This post was authored by John A. Spertus, MD, MPH, FACC, presenter at the 2016 Cardiovascular Summit.

Variations in care have been described for decades. For example, the Dartmouth Atlas has repeatedly shown >10-fold variations across the country in the use of different tests and treatments. The challenge with such reports, however, is that we don’t know what rate is right. Are the regions with the highest utilization overusing tests and treatments, or are the regions with the lowest rates underusing them? To better understand variation, we need more information.

The key to understanding the ‘right rate’ is stratifying the population into those who benefit greatly – and need treatment – and those at low risks for adverse outcomes in whom the treatment is unlikely to confer benefit and may be overused. Most treatments have a constant relative risk reduction (e.g. 40 percent), meaning that when applied to low-risk patients (e.g. a risk of 1 percent for a bad outcome) the benefits are small (reducing the risk to 0.6 percent or an absolute risk difference of 0.4 percent, meaning that we would have to treat 250 patients to prevent one event). In contrast, using the same treatment in a high-risk patient (e.g. 40 percent risk of a bad outcome) can result in a very effective benefit (reducing the absolute risk by 16 percent, meaning that only six patients need to be treated to prevent one event). Thus understanding variations in care necessitates knowing the benefits for the patients who are treated and those who are not.

In the field of cardiology, there have been numerous studies documenting a ‘risk-treatment paradox’, in which the lowest risk patients are preferentially treated and the highest risk patients are not. To correct this dysfunctional, ineffective, costly strategy requires that each hospital carefully examine how its practitioners tailor treatment to risk. If there is important variation – there almost always is – then these hospitals need to develop strategies to decrease the variability across physicians and to preferentially treat those who most benefit. After all, patients should be treated on basis of who they are (how much they benefit from treatment) and not who they happen to see. A recent publication showed a remarkable 100-fold variation in the use of any bleeding avoidance strategy in patients at the highest risk of bleeding across providers. This is a great threat to both patients’ outcomes and hospitals’ bottom lines. It needs to be corrected.

The best way to improve the consistency of care is to develop evidence-based protocols that tailor treatment to risk. Fortunately, the ACC has created extremely valuable risk models from its NCDR that can be used to examine whether or not physicians are treating the right patients. Once these risk models are integrated into protocols of care and implemented, feedback reports to clinicians about their adherence rates to these risk-based protocols can be performed. At Saint Luke’s Mid America Heart Institute, the quality bonuses of cardiologists were linked to reducing the variability across physicians in bivalirudin use as a function of bleeding risks. A remarkable decrease in variability across physicians was shown, while saving hundreds of thousands of dollars for the hospital. Moreover, the predicted bleeding risk for 2013 was 6.5 percent and the observed rate was only 2.4 percent.

Clearly there are times when variations in care are a sign of good quality, particularly when there are unique patient circumstances that warrant deviating from risk-based protocols. However, the vast majority of such variations are due to physician preference, rather than patient benefit. Eliminating these is a critical step towards improving the consistency, quality and cost-effectiveness of care. This requires that hospitals begin developing evidence-based protocols (based upon patients’ risks and benefits), implement these protocols, monitor adherence across physicians and establish accountability mechanisms to insure that care is consistent and reliable.

This post is part of a series of posts from the 2016 Cardiovascular Summit: Solutions for Thriving in a Time of Change, taking place Feb. 18 – 20 in Las Vegas, NV. Stay tuned to the ACC in Touch Blog for additional perspectives and recaps from the meeting.

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