It is a fact that clinical practices may vary considerably between different areas within a country. Doctors seem to differ in their decisions about health care treatments and medicines, independent of the patients’ characteristics.
Moritz et al. (1997) have done an experiment on breast cancer in England and the connection between the mastectomy rate and cancer cases per doctor. They found evidence on variations in the number of patients who receive a mastectomy, even though the size of the tumors was similar. In the course “Economics of health and health care” it is suggested that these variations can be explained with uncertainty about technology and differences in demand and cost conditions across regions. Technology uncertainty will lead to dispersion in practices, but this explanation is not fully satisfactory. The same applies to differences in demand and cost conditions. If people are similar across regions, one should think that their treatments would be similar too.
Another example of variations in effective care, and also patient safety, is the underuse of beta blockers at time of discharge from hospital after a heart attack. The Dartmouth atlas documents show variation among 37 hospital referral regions containing one or more of the academic medical centres identified as the 50 best US hospitals for the treatment of cardiovascular disease by US News and World Report. In the region with the best record only 83% of ideal candidates received a beta blocker; in the region with the lowest record less than 40% did. This variation is a risk for patient safety, when in some areas the patients are not receiving the needed medical treatment to cope with their illnesses.
In an article by Martin Sipkoff (2003), nine things that health plans and provider organizations should do to reduce unwarranted practice variations are formulated. For example, high-risk patients must be identified by collecting data which identifies those who have the potential for using the most resources. Also, physicians should be given incentives to follow treatment guidelines etc. In Norway, doctors are given an incentive to give their patients the best care possible through the primary doctor system. They receive a higher wage if they have a full patient list, and a full patient list only comes with a good reputation. Furthermore, we need continuous quality improvement, implementation of disease management programs, investment in information technology and an increased patient involvement in their own health.
There is a problem when you find that the approach in one city is to operate, and in another city it’s watchful waiting. In many regions, physicians are not using evidence-based medicine to guide their care. The practices are not up to date with the medical knowledge, causing much confusion and variations in a wide range of treatments. Patients are getting worse, or even dying, because of this.