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Dr. David Goodman, Dartmouth Atlas

Pediatric care varies due to doc preference, not patient need, Dartmouth report says

By Andis Robeznieks
Posted: December 11, 2013 - 7:00 pm ET

(Story updated with comment at 7:10 p.m. ET.)

Variations in physician services, hospitalizations, surgeries, imaging and prescriptions show that the medical care children receive is often the result of provider preference and not patient need, according to a new report by the Dartmouth Atlas Project (PDF).

Using claims data generated between 2007 and 2010 from an all-payer data set for patients younger than 18 years old in Maine, New Hampshire and Vermont, Dartmouth researchers found wide variations in care for children in those three states.

According to the report, children in Dover, N.H., had close to twice as many emergency department visits as those in Burlington, Vt.; more than twice as many kids in Lebanon, N.H., had their tonsils taken out as those in Bangor, Maine; and similar variances were found in the rates for computerized tomography, or CT, scans across the region.

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“While there are many examples of excellent care for children, the inconsistency in care across a relatively small geographic region raises troubling questions about whether medical practice patterns reflect the care that infants and children need and that their families want, or whether they are primarily the result of differences in physician and hospital practice styles,” Dr. David Goodman, the report's lead author and a professor of pediatrics at Dartmouth's Geisel School of Medicine, said in a news release (PDF).

The authors suggested that both physicians' practice style and “a lack of consensus regarding the optimal approach to medication use” likely influenced the wide variation in prescribing patterns.

The researchers also concluded that variation in the local supply or capacity of healthcare resources may influence the rates of surgical procedures and imaging, stating that “pediatric capacity is generally not located where the need is greatest.” In New England, physicians responsible for the care of children “tend to locate in areas with lower levels of pediatric health risk.”

“It is not clear whether higher pediatric hospitalization rates reflect lower use of primary-care services or poorer ambulatory care quality,” they wrote in the report. “There is some evidence that higher hospitalization rates are associated with higher availability of hospital beds for children in an area, and that this leads to a lower threshold for admission.”

This theory was first postulated by Dr. Milton Roemer, a UCLA public health professor who wrote in 1959 that “hospital beds built tend to be used.” This went on to become known as “Roemer's Law.” The Dartmouth Atlas Project, mining Medicare data in a series of attention-grabbing reports over the past 20 years, has developed its own variation on this theme: “In healthcare, geography is destiny,” and this idea was repeated in the report.

“Whether the care is lead screening, tonsillectomies, mental health hospital admissions or prescriptions for psychotropic medications, healthcare depends a great deal on where children live and receive their care,” the authors declared.

The authors stated that their findings “should challenge the idea that children's healthcare only needs more resources.”

Instead, they suggested that there needs to be more pediatric quality measures and more public reporting of those measures in order to improve both clinician performance and shared decisionmaking. “The scarcity of data available for research and evaluation of children's healthcare has slowed our pace of improvement.”

Dr. Jack Percelay, chairman of the American Academy of Pediatrics' committee on hospital care, agreed with that statement.

“It doesn't surprise me that the pediatric population experiences the same variation as the adult population and it reflects a need—in pediatrics in particular—for developing comparative effectiveness data to drive high quality care,” said Percelay, a pediatric hospitalist and a clinical professor at Pace University in New York. He added that the AAP has supported this effort through the development of its own guidelines and by participating in the Choosing Wisely campaign, which seeks to reduce unnecessary tests and procedures.

“It is simply inadequate to apply adult measures to the pediatric population,” he said. “Kids aren't just small adults, so it's important that these efforts be appropriately resourced.”

That said, Percelay added that there is a concern about fragmentation of quality efforts if too many entities jump on the guideline bandwagon. This is because, while Medicare pays senior citizens' healthcare and lends itself well to the development of uniform standards, much pediatric care is funded by state-run Medicaid agencies.

“There is the potential of having 50 different state quality measures and a Balkanization of the effort,” Percelay explained. He cited the example of the Joint Commission's Children's Asthma Care core measure set as an example of how a uniform approach can successfully improve quality. Another example is the Pediatric Health Information System, in which the nation's top children's hospitals have pooled resources to improve care.

And, while he agreed with the Dartmouth Atlas report's findings, Percelay didn't find the study all that groundbreaking. He noted how the August issue of the AAP's Pediatrics journal published three articles on variations in children's care.

“We're all aware of the variations,” Percelay said. “It's time to stop this talking about variation and do things about it.”

Follow Andis Robeznieks on Twitter: @MHARobeznieks

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