Opportunities for Value Improvement

An Analysis of Health Care Costs and Quality For

Southeastern Florida

January 25, 2005

Presented to the Florida Health Care Coalition by

James Mortimer j.mortimer@earthlink.net

Source: Dartmouth Atlas of Health Care

www.dartmouthatlas.org

Opportunities for Value Improvement

An Analysis of Health Care Costs and Quality

For Southeastern Florida

January 25, 2005 Introduction Health care services are increasingly expensive. As better information systems become available, we are learning that the quality of care varies significantly from one area of the U.S. to another. This report will provide pictures of variations in the cost and quality of health care in Southeastern Florida visible using the Dartmouth Atlas of Health Care available on Dartmouth Medical School’s website www.dartmouthatlas.org. Data for the report are drawn primarily from the claim experience of Medicare for 2001. This information is intended to give health care leaders, practitioners and health care purchasers a starting point for identifying worthwhile opportunities for improvement in the performance of valuable health care resources. The Florida Health Care Coalition is in a position to collaborate with leaders to organize local efforts to these health services Report Outline The report will show you through a series of maps and charts:

• The clinical geography of Southeastern Florida • Profiles of health care cost and utilization at a regional and local level • Variations in cost and health care practice compared to US statistics

It will conclude with a few recommendations for action and further development of project options. Clinical Geography Dartmouth Atlas (Atlas) data are compiled for the United States at two levels. Hospital Referral Regions (HRRs) have been defined for 306 areas based on population access for heart disease care. Hospital Service Areas (HSAs) are much smaller and define more than 3000 local areas where patients go for acute care. We will look first at HRR maps and some data.

1

Hospital Referral Region Map

Total Medicare Reimbursements per Beneficiary 2001

There are two HRRs defined by Dartmouth for Southeastern Florida: Fort Lauderdale and Miami. These larger regions allow us to look at data for many treatments that cannot be seen at the local level due to statistical limitations. The map above shows how the SE FL total reimbursements from Medicare in 2001 compared with nearby parts of the state and the nation. Medicare’s costs in SE FL are in the highest category for the nation. One of the major reasons for this high cost is the custom of hospitalizing people during their last six months of life in SE FL. The chart on the next page shows how these hospital costs compare with the national average for several HRRs in Florida.

2

Reimbursements per decedent for inpatient hospitalizations during the last six months of life (2001) Area Population Value Ratio Surplus/ Deficit *National Benchmark 1,459,235 12,347.7 - - Miami, FL 10,123 19,558.0 1.58 72,989,783 Fort Lauderdale, FL 14,141 13,676.2 1.11 18,787,142 Orlando, FL 17,568 11,292.0 0.91 -18,545,375 Tampa, FL 4,459 11,215.5 0.91 -5,048,215 Tallahassee, FL 4,247 8,825.3 0.71 -14,959,500 If Medicare patients in Miami and Fort Lauderdale HRRs were treated like the national average in 2001, Medicare would have saved $91,776,925. Hospital Service Areas We have identified 17 Hospital Service Areas in the three county area of Southeast Florida. They are listed with their corresponding HRRs on the next page.

3

Hospital Service Areas (HSA) for South Florida Dartmouth Atlas Study

HSA HRR

(Hospital Referral Region)

Fort Lauderdale Miami Atlantis X Boca Raton X Boynton Beach X Delray Beach X Fort Lauderdale X Hialeah X Hollywood X Jupiter X Miami Beach X Miami X Palm Beach Gardens X Pembroke Pines X Plantation X Pompano Beach X Stuart X Tamarac X West Palm Beach X The map on the next page shows how these areas are laid out in the two HRRs for SE FL.

4

Hospital Service Area Map Total Medicare Reimbursements per Beneficiary - 2001

5

The chart below shows how these costs break down at the Hospital Service Area level in the region. These terminal hospital costs per Medicare beneficiary in Hialeah, FL are almost twice the national average. If Medicare patients in Hialeah, Fl were treated like the national average of Medicare patients, $12,716,179 would have been saved by Medicare there in 2001.

