Consistency and cost: Why reducing variability in health care matters

Many doctors still chafe at practicing "cookbook medicine." (Tim Sackton/Flickr)
The argument that 'I do not practice cookbook medicine' still resonates with many practitioners. (Tim Sackton/Flickr)
Mark Neuman, MD, MPH, practices emergency medicine at Boston Children’s Hospital and is director of Fellow Research and Research Education. Vincent Chiang, MD, chief of Children’s Inpatient Services (CHIPS), contributed to this post, adapted from their recent commentary in Pediatrics.

It’s no secret that the U.S. health care system is in the midst of a financial crisis. As a nation, we spend nearly 18 percent of our Gross Domestic Product on health care, and health care costs remain the largest contributor to the national debt. In 2011 alone, the cost of maintaining the nation’s 5,700 hospitals exceeded $770 billion.

If ever there was a time for a societal mandate to reduce health care costs, that time is now.

It’s widely accepted that one of the first steps to reigning in runaway health care costs is reducing variability in the manner in which care is delivered. Well-defined and well-disseminated best practice guidelines can improve the reproducibility and standardization of care. In time, these guidelines may reduce costly and unnecessary tests and hospitalizations, while providing a platform on which to measure and enhance quality. More consistency may also allow providers to be more efficient with their time, space and personnel.

If it’s so costly, why is health care variability so abundant?

Neuman
Neuman
One reason is that many clinicians are more apt to trust personal experience over evidence-based literature, especially when such guidelines differ from their own instincts. The argument that “I do not practice cookbook medicine” still resonates with many practitioners.

Chiang
Chiang
Recently, Pediatrics published three studies demonstrating widespread variation in resource utilization in the treatment of children with asthma, pneumonia and diabetic ketoacidosis, leading to unnecessary testing and treatment.

Analyzing 100,615 Emergency Department (ED) visits to 36 hospitals, Todd Florin, MD, MSCE, of Cincinnati Children’s Hospital Medical Center, observed significant variation in the management of children with pneumonia, particularly in the use of complete blood counts, blood cultures and chest X-rays. Of note, the EDs that used less diagnostic testing and fewer resources also had lower hospitalization rates, without a corresponding increase in repeat visits to the ED.

In another paper, Jane Knapp, MD, and colleagues at Children’s Mercy Hospitals and Clinics, report a sharp increase in the use of chest X-rays for children with asthma visiting U.S. EDs between 1995 and 2009. Pediatric-focused EDs used significantly fewer radiographs for asthma, bronchiolitis and croup—without compromising care—suggesting that wider adoption of these ED practices could both reduce cost and radiation exposure to young patients.

In the third paper, Joel Tieder, MD, MPH, from Seattle Children’s Hospital, looked at 38 children’s hospitals and report wide variation in the care provided to children hospitalized with diabetic ketoacidosis, as well as differences among hospitals in resource utilization, length of stay, costs and rates of re-admission. Based on their findings, the researchers call for more cost-effective strategies for managing diabetes across the continuum of care.

These studies, and others like them, indicate that inconsistency in health care can be costly, and in some cases may compromise the health of the children we care for. As fee-for-service health care models begin to be replaced by accountable care organizations, physicians and hospitals must rethink the care they provide and look for any opportunities to reduce unnecessary, or low-value, diagnostic testing.

Of course, a degree of variation is unavoidable in many cases and is sometimes in the patient’s best interest. Severity of illness or lack of resources and personal experience will always inform care. So long as individual physicians are caring for individual patients, many care management decisions will be based on a host of complex and individualized details, which is as it should be.

But it’s clear that our current levels of discrepancy are too high and with too little justification. As physicians, we need to make more of an effort to identify and adopt optimal ways to manage specific diseases now, or risk contributing to snowballing costs of care in the future.