Why do doctors call it “practice variation” instead of poor care?

Did you know that your medical treatment may depend on where you live?  It even has a name: doctors call it “practice variation”. A new U.S. study suggests, for example, that a person living in St. Cloud, Minnesota is twice as likely to undergo invasive back surgery as a patient with a virtually identical diagnosis living in Rochester.  There are a number of reasons for this strange disparity, but one might be that Rochester is the home of the non-profit Mayo Clinic, where surgeons are paid a salary. No matter how many surgeries they do, they earn the same paycheque.  But other physicians elsewhere who are paid per surgery may be inclined to do more surgeries.

Such “practice variation” is not just seen at Mayo. Medicare patients in Fort Myers, Florida, are more than twice as likely to receive hip replacement surgeries compared to their counterparts across the Everglades in Miami, according to Dartmouth Health Atlas researchers.


They also noted that during the same period, Manhattan had the lowest rate of knee replacement surgeries (4.0 per 1,000) while Lincoln, Nebraska, had the highest rate (15.7 per 1,000). And despite evidence that the survival rate is the same for breast cancer lumpectomies as it is for mastectomies, the rates of mastectomy for breast cancer per 1,000 Medicare enrollees in Pennsylvania varied from 0.8 to 2.4 depending on which Pennsylvania hospital you happened to be admitted to.

This Dartmouth work has created quite a stir in the health care community, mainly because it overtly asks the question:

“Is more care better care?”

But even in the U.K., where doctors (just as at Mayo) are rarely paid on a fee-for-service basis, doctors in Oxford do one type of hip replacement at rates up to 16 times greater than in other cities like London, according to the National Health Service. And as the Dartmouth Health Atlas researchers observed about the British stats:

“These illustrate the fact that doctors tend to favor the treatments they’re trained to provide, even when money isn’t a factor.”

According to a report from the National Committee for Quality Assurance, 57,000 lives are lost annually because physicians are not using evidence-based medicine to guide their care. Peggy O’Kane, president of NCQA, explained:

“We’re literally dying, waiting for the practice of medicine to catch up with medical knowledge. Our report, ‘The State of Health Care Quality’, says these deaths should not be confused with those attributable to medical errors or lack of access to health care.

“This report shows that a thousand people die each week because the care they get is not consistent with the care that medical science tells us they should get.”

But before you even get to those treatments, you first have to get past those diagnostic gatekeepers in medicine.

In 2009, a team of scientists led by the New England Research Institutes published an interesting study in the journal Medical Decision Making that looked at levels of doctors’ diagnostic certainty in identifying heart disease among patients in three countries (U.S., Germany and England).  Researchers found(1) significant differences between health care systems, with American physicians claiming the highest levels of certainty and German physicians showing the least.

To the surprise of few if any female heart patients, all physicians were least certain of coronary heart disease diagnoses with female patients.

The more certain about the presenting problem that these docs felt, as you might imagine, the more likely they were to recommend several clinical actions, including ordering diagnostic tests, writing prescriptions, referrals to specialists, and building in time to follow up.

As a heart attack survivor, I am particularly interested in reports on cardiac procedures.

For example, an earlier Dartmouth study examined the rates of open heart coronary artery bypass graft surgeries (CABG) for four California hospitals in San Francisco, Los Angeles, Modesto, and Redding.  The CABG rates for Redding were significantly higher than for the other three cities, all of which have far larger populations. The Dartmouth researchers concluded that the much higher rate reflects the number of CABG surgeries performed by two heart surgeons in Redding who were associated with Tenet Healthcare’s Redding Medical Center when the survey was taken. In fact, Dr. Woodrow Myers, chief medical officer for Blue Cross of California was later quoted in The Los Angeles Times: 

“A review by independent cardiologists of 52 bypass operations had concluded that 85% of the surgeries at Redding had been unnecessary.”

In fact, a 2008 U.S. congressional investigation titled How Peer Review Failed at Redding Medical Center(2), pulled no punches in describing this scandal:

For 10 years, eye-catching statistics on catheterizations and coronary bypass operations were reported annually and were well-known to federal and state officials.

Yet no agency sought as much as an explanation. It was not until a skeptical heart patient called the FBI that an investigation began. One key finding that emerged from the investigation was that corporate officers, the administrators of Redding Medical Center, and the directors of the cardiology and cardiac surgery programs, Dr. Chae Hyun Moon and Dr. Fidel Realyvasquez respectively, blocked peer review in the cardiac programs. As a result, hundreds of patients underwent unnecessary bypass and valve surgery from which some suffered debilitating injuries and others died.”

