elliott fisher | monitoring variation in health care

Monitoring variation in healthcare quality -an evidence base to improve healthcare

HARC is a as a partnership between the Sax Institute, Clinical Excellence Commission and the Greater Metropolitan Clinical Taskforce

Welcome to the 5th HARC Forum

Professor Elliott FisherProfessor of Community and Family Medicine at Dartmouth Medical School and Director of the Center for Health Policy Research at the Dartmouth Institute for Health Policy and Clinical Practice

US Dartmouth Atlas of Health Care Project -monitoring and explaining variation in healthcare to improve the health system

Keynote Speaker

Monitoring Variation in Health Care: An approach to improving the

evidence base for practice and policy

Elliott S. Fisher, MD, MPH

Professor of Medicine and Communityand Family Medicine

Dartmouth Medical School

Director for Population Health and PolicyThe Dartmouth Institute for Health Policy

and Clinical Practice

The usual suspects:Rising costsUneven qualityDeclining access to care

Houston, we’ve got a problem…

Some looming challengesLoss of professional authority of physiciansIntegrity and relevance of academic medicine

Traditional diagnoses:A shortage of moneyA shortage of doctorsA shortage of economists

Houston, we’ve got a problem…

Prescriptions:Spend moreTrain moreFocus on prices

Every system is perfectly designed to get theresults that it achieves

Paul Batalden

Insanity: doing the same thing day after day andexpecting different results

Einstein

Rethinking health careOrigins of the Dartmouth Institute – and Dartmouth Atlas Project

Science, December 14, 1973; Volume 182, pp 1102-08

Rethinking health careA simple analytic framework; a shared vision

Application of epidemiologic methods to health care servicesDefine population at riskDefine eventsExamine variations across relevant systems -- providersAsk good questions

Organizational DevelopmentIndependent institute within Medical SchoolInterdisciplinary research group; all with departmental appointmentsGovernance through a shared vision:

Exploring the causes and consequences of unwarranted variationsCommitment to making a difference (locally, regionally, nationally)

Major long-term funding helps maintain focus

Rethinking health careThe Dartmouth Atlas of Health Care

Methods:Population at risk – over 65Compare Hospital Referral RegionsEvents of interest -- many


Categories of careSafe and effective carePreference sensitive careSupply-sensitive care

3.0

5.0

7.0

9.0

11.0

13.0

15.0

TUR

P fo

r BPH

Rethinking health carePreference-sensitive care Transurethral Prostatectomy for

Benign Prostatic Hypertrophy per 1000

2.0

4.0

6.0

8.0

10.0

12.0

30-D

ay M

orta

lity

Follo

win

g C

AB

G (%

)

Rethinking health careSafe and Effective Care

30 Day Mortality Following CABG

5,000

7,000

9,000

11,000

13,000

15,000

Med

icar

e sp

endi

ng p

er e

nrol

lee

Rethinking health careSpending – and supply sensitive care

Medicare Spending per capita

20,000

40,000

60,000

80,000

100,000

120,000

Inpa

tient

+ P

art B

spe

ndin

g pe

r dec

eden

t

UCLA Medical Center 72,793New York-Presbyterian 69,962Johns Hopkins 60,653UCSF Medical Center 56,859Univ. of Washington 50,716Mass. General 47,880Barnes-Jewish 44,463Duke University Hosp. 37,765Mayo Clinic (St. Mary's) 37,271Cleveland Clinic 35,455

Rethinking health careSpending – and supply sensitive care Hospital and Physician Spending

last 2 years of life at USN&WR top 10 hospitals

How can the best medical care in the world cost twice as much as the best medical care in the world?

Uwe Reinhardt

1. What we know – 3 case studies2. What I think we’ve learned3. Translating evidence to policy4. Is there reason for hope?


