The Role of Shared Decision Making in Reducing Unwarranted Variation in Health Care A Talk by Jack...
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The Role of Shared Decision Making in Reducing The Role of Shared Decision Making in Reducing Unwarranted Variation in Health CareUnwarranted Variation in Health Care
A Talk by Jack WennbergA Talk by Jack Wennberg
Implementing shared decision making: Implementing shared decision making: lessons from the frontlessons from the front
May 26, 2011May 26, 2011
Understanding Variations in the Way Medicine is PracticedUnderstanding Variations in the Way Medicine is Practiced
The Vermont StoryThe Vermont Story
The Maine StoryThe Maine Story
The Dartmouth Atlas ProjectThe Dartmouth Atlas Project
New Hampshire
Massachusetts
New York
Quebec
From From “Science,”“Science,” December 14, 1973.December 14, 1973.
Vermont Map from “Science”Vermont Map from “Science”
Morrisville and Waterbury CenterMorrisville and Waterbury Center
Tonsillectomy Rate per 10,000 Children Among 13 Tonsillectomy Rate per 10,000 Children Among 13 Vermont Hospital Service AreasVermont Hospital Service Areas
00
5050
100100
150150
200200
250250
300300
350350
400400
450450MorrisvilleMorrisville
19691969
Stages of Facing RealityStages of Facing Reality
• Stage 1. “The data are wrong.”Stage 1. “The data are wrong.”• Stage 2. “The data are right, but it’s not a Stage 2. “The data are right, but it’s not a
problem.”problem.”• Stage 3. “The data are right; it is a problem; but it Stage 3. “The data are right; it is a problem; but it
is not my problem.”is not my problem.”• Stage 4. “I accept the burden of improvement.”Stage 4. “I accept the burden of improvement.”
Tonsillectomy Rate per 10,000 Children Among 13 Tonsillectomy Rate per 10,000 Children Among 13 Vermont Hospital Service AreasVermont Hospital Service Areas
00
5050
100100
150150
200200
250250
300300
350350
400400
450450
MorrisvilleMorrisville
MorrisvilleMorrisville
19691969 19731973
Understanding Variations in the Way Medicine is PracticedUnderstanding Variations in the Way Medicine is Practiced
The Vermont StoryThe Vermont Story
The Maine StoryThe Maine Story
The surgical signatures of the five most The surgical signatures of the five most populous HSAs in Maine (1975)populous HSAs in Maine (1975)
0.00.0
1.01.0
2.02.0
3.03.0
PortlandPortland LewistonLewiston AugustaAugusta WatervilleWaterville BangorBangor
Rat
io t
o s
tate
ave
rag
eR
atio
to
sta
te a
vera
ge
Tonsillectomy Hysterectomy Varicose Veins
Prostatectomy Hemorrhoidectomy Total Procedures
Testing BPH TheoriesTesting BPH Theories
• The Preventive Theory of SurgeryThe Preventive Theory of Surgery
• The Quality of Life Theory of SurgeryThe Quality of Life Theory of Surgery
Which rate is right? Impact of improved Which rate is right? Impact of improved decision quality on surgery rates: BPHdecision quality on surgery rates: BPH
Knowledge of relevant treatment
options and outcomes
Concordance between patient values
and care received
Understanding Variations in the Way Medicine is PracticedUnderstanding Variations in the Way Medicine is Practiced
The Vermont StoryThe Vermont Story
The Maine StoryThe Maine Story
The Dartmouth Atlas ProjectThe Dartmouth Atlas Project
The Dartmouth Atlas Project: 306 hospital referral regionsThe Dartmouth Atlas Project: 306 hospital referral regionsOngoing Study of Traditional Medicare Population USAOngoing Study of Traditional Medicare Population USA
Unwarranted Variation in Health Care Delivery:Unwarranted Variation in Health Care Delivery:
Variation that can’t be explained by illness Variation that can’t be explained by illness
or patient preferencesor patient preferences
The Three Categories of Unwarranted The Three Categories of Unwarranted Variation in Health Care DeliveryVariation in Health Care Delivery
Effective CareEffective CareEE
vviiddeennccee--bbaasseedd ccaarree tthhaatt aallll wwiitthh nneeeedd sshhoouulldd rreecceeiivvee
Preference-Sensitive CarePreference-Sensitive Care
Supply-Sensitive CareSupply-Sensitive Care
Preference-Sensitive Care Preference-Sensitive Care
• Involves tradeoffs -- more than one treatment exists Involves tradeoffs -- more than one treatment exists and the outcomes are differentand the outcomes are different
• Decisions should be based on the patient’s own Decisions should be based on the patient’s own preferencespreferences
• But Provider Opinion Often Determines Which But Provider Opinion Often Determines Which Treatment is UsedTreatment is Used
