Treatment variations a clue to possible overuse

July 31, 2014
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By Csaba Mera, M.D., Deputy Chief Medical Officer

Complexity is one of the most pressing issues in medical care.1 Some estimates reckon that medical knowledge doubles about every eight years. One-fifth of highly cited research is later contradicted. More than 20 percent of core clinical practices are changed within a year based on new evidence or guidelines.2 Doctors must constantly evaluate what we know and how we treat patients.

Researchers taking a deep look at medical practice find that doctors vary in how we treat the same conditions. Sometimes this is a matter of fitting the treatment to the patient. But significant variation for similar complaints indicates medical care is potentially unnecessary.

Why is it, for example, that Honolulu has 3.4 knee replacements per 1,000 Medicare enrollees, while Idaho Falls has 15.8?3 This is a classic finding of the Dartmouth Atlas of Health Care, which has been examining variations in care for more than 20 years. Are the populations so different? What clinical standards guide these decisions?

Patient choice. Variation is especially prevalent in treatments with a high degree of choice. Some examples are knee and hip replacements and spinal fusions. There are several ways to treat complaints of persistent pain in the joints, from physical therapy and home exercise to surgery.  It’s important for patients to know the risks and outcomes of each option.   

Patient safety. Take back pain, for example -- the most prevalent complaint among working people. A number of studies have shown that surgery for uncomplicated herniated disc had no better outcomes than conservative, activity-based home rehabilitation programs. 4

Additionally, about two out of every three workers who received spinal fusion were still disabled after two years, according to a Washington State Department of Labor and Industries study, and more than half reported no improvement in pain or ability to function.

If patients knew the high probability of continuing pain and possible disability, would they rush to surgery – with its pain, risk, lost work time and costs – or stick with an active home rehab program? 

Patient advocate. Because the state of research changes so quickly, health insurers have become an advocate for engaging patients in treatment decisions like these. One way we do this is through a program called prior authorization. You may have encountered this if your doctor has told you a certain treatment must first be approved by the health insurance company to be covered under your policy. Regence publishes prior authorization policies on its website for doctors and other providers to review.

Proceed with caution. Think of prior authorization as a flashing yellow light: It means there are questions to be asked, choices to be weighed, and decisions to be made about the recommended treatment, based on the best available medical evidence.

Some treatments really are better than others, while some do not measurably help the patient -- yet cost the patient money, and increase the cost of health care for all. When we’re looking at how to make our health care system affordable and economically sustainable, variations in treatment offer a good place to start looking at safety, quality and avoidable costs.

In a future post, I’ll talk about how prior authorization works to educate providers and engage patients.

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1 Atul Gawande, surgeon, author of The Checklist Manifesto

2 http://www.medicine20congress.com/ocs/index.php/med/med2012/paper/view/1028

3 Dartmouth University Atlas of Health Care research

4  Roger Chou, Oregon Health and Sciences University: “Surgery for Lower Back PainSpine 2009;34:1094–1109

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