The Role of Shared Decision Making in Reducing The Role of Shared Decision Making in Reducing Unwarranted Variation in Health CareUnwarranted Variation in Health Care

A Talk by Jack WennbergA Talk by Jack Wennberg

Implementing shared decision making: Implementing shared decision making: lessons from the frontlessons from the front

May 26, 2011May 26, 2011

Understanding Variations in the Way Medicine is PracticedUnderstanding Variations in the Way Medicine is Practiced

The Vermont StoryThe Vermont Story

The Maine StoryThe Maine Story

The Dartmouth Atlas ProjectThe Dartmouth Atlas Project

New Hampshire

Massachusetts

New York

Quebec

From From “Science,”“Science,” December 14, 1973.December 14, 1973.

Vermont Map from “Science”Vermont Map from “Science”

Morrisville and Waterbury CenterMorrisville and Waterbury Center

Tonsillectomy Rate per 10,000 Children Among 13 Tonsillectomy Rate per 10,000 Children Among 13 Vermont Hospital Service AreasVermont Hospital Service Areas

00

5050

100100

150150

200200

250250

300300

350350

400400

450450MorrisvilleMorrisville

19691969

Stages of Facing RealityStages 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 Stage 2. “The data are right, but it’s not a

problem.”problem.”• Stage 3. “The data are right; it is a problem; but it Stage 3. “The data are right; it is a problem; but it

is not my problem.”is not my problem.”• Stage 4. “I accept the burden of improvement.”Stage 4. “I accept the burden of improvement.”

Tonsillectomy Rate per 10,000 Children Among 13 Tonsillectomy Rate per 10,000 Children Among 13 Vermont Hospital Service AreasVermont Hospital Service Areas

00

5050

100100

150150

200200

250250

300300

350350

400400

450450

MorrisvilleMorrisville

MorrisvilleMorrisville

19691969 19731973

Understanding Variations in the Way Medicine is PracticedUnderstanding Variations in the Way Medicine is Practiced

The Vermont StoryThe Vermont Story

The Maine StoryThe Maine Story

The surgical signatures of the five most The surgical signatures of the five most populous HSAs in Maine (1975)populous HSAs in Maine (1975)

0.00.0

1.01.0

2.02.0

3.03.0

PortlandPortland LewistonLewiston AugustaAugusta WatervilleWaterville BangorBangor

Rat

io t

o s

tate

ave

rag

eR

atio

to

sta

te a

vera

ge

Tonsillectomy Hysterectomy Varicose Veins

Prostatectomy Hemorrhoidectomy Total Procedures

Testing BPH TheoriesTesting BPH Theories

• The Preventive Theory of SurgeryThe Preventive Theory of Surgery

• The Quality of Life Theory of SurgeryThe Quality of Life Theory of Surgery

Which rate is right? Impact of improved Which rate is right? Impact of improved decision quality on surgery rates: BPHdecision quality on surgery rates: BPH

Knowledge of relevant treatment

options and outcomes

Concordance between patient values

and care received

Understanding Variations in the Way Medicine is PracticedUnderstanding Variations in the Way Medicine is Practiced

The Vermont StoryThe Vermont Story

The Maine StoryThe Maine Story

The Dartmouth Atlas ProjectThe Dartmouth Atlas Project

The Dartmouth Atlas Project: 306 hospital referral regionsThe Dartmouth Atlas Project: 306 hospital referral regionsOngoing Study of Traditional Medicare Population USAOngoing Study of Traditional Medicare Population USA

Unwarranted Variation in Health Care Delivery:Unwarranted Variation in Health Care Delivery:

Variation that can’t be explained by illness Variation that can’t be explained by illness

or patient preferencesor patient preferences

The Three Categories of Unwarranted The Three Categories of Unwarranted Variation in Health Care DeliveryVariation in Health Care Delivery

Effective CareEffective CareEE

vviiddeennccee--bbaasseedd ccaarree tthhaatt aallll wwiitthh nneeeedd sshhoouulldd rreecceeiivvee

Preference-Sensitive CarePreference-Sensitive Care

Supply-Sensitive CareSupply-Sensitive Care

Preference-Sensitive Care Preference-Sensitive Care

• Involves tradeoffs -- more than one treatment exists Involves tradeoffs -- more than one treatment exists and the outcomes are differentand the outcomes are different

• Decisions should be based on the patient’s own Decisions should be based on the patient’s own preferencespreferences

• But Provider Opinion Often Determines Which But Provider Opinion Often Determines Which Treatment is UsedTreatment is Used

Knee Replacement: An Example of Preference-Sensitive CareKnee Replacement: An Example of Preference-Sensitive Care

Ratio of knee replacement rates to the U.S. average (2005Ratio of knee replacement rates to the U.S. average (2005))