Preference Sensitive CareBuilding the evidence: the Prostate Patient Outcome Research TeamExploring the causes of variations in TURP for BPHInterdisciplinary team; multiple methods

Focus groups of urologists to determine clinical theoriesPreventive hypothesis: must operate early in a progressive diseaseQuality of life hypothesis

Clinical research: decision-analysis, cohort studiesNo survival benefit from surgeryBenefit of surgery depends upon patients’ values (symptoms vs sexual

dysfunction)Patients’ values differed dramatically

Implications:Broadly applicable – orthopedics, cardiology, oncology, etcNeed for accurate information on risks and benefitsStructured approach to supporting informed patient choiceStudies have now demonstrated effectiveness of decision aids

Preference Sensitive CareBuilding the evidence: the Prostate PORT

Interdisciplinary team; multiple methodsFocus groups of urologists to determine clinical theories

Preventive hypothesis: must operate early in a progressive diseaseQuality of life hypothesis

Clinical research: decision-analysis, cohort studiesNo survival benefit from surgeryBenefit of surgery depends upon patients’ values (symptoms vs sexual

dysfunction)Patients’ values differed dramatically

Implications:Broadly applicable – orthopedics, cardiology, oncology, etcNeed for accurate information on risks and benefitsStructured approach to supporting informed patient choiceStudies have now demonstrated effectiveness of decision aids

Preference Sensitive CareTranslating evidence into policy

Underlying problemsInadequate information on risks and benefits of biologically targeted treatmentsProvider-dominated decision-making

RemediesOutcomes research (comparative effectiveness)Informed patient choice

Policy implications and progressMajor investment in comparative effectiveness researchNational standards now include informed choice as core quality measureMany integrated delivery systems are moving to adopt shared decision-makingStates moving to require informed patient choice as legal standard

Safe and Effective carePopulation: Patients undergoing Coronary Artery Bypass GraftProviders: Cardiovascular surgery centers in New England

Fletcher Allen Health Care

Eastern Maine Medical Center

Maine Medical Center

Dartmouth Hitchcock Medical Center

Concord Hospital

Northern New England Cardiovascular Disease

Study Group

Origins: threatened public report of unadjusted CABG mortality rates

New England rates varied two fold: 3.1% to 6.3%

Surgeons agreed to collect relevant clinical data

Safe and Effective carePopulation: Patients undergoing Coronary Artery Bypass GraftProviders: Cardiovascular surgery centers in New England

0

1

2

3

4

5

6

7

1 2 3 4 5Center

In-H

ospi

tal M

orta

lity

Rat

e

O’Connor et al, JAMA, 1991;266:803-809

Adjusted mortality no less variable:

2.3% to 6.3%

Near death experience of study group

Now over 20 years ofexperience; 100+papers published; allsites still participatingin 3 meetings per year

Safe and Effective CareImprovement achieved as research advanced

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1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999Year

Mor

talit

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)

Mode of death study- low output heart failure major cause of in-hospital mortality

Process mapping and identification of high leverage areas

Initial intervention-data feedback, site visits and CQI training

Safe and Effective CareTranslating evidence into policy

Underlying problemsInadequate data: on patient attributes, process of care and outcomesSmall numbers, lack of follow-up prevent learningFlawed professional model: individual responsibility and autonomy

RemedyTechnical: registries to support ongoing study of variation in outcomes

Define relevant local care system / teams (to allow comparison with others)Measure and compare processes and outcomes

Cultural: create teams and systems capable of learningEngage clinicians in practice-based research and improvementEnable reflective practice – timely, relevant feedback

Policy implications and progressPotential benefits – to patients, physicians, managers and policy-makers -- of

practice-based research networks is substantialLack of government support remains challenge. Most efforts are voluntary, self-

funded.

Variations in spendingBuilding the evidence base

“How can the best medicalcare in the world cost twiceas much as the best medicalcare in the world?

