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Oslo bernal delgado 20180529

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E.Bernal-Delgado in The 20th National Health Economics Conference 2018 University of Oslo speaking about 'Unwarranted variations in health care: magnitude, underlying causes and potential remedies', E.Bernal-Delgado

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Oslo bernal delgado 20180529

  1. 1. www.echo-health.eu Unwarranted variations in health care: magnitude, underlying causes and potential remedies Enrique Bernal-Delgado, MD PhD ebernal.iacs@aragon.es
  2. 2. www.echo-health.eu www.atlasvpm.org www.echo-health.eu
  3. 3. www.echo-health.eu UNWARRANTED VARIATIONS Definition - background Underlying causes – a taxonomy for policy change Remedies
  4. 4. www.echo-health.eu Tonsillectomy England 1920’s Glover JA. The incidence of tonsillectomy in school children. Proc Royal Society Med. 1938;31:1219-36.
  5. 5. www.echo-health.eu “... el Dr. Garrow reduced tonsillectomy rates in 1929, his first year in the programme, from 186 (2.9% of kids) en 1928 to 13 (0.2%) in the following 8 years”
  6. 6. www.echo-health.eu Unwarranted variations may produce harm
  7. 7. www.echo-health.eu Not just tonsillectomy
  8. 8. www.echo-health.eu McPherson K, Wennberg JE, Hovind OE, Clifford P. Small-area variations in the use of common surgical procedures: an international comparison of New England, England, and Norway. N Eng J Med 1982; 307:1310-1314. Widespread within and across health systems
  9. 9. www.echo-health.eu THE UNDERLYING CAUSES OF VARIATION The dramatic geographic variations are unrelated to differences in need or epidemiology, but rather amenable to a “prescription signature phenomenon” based on physician beliefs or unbounded enthusiasm.
  10. 10. www.echo-health.eu Appleby et al, The King’s Fund 2011. Uncertainty Ignorance
  11. 11. www.echo-health.eu LOW VALUE CARE Underuse of effective interventions Effective interventions performed on non-eligible patients Interventions with a more cost-effective alternative Essentially ineffective interventions Low quality interventions Unsafe interventions
  12. 12. www.echo-health.eu 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 Q1 Q2 Q3 Q4 Q5 Underuse of effective care [PCI burden of ischemic disease and social gradient] PCIstandardizedrate Burden of ischemic disease 0 6 12 18 24 30 2002 2003 2004 2005 2006 2007 2008 2009 Standardised Rate Q1 Q2 Q3 Q4 Q5 Blue line represents PCI rate in the less affluent areas; red line represents PCI rates in the better off areas. Is there underuse in the worse off areas? Each dot represents a healthcare area – age-sex standardized rate. Q1 to Q5 represent quintiles of ischemic disease rates. Q1 the lowest burden, Q5 the highest burden. Is there underuse of PCI in the areas in Q5 inside circle?
  13. 13. www.echo-health.eu DENMARK ENGLAND PORTUGAL SLOVENIA SPAIN SR 40.13 19.55 7.02 21.45 8.58 EQ5-95 1.66 4.69 46.80 3.54 35.36 SCV 0.16 0.28 2.19 0.20 1.26 . Effective surgery in non-eligible patients [C-section in low risk deliveries] Dots represent areas – age-sex standardized rates (natural scale on the left, normalized scale on the right). SR: standardized rate; EQ5-95: ratio between the 5th and 95th percentile. SCV: Systematic Component of Variation. Map represents standardized utilization ratio – bluish areas are above the expected
  14. 14. www.echo-health.eu Intervention with existing more cost-effective alternative [Hysterectomy in benign conditions] DENMARK ENGLAND PORTUGAL SLOVENIA SPAIN SR 21.84 19.01 21.44 18.18 14.77 EQ5-95 1.98 2.27 1.83 2.34 2.95 SCV 0.14 0.07 0.09 0.04 0.09 Dots represent areas – age-sex standardized rates (natural scale on the left, normalized scale on the right). SR: standardized rate; EQ5-95: ratio between the 5th and 95th percentile. SCV: Systematic Component of Variation. Map represents standardized rates– the darker the colour, the higher the rate.
  15. 15. www.echo-health.eu Essentially ineffective care [Tonsillectomy in children] DENMARK ENGLAND PORTUGAL SLOVENIA SPAIN SR 33.4 39.8 62.3 83.7 30.1 EQ5-95 3.9 2.5 3.4 2.5 4.8 SCV 0.21 0.09 0.34 0.66 0.23 Dots represent areas – age-sex standardized rates (natural scale on the left, normalized scale on the right). SR: standardized rate; EQ5-95: ratio between the 5th and 95th percentile. SCV: Systematic Component of Variation. Map represents excess cases with regard to areas in Percentile 10th of the distribution of rates – the darker the colour, the higher the excess-cases.
  16. 16. www.echo-health.eu -50 0 50 100 150 200 AdjustedCaseFatalityRatex1,000patients 0 500 1000 1500 Patient undergoing surgery CI-95 CI-99 RISK-ADJUSTEDCASEFATALITYRATES-(CABG)Low quality care [Mortality after CABG] Dots represent hospitals - adjusted case-fatality rate in patients undergoing CABG. Hospitals beyond the upper confidence interval represent either alerts (beyond the red line) or alarms (beyond the dashed-line) Conversely, those hospitals beyond the lower confidence intervals are good or the best performers.
  17. 17. www.echo-health.eu Unsafe care [PTE & DVT after surgery] Denmark England Portugal Slovenia Spain aIR 1,43 7,55 0,87 4,36 1,87 EQ 25-75 2,11 1,48 3,84 2,04 3,16 Dots represent hospitals - adjusted incidence of Pulmonary Thromboembolism and Deep Venous Thrombosis (natural scale on the left, normalized scale on the right). Table: aIR: adjusted incidence rate; EQ25-75: ratio between the 1st and 3rd quartile.
  18. 18. www.echo-health.eu COROLLARY The uneasy evidence of large unwarranted variations may be a reflection of unequal access to effective and high quality services; entailing high opportunity costs for the societies (and individuals) enduring extreme rates.
  19. 19. www.echo-health.eu •  Macro – insurer/payer level –  Priori authorization / Selective Dropping / Limiting indications –  Value based insurance design –  Promotion of tax-payers’ or patients’ choice •  Meso – purchasers –  Risk sharing –  Capitation / Pay for performance –  Care coordination –  Utilization review –  Benchmarking on performance profiles •  Micro – clinical –  Clinical decision support tool –  Audit and clinician feed back –  Benchmarking on performance profiles –  Patient education and empowerment Remedies to reduce unwarranted variation Colla C Swimming Against the Current – What might work to reduce low-value care NEJM 2014;371:1280-3 … and increase value
  20. 20. www.echo-health.eu IT IS VALUE, NOT SAVINGS

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