Unwarranted variation

Unwarranted variation (or geographic variation) in health care service delivery, first so termed by Dr. John Wennberg,[1] refers to differences that cannot be explained by illness, medical need, or the dictates of evidence-based medicine. It can be caused by shortfalls in three areas:

History

In 1967, while working in the Regional Medical Program created with a $350,000 grant from President Lyndon Johnson, Wennberg was analyzing Medicare data to determine how well hospitals and doctors were serving their communities. He found 4 types of variation: the underuse of effective care, variations in outcomes attributable to the quality of care, the misuse of preference-sensitive treatments, the overuse of supply-sensitive services.[3]

According to Health Dialog, a privately held, for-profit disease-management company that was established to address unwarranted variation:

If you live in northern Idaho, and you develop back pain, chances are good that you’ll undergo surgery to treat your pain. Move to the southern tip of Texas, however, and the chances that you’ll undergo that same surgery will drop by a factor of 6. The surgery is no more effective in Idaho than it is in Texas. It’s just that doctors in the northwest are more likely than those in southern Texas to recommend surgery. This phenomenon, in which doctors practice medicine differently depending on where they’re from, is called practice pattern variation. And it isn’t limited to treating back pain, or even surgical decisions. There is also variation in treatment for chronic conditions, such as use of beta blockers for individuals with Congestive Heart Failure (CHF) or lipid testing for those with diabetes.[4]

Dr. Wennberg and his colleagues at the Dartmouth Center for Evaluative Clinical Sciences have documented these wide variations in how healthcare is practiced around the country. They have also asserted that most of this variation is, in fact, unwarranted. Health Dialog was built to directly address unwarranted variation in healthcare: the overuse, underuse and misuse of medical care. Wennberg and his colleagues further concluded that if unwarranted variation in the healthcare system could be reduced, the quality of care would go up and healthcare costs would go down. Studies have shown that if unwarranted variation could be reduced in the Medicare population, quality of care would rise dramatically and costs could be lowered by as much as 30%.[5]

Extent

Unwarranted variation in medical practice, as noted by Martin Sipkoff in 9 Ways To Reduce Unwarranted Variation, is costly and deadly. Analysis of Medicare data reveals that per-capita spending per enrollee in Miami is almost 2.5 times as great as in Minneapolis, even after adjusting data for age, sex, and race.

Worse, 57,000 lives are lost annually because physicians are not using evidence-based medicine to guide their care, according to a recent report from the National Committee for Quality Assurance.[6]

"We're literally dying, waiting for the practice of medicine to catch up with medical knowledge," says Margaret O'Kane, president of NCQA. The report, "The State of Health Care Quality 2003," says that the deaths "should not be confused with those attributable to medical errors or lack of access to health care. This report shows that a thousand Americans die each week because the care they get is not consistent with the care that medical science tells us they should get."[6]

"Practice variation is one of the greatest problems we face in controlling costs, but we believe that it is something we can do something about." Dwayne Davis, MD, medical director of Geisinger Health Care[6]

United States

NHS England

Inspired by the work of Wennberg, the first NHS Atlas of Variation in Healthcare was published in November 2010 by the Department of Health QIPP Right Care programme.[7] 34 topics, selected by clinicians as being important to their speciality, were mapped by Primary Care Trust area, then the healthcare commissioning body. The Atlas was published as a challenge to commissioners to consider the opportunities to maximise health outcome and minimise inequalities by addressing unwarranted variation.

"Awareness is the first important step in identifying and addressing unwarranted variation; if the existence of variation is unknown, the debate about whether it is unwarranted cannot take place"[7]:15

The 2010 Atlas revealed widespread variations in outcome, quality, cost and activity:

A further extended Atlas was published in November 2011, mapping variation across 71 indicators and a follow-on series of Atlases focussing on specific themes in more depth like children and young people, diabetes, kidney disease and respiratory disease. A forthcoming atlas will be about liver disease, diagnostics, organ donation and transplantation. Publication of the Atlases has been well-received within the NHS and by patient groups and clinical societies.

In 2012, the British Department of Health published a Mandate for the new NHS Commissioning Board. The Mandate to the NHS Commissioning Board set out the objectives for the NHS and highlights the areas of health and care where the Government expects to see improvements. On variation in healthcare, the Mandate charged the Board with the responsibility to "shine a light on variation" and "to make significant progress... in reducing unjustified variation.... Success will be measured not only by the average level of improvement but also by progress in reducing health inequalities and unjustified variation."[8]:7,13,27

See also

References

  1. ↑ Medical Guesswork Businessweek.com Archived November 5, 2007, at the Wayback Machine.
  2. ↑ Unwarranted Variation Health Dialog, healthdialog.com Archived December 11, 2007, at the Wayback Machine.
  3. ↑ Michael T. McCue Clamping down on variation - Managed Healthcare Executive, February 01, 2003
  4. 1 2 The Dartmouth Atlas of Healthcare, 1999.
  5. ↑ Fisher E.S., Wennberg D.E., Stukel T.A., et al. The implications of regional variations in Medicare spending. Part 1. Ann Intern Med. 2003; 138: 273-287.
  6. 1 2 3 9 Ways To Reduce Unwarranted Variation Managed Care Magazine, November 2003
  7. 1 2 The NHS Atlas of Variation in Healthcare NHS, 2010
  8. ↑ The Mandate: A mandate from the Government to the NHS Commissioning Board April 2013 to March 2015, Department of Health, November 2012

Newspaper publications

Academic publications

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