Perspective
Practice Variations And Health Care Reform:
Connecting The Dots
A focus on medical error is preventing sufficient focus on improving
the quality of patient decision making to reduce practice variations
(and costs) in today’s health care system.
by John E. Wennberg
ABSTRACT: Unwarranted variation is a ubiquitous feature of U.S. health care. Remedies
for variations exist, and several are described in the current collection of Health Affairs pa-
pers. Several obstacles stand in the way of widespread adoption of these remedies: (1) a
quality agenda that has yet to focus on improving the quality of patient decision making; (2)
economic incentives that do not reward exemplary practice; and (3) the poor state of clini-
cal science. Medicare reform legislation creates the opportunity for a demonstration pro-
ject to redesign health care to address these barriers. We also must grapple with the cul-
tural bias that more care is better and that physicians must know best.
Several papers in this Health Affairs
collection show once again that unwar-
ranted variation—variation not ex-
plained by illness, patient preference, or the
dictates of evidence-based medicine—is a
ubiquitous feature of U.S. health care.1As
shown in several of these papers, health care
systems fail to provide in full measure such
simple life-saving, morbidity-sparing inter-
ventions as immunizations, diabetic glucose
monitoring, and the use of drugs for those
with heart attacks. Every region and every
state exhibits underuse of effective care, some
more so than others.2James Weinstein and
his colleagues provide further evidence that
the incidence of discretionary surgery, the use
of which should depend on patient prefer-
ence, is unduly influenced by local physician
opinion, which has resulted in striking long-
term variation in the risk of surgery among lo-
cal regions—the “surgical signature” phe-
nomenon.3Elliott Fisher and his colleagues
show that among the chronically ill, the fre-
quency of physician visits, diagnostic testing,
and hospitalization and the chances of being
admitted to an intensive care unit (ICU) de-
pend largely on where patients live and the
health care system they routinely use, inde-
pendent of the illness they have or its sever-
ity.4Katherine Baicker and her colleagues
show that variation affects minority groups
as it does white Americans, which clouds the
interpretation of racial and ethnic disparities
based on national average rates.5
While noting that the U.S. supply of physi-
cians grew remarkably over the past twenty
years, David Goodman shows that growth in
aggregate supply does not “cure” variations: In
1999 the per capita supply of generalist physi-
cians varied more than twofold and that of
medical specialists more than fivefold among
regions.6I and my colleagues document that
Perspectives
VAR-140 7 October 2004
DOI 10.1377/hlthaff.var.140 ©2004 Project HOPE–The People-to-People Health Foundation, Inc.
Dartmouth Medical Schoolin Hanover, New Hampshire.
