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What's Enough, What's Too Much?
Every clinician-scientist admires the randomized, controlled trial (RCT) as the best-known method for studying the effects of a treatment on specified outcomes. A good RCT eliminates (by random assignment) any statistical linkages between the characteristics of the participants (for example, age, unmeasured comorbid conditions) and outcomes. Alas, we have no RCTs for many medical interventions. However, several valuable alternatives have emerged, including case–control analyses and analysis of regional variations in treatment patterns and medical outcomes (“small-area variations”). In this issue, Fisher and colleagues (1, 2) use small-area variation analysis to illuminate the effects of medical resource use on patients presenting with hip fracture, colorectal cancer, and acute myocardial infarction.
The authors characterized a region's propensity to use medical resources based on the overall spending patterns in Medicare patients' last half-year of life. These expenditure patterns depended mostly on inpatient treatment choices and specialist and subspecialist use, usually involving discretionary care, in contrast with relatively uniform patterns for “evidence-based medicine” interventions. This supports the premise that regional variations arise from disagreements about proper uses of medical interventions (3, 4).
Most important, the second of the two …
