1
DHMCDHMC
Dr James N WeinsteinProfessor and Chairman Department of Orthopedic Surgery
Co-Director Clinical Trials CenterSenior Member Center for the Evaluative Clinical Sciences
Dartmouth Medical School
HEALTHCARE in The New Millenium The Heart of “Leadership”Figuring on what is going on in a complex world
•Challenges and Solutions ?
•Disparity (economic, ethnic & racial, medical errors, work hours, etc.)
•Physician vs Patient Perspective
•Industry Reaction
•Variations in Delivery
•Conflict of Interest
•Evidence based Practice—Practical applications in clinical practice and research
Medicine and EconomicsOverall Health of a Nation
U.S. ranks 37th in the world
The state of our health as a nation(US)is not the best in the world
despite spending more than one trillion dollars/year - - - - why?
‘ The Facts’--
Public Perception
Why should you care ?------- Choice:
Proactive vs. Reactive
Richard G. Wilkinson, 1996, Routledge, UK.
The
H(w)ealth
of a Nation
Economic Disparity
2
Racial Disparity ? Total Knee Arthroplasty (NEJM, Oct 3, 2003 )
Black vs White
Racial Disparity ? Total Knee Arthroplasty (NEJM, Oct 3 , 2003)
Hispanic vs White
No Change in Surgeons’Weekly Hours of Work
0
10
20
30
40
50
60
Hours Per Week
1989 1999
Source: AMA, 1987 and 2000-02
Physician Perspective
Real Income Staying About the Same (Net Income By Selected Specialty in 2000$$, 1988-98)
0.050.0
100.0150.0200.0250.0300.0350.0400.0450.0
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
Net
Inco
me
(Tho
usan
ds, i
n 20
00$)
Orthopedic Surg.General Surg.CardiovascularPediatricsAnesthesiologist
Source: Physician Socioeconomic Statistics, 2000-2002 (AMA)
ReimbursementIncome = Price x Quantity – Costs
...And the (inflation adjusted) THR price has fallen by 54%
$0
$500
$1,000
$1,500
$2,000
$2,500
$3,000
$3,500
1989 2000
Source: Letter of 7/17/2000 from HR Desmarais to S. Bastacky
Avg. Medicare Payment for THR (CPT 27130) in 2000$$
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So Productivity (Q/Surgeon) is Rising at About the Same Rate Reimbursements (P) Are Falling
Richard Doyle, 1844, http://vassun.vassar.edu/~sttaylor/FAMINE/Punch/Burden/Sisyphus.gif
Estimated Dollars Available Under MedicareRisk Contracts in Excess of Amount Available to
Residents of Minneapolis
$3,1
83
$2,4
73
$1,7
88
$4,3
53
$4,1
81
00
500500
1,0001,000
1,5001,500
2,0002,000
2,5002,500
3,0003,000
3,5003,500
4,0004,000
4,5004,500
MiamiMiami ManhattanManhattan LosLosAngelesAngeles
ChicagoChicago AtlantaAtlanta
AA
PC
C p
er E
nro
llee
(199
7)A
AP
CC
per
En
rolle
e (1
997)
J Wennberg MD MPH
Dartmouth Atlas HealthcareReimbursement Disparity based on where you live !
More Medicare Spending Doesn’tCure Under Service
R2 = 0.011010
1515
2020
2525
3030
3535
4040
4545
2,0002,000 4,0004,000 6,0006,000 8,0008,000 10,00010,000
Fully Adjusted Medicare ReimbursementsFully Adjusted Medicare Reimbursementsper capita (1996)per capita (1996) J. J. WennbergWennberg MD, MPHMD, MPH
E. E. Fisher Fisher MD, MPHMD, MPHAnnals of Annals of IntInt MedMed
Ind
ex o
f C
are
(199
5In
dex
of
Car
e (1
995 --
96)
96)
Fortune 500 Companies
What else ?Industry is no longer waiting in the wings !!
