Technology in Healthcare

Amitabh ChandraHARVARD UNIVERSITY

International Comparison of Spending on Health, 1980–2010

Average spending on healthper capita ($US PPP)

Notes: PPP = purchasing power parity; GDP = gross domestic product.Source: Commonwealth Fund, based on OECD Health Data 2012.

Why?

• Aging?• Obesity and Sickness?• Waste and Inefficiency?• Medical Malpractice?• Technology

Technology in Healthcare

• Challenge: – High fixed-cost, low marginal cost– Heterogenous benefits (large value for some

patients!)– Trials are often done in most appropriate patients– Financial incentives push for overuse in others

A Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee

J. Bruce Moseley, M.D., Kimberly O'Malley, Ph.D., Nancy J. Petersen, Ph.D., Terri J. Menke, Ph.D., Baruch A. Brody, Ph.D., David H. Kuykendall, Ph.D., John C. Hollingsworth, Dr.P.H., Carol M. Ashton, M.D., M.P.H. and Nelda P. Wray, M.D., M.P.H.

N Engl J MedVolume 347;2:81-88

July 11, 2002

Mean Values (and 95 Percent Confidence Intervals) on the Knee-Specific Pain Scale

Moseley, J. et al. N Engl J Med 2002;347:81-88

Patients Receiving Procedure

0

Benefit from Procedure

100 percent

Rapid Angioplasty within 2 hours of AMI

“Late” Angioplasty within 2 days of AMI

Angioplasty for Stable Coronary Disease

OVERUSE? OVERUSE?

Rapid Stenting: US vs. UK Late Stenting: US vs. UK

Highest Highest PerformancPerformanc

e e

Lowest Lowest PerformanPerforman

ce ce

Source: Chandra, Staiger, Skinner (IOM, 2010)

Rates of All Harms, Preventable Harms, and High-Severity Harms

Landrigan CP et al. N Engl J Med 2010;363:2124-2134.

The Dark Side

• Can technology cause distractions?• Theory of Technology Spillovers

What do Boards do on quality?• Surveyed Board chairpersons from 1000 hospitals• Received 78% response• Oversampled “best” and “worst” hospitals on HQA

processes• Asked about priorities, perceptions, and activities

around quality

Jha and Epstein, Health Affairs, 2010

Perception of Quality Performance

Note: Perception of their hospital’s performance on the TJC/HQA measures compared to typical U.S. hospital

Board’s Attention to Quality

So what’s the bottom line?• Technology growth drives healthcare

spending• New Technologies have ‘high-fixed-cost,

low marginal cost’ profile• New technologies have heterogeneous

benefits– cost effectiveness very hard to do!

• Spending is weakly correlated with outcomes

• Outcomes are affected by professionalism, diligence, and safety culture

• Real cost of technology is that it distracts from safety

• Hard choices ahead– don’t be fooled by prevention as a solution for technology growth