White River Junction, VT, United States
White River Junction, VT, United States

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Davies L.,Veterans Affairs Outcomes Group | Davies L.,Dartmouth Institute for Health Policy and Clinical Practice | Rhodes L.A.,University of Washington | Grossman D.C.,Center for Health Studies | And 2 more authors.
Laryngoscope | Year: 2010

Objectives/Hypothesis: To describe patterns of patient involvement in head and neck cancer decision making. Study Design: Prospective longitudinal ethnography of otolaryngology patients making treatment decisions. Methods: Grounded theory analysis of verbatim transcripts and original voice recordings from: 1) participant-driven diaries, 2) participants' office visits with their physicians, and 3) semistructured interviews completed after a treatment decision had been made. Results: Patients with serious illness and experiencing considerable pain, discomfort, or alteration in the ability to perform activities of daily living, and who fear for their life, do not make decisions in a way that adheres to the conventional model of decision making, which presumes a sequential, office-based interaction with clear patient autonomy. These patients have the ability to interpret information they receive during office visits, but they describe making a treatment decision as "deciding to do something" not choosing a specific treatment. This group also describes "trust" or "confidence" in the physician as the most important factor in making a decision, not the type or amount of information received. They move through providers toward treatment in a linear fashion, from one physician specialty to the next, usually without doubling back to revisit previous decisions or discussions. Conclusions: Decision making in serious illness unfolds differently than in less serious problems. The conventional model does not fit this patient population, and reliance on trust of the physician figures prominently. Decision support should be aimed at physician decision making, promoting explicit incorporation of patient-specific data into the process. Copyright © 2010 The American Laryngological, Rhinological, and Otological Society, Inc.

Song Y.,Dartmouth Institute for Health Policy and Clinical Practice | Skinner J.,Dartmouth Institute for Health Policy and Clinical Practice | Skinner J.,Dartmouth College | Skinner J.,National Bureau of Economic Research | And 4 more authors.
New England Journal of Medicine | Year: 2010

Background: Current methods of risk adjustment rely on diagnoses recorded in clinical and administrative records. Differences among providers in diagnostic practices could lead to bias. Methods: We used Medicare claims data from 1999 through 2006 to measure trends in diagnostic practices for Medicare beneficiaries. Regions were grouped into five quintiles according to the intensity of hospital and physician services that beneficiaries in the region received. We compared trends with respect to diagnoses, laboratory testing, imaging, and the assignment of Hierarchical Condition Categories (HCCs) among beneficiaries who moved to regions with a higher or lower intensity of practice. Results: Beneficiaries within each quintile who moved during the study period to regions with a higher or lower intensity of practice had similar numbers of diagnoses and similar HCC risk scores (as derived from HCC coding algorithms) before their move. The number of diagnoses and the HCC measures increased as the cohort aged, but they increased to a greater extent among beneficiaries who moved to regions with a higher intensity of practice than among those who moved to regions with the same or lower intensity of practice. For example, among beneficiaries who lived initially in regions in the lowest quintile, there was a greater increase in the average number of diagnoses among those who moved to regions in a higher quintile than among those who moved to regions within the lowest quintile (increase of 100.8%; 95% confidence interval [CI], 89.6 to 112.1; vs. increase of 61.7%; 95% CI, 55.8 to 67.4). Moving to each higher quintile of intensity was associated with an additional 5.9% increase (95% CI, 5.2 to 6.7) in HCC scores, and results were similar with respect to laboratory testing and imaging. Conclusions: Substantial differences in diagnostic practices that are unlikely to be related to patient characteristics are observed across U.S. regions. The use of clinical or claims-based diagnoses in risk adjustment may introduce important biases in comparative-effectiveness studies, public reporting, and payment reforms. Copyright © 2010 Massachusetts Medical Society.

Wiener R.S.,Edith Nourse Rogers Memorial Veterans Hospital | Wiener R.S.,Boston University | Wiener R.S.,Dartmouth Institute for Health Policy and Clinical Practice | Gould M.K.,Kaiser Permanente | And 8 more authors.
JAMA Internal Medicine | Year: 2014