11.30.30 to to 11.75.75 (46)(46)11.10.10 to < to < 11.30.30 (78)(78)00.90.90 to < to < 11.10.10 (106)(106)00.75.75 to < to < 00.90.90 (53)(53)00.41.41 to < to < 00.75.75 (23)(23)Not PopulatedNot Populated

Total Knee replacement for Arthritis per 1,000 Medicare Total Knee replacement for Arthritis per 1,000 Medicare enrollees among 306 Hospital Referral Regionsenrollees among 306 Hospital Referral Regions

1.01.0

3.03.0

5.05.0

7.07.0

9.09.0

11.011.0

1992-93 2000-01

Red dot = U.S. average:Red dot = U.S. average: 4.034.03 5.64 40% increase5.64 40% increase

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

0.00.0

2.02.0

4.04.0

6.06.0

8.08.0

10.010.0

12.012.0

0.00.0 2.02.0 4.04.0 6.06.0 8.08.0 10.010.0 12.012.0

Knee Replacement (1992-93)Knee Replacement (1992-93)

Kn

ee R

epla

cem

ent

(200

0-01

)K

nee

Rep

lace

men

t (2

000-

01)

R2 = 0.75

Determining the Need for Hip and Knee Arthroplasty: Determining the Need for Hip and Knee Arthroplasty: The Role of Clinical Severity and Patients’ Preferences The Role of Clinical Severity and Patients’ Preferences

. . . Among those with severe arthritis, no . . . Among those with severe arthritis, no more than 15% were definitely willing to undergo more than 15% were definitely willing to undergo (joint replacement), emphasizing the importance (joint replacement), emphasizing the importance of considering both patients’ preference and of considering both patients’ preference and surgical indications in evaluating need and surgical indications in evaluating need and appropriateness of rates of surgeryappropriateness of rates of surgery

Bottom Line Implication: Bottom Line Implication:

Clinical Appropriateness should be based on sound Clinical Appropriateness should be based on sound evaluation of treatment options (outcomes research)evaluation of treatment options (outcomes research)

To Avoid Wrong Patient Surgery, Medical Necessity To Avoid Wrong Patient Surgery, Medical Necessity should be based on Informed Patient Choice among should be based on Informed Patient Choice among Clinically Appropriate OptionsClinically Appropriate Options

Conditions involving preference-sensitive Conditions involving preference-sensitive surgical decisionssurgical decisions

ConditionCondition Treatment Options Treatment Options

• Silent GallstonesSilent Gallstones Surgery versus watchful waiting Surgery versus watchful waiting

• Chronic Stable Angina PCI vs. surgery vs. other methodsChronic Stable Angina PCI vs. surgery vs. other methods

• Hip and Knee ArthritisHip and Knee Arthritis Joint replacement vs. pain meds Joint replacement vs. pain meds

• Carotid Artery Stenosis Surgery vs. aspirinCarotid Artery Stenosis Surgery vs. aspirin

• Herniated DiscHerniated Disc Back surgery vs. other strategies Back surgery vs. other strategies

• Early Prostate Cancer Early Prostate Cancer Surgery vs. radiation vs. waiting Surgery vs. radiation vs. waiting

• Enlarged ProstateEnlarged Prostate Surgery vs. other strategies Surgery vs. other strategies

• Early Stage Breast Cancer Lumpectomy vs. mastectomy Early Stage Breast Cancer Lumpectomy vs. mastectomy

Knee replacement per 1,000 Medicare Knee replacement per 1,000 Medicare enrollees (2003-07)enrollees (2003-07)

WenatcheeWenatchee 9.29.2SpokaneSpokane 9.19.1OlympiaOlympia 8.78.7TacomaTacoma 8.38.3Port AngelesPort Angeles 8.08.0PuyallupPuyallup 7.97.9BellevueBellevue 7.87.8VancouverVancouver 7.67.6RentonRenton 7.57.5BremertonBremerton 7.57.5YakimaYakima 7.47.4BellinghamBellingham 7.27.2SeattleSeattle 6.86.8EverettEverett 6.56.5

2.02.0

4.04.0

6.06.0

8.08.0

10.010.0

12.012.0

14.014.0

TURP for BPH per 1,000 male Medicare TURP for BPH per 1,000 male Medicare enrollees (2003-07)enrollees (2003-07)

WenatcheeWenatchee 9.99.9Port AngelesPort Angeles 7.87.8PuyallupPuyallup 7.87.8BremertonBremerton 6.76.7SpokaneSpokane 6.06.0EverettEverett 4.44.4TacomaTacoma 4.04.0YakimaYakima 3.23.2VancouverVancouver 2.82.8BellinghamBellingham 2.52.5SeattleSeattle 2.42.4OlympiaOlympia 2.32.3RentonRenton 2.22.2BellevueBellevue 1.71.7

1.01.0

3.03.0

5.05.0

7.07.0

9.09.0

11.011.0

Dartmouthatlas.orgDartmouthatlas.org

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