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 Too Much Prevention: What Not to Do in the Primary Care SettingAgency for Healthcare Research and QualityBethesda, MD September 15, 2009Shannon Brownlee, MSSenior Research Fellow, New America FoundationAuthor: Overtreated : Why Too Much Medicine Is Making Us Sicker and Poorerbrownlee@newamerica.net Slide 2 DISCLAIMERNo financial conflicts of interest to declareSlide 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 economySource: CBO Slide 4 Graph: Sources of Growth in Projected Federal Spending on Medicare and MedicaidSource: CBO Slide 5 Busting state budgetsCartoon 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 testHeart disease - 64-slice CT scanLung cancer - CT scanProstate cancer - PSA testColon cancer - colonoscopyOsteoporosis - Dexa scanCarotid artery disease - DopplerOvarian cancer - Ca125 testBreast cancer - mammograms and BRCA testCOPD - spirometry Slide 9 Prevention = Surgery (head it off at the pass)Silent gall stonesChronic stable anginaCarotid artery stenosisHerniated discEarly prostate cancerEnlarged prostate (BPH) Slide 10 Dr. Michael LeFevreUSPSTFEvidence for screening testsPressures on Physicians Slide 11 Preference-Sensitive CareInvolves tradeoffs -- more than one treatment exists; not getting treated at all is an option; and the outcomes are different depending upon the patient's choiceDecisions should be based on the patient's own preferencesBut provider opinion (preference) often determines which treatment is used Slide 12 TURP for BPH per 1,000 male Medicare enrollees (2005) HRRRatio to lowestProvidence, RI2.67Lubbock, TX2.63Bismarck, ND2.46Washington, DC2.07Burlington, VT2.05Hartford, CT1.92St. Paul, MN1.89Worcester, MA1.89Baltimore, MD1.85Minneapolis, MN1.79White Plains, NY1.74Bangor, ME1.74Manhattan, NY1.74Portland, ME1.57Seattle, WA1.48Salt Lake City, UT1.44Casper, WY1.43Wilmington, DE1.36Richmond, VA1.17Baton Rouge, LA1.03Lebanon, NH1.00 Slide 13 CABG surgery per 1,000 Medicare enrollees (2005) HRRRatio to lowestLubbock, TX2.59Baton Rouge, LA2.34Baltimore, MD1.88 Providence, RI1.16Worcester, MA1.15Seattle, WA1.14 Slide 14 Percutaneous coronary intervention per 1,000 Medicare enrollees (2005) HRRRatio to lowestLubbock, TX2.59Worcester, MA1.86Baltimore, MD1.77 Providence, RI1.21Seattle, WA1.09Baton Rouge, LA1.05Slide 15 Back surgery per 1,000 Medicare enrollees (2005) HRRRatio to lowestCasper, WY5.41Lubbock, TX3.23Bismarck, ND3.17Salt Lake City, UT2.91Baltimore, MD2.81St. Paul, MN2.79Minneapolis, MN2.57Seattle, WA2.54Washington, DC2.41Richmond, VA2.25Portland, ME1.97Wilmington, DE1.85Hartford, CT1.63Worcester, MA1.63Bangor, ME1.48Baton Rouge, LA1.45White Plains, NY1.37Providence, RI1.36Burlington, VT1.24Lebanon, NH1.17Manhattan, NY1.00 Slide 16 Preventive Surgery ConditionTreatment OptionsSilent gall stonesSurgery versus watchful waitingChronic stable anginaPCI vs CABG vs other methodsCarotid artery stenosisEndarterectomy vs drugsHerniated discBack surgery vs other strategiesEarly prostate cancerSurgery vs radiation vs waitingEnlarged prostate (BPH)Surgery vs other strategies Slide 17 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: BPHKnowledge of relevant treatment options and outcomesConcordance between patient values and care receivedSource: John E. Wennberg Slide 19 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 VariationPie ChartPreference Sensitive Care - 25%Effective Care - 12%Supply Sensitive Care - 63%Source: John E. Wennberg and Dartmouth Atlas Slide 21 THE HEALTH CARE TRAIN WRECKWe're wasting $600 - 800 BILLION annually on unnecessary carePart 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