# Presentation: 045171

## Quality and Cost:

**Quality and Cost:**
**What You Can't Afford to Ignore**

**Brent C. James, M.D., M.Stat.**
- Executive Director, Institute for
-     Health Care Delivery Research
- Intermountain Health Care
- Salt Lake City, Utah, USA

## The emergence of modern medicine

***~1860 - 1910:***

***  ******new high standards for clinical education***
***  ******strict requirements for professional licensing***
***  ******clinical practice founded on scientific research***
***  ******new internal organization for hospitals***

## 1912:  The ‘Great Divide’

***"... for the first time in human history, a ***
***random patient with a random disease***
***consulting a doctor chosen at random ***
***stands a better than 50/50 chance of ***
***benefiting from the encounter.“***
***Harvard Professor L. Henderson***
- (Harris, Richard. *A Sacred Trust *.  New York, NY: New American Library, 1966)

## Current health care

***is the best the world has ever seen***
***A few simple examples:***
***From 1900 to 2000, average life expectancy at birth******	******increased from only ******49 years ******to almost  ******80 years******.***
***Since 1960, age-adjusted mortality from heart disease ******(#1) ******	******has decreased by  ******56%; ******and ******(from 307.4 to 134.6 deaths / 100,000)***
***Since 1950, age-adjusted mortality from stroke ******(#3) ******has ******	******decreased by ******70%****** ******(from 88.8 to 26.5 deaths / 100,000)***

***Initial life expectancy gains almost all resulted from public health ***
***initiatives -- clean water, safe food, and (especially) widespread***
***control of epidemic infectious disease.  But since about 1960, direct ***
***disease treatment has made increasingly large contributions.***

**Centers for Disease Control.  Decline in deaths from heart disease and stroke****―****United States, 1900-1999. *****JAMA *****1999; 282(8):724-6   (Aug 25).**
**National Center for Health Statistics.   *****Health, United States, 2000 with Adolescent Health Chartbook. *****Hyattsville, MD:   U.S. Dept. of  Health and Human Services, Center for Disease Control and Prevention, 2000; pg. 7 (DHHS Publication No. (PHS)  2000-1232-1).**
**U.S. Department of Health and Human Services, Public Health Service.   *****Healthy People 2000: National Health Promotion and  Disease Prevention Objectives. *****Washington, DC: U.S. Government Printing Office, 1991 (DHHS Publication No. (PHS) 91-50212).**

## Dr. John Wennberg

***Geography is destiny ******("Who you see is what you get"  *************)***

*******

***There is no health care "system"***

***Supplier-induced demand:***

***  ******Field of Dreams approach: build it and they will come***
***  ******James T. Kirk:  Do something, Bones!  She's dying!***
***  ******Eddy:  more is better ******―****** if it might work, do it***
***  ******Chassin:  enthusiasm for unproven methods***
***  ******Boston City / Boston University Hospital, 1998:***

*** ******Same house/staff on both services***
*** ******More beds / easier access to resources on Boston University service***
*** ******Boston University readmit rate ~50% higher***

**********Richard Deyo, MD, MPH - in: Cherken, Deyo, Wheeler and Ciol.  Physician variation in diagnostic testing for low back pain. *****Arth & Rheum *****1994; 37(1):15-22 (Jan).***

## Medicare cost versus quality

## November 30, 1999:

***The Institute of Medicine***
***  ******Committee on Quality of Health Care in America***
***announces its first report:***
***  ******To Err is Human:  ******Building a Safer Health System***

## Medical injuries

***Account for***

***44,000 ******-****** 98,000 deaths per year***

***in the United States***

***More people die from medical injuries than from***
***breast cancer or AIDS or motor vehicle accidents***

- Brennan et al. *New Engl J Med 1991 *
- Thomas et al. *1999*

***Direct health care costs totaling***

***$9 ******-****** 15 billion per year***

- Thomas et al. *1999 *
- Johnson et al. *1992*

## November 20, 2003:

***The Institute of Medicine***
***  ******Committee on Patient Safety Data Standards***
***announces a major follow-on report:***
***  ******Patient Safety:  ******Achieving a New Standard of Care***

## November 20, 2003:

***The Institute of Medicine***
***  ******Committee on Patient Safety Data Standards***
***announces a major follow-on report:***
***  ******Patient Safety:  ******Achieving a New Standard of Care***

## How good is American health care?

**Allison JJ *****et al*****. Relationship of hospital teaching with quality of care and mortality for Medicare patients with acute MI.  *****JAMA***** 2000; 284(10):1256-62 (Sep 13).**

## How good is American health care?

***91.2***

***63.7***

***48.8***

***55.5***

***86.4***

***60.0***

***40.3***

***58.9***

***81.4***

***58.0***

***36.4***

***55.2***

***0***

***10***

***20***

***30***

***40***

***50***

***60***

***70***

***80***

***90***

***100***

***Aspirin***

***ACE inhibitors***

***Beta-blockers***

***Reperfusion***

***Medication***

***% "ideal patients" receiving***

***Major teaching***

***Minor teaching***

***Nonteaching***

**Allison JJ *****et al*****. Relationship of hospital teaching with quality of care and mortality for Medicare patients with acute MI.  *****JAMA***** 2000; 284(10):1256-62 (Sep 13).**

## 54.9%

***"gets it ******right******“***
***54.9%***
***of the time.***

- McGlynn EA, Asch SM, Adams J, *et al*.  The quality of health care delivered to adults in the
-       United States.    *N Engl J Med *2003; 348(26):2635-45 (June 26).

