OECD Health Policy Studies

2074-319X (online)
2074-3181 (print)
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This series of publications analyses the organisation and performance of health systems, and factors explaining performance variations. Studies are conducted on such topics as co-ordination of care, pharmaceutical pricing, long-term care and disability, health workforce and international migration of health workers, information and communications technologies in health care, and the economics of prevention. 
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Geographic Variations in Health Care

Geographic Variations in Health Care

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16 Sep 2014
9789264216594 (PDF) ;9789264216587(print)

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Variations in health care use within a country are complicated. In some cases they may reflect differences in health needs, in patient preferences or in the diffusion of a therapeutic innovation; in others they may not. There is evidence that some of the observed variations are unwarranted, signalling under- or over-provision of health services, or both. This study documents geographic variations for high-cost and high-volume procedures in select OECD countries. It finds that there are wide variations not only across countries, but within them as well. A mix of patient preferences and physician practice styles likely play an important part in this, but what part of the observed variations reflects over-provision, or whether there are unmet needs, remain largely unexplained. This report helps policy makers better understand the issues and challenges around geographic variations in health care provision and considers the policy options.

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  • Foreword and Acknowledgements

    Whether or not you will receive a particular health service depends to a very great extent on the country in which you live – even countries with similar standards of living deliver very different packages of health services – but also on the region where you live within a country. To the extent that variations in the use of different diagnostic or therapeutic procedures reflect differences in health needs or patient preferences, there is no cause for concern. But if they do not, they are unwarranted, signalling either under- or over-utilisation of care in some areas, which in turns raises questions about the equity and the efficiency of health systems and overall health system performance.

  • Acronyms and abbreviations
  • Executive summary

    Geographic variations in health care use across and within countries have been widely documented, for a limited number of countries including the United States, Canada, the United Kingdom and Nordic countries. While some of these variations reflect differences in patient needs and/or preferences, others do not. Instead, they are due to variations in medical practice styles, the ability of providers to generate demand beyond what is clinically necessary, or to unequal access to health care services. These unwarranted variations raise concerns about the equity and the efficiency of health systems.

  • Geographic variations in health care use in 13 countries: A synthesis of findings

    This chapter summarises the main findings of this project on geographic variations in health care use across and within a number of OECD countries, and identifies a range of policy levers that can be used to reduce unwarranted variations, defined as variations that cannot be explained by patient needs and/or preferences. This summary draws mainly on the 13 national reports from Australia, Belgium, Canada, the Czech Republic, Finland, France, Germany, Israel, Italy, Portugal, Spain, Switzerland and the United Kingdom (England) which are published in the following chapters. The analysis focusses on a selected set of health care activities and procedures, including hospital medical admissions and some high-volume and high-cost diagnostic and surgical procedures. The results show that large variations in health care use persist, across and within countries, even after taking into account differences in demographic structures. While the analysis in this study does not allow to determine precisely how much of these variations are unwarranted, some of these variations are too large to be explained solely by patient needs and/or preferences. A number of policy interventions have been used in different countries to address unwarranted variations in health care use, including public reporting, the development and monitoring of clinical guidelines, the diffusion of decision aids for patients to complement the information they receive from physicians, and changes in financial incentives to try to reduce the inappropriate use of certain procedures.

  • Australia: Geographic variations in health care

    This chapter summarises data and utilisation rates of a select number of health care procedures and activities within Australia, analysed by Medicare Local.

    In 2010-11, the amount of variation across Medicare Locals was smallest for caesarean sections (a 1.6-fold variation) and largest for cardiac catheterisation (a 7.4-fold variation). Variations were somewhat lower when based on the 10th and 90th percentile values of the distribution of procedure rates, ranging from 1.3-fold for caesarean section to two-fold for cardiac catheterisation and knee arthroscopy. Cardiac revascularisation procedures, hysterectomy and knee replacement showed relatively middle range variation across Medicare Locals.

    The chapter also describes policies that have been used to address variations, such as the establishment and promotion of national clinical guidelines for cardiac care; the development of criteria to define priorities for hip and knee replacements; and the introduction of payment incentives to encourage the provision of evidence-based health care.

  • Belgium: Geographic variations in health care

    This chapter looks at variations in medical practice across provinces in Belgium, for hospital medical admissions and a number of diagnostic and surgical procedures, drawing on data from 2009. While variations across provinces are relatively small for hospital admissions and some surgical procedures such as caesarean sections, variations are larger in the use of diagnostic procedures such as knee arthroscopy, cardiac catheterisation, MRI exams and CT exams.

    In the case of MRI and CT exams, there is strong evidence of a "substitution" effect in the use of these two diagnostic exams. Furthermore, differences in utilisation rates are due at least partly to a greater number of MRI units in the Flemish provinces. A strategy involving co-operation with stakeholders was developed to reduce exposure to ionising radiation from imaging tests by 25%.

    Persisting geographic variations in medical practice in Belgium requires a variety of strategies and approaches to engage governments, providers and patients in continuously improving health service delivery.

