{"id":8062,"date":"2010-12-20T14:01:02","date_gmt":"2010-12-20T18:01:02","guid":{"rendered":"http:\/\/pmedicine.org\/epatients\/?p=8062"},"modified":"2013-10-06T12:06:55","modified_gmt":"2013-10-06T16:06:55","slug":"practice-variation-an-essential-e-patient-awareness-topic","status":"publish","type":"post","link":"https:\/\/participatorymedicine.org\/epatients\/2010\/12\/practice-variation-an-essential-e-patient-awareness-topic.html","title":{"rendered":"&#8220;Unwarranted practice variation&#8221;: an essential e-patient awareness topic"},"content":{"rendered":"<p><i>Headline and body edited Oct 6, 2013: the original post talked about &#8220;practice variation,&#8221; but that was bad wording. The problem is <strong>unwarranted<\/strong> practice variation: variation that, when studied, is not warranted by actual differences between cases.<br \/>\n___________<br \/>\n<\/i><\/p>\n<p><em>This is the first of the follow-up posts I hope to write from participating last week in the Salzburg Global Seminar titled <a href=\"http:\/\/www.salzburgglobal.org\/2009\/Sessions.cfm?IDSPECIAL_EVENT=2754\" target=\"_blank\">\u201cThe Greatest Untapped Resource in Healthcare? Informing and Involving Patients in Decisions about Their Medical Care.\u201d<\/a><\/em><\/p>\n<p>One of our purposes on this site is to help people develop e-patient skills, so they can be more effectively engaged in their care. One aspect is shared decision making, which <a href=\"https:\/\/participatorymedicine.org\/epatients\/archives\/2010\/09\/informed-medical-decision-making-the-challenges-of-doctor-patient-communication.html\" target=\"_blank\">we wrote about<\/a> in September. A related topic, from August, is <a href=\"https:\/\/participatorymedicine.org\/epatients\/archives\/2010\/08\/essential-e-patient-topic-understanding-the-challenges-of-pathology-and-diagnosis.html\">understanding the challenges of pathology and diagnosis<\/a>. Both posts teach about being better informed partners for our healthcare professionals.<\/p>\n<p>I&#8217;ve recently learned of an another topic, which I&#8217;m sure many of you know: <strong>unwarranted practice variation.<\/strong> This is a big subject; I&#8217;ll have several posts about it. It&#8217;s complex, the evidence about it is overwhelming, and its cost is truly enormous. I&#8217;m no expert at it yet, but I also know it&#8217;s important, so let&#8217;s get started. Corrections welcome. Here it is, in \u00a0a nutshell:<\/p>\n<ul>\n<li>Very large parts of healthcare are delivered inconsistently from area to area.<\/li>\n<li>In other words, the care you get depends on <em>where you live<\/em>.\n<ul>\n<li>That&#8217;s right; very often, care decisions aren&#8217;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. <em>Very <\/em>often.<\/li>\n<li>Which one is right? Is one overtreated, or is the other \u00a0undertreated?<\/li>\n<\/ul>\n<\/li>\n<li>This isn&#8217;t a matter of economics: it&#8217;s a matter of local medical <em>practice.<\/em> It cuts across all economic levels.\n<ul>\n<li>That&#8217;s why it&#8217;s not called discrimination, it&#8217;s called practice variation.<\/li>\n<\/ul>\n<\/li>\n<li><em>The people involved &#8211; the doctors &#8211; mostly don&#8217;t know they&#8217;re doing it.<\/em><\/li>\n<li><em> <\/em>Bottom line: depending on where you live, you may be getting care you don&#8217;t need &#8211; hospitalizations and even surgery.\n<ul>\n<li>Since both of those carry risks of infection and even death, e-patients need to be aware so they can make informed, empowered choices.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>Pardon the heavy italics; I&#8217;m trying to convey concisely the things you&#8217;ll see when\/if you start studying this. Examples:<!--more--><\/p>\n<ul>\n<li>For decades, tonsillectomies were performed in some regions 3-4x more often than in others. (Even between neighboring towns.)\n<ul>\n<li><a href=\"http:\/\/www.springerlink.com\/content\/17w02h6w57u8r341\/fulltext.pdf\" target=\"_blank\">Here<\/a> is a seven page paper from the United Kingdom showing a threefold variation in how many kids got tonsillectomies. <strong>It&#8217;s from 1938<\/strong>, and Dartmouth researchers found the same in the US in the 1970s and 80s.<\/li>\n<li>The end of the report carries the nasty impact: in one year the nation had sixty deaths from tonsillitis, and<strong> over 500 deaths from tonsillectomies<\/strong> &#8211; most of them children. Unnecessarily dead children because of this issue.<\/li>\n<\/ul>\n<\/li>\n<li>The same has often been true with hysterectomies. And gall bladder surgery. And coronary bypass grafts. And many other things.\n<ul>\n<li>A current non-US example:\u00a0a <a href=\"http:\/\/www.npr.org\/blogs\/health\/2010\/12\/17\/132135209\/uk-health-maps-show-a-shared-problem-across-the-pond\" target=\"_blank\"><strong>post on the NPR blog<\/strong><\/a>, written at the end of last week&#8217;s seminar by participant Chris Weaver (@cdweaver) of Kaiser Health News: UK citizens in Oxford are <em>16 times more likely<\/em> to get a particular type of hip replacement than similar people in London.<\/li>\n<\/ul>\n<\/li>\n<li>For any given condition, your odds of being hospitalized are often proportional to how many hospital beds are in your area.\n<ul>\n<li>Yes, that&#8217;s true after controlling for demographics, severity of illness, everything.<\/li>\n<\/ul>\n<\/li>\n<li>At the end of life, your odds of <strong>dying in an ICU<\/strong> are proportional to <em>how many ICU <strong>beds<\/strong><\/em> your region has.