Improving Health Care Value: 

A VA-Health Services Researcher’s 

Journey to Identify, Communicate and 

Implement High Value Care

Timothy J. Wilt, MD, MPH

Minneapolis VA 

Center for Chronic Diseases Outcomes Research
Awardee Assessment Metrics

• Improving our understanding of factors that 

affect the health of Veterans and the quality 

of their care

• Contributing to the future of VA health 

services research by inspiring and training a 

new generation of investigators

• Enhancing the visibility of VA research through 

national recognition within the research 

community.
Slow and Old! 


Me
High-value Healthcare

 Practice Policy

Research
My Research Goals

• Improve health care delivery by 

defining, identifying, communicating 

and implementing high-value care with 

an emphasis on reducing overuse of 

low-value care.
Research Focus 

• Health Promotion and Disease 

Prevention, Detection & Treatment

– Chronic Conditions in Older Adults

– Cancer screening & treatment

– Urological diseases
Research Methods 

• Primary research to identify new evidence

– RCT’s, databases, observational

• Systematic reviews to evaluate existing 

evidence

• Clinical Practice Guidelines to disseminate 

& implement best evidence
Key to success

An Outstanding Nominator

Maureen Murdoch
A Great Research Team
Supportive Leadership
Opportunities, Collaborators, Funders



Original Research in Prostate 

Cancer Screening & Treatment
Prostate Cancer Background

• Common

– 200,00 men diagnosed per year 

• Serious 

– 30,000 deaths per year

• Health Care Utilization High

– 90% undergo early Tx; > US $12 billion/yr

• Detection & Treatment Uncertain

– PSA screening benefits, harms & costs

– Treatment options: WW, AS, RP, EBRT

• PCP Have Important Role

Early “Healthy Skepticism” 

Higher Value!
An Evaluation of Radical Prostatectomy at Veterans 

Affairs Medical Centers: Time Trends and Geographic 

Variation in Utilization and Outcomes. 

Wilt, TJ; Cowper, DC; Gammack, JK; Going, DR.; Nugent, S; Borowsky, SJ. 

Medical Care. 37(10) October 1999


Conclusions 

Utilization of RP @ VAMC increased over time 

and varied across geographic areas

Differences in utilization may be due to 

uncertainty regarding effectiveness of early 

detection and treatment of prostate cancer. 

Overall survival
Adverse events
Conclusion 

• Assessment of the comparative 

effectiveness and harms of early stage 

prostate cancer treatment is difficult due 

to the limitations in the evidence. 
VA, NCI, AHRQ Cooperative Study #407: 

Prostate cancer 

Intervention Versus Observation Trial

(PIVOT)

Timothy J. Wilt, MD, MPH 

Minneapolis VA 

Center for Chronic Disease Outcomes 

Research

 

 
Objective

Among men with clinically localized 

prostate cancer detected during the 

early PSA era, does the intent to treat 

with radical prostatectomy reduce 

all-cause & prostate cancer mortality 

compared to observation?
“I am afraid that although this is an 

excellent question...I would 

recommend that this proposal not be 

entertained, because in my opinion it 

would never be completed” 

Anonymous CSP Reviewer, 1992
Such a study would be far more 

important than virtually any study 

ongoing in the U.S. for prostate cancer

Anonymous CSP Reviewer, 1992
1904

Young first 

RP for CaP 

Jan 2010

 

Close-Out

Timeline of Prostate Cancer Treatment

 PIVOT 

July 2012

 

December, 1992

PIVOT planning 

approved

1960’s- 70s

VA-CURG CaP Treatment 

Trials begin

April, 1st 1994 

No April Fool’s Joke !!!

 

funding approved 

PIVOT

40
41
42



 1999-Judgment Day: 

PIVOT faced...Termination! 

46



Results

Notification of 10 Outcome

Tim,

Rather than preface this with a drum roll or a big fanfare, 

thought I’d just send along the primary outcome analysis 

for your review (survival analysis and curves). I’m not 

sure whether or not you had an inkling of this but, as 

you can see... 
Results

Notification of 10 Outcome

Tim,

Rather than preface this with a drum roll or a big fanfare, 

thought I’d just send along the primary outcome analysis 

for your review (survival analysis and curves). I’m not 

sure whether or not you had an inkling of this but, as 

you can see... I’m leaving the office for the day so I’ll 

leave you to digest overnight.

