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 U01-AR45444-01A1 Copyright  1999, Trustees of Dartmouth College

What can you and I do to. make a difference What can you and I do to make a difference? SPORT a surrogate model for What a health system can do!! Copyright  1999, Trustees of Dartmouth College

“Imagination is more important than knowledge” Albert Einstein Copyright  1999, Trustees of Dartmouth College J Weinstein, Dartmouth

“The significant problems that we face cannot be solved by the same level of thinking that created them” Albert Einstein Copyright  1999, Trustees of Dartmouth College J Weinstein, Dartmouth

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

Economics of Healthcare Healthcare Financing Copyright  1999, Trustees of Dartmouth College

Medical care now accounts for % of GDP : U.S. >14% Canada < 10% Australia 9% Great Britain 7% Copyright  1999, Trustees of Dartmouth College

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

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

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

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

Organization & delivery of services Differences in training Copyright  1999, Trustees of Dartmouth College

Organization & delivery of services Professional uncertainty Copyright  1999, Trustees of Dartmouth College

Copyright  1999, Trustees of Dartmouth College

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

Medical & surgical Signatures of Communities Copyright  1999, Trustees of Dartmouth College

“What you get depends on Where you live and Who you see” j weinstein Copyright  1999, Trustees of Dartmouth College

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

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

Supply Induced Demand Copyright  1999, Trustees of Dartmouth College

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

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

“What you get depends on Where you live and Who you see” j weinstein Copyright  1999, Trustees of Dartmouth College

Which rate is right? Supported by NIAMS U01-AR45444-01A1 Copyright  1999, Trustees of Dartmouth College

Outcomes Research ...typically studies healthcare effectiveness, (how well it actually works when applied in routine care) Supported by NIAMS U01-AR45444-01A1 Copyright  1999, Trustees of Dartmouth College

Randomized Trials ...tell us about treatment efficacy, (whether the treatment can work under ideal circumstances) Supported by NIAMS U01-AR45444-01A1 Copyright  1999, Trustees of Dartmouth College

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

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

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

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

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

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

The Real Question What do we mean by BETTER? Copyright  1999, Trustees of Dartmouth College

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

Shared Decision Making 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 U01-AR45444-01A1 Copyright  1999, Trustees of Dartmouth College

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

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 U01-AR45444-01A1 Copyright  1999, Trustees of Dartmouth College AHCPR HS#08079

“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 U01-AR45444-01A1 Copyright  1999, Trustees of Dartmouth College

Patients who saw video were better informed Randomized Trial HNP 30% Spinal Stenosis 10% Patients who saw video were better informed Copyright  1999, Trustees of Dartmouth College

Copyright  1999, Trustees of Dartmouth College

You must be part of the PROCESS Copyright  1999, Trustees of Dartmouth College

Video Tape Evaluation Informational Content Copyright  1999, Trustees of Dartmouth College

Video Tape Evaluation: Length Copyright  1999, Trustees of Dartmouth College

Copyright  1999, Trustees of Dartmouth College

59 Year Old Male L4-5 Disc Herniation (Surgical) Copyright  1999, Trustees of Dartmouth College

47 Year Old Female L3-4 Disc Herniation (Non-surgical) Copyright  1999, Trustees of Dartmouth College

Thank You Copyright  1999, Trustees of Dartmouth College

Copyright  1999, Trustees of Dartmouth College

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 U01-AR45444-01A1 Copyright  1999, Trustees of Dartmouth College

A model for Assessing Clinical Outcomes Spine Surgery By Dr. James Weinstein Supported by NIAMS U01-AR45444-01A1 Copyright  1999, Trustees of Dartmouth College

Medical care now accounts for: >14% of U.S. GDP Canada < 10% Australia 9% Great Britain 7% Copyright  1999, Trustees of Dartmouth College

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

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

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

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

Geographic Variations Supported by NIAMS U01-AR45444-01A1 Copyright  1999, Trustees of Dartmouth College

Dartmouth Atlas of Musculo-skeletal Healthcare Supported by NIAMS U01-AR45444-01A1 Copyright  1999, Trustees of Dartmouth College

Rates Epidemiological Data 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

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

Wennberg JE, McPherson K, & Caper P: N Engl J Med 311:295-300, 1984. “If physicians know what they are doing, why do such wide variations occur?” Wennberg JE, McPherson K, & Caper P: N Engl J Med 311:295-300, 1984. Supported by NIAMS U01-AR45444-01A1 Copyright  1999, Trustees of Dartmouth College

Which rate is right? Supported by NIAMS U01-AR45444-01A1 Copyright  1999, Trustees of Dartmouth College

What is outcomes research? Supported by NIAMS U01-AR45444-01A1 Copyright  1999, Trustees of Dartmouth College

