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Tracking MedicineTracking Medicine
A Lecture by Jack WennbergA Lecture by Jack Wennberg
GroupHealth Innovation ConferenceGroupHealth Innovation Conference
March 25March 25thth 2011 2011
Understanding Variations in the Way Medicine is PracticedUnderstanding Variations in the Way Medicine is Practiced
The Vermont StoryThe Vermont Story
The Maine StoryThe Maine Story
The Dartmouth Atlas ProjectThe Dartmouth Atlas Project
New Hampshire
Massachusetts
New York
Quebec
From From “Science,”“Science,” December 14, 1973.December 14, 1973.
Vermont Map from “Science”Vermont Map from “Science”
Morrisville and Waterbury CenterMorrisville and Waterbury Center
Tonsillectomy Rate per 10,000 Children Among 13 Tonsillectomy Rate per 10,000 Children Among 13 Vermont Hospital Service AreasVermont Hospital Service Areas
00
5050
100100
150150
200200
250250
300300
350350
400400
450450MorrisvilleMorrisville
19691969
Stages of Facing RealityStages of Facing Reality
• Stage 1. “The data are wrong.”Stage 1. “The data are wrong.”• Stage 2. “The data are right, but it’s not a Stage 2. “The data are right, but it’s not a
problem.”problem.”• Stage 3. “The data are right; it is a problem; but it Stage 3. “The data are right; it is a problem; but it
is not my problem.”is not my problem.”• Stage 4. “I accept the burden of improvement.”Stage 4. “I accept the burden of improvement.”
Tonsillectomy Rate per 10,000 Children Among 13 Tonsillectomy Rate per 10,000 Children Among 13 Vermont Hospital Service AreasVermont Hospital Service Areas
00
5050
100100
150150
200200
250250
300300
350350
400400
450450
MorrisvilleMorrisville
MorrisvilleMorrisville
19691969 19731973
1.5-2 x
2-3 x
1.5-2 x
2-3 x
Table 2.1. A Test of Consumer Contribution to Small Area Variations in Health Care Delivery: Randolph and Middlebury, VT (continued)
Middlebury Randolph,
Vermont VermontAccess to physician Contact with physician within year 73% 73%
“Post-access” utilization of health care Hospital discharges per 1,000 132 220 Surgery discharges per 1,000 49 80 Medicare Part B spending per Enrollee ($) 92 142
Source: Adapted from Wennberg, J and Fowler, FJ. 1977. A Test of Consumer Contributions to Small Area Variations in Health Care Delivery. Journal of the Maine Medical Association. 68(8):275-279.
Science, 14 December, 1973Science, 14 December, 1973
“ “ Given the Magnitude of these variations, theGiven the Magnitude of these variations, the
possiblty of too much medical care and and the possiblty of too much medical care and and the attendant likelihood of iatrogenic illness is attendant likelihood of iatrogenic illness is presumably as strong as the possibilty of not presumably as strong as the possibilty of not enough services and unattended morbidity and enough services and unattended morbidity and mortality”mortality”
Understanding Variations in the Way Medicine is PracticedUnderstanding Variations in the Way Medicine is Practiced
The Vermont StoryThe Vermont Story
The Maine StoryThe Maine Story
Which rate is right? Impact of improved Which rate is right? Impact of improved decision quality on surgery rates: BPHdecision quality on surgery rates: BPH
Knowledge of relevant treatment
options and outcomes
Concordance between patient values
and care received
Learning what works and what patients wantLearning what works and what patients want
The Vermont StoryThe Vermont Story
The Maine StoryThe Maine Story
The Dartmouth Atlas ProjectThe Dartmouth Atlas Project
The Dartmouth Atlas Project: 306 hospital referral regionsThe Dartmouth Atlas Project: 306 hospital referral regionsOngoing Study of Traditional Medicare Population USAOngoing Study of Traditional Medicare Population USA
Unwarranted Variation in Health Care Delivery:Unwarranted Variation in Health Care Delivery:
Variation that can’t be explained by illness Variation that can’t be explained by illness
or patient preferencesor patient preferences
The Three Categories of Unwarranted The Three Categories of Unwarranted Variation in Health Care DeliveryVariation in Health Care Delivery
Effective CareEffective CareEE
vviiddeennccee--bbaasseedd ccaarree tthhaatt aallll wwiitthh nneeeedd sshhoouulldd rreecceeiivvee
