understanding practice variations: a focus on academic medical centers

Understanding Practice Variations: Understanding Practice Variations:

A Focus on Academic Medical Centers A Focus on Academic Medical Centers

The Eisenberg Legacy LectureThe Eisenberg Legacy Lecture

Stanford, CaliforniaStanford, California

Presentation by John WennbergPresentation by John Wennberg

November 2, 2005November 2, 2005

The Three Categories of CareThe Three Categories of Care

• Effective CareEffective Care

• Preference-sensitive CarePreference-sensitive Care

• Supply-sensitive CareSupply-sensitive Care

The Dartmouth Atlas Project: 306 Hospital The Dartmouth Atlas Project: 306 Hospital Referral RegionsReferral RegionsOngoing Study of Traditional Medicare Population Ongoing Study of Traditional Medicare Population

11.30.30 or Moreor More (0)(0)11.10.10 to < to < 11 .30.30 (56)(56)00.90.90 to < to < 11 .10.10 (204)(204)00.75.75 to < to < 00 .90.90 (45)(45)00.65.65 to < to < 00 .75.75 (1)(1)Not PopulatedNot Populated

A Rare Example of Regional Variation for A Rare Example of Regional Variation for Effective Care Effective Care

that Reflects Illness: Hospitalization for Hip that Reflects Illness: Hospitalization for Hip FractureFracture

Ratio of Rates of Hip Fracture to the U.S. Ratio of Rates of Hip Fracture to the U.S. Average Average

(1995-96) Among the 306 Hospital Referral (1995-96) Among the 306 Hospital Referral RegionsRegions

Variation in Quality Scores for Care Related to Variation in Quality Scores for Care Related to Pneumonia Among Medicare Enrollees Receiving Most Pneumonia Among Medicare Enrollees Receiving Most of Their Care at Academic Medical Centers (2004)of Their Care at Academic Medical Centers (2004)

45.045.0

55.055.0

65.065.0

75.075.0

85.085.0

95.095.0

Variation in Quality Scores for Care Related to Variation in Quality Scores for Care Related to Pneumonia Among Medicare Enrollees Receiving Most Pneumonia Among Medicare Enrollees Receiving Most of Their Care at Academic Medical Centers (2004)of Their Care at Academic Medical Centers (2004)

45.045.0

55.055.0

65.065.0

75.075.0

85.085.0

95.095.0

Stanford Hospital 64.7UCSD Medical Center 62.3

UCSF Medical Center 55.0UC Davis Medical Center 53.3UC Irvine Medical Center 52.3UCLA Medical Center 52.3

Benefit to Patients

Benefit to Patients

% Use of Effective Care% Use of Effective Care

U.S. issome-wherein thiszone

Shape of the Benefit-Utilization CurveShape of the Benefit-Utilization CurveEffective Care & Patient SafetyEffective Care & Patient Safety

Variation in Preference-Sensitive Care, Typified Variation in Preference-Sensitive Care, Typified by Elective Surgery, Reflects Idiosyncratic by Elective Surgery, Reflects Idiosyncratic Practice Style, Usually Independent of CapacityPractice Style, Usually Independent of Capacity

0.2

1.0

4.0

HipHipFractureFracture(13.8)(13.8)

KneeKneeReplacementReplacement

(55.0)(55.0)

HipHipReplacementReplacement

(67.2)(67.2)

BackBackSurgerySurgery(93.6)(93.6)

2.72

1.242.22

1.00

1.00

1.14

1.63

1.26

1.00

0.00.0

1.01.0

2.02.0

3.03.0

4.04.0

5.05.0

6.06.0

Hip replacementHip replacementKnee replacementKnee replacement Back surgeryBack surgery

Discharge rate

Discharge rate

Stanford San Francisco Los Angeles

Rates of Orthopedic Procedures in HSAs Rates of Orthopedic Procedures in HSAs Served by Three California Academic Served by Three California Academic Medical Centers (2002-3)Medical Centers (2002-3)

(Ratios are to the Lowest (Ratios are to the Lowest HSA.)HSA.)