Mark Chassin
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The Clinician and
The Public Dilemma
Clinical and public health policies, like other public policies, may sometimes be based less on rational decision-making than on the
combined influences of partisan interests.
The scientific evidence may be one of these interests, but not always the dominant one, i.e.
Science is not always the driver of healthcare utilization
Ratios of Back Surgery Rates in selected countries/provinces to those of the US.
0
0.2
0.4
0.6
0.8
1
SCO ENG MAN SWE NZ AUS ONT NOR FIN DEN NET US
Cherkin DC, Deyo RA, Loeser JD et al:Spine 19:1201-1206, 1994.
An In depth look at Spine Surgery
Health Disparities in Musculoskeletal
Disease
James N. WeinsteinData from the Dartmouth Atlas
Working GroupDartmouth Medical School
NIAMS Conference on Health Disparities in Arthritis and Musculoskeletal and Skin DiseasesDecember 15-16, 2000
Bethesda, MD
WHO is PerformingSpine Surgery in U.S.
1996 %Total Ortho 31321 Neuro 55954 ~~ 70%
87275
Ratio of Rates of OrthopedicSurgeons to the U.S. Average (1996)
1.30 to 1.71 (33)1.10 to < 1.30 (48)0.90 to < 1.10 (105)0.75 to < 0.90 (83)0.39 to < 0.75 (37)Not Populated
Ratio of Rates of Surgery for LumbarSpinal Stenosis per 1,000 MedicareEnrollees to the U.S. Averageby 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
Geography is destiny ?
Supply-Induced Demand
Workforce How many Orthopedic Surgeons do we need?
Not sure this is the right question!
vs.
Where one lives !
5
Spine Surgery per 1,000 Medicare Enrollees (1996-97)
1.01.0
2.02.0
3.03.0
4.04.0
5.05.0
6.06.0
7.07.0
8.08.0
9.09.0
Sp
ine
Su
rger
y (1
996
Sp
ine
Su
rger
y (1
996 --
97)
97)
Bend, Or
3.42 U.S
3.83 Phoenix
5.36 Tuscon
Spine Surgery per 1,000 Medicare Enrollees (1996-97)
Red Dots Indicate HRRs Containing At Least One Medical School
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
Sp
ine
Su
rger
y (1
996-
97)
0.53 0.44 1.530.40 0.52 1.700.41 0.45 1.440.68 0.91 1.920.48 0.66 1.180.26 0.71 0.750.53 0.62 0.840.56 1.01 1.510.49 0.72 1.63
Cervical Spine
Surgery
Lumbar Discectom
y
Decompression for
Lumbar Stenosis
1.09 0.61 0.940.83 0.72 1.040.84 0.62 0.881.39 1.27 1.180.98 0.92 0.720.53 0.98 0.461.08 0.86 0.511.16 1.41 0.93
0.61 0.
72
0.62
0.92 0.
98
0860.
94 1.04
0.88
1.1
0.72
0.46
1.09
0.83 0.84
0.98
0.53
0.0
0.2
0.4
0.6
0.8
1.0
1.2
Fresno Modesto AlamedaCounty
Salinas SanFrancisco
San Jose
Rat
io to
U.S
. Ave
rage
(199
6-9
Lumbar DiscectomyDecompression for Lumbar StenosisCervical Spine Surgery
R2 = 0.221.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
5.0 20.0 35.0 50.0 65.0 80.0
CT/MRI (1996-97)
Spin
e Su
rger
y (1
996-
97)
0.2
1.0
3.0
0.5
2.0
Sta
nd
ard
ized
Dis
char
ge
Rat
io(L
og
Sca
le)
Hip
Fra
ctu
reR
epai
r
Co
lect
om
y
Ch
ole
cyst
-ec
tom
y
CA
BG
Hip
Re-
pla
cem
ent
Bac
kS
urg
ery
Car
oti
dE
nd
art.
PT
CA
L.E
.B
ypas
s
Rad
ical
Pro
st.