Preference-Sensitive CarePreference-Sensitive Care
Supply-Sensitive CareSupply-Sensitive Care
Preference-Sensitive Care Preference-Sensitive Care
• Involves tradeoffs -- more than one treatment exists Involves tradeoffs -- more than one treatment exists and the outcomes are differentand the outcomes are different
• Decisions should be based on the patient’s own Decisions should be based on the patient’s own preferencespreferences
• But Provider Opinion Often Determines Which But Provider Opinion Often Determines Which Treatment is UsedTreatment is Used
Conditions involving preference-sensitive Conditions involving preference-sensitive surgical decisionssurgical decisions
ConditionCondition Treatment Options Treatment Options
• Silent GallstonesSilent Gallstones Surgery versus watchful waiting Surgery versus watchful waiting
• Chronic Stable Angina PCI vs. surgery vs. other methodsChronic Stable Angina PCI vs. surgery vs. other methods
• Hip and Knee ArthritisHip and Knee Arthritis Joint replacement vs. pain meds Joint replacement vs. pain meds
• Carotid Artery Stenosis Surgery vs. aspirinCarotid Artery Stenosis Surgery vs. aspirin
• Herniated DiscHerniated Disc Back surgery vs. other strategies Back surgery vs. other strategies
• Early Prostate Cancer Early Prostate Cancer Surgery vs. radiation vs. waiting Surgery vs. radiation vs. waiting
• Enlarged ProstateEnlarged Prostate Surgery vs. other strategies Surgery vs. other strategies
• Early Stage Breast Cancer Lumpectomy vs. mastectomy Early Stage Breast Cancer Lumpectomy vs. mastectomy
Knee Replacement: An Example of Preference-Sensitive CareKnee Replacement: An Example of Preference-Sensitive Care
Ratio of knee replacement rates to the U.S. average (2005Ratio of knee replacement rates to the U.S. average (2005))
11.30.30 to to 11.75.75 (46)(46)11.10.10 to < to < 11.30.30 (78)(78)00.90.90 to < to < 11.10.10 (106)(106)00.75.75 to < to < 00.90.90 (53)(53)00.41.41 to < to < 00.75.75 (23)(23)Not PopulatedNot Populated
Total Knee replacement for Arthritis per 1,000 Medicare Total Knee replacement for Arthritis per 1,000 Medicare enrollees among 306 Hospital Referral Regionsenrollees among 306 Hospital Referral Regions
1.01.0
3.03.0
5.05.0
7.07.0
9.09.0
11.011.0
1992-93 2000-01
Red dot = U.S. average:Red dot = U.S. average: 4.034.03 5.64 40% increase5.64 40% increase
Relationship Between Knee Replacement Rates Among Relationship Between Knee Replacement Rates Among Hospital Referral Regions in 1992-93 and 2000-01Hospital Referral Regions in 1992-93 and 2000-01
0.00.0
2.02.0
4.04.0
6.06.0
8.08.0
10.010.0
12.012.0
0.00.0 2.02.0 4.04.0 6.06.0 8.08.0 10.010.0 12.012.0
Knee Replacement (1992-93)Knee Replacement (1992-93)
Kn
ee R
epla
cem
ent
(200
0-01
)K
nee
Rep
lace
men
t (2
000-
01)
R2 = 0.75
Determining the Need for Hip and Knee Arthroplasty: Determining the Need for Hip and Knee Arthroplasty: The Role of Clinical Severity and Patients’ Preferences The Role of Clinical Severity and Patients’ Preferences
. . . Among those with severe arthritis, no . . . Among those with severe arthritis, no more than 15% were definitely willing to undergo more than 15% were definitely willing to undergo (joint replacement), emphasizing the importance (joint replacement), emphasizing the importance of considering both patients’ preference and of considering both patients’ preference and surgical indications in evaluating need and surgical indications in evaluating need and appropriateness of rates of surgeryappropriateness of rates of surgery
Seattle 4.7
Tacoma 5.9
Spokane 6.9
Everett 4.0
Wenatchee 7.9
Wenatchee 9.2
Spokane 9.1
Tacoma 8.3
Seattle 6.8
Everett 6.5
Wenatchee 9.9
Seattle 2.4
Tacoma 4.0
Spokane 6.0
Bellevue 1.7
Spokane 4.3
Tacoma 3.5
Seattle 2.5
Renton 2.2
Tacoma 8.9
Spokane 8.9
Seattle 6.4
Port Angels 5.0
Bellingham 14.9
Bellingham 19.0
Spokane 13.2
Tacoma 12.3
Seattle 8.9
Port Angels 8.2
Bottom Line Implication: Bottom Line Implication:
Clinical Appropriateness should be based on sound Clinical Appropriateness should be based on sound evaluation of treatment options (outcomes research)evaluation of treatment options (outcomes research)
