Making wise choices Healthcare Revolution Will

Making wise choices. . . Healthcare Revolution Will we be able to provide same service for -less $$-------or not all!!! The volume is being turned up but is anyone listening? Is there waste or are we being wasteful? Supported by NIAMS U 01 -AR 45444 -01 A 1 Copyright 1999, Trustees of Dartmouth College -------

Making wise choices. . . Reasons for differences in practice Healthcare financing Organization & delivery of services Differences in training Professional uncertainty Medical & surgical signatures of communities Supply-induced demand (Boston vs New Heaven) What will we do about it ? Copyright 1999, Trustees of Dartmouth College

Making wise choices. . . Usual Concept of Health Care Costs Health Benefit Costs Deyo RA and Weinstein JN in The Spine, 4 th Edition Vol I, Herkowitz et. al. (Ed. )W. B. Saunders, Philadelphia, 1999. Copyright 1999, Trustees of Dartmouth College

Making wise choices. . . More Likely View of Health Care Costs Health Benefit Costs Deyo RA and Weinstein JN in The Spine, 4 th Edition Vol I, Herkowitz et. al. (Ed. )W. B. Saunders, Philadelphia, 1999. Copyright 1999, Trustees of Dartmouth College

Making wise choices. . . Where Are We? Y Health Benefit Z X X: Industry Y: Providers Costs Z: Administrators Deyo RA and Weinstein JN in The Spine, 4 th Edition Vol I, Herkowitz et. al. (Ed. )W. B. Saunders, Philadelphia, 1999. Copyright 1999, Trustees of Dartmouth College

Making wise choices. . . Healthcare financing Organization & delivery of services Differences in training Professional uncertainty Medical & surgical signatures of communities Supply-induced demand Copyright 1999, Trustees of Dartmouth College

Making wise choices. . . Epidemiological Data Rates Back pain & disc disease are approximately equal among different countries. Therefore the variation of rates in procedures for surgery needs explanation. Copyright 1999, Trustees of Dartmouth College

Making wise choices. . . Ratio’s of Back Surgery Rates in selected countries/provinces to those of the US. Cherkin DC, Deyo RA, Loeser JD et al: Spine 19: 1201 -1206, 1994. Copyright 1999, Trustees of Dartmouth College

Making wise choices. . . Back Surgery per 1, 000 Enrollees Distribution of Back Surgery Rates (1994 -95) 8 7 6 5 4 3 2 1 Source: The Dartmouth Atlas of Health Care, 1998 Copyright 1999, Trustees of Dartmouth College

Making wise choices. . . Ratio of Rates of Surgery for Lumbar Spinal Stenosis per 1, 000 Medicare Enrollees to the U. S. Average by Hospital Referral Region (1996 -97) 1. 50 or More (51) 1. 25 to < 1. 50 (38) 0. 75 to < 1. 25 (155) 0. 50 to < 0. 75 (50) Less than 0. 50 (12) Not Populated Copyright 1999, Trustees of Dartmouth College

Making wise choices. . . Ratio of Rates of Surgery for Lumbar Disc Herniation per 1, 000 Medicare Enrollees to the U. S. Average by Hospital Referral Region (1996 -97) 1. 50 or More (51) 1. 25 to < 1. 50 (38) 0. 75 to < 1. 25 (155) 0. 50 to < 0. 75 (50) Less than 0. 50 (12) Not Populated Copyright 1999, Trustees of Dartmouth College

Making wise choices. . . Outcomes Research. . . typically studies healthcare effectiveness, (how well it actually works when applied in routine care) Supported by NIAMS U 01 -AR 45444 -01 A 1 Copyright 1999, Trustees of Dartmouth College

Making wise choices. . . Randomized Trials. . . tell us about treatment efficacy, (whether the treatment can work under ideal circumstances) Supported by NIAMS U 01 -AR 45444 -01 A 1 Copyright 1999, Trustees of Dartmouth College