Reimbursements per decedent for inpatient hospitalizations during the last six months of life (2001) Area Population Value Ratio Surplus/ Deficit *National Benchmark 1,459,235 12,347.7 - - Hialeah, FL 1,041 24,563.0 1.99 12,716,179 Miami Beach, FL 713 22,486.2 1.82 7,228,787 Miami, FL 5,914 20,249.7 1.64 46,732,586 Delray Beach, FL 1,020 15,645.7 1.27 3,364,026 Boynton Beach, FL 1,168 15,156.3 1.23 3,280,470 Hollywood, FL 1,267 14,977.9 1.21 3,332,554 Pembroke Pines, FL 447 14,961.0 1.21 1,168,153 Boca Raton, FL 1,620 14,673.8 1.19 3,768,362 Plantation, FL 784 14,248.2 1.15 1,490,032 Fort Lauderdale, FL 2,526 13,674.1 1.11 3,350,478 Palm Beach Gardens, FL 537 13,533.7 1.10 636,893 Pompano Beach, FL 739 13,035.9 1.06 508,591 Atlantis, FL 832 13,004.0 1.05 546,058 West Palm Beach, FL 1,586 12,652.7 1.02 483,757 Stuart, FL 1,175 11,464.3 0.93 -1,038,003

6

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The cost of inpatient health care in the final days of life is not an economic issue of direct concern to most employers. It is a significant issue for Medicare. We used it here to show how data for HRRs and HSAs connect and, to illustrate a potentially important subject if Medicare is involved in the discussions of these data with the Florida Health Care Coalition. Our analysis will begin looking at Community Profile data for the HRRs and HSAs in SE FL. We have organized the variables for this analysis into three segments:

• Florida DRGs the Coalition is already studying • Costs • Other Quality Indicators

Below is table of the Atlas variables for these three segments: DRG – Atlas Variable Cross Walk

FL DRG Related Atlas Variables Acute MI Acute MI Discharges

Cerebrovascular Discharges Cardiac Arrhythmia Transient Ischemic Attack

CABG CABG Aortic Mitral Valve replacement

Chest Pain Chest Pain PTCA Percutaneous Coronary Interventions

Coronary Angiography COPD Pleural Effusion and Respiratory Discharges Pneumonia Respiratory Infection Discharges Total Hip Replacement Hip Replacement Total Knee Replacement Knee Replacement Small/Large Bowel Surg. GI Hemorrhage

GI Obstruction Hysterectomy None Costs Total Medicare Reimbursements per Beneficiary

Part A Medicare Reimbursements per Beneficiary Short Stay Inpatient Reimbursements Long Stay Inpatient Reimbursements Outpatient Services Reimbursements Part B Medicare Reimbursements per Beneficiary Professional and Lab Services Medical and Surgical Services Diagnostic, Lab and X-Ray Services Medical Care Surgical Services Durable Medical Equipment

Other Quality Indicators High Variation Medical Discharges Seizure and Headache Discharges Medical Back Discharges Back Surgery Discharges Nutritional and Metabolic Discharges Septicemia Discharges Hip Fracture Repair Colon Resection Lower Extremity Revascularization

Community Profiles

Name Pages HRRs Fort Lauderdale 9-11 Miami 12-14 HSAs Atlantis 15-17 Boca Raton 18-20 Boynton Beach 21-23 Delray Beach 24-26 Fort Lauderdale 27-29 Hialeah 30-32 Hollywood 33-35 Jupiter 36-38 Miami Beach 39-41 Miami 42-44 Palm Beach Gardens 45-47 Pembroke Pines 48-50 Plantation 51-53 Pompano Beach 54-56 Stuart 57-59 Tamarac 60-62 West Palm Beach 63-65 Community profiles display the study variables as a percentile of the national distribution. For example a variable ranked at the 90th percentile means that it is greater than 90 percent of all of the other HRRs or HSAs in the United States. You will see a unique pattern of variation of cost and quality variables for each HRR/HSA displayed on the three graphs for each location. We offer an observation of potential improvement opportunities at the bottom of most pages.

8

Possible overuse: TIA discharges, Aortic/Mitral Valve Replacement, Chest Pain discharges, Hip Replacements

9

Pricing concerns for Physician charges and other practitioner services

10

Utilization Rates at or below national averages

11

Potential overuse: AMI discharges, TIA discharges, Chest Pain Discharges, Respiratory Conditions, GI Obstruction discharges

12

Miami HRR is well above the 90th percentile for all but one of these cost indicators

13

Overuse of inpatient care for medical treatment that can be done outpatient.

14

Potential overuse: Chest Pain and Hip replacement discharges

15

Pricing concerns for outpatient services and providers’ charges

16

No comment

17

Potential overuse: Aortic/Mitral Valve discharges, Chest Pain Discharges, PTCA, Coronary Angiography, Hip Replacement.

18

Pricing concerns for physician’s charges and related services

19

No comment

20

Possible Overuse: Cardiac Arrhythmia, Aortic Mitral Valve, Chest Pain, Coronary Angiography, Hip Replacement, GI Obstructions

21

Pricing concerns for Outpatient care, Physician’s charges and related services

22

Potential overuse of Back Surgery

23

Potential Overuse: CABG, Aortic/Mitral Valve Replacement, Chest Pain Discharges, PTCA, Coronary Angiography, Hip Replacement, GI Obstruction discharges

24

Pricing concerns for Physician charges and related services

25

Potential Overuse: Back Treatments and Surgery

26

Potential Overuse: TIA discharges, GI Obstruction discharges

27

Pricing Concerns for physician charges and related services

28

No comment

29

Potential Overuse: AMI discharges, Cerebrovascular discharges, TIA discharges, Chest Pain discharges, Respiratory conditions, GI conditions.