To Avoid Wrong Patient Surgery, Medical Necessity To Avoid Wrong Patient Surgery, Medical Necessity should be based on Informed Patient Choice among should be based on Informed Patient Choice among Clinically Appropriate OptionsClinically Appropriate Options
Supply-Sensitive Care Supply-Sensitive Care
• The frequency of use is governed by the assumption that The frequency of use is governed by the assumption that resources should be fully utilized, i.e. that more is betterresources should be fully utilized, i.e. that more is better
• Specific medical theories and medical evidence play little role in Specific medical theories and medical evidence play little role in governing frequency of usegoverning frequency of use
• In the absence of evidence, and under the assumption that more In the absence of evidence, and under the assumption that more is better, available supply governs frequency of useis better, available supply governs frequency of use
Hip FractureR2 = 0.06
All MedicalConditionsR2 = 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 6.06.0Acute Care BedsAcute Care Beds
Dis
cha
rge
Rat
eD
isch
arg
e R
ate
Association between hospital beds per 1,000 and discharges Association between hospital beds per 1,000 and discharges per 1,000 among Medicare Enrollees: 306 Hospital Regionsper 1,000 among Medicare Enrollees: 306 Hospital Regions
R2 = 0.49Nu
mb
er
of
Vis
its
to C
ard
iolo
gis
tsN
um
be
r o
f V
isit
s to
Ca
rdio
log
ists
0.00.0
0.50.5
1.01.0
1.51.5
2.02.0
2.52.5
0.00.0 2.52.5 5.05.0 7.57.5 10.010.0 12.512.5 15.015.0
Number of Cardiologists per 100,000Number of Cardiologists per 100,000
Association between cardiologists and visits per person Association between cardiologists and visits per person
to cardiologists among Medicare enrollees: 306 Regionsto cardiologists among Medicare enrollees: 306 Regions
Contrasting Practice Patterns in Managing Chronic Illness Contrasting Practice Patterns in Managing Chronic Illness During Last Two Years of Life (Deaths 2001-2005) During Last Two Years of Life (Deaths 2001-2005)
Regions in Highest and Lowest HCI Index Quintiles Regions in Highest and Lowest HCI Index Quintiles
Resource input Lowest Quintile
Highest Quintile
Ratio H/L
Medicare $ per capita $38,300 $60,800 1.59
Physician Labor/1,000
All Physicians 16.6 29.5 1.78
Medical Specialists 5.6 13.1 2.35
Primary Care Doctors 7.4 11.5 1.55
Source: Dartmouth Atlas Database
Contrasting Practice Patterns in Managing Chronic Illness Contrasting Practice Patterns in Managing Chronic Illness in Regions (HRRs) Ranked in Highest and Lowest in Regions (HRRs) Ranked in Highest and Lowest
Utilization Quintile (patients in their last 2 years of life)Utilization Quintile (patients in their last 2 years of life)
Low HRRsLow HRRs High HRRsHigh HRRs Ratio H/LRatio H/L
End of Life CareEnd of Life Care
Hospital Days (L6M)Hospital Days (L6M) 8.58.5 15.615.6 1.831.83
Hospital MD Visit (L6M)Hospital MD Visit (L6M) 12.912.9 36.336.3 2.822.82
% Seeing 10 or more MDs% Seeing 10 or more MDs 20.820.8 43.743.7 2.162.16
% Deaths in ICUs % Deaths in ICUs 14.314.3 23.223.2 1.631.63
End of life care for Chronic Illness at selected End of life care for Chronic Illness at selected academic medical centers (deaths 2001-05)academic medical centers (deaths 2001-05)
% of deaths% of deathswith ICUwith ICU
admissionadmission
35.135.1
37.937.9
26.226.2
23.223.2
28.528.5
23.523.5
28.628.6
22.522.5
23.123.1
21.821.8
16.116.1
Hospital NameHospital Name
NYU Medical CenterNYU Medical Center
UCLA Medical CenterUCLA Medical Center
Brigham and Women'sBrigham and Women's
Johns HopkinsJohns Hopkins
Tufts-New EnglandTufts-New England
Beth Israel DeaconessBeth Israel Deaconess
Boston Medical CenterBoston Medical Center
Massachusetts GeneralMassachusetts General
Cleveland ClinicCleveland Clinic
Mayo Clinic (St. Mary's)Mayo Clinic (St. Mary's)
University of WisconsinUniversity of Wisconsin
TotalTotalMedicareMedicarespendingspending
105,068105,068
93,84293,842
87,72187,721
85,72985,729
85,38785,387
83,34583,345
79,67279,672
78,66678,666
55,33355,333
53,43253,432
49,47749,477
Dartmouthatlas.orgDartmouthatlas.org
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