Dartmouth Atlas Takes Aim at Excess Utilization of Medical Resources

With nearly 2.5 million members and approximately 100,000 physicians in its HMO and PPO networks, the scale of using videotapes as coaching tools was a challenge. HealthNet physicians preview the videotapes, which refer to evidence-based treatment options, percentages of patients who chose various options, and patient outcomes. Patients can also view Decision Power videos on the Internet. They can also receive personal coaching about the treatment options portrayed in the videotapes through nurse-staffed call centers operating 24/7.

When asked if videotapes and coaching were sophisticated forms of gatekeeping rather than a decision-making tool, Dr. Lang said no. All the evidence-based material presented in the videotapes is vetted by Dartmouth Atlas. For example, there’s a module for otitis media, which suggests that parents have a choice-to treat with or without antiobiotics. He added, Coaching helps physicians as well as patients. Once they learn the evidence, they usually change their practice habits. Patients are much more conservative with their bodies than we doctors are. We’re trained to fix things, and coaching helps patients examine treatment options. It’s an ‘aha’ moment when a patient realizes he can get better without surgery or some other invasive procedure. (To view a CBS News video clip of one of Dartmouth-Hitchcock Hospital’s program’s coaching modules, visit www.youtube.com/watch?v=5HD2nTQB1WI.)

Even as the Dartmouth Atlas’ research seems to be picking up steam, it has detractors. Some physicians at the Mayo Clinic caution that the DA’s piecemeal approach may be too simplistic. Big picture thinkers have complained that physician-led studies rely on volunteers rather than all of a doctor’s patients, and that pilot studies based on small samples may not produce valid and reliable data. Finally, state medical associations say that DA’s approach clashes with the altruistic and professional side of medicine. Still, the DA has momentum on its side.

More Food for Thought

As medicine grows increasingly sophisticated, looking at the relationships between diagnosis and treatment outcomes becomes critical. Here are two examples of recent findings for head and neck surgery:

• A retrospective study of 54 patients receiving prophylactic treatment of contralateral N0 neck in early squamous cell carcinoma (SCC) of the oral tongue showed that ipsilateral elective neck management is indicated for stage I and II SCC. On the other hand, contralateral occult lymph node metastasis was unlikely in early-stage oral tongue SCC, and that there was no survival benefit for patients who underwent elective neck dissection in place of observation (Lim YC et al. Treatment of contralateral N0 neck in early squamous cell carcinoma of the oral tongue: elective neck dissection versus observation. Laryngoscope 2006;116(3):461-5).
• The increasing incidence of thyroid cancer in the United States is predominantly due to the increased detection of small papillary cancers. These trends, combined with the known existence of a substantial reservoir of subclinical cancer and stable overall mortality, suggest that increasing incidence reflects increased detection of subclinical disease, not an increase in the true occurrence of thyroid cancer (Davies L et al. Increasing incidence of thyroid cancer in the United States, 1973-2002. JAMA 2006;295:2164-7).

Dartmouth Atlas Otolaryngology- Head and Neck Surgery Participants and Their Projects

• Advocate Illinois Masonic Medical Center, Chicago: Operative Techniques in Otolargyngology
• Lahey Clinic, Burlington, MA: Allergic Rhinitis, Evaluation of the Relative Prevalence of Psychosocial Distress in Otolaryngology Patients
• Loyola University Medical Center, Maywood, IL: The Spectrum of Dysphonia
• Saint Louis University Cancer Center: Assessment of Quality of Life of Patients Treated for Otolaryngology Cancer
• Tel Aviv Sourasky Medical Center: Head and Neck Surgery in Elderly Patients

News & Notes

DNA in Saliva May Help Detect Early HNSCC

DNA in saliva may detect early signs of head and neck squamous cell cancer (HNSCC), according to research presented at the 2008 Annual Meeting of the American Association for Cancer Research.