choosing wisely; the dutch way of evaluation · 2015. 11. 13. · surgical numbers/yr ncch •6200...
TRANSCRIPT
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Wilco Peul, MD, PhD, MBAProfessor-Chair Dept. Of Neurosurgery
Leiden & The Hague, Holland
Choosing Wisely; The Dutch way of evaluation
What are expectations of patients & society ?Cooperation between Policy makers and MD ’s
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Conflict of interest
I work at a
neurosurgical
department
I am a spine surgeon
I received grants
from ZonMW (Dutch
heath care
authorities) on
several trials
My department
receives funding from
Insurance Companies
for research
I am co-applicant on
a trial on surgery vs
conservative
interventions for
Odontoid fractures
Medtronic, Paradigm
& Braun sponsor
studies (investigator
Initiated
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Scientific Freedom
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Neurosurgical Cooperation Holland,
Leiden &The Hague
•LUMC
•MCH
•HAGA
•LUMC •MCH •HAGA
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Surgical Numbers/yr NcCH• 6200 surgical interventions
– 3300 pts deg. spine (no instrumentation)
– 500 pts instrumented spine surgery
• 154 spinal tumor
• 60 craniocervical deformity
• 42 degenerative scoliotic deformity
• 244 fusion for failed back (?)
• Costs Spinal Implants 3.1 miljon euro
• Costs WBMV Neurosurgery 5.2 miljon euro5
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Ladies and GentlemanLadies and GentlemanLadies and GentlemanLadies and Gentleman,
“We do Have A Problem to Solve”
PracticeVa r i a t i o N !
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> 50 % Healthcare Costs
Are we really that ineffective ?
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9
Thoracic tumor
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WFNS Boston 2009 10
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Summer University Berlin 2009
11
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4 - 53 - 42 - 31 - 20 - 1No data
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Summer University Berlin 2009
13
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Summer University Berlin 2009
14
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Surgical Skills “You can teach a monkey to perform surgery”
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Rational Thinking“You cannot teach a monkey when not to perform surgery”
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Do No Further Harm
You should not perform surgery for non correlating nerve root problems?
Beware of yellow flags !
Do not perform surgery without informing patients about worse outcome !
You should not believe in surgery for scar tissue !
Do not believe in low back surgery without structural abnormalities
Do not believe in new methods without Evidence Based Medicine.
…………..
I do believe in God, everybody else should bring data !
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Diapositiva 18
2 Wilco Peul; 26.08.2012
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Health Aid 19
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Summer University Berlin 200920
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Summer University Berlin 2009
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Toys for boys !?
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Summer University Berlin 2009
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I’m sorry for you all, but……W.C.2
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Diapositiva 24
W.C.2 Wilco C. Peul; 29.06.2009
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0 4 8 12 16 20 24 28 32 36 4 0 4 4 48 5 2
w eeks
0, 0
0, 1
0, 2
0, 3
0, 4
0, 5
0, 6
0, 7
0, 8
0, 9
1,0
Cum
ulat
ive P
roba
bilty
of R
ecov
ery
C onse rva t ive T rea tm en t
Ear ly Su r ge ry
C o x P rop o rtio n a l H a zard R a tio ( 95% C I) ‡ 1 .97 ( 1 . 7 2 -2.22) p < 0 .0 01
0 4 8 12 16 20 24 28 32 36 40 44 48 52
20
40
60
LE
G P
AIN
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AUC conservative 977.0 ± 68.3
AUC surgery 635.3 ± 58.6
Mean difference of VAS leg pain AUC’s (CI) 341.7 (163.8—519.6) *
weeks
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Relation between practice variation in herniated disc surgery
and total disc problem related healthcosts at regionlevel 2009
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Practice variation due to disc surgery at city-
provincial region level 2010
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Famous Famous Famous Famous ““““DutchDutchDutchDutch”””” Clinic in MunchenClinic in MunchenClinic in MunchenClinic in Munchen
31 mei 2007Sciatica 2007 28
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Precision Medicine“Choosing Wisely”
Bring Science to the Art of Spinal Surgery
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first wise choices NL (‘verstandige
keuzes’)
December 2013: Publication 5 wise choices
Herniated Disc
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Choosing Wisely (Do Not’s) LDH
surgery
1. Low Back Pain only
2. Do not operate within a short period of sciatica ( 9 mnths
3. Early MRI while recovering
4. Non-dermatomal pain distribution
5. Innovative technique (or implant) without RCT
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EBM Bandwidth
Indication surgery LDH
Weeks of Sciatic Neuralgia
Optimale
operatie
window
Keuze
patiënt
Keuze
patiënt
Onverstandig? Onverstandig ?
