The medical lottery: treatment rates vary wildly from one city to another

A look at the highest and lowest rates of surgery in the country



Ghislain & Marie David de Lossy/cultura/Corbis

Ewan Affleck, medical director of Yellowknife’s health and social services, describes it as “a huge issue that is largely unaddressed” in Canadian health care, in many ways “a hidden secret.” He’s seen it in the places he’s worked as a family doctor, from urban clinics in Montreal to hospitals and nursing stations in the Inuit villages of northern Quebec, and now in the primary-care centres of the sprawling Northwest Territories.

The secret is “unwarranted variation”: the stark and sometimes alarming regional differences in the health care patients receive, determined by things like the capacity of the local system on a given day or the preference of the doctor instead of actual need or even medical evidence. Canadians participate in a lottery every time they have a brush with the health care system; it can mean the difference between getting screened for prostate cancer or not, or whether or not you have your uterus removed. Though medicine is now supposed to be evidence-based, the simple fact of where you get care, and from whom, can influence your treatment as much as the latest science.

This arbitrariness disturbed Affleck, who has the lean frame and single-minded focus of the ultra-marathon runner that he is. “This is a national issue,” he says. “Who drives the Canadian health system? The day-to-day drivers are mostly doctors and other health professionals.”

The decisions those doctors and nurses make lead to jaw-dropping variations in care. According to an October report released by the Canadian Institute for Health Information (CIHI), an independent non-profit, there’s a huge range in the kinds of surgical breast cancer treatments Canadian women receive. A woman is much more likely to undergo a mastectomy (removal of the cancerous breast) instead of a less invasive lumpectomy in Newfoundland and Labrador, where mastectomy rates are 69 per cent, than in Quebec, where they’re 26 per cent. This despite the fact that for decades, the medical community has known that the breast-preserving lumpectomy with radiation can have equivalent health outcomes.

CIHI reported that, in 2010, rates for hysterectomies fluctuated similarly, from 435 per 100,000 women in Saskatchewan to about half that—258—in Nunavut. Such aberrations are not confined to women’s health. The same year, knee-replacement surgeries ranged from 490 per 100,000 people aged 20 and older in Nunavut to a mere 136 in Newfoundland and Labrador. The rate of patients getting heart bypass surgery was 79 per 100,000 in Saskatchewan compared to only 43 per 100,000 in neighbouring Alberta.

“Clearly, when you see a two-fold variation in hysterectomy rates,” says Brian Goldman, an ER doctor in Toronto and a Canadian health-care analyst, “some of them have to be unnecessary.” Goldman points out there can be variations in practice patterns for open versus laparoscopic hysterectomy, or based on drug shortages; there may be a local expert who influences practice. “Patients should care if they are getting an operation they don’t need,” he says.

Those who study regional discrepancies estimate that as much as 20 to 30 per cent of care doctors provide is unnecessary—which can mean pointless

Graphic by Taylor Shute

surgeries, wasted days in hospital, squandered resources and, worst of all, avoidable complications and deaths. Yet, as Affleck says, “If what we’re doing may be supply-driven or preference-driven, not necessarily based on effective care, most doctors don’t know that, because we haven’t had the capacity to measure ourselves.”

Until now. Affleck is part of a new generation of front-line health workers using data from their own clinics to identify and minimize haphazardness where care deviates from best practices and, with any luck, to improve patient outcomes along the way.

Gathering data on health care trends and outcomes has traditionally been the domain of public-health officials or epidemiologists, who take a bird’s-eye view, looking at health regions or provinces. The phrase “unwarranted variation” was coined by an epidemiologist, John Wennberg. In sweeping studies of the U.S. system that have been going on for about half a century, Wennberg found a counterintuitive relationship between higher spending in health regions and worse outcomes, concluding that supply—or the availability of medical services—drove usage, instead of science or patient need. In other words, more in medicine is not necessarily better.

In recent years, the profession has tried to address this paradox, in part by determining what works. Hospitals have begun to track and publish indicators like readmission or surgical complication rates. In the U.S., they are even being paid according to how well they hit these targets.