## American health care is very good ...

***American health care is ******very good ******...***
***but it could be ******much better***

*** ***

*** ***

** ****Complexity**
-   How many factors can the human mind simultaneously
- 	balance to optimize an outcome? ― Alan Morris, M.D.
-   "The complexity of modern American medicine exceeds
- 	the capacity of the unaided human mind“― David Eddy, M.D.
** ****Lack of valid clinical knowledge **(poor evidence)
** ****Reliance on subjective judgment**
-   Subjective evaluation is notoriously poor across groups
- 	or over time
*** ******Enthusiasm for unproven methods ... ***Mark Chassin, M.D.
*** ******If it might work, do it ... ***David Eddy, M.D., Ph.D.
*** ******Quality = spare no expense ... ***Brent James, M.D., M.Stat.

***Clinical uncertainty:***

## Medicine used to be simple, ineffective, and relatively safe.

***Now it is ******complex******, ******effective******, and potentially ******dangerous******.***

- Neal G.  Reducing risks in the practice of hospital general medicine.  In *Clinical Risk Management, 2nd edition*.  British Medical Journal, 2001.
- Chantler, Cyril.  The role and education of doctors in the delivery of health care. *Lancet* 1999; 353:1178-81.

*Sir Cyril Chantler*

*** ***

***      ******The price we pay***
***                        ******(for)***
***         ******diseases of medical progress***

## Beta blockers at discharge

## Cardiac discharge medicines

- CHF = Chronic heart failure;  IHD = Ischaemic heart disease

## Neo-natal intensive care unit (NICU) admits by weeks gestation

## Elective inductions < 39 weeks

## Unplanned c-section rates

## Average hours in labor & delivery

## Primiparous elective inductions

## Labor & delivery variable cost

## Well newborn bilirubin testing

## Slide 27

## Newborns w/ hyperbilirubinemia

## Hyperbilirubinemia readmissions

## Protocols can improve care

***A multidisciplinary team of health professionals ******―***
***Select a high priority care process***
***Generate an evidence-based "best practice" guideline***
***Blend the guideline into the flow of clinical work***
*** ******staffing***
*** ******training ***
*** ******supplies***
*** ******physical layout***
*** ******measurement / information flow***
*** ******educational materials***
***Use the guideline as a shared baseline, with clinicians ***
***	******  ******free to vary based on individual patient needs***
***Measure, learn from, and (over time) eliminate variation ***
***	******  ******arising from professionals; retain variation arising ***
***	******  ******from patients              ******("mass customization")***

## Lean production

*** ******standardized processes ******with***
*** ******"smart cogs“ ******that***
*** ******adapt to individual needs***
***That is, "mass customization:“***
***efficient processes that can***
***deal with complexity***

## Idea #2

***The health professions - and health care delivery –***
***are ******changing ******...***
***From ******craft-based practice****** ***
*** ******individual physicians, working alone ******(house/staff = apprentices)***
*** ******handcraft a customized solution for each patient***
*** ******based on a core ethical commitment to the patient and***
*** ******vast personal knowledge gained from training and experience***
***To ******profession-based practice***
*** ******groups of peers, treating similar patients in a shared setting***
*** ******plan coordinated care delivery processes ******(e.g., standing order sets)***
*** ******which individual clinicians adapt to specific patient needs ***
***  ******early experience shows***
*** ******less expensive ******(facility can staff, train, supply an organize to a single core process)***
*** ******less complex ******(which means fewer mistakes and dropped handoffs, less conflict) ***
*** ******better patient outcomes***

*** ***

## Why “profession-based” practice?

***It produces better outcomes for our patients***
***It eliminates waste, reduces costs, and ***
***	******increases available resources for patient care***
***It puts the caring professions back in control ***
***	******of care delivery***
***It is the foundation for useful shared electronic ***
***	******	******data ******―****** an important next step in care delivery improvement***

## Quality controls cost

_***Quality***_

_***  ***__***Cost  ***_

_*** ***__***Forum ***_

***internal***

***internal***

***Cost-benefit***

***society***

- 

***Waste:***

***(Potential)***
_***Savings ***_

***25-40%***

***> 50%***

***(none)***

*Inefficiency waste *

*Quality waste*

_***Mechanism      ***_

## Idea #3

***Better ******care can be ***_***much cheaper ***_***care ...***
***if you set things up right.***

## Slide 36