SALZBURG, Austria – Medicare patients in Fort Myers, Fla., were more than twice as likely to receive hip replacement surgeries in 2005 and 2006 as their counterparts across the Everglades in Miami, according to a finding by Dartmouth Health Atlas researchers that may sound familiar to Shots readers.
But, before you blame such inconsistencies on America’s money-driven health system, take a look at Britain’s effort to anglicize the Dartmouth work: Doctors in some areas such as the college town of Oxford do one type of hip replacement at rates up to 16 times greater than in places like London, according to a November atlas by the National Health Service.
The British atlas is surprising because “doctors are not by and large paid on a fee for service basis in the NHS,” Angela Coulter, director of global initiatives for the Dartmouth Atlas-associated Foundation for Informed Medical Decision Making, said at a Salzburg Global Seminar session this week. “It illustrates the fact… that doctors tend to favor the treatments they’re trained to provide,” even when money isn’t a factor. Most British doctors get salaries rather than payments for each procedure like their American colleagues.
Variations in the way doctors treat patients are “independent of the way health care’s organized and financed,” Dr. Jack Wennberg, the godfather of Dartmouth’s variation research, said in an interview here Thursday, noting that his work uncovered similar patterns in Britain and Norway in the 1970s. What matters when it comes to medical tests and surgeries, he says, is whether there’s clear evidence that treatments work.
When there’s not, patients’ preferences could play a crucial role in controlling the whims of physicians whose decisions are guided by habit rather than science, Wennberg argues. For instance, some urologists prefer treating non-life-threatening swelling of the prostate with surgery that can leave patients with sexual dysfunction but improved urination. For patients, Wennberg said, “It’s a choice between peeing and sex.” (Here’s an NHS primer on the condition.)
When doctors, rather than patients, make that choice, it can lead to much higher rates of specific procedures in some places, Wennberg says. Informed patients tend to choose less aggressive approaches, he says, reducing what’s known as “unwarranted variation.”
A cottage industry has grown up around this idea. In Wales, Glyn Elwyn, a professor at Cardiff University, builds tools like BresDex, an online decision aid that spells out the risks and benefits of breast-cancer screening tests.
Health Dialog, a Boston company where Wennberg’s son, David, is an executive, provides decision tools and “health coaching” to members of health insurance plans in the U.S. and elsewhere. A recent study suggests their work reduced insurers’ medical spending by $6 a month for each patient. Health Dialog was acquired in 2008 by the London-based health care conglomerate Bupa.
(Disclosure: Both companies sponsored the Salzburg session, and Coulter’s foundation works very closely with Health Dialog; this reporter attended with funding from the Knight Foundation, which sponsors journalists’ education.)
Researchers and physicians here insist their work is not about the money. They say high levels of variation show patients are getting treatment they wouldn’t want if they had all the facts. That’s ethics, not economics, they say.
“We have to get over the fact that this isn’t right,” said Dr. Simon Eaton, a NHS diabetes specialist who practices in North Tyneside. “If we don’t we just tweak at the edges. We don’t fix this.”