Choosing Wisely; The Dutch way of evaluation · 2015. 11. 13. · Surgical Numbers/yr NcCH •6200 surgical interventions –3300 pts deg. spine (no instrumentation) –500 pts instrumented

Wilco Peul, MD, PhD, MBAProfessor-Chair Dept. Of Neurosurgery

Leiden & The Hague, Holland

Choosing Wisely; The Dutch way of evaluation

What are expectations of patients & society ?Cooperation between Policy makers and MD ’s

Conflict of interest

I work at a

neurosurgical

department

I am a spine surgeon

I received grants

from ZonMW (Dutch

heath care

authorities) on

several trials

My department

receives funding from

Insurance Companies

for research

I am co-applicant on

a trial on surgery vs

conservative

interventions for

Odontoid fractures

Medtronic, Paradigm

& Braun sponsor

studies (investigator

Initiated

Scientific Freedom

Neurosurgical Cooperation Holland,

Leiden &The Hague

•LUMC

•MCH

•HAGA

•LUMC •MCH •HAGA

Surgical Numbers/yr NcCH• 6200 surgical interventions

– 3300 pts deg. spine (no instrumentation)

– 500 pts instrumented spine surgery

• 154 spinal tumor

• 60 craniocervical deformity

• 42 degenerative scoliotic deformity

• 244 fusion for failed back (?)

• Costs Spinal Implants 3.1 miljon euro

• Costs WBMV Neurosurgery 5.2 miljon euro5

Ladies and GentlemanLadies and GentlemanLadies and GentlemanLadies and Gentleman,

“We do Have A Problem to Solve”

PracticeVa r i a t i o N !

> 50 % Healthcare Costs

Are we really that ineffective ?

9

Thoracic tumor

WFNS Boston 2009 10

Summer University Berlin 2009

11

4 - 53 - 42 - 31 - 20 - 1No data


13


14

Surgical Skills “You can teach a monkey to perform surgery”

Rational Thinking“You cannot teach a monkey when not to perform surgery”

Do No Further Harm

You should not perform surgery for non correlating nerve root problems?

Beware of yellow flags !

Do not perform surgery without informing patients about worse outcome !

You should not believe in surgery for scar tissue !

Do not believe in low back surgery without structural abnormalities

Do not believe in new methods without Evidence Based Medicine.

…………..

I do believe in God, everybody else should bring data !

Diapositiva 18

2 Wilco Peul; 26.08.2012

Health Aid 19


22

Toys for boys !?


24

I’m sorry for you all, but……W.C.2

Diapositiva 24

W.C.2 Wilco C. Peul; 29.06.2009

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w eeks

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AUC conservative 977.0 ± 68.3

AUC surgery 635.3 ± 58.6

Mean difference of VAS leg pain AUC’s (CI) 341.7 (163.8—519.6) *

weeks

Relation between practice variation in herniated disc surgery

and total disc problem related healthcosts at regionlevel 2009

Practice variation due to disc surgery at city-

provincial region level 2010

Famous Famous Famous Famous ““““DutchDutchDutchDutch”””” Clinic in MunchenClinic in MunchenClinic in MunchenClinic in Munchen

31 mei 2007Sciatica 2007 28

Precision Medicine“Choosing Wisely”

Bring Science to the Art of Spinal Surgery

first wise choices NL (‘verstandige

keuzes’)

December 2013: Publication 5 wise choices

Herniated Disc

Choosing Wisely (Do Not’s) LDH

surgery

1. Low Back Pain only

2. Do not operate within a short period of sciatica ( 9 mnths

3. Early MRI while recovering

4. Non-dermatomal pain distribution

5. Innovative technique (or implant) without RCT

EBM Bandwidth

Indication surgery LDH

Weeks of Sciatic Neuralgia

Optimale

operatie

window

Keuze

patiënt

Keuze

patiënt

Onverstandig? Onverstandig ?

Nu

mb

er

of

surg

eri

es

2009 region The Hague-Leiden

Weeks of Sciatica

(Too early surgery hospital /regio (Too) late surgeryd hospital/regionOptimal hospital/ region

Optimale

operatie

window

Choice

patiënt

Choice

paiëntUnwise ? Unwise ?

