- Hardcover: 344 pages
- Publisher: Oxford University Press; 1 edition (August 26, 2010)
- Language: English
- ISBN-10: 0199731780
- ISBN-13: 978-0199731787
- Product Dimensions: 9.8 x 1.1 x 6.1 inches
- Shipping Weight: 1.4 pounds (View shipping rates and policies)
- Average Customer Review: 4.8 out of 5 stars See all reviews (11 customer reviews)
- Amazon Best Sellers Rank: #611,783 in Books (See Top 100 in Books)
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Tracking Medicine: A Researcher's Quest to Understand Health Care 1st Edition
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"There are many books on healthcare reform, health delivery, or systems research, but none that combine the science with practical experience like this one does." --Doody's
"The cost crisis now facing the US health care system urgently calls for more effective control than the new legislation provides. That is why a new book by Dr. John E. Wennberg, Tracking Medicine, is so important and timely." --The New York Review of Books
"Tracking Medicine should be required reading for all health care professionals, and indeed for all who are intrested in truly reforming health care... Highly recommended." --Choice
"The title of this book hints at a personal history:'researcher's quest . . .' Yet, John Wennberg has been the dominant force over several decades in studies to describe and understand American medicine. Thus, this personal narrative is also an excellent summary of our current understanding of US health care." -- American Journal of Epidemiology
About the Author
John E. Wennberg, MD, MPH, is Peggy Y. Thomson Professor (Chair) in the Evaluative Clinical Sciences, and Founder and Director Emeritus of The Dartmouth Institute for Health Policy and Clinical Practice.
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Top Customer Reviews
My dad who was a research physicist would have called this a corollary to Parkinson's Law--"the work expands to meet the time available"-- updated to" the amount of health care delivered expands to meet the resources available."
The last chapter has concrete suggestions for bending this cure, but given our dysfunctional political system and the strength of the medical-industrial complex, it's doubtful we'll live to see any significant change.
At least when the new Health Care Law goes into effect, if we don't increase the number of hospital beds and health care providers and Dr Wennberg is right, the system should be able to absorb the influx of new patients without a decrease in care quality (but not without a lot of screaming).
It always a pleasure to hear a brilliant scientist explain his work. But it is also a revelation to hear such a figure explain how he worked his way through the data with a good deal of self observation, willingness to acknowledge mis-steps and point-by-point response to those who try to provide alternative explanations to his results. Wennberg explains the studies done by the Dartmouth Health Atlas Project, how they altered his original beliefs and gradually caused him to recognize the omnipresence of self-delusion in much of the
Wennberg's original mission was to examine practices across the state of Vermont to make sure that rural areas were receiving the same "excellent" care as those living near academic medical centers. Looking for underserved populations, he developed a map of regions served by various medical centers and began looking at the frequency of various procedures corrected for population size. In one town, 60% of the children had had their tonsils removed by age 15, while in the next town over only 20% of the kids were tonsils free. The odds that a women had had a hysterectomy varied fourfold from region to region. Hospitalization for digestive diseases varied two fold, and for respiratory ailments, threefold. Given the relative homogeneity of the population, these differences in practice patterns made no sense. And death rates, and average age at death, were indistinquishable across regions. Rather than justifying his original concern over undertreatment, Wennberg's data made a strong case for overutilization of dubiously effective procedures favored in the local community. Furthermore, it was not the case that one region had higher utilization rates for all procedures or hospitalizations. A region with high rates for one procedure might have the lowest rate for another. Thus was born his insight that, in healthcare, "geography is destiny". What kind of medical care a patient received seems to be largely a result of local medical culture and beliefs rather than some uniform (i.e., scientifically validated) standard. A series of larger and larger projects let Wennberg and his colleagues examine different states and eventually the entire U.S. But the original patterns held - wide practice variability that followed no coherent pattern and without demonstrable benefit for outcomes.
Because he's a physician, Wennberg was able to sit down with surgeons and try to get them to explain how they decided surgery was necessary in a given case. What he found was that the decision rules used by one surgeon were totally different from, and sometimes contradictory to, another surgeon's rules. In the course of trying to understand all of this, he stumbled across a forgotten study looking at referrals for tonsillectomy in New York City schools. When 400 children were examined, half were felt to need a tonsillectomy. When those not referred were blindly re-examined, another 40% were referred for the procedure. For the kids rejected twice, and again blindly re-examined, another 44% were recommended. In short, referral seemed to driven not by any objective reason but a belief that half of all children seen should be referred!! This is what passes for medical science?
After many years, Wennberg believes there are three types of medical care:
- Effective Care (about 15% of Medicare expenditures) where there is little regional variability and strong evidence of necessity and improved outcomes. The best example is hip fracture surgery.
- Preference-Sensitive Care (about 25% of Medicare expenditures) where outcomes are complex but utilization is largely driven by physician preference rather than patient preference because patients almost always defer the decision to their physician but shouldn't. When patients fully comprehend the mix of beneficial and adverse outcomes, they choose nontreatment much more often than their physicians choose for them. The besr example is prostate surgery where patients often suffer grievously from "side effects" (incontinence, impotence) and are unlikely to actually benefit from the stated purpose of the surgery - enhanced longevity.
- Supply-Sensitive Care (about 60% of Medicare expenditures) where use seems to be determined primarily by the available resources - the number of hospital beds or surgeons or CT scanners. These are areas of practice where little or no evidence of benefit exists and physicians, unconsciously, fill up the available space.
How can a system be devised which protects patients from these kind of irrational variations in care? How can we hold Medicine's feet to the fire of scientific validation? "Evidence-Based Care" is hard work, time-consuming and must consume a much larger proportion of our healthcare research dollars. When patient outcomes are more important in medical research than biomechanisms, we will be on the right path.