Geography is Destiny:Geography is Destiny:
The Epidemiology of Health Care
David C. Goodman, MD MS
Director, Center for Health Policy Research
September 2009
Cholera EpidemicsFarr and Snow, London, 1840
The School Medical Service - England
The English School Medical ServiceThe English School Medical Service
• Enlarged adenoids and tonsils were a common condition.• Tonsillectomy rates began to increase• Tonsillectomy rates began to increase.• In 1924, Committee on Enlarged Adenoids and Tonsils
was established.• In 1931:
– 6% of students were diagnosed with “adenoids and enlarged t il ”tonsils”
– 84,000 tonsillectomies and adenoidectomies were performed.– Thought to be ¾ of all procedures in England.g p g
Glover Tonsillectomy Annual Incidence (1936)5 - 14 years5 14 years
6.06.0
5.05.0
dren
dren
4.04.0
100
child
100
child
Blyth MB 5.7Oxford CB 3 1
3.03.0
tom
y pe
r to
my
per Oxford CB 3.1
London 2.2Cambridge MB 1.0
2.02.0
Tons
illec
tTo
nsill
ect
1.01.0
TT
0.00.0Source: Glover JA. The incidence of tonsillectomy in school children. Proceedings of the Royal Society of
Medicine 1938;31:95-112.
“A study of the geographic distribution in elementary school children discloses no correlationschool children discloses no correlation
between...any other factor, such as overcrowding, poverty bad housing or climatepoverty, bad housing, or climate.
In fact it defies any explanation, save that of variation f di l i i th i di ti f ti ”of medical opinion on the indications for operation.”
1973 H it l S i A i VT1973 - Hospital Service Areas in VT
Source: Wennberg and Gittelsohn. Small Area Variation in Health Care Delivery. Science 1973.
Tonsillectomies by Vermont Hospital Service AreasHospital Service Areas
Wennberg, et al. Pediatrics 1977;59;821-826
Today, we have a problem with financing:Medicare Funding as
% of Gross Domestic Product
Part A is “exhausted”;Part A is exhausted ; Part B and D premiums soar.
Today, we have problems with outcomesy p
Black Non-blacks Total Black Non black17
15
130 Li
ve B
irths Total
13
15
17
Nicaragua
Turkey
13
11
9ght P
er 1
00
9
11
13
Ghana
Tanzania
Nicaragua
9
7
5w B
irth
Wei
g
5
7
9
CanadaAustralia U.S.
Ghana
3
5
Low
Healthy People 2010 Goal
Singleton Low Birth Weight Rates Across 246
3
5Sweden
Singleton Low Birth Weight Rates Across 246 U.S. Low Birth Weight Regions, 1998
Unwarranted variation in health care is i i h b l i d bvariation that cannot be explained by:
• Patient illness• Dictates of evidence-based medicineDictates of evidence based medicine• Patient preference
Unwarranted variation is caused by differences in the effectiveness anddifferences in the effectiveness and
efficiency of health care delivery s stemssystems.
Small area analysis reveals the regional i i i h l h d livariation in health care delivery
• Reveals variation in medical resources, utilization, and outcomes
• Often attributable to a system of care• Offers:Offers:
– specific information about health systems – high and low performing health care systemsand low performing health care systems
– generalizable information about the functioning of our health care system:y
• Are resources found in areas with greater need?• Is more better?• Is care aligned with patient (and family) preferences?