Yet these efforts to measure and reward quality have been far removed from the drivers of the system, as Affleck put it. That’s partly because quality primary care—counselling a grieving patient, comforting the worried well—tends to be less measurable than, say, surgical outcomes. But it’s also because, before electronic medical records (EMR), measurement in clinics was tedious, almost impossible. The lone GP would need to crunch data and look for trends in thousands of patient charts. But with EMRs, Goldman notes, “Now you can do this at the touch of a few buttons.”

In 2005, Affleck helped launch what has evolved into a territorial EMR covering more than half of the 41,000 patients who populate a 1.3 million-sq.-km expanse. It has allowed him to begin to grapple with variations in care that may be occurring in Yellowknife.

About a year and a half ago, he introduced “mentorship rounds.” Every two weeks, doctors and other health professionals gather at the Yellowknife Primary Care Centre. “We take a turn pulling data off the EMR,” says Affleck, “and compare what we’re doing with, for example, screening for prostate cancer, to what international standards or guidelines are.” In looking at the number of PSA prostate screening tests that were ordered, they found they had doubled their requests in the previous year. Why was this? Affleck and his team discussed the question. “Is this driving care that may not be warranted?” he asks.

They also looked at whether they were doing enough to help patients quit smoking, and whether diabetics were being looked after to guideline standards. “When we’re extracting data, we’re looking at outcomes,” says Affleck. If the blood sugar of diabetics in the region is higher than average, doctors can adjust the care they offer—perhaps introduce group teaching sessions—and begin tracking patients’ levels over time. “You can monitor these patients to see if they’re improving or not.”

Though these are early days, Affleck believes that simply reflecting on your practice using data may improve quality, and he’s trying to instill that idea in the next generation of doctors. “Data is not something we’re brought up to embrace,” he says of Canadian family practice. But it can be a useful tool.

In Taber, Alta.—a town just north of the U.S. border—family doctors are using their EMR system as the foundation of a larger plan to reduce unwarranted variation. Rob Wedel, who moved there from Calgary in 1976, is the physician lead at the Taber Clinic, which serves a geriatric population mixed with younger new Canadians. He wanted to know whether screening for colorectal cancer was reaching the over-50 population that guidelines recommend be targeted. So he used his clinic’s EMR to find those patients, and began calling them to get their tests done. He also created an alert that reminded clinic workers to ask eligible patients who came in whether they wanted a colonoscopy. “It became a joke here,” Wedel laughs. “Patients would come in for a sore throat and leave with a booking for a colonoscopy.”

When he began the project in 2000, colorectal-cancer screening was reaching about 10 per cent of eligible patients. “Now, 80 to 90 per cent of people who should get screened are getting it.” A bit of data extracting and feedback reduced the randomness of who got tested, and Taber now meets the national standard.

More startlingly, Wedel improved outcomes for asthmatic patients. Asthma is prevalent in Taber because of agricultural work. Wedel found the asthmatics in his practice on his EMR and designed a program that involved regularly calling them to talk about how to manage their asthma. He calls it “proactive surveillance,” and the result was that visits to the ER for asthma dropped from 450 to 24 per year. “Asthma is no longer even on the top 10 reasons for people to come to emergency anymore.”

Whether these efforts lead to better overall health remain to be seen. But Wedel and Affleck point out that, in a time when questions of health-system sustainability and cuts abound, a little reflection can’t hurt. “Let’s look at what we’re doing,” Affleck says. “In our industry, we understand what quality is, and ultimately the goal is to deliver quality care. So if there’s a uniform understanding of what quality is, how can there be significant variations?”


The medical lottery: treatment rates vary wildly from one city to another

  1. Great idea (sarcastic) have big brother tell you what tests you must get, if not you will be harassed until you comply. Any way to opt out – nope no alternative except comply or face harassment. Can’t wait until the Taber model reaches my town, hope I’m dead by then. Who decides who “should get screened” the screening police?

