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$$

3

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

4

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

6

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

7

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?

9

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