{"id":8096,"date":"2011-03-11T03:38:58","date_gmt":"2011-03-11T08:38:58","guid":{"rendered":"http:\/\/pmedicine.org\/epatients\/?p=8096"},"modified":"2011-03-11T17:04:14","modified_gmt":"2011-03-11T22:04:14","slug":"the-discovery-of-practice-variation-follow-the-data","status":"publish","type":"post","link":"https:\/\/participatorymedicine.org\/epatients\/2011\/03\/the-discovery-of-practice-variation-follow-the-data.html","title":{"rendered":"The discovery of practice variation: follow the data"},"content":{"rendered":"<blockquote>\n<p style=\"text-align: left;\">It is a capital mistake to theorize before one has data. Insensibly one\u00a0begins to twist facts to suit theories, instead of theories to suit facts.<\/p>\n<p style=\"text-align: right;\">Sherlock Holmes, in <em><a href=\"http:\/\/en.wikiquote.org\/wiki\/Sherlock_Holmes#A_Scandal_in_Bohemia\" target=\"_blank\">Scandal in Bohemia<\/a><\/em><\/p>\n<\/blockquote>\n<p>I\u2019ve been reading Jack Wennberg\u2019s new book <em>Tracking Medicine<\/em>, which is about his lifetime of work in understanding the reality of how medicine is practiced, as a route to helping us achieve the best care possible for each of us.\u00a0<a href=\"https:\/\/participatorymedicine.org\/epatients\/archives\/2010\/12\/salzburg-global-seminar-december-2010-informing-and-involving-patients-in-medical-decision-making.html\">My first post about this<\/a> was three months ago, en route to a seminar on SDM (shared decision making); my first post <a href=\"https:\/\/participatorymedicine.org\/epatients\/archives\/2010\/12\/practice-variation-an-essential-e-patient-awareness-topic.html\">after the seminar<\/a> was shortly after. The whole subject has bent my thinking about healthcare so severely that it\u2019s taken me this long to decide what to say next.<\/p>\n<p><strong>Key findings:<\/strong><\/p>\n<ul>\n<li>Your doctors, with the best of intentions and the best of training, may unwittingly be prescribing treatments that aren&#8217;t necessary for you, or not prescribing things that are. (\u201cYou\u201d includes anyone you\u2019re caring for.)<!--more--><\/li>\n<li>This realization was developed not through people\u2019s opinions but by looking at cold hard numbers. After controlling for all variables, the odds of a given patient getting a given treatment vary by <em>hundreds <\/em>of percent from region to region.<\/li>\n<li>For whatever reason, decades of efforts to change this have been fruitless, so the risks from unnecessary treatments continue and inappropriate care continues.<\/li>\n<li>Part of the reason is that we&#8217;re in denial (patients and providers alike), and part of the reason for <em>that <\/em>seems to be that the causes are unconscious. (See below.)<\/li>\n<li>This doesn\u2019t mean your doctors are incompetent &#8211; the forces at play seem to be universal. The problem is that virtually nobody realizes it\u2019s happening &#8211; neither we as consumer\/patients nor the physicians.<\/li>\n<li><strong>E-patient takeaway:<\/strong> If you want the best care for yourself and your family, do what you can to understand these issues and have empowered, engaged, participatory conversations with your providers.<\/li>\n<\/ul>\n<p><strong>Wennberg\u2019s method<\/strong> was to crawl through databases. From the start of his book:<\/p>\n<blockquote><p>Early in my career, I was hired as director of a federally sponsored program whose goal was to ensure that all Vermonters had access to recent advances in the treatment of heart disease, cancer, and stroke.\u2026 As the results came in, however, rather than evidence for underuse\u2026 we found extensive and seemingly inexplicable variation in the way health care was delivered from one Vermont community to another.<\/p><\/blockquote>\n<p>This &#8220;practice variation&#8221; is described in <a href=\"https:\/\/participatorymedicine.org\/epatients\/archives\/2010\/12\/practice-variation-an-essential-e-patient-awareness-topic.html\">my previous post<\/a>. Today&#8217;s post presents a \u00a0top-level introduction to what has taken thirty years of analysis and testing to confirm. It&#8217;s hard to imagine this is true; read the book. In short, Wennberg and his colleagues have established that healthcare decisions in reality can be categorized in three groups:<\/p>\n<ul>\n<li><strong>Effective care:<\/strong> situations where there&#8217;s no debate &#8211; all eligible patients should get this. Example: if you have a broken hip, you should have a hip replacement.\n<ul>\n<li>This is about 15% of Medicare spending.<\/li>\n<li>As a separate cause for concern (not cited in this book), other studies have found that doctors only recommend &#8220;the standard of care&#8221; about half the time. (Isn&#8217;t that amazing and eye-opening?)<\/li>\n<li>Note: this is only 15%. <strong>85% of the time,<\/strong> the decision is open to consideration, and you should be presented with options.<\/li>\n<\/ul>\n<\/li>\n<li><strong>Elective or &#8220;preference-sensitive&#8221; care:<\/strong> there&#8217;s more than one option, and outcomes vary depending on which option you choose.\n<ul>\n<li>This is about 25% of Medicare spending.<\/li>\n<li>Includes decisions about some surgery, and some screening tests.<\/li>\n<li>These decisions are preference sensitive \u2013 they have different quality of life (QOL) implications, so the \u201cright\u201ddecision for proper care <em>cannot be made without knowing the patient\u2019s preference. You should be asked.