Making wise choices. . . SPORT Spine patient outcomes research trial Funded by: The National Institute of Arthritis and Musculoskeletal and Skin Diseases and the Office of Research on Women's Health, the National Institutes of Health, and the National Institute of Occupational Safety and Health, the Centers for Disease Control and Prevention Copyright 1999, Trustees of Dartmouth College

Making wise choices. . . Why SPORT? • Low back pain is one of the most widely experienced health problems in the world. • Second only to common cold as reason cited for physician visit or days lost from work. • Estimated costs from $30 -70 billion annually. • 8 -fold geographic variation in rates of spinal surgeries. • Little evidence demonstrating efficacy/effectiveness of surgery versus non-surgical therapy. Copyright 1999, Trustees of Dartmouth College

Making wise choices. . . Fit eligibility criteria for inclusion in IDH, Sp. S, or DS cohorts View videotape for IDH or SPS (DS) Consent to participate in RCT or Observational Cohort? No Yes Observational Cohort IDH & Sp. S Choose Surgery Non-op therapy DS Choose RCT Cohort IDH & Sp. S Randomize Non-op Surgerytherapy Surgery Fusion Surgery. No Fusion DS Randomize Non-op Surgerytherapy Fusion Surgery. No Fusion Copyright 1999, Trustees of Dartmouth College Non-op therapy

Making wise choices. . . SPORT Sites ! Rothman Institute, Phil, PA Hospital for Special Surgery, NY Univ. of Calif. , SF, Calif Hospital for Joint Disease, NY Washington U. , St. Louis, MO Nebraska Spine Surgeons, Omaha, Ne. Beaumont Hospital, Dea, MI Rush-Presbyterian-St. Luke’s, Chi. , Ill Case Western Reserve, Cl, OH Emory Spine Ctr. , Atl. GA Dartmouth, Hanover, NH Copyright 1999, Trustees of Dartmouth College

Making wise choices. . . SPORT Cores • Study Coordinating Center at Dartmouth • Statistics, Epidemiology, and Data Management Core • Statistics/Epidemiology Group • Data Management Group • Cost-Effectiveness Core Copyright 1999, Trustees of Dartmouth College

Making wise choices. . . The Big Question Is Surgery BETTER than Nonsurgical therapy for patients with Intervertebral Disc Herniation, Spinal Stenosis, and/or Spinal Stenosis with Degenerative Spondylolisthesis? Copyright 1999, Trustees of Dartmouth College

Making wise choices. . . Main Health Outcome Measures 4 Functional Health Status – Disease Specific Health Status – Generic Health Status 4 Quality-Adjusted Life Years (QALYs) – Preference Classification Systems • Societal perspective – Direct Utility Assessment • Individual perspective Copyright 1999, Trustees of Dartmouth College

Making wise choices. . . Physicians typically underestimate patient’s desire for information Strull WM, et al “Do patients want to participate in medical decision-making? ” JAMA 1984 252: 2990 -2994. Supported by NIAMS U 01 -AR 45444 -01 A 1 Copyright 1999, Trustees of Dartmouth College

Making wise choices. . . POTENCY OF TELEVISION • 32% indicated that information received from “ER” helps them make family healthcare choices • 12% have contacted their doctor with questions from “ER” Copyright 1999, Trustees of Dartmouth College

Making wise choices. . . Involving Patients in Clinical Decisions: Impact of an interactive video program on use of back surgery RA Deyo, DC Cherkin, JN Weinstein, JF Howe, MA Ciol, A Mulley Supported by NIAMS U 01 -AR 45444 -01 A 1 Copyright 1999, Trustees of Dartmouth College AHCPR HS#08079

Making wise choices. . . “Helping Patients Decide About Back Surgery: An RCT of an Interactive Video Program” EA Phelan, RA Deyo, DC Cherkin, JN Weinstein, MA Ciol, JF Howe Submitted to JGIM Supported by NIAMS U 01 -AR 45444 -01 A 1 Copyright 1999, Trustees of Dartmouth College

Making wise choices. . . Technology Assessment & Decisions Methods and Practical Issues in Planning a Multi-center Trial e. g. , Low Back Pain By Dr. James Weinstein Supported by NIAMS U 01 -AR 45444 -01 A 1 Copyright 1999, Trustees of Dartmouth College

