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Understanding Practice Variations: A Focus on Academic Medical Centers

Understanding Practice Variations: A Focus on Academic Medical Centers. The Eisenberg Legacy Lecture Stanford, California Presentation by John Wennberg November 2, 2005. The Three Categories of Care. Effective Care Preference-sensitive Care Supply-sensitive Care.

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Understanding Practice Variations: A Focus on Academic Medical Centers

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  1. Understanding Practice Variations: A Focus on Academic Medical Centers The Eisenberg Legacy Lecture Stanford, California Presentation by John Wennberg November 2, 2005

  2. The Three Categories of Care • Effective Care • Preference-sensitive Care • Supply-sensitive Care

  3. The Dartmouth Atlas Project: 306 Hospital Referral RegionsOngoing Study of Traditional Medicare Population The essence of practice variation studies is the comparison of rates of use of medical care among defined populations

  4. 1 .30 or More (0) 1 .10 to < 1 .30 (56) 0 .90 to < 1 .10 (204) 0 .75 to < 0 .90 (45) 0 .65 to < 0 .75 (1) Not Populated A Rare Example of Regional Variation for Effective Care that Reflects Illness: Hospitalization for Hip Fracture Ratio of Rates of Hip Fracture to the U.S. Average (1995-96) Among the 306 Hospital Referral Regions

  5. 95.0 85.0 75.0 65.0 55.0 45.0 Variation in Quality Scores for Care Related to Pneumonia Among Medicare Enrollees Receiving Most of Their Care at Academic Medical Centers (2004)

  6. 95.0 85.0 75.0 65.0 Stanford Hospital 64.7 UCSD Medical Center 62.3 UCSF Medical Center 55.0 UC Davis Medical Center 53.3 UC Irvine Medical Center 52.3 UCLA Medical Center 52.3 55.0 45.0 Variation in Quality Scores for Care Related to Pneumonia Among Medicare Enrollees Receiving Most of Their Care at Academic Medical Centers (2004)

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

  8. Hip Fracture (13.8) Knee Replacement (55.0) Hip Replacement (67.2) Back Surgery (93.6) Variation in Preference-Sensitive Care, Typified by Elective Surgery, Reflects Idiosyncratic Practice Style, Usually Independent of Capacity

  9. 6.0 2.72 5.0 1.26 1.24 2.22 4.0 1.00 1.63 Discharge rate 3.0 1.14 1.00 1.00 2.0 1.0 0.0 Hip replacement Knee replacement Back surgery Stanford San Francisco Los Angeles Rates of Orthopedic Procedures in HSAs Served by Three California Academic Medical Centers (2002-3) (Ratios are to the Lowest HSA.)

  10. 12.0 10.0 8.0 Knee Replacement 6.0 4.0 2.0 R2 = 0.00 0.0 0.0 3.0 6.0 9.0 12.0 15.0 Orthopedic Surgeons Relationship Between Supply of Orthopedic Surgeons (1999) and Knee Replacement Rates (2000-01) Among Hospital Regions

  11. Association Between Surgery Rate ( 2000-01) and Supply of Surgeons (1999); 10 Preference-Sensitive Procedures (R2) Procedure Specialty Association of Surgeon (R2) Knee Replacement Orthopedic .00 Hip Replacement Orthopedic .08 Back Surgery Orthopedic .02 CABG Cardiac Surg. .08 PCI Cardiologist .06 TURP for BPH Urologist .00 Prost. For CA Urologist .01 Gall bladder General Surg. .01 Carotid endart. General Surg. .04 Lower extremity bypass Vasc. Surgeon .09

  12. 12.0 10.0 8.0 Knee Replacement (2000-01) 6.0 4.0 2.0 R2 = 0.75 0.0 0.0 2.0 4.0 6.0 8.0 10.0 12.0 Knee Replacement (1992-93) Relationship Between Knee Replacement Rates in 1992-93 and 2000-01

