European Journal of Public Health, Vol. 25, Supplement 1, 2015, 1–2 ß The Author 2015. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. doi:10.1093/eurpub/cku223
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Editorial
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Variations in health care delivery within the European Union Salvador Peiro´1,2, Alan Maynard3 1 Fundacio´n para el Fomento de la Investigacio´n Sanitaria y Biome´dica de la Comunidad Valenciana (FISABIO), Valencia, Spain 2 Red de Investigacio´n en Servicios de Salud en Enfermedades Cro´nicas (REDISSEC), Valencia, Spain 3 Department of Health Sciences, University of York, York, UK Correspondence: Salvador Peiro´, FISABIO, Valencia, Spain, Tel: +34 961 925 916, Fax: +34 961 925 703, e-mail: [email protected]
.........................................................................................................
uropean Union (EU) healthcare systems, whether they are
ENational Health Services or Social Insurance systems, are going
through difficult times. Governments, the healthcare community and the public are increasingly concerned about the growth of health spending and the sustainability of their healthcare systems. The current economic crisis—the most intense, comprehensive and long lasting in post-war Europe—with its corollary of tax revenue falling, increased social needs and financial failure of the States, has contributed decisively to accentuate this concern, and placed health spending (along other items of social spending) as a critical aspect of the policies to control public sector deficits. While some of the contemporary concerns are directly related to the current economic crisis the recession has exerabated pre-existing problems. The pressures on all healthcare systems are familiar but resistant to resolution. First, there have been changes in morbidity patterns with the emergence of chronicity and multi-morbidities as the main drivers of healthcare utilization in developed countries. Disease is now evolving into a continuum of exacerbations and relapses leading to long-term functional impairment. These new morbidity patterns require changes in existing organizational structures and the integration of fragmented healthcare delivery systems. Unfortunately an evidence base to facilitate such innovation is absent. Second, the acceleration of technological change (in preventive, diagnostic, therapeutic, surgical, biological, imaging and other technologies), with a very rapid incorporation of new drugs, tests and devices into routine clinical practice has fuelled expenditure inflation. These new technologies sometimes involve significant clinical innovations (although not always cost-effectively) and, in other cases, the ‘innovation’ is limited to increased in prices (rather than to improved clinical outcomes). The combination of new drugs and technologies of extraordinarily high price, suitable for use in high prevalent chronic diseases and repeatedly for long periods of time, is challenging the sustainability of all health systems. Technological change and multiple morbidities, rather than aging as is commonly believed, have become the main driver of expenditure inflation. Third, there is robust evidence of a significant misuse of medical technologies, medicines, tests and healthcare services, both by overuse (treatments or tests unnecessary in the specific condition of a particular patient) or underuse (absence of use of a treatment or required testing that the patient’s condition requires). These unwarranted variations in clinical practice undermine the quality of patient care and raise major concerns about the safety of medical practices and the impact of adverse events and poor clinical practice on the population health.
In addition, healthcare systems face the development of information technology such as electronic medical records and communication technology, picture archiving and communication systems, electronic prescribing and other computerized physician entry systems, automated systems of decision support and other aspects of telemedicine. The potential of these investments to transform patient care is considerable. They could enhance systems of professional self governance and inform patient decision making and self care. Such innovations if applied cost effectively could reduce medical errors and improve transparency and accountability. Such improvements are demanded by patients and the public and private funders of health care. However, investment in these innovations is expensive and has to be evidence based.