30

Pricing concerns for all inpatient and outpatient care. Hialeah is the highest cost HSA in the SE FL region

31

Potential Overuse of inpatient services for conditions treatable outside the hospital. Can be caused by oversupply of hospital beds

32

Potential Overuse: AMI discharges, Aortic/Mitral Valve discharges, PTCA

33

Pricing concerns for Inpatient, Outpatient care and physicians’ charges and services

34

Potential overuse of Colon surgery

35

Potential Overuse: Cardiac Arrhythmia discharges, TIA discharges, Chest Pain discharges, Coronary Angiography, Hip and Knee Replacements

36

Pricing concerns for Physician charges and related services

37

No comment

38

Potential Overuse of TIA discharges, Chest Pain Discharges, Coronary Angiography, GI Obstruction discharges

39

Pricing concerns for all inpatient, outpatient and physician-related services

40

Potential overuse of hospital services for conditions treatable in office, Medical Back discharges, Hip Fractures??

41

Potential Overuse: TIA discharges, Respiratory discharges, GI Obstructions

42

Pricing concerns for all inpatient, outpatient, and physician-related services

43

Possible Overuse: Inpatient care of conditions treatable in the office.

44

Potential overuse: TIA discharges, Hip replacements

45

Pricing concerns for outpatient care and all physician-related services

46

No comment

47

Possible Overuse: AMI discharges, PTCA

48

Pricing concerns for all physician related services and DME

49

No comment

50

Possible Overuse: TIA discharges, Coronary Angiography, GI Obstructions

51

Pricing concerns for physician charges and relates services

52

Possible Overuse: Colon Cancer surgery.

53

Possible Overuse: AMI discharges, TIA discharges, Chest Pain discharges

54

Pricing concerns for all inpatient and physician related charges and services

55

Possible Overuse: Medical back admissions

56

Possible Overuse: Aortic/Mitral Valve discharges, Coronary Angiography, Hip and Knee Replacements

57

Pricing concerns for physicians’ charges and related services

58

No comment

59

Possible Overuse: Cardiac Arrhythmia discharges, TIA discharges, Chest Pain Discharges, GI Obstructions

60

Pricing concern for all inpatient, outpatient, and physician-related charges

61

No comment

62

Possible Overuse, Chest Pain discharges

63

Pricing concerns for physician related charges

64

65

No comment

National Comparisons

Distribution Graphs for HSA Data

Florida Coalition Variables Page Total Medicare reimbursements per Enrollee 67 Acute Myocardial Infarction Discharges 68 Cerebrovascular Disorders Except TIA 69 Cardiac Arrhythmia Discharges 70 Transient Ischemic Attack Discharges 71 Coronary Artery Bypass Graft Discharges 72 Aortic/Mitral Valve Replacement Discharges 73 Chest Pain Discharges 74 Percutaneous Coronary Interventions 75 Coronary Angiography 76 Pleural Effusion discharges 77 Respiratory Infection Discharges 78 Hip Replacement Discharges 79 Knee Replacement Discharges 80 GI Hemorrhage Discharges 81 GI Obstruction Discharges 82 Other Variables High-Variation Medical Discharges 83 Seizure and Headache Discharges 84 Medical Back Problem Discharges 85 Back Surgery Discharges 86 Nutritional and Metabolic Disorder Discharges 87 Septicemia Discharges 88 Hip Fracture Repair Discharges 89 Mastectomy for Cancer Discharges 90 Resection for Colon Cancer discharges 91 Lower Extremity Revascularization Discharges 92 TURP for BPH Discharges 93 Actual values for the variable in each HSA are shown in the tables below each distribution graph. The graph overlays the HSA values on the distribution of HRR values for the nation. This display may help to convene the best performers with those who have an opportunity for improvement in the regions. Hialeah, Miami and Delray Beach are high outliers in many of the graphs.

