Series on variation sparks intense, varied response

This weekend, we launched a series in The San Francisco Chronicle about variation in medical care. Variation occurs when certain medical procedures are performed at dramatically different rates from place to place, which affects the quality and cost of health care.

When I started reporting, I knew that variation was a growing concern in the healthcare policy world, and that there are increased efforts to rein it in, both to lower costs and reduce potential medical complications for patients.

What I didn’t realize was just how much.

Since the series ran, we have heard from doctors, university researchers and health insurance plan administrators, all telling us about their work in studying or reducing variation. We also got mail from residents of the Clearlake area, who have had the highest rates of two heart procedures, elective angiography and elective angioplasty, in the state. By far.

Robert Moore is chief medical officer of Partnership HealthPlan of California, a managed care plan that serves about 200,000 Medi-Cal members in six Northern California counties.

He noted that the study we wrote about by Stanford University professor Laurence Baker showed that the areas with the highest use of the heart procedures also have low rates of managed care. Could there be a correlation, he wondered?

“As a managed care organization, we review requests for major procedures to ensure that they meet standards of medical necessity.”

His organization and others follow an established protocol that lists criteria for medical procedures and hospitalization before they occur.

Also in an effort to get some consistency in care, he works with physicians, offering educational events for them, having conversations with them and even reaching out through social media such as Twitter and blogging.

“The other way to change behavior is through changing knowledge, attitudes and behavior of physician thought leaders in the community and other front line clinicians. … I realize that a key is to have some core messages that are repeated with different media to maximize opportunity for change (a real social marketing approach.) Influencing patient behavior is part of this.”

Joseph Carey wrote to share some data on heart procedures that he and his colleagues at the University of California, Irvine, have compiled. Carey is a professor at the UCI School of Medicine and co-director of the California Cardiac Surgery and Intervention Project.

You can see his data here. Angioplasty is called PCI in his data.

You’ll see that elective angioplasty, which takes place when there’s not a concurrent cardiac emergency, has been going down since 2004. This matches Baker’s findings.

You’ll also see that California has lower rates of angioplasty than New York and Massachusetts, but higher than the United Kingdom.

Carey said he doesn’t know why the Golden State’s rates are lower than other states.

“It may be that Californians are healthier…? We do have a lower incidence of smoking and obesity.”

A Lake County woman wrote to us, saying that her father-in-law is a patient of one of the Clearlake cardiologists we mention in our story. Through this doctor, her father-in-law had an angiogram and an angioplasty, which she believes were necessary procedures.

The reader, who asked that her name not be used, is concerned, however, about the follow-up visits. She said the doctor requires her father-in-law to come in for too many appointments, and will only release test results in person.

“Those office visits are paid by Medicare and I consider them to be an overuse of the system for more income for the doctor.”

In our series, we also described efforts to tackle variation, including a collaboration between doctors, hospitals and an insurance company in Sacramento and San Francisco.

Kate O’Hanlan, a gynecologic oncologist in private practice in Redwood City, wrote to say that she was pleased that the partnership had identified invasive hysterectomies as a problem, and was training doctors in less-invasive, laparoscopic techniques.

“In my practice 98 percent of hysterectomies are accomplished laparoscopically. Nationwide, only about 30 percent are accomplished using minimally invasive techniques. It is my passion and mission to make minimally invasive hysterectomy available to more women who need this procedure.”

She offers courses to train surgeons in these less-invasive techniques. The next will be in San Francisco next week, she said.

“I have so many patients who have told me that they asked their gynecologists if their indicated hysterectomy could be performed laparoscopically, and heard that it could not be done, should not be done, or was not the right approach for her case. And they knew that their neighbor had already had a laparoscopic hysterectomy for their very same condition or worse.”

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