  • Canada: Geographic variations in health care

    In Canada, there continues to be large variations in medical practice across provinces and territories as well as across health regions in each province, raising questions about the efficiency and equity of health service delivery. This chapter focusses on the use of nine health care activities and procedures between 2003 and 2010. Hospital medical admissions have generally declined in Canada and are low compared with other OECD countries, but there remain substantial variations across provinces (nearly two-fold difference) and health regions (nearly four-fold difference). Knee replacement surgery has increased in all provinces since 2003, with no reduction in the large variations across provinces and health regions. This contrasts with coronary angioplasty, which has also increased in all provinces, but more so in provinces that started with a low level in 2003, indicating a certain degree of convergence in the treatment of people following heart attack. There has also been a strong rise in the use of MRI and CT scans, but despite some reduction in the variation in MRI exams across provinces, substantial variation remains (nearly two-fold difference). In 2013, the Canadian Medical Association, in co-operation with some universities and patient groups, adapted the Choosing Wisely campaign initially developed in the United States to promote more informed discussions between doctors and patients and to reduce unnecessary diagnostic tests and procedures. The impact of this new initiative should be closely monitored.

  • Czech Republic: Geographic variations in health care

    This chapter gives an overview of geographic variations in the Czech Republic for hospital medical admissions, caesarean section, knee replacement, hip replacement, and hysterectomy. Age- and gender-standardised rates of utilisation are reported for the 14 regions and the 77 former districts, in 2011.

    While the number of caesarean sections and knee and hip replacements is increasing, the number of hysterectomies is gradually declining. Geographic variations are particularly high for hysterectomy and, to a lesser extent for knee replacement. Regions do not constantly show a low or high prevalence for all health care interventions. Prague has a high prevalence of caesarean sections but low prevalence of knee and hip replacements and hysterectomies. Regions with a lower socioeconomic profile have heterogeneous patterns. While Northwest Bohemia has a low prevalence of caesarean sections, North Moravia has the highest rate. At the district level, high prevalence of gynaecological procedures (caesarean section or hysterectomy) in some areas cannot fully be explained by patient preferences and provider motivations require further investigation.

  • Finland: Geographic variations in health care

    This chapter describes geographic variations in the rates of medical admissions to hospitals and in eight surgical procedures performed for 20 hospital districts over the period 2001 to 2011. While medical admission rates decreased by over 20% and hysterectomy rates by over 40% over this period, knee replacements increased by 80% and coronary revascularisations by 30%. These changes obviously reflect the trends in developing treatments and care.

    There were also changes in the extent of geographic variation in hospital use, such as a decrease in variations of knee interventions and an increase in variations for coronary revascularisations. These trends may be associated with several factors, such as differences in resource development and the adoption of new practices, but also with policy measures adopted (for instance for hysterectomy and knee interventions).

    In Finland, several measures have already been introduced to tackle practice variations, such as the establishment of comprehensive health care registers, the production of performance indicators, and the development of national clinical guidelines and common criteria for treatments. More systematic implementation and monitoring of these measures may be needed.

  • France: Geographic variations in health care

    In France, awareness about practice variations has been growing in recent years due to the harsh economic context and changes in regional governance. This chapter provides information on variations in the use of eight specific hospital procedures and activities across departments for 2005 and 2011. It then provides an overview of the major policy instruments used in France for tackling variations in medical practice.

    The results confirm systematic variations between departments in the hospitalisation rates that are difficult to justify simply by the differences in local populations. The relative magnitude of the variations observed by procedure is coherent with the literature: it is highest in revascularisation and knee procedures and lowest for surgery after hip fracture. Cross-departmental variations for most procedures decreased between 2005 and 2011. Further work is called for to develop a better understanding of the causes and consequences of these variations in different types of care and to determine the margins for improvement in terms of equity, quality and efficiency.

  • Germany: Geographic variations in health care

    This report documents geographic variations in health care use in Germany, for a number of hospital-based activities (medical admissions, caesarean sections, coronary procedures, knee replacements and hysterectomies), across Länder and across Spatial Planning Regions. It complements information from other contemporary work. Although possible explanations for variation beyond demographics are drawn from existing research (e.g. need and supply-side factors), a substantial amount of variation is still unexplained and thus possibly unwarranted, given current knowledge. It is therefore recommended that research should continue, alongside the engagement of stakeholders, including those responsible for health care decision making in various contexts. In particular it is recommended that sustained efforts be undertaken to strengthen the evidence base regarding the appropriateness of interventions, thus providing more reliable information for necessary discussions between payers/purchasers, providers and patients. Considerable effort going beyond a more sophisticated analysis of variation is therefore needed to promote evidence-based changes that would either reduce variation or inspire trust that variation in health care use is warranted because it reflects patient needs and has health benefits.

