Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

Practice variation from the perspective of an e-patient

Dave deBronkart
Policy
May 18, 2011
Share
Tweet
Share

One of our purposes e-Patients.net is to help people develop e-patient skills, so they can be more effectively engaged in their care. One aspect is shared decision making. A related topic, is understanding the challenges of pathology and diagnosis. Both posts teach about being better informed partners for our healthcare professionals.

I’ve recently learned of an another topic, which I’m sure many of you know: practice variation. It’s complex, the evidence about it is overwhelming, and its cost is truly enormous. I’m no expert at it yet, but I also know it’s important, so let’s get started. Corrections welcome.

Here it is, in  a nutshell:

  • Very large parts of healthcare are delivered inconsistently from area to area.
  • In other words, the care you get depends on where you live.
    • That’s right; very often, care decisions aren’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. Very often.
    • Which one is right? Is one overtreated, or is the other  undertreated?
  • This isn’t a matter of economics: it’s a matter of local medical practice.It cuts across all economic levels.
    • That’s why it’s not called discrimination, it’s called practice variation.
  • The people involved – the doctors – mostly don’t know they’re doing it.
  • Bottom line: depending on where you live, you may be getting care you don’t need – hospitalizations and even surgery.
    • Since both of those carry risks of infection and even death, e-patients need to be aware so they can make informed, empowered choices.

Examples:

  • For decades, tonsillectomies were performed in some regions 3-4x more often than in others. (Even between neighboring towns.)
    • Here is a seven page paper from the United Kingdom showing a threefold variation in how many kids got tonsillectomies. It’s from 1938,and Dartmouth researchers found the same in the US in the 1970s and 80s.
    • The end of the report carries the nasty impact: in one year the nation had sixty deaths from tonsillitis, andover 500 deaths from tonsillectomies – most of them children. Unnecessarily dead children because of this issue.
  • The same has often been true with hysterectomies. And gall bladder surgery. And coronary bypass grafts. And many other things.
    • A current non-US example: a post on the NPR blog, by Chris Weaver (@cdweaver) of Kaiser Health News: UK citizens in Oxford are 16 times more likely to get a particular type of hip replacement than similar people in London.
  • For any given condition, your odds of being hospitalized are often proportional to how many hospital beds are in your area.
    • Yes, that’s true after controlling for demographics, severity of illness, everything.
  • At the end of life, your odds of dying in an ICU are proportional to how many ICU beds your region has.
    • I’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 – even if she requests it – simply depending on how many ICU beds your local hospitals have.
    • There are tons of data to support this.  It’s been validated and cross-checked every which-way from Sunday, for years and years.

Yes, to a large extent, recommendations for some types of surgery and hospitalization are driven by local superstition and the mere availability of empty beds (or a particular type of specialist).

This is generally not medical plundering. Doctors generally do not know they’re doing this. (I imagine some do, but this is not a matter of rooting out greed – there’s a bigger issue of widespread denial about how things work.)

This is by far the hardest healthcare issue to comprehend I’ve ever seen. Neither the problem itself nor its intractability – its resistance to change –  make any sense to me. Most of the people involved can’t even believe it’s happening – even though they’re doing it, and the evidence is clear.

When that happens, it’s a sure sign we’ve been overlooking something big. And our efforts to argue for change are doomed until we understand the actual situation.

Impact

I see two major impacts.

  • Cost of unnecessary hospitalizations.
    • Cost to society
    • Cost to the patient and family for the care
    • Lost income
  • Risk of harm, including infection and death.
    • And the cost of those complications.

E-patient takeaways

Smart people have been trying to change this for decades, and it hasn’t changed. While they work on it, the matter is in our hands. In my view empowered, engaged, educated patients need to:

  • Realize this happens
  • Educate ourselves about the region we live in
    • Information is available about which areas are high-utilization. More on this in upcoming posts.
  • Get to work at spreading the word.

As I said, this is all part of a larger issue, SDM – shared decision making, which is a bigtime participatory medicine topic.

Dave deBronkart, also known as e-Patient Dave, blogs at e-Patients.net and is the author of Laugh, Sing, and Eat Like a Pig: How an Empowered Patient Beat Stage IV Cancer and Let Patients Help!

Prev

Emergency medicine, we can do better

May 18, 2011 Kevin 15
…
Next

Direct primary care and the Marcus Welby vision of primary care

May 18, 2011 Kevin 8
…

Tagged as: Patients, Public Health & Policy

Post navigation

< Previous Post
Emergency medicine, we can do better
Next Post >
Direct primary care and the Marcus Welby vision of primary care

ADVERTISEMENT

More by Dave deBronkart

  • Googling is a sign of an engaged patient

    Dave deBronkart
  • a desk with keyboard and ipad with the kevinmd logo

    Women’s right to vote and the e-patient movement

    Dave deBronkart
  • a desk with keyboard and ipad with the kevinmd logo

    Does shared decision making really increase health costs?

