1 / 30

The Dartmouth Atlas: Too Much Treatment? The Iowa Advantage

The Dartmouth Atlas: Too Much Treatment? The Iowa Advantage. David C. Goodman, MD MS Professor of Pediatrics and of Community and Family Medicine The Dartmouth Institute for Health Policy and Clinical Practice Dartmouth Medical School Hanover, NH October 2008. IA.

ciqala
Download Presentation

The Dartmouth Atlas: Too Much Treatment? The Iowa Advantage

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. The Dartmouth Atlas: Too Much Treatment?The Iowa Advantage David C. Goodman, MD MS Professor of Pediatrics and of Community and Family Medicine The Dartmouth Institute for Health Policy and Clinical Practice Dartmouth Medical School Hanover, NH October 2008

  2. IA The US has a Problem, Iowa Has an Advantage: Baiker K, et al. Health Affairs 2004.

  3. We Have a Problem: Medicare Funding as % of Gross Domestic Product Part A is “exhausted”; Part B and D premiums soar.

  4. www.dartmouthatlas.org John Wennberg Lead Author Co-authors: Elliott Fisher, MD MPH David Goodman, MD MS Jonathan Skinner, PhD

  5. Variation in Per-Capita Medicare Spending Across Hospital Referral Regions (N=306)

  6. What Can We Learn From Variation in Care? • Variation in three parts: • Effective care • Preference sensitive care • Supply sensitive care • What are the opportunities in the Iowa advantage?

  7. Red Dots Indicate HRRs Served by U.S. News 50 Best Hospitals for Cardiovascular Care Systematic Under Use of Effective Care 100.0 80.0 AMI Patients % Receiving Beta Blockers 60.0 40.0 20.0 0.0

  8. Domains of Effective Care Nearly completely Implemented Partially Implemented Proven Effective Possibly Efficacious Basic Science Knowledge

  9. Domains of Effective Care Health, Disease, and Treatments Unknowns Partially Implemented Proven Efficacious Possibly Efficacious Basic Science Knowledge

  10. What Can We Learn From Variation in Care? • Variation in three parts: • Effective care • Preference sensitive care • Supply sensitive care • What are the opportunities in the Iowa advantage?

  11. Preference-Sensitive Care • Involves tradeoffs • Decisions that should be based on the patient’s own preferences • The effect of supply is variable • Patient and provider values are often in conflict • Scientific uncertainty often substantial

  12. Variation in Surgery and Scientific Uncertainty(Dartmouth Atlas 306 Regions) 5.0                                                                                                                                                                                                                                      1.0                                                                                                                                                                                                                                                                                                                                                                                              Colectomy for Colorectal Cancer Radical Prostatectomy 0.2

  13. 2.4 2.0 1.6 1.2 Back surgery: Ratio to Iowa average 0.8 0.4 0.0 Ratios of Back Surgery Discharge Rates to State RateIowa Hospital Service Areas, ≥ age 65 1980 2002-03 State rate 0.7 per 1,000 4.9 per 1,000

  14. What Can We Learn From Variation in Care? • Variation in three parts: • Effective care • Preference sensitive care • Supply sensitive care • What are the opportunities in the Iowa advantage?

  15. Supply Sensitive Care • Strongly correlated with resource supply • Generally provided in the absence of specific clinical theories governing relative frequency • Medical evidence weak or nonexistent • Patient preferences and values should play a central role in some cases

  16. 2.0 1.8 1.6 1.4 1.2 COPD: Ratio to Iowa average 1.0 0.8 0.6 0.4 0.2 Ratios of COPD Discharge Rates to State RateIowa Hospital Service Areas, ≥ age 65 1980 2002-03 State rate 8.7 per 1,000 9.2 per 1,000

  17. 350.0 300.0 250.0 Medical Discharges per 1,000 Medicare Enrollees (1995-96) 200.0 150.0 2 R = 0.56 100.0 1.0 2.0 3.0 4.0 5.0 6.0 Acute Care Beds per 1,000 Residents (1996) Hospital Beds (1996) vs. Adjusted Discharge Rates for Medical Conditions (1995-96)

  18. Regional Variation: • Marked regional variation in capacity, utilization, and spending. • More spending is not better (i.e. quality and outcomes). • High spending associated with discretionary services (visits, hospital days, tests). • Implication: low spending regions are more efficient. • Low spending regions and health systems can serve as benchmarks.

