1. Understanding Practice Variations: A Focus on Academic Medical Centers The Eisenberg Legacy Lecture The Eisenberg Legacy Lecture Stanford, California Presentation by John Wennberg November 2, 2005

2. The Three Categories of Care Effective CareEffective Care Preference-sensitive CarePreference-sensitive Care Supply-sensitive CareSupply-sensitive Care

3. The Dartmouth Atlas Project: 306 Hospital Referral Regions Ongoing Study of Traditional Medicare Population The essence of practice variation studies is the comparison of rates of use of medical care among defined populations

4. 1.30 or More or More (0) (0)1.10 to < to < 1.30.30 (56) (56) 0.90 to < to < 1.10.10 (204) (204) 0.75 to < to < 0.90.90 (45) (45) 0.65 to < to < 0.75.75 (1) (1) Not Populated A Rare Example of Regional Variation for Effective Care that Reflects Illness: Hospitalization for Hip Fracture Ratio of Rates of Hip Fracture to the U.S. Average (1995-96) Among the 306 Hospital Referral Regions

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

6. 45.0 55.0 65.0 75.0 85.095.0 Stanford Hospital64.7 UCSD Medical Center62.3 UCSF Medical Center55.0 UC Davis Medical Center53.3 UC Irvine Medical Center52.3 UCLA Medical Center52.3

7. Benefit to Patients % Use of Effective Care U.S. is some- where in this zone Shape of the Benefit-Utilization Curve Effective Care & Patient Safety

8. Variation in Preference-Sensitive Care, Typified by Elective Surgery, Reflects Idiosyncratic Practice Style, Usually Independent of Capacity HipFracture(13.8)KneeReplacement(55.0)HipReplacement(67.2)BackSurgery(93.6)

9. 2.72 1.24 2.22 1.00 1.14 1.63 1.26 1.00 0.0 1.0 2.0 3.0 4.0 5.06.0 Hip replacement Knee replacement Back surgery Discharge rate StanfordSan FranciscoLos Angeles Rates of Orthopedic Procedures in HSAs Served by Three California Academic Medical Centers (2002-3) (Ratios are to the Lowest HSA.)

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

11. Association Between Surgery Rate ( 2000-01) and Supply of Surgeons (1999); 10 Preference-Sensitive Procedures (R 2 ) Procedure Specialty Association of Surgeon (R2) of Surgeon (R2) Knee Replacement Orthopedic.00 Hip Replacement Orthopedic.08 Back Surgery Orthopedic.02 CABG Cardiac Surg..08 PCI Cardiologist.06 TURP for BPH Urologist.00 Prost. For CA Urologist.01 Gall bladder General Surg..01 Carotid endart. General Surg..04 Lower extremity bypass Vasc. Surgeon.09

12. Relationship Between Knee Replacement Rates in 1992-93 and 2000-01

13. Association Between Surgery Rate ( 2000-01) and Surgery Rate (1992-93) (R 2 ) Procedure Association R2 R2 Knee.75 Hip.81 Back.51 CABG.39 PCI.34 TURP for BPH.28 Prost. For CA.25 Gall bladder.32 Carotid endart..53 L.E. Bypass.56

15. Reducing Misuse of Preference- Sensitive Care Major focus: shared decision makingMajor focus: shared decision making

16. Which Rate is Right? Impact of Improved Decision Quality on Surgery Rates: BPH Knowledge of relevant treatment options and outcomes Concordance between patient values and care received

17. Reducing Misuse of Preference- Sensitive Care Major focus: shared decision makingMajor focus: shared decision making New focus: report cards measuring decision qualityNew focus: report cards measuring decision quality

18. Benefit to Patients UNKNOWN Units of Discretionary Surgery Shape of the Benefit-Utilization Curve: Preference-Sensitive Surgery

19. Primary care visits (16.2) CHF discharges (24.6) COPD discharges (34.5) Medical specialist visits (36.8) Standardized ratio (log scale) Variation in Supply-Sensitive Care Reflects Idiosyncratic Practice Style in Disequilibrium with Capacity Variation in Supply-Sensitive Care Reflects Idiosyncratic Practice Style in Disequilibrium with Capacity

20. Primary care visits (16.2) CHF discharges (24.6) COPD discharges (34.5) Medical specialist visits (36.8) Standardized ratio (log scale) Variation in Supply-Sensitive Care Reflects Idiosyncratic Practice Style in Disequilibrium with Capacity Variation in Supply-Sensitive Care Reflects Idiosyncratic Practice Style in Disequilibrium with Capacity

