1. 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-AR A1
Copyright  1999, Trustees of Dartmouth College

2. 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

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

4. “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

5. 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 Haven) What will we do about it ?
Copyright  1999, Trustees of Dartmouth College

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

7. 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

8. 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

9. 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

10. 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

11. Copyright  1999, Trustees of Dartmouth College

12. 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

13. Medical & Surgical Signatures of Communities
Copyright  1999, Trustees of Dartmouth College

14. 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: , 1994.
Copyright  1999, Trustees of Dartmouth College

15. 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

16. Supply Induced Demand
Copyright  1999, Trustees of Dartmouth College

17. Ratio of Rates of Surgery for Lumbar
Spinal Stenosis per 1,000 Medicare
Enrollees to the U.S. Average
by Hospital Referral Region ( )
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

18. Ratio of Rates of Surgery for Lumbar
Disc Herniation per 1,000 Medicare
Enrollees to the U.S. Average
by Hospital Referral Region ( )
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

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

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

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

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

23. 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

24. 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

25. 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

26. 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 Diseases, 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

27. 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

28. 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

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

30. 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

31. Shared Decision Making
Copyright  1999, Trustees of Dartmouth College

32. Physicians typically underestimate patient’s desire for information
Strull WM, et al “Do patients want to participate in medical decision-making?” JAMA :
Supported by NIAMS U01-AR A1
Copyright  1999, Trustees of Dartmouth College

33. 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

34. “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
Supported by NIAMS U01-AR A1
Copyright  1999, Trustees of Dartmouth College

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

36. Copyright  1999, Trustees of Dartmouth College

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

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

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

40. Copyright  1999, Trustees of Dartmouth College

41. 59 Year Old Male L4-5 Disc Herniation (Surgical)
Copyright  1999, Trustees of Dartmouth College

42. 47 Year Old Female L3-4 Disc Herniation (Non-surgical)
Copyright  1999, Trustees of Dartmouth College

43. Thank You
Copyright  1999, Trustees of Dartmouth College

44. Copyright  1999, Trustees of Dartmouth College