Elliott Fisher | Monitoring Variation in Health Care

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Professor Elliott Fisher, Professor 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 spoke at the 5th HARC Forum in November 2009.

The purpose of this forum was to consider how we can create and use new evidence about health system performance in order to inform policy and practice.

Professor Fisher gave an overview of the internationally leading Dartmouth Atlas Project. This project has documented glaring variations in US healthcare delivery and has radically changed the way we think about effectiveness and efficiency of health care.

HARC stands for the Hospital Alliance for Research Collaboration. HARC is a collaborative network of researchers, health managers, clinicians and policy makers based in NSW, Australia managed by the Sax Institute.

HARC Forums bring members of the HARC network together to discuss the latest research and analysis about important issues facing our hospitals.

For more information visit saxinstitute.org.au.

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Elliott Fisher | Monitoring Variation in Health Care

  1. 1. Welcome to the 5th HARC ForumMonitoring 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
  2. 2. Keynote SpeakerProfessor Elliott Fisher Professor of Community and Family Medicine at Dartmouth Medical School and Director of the Centerfor 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 toimprove the health system
  3. 3. 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 Community and Family Medicine Dartmouth Medical SchoolDirector for Population Health and PolicyThe Dartmouth Institute for Health Policy and Clinical Practice
  4. 4. Houston, we’ve got a problem…The usual suspects: Rising costs Uneven quality Declining access to careSome looming challenges Loss of professional authority of physicians Integrity and relevance of academic medicine
  5. 5. Houston, we’ve got a problem… Traditional diagnoses: Prescriptions: A shortage of money Spend more A shortage of doctors Train more A shortage of economists Focus on pricesEvery system is perfectly designed to get theresults that it achieves Paul BataldenInsanity: doing the same thing day after day andexpecting different results Einstein
  6. 6. Rethinking health careOrigins of the Dartmouth Institute – and Dartmouth Atlas Project Science, December 14, 1973; Volume 182, pp 1102-08
  7. 7. Rethinking health careA simple analytic framework; a shared visionApplication of epidemiologic methods to health care services Define population at risk Define events Examine variations across relevant systems -- providers Ask good questionsOrganizational Development Independent institute within Medical School Interdisciplinary research group; all with departmental appointments Governance through a shared vision: Exploring the causes and consequences of unwarranted variations Commitment to making a difference (locally, regionally, nationally) Major long-term funding helps maintain focus
  8. 8. Rethinking health careThe Dartmouth Atlas of Health Care Methods: Population at risk – over 65 Compare Hospital Referral Regions Events of interest -- many
  9. 9. Rethinking health careThe Dartmouth Atlas of Health Care Categories of care Safe and effective care Preference sensitive care Supply-sensitive care
  10. 10. Rethinking health carePreference-sensitive care Transurethral Prostatectomy for Benign Prostatic Hypertrophy per 1000 15.0 13.0 TURP for BPH 11.0 9.0 7.0 5.0 3.0
  11. 11. Rethinking health careSafe and Effective Care 30 Day Mortality Following CABG 30-Day Mortality Following CABG (%) 12.0 10.0 8.0 6.0 4.0 2.0
  12. 12. Rethinking health careSpending – and supply sensitive care Medicare Spending per capita 15,000 Medicare spending per enrollee 13,000 11,000 9,000 7,000 5,000
  13. 13. Rethinking health careSpending – and supply sensitive care Hospital and Physician Spending last 2 years of life at Inpatient + Part B spending per decedent USN&WR top 10 hospitals 120,000 UCLA Medical Center 72,793 100,000 New York-Presbyterian 69,962 How can the best medical care in the world cost twice as much as Johns Hopkins 60,653 the best medical care in the world? 80,000 UCSF Medical Center 56,859 Uwe Reinhardt Univ. of Washington 50,716 60,000 Mass. General 47,880 Barnes-Jewish 44,463 Duke University Hosp. 37,765 40,000 Mayo Clinic (St. Marys) 37,271 Cleveland Clinic 35,455 20,000
  14. 14. Rethinking health careThe Dartmouth Atlas of Health Care 1. What we know – 3 case studies 2. What I think we’ve learned 3. Translating evidence to policy 4. Is there reason for hope?
  15. 15. 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 theories Preventive hypothesis: must operate early in a progressive disease Quality of life hypothesis Clinical research: decision-analysis, cohort studies No survival benefit from surgery Benefit of surgery depends upon patients’ values (symptoms vs sexual dysfunction) Patients’ values differed dramaticallyImplications: Broadly applicable – orthopedics, cardiology, oncology, etc Need for accurate information on risks and benefits Structured approach to supporting informed patient choice Studies have now demonstrated effectiveness of decision aids
