Cutting Edge Issues

eHealth:
Towards A New World of Communications in Medicine

Case Study: Overlake Hospital Medical Center

Information on Demand: Consumer-Controlled Medical Records

Finding Leaders for Internet Health Care

Building the Security-Capable Enterprise

Planning Business Strategies with Internet Support

Internet Use as a Survival Strategy

Case Study Zone

Who is eMed?

Planning Business Strategies with Internet Support

Part 4

This study found that the institutional rates of coronary artery bypass grafting ranged from seven to 23 patients per 10,000 members of the population. This is more than threefold variability.

THE COST OF VARIABILITY

The impact of variability is best considered from an employer’s perspective. Suppose that the employer is contracting for the health insurance of 10,000 employees. Some of those employees (5%, or 500) have coronary disease. Most are treated medically, but seven (or the low end of the range found in the 1986 study) are treated surgically. The cost of medical treatment is $500 for each of the 493 patients, or $246,500 for the medical treatment of coronary disease in this population of 10,000. Bypass surgery costs $38,000 for each of the seven patients, so the cost of surgical treatment of coronary disease in this population is $266,000. The combined cost of treatment for coronary disease is $512,500.

The cost of surgery is often presumed to have a greater effect on overall costs than whether a patient has surgery does. If surgery costs increased dramatically, to $46,000, this employer’s costs would be $322,000 for surgery and $246,500 for medical therapy, for a total of $568,500. This represents an increase of approximately 10%. If, however, the cost of surgery remained at $38,000, but the number of patients undergoing surgery increased to the high end of the range found in the 1986 study (23), surgical therapy for this population would cost $874,000. Combined with medical therapy’s cost of $246,500, this would bring the total cost of treatment of coronary artery disease to $1.12 million, more than doubling the cost of caring for this population. The variability in treatment to be found at a local level is almost certainly larger than the range of 7 to 23 found in the 1986 study, so the opportunity to affect both cost and quality of care by changing how patients are managed is considerable.

Improving Care Delivery

Knowing what to do is not enough. The Cooperative Cardiovascular Project of the Health Care Financing Administration [1] was a four-state pilot study involving Alabama, Iowa, Connecticut, and Wisconsin. In 1992 and 1993, every one of more than 18,000 Medicare admissions in those states for acute myocardial infarction had its chart abstracted. Criteria were then set up to determine which patients would have been ideal candidates for particular types of therapy. The investigators next noted the actual treatment received by these patients. Even though there had, by that time, been at least eight randomized clinical trials supporting the use of b-blockers after acute myocardial infarction, fewer than half of the ideal candidates for this therapy received it.