Help Me in My Confusion Should We Think More Abou

Authors: Joseph O’Donnell

Publish Date: 2010/11/09

Volume: 25, Issue: 4, Pages: 471-472

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Abstract

I live in an institution Dartmouth that has the recent history of making trouble by raising questions and questioning assumptions Our Godfather for these disruptions Dr Jack Wennberg I’d highly recommend his autobiographical book called Tracking Medicine A Researcher’s Quest to UnderStand Healthcare 1 started the whole field that he has coined “the evaluative clinical sciences” Jack noticed isn’t it great that a first step often occurs when one notices and wonders about something that in his own town in Vermont all of his children’s friends had had their tonsils out whereas in nearby towns this wasn’t the case He began looking at variations for other things like Cesarean Sections and they varied widely too He became fascinated by these observations and has devoted his career to trying to find out why such variations occur The answer it has turned out is not because of applying the right science to these problems These variations are due to many other things We call these practice patternsWhen Mrs Clinton was designing the plan she was trying to implement to bring about healthcare reform she really resonated with Dr Wennberg’s findings and thought dealing with variations might be one way to control costs and get higher quality of care Value is directly related to quality and inversely related to cost As we all know her plan was crushed but Jack and his colleagues who had produced reams of data decided to use it by publishing something called the Dartmouth Atlas of Healthcare which details the profound variations that characterize our healthcare system He thought that studying these data could yield insightsJack and his colleagues in subsequent work have divided care into what they call effective care supply sensitive care and preference sensitive care Effective care includes things like getting a hip replacement after a fractured hip or getting beta blockers after an MI or in our field getting Pap smears For supply sensitive care there is more care where there are conditions like more beds more specialists and more technology for instance where there are more cardiologists patients are seen more frequently costs rise but outcomes do not differ There were several presentations at this year’s annual meeting particularly those by editorial board member Dr Frank Johnson that address issues of supply sensitive care I will ask him to write an editorial on this for a future issueThe third type of care preference sensitive care is where I’m confused A preference sensitive decision might be when or whether to do a knee replacement for someone with degenerative joint disease in the knee It is very clear to me now that the use of the PSA lies within this preference sensitive domain It depends on values risks and benefits and is not just a simple decision The strategy of shared decision making is the way to approach a decision like getting a PSA and that is how we are applying this decisionor at least should be applying or teaching how to applyMammography is a strategy that is looking more to me like a preference sensitive decision particularly in the decade of the forties There is no question that breast cancer is a far too common and far too lethal disease but not in everyone One of my colleagues at Dartmouth Dr Gil Welch has convinced me that there are cases that the woman will die with it rather than of it And there is no question that mammography saves lives The questions appear to me to be about risks and benefits and ultimately values Mammography can lead to worry biopsies costs and other things It is not a slam dunk to say that a solution to disparities is just to have women get mammograms which is what many articles in this journal seem to imply I suspect like PSA we need to teach about shared decision making

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