1. Technology in Healthcare Amitabh Chandra HARVARD UNIVERSITY

2. International Comparison of Spending on Health, 1980–2010 Average spending on health per capita ($US PPP) Notes: PPP = purchasing power parity; GDP = gross domestic product. Source: Commonwealth Fund, based on OECD Health Data 2012.

3. Why? Aging? Obesity and Sickness? Waste and Inefficiency? Medical Malpractice? Technology

4. Technology in Healthcare Challenge: – High fixed-cost, low marginal cost – Heterogenous benefits (large value for some patients!) – Trials are often done in most appropriate patients – Financial incentives push for overuse in others

5. A Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee J. Bruce Moseley, M.D., Kimberly O'Malley, Ph.D., Nancy J. Petersen, Ph.D., Terri J. Menke, Ph.D., Baruch A. Brody, Ph.D., David H. Kuykendall, Ph.D., John C. Hollingsworth, Dr.P.H., Carol M. Ashton, M.D., M.P.H. and Nelda P. Wray, M.D., M.P.H. N Engl J Med Volume 347;2:81-88 July 11, 2002

6. Mean Values (and 95 Percent Confidence Intervals) on the Knee-Specific Pain Scale Moseley, J. et al. N Engl J Med 2002;347:81-88

15. Patients Receiving Procedure 0 Benefit from Procedure 100 percent Rapid Angioplasty within 2 hours of AMI “Late” Angioplasty within 2 days of AMI Angioplasty for Stable Coronary Disease OVERUSE? OVERUSE?

16. Rapid Stenting: US vs. UK Late Stenting: US vs. UK

17. HighestPerformance LowestPerformance Source: Chandra, Staiger, Skinner (IOM, 2010)

18. Rates of All Harms, Preventable Harms, and High-Severity Harms Landrigan CP et al. N Engl J Med 2010;363:2124-2134.

19. The Dark Side Can technology cause distractions? Theory of Technology Spillovers

20. What do Boards do on quality? Surveyed Board chairpersons from 1000 hospitals Received 78% response Oversampled “best” and “worst” hospitals on HQA processes Asked about priorities, perceptions, and activities around quality Jha and Epstein, Health Affairs, 2010

21. Perception of Quality Performance Note: Perception of their hospital’s performance on the TJC/HQA measures compared to typical U.S. hospital

22. Board’s Attention to Quality

23. So what’s the bottom line? Technology growth drives healthcare spending New Technologies have ‘high-fixed-cost, low marginal cost’ profile New technologies have heterogeneous benefits– cost effectiveness very hard to do! Spending is weakly correlated with outcomes Outcomes are affected by professionalism, diligence, and safety culture Real cost of technology is that it distracts from safety Hard choices ahead– don’t be fooled by prevention as a solution for technology growth