Profiles of Variation for Ten Common Surgical Procedures (1995-96)
Professional Uncertainty New Yorker Magazine
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An Opportunity!
Proliferation “Evidence”
Consensus analysis– only 10-14% useful
information
Citation Analysis– Most articles (~50%)
never cited again
Fodder for the government, HMO’s, large payers, unions and legal professions,etc.
Branscomb LM. Scientific Research, 1968;3:49-56.Goffman W. In: Coping with Biomedical Literature. Praeger, 1981;31-46.Lock S. Br Med J, 1982;284:1289-90.
?
Lack of evidence-Doctor rules
Doctor or Patient
But who knows
and who cares
20 fold
0.2--2.2/1000
Literature
Consequences
Public Trust ErodesClinical Unrest
Policy Decisions, e.g.Funding Redirected
Reimbursement Reduced
1992-2002 Spine Medicare Fee Schedule
Surgical conversion factor 17% -12%Non-surgical conversion factor 17% 7%
CPT Descriptor 1992 1997 200292-02% ?
97-02% ?
22554 Arthrodesis,cervical below C2
$1,354 $1,662 $1,306 -4% -21%
22612 Arthrodesis, singlelevel, lumbar
$1,255 $1,807 $1,449 15% -20%
22614 Arthrodesis, eachaddtl. Vertebra
N/a $533 $399 N/a -25%
22842 Posterior Segmntl.Instrumentation;3-6 segments
$1,414 $842 $776 -45% -8%
What is our responsibility ? To the extent the public and their representatives distrust the profession, they are likely to demand greater regulation of
practice and research and are likely to provide fewer resources for both.
Since the acts of individual physicians can affect public confidence in the whole profession, individual professionals have an obligation, both to the public and to the profession, to make sure their own conduct does not impair their colleagues capacity to practice medicine or conduct research.
Thompson, D.F.
NEJM 1993
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Conflict of InterestAuthors are much more likely to support calcium-channel blockers for cardiac conditions if they had a financial relationship with the
manufacturer(drug company)70 articles were reviewed (march ‘95-sept ‘96)
23 critical30 supportive
17 neutral
2/3 had a financial relationship
** only two authors disclosed the potential conflict
96% of supportive manuscripts had financial relationships
Stelfox, HT
NEJM 1998
The MarketAnalgesics vs. NSAIDS
• 184 patients with osteoarthritis• Randomized, double-blind trial• 2400 or 1200 mg of ibuprofen per day or 4000 mg
of acetaminophen per dayBradley et al. N Engl. J Med. 1991; 325:87-91.
Yet the market drives the clinical use of non-steroidals
NY TimesNov. 21, 2001
Take home message:Company-funded trials have a high
likelihood of favoring the company’s product.
Adds to public suspicionDecember 18, 2002JAMACardiovascular Outcomes of Antihypertensive TreatmentsIn an editorial, Appel concludes that thiazide diuretics should
be considered the preferred initial therapy for hypertension.
EditorialThe Verdict From ALLHAT Thiazide Diuretics Are the Preferred Initial Therapy for Hypertension
Lawrence J. Appel, MD, MPHQuite simply, the Antihypertensive and Lipid-Lowering Treatment to
Prevent Heart Attack Trial (ALLHAT) is one of the most importanttrials of antihypertensive therapy.
Conflict of Interest: Art or Science? The Hippocratic Solution“Conflict of interest need not be a conflict within our minds. We
must remain guided by our Hippocratic principles and our individual values. Physician/scientists need the freedom to explore openly and honestly and not fear the reprisals of a system. This can
occur as long as we continue to respect and improve that system with continued open and honest discourse.” ---------
J Weinstein
Spine 2002
Editorial
Conflict of Interest; Art or Science? The Hippocratic Solution
Conflict of interest need not be a conflict within our minds
Guiding Principles1) Veracity of results cannot be compromised.2) Oversight is imperative-by a disinterested party.3) Financial and non-financial incentives must be
addressed from the outset as must institutional and investigator requirements to disclose.
