Saturday, December 04, 2010

Healthcare quality 101

There are superb French (and other) pastries all around the island of Montreal, but Minneapolis St. Paul pastries peak at mediocre. The Twin Cities are richer than Montreal, but money can't buy everything. In health care terms we'd call this a kind of variability.

The pastry variation is cultural. Minnesotans don't love the chocolate, flour and licquer pastries I grew up with, so there's no competitive market in my favorite food.

There's cultural variation in health care quality too. The best description of the causes of this variation, better than any prior academic publication, appeared in a 2009 New Yorker essay by Atul Gawande.

There's a different kind of variation that Gawande doesn't talk about. It's the difference between "Cicely" Alasaka and Rochester Minnesota.

Rochester is the home of the Mayo Clinic. It's the champion of conventional health care delivery.  The combination of a small city and an international service business generates enough revenue to support a full range of health care technologies and care givers. There's a culture of process monitoring and improvement that kicks it up a level above most referral centers.

Cicely is a mythical rural community. It's the archetype for communities with small populations that can only support a limited range of local health care delivery. At its best this will involve a reasonable number of family physicians, PAs and nurses and a smaller number of specialists. There may be only 1-2 pediatricians,  maybe some hospitalists, 1 orthopedic surgeon, 2-3 general surgeons, and so on. There's unlikely to be a colorectal surgeon. There's probably 1-2 obstetricians, but obstetrical epidural anesthesia may be hard to get.

Care in this mythical Cicely, the care experienced by 17% of Americans, is different from care in Rochester.

In some ways Cicely is better. Primary care physicians are experienced. Care communication is much better than in large centers. Reputations are known, and they matter. Patients don't get missed or lost as easily. Most of us don't want to die, but we particularly don't want to die miserably. If I'm ready to die, I'd rather be in Cicely than at the Mayo.

In other ways Rochester is better. Cicely is probably not the best place for a child with Cystic Fibrosis. When there's only 1-2 specialists in a community that needs at least one, choice may be limited. Many procedures aren't available, or shouldn't be available, outside of specialty centers. Health care will often involve travel to a place like Mayo (back in the day I liked Marshfield Clinic -- almost as good as Mayo, and a lot closer).

It's good to understand that there are different kinds of health care variability. The pastry-kind of variation is fixable. The Mayo model, or a cheaper variant that's 80% as good, could be applied elsewhere (it's not the water). Other kinds of variability are much more persistent; they're driven by local market size more than culture. Cicely will never be a good place to have a glioma removed; though it's the place I'd want for care of an untreatable glioma.

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