Practice variation from the perspective of an e-patient

One of our purposes e-Patients.net is to help people develop e-patient skills, so they can be more effectively engaged in their care. One aspect is shared decision making. A related topic, is understanding the challenges of pathology and diagnosis. Both posts teach about being better informed partners for our healthcare professionals.

I’ve recently learned of an another topic, which I’m sure many of you know: practice variation. It’s complex, the evidence about it is overwhelming, and its cost is truly enormous. I’m no expert at it yet, but I also know it’s important, so let’s get started. Corrections welcome.

Here it is, in  a nutshell:

  • Very large parts of healthcare are delivered inconsistently from area to area.
  • In other words, the care you get depends on where you live.
    • That’s right; very often, care decisions aren’t based on some objective standard of care. The same patient in a different local area might or might not get a prescription for treatment. Very often.
    • Which one is right? Is one overtreated, or is the other  undertreated?
  • This isn’t a matter of economics: it’s a matter of local medical practice.It cuts across all economic levels.
    • That’s why it’s not called discrimination, it’s called practice variation.
  • The people involved – the doctors – mostly don’t know they’re doing it.
  • Bottom line: depending on where you live, you may be getting care you don’t need – hospitalizations and even surgery.
    • Since both of those carry risks of infection and even death, e-patients need to be aware so they can make informed, empowered choices.

Examples:

  • For decades, tonsillectomies were performed in some regions 3-4x more often than in others. (Even between neighboring towns.)
    • Here is a seven page paper from the United Kingdom showing a threefold variation in how many kids got tonsillectomies. It’s from 1938,and Dartmouth researchers found the same in the US in the 1970s and 80s.
    • The end of the report carries the nasty impact: in one year the nation had sixty deaths from tonsillitis, andover 500 deaths from tonsillectomies – most of them children. Unnecessarily dead children because of this issue.
  • The same has often been true with hysterectomies. And gall bladder surgery. And coronary bypass grafts. And many other things.
    • A current non-US example: a post on the NPR blog, by Chris Weaver (@cdweaver) of Kaiser Health News: UK citizens in Oxford are 16 times more likely to get a particular type of hip replacement than similar people in London.
  • For any given condition, your odds of being hospitalized are often proportional to how many hospital beds are in your area.
    • Yes, that’s true after controlling for demographics, severity of illness, everything.
  • At the end of life, your odds of dying in an ICU are proportional to how many ICU beds your region has.
    • I’m not making this up; this is well-vetted, carefully-culled data, controlled for confounding variables. For any given illness, your mother is less likely to die at home – even if she requests it – simply depending on how many ICU beds your local hospitals have.
    • There are tons of data to support this.  It’s been validated and cross-checked every which-way from Sunday, for years and years.

Yes, to a large extent, recommendations for some types of surgery and hospitalization are driven by local superstition and the mere availability of empty beds (or a particular type of specialist).

This is generally not medical plundering. Doctors generally do not know they’re doing this. (I imagine some do, but this is not a matter of rooting out greed – there’s a bigger issue of widespread denial about how things work.)

This is by far the hardest healthcare issue to comprehend I’ve ever seen. Neither the problem itself nor its intractability – its resistance to change –  make any sense to me. Most of the people involved can’t even believe it’s happening – even though they’re doing it, and the evidence is clear.

When that happens, it’s a sure sign we’ve been overlooking something big. And our efforts to argue for change are doomed until we understand the actual situation.

Impact

I see two major impacts.

  • Cost of unnecessary hospitalizations.
    • Cost to society
    • Cost to the patient and family for the care
    • Lost income
  • Risk of harm, including infection and death.
    • And the cost of those complications.

E-patient takeaways

Smart people have been trying to change this for decades, and it hasn’t changed. While they work on it, the matter is in our hands. In my view empowered, engaged, educated patients need to:

  • Realize this happens
  • Educate ourselves about the region we live in
    • Information is available about which areas are high-utilization. More on this in upcoming posts.
  • Get to work at spreading the word.

As I said, this is all part of a larger issue, SDM – shared decision making, which is a bigtime participatory medicine topic.

Dave deBronkart, also known as e-Patient Dave, blogs at e-Patients.net and is the author of Laugh, Sing, and Eat Like a Pig: How an Empowered Patient Beat Stage IV Cancer and Let Patients Help!

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  • http://e-patients.net e-Patient Dave

    Thanks, Kevin, for giving your excellent visibility to this issue. Readers who want to pursue this topic more on e-patients.net can find it here.

    What I like about the study of practice variation is that, for providers as well as patients, it sheds light (with good, evidence-driven science) on deviation from the scientific method, even by the best trained among us. This lets us improve.

  • http://www.watson.md Steve Watson MD

    My wife recently had minor surgery with major anesthesia. She dry-heaved for 10 hours and was sick most of the week. She was visited preop by TWO nurse-anesthetists who were job-sharing that day. She begged for local anesthesia, but the surgeon said “we’ll see”, and so she signed the consent. I saw the chart; they “dropped” her at the very start of the procedure. I doubt the surgeon even knew how to give a local.