\n<ul>\n<li>I&#8217;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 &#8211; even if she requests it &#8211; simply depending on how many ICU beds your local hospitals have.<\/li>\n<li>There are <em>tons <\/em>of data to support this. \u00a0It&#8217;s been validated and cross-checked every which-way from Sunday, for years and years.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>Yes, to a large extent, recommendations for some types of surgery and hospitalization are driven by\u00a0<em>local superstition<\/em> and the\u00a0<em>mere availability of empty beds<\/em> (or a particular type of specialist).<\/p>\n<p><em>This is generally not medical plundering. <\/em>Doctors generally <em>do not know they&#8217;re doing this<\/em>. (I imagine some do, but this is not a matter of rooting out greed &#8211; there&#8217;s a bigger issue of widespread denial about <em>how things work<\/em>.)<\/p>\n<p>This is by far the hardest healthcare issue to comprehend I&#8217;ve ever seen. Neither the problem itself nor its intractability &#8211; its resistance to change &#8211; \u00a0make any sense to me. Most of the people involved can&#8217;t even believe it&#8217;s happening &#8211; even though they&#8217;re doing it, and the evidence is clear!<\/p>\n<p>When that happens, it&#8217;s a sure sign we&#8217;ve been overlooking something big. And our efforts to argue for change are doomed until we understand the actual situation.<\/p>\n<p><strong>Impact<\/strong><\/p>\n<p>I see two major impacts.<\/p>\n<ul>\n<li>Cost of unnecessary hospitalizations.\n<ul>\n<li>Cost to society<\/li>\n<li>Cost to the patient and family for the care<\/li>\n<li>Lost income<\/li>\n<\/ul>\n<\/li>\n<li>Risk of harm, including infection and death.\n<ul>\n<li>And the cost of those complications.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p><strong>E-patient Takeaways:<\/strong><\/p>\n<p>Smart people have been trying to change this for decades, and it hasn&#8217;t changed. While they work on it, the matter is in our hands. In my view empowered, engaged, educated patients need to<\/p>\n<ul>\n<li>Realize this happens<\/li>\n<li>Educate ourselves about the region we live in\n<ul>\n<li>Information is available about which areas are high-utilization. More on this in upcoming posts.<\/li>\n<\/ul>\n<\/li>\n<li>Get to work at spreading the word.<\/li>\n<\/ul>\n<p>As I said, this is all part of a larger issue, SDM &#8211; shared decision making, which is a <em>bigtime <\/em>participatory medicine topic. We&#8217;ll have much to say about this in the coming weeks. The first posts will discuss more about practice variation.<\/p>\n<p>&#8212;&#8212;<\/p>\n<p><strong>Background \/ homework: <\/strong>I&#8217;ve started reading the new (2010) book <em><a href=\"http:\/\/trackingmedicine.com\" target=\"_blank\">Tracking Medicine<\/a><\/em>, by Jack Wennberg of Dartmouth, which chronicles his 30+ years working on this. You can <a href=\"http:\/\/www.amazon.com\/Tracking-Medicine-Researchers-Understand-ebook\/dp\/B004A16LFS\/ref=kinw_dp_ke?ie=UTF8&amp;m=AG56TWVU5XWC2\" target=\"_blank\">buy it on Kindle<\/a> if you want and start reading immediately. (You don&#8217;t need a Kindle; there are free Kindle apps for almost everything including smartphones.) Or if you&#8217;re like me, you&#8217;ll want to scribble all over the pages of a paper copy.<\/p>\n<p>&nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Headline and body edited Oct 6, 2013: the original post talked about &#8220;practice variation,&#8221; but that was bad wording. The problem is unwarranted practice variation: variation that, when studied, is [&hellip;]<\/p>\n","protected":false},"author":4,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"give_campaign_id":0,"_et_pb_use_builder":"","_et_pb_old_content":"","_et_gb_content_width":"","_price":"","_stock":"","_tribe_ticket_header":"","_tribe_default_ticket_provider":"","_tribe_ticket_capacity":"0","_ticket_start_date":"","_ticket_end_date":"","_tribe_ticket_show_description":"","_tribe_ticket_show_not_going":false,"_tribe_ticket_use_global_stock":"","_tribe_ticket_global_stock_level":"","_global_stock_mode":"","_global_stock_cap":"","_tribe_rsvp_for_event":"","_tribe_ticket_going_count":"","_tribe_ticket_not_going_count":"","_tribe_tickets_list":"[]","_tribe_ticket_has_attendee_info_fields":false,"jetpack_post_was_ever_published":false,"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_publicize_message":"","jetpack_publicize_feature_enabled":true,"jetpack_social_post_already_shared":false,"jetpack_social_options":{"image_generator_settings":{"template":"highway","default_image_id":0,"font":"","enabled":false},"version":2}},"categories":[21,4237,4236,226,2304],"tags":[],"coauthors":[],"class_list":["post-8062","post","type-post","status-publish","format-standard","hentry","category-e-ptsresources","category-practice-variation-shared-decision-making","category-shared-decision-making","category-understanding-statistics","category-why-pm"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.3 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>&quot;Unwarranted practice variation&quot;: an essential e-patient awareness topic - SPM Blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/participatorymedicine.org\/epatients\/2010\/12\/practice-variation-an-essential-e-patient-awareness-topic.html\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"&quot;Unwarranted practice variation&quot;: an essential e-patient awareness topic - SPM Blog\" \/>\n<meta property=\"og:description\" content=\"Headline and body edited Oct 6, 2013: the original post talked about &#8220;practice variation,&#8221; but that was bad wording. 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