66

Total Medicare reimbursements per enrollee (Part A and B) (2001) Hialeah, FL 12,284.0 Miami, FL 10,626.1 Tamarac, FL 9,918.7 Miami Beach, FL 9,482.1 Hollywood, FL 8,629.3 All of Southeast Florida is above the

national average Medicare cost per enrollee. Hialeah leads the pack for 2001

Plantation, FL 8,405.2 Boynton Beach, FL 8,265.4 Pompano Beach, FL 8,073.5 Boca Raton, FL 7,637.0 Delray Beach, FL 7,613.5 Fort Lauderdale, FL 7,583.7 Jupiter, FL 7,552.3 Pembroke Pines, FL 7,393.2 West Palm Beach, FL 7,281.4 Palm Beach Gardens, FL 6,985.9 Atlantis, FL 6,910.0 Stuart, FL 6,455.9

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Acute Myocardial Infarction Discharges per 1,000 Medicare Enrollees (2001) Hialeah, FL 18.7 Pembroke Pines, FL 14.8 Pompano Beach, FL 13.7 Hollywood, FL 12.6 Miami, FL 12.0 The rate of hospitalizations for AMI

in Hialeah is more than three times the rate in Palm Beach Gardens and 4/1000 more than the next highest SE FL HSA

Plantation, FL 10.1 Boca Raton, FL 10.1 Stuart, FL 9.8 Miami Beach, FL 9.8 West Palm Beach, FL 9.3 Tamarac, FL 9.1 Boynton Beach, FL 8.9 Jupiter, FL 8.6 Fort Lauderdale, FL 8.2 Delray Beach, FL 8.0 Atlantis, FL 6.4 Palm Beach Gardens, FL 5.8

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Discharges for Cerebrovasc. Disorders (ex. TIA) per 1,000 Medicare Enrollees (2001) Hialeah, FL 12.7 Miami, FL 11.6 Pompano Beach, FL 11.1 Plantation, FL 10.3 Miami Beach, FL 10.2 Stuart, FL 10.1

Hospitalization rates for Cerebrovascular Disorders is more moderate, but Hialeah is still at the top of the distribution and well above the national average

Hollywood, FL 9.8 Atlantis, FL 9.7 Palm Beach Gardens, FL 9.6 Fort Lauderdale, FL 9.2 Pembroke Pines, FL 8.8 West Palm Beach, FL 8.6 Boynton Beach, FL 8.4 Boca Raton, FL 8.2 Delray Beach, FL 7.8 Jupiter, FL 7.5 Tamarac, FL 7.0

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Cardiac Arrhythmia Discharges per 1,000 Medicare Enrollees (2001) Jupiter, FL 13.6 Tamarac, FL 12.2 Boynton Beach, FL 11.9 Boca Raton, FL 11.6 Pompano Beach, FL 11.4

Jupiter stands out with a high rate of hospitalizations for Arrhythmia

Delray Beach, FL 11.1 Hialeah, FL 11.0 Palm Beach Gardens, FL 11.0 West Palm Beach, FL 10.3 Plantation, FL 10.3 Fort Lauderdale, FL 10.3 Pembroke Pines, FL 10.0 Miami Beach, FL 9.7 Atlantis, FL 9.3 Stuart, FL 9.3 Miami, FL 9.1 Hollywood, FL 8.8

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Transient Ischemic Attack Discharges per 1,000 Medicare Enrollees (2001) Hialeah, FL 12.5 Miami, FL 8.7 Tamarac, FL 8.0 Fort Lauderdale, FL 7.2 Pompano Beach, FL 6.8

There is more than a three-fold variation across the SE FL HSAs for TIA hospitalizations. Hialeah again is the outlier. This may be an opportunity for collaboration among high and low rate HSAs to plan quality improvements that reduce costs.

Miami Beach, FL 6.8 Jupiter, FL 6.4 Palm Beach Gardens, FL 6.3 Plantation, FL 6.2 Boynton Beach, FL 5.9 Atlantis, FL 5.9 Stuart, FL 5.8 Boca Raton, FL 5.5 Delray Beach, FL 5.3 West Palm Beach, FL 5.0 Hollywood, FL 4.1 Pembroke Pines, FL 4.0

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Coronary Artery Bypass Grafting (CABG) per 1,000 Medicare Enrollees (2001) Delray Beach, FL 8.3 Fort Lauderdale, FL 7.0 Pompano Beach, FL 6.9 Jupiter, FL 6.5 Boca Raton, FL 6.4

Variation in hospitalization rates for CABG is less than other conditions in SE FL. Delray Beach, however is high for this treatment at more than two times the surprisingly low Miami hospitalization rate.

Plantation, FL 6.2 Boynton Beach, FL 6.2 Palm Beach Gardens, FL 5.9 Stuart, FL 5.8 Pembroke Pines, FL 5.5 Hollywood, FL 5.4 Atlantis, FL 4.9 Miami Beach, FL 4.7 Tamarac, FL 4.7 Hialeah, FL 4.6 West Palm Beach, FL 4.4 Miami, FL 4.1

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Aortic/Mitral Valve Replacement per 1,000 Medicare Enrollees (2001) Delray Beach, FL 2.7 Boca Raton, FL 2.2 Hollywood, FL 2.1 Stuart, FL 1.8

Since this is a less common condition, many of the HSAs do not have enough cases to create a statistically valid treatment rate. Delray Beach, However is high at the SE FL and national levels.

