Wednesday, September 28, 2011

Geographical disparities in medical treatment

The California HealthCare Foundation's Center for Health Reporting released a report earlier this month finding residents of a rural Northern California town, Clearlake, California, undergo two common surgical heart procedures more than any other Californians. Clearlake residents underwent elective angioplasty and angiography more than five times the rate of other Californians. In 2005, 2006, and 2007, residents of Clearlake had the highest inpatient angioplasty rate in the country.

Angioplasty is used to open blocked arteries that supply blood to the heart, and angiography is a diagnostic test that detects coronary artery blockages. The variations in the administration of these procedures have far-reaching health and financial implications.

These results are part of a study being conducted by Stanford health research and policy Professor Laurence Baker. Baker analyzed statewide hospital data, including the three most recent years of Medicare data (from 2005 through 2007). His research revealed that the use of certain elective procedures varies significantly with geography. Baker hypothesizes that this extreme variation in elective procedures is not necessarily tied only to the conditions of the local population. Some of the disparity may be linked to differences in how doctors treat diseases.

If variations in elective procedures are tied to how doctors in certain areas treat diseases, where you live in California will affect what medical care you receive. John Wennberg, a professor at Dartmouth Medical School, conducted the Medicare analysis with Baker. Mr. Wennberg explained:
Depending on where people with chronic illnesses live, and which hospital or doctor they are loyal to, they receive very different levels of care.
To account for variations in local health conditions, Baker adjusted the rates of both heart procedures to eliminate the differences in the health of the populations and their access to health care. The raw data showed Clearlake residents undergoing the two heart procedures at a rate seven times the state average. After accounting for variables such as rates of heart attack hospitalization and diabetes diagnoses during hospital stays (both variables that suggest higher local need for the heart procedures), Clearlake residents still appear to have the two procedures at a rate more than five times the state average.

Assuming Baker's adjustments successfully rule out local population differences, the fact that radical variations in treatment practices persist suggests that the difference may come down to how physicians practice in their communities (sometimes called "physician culture"). This may be particularly true when physicians have discretion in how to treat illnesses.

For those who dispute the results of Baker's analysis, Baker points out that Californians in 23 other regions had higher heart attack rates than in Clearlake, yet showed a much lower use of angioplasty and angiography procedures. So, how are local communities dealing with variations in treatment, if at all?

In the Sacramento, California region, Blue Shield worked with Hill Physicians and Catholic Healthcare West to reduce variation. The group shared and analyzed treatment data to determine which procedures had high rates of variation across the region. They found higher rates of variation for knee surgeries, weight-loss surgeries, and invasive hysterectomies in the Sacramento area.

In hopes of remedying these high variation rates, Hill Physicians looked specifically at the hysterectomy rates. They learned that some physicians had never received training in less invasive techniques. They then worked with doctors to determine which patients were candidates for the less invasive procedure and trained other doctors on how to perform the newer procedure. According to Tricia Griffin, a spokesperson for Catholic Healthcare West, recent results show a decline in invasive hysterectomies in the Sacramento region.

Blue Shield is now teaming with San Francisco hospitals to implement a similar program to combat the high variation in patient care among hospitals.

I am skeptical, however, that these programs studying variations will be successful in targeting the root cause of this disparity in rural communities. If the communities where certain treatments are more heavily used are the same communities where there is a shortage of primary care doctors, these efforts may not help much. In rural communities with less access to health care, perhaps by the time they see a doctor, their cases are so advanced that the more invasive procedures are necessary. There seem to be other variables that should be accounted for before we can universally and confidently conclude that variations in treatment are significantly linked to doctor preference and training.

In the meantime, people should be prepared to take control of their treatment. They should ask their doctors questions about their options and come to an informed decision together.


JLS said...

Very interesting. Another issue to consider in disparity of treatment is remoteness and access to preventative care. What kinds of procedures will people elect to have if they have to travel very far to get it? What will they be forced to do if lack of access causes them to neglect their health until it is too late?

Jade Graham said...
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