, available supply governs frequency of useis better, available supply governs frequency of 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

cha

rge

Rat

eD

isch

arg

e 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 = 0.49Nu

mb

er

of

Vis

its

to C

ard

iolo

gis

tsN

um

be

r o

f V

isit

s to

Ca

rdio

log

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

to cardiologists among Medicare enrollees: 306 Regionsto cardiologists among Medicare enrollees: 306 Regions

Contrasting Practice Patterns in Managing Chronic Illness Contrasting Practice Patterns in Managing Chronic Illness During Last Two Years of Life (Deaths 2001-2005) During Last Two Years of Life (Deaths 2001-2005)

Regions in Highest and Lowest HCI Index Quintiles Regions in Highest and Lowest HCI Index Quintiles

Resource input Lowest Quintile

Highest Quintile

Ratio H/L

Medicare $ per capita $38,300 $60,800 1.59

Physician Labor/1,000

All Physicians 16.6 29.5 1.78

Medical Specialists 5.6 13.1 2.35

Primary Care Doctors 7.4 11.5 1.55

Source: Dartmouth Atlas Database

Contrasting Practice Patterns in Managing Chronic Illness Contrasting Practice Patterns in Managing Chronic Illness in Regions (HRRs) Ranked in Highest and Lowest in Regions (HRRs) Ranked in Highest and Lowest

Utilization Quintile (patients in their last 2 years of life)Utilization Quintile (patients in their last 2 years of life)

Low HRRsLow HRRs High HRRsHigh HRRs Ratio H/LRatio H/L

End of Life CareEnd of Life Care

Hospital Days (L6M)Hospital Days (L6M) 8.58.5 15.615.6 1.831.83

Hospital MD Visit (L6M)Hospital MD Visit (L6M) 12.912.9 36.336.3 2.822.82

% Seeing 10 or more MDs% Seeing 10 or more MDs 20.820.8 43.743.7 2.162.16

% Deaths in ICUs % Deaths in ICUs 14.314.3 23.223.2 1.631.63

End of life care for Chronic Illness at selected End of life care for Chronic Illness at selected academic medical centers (deaths 2001-05)academic medical centers (deaths 2001-05)

% of deaths% of deathswith ICUwith ICU

admissionadmission

35.135.1

37.937.9

26.226.2

23.223.2

28.528.5

23.523.5

28.628.6

22.522.5

23.123.1

21.821.8

16.116.1

Hospital NameHospital Name

NYU Medical CenterNYU Medical Center

UCLA Medical CenterUCLA Medical Center

Brigham and Women'sBrigham and Women's

Johns HopkinsJohns Hopkins

Tufts-New EnglandTufts-New England

Beth Israel DeaconessBeth Israel Deaconess

Boston Medical CenterBoston Medical Center

Massachusetts GeneralMassachusetts General

Cleveland ClinicCleveland Clinic

Mayo Clinic (St. Mary's)Mayo Clinic (St. Mary's)

University of WisconsinUniversity of Wisconsin

TotalTotalMedicareMedicarespendingspending

105,068105,068

93,84293,842

87,72187,721

85,72985,729

85,38785,387

83,34583,345

79,67279,672

78,66678,666

55,33355,333

53,43253,432

49,47749,477

Dartmouthatlas.orgDartmouthatlas.org

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