IMPORTANCE Pulmonary nodules are common, and more will be found with implementation of lung cancer screening. How potentially malignant pulmonary nodules are evaluated may affect patient outcomes, health care costs, and effectiveness of lung cancer screening programs. Guidelines for evaluating pulmonary nodules for cancer exist, but little is known about how nodules are evaluated in the usual care setting. OBJECTIVE To characterize nodule evaluation and concordance with guidelines. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort studywas conducted including detailed review of medical records from pulmonary nodule detection through evaluation completion, cancer diagnosis, or study end (December 31, 2012). The participants included 300 adults with pulmonary nodules from 15 Veterans Affairs hospitals. MAIN OUTCOMES AND MEASURES Resources used for evaluation at any Veterans Affairs facility and guideline-concordant evaluation served as the main outcomes. RESULTS Twenty-seven of 300 patients (9.0%) with pulmonary nodules ultimately received a diagnosis of lung cancer: 1 of 57 (1.8%) with a nodule of 4mmor less, 4 of 134 (3.0%) with a nodule of 5 to 8 mm, and 22 of 109 (20.2%) with a nodule larger than 8 mm. Nodule evaluation entailed 1044 imaging studies, 147 consultations, 76 biopsies, 13 resections, and 21 hospitalizations. Radiographic surveillance (n = 277) lasted a median of 13 months but ranged from less than 0.5 months to 8.5 years. Forty-six patients underwent invasive procedures (range per patient, 1-4): 41.3%(19 patients) did not have cancer and 17.4%(8) experienced complications, including 1 death. Notably, 15 of the 300 (5.0%) received no purposeful evaluation and had no obvious reason for deferral, seemingly "falling through the cracks." Among 197 patients with a nodule detected after release of the Fleischner Society guidelines, 44.7%received care inconsistent with guidelines (17.8%overevaluation, 26.9% underevaluation). In multivariable analyses, the strongest predictor of guideline-inconsistent care was inappropriate radiologist recommendations (overevaluation relative risk, 4.6 [95% CI, 2.3-9.2]; underevaluation, 4.3 [2.7-6.8]). Other systems factors associated with underevaluation included receiving care at more than 1 facility (2.0 [1.5-2.7]) and nodule detection during an inpatient or preoperative visit (1.6 [1.1-2.5]). CONCLUSIONS AND RELEVANCE Pulmonary nodule evaluation is often inconsistent with guidelines, including cases with no workup and others with prolonged surveillance or unneeded procedures that may cause harm. Systems to improve quality (eg, aligning radiologist recommendations with guidelines and facilitating communication across providers) are needed before lung cancer screening is widely implemented. Copyright 2014 American Medical Association. All rights reserved.

Davis M.A.,Dartmouth Institute for Health Policy and Clinical Practice | Sirovich B.E.,Dartmouth Institute for Health Policy and Clinical Practice | Sirovich B.E.,Veterans Affairs Outcomes Group | Weeks W.B.,Dartmouth Institute for Health Policy and Clinical Practice
Health Services Research | Year: 2010

Objective. To investigate national utilization and expenditures on chiropractic care between 1997 and 2006. Data Source. The nationally representative Medical Expenditure Panel Survey (MEPS). Study Design. We performed descriptive analyses and generated national estimates from data obtained from U.S. adult (≥18 years) MEPS respondents who reported having visited a chiropractor (annual sample size between 789 and 1,082). For each year, we examined the estimated total national expenditure, the total number of U.S. adults who received chiropractic care, the total number of ambulatory visits to U.S. chiropractors, and the inflation-adjusted charges and expenditures per U.S. adult chiropractic patient. Principal Findings. The total number of U.S. adults who visited a chiropractor increased 57 percent from 7.7 million in 2000 to 12.1 million in 2003. From 1997 to 2006, the inflation-adjusted national expenditures on chiropractic care increased 56 percent from U.S.$3.8 billion to U.S.$5.9 billion. Inflation-adjusted total mean expenditures per patient and expenditures per office visit remained unchanged. Conclusion. The large increase in U.S. adult expenditures on chiropractic care between 1997 and 2006 was due to a 57 percent increase in the total number of U.S. adult chiropractic patients that occurred from 2000 to 2003. From 2003 to 2006, the total number of U.S. adult chiropractic patients has remained stable. © Health Research and Educational Trust.

Schroeck F.R.,University of Michigan | Schroeck F.R.,Dartmouth Hitchcock Medical Center | Schroeck F.R.,Veterans Affairs Outcomes Group | Kaufman S.R.,University of Michigan | And 2 more authors.
Journal of Urology | Year: 2015

