Geography is Destiny: The Epidemiology of Health … is Destiny:Geography is Destiny: The Epidemiology of Health Care David C. Goodman, MD MS Director, Center for Health Policy Research

Geography is Destiny:Geography is Destiny:

The Epidemiology of Health Care

David C. Goodman, MD MS

Director, Center for Health Policy Research

September 2009

Cholera EpidemicsFarr and Snow, London, 1840

The School Medical Service - England

The English School Medical ServiceThe English School Medical Service

• Enlarged adenoids and tonsils were a common condition.• Tonsillectomy rates began to increase• Tonsillectomy rates began to increase.• In 1924, Committee on Enlarged Adenoids and Tonsils

was established.• In 1931:

– 6% of students were diagnosed with “adenoids and enlarged t il ”tonsils”

– 84,000 tonsillectomies and adenoidectomies were performed.– Thought to be ¾ of all procedures in England.g p g

Glover Tonsillectomy Annual Incidence (1936)5 - 14 years5 14 years

6.06.0

5.05.0

dren

dren

4.04.0

100

child

100

child

Blyth MB 5.7Oxford CB 3 1

3.03.0

tom

y pe

r to

my

per Oxford CB 3.1

London 2.2Cambridge MB 1.0

2.02.0

Tons

illec

tTo

nsill

ect

1.01.0

TT

0.00.0Source: Glover JA. The incidence of tonsillectomy in school children. Proceedings of the Royal Society of

Medicine 1938;31:95-112.

“A study of the geographic distribution in elementary school children discloses no correlationschool children discloses no correlation

between...any other factor, such as overcrowding, poverty bad housing or climatepoverty, bad housing, or climate.

In fact it defies any explanation, save that of variation f di l i i th i di ti f ti ”of medical opinion on the indications for operation.”

1973 H it l S i A i VT1973 - Hospital Service Areas in VT

Source: Wennberg and Gittelsohn. Small Area Variation in Health Care Delivery. Science 1973.

Tonsillectomies by Vermont Hospital Service AreasHospital Service Areas

Wennberg, et al. Pediatrics 1977;59;821-826

Today, we have a problem with financing:Medicare Funding as

% of Gross Domestic Product

Part A is “exhausted”;Part A is exhausted ; Part B and D premiums soar.

Today, we have problems with outcomesy p

Black Non-blacks Total Black Non black17

15

130 Li

ve B

irths Total

13

15

17

Nicaragua

Turkey

13

11

9ght P

er 1

00

9

11

13

Ghana

Tanzania

Nicaragua

9

7

5w B

irth

Wei

g

5

7

9

CanadaAustralia U.S.

Ghana

3

5

Low

Healthy People 2010 Goal

Singleton Low Birth Weight Rates Across 246

3

5Sweden

Singleton Low Birth Weight Rates Across 246 U.S. Low Birth Weight Regions, 1998

Unwarranted variation in health care is i i h b l i d bvariation that cannot be explained by:

• Patient illness• Dictates of evidence-based medicineDictates of evidence based medicine• Patient preference

Unwarranted variation is caused by differences in the effectiveness anddifferences in the effectiveness and

efficiency of health care delivery s stemssystems.

Small area analysis reveals the regional i i i h l h d livariation in health care delivery

• Reveals variation in medical resources, utilization, and outcomes

• Often attributable to a system of care• Offers:Offers:

– specific information about health systems – high and low performing health care systemsand low performing health care systems

– generalizable information about the functioning of our health care system:y

• Are resources found in areas with greater need?• Is more better?• Is care aligned with patient (and family) preferences?