  16. 16. Preference Sensitive CareBuilding the evidence: the Prostate PORTInterdisciplinary team; multiple methods Focus groups of urologists to determine clinical theories Preventive hypothesis: must operate early in a progressive disease Quality of life hypothesis Clinical research: decision-analysis, cohort studies No survival benefit from surgery Benefit of surgery depends upon patients’ values (symptoms vs sexual dysfunction) Patients’ values differed dramaticallyImplications: Broadly applicable – orthopedics, cardiology, oncology, etc Need for accurate information on risks and benefits Structured approach to supporting informed patient choice Studies have now demonstrated effectiveness of decision aids
  17. 17. Preference Sensitive CareTranslating evidence into policyUnderlying problems Inadequate information on risks and benefits of biologically targeted treatments Provider-dominated decision-makingRemedies Outcomes research (comparative effectiveness) Informed patient choicePolicy implications and progress Major investment in comparative effectiveness research National standards now include informed choice as core quality measure Many integrated delivery systems are moving to adopt shared decision-making States moving to require informed patient choice as legal standard
  18. 18. Safe and Effective carePopulation: Patients undergoing Coronary Artery Bypass GraftProviders: Cardiovascular surgery centers in New England Northern New England Cardiovascular Disease Study Group Origins: threatened public report of unadjusted CABG Eastern Maine mortality rates Medical Center Fletcher Allen Health Care New England rates varied two Dartmouth Maine Hitchcock Medical fold: 3.1% to 6.3% Medical Center Center Surgeons agreed to collect Concord Hospital relevant clinical data
  19. 19. Safe and Effective carePopulation: Patients undergoing Coronary Artery Bypass GraftProviders: Cardiovascular surgery centers in New England 7 6 In-Hospital Mortality RateAdjusted mortalityno less variable: 5 2.3% to 6.3% 4Near death experience 3of study group 2Now over 20 years of 1experience; 100+papers published; all 0sites still participating 1 2 3 4 5in 3 meetings per year Center O’Connor et al, JAMA, 1991;266:803-809
  20. 20. Safe and Effective CareImprovement achieved as research advanced 6 Initial intervention-data feedback, site visits and CQI training 5 Mortality rate (%) 4 3 2 Mode of death study- low output heart failure major Process mapping cause of in-hospital 1 and identification mortality of high leverage areas 0 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 Year
  21. 21. Safe and Effective CareTranslating evidence into policyUnderlying problems Inadequate data: on patient attributes, process of care and outcomes Small numbers, lack of follow-up prevent learning Flawed professional model: individual responsibility and autonomyRemedy Technical: 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 learning Engage clinicians in practice-based research and improvement Enable reflective practice – timely, relevant feedbackPolicy implications and progress Potential benefits – to patients, physicians, managers and policy-makers -- of practice-based research networks is substantial Lack of government support remains challenge. Most efforts are voluntary, self- funded.
  22. 22. Variations in spendingBuilding the evidence base “How can the best medical care in the world cost twice as much as the best medical care in the world?
  23. 23. Variations in spending Building the evidence base Health implications of variations in spending Study 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 careRobert Wood Johnson FoundationNational Institute of AgingCalifornia Healthcare FoundationAetna FoundationWellpoint FoundationUnited Healthcare Foundation(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
  24. 24. What do they get more of?Effective Care: benefit clear for all If bar on this side Reperfusion in 12 hours (Heart attack) higher spending Aspirin at admission (Heart attack) regions get more Mammogram, Women 65-69 Pap Smear, Women 65+ Pneumococcal Immunization (ever)Preference Sensitive: values matter Total Hip Replacement Total Knee Replacement Back Surgery CABG following heart attackSupply sensitive: often avoidable care Total Inpatient Days Inpatient Days in ICU or CCU Evaluation and Management (visits) Imaging Diagnostic Tests 0.5 1.00 1.5 2.0 2.5 Ratio of rate in high spending to low spending regions
  25. 25. Outcomes and Quality High spending compared to low spending regions Physician’s Patient-Perceived Health Outcomes Perceptions Quality Worse Lower satisfaction No gain in survival communication with hospital care Greater difficulty Worse access to No better function ensuring coordination primary care Greater perception No sense that care of scarcity is rationed(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
  26. 26. 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.
  27. 27. Variations in spendingWhat’s going on? General attributes of U.S. health care 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)
  28. 28. Variations in spendingWhat’s going on? Exploring causes of regional variations Patient Malpractice Demand Less than 10% of Little difference difference
  29. 29. Variations in spendingWhat’s going on? Exploring causes of regional variations Patient Malpractice Supply & payment Demand Less than 10% of Little difference Powerful influence difference Explains less than 50% of difference