Medical practice variation: geography matter How many, when, where, why, how and for how long Europeans are hospitalized or treated, what kind of treatment do they receive, what is the cost of care episodes and what outcomes in terms of improved length and quality of life for patients do they achieve? These are critical questions for all healthcare systems. Sadly the answer to these questions may depend more on which municipality people are living, than on how sick they are. At the population level, geography, not morbidity, is the main determinant of healthcare utilization and health expenditure. Furthermore, higher spending regions are failing to achieve better outcomes.1,2 After the seminal works from Wennberg and Gittelsohn 40 years ago,3,4 researchers have consistently demonstrated remarkable unwarranted variations in clinical practice. Such waste deprives potential patients of care from which they could benefit. It is unethical.5 The three core findings of clinical practice variation research are6: (i) geographical variations in healthcare utilization and spending are systematic (not just random noise), substantial, pervasive and persistent over time, (ii) risk adjustment for individuals’ characteristics and health status attenuates but does not remove variation and (iii) there is no correlation between healthcare utilization/spending and healthcare quality or superior outcomes. Medical practice variations are not explained by differences in population morbidity or in the patients’ clinical status. Beyond concerns about social or access inequalities, the most disconcerting message from these unwarranted variations is the one that strongly suggest physicians provide very different care for patients with similar clinical conditions, undermining the traditional belief that health professionals apply uniformly a unequivocally appropriate treatment for each health problem.
Downloaded from http://eurpub.oxfordjournals.org/ by guest on November 14, 2015
Health care systems over troubled water
2
European Journal of Public Health
Unwarranted variations suggest that an important part of health spending is associated with practice patterns that do not translate into improved outcomes for patients and populations. Thus, mitigation of variations in medical practice is a way to reduce health spending without harming the health of patients. The resources saved can be redirected to provide beneficial care to other patients. Both alternatives are (always) important for public health systems. Both are even more important in turbulent times. In addition, studies on medical practice variations suggest that dysfunctional geographical areas are characterized by hospitals providing fragmented, expensive and not always appropriate care. Therefore, it is likely that reduction of variations may result in better outcomes for people living in these areas.
The ECHO project: a wake-up call for European policymakers
Funding This work was partially funded by the grant RD12/0001/0005 from the Instituto de Salud Carlos III, Spanish Ministry of Science and
Conflicts of interest: None declared.
References 1
Fisher ES, Wennberg DE, Stukel TA, et al. The implications of regional variations in Medicare spending. Part 1: the content, quality, and accessibility of care. Ann Intern Med 2003;138:273–87.
2
Fisher ES, Wennberg DE, Stukel TA, et al. The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care. Ann Intern Med 2003;138:288–98.
3
Wennberg J, Gittelsohn A. Small area variations in health care delivery. Science 1973;182:1102–8.
4
Wennberg J, Gittelsohn A. Variations in medical care among small areas. Sci Am 1982;246:120–34.
5
Corallo AN, Croxford R, Goodman DC, et al. A systematic review of medical practice variation in OECD countries. Health Policy 2014;114:5–14.
6
Fisher E, Skinner J. Making sense of geographic variations in health care: the new IOM report. Health Aff Blog 2013. July 24. Available at: http://healthaffairs.org/blog/2013/07/ 24/making-sense-of-geographic-variations-in-health-care-the-new-iom-report/ (9 December 2014, date last accessed).
7
The Dartmouth Atlas of Healthcare. Available at: http://www.dartmouthatlas.org (9 December 2014, date last accessed).
8
Atlas de variaciones en la pra´ctica me´dica en el Sistema Nacional de Salud [The Atlas of Medical Practice Variation in the Spanish National Health System]. Available at: www.atlasvpm.org (9 December 2014, date last accessed).
9
NHS Atlas of Variations in Healthcare. Available at: http://www.rightcare.nhs.uk/ index.php/nhs-atlas/ (9 December 2014, date last accessed).