With frightening reports like these, the University of British Columbia in Vancouver, through their Division of Health Care Communication, now trains physicians how to pro-actively help patients take an informed and shared role (some might call it a defensive role!) in making decisions about their own health care, like whether or not that back, hip, knee or heart surgery is really the best option for them.

“The patient, helped by the health professional to assess the evidence, evaluates the choices available and becomes informed of the risks and benefits. The client is then able to exercise reasonable autonomy and share in the decisions for medical treatment and health care.”

Informed shared decision-making merges two trends in health care: patient-centred care and evidence-based decision-making.

But according to UBC experts, despite the reality of improved health care outcomes when patients are involved in important decisions about their own health care, there are still many barriers to practicing informed shared decision-making, including:

  • habitual patterns of communication shaped during medical training
  • perceived lack of time
  • fear of jeopardizing rapport

Meanwhile, at Mayo Clinic, where shared decision-making helps to inform patients about their treatment options in advance, patients are also shown visual aids about the risks of treatment and medications, helping them to address these questions:

1.  What are my options?

2.  What are the possible outcomes of those options?

3.  How likely are each of those outcomes to occur?

Dr. Victor Montori, Mayo Clinic professor of medicine and an expert in evidence-based medicine, was interviewed recently by Fox 9 News investigative reporter Jeff Baillon. He explained:

“There are two experts in the room. One is an expert about science, and one is an expert about their life, and about their context, and about their values. And if you only use one of those experts, you’re going to get it wrong.”

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(1) Lutfey KE, “Diagnostic certainty as a source of medical practice variation in coronary heart disease: results from a cross-national experiment of clinical decision-making”. Med Decis Making. 2009 Sep-Oct;29(5):606-18.
(2) Gerald N. Rogan, MD · Frank Sebat, MD · Ian Grady, MD. “How Peer Review Failed at Redding Medical Center, Why It Is Failing Across the Country and What Can Be Done About It”.   Disaster Analysis, Redding Medical Center. Congressional Report, June 1, 2008

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See also:   Cardiac gender bias: We Need less TALK and more WALK

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13 thoughts on “Why do doctors call it “practice variation” instead of poor care?

  1. Excellent report on the abuses of medical treatment. One piece missing is the active role patients play in promoting this behavior. You cited the Univ British Columbia study which identifies several barriers when patients are involved in medical decision making but leaves out the active role of patients.

    Let me illustrate. If a patient sees that a friend had a “procedure” that the doctor did not offer him/her, the patient may go “doctor shopping” and the conscientious physician loses a patient. One outcome is that the doctor now is certain to offer such “procedure.” My guess is that often these patient choices are driven by promotional drives in the media which sometimes have the blessing of academic institutions wanting to tout their “new discoveries.”

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      • Carolyn, I m glad you have addressed the issue of patient’s demands. But I was also attempting to address, rather clumsily, the academic world complicity in these calculations. For instance: How often have we seen “The Univ of ……. has a group of world renowned surgeons that have pioneered a new technique considered at the forefront of medical science for ….”?

        I mean: Who would not want these experts to have a crack at what’s ailing you? And soon the patients will be asking their physicians if they know someone who can do this revolutionary technique that the university is offering.

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  2. Carolyn,

    Great post

    You answered your title question “Why do doctors call it “practice variation” instead of poor care?” with the question in the middle of the article “Is more care better care?” which of course begs the question “Is less care better care?”

    The presumption of much of what is in blogosphere is that less is better but we don’t know. It’s also complicated by the messages that there are “variations and gaps” between genders and in certain ethnic and racial groups. If these concepts are both true (Less is better and there are group variations) then the groups getting less care should be the goal not the other way around.

    For practicing physicians the health policy and health data is above our pay grade and dealing with the patient in front of us and following the great advice you’ve cited from Dr. Victor Montori is the best approach.

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    • Hi Dr. Seth,
      To most of us patients, it’s not so much about “more care” vs “less care”. It’s about appropriate care.

      For example, when cardiologist Dr. Sharonne Hayes at Mayo Clinic was asked recently if the medical profession needs to develop different protocols for assessing/treating female heart attacks, she said NO – what we need is for doctors to follow existing guidelines for both men AND women – which is not the case now. So it’s not just us dull-witted heart attack survivors in the blogosphere who are asking why this is not already happening.
      regards,
      C.
      PS UPDATE: See this Heart Sisters post on cardiac gender bias.

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  3. For the whole horrifying story of Dr. Chae Hyun Moon and Dr. Fidel Realyvasquez in the introduction of this topic, there is a book published titled Coronary: a true story of medicine gone awry / Stephen Klaidman.
    Publication info. New York : Scribner, c2007.

