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In Healthcare,Is More Always Better?
Thérèse Stukel Institute for Clinical Evaluative Sciences, Toronto
Dartmouth Medical School, US
Graham WoodwardCancer Care Ontario
Canadian Health Services Research Foundation
October 15, 2008
Researcher on Call
Common Assumptions
• Higher spending is due to greater use of treatments of proven benefit to sick patients.
• More is better.
— Wennberg, Gittelsohn. Science (1973)
0.2
1.0
5.0Hip
FractureHeart
Failure
Huge U.S. regional variations exist in hospitalization rates for common conditions
Hip FractureR2 = 0.06
All MedicalConditions
R2 = 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 6.06.0
Dis
cha
rge
Rat
eD
isch
arg
e R
ate
U.S. regional hospitalization rates are strongly related to hospital bed supply
Acute Care BedsAcute Care Beds
Huge U.S. regional variations existin spending intensity during L6M*
L6M
$ per capita
Total Medicare $ per capita
9,074 3,922
10,636 4,439
11,559 4,940
12,598 5,444
14,644 6,304
(r = 0.81)
*L6M = Last 6 months of life
Costs reflect health care resource availabilityComparison of Highest & Lowest 20th-percentile Spending Regions
Lowest
20th Percentile Spending
Highest
20th Percentile Spending
Ratio Highest- Lowest
Regional Medicare spending (per capita)
$3,963 $6,298 1.59
Regional supply of health care resources (per capita)
Hospital beds per 1000 2.4 3.2 1.33
Physician supply (per 100K)
– Medical specialists 28 44 1.59
– General Internists 23 37 1.63
– Family practitioners/GPs 35 27 0.75
– Surgeons 44 56 1.27
– Other specialists 59 78 1.32
Rates of evidence-based carewere lower or similar in high spending regions (RR<1)*
1.00 1.5 2.00.5 25 3.0
1.0 1.5 2.00.5 25 3.0
Reperfusion in 12 hours for AMI
Beta blockers at admissionAspirin at admission
Beta blockers at dischargeAspirin at discharge
Acute MI
Mammogram, Women 65-69
Flu shot during past yearPap smear, Women 65+
Pneumococcal immunization
General Population
Lower in High Spending Regions (RR<1) Higher in High Spending Regions (RR>1)
*RR=Relative Rate
Rates of Physician-Driven Carewere higher in high spending regions (RR>1)*
1.00 1.5 2.00.5 25 3.0
1.0 1.5 2.00.5 25 3.0
Office visits
Initial inpatient specialist consultationsInpatient visits
Psychotherapy visits% of patients seeing 10 or more MDs
Physician Visits
Chest X-ray
Ventilation perfusion scanCT / MRI brain
Imaging Tests
Upper GI endoscopy
Pulmonary function testBronchoscopy
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
Rates of Hospital-Driven carewere higher in high spending regions (RR>1)*
1.00 1.5 2.00.5 25 3.0
1.0 1.5 2.00.5 25 3.0
Inpatient days in ICU or CCU
DischargesTotal inpatient days
Hospital Utilization
Feeding tube placement
Inpatient daysICU 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
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.
Ontario regional hospitalization rates are strongly related to hospital bed supply
System Misalignment:Ontario regional AMI admission rates are
inversely related to cardiology supply
Probability of death after lung cancer surgery varies 1-8% depending where you get care
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?
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)
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
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.
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
Distribution of Annual Colonoscopy Volumes by Endoscopist (Ontario 2006/07)
0
50
100
150
200
250
1 to 99 100 to 199 200 to 299 300 to 399 400 to 499 500 to 599 600 to 699 700 to 799 800 to 899 900 to 999 1000+
# of Colonoscopies Performed in 2006/07
# o
f E
nd
oc
so
pis
ts
Currently, 1/3 of physicians do not meet the standard of 200+ colonoscopies per year.
Too many hospitals provide lung cancer surgery:Cancer Care Ontario is reducing this to 10-15 hospitals
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
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