Small-area analysis has revealed large variations in medical practice styles between geographical areas, especially for conditions with uncertain treatment effectiveness. The availability of healthcare services leads to more use of those services. Outcomes research analyzes real-world healthcare data to help patients make informed decisions based on treatment risks and benefits. Reporting errors and outcomes can drive quality improvement, but biases and inequities must also be addressed.

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CHAPTER 28
Health Services
Research:
Finding What
Works

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Small-Area Analysis
 Small-area analysis revealed:
– Large variations in practice style by geographical area exist for many medical
conditions.
– Greatest care variation is in conditions with the least known about the effectiveness
and appropriateness of diagnostic and treatment approaches.
– Sometimes more than one therapy may be appropriate.
– Doctors may adjust behavior when informed of other doctors’ practice patterns.

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Field of Dreams Effect
 Availability of services leads to more use of these services.
– More back surgeons, more back surgeries
– More hospital beds, more hospitalizations
– More hospital beds, more patients dying in hospitals than homes
 There is evidence in some cases that financial considerations may affect
medical decisions.

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Outcomes Research
 Is the epidemiologic study of medical care
 Analyzes data generated by everyday practice of medicine, e.g., from Medicare
records
 Should allow patients to make informed decisions based on their own values
 Benign prostatic hyperplasia (BPH) was a high-variation procedure.
– Watchful waiting and prostatectomy are weighed.
– Prostatectomy benefits are overstated, and complications are understated.
– Patients need to be informed so they can choose.
– PSA screening for prostate cancer leads to more invasive tests.
• There is no evidence that it reduces mortality from cancer.

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Agency for Health Care Research and Quality
 The agency was mandated by Congress in 1989 to develop guidelines for
treatment.
 When it recommended less back surgery (1994), political pressure from back
surgeons almost forced elimination of the agency.
 Now the agency has recovered.
 There is continued interest in improving medical outcomes while controlling
costs.

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Medical Errors
 Series of medication errors and wrong-side surgeries led to the 1999 Institute of
Medicine report.
– It estimated errors cause 44,000–98,000 deaths per year.
– It recommended shifting focus from blaming individuals to focusing on improving a
system decentralized, fragmented, and rife with poor communication and more.
 Detailed recommendations included:
– Create the Center for Patient Safety.
– Set national goals, track progress, do research.
– Report and investigate errors.
– Change drug naming, packaging, and labeling to minimize confusion.

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Medical Care Report Cards
 Managed care plans are easier to evaluate than other plans.
– Data is available.
– Managed care organizations are accredited.
– Annual reports are created.
 Report cards can evaluate quality of care for some procedures.
– New York State measures outcomes of coronary bypass surgery.
• Outcomes of individual hospitals and surgeons are reported.
• Reports have led to improvement in outcomes.
• High volume surgeons and hospitals do better.

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Inequities in Medical Care
 Medical care is rationed by ability to pay.
 Racial inequities in care exist, even when ability to pay is the same.
 Blacks and Hispanics receive poorer treatment for many conditions.
– E.g., less likely to be recommended for mammograms.
 Institute of Medicine reports bias, prejudice, and stereotyping.

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Relative Importance of Medical Care for Public Health
 International comparisons show health is proportional to wealth (national GDP).
 Health isn’t proportional to amount of physicians.
 More spending does not improve health and may even increase the mortality
rate.
 RAND Health Insurance Experiment revealed:
– For people with generous insurance, many healthcare services may be wasted.
– For the poor and chronically ill, free care does improve health status.

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Discussion Question 1
 What are three or more reasons why treatments for some illnesses vary from
one geographic area to another?
 Do you think this is a problem and that the government should do more about
it?

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Discussion Question 2
 Describe three or more ways in which outcomes research can improve the
health of the population.

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Discussion Question 3
 Discuss the relative importance of human biology, lifestyle, the environment,
and medical care in contributing to the health of the population.

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Discussion Question 4
 Visit the website of the Agency for Healthcare Research and Quality (AHRQ),
www.ahrq.gov.
 Review press releases for the past few months.
 What issues is the AHRQ concerned about recently?

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Discussion Question 5
 Visit Cochrane’s website, www.cochrane.org.
 The organization is an international, nonprofit organization that collects and
synthesizes evidence on outcomes research.
 Review the most recent newsletters.
 What new findings has the organization produced?