Variation in utilization of health care resources in different geographic areas is a long-standing area of health policy study. Why does that variation exist? No one seems to have a really good explanation; common hypotheses include patient preferences or a local medical culture. Increasingly it appears that the issue isn’t delivery of more or less units of appropriate or inappropriate care, but the overall level of care of both types. New research published in the journal Health Affairs supports the idea that areas with high levels of care utilization have more appropriate as well as more inappropriate care and areas with low levels of utilization have lower levels of both types of care. (HA Article) The researchers examined prostate imaging for cancer patients. Although there are fairly clear and well-accepted guidelines for the use of imaging for prostate cancer, wide variation exists in ordering of these tests.
Looking at over 29,000 men diagnosed with prostate cancer in 2004 and 2005, the researchers examined use of imaging and judged appropriateness given the patient and disease characteristics. Basically they were ascertaining whether high-risk patients got a scan and whether low-risk ones didn’t. Rates of both inappropriate and appropriate imaging varied widely, with inappropriate ranging from 65% in New Jersey to 24% in Utah and appropriate from 50% in Atlanta to 79% in Utah. But the most striking finding was that rates of inappropriate and appropriate imaging were highly correlated. Therefore, the researchers caution that policy responses designed to lower inappropriate imaging may also lower appropriate imaging. Efforts to decrease excessive utilization need to be carefully targeted. One conclusion that can be drawn is that notwithstanding all the talk about evidence-based medicine, many physicians simply don’t have a good knowledge base for when certain diagnostics or treatments are appropriate for a patient and need more education and better clinical decision support tools to help guide them in providing appropriate care.