Researchers at the Center for the Evaluative Clinical Sciences reach across disciplines to understand the factors that produce high-quality health care
When Dr. John Jack Wennberg started investigating how United States health care resources were distributed in the early 1970s, he didnt realize how contrary his findings would be to the conventional wisdom at the time. The results of his first studythat disparities in the distribution and use of health resources were largely driven by uncertainty among doctors about what treatments were effectivewere so counterintuitive to the medical profession that he had a difficult time getting them published by medical and scientific journals.
But by the time Wennberg founded the Center for the Evaluative Clinical Sciences (CECS) at Dartmouth in 1988, his research about the factors that contribute to quality health care was more widely accepted.
Since then, CECS scholars, who include physicians, sociologists, economists, statisticians and others, have pioneered research about the quality and quantity of health care Americans receive. The work done at the CECS is multifaceted and interdisciplinary, with implications for public policy, physician education programs, and the insurance and medical technology industries, not to mention how individual doctors practice medicine. And always at the core of the Centers work is a fundamental question: Is the health care system providing the best possible care for patients? In a disconcerting number of CECS studies over the years, the answer has been a resounding no. Among the Centers most significant findings:
- The broad disparities in the distribution and use of health care resources from region to region are not driven by different levels of health or illness.
- Differences in spending from region to region appear to be a result of greater reliance on expensive technologies and specialists; however, higher-spending regions dont have better outcomes. In fact, in many cases they actually have worse health outcomes and lower patient satisfaction.
- The rate at which health care resources are used appears to be driven by availability rather than need. In other words, it is the supply of doctors or hospital beds or MRI machines that drives the demand, not consumer health.
Perhaps the most well-known products of CECS research are the various editions of The Dartmouth Atlas of Health Care. These books illustrate, through data and maps, how U.S. health care resources are distributed and used. But the Atlas project represents just a small part of CECS research.
Helping Patients Choose From a Bewildering Array of Options
New Hampshire gardens in early spring are still just plots on paper and hopeful stacks of seed packets; nonetheless, Dr. David Goodman, Associate Professor of Pediatrics and Community and Family Medicine, has bees on his mind. Its the third Thursday of the monthbee-sting clinic day at Dartmouth-Hitchcock Medical Center (DHMC)and the pediatric allergist sits in the office he shares with another physician reviewing the days schedule.
First up are three new patients, followed by the regulars returning for their allergy shots. There arent a lot of treatment options for people with bee allergies, and the stakes can be very high, he explains, noting that the condition can sometimes be life-threatening. However, if discovered while a patient is still a child, the allergy can often be eliminated entirely through regular injections of bee venom. Immunotherapy is a very well-established treatment that we know is effective, he says as he rises to greet his first patient for the day.
The fact that the effectiveness of immunotherapy is so well documented makes it the exception rather than the rule in modern medicine. Many consumers would be surprised to discover how little evidence there is to support many of the treatments their doctors prescribe, Goodman says. In the absence of evidence-based studies, physicians must rely on instinct and experience to decide what treatments are most appropriate for individual patients. And while it makes sense for doctors to use the tools available to them in making these decisions, they often fall short by not letting patients know that there are multiple treatment options, each with tradeoffs, he says.
The best treatment options need to be understood in the context of how patients value the possible outcomes, says Goodman. Often the best medical outcome introduces other inconveniences and risks that are less acceptable to the patient than the original condition. For example, a CECS study of men facing optional prostate surgery found that those who participate in programs promoting greater patient responsibility in choosing their health care treatments opt for the surgery at a much lower rate than the national average. In many cases, the patients decide that the potential side effects of the surgery, which can include sexual dysfunction, are more objectionable than living with their condition. Later studies of other conditions, including breast cancer, have demonstrated that patients prefer less invasive treatment options when given the choice. The results are lower costs and higher patient satisfaction.
Even in the case of bee allergies, where there is an evidence-based treatment, patient preference comes into play when its time to decide to stop treatment. Deciding when they feel safe is a risk patients can control, Goodman says.
Its one thing to say patients should take a more active role in making their health care decisions, but its quite another to empower them to do so. American consumers, so savvy in other areas, have been conditioned to leave their medical decisions to physicians. Doctors, too, are most familiar with this model. Changing this mindset to create a more equal relationship between patient and doctor requires education on both sides of the stethoscope.
Researchers in the Health Decision Research Program at the CECS want to help both groups make this transition. Led by Professor of Community and Family Medicine Hilary Llewellyn-Thomas, the group studies how people make decisions; it also creates and evaluates decision aids that give patients the tools they need to select among treatment options.
Kate Clay is program director for the Center for Shared Decision Making at DHMC, where Llewellyn-Thomass research is used with patients. Clay works directly with patients faced with treatment decisions, as well as with physicians grappling with questions about how to present options to their patients.
The people who come to see me are being asked by their providers to choose between treatment options because there is evidence that both choices will result in roughly equal outcomes, or there is little clinical evidence to demonstrate that one option is clearly better than the other. If youre not deciding what to do based on clinical evidence, then youre choosing based on values, says Clay. The part of shared decision making that people are unaccustomed to is the values clarification part.
Each blue dot represents the frequency within a particular region that patients with prostate cancer chose surgery. The black dot is the rate people in an HMO chose surgery before shared decision making, and the red is the rate in the same HMO after shared decision making.
Demand for her services has increased dramatically: In the first quarter of 2003, her office loaned out four times as many decision aids and counseled approximately twice as many patients as the same quarter of 2002.
Were sort of a clinical laboratory for the folks at CECS to put into practice what theyve been researching, she says, noting that data gathered about their activities are included in CECS research. As a result, Clay often gets inquiries from people at other hospitals and institutions who want to set up similar centers.
The Spine Center at DHMC, created from scratch by Professor of Surgery and Community and Family Medicine Dr. James Weinstein, also is a model program that puts CECS ideas and research into action. Patients with back or spine problems often dont know what the source of their condition is and are confused about what kind of physician to consult. Founded in 1998, the Spine Center solved this problem by bringing together medical professionals from several specialties, including anesthesiology; family, occupational and internal medicine; neurosurgery; orthopedics and rheumatology. The physicians work together to treat the whole person, which not only improves functionality, but also raises patients sense of control over their own condition.
One aspect of the Spine Centers innovative approach is a two-week intensive outpatient rehabilitation program, in which patients participate in daily stretching and conditioning sessions, receive coping skills therapy, attend patient education sessions and are assisted in setting individual goals, among other activities. In line with the overall goals and mission of the CECS, the Spine Center continuously measures and evaluates treatment outcomes, as well as how satisfied patients are with their care. The success of Weinstein and his staff can be measured with solid data. Compared to the general population of patients with back and spine conditions, people who come to the Spine Center for treatment return to work sooner, receive less surgery and make fewer emergency room visits.