According to Dartmouth Atlas (DA) researchers, too much of a good thing may be a bad thing-including doctor visits, medical tests, procedures and days spent in the hospital. For 35 years John Wennberg, MD, and his Dartmouth colleagues have generated a data tsunami indicating that distributional inequity- i.e., the numbers of specialists and hospitals in largely urban areas-drives patient care. Their goal is to vaporize the status quo by substituting evidence-based treatment options that physician/patient partners evaluate together, rather than the supply-driven misutilization of medical resources that predominates.
Explore This IssueJune 2008
Dartmouth Atlas proponents argue that hospitals need to fill their beds and physicians their appointment books. That hurts rather than helps patients. In a 2007 DA report on utilization and equity, Dartmouth authors stated that Miami, Los Angeles, and Manhattan have overbuilt their acute care sectors, whereas Minneapolis, Salt Lake City, and Portland, OR have been frugal, using fewer hospital beds, less physician labor, and fewer expensive technologies such as intensive care unit (ICU) beds and medical imaging. Dr. Wennberg sees excessive utilization worsening, with care intensity increasing everywhere, and growth in medical specialist visits and ICU stays escalating rapidly in high-cost regions.
Distributional inequities, according to Dartmouth’s reasoning, lead to unwarranted variations in the practice of medicine and the use of medical resources. Such variation comes from three sources: underuse of effective care, such as not using beta blockers for heart attack; misuse, from the failure to accurately communicate the risks and benefits of alternative treatments; and overuse, from practices such as admitting patients with chronic conditions, then subjecting them to redundant tests and procedures rather than treating them less invasively as outpatients. Eliminating such unwarranted variations in care, by DA logic, should improve patient outcomes and lower costs.
In the fight against unwarranted variation, physicians and their informed patients play the starring roles. Otolaryngologists and head and neck surgeons are among them (see sidebar listing otolaryngology projects). Lee M. Akst, MD, Assistant Professor of Otolaryngology at Loyola University Chicago Stritch School of Medicine, indicates how DA findings move from clinical practice to actionable treatment options. Studying the spectrum of dysphonia, Dr. Akst encourages all new clinic patients with complaints of hoarseness to complete a survey-QualityMetric’s SF-12v2, a voice-related quality-of-life survey-as part of routine paperwork.
Dr. Akst’s goal is to use a quality-of-life measure to discover how hoarseness limits a patient’s functioning in various situations: at work, going out socially, and the effect on the patient’s energy level and emotions. I am interested in how voice disorders impact the patient’s quality of life, and creating a database to determine how treating their hoarseness impacts it, he said. There is increasing concern among patients and payers about the quality of care that physicians give. Eventually it will be necessary to prove that our patients are improving with the selected treatments we give them, he added.
Dr. Akst is aiming for 50 participants in the pilot study; then he plans to work with colleagues at Emory University and other sites with similar interests. By collecting enough surveys for a database, they are trying to demonstrate that treating hoarseness is on par with treating heart and lung conditions. As we measure the impact of dysphonia on a patient’s quality of life and measure outcomes, we hope to show that it is a medical condition deserving of serious consideration, he said.
Working to Enable Better Treatment Decisions
As research such as Dr. Akst’s progresses, providers at QualityMetric Health Outcomes Solutions, a purveyor of health status and outcomes measurement products and services that use proprietary and analytical methodologies to capture, benchmark, and interpret actionable patient-reported health information, will record Dr. Akst’s findings. Surveys like Dr. Akst’s that capture patient-reported health information are added to QualityMetric’s database of 7500 peer-reviewed articles and 1000 clinical studies. They are also added to specialty-related bibliographies and disseminated to other clinician/researchers who are contributing similar data.
QualityMetric’s long-term goals are evaluating treatment effectiveness, differentiating between outcomes produced by a wide range of treatments, and enabling evaluation of treatment benefits in relation to health costs and utilization of services. With this information, physicians can work with their patients to make better-informed treatment decisions.
