QUALITY: The sociology & economics of practice patterns & decision aids

More from Matthew at the FIMDM conference

David Jones, Harvard medical historian on revascularization

Why do you need a randomized clinical trial (RCT)? From the 1960s surgeons could show that CABGs opened veins (removed plaque) so why was there a need?  As it turns out, it’s not the large plaque in the vein that kills you but instead it’s the smaller “fragile” plaque which ruptures & causes heart attacks—it’s not the big blockage that causes the heart attack. Angioplasty (PCI) doesn’t get that fragile plaque out, so it shouldn’t be used as much as it is. Of course that’s not what happened. We’d already been shown that by Lee Lucas that there was lots more angioplasty when this theory became well known

However in fact the theory about these fragile plaque rupture was in the obscure cardiology pathology literature in the 1960s but didn’t break through to the mainstream cardiologist opinion until the late 1990s.

So the question is, why didn’t that break through earlier? Jones’ theory is that CABG techniques came on at the time that these theories were being postulated, and the cardiac surgeons believed that the large plaque blockage was that caused heart attacks. So the practice (esp after more imaging developments) “informed” the surgeons that it worked. But the problem is that plaque rupture didn't fit that model. Worse the model suggests that every male above 35 have a fragile plaque just waiting to blow, and you wouldn't know! It also doesn't lend itself well to treatment — so what do you do? So that model leaves a lot more people in trouble, with not much to do, and (unspoken by David) cardiac surgeons and cardiologists want to do something!

Meanwhile, no one went to look at impact of neurological dysfunction caused by the surgery (putting people on a heart-lung machine during the procedure). In fact this was a really high number—up to 60% having some neurological problem. But this was recognized very slowly—first reported in 1954! Only really came out in the late 1990s! By then of course people are doing surgery on beating hearts, or doing more angio—early data suggests that this makes little difference to neurological function. And of course the heart condition is right in front of the surgeon, while the neuro risk is later.

Then there’s the huge geographic variation in CABGs. How have cardiac surgeons/ cardiologists responded? Most people say that it’s just financially driven. But David wants to go deeper and find out more?

Very short, David Meltzer, Univ Chicago, on economics of decision aids. His research shows that decision aids can increase or decrease costs—studies are small, but no clear message that they work to decrease costs, and many of the current aids are on low ticket items—where the impact cant be that big one way or the other. The welfare effect of decision aids is much more positive. My guess is that this isn’t probably the exact message that Health Dialog (which funds FIMDM) wanted to hear!

David Wennberg, Health Dialog, got onto the topic—does disease management save any money? The literature sucks, so they did an RCT on use of decision aids with a couple of health plans—HealthNet and Highmark Blues in Pennsylvania who found 7 big varied employee groups with 180K eligble members total. They looked at households, some of whom got standard care, others got that plus the decision aid intervention from Health Dialog….all ended up being essentially same health, risk & cost profiles. They looked at five groups by health status those with 1) chronic condiitions, 2) preference sensitive (e.g. back surgery), 3) chronic PLUS preference sensitive, 4) other coachable stuff (obesity), 5) the rest.

So what happened? For those groups there were reductions in hospital admissions of between 2.9 – 13.4% reduction in visits. ER visits was about the same, and marginal change in physician services. Overall significant reduction in surgical procedure in these groups (about 30% less PCI). The savings were overall $10 pmpm about 5% of costs. Of that savings, essentially all the savings were in inpatient & outpatient surgery, but drug costs went up. So you can increase drug costs, while reducing over all costs. Of the groups the chronic and chronic plus groups provided 60% of those cost savings. BUT these were gross savings—the actual savings were a little lower (about 1% less). So it looks like it worked, and also worked about the same percentage in different cost regions.

But if you assume that this means you can buy Health Dialog stock and get rich, sadly British insurer BUPA beat you to it! Of course,they can still get Pfizer to pay for the next one! (Just kidding!!).