Medical variation

All healthcare systems and doctors are not created equal

DRUG BUST
by Alan Cassels

Let’s compare doctor A and doctor B.

A 70-year-old man with high blood pressure and high cholesterol goes to see Dr. A. Even though the man is otherwise healthy, Dr. A thinks a few pills might bring down his blood pressure so he prescribes hydrochlorothiazide (a diuretic) and ramipril (an ACE-Inhibitor). He also writes a script for rosuvastatin for the high cholesterol. Because high blood pressure and elevated cholesterol are associated with an increased risk of heart attacks, the doctor is trying to reduce those risks. Later, the patient complains about his aching muscles – possibly caused by the statin – so Doc A also prescribes an anti-inflammatory drug. This man has two ‘conditions’ identified and four drugs recommended.

Imagine, instead, that the same man went to see Dr. B. This doctor doesn’t seem too worried by this patient’s high blood pressure. After all, ‘high-normal’ doesn’t constitute much risk so he tells the man to exercise more and watch how much salt he puts in his food. He jokes that, if his patient got off the couch more often and lost 10 pounds, his blood pressure would probably come back to normal. He also doesn’t think his high cholesterol is worth treating and he tells him not to stop eating the foods he loves just because of cholesterol worries. So with doctor B, the patient walks out of the clinic with the same condition, but no drugs whatsoever.

Of course, the big question we all have is “Does the 70-year-old man with high blood pressure and cholesterol live longer (or better) under doctors who practise like Dr. A or Dr. B?”

This is known as “medical variation,” a very important aspect of the practice of medicine. And it is worth studying if you want to make healthcare safer, of higher value and more effective. Studying the differences between healthcare systems can tell us a lot about whether high-spending areas versus low-spending areas get better or worse outcomes. The most famous of medical variation studies is probably the Dartmouth Atlas, which 20 years ago began looking at the differences in medical variations across the US. It found that although some states spent three times more per capita on certain medical procedures, those patients were no healthier and didn’t live any longer.

Last month, a report entitled “Unnecessary Care in Canada” came out, created by the people at the Canadian Institutes of Health Information and Choosing Wisely Canada. Choosing Wisely is a “national, clinician-led campaign committed to helping patients and clinicians engage in conversations about unnecessary care.” For the last few years, the group has compiled lists from almost every medical speciality on what is considered unnecessary or questionable care. For example, ordering a patient to have a CT scan for a mild head injury or an X-ray for lower back pain are unlikely to produce information of any value and shouldn’t be routinely done. With over 70 specialties producing lists of questionable care (see www.choosingwiselycanada.org), I’d encourage anyone who might be facing a medical procedure or test to see whether it might be considered unnecessary and potentially harmful. It might be too early to say if these lists are affecting the kind of care Canadians are getting, but I’m hoping they are giving ammunition to patients – and a good rationale for doctors – to start asking, “Is that test, drug or procedure really necessary?”

Knowing that unneeded tests or treatments can be harmful and lead to more wasted health care resources, the Choosing Wisely people have also examined the fact of medical variation in Canada.

One example is what is called preoperative testing, the kinds of tests and blood lab work you may be asked to undergo before you have an operation. If you’re asked to take tests, have X-rays or give blood samples before surgery, do they actually make a noticeable difference in the kind of healthcare that results? Choosing Wisely’s report said that one in three patients having eye surgery had a preoperative test in Ontario, yet that rate in Alberta for the same surgery is about one in five. Do patients in Ontario do that much better than patients in Alberta? Not at all.

There are some very good reasons why two different healthcare professionals (or clinics, hospitals or even health systems) treat the same patient in vastly different ways. For one, the doctors may have different training, they may be more or less influenced or aware of evidence-based recommendations or guidelines or they may just be expressing the culture of the clinic or group they work with. Health agencies’ policies, insurance and patient demand all go into determining the rate at which certain tests, treatments or drugs are ordered.

I called up Don Husereau in Ontario – he’s an expert on using and interpreting health research and also a former pharmacist – and asked what he thought about medical variation.

“It sometimes gets abused,” Don tells me. “They find variation and then say it’s just ‘uninformed clinicians’ who are deviating from a ‘gold standard.’ But sometimes there is something not accounted for in the variation. This notion that they are doing it poorly and are not evidence based and that they are ‘stupid’ is an overinterpretation of data.”

He says that, ultimately, “Data sometimes doesn’t tell the whole story.” There may be real differences between patients and he sees this in reference to vascular surgeons he works with. He says, “Some take high risk patients. Some won’t. Some might do more heroic things or seek out the highest risk patients.

“When we looked at the adoption of a new minimally-invasive approach to repairing damaged aortas, it is clear Canadian doctors were less enthusiastic than their US counterparts.” He went on to say, “Canadian doctors used the new approach half as much, were likely less susceptible to promotion and peer pressure and knew there was no clear evidence that either approach was better.”

I agree with Don Husereau that we have to be very careful when we compare doctors or health systems because there may be other factors affecting how much or what kind of medicine is being offered.

For me, a major difference comes down to the patient and their preferences. Even though doctors are trained to encourage “patient empowerment,” they may not have enough time to really probe what it is their patient actually wants. If the doctor feels the patient won’t be satisfied leaving without a script, guess what happens? They’re likely going to get one. Equally true is that if your physician doesn’t think you really want any drugs, she is also likely going to respect that, hopefully explaining the pros and cons of avoiding a new prescription.

So the next time you’re waiting at the doctor’s clinic, take some time to think about variation. Ask yourself if what you’re being offered is due to the doctor, the culture or the rules or regulations of a clinic? And maybe ask yourself what you can do to respectfully present your preferences. Take a look at what Choosing Wisely says about the conditions you’re interested in because those lists will remind you of a very important fact: some of the medical care being offered may not be necessary or perhaps is even harmful and worth asking questions about.

We should expect some degree of variation in the kind of care our doctors and health systems deliver. We can accept that every patient is different.

Whether you go to Doctor A or Doctor B, your job is to learn what you can. Take the effort to make your preferences known –in very clear ways – because at the end of the day, you are the one that has to swallow the medicine.

For you, asking questions and questioning answers are about the most important things you can do to stay healthy.

Alan Cassels is a former drug policy researcher, a writer and the author of several books on the pharmaceutical industry. www.alancassels.com

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