The Other Partner
Dartmouth Atlas proponents recognize that physicians greatly influence the appropriate utilization of health care, and that their patients have to play their part as well in reducing overuse and misuse. In a culture with a more is better attitude toward many things, including consuming medical care, attitudes for patients’ opting for lower, but still appropriate, levels of care are hard to achieve. The physician’s challenge is to work with each patient on choosing the right treatment option, thereby chipping away at unwarranted variations in the practice of medicine, one patient at a time.
Lance Lang, MD, Vice President and Senior Medical Director of Quality Management at HealthNet, Inc., a Woodland Hills, CA-based health care organization with members in various regions throughout the country, has incorporated the Dartmouth Atlas’s findings on geographical variations in medical treatments in a patient-friendly format. Describing himself as a disciple of John Wennberg, Dr. Lang viewed an early test of turning DA data into patient decision-making tools, videotapes of physicians discussing treatment options for men with enlarged prostates. The Decision Power videotapes, decision-support tools around elective surgery, were very impressive, so HealthNet decided to work with Health Dialog, a DA partner on developing such tools for our members, said Dr. Lang.
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.
Researchers from Henry Ford Hospital in Detroit, led by Seema Sethi, MD, took saliva samples from 27 patients with HNSCC and 10 healthy controls. They analyzed DNA from the saliva with a multiplex ligation-dependent probe amplification assay and examined 82 genes with known associations to HNSCC.
They found that 11 genes showed a high individual predictive ability for HNSCC. In particular, the researchers found that an increase in PMAIP1, a tumor suppression gene on chromosome 18, either alone or with an increase in PTPN1, an oncogene on chromosome 20, identified all subjects with HNSCC with 100% sensitivity and 100% specificity. Further validation results showed a sensitivity of 96% and a specificity of 90%.
Dr. Sethi emphasized that the results of the study are preliminary, but she hopes that this could lead to HNSCC detection at its earliest stage. HNSCC affects more than 40,000 Americans, and approximately 12,000 die of it annually.
Scalp/Neck Melanomas Seem More Lethal than Other Melanomas
People with scalp or neck melanomas die at nearly twice the rate of people with melanoma elsewhere on the body, including the face and ears, according to a study in the April issue of the Archives of Dermatology.
Researchers from the University of North Carolina at Chapel Hill, led by Anne Lachiewicz, a student in the School of Medicine, and Nancy Thomas, MD, PhD, Associate Professor of Dermatology and a member of the Lineberger Comprehensive Cancer Center, analyzed 51,704 melanoma cases in the United States. They used data from 13 National Cancer Institute Surveillance Epidemiology and End Results (SEER) registries in nine states.
The researchers found that individuals with scalp or neck melanomas die at a rate 1.84 times higher than those with melanomas on the extremities, after controlling for age, gender, tumor thickness, and ulceration. The five-year melanoma-specific survival rate for patients with scalp or neck melanoma was 83%, compared with 92% for patients with melanomas at other sites. The 10-year survival rate was 76% for scalp or neck melanomas, compared with 89% for other melanomas.
Conservative Strategy for Management of Vestibular Schwannoma
Surgery has traditionally been the treatment of choice for vestibular schwannoma (VS), with the goal being complete removal of the tumor and, where possible, preserving hearing and facial nerve integrity. However, because the surgery is highly challenging and the tumors tend to grow very slowly, conservative management of VS is being proposed more frequently today as a primary therapeutic option. Gian Gaetano Ferri, MD, and associates found that in 47 nonsurgically treated patients, no growth at all was observed in 30 patients during the entire follow-up period. This report is an update on their experience, with a larger group of patients and a longer follow-up period.
Over a 25-year span, the investigative team treated 464 patients with VS. All were informed of the various treatment options, including their risks and possible complications. Of these patients, 336 (72.4%) patients were treated surgically, 125 (27.1%) with a wait and scan policy, and two (0.4%) with radiotherapy. The authors noted that over the years there was a progressive increase in the number of primarily observed patients compared with the number of surgically treated patients.
