John H Wasson

• MD
• Professor Emeritus at Geisel School of Medicine at Dartmouth

A May 2021 report from the National Academies of Sciences, Engineering, and Medicine (NASEM) described the critical role of high-quality primary care in improving the health of the nation’s population and reducing health disparities.¹ The authors concluded that “primary care in the United States is fragile and weakening,” and recommended paying pri...

Purpose To rectify the significant mismatch observed between what matters to patients and what clinicians know, our research group developed a standardized assessment, information, and networking technology (SAINT).Methods Controlled trials and field tests involving more than 230,000 adults identified characteristics of a successful SAINT—www.HowsY...

P6 an outpatient repeatedly sees the same practitioner, is his care influenced? This double-blind randomized trial examines the effects of outpatient health care provider continuity on the process and outcome of the medical care for 776 men aged 55 years and older. Participants were randomized to two different groups of provider care: provider disc...

Randomized trial. A primary care clinic. Four hundred ninety-seven men aged 54 years or older. We examined the hypothesis that substituting clinician-initiated telephone calls (telephone care) for some clinic visits would reduce medical care utilization without adversely affecting patient health. Clinicians were asked to double their recommended in...

During college and medical school, the author's summer employment acquainted him with members of organized crime families. After a full career as a primary care clinician and geriatrician with research on improving health care delivery, the author opines that several insights from organized crime should be of interest to health care professionals:...

A "What Matters Index" (WMI) represents the distillation of many self-reported measures about what matters. The WMI for adults contains only 5 items that efficiently identify important needs, reliably identify people at risk for future problems, and provide guidance for improving health care and well-being. This report uses data from 10 000 respond...

Patient-reported health confidence is a valuable indicator of effective patient-clinician communication, which improves outcomes and reduces costly care use. This national survey examines health confidence attainment in the United States before the COVID pandemic strained health care resources. Health confidence was low for both the percentage of r...

Using responses to HowsYourHealth.org from 9068 patients aged 65 years or older, I illustrate measurement compromises for quality-of-life assessment and management.This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download...

A growing list of studies, including Yoon and colleagues' multicenter trial (1), do not support the hypothesis that providing intensive management to patients at high risk for costly health care will save money. Moreover, recognition that computer-based designations of being at risk for costly care (also decorously called predictive analytics) vary...

Introduction Current health care delivery relies on complex, computer-generated risk models constructed from insurance claims and medical record data. However, these models produce inaccurate predictions of risk levels for individual patients, do not explicitly guide care, and undermine health management investments in many patients at lesser risk....

(Text A) Further WMI verification in alternative population samples. (Table A) Additional Information for the Patient Populations Included in this Report. (Text B) Results of secondary validations. (Table B) Actual Uses Within the Subsequent Year Per 100 Patients in Each WMI-Based Risk Group. (Text C) Examples of a What Matters Index for Public Use...

Introduction: Targeting resources for a designated higher-risk subgroup is a strategy for chronic care management. However, risk-designation has several limitations: it is inaccurate, seldom helpful for care guidance, and potentially misallocates care away from many patients. Methods: To address limitations of risk designation, we tested a "what...

The patient-centered medical home (PCMH) costs a lot to build and maintain. Deficiencies have become apparent: it has provided few of its advertised benefits and is becoming a troubled asset. A troubled asset relief program for the PCHM is needed (PCMH-TARP). This report presents a PCMH-TARP that places patients' interests first. The PCMH-TARP addr...

Patient reported outcome measures (PROMs) movement has largely been driven by the agenda of researchers or service payers and has failed to focus effectively on improving the quality of care from the patient’s perspective. We use two examples to show how the use of PROMs in everyday practice has the potential to narrow the gap between the clinician...

Regular exercise is a healthy behavior associated with desirable benefits. Regular exercise also makes manifest 2 fundamental behaviors-a choice and the discipline to continuously act on that choice. This cross-sectional analysis of more than 10 000 adults examines the association of regular exercise with unhealthy behaviors. Compared with people w...

We use an Internet-based health assessment and feedback system to examine the range of needs and diverse experiences of 520 hospitalized adults in transition and the factors most strongly associated with their self-reported health confidence. Our results strongly suggest that patient engagement prior to admission and the quality of care coordinatio...

Patient health confidence is an easy-to-obtain proxy measure for patient engagement and patient activation. In evidence-based literature syntheses, longitudinal studies, and empiric analyses, this measure is related to desirable consequence of medical care. Adult patients from 15 primary care practices and a national sample report on changes in hea...

As part of a health "checkup," a large national sample of adults used an Internet technology that also asks about adverse experiences. About half of all respondents do not feel very confident they can manage and control most of their health problems, almost 30% consider that their hospital or emergency department use was unnecessary, 20% believe th...

