Monday, June 9, 2008

regional variation , limits of health care - Can Health Inequalities Be Narrowed?

I see by the June 5 New York Times “ Research Finds Wide variation in Health Care by Race and Region,” that the Robert Wood Johnson Foundation will fund a three year $300 million initiative to narrow health care variations by race and region.

According to the article, a black diabetic has five times the chance of having a leg amputated as a white person, and women in Mississippi have much lower mammography rates than elsewhere in the country.

The director of the project, Bruce Siegel, MD of George Washington University Medical Center, is under no illusions, “In my book health care is local, just like politics, so you’re going to see a lot of differences in what communities do?

Doctor Siegel might have added that experience to data indicate it is difficult to significantly narrow practice patterns and disease outcomes.

• Thirty five years ago, Wennberg at Dartmouth decried variations in practice for Medicare patients in different sections of the country “ Small Area Variations in Health Care Delivery (Science, 1973). He and his colleagues have repeated the message ever since Yet little has changed, even in leading academic centers. Doctors and health systems, it seems, respond to regional and local cultures rather than pledging obedience to national authorities.

• Today, according to a study of 22 European nations, socioeconomic inequalities in health care are more of a function of national cultures, education , income, socioeconomic differences, lifestyle, and alcoholic and nicotine use rather than national health systems promising equal care (J.P. Mackenbach et al, “Socioeconomic Inequalities in Health in 22 European Countries, New England Journal of Medicine, June 5, 2008).

For at least 20 years researchers have known national health systems, despite their social justice virtues, and managed care companies with care controls, have little to do with reducing death rates or extending life expectancies (L. Sagan, The Health of Nations; The True Causes of Health and Well Being, Basic Books, 1987, and D. Sather, and R. Pamies, Multicultural Medicine and Health Differences, McGraw Hill, 2006). Medical Care accounts for about 15% of the health status of any population, life style for 20% to 30%m, and other factors – poverty, inferior education, income differences, and lack of social cohesion – for the other 55%. This does not mean we should stop trying to narrow health care outcomes among various groups and across regions.

We certainly wish Dr. Siegel and the Robert Wood Johnson Foundation luck, but we caution them to keep their expectations now.

No two patients, no two doctors, no two regions, no two races, and no two cultures are the same, and they do not easily bend to cries for national uniformity, standardization, and top-down controls. Calls for uniform distribution of care throughout any society and for cooperation with government or health management authorities do not necessarily gain the obedience of health professionals or individual citizens who lack the larger herd instinct.


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