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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 FoundationAuthor: Overtreated: Why Too Much Medicine Is

Making Us Sicker and Poorer

[email protected]



DISCLAIMER

• No financial conflicts of interest to declare



Source: CBO

Source: CBO



Busting state budgets



The Solution?

70% of Americans consider PREVENTION

the most important aspect of health carereform (other than covering everybody)



The Solution? Prevention!

Max Baucus: “Reforming our system to focus on prevention will drive down costs and produce better healthoutcomes.”

Ron Wyden: “Prevention and wellness come first. Theseare 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 billionannually within five years.”



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



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)



Dr. Michael LeFevre

• USPSTF

•

Evidence for screening tests

• Pressures on Physicians



Preference-Sensitive Care

• Involves tradeoffs -- more than one treatmentexists; not getting treated at all is an option; andthe outcomes are different depending upon the

patient’s choice

• Decisions should be based on the patient’s ownpreferences

• But provider opinion (preference) oftendetermines which treatment is used



TURP for BPH per 1,000 male Medicareenrollees (2005)

0.5 1.5 2.5 3.5 4.5 5.5 6.5 7.5 8.5 9.5

Ratio to

HRR lowestProvidence, 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 1.89Worcester, MA 1.89

Baltimore, MD 1.85

Minneapolis, MN 1.79

White Plains, NY 1.74

Bangor, ME 1.74

Manhattan, NY 1.74Portland, 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 1.03Lebanon, NH 1.00



CABG surgery per 1,000 Medicare enrollees(2005)

2.0

4.0

6.0

8.0

10.0 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



Percutaneous coronary intervention per1,000 Medicare enrollees (2005)

2.0

10.0

18.0

26.0

34.0

42.0 Ratio to

HRR lowest

Lubbock, TX 2.59

Worcester, MA 1.86

Baltimore, MD 1.77

Providence, RI 1.21

Seattle, WA 1.09




Back surgery per 1,000 Medicare enrollees(2005)

1.0

3.0

5.0

7.0

9.0

11.0

Ratio to

HRR lowestCasper, 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 2.57Seattle, WA 2.54

Washington, DC 2.41

Richmond, VA 2.25

Portland, ME 1.97

Wilmington, DE 1.85

Hartford, CT 1.63Worcester, MA 1.63

Bangor, ME 1.48


White Plains, NY 1.37

Providence, RI 1.36

Burlington, VT 1.24

Lebanon, NH 1.17Manhattan, NY 1.00



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



Whi h i i h ? I f i d



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

Knowledge of relevant treatmentoptions and outcomes

Concordance between patient

values and care received

Source: John E. Wennberg



Bottom Line Implications:

1. Clinical appropriateness should be basedon sound evaluation of treatment options

(comparative effectiveness and outcomesresearch)

2. Medical necessity should be based onInformed Patient Choice among clinically

appropriate options -- high quality shared decision-making



63%

12%

25%

PreferenceSensitive Care

Effective Care

Supply Sensitive Care

Proportion of Medicare Spending Attributed to

Each Category of Unwarranted Variation

Source: John E. Wennberg and Dartmouth

Atlas



We’re wasting $600 – 800 BILLION

annually on unnecessary care

Part of the solution requires

rethinking prevention and clinicaldecision making

THE HEALTH CARE TRAINWRECK

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