Tumor size at presentation ranged from 2 to 28 mm; almost half were intracanalicular tumors. Each radiologically observed patient received a second MRI scan after six months; tumor growth was defined as a dimensional increase of 2 mm or more in comparison to the previous scan, and a decrease of 2 mm or more defined tumor shrinkage. Audiometric assessment was conducted during the entire period of observation. The mean follow-up period was 57.4 months.
Among the patients for whom the wait and scan approach was used, no evidence of tumor growth was recorded during the entire period of observation for 59.7% of the cases. Tumors shrank in 4.8% of cases, and grew in 35.5%. Of the tumors that grew, enlargement was detected during the first year of observation in 45.4% of cases, whereas in 22.7% of cases, the growth was observed at least three years after diagnosis. No tumor growth was discovered after six or more years of observation. The average growth rate of the growing tumors was 1.2 mm/year. Sixteen (36.3%) patients with growing tumors had them treated surgically; all had favorable outcomes, indicating that surgical delay does not affect postoperative outcome.
The investigators conclude that conservative management of VS appears to be a safe and effective option because most tumors do not grow over the course of time, and surgical outcomes are not affected by delaying surgery. Furthermore, almost three-fourths of patients in the study maintained useful hearing during the observation period, and no differences were recorded in relation to tumor growth rate. Future research should look for predictive factors for the growth of tumors.
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Video Presentation: Endoscopic Removal of Juvenile Nasopharyngeal Angiofibromas
Juvenile nasopharyngeal angiofibroma (JNA) is a relatively rare, benign neoplasm characterized by nasal airway obstruction, recurrent unilateral epistaxis, headache, and facial swelling. JNAs arise in close proximity to the posterior attachment of the middle turbinate, near the superior border of the sphenopalatine foramen, and can extend into the nasal cavity, sphenoid sinus, and pterygopalatine fossa. In the past, surgical management of JNA included lateral rhinotomy, transpalatal and transmaxillary routes, and mid-face degloving. However, endoscopic sinus surgery for resection of JNA is a relatively new phenomenon that has recently become the standard approach for tumors that are limited to the nasal cavity and nasopharynx. Studies have shown that patients who underwent endoscopic JNA resection had less intraoperative blood loss, shorter hospital stays, lower complication rates, and fewer recurrences. In this video presentation, available online, Daekeun Joo, MD, Dinesh K. Chhetri, MD, and Marilene B. Wang, MD, demonstrate the procedure.
The patient was a 12-year-old boy with no major past medical history who presented with a fleshy, polypoid mass completely filling the right nasal cavity and nasopharynx. Imaging studies showed a 3.5-cm tumor located posterior to the right middle turbinate without evidence of intracranial extension. An endoscopic, endonasal approach was used to resect this tumor.
After the tumor was removed, the nasal cavity and sinuses were inspected and no active bleeding was noted. There were no complications from the procedure, and the estimated blood loss was about 25 mL. The patient tolerated the procedure well, was discharged from the hospital the day after surgery, and has shown no evidence of recurrence.
News & Notes
Increasing Demand for Geriatric Care Requires Attention
The rising number of elderly in the nation calls for special health considerations, including geriatric training, policy efforts, and patient diligence, according to a recent statement by the American Medical Association (AMA).
Cecil B. Wilson, MD, an AMA board member, reported that in 12 years there will be more than 70 million seniors in the United States, but with physician and nursing shortages, it will be impossible to train the anticipated 36,000 geriatricians needed to care for the aging population. The AMA is committed to prepare medical students and practicing physicians to care for individuals at all stages of life, including seniors.
Dr. Wilson also announced that the AMA has created a Web site (www.patientsactionnetwork.org ) to promote the Save Medicare Act, which was introduced in the US Senate and is aimed at stopping Medicare payment cuts and preserving seniors’ access to health care. Over nine years, government cuts of Medicare will total about 40%, while practice costs will increase 20%.
Dr. Wilson encouraged a team effort among health care professionals, seniors, and their families for the promotion of seniors’ health. For example, seniors and their caregivers should bring a list of medications to physician appointments, write down care instructions, and seek to understand treatment plans.
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©2008 The Triological Society