Boynton Beach, FL 1.8 Fort Lauderdale, FL 1.6 West Palm Beach, FL 1.5 Miami, FL 1.4 Hialeah, FL 1.2 Plantation, FL Suppressed Miami Beach, FL Suppressed Pembroke Pines, FL Suppressed Atlantis, FL Suppressed Palm Beach Gardens, FL Suppressed Tamarac, FL Suppressed Pompano Beach, FL Suppressed Jupiter, FL Suppressed

73

Chest Pain Discharges per 1,000 Medicare Enrollees (2001) Pompano Beach, FL 13.5 Delray Beach, FL 12.5 Boca Raton, FL 12.2 Hialeah, FL 12.2

Pompano Beach and Delray Beach lead seven SE FL HSAs that are near the top of the national rate for chest pain hospitalizations.

Atlantis, FL 11.6 Jupiter, FL 11.6 Tamarac, FL 11.3 West Palm Beach, FL 10.8 Boynton Beach, FL 10.8 Miami, FL 10.0 Miami Beach, FL 10.0 Fort Lauderdale, FL 8.6 Plantation, FL 8.5 Palm Beach Gardens, FL 7.9 Stuart, FL 7.3 Hollywood, FL 6.0 Pembroke Pines, FL 5.3

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Percutaneous Coronary Interventions per 1,000 Medicare Enrollees (2001) Delray Beach, FL 15.4 Pembroke Pines, FL 13.6 Hollywood, FL 13.2 Boca Raton, FL 12.5 Plantation, FL 11.9 Jupiter, FL 11.9

Delray Beach again is the SE FL high outlier for PTCA type procedures.

Boynton Beach, FL 11.7 Stuart, FL 11.1 Pompano Beach, FL 10.7 Palm Beach Gardens, FL 10.4 Tamarac, FL 10.2 Miami, FL 10.2 Miami Beach, FL 10.1 Fort Lauderdale, FL 9.7 West Palm Beach, FL 9.3 Hialeah, FL 8.9 Atlantis, FL 8.4

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Coronary Angiography per 1,000 Medicare Enrollees (2000) Delray Beach, FL 29.2 Boynton Beach, FL 27.1 Miami Beach, FL 27.0 Stuart, FL 26.8 Boca Raton, FL 26.4 Delray Beach cardiologists may be more

inclined to test Medicare enrollees for heart disease.

Jupiter, FL 26.1 Plantation, FL 25.6 Tamarac, FL 25.2 Hollywood, FL 25.1 Atlantis, FL 24.5 Miami, FL 23.5 Pompano Beach, FL 23.2 Palm Beach Gardens, FL 23.2 Fort Lauderdale, FL 21.9 West Palm Beach, FL 19.9 Pembroke Pines, FL 19.6 Hialeah, FL 18.6

76

Pleural Effusion and Respiratory Discharges per 1,000 Medicare Enrollees (2001) Hialeah, FL 3.9 Miami, FL 3.8 Miami Beach, FL 2.8 Fort Lauderdale, FL 2.7 Stuart, FL 2.3 Hollywood, FL 2.3 Plantation, FL 2.1 West Palm Beach, FL 2.1 Atlantis, FL 2.0 Boca Raton, FL 1.7 Pompano Beach, FL 1.7 Palm Beach Gardens, FL 1.5 Boynton Beach, FL 1.2 Delray Beach, FL 0.9 Jupiter, FL Suppressed Tamarac, FL Suppressed Pembroke Pines, FL Suppressed

Hialeah and Miami are significantly higher in hospitalizations for these respiratory conditions than the nation or the rest of SE FL HSAs.

77

Discharges for Respiratory Infections per 1,000 Medicare Enrollees (2001) Hialeah, FL 9.4 Miami, FL 8.4 Boca Raton, FL 6.0 Tamarac, FL 5.9

Hialeah and Miami practice patterns emphasize hospitalizafor respiratory infection

tion s.

Plantation, FL 5.6 Palm Beach Gardens, FL 5.6 Atlantis, FL 5.4 Jupiter, FL 5.2 West Palm Beach, FL 4.9 Miami Beach, FL 4.9 Pompano Beach, FL 4.6 Stuart, FL 4.6 Fort Lauderdale, FL 4.5 Pembroke Pines, FL 4.3 Boynton Beach, FL 4.0 Delray Beach, FL 3.9 Hollywood, FL 3.7

78

Hip Replacement per 1,000 Medicare Enrollees (2001) Boynton Beach, FL 4.5 Atlantis, FL 4.5 Boca Raton, FL 4.4 Jupiter, FL 4.1 Delray Beach, FL 4.0 Five HSAs have more than

4/1000 enrollees treated with hip replacements in 2001. Miami and Hialeah are low for this procedure - offering a benchmarking opportunity.