  2. “Higher spending and worse outcomes” translates into “overdiagnosis”. PSA tests have been repeatedly discredited as leading to unwarranted/useless surgeries. Unless a patient is considered at risk, routine colonoscopies are just a money mill. Mammograms carry more risk than benefit.
    “Asthma is prevalent in Taber because of agricultural work”?? How does agricultural work cause asthma? Wouldn’t be the use of pesticides like Roundup would it? Nailing down the cause and practising actual prevention would be a really useful medical approach. Instead someone is plugging”symptom management”.
    “Unwarranted variation” is a risk to patients, and so is “overdiagnosis”.
    The medical industry certainly does not know what “quality” is. It’s pretty much devolved into sick care where patients are simply manipulated to suit the system.
    Really people, take charge of your own health and don’t be sold on medical procedures or even diagnostic tests without fully informing yourself about the real risks/benefits. Diagnostic testing is not prevention — it’s diagnostic testing.

    • Research into the causes of asthma is a very active endeavour in many centers across the country. The link to agricultural work is more likely through inhaled grain dust, pollens, etc., I’m not sure what the basis is for your assertion that Roundup would be a likely precipitant.

      But anyways that is not the issue here: as a GP in a small agricultural community, working directly with patients experiencing symptoms, your job is to take care of these people. In this case they implemented what sounds like an excellent secondary prevention program. You can knock “symptom management” all you want, but in the end as a physician taking care of your patients and dealing with their symptoms is your number one task.

      • You must be the only person around who doesn’t know about pesticide toxicity, especially glyphosate as causing epigenetic damage. That damage frequently shows up as some kind of immune system dysfunction, the most common of which is allergies.
        The issue here is quality of care, which as the article points out is obviously not standardized. However it then meanders into some justification for prescribing tests that have been shown to be a means to overdiagnosis, which is the antithesis of patient care.
        I don’t see any evidence of any “secondary prevention program”… how do you figure that calling people to talk about their problem is “prevention”? They already HAVE the problem.

        • Given that a quick PubMed search for the terms “glyphosate” and “asthma” returns exactly zero hits, I doubt I’m the only one not aware of this connection you speak of. I don’t deny that Roundup may have some toxicities we are not aware of, but I would love to hear about the evidence behind your claim. I would also be curious to hear how coloscopies “have been shown to be a means to overdiagnosis, which is the antithesis of patient care”. Last I checked there was good evidence that screening programs reduced rates of death from colon cancer. The same is not true for PSA and mammographies, which may just be why this article on the use of scientific evidence to improve patient care does not mention those tests.

          As for secondary prevention, it is defined as the prevention of adverse outcomes after a diagnosis has already been made. This includes controlling blood sugars in people with diabetes, putting patients who’ve had a stroke or MI on antiplatelet medications or controlling people’s asthma so they don’t have to be admitted to hospital in acute respiratory distress. As much as we would love to prevent all disease before it happens, that’s not always possible.

          • You should realize that PubMed is not the only source of information available. Next time, though, search under pesticides.
            Colonoscopies are also on the list of diagnostic tests leading to over-diagnosis.
            Did you realize that adverse reactions from prescription drugs are one of the leading causes of emergency room visits?
            “Secondary prevention” is not prevention either. It’s treatment aimed at suppressing symptoms that already exist.
            Conventional medicine is incapable of preventing or curing disease — it’s only a means of symptom management, which sometimes works and sometimes doesn’t, and generally creates other problems.

          • Pesticides and asthma – The alternative source of information you provide me is from the “Northwest Coalition for Alternatives to Pesticides”, clearly not an unbiased source. The evidence of mutagenicity is from a handful of studies on mouse models and cell lines. There is a case report of an acute dermatological reaction following significant skin exposure.Sorry, that doesn’t quite convince me that the high incidence of asthma associated with agricultural work is actually due to Roundup or other pseticides. The link between asthma and inhaled dust, pollens, fungal spores, etc is solid, why grasp at straws?

            Colonoscopies – Again studies show a net benefit. Of course some false positives will be identified and lead to unnecessary work-up, but overall lives will be saved.

            Adverse drug reactions – yes this is well known and any good physician will endorse this. Adverse reactions are also a leading cause of death within hospital populations. However, they are also a leading cause of people getting better and going on with their lives, which is why we keep using them.