10 Medizinischen Versorgungatlas in Deutschland [Atlas of Medical Care in Germany.]. Available at: http://www.versorgungsatlas.de/ (9 December 2014, date last accessed). 11 Healthcare Fact Check. Regional Variations in German Healthcare. Available at: https:// faktencheck-gesundheit.de/fileadmin/daten_fcg/Downloads/Uebersichtsreport/ Healthcare_Fact_Check__Regional_Variations.pdf (9 December 2014, date last accessed). 12 OECD. Geographic Variations in Health Care. What Do We Know and What Can Be Done to Improve Health System Performance?. OECD Publishing, 2014, Available at: http://www.oecd-ilibrary.org/social-issues-migration-health/geographic-variationsin-health-care_9789264216594-en (9 December 2014, date last accessed). 13 European Collaboration for Health Optimization (ECHO) project. Available at: http://echo-health.eu (9 December 2014, date last accessed). 14 Thygesen LC, Baixauli-Pe´rez C, Librero-Lo´pez J, et al. on behalf of the ECHO Consortium. Comparing variation across European countries: building geographical areas to provide sounder estimates. Eur J Public Health 2015;25:8–14. 15 Gutacker N, Bloor K, Cookson R. Comparing the performance of the Charlson/ Deyo and Elixhauser comorbidity measures across five European countries and three conditions. Eur J Public Health 2015;25:15–20. 16 Cookson RA, Gutacker N, Garcia-Armesto S, et al. Socioeconomic inequality in hip replacement in four European countries from 2002 to 2009—area-level analysis of hospital data. Eur J Public Health 2015;25:21–7. 17 Thygesen LC, Christiansen T, Garcia-Armesto S, et al. on behalf of ECHO Consortium. Potentially avoidable hospitalisations in five European countries in 2009 and time trends from 2002 to 2009 based on administrative data. Eur J Public Health 2015;25:35–43. 18 Garcı´a-Armesto S, Angulo E, Martı´nez-Lizaga N, et al. Potential of geographical variation analysis in realigning providers to value-based care. ECHO case study on lower-value indications of C-section in Five European countries. Eur J Public Health 2015;25:44–51. 19 Mateus C, Joaquim I, Nunes C. Measuring hospital efficiency—comparing four European countries. Eur J Public Health 2015;25:52–8. 20 Gutacker N, Bloor K, Cookson R, et al. Comparing hospital performance within and across countries: an illustrative study of coronary artery bypass graft surgery in England and Spain. Eur J Public Health 2015; 25:28–34.
Downloaded from http://eurpub.oxfordjournals.org/ by guest on November 14, 2015
The importance of unwarranted variations in medical care has not gone unnoticed in Europe. Following the influential US Dartmouth Atlas of Health Care,7 several European countries have developed their own national atlases of medical practice variation. Early in the 2000s, Spain launched the ‘Atlas of Variations in Medical Practice in the Spanish National Health System’ series.8 More recently, England,9 Germany10 and Holland11 have published their national atlases. There are also several variation studies in other European countries as Italy, France, Switzerland and the Nordic countries. Outside the EU and the US, countries such as Australia, New Zealand or Canada, have analysed practice variations. The nature and implications of unjustified medical care variations for health systems has also been recognized by the OECD in a recently published a monography with variation studies in 13 countries.12 The European Collaboration for Health Optimization (ECHO)13 project is an effort to bring together national hospital databases of several European countries to move from diverse national perspectives to one European cross-national perspective. The advantages of this cross-national approach are visible in the articles published in this supplement of the European Journal of Public Health. The conjunction of researchers from different countries with different backgrounds and skills has helped to address methodological aspects (size of the areas,14 the role of comorbidity index in risk adjustment15) that nationally have less external validity. The comparisons between countries (in equity,16 performance17–19 or clinical outcomes20) allow to learn from each another and every country from the whole. The ECHO project is developing some of the tools need to inform decisions about the performance of European health services and their information provides a useful analysis of some current policy issues. Some of the papers of this European Journal of Public Health Supplement may act a wake-up call for dormant European policymakers. The lessons of the ECHO project are both practical and methodological. First, the methods used need replication and development across a wider range of EU countries and a wider range of medical conditions. Second, it has revealed a lack of consistence in the definition of data across countries. International collaboration is needed to improve both clinical and administrative data systems so that they complement each other cost effectively. Third, such developments will require increased investment in research capacity, which is uneven across EU member states. The ECHO project is an initial step towards quantitative comparative analysis of EU healthcare systems. Hopefully, it provides other an incentive to develop and improve our efforts.