Primary Care Service Areas - v2 (N = 6,542)
Counties provide coarse measures of primary care physician supply:
*
* *
Counties Primary Care Service Areas
The Dartmouth Atlas of Health Care
Collaborators Support• John Wennberg, MD MPH • Elliott Fisher, MD MPH• Jonathan Skinner PhD
• The Robert Wood Johnson Foundation
• Jonathan Skinner, PhD• Chiang-hua Chang, MS• Therese Stukel, PhD• Julie Bynum, MD
• National Institute on Aging
• WellPoint Foundation• Jason Sutherland, PhD• Douglas Staiger, PhD• James Weinstein, MD MS• Dongmei Wang MS
• Aetna Foundation
• United Health FoundationDongmei Wang, MS• Sally Sharp, SM• Stephanie Raymond• Phyllis Wright-Slaughter, MHA
D i l G ttli b MS
United Health Foundation
• California HealthCare Foundation
• Daniel Gottlieb, MS• Kristen Bronner, MA• Megan McAndrews, MBA, MS• Jia Lan, MS• Jon Lurie, MD MS• Tom Bubolz, PhD• Rebecca Townsend
www dartmouthatlas orgwww.dartmouthatlas.org
Elliott Fisher, MD MPHDavid Goodman, MD MSJohn Wennberg, MD MPH
Jonathan Skinner, PhD
The Dartmouth Atlas of Healthcaret t d i tireports on unwarranted variation
First 6 months 2009:118 million media impressions
About 2,000 unique media markets
Variation in Per-Capita Medicare Spending Across Hospital Referral Regions (N=306) (2006)Across Hospital Referral Regions (N 306) (2006)
$8,800 to 16,352 (61)8,100 to < 8,800 (61)7 550 t 8 100 (60)7,550 to < 8,100 (60)6,900 to < 7,550 (62)5,310 to < 6,900 (62)
Not PopulatedNot Populated
Types of Unwarranted Variation
Unwarranted Variation in:Unwarranted Variation in:
Effective CareEffective CarePreference Sensitive Care
S l S iti CSupply Sensitive Care
New York CityAcute Myocardial Infarction CareAcute Myocardial Infarction Care
ACE PCI < 90 Smoking Inhibitors minutes cessation
Beth Israel Medical Center 98% 69% 97%
Montefiore Medical Center 82% 83% 100%
Mount Sinai Hospital 97% 88% 99%
New York-Presbyterian 87% 64% 95%New York-Presbyterian 87% 64% 95%
NYU Medical Center 83% 75% 85%
U.S. Average 90% 73% 94%
Source: CMS, Hospital Compare, 10/06 - 9/07
Domains of Effective Care
Nearly completely Implemented
Partially Implemented
Possibly Efficacious
Proven Effective
Possibly Efficacious
Basic Science Knowledge
Domains of Effective Care
Partially Implemented
B i S i K l d
Possibly Efficacious
Proven Efficacious
Implemented
Basic Science Knowledge
Health, Disease, , ,and Treatments Unknowns
Supply Sensitive Care
• Care strongly correlates with resource supply• Care strongly correlates with resource supply(i.e. capacity of hospital beds & doctors.)
• Generally provided in the absence of specific clinical theories governing the “right rate ”clinical theories governing the right rate.
• Generally the care is one of many optionsGenerally, the care is one of many options.
• Medical evidence weak or nonexistent• Medical evidence weak or nonexistent.
• Responsible for a high proportion of variation in• Responsible for a high proportion of variation in costs.
Neonatologists per 1,000 Live Births
(Neonatal Intensive Care Regions)
Neonato log is ts per1,000 L ive B ir ths
8.57 to 25.64 (50)6.39 to 8.57 (49)4.88 to 6.39 (51)
,
( )3.55 to 4.88 (46)0.56 to 3.55 (51)
Health Care Capacity is not Located Where Needs are Greater
1995 Neonatal Intensive Care Regions
Neonatologists Intensive Care Beds30 ●14
●
●25
ists irths R2=0.04 ●
10
12
14
birth
s R2=0.07
●
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4 5 6 7 8 9 10 11 12 13
Bed
Percent Low Birth Weight Percent Low Birth WeightGoodman, et al. Pediatrics, 2001.
Are cardiologists located where cardiac needs are greater?(306 Hospital Referral Regions, Dartmouth Atlas)
10 0
12.0
8.0
10.0
per
100K
There is virtually no relationship between regional
6.0
iolo
gist
s p relationship between regional
physician supply and cardiovascular risk.