4) Proprietary rights and intellectual property should be acknowledged-the right to publish must be assured.
James N. Weinstein, Editor-in-Chief SPINE 2002;27:3-5
Jim Weinstein
Editor-in-Chief
The Role of the Editor
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Given limited dollars
The public wants healthcare to improve and they want their doctors to
to improve it!
Have we lost our way?
I don’t believe so!!
But if the science has been lost in the rush for money.
We have lost our way. Jim Weinstein
How do we, as physicians, re-establish ourselves as
stewards of our profession?
• We accept accountability
• We work together - Collaborative Learning
• We must be willing to change our behavior
• We must rely on good data to drive that change
Evidence-Based Practice al a Cochrane
1) Identify specific question from practice(diagnosis, treatment, etiology, prognosis)
2) Search and retrieve external evidence(literature)
3) Critically appraise re: the quality of material
4) Distill raw data into clinically relevant information
5) Implementing information into clinical decisions,e.g., integrating external and internal information with patient expectations and preferences
So, --How good are we at using the evidence to practice?
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Five Year Trends in Spine Surgery
SpineSurgery: 37%Fusion: 72%Fusion +Hardware: 106%
0
1
2
3
4
1993 1994 1995 1996 1997
Year
Pro
ced
ure
s p
er 1
,000
Med
icar
eE
nro
llees
Spine SurgeryFusionFusion +Hardware
Increase
Dartmouth Atlas Musculoskeletal Health Care 2000 Medicare Part B 1993-1997
Is Spine Surgery effective? The Surgical Signature for Spine Surgery in Eight California HRRs (1996-97)
0.61 0.
72
0.62
1.27
0.92 0.
98
0.86
1.41
0.94 1.
04
0.88
1.18
0.72
0.46 0.51
0.93
1.09
0.83
0.84
1.39
0.98
0.53
1.08 1.
16
0.00.0
0.20.2
0.40.4
0.60.6
0.80.8
1.01.0
1.21.2
1.41.4
1.61.6
FresnoFresno ModestoModesto AlaAla--medameda
CountyCounty
SalinasSalinas SanSanFranFran--ciscocisco
SanSanJoseJose
SanSanMateoMateo
CountyCounty
StocktonStockton
Rat
io t
o U
.S. A
vera
ge
(199
6R
atio
to
U.S
. Ave
rag
e (1
996 --
97)
97)
Lumbar Discectomy Lumbar Decompression Cervical Spine Surgery
Spine Surgery (1996)
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
65-69 70-74 75-79 80-84 85-99
NonBlack Male
NonBlack Female
Black Male
Black Female
Unexplained Disparities by Age, Sex, and Race Percent of Diabetic Medicare EnrolleesReceiving Annual HgbA1c Testing (1995-96)
8080 or Moreor More (0)(0)6060 to < to < 8080 (6)(6)4040 to < to < 6060 (104)(104)2020 to < to < 4040 (177)(177)Less than 20Less than 20 (19)(19)Not PopulatedNot Populated
Using the Evidence
Percent of “Ideal” Patients Receiving Aspirin at Discharge Following AMI (1994-95)
8080 or Moreor More (123)(123)6060 to < to < 8080 (175)(175)4040 to < to < 6060 (8)(8)2020 to < to < 4040 (0)(0)Less than 20Less than 20 (0)(0)Not PopulatedNot Populated
Ratio of Rates of Mastectomy for Breast Cancer to the U.S. Average (1995-96)
1.30 to 1.81 (42)1.10 to < 1.30 (68)0.90 to < 1.10 (106)0.75 to < 0.90 (61)0.45 to < 0.75 (29)Not Populated
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Which rate is right?Given good(evidence-based) information
the Patient should decide
Interesting Information but what do we do about it?Solution(s)
Patient Doctor
Treatment
Shared Decision-Making
Informed Choice
A Possible Solution to Variation
17 Decision aid trials
• Surgical
Coronary (2)
Prostate (2)
Breast (1)
Circumcision (2)
Dental (1)
Spine (2)**
Hip(In process AAOS)
Knee(In process AAOS)
• Medical– Hormones (2)
• Vaccine– Hep B (1)
• Screening/Testing– PSA (3)
– Amniocentesis (2)
– BRCA1 gene testing (1)
Results of Shared Decision Making
“Involving Patients in Clinical Decisions: Impact of an interactive video program on use of back surgery” Medical Care and
Spine, 2000
HNP 30%
Stenosis 10%Patients felt better informed and more knowledgeable
Amount of information received versus how much wanted
Much more7%
About right86%
A little less7%
Physicians Typically Underestimate Patient Desire
for Information Strull WM, et al “Do patients want to participate in medical decision-making?”