Relationship Between Supply of Orthopedic Surgeons Relationship Between Supply of Orthopedic Surgeons (1999) and Knee Replacement Rates (2000-01) Among (1999) and Knee Replacement Rates (2000-01) Among Hospital RegionsHospital Regions

R2 = 0.000.00.0

2.02.0

4.04.0

6.06.0

8.08.0

10.010.0

12.012.0

0.00.0 3.03.0 6.06.0 9.09.0 12.012.0 15.015.0

Orthopedic SurgeonsOrthopedic Surgeons

Knee Replacement

Knee Replacement

Association Between Surgery Rate ( 2000-01) and Association Between Surgery Rate ( 2000-01) and Supply Supply of Surgeons (1999); 10 Preference-Sensitive of Surgeons (1999); 10 Preference-Sensitive

Procedures (RProcedures (R22))

Procedure Specialty Procedure Specialty AssociationAssociation

of Surgeon of Surgeon (R2) (R2)

Knee Replacement OrthopedicKnee Replacement Orthopedic .00.00Hip Replacement OrthopedicHip Replacement Orthopedic .08 .08Back Surgery OrthopedicBack Surgery Orthopedic .02 .02CABG Cardiac Surg.CABG Cardiac Surg. .08 .08PCI CardiologistPCI Cardiologist

.06 .06 TURP for BPH UrologistTURP for BPH Urologist .00 .00Prost. For CA UrologistProst. For CA Urologist .01 .01

Gall bladder General Surg.Gall bladder General Surg. .01 .01

Carotid endart. General Surg.Carotid endart. General Surg. .04 .04

Lower extremityLower extremitybypass Vasc. Surgeonbypass Vasc. Surgeon .09 .09

Relationship Between Knee Relationship Between Knee Replacement Rates in 1992-93 and Replacement Rates in 1992-93 and

2000-012000-01

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)

Knee Replacement (2000-01)

Knee Replacement (2000-01)

R2 = 0.75

Association Between Surgery Rate ( 2000-01) and Association Between Surgery Rate ( 2000-01) and

Surgery Rate (1992-93) (RSurgery Rate (1992-93) (R22))

Procedure AssociationProcedure Association R2 R2

Knee .75Knee .75Hip .8Hip .8

11Back .51Back .51CABG .39CABG .39PCI .3PCI .3

44TURP for BPH .28TURP for BPH .28Prost. For CA .25Prost. For CA .25Gall bladder .32Gall bladder .32Carotid endart. .53Carotid endart. .53L.E. Bypass .56L.E. Bypass .56

Reducing Misuse of Preference-Reducing Misuse of Preference-Sensitive CareSensitive Care

• Major focus: shared decision making Major focus: shared decision making

Which Rate is Right? Impact of Which Rate is Right? Impact of Improved Decision Quality on Surgery Improved Decision Quality on Surgery

Rates: BPHRates: BPH

Knowledge of relevant treatment

options and outcomes

Concordance between patient values

and care received

Reducing Misuse of Preference-Reducing Misuse of Preference-Sensitive CareSensitive Care

• Major focus: shared decision makingMajor focus: shared decision making• New focus: report cards measuring New focus: report cards measuring decision qualitydecision quality

Benefit to Patients

Benefit to Patients UNKNOWN

Units of Discretionary SurgeryUnits of Discretionary Surgery

Shape of the Benefit-Utilization Curve:Shape of the Benefit-Utilization Curve:Preference-Sensitive SurgeryPreference-Sensitive Surgery

0.2

1.0

4.0

Primary care visits

(16.2)

CHFdischarge

s

(24.6)

COPDdischarge

s

(34.5)

Medical speciali

st visits

(36.8)

Standardized ratio (log scale)

Variation in Supply-Sensitive Care Reflects Variation in Supply-Sensitive Care Reflects IdiosyncraticIdiosyncratic Practice Style in Disequilibrium with Practice Style in Disequilibrium with CapacityCapacity