Health implications of variations in spendingStudy population: Medicare patients with AMI, colon cancer, hip fracture Comparison: across (1) regions; (2) academic medical centers – grouped

according to “intensity” – price and illness adjusted spending. Measures: content, quality and outcomes of care

(1) Fisher et al. Ann Intern Med: 2003; 138: 273-298 (2) Baicker et al. Health Affairs web exclusives, October 7, 2004(3) Fisher et al. Health Affairs, web exclusives, Nov 16, 2005(4) Skinner et al. Health Affairs web exclusives, Feb 7, 2006(5) Sirovich et al Ann Intern Med: 2006; 144: 641-649(6) Fowler et al. JAMA: 299: 2406-2412

Variations in spendingBuilding the evidence base

Robert Wood Johnson FoundationNational Institute of AgingCalifornia Healthcare FoundationAetna FoundationWellpoint FoundationUnited Healthcare Foundation

1.00 1.5 2.00.5 2.5

Reperfusion in 12 hours (Heart attack)Effective Care: benefit clear for all

Ratio of rate in high spending to low spending regions

Preference Sensitive: values matter

Supply sensitive: often avoidable care

Evaluation and Management (visits)ImagingDiagnostic Tests

Inpatient Days in ICU or CCUTotal Inpatient Days

Total Hip ReplacementTotal Knee ReplacementBack SurgeryCABG following heart attack

Aspirin at admission (Heart attack)Mammogram, Women 65-69Pap Smear, Women 65+Pneumococcal Immunization (ever)

If bar on this side higher spending regions get more

What do they get more of?

Outcomes and QualityHigh spending compared to low spending regions

(1) Fisher et al. Ann Intern Med: 2003; 138: 273-298 (2) Baicker et al. Health Affairs web exclusives, October 7, 2004(3) Fisher et al. Health Affairs, web exclusives, Nov 16, 2005(4) Skinner et al. Health Affairs web exclusives, Feb 7, 2006(5) Sirovich et al Ann Intern Med: 2006; 144: 641-649(6) Fowler et al. JAMA: 299: 2406-2412

Health Outcomes

No gain in survival

No better function

Physician’s Perceptions

Worse communication

Greater difficulty ensuring coordination

Greater perception of scarcity

Patient-Perceived Quality

Lower satisfaction with hospital care

Worse access to primary care

No sense that care is rationed

The paradox of plentyPop Quiz….

If we cut spending so that all U.S. regions were receiving the same per-capita amount as the lowest spending regions, which of the following would apply:

1. U.S. healthcare spending would fall by 20% to 30%

2. The Medicare Trust Fund might survive a few years past it’s predicted collapse in 2017 (the year I become eligible).

3. We could send a third of the U.S. healthcare workforce to Africa and improve the health of both continents.

4. All of the above.

Assumption that more is better

Inadequate information on risks and benefits

Growing tension between science and professionalism --and -- market approach (health care as a commodity)

Variations in spendingWhat’s going on? General attributes of U.S. health care

Patient Demand

Little difference

Malpractice

Less than 10% of difference

Variations in spendingWhat’s going on? Exploring causes of regional variations

Patient Demand

Little difference

Malpractice


Supply & payment

Powerful influence

Explains less than 50% of difference


Patient Demand

Little difference

Malpractice


Supply & payment

Powerful influence


1.0

3.0

4.0

10

40

50

30

202.0

Hospital Beds Medical SpecialistsLow High Low High

32% higher

65% higher

RegionalSpending


Patient Demand

Little difference

Malpractice


Supply & payment

Powerful influence



Patient Demand

Little difference

Malpractice


Supply & payment

Powerful influence


New York TimesAugust 18, 2006


Patient Demand

Little difference

Malpractice


Supply & payment

Powerful influence



Evidence-based decisions – drawn from guidelinesDoctors sometimes disagreed – but was unrelated to regional differences in spending

Gray area decisions (more judgment required): For a patient with well-controlled high blood pressure and no other medical problems, when would you schedule the next visit?

Variations in spendingExploring causes -- gray area decisions

Physician - PatientEncounter

Clinical EvidenceProfessionalism

Clinical evidence is an important -- but limited --influence on clinical decision-making.

Consequence: reasonable individual clinical and local decisions lead, in aggregate, to higher utilization rates,greater costs -- and inadvertently -- worse outcomes

Physicians practice within a local organizationalcontext that profoundly influences their decision-making.

