1. Accelerating Value Creation: An orthopedic example Thomas L. Walsh PhD MS MSPT

2. My Two Overarching Objectives Start a relationship Learn El Paso secrets that could improve the Big Green Football team

3. Big Green Red Raiders

4. CEO Dartmouth-Hitchcock Health System Jim Weinstein DO, MS “We must find a sustainable health system for patients, providers, payers, and our communities”

5. Healthcare Productivity in Theory & Practice A DB C The Implementation Gap Outcome Spending A.Current outcome per dollar spent in clinical service line B.Proven efficacy Improved outcomes with more spending C.Real world effectiveness. All the added spending, but little or no observed improvement in outcomes. D.Fast & frugal options/Reverse Innovation bridge the Implementation Gap, achieve better outcomes at same or slightly higher spending

6. The Value Equation

7. We need to design systems of care and inquiry to accelerate value creation

8. Clinically Relevant & Actionable Data to Support Vision Achievement Real-time data in the clinic to improve quality of care for each patient Measure outcomes / improvement for the Microsystem over time

9. The Spine Center’s Data Collection

10. Available and Actionable

11. Case 1

13. Case 2

15. Case 3

16. Case 2

17. Preference Diagnosis http://www.kingsfund.org.uk/publications/patients%E2%80%99- preferences-matter

18. Preference Diagnosis Canadian surgeons identified patients “eligible” for knee replacement based on x-ray only – Of the fully informed sample, 15% wanted the procedure – Hawker 2001 Doctors believe 71% of women with breast cancer rate “keeping my breast” as a top priority – 7% of women report “keeping my breast” as a top priority – Lee 2010

19. Providers are not yet trained to make preference diagnoses

20. Preference Misdiagnosis Well informed – men with prostate disease choose surgery 40% less often – Wagner 1995 – Patients with heart disease choose percutaneous intervention 20% less often – Morgan 2000 – Patients with disc herniation choose surgery 30% less often – Deyo 2000 – Patients with spinal stenosis choose surgery 30% more often – Deyo 2000

21. Two Types of Medical Errors Medical Error 1 – Sue tears her right anterior cruciate ligament, but has her left knee operated on Medical Error 2 – Joe has his right knee replaced then learns about alternative treatments and wishes he did not have the operation

22. Preferences are the Silent Misdiagnosis

23. Getting the Preference Diagnosis Right Meta Analysis of 86 RCTs demonstrating patients make better decisions when fully informed More knowledgeable about the condition Treatment more likely to be congruent with stated preferences Less decisional regret – Stacy et. al. Cochrane Review 2010

24. Getting the Preference Diagnosis Right Group Health Experiment 2012 emphasized the use of clinical data to ensure steps were taken to get the preference diagnosis correct

25. CLINIC LEVEL OUTCOMES AS A LEARNING TOOL

26. Learning as a Clinical Microsystem 26

27. www.innerbody.com Anatomy of the Spine Center Patients 4 th Quartile* 732 patients from 1/1/01 to 3/31/02 *4 th Quartile is defined as 25% of the patients from entire cohort (N= 2,928) who scored the lowest on an average index of MCS and PCS from the SF-36 Health Status Survey, and Oswestry Disability Index from a spine disease specific survey that assesses disability (ODI converted to higher is better & 100 point scale). 15% spine diagnosis in upper back (Occ to T10) The aim of this poster is to provide a forum to assist the Spine Center in interpretation of the collected data and to identify opportunities which can lead to improvements in access (matching supply and demand in the most efficient manner). This is the first part of the Practice Profile, Know your Patients. Interesting Facts MCS 2.5% of US population are expected to score 30 or less 14.8% of Spine Center initial visit patients scored 30 or less 40.4% of the 4 th Quartile scored 30 or less Interesting Facts PCS 2.5% of US population are expected to score 30 or less 52.7% of Spine Center initial visit patients scored 30 or less 87.4% of the 4 th Quartile scored 30 or less Interesting Facts The 4 th Quartile patients are 3 times more likely to participate in the Functional Restoration Program compared to the other patients. The 4 th Quartile patients are almost 2 times more likely to have surgery compared to the other patients. Nucleus Communications, Inc 53% spine diagnosis in lower back (T11 to Ileum) Herniated disc, also known as ruptured disc, is when a portion of the intervertebral disc material bulges and sticks out into the neural canal. Charges: One year episode spine specific ICD-9 codes Interesting Facts Charges +8% -8% 25% The 4 th Quartile patients are distributed evenly among departments for initial visit. Outcome: Difference between Follow-up and Initial. Follow-up was latest survey between 3 to 7 months (average 5 months between initial and follow-up surveys)