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

Discharge Rate

Discharge Rate

Association Between Hospital Beds per 1,000 Association Between Hospital Beds per 1,000 Residents and Discharges per 1,000 Medicare Residents and Discharges per 1,000 Medicare Enrollees: 306 Hospital Referral RegionsEnrollees: 306 Hospital Referral Regions

R2 = 0.49Number of Visits to Cardiologists

Number of Visits to Cardiologists

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 Association Between Cardiologists and Visits per Person to Cardiologists among Medicare per Person to Cardiologists among Medicare

Enrollees: 306 RegionsEnrollees: 306 Regions

Hospital Days During the Last Six Months of Life Hospital Days During the Last Six Months of Life among Medicare Enrollees Receiving Most of Their among Medicare Enrollees Receiving Most of Their

Care at Academic Medical Centers (1999-2003)Care at Academic Medical Centers (1999-2003)

8.08.0

13.013.0

18.018.0

23.023.0

28.028.0

33.033.0

UCLA Medical Center 19.2

UC Irvine Medical Center 16.0UCSD Medical Center 14.1UCSF Medical Center 13.2Stanford Hospital 12.0UC Davis Medical Center 11.6

0.00.0

10.010.0

20.020.0

30.030.0

40.040.0

0.00.0 10.010.0 20.020.0 30.030.0 40.040.0

Cancer patientsCancer patients

CHF patients

CHF patients

R2 = 0.78

Hospital DaysHospital Days

Association Between Utilization Rates During the Association Between Utilization Rates During the Last Six Months of Life for Patients with Cancer Last Six Months of Life for Patients with Cancer

and Congestive Heart Failure among Academic and Congestive Heart Failure among Academic Medical Centers (1999-2003)Medical Centers (1999-2003)

HospitalHospitaldaysdays

Black & Non-BlackBlack & Non-Black 0.670.67

Male & FemaleMale & Female 0.920.92

Younger & OlderYounger & Older 0.820.82

Medicaid & Non-MedicaidMedicaid & Non-Medicaid 0.840.84

Association (R2) Between Utilization Rates During Association (R2) Between Utilization Rates During the Last Six Months of Life for Patient Cohorts the Last Six Months of Life for Patient Cohorts According to Demographic Characteristics among According to Demographic Characteristics among

Academic Medical Centers (1999-2003)Academic Medical Centers (1999-2003)

Hospital DaysHospital Days

R2 = 0.740.00.0

5.05.0

10.010.0

15.015.0

20.020.0

25.025.0

30.030.0

35.035.0

0.00.0 2.02.0 4.04.0 6.06.0 8.08.0

19-24 months before death19-24 months before death

Last six months of life


Association Between Utilization Rates 19-24 Association Between Utilization Rates 19-24 Months Before Death and During the Last Six Months Before Death and During the Last Six

Months of Life among Academic Medical Centers Months of Life among Academic Medical Centers (1999-2003)(1999-2003)

ICU Days During the Last Six Months of Life Among ICU Days During the Last Six Months of Life Among Medicare Enrollees Receiving Most of Their Care Medicare Enrollees Receiving Most of Their Care

at Academic Medical Centers (1999-2003)at Academic Medical Centers (1999-2003)

1.01.0

2.02.0

3.03.0

4.04.0

5.05.0

6.06.0

7.07.0

8.08.0

9.09.0

10.010.0

11.011.0

12.012.0


UC Davis Medical Center 6.8UCSD Medical Center 6.3

UC Irvine Medical Center 8.2

Stanford Hospital 3.7UCSF Medical Center 3.3

Physician Visits During the Last Six Months of Physician Visits During the Last Six Months of Life Among Medicare Enrollees Receiving Most of Life Among Medicare Enrollees Receiving Most of Their Care at Academic Medical Centers (2000-03)Their Care at Academic Medical Centers (2000-03)

