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Too Much Prevention: What Not to Do in the Primary Care Setting

Too Much Prevention: What Not to Do in the Primary Care Setting. Agency for Healthcare Research and Quality Bethesda, MD September 15, 2009 Shannon Brownlee, MS Senior Research Fellow, New America Foundation Author: Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer

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Too Much Prevention: What Not to Do in the Primary Care Setting

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  1. Too Much Prevention: What Not to Do in the Primary Care Setting Agency for Healthcare Research and Quality Bethesda, MD September 15, 2009 Shannon Brownlee, MS Senior Research Fellow, New America Foundation Author: Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer brownlee@newamerica.net

  2. DISCLAIMER • No financial conflicts of interest to declare

  3. Source: CBO Source: CBO

  4. Source: CBO Source: CBO

  5. Busting state budgets

  6. The Solution? 70% of Americans consider PREVENTION the most important aspect of health care reform (other than covering everybody)

  7. The Solution? Prevention! Max Baucus: “Reforming our system to focus on prevention will drive down costs and produce better health outcomes.” Ron Wyden: “Prevention and wellness come first. These are cost-effective solutions that will improve quality of life, prevent disease, and most important save lives.” Kay Granger (R-TX): "An investment of just $10 per person per year could save this country more than $16 billion annually within five years.”

  8. PREVENTION = SCREENING (Catch it early) • Heart disease – cholesterol test • Heart disease – 64-slice CT scan • Lung cancer – CT scan • Prostate cancer – PSA test • Colon cancer – colonoscopy • Osteoporosis – Dexa scan • Carotid artery disease – Doppler • Ovarian cancer – Ca125 test • Breast cancer – mammograms and BRCA test • COPD – spirometry

  9. Prevention = Surgery (head it off at the pass) • Silent gall stones • Chronic stable angina • Carotid artery stenosis • Herniated disc • Early prostate cancer • Enlarged prostate (BPH)

  10. Dr. Michael LeFevre • USPSTF • Evidence for screening tests • Pressures on Physicians

  11. Preference-Sensitive Care • Involves tradeoffs -- more than one treatment exists; not getting treated at all is an option; and the outcomes are different depending upon the patient’s choice • Decisions should be based on the patient’s own preferences • But provider opinion (preference) often determines which treatment is used

  12. 9.5 8.5 7.5 6.5 5.5 4.5 3.5 2.5 1.5 0.5 TURP for BPH per 1,000 male Medicare enrollees (2005) Ratio to HRR lowest Providence, RI 2.67 Lubbock, TX 2.63 Bismarck, ND 2.46 Washington, DC 2.07 Burlington, VT 2.05 Hartford, CT 1.92 St. Paul, MN 1.89 Worcester, MA 1.89 Baltimore, MD 1.85 Minneapolis, MN 1.79 White Plains, NY 1.74 Bangor, ME 1.74 Manhattan, NY 1.74 Portland, ME 1.57 Seattle, WA 1.48 Salt Lake City, UT 1.44 Casper, WY 1.43 Wilmington, DE 1.36 Richmond, VA 1.17 Baton Rouge, LA 1.03 Lebanon, NH 1.00

  13. 10.0 8.0 6.0 4.0 2.0 CABG surgery per 1,000 Medicare enrollees (2005) Ratio to HRR lowest Lubbock, TX 2.59 Baton Rouge, LA 2.34 Baltimore, MD 1.88 Providence, RI 1.16 Worcester, MA 1.15 Seattle, WA 1.14

  14. 42.0 34.0 26.0 18.0 10.0 2.0 Percutaneous coronary intervention per 1,000 Medicare enrollees (2005) Ratio to HRR lowest Lubbock, TX 2.59 Worcester, MA 1.86 Baltimore, MD 1.77 Providence, RI 1.21 Seattle, WA 1.09 Baton Rouge, LA 1.05

  15. 11.0 9.0 7.0 5.0 3.0 1.0 Back surgery per 1,000 Medicare enrollees (2005) Ratio to HRR lowest Casper, WY 5.41 Lubbock, TX 3.23 Bismarck, ND 3.17 Salt Lake City, UT 2.91 Baltimore, MD 2.81 St. Paul, MN 2.79 Minneapolis, MN 2.57 Seattle, WA 2.54 Washington, DC 2.41 Richmond, VA 2.25 Portland, ME 1.97 Wilmington, DE 1.85 Hartford, CT 1.63 Worcester, MA 1.63 Bangor, ME 1.48 Baton Rouge, LA 1.45 White Plains, NY 1.37 Providence, RI 1.36 Burlington, VT 1.24 Lebanon, NH 1.17 Manhattan, NY 1.00

  16. Preventive Surgery Condition Treatment Options • Silent gall stones Surgery versus watchful waiting • Chronic stable angina PCI vs CABG vs other methods • Carotid artery stenosis Endarterectomy vs drugs • Herniated disc Back surgery vs other strategies • Early prostate cancer Surgery vs radiation vs waiting • Enlarged prostate (BPH) Surgery vs other strategies

  17. Knowledge of relevant treatment options and outcomes Concordance between patient values and care received Which rate is right? Impact of improved decision quality on surgery rates: BPH Source: John E. Wennberg

  18. Bottom Line Implications: 1. Clinical appropriateness should be based on sound evaluation of treatment options (comparative effectiveness and outcomes research)2. Medical necessity should be based on Informed Patient Choice among clinically appropriate options -- high quality shared decision-making

  19. Proportion of Medicare Spending Attributed to Each Category of Unwarranted Variation Effective Care Supply Sensitive Care Preference Sensitive Care Source: John E. Wennberg and Dartmouth Atlas

  20. We’re wasting $600 – 800 BILLION annually on unnecessary carePart of the solution requires rethinking prevention and clinical decision makingTHE HEALTH CARE TRAIN WRECK

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