Abstract
OBJECTIVE: Our purpose is a descriptive analysis of variations in hospital use among small areas of Maryland. DATA SOURCE: The data are Maryland patient discharge records from acute care hospitals for 1985-1987 and small area population estimates by age, gender, race, and income. FINDINGS: The common finding was excess geographic variability among Maryland's 115 areas. The hypothesis of uniform rates was rejected for most DRGs, including low-variation mastectomy and hernia repair. Clustering of high-use rates occurred in neighboring areas for orthopedic, vascular, and elective procedures. Admission rates for most nondiscretionary procedures and medical DRGs were reduced in affluent areas while discretionary surgery increased with income level. Elective procedures had extreme variation and were related to income. Coronary artery disease rates declined with income while coronary artery procedure rates increased, indicating that access and patient selection were factors in the use of coronary bypass and angioplasty. CONCLUSIONS: The issue is not the ubiquitous variation among small areas but its extent and identification of geographic patterns. Hospital use is related to demography, morbidity, medical resources, access, selection for care, and physician practice patterns. Heterogeneity of these factors ensures that uniform delivery of health care rarely holds. There is little evidence that incidence of surgical disease is the main source of variation in use of discretionary surgery. Rather, variations reflect differing medical opinion on appropriate use. Without evaluation, excessive use cannot be distinguished from underservice. Morbidity explains the variability of nondiscretionary surgery and conditions related to lifestyle. Access plays an important role for discretionary surgery. Geographic analysis can identify variation and relate incidence to socioeconomic and specific local effects. Hospital data do not permit direct assessment of appropriate care. Understanding the reasons for variation requires information beyond incidence data. The challenge is to identify and explain small area variations or to fix them.
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- Barnes B. A., O'Brien E., Comstock C., D'Arpa D. G., Donahue C. L. Report on variation in rates of utilization of surgical services in the Commonwealth of Massachusetts. JAMA. 1985 Jul 19;254(3):371–375. [PubMed] [Google Scholar]
- Cain K. C., Diehr P. Testing the null hypothesis in small area analysis. Health Serv Res. 1992 Aug;27(3):267–294. [PMC free article] [PubMed] [Google Scholar]
- Chassin M. R., Kosecoff J., Park R. E., Winslow C. M., Kahn K. L., Merrick N. J., Keesey J., Fink A., Solomon D. H., Brook R. H. Does inappropriate use explain geographic variations in the use of health care services? A study of three procedures. JAMA. 1987 Nov 13;258(18):2533–2537. [PubMed] [Google Scholar]
- Gittelsohn A. M., Halpern J., Sanchez R. L. Income, race, and surgery in Maryland. Am J Public Health. 1991 Nov;81(11):1435–1441. doi: 10.2105/ajph.81.11.1435. [DOI] [PMC free article] [PubMed] [Google Scholar]
- LEMBCKE P. A. Medical auditing by scientific methods; illustrated by major female pelvic surgery. J Am Med Assoc. 1956 Oct 13;162(7):646–655. doi: 10.1001/jama.1956.72970240010009. [DOI] [PubMed] [Google Scholar]
- Leape L. L. Unnecessary surgery. Health Serv Res. 1989 Aug;24(3):351–407. [PMC free article] [PubMed] [Google Scholar]
- Lewis C. E. Variations in the incidence of surgery. N Engl J Med. 1969 Oct 16;281(16):880–884. doi: 10.1056/NEJM196910162811606. [DOI] [PubMed] [Google Scholar]
- McPherson K., Wennberg J. E., Hovind O. B., Clifford P. Small-area variations in the use of common surgical procedures: an international comparison of New England, England, and Norway. N Engl J Med. 1982 Nov 18;307(21):1310–1314. doi: 10.1056/NEJM198211183072104. [DOI] [PubMed] [Google Scholar]
- Notzon F. C., Placek P. J., Taffel S. M. Comparisons of national cesarean-section rates. N Engl J Med. 1987 Feb 12;316(7):386–389. doi: 10.1056/NEJM198702123160706. [DOI] [PubMed] [Google Scholar]
- Wennberg J. E. Population illness rates do not explain population hospitalization rates. A comment on Mark Blumberg's thesis that morbidity adjusters are needed to interpret small area variations. Med Care. 1987 Apr;25(4):354–359. [PubMed] [Google Scholar]
- Wennberg J., Gittelsohn Small area variations in health care delivery. Science. 1973 Dec 14;182(4117):1102–1108. doi: 10.1126/science.182.4117.1102. [DOI] [PubMed] [Google Scholar]