Patient-reported experience of care predicts health care outcomes. Fourteen US and Canadian practices intercalated a standard ambulatory care Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey within their usual Internet-based survey to compare results from the Internet survey, Internet CAHPS survey, and a mailed CAHPS survey. T...

With the phrase "the medium is the message", Marshall McLuhan argued that technologies are the messages themselves and not just the medium. Almost 50 years later, we understand that modern information and communication technologies expand our ability to perceive our world to an extent that would be impossible without the medium. In this article, we...

To the Editor: In the United States, recent surveys suggest an increasing prevalence of non-medical tattooing in younger age cohorts compared to surveys performed only a few years earlier 1. Given the high use of the internet by young adults, we sought to estimate the current national prevalence of non-medical tattoos using a widely disseminated on...

There is a large gap between the promise of patient-centered medical home (PCMH) and our current capacity to define and measure it. The purpose of this article is to describe the findings of "real-time" patient-reported data about constructs of the PCMH and to demonstrate how an Internet-based method can be useful for obtaining patient report about...

Medical practice redesign refers to the intentional efforts to improve practice processes and outcomes. Efforts to redesign office-based medical care go back some forty years. We divide the history of practice redesign into three overlapping phases: basic investigation, model development, and dissemination. The "medical home" movement in primary ca...

Previous studies suggest a negative relationship between regional intensity of healthcare services and Medicare patients' perceptions of healthcare quality. However, no studies to date have examined the relationship across a broad age range of the population. We describe the responses of 64 088 respondents aged 19 to 69 years to an online interacti...

The Institute for Healthcare Improvement has long supported the use of balanced measures to assess improvement among patients at both the individual and the population levels. Although biomedical outcomes and process measures have been widely accepted, patient-reported measures are still not in widespread use. The most common use of such measures i...

CARE Vital Signs refers to a standard form created by practices to Check what matters to patients, Act on that assessment, Reinforce the actions, and systematically Engineer or incorporate actions into staff roles and clinical processes. On its face, CARE Vital Signs is a deceptively simple tool that, when properly used, can help a practice attain...

The Institute for Healthcare Improvement and others have spent a decade transforming the concept of patient-centered care from the realm of idea to the reality of practice. In this introduction, we provide a summary of this transformation, and the practical steps practices and health systems can take to make their transition to providing more patie...

To the Editor:—For more than 40 years there has been interest in answering these questions: Is provider continuity beneficial and how do we measure it? From many correlative studies based on patient report, provider continuity seems beneficial.1 If we seek stronger evidence than correlative studies we have the results of one controlled, double-bli...

Background: Usual medical care in the United States is frequently not a satisfying experience for either patients or primary care physicians. Whether primary care can be saved and its quality improved is a subject of national concern. An increasing number of physicians are using microsystem principles to radically redesign their practices. Small,...

Intravenous administration of 8 mg. dexamethasone has been found to suppress completely the plasma 11-hydroxycorticosteroid (11-OHCS) response to insulin-induced hypoglycaemia in 6 patients with rheumatoid arthritis. It is suggested that the 'stress' response fails to override the negative feedback mechanism if the circulating level of corticostero...

Morphine in therapeutic dosage has been shown to impair the plasma 11-hydroxy corticosteroid response to the stress of insulin-induced hypoglycaemia. Nalorphine in similar dosage produced no impairment of the response to hypoglycaemia.

Background: Wherever, however, and whenever health care is delivered-no matter the setting or population of patients-the body of knowledge on clinical microsystems can guide and support innovation and peak performance. Many health care leaders and staff at all levels of their organizations in many countries have adapted microsystem knowledge to th...

With ever increasing pressure on doctors’ time, Iona Heath (doi: 10.1136/bmj.39532.671319.94) wonders whether primary care really meets the needs of elderly people at all, while John Wasson suggests ways for doctors to improve the care of older patients that don’t require extra resources or staffingMultiple health problems are not unique to older p...

There is a paucity of information about confidence with self-management in primary care practice. This study examines changes over time in patient-reported confidence with self-management on the basis of 1047 patients aged 50-69 who had common chronic diseases, bothersome pain, or emotional problems. We examined the relationship between patients' s...

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The problem faced by primary care physicians is that they can only maintain or increase their (inflation adjusted) incomes by increasing the volume of visits and associated services. The fundamental flaw in a fee-for-service system is that only paying for individual services creates incentives for more services. This article offers a very different...

As patients directly experience harm from adverse events, investigators have proposed patient-report to complement professional reporting of adverse events. To investigate how an automated health assessment system can be used to identify adverse events. Design and Internet survey responses from April 2003 to April 2005 involving communities and cli...

"Patient-centered, collaborative care" is healthcare jargon. But underlying the jargon is the principle that a patient who receives such care strongly agrees that "I receive exactly the healthcare I want and need exactly when and how I want and need it." Currently only about 1 in 4 Americans who have adequate financial resources can make this claim...