Palm Beach Gardens, FL 3.9 Stuart, FL 3.7 West Palm Beach, FL 3.5 Pompano Beach, FL 3.4 Fort Lauderdale, FL 2.7 Plantation, FL 2.7 Pembroke Pines, FL 2.7 Hollywood, FL 2.5 Miami Beach, FL 2.5 Miami, FL 1.5 Hialeah, FL 1.1 Tamarac, FL Suppressed

79

Knee Replacement per 1,000 Medicare Enrollees (2001) Jupiter, FL 9.0 Stuart, FL 7.9 Palm Beach Gardens, FL 6.7 Boynton Beach, FL 4.8 Plantation, FL 4.7

All but three HSAs are very low for this procedure. Jupiter, Stuart and Palm Beach Gardens may be able to use information from other providers in the SE FL region.

West Palm Beach, FL 4.5 Atlantis, FL 4.4 Delray Beach, FL 4.4 Fort Lauderdale, FL 4.4 Pompano Beach, FL 4.2 Boca Raton, FL 4.1 Pembroke Pines, FL 3.8 Hialeah, FL 3.8 Miami, FL 3.6 Hollywood, FL 3.4 Tamarac, FL 3.2 Miami Beach, FL 2.7

80

Gastro-Intestinal Hemorrhage Discharges per 1,000 Medicare Enrollees (2001) Hialeah, FL 12.6 Pompano Beach, FL 9.7 Miami, FL 9.4 Atlantis, FL 9.2 Stuart, FL 9.2

Hialeah again stands out as a high outlier for this condition. Hospitalizations there are almost twice the rate in Pembroke Pines

Boca Raton, FL 9.1 Delray Beach, FL 8.7 Fort Lauderdale, FL 8.6 West Palm Beach, FL 8.0 Plantation, FL 8.0 Miami Beach, FL 8.0 Boynton Beach, FL 7.9 Palm Beach Gardens, FL 7.8 Tamarac, FL 7.8 Hollywood, FL 7.2 Jupiter, FL 6.6 Pembroke Pines, FL 6.5

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Gastro-Intestinal Obstruction Discharges per 1,000 Medicare Enrollees (2001) Plantation, FL 5.4 Hialeah, FL 5.3 Miami, FL 5.3 Boynton Beach, FL 4.8 Fort Lauderdale, FL 4.5 Miami Beach, FL 4.5

Hialeah and Miami are joined by Plantation near the top of this graph of GI Obstruction hospitalizations.

Tamarac, FL 4.3 Delray Beach, FL 4.3 Palm Beach Gardens, FL 3.7 Boca Raton, FL 3.5 Hollywood, FL 3.5 Jupiter, FL 3.4 Pembroke Pines, FL 3.2 West Palm Beach, FL 3.2 Atlantis, FL 3.1 Stuart, FL 3.0 Pompano Beach, FL 2.9

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High Variation Medical Discharges per 1,000 Medicare Enrollees (2001) Hialeah, FL 349.9 Miami, FL 290.0 Miami Beach, FL 278.3 Plantation, FL 238.3 Pompano Beach, FL 232.0 Hialeah, Miami, and Miami Beach show

many admissions for this collection of treatments that can be done in an outpatient setting. Dartmouth research has shown this high rate is commonly found in areas with an abundance of hospital beds per 1000 residents.

Tamarac, FL 219.4 Fort Lauderdale, FL 216.1 Atlantis, FL 215.2 Boca Raton, FL 214.7 West Palm Beach, FL 211.1 Jupiter, FL 209.0 Delray Beach, FL 203.5 Boynton Beach, FL 201.6 Hollywood, FL 194.8 Palm Beach Gardens, FL 191.5 Stuart, FL 183.5 Pembroke Pines, FL 176.6

83

Seizure and Headache Discharges per 1,000 Medicare Enrollees (2001) Hialeah, FL 4.1 Miami, FL 3.0 Stuart, FL 2.3 West Palm Beach, FL 2.1

Hialeah again shows high rates for this less common reason for hospitalization.

