Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Dr Al Mulley: The Secret to Reducing Unwarranted Variations

1,676 views

Published on

Dr Al Mulley, Director of the Dartmouth Center for Health Care Delivery Science at Dartmouth College, introduces the theory behind good and bad health care variation, looking at the work of Dr Jack Wennberg in the United States.

Published in: Health & Medicine
  • Be the first to comment

  • Be the first to like this

Dr Al Mulley: The Secret to Reducing Unwarranted Variations

  1. 1. Reducing Unwarranted Variations in Health Care Promoting the Good and Minimizing the BadALBERT G. MULLEY, JR., MD, MPPTHE DARTMOUTH CENTER FOR HEALTH CARE DELIVERY SCIENCEINTERNATIONAL VISITING FELLOW, THE KING’S FUNDSEPTEMBER 14, LONDON
  2. 2. Practice Variation: Rediscovery by Wennberg Variations in: • Tonsillectomy: 17-fold • Hysterectomy: 6-fold • Prostatectomy: 4-fold • ‘The need for assessing outcome of common medical practices’ • ‘Professional uncertainty and the problem of supplier- induced demand’John E. Wennberg, 1973
  3. 3. Practice Variation: US, Norway and the UK • Geographic variation in rates of surgical procedures • Different rates between countries (US>UK>Norway, or US>Norway>UK) • Regional variation within countries similar McPherson • higher variation: tonsillectomy, hemorroidectomy, hysterectomy, prostatectomy • lower variation: appendectomy, Hovind hernia repair, cholecystectomy • Variation a characteristic of the procedure Wennberg • Within country variation not associated with organization or financing of care, but with professional uncertaintyN Engl J Med 1982; 307: 1310
  4. 4. Variation: The Bad and the Good Bad variation (care not evidence-based) • Poor research  professional uncertainty • Poor knowledge  professional ignorance Good variation (care is patient-centered) • Clinical differences among patients • Personal differences among patients If all variation were bad, it would be easyJAMA, 1988 to stop it. What is difficult is reducing the bad variation while keeping the good.
  5. 5. The Complexity of Health Care Delivery HighDisagreement about Chaos Preferences Complexity Control Low Low High Uncertainty about Outcomes Knowledge-Based
  6. 6. Variation: The Bad and the GoodDECREASING BAD VARIATION (evidence-based care)• Improve knowledge management• Improve communication• No avoidable ignoranceINCREASING GOOD VARIATION (patient-centered care)• Recognize clinical differences among patients• Honor personal differences among patients The efficient way to reduce overuse, underuse, and misuse of care
  7. 7. Support for personal knowledge: BPH How bothersome is urinary dysfunction?How bothersome will sexual dysfunction be?
  8. 8. Simple measures of decision quality: BPH Knowledge of relevant treatment Concordance between patient options and outcomes values and care received1. Are my symptoms likely to be life- 1. How much am I bothered by mythreatening? What if I do nothing? symptoms?2. Is surgery the only option? How 2. How much will I be bothered by amuch can other treatments help? possible change in experience of sex?3. Will surgery change my sexualfunction? In what ways? OR = 7.0 Least Most valued valued OR = 0.2
  9. 9. Simple measures of decision quality: CHD Knowledge of relevant treatment Concordance between patient options and outcomes values and care received 1. Are my symptoms likely to be life- 1. How much am I bothered by my threatening? What if I do nothing? symptoms? 2. Is surgery the only option? How much 2. How much will I be bothered by a can other treatments help? possible change in cognitive abilities? 3. Will surgery change my ability to think clearly? In what ways? What else can I expect in the future?10090 CABG807060 Medical Therapy5040 0 2 4 6 8 10 12
  10. 10. Impact of Better Decisions for BPH & CHD Toronto trialProstatectomy rates decreased CABG rates decreased 26% to40% to a rate lower than all but a rate lower than all 306 one of 306 regions
  11. 11. The New Yorker, June 1, 2009
  12. 12. A Tale of Two Cities: McAllen and El PasoMcAllen $14,946 El Paso $ 7,504
  13. 13. Questions raised but not answered
  14. 14. Glover’ s discovery and the ethical imperative •10-fold variation in tonsillectomy •8-fold risk of death with surgical treatment •The response: •“…these strange bare facts of incidence…” •“… tendency for the operation to be performed for no particular reason and no particular result.” •“…sad to reflect that many of the anesthetic deaths… were due to unnecessary operations.”J Allison Glover, 1938

×