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

Slide presentation from the AHRQ 2009 conference.

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

Slide 1

Slide 1. Too Much Prevention: What Not to Do in the Primary Care Setting
 

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

Slide 2. DISCLAIMER
 

DISCLAIMER

No financial conflicts of interest to declare

Slide 3

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
 

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

Slide 4. Graph: Sources of Growth in Projected Federal Spending on Medicare and Medicaid 
 

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

Source: CBO

 

 

Slide 5

Slide 5. Busting State Budgets 
 


Busting state budgets

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

 

Slide 6

Slide 6. The Solution?
 

The Solution?

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

 

Slide 7

Slide 7. The Solution? Prevention!
 

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

Slide 8. PREVENTION = SCREENING (Catch it early)
 

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

 

Slide 9

Slide 9. Prevention = Surgery (head it off at the pass)
 

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

Slide 10. Dr. Michael LeFevre
 

Dr. Michael LeFevre

  • USPSTF
  • Evidence for screening tests
  • Pressures on Physicians

 

Slide 11

Slide 11. Preference-Sensitive Care
 

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

Slide 12. TURP for BPH per 1,000 male Medicare enrollees (2005)
 

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

 
HRRRatio to lowest
Providence, RI2.67
Lubbock, TX2.63
Bismarck, ND2.46
Washington, DC2.07
Burlington, VT2.05
Hartford, CT1.92
St. Paul, MN1.89
Worcester, MA1.89
Baltimore, MD1.85
Minneapolis, MN1.79
White Plains, NY1.74
Bangor, ME1.74
Manhattan, NY1.74
Portland, ME1.57
Seattle, WA1.48
Salt Lake City, UT1.44
Casper, WY1.43
Wilmington, DE1.36
Richmond, VA1.17
Baton Rouge, LA1.03
Lebanon, NH1.00

 

Slide 13

Slide 13. CABG surgery per 1,000 Medicare enrollees (2005)
 

CABG surgery per 1,000 Medicare enrollees (2005)

 
HRRRatio to lowest
Lubbock, TX2.59
Baton Rouge, LA2.34
Baltimore, MD1.88
  
Providence, RI1.16
Worcester, MA1.15
Seattle, WA1.14

 

Slide 14

Slide 14. Percutaneous coronary intervention per 1,000 Medicare enrollees (2005)
 

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

 
HRRRatio to lowest
Lubbock, TX2.59
Worcester, MA1.86
Baltimore, MD1.77
  
Providence, RI1.21
Seattle, WA1.09
Baton Rouge, LA1.05

Slide 15

Slide 15. Back surgery per 1,000 Medicare enrollees (2005)
 

Back surgery per 1,000 Medicare enrollees (2005)

 
HRRRatio to lowest
Casper, WY5.41
Lubbock, TX3.23
Bismarck, ND3.17
Salt Lake City, UT2.91
Baltimore, MD2.81
St. Paul, MN2.79
Minneapolis, MN2.57
Seattle, WA2.54
Washington, DC2.41
Richmond, VA2.25
Portland, ME1.97
Wilmington, DE1.85
Hartford, CT1.63
Worcester, MA1.63
Bangor, ME1.48
Baton Rouge, LA1.45
White Plains, NY1.37
Providence, RI1.36
Burlington, VT1.24
Lebanon, NH1.17
Manhattan, NY1.00

 

Slide 16

Slide 16. Preventive Surgery
 

Preventive Surgery

 
ConditionTreatment Options
Silent gall stonesSurgery versus watchful waiting
Chronic stable anginaPCI vs CABG vs other methods
Carotid artery stenosisEndarterectomy vs drugs
Herniated discBack surgery vs other strategies
Early prostate cancerSurgery vs radiation vs waiting
Enlarged prostate (BPH)Surgery vs other strategies

 

Slide 17

Slide 17. Image of Journal Article: Decision aids for patients facing health treatment or screening decisions: systematic review
 

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

 

Slide 18

Slide 18. Which rate is right? Impact of improved decision quality on surgery rates: BPH 
 

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

 

Slide 19

Slide 19. Bottom Line Implications:
 

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

Slide 20. Proportion of Medicare Spending Attributed to Each Category of Unwarranted Variation
 

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

Slide 21. Image - THE HEALTH CARE TRAIN WRECK
 

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.

Current as of December 2009
Internet Citation: Too Much Prevention: What Not to Do in the Primary Care Setting (Text version). December 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/conference/2009/brownlee/index.html