<\/em><\/li>\n<li>Example: if you have an enlarged prostate, one option is to just keep an eye on it (&#8220;watchful waiting&#8221; or &#8220;active surveillance&#8221;). The surgical option has significant risk of side effects: impotence, leakage, other issues. Years of research has shown that the importance of each side effect varies widely by patient. <em>The correct decision can&#8217;t be made by the doctor alone.<\/em><\/li>\n<li>But many (perhaps most?) clinicians don&#8217;t present us with the range of options &#8211; they make the choice for us (perhaps with the best of intentions) and then ask our consent. (This is the &#8220;informed consent&#8221; form we&#8217;re asked to sign.)<\/li>\n<li>Most patients don\u2019t know about this, so they don\u2019t ask and they don&#8217;t get involved with decisions. But when the options and trade-offs are presented, people often opt <em>not <\/em>to have surgery. That&#8217;s informed <em>choice<\/em>, vs informed consent.<\/li>\n<li>Here&#8217;s something to think about: some people at the Foundation for Informed Medical Decision Making (<a href=\"http:\/\/fimdm.org\" target=\"_blank\">FIMDM<\/a>) propose that operating on a patient without knowing their preference can be as much of a medical error as operating on the wrong limb! (In both cases you may be cutting something that shouldn&#8217;t be cut &#8211; a clear mistake.)<\/li>\n<\/ul>\n<\/li>\n<li><strong>Supply-sensitive care:<\/strong> 60% of Medicare spending (sixty percent!)\n<ul>\n<li>As described in the previous post, in <em>a majority<\/em> of cases your likelihood of having a treatment recommended <em>is proportional to how available it is in your area <\/em>&#8211; <span style=\"text-decoration: underline;\">not<\/span> related to your need. Even the chance that your death will occur in an ICU is proportional to the supply of ICU beds in your area.<\/li>\n<li>Yes, there is vast historical evidence for this. (See Sherlock Holmes above.)<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>&#8220;Supply-sensitive care&#8221; smacks of\u00a0Parkinson\u2019s Law (&#8220;Work expands so as to fill the time available for its completion,&#8221;), or, according to Wikipedia, a <a href=\"http:\/\/en.wikipedia.org\/wiki\/Parkinson's_Law#Generalization\" target=\"_blank\">generalization<\/a>: \u201cThe demand upon a resource tends to expand to match the supply of the resource.\u201d Indeed, a similar law,\u00a0<strong><a href=\"http:\/\/en.wikipedia.org\/wiki\/Roemer's_law\" target=\"_blank\">Roemer\u2019s Law<\/a>,<\/strong> is widely accepted by people I&#8217;ve talked to: &#8220;A bed built is a bed filled.&#8221; (No matter how much hospital capacity you build, it&#8217;ll get used up.)<\/p>\n<p><em>And the doctors who recommend that we be hospitalized to the gills generally don&#8217;t realize they&#8217;re doing it.<\/em><\/p>\n<p>Think this is a complaint about American healthcare? It&#8217;s not. For instance, in 1992 it was noted in the Netherlands: <a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/1600289\">http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/1600289<\/a><\/p>\n<p><strong>e-Patient take-aways &#8211; Things for engaged \/ activated patients to realize:<\/strong><\/p>\n<p>I can\u2019t overstate the importance of realizing this as we approach any decision about a treatment, especially surgery. It\u2019s especially important to realize that your own physician, with the best of intentions, may not be aware of the invisible influences driving the treatment recommendations of his or her peers in the local community.<\/p>\n<p>It seems clear to me that we must, must, must create discussion tools \u2013 an index card, a flyer, a website \u2013 from a respected source to help clinicians listen when we ask, \u201cIs this treatment necessary?\u201d and ask for help in researching the rationale for the decision, including researching the relative frequency of recommending it locally compared to other hospital referral regions.<\/p>\n<p>We need to educate clinicians, patient advocates, insurance companies and health plans, and each other about this issue. What\u2019s at stake is patient safety: every hospitalization and treatment carries a risk of harm as well as the possibility of improvement. I\u2019ve heard from many people that their physicians are sometimes offended when patients ask. (Of course, many other physicians aren\u2019t.)<\/p>\n<p>Our society&#8217;s definition of participatory medicine talks about patients becoming &#8220;responsible drivers&#8221; of their care. Clearly, shared decision making is essential: we need to stand up for our right to be responsible for what happens to our bodies.<\/p>\n<p>&nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>It is a capital mistake to theorize before one has data. Insensibly one\u00a0begins to twist facts to suit theories, instead of theories to suit facts. Sherlock Holmes, in Scandal in [&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":[4237,4236],"tags":[],"coauthors":[],"class_list":["post-8096","post","type-post","status-publish","format-standard","hentry","category-practice-variation-shared-decision-making","category-shared-decision-making"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.3 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>The discovery of practice variation: follow the data - 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\/2011\/03\/the-discovery-of-practice-variation-follow-the-data.html\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"The discovery of practice variation: follow the data - SPM Blog\" \/>\n<meta property=\"og:description\" content=\"It is a capital mistake to theorize before one has data. 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