JAMA 1984 252:2990-2994 New York times Sun 3 15 03 In Orthopedics---many times there isn’t necessarily one obvious treatment,
one solution that’s right for a particular patient.
How to Choose?
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Operative vs Non Operative Treatment
How do you present complicated information to patients
TouchpadPatient Summary
Report
Video
S P O R TWeb
Randomization and Data Collection
Imaging Archive
3-D Surgical Prep
Challenges and Solutions
Incorporating Technology into practice:In Orthopedics at Dartmouth
1
Making Shared Decision-Making (Informed Choice) Part of the Process
EnrollmentAssignment
EnrollmentAssignment OrientationOrientation
InterdisciplinaryPatient
Assessment
InterdisciplinaryPatient
Assessment
Functional Restoration
Program
Functional Restoration
Program
Sub AcuteCare
Management
Sub AcuteCare
Management
People withhealthcare needs
People withhealthcareneeds met
SharedDecisionMaking
SharedDecisionMaking
PreventiveCare
Management
PreventiveCare
Management
DisenrollmentDisenrollment
Satisfaction of need, monitoring, assessment of outputs
Customer knowledge, including knowledge of customer’s life while not in direct contact with health care system
NSNNSNOutcomesOutcomesSurveySurvey
NSNNSNOutcomesOutcomesSurveySurvey
BataldenBatalden, Nelson. Adapted, Brown, Weinstein, with permission, 1998, Nelson. Adapted, Brown, Weinstein, with permission, 1998
ClinicalBiological
Status
SatisfactionagainstExpectations
Costs
FunctionalHealth Status
ClinicalBiological
Status Expectations
Costs
FunctionalHealth Status
Clinical trials are indispensable.They will continue to be an ordeal. They lack
glamour, they strain our resources and patience, and they protract the moment of truth to excruciating limits. Still, they are among the most challenging
tests of our skills. I have no doubt that when the problem is well
chosen, the study is appropriately designed, and that when all the populations concerned are made aware
of the route and the goal, the reward can be commensurate with the effort.
If, in major medical dilemmas, the alternative is to pay the cost of perpetual uncertainty, have we really
any choice?Donald Fredrickson, 1968
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S P O R TS P O R TSpine Patient Outcomes Spine Patient Outcomes
Research Trial(s) Research Trial(s) model of new of potential partnershipsmodel of new of potential partnerships
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
Can Patients and Their Doctors Make Better Decisions?
YES!!
• Informed Choice(SDM) using
“evidence-based medicine”
San Francisco
Omaha
St. Louis
Chicago
Detroit
Cleveland
Atlanta
Philadelphia New York (2)
Hanover
SPORT Sites
Copyright 1999, Trustees of Dartmouth College
------working together we can make a difference!!
**
****
Which rate is right?Given useful,
evidence-based information the patient should decide!!
“Knowledge is Power”
Norman Rockwell, The Saturday Evening Post, October 27, 1917
The Heart of Leadership__________________________________
Figuring out what is going on in a complex world
Shared Decision Making
Informed Choice