  13. Association Between Surgery Rate ( 2000-01) and Surgery Rate (1992-93) (R2) Procedure Association R2 Knee .75 Hip .81 Back .51 CABG .39 PCI .34 TURP for BPH .28 Prost. For CA .25 Gall bladder .32 Carotid endart. .53 L.E. Bypass .56

  14. Reducing Misuse of Preference-Sensitive Care • Major focus: shared decision making

  15. Knowledge of relevant treatment options and outcomes Concordance between patient values and care received Which Rate is Right? Impact of Improved Decision Quality on Surgery Rates: BPH

  16. Reducing Misuse of Preference-Sensitive Care • Major focus: shared decision making • New focus: report cards measuring decision quality

  17. UNKNOWN Benefit to Patients Units of Discretionary Surgery Shape of the Benefit-Utilization Curve:Preference-Sensitive Surgery

  18. Standardized ratio (log scale) Primary care visits (16.2) Medical specialist visits (36.8) CHF discharges (24.6) COPD discharges (34.5) Variation in Supply-Sensitive Care Reflects Idiosyncratic Practice Style in Disequilibrium with Capacity

  19. Standardized ratio (log scale) Primary care visits (16.2) Medical specialist visits (36.8) CHF discharges (24.6) COPD discharges (34.5) Variation in Supply-Sensitive Care Reflects Idiosyncratic Practice Style in Disequilibrium with Capacity

  20. 400 All Medical Conditions R2 = 0.54 350 300 250 Discharge Rate 200 150 100 Hip Fracture R2 = 0.06 50 0 1.0 2.0 3.0 4.0 5.0 6.0 Acute Care Beds Association Between Hospital Beds per 1,000 Residents and Discharges per 1,000 Medicare Enrollees: 306 Hospital Referral Regions

  21. 2.5 2.0 Number of Visits to Cardiologists 1.5 1.0 0.5 R2 = 0.49 0.0 0.0 2.5 5.0 7.5 10.0 12.5 15.0 Number of Cardiologists per 100,000 Association Between Cardiologists and Visits per Person to Cardiologists among Medicare Enrollees: 306 Regions

  22. 33.0 28.0 23.0 UCLA Medical Center 19.2 18.0 UC Irvine Medical Center 16.0 UCSD Medical Center 14.1 UCSF Medical Center 13.2 Stanford Hospital 12.0 UC Davis Medical Center 11.6 13.0 8.0 Hospital Days During the Last Six Months of Life among Medicare Enrollees Receiving Most of Their Care at Academic Medical Centers (1999-2003)

  23. 40.0 30.0 CHF patients 20.0 10.0 R2 = 0.78 0.0 0.0 10.0 20.0 30.0 40.0 Cancer patients Hospital Days Association Between Utilization Rates During the Last Six Months of Life for Patients with Cancer and Congestive Heart Failure among Academic Medical Centers (1999-2003)

  24. Hospital days Black & Non-Black 0.67 Male & Female 0.92 Younger & Older 0.82 Medicaid & Non-Medicaid 0.84 Association (R2) Between Utilization Rates During the Last Six Months of Life for Patient Cohorts According to Demographic Characteristics among Academic Medical Centers (1999-2003)

  25. 35.0 30.0 25.0 20.0 Last six months of life 15.0 10.0 5.0 R2 = 0.74 0.0 0.0 2.0 4.0 6.0 8.0 19-24 months before death Hospital Days Association Between Utilization Rates 19-24 Months Before Death and During the Last Six Months of Life among Academic Medical Centers (1999-2003)

  26. 12.0 UCLA Medical Center 11.4 11.0 10.0 9.0 UC Irvine Medical Center 8.2 8.0 7.0 UC Davis Medical Center 6.8 UCSD Medical Center 6.3 6.0 5.0 Stanford Hospital 3.7 UCSF Medical Center 3.3 4.0 3.0 2.0 1.0 ICU Days During the Last Six Months of Life Among Medicare Enrollees Receiving Most of Their Care at Academic Medical Centers (1999-2003)

