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tracking medicine
This page intentionally left blank
TRACKING
MEDICINE
a researcher’s quest to
understand health care

JOHN E. WENNBERG

1
2010
 3
Oxford University Press, Inc., publishes works that further
Oxford University’s objective of excellence
in research, scholarship, and education.

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Copyright © 2010 by Oxford University Press

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www.oup.com

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All rights reserved. No part of this publication may be reproduced,

stored in a retrieval system, or transmitted, in any form or by any means,
electronic, mechanical, photocopying, recording, or otherwise,
without the prior permission of Oxford University Press.

Library of Congress Cataloging-in-Publication Data

CIP data on file
ISBN 978-0-19-973178-7

1 3 5 7 9 8 6 4 2
Printed in the United States of America
on acid-free paper
For Corky and Emma
This page intentionally left blank
 Foreword

New forms of knowledge with the power to reshape a major field of human
practice emerge once in a generation. This book presents such a body of
knowledge. It describes how, as a young physician and epidemiologist, Jack
Wennberg first detected and worked to explain striking variations in the deliv-
ery of health care services among local areas in the United States. It shows
how, over time, Wennberg and his colleagues harnessed these initial discov-
eries to build a scientific field for the study of practice variation and compar-
ative effectiveness in health care. And it applies findings from this field to set
an agenda for action to save our nation’s beleaguered health system.
Wennberg’s research rises above partisan divisions to provide an objec-
tive common ground for critical health policy decisions. It reminds us that
health care reform must tackle more than the problem of insurance coverage.
Reform efforts must also address performance variation in the delivery strate-
gies that actually bring services to patients. This is the only way to engage the
levers that truly drive health care costs and that shape the outcomes patients
experience within our health care system. We can be certain that any reform
effort that fails to incorporate Wennberg’s insights will fall short of success.
The good news from Washington is that Wennberg and his colleagues at The
Dartmouth Institute for Health Policy and Clinical Practice have become
pivotal references for increasing numbers of policy makers across the political
spectrum.

vii
viii foreword

The policy solutions Wennberg proposes will not gain easy acceptance. His
recommendations imply a profound reconfiguration of health care delivery
patterns from which some actors have profited handsomely. The story that
Wennberg tells of the “birth and near death” of federal government support
for comparative effectiveness research in the 1990s provides an object lesson. It
reminds us that some interests will be threatened by resolute action to address
unwarranted variation and the overuse of health care. But Wennberg’s anal-
yses also make clear how much the health care system, and our country as a
whole, stand to gain from the measures he recommends. Equally important,
Wennberg documents settings where, in local health care systems from New
Hampshire to Minnesota to California, these transformations have already
begun to happen, with major gains in efficiency and improved outcomes for
patients.
Wennberg argues that health care reform should focus on four goals: (1)
promoting organized local systems of care delivery that build on the best
examples that currently exist; (2) fighting misuse of medical services by estab-
lishing shared decision making between patient and provider as the norm for
choices on elective surgeries, tests, and other procedures; (3) strengthening
the science of health care delivery; and (4) constraining undisciplined growth
in health care capacity that fuels the upward spiral in spending.
All four of these aims are critical. Together, they will give us a health care
system that uses its resources much more efficiently, that will have a shot at
reining in runaway health care costs, and that will improve outcomes for a
large number of Americans who are not now receiving the high-quality care
they deserve.
In my own view, it is the third of Wennberg’s goals—strengthening the
science of health care delivery—that has been the least clearly understood by
policy makers and the general public, while it is in some respects the most
fundamental. The task of improving health care delivery and putting effec-
tive delivery on a solid scientific foundation holds the key to all the other
objectives. If we fail to attain this goal, we will miss the others, too. For too
long, we have assumed that, to improve health care, it was enough to ensure
the rapid development of new drugs and technologies. The scientific study
of how these technologies are actually delivered to patients by providers, and
how those delivery processes can be optimized, was given little or no impor-
tance. Witness the fact that students at our major medical schools, while
they are rigorously drilled in molecular biology, receive no formal training in
delivery science or management skills, or processes that would permit mean-
ingful, informed patient participation in decision making.
 foreword ix