Making wise choices. . . Several concepts of healthcare costs The Usual Health Benefit Costs Deyo RA, Weinstein JN in Rothman-Simeone The Spine, 4 th edition, pp. 173 -183, 1999. Copyright 1999, Trustees of Dartmouth College

Making wise choices. . . Several concepts of healthcare costs: More Likely Health Benefit Costs Deyo RA, Weinstein JN in Rothman-Simeone The Spine, 4 th edition, pp. 173 -183, 1999. Copyright 1999, Trustees of Dartmouth College

Making wise choices. . . Several concepts of healthcare costs Where are We? X = Industry Y = Providers Health Benefit Y X Z Z = Administrators Costs Deyo RA, Weinstein JN in Rothman-Simeone The Spine, 4 th edition, pp. 173 -183, 1999. Copyright 1999, Trustees of Dartmouth College

Making wise choices. . . Ratios of Back Surgery Rates in selected countries/provinces to those of the US. Cherkin DC, Deyo RA, Loeser JD et al: Spine 19: 1201 -1206, 1994. Copyright 1999, Trustees of Dartmouth College

Making wise choices. . . Epidemiological Data Rates Back pain & disc disease are approximately equal among different countries. Therefore the variation of rates in procedures for surgery needs explanation. Copyright 1999, Trustees of Dartmouth College

Making wise choices. . . Reasons for differences in practice Supply-induced demand Differences in training Healthcare financing Organization & delivery of services Professional uncertainty Medical & surgical signatures of communities Copyright 1999, Trustees of Dartmouth College

Making wise choices. . . “If physicians know what they are doing, why do such wide variations occur? ” Wennberg JE, Mc. Pherson K, & Caper P: N Engl J Med 311: 295 -300, 1984. NIAMS U 01 -AR 45444 -01 A 1 Supported by Copyright 1999, Trustees of Dartmouth College

Making wise choices. . . Randomized Trials. . . tell us about treatment efficacy, (whether the treatment can work under ideal circumstances) Supported by NIAMS U 01 -AR 45444 -01 A 1 Copyright 1999, Trustees of Dartmouth College

Making wise choices. . . Outcomes Research. . . typically studies healthcare effectiveness, (how well it actually works when applied in routine care) Supported by NIAMS U 01 -AR 45444 -01 A 1 Copyright 1999, Trustees of Dartmouth College

Making wise choices. . . Why SPORT? • Low back pain is one of the most widely experienced health problems in the world. • Second only to common cold as reason cited for physician visit or days lost from work. • Estimated costs from $30 -70 billion annually. • 15 -fold geographic variation in rates of spinal surgeries. • Little evidence demonstrating efficacy/effectiveness of surgery versus non-surgical therapy. Copyright 1999, Trustees of Dartmouth College

Making wise choices. . . Fit eligibility criteria for inclusion in IDH, Sp. S, or DS cohorts View videotape for IDH or SPS (DS) Consent to participate in RCT or Observational Cohort? No Yes Observational Cohort IDH & Sp. S Choose Surgery Non-op therapy DS Choose RCT Cohort IDH & Sp. S Randomize Non-op Surgerytherapy Surgery Fusion Surgery. No Fusion DS Randomize Non-op Surgerytherapy Fusion Surgery. No Fusion Copyright 1999, Trustees of Dartmouth College Non-op therapy

Making wise choices. . . Where SPORT? Dartmouth Emory Spine Ctr. , GA Rothman Institute, PA Spine Institute for Special Surgery, KY UCSF Washington U. , MO Beaumont Hospital, MI Case Western Reserve Georgetown Hospital for Special Surgery, NY Nebraska Spine Surgeons Rush-Presbyterian-St. Luke’s, Chicago SUNY-Syracuse Tulane University of Iowa Vanderbilt Copyright 1999, Trustees of Dartmouth College

