Variations Among Regions and Hospitals in Managing Chronic Illness: How Much Care Is Enough? Seventeenth Annual Herbert Lourie Memorial Lecture on Health Policy.

Classic epidemiology looks at what happens to people who live in a defined region over time. For example, birth rate, the number of births that occur among populations over a year, is a common statistics that we're all familiar with. Since the early 1990s we have conducted research at Dartmouth Medical School to convert that classic epidemiologic perspective into looking at what is happening in terms of the health care system itself. We ask how much care people are getting in different regions of the country. We want to know the patterns of that care. And we want to get into the causes of so-called unwarranted variation, that is, differences that cannot be explained on the basis of patient illness, the dictates of scientific medicine, or the preferences of patients. Those three key words--illness, preference, and science--ultimately don't explain very much of the variation we see. We began the Dartmouth Atlas Project in 1993 as a study of health care markets in the United States, measuring variations in health care resources and their utilization among geographic areas. In recent years, we have expanded our research agenda to include the resources and utilization among patients at specific hospitals. We use very large claims databases from the Medicare program and other sources to define where people go for medical care, what kind of care they receive, and whether increasing investments in health care resources and their use result in better health outcomes.nursing home, Medicare, Medicaid, long-term care, elderly, social welfare.

Is Less Better? Greater Efficiency With Fewer Resources Expended

Summarizes an analysis of Medicare spending to assess the relative efficiency of healthcare providers in managing patients with severe chronic illnesses in California. Highlights the need to redesign the payment system to improve healthcare efficiency

The Effect of a Shared Decisionmaking Program on Rates of Surgery for Benign Prostatic Hyperplasia. Pilot Results.

Mulley at al hypothesized that active efforts to involve patients in devisions made about their care should improve outcomes by better matching treatments with patient values and needs. How utilization of various treatments would be affected is a critical element of the evaluation of such efforts. The Shared Decisionmaking Program for benign prostatic hyperplasia (SDP-BPH) is an interactive videodisc-based patient education program designed to help patients make an informed choice about whether to elect a transurethral resection of the prostate (TURP) or to follow a program of expectant management called watchful waiting. The BPH-SDP was piloted by two urology groups serving two large prepaid group practices that maintain reliable computerized information on surgical utilization. In this article, the effect of the SDP on patient preferences for treatment is examined, and secular trends in population-based TURP rates in those regions piloting the SDP with trends in regions of the same prepaid group practices not using the SDP are compared

Vermont Surgery Study, 1969-1971: On the Incidence of Tonsillectomy and Other Common Types of Surgery

The tonsils and adenoids have been subject to a widespread uncontrolled therapeutic experiment over the past half century so that at times and in certain segments of the society, less than half of the children have reached adulthood with these organs intact. While the operation has been recorded in ancient history, its popularity is associated with the advent of modern surgery and anesthesia. Tonsillectomy began to increase in frequency early in the century with a precipitous rise following World War I. Procedure rates continued at high levels since the 1930s and only in the past decade has there been evidence of a decline. Presently, over 1 million tonsillectomies are performed each year in the United States at a total cost estimated to exceed 250 million dollars. It continues to be the single most common surgical procedure performed in the United States and Canada and is the main reason for the hospitalization of children

