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Developing Sustainable Methods of Health Care: A Global Challenge
The Dartmouth Center for Health Care Delivery Science
Thom Walsh PhD, MS, MSPTthom.walsh@dartmouth.edu | twitter.com/@thomwalsh
The Dartmouth Center for Health Care Delivery Science
Created in 2010, the Dartmouth Center for Health Care Delivery Science draws upon unique resources from across disciplines, forming innovative global partnerships that bring the discipline of science to the questions of service delivery while building a deeper understanding of the personal dimension of health and health care.
“We must find a sustainable health system for patients, providers, payers, and our communities”
CEO Dartmouth-Hitchcock Health System
Jim Weinstein DO, MS
The Dartmouth Center for Health Care Delivery Science
Master of Health Care Delivery Science
Research
A Health Care Delivery Science Post-Doc’s Life
Best ThinkersBest Thinkers Across
Disciplines
Best Doers Across
Contexts
Best Communicators
Across Constituencies
Best Doers
Best Thinkers Across
Disciplines
Best Doers Across
Contexts
Best Communicators
Across Constituencies
Best Communicators
Best Thinkers Across
Disciplines
Best Doers Across
Contexts
Best Communicators
Across Constituencies
Health Care Delivery Science
A
D B
C
The Implementation
Gap
Out
com
e
Spending
Health Care Delivery Science
The Dartmouth Center for Health Care Delivery Science
Across Countries and Contexts
Dr. Lisa Adams in Rwanda Dr. Jaime Bayona in TanzaniaHealth Coaches in Peru
Health & Health Care
Clinical training teaches us to link outcomes and exposures
• Upper respiratory infection viruses• Cancer carcinogens• Obesity calories in/calories out
There Is More to the Story…
The Field Model
McKinlay & McKinlay 2005[1997]. Pp. 7 - 19 Sociology of Health & Illness
Haiti• Affordable housing and
health: The $300 House Project
• Medical education: weekly video lecture series in “grand rounds” style to seven sites in Haiti.
Haiti: The $300 House Project
• Cross-disciplinary approach to health care: Studio Art / Architecture, Thayer Engineering, Tuck Business, Undergraduate Arts & Sciences, Graduate Studies, Geisel School of Medicine
Molly Bode at Dartmouth site visit for $300 House Project
The Epidemiologic Transition
Wilkinson, R: Unhealthy Societies 1996
The Epidemiologic Transition
Medical Education in Haiti
• Dartmouth, Haiti Medical Education (HME) Project & McGill University weekly video lecture series and curriculum development
• Building an education network
Peru: Partnership Overview
• Oncology systems with National Cancer Institute
• Emergency preparedness • Primary care • Maternal mortality
prevention • Shared decision making• Geisel, Tuck, Thayer, and
Arts & Sciences collaborating on projects
Dartmouth undergraduate and medical students in Lima, Peru
Rwanda
Dr. Agnes Binagwaho, Minister of Health of Rwanda, receiving an honorary degree from Dartmouth President, Dr. Jim Yong Kim, in 2010.
