Variation in the Delivery of Health Care: The Stakes Are High

Editorials15 May 1998Variation in the Delivery of Health Care: The Stakes Are HighDavid E. Wennberg, MD, MPHDavid E. Wennberg, MD, MPHMaine Medical Center; Portland, ME 04102-3175Author, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-128-10-199805150-00012 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail A generation ago, the remarkable variation in the delivery of health care across populations was brought to light [1]. Since then, numerous articles have documented variations across small and large areas of the United States in surgical procedures, health system capacity (such as physicians per capita), use of pharmaceuticals in chronic conditions, and intensity of diagnostic testing [2-6]. The principal finding of these studies has not changed: For medical care, geography is destiny.However, one thing has changed. Although clinicians may have had difficulty in finding implications in these studies for their personal practices, variation can no longer be seen ...References1. Wennberg J, Gittelsohn A. Small area variations in health care delivery. Science. 1973; 182:1102-8. Google Scholar2. Schein OD, Steinberg EP, Javitt JC, Cassard SD, Tielsch JM, Steinwachs DM, et al. Variation in cataract surgery practice and clinical outcomes. Ophthalmology. 1994; 101:1142-52. Google Scholar3. Goodman DC, Fisher ES, Bubolz TA, Mohr JE, Poage JF, Wennberg JE. Benchmarking the US physician workforce. An alternative to needs-based or demand-based planning. JAMA. 1996; 276:1811-7. Google Scholar4. Ellerbeck EF, Jencks SF, Radford MJ, Kresowik TF, Craig AS, Gold JA, et al. Quality of care for Medicare patients with acute myocardial infarction. A four-state pilot study from the Cooperative Cardiovascular Project. JAMA. 1995; 273:1509-14. Google Scholar5. Wennberg DE, Kellett MA, Dickens JD, Malenka DJ, Keilson LM, Keller RB. The association between local diagnostic testing intensity and invasive cardiac procedures. JAMA. 1996; 275:1161-4. Google Scholar6. Carey TS, Garrett J. Patterns of ordering diagnostic tests for patients with acute low back pain. The North Carolina Back Pain Project. Ann Intern Med. 1996; 125:807-14. Google Scholar7. Iezzoni LI, Ash AS, Shwartz M, Daley J, Hughes JS, Mackiernan YD. Predicting who dies depends on how severity is measured: implications for evaluating patient outcomes. Ann Intern Med. 1995; 123:763-70. Google Scholar8. Salem-Schatz S, Moore G, Rucker M, Pearson SD. The case for case-mix adjustment in practice profiling. When good apples look bad. JAMA. 1994; 272:871-4. Google Scholar9. Dartmouth Medical School. Center for the Evaluative Clinical Sciences. The Dartmouth Atlas of Health Care in the United States. Chicago: American Hospital Publishing; 1998. Google Scholar10. Jencks SF, Wilensky GR. 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Unconventional medicine in the United States. Prevalence, costs and patterns of use. N Engl J Med. 1993; 328:246-52. Google Scholar15. Silberg WM, Lundberg GD, Musacchio RA. Assessing, controlling and assuring the quality of medical information on the Internet: Caveant Lector et viewor-Let the reader and viewer beware [Editorial]. JAMA. 1997; 277:1244-5. Google Scholar16. Keller RB, Soule DN, Wennberg JE, Hanley DF. Dealing with geographic variations in the use of hospitals. The experience of the Maine Medical Assessment Foundation Orthopaedic Study Group. J Bone Joint Surg [Am]. 1990; 72:1286-93. Google Scholar17. Nease RF Jr, Kneeland T, O'Connor GT, Sumner W, Lumpkins C, Shaw L, et al. Variation in patient utilities for outcomes of the management of chronic stable angina. Implications for clinical practice guidelines. Ischemic Heart Disease Patient Outcomes Research Team. JAMA. 1995; 273:1185-90. Google Scholar18. Morgan MW, Debar RB, Llewellyn-Thomas HA, et al. A randomized trial of the ischemic heart disease shared decision making program: an evaluation of a decision aid [Abstract]. J Gen Intern Med. 1996; 12:62. Google Scholar19. Laine C, Davidoff F. Patient-centered medicine. A professional evolution. JAMA. 1996; 275:152-6. Google Scholar Author, Article, and Disclosure InformationAffiliations: Maine Medical Center; Portland, ME 04102-3175Corresponding Author: David E. Wennberg, MD, MPH, Director, Division of Health Services Research, Maine Medical Center, 22 Bramhall Street, Portland, ME 04102-3175. 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