Karen

 email...1:58 pm August 10, 2010
Publication acceptance 

(4/23/12)

Dear Dr. Wilt and co-authors, 

Thank you for the article, "Radical Prostatectomy Versus 

Observation for Localized Prostate Cancer," which the 

Journal is pleased to accept for publication...

Sincerely yours,

 

Jeffrey M. Drazen, M.D.

Editor-in-Chief

New England Journal of Medicine

Distinguished Parker B. Francis Professor of Medicine 

Harvard Medical School

HR = 0.88; (95%CI= 0.71 to 1.08); p = 0.22

ARR = 2.9%; (95%CI= -4.1 to 10.3)
HR=0.63; (95%CI= 0.36 to 1.09); P=0.09

AR=2.6%; (95%CI= -1.3 to 6.2) 
HR = 0.92; (0.44 to 1.91); P = 0.82

ARR= 0.3%; (-4.1 to 4.8)

Prostate cancer Mortality

PSA <= 10 ng/mL
HR= 1.48; 95%CI, 0.42 to 5.42, P = 0.54

ARR = -1.4 (-6.2 to 3.2)

Prostate cancer Mortality

Low Risk 
Improving Screening and 

Treatment Value

• Recommend Observation/AS 

– Maintain overall, prostate cancer mortality & QOL

– Reduce treatment harms

– Lower resource utilization and health care costs
Evidence Synthesis to 

Inform Clinical Practice & Policy

 DVA

 Operational Partner

No data supporting use of the pelvic examination in asymptomatic 

average risk women...may cause pain, fear, discomfort, anxiety 

and/or embarrassment in about 30% of women

Linda Kinsinger Linda Humphrey

Hanna Bloomfield et al
Health Care Policy and 

Clinical Practice Guidelines

University of Missouri - Columbia 

Family Medicine 

...the timing and manner of their release has done more to set back 

healthcare and the cause of evidence-based medicine than anything I 

can imagine. The potential damage of releasing such a shocking 

reversal of recommendations on an extremely emotional disease with 

no preparation or education of the public in the midst of a contentious 

debate on healthcare reform should have been so obvious that it's 

difficult to conclude that that damage was not inflicted on purpose. 

What in heaven's name were you people thinking? I happen to be in 

favor of evidence-based medicine and wonder whether you are, too. 

Scottsdale, AZ
The VHA recommends screening for breast cancer with mammography 

every 2 years for average risk women age 50 through 74.

The decision to start regular screening every 2 years with 

mammography for average risk women age 40 to 49 years should be 

an individual decision and take the patient's values into account 

including values about specific benefits and harms.

The VHA neither recommends for or against screening for breast cancer 

for women age 75 and older. The current evidence is insufficient to 

assess the balance of benefits and harms of screening for breast cancer 

with mammography in women age 75 and older. If screening for breast 

cancer with mammography is offered, patients should understand the 

uncertainty about the balance of benefits and harms.

Mammography Screening 

for Breast Cancer
68 

http://www.uspreventiveservicestaskforce.org/prostatecancerscreening.htm 

...VHA recommends that any decision to initiate or continue prostate 

cancer screening with PSA for any man should be based on a decision 

between the patient and the provider...

VHA does not recommend prostate cancer screening with PSA for:

•Men ages 45-70 who are NOT at increased risk of prostate cancer,

•Men younger than age 45 or older than 70, and

•Men of any age or risk status who have an estimated life expectancy 

of less than approximately 15 years....

 

PSA screening 

for Prostate Cancer


Who recommends PSA screening? 

1) USPSTF 

2) AUA

3) ACS

4) ACP

5) ASCO

6) VA
Future Goals Made Possible by 

VA Undersecretary’s Award

• Develop High Value Care Center: 

 HiVACC 

• Mission:

