Eliminate Variation, Part 2

A piece in the BMJ by John Wennberg summarizes much of the knowledge around variation in medical practice. He breaks unwanted variation into three categories, effective care, preference sensitive care and supply sensitive care.

• Effective care. This is care that is the right treatment for the vast majority of patients, and variation in this element relates to underuse, e.g. vaccination
• Preference Sensitive Care. This is care provided when there are more than one effective treatment, and choice of therapy should be dictated by patient preference; in fact, physician choice often determines this. Mastectomy rather than lumpectomy plus radiation for breast cancer for example. 
• Supply sensitive care. This is care that is dependent on the supply of services in a region. Roehmers law is one example of this; this states that in an insured popualtion, a hosoital bed is a filled bed. Dartmouth have found no corrleation between the amount of care received and outcomes, suggesting that there are areas with massive overuse of resources. Gawande in a brilliant article two years ago examined this discrepancy.

Also check out the NHS health Atlas. There are huge variations in care evident. Likely that this occurs everywhere.

Eliminate Variation

One of the godfathers of determining the extent of variation in medical practice and founder of the Dartmouth Health Atlas, Jack Wennberg, has recently published a book, "Tracking Medicine", available here. I have just downloaded it, will review it when finished, but it gets a great review here.