We measured geographic differences in the use of medical and surgical services during 1981 by Medicare beneficiaries (age greater than or equal to 65) in 13 large areas of the United States. The average number of Medicare beneficiaries per site was 340,000. We found large and significant differences in the use of services provided by all medical and surgical specialties. Of 123 procedures studied, 67 showed at least threefold differences between sites with the highest and lowest rates of use. Use rates were not consistently high in one site, but rates for procedures used to diagnose and treat a specific disease varied together, as did alternative treatments for the same condition. These results cannot be explained by the actions of a small number of physicians. We do not know whether physicians in high-use areas performed too many procedures, whether physicians in low-use areas performed too few, or whether neither or both of these explanations are accurate. However, we do know that the differences are too large to ignore and that unless they are understood at a clinical level, uninformed policy decisions that have adverse effects on the health of the elderly may be made.
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Mirvis, D. M., Chang, C. F.
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157: 385-388
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Soumerai, S. B., McLaughlin, T. J., Spiegelman, D., Hertzmark, E., Thibault, G., Goldman, L.
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Siddique, R. M., Siddique, M. I., Connors, A. F. Jr, Rimm, A. A.
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156: 2343-2347
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156: 2051-2056
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276: 476-480
[Abstract]
Pearson, S. D., Goulart-Fisher, D., Lee, T. H.
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123: 941-948
[Abstract][Full Text]
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333: 573-578
[Abstract][Full Text]
Miller, M. E., Holahan, J., Welch, W. P.
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52: 252-278
[Abstract]
Weiner, J. P., Parente, S. T., Garnick, D. W., Fowles, J., Lawthers, A. G., Palmer, R. H.
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273: 1503-1508
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Payne, S. M. C., Donahue, C., Rappo, P., McNamara, J. J., Bass, J., First, L., Kulig, J., Palfrey, S., Siegel, B., Homer, C.
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149: 162-169
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Chilingerian, J. A., Glavin, M. P. V.
(1994). Temporary Firms in Community Hospitals: Elements of a Managerial Theory of Clinical Efficiency. Med Care Res Rev
51: 289-335
Tamblyn, R.
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17: 198-221
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13: 293-301
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50: 1098-1103
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Feldman, S. E., Rundall, T. G.
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50: 123-152
Zinn, J. S.
(1993). Inter-SMSA Variation in Nursing Home Staffing and Resident Care Management Practices. Journal of Applied Gerontology
12: 206-224
[Abstract]
Javitt, J. C., McBean, A. M., Sastry, S. S., DiPaolo, F. Jr
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111: 605-607
[Abstract]
Welch, W. P., Miller, M. E., Welch, H. G., Fisher, E. S., Wennberg, J. E.
(1993). Geographic Variation in Expenditures for Physicians' Services in the United States. NEJM
328: 621-627
[Abstract][Full Text]
Oliver, T. R.
(1993). Analysis, Advice, and Congressional Leadership: The Physician Payment Review Commission and the Politics of Medicare. Journal of Health Politics, Policy and Law
18: 113-174
[Abstract]
Charles, C., DeMaio, S.
(1993). Lay Participation in Health Care Decision Making: A Conceptual Framework. Journal of Health Politics, Policy and Law
18: 881-904
[Abstract]
Powe, N. R., Griffiths, R. I., de Lissovoy, G., Anderson, G. F., Watson, A. J., Greer, J. W., Herbert, R. J., Eggers, P. W., Milam, R. A., Whelton, P. K.
(1992). Access to Recombinant Erythropoietin by Medicare-Entitled Dialysis Patients in the First Year After FDA Approval. JAMA
268: 1434-1440
[Abstract]
Jencks, S. F., Wilensky, G. R.
(1992). The Health Care Quality Improvement Initiative: A New Approach to Quality Assurance in Medicare. JAMA
268: 900-903
[Abstract]
Pearson, S. D., Margolis, C. Z., Davis, S., Schreier, L. K., Gottlieb, L. K.
(1992). The Clinical Algorithm Nosology: A Method for Comparing Algorithmic Guidelines. Med Decis Making
12: 123-131
[Abstract]
Goldberg, K. C., Hartz, A. J., Jacobsen, S. J., Krakauer, H., Rimm, A. A.
(1992). Racial and Community Factors Influencing Coronary Artery Bypass Graft Surgery Rates for All 1986 Medicare Patients. JAMA
267: 1473-1477
[Abstract]
Epstein, A. M.
(1991). Changing Physician Behavior: Increasing Challenges for the 1990s. Arch Intern Med
151: 2147-2149
[Abstract]
Brook, R. H.
(1991). Quality of Care: Do We Care?. ANN INTERN MED
115: 486-490
[Abstract]
Richardson, S. L., Renz, K. K., Vogel, T. T., Graham, J. E. JR, Kaufman, J.
(1991). Small Area Analysis Shows Differences in Utilization. American Journal of Medical Quality
6: 91-94
[Abstract]
Stano, M.
(1991). Further Issues in Small Area Variations Analysis. Journal of Health Politics, Policy and Law
16: 573-588
[Abstract]
Holtgrave, D. R., Lawler, F., Spann, S. J.
(1991). Physicians' Risk Attitudes, Laboratory Usage, and Referral Decisions: The Case of an Academic family Practice Center. Med Decis Making
11: 125-130
[Abstract]
Topol, E. J., Holmes, D. R., Rogers, W. J.