Today’s spiraling health care costs, for care that too often fails to yield
value for patients, are the consequence of this neglect of the field of delivery.
Recalling the initial promise of the national Agency for Health Care Policy
and Research, briefly supported by the federal government in the late 1980s
and early 1990s, Jack Wennberg makes the case for ensuring that a focus on
delivery science is front and center in the rebuilding of our health care system
that we know is unavoidable.
Recent health care reform debates have again highlighted the need to lay
solid foundations for the young science of health care delivery in the United
States. We need a national institute of health care delivery science that can
support and sustain cutting-edge research on delivery problems. The creation
of such an institution would be an opportunity to reestablish American lead-
ership in a critical area of knowledge production. A national institute dedi-
cated to health care delivery would provide the objective evidence needed to
guide the ongoing reform and improvement of our health system that must
and will unfold in the decades ahead.
The evidence Jack Wennberg distills from his own four decades at the
forefront of practice variation research shows the direction we must follow.
The future of our health care system and the well-being of our people will
depend to a substantial degree on the energy and commitment with which
Wennberg’s recommendations are taken up by those in a position to shape
public policy.

Jim Yong Kim, M.D., Ph.D.

President
Dartmouth College
This page intentionally left blank
 Acknowledgments

My book is a record of a long intellectual journey to deal with fundamental

contradictions in the patterns of medical practice. I have had the incredible
good fortune to share this journey with many colleagues, friends, and fam-
ily who have joined together in an effort to understand and seek remedy for
unwarranted variation. Needless to say, but important to emphasize, this has
been and remains a team effort.
Let me begin with the project that started it all—the uncovering of small
area variations in Vermont. First and foremost, I want to acknowledge the
contribution of Alan Gittelsohn, then professor of biostatistics at the Johns
Hopkins School of Hygiene. Our collaboration set the stage for most of the
research reported in this book. The project would not have been possible
without the dedication and innovative work of John Senning, Pat Hickcox,
Roger Gillam, David Herr, and Karen Provost; they formed the techni-
cal staff that made it possible to solve the numerous, first-of-a-kind tasks
encountered in building and analyzing large databases using the primitive
computers available at that time. I also want to recognize the contribution of
Kerr White, who taught me the importance of using the tools of epidemiol-
ogy to study the health care system, and of John Mazuzan, who, as assistant
dean for regional affairs at the University of Vermont, supported my decision
to use RMP funds to build the database and helped interpret its findings to
the physicians of Vermont.

xi
xii acknowledgments

Our work in Maine was made possible by the firm commitment of pro-
fessional leaders to address the unsettling implications of practice variation.
I want to acknowledge the pivotal importance of two Maine physicians: Dan
Hanley, who challenged Maine physicians to address the inconsistency in
their practice patterns and undertake the research required to address scien-
tific uncertainty; and Robert Keller, who kept the commitment alive when
he succeeded Dan as director of the Maine Medical Assessment Foundation.
Other practicing physicians in Maine who contributed time and energy to the
feedback process are Buell Miller, Robert Timothy, Terrance Sheehan, John
Adams, and Dennis Shubert. The Maine project also depended on the work
of David Soule and John Putnam, who, working for Blue Cross of Maine,
built the first Maine database, and Alice Chapin, David Smith, and Suanne
Singer of the Maine Health Information Center, and Ellen Schneiter of the
Maine Medical Assessment Foundation, who kept the database current and
the feedback channels open.
Further development of the small area analysis methodology took place
at Dartmouth when I moved there in 1979. For work in the 1980s and early
1990s, Loredo Sola, for his skill and wisdom in managing an ever expand-
ing database in an environment of rapid change in computer technology
and a tight budget, and Tom Bubolz for his special knowledge of hospital
discharge databases and how to analyze them, need special recognition. The
Dartmouth Atlas Project, which began in 1992, greatly expanded the size
and complexity of the database. Jim Dykes undertook the required upgrade
of our computer software and hardware systems. Megan Cooper came on
board as the Atlas editor. In 1990, I had the good fortune to hire Sally Sharp,
who had years of experience with claims data. Soon after, Kristy Bronner, a
recent Dartmouth graduate, and Stephanie Raymond joined the staff, fol-
lowed by Zhao Peng, Jia Lan, Dongmei Wang, Phyllis Wright-Slaughter,
and Dean Stanley. These folks, the core of the Atlas Project production
team, are still on the job today. Special thanks also go to Vin Fusca for pro-
viding project management for the Dartmouth Atlas. Without the team’s
problem-solving skills, corporate memories, and commitment to the goals
of the Atlas Project, I am sure we would have lost the war to make sense
out of the national Medicare database. Faculty members who have contrib-
uted as coauthors of the Dartmouth Atlas series include Elliott Fisher, Alan
Gittelsohn, David Goodman, Jonathan Skinner, and Therese Stukel. Special
editions of the Dartmouth Atlas were authored by John Birkmeyer, Jack
Cronenwett, and David Wennberg.
I need to acknowledge and thank several individuals for their efforts to
establish the Foundation of Informed Medical Decision Making: Al Mulley,
 acknowledgments xiii

