thom walsh phd, ms, mspt thom.walsh@dartmouth.edu |   twitter.com/@thomwalsh

Developing Sustainable Methods of Health Care: A Global Challenge

The Dartmouth Center for Health Care Delivery Science

Thom Walsh PhD, MS, MSPTthom.walsh@dartmouth.edu | twitter.com/@thomwalsh

The Dartmouth Center for Health Care Delivery Science

Created in 2010, the Dartmouth Center for Health Care Delivery Science draws upon unique resources from across disciplines, forming innovative global partnerships that bring the discipline of science to the questions of service delivery while building a deeper understanding of the personal dimension of health and health care.

“We must find a sustainable health system for patients, providers, payers, and our communities”

CEO Dartmouth-Hitchcock Health System

Jim Weinstein DO, MS

The Dartmouth Center for Health Care Delivery Science

Master of Health Care Delivery Science

Research

A Health Care Delivery Science Post-Doc’s Life

Best ThinkersBest Thinkers Across

Disciplines

Best Doers Across

Contexts

Best Communicators

Across Constituencies

Best Doers

Best Thinkers Across

Disciplines

Best Doers Across

Contexts

Best Communicators

Across Constituencies

Best Communicators

Best Thinkers Across

Disciplines

Best Doers Across

Contexts

Best Communicators

Across Constituencies

Health Care Delivery Science

A

D B

C

The Implementation

GapOut

com

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Spending

Health Care Delivery Science

The Dartmouth Center for Health Care Delivery Science

Across Countries and Contexts

Dr. Lisa Adams in Rwanda Dr. Jaime Bayona in TanzaniaHealth Coaches in Peru

Health & Health Care

Clinical training teaches us to link outcomes and exposures

• Upper respiratory infection viruses• Cancer carcinogens• Obesity calories in/calories out

There Is More to the Story…

The Field Model

McKinlay & McKinlay 2005[1997]. Pp. 7 - 19 Sociology of Health & Illness

Haiti• Affordable housing and

health: The $300 House Project

• Medical education: weekly video lecture series in “grand rounds” style to seven sites in Haiti.

Haiti: The $300 House Project

• Cross-disciplinary approach to health care: Studio Art / Architecture, Thayer Engineering, Tuck Business, Undergraduate Arts & Sciences, Graduate Studies, Geisel School of Medicine

Molly Bode at Dartmouth site visit for $300 House Project

The Epidemiologic Transition

Wilkinson, R: Unhealthy Societies 1996

The Epidemiologic Transition

Medical Education in Haiti

• Dartmouth, Haiti Medical Education (HME) Project & McGill University weekly video lecture series and curriculum development

• Building an education network

Peru: Partnership Overview

• Oncology systems with National Cancer Institute

• Emergency preparedness • Primary care • Maternal mortality

prevention • Shared decision making• Geisel, Tuck, Thayer, and

Arts & Sciences collaborating on projects

Dartmouth undergraduate and medical students in Lima, Peru

Rwanda

Dr. Agnes Binagwaho, Minister of Health of Rwanda, receiving an honorary degree from Dartmouth President, Dr. Jim Yong Kim, in 2010.

Moving from Infectious to Chronic Disease & Unintended

Consequences

The Distribution of Health Care Spending

Per Condition for Similar PatientsAdapted from “Cowboys and Pit Crews” by Atul Gawande, The New Yorker. May 26, 2011

The Distribution of Quality Health Care Provision

Per Condition for Similar Patients

What We Believe

Cost & Quality Curves Match

ImplicationCurves match

– Reducing health care spending impairs quality

What the Data Tell Us

Cost & Quality Curves Do Not Match

Some Areas Provide Above Average Quality at Below Average Spending

ImplicationCurves do not match

– It is possible to reduce spending and improve quality

• National & Regional Dartmouth Atlases

• A High Value Health Care Collaborative

• New Models of Primary Care• Leadership Training Programs

Health Care Reform in ChinaDartmouth’s Approaches to Serve China

Chinese Provinces

Different Contexts

• Developing, emerging, & sustaining economies

• Single payer & multi-payer health care systems

Similar Interventions

• Assessment of variation as a catalyst for change

• Networks– Improvement– Education

• Reforming & revitalizing primary care– Community integrated care

• Shared Decision Making

Master of Health Care Delivery Science (MHCDS) Faculty

Dartmouth College Master of Health Care Delivery Science

On-Line Synchronous Platform

Create a medical home system to

divert future unnecessary emergency

department visits

Implement evidence-based quality-of-life care in a high-intensity facility

for end-stage COPD care

Design benefits package for first

state-based single-payer health care system in US

Learning in Action 2013

Break

C. Monet(1840-1926)Research Focus

The Value Equation

V = OP / C

Value = Patient Outcome / Cost of Care

Bringing the Numerator to Life

The Spine Center’s Data Collection

Available and Actionable

Case 1

Case 1

Case 2

Case 2

Case 3

Case 3

Case 2

The Value Equation

V = OP / C

Value = Patient Outcome / Cost of Care

Preference Diagnosis

http://www.kingsfund.org.uk/publications/patients%E2%80%99-preferences-matter

Preference Diagnosis

71% of physicians rated “keeping my breast” as a top priority for women with breast CA