Purpose We evaluated whether patients with prostate cancer who received best care according to a set of 5 nationally endorsed quality measures had decreased treatment related morbidity and improved cancer control. Materials and Methods In this retrospective cohort study we included 38,055 men from the SEER (Surveillance, Epidemiology and End Results)-Medicare database treated for localized prostate cancer between 2004 and 2010. We determined whether each patient received best care, defined as care adherent to all applicable measures. We measured associations of best care with the need for interventions, addressing treatment related morbidity, and with the need for secondary cancer therapy using Cox proportional hazards models. Results Only 3,412 men (9.0%) received best care. Five years after treatment these men and men who did not receive best care had a similar likelihood of undergoing procedures for urinary morbidity (prostatectomy subset 10.7% vs 12.9%, p = 0.338) and secondary cancer therapy (prostatectomy for high risk prostate cancer subset 40.9% vs 37.3%, p = 0.522). However, they were more likely to be treated with a procedure for sexual morbidity (prostatectomy 17.3% vs 10.8%, p <0.001). Similar trends were observed in men treated with radiotherapy. Conclusions Overall men who received best care did not fare better in regard to treatment related morbidity or cancer control. Collectively our findings suggest that the current process of care measures are not tightly linked to outcomes and further research is needed to identify better measures that are meaningful and important to patients. © 2015 American Urological Association Education and Research, Inc.

Howlader N.,U.S. National Institutes of Health | Mariotto A.B.,U.S. National Institutes of Health | Woloshin S.,Dartmouth Institute for Health Policy and Clinical Practice | Woloshin S.,Dartmouth Hitchcock Medical Center | And 4 more authors.
Journal of the National Cancer Institute - Monographs | Year: 2014

Background: To isolate progress against cancer from changes in competing causes of death, population cancer registries have traditionally reported cancer prognosis (net measures). But clinicians and cancer patients generally want to understand actual prognosis (crude measures): the chance of surviving, dying from the specific cancer and from competing causes of death in a given time period. Objective To compare cancer and actual prognosis in the United States for four leading cancers-lung, breast, prostate, and colon-by age, comorbidity, and cancer stage and to provide templates to help patients, clinicians, and researchers understand actual prognosis. Method: Using population-based registry data from the Surveillance, Epidemiology, and End Results (SEER) Program, we calculated cancer prognosis (relative survival) and actual prognosis (five-year overall survival and the "crude" probability of dying from cancer and competing causes) for three important prognostic determinants (age, comorbidity [Charlson-score from 2012 SEER-Medicare linkage dataset] and cancer stage at diagnosis). Result: For younger, healthier, and earlier stage cancer patients, cancer and actual prognosis estimates were quite similar. For older and sicker patients, these prognosis estimates differed substantially. For example, the fiveyear overall survival for an 85-year-old patient with colorectal cancer is 54% (cancer prognosis) versus 22% (actual prognosis)-the difference reflecting the patient's substantial chance of dying from competing causes. The corresponding five-year chances of dying from the patient's cancer are 46% versus 37%. Although age and comorbidity lowered actual prognosis, stage at diagnosis was the most powerful factor: The five-year chance of colon cancer death was 10% for localized stage and 83% for distant stage. Conclusion: Both cancer and actual prognosis measures are important. Cancer registries should routinely report both cancer and actual prognosis to help clinicians and researchers understand the difference between these measures and what question they can and cannot answer. We encourage them to use formats like the ones presented in this paper to communicate them clearly.

Cho H.,U.S. National Institutes of Health | Cho H.,National Cancer Center | Mariotto A.B.,U.S. National Institutes of Health | Schwartz L.M.,U.S. National Institutes of Health | And 8 more authors.
Journal of the National Cancer Institute - Monographs | Year: 2014

Background: It is often assumed that increases in cancer survival reflect true progress against cancer. This is true when these increases are accompanied by decreased burden of disease: Fewer people being diagnosed or dying from cancer (ie, decreased incidence and mortality). But increased survival can also occur even when incidence is increasing and mortality is unchanged. Objective To use trends in cancer burden-incidence and mortality-to illustrate when changes in survival reflect true progress. Methods: Using data from 1975 to 2010 collected by the Surveillance, Epidemiology, and End Results Program (incidence, survival) and the National Center for Health Statistics (mortality), we analyzed US trends in five-year relative survival, age-adjusted incidence, and mortality for selected cancers to identify patterns that do and do not reflect progress. Results: Among the nine common cancers examined, survival increased in seven, and changed little or not at all for two. In some cases, increased survival was accompanied by decreased burden of disease, reflecting true progress. For example, from 1975 to 2010, five-year survival for colon cancer patients improved (from 48% to 68%) while cancer burden fell: Fewer cases (incidence decreased from 60 to 41 per 100 000) and fewer deaths (mortality decreased from 28 to 16 per 100 000), a pattern explained by both increased early detection (with removal of cancer precursors) and more effective treatment. In other cases, however, increased survival did not reflect true progress. In melanoma, kidney, and thyroid cancer, five-year survival increased but incidence increased with no change in mortality. This pattern suggests overdiagnosis from increased early detection, an increase in cancer burden. Conclusions: Changes in survival must be interpreted in the context of incidence and mortality. Increased survival only represents progress when accompanied by a reduction in incidence, mortality, or ideally both.