    Dave deBronkart

More in Policy

  • Health equity in Inland Southern California requires urgent action

    Vishruth Nagam
  • How American medicine profits from despair

    Jenny Shields, PhD
  • What I learned about health care by watching who gets left behind

    Maanyata Mantri
  • How the One Big Beautiful Bill could reshape your medical career

    Kara Pepper, MD
  • Why the U.S. Preventive Services Task Force is essential to saving lives

    J. Leonard Lichtenfeld, MD
  • Brooklyn hepatitis C cluster reveals hidden dangers in outpatient clinics

    Don Weiss, MD, MPH
  • Most Popular

  • Past Week

    • Health equity in Inland Southern California requires urgent action

      Vishruth Nagam | Policy
    • Could antibiotics beat heart disease where statins failed?

      Larry Kaskel, MD | Conditions
    • How restrictive opioid policies worsen the crisis

      Kayvan Haddadan, MD | Physician
    • Why palliative care is more than just end-of-life support

      Dr. Vishal Parackal | Conditions
    • How Filipino cultural values shape silence around mental health

      Victor Fu and Charmaigne Lopez | Education
    • How Japan and the U.S. can learn from each other to strengthen health care [PODCAST]

      The Podcast by KevinMD | Podcast
  • Past 6 Months

    • Why transgender health care needs urgent reform and inclusive practices

      Angela Rodriguez, MD | Conditions
    • COVID-19 was real: a doctor’s frontline account

      Randall S. Fong, MD | Conditions
    • Why primary care doctors are drowning in debt despite saving lives

      John Wei, MD | Physician
    • New student loan caps could shut low-income students out of medicine

      Tom Phan, MD | Physician
    • Why pain doctors face unfair scrutiny and harsh penalties in California

      Kayvan Haddadan, MD | Physician
    • mRNA post vaccination syndrome: Is it real?

      Harry Oken, MD | Conditions
  • Recent Posts

    • How Japan and the U.S. can learn from each other to strengthen health care [PODCAST]

      The Podcast by KevinMD | Podcast
    • Will longevity medicine put doctors out of work?

      Tomi Mitchell, MD | Physician
    • When doctors don’t talk: a silent failure in modern medicine

      Cesar Querimit, Jr. | Conditions
    • The many faces of physician grief

      Annia Raja, PhD | Conditions
    • Why the doctor-patient relationship needs a redesign

      Alexandra Novitsky, MD | Physician
    • Health equity in Inland Southern California requires urgent action

      Vishruth Nagam | Policy

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 10 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

ADVERTISEMENT

  • Most Popular

  • Past Week

    • Health equity in Inland Southern California requires urgent action

      Vishruth Nagam | Policy
    • Could antibiotics beat heart disease where statins failed?

      Larry Kaskel, MD | Conditions
    • How restrictive opioid policies worsen the crisis

      Kayvan Haddadan, MD | Physician
    • Why palliative care is more than just end-of-life support

      Dr. Vishal Parackal | Conditions
    • How Filipino cultural values shape silence around mental health

      Victor Fu and Charmaigne Lopez | Education
    • How Japan and the U.S. can learn from each other to strengthen health care [PODCAST]

      The Podcast by KevinMD | Podcast
  • Past 6 Months

    • Why transgender health care needs urgent reform and inclusive practices

      Angela Rodriguez, MD | Conditions
    • COVID-19 was real: a doctor’s frontline account

      Randall S. Fong, MD | Conditions
    • Why primary care doctors are drowning in debt despite saving lives

      John Wei, MD | Physician
    • New student loan caps could shut low-income students out of medicine

      Tom Phan, MD | Physician
    • Why pain doctors face unfair scrutiny and harsh penalties in California

      Kayvan Haddadan, MD | Physician
    • mRNA post vaccination syndrome: Is it real?

      Harry Oken, MD | Conditions
  • Recent Posts

    • How Japan and the U.S. can learn from each other to strengthen health care [PODCAST]

      The Podcast by KevinMD | Podcast
    • Will longevity medicine put doctors out of work?

      Tomi Mitchell, MD | Physician
    • When doctors don’t talk: a silent failure in modern medicine

      Cesar Querimit, Jr. | Conditions
    • The many faces of physician grief

      Annia Raja, PhD | Conditions
    • Why the doctor-patient relationship needs a redesign

      Alexandra Novitsky, MD | Physician
    • Health equity in Inland Southern California requires urgent action

      Vishruth Nagam | Policy

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Practice variation from the perspective of an e-patient
10 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...