Innovation (cofinanced by the European Regional Development Fund).
.........................................................................................................
Editorial
.........................................................................................................
Variations in health care delivery within the European Union Salvador Peiro´1,2, Alan Maynard3 1 Fundacio´n para el Fomento de la Investigacio´n Sanitaria y Biome´dica de la Comunidad Valenciana (FISABIO), Valencia, Spain 2 Red de Investigacio´n en Servicios de Salud en Enfermedades Cro´nicas (REDISSEC), Valencia, Spain 3 Department of Health Sciences, University of York, York, UK Correspondence: Salvador Peiro´, FISABIO, Valencia, Spain, Tel: +34 961 925 916, Fax: +34 961 925 703, e-mail: [email protected]
.........................................................................................................
uropean Union (EU) healthcare systems, whether they are
ENational Health Services or Social Insurance systems, are going
through difficult times. Governments, the healthcare community and the public are increasingly concerned about the growth of health spending and the sustainability of their healthcare systems. The current economic crisis—the most intense, comprehensive and long lasting in post-war Europe—with its corollary of tax revenue falling, increased social needs and financial failure of the States, has contributed decisively to accentuate this concern, and placed health spending (along other items of social spending) as a critical aspect of the policies to control public sector deficits. While some of the contemporary concerns are directly related to the current economic crisis the recession has exerabated pre-existing problems. The pressures on all healthcare systems are familiar but resistant to resolution. First, there have been changes in morbidity patterns with the emergence of chronicity and multi-morbidities as the main drivers of healthcare utilization in developed countries. Disease is now evolving into a continuum of exacerbations and relapses leading to long-term functional impairment. These new morbidity patterns require changes in existing organizational structures and the integration of fragmented healthcare delivery systems. Unfortunately an evidence base to facilitate such innovation is absent. Second, the acceleration of technological change (in preventive, diagnostic, therapeutic, surgical, biological, imaging and other technologies), with a very rapid incorporation of new drugs, tests and devices into routine clinical practice has fuelled expenditure inflation. These new technologies sometimes involve significant clinical innovations (although not always cost-effectively) and, in other cases, the ‘innovation’ is limited to increased in prices (rather than to improved clinical outcomes). The combination of new drugs and technologies of extraordinarily high price, suitable for use in high prevalent chronic diseases and repeatedly for long periods of time, is challenging the sustainability of all health systems. Technological change and multiple morbidities, rather than aging as is commonly believed, have become the main driver of expenditure inflation. Third, there is robust evidence of a significant misuse of medical technologies, medicines, tests and healthcare services, both by overuse (treatments or tests unnecessary in the specific condition of a particular patient) or underuse (absence of use of a treatment or required testing that the patient’s condition requires). These unwarranted variations in clinical practice undermine the quality of patient care and raise major concerns about the safety of medical practices and the impact of adverse events and poor clinical practice on the population health.
In addition, healthcare systems face the development of information technology such as electronic medical records and communication technology, picture archiving and communication systems, electronic prescribing and other computerized physician entry systems, automated systems of decision support and other aspects of telemedicine. The potential of these investments to transform patient care is considerable. They could enhance systems of professional self governance and inform patient decision making and self care. Such innovations if applied cost effectively could reduce medical errors and improve transparency and accountability. Such improvements are demanded by patients and the public and private funders of health care. However, investment in these innovations is expensive and has to be evidence based.
