The unvarying story of health care variations – Dartmouth Atlas on children’s care

Jack Wennberg made his mark by documenting health care variations in the way certain services were utilized – even in adjacent communities in New England. One of the early signs that caught his attention was when his own kids were of the tonsillectomy age. He found, as Reuters recalls, “that rates of tonsillectomy are 60 percent in some places and less than 20 percent in others. The difference, they found, could not be explained by underlying medical conditions among the children, and was instead more likely due to the local medical culture: Some doctors believe in removing tonsils and others don’t.

That was 40 years ago.”

Fast forward to today and the story of variations hasn’t changed much. Sharon Begley of Reuters reports:

“Children in Lebanon, New Hampshire, are more than twice as likely to have their tonsils removed as those in Bangor, Maine. Kids in Lewiston, Maine, are 50 percent more likely to have a CT scan of their head than are kids in Portland, Maine, or Lebanon and Burlington, Vermont.

Lebanon’s children don’t have especially infection-prone tonsils, and Lewiston’s don’t fall on their heads more than kids elsewhere do. Instead, according to a report released on Wednesday, the glaring variation means that in some cases “children are not receiving enough good care,” said pediatrician and health policy analyst Dr David Goodman of the Geisel School of Medicine at Dartmouth University, who led the study for the Dartmouth Atlas Project. But in other cases they “may be receiving unnecessary care that is harmful.”

Dr Vikas Saini, a cardiologist and president of the Lown Institute, a healthcare think tank in Boston, is quoted by Reuters:

“Most of what we do in medicine doesn’t have empirical evidence” for whether it works and for whom, said Saini. “Instead, it’s driven by anecdotal evidence and professional opinion,” which doctors who practice in the same area are likely to hear about and be influenced by, especially early in their careers.

The tonsillectomy data is just one part of a broader Dartmouth Atlas report on Children’s Health Care in Northern New England, available as a pdf online.


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