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 in April 2010.
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* 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**, 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.”
* 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.
**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