Wednesday, March 9, 2011
The Disease Management Care Blog's travels frequently takes it down a Pennsylvania interstate. One exit off that interstate forces the DMCB to merge into a left passing lane of a roadway that is in close proximity to another left sided exit ramp. As on-coming vehicles slow, accelerate, weave and jockey for position, the DMCB's predilection for maximum courtesy often fails. Over time, despite the best of intentions, it occasionally cuts some drivers off. Their reactions vary from politely yielding to tailgating to veering in front of the DMCB to one memorably obscene gesture of an elderly bespeckled woman with an ample supply of chutzpah and a visibly bad case of arthritis in the third digit of her right hand.
Driver variability not only brings unwanted adventure to motoring, but speaks to the spectrum of human skills, intelligence, emotions at all levels of society. This is no secret to physicians, who know their "art" of medicine is to accommodate each patient's unique mix of individual traits. While the underlying disease - cancer, high blood pressure, diabetes or migraine - may have a narrow scientific basis, the treatment always has a wide social basis. Some patients meekly accept a doc's recommendations, most want some input and occasionally others get obscenely angry.
Which brings the DMCB to the topic of the Dartmouth Atlas. Its groundbreaking work amply demonstrates that much of the highly variable frequency and accompanying expense of health care appears to be unrelated to patient factors. Thanks to the DA's multi-colored maps, its easy to wonder why hip replacements and diabetes testing seems to be more related to where patients live and how close they are to certain health care services. Unfortunately, one result of the Atlas is that medical "variability" in general - no matter what the cause - as gotten a bad rap among naive policy makers and politicians.
Given that patients also vary considerably, the DMCB is waiting for a discussion and consensus on "Variability 2.0," where we recognize that some cancer victims don't want to sign living wills, where some hypertensives don't want to take pills, where some diabetics don't mind having an A1c of 7.5% and some migraineurs want another unnecessary head scan.
In other words, once we minimize the variation in the supply side, how will we accommodate the considerable variation in the demand side? Sooner or later, in the opinion of the DMCB, we'll need to tackle this.
Discussion topics in Variability 2.0:
What are the drivers of patient variability, how can they be quantified and should attempts be made to modify them? Genetics? Education? Social supports? Are persons with diabetes, after being made fully aware of every treatment option, allowed to choose pills over insulin even if it means having an A1c that is not optimal? Can women refuse to have mammograms? How many?
How do we measure and report an optimum average rate as well as the "spread" of performance around that average rate? For example, what percent of persons with diabetes with an A1c more than 7.5% is acceptable given a certain average rate of say, 7.1%?
How do we risk adjust quality measures - and physician pay for performance - based on patient variability?
How much technology (and expense) are we willing to accommodate in the pursuit of patient variability? For example, some patients with cancer will benefit from a highly toxic and pricey course of chemotherapy. Should all patients therefore be offered that treatment?
Is "disruptive" and less expensive technology a pipe dream when it comes to health care? While cheaper innovations occur (for example, convenient care clinics), the dawning of customized treatments (for example, genomic medicine) that accommodate patient variability promises to be more, not less expensive.
To what degree is patient variability contributing to overlapping, redundant and incompatible technologies? Sometimes CAT scans miss subtle brain tumors, so is the approach to have everyone with a headache get a CAT scan first and those with normal scans then get more expensive MRI scans? Is there a better way?
More on this in a post tomorrow - it's called Variability 3.0.