Fort Lauderdale, FL 2.0 Boca Raton, FL 1.8 Hollywood, FL 1.7 Delray Beach, FL 1.7 Boynton Beach, FL 1.4 Palm Beach Gardens, FL Suppressed Pembroke Pines, FL Suppressed Atlantis, FL Suppressed Tamarac, FL Suppressed Pompano Beach, FL Suppressed Plantation, FL Suppressed Jupiter, FL Suppressed Miami Beach, FL Suppressed

84

Discharges for Medical Back Problems per 1,000 Medicare Enrollees (2001) Pompano Beach, FL 3.8 Miami Beach, FL 3.7 Delray Beach, FL 3.6 Hialeah, FL 3.5 Miami, FL 3.3

Plantation, FL 3.2 Boca Raton, FL 3.1 Palm Beach Gardens, FL 3.1 Tamarac, FL 3.0 Atlantis, FL 3.0 Fort Lauderdale, FL 2.9 West Palm Beach, FL 2.7 Stuart, FL 2.5 Boynton Beach, FL 2.5 Hollywood, FL 2.4 Pembroke Pines, FL 2.1 Jupiter, FL Suppressed

SE FL shows relatively low rates for inpatient medical careof back problems compared to the nation.

85

Back Surgery per 1,000 Medicare Enrollees (2001) Delray Beach, FL 6.0 Boynton Beach, FL 6.0 Atlantis, FL 5.0

Delray Beach and Boynton Beach are the two HSAs above the national average for this surgical procedure in SE FL.

Pembroke Pines, FL 4.7 Boca Raton, FL 4.7 Stuart, FL 4.6 Palm Beach Gardens, FL 4.6 Hialeah, FL 4.6 Pompano Beach, FL 4.4 Plantation, FL 4.1 Fort Lauderdale, FL 4.0 Hollywood, FL 3.6 Jupiter, FL 3.6 Miami Beach, FL 3.5 Tamarac, FL 3.5 West Palm Beach, FL 3.2 Miami, FL 2.6

86

Discharges for Nutritional and Metabolic Disorders per 1,000 Medicare Enrollees (2001) Hialeah, FL 12.0 Miami, FL 10.3 Miami Beach, FL 9.5 Jupiter, FL 9.0 Plantation, FL 8.9

Hialeah and Miami are the two HSAs above the national average in SE FL for these hospitalizations.

Fort Lauderdale, FL 8.4 West Palm Beach, FL 8.4 Hollywood, FL 8.4 Atlantis, FL 8.4 Boca Raton, FL 8.2 Pompano Beach, FL 8.1 Palm Beach Gardens, FL 7.2 Stuart, FL 6.6 Boynton Beach, FL 6.4 Tamarac, FL 6.2 Delray Beach, FL 6.0 Pembroke Pines, FL 5.1

87

Septicemia Discharges per 1,000 Medicare Enrollees (2001) Hialeah, FL 8.4 Plantation, FL 7.9 Miami, FL 7.2 Atlantis, FL 6.7 Tamarac, FL 6.5

The Septicemia DRG includes a variety of specific infections. Some of these cases can be treated as an outpatient. Hialeah and Miami are joined by Plantation at the upper end of this graph.

Stuart, FL 6.4 Miami Beach, FL 6.0 Pembroke Pines, FL 6.0 Hollywood, FL 5.7 Delray Beach, FL 5.7 Fort Lauderdale, FL 5.4 West Palm Beach, FL 5.4 Palm Beach Gardens, FL 5.0 Boca Raton, FL 4.9 Boynton Beach, FL 4.6 Jupiter, FL 3.3 Pompano Beach, FL 3.2

88

Hip Fracture Repair per 1,000 Medicare Enrollees (2001) Miami Beach, FL 9.6 Hollywood, FL 9.2 Boynton Beach, FL 8.7 Pompano Beach, FL 8.7 Atlantis, FL 8.6

Dr Wennberg often uses Hip Fracture hospitalizations where the condition is easy to detect and admission for treatment is not debated as a benchmark. Nevertheless, Miami still tops the chart for SE FL HSAs.

Pembroke Pines, FL 7.9 West Palm Beach, FL 7.8 Tamarac, FL 7.8 Fort Lauderdale, FL 7.8 Boca Raton, FL 7.8 Stuart, FL 7.7 Miami, FL 7.6 Palm Beach Gardens, FL 7.4 Jupiter, FL 7.4 Hialeah, FL 7.0 Plantation, FL 6.9 Delray Beach, FL 6.7

89

Mastectomy for Cancer per 1,000 Female Medicare Enrollees (2001) West Palm Beach, FL 1.2 Miami, FL 1.2 Fort Lauderdale, FL 1.1 Boynton Beach, FL 1.0

It looks like radical mastectomy is a rare procedure in SE FL. Further analysis of the rate of breast-sparing surgery may help complete this picture.

