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What Works in Health Care

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Policy makers tap Dartmouth experts for advice on fixing the system

The designation of $1.1 billion for comparative effectiveness research in President Barack Obama's just-enacted stimulus bill has a lot of people boning up on just what comparative effectiveness is and what they'd have to do to get some of this funding. Washington is turning to the Dartmouth Institute for Health Policy and Clinical Practice (TDI), where researchers have been at the forefront of this work for more than two decade

weinsteinJames Weinstein, director of the Dartmouth Institute for Health Policy and Clinical Practice (TDI). Building on the work of Dr. John Wennberg, TDI investigates variations in American health care. The research reveals ways to lower costs and improve care. (Photo by Mark Washburn)

"The movement around comparative effectiveness is just putting a name to something that Dartmouth has thought about and worked on since the 1980s, beginning with Dr. John Wennberg and his research into variation in health care practices," explains James N. Weinstein, director of TDI. Weinstein is also a leading researcher and spine surgeon and chair of the Departments of Orthopaedics at Dartmouth Medical School (DMS) and Dartmouth-Hitchcock Medical Center (DHMC).

TDI builds on Wennberg's pioneering work examining patterns of U.S. health care delivery and practice, and evaluating the quality of care. The research, published in the Dartmouth Atlas of Health Care, reveals striking variations in the amount of health care patients receive depending on where they live. These variations exist across states and regions and even within individual states and cities.

Elliott Fisher, director of the Center for Health Policy Research in the Dartmouth Institute for Health Care Policy and Clinical Practice, speaks about the importance of comparative effectiveness research in this Feb. 15 New York Times article on the economic stimulus package.

More about Dr. John Wennberg's pioneering work on health care variations and outcomes.

More about James Weinstein's Spine Patient Outcomes Research Trial (SPORT).

More about the Dartmouth Institute.

"The disparities in care harm patients-our research has repeatedly documented that more care often results in worse outcomes for patients," says Weinstein. "These disparities also represent billions of dollars in wasteful and unnecessary spending."

Weinstein spoke with VOX of Dartmouth about comparative effectiveness and Dartmouth's role in this growing-and critical-field.

What is comparative effectiveness?

To me, it's about getting to the truth. Comparative effectiveness research examines health care and asks: What works, what doesn't work, what are the risks, what are the benefits, how well does this therapy or treatment or device work when compared with another one? We need this information so we can share it with our patients and empower them to make decisions about their health care.

People think that health care is based on science and are often shocked to find that isn't true. In fact, most of what's done in health care today is because it's what the physician thinks and hopes is best for the patient. But I can tell you as a physician that, while we are always trying to do what's best for our patients, we are frequently making decisions without the benefit of objective evidence.

Can you give an example?

Take hip fractures. We have 250,000 hip fractures a year in this country. You can fix the fracture with a device that costs three times as much and is associated with increased morbidity and mortality, or you can use a cheaper device that turns out to be safer and more effective. Shouldn't patients have that information? And shouldn't we as a nation understand these issues? But until we get at that information by comparing effectiveness of the different treatment options, we don't have the tools to make good decisions.

That's why I, as a spine surgeon, began the Spine Patient Outcomes Research Trial (SPORT) study, which looked at the three most common reasons [spinal stenosis, degenerative spondylolisthesis, and lumbar herniated disc] for which back surgery is performed. I wanted to know, am I doing the right thing for my patients? Is surgery better than non-operative care?

What did you discover?

As it turns out, in two of the three cases, surgery is better. But in the third [herniated disk], while you get great results with surgery, patients who don't have the operation do almost as well. That's important information for me to have and to share with patients.

In the case of surgery for herniated disk, 30 percent of patients who went through the shared decision-making process in the study decided not to have surgery. Applied nationally, that trend alone would result in billions of dollars in savings.

Will Dartmouth and TDI have a role in the expanded comparative effectiveness effort?

We've already had a huge impact and that will continue. Great Dartmouth/TDI colleagues like Elliott Fisher and Jon Skinner are in Washington regularly and are sought out by policy makers for their insights, both into what's wrong with the system and how we can improve it. TDI is at the center of research, education, and collaboration to improve the delivery of health care. We continue to show that we can make care safer, better, more coordinated, and less wasteful.

Are there places where the research has been put into practice?

TDI is one of the few organizations that have made reforms in clinical practice. With DHMC, we started the first-in-the-nation Center for Shared Decision-Making. Within orthopaedics, we started the multidisciplinary Spine Center, which has become an international model for care delivery. Both of these initiatives apply the tools of comparative effectiveness to empower patients to make informed choices. That results in better outcomes, higher patient satisfaction, and lower costs.

You often invoke the Dartmouth motto-"Vox clamantis in deserto"-when you talk about the early days of measuring outcomes and trying to raise awareness that something in the health care system was broken.

I've always thought the "voice crying out in the wilderness" was an appropriate statement for TDI, because for so many years we called out and it seemed like no one was listening. But recently that's been changing. I was at a national meeting in Washington a few months ago and a senior person at the National Institutes of Health said to me, "Everywhere I go, any time there's a conversation about how we fix the system, the Dartmouth work is part of the discussion!"

That's gratifying. It's also good to hear [incoming Director of the Office of Management and Budget] Peter Orszag and congressional leaders referencing the Dartmouth Atlas of Health Care and other TDI research. The sad part is that the voice in the wilderness was ignored for so long that now we're in a crisis.

What outcome do you hope for with this national focus on comparative effectiveness?

We have a great opportunity today with the money being provided through the stimulus bill. But we must be very careful and thoughtful about how that money is distributed. There has to be an overall strategy that gets us to less variation in care delivery in the U.S.-care that's not rationed, but rational-and uses these resources to improve the opportunities for all patients. If we can do that, the nation as a whole will benefit.

Innovation isn't just new drugs and devices. Innovation is knowledge. And our knowledge gained, through what we're now calling comparative effectiveness research, will have more positive impact on the system, I believe, than any device or medication.

By DEBORAH KIMBELL



Questions or comments about this article? We welcome your feedback.

Last Updated: 2/27/09