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In one of the great comedy skits of the 20th century, Geraldine Jones, played by comedian Flip Wilson in drag, delivers chicken to football player Jim Brown. Geraldine holds up the bucket of fried chicken, wiggles her hips and says, “No fancy ribbons on our meat. What you see is what you get!”
In medicine, it’s not so much what you see as who you see that determines what you get. In a new report (by the Health Policy Program’s Shannon Brownlee and Vanessa Hurley, based on analysis by Stanford’s Laurence Baker), the California HealthCare Foundation argues that who you see for your care (and where you live) have a huge effect on the likelihood of receiving a broad variety of elective medical procedures. The variation can’t be explained away by levels of illness in different communities—the study controlled for a number of factors related to illness, including income, level of education, and rates of heart attack and diabetes in the area, as well as typical controls like age, sex, and race. Even after adjusting for all of those factors, the variation didn’t disappear. Areas with the highest usage of angioplasty*, for instance, had rates ten times as high as areas with the lowest use.
Some readers of this blog have heard this before, but it bears repeating: Poor patient understanding of treatment options is a primary cause of such unwarranted variation. When patients don’t have enough information, or information they can understand in order to participate fully in their treatment decisions, the choice of how to manage a condition falls to their doctor.
Doctors have well-documented practice patterns that can vary widely from physician to physician. Everything from where physicians do their residencies to the local “style” for treating a condition can influence their decisions. Payment systems have an effect, too, by encouraging doctors to perform more highly-reimbursed invasive procedures. In some cases those variations persist even in the face of solid medical evidence. Even when professional bodies have created very clear criteria for when a procedure is appropriate (like the American College of Cardiology has done for angioplasties and stents), doctors have varying opinions on when to do the procedure.
One huge problem that variation creates is the mismatch between patient preferences and treatment choices. Evidence suggests that doctors aren’t very good at predicting what their patients value. The authors of the report point to shared decision-making (SDM) as a promising strategy for reducing variation and ensuring patients get the care they both need and want.
SDM is a process in which patients talk through treatment options with their caregivers, using the best medical evidence available and the patient’s own values to come to a treatment decision. It’s the full realization of informed consent, in which the patient has the best information possible and consents to treatment from a position of complete information. For more information on shared decision-making, take a look at our white paper on SDM and patient decision aids.
Tackling unwarranted variation is a major component of improving treatment, and shared decision making should play a major role. We’ll be much more comfortable when medicine is about what you want, not who you know.
*Also known as percutaneous coronary intervention, or PCI—a procedure to open narrowed arteries in the heart, often using a stent—a wire mesh that holds the artery open.