Randomized Trials ...tell us about treatment efficacy, (whether the treatment can work under ideal circumstances) Supported by NIAMS U01-AR45444-01A1 Copyright  1999, Trustees of Dartmouth College

Outcomes Research ...typically studies healthcare effectiveness, (how well it actually works when applied in routine care) Supported by NIAMS U01-AR45444-01A1 Copyright  1999, Trustees of Dartmouth College

Clinical Trials An Overview Supported by NIAMS U01-AR45444-01A1 Copyright  1999, Trustees of Dartmouth College

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

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

Spine Institute for Special Surgery, KY UCSF Washington U., MO 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 University of Iowa Vanderbilt Copyright  1999, Trustees of Dartmouth College

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

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

What do we mean by BETTER? The Real Question What do we mean by BETTER? Copyright  1999, Trustees of Dartmouth College

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

47 Year Old Female L3-4 Disc 6 weeks of Physical Therapy Copyright  1999, Trustees of Dartmouth College

59 Year Old Male L4-5 Disc six months post-op 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.

12% have contacted their doctor with questions from “ER” 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

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:S110.

Evidence Based Medicine From the Classroom to the Clinic (Shared Decision Making) Explosion of Scientific Knowledge keeping up with the scientific literature synthesizing all this information efficiently and practically Supported by NIAMS U01-AR45444-01A1 Copyright  1999, Trustees of Dartmouth College

Shared Decision-Making Programs (VHS, CD-ROM, Interactive video) combine information from: clinical trials literature syntheses other outcomes studies with concerns of patients and physicians elicited in focus groups.

Video Tape Evaluation Informational Content Copyright  1999, Trustees of Dartmouth College

Video Tape Evaluation: Length Copyright  1999, Trustees of Dartmouth College

Findings: Need for More Information on Specific Treatments Options Copyright  1999, Trustees of Dartmouth College

HNP Findings: Mean Score 2 HNP Findings: Mean Score 2.55 Significant Degree of Decisional Conflict Copyright  1999, Trustees of Dartmouth College

The Voice of the Patient 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

Copyright  1999, Trustees of Dartmouth College

59 Year Old Male L4-5 Disc Herniation (Surgical) Copyright  1999, Trustees of Dartmouth College

47 Year Old Female L3-4 Disc Herniation (Non-surgical) Copyright  1999, Trustees of Dartmouth College

Thank You Copyright  1999, Trustees of Dartmouth College

Northern New England Cardiovascular Disease Study Group 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, multi-disciplinary 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. Eastern Maine Medical Center Fletcher Allen Health Care Maine Medical Center Dartmouth Hitchcock Medical Center Catholic Medical Center Beth Israel- Deaconess Medical Center Copyright  1999, Trustees of Dartmouth College

NNECDSG 1987-89 Prospective study of in-hospital mortality-rate 2-6% across 5 centers 1990-91 CABG Improvement Intervention-overall 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 in-hospital mortality associated with coronary artery bypass grafting- (1987-89) 7 6 5 In-hospital 4 Mortality Rate (%) 3 2 1 1 2 3 4 5 Center O’Connor, GT et al. JAMA, 1991;266:803-809 Copyright  1999, Trustees of Dartmouth College

Three interventions aimed at reducing CABG mortality 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) 1 2 3 4 5 6 7 8 9 10 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 Observed Expected Intervention N = 1,969 Pre-intervention N = 6,638 Post-intervention N = 6,488 Copyright  1999, Trustees of Dartmouth College O’Connor, GT et al. JAMA 1996;275:841-6

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 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, multi-disciplinary 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. Eastern Maine Medical Center Fletcher Allen Health Care Maine Medical Center Dartmouth Hitchcock Medical Center Catholic Medical Center Beth Israel- Deaconess Medical Center Copyright  1999, Trustees of Dartmouth College

NNECDSG 1987-89 Prospective study of in-hospital mortality-rate 2-6% across 5 centers 1990-91 CABG Improvement Intervention-overall 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 in-hospital mortality associated with coronary artery bypass grafting- (1987-89) 7 6 5 In-hospital 4 Mortality Rate (%) 3 2 1 1 2 3 4 5 Center O’Connor, GT et al. JAMA, 1991;266:803-809 Copyright  1999, Trustees of Dartmouth College

Three interventions aimed at reducing CABG mortality 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) 1 2 3 4 5 6 7 8 9 10 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 Observed Expected Intervention N = 1,969 Pre-intervention N = 6,638 Post-intervention N = 6,488 Copyright  1999, Trustees of Dartmouth College O’Connor, GT et al. JAMA 1996;275:841-6

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

Supported by NIAMS U01-AR45444-01A1 Copyright  1999, Trustees of Dartmouth College