Knee Replacement: An Example of Preference-Sensitive CareKnee Replacement: An Example of Preference-Sensitive Care
Ratio of knee replacement rates to the U.S. average (2005Ratio of knee replacement rates to the U.S. average (2005))
11.30.30 to to 11.75.75 (46)(46)11.10.10 to < to < 11.30.30 (78)(78)00.90.90 to < to < 11.10.10 (106)(106)00.75.75 to < to < 00.90.90 (53)(53)00.41.41 to < to < 00.75.75 (23)(23)Not PopulatedNot Populated
Total Knee replacement for Arthritis per 1,000 Medicare Total Knee replacement for Arthritis per 1,000 Medicare enrollees among 306 Hospital Referral Regionsenrollees among 306 Hospital Referral Regions
1.01.0
3.03.0
5.05.0
7.07.0
9.09.0
11.011.0
1992-93 2000-01
Red dot = U.S. average:Red dot = U.S. average: 4.034.03 5.64 40% increase5.64 40% increase
Relationship Between Knee Replacement Rates Among Relationship Between Knee Replacement Rates Among Hospital Referral Regions in 1992-93 and 2000-01Hospital Referral Regions in 1992-93 and 2000-01
0.00.0
2.02.0
4.04.0
6.06.0
8.08.0
10.010.0
12.012.0
0.00.0 2.02.0 4.04.0 6.06.0 8.08.0 10.010.0 12.012.0
Knee Replacement (1992-93)Knee Replacement (1992-93)
Kn
ee R
epla
cem
ent
(200
0-01
)K
nee
Rep
lace
men
t (2
000-
01)
R2 = 0.75
Determining the Need for Hip and Knee Arthroplasty: Determining the Need for Hip and Knee Arthroplasty: The Role of Clinical Severity and Patients’ Preferences The Role of Clinical Severity and Patients’ Preferences
. . . Among those with severe arthritis, no . . . Among those with severe arthritis, no more than 15% were definitely willing to undergo more than 15% were definitely willing to undergo (joint replacement), emphasizing the importance (joint replacement), emphasizing the importance of considering both patients’ preference and of considering both patients’ preference and surgical indications in evaluating need and surgical indications in evaluating need and appropriateness of rates of surgeryappropriateness of rates of surgery
Bottom Line Implication: Bottom Line Implication:
Clinical Appropriateness should be based on sound Clinical Appropriateness should be based on sound evaluation of treatment options (outcomes research)evaluation of treatment options (outcomes research)
To Avoid Wrong Patient Surgery, Medical Necessity To Avoid Wrong Patient Surgery, Medical Necessity should be based on Informed Patient Choice among should be based on Informed Patient Choice among Clinically Appropriate OptionsClinically Appropriate Options
Conditions involving preference-sensitive Conditions involving preference-sensitive surgical decisionssurgical decisions
ConditionCondition Treatment Options Treatment Options
• Silent GallstonesSilent Gallstones Surgery versus watchful waiting Surgery versus watchful waiting
• Chronic Stable Angina PCI vs. surgery vs. other methodsChronic Stable Angina PCI vs. surgery vs. other methods
• Hip and Knee ArthritisHip and Knee Arthritis Joint replacement vs. pain meds Joint replacement vs. pain meds
• Carotid Artery Stenosis Surgery vs. aspirinCarotid Artery Stenosis Surgery vs. aspirin
• Herniated DiscHerniated Disc Back surgery vs. other strategies Back surgery vs. other strategies
• Early Prostate Cancer Early Prostate Cancer Surgery vs. radiation vs. waiting Surgery vs. radiation vs. waiting
• Enlarged ProstateEnlarged Prostate Surgery vs. other strategies Surgery vs. other strategies
• Early Stage Breast Cancer Lumpectomy vs. mastectomy Early Stage Breast Cancer Lumpectomy vs. mastectomy
Knee replacement per 1,000 Medicare Knee replacement per 1,000 Medicare enrollees (2003-07)enrollees (2003-07)
WenatcheeWenatchee 9.29.2SpokaneSpokane 9.19.1OlympiaOlympia 8.78.7TacomaTacoma 8.38.3Port AngelesPort Angeles 8.08.0PuyallupPuyallup 7.97.9BellevueBellevue 7.87.8VancouverVancouver 7.67.6RentonRenton 7.57.5BremertonBremerton 7.57.5YakimaYakima 7.47.4BellinghamBellingham 7.27.2SeattleSeattle 6.86.8EverettEverett 6.56.5
2.02.0
4.04.0
6.06.0
8.08.0
10.010.0
12.012.0
14.014.0
TURP for BPH per 1,000 male Medicare TURP for BPH per 1,000 male Medicare enrollees (2003-07)enrollees (2003-07)
WenatcheeWenatchee 9.99.9Port AngelesPort Angeles 7.87.8PuyallupPuyallup 7.87.8BremertonBremerton 6.76.7SpokaneSpokane 6.06.0EverettEverett 4.44.4TacomaTacoma 4.04.0YakimaYakima 3.23.2VancouverVancouver 2.82.8BellinghamBellingham 2.52.5SeattleSeattle 2.42.4OlympiaOlympia 2.32.3RentonRenton 2.22.2BellevueBellevue 1.71.7
1.01.0
3.03.0
5.05.0
7.07.0
9.09.0
11.011.0
Dartmouthatlas.orgDartmouthatlas.org
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