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