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Small Area Analysis and the Challenge of Practice Variation

  • John WennbergEmail author
  • Klim McPherson
  • David Goodman
Living reference work entry
Part of the Health Services Research book series (HEALTHSR)

Abstract

The study of variations has challenged long-standing theories that the utilization of medical services is primarily determined by the incidence of illness, the constraints of medical science, or patient preferences. This chapter traces the development of empirical research in small area variation in the United States, England, and other countries and the concurrent evolution of explanatory theories. Variations in health services are marked across every level of care – small areas, tertiary regions, and health care providers. The majority of this variation is not explained by patient differences. We categorize different sources of variation into (1) effective care, where benefits far exceed harm, (2) preference-sensitive care, where there are a variety of options for patients, each with benefits and trade-offs, and (3) supply-sensitive care, where varying supplies of health care resources lead to differences in the frequency of care, with scant evidence that more services benefit patients. Each of these explanatory categories is linked to specific clinical and policy remedies that, if implemented, would significantly improve health care.

Keywords

Practice Variation Benign Prostatic Hypertrophy Medical Opinion Surgical Signature Medicare Spending 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Supplementary material

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References

  1. Appleby J, Raleigh V, Frosini F, et al. Variations in health care. The good, the bad and the inexplicable. London: King’s Fund; 2011.Google Scholar
  2. Bunker JP. Surgical manpower: a comparison of operations and surgeons in the United States and in England and Wales. N Engl J Med. 1970;282:135–44.CrossRefPubMedGoogle Scholar
  3. Burton M. Tonsillectomy – then and now. Int J Epidemiol. 2008;37:23–5.CrossRefPubMedGoogle Scholar
  4. Department of Health. The NHS atlas of variation in healthcare. 2010. http://www.rightcare.nhs.uk
  5. Dyck FJ, Murphy FA, Murphy JK, et al. Effect of surveillance on the number of hysterectomies in the province of Saskatchewan. N Engl J Med. 1977;2:1326–8.CrossRefGoogle Scholar
  6. Fisher ES, Wennberg DE, Stukel TA, et al. The implications of regional variations in Medicare spending: part 2. Health outcomes and satisfaction with care. Ann Intern Med. 2003;138:288–98.CrossRefPubMedGoogle Scholar
  7. Glover JA. The incidence of tonsillectomy in school children. Proc R Soc Med. 1938;31:1219–36. Reprinted in the Int J Epidemiol. 2008;37:9–19.PubMedCentralPubMedGoogle Scholar
  8. Kuhn TS. The structure of scientific revolutions. 50th anniversary. Ian Hacking (intro.). 4th ed. University of Chicago Press; 2012. p. 264. ISBN 978-0-226-45811-3. LCCN 2011042476.Google Scholar
  9. Lembcke PA. Measuring the quality of medical care through vital statistics based on hospital service areas: 1. comparative study of appendectomy rates. Am J Public Health Nations Health. 1952;42(3):276–86. doi:10.2105/AJPH.42.3.276.PubMedCentralCrossRefPubMedGoogle Scholar
  10. Lewis CE. Variations in the incidence of surgery. N Engl J Med. 1969;281:880–4.CrossRefPubMedGoogle Scholar
  11. Lichner EA, Pflanz M. Appendectomy in the Federal Republic of Germany: epidemiology and medical care patterns. Med Care. 1971;9:311–8.CrossRefGoogle Scholar
  12. McPherson K. International differences in medical care practices. In: International comparison of health care financing and delivery: data and perspectives. Health Care Financing Administration; Washington: U.S. Government Printing Office, Dec. 1989, (Annual Supplement) pp. 9–20.Google Scholar
  13. McPherson K, Bunker JP. Costs, risks and benefits of surgery: a milestone in the development of health services research. J R Soc Med. 2007;100:387–90.PubMedCentralCrossRefPubMedGoogle Scholar
  14. McPherson K, Wennberg JE, Hovind OB, Clifford P. Small-area variations in the use of common surgical procedures: an international comparison of New England, England and Norway. N Engl J Med. 1982;307:1310–4.CrossRefPubMedGoogle Scholar
  15. McPherson K, Downing A, Buirski D. Systematic variation in surgical procedures and hospital admission rates, PHP publication no 23. London: London School of Hygiene and Tropical Medicine; 1996.Google Scholar