Primary Care Service Areas - v2 (N = 6,542)

Counties provide coarse measures of primary care physician supply:

*

* *

Counties Primary Care Service Areas

The Dartmouth Atlas of Health Care

Collaborators Support• John Wennberg, MD MPH • Elliott Fisher, MD MPH• Jonathan Skinner PhD

• The Robert Wood Johnson Foundation

• Jonathan Skinner, PhD• Chiang-hua Chang, MS• Therese Stukel, PhD• Julie Bynum, MD

• National Institute on Aging

• WellPoint Foundation• Jason Sutherland, PhD• Douglas Staiger, PhD• James Weinstein, MD MS• Dongmei Wang MS

• Aetna Foundation

• United Health FoundationDongmei Wang, MS• Sally Sharp, SM• Stephanie Raymond• Phyllis Wright-Slaughter, MHA

D i l G ttli b MS

United Health Foundation

• California HealthCare Foundation

• Daniel Gottlieb, MS• Kristen Bronner, MA• Megan McAndrews, MBA, MS• Jia Lan, MS• Jon Lurie, MD MS• Tom Bubolz, PhD• Rebecca Townsend

www dartmouthatlas orgwww.dartmouthatlas.org

Elliott Fisher, MD MPHDavid Goodman, MD MSJohn Wennberg, MD MPH

Jonathan Skinner, PhD

The Dartmouth Atlas of Healthcaret t d i tireports on unwarranted variation

First 6 months 2009:118 million media impressions

About 2,000 unique media markets

Variation in Per-Capita Medicare Spending Across Hospital Referral Regions (N=306) (2006)Across Hospital Referral Regions (N 306) (2006)

$8,800 to 16,352 (61)8,100 to < 8,800 (61)7 550 t 8 100 (60)7,550 to < 8,100 (60)6,900 to < 7,550 (62)5,310 to < 6,900 (62)

Not PopulatedNot Populated

Types of Unwarranted Variation

Unwarranted Variation in:Unwarranted Variation in:

Effective CareEffective CarePreference Sensitive Care

S l S iti CSupply Sensitive Care

New York CityAcute Myocardial Infarction CareAcute Myocardial Infarction Care

ACE PCI < 90 Smoking Inhibitors minutes cessation

Beth Israel Medical Center 98% 69% 97%

Montefiore Medical Center 82% 83% 100%

Mount Sinai Hospital 97% 88% 99%

New York-Presbyterian 87% 64% 95%New York-Presbyterian 87% 64% 95%

NYU Medical Center 83% 75% 85%

U.S. Average 90% 73% 94%

Source: CMS, Hospital Compare, 10/06 - 9/07

Domains of Effective Care

Nearly completely Implemented

Partially Implemented

Possibly Efficacious

Proven Effective

Possibly Efficacious

Basic Science Knowledge

Domains of Effective Care

Partially Implemented

B i S i K l d

Possibly Efficacious

Proven Efficacious

Implemented

Basic Science Knowledge

Health, Disease, , ,and Treatments Unknowns

Supply Sensitive Care

• Care strongly correlates with resource supply• Care strongly correlates with resource supply(i.e. capacity of hospital beds & doctors.)

• Generally provided in the absence of specific clinical theories governing the “right rate ”clinical theories governing the right rate.

• Generally the care is one of many optionsGenerally, the care is one of many options.

• Medical evidence weak or nonexistent• Medical evidence weak or nonexistent.

• Responsible for a high proportion of variation in• Responsible for a high proportion of variation in costs.

Neonatologists per 1,000 Live Births

(Neonatal Intensive Care Regions)

Neonato log is ts per1,000 L ive B ir ths

8.57 to 25.64 (50)6.39 to 8.57 (49)4.88 to 6.39 (51)

,

( )3.55 to 4.88 (46)0.56 to 3.55 (51)

Health Care Capacity is not Located Where Needs are Greater

1995 Neonatal Intensive Care Regions

Neonatologists Intensive Care Beds30 ●14

●

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ists irths R2=0.04 ●

10

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Bed

Percent Low Birth Weight Percent Low Birth WeightGoodman, et al. Pediatrics, 2001.

Are cardiologists located where cardiac needs are greater?(306 Hospital Referral Regions, Dartmouth Atlas)

10 0

12.0

8.0

10.0

per

100K

There is virtually no relationship between regional

6.0

iolo

gist

s p relationship between regional

physician supply and cardiovascular risk.