(1991). Coronary Angiography after Thrombolytic Therapy for Acute Myocardial Infarction. ANN INTERN MED
114: 877-885
[Abstract]
Folland, S., Stano, M.
(1990). Small Area Variations: A Critical Review of Propositions, Methods, and Evidence. Med Care Res Rev
47: 419-465
Brook, R. H., Park, R. E., Chassin, M. R., Kosecoff, J., Keesey, J., Solomon, D. H.
(1990). Carotid Endarterectomy for Elderly Patients: Predicting Complications. ANN INTERN MED
113: 747-753
[Abstract]
Wenneker, M. B., Weissman, J. S., Epstein, A. M.
(1990). The Association of Payer With Utilization of Cardiac Procedures in Massachusetts. JAMA
264: 1255-1260
[Abstract]
Woolf, S. H.
(1990). Practice Guidelines: A New Reality in Medicine: I. Recent Developments. Arch Intern Med
150: 1811-1818
[Abstract]
Lee, P. R., LeRoy, L. B., Ginsberg, P. B., Hammons, G. T.
(1990). Physician Payment Reform: An Idea Whose Time Has Come. Med Care Res Rev
47: 137-163
Evans, R. G.
(1990). Tension, Compression, and Shear: Directions, Stresses, and Outcomes of Health Care Cost Control. Journal of Health Politics, Policy and Law
15: 101-128
[Abstract]
Leape, L. L., Park, R. E., Solomon, D. H., Chassin, M. R., Kosecoff, J., Brook, R. H.
(1990). Does Inappropriate Use Explain Small-Area Variations in the Use of Health Care Services?. JAMA
263: 669-672
[Abstract]
Flanagin, A., Lundberg, G. D.
(1990). Clinical Decision Making: Promoting the Jump From Theory to Practice. JAMA
263: 279-280
[Abstract]
Eddy, D. M.
(1990). The Challenge. JAMA
263: 287-290
[Abstract]
Chang, H. J., Bell, J. R., Deroo, D. B., Kirk, J. W., Wasson, J. H., Dartmouth Primary Care COOP Project,
(1990). Physician Variation in Anticoagulating Patients With Atrial Fibrillation. Arch Intern Med
150: 83-86
[Abstract]
Brook, R. H.
(1989). Practice Guidelines and Practicing Medicine: Are They Compatible?. JAMA
262: 3027-3030
[Abstract]
Cebul, R. D., Whisnant, J. P.
(1989). Carotid Endarterectomy. ANN INTERN MED
111: 660-670
[Abstract]
Wenneker, M. B., Epstein, A. M.
(1989). Racial Inequalities in the Use of Procedures for Patients With Ischemic Heart Disease in Massachusetts. JAMA
261: 253-257
[Abstract]
Ginzberg, E.
(1988). US Health Policy--Expectations and Realities. JAMA
260: 3647-3650
[Abstract]
Kelly, J. T.
(1988). Assessing Quality. JAMA
260: 2715-2716
[Abstract]
Kahn, K. L., Kosecoff, J., Chassin, M. R., Solomon, D. H., Brook, R. H.
(1988). The Use and Misuse of Upper Gastrointestinal Endoscopy. ANN INTERN MED
109: 664-670
[Abstract]
Winslow, C. M., Kosecoff, J. B., Chassin, M., Kanouse, D. E., Brook, R. H.
(1988). The Appropriateness of Performing Coronary Artery Bypass Surgery. JAMA
260: 505-509
[Abstract]
Berwick, D. M.
(1988). The Society for Medieal Deeision Making: The Right Place at the Right Time. Med Decis Making
8: 77-80
Wennberg, J. E., Mulley, A. G. Jr, Hanley, D., Timothy, R. P., Fowler, F. J. Jr, Roos, N. P., Barry, M. J., McPherson, K., Greenberg, E. R., Soule, D., Bubolz, T., Fisher, E., Malenka, D.
(1988). An Assessment of Prostatectomy for Benign Urinary Tract Obstruction: Geographic Variations and the Evaluation of Medical Care Outcomes. JAMA
259: 3027-3030
[Abstract]
Kelly, J. T., Moncrief, W. H. JR, Ross, J. E. H.
(1988). Uses of the Peer Review Organization Medicare Database. American Journal of Medical Quality
3: 53-56
[Abstract]
Chassin, M. R., Kosecoff, J., Park, R.E., Winslow, C. M., Kahn, K. L., Merrick, N. J., Keesey, J., Fink, A., Solomon, D. H., Brook, R. H.
(1987). Does Inappropriate Use Explain Geographic Variations in the Use of Health Care Services? A Study of Three Procedures. JAMA
258: 2533-2537
[Abstract]
Chassin, M. R., Kosecoff, J., Solomon, D. H., Brook, R. H.
(1987). How Coronary Angiography Is Used: Clinical Determinants of Appropriateness. JAMA
258: 2543-2547
[Abstract]
Sager, M. A., Leventhal, E. A., Easterling, D. V.
(1987). The Impact of Medicare's Prospective Payment System on Wisconsin Nursing Homes. JAMA
257: 1762-1766
[Abstract]
GILLICK, M. R.
(1987). The Impact of Health Maintenance Organizations on Geriatric Care. ANN INTERN MED
106: 139-143
[Abstract]
Merrick, N. J., Brook, R. H., Fink, A., Solomon, D. H.
(1986). Use of Carotid Endarterectomy in Five California Veterans Administration Medical Centers. JAMA
256: 2531-2535
[Abstract]
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