  30. 30. Variations in spendingWhat’s going on? Exploring causes of regional variations Patient Malpractice Supply & payment Demand Less than 10% of Little difference 32% 65% Powerful influence difference 4.0 higher 50 higher 40 Explains less than 3.0 30 50% of difference 2.0 20 1.0 10 Regional Spending Low High Low High Hospital Beds Medical Specialists
  31. 31. Variations in spendingWhat’s going on? Exploring causes of regional variations Patient Malpractice Supply & payment Demand Less than 10% of Little difference Powerful influence difference Explains less than 50% of difference
  32. 32. Variations in spending What’s going on? Exploring causes of regional variations Patient Malpractice Supply & payment Demand Less than 10% of Little difference Powerful influence difference Explains less than 50% of differenceNew York TimesAugust 18, 2006
  33. 33. Variations in spendingWhat’s going on? Exploring causes of regional variations Patient Malpractice Supply & payment Demand Less than 10% of Little difference Powerful influence difference Explains less than 50% of difference
  34. 34. Variations in spendingExploring causes -- gray area decisionsEvidence-based decisions – drawn from guidelinesDoctors sometimes disagreed – but was unrelated to regionaldifferences in spendingGray area decisions (more judgment required):For a patient with well-controlled high blood pressure and no othermedical problems, when would you schedule the next visit?
  35. 35. Variations in spending Exploring causes -- gray area decisionsClinical evidence is an important -- but limited --influence on clinical decision-making. Policy EnvironmentPhysicians practice within a local organizational (e.g. payment system)context that profoundly influences their decision-making.Payment system ensures that existing capacityis fully utilized. Physicians adapt to available resources:more referrals, more admissions, more ICU stays Local Organizational ContextConsequence: reasonable individual clinical and local (e.g. capacity - culture)decisions lead, in aggregate, to higher utilization rates,greater costs -- and inadvertently -- worse outcomesThe more complicated carebecomes, the more likely Clinical Physician - Patientmistakes are to occur. Evidence EncounterHospitals are dangerous places if Professionalismyou don’t need to be there.
  36. 36. Culture? Capacity? Both?Differences in spending and practice across top academic centers Medicare beneficiaries with chronic illness, 2001-2005
  37. 37. Variations in spendingExploring causes: case studies beginning to shed light 2006 Spending 92-06 Growth McAllen $14,946 8.3% La Crosse $5,812 3.9%
  38. 38. 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 2006 Spending 92-06 Growth McAllen $14,946 8.3% La Crosse $5,812 3.9%
  39. 39. 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 2006 Spending 92-06 Growth McAllen $14,946 8.3% La Crosse $5,812 3.9% “…a culture that focuses onthe wellbeing of thecommunity, not just thefinancial health of our system.” Jeff Thompson, MD CEO Gunderson-Lutheran La Crosse, WI
  40. 40. What I think we knowPutting the pieces together: the IOM system of effect La Crosse McAllen Aims Micro-system Organization How care is provided e.g. capacity, policies to each patient practices, norms Environment e,g, payment, regulations measures, cultureInstitute of Medicine: Crossing the Quality Chasm
  41. 41. 41 What I think we know Underlying problems – and principles to guide reformUnderlying problem Key principlesConfusion about aims – what Clarify aims: Better health, better carewe’re trying to produce lower costsBad data allow MDs to discount it, Better information that engagesand public to assume that medicine physicians, creates tension for change,is science and that more is better. supports improvement; informs consumersFlawed conceptual model. Health New model: It’s the system. Establishis produced by individual actions of teams and organizations accountable for“good” clinicians, working hard. aims and capable of improving practiceWrong incentives reinforce model, Rethink our incentives: Realignreward fragmentation, induce more incentives – both financial andcare and entrepreneurial behavior. professional – with aims.
  42. 42. Translating evidence to policyAims and Performance MeasurementEmerging alignment on aims: National Priorities Partners Improving population health Improving safety & reliability and coordination of care Engaging patients in managing their care and making informed decisions Eliminating overusePerformance measurement: the critical lever National 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 multidimensional Requires organizational accountability – over time
  43. 43. Translating evidence to policyPerformance Measurement – across episodes Post AMI Trajectory 1 (T1) Relatively healthy adult Assessment of Preferences Focus on: • Quality of Life • Functional Status Population at Risk • 20 Prevention Strategies 10 Prevention • Rehabilitation (no known CAD) • Advanced care planning Post Acute/ 20 Prevention Acute Rehabilitation 20 Prevention (CAD no prior AMI) Phase Phase 20 Prevention (CAD with prior AMI) PHASE 2 PHASE 3 PHASE 4 Post AMI Trajectory 2 (T2) Advanced Care Planning Adult with multiple co-morbidities PHASE 1 Focus on: • Quality of Life Living w/ Illness/Disability (T1) • Functional Status Staying Healthy Getting Better Coping w/ End of Life (T2) • 20 Prevention Strategies • Advanced Care Planning Traditional model Needed model • Advanced Directives • Palliative Care/Symptom Control Autonomy Accountability Individual Responsibility Episode begins – Shared Episode ends – Responsibility onset of symptoms 1 year post AMI© NQF
