Small area variation in the use of health care resources.

In this new Physician Exeutive column, Professor John Kralewski and his colleagues at the University of Minnesota will summarize major research studies and their findings. The goal of the series will be to interpret the purpose and results of significant research in the context of both national health policy and the management of health care institutions. In this first column, the author discusses a federally funded project in outcomes research.

While it has been known for at least two decades that there are wide variations in the use of resources by physicians to treat similar patients, the issue now at the forefront of public policy initiatives is reductions in health care costs. Wennberg and others have shown that health care outcomes are often equal or better when fewer resources are used and that significant savings can be achieved if physicians adopt more cost-effective practice styles. Faced with rising health care costs, Congress found a great deal of merit in this line of reasoning and authorized funding for a major research effort focused on variations in the use of resources and their effects on outcomes. This research, termed the Patient Outcomes Assessment Research Program, is organized around 14 areas:

* Back pain: University of Washington, Richard A. Deyo, MD, MPH, principal investigator.

* Acute MI: Harvard Medical School, Barbara McNeil, MD, PhD, principal investigator.

* Cataract management: Johns Hopkins University, Earl P. Steinberg, MD, MPP, principal investigator.

* Benign prostatic hypertrophy and localized prostate cancer: Dartmouth Medical School, John E. Wennberg, MD, MPH, principal investigator.

* Total knee replacements: Indiana University, Deborah A. Freund, PhD, principal investigator.

* Management outcomes of diabetes: New England Medical Center, Sheldon Greenfield, MD, principal investigator.

* Ischemic heart disease: Duke University Medical Center, David Pryor, MD, principal investigator.

* Hip fracture repair and osteoarthritis: University of Maryland, James I. Hudson, MD, principal investigator.

* Biliary tract disease: University of Pennsylvania, J. Sanford Schwartz, MD, principal investigator.

* Childbirth: RAND Corporation, Emmett Keeler, PhD, principal investigator.

* Pneumonia: University of Pittsburgh, Wishwa N. Kapoor, MD, MPH, principal investigator.

* Secondary and tertiary prevention of stroke: Duke University Medical Center, David Matchar, MD, principal investigator.

* Schizophrenia: University of Maryland, Anthony F. Lehman, MD, MSPH, principal investigator.

* Low birthweight in minority and high-risk women: University of Alabama, Robert L. Goldenberg,

MD, principal investigator.

Many feel that major gains in the adoption of cost-effective medical practice patterns will be achieved by health insurance plans and physicians working together at the local level. Medical group practices and HMOs are already in the forefront of this effort. In Minneapolis, an HMO and three medical groups recently announced the formation of an institute to address these issues and committed $10 million to support the effort. Many similar but somewhat more limited efforts are under way by other medical group practices that are attempting to improve the costeffectiveness of their services.

There are several fundamental research issues that must be dealt with in order to further these efforts. First, quantification of patient care outcomes presents a major challenge. Second, the availability of data on a sufficient number of cases is problematic in some groups. Often it is impossible to conduct the research without gaining access to larger data sets. HMOs and insurance plans are important sources of these data. Finally, once cost-effective protocols have been developed, the group practice, HMO, or insurance plan faces the problem of gaining physicians' compliance. This may be one of the most important areas for future research in the quest to improve the cost-effectiveness of medical care. More will be said about research in these areas in a future column.

Some important reference publications include:

Cain, K. "Testing the Null Hypothesis in Small Area Analysis." Health Services Research 27(3): 267-94, Aug. 1992.

Chassin, M. "Variations in the Use of Medical and Surgical Services by the Medicare Population." New England Journal of Medicine 314(5):285-90, Jan. 30. 1986.

Diehr, P. "Small Area Statistics: Large Statistical Problems." American Journal of Public Health 74(4):3134, April 1984.

Greenwald, H., and Henke, C. "HMO Membership, Treatment, and Mortality Risk among Prostatic Cancer Patients." American Journal of Public Health 82(8):1099104, Aug. 1992.

Wennberg, J., and others. "An Assessment of Prostatectomy for Benign Urinary Tract Obstruction. Geographic Variations and the Evaluation of Medical Care Outcomes." JAMA 259(20):3027-30, May 7, 1988.

Wennberg, J., and others. "Changes in tonsillectomy Rates Associated with Feedback and Review." Pediatrics 59(6):821-6, June 1977.