In this article, we use self-reported information from 13,271 older adults and the results from several controlled trials to construct a planned-care management strategy that cuts across diseases and conditions and also addresses health disparities attributed to low socioeconomic status. Three strata result from the interaction of patients' financi...

Pain, a common reason for visits to primary care physicians, is often not well managed. The objective of this study was to determine the effectiveness of pain management interventions suitable for primary care physicians. Patients from 14 rural primary care practices (47 physicians) who reported diverse pain problems with (n = 644) or without (n =...

Collaborative Care refers to a partnership between healthcare professionals and patients who feel confident to manage their health conditions. Using an Internet-based assessment of health needs and healthcare quality, we surveyed 24,609 adult Americans aged 19 to 69 who had common chronic diseases or significant dysfunction. In these patients, we e...

Ideal Micro Practices are capable of delivering patient-centered collaborative care. With respect to comparable adult patients in "usual" care settings, twice as many patients who use Ideal Micro Practices report they receive care that is "exactly what they want and need exactly when and how they want and need it" (68% vs 35%). Compared to usual ca...

In this report, we compare healthcare processes for patients with low (n = 7467) and adequate financial status (n = 43,701) after adjustment for age, gender, burden of illness, and health behaviors. Patients with low financial status were 10% to 30% less likely to report good service and collaborative care; they report that markers of disease manag...

This article addresses 2 questions. First, how useful is adult patients' information about health and healthcare when they use the Internet for a "health checkup"? We find that patietns' reports are very strongly associated with medical record information for blood pressure, cholesterol, and blood glucose. Second, what are the biases in information...

The Functional Interference Estimate (FIE) is a brief, 5-item self-report measure that assesses the degree to which pain interferes with daily functioning. While the FIE has demonstrated reliability and validity with a small normative sample, not much is known about its reliability and validity with a broad sample of individuals with pain. The curr...

A community health alliance brings together divergent interests within a community for the betterment of personal and population health. In this report we describe how a community responsive strategy in Chicago is facilitating the improvement of healthcare by providing local information of what needs to be done, supporting change at the practice le...

Background: Clinical microsystems are the essential building blocks of all health systems. At the heart of an effective microsystem is a productive interaction between an informed, activated patient and a prepared, proactive practice staff. Support, which increases the patient's ability for self-management, is an essential result of a productive i...

Background: Strategic focus on the clinical microsystems--the small, functional, frontline units that provide most health care to most people--is essential to designing the most efficient, population-based services. The starting place for designing or redesigning of clinical microsystems is to evaluate the four P's: the patient subpopulations that...

The relationship of trauma history to physical and emotional functioning in primary care pain patients was examined. Data were drawn from a mailed screening questionnaire for a larger study designed to evaluate an intervention for improving pain management in primary care. Results indicated that 50.4% of the pain patients reported experiencing at l...

A rich information environment supports the functioning of the small, functional, frontline units--the microsystems--that provide most health care to most people. Three settings represent case examples of how clinical microsystems use data in everyday practice to provide high-quality and cost-effective care. At The Spine Center at Dartmouth, Lebano...

Clinical microsystems are the small, functional, front-line units that provide most health care to most people. They are the essential building blocks of larger organizations and of the health system. They are the place where patients and providers meet. The quality and value of care produced by a large health system can be no better than the servi...

The authors describe their study of 20 high-performing clinical units and discuss its practical implications for leaders seeking to improve performance.

Authorities discourage prostate screening in men who are likely to die from causes other than prostate cancer. Use of prostate biopsy-a proxy for screening-in men aged 65 and older with limited life expectancy (i.e., estimated to be less than 10 years). Five percent samples of Part A (hospital) and Part B (physician) Medicare claims for 1993 throug...

To measure the impact of an educational intervention directed at both patients and their primary care physicians about prostate-related conditions. We used a randomized, control design for 50 physicians in 33 rural primary care practices from New England and Arkansas and a probability sample of 2402 of their male patients. For the physicians, we ma...

To examine the temporal trends in radical prostatectomy (RP), brachytherapy (BT), and external beam radiotherapy (EBRT) rates among men aged 65 years or older for the period 1984 to 1997. We used the retrospective population-based analysis of treatments for prostate cancer among Medicare beneficiaries. The rates of RP were obtained from Part A (hos...

Although pain is an extremely common symptom presenting to primary care physicians, it frequently is not optimally managed. The purpose of this feasibility study was to develop and pilot-test an efficient, rapid assessment and management approach for pain in busy community practices. The intervention utilized the Dartmouth COOP Clinical Improvement...

In the clinic, one method for improving the interaction is to ask patients to systematically report their health status, give them standard advice based on their responses, and ask them to discuss this advice with a health practitioner. In the school system, this approach provides aggregate information for targeting programs to meet student needs....