Mariotto A.B.,U.S. National Cancer Institute | Noone A.-M.,U.S. National Cancer Institute | Howlader N.,U.S. National Cancer Institute | Cho H.,U.S. National Cancer Institute | And 9 more authors.
Journal of the National Cancer Institute - Monographs | Year: 2014

Survival statistics are of great interest to patients, clinicians, researchers, and policy makers. Although seemingly simple, survival can be confusing: there are many different survival measures with a plethora of names and statistical methods developed to answer different questions. This paper aims to describe and disseminate different survival measures and their interpretation in less technical language. In addition, we introduce templates to summarize cancer survival statistic organized by their specific purpose: research and policy versus prognosis and clinical decision making.

Woloshin S.,Dartmouth Institute for Health Policy and Clinical Practice | Woloshin S.,Veterans Affairs Outcomes Group | Schwartz L.M.,Dartmouth Institute for Health Policy and Clinical Practice | Schwartz L.M.,Veterans Affairs Outcomes Group | And 3 more authors.
Annals of the American Thoracic Society | Year: 2014

Rationale: Standard radiology report forms do not guide ordering clinicians toward evidence-based practice. Objectives: To test an enhanced radiology report that estimates the probability that a pulmonary nodule is malignant and provides explicit, professional guideline recommendations. Methods: Anonymous, institutional review board-approved, internet-based survey of all clinicians with privileges at the Dartmouth-Hitchcock Medical Center comparing a standard versus an enhanced chest computed tomography report for a 65-year-old former smoker with an incidentally detected 7-mm pulmonary nodule. Measurements and Main Results: A total of 43% (n = 447) of 1045 eligible clinicians answered patient management questions after reading a standard and then an enhanced radiology report (which included the probability of malignancy and Fleischner Society guideline recommendations). With the enhanced report, more clinicians chose the correct management strategy (72% with enhanced versus 32% with standard report [40% difference; 95% confidence interval (CI) = 35-45%]), appropriately made fewer referrals to pulmonary for opinions or biopsy (21 vs. 41% [-40% difference; 95% CI = -25 to -16%]), ordered fewer positron emission tomography scans (3 versus 13%; -10% difference; 95% CI = -13 to -7%), and fewer computed tomography scans outside the recommended time interval (2 versus 7%; -5% difference; 95% CI = -7 to -2%). Most clinicians preferred or strongly preferred the enhanced report, and thought they had a better understanding of the nodule's significance and management. Conclusions: An enhanced radiology report with probability estimates for malignancy and management recommendations was associated with improved clinicians' response to incidentally detected small pulmonary nodules in an internet-based survey of clinicians at one academic medical center, and was strongly preferred. The utility of this approach should be tested next in clinical practice.

PubMed | Veterans Affairs Outcomes Group
Type: Journal Article | Journal: Annals of internal medicine | Year: 2011

Despite limited evidence, it is often asserted that natural frequencies (for example, 2 in 1000) are the best way to communicate absolute risks.To compare comprehension of treatment benefit and harm when absolute risks are presented as natural frequencies, percents, or both.Parallel-group randomized trial with central allocation and masking of investigators to group assignment, conducted through an Internet survey in September 2009. (ClinicalTrials.gov registration number: NCT00950014)National sample of U.S. adults randomly selected from a professional survey firms research panel of about 30,000 households.2944 adults aged 18 years or older (all with complete follow-up).Tables presenting absolute risks in 1 of 5 numeric formats: natural frequency (x in 1000), variable frequency (x in 100, x in 1000, or x in 10,000, as needed to keep the numerator >1), percent, percent plus natural frequency, or percent plus variable frequency.Comprehension as assessed by 18 questions (primary outcome) and judgment of treatment benefit and harm.The average number of comprehension questions answered correctly was lowest in the variable frequency group and highest in the percent group (13.1 vs. 13.8; difference, 0.7 [95% CI, 0.3 to 1.1]). The proportion of participants who passed the comprehension test (13 correct answers) was lowest in the natural and variable frequency groups and highest in the percent group (68% vs. 73%; difference, 5 percentage points [CI, 0 to 10 percentage points]). The largest format effect was seen for the 2 questions about absolute differences: the proportion correct in the natural frequency versus percent groups was 43% versus 72% (P < 0.001) and 73% versus 87% (P < 0.001).Even when data were presented in the percent format, one third of participants failed the comprehension test.Natural frequencies are not the best format for communicating the absolute benefits and harms of treatment. The more succinct percent format resulted in better comprehension: Comprehension was slightly better overall and notably better for absolute differences.Attorney General Consumer and Prescriber Education grant program, the Robert Wood Johnson Pioneer Program, and the National Cancer Institute.

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