    Carolyn, I am also concerned about receiving the care I need: no more, no less, within reasonable bounds of any doctor’s knowledge base. (No one, not even doctors, knows everything, even in their field.)

    And how in the world can we know how well any physician knows their field? And how can we know how “honestly” they practice, even if they know plenty? How can we know whether they are reimbursed, so to speak, for doing procedures, necessary or not? The patients of the two doctors in the book above gave every appearance, to the patients at least, that they knew exactly what they were doing. (Doctors, nurses and ancillary staff were raising eyebrows and reporting concerns right and left but that’s another issue.)

    For example, I was urged to have a major rotator cuff repair. This is an “iffy” surgery, which I only found out by searching and searching for information. Keep in mind much of the info on medical procedures online is put there by surgeons who do that surgery. I sought 4 (yep, four) opinions on what to do as I was getting conflicting advice and information. One surgeon insisted I needed the surgery on both shoulders. Another said, “no, just the right.” After a repeat MRI, he reversed that, and recommended surgery on only the left but emphasized that this surgery couldn’t wait long due to the nature of the tear.

    I can’t for the life of me remember why, but the message was that this tear could cause even worse damage. I was all set to have the surgery, despite my pain disappearing, fearing what might happen otherwise, but I went back for one more talk since I was so confused. When this doctor found my pain was gone, his comment: “Then what are you doing HERE?!” Wow. I would have had that surgery for no reason at all.

    And guess what? I have been 100% pain free for 3 solid years now! NONE of the four specialists mentioned this was even possible!

    Again I ask: HOW do we know whether we are being treated appropriately?

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    • Your story is, sadly, more common than it should be. Most patients, unlike you, do not seek further information and thus feel compelled to follow the counsel of their physicians. Why wouldn’t they? Sometimes it’s only after the fact (as in the current controversies over stent-happy U.S. cardiologists – or conversely, when patients like me with textbook heart attack symptoms are misdiagnosed with indigestion and sent home from the E.R.) that many patients learn their diagnoses/treatments were not appropriate.

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  4. I am really impressed with the attitude expressed here on The Nag: simple, open, honest, caring, hardworking and sincere, and all the discussion continues through blog comments. Very useful and unique.

    Like

  5. Here is a loosely related story: I have encountered an alarming and disheartening number of incompetent doctors, but this goes beyond the medical field: Not too long after our economy went belly up, I was babysitting at the home of a dentist. I was at loose ends one night as the (very nice) couple was out late and I had neglected to bring anything from home with which to occupy myself.

    I saw a professional dentist journal on the coffee table and picked it up to read. I turned to an article on how to survive the recession. It counseled that dentists should give ALL their patients their best care, and not just a select few! It didn’t say enough about what best was, but the idea that a dentist gave different levels deliberately to different patients was shocking even to me.

    Then I discovered that there are factors in the diet beyond sugar and good oral hygiene which affect the health of teeth. (This was information which I only stumbled on, never informed of by my dentist.) When I asked the receptionist about it she said she’d be glad to make me an appt. so the dentist could give me that talk. (!) I can’t recall now how much my dentist (who I’d thought was one of the best, and perhaps he still is) charged for sharing this information but I do remember it was far more than spare change.

    To think I was never even told there was such information out there, and then to learn I had to pay for my dentist to simply give me that information. Maybe I wasn’t one of the “select few” referred to in the dental journal!

    This is a scary world for patients. All patients.

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    • This is appalling, Bev. Would you care to share with us what you learned from that journal article about those other factors that affect our dental health?

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  6. Dr. Moon performed multiple surgeries on my grandpa, all of that were unnecessary. This was the time period that he was being monitored by the FBI meaning he had to make it look like he wasn’t killing his patients. While he was being monitored, my grandpa got two heart surgeries because Dr. M had to prove that his patients were living. My grandpa didn’t need any of the surgeries he received. He was operated on because Dr. M knew that his surgeries would create complications that would soon lead to his death. He told my family that my grandpa would need a bypass surgery and immediately. My grandpa died during surgery. Not even 8 months later, Dr. M was facing lawsuits. It’s sad because my grandpa was my absolute best friend and he didn’t have to die. Dr. Moon is a sick man and if he can tell my 9 year old self that my grandpa was going to die, then he’d do and say just about anything to kill his patients. I wish that I could somehow get a hold of him and send him the picture of me and my grandpa moments before he went into surgery the day he died because I know for a fact he would remember my face when he told me that my grandpa, my best friend was dying. I feel nothing but hate for this man. No amount of money could change what he did to my family. I will never forgive Dr. M.

    Like

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