– Bring together clinicians, researchers, 

educators, policy makers and patients to 

define, identify, communicate and implement 

high-value care with an emphasis on reducing 

overuse of low-value care

High-Value care = good benefit relative to harms & costs

Doug Owens Paul Shekelle Linda Humphrey

High Value Cancer Screening

• Screening intensity

–Population Screened

–Screen frequency

–Screen sensitivity

Russ Harris
Five Screening Value Concepts

1. Screening is a cascade of events 

2. Cancers are heterogeneous

3. Individuals are heterogeneous

4. Screening is a double-edged sword

5. Increasing screening beyond an optimal 

point leads to disproportionate increase in 

harms and costs, and lower value
Screening Strategies & Value

• Maximum detection strategy

– Seeks to maximize cancer detection and prevention

– High Intensity

– Not always highest value 

• Small incremental benefits; large increase harms/cost

• Value strategy

– Science-based incorporation of screening & treatment 

decision making factors (benefits, harms & costs)

– Optimizes balance between benefits, harms & costs 

– Ethical cost-conscious stewardship of health care 

resources

– Often lower intensity

– Maximizes value
Screening Strategy Value

Cancer 

Type

High Value* Cancer Screening: 

Population-Test, Frequency

Encourage or Neutral 

Discussion

Low Value* Cancer Screening:

Population-Test

Discourage 

Breast Women ages 60-69†-

(encourage): 

Biennial mammography

Women ages 40-59 and 70-75 in 

good health (neutral discussion): 

Discuss once (or more as patient 

requests) with women in good 

health: Biennial mammography

 

Women aged < 40 or > age 75; 

women of any age with life 

expectancy less than 15 

years; Mammography

Any group: Annual 

mammography; MRI; 

tomosynthesis

Any group: Regular systemic

Breast self-exam

Wilt & Harris
Screening Strategy Value

Cancer 

Type

High Value* Cancer Screening: 

Population-Test, Frequency

Encourage or Neutral 

Discussion

Low Value* Cancer Screening:

Population-Test

Discourage 

Breast Women ages 60-69†-

(encourage): 

Biennial mammography

Women ages 40-59 and 70-75 in 

good health (neutral discussion): 

Discuss once (or more as patient 

requests) with women in good 

health: Biennial mammography

 

Women aged < 40 or > age 75; 

women of any age with life 

expectancy less than 15 

years; Mammography

Any group: Annual 

mammography; MRI; 

tomosynthesis

Any group: Regular systemic

Breast self-exam

Wilt & Harris
Screening Strategy Value

Cancer 

Type

High Value* Cancer Screening: 

Population-Test, Frequency

Encourage or Neutral 

Discussion

Low Value* Cancer Screening:

Population-Test

Discourage 

Breast Women ages 60-69†-

(encourage): 

Biennial mammography

Women ages 40-59 and 70-75 in 

good health (neutral discussion): 

Discuss once (or more as patient 

requests) with women in good 

health: Biennial mammography

 

Women aged < 40 or > age 75; 

women of any age with life 

expectancy less than 15 

years; Mammography

Any group: Annual 

mammography; MRI; 

tomosynthesis

Any group: Regular systemic

Breast self-exam

Wilt & Harris
Prostate None Men ages 55-69 who have not had an informed 

discussion and have expressed a clear 

preference for testing after the discussion: PSA 

Men aged < 50 or > 70; men of any age with life 

expectancy less than 15 years: PSA

Cancer 

Type

High Value* 

Cancer Screening:

Encourage

Low Value* Cancer Screening:

Population-Test

Discourage 
VHA effort to provide High-Value Care by 

reducing inappropriate cancer screening

• Prostate cancer screening

– PSA in men > 75 years

• Cervical cancer screening

– Women > 65 with adequate Pap smears

– Women with total hysterectomy for benign Dz

• Colorectal cancer screening

– Adults > 85

– Redundant screening

– Screening colonscopy intervals < 10 years
Summary

• My career journey as a VA-HSR&D researcher 

has been exciting and fun. It has provided me 

rewarding opportunities to learn from others 

and contribute to improving the health care 

we deliver and resulting health outcomes. 

• The future is likely to be equally enjoyable and 

hopefully productive! 
Lessons Learned







Words Matter

Thank You!!!
Questions, Comments, Collaborations

• Timothy Wilt: Minneapolis VA Center for 

Chronic Disease Outcomes Research, 1 

Veterans Drive, Minneapolis, MN 55417

• CCDOR Web (and my) Link

– www.hsrd.minneapolis.med.va.gov/ 

– http://www.hsrd.minneapolis.med.va.gov/PI_Wilt

.asp 

• Email: tim.wilt@va.gov