Dr. John E. Wennberg of Dartmouth has earned the prestigious 2008 Gustav O. Lienhard award from the Institute of Medicine for landmark research that has stretched over four decades. By recognizing Wennberg, the IOM paid tribute this week to Wennberg’s leading role in reshaping the U.S. health care system to focus on objective evidence and outcomes rather than on a “doctor knows best” approach to treatment decisions. Wennberg’s efforts have also led to the empowerment of patients as partners with physicians in decisions about their own care.

In presenting the award, Dr. Harvey V. Fineberg, president of the IOM, said: “John Wennberg is duly renowned for his impact on the evolution of health care delivery in the United States. His painstaking documentation of deep, regional differences in health care delivery and quality provided the foundation for many important changes in health care, including increasing recognition of the importance of evidence-based medicine to guide health care delivery . . . . He is a man of courage, steadfast determination, and keen intelligence whose work is the basis for many improvements in health care quality and efficiency.

Wennberg holds the Peggy Y. Thompson Chair for Evaluative Clinical Sciences at Dartmouth Medical School and is the founder and director emeritus of the Dartmouth Institute for Health Policy and Clinical Practice. Beginning in the early 1970s, Wennberg and his colleague Alan Gittelsohn analyzed clinical practice patterns in small geographic areas in Vermont. Their research showed that rates of procedures in areas with similar populations varied greatly. Subsequent analysis showed  that the variations stemmed primarily from differences in the treatment decisions of physicians. Their findings challenged the medical profession to acknowledge that most care was based on tradition or opinion — what they dubbed the “practice style factor” — rather than on objective evidence of what is most effective.

In the early years of his research pursuits, Wennberg’s work was mostly not accepted by the medical profession, and leading journals in the field responded to his submissions with flat rejections. When asked in an interview why he selected Science to publish his first paper on small-area variations in 1973 in a nonmedical periodical, Wennberg responded: “I didn’t choose it. We tried the conventional medical journals and received form-letter rejections. This still happens. Generally, we don’t bring good news. Science was the journal of last resort, but we were delighted to get the paper accepted.”

While organized medicine turned its collective nose up at Wennberg’s research early on, the IOM acknowledged that he was onto something about the nature of medical practice. The institute convened a conference in 1983 of 40 leaders (30 of whom were physicians) to assess why variations in clinical practice patterns persisted and to develop ways to address the phenomenon. Dr. Frederick C. Robbins, president of the IOM at the time, said in concluding remarks that no practitioner “can get away with the potentially damning evidence that these great variations represent. You can cover it up all you want, but it looks bad, and it looks bad because it is bad. It is not an appropriate way for a profession to behave.”

Since then, a substantial amount of the research produced by Wennberg and his colleagues has been published by Health Affairs. Indeed, Project HOPE’s journal has published 23 papers either authored or coauthored by Wennberg since 1984. When I first met Jack the year before that, it was for the purpose of proposing that Health Affairs devote a thematic issue of the journal to “variations in medical practice.” Wennberg readily agreed, and with support from the John A. Hartford Foundation, Health Affairs published its first full-fledged theme issue (Variations Revisited, Summer 1984). Wennberg wrote the lead paper, entitled, “Dealing with Medical Practice Variations: A Proposal for Action.” The issue included a summary of perhaps the first of many international conferences that have sprouted since Wennberg began his quest to understand variations.

In more recent years, Wennberg’s research has been influential in creating more support in the medical community for the notion that patients should be actively involved with doctors in making treatment decisions. This milestone led naturally to the next phase of research that Wennberg and his colleagues pursued: the development of decision aids to help patients sort out the complexity of treatment choices. His research team took advantage of the interactive video technology that was becoming available at the time to develop a program to inform patients. One of their early findings was that once patients are informed about what is at stake, most are willing and eager to participate in the choice of their own treatment.

Throughout his impressive career, Wennberg has often found himself at odds with the conventional order, whether it be in challenges to the medical profession, in striving to ensure support for evaluation of the clinical sciences in the Clinton health plan, or in waging a losing battle to penetrate the National Institutes of Health (NIH) with his research ideas. In his interview with Wennberg, Fitzhugh Mullan recounted that he had an exchange of views months earlier with Dr. Elias Zerhouni, NIH director.  When Zerhouni was asked whether NIH should play a larger role in conducting and supporting health services research, Mullan said that Zerhouni responded with a comment to the effect that NIH can do basic research that looks for new science or it can do research that looks at “the difference between Coke and Pepsi.” Zerhouni said that he did not believe that NIH could do both well, and he favored the pursuit of new science.

Asked to respond, Wennberg said: “That’s a mindset that needs to be challenged, especially among people who believe in science. Medical theories need to be tested, and we’re awash in untested theories. Even new technologies that have passed the muster of a clinical trial (and many have not) move into practice in many unevaluated ways. What is done with a new technology once it’s in the market depends on the inventiveness of physicians, and they’re terribly inventive. Untested theories and practices are huge, expensive, and dangerous problems.”

One of the lasting legacies of Wennberg’s work will be the Dartmouth Atlas Project, which began in 1993 as a study of health care markets in the United States. It began by measuring variations in health care resources and their utilization by geographic areas. Most recently, the research agenda has expanded to report on the resources and utilization among patients at specific hospitals. The project has been funded largely by the Robert Wood Johnson Foundation, a private philanthropy that has been the major supporter of Wennberg’s work for many years. The work of Wennberg and his colleagues, including the Dartmouth Atlas data, is regularly cited by members of Congress; it formed the basis of much of Peter Orszag’s work for the Congressional Budget Office; and it has influenced the work of the Medicare Payment Advisory Commission (MedPAC). This merging with the mainstream of U.S. policy discourse suggests that what was once seen as objectionable, even radical, is now understood to capture an essential issue in U.S. health care that policymakers must grapple with going forward.

This entry was posted on Wednesday, October 15th, 2008 at 4:05 pm and is filed under All Categories, Effectiveness, Physicians, Policy, Quality. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.