2.0

4.0

Car

d

3.0 6.0 9.0 12.0 15.0 18.0

Acute Myocardial InfarctionRate per 1,000 Medicare Enrolleesp ,

Source: Wennberg D, et al. Dartmouth Cardiovascular Atlas

Hospital Beds (1996) vs. Adjusted Discharge Rates for Medical Conditions (1995-96)for Medical Conditions (1995-96)

350.0350.0

300.0300.0

r 1,

000

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6)

250.0250.0

rges

per

lees

(19

200.0200.0

Dis

char

re E

nrol

l

R2 0 56

150.0150.0

Med

ical

M

edic

ar

R2 = 0.56100.0100.0

1.01.0 2.02.0 3.03.0 4.04.0 5.05.0 6.06.0

M M

Acute Care Beds per 1,000 Residents (1996)

Variation in Per-Capita Medicare Spending Is Mostly Caused by Supply Sensitive CareIs Mostly Caused by Supply Sensitive Care

$8,800 to 16,352 (61)8,100 to < 8,800 (61)7 550 t 8 100 (60)7,550 to < 8,100 (60)6,900 to < 7,550 (62)5,310 to < 6,900 (62)

Not PopulatedNot Populated

Is more spending

(Hospital Days, ICU Days, CT Scans, MRI Scans)

necessarily better?necessarily better?

Lessons from Regional Variation:Lessons from 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 servicesHigh spending associated with discretionary services (physician visits, hospital days, tests).

• Implication: low spending regions are more efficientImplication: low spending regions are more efficient.

Fisher ES et al. Ann Intern Med 2003 Feb 18; 138(4): 273-87, 288-98.Goodman DC et al NEJM 2002; 346: 1538-1544Goodman DC, et al. NEJM 2002; 346: 1538-1544.Goodman DC, et al NEJM 2008;358:1658-1661.

Total Medicare Spending per Decedent During the Last Two Years of Life (2001-05)the Last Two Years of Life (2001 05)

120,000

110,000

nt

UCLA Medical Center 93,842New York-Presbyterian 91,113Brigham and Women's 87,72190 000

100,000

r dec

eden

Johns Hopkins Hospital 85,729Hospital of the U of PA 80,727Massachusetts General 78,666UCSF Medical Center 78 046

80,000

90,000

ndin

g pe

r

UCSF Medical Center 78,046U of WA Medical Center 70,245Duke University Hospital 57,411Cleveland Clinic 55,333

60 000

70,000

care

spe

n

Mayo Clinic (St. Mary's) 53,432

50,000

60,000

Med

ic

40,000

Average Number of Hospital Days per Decedent During the Last Six Months of Life (2001-05)During the Last Six Months of Life (2001 05)

33.0

29.0New York-Presbyterian 22.7UCLA Medical Center 18.5Hospital of the U of PA 17.625.0

eced

ent

Massachusetts General 17.3Johns Hopkins Hospital 16.5Brigham and Women's 16.1Cleveland Clinic 14 8

21.0

ys p

er d

e

Cleveland Clinic 14.8Duke University Hospital 13.8UCSF Medical Center 13.5U of WA Medical Center 13.2

17.0

spita

l day

Mayo Clinic (St. Mary's) 12.0

13.0

Hos

9.0

Average Number of Days in ICU per Decedent During the Last Six Months of Life (1999-2003)During the Last Six Months of Life (1999 2003)

12 0

10.0

12.0

UCLA Medical Center 11.4New York-Presbyterian 5.0Barnes-Jewish 4.58.0

eden

t

Johns Hopkins 4.3Mayo Clinic (St. Mary's) 3.9Cleveland Clinic 3.5Duke University Hosp 3 3

6.0per d

ece

Duke University Hosp. 3.3UCSF Medical Center 3.3Univ. of Washington 3.2Mass. General 2.8

4.0

CU

day

s

2.0

IC

0.0

Physician FTEs per 1,000 end-of-lifeMedicare beneficiaries

PrimaryMedical

NYU Medical Center

15 08 828 3 FTE

Primary Care

Medical SpecialistsTotal

15.08.828.3 FTEs

PrimaryMedical

Mayo Clinic

Primary Care

Medical SpecialistsTotal

3.93.08.9 FTEs

Source: Goodman, Health Affairs,March/April 2006.

“What will we ever think about now that the genome project is almost complete?”genome project is almost complete?

Think about the science and geography of health care delivery!