  19. Months Prior to Death 24 12 6 Death 6 Death Measuring Longitudinal Efficiency

  20. Months Prior to Death 24 12 6 Death 6 Death Measuring Longitudinal Efficiency

  21. 33.0 29.0 25.0 21.0 Hospital days per decedent 17.0 13.0 9.0 Average Number of Hospital Days per Decedent During the Last Six Months of Life (2001-05) New York-Presbyterian 22.7 UCLA Medical Center 18.5 Hospital of the U of PA 17.6 Massachusetts General 17.3 Johns Hopkins Hospital 16.5 Brigham and Women's 16.1 Cleveland Clinic 14.8 Duke University Hospital 13.8 UCSF Medical Center 13.5 U of WA Medical Center 13.2 Mayo Clinic (St. Mary's) 12.0

  22. 35.0 30.0 25.0 20.0 Hospital days per decedent 15.0 10.0 5.0 Average Number of Hospital Days per Decedent During the Last Six Months of Life (1999-2003) Genesis (Davenport) 15.2 Iowa Methodist (Des Moines) 15.0 Mercy Capitol (Des Moines) 13.9 Mary Greeley (Ames) 13.4 Mercy (Cedar Rapids) 13.1 Mercy (Sioux City) 13.0 St. Luke's (Cedar Rapids) 11.9 St. Luke's (Sioux City) 11.5 Allen Memorial (Waterloo) 10.8 Mercy (Mason City) 7.7

  23. 120,000 110,000 100,000 90,000 80,000 Medicare spending per decedent 70,000 60,000 50,000 40,000 Total Medicare Spending per Decedent During the Last Two Years of Life (2001-05) UCLA Medical Center 93,842 New York-Presbyterian 91,113 Brigham and Women's 87,721 Johns Hopkins Hospital 85,729 Hospital of the U of PA 80,727 Massachusetts General 78,666 UCSF Medical Center 78,046 U of WA Medical Center 70,245 Duke University Hospital 57,411 Cleveland Clinic 55,333 Mayo Clinic (St. Mary's) 53,432

  24. Average Number of ICU Days per Decedent During the Last Six Months of Life (1999-2003) 12.0 10.0 8.0 6.0 ICU days per decedent 4.0 2.0 0.0 St. Luke's (Sioux City) 3.6 Genesis (Davenport) 3.6 Mercy (Sioux City) 3.6 Mercy (Cedar Rapids) 3.2 Mercy Capitol (Des Moines) 2.0 Allen Memorial (Waterloo) 1.8 St. Luke's (Cedar Rapids) 1.6 Iowa Methodist (Des Moines) 1.5 Mary Greeley (Ames) 1.4 Mercy (Mason City) 1.1

  25. Total Medical Specialist Primary Care 28.3 FTEs 8.8 15.0 Total Medical Specialist Primary Care Mayo Clinic 8.9 FTEs 3.0 3.9 Physician FTEs per 1,000 end-of-life Medicare beneficiaries NYU Medical Center Source: Goodman, Health Affairs,March/April 2006.

  26. 70.0 60.0 50.0 40.0 % seeing 10 or more physicians 30.0 20.0 10.0 % Patients Seeing 10 or more Different Physicians During the Last Six Months of Life (1999-2003) Mercy Capitol (Des Moines) 43.9% Iowa Methodist (Des Moines) 37.0 Mary Greeley (Ames) 32.7 St. Luke's (Sioux City) 28.1 Genesis (Davenport) 27.7 Mercy (Sioux City) 27.0 Allen Memorial (Waterloo) 26.0 St. Luke's (Cedar Rapids) 22.4 Mercy (Cedar Rapids) 21.6 Mercy (Mason City) 16.1

  27. Supply Sensitive Care • Strongly correlated with resource supply • Generally provided in the absence of specific clinical theories governing relative frequency • Medical evidence weak or nonexistent • Patient preferences and values should play a central role in some cases

  28. What Can We Learn From Variation in Care? • Variation in three parts: • Effective care • Preference sensitive care • Supply sensitive care • What are the opportunities in the Iowa advantage?

  29. Opportunities for Iowa in Quality and Efficiency • What doctors and nurses do is very important: Continue improvement efforts. • Invest in developing organizations and systems of care, not places of care. • Common electronic medical records • Teams organized for quality • Accountability of clinics, teams, services, health systems • Invest in the labor and capital of improvement • Promote patient preference driven care: implement decision aids • Manage growth capacity carefully, or you will lose your advantage!

More Related