    In ’95 I watched my local orthopedic colleagues destroy the Agency for Health Care Policy Research for publishing the conclusion that back surgery is almost never warranted. It only cost them a few thousand dollars in campaign contributions to secure the help of their local congressman.

    Specialists are deep into the problem, and government is not the solution either. Primary care docs could change much of this, but are beaten down and will need a lot of love and support from their patients.

    Thanks for a clear and candid review. Ask yourself: is “doing the right thing” in healthcare worthwhile, and will we do it?

  • Dr Chris

    I remember reading that an area of Maine had one of the highest rates of hysterectomies in the country-this was before med school. One of my neighbors from the area explained that birth control was not sanctioned by the church, but a hysterectomy was.There may be underlying cultural issues for some procedures we are not aware of.
    As for the back surgery-I agree that this has been hidden.
    I also think part of the problem is that physicians tend to do what they were trained to do in residency. A very good review on this was Jerome Groopman’s book, “How Doctors Think “.
    The point is that some things are not malicious doctors trying to make money, although that may be the result.

  • http://www.DocRate.net Angela N. Vance

    Love this blog post! I checked out the site as well. The scariest thing for any person, is to feel out of control when it comes to medical care for themselves or a loved one. I am a firm believer in patient empowerment, and physicians that encourage it. Thanks for sharing!

  • http://www.rabn.org Amy V. Haas

    Right on the money, but why don’t you even mention Cesarean sections? It is known that 50% of Cesarean sections are medically unnecessary. Need to see the research? I would be happy to send it to you.

  • Emily

    I am a doula, which is a professional labor support person. I have seen births in several hospitals and have seen a wide variation of practices for no other reason than “that’s the way we do it.” A laboring woman actually needs very little in the way of treatment, and the policies concerning her options are often based on convenience for the staff rather than her safety. Everything from what she wears, to whether she is allowed to go to the bathroom, to whether she has surgery often depends on where she gives birth.

  • http://www.rabn.org Amy V. Haas

    Absolutely, Emily!
    People seem to forget that Obstetrics is one of the most lucrative voluntary areas of any hospital. Some hospitals have cesarean rates as high as 80% and some as low as 20%. This, in spite of the fact that the World Health Organization has determined that a safe rate would be between 10 and 15% for any given country around the world. It is really highlighted when you realize that this type of practice results in contributing to the US having the highest maternal and infant mortality rates than any other industrialized country in the world. We rank around 29th in infant mortality. But no one seems to care. I have been working on some preliminary research into how much medical intervention is truly necessary during birth, and the numbers are shocking. While 80 – 95% of women receive some sort of intervention, evidence points to only about 20% or less actually medically needing it. And yes, this too varies by place of birth, and type of attendant.

  • http://www.rabn.org Amy V. Haas

    “$13 to $20 billion a year could be saved in health care costs by demedicalizing childbirth, developing midwifery, and encouraging breastfeeding.”
    Frank Oski, MD, Professor and Director, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD

  • kgapo

    Dave has given a very good gist of Prof. John Wennberg’s book “Tracking Medicine” and of his lectures last December at Salzburg Global Seminar (http://www.salzburgglobal.org/current/sessions.cfm?nav=lectures&IDSPECIAL_EVENT=2754).
    If people understood variation in practice and what it means for them, for the healthcare services they receive as patients and they pay as taxpayers, they would rally for its abolition.

    Amy and Emily, I fully agree with you, also in Greece C-sections have become an epidemic, obstetricians lead pregnant women to C-section for a host of alleged reasons, and women have an inclination for C-sections because they fear labor, because they are working and they want to plan birth, etc.. Needless to say that a C-section is a heavily medicalised intervention, thus partly taking out the happiness of enjoying the first days of the new baby. As the majority of Greek women give birth at private hospitals for cultural reasons, there is no doubt that C-sections are a very lucrative business for HCPs…
    Similar situation was in the nineties with breast cancer, most surgeons would insist on a major operation without a solid medical reason for it, i.e. mastectomy and would not listen to patients enquiries about more conservative interventions like lumpectomies.
    I am sure there are a lot of examples of variations in practice in many countriew and patients should educate themselves so that they can discuss openly with their HCP about the necessity and the real value for their health of any suggested medical intervention.

  • http://www.healthinnovationpartners.com Paulo Machado

    Thanks Dave for this article.
    Patients can improve this situation by asking questions and being informed. AHRQ & NCQA will need to identify & drive rapid adoption of EBM/best practices. Finally Payers will need to reinforce rapid HCP adoption by ensuring the proper incentives (carrots & sticks) are in place. Isn’t it time that the Art of Medicine became more of a Science? Health IT will enable this much overdue transformation!