17.017.0

27.027.0

37.037.0

47.047.0

57.057.0

67.067.0

77.077.0


UC Irvine Medical Center 39.7

UCSF Medical Center 30.4UCSD Medical Center 30.1

Stanford Hospital 24.0UC Davis Medical Center 23.2

Percent of patients seeing 10 or more physicians Percent of patients seeing 10 or more physicians during the last six months of life among Medicare during the last six months of life among Medicare decedents receiving most of their care at decedents receiving most of their care at academic medical centers (2000-03)academic medical centers (2000-03)

10%10%

20%20%

30%30%

40%40%

50%50%

60%60%

70%70%

UCLA Medical Center 57.7%

UC Irvine Medical Center 43.4%UCSF Medical Center 42.2%UCSD Medical Center 41.1%UC Davis Medical Center 34.7%Stanford Hospital 28.9%

Ratio of Medical Specialist to Primary Care Ratio of Medical Specialist to Primary Care Physician Visits During the Last Six Months of Physician Visits During the Last Six Months of Life Among Medicare Enrollees Receiving Most of Life Among Medicare Enrollees Receiving Most of Their Care at Academic Medical Centers (2000-03)Their Care at Academic Medical Centers (2000-03)

0.250.25

0.750.75

1.251.25

1.751.75

2.252.25

2.752.75

3.253.25


UC Irvine Medical Center 1.55UC Davis Medical Center 1.19UCSD Medical Center 1.16Stanford Hospital 1.15

UCSF Medical Center 0.68

Association Between Medical Specialist and Association Between Medical Specialist and Primary Care Physician Visits During the Last Six Primary Care Physician Visits During the Last Six

Months of Life Among Academic Medical Centers Months of Life Among Academic Medical Centers (2000-03)(2000-03)

R2 = 0.170.00.0

10.010.0

20.020.0

30.030.0

40.040.0

50.050.0

60.060.0

0.00.0 5.05.0 10.010.0 15.015.0 20.020.0 25.025.0

Primary care visitsPrimary care visits

Medical specialist visits

Medical specialist visits

R2 = 0.660.00.0

20.020.0

40.040.0

60.060.0

80.080.0

0.00.0 10.010.0 20.020.0 30.030.0 40.040.0

Hospital daysHospital days

Physician visits

Physician visits

Association Between Hospital Days and Physician Association Between Hospital Days and Physician Visits During the Last Six Months of Life Among Visits During the Last Six Months of Life Among

Academic Medical Centers (1999-2003)Academic Medical Centers (1999-2003)

0.00.0

10.010.0

20.020.0

30.030.0

40.040.0

0.00.0 10.010.0 20.020.0 30.030.0 40.040.0


CHF patients

CHF patients

R2 = 0.78

Hospital daysHospital days Physician visitsPhysician visits

0.00.0

20.020.0

40.040.0

60.060.0

80.080.0

100.0100.0

0.00.0 20.020.0 40.040.0 60.060.0 80.080.0 100.0100.0


CHF patients

CHF patients

R2 = 0.61

Association Between Utilization Rates During the Association Between Utilization Rates During the Last Six Months of Life for Patients With Cancer Last Six Months of Life for Patients With Cancer

and Congestive Heart Failure Among Academic and Congestive Heart Failure Among Academic Medical Centers (1999-2003)Medical Centers (1999-2003)

Hospital daysHospital days

R2 = 0.740.00.0

5.05.0

10.010.0

15.015.0

20.020.0

25.025.0

30.030.0

35.035.0

0.00.0 2.02.0 4.04.0 6.06.0 8.08.0




Physician visitsPhysician visits

R2 = 0.670.00.0

20.020.0

40.040.0

60.060.0

80.080.0

0.00.0 5.05.0 10.010.0 15.015.0 20.020.0 25.025.0




Association Between Utilization Rates 19-24 Association Between Utilization Rates 19-24 Months Before Death and During the Last Six Months Before Death and During the Last Six