Making wise choices. . . SPORT Cores • Study Coordinating Center at Dartmouth • Statistics, Epidemiology, and Data Management Core • Statistics/Epidemiology Group • Data Management Group • Cost-Effectiveness Core Copyright 1999, Trustees of Dartmouth College

Making wise choices. . . The Big Question Is Surgery BETTER than Non-surgical therapy for patients with Intervertebral Disc Herniation, Spinal Stenosis, and/or Spinal Stenosis with Degenerative Spondylolisthesis? Copyright 1999, Trustees of Dartmouth College

Making wise choices. . . Main Health Outcome Measures Functional Health Status Disease Specific Health Status Generic Health Status Quality-Adjusted Life Years (QALYs) Preference Classification Systems Societal perspective Direct Utility Assessment Individual perspective Copyright 1999, Trustees of Dartmouth College

Physicians typically underestimate patient’s desire for information Strull WM, et al “Do patients want to participate in medical decision-making? ” JAMA 1984 252: 2990 -2994. Supported by NIAMS U 01 -AR 45444 -01 A 1 Copyright 1999, Trustees of Dartmouth College

Making wise choices. . . POTENCY OF TELEVISION 32% indicated that information received from “ER” helps them make family healthcare choices 12% have contacted their doctor with questions from Copyright 1999, Trustees of Dartmouth College

Patient participation may result in better outcomes Greenfield S, et al Ann Int Med 1985, 102: 520; J Gen Med 1988, 3: 448; Med Care 1989, 27: S 110. Supported by NIAMS U 01 -AR 45444 -01 A 1 Copyright 1999, Trustees of Dartmouth College

Evidence Based Medicine From the Classroom to the Clinic (Shared Decision Making) Making wise choices. . . Explosion of Scientific Knowledge 4 keeping up with the scientific literature 4 synthesizing all this information efficiently and practically Supported by NIAMS U 01 -AR 45444 -01 A 1 Copyright 1999, Trustees of Dartmouth College

Shared Decision-Making Programs (VHS, CD-ROM, Interactive video) combine information from: 4 clinical trials 4 literature syntheses 4 other outcomes studies with 4 concerns of patients and physicians elicited in focus Supported by NIAMS U 01 -AR 45444 -01 A 1 Copyright 1999, Trustees of Dartmouth College

The Voice of the Patient Making wise choices. . . Professional Skater: Second Opinion “paralyzed with fear”, on the couch. Told by PCP surgery only option After viewing SDM-Choose surgery, very comfortable with decision. Mathematician: “Right amount” of narrative and right amount of statistics. Enough info to “Wait”. Copyright 1999, Trustees of Dartmouth College

Northern New England Cardiovascular Disease Study Group Making wise choices. . . Fletcher Allen Health Care Eastern Maine Medical Center Maine Dartmouth Medical Hitchcock Center Medical Center Catholic Medical Center Beth Israel. Deaconess Medical Center The Northern New England Cardiovascular Disease Study Group exists to develop and exchange information concerning the treatment of cardiovascular disease. It is a regional, voluntary, multidisciplinary group of clinicians, hospital administrators, and health care research personnel who seek to improve continuously the quality, safety, effectiveness, and cost of medical interventions in cardiovascular disease. Copyright 1999, Trustees of Dartmouth College

NNECDSG Making wise choices. . . 1987 -89 Prospective study of in-hospital mortality-rate 2 -6% across 5 centers 1990 -91 CABG Improvement Interventionoverall mortality reduced 24% 1992 -95 Examined the Cause of Death 1996 -98 Focused look at low output heart failure 1999 -01 American Heart Association Patient Care and Outcomes Research Grant Improvement Grant to reduce mortality from low output heart failure Copyright 1999, Trustees of Dartmouth College

A regional prospective study of inhospital mortality associated with coronary artery bypass grafting- (198789) Making wise choices. . . 7 6 5 In-hospital Mortality Rate (%) 4 3 2 1 0 1 2 3 4 5 Center Copyright 1991; 266: 803 -809 O’Connor, GT et al. JAMA, 1999, Trustees of Dartmouth College

