1. The Role of Shared Decision Making in Reducing Unwarranted Variation in Health Care A Talk by Jack Wennberg A Talk by Jack Wennberg Implementing shared decision making: lessons from the front Implementing shared decision making: lessons from the front May 26, 2011 May 26, 2011

2. Understanding Variations in the Way Medicine is Practiced The Vermont Story The Vermont Story The Maine Story The Dartmouth Atlas Project

4. New Hampshire Massachusetts New York Quebec From “Science,” December 14, 1973. Vermont Map from “Science”

5. Morrisville and Waterbury Center

8. Tonsillectomy Rate per 10,000 Children Among 13 Vermont Hospital Service Areas 0 50 100 150 200 250 300 350 400 450 Morrisville 1969

9. Stages 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 problem.”Stage 2. “The data are right, but it’s not a problem.” Stage 3. “The data are right; it is a problem; but it is not my problem.”Stage 3. “The data are right; it is a problem; but it is not my problem.” Stage 4. “I accept the burden of improvement.”Stage 4. “I accept the burden of improvement.”

10. Tonsillectomy Rate per 10,000 Children Among 13 Vermont Hospital Service Areas 0 50 100 150 200 250 300 350 400 450 Morrisville Morrisville 19691973

11. Understanding Variations in the Way Medicine is Practiced The Vermont Story The Vermont Story The Maine Story

12. The surgical signatures of the five most populous HSAs in Maine (1975) 0.0 1.0 2.03.0PortlandLewistonAugustaWatervilleBangor Ratio to state average TonsillectomyHysterectomyVaricose Veins ProstatectomyHemorrhoidectomyTotal Procedures

13. Testing BPH Theories The Preventive Theory of SurgeryThe Preventive Theory of Surgery The Quality of Life Theory of SurgeryThe Quality of Life Theory of Surgery

17. Which rate is right? Impact of improved decision quality on surgery rates: BPH Knowledge of relevant treatment options and outcomes Concordance between patient values and care received

18. Understanding Variations in the Way Medicine is Practiced The Vermont Story The Vermont Story The Maine Story The Dartmouth Atlas Project

19. The Dartmouth Atlas Project: 306 hospital referral regions Ongoing Study of Traditional Medicare Population USA

20. Unwarranted Variation in Health Care Delivery: Variation that can’t be explained by illness Variation that can’t be explained by illness or patient preferences or patient preferences

21. The Three Categories of Unwarranted Variation in Health Care Delivery Effective Care Evidence-based care that all with need should receive Preference-Sensitive Care Supply-Sensitive Care

22. Preference-Sensitive Care Involves tradeoffs -- more than one treatment exists and the outcomes are differentInvolves tradeoffs -- more than one treatment exists and the outcomes are different Decisions should be based on the patient’s own preferencesDecisions should be based on the patient’s own preferences But Provider Opinion Often Determines Which Treatment is UsedBut Provider Opinion Often Determines Which Treatment is Used

23. Knee Replacement: An Example of Preference-Sensitive Care Ratio of knee replacement rates to the U.S. average (2005 ) 1.30 to to1.75 (46) (46) 1.10 to < to <1.30 (78) (78) 0.90 to < to <1.10 (106) (106) 0.75 to < to <0.90 (53) (53) 0.41 to < to <0.75 (23) (23) Not Populated

24. Total Knee replacement for Arthritis per 1,000 Medicare enrollees among 306 Hospital Referral Regions 1.0 3.0 5.0 7.0 9.011.0 1992-932000-01 Red dot = U.S. average: 4.03 5.64 40% increase

25. Relationship Between Knee Replacement Rates Among Hospital Referral Regions in 1992-93 and 2000-01

27. Determining the Need for Hip and Knee Arthroplasty: The Role of Clinical Severity and Patients’ Preferences... Among those with severe arthritis, no more than 15% were definitely willing to undergo (joint replacement), emphasizing the importance of considering both patients’ preference and surgical indications in evaluating need and appropriateness of rates of surgery... Among those with severe arthritis, no more than 15% were definitely willing to undergo (joint replacement), emphasizing the importance of considering both patients’ preference and surgical indications in evaluating need and appropriateness of rates of surgery

28. Bottom Line Implication: Clinical Appropriateness should be based on sound evaluation of treatment options (outcomes research) To Avoid Wrong Patient Surgery, Medical Necessity should be based on Informed Patient Choice among Clinically Appropriate Options

29. Conditions involving preference-sensitive surgical decisions Condition Treatment Options Condition Treatment Options Silent Gallstones Surgery versus watchful waitingSilent Gallstones Surgery versus watchful waiting Chronic Stable Angina PCI vs. surgery vs. other methodsChronic Stable Angina PCI vs. surgery vs. other methods Hip and Knee Arthritis Joint replacement vs. pain medsHip and Knee Arthritis Joint replacement vs. pain meds Carotid Artery Stenosis Surgery vs. aspirinCarotid Artery Stenosis Surgery vs. aspirin Herniated Disc Back surgery vs. other strategiesHerniated Disc Back surgery vs. other strategies Early Prostate Cancer Surgery vs. radiation vs. waitingEarly Prostate Cancer Surgery vs. radiation vs. waiting Enlarged Prostate Surgery vs. other strategiesEnlarged Prostate Surgery vs. other strategies Early Stage Breast Cancer Lumpectomy vs. mastectomyEarly Stage Breast Cancer Lumpectomy vs. mastectomy

31. Knee replacement per 1,000 Medicare enrollees (2003-07) Wenatchee9.2 Spokane9.1 Olympia8.7 Tacoma8.3 Port Angeles8.0 Puyallup7.9 Bellevue7.8 Vancouver7.6 Renton7.5 Bremerton7.5 Yakima7.4 Bellingham7.2 Seattle6.8 Everett6.5

32. TURP for BPH per 1,000 male Medicare enrollees (2003-07) Wenatchee9.9 Port Angeles7.8 Puyallup7.8 Bremerton6.7 Spokane6.0 Everett4.4 Tacoma4.0 Yakima3.2 Vancouver2.8 Bellingham2.5 Seattle2.4 Olympia2.3 Renton2.2 Bellevue1.7

33. Dartmouthatlas.org Thank You!!!!! Thank You!!!!!