Months of Life Among Academic Medical Centers Months of Life Among Academic Medical Centers (1999-2003)(1999-2003)

Variations During the Last Six Months of Life Variations During the Last Six Months of Life Among Medicare Enrollees Receiving Most of Their Among Medicare Enrollees Receiving Most of Their Care at Hospitals Belonging to Large Academic Care at Hospitals Belonging to Large Academic

Medical Systems (1999-2003)Medical Systems (1999-2003)

ICU Days Per Patient During the Last Six Months ICU Days Per Patient During the Last Six Months of Life Among Medicare Enrollees Receiving Most of Life Among Medicare Enrollees Receiving Most of Their Care at Hospitals Belonging to Large of Their Care at Hospitals Belonging to Large Academic Medical Systems (1999-2003) (Weighted Academic Medical Systems (1999-2003) (Weighted System Average on Right)System Average on Right)

0.00.0 2.02.0 4.04.0 6.06.0 8.08.0 10.010.0 12.012.0

Mayo 2.8

UPMC 2.9

BJC 4.6

Cleve. Clin. 4.6

UHHS 3.4

Fairview 2.0

CareGroup 3.1

Univ. of CA 7.6

Partners 2.7

HA of Cin. 3.4

Baylor 3.8

Jefferson 7.9

Physician Visits Per Patient During the Last Six Physician Visits Per Patient During the Last Six Months of Life Among Medicare Enrollees Receiving Months of Life Among Medicare Enrollees Receiving Most of Their Care at Hospitals Belonging to Most of Their Care at Hospitals Belonging to Large Academic Medical Systems (2000-2003) Large Academic Medical Systems (2000-2003) (Weighted System Average on Right)(Weighted System Average on Right)

13.013.0 23.023.0 33.033.0 43.043.0 53.053.0 63.063.0

Mayo 23.3

UPMC 39.3

BJC 33.6

Cleve. Clin. 36.7

UHHS 31.7

Fairview 24.7

CareGroup 32.7

Univ. of CA 38.9

Partners 35.4

HA of Cin. 30.8

Baylor 34.0

Jefferson 50.0

Ratio of Medical Specialist to Primary Care Ratio of Medical Specialist to Primary Care Physician Visits During the Last Six Months of Physician Visits During the Last Six Months of Life Among Medicare Enrollees Receiving Most of Life Among Medicare Enrollees Receiving Most of Their Care at Hospitals Belonging to Large Their Care at Hospitals Belonging to Large Academic Medical Systems (Weighted System Average Academic Medical Systems (Weighted System Average on Right)on Right)

0.00.0 0.50.5 1.01.0 1.51.5 2.02.0 2.52.5 3.03.0

Mayo 0.81

UPMC 1.10

BJC 0.90

Cleve. Clin. 1.19

UHHS 0.98

Fairview 0.54

CareGroup 0.91

Univ. of CA 1.59

Partners 0.94

HA of Cin. 1.06

Baylor 1.14

Jefferson 1.97

Per Capita Resource inputs and Health Per Capita Resource inputs and Health Outcomes:Outcomes:

Ratio High/Low Quintiles of SpendingRatio High/Low Quintiles of Spending

Resource InputsResource Inputs

Medicare SpendingMedicare Spending 1.61 1.61

Hospital Beds (1000) Hospital Beds (1000) 1.321.32

Physician Supply* Physician Supply*

All PhysiciansAll Physicians 1.31 1.31

Medical Specialists Medical Specialists 1.651.65

General Internists General Internists 1.751.75

Family PracticeFamily Practice 0.74 0.74

SurgeonsSurgeons 1.37 1.37• Per 10,000Per 10,000

Cohort Health OutcomesCohort Health Outcomes

DeathDeath R.R. R.R. 95% CL95% CL

Hip Fracture 1.019 Hip Fracture 1.019 1.001-1.0391.001-1.039

Colon Cancer 1.012 Colon Cancer 1.012 1.018-1.018-

1.0941.094 Heart Attack Heart Attack 1.052 1.052 1.018-1.0941.018-1.094

Functional Status WorseFunctional Status Worse

SatisfactionSatisfaction Same Same

Percent of deaths associated with admission to Percent of deaths associated with admission to intensive care among Medicare decedents receiving intensive care among Medicare decedents receiving most of their care at most of their care at academic academic medical centers (1999-2003)medical centers (1999-2003)