Medical practice variation: geography matter How many, when, where, why, how and for how long Europeans are hospitalized or treated, what kind of treatment do they receive, what is the cost of care episodes and what outcomes in terms of improved length and quality of life for patients do they achieve? These are critical questions for all healthcare systems. Sadly the answer to these questions may depend more on which municipality people are living, than on how sick they are. At the population level, geography, not morbidity, is the main determinant of healthcare utilization and health expenditure. Furthermore, higher spending regions are failing to achieve better outcomes.1,2 After the seminal works from Wennberg and Gittelsohn 40 years ago,3,4 researchers have consistently demonstrated remarkable unwarranted variations in clinical practice. Such waste deprives potential patients of care from which they could benefit. It is unethical.5 The three core findings of clinical practice variation research are6: (i) geographical variations in healthcare utilization and spending are systematic (not just random noise), substantial, pervasive and persistent over time, (ii) risk adjustment for individuals’ characteristics and health status attenuates but does not remove variation and (iii) there is no correlation between healthcare utilization/spending and healthcare quality or superior outcomes. Medical practice variations are not explained by differences in population morbidity or in the patients’ clinical status. Beyond concerns about social or access inequalities, the most disconcerting message from these unwarranted variations is the one that strongly suggest physicians provide very different care for patients with similar clinical conditions, undermining the traditional belief that health professionals apply uniformly a unequivocally appropriate treatment for each health problem.
Downloaded from http://eurpub.oxfordjournals.org/ by guest on November 14, 2015
Health care systems over troubled water
2
European Journal of Public Health
Unwarranted variations suggest that an important part of health spending is associated with practice patterns that do not translate into improved outcomes for patients and populations. Thus, mitigation of variations in medical practice is a way to reduce health spending without harming the health of patients. The resources saved can be redirected to provide beneficial care to other patients. Both alternatives are (always) important for public health systems. Both are even more important in turbulent times. In addition, studies on medical practice variations suggest that dysfunctional geographical areas are characterized by hospitals providing fragmented, expensive and not always appropriate care. Therefore, it is likely that reduction of variations may result in better outcomes for people living in these areas.
The ECHO project: a wake-up call for European policymakers
Funding This work was partially funded by the grant RD12/0001/0005 from the Instituto de Salud Carlos III, Spanish Ministry of Science and
Conflicts of interest: None declared.
References 1
Fisher ES, Wennberg DE, Stukel TA, et al. The implications of regional variations in Medicare spending. Part 1: the content, quality, and accessibility of care. Ann Intern Med 2003;138:273–87.
2
Fisher ES, Wennberg DE, Stukel TA, et al. The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care. Ann Intern Med 2003;138:288–98.
3
Wennberg J, Gittelsohn A. Small area variations in health care delivery. Science 1973;182:1102–8.
4
Wennberg J, Gittelsohn A. Variations in medical care among small areas. Sci Am 1982;246:120–34.
5
Corallo AN, Croxford R, Goodman DC, et al. A systematic review of medical practice variation in OECD countries. Health Policy 2014;114:5–14.
6
Fisher E, Skinner J. Making sense of geographic variations in health care: the new IOM report. Health Aff Blog 2013. July 24. Available at: http://healthaffairs.org/blog/2013/07/ 24/making-sense-of-geographic-variations-in-health-care-the-new-iom-report/ (9 December 2014, date last accessed).
7
The Dartmouth Atlas of Healthcare. Available at: http://www.dartmouthatlas.org (9 December 2014, date last accessed).
8
Atlas de variaciones en la pra´ctica me´dica en el Sistema Nacional de Salud [The Atlas of Medical Practice Variation in the Spanish National Health System]. Available at: www.atlasvpm.org (9 December 2014, date last accessed).
9
NHS Atlas of Variations in Healthcare. Available at: http://www.rightcare.nhs.uk/ index.php/nhs-atlas/ (9 December 2014, date last accessed).