            Secondary prevention – PREVENTS further symptoms from developing. Controlling blood sugars in someone who already has diabetes will prevent progression or retinopathy, nephropathy, neuropathy. Yes they already have diabetes but hopefully you can prevent them from losing their sight, their foot, or having to be hooked up to a dialysis machine three times a week for the rest of their lives until they can get a transplant.

            Conventional medicine – I hope you live a long healthy life and never come down with an illness that requires actual treatment, as I gather from your response that you would stay away from the hospital. Medicine can’t cure disease? Tell that to any kid who has survived a childhood cancer. Overall cure rates are in the area of 90% these days, drastically improved over the past few decades. Medicine can’t prevent illness? How many people do you know to have died of smallpox or polio recently?

          • Smallpox and polio were already virtually eradicated before vaccines were trotted out — Europe never endorsed mass polio vaccination and their disease incidence declined more rapidly. The first polio vaccines also caused cancer. There is currently an epidemic of polio-vaccine induced “flaccid paralysis” (note the name change). Polio has not been eradicated. The pathogen has mutated thanks to the vaccine.
            Parapertussis has actually incubated in the pertussis vaccine.
            It has been shown that type 2 diabetes can be reversed through dietary changes, no medical interventions necessary.
            Colonoscopies carry serious adverse risks such as bowel perforation, infection, and others. Unless someone has been identified as high risk they should avoid routine colonoscopies.
            Nobody is grasping at straws when they issue warnings about the dangers of chemical contaminants, pesticides etc. It’s estimated that there are about 50,000 toxic chemicals in existence and a mere handful have been tested for carcinogenisis. The medical industry fluffs these off as “sensitivities” rather than allergies.
            Medical doctors have one of the highest mortality rates in the actuarial tables. Guess they take their own advice too often.
            The medical industry deems cancer “survival” as being a period of 5 years.

          • I said nothing about vaccines, just that illnesses that in the past ravaged populations are now effectively controlled or prevented by science-based medical approaches. Some of the greatest gains have been made through basic interventions such as improved sanitation, provision of clean water and improved nutrition. But beyond this there are countless effective diagnostic tests and treatments that have been shown to reduce morbidity and mortality. If you don’t believe this, I’m not going to convince you. Again, I wish you all the best with whatever approach to health care you do believe in.

          • “Science-based medical approaches” had nothing to do with public sanitation or water purification whatsoever. In fact concensus of opinion has mostly driven mainstream medicine for generations and is generally still the most prevalent factor. Why do you suppose patients are encouraged to seek a second or third opinion when it comes to major medical interventions?
            Orthomolecular medicine holds the key to real prevention. It should really become the cornerstone of clinical practise.

          • I’m just trying to understand your position: do you not believe in the
            germ theory of disease, not consider to fall under “science-based
            medical approaches”, or not consider it as the basis for measures for
            improved sanitation and clean water? Your assertion that the cornerstone
            of clinical practice should be an approach for which there is
            absolutely no scientific evidence, and which is regarded by most as quackery, really makes me wonder how you feel
            about science in general.

          • Medicine is actually classified as health care technology, not science. It cannot take credit for public sanitation or water purification.
            I suggest you subscribe to the Journal of Orthomolecular Medicine (it’s free) and has links to hundreds of scientific studies. Or do you think that Linus Pauling got a Nobel Prize for the discovery of vitamin C as a fluke?
            You may opine that nutritional-based science is “quackery” as you’re going through the drive-through and super-sizing your coke and fries. Have extra aspartame and acrylamide. You can then sign up for bariatric surgery as a form of symptom suppression.
            I love science and abhor Scientism.

          • The science/technology distinction is completely irrelevant to my question, purely a mater of semantics but allows you to avoid providing an answer. Linus Pauling did not discover vitamin C, his nobel prize was for his work on chemical structure. He did advocate taking high doses of vitamin C in his later years, a view that has been highly criticized. You know nothing about my dietary intake, yet you feel the need to comment on it. You claim to love science, but ignore the scientific consensus based on overwhelming weight of evidence. I will now leave you to read your free “Journal of Orhomolecular Medicine” in peace, to each his own.

          • Why not just link to whale.to, mercola, or naturalnews? Go back to your chiropractor / homeopath / witchdoctor and leave the rest of us alone. Next!

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