the cofounder of the foundation; Lyn Hutton, treasurer of Dartmouth

College, and Adam Keller, chief financial officer for the medical school, who
persuaded the college to make a critical investment that saved the foundation
during its start-up phase; Bob Derzon, the first chairman of the board; my
colleagues who have served as president of the Foundation: John Billings,
Joe Kasper, David Jensen, Jack Fowler, and Mike Barry; and Joe Henderson
and Gary Schwitzer, who made major contributions to the design and pro-
duction of the interactive patient decision aids in the early days of the foun-
dation. Since 1997, because of the success of its commercial partner, Health
Dialog, in developing a business model to support shared decision making,
the foundation has been on firm financial ground. For this, my thanks go to
Health Dialog’s founders, George Bennett and Chris McKown; its CEO, Pat
Flynn; and my son, David Wennberg, president of Health Dialog Analytics.
I am particularly pleased that the Dartmouth-Hitchcock Medical Center
can claim to be the first medical center in the United States to implement
shared decision making in the routine management of patient care. Among
others, thanks for this go to Jim Weinstein, Dale Collins, Kate Clay, Ann
Flood, Hilary Llewellyn-Thomas, Annette O’Connor, Blair Brooks, and Nan
Cochran.
I am completely in the debt of my colleagues and fellow faculty mem-
bers who have played major roles in sustaining the intellectual effort to
come to terms with practice variation. Several came from outside the walls
of Dartmouth, beginning with Alan Gittelsohn. Jack Fowler, whom I first
met in 1970, is part of many research stories reported in this book, as is Klim
McPherson, whom I met in 1977. I first met Al Mulley in 1983 when he
attended a seminar at Dartmouth on practice variations; not long after, Jack,
Al, and Mike Barry joined the Maine project to form the nucleus of the
research team that would eventually become the Patient Outcomes Research
Team (PORT) for prostate disease, which I discuss in Chapters 6 and 7. We
have continued to collaborate ever since.
While the history of practice variation research at Dartmouth may have
officially begun in 1979 with my recruitment to the faculty by Jim Strickler,
dean of the Medical School and Mike Zubkoff, chairman of the Department
of Community Medicine, the story really began when Elliott Fisher joined
us in 1986, followed in 1990 by Gil Welch, David Goodman (1991), Therese
Stukel (1994), and Julie Bynum (2003). In 1995, our research team gained
strength when Jonathan Skinner joined the Department of Economics and
became an active member of the research team; subsequently, Jon recruited
Doug Staiger (1998), Katherine Baicker (1998), and Amitabh Chandra
(2000), to the Department of Economics, all of whom have made important
xiv acknowledgments