10 Medizinischen Versorgungatlas in Deutschland [Atlas of Medical Care in Germany.]. Available at: http://www.versorgungsatlas.de/ (9 December 2014, date last accessed). 11 Healthcare Fact Check. Regional Variations in German Healthcare. Available at: https:// faktencheck-gesundheit.de/fileadmin/daten_fcg/Downloads/Uebersichtsreport/ Healthcare_Fact_Check__Regional_Variations.pdf (9 December 2014, date last accessed). 12 OECD. Geographic Variations in Health Care. What Do We Know and What Can Be Done to Improve Health System Performance?. OECD Publishing, 2014, Available at: http://www.oecd-ilibrary.org/social-issues-migration-health/geographic-variationsin-health-care_9789264216594-en (9 December 2014, date last accessed). 13 European Collaboration for Health Optimization (ECHO) project. Available at: http://echo-health.eu (9 December 2014, date last accessed). 14 Thygesen LC, Baixauli-Pe´rez C, Librero-Lo´pez J, et al. on behalf of the ECHO Consortium. Comparing variation across European countries: building geographical areas to provide sounder estimates. Eur J Public Health 2015;25:8–14. 15 Gutacker N, Bloor K, Cookson R. Comparing the performance of the Charlson/ Deyo and Elixhauser comorbidity measures across five European countries and three conditions. Eur J Public Health 2015;25:15–20. 16 Cookson RA, Gutacker N, Garcia-Armesto S, et al. Socioeconomic inequality in hip replacement in four European countries from 2002 to 2009—area-level analysis of hospital data. Eur J Public Health 2015;25:21–7. 17 Thygesen LC, Christiansen T, Garcia-Armesto S, et al. on behalf of ECHO Consortium. Potentially avoidable hospitalisations in five European countries in 2009 and time trends from 2002 to 2009 based on administrative data. Eur J Public Health 2015;25:35–43. 18 Garcı´a-Armesto S, Angulo E, Martı´nez-Lizaga N, et al. Potential of geographical variation analysis in realigning providers to value-based care. ECHO case study on lower-value indications of C-section in Five European countries. Eur J Public Health 2015;25:44–51. 19 Mateus C, Joaquim I, Nunes C. Measuring hospital efficiency—comparing four European countries. Eur J Public Health 2015;25:52–8. 20 Gutacker N, Bloor K, Cookson R, et al. Comparing hospital performance within and across countries: an illustrative study of coronary artery bypass graft surgery in England and Spain. Eur J Public Health 2015; 25:28–34.
Downloaded from http://eurpub.oxfordjournals.org/ by guest on November 14, 2015
The importance of unwarranted variations in medical care has not gone unnoticed in Europe. Following the influential US Dartmouth Atlas of Health Care,7 several European countries have developed their own national atlases of medical practice variation. Early in the 2000s, Spain launched the ‘Atlas of Variations in Medical Practice in the Spanish National Health System’ series.8 More recently, England,9 Germany10 and Holland11 have published their national atlases. There are also several variation studies in other European countries as Italy, France, Switzerland and the Nordic countries. Outside the EU and the US, countries such as Australia, New Zealand or Canada, have analysed practice variations. The nature and implications of unjustified medical care variations for health systems has also been recognized by the OECD in a recently published a monography with variation studies in 13 countries.12 The European Collaboration for Health Optimization (ECHO)13 project is an effort to bring together national hospital databases of several European countries to move from diverse national perspectives to one European cross-national perspective. The advantages of this cross-national approach are visible in the articles published in this supplement of the European Journal of Public Health. The conjunction of researchers from different countries with different backgrounds and skills has helped to address methodological aspects (size of the areas,14 the role of comorbidity index in risk adjustment15) that nationally have less external validity. The comparisons between countries (in equity,16 performance17–19 or clinical outcomes20) allow to learn from each another and every country from the whole. The ECHO project is developing some of the tools need to inform decisions about the performance of European health services and their information provides a useful analysis of some current policy issues. Some of the papers of this European Journal of Public Health Supplement may act a wake-up call for dormant European policymakers. The lessons of the ECHO project are both practical and methodological. First, the methods used need replication and development across a wider range of EU countries and a wider range of medical conditions. Second, it has revealed a lack of consistence in the definition of data across countries. International collaboration is needed to improve both clinical and administrative data systems so that they complement each other cost effectively. Third, such developments will require increased investment in research capacity, which is uneven across EU member states. The ECHO project is an initial step towards quantitative comparative analysis of EU healthcare systems. Hopefully, it provides other an incentive to develop and improve our efforts.
Innovation (cofinanced by the European Regional Development Fund).
