Dr Jack Wennberg, founder and director of the Dartmouth Institute for Health Policy and Clinical Practice, and founding editor of the Dartmouth Atlas of Health Care, gives his perspective on the challenges faced by the health system in England in reducing unwarranted variation.

1. Tracking Medicine John E. Wennberg

2. Small Area Variations in Health Care Delivery

3. Vermont Map from ‘Science’ From ‘Science’, 14 December 1973 New Hampshire Massachusetts New York Quebec

4. Morrisville and Waterbury Center

7. Tonsillectomy rate per 10,000 children among 13 Vermont Hospital service areas 0 50 100 150 200 250 300 350 400 450 Morrisville 1969

8. Tonsillectomy rate per 10,000 children among 13 Vermont Hospital service areas 0 50 100 150 200 250 300 350 400 450 Morrisville Morrisville 1969 1973

9. 1.5-2 x 2-3 x 1.5-2 x 2-3 x

16. Knee replacement: an example of preference-sensitive care Ratio of knee replacement rates to the U.S. average (2002-03) 1 .30 to 1 .78 (40) 1 .10 to < 1 .30 (75) 0 .90 to < 1 .10 (120) 0 .75 to < 0 .90 (46) 0 .36 to < 0 .75 (25) Not Populated

17. Knee replacement per 1,000 Medicare enrollees Red dot = U.S. average: 4.03 5.64 40% increase 1.0 3.0 5.0 7.0 9.0 11.0 1992-93 2000-01

18. Relationship between knee replacement rates among hospital referral regions in 1992-93 & 2000-01 0.0 2.0 4.0 6.0 8.0 10.0 12.0 0.0 2.0 4.0 6.0 8.0 10.0 12.0 Knee Replacement (1992-93) Knee Replacement (2000-01) R 2 = 0.75

23. Association between hospital beds per 1,000 and discharges per 1,000 among Medicare Enrollees: 306 hospital regions Hip fracture R 2 = 0.06 All medical conditions R 2 = 0.54 0 50 100 150 200 250 300 350 400 1.0 2.0 3.0 4.0 5.0 6.0 Acute care beds Discharge rate

24. Association between cardiologists and visits per person to cardiologists among Medicare enrollees: 306 regions R 2 = 0.49 Number of visits to cardiologists 0.0 0.5 1.0 1.5 2.0 2.5 0.0 2.5 5.0 7.5 10.0 12.5 15.0 Number of cardiologists per 100,000

25. Contrasting practice patterns in managing chronic illness during the last two years of life Regions in highest and lowest utilisation 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

26. Relationship between Resource Inputs and Outcomes: Highest versus lowest quintiles of spending Cohort Health Outcomes Survival: Worse Functional status: Same Satisfaction: Worse Perceived access: Worse Objective quality: Worse

27. Evaluating relative efficiency among academic medical centers in managing chronic illness

28. End of life care at selected academic medical centers (deaths 2001-05) Hospital Name NYU Medical Center UCLA Medical Center Brigham and Women's Johns Hopkins Tufts-New England Beth Israel Deaconess Boston Medical Center Massachusetts General Cleveland Clinic Mayo Clinic (St. Mary's) University of Wisconsin Total Medicare spending 105,068 93,842 87,721 85,729 85,387 83,345 79,672 78,666 55,333 53,432 49,477

29. End of life care at selected academic medical centers (deaths 2001-05) Hospital Name NYU Medical Center UCLA Medical Center Brigham and Women's Johns Hopkins Tufts-New England Beth Israel Deaconess Boston Medical Center Massachusetts General Cleveland Clinic Mayo Clinic (St. Mary's) University of Wisconsin Total Medicare spending 105,068 93,842 87,721 85,729 85,387 83,345 79,672 78,666 55,333 53,432 49,477 All physicians 50.8 38.5 29.3 25.7 26.9 27.6 23.1 29.5 26.1 20.3 17.3

30. End-of-life care at selected academic medical centers (deaths 2001-05) Hospital Name NYU Medical Center UCLA Medical Center Brigham and Women's Johns Hopkins Tufts-New England Beth Israel Deaconess Boston Medical Center Massachusetts General Cleveland Clinic Mayo Clinic (St. Mary's) University of Wisconsin Total Medicare spending 105,068 93,842 87,721 85,729 85,387 83,345 79,672 78,666 55,333 53,432 49,477 % of deaths with ICU admission 35.1 37.9 26.2 23.2 28.5 23.5 28.6 22.5 23.1 21.8 16.1 All physicians 50.8 38.5 29.3 25.7 26.9 27.6 23.1 29.5 26.1 20.3 17.3

31. End-of-life care at selected academic medical centers (deaths 2001-05) Hospital Name NYU Medical Center UCLA Medical Center Brigham and Women's Johns Hopkins Tufts-New England Beth Israel Deaconess Boston Medical Center Massachusetts General Cleveland Clinic Mayo Clinic (St. Mary's) University of Wisconsin Total Medicare spending 105,068 93,842 87,721 85,729 85,387 83,345 79,672 78,666 55,333 53,432 49,447 % of deaths with ICU admission 35.1 37.9 26.2 23.2 28.5 23.5 28.6 22.5 23.1 21.8 16.1 Average co- payments (past 2 years) $5,544 4,835 3,729 3,390 3,327 3,338 2,979 3,409 3,045 2,439 2,059 All physicians 50.8 38.5 29.3 25.7 26.9 27.6 23.1 29.5 26.1 20.3 17.3

32. Composite hospital compare technical quality measures for selected academic medical centers (2005) Hospital Name NYU Medical Center UCLA Medical Center St Mary’s Hospital (Mayo) University of Wisconsin Quality Score 88.2% 83.9% 94.1% 91.9%

33. End-of-life care at selected academic medical centers (deaths 2001-2005) Academic Medical Center Spending per decedent Full-time Equivalent Physicians/ 1000 decedents ICU deaths per decedent Copayment per decedent NYU Med Ctr. $105,068 50.8 FTE 35.1% $5,444 UCLA Med Ctr. 93,842 36.5 37.9 4.835 Mayo Clinic 53,432 20.3 21.8 2,439 U. Wisconsin 49,477 17.3 16.1 2,059

34. Pathways to Reform

37. Example of supply-sensitive care

38. Evaluating relative efficiency in managing chronic illness

39. Example of preference-sensitive care

40. Good and bad variation ‘ If all variation were bad, solutions would be easy. The difficulty is in reducing the bad variation which reflects the limits of professional knowledge and failures in its application, while preserving the good variation that makes care patient-centred.’ Professor Al Mulley BMJ 2010

41. Good variation: The NHS Atlas Model