Myth busted July 2008
Picture this: two 50-year-old men are experiencing chest pain and abnormal heart rhythms. One of the men is admitted for care at a local community hospital in a small town. The other is admitted at a teaching hospital in one of the nation's largest cities. It's natural to assume that the city-dweller will fare better, since his hospital spends more money and therefore has greater resources and provides more specialized care. In the same way, it's instinctive to think that the small-town patient will suffer worse outcomes, since his hospital has less money with fewer resources and poorer access to specialized care.
According to the research, however, when it comes to invasive procedures, and even diagnostic testing, "less is more . . . and better" i. In fact, compared to patients in regions that spend less, patients in high-spending regions are no more satisfied with their care, and actually experience a greater risk of harm and possibly even death. ii-iv
Where you live begets the care you receive
In many cases, it's difficult to determine whether patients receive appropriate care. What is known is that there is great variation in the amount of healthcare people receive that depends largely on where they live. v-xii For more than 15 years the Dartmouth Atlas Project, led by John E. Wennberg and Elliott S. Fisher, has tracked "glaring variations" in the distribution and use of healthcare resources in the United States. ii Based on U.S. Medicare data, the studies consistently show that more resources - specifically, frequent specialist visits, diagnostics, and specialist and hospital care - don't necessarily lead to better care (see table).
In one study involving nearly one million patients dispersed over 306 regions in the U.S. (based on where people go for hospital care), Fisher and colleagues found that patients in high-spending regions received 60 percent more care than those in the lower-spending areas. However, they did not experience lower mortality rates, better functional status or higher satisfaction. iv In fact, patients in the lower-spending regions actually received certain preventive services (influenza vaccination, Pap smear and mammography) more often than patients in the highest-spending areas. iii
Select Dartmouth Atlas studies comparing regional differences in spending and the content, quality and outcomes of care
(adapted with permission,xiii)
| ||High-spending regions compared to low-spending regionsª |
|Content and quality of care iii, v, xiv || |
- Less adherence to process-based measures of quality
- Little difference in rates of major elective surgery
- More hospital stays, physician visits, specialist referrals, imaging, and minor tests and procedures
|Health outcomes iv, xv, xvi || |
- Higher mortality over a five-year period following heart attack, hip fracture and colorectal cancer diagnosis
- Higher survival in regions that practiced medical versus invasive cardiac management of heart attack patients
- No difference in functional status
|Physician perceptions of quality xvii || |
- More likely to report poor communication among physicians
- More likely to report inadequate continuity of care
- Greater difficulty obtaining inpatient admissions or high-quality specialist referrals
|Patient-reported quality of care xviii || |
- Worse access to care and greater wait times
- No difference in satisfaction
ªHigh- and low-spending regions are defined as the U.S. hospital referral regions in the highest and lowest quintiles of per capita Medicare spending.iii
It's not just an American phenomenon. In Ontario, the Institute for Clinical Evaluative Sciences has documented large regional variations in the provision of healthcare for a range of services. Specifically, patients with conditions such as cardiac disease, viii stroke, ix arthritis, x asthma, xi and diabetes xii are getting varying degrees of care, despite the availability of evidence-based clinical guidelines in these areas.
Canadian research also highlights that in some cases, ready access to care can be a bad thing for patients. A Vancouver-based study that assessed the effectiveness of a range of elective surgeries found that cataract surgery was often ordered in the absence of significant visual impairment and that it left 27 percent of patients reporting no change or even deterioration in their visual function. xix
A built hospital bed is a filled one
Other predictors can also drive the use and, more specifically, the overuse of services. These include patient demand, a medical culture in which physicians often do more tests and interventions than are really necessary, and the fee-for-service structures that reward physicians for providing more and more care. xx One particularly strong predictor that factors into the equation is the availability of healthcare resources such as hospital beds and specialists. v As the 1960s health services researcher, Milton Roemer put it, "A built hospital bed is a filled hospital bed." v In practice, "Roemer's Law" can indicate inefficient systems that offer ineffective and inappropriate care for patients.