Nu
mb
er
of
surg
eri
es
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2009 region The Hague-Leiden
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34
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Weeks of Sciatica
(Too early surgery hospital /regio (Too) late surgeryd hospital/regionOptimal hospital/ region
Optimale
operatie
window
Choice
patiënt
Choice
paiëntUnwise ? Unwise ?
Wise Choices ----DSS-RHypothetical National Audit
Nu
mb
er
of
surg
eri
es
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This is my area, I do have
something to declare !
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Wise Choices Quality is also Efficiency
Wise Choices
Choosing Wisely Netherlands
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Wise Choices Quality is also Efficiency
Wise Choices• Physician led program
• Campaign initiated by the Dutch Association of Medical Specialists (OMS) and Netherlands Organization for Health Research andDevelopment (ZonMw)
• The Dutch Patient andConsumer Organization is partner (NPCF)
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Wise Choices Quality is also Efficiency
Improvement cycle Wise Choices
Describing
Good care
Describing
Good care
ImplementationImplementation
Measuring and
evaluation
Measuring and
evaluation
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Improvement cycle Wise Choices
Wise Choices builds on PDCA cycle which is the basis for quality assurance in specialist care
• (Evidence based) guidelines drawn up bymedical specialists, taking into account the
patient perspective
• Quality measurement to follow up on implementation, enable improvement, enable
patient choices
• External peer review through site visits, medicalaudit and continous assessment of individual
performance
• Continuous medical and professional education
• Scientific research
Describi
ng good
care
Implementat
ion
Implementat
ion
Measurem
ent and
evaluation
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Wise Choices Campaign
1. Wise Choices
2. Clinical Practice Variation
3. Effectiveness Research
4. Shared Decision Making
Describing
good care
ImplementationImplementationMeasurement
and evaluation
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Wise Choices • Proven recommendations (evidence) for a particular
test or treatment.
– Ideally embedded in evidence based guidelines
• Meant to stimulate doctors and patients to talk about the most suitable test or treatment at the
right moment.
• These conversations can significantly contribute to improving the quality of care.
• Cost management is not the primary goal (but will likely be a result)
• Published by the scientific associations of medical specialists.
• The NPCF (patients) helps to distribute the materials.
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Published Wise Choices:– Dutch Society of Neurosurgery,– Dutch Society for Pediatric
Medicine
– Dutch Society for Urology– Association of Surgeons of the
Netherlands
– Dutch Society of Internal Medicine(2x)
– Dutch Orthopedic Socieity– Dutch Society for Neurology– Dutch Society for Radiology
Wise Choices to be published thisfall
– Dutch Society for obstetrics andgynaecology
– Dutch Society for reumatology– Netherlands Society of Cardiology NVR – Dutch Society for Clinical Chemistry– Dutch Society for Ear, Nose and Throat
surgeons
Current status(phase 1 ending december 2015)
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Wise Choices Quality is also Efficiency
3 keypoints of interest• 1) 4 pillars organization
• 2 ) structured methodology per society
• 3) multi-displinary board
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Wise Choices Quality is also Efficiency
(1 ) Four pillars Campaign
Wise Choices (do’s & do not’s)
Clinical Practice Variation
Effectiveness Research
Shared Decision Making
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Wise Choices Quality is also Efficiency
(2) Methodology• Which topic per Medical Scientific Society (structured methodology)
• Research Knowledge Gaps (structured program)
• Guideline Development (specific attention wise choices)
• Practice Variation Research (pre- and post implementation)
• Process and performance Indicators (eg bandwidth treatment indication)
• Evaluation (impact analysis at macro and micro level)
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Wise Choices Quality is also Efficiency
(3) Multidisciplinary Board • Medical Doctors Leading (Marcel Daniels-Wilco Peul)
• Epidemiologist-Director (Marjon Kallewaard)
• Medical Decision Making Expert
• NPCF Netherlands & specific patient organizations
• Netherlands society of health care research (ZonMw)
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The Year of TransparancyThe Year of TransparancyThe Year of TransparancyThe Year of Transparancy
• 9 million for 30 diagnoses
• Insurance companies fund Q-Registries
• Collaborate Medical Universities NFU
• Program; “ Do or Do not”
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Wise Choices Quality is also Efficiency
Wise Choices Campaign
More information?
Folder
www.verstandigkiezen.nu
www.choosingwiselynetherlands.org
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The Netherlands Quality MovementBring science to the art of Neurosurgical Strategy
Wilco C. Peul, MD, PhD, MBA
Neurosurgeon & EpidemiologistProfessor and Chairman
Leiden University Medical CenterMedical Center The Hague