Too Much Prevention: What Not to Do in the Primary Care Setting (Text version)

On September 15, 2009, Shannon Brownlee, MS made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (1.5 MB).

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Slide 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

 

Slide 2

DISCLAIMER

No financial conflicts of interest to declare

Slide 3

Graph: Spending on Health Care as a Percentage of Gross Domestic Product Under an Assumption That Excess Cost Growth Continues at Historical Averages.

By 2052 healthcare accounts for 50 percent of the economy

Source: CBO

 

 

Slide 4

Graph: Sources of Growth in Projected Federal Spending on Medicare and Medicaid

Source: CBO

 

 

Slide 5

Busting state budgets

Cartoon of large fish labeled "Medicaid" eating smaller fish labeled "education," "roads."

 

Slide 6

The Solution?

70% of Americans consider PREVENTION the most important aspect of health care reform (other than covering everybody)

 

Slide 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."

 

Slide 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

 

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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)

 

 

Slide 10

Dr. Michael LeFevre

• USPSTF
• Evidence for screening tests
• Pressures on Physicians

 

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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

 

Slide 12

TURP for BPH per 1,000 male Medicare enrollees (2005)

HRR	Ratio to 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

 

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CABG surgery per 1,000 Medicare enrollees (2005)

HRR	Ratio to 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

 

Slide 14

Percutaneous coronary intervention per 1,000 Medicare enrollees (2005)

HRR	Ratio to 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

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Back surgery per 1,000 Medicare enrollees (2005)

HRR	Ratio to 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

 

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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

 

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Image of Journal Article: Decision aids for patients facing health treatment or screening decisions: systematic review

 

Slide 18

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

Knowledge of relevant treatment options and outcomes

Concordance between patient values and care received

Source: John E. Wennberg

 

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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

 

Slide 20

Proportion of Medicare Spending Attributed to Each Category of Unwarranted Variation

Pie Chart

Preference Sensitive Care - 25%
Effective Care - 12%
Supply Sensitive Care - 63%

Source: John E. Wennberg and Dartmouth Atlas
 

 

Slide 21

THE HEALTH CARE TRAIN WRECK

We're wasting $600 - 800 BILLION annually on unnecessary care

Part of the solution requires rethinking prevention and clinical decision making.