7% of women report “keeping my breast” as a top priority (Lee 2010)

Preference Misdiagnosis• Well informed

– men with prostate disease choose surgery 40% less often – Wagner 1995

– Patients with heart disease choose percutaneous intervention 20% less often – Morgan 2000

– Patients with disc herniation choose surgery 30% less often – Deyo 2000

– Patients with spinal stenosis choose surgery 30% more often – Deyo 2000

Two Types of Medical Errors

Medical Error 1 – Sue tears her right anterior cruciate ligament, but has her left knee operated on

Medical Error 2 – Joe has his right knee replaced then learns about alternative treatments and wishes he did not have the operation

Preferences are the Silent Misdiagnosis

Providers are not yet trained to make preference diagnoses

Steps for Diagnosing Patient Preferences

Team Talk

Option Talk

Decision Talk

Initial Preferences

Informed Preferences

D e l i b e r a t i o n

Long – Type Patient Decision Support

Short-Type Patient Decision Support

Long - Type Decision Support

Short -Type Decision Support

In situations of clinical equipoise– Outcomes depends on understanding what informed patients need

and want– Treatment options have proliferated– Patients need to be informed of options, risks and benefits– Providers need to elicit preferences & integrate informed patient

choice into treatment planning

How to measure a clinic or provider’s skill?

CollaboRATE

A fast, frugal & sustainable, patient reported measure of patient-centeredness during the clinical encounter

Simulation, level of SDM

Information Preference Elicitation

Preference Integration

Scenario 1No SDM

Little Explanation No Preference Elicitation

Scenario 2Low SDM

Detailed Explanation No Preference Elicitation

Scenario 3Low SDM

Little Explanation Preference Elicitation No Preference Integration

Scenario 4Moderate SDM

Detailed Explanation Preference Elicitation No Preference Integration

Scenario 5Moderate SDM

Little Explanation Preference Elicitation Preference Integration

Scenario 6High SDM

Detailed Explanation Preference Elicitation Preference Integration

The Value Equation

V = OP / C

Value = Patient Outcome / Cost of Care

Health Care Production Costs

The amount it takes to pay personnel, rent, and for materials used to provide health care.

Health Care Population Spending

The amount spent to reimburse providers of health care services & equipment.

Total population spending on iPads is rising, but the production costs of tablets are not.

Bending Population Spending Requires Bending Production Costs

Current Production Costs

Operating Margin 4-10%

Production Costs > Population Spending

Population Spending Estimates Based on Past Claims

New Production Costs Required to Maintain Margin

Time

$

Do Patient Decision Support Interventions (DESIs)

lead to health care savings?

DESIs = Savings?• Study characteristics• Risk of bias• Quality of the economic evaluation• Costs & resources allocation needed to

implement upstream• Savings downstream

– Consider knee replacement surgery

The Atlantic Monthly & The 141

• What ‘Health Care Costs’ Really Means• The 141:

What I'm talking about when I talk about costs and spending

The Value Equation

V = OP / C

Value = Patient Outcome / Cost of Care

Health Care Delivery Science

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D B

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The Implementation

Gap

Out

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Spending

Health Care Delivery Science

Broader access Better health care Better health Lower cost

PRESSING NEED

ModelsMethodsMetrics Value

UniversitiesGovernmentsPrivate sector New vision of health care delivery

REQUIRES NEW PARTNERSHIPS

FOR INNOVATION AND IMPLEMENTATION

Health Care Delivery is a Global Challenge

Health Care as a Right

Health Care as a Common

“All patients should receive the care they need, and no less. They should also receive the care they want, and no more.” - Al Mulley

Developing Sustainable Methods of Health Care: A Global Challenge

The Dartmouth Center for Health Care Delivery Science

Thom Walsh PhD, MS, MSPTthom.walsh@dartmouth.edu | twitter.com/@thomwalsh

Blog: The 141 With Jennifer B. Murray