Boca Raton, FL 0.9 Delray Beach, FL Suppressed Hialeah, FL Suppressed Atlantis, FL Suppressed Hollywood, FL Suppressed Pompano Beach, FL Suppressed Jupiter, FL Suppressed Miami Beach, FL Suppressed Palm Beach Gardens, FL Suppressed Pembroke Pines, FL Suppressed Plantation, FL Suppressed Stuart, FL Suppressed Tamarac, FL Suppressed

90

Resection for Colon Cancer per 1,000 Medicare Enrollees (2001) Plantation, FL 2.5 Hollywood, FL 2.3 Delray Beach, FL 1.9 Atlantis, FL 1.9 Miami, FL 1.9 Plantation’s rate for this

procedure is almost twice that of Fort Lauderdale. Another interesting benchmarking opportunity perhaps.

Miami Beach, FL 1.8 Stuart, FL 1.8 West Palm Beach, FL 1.8 Hialeah, FL 1.7 Boynton Beach, FL 1.7 Boca Raton, FL 1.4 Fort Lauderdale, FL 1.3 Pompano Beach, FL Suppressed Jupiter, FL Suppressed Pembroke Pines, FL Suppressed Tamarac, FL Suppressed Palm Beach Gardens, FL Suppressed

91

Lower Extremity Revascularization per 1,000 Medicare Enrollees (2001) Hollywood, FL 1.8 Fort Lauderdale, FL 1.8 Delray Beach, FL 1.7 Stuart, FL 1.6 Boynton Beach, FL 1.5

SE FL shows little potential overuse of this procedure compared to the nation.

Boca Raton, FL 1.4 West Palm Beach, FL 1.3 Miami, FL 1.3 Hialeah, FL 1.2 Pembroke Pines, FL Suppressed Pompano Beach, FL Suppressed Palm Beach Gardens, FL Suppressed Plantation, FL Suppressed Tamarac, FL Suppressed Miami Beach, FL Suppressed Atlantis, FL Suppressed Jupiter, FL Suppressed

92

TURP for BPH per 1,000 Male Medicare Enrollees (2001) Hollywood, FL 7.9 Palm Beach Gardens, FL 7.1 Hialeah, FL 6.9 Miami, FL 6.8 Atlantis, FL 6.5 Most SE FL HSAs are near the

national average for this discretionary prostate surgery procedure. An exchange of information between urologists in Hollywood and the three lowest HSAs may be useful.

West Palm Beach, FL 6.3 Boynton Beach, FL 6.2 Stuart, FL 6.0 Miami Beach, FL 5.7 Fort Lauderdale, FL 5.3 Plantation, FL 5.1 Delray Beach, FL 4.3 Boca Raton, FL 4.2 Pompano Beach, FL 3.3 Pembroke Pines, FL Suppressed Tamarac, FL Suppressed Jupiter, FL Suppressed

93

94

Conclusions and Recommendations Southeastern Florida is a very expensive place to purchase health care. Atlas data show it is at the 90th percentile and higher compared to the Medicare costs in other parts of the nation. The graphs, charts and tables in this report may help you to understand the unique opportunities available for improving the value of health services in this region.

1. Readers are invited to identify the hospitals and clinics located in each of the HSAs to help in choosing local areas that may be the best ones for initiating quality improvement projects to address specific problems. The community profile reports array data at the local level on pages. 10 – 67. Hialeah, Miami and Delray Beach tend to be among the high outliers in many of these graphs.

2. Another step may be considering projects at the SE FL region-wide level. Choosing a specific clinical topic using the distribution graphs on pages 68 – 95 may help get this started. Teams made up of high performers and those with opportunities for improvement can solve problems by collaboration. Another pattern is high physician charges across the region.

3. To assess the potential gain possible from solving a specific overuse problem, the “Benchmarking Graphs” tool on the Dartmouth Atlas website www.dartmouthatlas.org is well suited. Coalition staff and readers are free to experiment with this user-friendly tool at no cost by using the website. These tools also help one to find the best practice HRRs and HSAs in the nation as points of comparison.

4. The Coalition may wish to review this report with Dartmouth Medical School researchers directly to gain more insight into the variations found and to plan for communication on these issues with local provider leaders. Dr. John Wennberg or Dr. David Wennberg could be invited to make a presentation to a leadership group in the region.

5. The Coalition may wish to review some of the charts, graphs and tables with certain provider leaders to see what ideas they have for taking action. I recommend deleting the short comments at the bottom of the community profile pages and the distribution graphs before showing them to providers. They may have additional data that can clarify these variations.

6. The Coalition may decide to review the report with CMS and/or the Florida QIO for Medicare. More data may be found this way. Medicare is a potential project partner for quality improvement projects that would benefit employed populations and retirees.

7. Developing a list of key questions. The Coalition can determine next steps for this project by gathering key questions from those who see this report. Answering these questions through further analysis of the Atlas data or by clarifying the methods used in developing the report will point out the most important opportunities for value improvement.

It has been a pleasure to prepare this report. James Mortimer 634 Division St. Barrington, IL 60010