Abusive relationships are associated with several demographic factors and many clinical problems in women. However, practices often do not screen for abuse. This is a descriptive study of 1526 women aged 19 to 69 years who completed a health survey in 31 office practices. The 53-item survey included a question designed to screen for an abusive rela...

We examine the epidemiology and associated risks of transurethral resection of the prostate among Medicare beneficiaries for the period 1984 to 1997. We used hospital claims for transurethral resection of the prostate from a 20% national sample of Medicare beneficiaries for the period 1991 to 1997. Risk of mortality and reoperation were evaluated u...

Purpose We examine the epidemiology and associated risks of transurethral resection of the prostate among Medicare beneficiaries for the period 1984 to 1997. Materials and Methods We used hospital claims for transurethral resection of the prostate from a 20% national sample of Medicare beneficiaries for the period 1991 to 1997. Risk of mortality a...

Objectives: To develop an alternative healthcare benefit (called MediCaring) and to assess the preferences of older Medicare beneficiaries concerning this benefit, which emphasizes more home-based and supportive health care and discourages use of hospitalization and aggressive treatment. To evaluate the beneficiaries' ability to understand and mak...

The American Urological Association Prostate Cancer Clinical Guidelines Panel reviewed 12,501 publications on prostate cancer from 1955 to 1992 to determine whether the complication rates of external beam radiation therapy, interstitial radiotherapy and radical prostatectomy have decreased. Complications reported in at least 6 series, study duratio...

Nutritional care needs are overlooked in clinical practice. We review nutritional needs and describe an approach for improving nutritional care in clinical practice. Data from a controlled trial and several population cohorts. Primary care practices and a population survey in New Hampshire and Vermont, USA. The controlled trial involved 1651 person...

The interest in the economic impact of new health care interventions has increased dramatically over recent years; however, the results can be highly variable depending upon the economic assumptions made and the approaches taken in collecting the data and in conducting the analyses. This paper describes experiences from the VA Cooperative Studies P...

OBJECTIVE: Although longitudinal care constitutes the bulk of primary care, physicians receive little guidance on the fundamental question of how to time follow-up visits. We sought to identify important predictors of the revisit interval and to describe the variability in how physicians set these intervals when caring for patients with common medi...

The aim of this article is to introduce key concepts and approaches for building a better practice-based measurement. Physicians are being challenged to produce measurably higher quality of services, lower costs, and better clinical outcomes to remain viable. In the absence of provider-driven practice improvements and independent measurement system...

Because of time constraints in the office environment, problems of concern to elderly patients may not be raised during clinic visits. To facilitate communication about geriatric health problems, we examined the impact of a strategy that used patient self-assessment data to improve community practices. Twenty-two primary care practices were randomi...

Context: Responses to simple questions that predict subsequent health care utilization are of interest to both capitated health plans and the payer. Objective: To determine how responses to a single question about general health status predict subsequent health care expenditures. Design: Participants in the 1992 Medicare Current Beneficiary Su...

Today, managing care from the "outside in" is the predominant model for changing health care. The risk of this outside-in approach is that the health care system may lose sight of the people and communities for which it serves and cares. In this article, an "inside-out" model for viewing health care in a geriatric population is presented from the p...

Those age 80 years or older (80+) constitute a relatively small percentage of a health care system's population. However, because of the associated risks, costs, and variation of their medical care, 80+ patients are sentinel for elder care quality. This article describes the survey components of the 80+ Project. This project was designed to help cl...

Understanding the barriers to obtaining care that the population of people age 80 and older (80+) experiences is one of the first steps toward developing organizational and clinical strategies aimed at improving care. This article reviews the data from the 80+ Project's survey to assess the prevalence of barriers to care and identify the characteri...

This article describes a simple method for rating the patient-clinician interaction from the perspective of the older adult patient, with the goal of improving patient outcomes. A measure for rating the quality of an interaction with a patient who is bothered by a problem is called the Functional Education Index or FNXEI. Usually, sicker patients a...

At age 80, about 4 of every ten 10 men and 3 of every 10 women will die within 5 years. What should the very old expect of the dying experience? National data reveal that very old adults experience considerable variation in the use of the hospital during their last 6 months of life. Physicians report these patients most often need assistance with s...

This article describes an institutionwide geriatric educational initiative (called Geriatrics Awareness Month) that provided didactic and formal experiential learning designed for health professionals. From an educational perspective, to learn geriatrics requires systems thinking, and, to learn systems thinking, geriatrics provides an excellent cli...

This article describes some potential solutions to the many practical barriers that arise when trying to improve clinical care in everyday practice. A useful mnemonic for incorporating measurement into daily work is called GAPS--setting Goals, Assessing the current processes, Planning a new approach, and Starting it. The 80+ Project represents a fo...