1. Reducing Unwarranted Variations in Health Care Promoting the Good and Minimizing the BadALBERT G. MULLEY, JR., MD, MPPTHE DARTMOUTH CENTER FOR HEALTH CARE DELIVERY SCIENCEINTERNATIONAL VISITING FELLOW, THE KINGS FUNDSEPTEMBER 14, LONDON

2. Practice Variation: Rediscovery by Wennberg Variations in: Tonsillectomy: 17-fold Hysterectomy: 6-fold Prostatectomy: 4-fold The need for assessing outcome of common medical practices Professional uncertainty and the problem of supplier- induced demandJohn E. Wennberg, 1973 3. Practice Variation: US, Norway and the UK Geographic variation in rates of surgical procedures Different rates between countries (US>UK>Norway, or US>Norway>UK) Regional variation within countries similar McPherson higher variation: tonsillectomy, hemorroidectomy, hysterectomy, prostatectomy lower variation: appendectomy, Hovindhernia repair, cholecystectomy Variation a characteristic of the procedureWennberg Within country variation not associated with organization or financing of care, but with professional uncertaintyN Engl J Med 1982; 307: 1310 4. Variation: The Bad and the GoodBad variation (care not evidence-based) Poor research professional uncertainty Poor knowledge professional ignoranceGood variation (care is patient-centered) Clinical differences among patients Personal differences among patients If all variation were bad, it would be easyJAMA, 1988 to stop it. What is difficult is reducing thebad variation while keeping the good. 5. The Complexity of Health Care DeliveryHighDisagreement about ChaosPreferences Complexity ControlLow LowHighUncertainty about Outcomes Knowledge-Based 6. Variation: The Bad and the GoodDECREASING BAD VARIATION (evidence-based care) Improve knowledge management Improve communication No avoidable ignoranceINCREASING GOOD VARIATION (patient-centered care) Recognize clinical differences amongpatients Honor personal differences among patientsThe efficient way to reduce overuse, underuse, and misuse of care 7. Support for personal knowledge: BPHHow bothersome is urinary dysfunction?How bothersome will sexual dysfunction be? 8. Simple measures of decision quality: BPH Knowledge of relevant treatment Concordance between patient options and outcomesvalues and care received1. Are my symptoms likely to be life- 1. How much am I bothered by mythreatening? What if I do nothing?symptoms?2. Is surgery the only option? How2. How much will I be bothered by amuch can other treatments help? possible change in experience of sex?3. Will surgery change my sexualfunction? In what ways? OR = 7.0Least Mostvaluedvalued OR = 0.2 9. Simple measures of decision quality: CHDKnowledge of relevant treatmentConcordance between patientoptions and outcomes values and care received1. Are my symptoms likely to be life-1. How much am I bothered by mythreatening? What if I do nothing? symptoms?2. Is surgery the only option? How much2. How much will I be bothered by acan other treatments help? possible change in cognitive abilities?3. Will surgery change my ability to thinkclearly? In what ways? What else can Iexpect in the future?10090CABG807060Medical Therapy504002 468 10 12 10. Impact of Better Decisions for BPH & CHD Toronto trialProstatectomy rates decreased CABG rates decreased 26% to40% to a rate lower than all buta rate lower than all 306one of 306 regions 11. The New Yorker, June 1, 2009 12. A Tale of Two Cities: McAllen and El PasoMcAllen $14,946 El Paso $ 7,504 13. Questions raised but not answered 14. Glover s discovery and the ethical imperative 10-fold variation in tonsillectomy 8-fold risk of death with surgical treatment The response: these strange bare facts of incidence tendency for the operation to be performed for no particular reason and no particular result. sad to reflect that many of the anesthetic deaths were due to unnecessary operations.J Allison Glover, 1938