Payment system ensures that existing capacity is fully utilized. Physicians adapt to available resources:more referrals, more admissions, more ICU stays

Policy Environment(e.g. payment system)

LocalOrganizational Context(e.g. capacity - culture)

The more complicated care becomes, the more likely mistakes are to occur.

Hospitals are dangerous places if you don’t need to be there.

Variations in spendingExploring causes -- gray area decisions

Culture? Capacity? Both?Differences in spending and practice across top academic centers

Medicare beneficiaries with chronic illness, 2001-2005

2006 Spending 92-06 GrowthMcAllen $14,946 8.3%La Crosse $5,812 3.9%

Variations in spendingExploring causes: case studies beginning to shed light

“Here … a medical community came to treat patients the way subprime mortgage lenders treated home buyers: as profit centers.”

Atul Gawande



“…a culture that focuses on the wellbeing of the community, not just the financial health of our system.”

Jeff Thompson, MDCEO Gunderson-Lutheran

La Crosse, WI

“Here … a medical community came to treat patients the way subprime mortgage lenders treated home buyers: as profit centers.”

Atul Gawande



Organizatione.g. capacity, policies

practices, norms

Environmente,g, payment, regulations

measures, culture

Micro-systemHow care is provided

to each patient

Aims

Institute of Medicine: Crossing the Quality Chasm

La Crosse McAllen

What I think we knowPutting the pieces together: the IOM system of effect

Flawed conceptual model. Healthis produced by individual actions of“good” clinicians, working hard.

New model: It’s the system. Establish teams and organizations accountable for aims and capable of improving practice

Wrong incentives reinforce model, reward fragmentation, induce morecare and entrepreneurial behavior.

Rethink our incentives: Realign incentives – both financial and professional – with aims.

Underlying problem Key principles

41

Confusion about aims – what we’re trying to produce

Clarify aims: Better health, better carelower costs

Bad data allow MDs to discount it, and public to assume that medicine is science and that more is better.

Better information that engages physicians, creates tension for change, supports improvement; informs consumers

What I think we knowUnderlying problems – and principles to guide reform

Emerging alignment on aims: National Priorities PartnersImproving population healthImproving safety & reliability and coordination of careEngaging patients in managing their care and making informed decisionsEliminating overuse

Performance measurement: the critical leverNational Quality Forum “Episode measurement framework”Key notions

Core question: how did the patient do over the relevant time-course? Value: best judged from the patient’s perspective; is multidimensionalRequires organizational accountability – over time

Translating evidence to policyAims and Performance Measurement

Getting Better Living w/ Illness/Disability (T1)Coping w/ End of Life (T2)Staying Healthy

Post Acute/Rehabilitation Phase

20 Prevention

Episode begins –onset of symptoms

Post AMI Trajectory 2 (T2)Adult with multiple co-morbidities

Focus on:• Quality of Life• Functional Status• 20 Prevention Strategies• Advanced Care Planning• Advanced Directives• Palliative Care/Symptom Control

Assessment ofPreferences

AcutePhase

PHASE 1

PHASE 2 PHASE 3 PHASE 4

Episode ends –1 year post AMI

20 Prevention(CAD with prior AMI)Advanced Care Planning

Population at Risk 10 Prevention(no known CAD)

20 Prevention(CAD no prior AMI)

Post AMI Trajectory 1 (T1)Relatively healthy adult

Focus on:• Quality of Life• Functional Status• 20 Prevention Strategies• Rehabilitation• Advanced care planning

© NQF

Traditional modelAutonomy

Individual Responsibility

Needed modelAccountability

Shared Responsibility

Translating evidence to policyPerformance Measurement – across episodes

Effective registries are thus critical for a learning health system

To learn -- we need to know:Patient attributes and risks (including biologic markers)Specific targeted biologic interventions performedAttributes of system -- delivery methods -- where care providedHealth outcomes, patient experience and costs