  27. 77.0 67.0 57.0 UCLA Medical Center 52.1 47.0 UC Irvine Medical Center 39.7 37.0 UCSF Medical Center 30.4 UCSD Medical Center 30.1 27.0 Stanford Hospital 24.0 UC Davis Medical Center 23.2 17.0 Physician Visits During the Last Six Months of Life Among Medicare Enrollees Receiving Most of Their Care at Academic Medical Centers (2000-03)

  28. 70% 60% UCLA Medical Center 57.7% 50% UC Irvine Medical Center 43.4% UCSF Medical Center 42.2% UCSD Medical Center 41.1% UC Davis Medical Center 34.7% Stanford Hospital 28.9% 40% 30% 20% 10% Percent of patients seeing 10 or more physicians during the last six months of life among Medicare decedents receiving most of their care at academic medical centers (2000-03)

  29. 3.25 UCLA Medical Center 2.86 2.75 2.25 1.75 UC Irvine Medical Center 1.55 UC Davis Medical Center 1.19 UCSD Medical Center 1.16 Stanford Hospital 1.15 1.25 0.75 UCSF Medical Center 0.68 0.25 Ratio of Medical Specialist to Primary Care Physician Visits During the Last Six Months of Life Among Medicare Enrollees Receiving Most of Their Care at Academic Medical Centers (2000-03)

  30. 60.0 50.0 40.0 Medical specialist visits 30.0 20.0 10.0 R2 = 0.17 0.0 0.0 5.0 10.0 15.0 20.0 25.0 Primary care visits Association Between Medical Specialist and Primary Care Physician Visits During the Last Six Months of Life Among Academic Medical Centers (2000-03)

  31. 80.0 60.0 Physician visits 40.0 20.0 R2 = 0.66 0.0 0.0 10.0 20.0 30.0 40.0 Hospital days Association Between Hospital Days and Physician Visits During the Last Six Months of Life Among Academic Medical Centers (1999-2003)

  32. 40.0 100.0 80.0 30.0 60.0 CHF patients 20.0 CHF patients 40.0 10.0 20.0 R2 = 0.78 R2 = 0.61 0.0 0.0 0.0 10.0 20.0 30.0 40.0 0.0 20.0 40.0 60.0 80.0 100.0 Cancer patients Cancer patients Hospital days Physician visits Association Between Utilization Rates During the Last Six Months of Life for Patients With Cancer and Congestive Heart Failure Among Academic Medical Centers (1999-2003)

  33. 35.0 80.0 30.0 60.0 25.0 20.0 Last six months of life Last six months of life 40.0 15.0 10.0 20.0 5.0 R2 = 0.74 R2 = 0.67 0.0 0.0 0.0 5.0 10.0 15.0 20.0 25.0 0.0 2.0 4.0 6.0 8.0 19-24 months before death 19-24 months before death Hospital days Physician visits Association Between Utilization Rates 19-24 Months Before Death and During the Last Six Months of Life Among Academic Medical Centers (1999-2003)

  34. Variations During the Last Six Months of Life Among Medicare Enrollees Receiving Most of Their Care at Hospitals Belonging to Large Academic Medical Systems (1999-2003)

  35. Mayo 2.8 UPMC 2.9 BJC 4.6 Cleve. Clin. 4.6 UHHS 3.4 Fairview 2.0 CareGroup 3.1 Univ. of CA 7.6 Partners 2.7 HA of Cin. 3.4 Baylor 3.8 Jefferson 7.9 0.0 2.0 4.0 6.0 8.0 10.0 12.0 ICU Days Per Patient During the Last Six Months of Life Among Medicare Enrollees Receiving Most of Their Care at Hospitals Belonging to Large Academic Medical Systems (1999-2003) (Weighted System Average on Right)