Wise Choices ----DSS-RHypothetical National Audit

Nu

mb

er

of

surg

eri

es

This is my area, I do have

something to declare !

Wise Choices Quality is also Efficiency

Wise Choices

Choosing Wisely Netherlands


Wise Choices• Physician led program

• Campaign initiated by the Dutch Association of Medical Specialists (OMS) and Netherlands Organization for Health Research andDevelopment (ZonMw)

• The Dutch Patient andConsumer Organization is partner (NPCF)


Improvement cycle Wise Choices

Describing

Good care

Describing

Good care

ImplementationImplementation

Measuring and

evaluation

Measuring and

evaluation

Improvement cycle Wise Choices

Wise Choices builds on PDCA cycle which is the basis for quality assurance in specialist care

• (Evidence based) guidelines drawn up bymedical specialists, taking into account the

patient perspective

• Quality measurement to follow up on implementation, enable improvement, enable

patient choices

• External peer review through site visits, medicalaudit and continous assessment of individual

performance

• Continuous medical and professional education

• Scientific research

Describi

ng good

care

Implementat

ion

Implementat

ion

Measurem

ent and

evaluation

Wise Choices Campaign

1. Wise Choices

2. Clinical Practice Variation

3. Effectiveness Research

4. Shared Decision Making

Describing

good care

ImplementationImplementationMeasurement

and evaluation

Wise Choices • Proven recommendations (evidence) for a particular

test or treatment.

– Ideally embedded in evidence based guidelines

• Meant to stimulate doctors and patients to talk about the most suitable test or treatment at the

right moment.

• These conversations can significantly contribute to improving the quality of care.

• Cost management is not the primary goal (but will likely be a result)

• Published by the scientific associations of medical specialists.

• The NPCF (patients) helps to distribute the materials.

Published Wise Choices:– Dutch Society of Neurosurgery,– Dutch Society for Pediatric

Medicine

– Dutch Society for Urology– Association of Surgeons of the

Netherlands

– Dutch Society of Internal Medicine(2x)

– Dutch Orthopedic Socieity– Dutch Society for Neurology– Dutch Society for Radiology

Wise Choices to be published thisfall

– Dutch Society for obstetrics andgynaecology

– Dutch Society for reumatology– Netherlands Society of Cardiology NVR – Dutch Society for Clinical Chemistry– Dutch Society for Ear, Nose and Throat

surgeons

Current status(phase 1 ending december 2015)


3 keypoints of interest• 1) 4 pillars organization

• 2 ) structured methodology per society

• 3) multi-displinary board


(1 ) Four pillars Campaign

Wise Choices (do’s & do not’s)

Clinical Practice Variation

Effectiveness Research

Shared Decision Making


(2) Methodology• Which topic per Medical Scientific Society (structured methodology)

• Research Knowledge Gaps (structured program)

• Guideline Development (specific attention wise choices)

• Practice Variation Research (pre- and post implementation)

• Process and performance Indicators (eg bandwidth treatment indication)

• Evaluation (impact analysis at macro and micro level)


(3) Multidisciplinary Board • Medical Doctors Leading (Marcel Daniels-Wilco Peul)

• Epidemiologist-Director (Marjon Kallewaard)

• Medical Decision Making Expert

• NPCF Netherlands & specific patient organizations

• Netherlands society of health care research (ZonMw)

The Year of TransparancyThe Year of TransparancyThe Year of TransparancyThe Year of Transparancy

• 9 million for 30 diagnoses

• Insurance companies fund Q-Registries

• Collaborate Medical Universities NFU

• Program; “ Do or Do not”


Wise Choices Campaign

More information?

Folder

www.verstandigkiezen.nu

www.choosingwiselynetherlands.org

50

The Netherlands Quality MovementBring science to the art of Neurosurgical Strategy

Wilco C. Peul, MD, PhD, MBA

Neurosurgeon & EpidemiologistProfessor and Chairman

Leiden University Medical CenterMedical Center The Hague

Documents

Choosing Wisely; The Dutch way of evaluation · 2015. 11. 13. · Surgical Numbers/yr NcCH •6200 surgical interventions –3300 pts deg. spine (no instrumentation) –500 pts instrumented