Infrastructure would support Comparative effectiveness research: compare biologic and delivery

system interventions, controlling for patient and local attributes.Comparative performance assessment: compare providers and local

systems, controlling for patient attributes

Both are critical

Translating evidence to policyImplications for Health Information Technology

Accountable Care Organizations

Principles: Establish provider organizations that can effectively manage the full

continuum of care as a real or virtually integrated local delivery systemPerformance measurement – to support improvement and accountabilityPayment reform: establish target spending levels; shared savings

Potential ACOs Integrated delivery systems (Kaiser-Permanente, Group Health)Physician Networks; Hospital that employ primary care physiciansInsight from research:

Most physicians already practice within coherent local networksPerformance measurement at group level feasible Feasible to develop spending targets for most U.S. networks

Translating evidence to policyOrganizational Accountability and Payment Reforms

Fisher et al. Creating Accountable Care Organizations, Health Affairs 26(1) 2007:w44-w57.

Early pilots promising; many organizations supportivePhysician Group Practice demonstration successfulCongressional Budget Office scored as cost-savingSupport from key stakeholders has solidified

ACOs accepted as component of current billsSupport for extensive pilots, rapid expansion in House billsSenate Finance – voluntary program (not pilot) by 2012

Initiatives at state and local levelBrookings-Dartmouth supporting pilot development in multiple sitesPilots to start January 2010 in two (or more) sites (VA, KY, TX)Learning collaborative underway with 40+ health systemsMassachusetts, Vermont, others moving forward

Translating evidence to policyOrganizational Accountability and Payment Reforms

1. What we know – 3 stories2. What I think I know3. From insight to action4. Is there reason for hope?


Health care is a complex adaptive systemAutonomous actors continuously adapt their behaviorSystem held in place by “attractors”, self-reinforcing behaviors

Change in complex systems occurs through: Exploring variation and paradox to create a tension for change;Creating better alternatives (better policies, better models of care)Supporting interaction and learning – so others can see new ways to goNew attractors (performance measurement, payment, positive deviants)

Implications for research – and policyPublic reporting: creates a tension for change, raises good questionsPolicy relevant research: has undermined flawed assumptions;

suggested path toward reformRegistries, practice networks, have developed evidence, engaged

clinicians, engaged local systems and communities

48

Is there reason for hope?Theories of change – can they help frame our thinking

Everett, WASacramento, CALa Crosse, WICedar Rapids, IATemple, TX

Portland, MESayre, PARichmond, VAAsheville, NCTallahassee, FL

“How do they do that?”conference

Lighter colors = lower spending

Common themesShared aims, accountable to communityStrong foundation of primary carePhysician engagement as leadersOrganizational support importantUse of data to drive change

Is there reason for hope?Theories of change – have stimulated new conversations

Everett, WASacramento, CALa Crosse, WICedar Rapids, IATemple, TX

Portland, MESayre, PARichmond, VAAsheville, NCTallahassee, FL

“How do they do that?”conference

Lighter colors = lower spending

Common themesShared aims, accountable to communityPhysician engagement as leadersStrong foundation of primary careOrganizational support importantUse of data to drive changeHigh self-efficacy; high morale

Is there reason for hope?Theories of change – have stimulated new conversations

1973 2009

Trends in important things in U.S. healthcare

uninsured, spending

1983

Have we made a difference?

1973 2009

Trends in important things in U.S. healthcare

insights, evidence, tests of change

1983

Have we made a difference?

Flawed conceptual model. Healthis produced by individual actions of“good” clinicians, working hard.

New model: It’s the system. Establish teams and organizations accountable for aims and capable of improving practice

Wrong incentives reinforce model, reward fragmentation, induce morecare and entrepreneurial behavior.

Rethink our incentives: Realign incentives – both financial and professional – with aims. Question payfor performance.

Underlying problem Key principles

54

Confusion about aims – what we’re trying to produce

Clarify aims: Better health, better carelower costs

Bad data allow MDs to discount it, and public to assume that medicine is science and that more is better.

Better information that engages physicians, creates tension for change, supports improvement; informs consumers

Have we made a difference? Exploring variation has helped to advance knowledge and policy

elliott fisher | monitoring variation in health care

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