Moving from Infectious to Chronic Disease & Unintended
Consequences
The Distribution of Health Care Spending
Per Condition for Similar Patients
Adapted from “Cowboys and Pit Crews” by Atul Gawande, The New Yorker. May 26, 2011
The Distribution of Quality Health Care Provision
Per Condition for Similar Patients
What We Believe
Cost & Quality Curves Match
Implication
Curves match– Reducing health care spending impairs
quality
What the Data Tell Us
Cost & Quality Curves Do Not Match
Some Areas Provide Above Average Quality at Below Average Spending
Implication
Curves do not match– It is possible to reduce spending and
improve quality
• National & Regional Dartmouth Atlases
• A High Value Health Care Collaborative
• New Models of Primary Care• Leadership Training Programs
Health Care Reform in ChinaDartmouth’s Approaches to Serve China
Chinese Provinces
Different Contexts
• Developing, emerging, & sustaining economies
• Single payer & multi-payer health care systems
Similar Interventions
• Assessment of variation as a catalyst for change
• Networks– Improvement– Education
• Reforming & revitalizing primary care– Community integrated care
• Shared Decision Making
Master of Health Care Delivery Science (MHCDS) Faculty
Dartmouth College Master of Health Care Delivery Science
On-Line Synchronous Platform
Create a medical home system to
divert future unnecessary emergency
department visits
Implement evidence-based quality-of-life care in a high-intensity facility
for end-stage COPD care
Design benefits package for first
state-based single-payer health care system in US
Learning in Action 2013
Break
C. Monet(1840-1926)Research Focus
The Value Equation
V = OP / C
Value = Patient Outcome / Cost of Care
Bringing the Numerator to Life
The Spine Center’s Data Collection
Available and Actionable
Case 1
Case 1
Case 2
Case 2
Case 3
Case 3
Case 2
The Value Equation
V = OP / C
Value = Patient Outcome / Cost of Care
Preference Diagnosis
http://www.kingsfund.org.uk/publications/patients%E2%80%99-preferences-matter
Preference Diagnosis
71% of physicians rated “keeping my breast” as a top priority for women with breast CA
7% of women report “keeping my breast” as a top priority (Lee 2010)
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
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
Preferences are the Silent Misdiagnosis
Providers are not yet trained to make preference diagnoses
Steps for Diagnosing Patient Preferences
Team Talk
Option Talk
Decision Talk
Initial Preferences
Informed Preferences
D e l i b e r a t i o n
Long – Type Patient Decision Support
Short-Type Patient Decision Support
Long - Type Decision Support
Short -Type Decision Support
In situations of clinical equipoise– Outcomes depends on understanding what informed patients need
and want– Treatment options have proliferated– Patients need to be informed of options, risks and benefits– Providers need to elicit preferences & integrate informed patient
choice into treatment planning
How to measure a clinic or provider’s skill?
CollaboRATE
A fast, frugal & sustainable, patient reported measure of patient-centeredness during the clinical encounter
Simulation, level of SDM
Information Preference Elicitation
Preference Integration
Scenario 1No SDM
Little Explanation No Preference Elicitation
Scenario 2Low SDM
Detailed Explanation No Preference Elicitation
Scenario 3Low SDM
Little Explanation Preference Elicitation No Preference Integration
Scenario 4Moderate SDM
Detailed Explanation Preference Elicitation No Preference Integration
Scenario 5Moderate SDM
Little Explanation Preference Elicitation Preference Integration
Scenario 6High SDM
Detailed Explanation Preference Elicitation Preference Integration
The Value Equation
V = OP / C
Value = Patient Outcome / Cost of Care
Health Care Production Costs
The amount it takes to pay personnel, rent, and for materials used to provide health care.
Health Care Population Spending
The amount spent to reimburse providers of health care services & equipment.
Total population spending on iPads is rising, but the production costs of tablets are not.
Bending Population Spending Requires Bending Production Costs
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
Time
$
Do Patient Decision Support Interventions (DESIs)
lead to health care savings?
DESIs = Savings?• Study characteristics• Risk of bias• Quality of the economic evaluation• Costs & resources allocation needed to
implement upstream• Savings downstream
– Consider knee replacement surgery
The Atlantic Monthly & The 141
• What ‘Health Care Costs’ Really Means• The 141:
What I'm talking about when I talk about costs and spending
The Value Equation
V = OP / C
Value = Patient Outcome / Cost of Care
Health Care Delivery Science
A
D B
C
The Implementation
Gap
Out
com
e
Spending
Health Care Delivery Science
Broader access Better health care Better health Lower cost
PRESSING NEED
ModelsMethodsMetrics Value
UniversitiesGovernmentsPrivate sector New vision of health care delivery
REQUIRES NEW PARTNERSHIPS
FOR INNOVATION AND IMPLEMENTATION
Health Care Delivery is a Global Challenge
Health Care as a Right
Health Care as a Common
“All patients should receive the care they need, and no less. They should also receive the care they want, and no more.” - Al Mulley
Developing Sustainable Methods of Health Care: A Global Challenge
The Dartmouth Center for Health Care Delivery Science
Thom Walsh PhD, MS, MSPTthom.walsh@dartmouth.edu | twitter.com/@thomwalsh
Blog: The 141 With Jennifer B. Murray
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