  • Israel: Geographic variations in health care

    Medical variations between geographical areas in Israel have been widely discussed in the last years, especially regarding accessibility to medical services in the periphery of the country. However, this is the first report that focusses on a selected set of hospital interventions and procedures. The interventions with the lowest variation across districts were hospital medical admissions, PTCA and surgery after hip fracture, while the highest variation was for knee arthroscopy, with a 4.5-fold variation between the districts with the lowest and the highest rate. Regarding cardiac revascularisation procedures, the trend over time in PTCA rates varied across districts, with PTCA rates increasing in some districts (the Northern and Southern districts) while decreasing in others. This trend is attributed to a vast investment in manpower and infrastructures in the periphery. More generally, one of the main findings of this report is that the Israeli periphery (the Northern district in particular) tends to have higher rates of hospital medical admissions and surgical activities for many of the procedures reviewed in this report. This phenomenon is not attributed to a specific policy and needs to be further investigated.

  • Italy: Geographic variations in health care

    This chapter outlines variations for nine health care activities and procedures carried out in Italy for the timeframe 2007-11. During the study period, national and median provincial rates declined for almost all procedures, except for caesarean rates and knee replacements. The coefficient of variation remained generally stable, with the exception of a decrease in hospital medical admissions and increase in catheterisation and knee arthroscopy. However, the gap between the highest and lowest rates, except for hospital medical admissions, generally widened, showing that extreme values are still present and shall raise the concern of policy makers. The increased implementation of programmes on quality monitoring (National Outcomes Programme, Griglia LEA) and efficiency (Recovery Plans) may have contributed to the steady reduction in overall rates, such as the declining caesarean section rates observed in southern regions in 2012. However, targeted action is still needed to reduce the high level of variation found to persist across the country.

  • Portugal: Geographic variations in health care

    During the eight-year period covered in this report (2002-09), there has been a reduction in geographic variations in the use of some of the health care procedures selected in this study, such as cardiac catheterisation and coronary angioplasty. There has also been a reduction in geographic variations in caesarean section rates, although the variation between public and private hospitals rates continues to be wide. The Portuguese Ministry of Health recently asked a group of experts to develop a plan to reduce the inappropriate use of caesarean sections throughout the country.

    This study also shows that geographic variations in the use of some other procedures that are becoming less frequently used and replaced by other treatment options are increasing, for example for coronary artery bypass graft (CABG) and hysterectomy. This indicates that the reduction in the use of these procedures has not been uniform across the countries, and a need to promote greater convergence in clinical practices.

  • Spain: Geographic variations in health care

    This chapter outlines geographic variations in Spain at the provincial and regional levels in the period 2000-10. Hospital admission rates remained stable over time and across regions, with relatively little geographic variation. While caesarean section rates increased in Spain up to 2005, and then decreased, greater variation is observed at the province level. Caeserean section rates have continued to rise in private hospitals, while the trend has been reversed in public hospitals. The overall rates of hysterectomy and the variation across regions decreased during the study period. Cardiovascular procedures (CABG, PTCA and catheterisation) show great variations between provinces, although the variations have decreased over time for PTCA. The number of joint procedures increased over time, with great variation, particularly for knee arthroscopies and knee replacements. As expected, variations across regions have been lower and more stable for surgery after hip fracture. The recent experience in reducing caesarean section rates in many public hospitals provides a good example of the possibility of reducing the overuse of certain interventions through the development and implementation of clinical guidelines in a way that involves all key stakeholders. Nevertheless, the challenge remains to extend this approach to all regions and hospitals.

  • Switzerland: Geographic variations in health care

    This report presents the inter-cantonal differences between rates of utilisation of certain medical services in Switzerland. The analysis focuses on six procedures performed on an inpatient basis (caesarean section, coronary artery bypass graft (CABG), percutaneous transluminal coronary angioplasty (PTCA), cardiac catheterisation, knee replacement and knee arthroscopy) and two types of admission (medical hospital admission and admission for hip fracture) between 2005 and 2011. Cardiac procedures rates seem to converge over the years. With regard to knee arthroscopies the type of care (ambulatory/inpatient) varies from canton to canton, and the rates of utilisation of inpatient care for this medical practice differ to a certain extent. Lastly, the rates for the other procedures and the remaining two types of admission were already fairly close in 2005 and have remained so throughout the period of analysis.

  • United Kingdom (England): Geographic variations in health care

    This chapter presents data on geographic variations in England for hospital medical admissions and a number of surgical and diagnostic procedures (caesarean sections, revascularisation procedures, knee replacements, admission after hip fracture, and CT and MRI scans) based on the ten Strategic Health Authorities and 151 Primary Care Trusts that were in place in 2010-11. As expected, admission after hip fracture has the lowest rate of regional variation, as there is little discretion to operate a patient following a hip fracture. The highest degree of regional variations are for coronary artery bypass grafts, knee replacement and MRI scans, interventions for which there is a higher degree of physician discretion and also possibly regional variations in the capacity to deliver these procedures. Since 2009, the English NHS has started to monitor patient outcomes following knee replacement and other surgical interventions such as hip replacement to assess health improvements before and after the operations. These Patient Reported Outcome Measures (PROMs) show that the vast majority of patients who had a knee replacement in 2010-11 reported positive outcomes following their operation, both in regions with high rates and low rates of knee replacement.

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