contributions to Dartmouth research into practice variation and continue to

do so, although some have been recruited elsewhere.
I want to thank and acknowledge those who played an important role in
establishing “TDI”—The Dartmouth Institute for Health Policy and Clinical
Practice. As leaders of Harvard’s Center for the Analysis of Health Practices,
Howard Hiatt, Howard Frazier, John Bunker, Benjamin Barnes, and Fred
Mosteller were instrumental in showing how the evaluative sciences can be
organized to study health care. Dartmouth Medical School’s Dean Robert
McCollum, Associate Dean Bill Culp, and Mike Zubkoff receive my thanks
for their support in establishing in 1988 the Center for the Evaluative Clinical
Sciences (now called TDI) as “home base” for research on the science of
health care delivery. In addition to faculty members whose work has focused
primarily on practice variations and shared decision making, it is impor-
tant to acknowledge the contributions to the intellectual environment and
research productivity of TDI by Paul Batalden, Bill Black, David Malenka,
Gerry O’Connor, Rosemary Orgren, Lisa Schwartz, John Wasson, and Steve
Woloshin. My thanks and appreciation go to Jim Weinstein for assuming the
directorship of TDI when I stepped down in July 2007.
I also want to thank John Iglehart, founding editor of Health Affairs, and
Uwe Reinhardt, James Madison Professor of Political Economy and Professor
of Economics and Public Affairs at Princeton University’s Woodrow Wilson
School of Public & International Affairs, for their friendship and encourage-
ment that has helped me to sustain a focus on practice variation over the
years.
The research and efforts to reform medical practice reported in this book
would not have happened were it not for the support of a number of chari-
table foundations. The early stage of the Maine project was funded by the
Commonwealth Foundation. For more than ten years, thanks to the personal
attention of John Billings and Richard Sharpe, the Hartford Foundation pro-
vided the support that sustained the prostate research discussed in Chapter
6, including the development of the decision aid. Beginning in 1992, the
Robert Wood Johnson Foundation, thanks to the interest of Steve Schroeder
and Jim Knickman, has sustained the Dartmouth Atlas Project, and more
recently, the United Health Foundation, WellPoint Foundation, California
HealthCare Foundation, and Aetna, Inc. have joined RWJF in providing
support for the Atlas research. Our work has also received funding from the
Foundation for Informed Medical Decision Making, the National Institutes
of Health, and the Agency for Health Care Policy and Research. Over the
years, our research programs have also received generous support from a
number of donors who support the TDI mission, including George Bennett,
 acknowledgments xv

Bob Derzon, Ross and Eve Jaffe, Dick and Sue Levy, Gordon Russell, and
the Thomson Family, whose generous gift established the Peggy Y. Thompson
Chair in the Evaluative Sciences, of which I was privileged to be the first
occupant.
A number of colleagues and friends generously took time to read parts or
all of earlier versions this book. I want to thank Mike Barry, Don Berwick,
Catherine Coles, David Durenberger, Jack Fowler, Ben Moulton, Fitzhugh
Mullan, Jonathan Skinner, Lisa Schwartz, and Steve Woloshin for their
extremely helpful suggestions. Special thanks go to Jim Kim, president of
Dartmouth College, for contributing the foreword. I would also like to
thank Martha Smith for her splendid administrative support in putting this
manuscript together (many times), and Jonathan Sa’adah and Beth Adams
for preparing the figures and tables. My thanks go also to Oxford University
Press: to my editor Regan Hofmann, production editor Rachel Mayer, Soniya
Ashok and the Newgen team, and to Geronna Lyte and Mark LaRiviere for
the cover design.
I want to express my special appreciation to Shannon Brownlee, who has
been a constant mentor in the writing of this book. Shannon interviewed
me while writing Overtreated, which the New York Times named the num-
ber one economics book of the year in 2007. The book does a terrific job
of explaining the practice variation to the general public. It was my lucky
day when she agreed to help me make the complicated and interconnected
body of research discussed in this book accessible to a broad audience. We
worked as a team to bring this book to closure and the book would not have
been completed without her. For her skill, commitment, perseverance, good
humor, and support I am grateful, almost beyond words.
Finally, my wife, family, and our dear friend Sally Smith supported,
encouraged, and just plain put up with me over the years it took to write
this book.
This page intentionally left blank
 Contents

part i an introduction to the problem

of unwarranted variation
1. In Health Care, Geography Is Destiny 3
2. The Vermont Experience 14

part ii surgical variation: understanding

preference-sensitive care
3. Tonsillectomy and Medical Opinion 29
4. Interpreting the Pattern of Surgical Variation 38
5. Understanding the Market for Preference-Sensitive Surgery 54
6. Learning What Works and What Patients Want 66
7. The Birth and Near Death of Comparative Effectiveness Research 89

part iii medical variation: understanding

supply-sensitive care
8. Understanding Supply-Sensitive Care 119
9. Chronic Illness and Practice Variation 141
10. Is More Better? 156
11. Are “America’s Best Hospitals” Really the Best? 170
12. The Top Ten Reasons Why We Need to Reform the Way We
Manage Chronic Illness 189

part iv pathways to reform

13. Promoting Organized Care and Reducing Overuse 209
14. Establishing Shared Decision Making and Informed Patient Choice 225

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