  36. Mayo 23.3 UPMC 39.3 BJC 33.6 Cleve. Clin. 36.7 UHHS 31.7 Fairview 24.7 CareGroup 32.7 Univ. of CA 38.9 Partners 35.4 HA of Cin. 30.8 Baylor 34.0 Jefferson 50.0 13.0 23.0 33.0 43.0 53.0 63.0 Physician Visits Per Patient During the Last Six Months of Life Among Medicare Enrollees Receiving Most of Their Care at Hospitals Belonging to Large Academic Medical Systems (2000-2003) (Weighted System Average on Right)

  37. Mayo 0.81 UPMC 1.10 BJC 0.90 Cleve. Clin. 1.19 UHHS 0.98 Fairview 0.54 CareGroup 0.91 Univ. of CA 1.59 Partners 0.94 HA of Cin. 1.06 Baylor 1.14 Jefferson 1.97 0.0 0.5 1.0 1.5 2.0 2.5 3.0 Ratio of Medical Specialist to Primary Care Physician Visits During the Last Six Months of Life Among Medicare Enrollees Receiving Most of Their Care at Hospitals Belonging to Large Academic Medical Systems (Weighted System Average on Right)

  38. Resource Inputs Medicare Spending 1.61 Hospital Beds (1000) 1.32 Physician Supply* All Physicians 1.31 Medical Specialists 1.65 General Internists 1.75 Family Practice 0.74 Surgeons 1.37 Per 10,000 Cohort Health Outcomes Death R.R. 95% CL Hip Fracture 1.019 1.001-1.039 Colon Cancer 1.012 1.018-1.094 Heart Attack 1.052 1.018-1.094 Functional Status Worse Satisfaction Same Per Capita Resource inputs and Health Outcomes:Ratio High/Low Quintiles of Spending

  39. 45% 40% UCLA Medical Center 35.4% 35% UC Irvine Medical Center 30.8% UC Davis Medical Center 29.9% 30% UCSD Medical Center 24.0% UCSF Medical Center 23.1% Stanford Hospital 21.9% 25% 20% 15% 10% 5% 0% Percent of deaths associated with admission to intensive care among Medicare decedents receiving most of their care at academic medical centers (1999-2003)

  40. Frequency of Care Shape of the Benefit-Utilization Curve:Supply-Sensitive Services U.S. is some- where in this zone Life Expectancy

  41. Summary: “System” Causes of Unwarranted Variation Under-use of effective care. • Discontinuity of care (worse when more physicians are involved in the care) • Lack of infrastructure to assure outreach and the timely use of effective care • Finance “system” that fails to support infra-structure and rewards quantity, not quality

  42. Summary: “System” Causes of Unwarranted Variation Misuse of preference-sensitive care • Poor communication between MD and patient regarding the risks and benefits of alternative treatments; • Patient dependency on physician’s opinion in sorting out preferences; (flaws in agency model) • Inadequate evaluation of (evolving) treatment theory • Health care finance “system” that rewards procedures, not the quality of decision making

  43. Summary: “System” Causes of Unwarranted Variation Overuse of supply-sensitive care • Over-dependence on acute hospital care; • Lack of infrastructure to support population-based management of chronically ill patients; • Cultural assumption that more care is better care (without evidence at the clinical level that this is so) • Lack of accountability for the capacity of the health care system relative to the size of the population served • Finance “system” that rewards high intensity care and doesn’t pay for infrastructure, efficiency or learning

  44. The CMS 646 Opportunity(Medicare Health Care Quality Demonstration Programs) • Provider focus: group practices, integrated health care systems and regional coalitions can propose radical changes in health care delivery • Focus on improving quality and efficiency in all three categories of care • RFP seeks proposals to reform financing systems as well as the regulatory environment (and might include commercial as well as Medicaid programs) • Encourages collaboration between applicants, NIH and ARC to improve the scientific basis of clinical decision making • Five-year time horizon

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