Does the difference make a difference?
on the lines of: different doctors treating similarly sick patients in different ways because of the personal preferences of the doctors themselves. At one level, one wonders whether this is such a big deal. The GCC is a great example of where variations in treatment are likely to occur and because of the plural nature of the medical professions and the diversity of their training and practice. But if different doctors from different practices show different treatment preferences for similar types of patients, and those patients are on the whole satisfied, does it really matter? It does. Consider an experiment conducted in
T
New York City in the 1930s. A thousand children were selected randomly. Upon examination by a school doctor 60% were found to have already had tonsillectomies. Of the remainder, 40% were recommended by the doctor for the procedure. The remaining children were referred to another doctor who recommended that 40% of that group have the operation and then the remainder were referred to another doctor who recommended that 44% of the final group have the operation. By the end of the process only 65 children from the original group had not been referred for a tonsillectomy. A relatively simple procedure, one might think,
but it is actually quite risky. Over a four-year period in the United Kingdom, 424 children died as a result of undergoing tonsillectomies. Hindsight is a wonderful thing for sure. This procedure is no longer so common because we now know that it is not necessary in many cases, but the New York experiment is illustrative of a lot of modern practice. One problem is that individual clinicians are often not able to fully understand how successful they are in relation to alternative treatments. Personal anecdote and generally positive patient feedback sometimes convince them that they must be doing the right things. They are aware that there are alternatives but a lot of things prevent change. Often the evidence is only marginally compelling; altering practice requires some level of re-training; sometimes it’s a matter of confidence. But it is necessary for policy makers and the
profession to continue to think about how variations can be reduced. What is obvious is that some patients are being treated in a way that will give them a greater chance of improving their situation than others. Variation has a lot of cost implications too. Huge amounts of waste exist in the U.S health system, the biggest cause being unnecessary treatment. A staggering US$300b is spent on unnecessary care, and much of this is most certainly created by
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here is a widely held view that unwarranted variation is the great enemy to cost- effective and high-quality healthcare. The term unwarranted usually means something
clinicians simply over-ordering, over-prescribing and over-treating. A greater level of adherence to a more standardized approach to treatment is without question one of the solutions to resolving the cost crisis facing US healthcare. Middle Eastern countries, particularly those with the resources to do so, should take action now to capture data about variations. There are many difficulties in changing the behavior of clinicians but the first step is to understand the local problems in some detail.
Strengthening medical research is now on the agenda of many Middle Eastern countries and this area: the epidemiology of treatment (rather than that of disease), seems to me to be a worthwhile thing to sponsor because the business case for quality and cost are well evident. John Cochrane, a professor at the University of Chicago remarked last year, in respect of modern economics, that “Simple logical consistency is the first sign of beauty”. His remarks were not uncontroversial in that regard. Perhaps those same words are truer in modern healthcare than they are in contemporary economics.
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Philip Leonard is a Director with Ernst & Young and the Sector Leader for Healthcare Advisory Services in the Middle East & North Africa. He can be contacted at:
philip.leonard@bh.ey.com
EXPERTOPINION Philip Leonard
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