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

22. Association Between Cardiologists and Visits per Person to Cardiologists among Medicare Enrollees: 306 Regions

24. Hospital Days During the Last Six Months of Life among Medicare Enrollees Receiving Most of Their Care at Academic Medical Centers (1999-2003) UCLA Medical Center19.2 UC Irvine Medical Center16.0 UCSD Medical Center14.1 UCSF Medical Center13.2 Stanford Hospital12.0 UC Davis Medical Center11.6

25. 0.0 10.0 20.0 30.040.00.010.020.030.040.0 Cancer patients CHF patients R2R2 = 0.78 Hospital Days Association Between Utilization Rates During the Last Six Months of Life for Patients with Cancer and Congestive Heart Failure among Academic Medical Centers (1999-2003)

26. Hospitaldays Black & Non-Black 0.67 Male & Female 0.92 Younger & Older 0.82 Medicaid & Non-Medicaid 0.84 Association (R2) Between Utilization Rates During the Last Six Months of Life for Patient Cohorts According to Demographic Characteristics among Academic Medical Centers (1999-2003)

27. Hospital Days R2R2 = 0.74 0.0 5.0 10.0 15.0 20.0 25.0 30.035.00.02.04.06.08.0 19-24 months before death Last six months of life Association Between Utilization Rates 19-24 Months Before Death and During the Last Six Months of Life among Academic Medical Centers (1999-2003)

28. ICU Days During the Last Six Months of Life Among Medicare Enrollees Receiving Most of Their Care at Academic Medical Centers (1999-2003) UCLA Medical Center11.4 UC Davis Medical Center6.8 UCSD Medical Center6.3 UC Irvine Medical Center8.2 Stanford Hospital3.7 UCSF Medical Center3.3

29. Physician Visits During the Last Six Months of Life Among Medicare Enrollees Receiving Most of Their Care at Academic Medical Centers (2000-03) UCLA Medical Center52.1 UC Irvine Medical Center39.7 UCSF Medical Center30.4 UCSD Medical Center30.1 Stanford Hospital24.0 UC Davis Medical Center23.2

30. Percent of patients seeing 10 or more physicians during the last six months of life among Medicare decedents receiving most of their care at academic medical centers (2000-03) UCLA Medical Center57.7% UC Irvine Medical Center43.4% UCSF Medical Center42.2% UCSD Medical Center41.1% UC Davis Medical Center34.7% Stanford Hospital28.9%

31. Ratio of Medical Specialist to Primary Care Physician Visits During the Last Six Months of Life Among Medicare Enrollees Receiving Most of Their Care at Academic Medical Centers (2000-03) UCLA Medical Center2.86 UC Irvine Medical Center1.55 UC Davis Medical Center1.19 UCSD Medical Center1.16 Stanford Hospital1.15 UCSF Medical Center0.68

32. Association Between Medical Specialist and Primary Care Physician Visits During the Last Six Months of Life Among Academic Medical Centers (2000-03)

33. Association Between Hospital Days and Physician Visits During the Last Six Months of Life Among Academic Medical Centers (1999-2003)

34. 0.0 10.0 20.0 30.040.00.010.020.030.040.0 Cancer patients CHF patients R2R2 = 0.78 Hospital days Physician visits 0.0 20.0 40.0 60.0 80.0100.00.020.040.060.080.0100.0 Cancer patients CHF patients R2R2 = 0.61 Association Between Utilization Rates During the Last Six Months of Life for Patients With Cancer and Congestive Heart Failure Among Academic Medical Centers (1999-2003)

35. Hospital days R2R2 = 0.74 0.0 5.0 10.0 15.0 20.0 25.0 30.035.00.02.04.06.08.0 19-24 months before death Last six months of life Physician visits R2R2 = 0.67 0.0 20.0 40.0 60.080.00.05.010.015.020.025.0 19-24 months before death Last six months of life Association Between Utilization Rates 19-24 Months Before Death and During the Last Six Months of Life Among Academic Medical Centers (1999-2003)

36. Variations During the Last Six Months of Life Among Medicare Enrollees Receiving Most of Their Care at Hospitals Belonging to Large Academic Medical Systems (1999-2003)

37. ICU Days Per Patient During the Last Six Months of Life Among Medicare Enrollees Receiving Most of Their Care at Hospitals Belonging to Large Academic Medical Systems (1999-2003) (Weighted System Average on Right) 0.02.04.06.08.010.012.0 Mayo2.8 UPMC2.9BJC4.6Cleve. Clin.4.6UHHS3.4Fairview2.0CareGroup3.1Univ. of CA7.6Partners2.7HA of Cin.3.4Baylor3.8Jefferson7.9

38. Physician Visits Per Patient During the Last Six Months of Life Among Medicare Enrollees Receiving Most of Their Care at Hospitals Belonging to Large Academic Medical Systems (2000-2003) (Weighted System Average on Right) 13.023.033.043.053.063.0 Mayo23.3 UPMC39.3BJC33.6Cleve. Clin.36.7UHHS31.7Fairview24.7CareGroup32.7Univ. of CA38.9Partners35.4HA of Cin.30.8Baylor34.0Jefferson50.0