Although Canadians may feel better when they live in close proximity and have quick access to healthcare resources, the research suggests they may be experiencing a false sense of security. So is there such a thing as too much medicine? Almost certainly there is, according to a 2002 issue of the British Medical Journal. xxi And as everyday life becomes increasingly medicalized, with a new pill or procedure constantly in development, the problem is growing. xxi At the same time, some patients benefit from invasive, high-tech care, but better evaluation of healthcare performance is needed to identify these cases. Doing so would help in matching resources to population need, with a view to clinical and financial efficiency and overall improvements in quality of care.
i. Berwick, DM. 2006. Invasive Procedures: Less Is More … and Better. Newsweek.com http://www.msnbc.msn.com/id/15176095/site/newsweek/print/1/displaymode/1098/
ii. The Dartmouth Atlas Project. http://www.dartmouthatlas.org/
iii. Fisher ES. et al. 2003. "The implications of regional variations in Medicare spending. Part 1: The content, quality, and accessibility of care." Annals of Internal Medicine; 138(4): 273-287.
iv. Fisher ES. et al. 2003. "The implications of regional variations in Medicarespending. Part 2: Health outcomes and satisfaction with care". Annals of Internal Medicine; 138(4): 288-298.
v. Wennberg JE., Fisher ES., and Skinner JS. 2002. Geography and the debate over Medicare reform. Health Affairs; (Suppl. Web exclusive). w96-114.
vi. Gentleman JF. et al. 1996. "Surgical rates in sub-provincial areas across Canada: Rankings of 39 procedures in order of variation." Canadian Journal of Surgery; 39(5): 361-367.
vii. Roos NP. and Roos LL. 1982. "Surgical rate variations: Do they reflect the health or socioeconomic characteristics of the population?" Medical Care; 20(9): 945-958.
viii. Tu JV. et al. (Eds.) 2006. CCORT Canadian cardiovascular atlas. Toronto: Pulsus Group Inc and Institute for Clinical Evaluative Sciences. http://www.ccort.ca/CanadianCariovascularAtlas/tabid/77/Default.aspx
ix. Kapral MK. et al. 2006. Registry of the Canadian stroke network: Report on the 2002/03 Ontario stroke audit. Toronto: Institute for Clinical Evaluative Sciences. http://www.ices.on.ca/webpage.cfm?site_id=1&org_id=68&morg_id=0&gsec_id=0&item_id=4021&type=report
x. Badley EM. and Glazier RH. (Eds.) 2004. Arthritis and related conditions in Ontario: ICES Research Atlas. Toronto: Institute for Clinical Evaluative Sciences.
xi. To T. et al. 2004. Burden of childhood asthma: ICES investigative report. Toronto: Institute for Clinical Evaluative Sciences. www.ices.on.ca/file/ACF77.pdf
xii. Hux JE. et al. (Eds). 2003. Diabetes in Ontario: An ICES practice atlas. Toronto: Institute for Clinical Evaluative Sciences.
xiii. Wennberg JE. et al. 2008. Tracking the Care of Patients with Severe Chronic Illness:The Dartmouth Atlas of Health Care 2008. http://www.dartmouthatlas.org/atlases/2008_Chronic_Care_Atlas.pdf
xiv. Baicker K. and Chandra A. 2004. "Medicare spending, the physician workforce, and beneficiaries' quality of care." Health Affairs; (SupPl. Web exclusives): w184-197.
xv. Stukel TA, Lucas FE, and Wennberg DE. 2005. "Long-term outcomes of regional variations in intensity of invasive vs medical management of patients with acute myocardial infarction." Journal of the American Medical Association; 293(11): 1329-1337.
xvi. Skinner JS., Staiger DO., and Fisher ES. 2006. Is technological change in medicine always worth it? The case of acute myocardial infarction. Health Affairs; (Suppl. web exclusive). w34-37
xvii. Sirovich BE. 2006. "Regional variations in health care intensity and physician perceptions of quality of care." Annals of Internal Medicine; 144(9): 641-649.
xviii. Fisher ES. et al. 2004. "Variations in the longitudinal efficiency of academic medical centers." Health Affairs; (Suppl. Web exclusives): var19-32.
xix. Wright CJ. et al. 2002. "Evaluation of indications for and outcomes of elective surgery." Canadian Medical Association Journal; 167(5): 461-466.
xx. Juahar S. 2008. Many doctors, many tests, no rhyme or reason. New York Times. March 11. http://www.nytimes.com/2008/03/11/health/views/11essa.html
xxi. Moynihan R. and Smith R. (Eds.) British medical Journal. 2002. "Too much medicine?"; 324(7342):859-911.
Mythbusters are prepared by staff at the Canadian Health Services Research Foundation and published only after review by experts on the topic. The Foundation is an independent, not-for-profit corporation. Interests and views expressed by those who distribute this document may not reflect those of the Foundation.