Making wise choices. . . CABG Improvement 1990 -1991 A Prospective study Three interventions aimed at reducing CABG mortality Feedback of outcome data Training on continuous quality improvement techniques Site visits to other medical centers 4 Copyright 1999, Trustees of Dartmouth College

Expected/Observed mortality all patients (N = 15, 095) Making wise choices. . . 10 Pre-intervention Post-intervention N = 6, 488 Intervention N = 6, 638 9 N = 1, 969 8 7 6 5 4 3 2 1 0 7/87 10/87 1/88 4/88 7/88 10/88 1/89 4/89 7/89 10/89 1/90 4/90 7/90 10/90 1/91 4/91 7/91 10/91 1/92 4/92 7/92 10/92 1/93 4/93 Date of Beginning of Quarter Expected Observed Copyright 1999, Trustees of Dartmouth College O’Connor, GT et al. JAMA 1996; 275: 841 -6

Making wise choices. . . Lessons Learned Continued Participation After 13 years all cardiac surgeons continue to participate. Benchmarking Multicenter data allowed powerful insights and identification of “best practices”. Improved Care Patient care is substantially improved. A recent Duke study showed CABG outcomes in NNE to be the best in the US and the most improved. Academic Productivity The group have been very academically productive. Copyright 1999, Trustees of Dartmouth College

Northern New England Cardiovascular Disease Study Group Making wise choices. . . Fletcher Allen Health Care Eastern Maine Medical Center Maine Dartmouth Medical Hitchcock Center Medical Center Catholic Medical Center Beth Israel. Deaconess Medical Center The Northern New England Cardiovascular Disease Study Group exists to develop and exchange information concerning the treatment of cardiovascular disease. It is a regional, voluntary, multidisciplinary group of clinicians, hospital administrators, and health care research personnel who seek to improve continuously the quality, safety, effectiveness, and cost of medical interventions in cardiovascular disease. Copyright 1999, Trustees of Dartmouth College

NNECDSG Making wise choices. . . 1987 -89 Prospective study of in-hospital mortality-rate 2 -6% across 5 centers 1990 -91 CABG Improvement Interventionoverall mortality reduced 24% 1992 -95 Examined the Cause of Death 1996 -98 Focused look at low output heart failure 1999 -01 American Heart Association Patient Care and Outcomes Research Grant Improvement Grant to reduce mortality from low output heart failure Copyright 1999, Trustees of Dartmouth College

A regional prospective study of inhospital mortality associated with coronary artery bypass grafting- (198789) Making wise choices. . . 7 6 5 In-hospital Mortality Rate (%) 4 3 2 1 0 1 2 3 4 5 Center Copyright 1991; 266: 803 -809 O’Connor, GT et al. JAMA, 1999, Trustees of Dartmouth College

Making wise choices. . . CABG Improvement 1990 -1991 A Prospective study Three interventions aimed at reducing CABG mortality Feedback of outcome data Training on continuous quality improvement techniques Site visits to other medical centers 4 Copyright 1999, Trustees of Dartmouth College

Expected/Observed mortality all patients (N = 15, 095) Making wise choices. . . 10 Pre-intervention Post-intervention N = 6, 488 Intervention N = 6, 638 9 N = 1, 969 8 7 6 5 4 3 2 1 0 7/87 10/87 1/88 4/88 7/88 10/88 1/89 4/89 7/89 10/89 1/90 4/90 7/90 10/90 1/91 4/91 7/91 10/91 1/92 4/92 7/92 10/92 1/93 4/93 Date of Beginning of Quarter Expected Observed Copyright 1999, Trustees of Dartmouth College O’Connor, GT et al. JAMA 1996; 275: 841 -6

Making wise choices. . . Lessons Learned Continued Participation After 13 years all cardiac surgeons continue to participate. Benchmarking Multicenter data allowed powerful insights and identification of “best practices”. Improved Care Patient care is substantially improved. A recent Duke study showed CABG outcomes in NNE to be the best in the US and the most improved. Academic Productivity The group have been very academically productive. Copyright 1999, Trustees of Dartmouth College