image: John E. Wennberg, founding editor of the Dartmouth Atlas of Health Care, spoke about the early days of the project, Nov. 12, 2011, at the at the University of Chicago during the 23rd annual conference of the MacLean Center for Clinical Medical Ethics. view more
Credit: Bruce Powell for the University of Chicago Medical Center
The MacLean Center for Clinical Medical Ethics at the University of Chicago awarded the first MacLean Center Prize in Clinical Ethics and Health Outcomes to John E. Wennberg, MD, MPH, the Peggy Y. Thomson Professor for Evaluative Clinical Sciences at Dartmouth Medical School and founding editor of The Dartmouth Atlas of Health Care.
The $50,000 prize, awarded Nov. 12, 2011, at the center's 23rd annual conference, is the largest of its kind in the field of clinical medical ethics.
The Dartmouth Atlas examines the patterns of medical resource intensity and utilization in the United States, with an emphasis on end-of-life care, inequities in the Medicare reimbursement system and the underuse of preventive care.
The Atlas grew out of work Wennberg began in the early 1970s with colleague Alan Gittelsohn. They developed a strategy for studying the population-based rates of health resource allocation and utilization—how the use of health care resources varies by location.
From the start, these studies have produced surprises, according to Kenneth Polonsky, dean of the Division of the Biological Sciences and the Pritzker School of Medicine at the University of Chicago, who introduced Wennberg at the prize ceremony.
First was the "striking differences," Polonsky said, in the amount of health care provided in different regions. This was soon followed by the realization that neither the amount nor the cost of care delivered correlated with good outcomes.
"While John Wennberg is regarded as a health services researcher," said Mark Siegler, MD, director of the MacLean Center, "his fundamental work on patient preferences and shared decision making highlight his contributions to the field of clinical medical ethics."
In 2007, the journal Health Affairs named Wennberg as "the most influential health policy researcher of the past 25 years."
Fitzhugh Mullan, MD, former director of the Bureau of Health Professions in the U.S. Department of Health and Human Services, described Wennberg as "both the Christopher Columbus and the Johnny Appleseed of clinical variation," meaning he not only discovered the field but also brought it to the attention of the medical and health policy communities.
At the ethics conference, after noting that "when you get paid so much to give a lecture, you get a little nervous," Wennberg spoke about the early days of the Atlas and how these studies of practice variation in the mid-1970s "challenged the notion that science was driving utilization."
Instead, he found that decisions about surgical treatment for benign prostate hyperplasia revealed what the researchers called "surgical signatures," patterns of practice based on the beliefs of individual surgeons or surgical groups.
Wennberg's team developed short videos that explained the risks and benefits of surgical treatment, including taped interviews with two physicians who had made different decisions. After patients watched the balanced videos, the number who chose surgery declined.
"This was the first evidence," he said, "that engagement of patients could lead to the right utilization rate."
Only about 25 percent of medical care turns out to be so "preference-sensitive," however, forming what Wennberg calls "little islands of rationality."
Studies of end-of-life care found a far more limited role for shared decision making between patients and their caregivers. These decisions appear to be driven by supply rather than patient preference. Empty hospital beds and unused health care capacity strongly correlate with increased medical attention late in life. For example, more than twice as many patients at UCLA Medical Center as at Dartmouth were admitted to an intensive care unit in the last six months of life.
To close his talk at the ethics conference, Wennberg described his four goals for end-of-life care over the next five years. He hopes to "better inform patient choices, improve the science behind these decisions, promote organized care and constrain undisciplined capacity spending." At this point, he said, "we don't need more research, we need more action."
Wennberg is a member of the Institute of Medicine of the National Academy of Science and the Johns Hopkins University Society of Scholars. He has received many awards, including the Institute of Medicine's 2008 Gustav O. Lienhard Award, the Association for Health Services Research's Distinguished Investigator Award, the Richard and Hinda Rosenthal Foundation Award in Clinical Medicine, and the Baxter Foundation's Health Services Research Prize.
A graduate of Stanford University and the McGill University Faculty of Medicine, Wennberg became interested in the application of epidemiological principles to the health care system while pursuing a master's degree in public health at Johns Hopkins.
Wennberg and colleague Al Mulley are also co-founders of the Foundation for Informed Medical Decision Making, a non-profit corporation providing objective scientific information to patients about their treatment choices using interactive media.