While the world awaits some definitive analysis of geographic variation in spending, other researchers continue to peck away at the topic, trying to ascertain whether there is any association between spending in a region and quality, since a lack of association might imply that the higher spending regions are just wasting money. The latest contribution comes from a review published in the journal Medical Care. (Medical Care Article) The authors looked specifically at research published since 1978 on inappropriate use for specific medical treatments. To be included, the study had to compare actual utilization with a recognized, accepted guideline or standard for care and treatment. In addition to overuse, the authors tried to find data on underuse, since that may play into the debate on spending variation. After all the searching, the authors found only five studies meeting their criteria that looked at the relationship between geographic variation and appropriateness of use.
Three of these studies dealt with patients with colon cancer or heart attack and looked at both over and underuse. All of the studies looked at the Medicare population, which may be a problem because some research has shown that spending across regions may vary by type of insurance, and most used hospital referral regions as the geographic unit. In one study of colon cancer, the rate of inappropriate overuse was higher in high-spending areas, but the low-spending areas had more underuse. A similar pattern was found in another study of heart attack treatment. Other studies had results that also suggested that it may be that low-spending areas have under-utilization of recommended treatments as much or more than high-spending ones have overuse. As the authors say, there is little clinical evidence to support the theory that geographic variation in health spending reflects inappropriate overuse in high-spending regions. It may be that there is as much or more underuse, and if so, the net result if everyone got appropriate care might be no reduction in spending or even an increase.