0%0%

5%5%

10%10%

15%15%

20%20%

25%25%

30%30%

35%35%

40%40%

45%45%

UCLA Medical Center 35.4%

UCSD Medical Center 24.0%UCSF Medical Center 23.1%Stanford Hospital 21.9%

UC Irvine Medical Center 30.8%UC Davis Medical Center 29.9%

U.S. issome-wherein thiszone

Frequency of CareFrequency of Care

Life Expectancy

Life Expectancy

Shape of the Benefit-Utilization Curve:Shape of the Benefit-Utilization Curve:Supply-Sensitive ServicesSupply-Sensitive Services

Summary: “System” Causes of Unwarranted Summary: “System” Causes of Unwarranted VariationVariation

Under-use of effective careUnder-use of effective care..

• Discontinuity of care (worse when more physicians are Discontinuity of care (worse when more physicians are

involved in the care)involved in the care)

• Lack of infrastructure to assure outreach and the Lack of infrastructure to assure outreach and the timely use of effective caretimely use of effective care

• Finance “system” that fails to support infra-structure Finance “system” that fails to support infra-structure and rewards quantity, not quality and rewards quantity, not quality


Misuse of preference-sensitive careMisuse of preference-sensitive care

• Poor communication between MD and patient regarding Poor communication between MD and patient regarding the risks and benefits of alternative treatments; the risks and benefits of alternative treatments;

• Patient dependency on physician’s opinion in sorting Patient dependency on physician’s opinion in sorting out preferences; (flaws in agency model) out preferences; (flaws in agency model)

• Inadequate evaluation of (evolving) treatment theoryInadequate evaluation of (evolving) treatment theory

• Health care finance “system” that rewards procedures, Health care finance “system” that rewards procedures, not the quality of decision makingnot the quality of decision making


Overuse of supply-sensitive careOveruse of supply-sensitive care

• Over-dependence on acute hospital care; Over-dependence on acute hospital care;

• Lack of infrastructure to support population-based Lack of infrastructure to support population-based management of chronically ill patients; management of chronically ill patients;

• Cultural assumption that more care is better care Cultural assumption that more care is better care (without evidence at the clinical level that this is so)(without evidence at the clinical level that this is so)

• Lack of accountability for the capacity of the health Lack of accountability for the capacity of the health care system relative to the size of the population care system relative to the size of the population servedserved

• Finance “system” that rewards high intensity care and Finance “system” that rewards high intensity care and doesn’t pay for infrastructure, efficiency or learningdoesn’t pay for infrastructure, efficiency or learning

The CMS 646 OpportunityThe CMS 646 Opportunity(Medicare Health Care Quality Demonstration (Medicare Health Care Quality Demonstration

Programs)Programs)

• Provider focus: group practices, integrated health care Provider focus: group practices, integrated health care systems and regional coalitions can propose radical systems and regional coalitions can propose radical changes in health care deliverychanges in health care delivery

• Focus on improving quality and efficiency in all three Focus on improving quality and efficiency in all three categories of carecategories of care

• RFP seeks proposals to reform financing systems as well RFP seeks proposals to reform financing systems as well as the regulatory environment (and might include as the regulatory environment (and might include commercial as well as Medicaid programs)commercial as well as Medicaid programs)

• Encourages collaboration between applicants, NIH and ARC Encourages collaboration between applicants, NIH and ARC to improve the scientific basis of clinical decision to improve the scientific basis of clinical decision makingmaking

• Five-year time horizonFive-year time horizon

understanding practice variations: a focus on academic medical centers

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