  16. McPherson K, Gon G, Scott M. International variations in a selected number of surgical procedures. OECD Health Working Papers, No. 61, OECD Publishing; 2013. doi:10.1787/5k49h4p5g9mw-en.Google Scholar
  17. OECD Report. Geographic variations in health care: what do we know and what can be done to improve health system performance? OECD Health Policy Studies, OECD Publishing; 2014. doi:10.1787/9789264216594-en.Google Scholar
  18. Scott M, McPherson K, McKenzie I, et al. International variations in rates of a range of surgical procedures. Report to the Foundation for Informed Medical Decision Making. University of Oxford; 2008.Google Scholar
  19. Song Y, Skinner J, Bynum J, et al. Regional variations in diagnostic practices. N Engl J Med. 2010;363:45–53.PubMedCentralCrossRefPubMedGoogle Scholar
  20. Vayda E. A comparison of surgical rates in Canada and in England and Wales. N Engl J Med. 1973;289:1224–9.CrossRefPubMedGoogle Scholar
  21. Welch HG, Sharp SM, Gottlieb DJ, et al. Geographic variation in diagnosis frequency and risk of death among Medicare beneficiaries. JAMA. 2011;305(11):1113–8.PubMedCentralCrossRefPubMedGoogle Scholar
  22. Wennberg JE. Tracking medicine: a researcher’s quest to understand health care. New York: Oxford University Press; 2010. Chapters 6 and 7.Google Scholar
  23. Wennberg Anthology. 2015. http://www.wennberganthology.org.
  24. Wennberg JE, Cooper MM, editors. The Dartmouth Atlas of Health Care 1998. Chicago: American Hospital Publishing; 1998.Google Scholar
  25. Wennberg J, Fowler FJ. A test of consumer contributions to small area variations in health care delivery. J Maine Med Assoc. 1977;68:275–9.PubMedGoogle Scholar
  26. Wennberg J, Gittelsohn A. Small area variations in health care delivery: a population-based health information system can guide planning and regulatory decision-making. Science. 1973;182:1102–8.CrossRefPubMedGoogle Scholar
  27. Wennberg J, Gittelsohn A. Health care delivery in Maine I: patterns of use of common surgical procedures. J Maine Med Assoc. 1975;66:123–30, 149.PubMedGoogle Scholar
  28. Wennberg J, Gittelsohn A. Variations in medical care among small areas. Sci Am. 1982;246(4):120–34.CrossRefPubMedGoogle Scholar
  29. Wennberg JE, Fisher ES, Skinner JS. Geography and the debate over Medicare reform. 2002. Web-Exclusive on Health Affairs. http://content.healthaffairs.org/cgi/content/full/hlthaff.w2.96v1/DC1
  30. Wennberg J, Blowers L, Parker R, Gittelsohn AM. Changes in tonsillectomy rates associated with feedback and review. Pediatrics. 1977;59:821–6.PubMedGoogle Scholar
  31. Wennberg JE, Bunker J, Barnes B. The need for assessing the outcomes of common medical practices. Annu Rev Public Health. 1980;1:277–95.CrossRefPubMedGoogle Scholar
  32. Wennberg JE, McPherson K, Caper P. Will payment based upon diagnosis-related groups control hospital costs? N Engl J Med. 1984;311:295–300.CrossRefPubMedGoogle Scholar
  33. Wennberg JE, Freeman JL, Culp WJ. Are hospital services rationed in New Haven or over-utilized in Boston? Lancet. 1987;1(8543):1185–8.CrossRefPubMedGoogle Scholar
  34. Wennberg JE, Fisher ES, Baker L, Sharp SM, Bronner KK. Evaluating the efficiency of California providers in caring for patients with chronic illness. Web-Exclusive on Health Affairs. 2005. http://content.healthaffairs.org/cgi/content/full/hlthaff.w5.526/DC1
  35. Wennberg JE, Staiger DO, Sharp SM, et al. Observational intensity bias associated with illness adjustment: cross sectional analysis of insurance claims. BMJ. 2013;346:f549.PubMedCentralCrossRefPubMedGoogle Scholar
  36. Wennberg DE, Sharp SM, Bevan G, et al. A population health approach to reducing observational intensity bias in health risk adjustment: cross sectional analysis of insurance claims. BMJ. 2014;348:g2392.PubMedCentralCrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  • John Wennberg
    • 1
    Email author
  • Klim McPherson
    • 2
    • 3
  • David Goodman
    • 4
    • 5
    • 6
    • 7
  1. 1.The Dartmouth Institute for Health Policy and Clinical PracticeLebanonUSA
  2. 2.Nuffield Department of Obstetrics and GynaecologyNew CollegeOxford, OxfordshireUK
  3. 3.University of OxfordOxfordUK
  4. 4.The Dartmouth Institute for Health Policy and Clinical PracticeLebanonUSA
  5. 5.Department of PediatricsDartmouth Hitchcock Medical CenterLebanonUSA
  6. 6.Department of Community and Family MedicineDartmouth Hitchcock Medical CenterLebanonUSA
  7. 7.Geisel School of Medicine at DartmouthHanoverUSA

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