  44. 44. Translating evidence to policyImplications for Health Information TechnologyEffective registries are thus critical for a learning health systemTo learn -- we need to know: Patient attributes and risks (including biologic markers) Specific targeted biologic interventions performed Attributes of system -- delivery methods -- where care provided Health outcomes, patient experience and costsInfrastructure 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 attributesBoth are critical
  45. 45. Translating evidence to policy Organizational Accountability and Payment Reforms Accountable Care Organizations Principles: Establish provider organizations that can effectively manage the full continuum of care as a real or virtually integrated local delivery system Performance measurement – to support improvement and accountability Payment reform: establish target spending levels; shared savings Potential ACOs Integrated delivery systems (Kaiser-Permanente, Group Health) Physician Networks; Hospital that employ primary care physicians Insight from research: Most physicians already practice within coherent local networks Performance measurement at group level feasible Feasible to develop spending targets for most U.S. networksFisher et al. Creating Accountable Care Organizations, HealthAffairs 26(1) 2007:w44-w57.
  46. 46. Translating evidence to policyOrganizational Accountability and Payment ReformsEarly pilots promising; many organizations supportive Physician Group Practice demonstration successful Congressional Budget Office scored as cost-saving Support from key stakeholders has solidifiedACOs accepted as component of current bills Support for extensive pilots, rapid expansion in House bills Senate Finance – voluntary program (not pilot) by 2012Initiatives at state and local level Brookings-Dartmouth supporting pilot development in multiple sites Pilots to start January 2010 in two (or more) sites (VA, KY, TX) Learning collaborative underway with 40+ health systems Massachusetts, Vermont, others moving forward
  47. 47. Rethinking health careThe Dartmouth Atlas of Health Care 1. What we know – 3 stories 2. What I think I know 3. From insight to action 4. Is there reason for hope?
  48. 48. 48Is there reason for hope?Theories of change – can they help frame our thinkingHealth care is a complex adaptive system Autonomous actors continuously adapt their behavior System held in place by “attractors”, self-reinforcing behaviorsChange 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 go New attractors (performance measurement, payment, positive deviants)Implications for research – and policy Public reporting: creates a tension for change, raises good questions Policy relevant research: has undermined flawed assumptions; suggested path toward reform Registries, practice networks, have developed evidence, engaged clinicians, engaged local systems and communities
  49. 49. Is there reason for hope?Theories of change – have stimulated new conversations “How do they do that?” Common themes conference Shared aims, accountable to communityEverett, WA Portland, ME Strong foundation of primary careSacramento, CA Sayre, PALa Crosse, WI Richmond, VA Physician engagement as leadersCedar Rapids, IA Asheville, NC Organizational support importantTemple, TX Tallahassee, FL Use of data to drive change Lighter colors = lower spending
  50. 50. Is there reason for hope?Theories of change – have stimulated new conversations “How do they do that?” Common themes conference Shared aims, accountable to communityEverett, WA Portland, ME Physician engagement as leadersSacramento, CA Sayre, PALa Crosse, WI Richmond, VA Strong foundation of primary careCedar Rapids, IA Asheville, NC Organizational support importantTemple, TX Tallahassee, FL Use of data to drive change Lighter colors = lower spending High self-efficacy; high morale
  51. 51. Have we made a difference? Trends in important things in U.S. healthcare uninsured, spending 1973 2009 1983
  52. 52. Have we made a difference? Trends in important things in U.S. healthcare insights, evidence, tests of change 1973 2009 1983
  53. 53. 54 Have we made a difference? Exploring variation has helped to advance knowledge and policyUnderlying problem Key principlesConfusion about aims – what Clarify aims: Better health, better carewe’re trying to produce lower costsBad data allow MDs to discount it, Better information that engagesand public to assume that medicine physicians, creates tension for change,is science and that more is better. supports improvement; informs consumersFlawed conceptual model. Health New model: It’s the system. Establishis produced by individual actions of teams and organizations accountable for“good” clinicians, working hard. aims and capable of improving practiceWrong incentives reinforce model, Rethink our incentives: Realignreward fragmentation, induce more incentives – both financial andcare and entrepreneurial behavior. professional – with aims. Question pay for performance.

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