2.0
4.0
Car
d
3.0 6.0 9.0 12.0 15.0 18.0
Acute Myocardial InfarctionRate per 1,000 Medicare Enrolleesp ,
Source: Wennberg D, et al. Dartmouth Cardiovascular Atlas
Hospital Beds (1996) vs. Adjusted Discharge Rates for Medical Conditions (1995-96)for Medical Conditions (1995-96)
350.0350.0
300.0300.0
r 1,
000
95-9
6)
250.0250.0
rges
per
lees
(19
200.0200.0
Dis
char
re E
nrol
l
R2 0 56
150.0150.0
Med
ical
M
edic
ar
R2 = 0.56100.0100.0
1.01.0 2.02.0 3.03.0 4.04.0 5.05.0 6.06.0
M M
Acute Care Beds per 1,000 Residents (1996)
Variation in Per-Capita Medicare Spending Is Mostly Caused by Supply Sensitive CareIs Mostly Caused by Supply Sensitive Care
$8,800 to 16,352 (61)8,100 to < 8,800 (61)7 550 t 8 100 (60)7,550 to < 8,100 (60)6,900 to < 7,550 (62)5,310 to < 6,900 (62)
Not PopulatedNot Populated
Is more spending
(Hospital Days, ICU Days, CT Scans, MRI Scans)
necessarily better?necessarily better?
Lessons from Regional Variation:Lessons from Regional Variation:
• Marked regional variation in capacity, utilization, and spending.
• More spending is not better (i.e. quality and outcomes).
• High spending associated with discretionary servicesHigh spending associated with discretionary services (physician visits, hospital days, tests).
• Implication: low spending regions are more efficientImplication: low spending regions are more efficient.
Fisher ES et al. Ann Intern Med 2003 Feb 18; 138(4): 273-87, 288-98.Goodman DC et al NEJM 2002; 346: 1538-1544Goodman DC, et al. NEJM 2002; 346: 1538-1544.Goodman DC, et al NEJM 2008;358:1658-1661.
Total Medicare Spending per Decedent During the Last Two Years of Life (2001-05)the Last Two Years of Life (2001 05)
120,000
110,000
nt
UCLA Medical Center 93,842New York-Presbyterian 91,113Brigham and Women's 87,72190 000
100,000
r dec
eden
Johns Hopkins Hospital 85,729Hospital of the U of PA 80,727Massachusetts General 78,666UCSF Medical Center 78 046
80,000
90,000
ndin
g pe
r
UCSF Medical Center 78,046U of WA Medical Center 70,245Duke University Hospital 57,411Cleveland Clinic 55,333
60 000
70,000
care
spe
n
Mayo Clinic (St. Mary's) 53,432
50,000
60,000
Med
ic
40,000
Average Number of Hospital Days per Decedent During the Last Six Months of Life (2001-05)During the Last Six Months of Life (2001 05)
33.0
29.0New York-Presbyterian 22.7UCLA Medical Center 18.5Hospital of the U of PA 17.625.0
eced
ent
Massachusetts General 17.3Johns Hopkins Hospital 16.5Brigham and Women's 16.1Cleveland Clinic 14 8
21.0
ys p
er d
e
Cleveland Clinic 14.8Duke University Hospital 13.8UCSF Medical Center 13.5U of WA Medical Center 13.2
17.0
spita
l day
Mayo Clinic (St. Mary's) 12.0
13.0
Hos
9.0
Average Number of Days in ICU per Decedent During the Last Six Months of Life (1999-2003)During the Last Six Months of Life (1999 2003)
12 0
10.0
12.0
UCLA Medical Center 11.4New York-Presbyterian 5.0Barnes-Jewish 4.58.0
eden
t
Johns Hopkins 4.3Mayo Clinic (St. Mary's) 3.9Cleveland Clinic 3.5Duke University Hosp 3 3
6.0per d
ece
Duke University Hosp. 3.3UCSF Medical Center 3.3Univ. of Washington 3.2Mass. General 2.8
4.0
CU
day
s
2.0
IC
0.0
Physician FTEs per 1,000 end-of-lifeMedicare beneficiaries
PrimaryMedical
NYU Medical Center
15 08 828 3 FTE
Primary Care
Medical SpecialistsTotal
15.08.828.3 FTEs
PrimaryMedical
Mayo Clinic
Primary Care
Medical SpecialistsTotal
3.93.08.9 FTEs
Source: Goodman, Health Affairs,March/April 2006.
“What will we ever think about now that the genome project is almost complete?”genome project is almost complete?
Think about the science and geography of health care delivery!
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