29. Healthcare Production Costs The amount it takes to pay personnel, rent, and for materials used to provide healthcare. – Charges – Institutional costs – Healthcare costs

30. Healthcare Population Spending The amount spent to reimburse providers of healthcare services & equipment. – Societal costs – Expenditures – Reimbursement – Healthcare costs

31. Population Spending on iPads is rising, but the Production Costs of tablets are not.

32. Bending Population Spending Requires Bending Production Costs $ Time Current Production Costs Operating Margin 4-10% Production Costs > Population Spending Population Spending Estimates Based on Past Claims New Production Costs Required to Maintain Margin

33. THE POPULATION LEVEL

34. Founder of The Dartmouth Institute for Health Policy and Clinical Practice Jack Wennberg "Given the magnitude of the variations the possibility of too much medical care and the attendant possibility of illness that is caused by medical care is presumably as strong as the possibility of not enough service and unattended morbidity and mortality."

35. Distribution of Healthcare Spending Per Condition for Similar Patients Adapted from “Cowboys and Pit Crews” by Atul Gawande, The New Yorker. May 26, 2011

36. Distribution of Quality Healthcare Provision

37. Cost and Quality Curves Match

38. Implication Curves Match Reducing health care spending impairs quality

39. What the Data Tell Us Cost & Quality Curves Do Not Match Some Areas Provide Above Average Quality at Below Average Spending

40. Implication Curves do not match It is possible to reduce spending and improve quality

41. Types of Variation Effective care Benefits outweigh risks Problem of under-use Preference- sensitive care Significant tradeoffs between 2 or more treatment options that affect quality or length of life Problem of mis-use Supply-sensitive care Supply of resources governs the frequency of their use Problem of over-use Beta blocker use among patients post heart attack varies from 5%-92%, when it should approach 100% 71% of doctors rate breast conservation as one of the top 3 concerns of woman diagnosed with CA while 7% of woman rate it similarly Two similar cities with similar populations – one has twice as many hospital beds.

42. Ratio of Rate in Highest to Lowest Spending Regions (risk-adjusted) Reperfusion in 12 hours for AMI Mammogram, Women 65-69 Effective Care (HEDIS measures) Flu shot during past year, elderly Aspirin at admission for AMI Total Hip Replacement Back Surgery Cataract Extraction Preference Sensitive Care Total Knee Replacement Office Visits Initial Inpatient Specialist Consultations Pulmonary Function Test Total Inpatient Days Supply Sensitive Care Inpatient Visits Chest X-ray Inpatient Days in ICU or CCU 1.00 1.5 2.0 0.5 25 3.0 Lower in High Spending Regions Higher in High Spending Regions

43. Decreased Risk Relative Risk of Death Across Quintiles of Spending 1.001.051.10 0.95 Colorectal Cancer Q1 Hip Fracture Q1 Q2 Q3 Q4 Q5 Q2 Q3 Q4 Q5 Myocardial Infarction Q1 Q2 Q3 Q4 Q5 Increased Risk Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, and Pinder EL. The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care. Annals of Internal Medicine, 2003. 138: 288-98. Q1 = Lowest spending HSA’s Q5 = Highest spending

44. Benefit-Utilization Curve Effective Care

45. Benefit-Utilization Curve Preference-Sensitive Care

46. Benefit-Utilization Curve Supply Sensitive Care

47. Cost & Quality Curves Do Not Match Some Areas Provide Below Average Quality at Above Average Spending

48. Implication It is possible to reduce population spending and improve quality.

49. Healthcare Value

50. The Population Perspective Data within organizations – financial, operations, productivity – all point to increasing throughput & utilization to survive Relative Efficiency Comparisons – A Tale of Two Cities Larger perspective reveals a different perspective

51. Healthcare Productivity in Theory & Practice A DB C Outcome The Implementation Gap Spending

52. “All patients should receive the care they need, and no less. They should also receive the care they want, but no more.” Al Mulley, Director of The Dartmouth Center for Healthcare Delivery Science

53. Dartmouth College’s 12 th President John Sloan Dickey “ The world’s troubles are your troubles, …. and there is nothing wrong with the world that better human beings cannot fix.”