The Wennberg Anthology

In 1967, after finishing my postgraduate training at Johns Hopkins in internal medicine and epidemiology, I took a job at the University of Vermont in Burlington as Director of the Northern New England Regional Medical Program (RMP). The Vermont program was one of some fifty RMPs that blanketed the country as part of President Johnson’s Great Society program. The idea behind the RMP was that advances in biomedicine had so improved the outcomes of major killer diseases that it was critical to ensure that all Americans, not just those fortunate enough to live near an academic medical center, had access to these services. Epidemiologists are interested in what happens to groups of people: for example, how many get heart attacks (incidence) and what happens to patients (outcomes) according to the treatment they receive (prognosis). It was thus quite natural for me to want to use the tools of epidemiology to provide population-based information about the distribution of health care resources and the utilization of services among Vermont communities; after all, good planning for improvement requires knowledge about the current status of the health care system. Alan Gittelsohn, a biostatistician from Johns Hopkins who had also been my teacher, and I developed a strategy we called the small area analysis of health care delivery. The method defined the geographic boundaries of local health care markets, based on where patients actually went for their care, and described the per capita use of resources and services for the resident populations. Our first Vermont small area analysis (which we published in a 1973 article in Science) brought a big surprise. While we had expected to find a rural health care system characterized by underservice, we found instead a typology of care characterized by vast variations in the deployment of resources and the utilization of services among neighboring communities, without apparent rhyme or reason. The results forced me to re-examine the policy assumptions behind the RMP and a good deal else about the U.S. health care economy. It was evident that the problems facing regional and local health care markets were much more profound than the barriers to diffusion of new technology the RMP was designed to overcome. I have spent most of my career studying the variation phenomenon. In a recent book, “Tracking Medicine: A Researcher’s Quest to Understand Health Care”, I chronicled this research and the evolution of thinking on the causes and remedies for unwarranted variation. Several of my colleagues and students have asked if I would make our research papers—some of which are hard to find and some not yet published—available to a wider audience. This website is my effort to do this. I provide introductory remarks for each paper in an attempt to clarify the context, relationship to previous work and the role the ideas in these papers played in building an understanding of practice variation. Over the years I have had the good fortune of working together with colleagues who have shared my fascination with the story of practice variation, and who have contributed in fundamental ways to the ideas and concepts presented in these papers. The ordering is by topic, arranged in roughly chronological order: The Early Papers The Prostate Outcomes Studies The Epidemiology of Medical Care The Policy Papers Editorials, Commentaries & Perspective

Patient Reactions to a Program Designed to Facilitate Patient Participation in Treatment Decision for Benign Prostatic Hyperplasia

Patients often want considerable information about their conditions, and enhanced patient participation might reduce unwanted practice variation aad improve medical decisions. The authors assessed how men with benign prostatic hyperplasia reacted to an educational program designed to facilitate participation in declsionmaking and how strongly ratings of their symptom state and the prospect of complications predicted their treatment choice. A prospective cohort study was conducted in three hospital-based urology practices: two in prepaid group practices, and one Veterans Administration clinic. Four hundred twenty-one men with symptomatic benign prostatic hyperplasia without prior prostatectomy or benign prostatic hyperplasia complication were enrolled, and 373 provided usable ratings. Subjects partidpated in an Interactive videodisc-based shared decisionmaking prograrn adout benign prostatic hyperplasia and its treatment options, prostatectomy, and watchful walting. They rated the length, clarity, balance, and value of the program and were followed for 3 months to determine if they underwent surgery. Patients rated the program as generally clear, informative. and balanced. Across all three sites, 77% of patients were verv positive and 16% were generally positive about the program\u27s usefulness in making a treatment decision. Logistic models predicting choice of surgical treatment documented the independent importance of negative ratings of the current symptom state (odds ratio 7.0, 95% confidence interval 2.9-16.6), as well as he prospect of postoperatlve sexual dysfunction (odds ratio 0.20, 95% confidence interval 0.08-0.48) In decisionmaking. Patients rated the Shared Decisionmaking Program very posItIvely and made decisions consistent with their assessed preferences. These results suggest that patients can be helped to participate in treatment decisions, and support a randomized trial of the Shared Decisionmaking Program

Symptom Status and Quality of Life Following Prostatectomy

When symptom status is proposed as treatment for the symptoms of prostatism, the decision to operate should depend on how patients evaluate their symptoms and on objective information about the outcomes. We undertook a health interview study to determine the probabilities for symptom relief, improvement in the quality of life, and complications following surgery and to evaluate patient concern about the symptoms of prostatism. The operation was effective in reducing symptoms: 93% of severely and 79% of moderately symptomatic patients experienced improvement; however, a statistically significant improvement in indices of quality of life occurred only among patients with acute retention or severe symptoms prior top surgery. Short-term complications of varying severity occurred in 24% of patients; in addition, 4% reported persistent incontinence and 5%, impotence. Patients with similar symptoms reported considerable difference in the degree to which they were bothered by their symptoms. The result emphasizes the importance of patient participation in the decision to undergo prostatectomy