39. Ratio of Medical Specialist to Primary Care Physician Visits During the Last Six Months of Life Among Medicare Enrollees Receiving Most of Their Care at Hospitals Belonging to Large Academic Medical Systems (Weighted System Average on Right) 0.00.51.01.52.02.53.0 Mayo0.81 UPMC1.10BJC0.90Cleve. Clin.1.19UHHS0.98Fairview0.54CareGroup0.91Univ. of CA1.59Partners0.94HA of Cin.1.06Baylor1.14Jefferson1.97

41. Per Capita Resource inputs and Health Outcomes: Ratio High/Low Quintiles of Spending Resource Inputs Medicare Spending 1.61 Hospital Beds (1000) 1.32 Physician Supply* All Physicians 1.31 All Physicians 1.31 Medical Specialists 1.65 Medical Specialists 1.65 General Internists 1.75 General Internists 1.75 Family Practice 0.74 Family Practice 0.74 Surgeons 1.37 Surgeons 1.37 Per 10,000Per 10,000 Cohort Health Outcomes Cohort Health Outcomes Death R.R. 95% CL Death R.R. 95% CL Hip Fracture 1.019 1.001-1.039 Hip Fracture 1.019 1.001-1.039 Colon Cancer 1.012 1.018-1.094 Heart Attack 1.052 1.018-1.094 Functional Status Worse Satisfaction Same Satisfaction Same

43. Percent of deaths associated with admission to intensive care among Medicare decedents receiving most of their care at academic medical centers (1999-2003) UCLA Medical Center35.4% UCSD Medical Center24.0% UCSF Medical Center23.1% Stanford Hospital21.9% UC Irvine Medical Center30.8% UC Davis Medical Center29.9%

44. U.S. is some- where in this zone Frequency of Care Life Expectancy Shape of the Benefit-Utilization Curve: Supply-Sensitive Services

45. Summary: “System” Causes of Unwarranted Variation Under-use of effective care. Under-use of effective care. Discontinuity of care (worse when more physicians are involved in the care)Discontinuity of care (worse when more physicians are involved in the care) Lack of infrastructure to assure outreach and the timely use of effective care Lack of infrastructure to assure outreach and the timely use of effective care Finance “system” that fails to support infra-structure and rewards quantity, not qualityFinance “system” that fails to support infra-structure and rewards quantity, not quality

46. Summary: “System” Causes of Unwarranted Variation Misuse of preference-sensitive care Poor communication between MD and patient regarding the risks and benefits of alternative treatments;Poor communication between MD and patient regarding the risks and benefits of alternative treatments; Patient dependency on physician’s opinion in sorting out preferences; (flaws in agency model)Patient dependency on physician’s opinion in sorting out preferences; (flaws in agency model) Inadequate evaluation of (evolving) treatment theoryInadequate evaluation of (evolving) treatment theory Health care finance “system” that rewards procedures, not the quality of decision makingHealth care finance “system” that rewards procedures, not the quality of decision making

47. Summary: “System” Causes of Unwarranted Variation Overuse of supply-sensitive care Over-dependence on acute hospital care;Over-dependence on acute hospital care; Lack of infrastructure to support population-based management of chronically ill patients;Lack of infrastructure to support population-based management of chronically ill patients; Cultural assumption that more care is better care (without evidence at the clinical level that this is so)Cultural assumption that more care is better care (without evidence at the clinical level that this is so) Lack of accountability for the capacity of the health care system relative to the size of the population servedLack of accountability for the capacity of the health care system relative to the size of the population served Finance “system” that rewards high intensity care and doesn’t pay for infrastructure, efficiency or learningFinance “system” that rewards high intensity care and doesn’t pay for infrastructure, efficiency or learning

48. The CMS 646 Opportunity (Medicare Health Care Quality Demonstration Programs) Provider focus: group practices, integrated health care systems and regional coalitions can propose radical changes in health care deliveryProvider focus: group practices, integrated health care systems and regional coalitions can propose radical changes in health care delivery Focus on improving quality and efficiency in all three categories of careFocus on improving quality and efficiency in all three categories of care RFP seeks proposals to reform financing systems as well as the regulatory environment (and might include commercial as well as Medicaid programs)RFP seeks proposals to reform financing systems as well as the regulatory environment (and might include commercial as well as Medicaid programs) Encourages collaboration between applicants, NIH and ARC to improve the scientific basis of clinical decision makingEncourages collaboration between applicants, NIH and ARC to improve the scientific basis of clinical decision making Five-year time horizonFive-year time horizon